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Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

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

Just days after his firing of the brand-new director of the Centers for Disease Control and Prevention, a defiant Robert F. Kennedy Jr., the U.S. secretary of health and human services, defended that action and others before a sometimes skeptical Senate Finance Committee. Criticism of Kennedy’s increasingly anti-vaccine actions came not just from Democrats on the panel but from some Republicans who are also medical doctors.

Meanwhile, members of Congress have only a few weeks left to complete work on spending bills or risk a government shutdown, and time is also running out to head off the large increases in premiums for Affordable Care Act health plans likely to occur with additional Biden-era government subsidies set to expire.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of Pink Sheet, and Alice Miranda Ollstein of Politico.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

@jessiehellmann.bsky.social

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• The FDA approved this year’s covid booster for people older than 65 and for younger people with serious illnesses. Previously, it had been recommended more broadly. All eyes will now turn to the CDC’s Advisory Committee on Immunization Practices, which is scheduled to meet Sept. 18. Usually this panel would endorse these recommendations and perhaps offer more guidance on the booster’s use for specific populations. But it is not clear whether it will do so — or whether it might even impose more limitations.
• Kennedy’s firing of CDC Director Susan Monarez and the subsequent resignation of multiple senior scientists is raising questions about the agency’s future. Many staffers who were already on the fence about staying now are increasingly likely to leave. Many of these career scientists associate Kennedy’s history of harsh criticisms of public health workers with the recent CDC shooting in Atlanta. But since the shooting, Kennedy seems to have doubled down on his position.
• At the hearing before the Senate Finance Committee, even those Republicans who were critical of Kennedy were careful not to criticize President Donald Trump. There’s some speculation that this duality is meant to drive a wedge between Kennedy and the White House, and to communicate that the HHS secretary could be politically damaging.
• With vaccine policy in flux, red and blue states alike seem to be doing their own thing. Some, like California, Oregon, and Washington — which formed what they’re calling the West Coast Health Alliance — appear to be taking steps to protect access to vaccines. Red states could move in the other direction. For instance, this week, Florida Surgeon General Joseph Ladapo announced an effort to undo all statewide vaccine mandates, including those that require certain vaccines for children to attend school. If more states follow suit, it could lead to a geographic patchwork in which vaccine availability and requirements vary widely.
• This month is lawmakers’ last chance to reup the federal ACA tax subsidies. If Congress doesn’t act to extend them, an estimated 24 million people — many of whom live in GOP-controlled states like Georgia and Florida — will see significant increases in their health insurance premium costs. There’s some talk that Congress could opt for a short-term or limited extension that would postpone the pocketbook impact until after the midterm elections. But insurers are already factoring in the uncertainty as they set rates for the upcoming plan year.
• The Centers for Medicare & Medicaid Services announced a Medicare pilot program beginning next year that will use artificial intelligence to grant prior authorization decisions for certain procedures. There is irony here. United Healthcare and other private plans have already gotten into a lot of trouble for doing this, with AI systems often denying needed care.

Also this week, Rovner interviews KFF Health News’s Tony Leys, who discusses his “Bill of the Month” report about a woman’s unfortunate interaction with a bat — and her even more unfortunate interaction with the bill for her rabies prevention treatment.

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

Julie Rovner: ProPublica’s “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, and Pratheek Rebala.

Jessie Hellmann: KFF Health News’ “When Hospitals and Insurers Fight, Patients Get Caught in the Middle,” by Bram Sable-Smith.

Sarah Karlin-Smith: NPR’s “Leniency on Lice in Schools Meets Reality,” by Blake Farmer.

Alice Miranda Ollstein: Vox’s “Exclusive: RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer. Here’s What It Shows,” by Dylan Scott.

Also mentioned in this week’s podcast:

• The Washington Post’s “Florida Moves To End All School Vaccine Mandates, First in Nation To Do So,” by David Ovalle and Lori Rozsa.
• The 19th’s “Texas Passes Bill Banning Abortion Pills From Being Mailed to the State,” by Shefali Luthra.
• The New York Times’ “Medicare Will Require Prior Approval for Certain Procedures,” by Reed Abelson and Teddy Rosenbluth.

click to open the transcript

Transcript: On Capitol Hill, RFK Defends Firings at CDC

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Sept. 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Tony Leys, who reported and wrote the August “Bill of the Month” about a patient’s unfortunate run-in with a bat and an even more unfortunate run-in with the bill for rabies prophylaxis. But first, this week’s news.  

Well, it is safe to say that there has been quite a bit of health news since we last met in mid-August. Health and Human Services Secretary Robert F. Kennedy Jr. testified before the Senate Finance Committee yesterday, which we will talk about in a moment. But first, I want to catch us up on what you might’ve missed. Our story starts, kind of, with the FDA’s [Food and Drug Administration’s] approval of this year’s covid boosters, which are only being licensed for those over age 65 and those who are younger but have at least one condition that puts them at high risk of serious illness if they contract the virus. That leaves out lots of people that many doctors think ought to be boosted, like pregnant women and children. Sarah, what’s supposed to happen after the FDA acts? The next step happens at CDC [the Centers for Disease Control and Prevention], right? 

Karlin-Smith: Correct. So right now the CDC’s Advisory Committee on Immunization Practices is scheduled to meet Sept. 17 to 18, 18 to 19, but about two weeks from now. And they would typically vote on sort of endorsing use of these vaccines and, again, have like sort of a second chance to weigh in on which populations they would be used for. And that’s often important for triggering insurance coverage without copays. And also many states rely on the CDC recommendations for various state laws that say, again, who can get the vaccine or whether you can get it via a pharmacist or only at a doctor’s office, do you need a prescription, and things like that. So the CDC and FDA, I would say, in general is a little bit behind this year. I could think a lot of people have been trying to go out and get these new shots even though those steps haven’t happened yet. 

Rovner: That’s right. I mean, it is early. Even if there was nothing else going on, there is that little bit of a lag between when FDA acts and when the CDC acts, right? 

Karlin-Smith: Yeah, there usually is. I think in the past they’ve tried to have both FDA approval and the CDC act so that the vaccines could start rolling out more like late summer, early September. So they’re definitely behind, and there’s been a number of reports of covid kind of slowly rising as the summer winds down and school gets back in session. 

Rovner: Yeah, so there’s a lot of other things going on. Well, in the meantime, nothing that was supposed to happen has happened yet, and we still don’t know all the details, but it certainly appears that Susan Monarez, who was just confirmed by the Senate to lead the CDC a month ago, was fired after she refused to override her scientific advisers and approve the new restrictions on covid vaccine availability, even before the ACIP met. In turn, four top CDC leaders resigned as well, going public to warn that the agency is being politicized by the secretary. How much of a mess is the CDC in right now? And how long is it going to take to put the pieces back together? 

Karlin-Smith: I think they’re in a pretty bad place, because not only did they lose their director really quickly, but after she resigned, about I think it was eight or nine senior CDC leaders resigned last week as well. And so, really critical people to various parts of the operation that you don’t just replace very easily. And Kennedy has slotted in Jim O’Neill as the temporary director of the CDC and kind of indicated he wants to remake the agency. And I think there are questions as to how that remaking shapes both its priorities and how it handles public health throughout the U.S. 

Rovner: And of course, morale at CDC is awesome, in part because, as we discussed the last time we met, a gunman came and shot up the place, killing a policeman and leaving the staff pretty upset. And that gunman, who then took his own life, was later found to have had some discontent with vaccines. So things are just really bright and cheery there in Atlanta at the CDC. Alice, I see you nodding. 

Ollstein: These things kind of snowball, you know? I think there are likely to be a lot of staff who were already on the fence about staying and decided to stay because they trusted these pretty senior leaders with a lot of decades of expertise and institutional knowledge. And that was sort of the thread they were hanging on as well, at least: I’m with these people. And now that they’ve left, I think that could trigger a bigger exodus on top of the exodus that was already underway. 

Rovner: And it’s important to say — even though we say it, I think, every time — that these are career scientists who’ve worked for Democrats and Republicans over the years. These are not generally political people. They’re not political appointees. And they basically do their jobs. And until fairly recently, public health wasn’t this partisan, so it wasn’t that hard to be a career public health official just working for public health. That’s just not the case anymore, is it? 

Karlin-Smith: I think there’s been a lot of insult to injury added with what happened with the shooting at the CDC, because there is a sense that the kind of rhetoric that Kennedy in particular has used over the years, even before he came into HHS [the Department of Health and Human Services], on sort of his movement has sort of amplified the criticism of public health workers and put them in this situation where they’re dangerous. And Kennedy, instead of really acknowledging that and maybe apologizing or giving any sense that he was going to shift in a different direction, has actually really kind of doubled down on it. And even in some of the pieces he’s written recently about how he wants to reform the CDC, he kind of keeps criticizing the rank-and-file employees and so forth. So there’s a lot of tension between the political leadership and the career staff, I think, at this moment. 

Ollstein: And in normal times, most of the American public would not even know the names of these people. They’re not public figures. They’re just very behind-the-scenes scientists doing their work. And now their personal photos are being combed through and shared to attack them because they’ve criticized the administration. They’re getting threats. It’s just this whole level, like you said, of politicization that we haven’t seen before. 

Rovner: Well, so, in kind of a coincidence, Kennedy had already agreed to appear on Thursday before the Senate Finance Committee, which by the way doesn’t have jurisdiction over the CDC or the rest of the public health service. But no matter — a Senate hearing is a Senate hearing. And let’s just say it didn’t go that well for the secretary. Democrats were kind of withering in their criticism of Kennedy’s eight-month tenure so far. Here’s Colorado Sen. Michael Bennet. 

Sen. Michael Bennet: This is the last thing, by the way, our parents need when their kids are going back to school, is to have the kind of confusion and expense and scarcity that you’re creating as a result of your ideology. 

Rovner: Republicans weren’t that impressed, either, particularly the Republicans on the committee who are also doctors. [Sen.] Bill Cassidy, a doctor who’s on Finance but is also the chairman of the Health, Education, Labor, and Pensions Committee and is facing a primary challenge in Louisiana, seemed to tread pretty carefully. More surprising, at least to me, was Dr. Sen. John Barrasso of Wyoming, who’s also in the Senate leadership. 

Sen. John Barrasso: So over the last 50 years, vaccines are estimated to have saved 154 million lives worldwide. I support vaccines. I’m a doctor. Vaccines work. 

Rovner: I was super impressed that even the Republicans who criticized RFK were careful not to criticize President [Donald] Trump. In fact, there were several suggestions — this was clearly a talking point — that Trump should be given a Nobel Prize for his work overseeing Operation Warp Speed, just so the senators could kind of bifurcate their complaints. What impact, if any, is this hearing going to have on RFK’s future as secretary? 

Ollstein: Well, I think there was an attempt to, I think, what you just mentioned. That like dual criticism with praise of Trump was meant to drive a wedge and to get Trump to question RFK’s leadership. That does not seem to have worked so far. We don’t know what’s going to happen in the future, but I think it’s an attempt to get the message to Trump that RFK’s reputation and actions could be damaging to the administration overall. And there was some reporting that polling showing that most people do support vaccines was circulated amongst Republican members before the hearing. And so, I think it’s trying to, yeah, get the message that this is both damaging in a public health sense but also potentially damaging in a political sense as well. 

But so far, the reporting is that Trump is standing by RFK, that he liked how combative he was. And so I don’t know where those attempts to drive a wedge will go in the future, but like you said, it was notable that if folks like Barrasso, [Sen. Thom] Tillis, who’s not running for reelection, was also more vocally critical, and a couple others, not a lot. We’re not seeing a great dam breaking yet. But I think there’s more cracks than there used to be on the GOP side. 

Rovner: I did notice that Trump, he had a very strange Truth Social post earlier in the week that basically said that CDC is a mess and it has to be fixed. Kind of just Trump being the omniscient observer. And then, apparently at a dinner with tech titans after the hearing, he said that he had not watched the hearing but that he heard that Kennedy did well, which is not exactly what I would call a ringing endorsement. I feel like Trump is giving himself some runway to go either way depending on sort of how things continue to shake out. I see nodding. 

Karlin-Smith: Yeah. I saw a lot of people reposting that clip on social media last night who are frustrated with Kennedy and using it to try and ramp up their banks and say: Keep calling. Keep pressuring. This shows we have an opening. I think it’s really always hard to read the tea leaves with Trump and his language and words. He’s a harder person to interpret. But I also thought it was really interesting that in some ways Cassidy and some of the other Republicans were throwing RFK a bone and saying: This is your president. This was his greatest achievement. Can you support it? 

And RFK couldn’t even really twist himself into doing that. He sort of tried to, but he could never square it with the bulk of his remarks at the hearing, which were incredibly critical. MRNA vaccines and vaccines in general — he defended the massive cuts in this area for research. He defended people who have really said very untrue things about the harm caused by these vaccines. So in some ways I felt like Cassidy was trying to give him one more chance or something, and RFK couldn’t even take it when it was couched as this Trump achievement. 

Rovner: I can’t help but wonder if this is playing to Trump’s advantage because it’s distracting from Trump’s other problems, that perhaps Trump likes that there’s so much attention on this because it takes attention away from other things. 

Ollstein: Yeah. Although I do find the eagerness of Democratic members of Congress and other folks to wave away certain things as a distraction as a little bit questionable. This is all part of the agenda of the administration, and dismantling government bureaucracy is clearly a core, core part of the administration’s agenda, and so— 

Rovner: And flooding the zone. 

Ollstein: Exactly. Well, it might also serve as a distraction. I think that it should be considered a serious part of what they actually want to do as well. 

Rovner: So there were a couple of things that we learned about RFK Jr. from his confirmation hearings back in the winter. One is that he’s not at all deferential to elected officials, even calling them liars, which is pretty unheard of. And that he doesn’t really know how his department works. And it appears that eight months later, neither of those things have changed. How does he get away with being so rude? I mean, I’ve just never seen a Cabinet official who’s been so undeferential to the people who basically put him in office. Is it just me? 

Karlin-Smith: I think it’s part of the times where politics is really trumping behavior or policy, right? Even though there were a few Republicans that we’ve talked about who have kind of started to get frustrated with RFK and his vaccine policies. You saw at the beginning of the hearing, Chairman [Mike] Crapo was asked by the ranking Democrat, Sen. [Ron] Wyden, to basically swear Kennedy in because Wyden has felt like Kennedy has lied to the committee before. And Crapo just basically brushed that away and dismissed it. And I think, so, in many ways a lot of the Republicans on the committee endorsed Kennedy’s behavior kind of, maybe not overtly but indirectly, and that’s sort of been how they’ve been operating. It’s more of a political theater thing, and they’re OK with sort of this disrespect, of its sort of political fight that somebody on their side is taking up. 

Ollstein: I also think Congress’ unwillingness so far to actually sanction or take action in any way about anything RFK has done seems to have emboldened him. I think the fact that he has broken all these promises he made to Cassidy and other senators and there have been basically no consequences for him so far feeds into that. He kind of has a What are you going to do? attitude that was very evident in the hearing. 

Rovner: Yeah, I think that’s fair. Well, there were, as always, parochial question from senators about home state issues, but one topic I don’t think I expected to see come up as many times as it did was the future of the abortion pill, mifepristone, which is about to celebrate the 25th anniversary of its original approval by the FDA. Alice, what are you hearing about whether FDA is going to rein the drug back in, which is what a lot of these anti-abortion Republicans really want to see happen? 

Ollstein: Yeah, so I think there was nothing new in the hearing this week. What he said was what he’s been saying, that they’re looking into it, that they’re evaluating. He made no specific commitments. He gave no specific timelines. He said basically enough to keep the anti-abortion people thinking that they’re cooking up some restrictions but not explicitly promising that, either. And so I think we’re just where we were before. They continue to reference data put forward by an anti-abortion think tank that was not peer-reviewed and claiming that it is this solid scientific evidence, which it is not, about the risks posed by the pills, which many actual, credible, peer-reviewed studies have found to be very safe. And so we just don’t know what’s going to happen. I think any nationwide restrictions, which is what they’re mulling at the federal level, which would impact states where abortion is legally protected, that would be a potentially politically damaging move. And so it’s understandable why they might not want to pull that trigger right now. So, right. 

Rovner: And Trump has said, I mean, Trump has indicated that he does not really want to wade into this. 

Ollstein: Correct. But again, he’s also very good about not making hard promises in either direction and sort of keeping his options open, which is what they’re doing. The anti-abortion activists, this is not their only iron in the fire. This is just one of many strategies they have going on. They also have multiple pending lawsuits and court cases that are attempting to accomplish the same thing. They’re pursuing new policies at the state level, which we’ll probably talk about, Texas and others. 

Rovner: Next. 

Ollstein: And so yes, this pressure on FDA and HHS to use regulation to restrict the pills is only one of many ongoing efforts. 

Rovner: Well, you have anticipated my next question, which is that while we are on the subject of the abortion pill, Texas, because it is always Texas, has a new bill on its way to the governor for a signature to try to outlaw telemedicine prescribing of the abortion pill. What exactly would this Texas law do? And would it work? Because, obviously, this has been the biggest loophole about stopping abortion in these states that have banned abortion, is that people are still able to get these pills from other states via telemedicine. 

Ollstein: Yeah. So in one sense, nothing’s changed. Abortion was already illegal in Texas, whether you use a pill or have a procedure. And so this is just layered on top of that. The groups who backed this explicitly said the attempt is to have a chilling effect. What they’re hoping is that no lawsuits are even needed, because this just scares people away from ordering pills and scares groups in other states away from sending pills. One concern that I saw raised is that the law criminalizes simply the shipping of the pills. Somebody doesn’t even have to take them for a crime to have been committed. 

And so that’s raising concerns that anti-abortion activists will do kind of sting operations, sort of entrapment-y things where they order the pills solely in the interest of bringing a lawsuit. Because there is a cash bounty that you can get for filing a lawsuit — there’s an incentive. So that’s a concern. And then just the general concern of a chilling effect and people who are using less safe means than these pills to terminate their pregnancies out of fear, which studies have shown is already on the rise, people injuring themselves taking herbs and other substances, chemicals. So that’s a concern as well. 

Rovner: We’ll continue to watch this, but back to vaccine policy. With the status of federal vaccine recommendations in limbo, states appear to be going their own way. Blue states California, Washington, and Oregon are banding together in a consortium to make official recommendations in the absence of federal policy, and several blue-state governors are acting unilaterally to make sure covid vaccines, at least, remain available to most people. At the same time, some red states are going the other way, with Florida Surgeon General Joseph Ladapo, who we have talked about before, now vowing to get rid of all vaccine requirements for schoolchildren. Sarah, that would be a really big deal, right? 

Karlin-Smith: Right. I think the big fear then is that the school requirements is kind of what gets us to close to, in many cases, universal vaccine uptake in the country, because everybody needs their kids to be in school. Unless you’re homeschooled, you really must follow these vaccine requirements. And it not only hurts the kids who don’t end up getting vaccinated individually, but it can really hurt the idea of herd immunity and the protection we need for these diseases to disappear in the community. So there’s— 

Rovner: And protection for people who can’t be immunized for some reason. 

Karlin-Smith: Right. Who either can’t be immunized or don’t have an adequate response to the immunization because they’re going through cancer treatment or they have some other medical reason that their body is immunocompromised. 

Rovner: So, I mean, is this going to end up like abortion, where it’s availability absolutely depends on where you live? 

Karlin-Smith: I think that’s hard to say. I think that a policy like what Florida is trying to implement could very quickly and easily go wrong, I think, and be reversed, as we’ve seen, like what’s happening in Texas now, with measles outbreaks. You know you only need just very small fractions of decreases in vaccination to create huge public health crises in places. And so I think it would be more sort of visible, in a way, to some of these states and their populations, the potential harm that could be caused, than maybe it is to them the abortion harm. But we definitely are seeing some sense of, right, the Democratic-controlled states trying to implement policies that help people get better access to vaccines, even when the federal government is trying to maybe harm that, and red states not caring as much. 

So there is going to be some more of a patchwork. And I feel like, in talking to just sort of people outside of the health policy space, there is a lot of confusion about: Where can I get my covid vaccine? Am I going to have to pay? Do I qualify? Especially being in D.C., which has less generous, I guess, pharmacy laws, because of this. So people are confused. If I go to Maryland, which is really close, does that matter even though I live in D.C.? And it’s just all these things we kind of know end up leading to less people getting vaccinated. Because even if they want to do it, the hurdles end up driving people away. 

Rovner: Yeah, I think something you’d said earlier about the fact that we’re seeing kind of a covid spike, so people are anxious to get covid vaccines, I think, a little bit earlier than normal. It’s usually kind of a fall thing and it’s only the beginning of September, but I think there’s just this combination, this confluence of events that has a lot of people very excited about this right now. 

Karlin-Smith: Yeah, I think it does. And covid has been, I think there’s been lots of hope in the public health world that covid would become a little bit like the flu, where we could predict a little bit more when it would really peak and get everybody vaccinated around the same time as they’re getting flu vaccines. Just again, because we know when we make it easier on people to get vaccinated, if you could just one-and-done it, it would be good. Unfortunately, covid has tended to also still have summer peaks, and this year again it’s kind of a late summer peak. And a lot of people, including seniors, are still recommended really actually to get two vaccines a year. So many people are kind of coming due for that second update right now. 

Rovner: Well, we’ll keep watching that space. Moving on, as we kind of pointed out already, Congress is back in town, with just a couple weeks to go before the start of fiscal 2026 on Oct. 1. This was the year Congress was really, truly going to get all of its spending bills passed in time for the start of the new year. How’s that going, Jessie? 

Hellmann: It’s going great. I’m just kidding. There’s a lot of friction on the Hill right now. The White House budget chief is talking about doing more clawbacks of foreign aid, which is frustrating both Democrats and Republicans. It’s about $5 billion, and we’re seeing Democrats kind of start to put their neck out there a little more than they did earlier in the year when they were also kind of making noise about government funding. And they’re now saying that Republicans are going to have to go this alone and they’re not going to support partisan spending bills. So it’s kind of difficult to see where we go from here. And then— 

Rovner: Are we looking at a shutdown on Oct. 1? I mean, that’s what happens if the spending bills aren’t done. 

Hellmann: It’s hard to say. There might be a short-term spending bill, but anything longer-term than that, it seems really difficult at this point. And there are just massive differences between the health bills that the House came out with and the Senate came out with. I mean, there’s differences in all the other appropriations bills, too, but I was just going to focus on health. 

Rovner: Yes, please. 

Hellmann: The Senate bill would allow an increase for HHS, and the House bill would cut it pretty significantly. So it’s kind of hard to see how they could do anything more substantive when there’s so much light between the two. 

Rovner: Yeah. I mean, on the one hand, we have both the Senate and the House subcommittee that’s marked up the Labor HHS [Labor, Health and Human Services, Education, and Related Agencies] appropriation on record as not supporting at least the very deep cuts to the National Institutes of Health that were proposed by President Trump. But on the other hand, as you mentioned, we still have the administration, primarily budget office chief Russell Vought, making the case that the administration doesn’t have to spend money that Congress appropriates. And from all we can tell, at least as of now, there’s a lot of money that won’t be spent as of the end of the fiscal year, despite the fact that that is illegal. It’s known as a pocket rescission, a term I think we’re about to hear a lot more about. Alice, you referred to this earlier: Is Congress just going to quietly ignore the fact that the administration is usurping their power? 

Ollstein: I think that in many areas of politics, there is a faction that wants to play hardball and really use whatever leverage is possible and there’s a faction that wants to play nice and try to get what they can get by negotiation. And I think both parties always fear being blamed for shutdowns, and so that drives a lot of it. But I think there’s mounting frustration with Democratic leadership about not playing hardball enough. I mean, the jokes I hear are Democrats like to bring a spreadsheet to a gunfight, just seen as being unwilling, in the face of what many see as lawlessness, being unwilling to really put a check on that using the levers they have, including this federal spending. But I think we’ve seen that there are risks no matter what they do, and so I think people make reasonable points about the pros and cons of various strategies. 

Rovner: Well, we know that [Sen.] Susan Collins, who’s now the chair of the Senate Appropriations Committee, is very, very concerned — because Susan Collins is always very, very concerned. But she’s the one whose power is basically being thwarted at this point. People have gotten a lot of gray hair waiting for Susan Collins to stand up and be combative, but one would think if there was ever a time for her to do it, this would be it. Jessie, are we seeing, I was going to say, any indication that the appropriators are going to say, Hey, this is our job and our constitutional responsibility, and you’re supposed to do what we say when it comes to money? 

Hellmann: They are saying these things. I feel like we are seeing more Senate Republicans, at least, express discomfort with what the Trump administration is doing, saying things like: This is Congress’ job. We have the power of the purse. And then they are passing some of these spending bills through committee. But what else are they supposed to do? Unless Susan Collins wants to get on Fox News and start screaming about government funding, which I don’t really see happening and I don’t know if it would be effective, you kind of just wonder: What other options do they have at this point? 

Rovner: Yeah. Well, we’ll sort of see how this plays out over the next few weeks. Meanwhile, it’s not just the spending bills that Congress is facing deadlines for. This month is basically the last chance to re-up those, quote, “expanded subsidies” for Affordable Care Act plans before the sticker shock hits 24 million people in the face. Not only are premiums going up by an average of 18% from this year to next — that’s for a lot of reasons: increasing costs of health care, tariffs, drug prices — but eliminating those additional subsidies, or actually letting them expire, will cause some people to have to pay double or triple what they pay now. And it’s going to hit folks in red states like Georgia and Florida and Texas even harder because more folks there are on the Affordable Care Act plans, because those states didn’t expand Medicaid. Do Republicans not understand what’s about to happen to them? 

Hellmann: I think they understand, but they keep acting like there’s no urgency to the situation. They keep saying: We still have time. We have till the end of the year. Which I guess is technically true, but we’re already seeing insurers proposing these giant rate hikes. And it’s not easy to just go back and make changes to some of this. I guess the idea is— 

Rovner: So they really don’t have until the end of the year, though. Because people are going to get, they’re going to see the next year’s premiums that they have to start signing up in November. So, I mean, they basically have this month. 

Ollstein: If there’s uncertainty, they’re going to price very conservatively, aka high. They don’t want to be left holding the bag. And so, yeah, you and Jessie are exactly right that there isn’t time. These decisions are being made now. Even if they pass something to kick the can until after the midterms, I think some damage will already have been done. 

Rovner: Yeah. Jessie, I cut you off, though. I mean, the idea is that sort of their one chance to maybe do this before people actually start to get these bills, or at least see what they’re going to have to pay, would be wrapped into this end-of-fiscal-year continuing resolution. And maybe they can kick the appropriations down the road until November or December, but they can’t really kick the question of the subsidies down the road until November or December. 

Hellmann: Yeah. I think something would have to happen really quickly. We’re seeing some politically vulnerable Republicans, in the House, specifically, say that they want at least a year-long extension. It’s just a really difficult issue. We know, obviously, the Freedom Caucus is already making threats about it. They hate the ACA, maybe more than anything. It’s going to be really interesting how this turns out. I’ve also heard that maybe there might be a paired-back version of an extension that they could do, maybe messing with some of the income parameters. But I don’t know if that kind of compromise would be enough unless Republicans work with Democrats, which as we already said is complicated for other reasons. So it’s just a mess right now. 

Rovner: I love September on Capitol Hill. All right, finally this week Medicare has announced it will launch a pilot program next January to test the use of artificial intelligence to perform prior authorization for Medicare fee-for-service patients in six states. The program is aimed at just a handful of services right now that are considered to be often wasteful and of dubious value to patients. So, honestly, what could possibly go wrong here? This is a serious question. I mean, isn’t using AI to do prior authorization what got a lot of these private health plans in trouble over the last year? 

Karlin-Smith: Yeah, they did. UnitedHealthcare I think is sort of infamous for that. There was a lot of irony when they first announced this concept of doing a little more prior auth, essentially, in Medicare. It came right after they made another announcement where they were trying to say, We’re actually going to crack down on prior authorization for a health plan. So there’s a bit of, and I think they were trying to not have the, in this second announcement, not have the words “prior auth,” so that they kind of could get wins on both levels. Because I think they know that prior authorization is generally not popular with health consumers. People see it as kind of a barrier to care that their doctor has said they need and is largely stopped because of cost reasons. And then I think once you add in this idea that artificial intelligence is doing it, not a human being, I think people have less trust that it’s being done in the proper way and really that they’re stopping inappropriate care. 

Rovner: Well, to paraphrase RFK Jr. at the Senate Finance hearing, who said many times, both things can be true, even if they are contradictory. All right, that is this week’s news, or at least as much as we have time for. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our extra credits. 

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

Tony Leys: Glad to be here. Thanks, Julie. 

Rovner: So this month’s patient got a literal mouthful when she went to photograph the night sky in Arizona. Who is she and what happened? 

Leys: While Erica Kahn was taking photos at Glen Canyon last summer, a bat flew up, landed on her, and jammed itself between her camera and her face. Kahn screamed, as anyone would, and the bat went into her mouth. It only was in there for a few seconds, and she didn’t feel a bite. But she feared it could have infected her with a rabies virus, which bats frequently carry. 

Rovner: Yeah, not a great thing. So as with any run-in with a bat, Erica wisely reported to the nearest emergency room for preventive rabies treatment, which we know from previous “Bills of the Month” can total many thousands of dollars. How much did her treatment cost? 

Leys: Nearly $21,000, mostly for a series of vaccinations and other treatments, over the course of two weeks, aimed at preventing the deadly virus from gaining a foothold. 

Rovner: Yikes. 

Leys: Yikes, indeed. 

Rovner: Now, the problem here wasn’t so much that she was charged as what her insurance status was. What was her health insurance status? 

Leys: Well, Kahn had been laid off from her job as a biomedical engineer in Massachusetts, and she had turned down the COBRA [Consolidated Omnibus Budget Reconciliation Act] plan, which would’ve allowed her to stay on her employer’s insurance plan. The plan would’ve cost her about $650 a month, which seemed too much for her. And she was a young, healthy adult who was confident that she would quickly find a new job with health insurance. She also thought that if she became ill in the meantime, she could buy a private plan that would cover preexisting health conditions. 

Rovner: Yeah. That was the big problem, right? 

Leys: Right. 

Rovner: So what did she do? And then what happened? 

Leys: So before she went to the hospital for rabies prevention treatment, she signed up for a policy she found online. The policy, which she thought was full-fledged health insurance, apparently wasn’t. But she says the company selling it told her it would cover treatment of a life-threatening emergency, which this sure seemed to be. But the company later declined to cover any of the bills, citing a 30-day waiting period for coverage. 

Rovner: Yeah. Now, I mean, you can’t generally buy any kind of insurance after an insurable event happens. You can’t buy fire insurance the day after a fire or car insurance the day after an accident. Health insurance is no different. Although in her case, she could have actually resumed her previous coverage through COBRA, right? How would that have worked? 

Leys: So after you lose coverage from an employer, you generally have 60 days to decide whether to sign up for COBRA coverage, which would be retroactive to the day your old policy lapsed. Khan was within that period when the bat went in her mouth. So she could have retroactively bought COBRA coverage, but she didn’t know about that option. 

Rovner: Yeah. A lot of people, they initially lose their job or they leave their job and they don’t take COBRA, because it’s really expensive, as a rule — because it’s employer insurance and employer insurance is usually pretty generous — and they think they don’t need it. But this is one of those cases where she actually probably could have gotten it covered, right? 

Leys: Right, right. And in fairness, I’d never heard about that 60-day thing, either, and I’ve covered this, so— 

Rovner: I had, but I was there when COBRA was started. So what’s the takeaway here about people who don’t have insurance or think they can buy it at the last minute? 

Leys: Well, two things. One is you should have health insurance. 

Rovner: Because you never know when a bat’s going to fly in your mouth. 

Leys: And that a bat in the mouth does not count as a preexisting condition. 

Rovner: True. 

Leys: We know that now. 

Rovner: And what happened with this bill? 

Leys: She is still trying to get it worked out. 

Rovner: And presumably she’s going to be paying it off for some time to come. 

Leys: That’s what it sounds like. Yep. 

Rovner: But she won’t get rabies. 

Leys: Nope. 

Rovner: So happy ending of a sort. Tony Leys, thank you so much. 

Leys: Thank you for having me. Appreciate it. 

Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it? 

Karlin-Smith: I picked a piece that ran in NPR from KFF’s Blake Farmer, “Leniency on Lice in Schools Meets Reality,” because it’s about the one-year anniversary of my family getting lice from school. And I actually was exposed to this new reality, which is since I was in school, and it’s, I guess, a broader national policy that they no longer kick kids out of school once you see lice and make it kind of difficult before you can go back to school. And I guess the public health rationale is generally that lice is actually, while it’s quite itchy, it’s not really harmful. So trying to think about the best way to cause the least harm, letting kids stay in school while you treat the infection is seen as most appropriate now. 

But there’s been, as a story goes into, some pushback from parents who feel that then it’s just getting them in these cycles where they’re constantly getting lice and having to deal with it. And dealing with getting the shampoos and stuff for lice can be kind of costly. So I thought it was a slightly lighter health care story for people to think about in these times. 

Rovner: Yeah. Risks and benefits. Classic case of risks and benefits. Alice. 

Ollstein: Well, this is definitely more on the risks than the benefits side of things, but I have a very good piece from Vox. It’s an exclusive. It’s called “RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer.” And so they talked to these scientists who were commissioned to compile all of the data about the risk of drinking alcohol to having cancer. And it was compiling high-quality data that was already out there. And it really shows that no amount of drinking is totally safe. Even a very small, moderate amount of drinking includes a cancer risk, and that goes up the more you drink. 

And now, according to this report, the administration is not going to publish this. The authors turned it in in March, and they’ve just been sitting on it and they said they have no plans to publish it. And this is coming as the alcohol industry does a lot of lobbying to try to prevent stuff like this from being put out in the public consciousness. I just found this really fascinating. Already the younger generations are drinking a lot less. And so there does seem to be a growing awareness of the health risks of even moderate drinking. But I think that anything that keeps people from seeing this information is worrying, although this report did say that they are planning on publishing it in a peer-reviewed medical journal, which they were always planning anyways. But not having the federal government’s backing is a big deal. 

Rovner: It’s not exactly “radical transparency” is what they’ve been talking about. Jessie. 

Ollstein: And it’s not exactly “MAHA” [“Make America Healthy Again”]. They’re talking MAHA. They’re talking about lifestyle stuff. They’re talking about what you eat, but apparently not about what you drink. 

Rovner: Jessie. 

Hellmann: My story is from KFF Health News, from Bram Sable-Smith. It’s called “When Hospitals and Insurers Fight, Patients Get Caught in the Middle.” It is about what happens when providers and insurers have contract disputes. The one example in this story is in Missouri, and it kind of focuses on this family that’s caught in the middle of a dispute between the University of Missouri Health Care system and Anthem. And it means patients don’t get care. There’s not a lot of protections for them. There are provisions that were in the No Surprises Act kind of intended to ensure there was some continuity of care in these situations. But at least for this couple, they weren’t really able to access those protections. So unclear if those are working as intended. 

I just thought it was really interesting because it’s not a new problem, but it’s definitely something that we are hearing more and more. It just happened in the D.C .area a few weeks ago. It just happened in New York. And it kind of raises questions about: What are policymakers going to do about this? They complain about rising health care costs, but they don’t often do very much. They complain about competition and consolidation, and this is one of the effects of that. People lose access to care. So I thought this was a really interesting story. 

Rovner: Yeah. These are all the policy issues that policymakers are not working on but could be. My extra credit this week is from ProPublica. It’s called “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, Pratheek Rebala, and Sam Green. And it’s a deep data dive that found that more than 20,500 workers, or about 18% of the Health and Human Services Department workforce, have left or been pushed out in the first month of Trump 2.0. That includes more than a thousand regulators and safety inspectors and 3,000 scientists and public health specialists. The agency, in its official response to the story, said, quote, “Yes, we’ve made cuts — to bloated bureaucracies that were long overdue for accountability.” I guess we will have to see if America gets healthier. In the meantime, it’s good to have some data on where we were and now where we are at HHS. 

OK, that’s this week’s show. Thanks to our fill-in editor this week, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. As always, you can email us your comments or questions at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging out these days? Sarah. 

Karlin-Smith: Kind of everywhere. At Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

Ollstein: Mostly on Bluesky, @alicemiranda, and still on X, @AliceOllstein. 

Rovner: Jessie. 

Hellmann: I am on X, @jessiehellman. I’m also on LinkedIn. 

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

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Durante una cena bajo palmeras en la terraza de Mar-a-Lago en diciembre, el presidente electo Donald Trump tranquilizó a los directores ejecutivos de las farmacéuticas Eli Lilly y Pfizer diciéndoles que el activista antivacunas Robert F. Kennedy Jr. no sería una elección radical para dirigir el Departamento de Salud y Servicios Humanos (HHS).

“Creo que va a ser mucho menos radical de lo que imaginan”, aseguró Trump ese mismo mes durante una conferencia de prensa en su complejo turístico en Palm Beach, Florida.

Ocho meses después, Kennedy ha intensificado sus ataques contra el sistema de vacunación.

Uno de sus principales objetivos es un programa federal de compensación que resuelve reclamos de daños por vacunas.

Según algunos expertos legales y líderes en salud pública, su estrategia podría llevar a la quiebra o al debilitamiento del fondo, obligando a las farmacéuticas a asumir riesgos legales y costos que las llevarían a dejar de fabricar vacunas por completo.

“Es una agenda radical”, dijo Angela Rasmussen, viróloga de la Organización de Vacunas y Enfermedades Infecciosas de la Universidad de Saskatchewan en Canadá. “Está usando varios mecanismos distintos y realmente no hay límites. La gente va a empezar a darse cuenta, pero no será suficiente para detener la ola de muertes, incluidas las de niños”.

Kennedy ha dicho que es necesario reformar el sistema de vacunación en el país porque, según él —sin ofrecer evidencia—, las vacunas están relacionadas con el autismo, la neurotoxicidad, las alergias y la muerte. Es una de las figuras líderes del movimiento “Make America Healthy Again” (“Hagamos a Estados Unidos Saludable Otra Vez”), una campaña informal que rechaza la medicina tradicional y promueve la llamada “libertad médica”.

Muchos de sus seguidores se oponen a las vacunas y creen que son peligrosas, a pesar de la evidencia científica que demuestra lo contrario.

Kennedy ha reconocido que quiere reformar el fondo de vacunas, conocido como el Programa de Compensación por Lesiones Causadas por Vacunas (VICP, por sus siglas en inglés). El 28 de julio escribió en la red social X que “el VICP está roto, y pienso arreglarlo”. El Departamento de Salud y Servicios Humanos (HHS) está trabajando con el Departamento de Justicia para reformar el programa, que protege a las farmacéuticas de la mayoría de las demandas por lesiones.

El HHS no respondió a la solicitud de entrevista con Kennedy, pero funcionarios de la agencia dijeron que él no está en contra de las vacunas. “El secretario Kennedy no es antivacunas: está a favor de la seguridad, la transparencia y la rendición de cuentas”, dijo por correo electrónico Vianca Rodríguez Feliciano, vocera del HHS.

Sin embargo, según personas familiarizadas con las discusiones internas —que pidieron no ser identificadas porque no están autorizadas para hablar sobre el tema—, Kennedy ha estado trabajando en silencio para restringir la disponibilidad de vacunas ampliamente utilizadas.

Una estrategia con varios frentes

La estrategia comenzó a tomar forma en la primavera. El primer paso fue sembrar dudas infundadas sobre la seguridad de las vacunas. En una reunión de gabinete en abril, Kennedy le dijo a Trump que el HHS estaba realizando un estudio masivo para identificar la causa del aumento de diagnósticos de autismo para septiembre.

Según informes de prensa, Kennedy asignó la tarea a David Geier, un investigador que ha repetido la afirmación —ya desacreditada— de que las vacunas causan autismo.

Luego, Kennedy redobló la apuesta cuestionando el uso de aluminio, que se agrega a muchas vacunas para reforzar la respuesta inmunitaria. En una reunión de gobernadores en julio, lo vinculó con las alergias, a pesar de que un estudio reciente en la revista Annals of Internal Medicine no encontró ninguna conexión. Se espera ampliamente que pida a un comité asesor federal que revise el uso del aluminio.

La investigación sobre el autismo y las dudas sobre el aluminio fueron los primeros pasos en su ofensiva contra el fondo de compensación, según dos fuentes.

Ese fondo ofrece compensaciones a personas con lesiones causadas por vacunas y ha pagado más de $5.000 millones desde su creación en 1988, según la Administración de Recursos y Servicios de Salud (HRSA, por sus siglas en inglés).

Antes de presentar una demanda en un tribunal, las personas afectadas presentan sus reclamos ante el “tribunal de vacunas”, que no tiene jurado y evalúa la evidencia. El dinero proviene de un pequeño impuesto especial sobre cada vacuna.

La compensación se determina en parte por una tabla que mantiene la HRSA y supervisa el secretario del HHS. Esta lista enumera las vacunas y sus posibles efectos secundarios, y abarca las inmunizaciones de rutina recomendadas por los Centros para el Control y Prevención de Enfermedades (CDC), que están sujetas al impuesto. Las lesiones incluyen anafilaxia y encefalitis. Quienes sufran esas condiciones dentro de cierto tiempo después de vacunarse pueden recibir una indemnización.

Kennedy quiere que se incluyan el autismo o las alergias en esa tabla, según dos personas familiarizadas con las discusiones internas y con preocupaciones expresadas públicamente por farmacéuticas y ex funcionarios. Podría lograrlo, por ejemplo, si una investigación dirigida por el HHS vinculara las vacunas con el autismo, o si un comité asesor recomendara eliminar el aluminio de las vacunas.

“Dado el índice de autismo, si se presentan muchos casos, eso podría llevar a la quiebra del programa”, dijo Dorit Reiss, profesora de la Universidad de California en San Francisco.

Si eso ocurriera, algunas farmacéuticas podrían dejar de fabricar vacunas —que no suelen ser productos muy rentables— para evitar demandas largas y costosas de personas que no puedan ser compensadas porque el fondo federal se haya agotado, dijeron expertos en estas leyes y fabricantes.

“El fondo de compensación, si desaparece, afectaría la decisión de seguir adelante o no con las vacunas”, dijo David Dodd, presidente y director ejecutivo de GeoVax Labs, una empresa biotecnológica que desarrolla vacunas e inmunoterapias.

Kennedy ha puesto a personas de su confianza para llevar adelante esta estrategia. Ha presionado para que escépticos de las vacunas ocupen puestos clave en los CDC, que recomiendan las vacunas, y en la Administración de Alimentos y Medicamentos (FDA), que las aprueba.

También seleccionó a líderes del movimiento antivacunas para que evaluaran candidatos para su equipo.

El resultado ha sido una serie de decisiones regulatorias y políticas que han limitado el acceso a las vacunas y el desarrollo de nuevas.

Este mes, el HHS anunció que suspendía $500 millones en subvenciones y contratos para el desarrollo de vacunas de ARNm, incluidas versiones más duraderas contra covid.

El gobierno federal dejó de recomendar las vacunas contra covid para mujeres embarazadas sanas y para niños, sin consultar al comité asesor de vacunas que tradicionalmente participaba en esas decisiones.

Además, Kennedy reorganizó ese comité con miembros elegidos por él, incluidos escépticos de las vacunas, y eliminó como enlaces a grupos como la Asociación Médica Estadounidense, la Asociación Nacional de Enfermeras y otras organizaciones. El comité modificado recomendó no aplicar vacunas contra la gripe que contienen un conservante que erróneamente se ha vinculado con el autismo.

Las llamadas de la Casa Blanca

La intención de Kennedy de mantener a escépticos de las vacunas en puestos de supervisión se evidenció en un acuerdo que hizo recientemente con Trump y su equipo, según dos fuentes. El acuerdo se concretó un domingo de julio por la noche, cuando Kennedy recibió una llamada de la Casa Blanca.

El tema era Vinay Prasad, un alto regulador de vacunas de la FDA. Recientemente había provocado una oleada de críticas en la industria por haber participado en la decisión de la agencia de pedir a la empresa Sarepta Therapeutics que suspendiera la distribución de una terapia génica, por razones de seguridad.

Las redes sociales y comentaristas conservadores encendieron la polémica. Laura Loomer, una provocadora de extrema derecha, dijo el 21 de julio en X que Prasad debía ser despedido y lo llamó “liberal progresista autoproclamado y fanático de Bernie Sanders”, en referencia al senador Bernie Sanders (independiente por Vermont). Varios legisladores comenzaron a presionar a la Casa Blanca con preguntas.

La controversia llegó a Trump, quien quería que Prasad se fuera, según las fuentes. Pero Kennedy no quería perderlo. Consideraba que necesitaba a alguien crítico de las vacunas al frente de la supervisión en la agencia.

Así que Kennedy negoció. A Prasad se le pediría que renunciara como director del Centro de Evaluación e Investigación de Productos Biológicos de la FDA, que regula vacunas y productos biológicos como las terapias génicas. Y el centro se dividiría en dos operaciones, lo que le permitiría a Kennedy elegir quién estaría a cargo del área de vacunas.

Algunos líderes en salud pública compartieron públicamente detalles del acuerdo y expresaron su preocupación. Scott Gottlieb, ex comisionado de la FDA, dijo el 1 de agosto en CNBC que pensaba que “sería muy destructivo para la agencia”.

Después de dejar la agencia en julio, Prasad ahora regresa, aunque no está claro si en el mismo cargo.

Recientemente, Kennedy fue demandado por Ray Flores, abogado externo principal de Children’s Health Defense, una organización antivacunas fundada por el propio Kennedy.

La demanda —financiada por esa organización— alega que Kennedy no lanzó un grupo de trabajo para estudiar la seguridad de las vacunas, como supuestamente se exige. Sin embargo, según una fuente, Kennedy y sus aliados consideran que se trata de una demanda “amigable” porque busca un resultado que él mismo desea.

El 14 de agosto, el HHS anunció que reactivaría un panel federal —disuelto en 1998— para supervisar las vacunas pediátricas.

Las acciones de Kennedy contra las vacunas también han generado demandas en su contra, incluida una presentada por la Academia Americana de Pediatría y otros grupos de salud pública. Su decisión de detener el financiamiento para el desarrollo de vacunas de ARNm provocó una oleada de críticas en redes sociales.

“Esto es irresponsable. Es peligroso. Va a costar vidas. Debemos contraatacar”, escribió el 5 de agosto el senador Edward Markey (demócrata por Massachusetts) en X.

“Intenté mantenerme objetivo y sin alarmismo frente a las acciones del HHS, pero sinceramente, esta medida va a costar vidas”, dijo ese mismo día Jerome Adams, ex cirujano general de Estados Unidos durante el anterior gobierno de Trump.

Kennedy y sus seguidores siguen decididos. En respuesta, sus aliados lanzaron una campaña de relaciones públicas sin precedentes para promover la figura del secretario de Salud, alimentando la especulación de que podría estar considerando una candidatura presidencial en 2028.

La organización sin fines de lucro MAHA Action organizó una llamada en julio para movilizar a los seguidores de Kennedy e inició una campaña publicitaria de seis cifras elogiando a Kennedy y a las iniciativas de salud del gobierno de Trump.

“Que no quepa duda: esta es una revolución que cambiará el rostro de las políticas de salud pública”, dijo Tony Lyons, presidente de MAHA Action, en un comunicado. “Los estadounidenses están exigiendo una transparencia radical y ciencia de primer nivel”.

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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The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

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

A new executive order from President Donald Trump has potentially broad implications for the future of the federal research enterprise by transferring direct funding decisions away from career professionals to political appointees.

And a gunman, reportedly disgruntled over covid vaccines, attacked the headquarters of the Centers for Disease Control and Prevention in Atlanta, highlighting how increasingly inflammatory rhetoric from health critics endangers the public health workforce.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Shefali Luthra
The 19th

@shefali.bsky.social

Read Shefali's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• Trump’s executive order highlights the tension between how Congress has directed federal science funding and what the administration can do to alter that course. Congress has traditionally set the parameters and experts have made the judgments for moving forward. The National Institutes of Health, considered an American crown jewel, specifically has remained apolitical. But this step opens the door to concerns about grant cancellation and adds to growing uncertainty in scientific research. Even investors are starting to hold back. The ripple effects could be much bigger than the Trump administration anticipates.
• Many CDC staffers blame Health and Human Services Secretary Robert F. Kennedy Jr. and other agency leaders for stoking the negative climate that led to last week’s attack. Kennedy appears to have doubled down on his language, however, announcing decisions and policies that continue to fuel vaccine opposition and hesitation.
• This week, Kennedy also made the unprecedented move of calling on the Annals of Internal Medicine, a medical journal, to retract a study that found that the aluminum adjuvant in many childhood vaccines did not cause harm. The journal refused to retract the study based on Kennedy’s scientifically unsubstantiated claims that the additive was damaging.
• More fallout is emerging about the GOP-backed sweeping budget law enacted this summer. Republicans have argued that its cuts to Medicaid — most of which will not kick in until after the midterm elections — would touch only waste, fraud, abuse, and people who weren’t entitled to the coverage. In reality, the sprawling nature of Medicaid is already becoming clear as institutions — ranging from hospitals to community health centers — prepare for cuts that could limit their ability to provide services.
• The CDC reported this week that Americans are eating less ultra-processed food but that it is still a big part of the American diet. The Trump administration has talked a big game about addressing this public health issue yet has seemed loath to require the food industry to do anything. Much of the administration’s efforts have focused on “voluntary” changes. Former FDA chief David Kessler this week highlighted a regulatory, legal way the administration could compel more action.

Also this week, Rovner interviews Aaron Carroll, president and CEO of the health services research group AcademyHealth, about how to restore the public’s trust in public health.

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

Julie Rovner: ProPublica’s “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman.

Alice Miranda Ollstein: The New York Times-KFF Health News’ “Why Young Americans Dread Turning 26: Health Insurance Chaos,” by Elisabeth Rosenthal and Hannah Norman.

Sarah Karlin-Smith: The New York Times’ “This Ohio Farm Community Is a Mecca for the ‘MAHA Mom,’” by Caroline Kitchener.

Shefali Luthra: Stat’s “Inside the American Medical Association’s Sudden Strategy Shift in Washington,” by Theresa Gaffney.

Also mentioned in this week’s podcast:

• The Washington Post’s “This Phrase Was Meant To Increase Trust in Science. It Backfired,” by Aaron E. Carroll.
• Stat’s “Former Surgeon General: The CDC Shooting Must Be a Wakeup Call,” by Jerome Adams.
• PBS NewsHour’s “Federal mRNA Funding Cut Is ‘Most Dangerous Public Health Decision’ Ever, Expert Says,” by Geoff Bennett and Karina Cuevas.
• The Washington Post’s “How Schools Could Be Hit by Medicaid Cuts,” by Terell Wright.

Click to open the transcript

Transcript: Trump Further Politicizes Science

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 14, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Sarah Karlin-Smith: Good morning, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi. 

Rovner: Later in this episode we’ll have my interview with Aaron Carroll, president and CEO of AcademyHealth. He’ll talk about how the public has lost trust in public health and how public health might win it back again. But first, this week’s news. 

I want to start this week with a story that maybe hasn’t gotten as much attention as I think it should. Last week, President [Donald] Trump issued yet another executive order, this one called “Improving Oversight of Federal Grantmaking.” It really should be called “Implementing Political Oversight of Federal Grantmaking” because that’s what it does. Sarah, before we get into this, explain how federal science grants work now and the role of political appointees vis-à-vis career and outside experts. 

Karlin-Smith: I guess I would say right now there’s very little political oversight. You have various scientific committees and federal experts that make the decision of how to reward the money, and it’s going to be very broken down by people’s areas of scientific specialty. So, and this order is really trying to put it more in the hands of political people that have a lot less scientific knowledge. 

Rovner: That’s a polite way to put it. 

Karlin-Smith: I think the reason why maybe it hasn’t gotten attention is this is sort of an extension of a lot of stuff they have tried to do throughout the administration, but they’ve either gotten pushback from universities or other parties or through the courts. And part of what seems to be going on here is they maybe have learned some lessons about their legal failures and they are trying to see if they can kind of adjust their strategy to maybe make it more foolproof. But there’s a lot of tension between how Congress has directed this federal funding to be spent and what the administration can really do to change the process around it. 

Rovner: Yeah, I mean, I feel like until now this has been very much Congress setting the parameters and career people and outside experts making the judgments about what kind of science should be funded, right? Am I missing something here? 

Karlin-Smith: I don’t think you are. I guess one thing that strikes me about this is I think that the U.S. scientific infrastructure and NIH [the National Institutes of Health] in general has not been political in the way I think other parts of our health system, our public health system in particular, have been over the years. Like, NIH, it’s gone through some periods maybe in the past decade or so where the funding wasn’t quite where people want it. But in general it’s been a pretty bipartisan priority. People do not want to mess with this system. It’s kind of a crown jewel of the U.S. that has helped spur both our universities and private industry and technology. So I think this is just a bit of a very different kind of strategy and approach from the Trump administration than we’ve seen from other administrations in terms of even trying to do this. 

Rovner: It has been political in the sense of Disease Group A goes to members on Capitol Hill and say, Please fund our disease, and then they’ll put a line in the Appropriations Committee report to Please fund this disease. But when it comes to how, what specifically the kinds of research for that disease gets funded, that’s been left up to experts. So, under this order, not only will political appointees be in charge of potential funding announcement as well as grant approvals, but it also orders creation of a system to cancel ongoing grants for, quote, “convenience,” meaning apparently any reason that the administration might want to invoke. That’s something, as Sarah points out, that this administration has been doing since January, although various courts have pointed out kind of repeatedly that that’s not legal. But this could create so much uncertainty in scientific research so as to just basically bring things to a screeching halt. I see you nodding, Alice. 

Ollstein: Yeah, I think that this is going to deter a lot of researchers from even embarking on the process, because why would you pour years of effort into writing these grants, recruiting subjects, setting up these labs when you know that the funding could be yanked at any time? That kind of uncertainty doesn’t comport with the years-long stability required to really get somewhere with this kind of research. And it’s no wonder that other countries right now are aggressively recruiting American scientists and American scientists are saying, Yeah, I would rather go abroad and have more stability, more of a guarantee that my research won’t be messed with and won’t be suddenly defunded, rather than stay here. And that’s going to be an enormous loss of knowledge here and an enormous loss of economic power over time. 

Karlin-Smith: The other thing about, in talking to some of the groups that advocate for the universities here, that they were saying even prior to this order, with some of the earlier actions, what they were hearing, what was happening is is that other countries are actually recruiting scientists to work for them or fund them, but letting them stay in the U.S. And here so they’ve even come up with ways to even make it pretty easy for people to switch. But then the catch is probably that that research or IP [intellectual property] and so forth will actually belong to other countries, particularly China is one that is interested in that, in the many ways an adversary of the U.S. 

Rovner: So, yeah, because I was going to say, one of the headlines I saw this morning was of investors who were starting to hold back because of all the uncertainty about the U.S. research establishment. I mean, this is a big chunk of the economy. I mean, it feels like the Trump administration trying to punish Harvard and Columbia and other universities, but I feel like the ripple effects of this could be much bigger than even they anticipate. 

Ollstein: Well, absolutely, and I know we’re going to talk a lot about trust in health science and where that’s going, but I think there are two sides to people’s fears about this right now. One, that good, gold-standard, important research won’t get funded but also that shoddy or biased research will get funded. If you politicize that, you have both risks. 

Rovner: Yeah, that’s true. Well, to segue, meanwhile, as if federal health officials aren’t uncertain enough right now, a gunman shot up the headquarters of the Centers for Disease Control and Prevention in Atlanta last week, killing a law enforcement official. Reports differ, but there’s evidence that the gunman, who apparently shot himself, blamed his covid vaccine for his mental health woes and wished to get back at the public health agency. To quote Jerome Adams, surgeon general in Trump’s first administration, in a Stat op-ed published over the weekend, quote: “One thing is clear: This tragedy is not an isolated event. It is a dire reflection of ever escalating threats public health workers face in a climate increasingly shaped by misinformation, politicization, and inflammatory rhetoric,” close quote. And it’s not just the shooting itself. Apparently the way higher HHS [Department of Health and Human Services] officials have tried to calm the nerves of CDC staff hasn’t really worked very well, from what we’re hearing. 

Karlin-Smith: I mean, I think there’s a lot of CDC staff, and people in the public health space, blame the leadership of this current HHS for stoking these fears, and the rhetoric that they were using for a number of years prior to coming into office, for kind of creating a situation where this happened. And not only have they not really wanted to take that on head-on and talk about it or take any responsibility for it, they’ve sort of fueled the flames with comments HHS Secretary Robert F. Kennedy has made since the incident on news outlets, continuing to kind of double down on the language that suggested. And of course in the past few weeks they’ve made other decisions that have, I think, to people who have questioned vaccines and some of the technology that this person might’ve been upset about, sort of seem to back up their concerns, unfortunately, unscientifically, like pulling back on mRNA vaccine research funding. 

Luthra: I was going to say, I think there’s another point that you made, Julie, that’s really important, which is looking at this in the broader context even of the past five years. And we’ve seen this real escalation of threats against public health workers across the country, and that really took off in a different way with the right-stoked skepticism around the covid vaccine, which we’ll talk about in a moment. But that’s had consequences already, whether that is people not wanting to enter public health, people leaving the profession, and it’s affecting our ability to monitor diseases, to do public health prevention, to do all those kinds of things that are becoming even more important and even more difficult as other parts of the health care safety net are being constrained. 

Rovner: Yeah. And the mantra that we keep repeating is that public health, when it works, is invisible. Well, if it’s not there and it doesn’t work, it’s not going to be invisible anymore. 

Ollstein: Well, and also this is coming at a time when a lot of people, if they’re not being straight-up laid off from these agencies, are feeling driven out in other ways by the uncertainty, by My department was cut, and then it was restored because of a lawsuit, and then it was cut again, and thinking, Why should I put up with this, the way the administration has disparaged bureaucrats, basically? But also these nonpartisan scientists who work for the government. And so this is coming on top of all of that. And so if someone was on the fence about, Should I stay and keep working for CDC or not? — this certainly isn’t going to convince them to stay, both the fear as well as the agency’s response to the incident. 

Rovner: So HHS Secretary Kennedy was not very quick to respond to the CDC shootings, but he has been busy with other things this past week. One was an unsuccessful effort to get a prominent medical journal, the Annals of Internal Medicine, to retract a large vaccine study out of Denmark — and by “large” I mean 1.2 million children — that found that cumulative aluminum exposure to children via vaccines is not a safety risk. I honestly can’t remember an HHS secretary ever demanding a study be retracted because they disagreed with its finding. How unusual is this? 

Karlin-Smith: Very unusual. I mean, I think the scientific basis for what he’s saying and pushing for. And the journal has already said, No, we are not retracting this, pretty bluntly. And this adjuvant has been something people have been worried about Kennedy going after. It came up a little bit the last CDC advisory committee on vaccines. 

Rovner: Yeah, explain what aluminum adjuvant is. 

Karlin-Smith: And it’s basically something they’ve been putting in vaccines since I think the 1930s. And it helps basically boost your body’s response to it. So it makes the vaccines better. And the last CDC advisory committee on vaccines, after Kennedy sort of overhauled the panel and put a lot of his people on there who don’t really trust vaccines very much, they removed thimerosal as an adjuvant for a flu vaccine, which I think was seen as problematic but won’t have huge, huge consequences, especially for the U.S. But they did— 

Rovner: Because it had already been removed from most vaccines. 

Karlin-Smith: Right. But they did also sort of tease that they were going to look at this adjuvant. And when I talked to people about that, they were much more concerned about it, because it’s in many more products and they don’t believe there’s really good alternatives for it. And it could basically be a move to push companies out of this space of making a lot of vaccines that children really need and benefit from. 

Rovner: Or make vaccines less effective. 

Karlin-Smith: Right. So they just don’t have good alternatives. So, yeah, it’s one thing people have been watching, is kind of the next step of where they go in vaccine politics here. 

Rovner: What they’re going to go after. Well, meanwhile, the fallout continues over Kennedy’s cancellation of half a billion dollars in research on mRNA vaccines, which somebody mentioned earlier. This week, an international virologist group representing more than 80 labs reaffirmed their support for the technology. Michael Osterholm, one of the nation’s very top epidemiologists, said on the “PBS News Hour” that this was, quote, “unequivocally … the most dangerous public health decision I have ever seen made by a government body.” Why are scientists reacting so strongly to this particular policy change? 

Karlin-Smith: One of the big reasons is because of how fast this technology can be used to develop vaccines and the ability for it to be helpful in a pandemic. So while we have other, older vaccine technologies, this one is really much faster in being able to update vaccines and make new vaccines. So that’s a crucial public health benefit to it, and that, I think, really scares people. 

Rovner: Yeah, I know that the flu vaccine is still made using chicken eggs, right? 

Karlin-Smith: Right. It’s grown in an egg. So, right, if you think about potential of flu pandemics, bird flu comes up. That’s one place where having the new mRNA technology would be really valuable. It’s also being studied for all different types of diseases outside of it, the infectious disease space, and cancer. And people are really excited about that, too. At this point, it doesn’t seem like the administration is as interested in cutting off that sort of funding. 

Rovner: Yeah, well, we will have to see. Well, meanwhile, over at the FDA [Food and Drug Administration], we note the return of Vinay Prasad as head of the Center for Biologics. Sarah, didn’t he quit just, like, two weeks ago? What is going on over there? 

Karlin-Smith: Strange times. Yeah, I think he was gone for maybe it might’ve been about 10 days. I don’t even think it was two weeks. He was kind of forced out. He drew attention from some right-wing allies of Trump, particularly Laura Loomer, after he halted the shipping of a gene therapy product after some safety events, some deaths. And that caused a lot of right-wing people that hadn’t really maybe paid much attention to the FDA or Prasad to look into his history. They pulled up some of his past, which was, he was probably, he was fairly Democratic and aligned with more of the left wing prior to maybe the covid pandemic. He had really strongly criticized Trump and made pretty, I mean, he’s quite a character in his colorful statements. So he had talked about having a voodoo doll of Trump, and I think if you know Trump, that’s not the kind of thing he’s probably going to personally stand for. 

So it seems as if the White House pushed him out. But Martin Makary, the head of the FDA, and even HHS Secretary Kennedy seemed to eventually sort of convince the White House to let him back. And here he is. The question, I think, in a lot of people’s minds is does he have to sort of modify his decision-making or regulatory philosophy now that he’s brought back, whether it’s to sort of appeal to these right-wingers who basically have heralded Trump as this sort of head of a right-to-try movement, and this idea that there should be a more libertarian attitude toward regulation of medicine and people should basically have more options to try things. 

Rovner: Yeah. It goes back to sort of the whole right-to-try thing and this drug for muscular dystrophy, right? Isn’t that sort of what prompted the big kerfuffle? 

Karlin-Smith: Right. Right. So this Duchenne muscular dystrophy treatment has a really sort of long, complicated, controversial track record because Peter Marks, who used to have Vinay Prasad’s job before him, actually overruled a lot of his scientific reviewers in approving the product. And Prasad had a long history of criticizing Marks for doing that. And then right over the past few months it came out there had been some deaths in the space, mostly in non-ambulatory people. So this is a very devastating muscle-wasting disease, and eventually most people end up wheelchair-bound. And what ended up happening right before Prasad left is they agreed to let the drug back on the market for people that are still ambulatory, where they think the safety risk is less. And it’s still right now off the market for those. 

But yeah, it’s sort of ironic because Prasad, while he’s sort of repeated a lot of the anti-vaccine rhetoric of Kennedy and Makary, particularly when it comes to covid vaccines, his philosophy, and what he was known for prior to coming to the FDA, was actually having kind of stricter standards for approval than many at FDA maybe had, or he would argue. And that doesn’t really align with the Trump philosophy or this libertarian, right-wing philosophy around this idea of right to try and people should have access to things if they’re willing to take the risks. So that’s where I think we’re watching moving forward, because actually outside of the covid vaccine space where he was sort of heavy-handed, he also made a number of decisions around gene therapies besides this one in his first, short stent at the FDA that did seem, again, a little bit more anti that right-to-try philosophy. 

Rovner: Yeah. Well, we will definitely be watching that one closely. All right, moving on. We are seeing still more fallout of the big budget bill that passed earlier this summer. In rural New Hampshire, a community health center is closing at the end of October, citing Medicaid cuts, among other things. The Washington Post has a story this week about how the Medicaid reductions could lead to a decrease in services and an increase in wait times for things like counseling and speech therapy provided at schools for children with disabilities. I know Republicans were counting on these cuts not really having much of an impact prior to next year’s midterms. And they keep swearing that services won’t be cut except for people who are undocumented or who refuse to work. But that’s not how this is all playing out, right? 

Luthra: There’s just no way that is how it can play out. And I think what we’re seeing in real time is how sprawling Medicaid is. It touches so many corners of so many people’s lives. There’s a reason it became this really sacred-cow component of things you can and can’t touch. And I think one thing that will be really interesting is, just again, as we think about something like community health centers, which Republicans also often tout as this really great model. We talk about that for family planning, especially. Oh, you can go there — you don’t need your Planned Parenthood, for instance. And what does happen when all of these places that so many people rely on are gone? 

And I think one thing that you pointed out, Julie, that’s also so important is that many cuts may not be taking effect right away, but institutions have to make plans now. They are anticipating that that money isn’t coming back. And even if we don’t see some of the formal cuts having their start date until later on, it’s just not possible, I think, to imagine that we won’t see institutions have to adapt and scale back and see people navigate what that means. 

Rovner: Yeah. If there are 10 million more people mostly without Medicaid, all of these places like community health centers who get a lot of their funding from Medicaid are going to lose a lot of their funding. I think this just didn’t carry through. I mean, we heard a lot from the hospitals, but it didn’t carry through to the other providers whose livelihoods basically depend on their patients having some form of insurance. And usually that’s Medicaid. 

Ollstein: Right, and even with the hospitals, Congress was pressured into creating this kind of rural hospital slush fund to prop up the places that might be most impacted by this. But if all of the people who will be going to those hospitals lose their coverage, that might not be enough to make up for the loss, not to mention all of the hospitals that aren’t eligible for that money. And so I think Shefali’s absolutely right. The lesson in 2017 that Medicaid is not just the poor-people program was not learned. It didn’t stick. And now you’re seeing people relearning that, Oh, this impacts seniors in nursing homes. Oh, this impacts kids getting special services in schools. Oh, this impacts all of these groups that aren’t the working poor. 

Rovner: Yeah, I think we’re going to continue to see this sort of spool out as we go. Well, finally this week, a priority for the Trump administration that’s shared by most of the public — cutting down on so-called ultraprocessed food. The CDC reported last week that Americans are eating fewer of their calories via ultraprocessed food, but it is still more than half of the calories consumed. And pushing for at least a partial solution is not the current FDA commissioner but a former one, David Kessler, who served under Presidents George H.W. Bush and [Bill] Clinton and has campaigned against processed food for pretty much as long as I can remember. While Trump administration officials have been urging food companies to do things voluntarily, Kessler this week filed a petition arguing that the FDA has the authority to declare certain ingredients used in ultraprocessed food as not, quote, “generally recognized as safe.” Making food companies prove these processed ingredients actually are safe could be a real tool in the fight against these foods, right? I mean, Sarah, this whole “generally recognized as safe” has been one of the big FDA loopholes over the years. 

Karlin-Smith: Right. So, basically since the 1990s, due in some degree to probably staffing shortages and so forth, FDA has kind of allowed companies to self-certify that a lot of these ingredients are considered “generally recognized as safe.” And I think now there’s sort of some sense that maybe that wasn’t scientifically, and health, the best idea. So, Kessler’s basically saying you should give companies some cushion, maybe like 12 months or so, and say, Look, you either need to pull these ingredients out of your food or really, truly prove to us with the science that these are safe. Then he’s kind of calling Kennedy’s bluff a little bit and basically being like: Look, you keep talking about this. You’re really furious about the ultraprocessed food. Look, I found your regulatory hook, your legal way to do it. Now go do it. 

And I think the food industry, like many other big industries in the U.S., are pretty powerful, as you said. Given the amount of food we consume with these ingredients, it’s a huge — it would be probably quite difficult to make these changes in a year or so forth. But Kessler’s pretty smart. He was the person that really led the regulation of tobacco at FDA. And so I think he’s basically trying to say, Look, here’s a strategy — now go do it, and see if they’ll really follow through on anything. 

Rovner: Yeah, I was absolutely fascinated by this in terms of sort of calling the bluff, because that’s what you were saying. On the one hand, they’ve talked a big game on something that, unlike the Medicaid cuts, is popular with the public. On the other hand, they seem very loath to require the food industry to do anything. 

Karlin-Smith: Right. I mean, their main food achievement so far is getting commitments on certain food dyes, which for the most part actually aren’t that used anymore. And I think even the safety concern around them is generally seen as pretty low. Now they’re not really adding anything to your food other than color. So there’s an argument that even if there’s just even some slight hypothesis that there’s the danger, you should get them out. But the theme, and we talked a lot about this a little bit last week in the podcast, is they’re talking a lot more than they’re actually making achievements so far in the public health space. 

Rovner: I guess you can sum this up in: It’s less What color are your Froot Loops? than Should you be eating Froot Loops at all? Or, Should you be feeding them to your children? 

Karlin-Smith: That’s perfect. 

Rovner: Yeah. All right. Well, I’ll be fascinated to see if they actually follow up on this. All right, that is this week’s news. Now we’ll play my interview with AcademyHealth president and CEO Aaron Carroll, and then we’ll come back and do our extra credits. 

I am so pleased to welcome Aaron Carroll to the podcast. Aaron is president and CEO of AcademyHealth, the leading national organization for health system researchers, in addition to being a top-notch health policy expert himself. Aaron is also a pediatrician and formerly a pediatrics professor and associate dean at the Indiana University School of Medicine. Aaron Carroll, thanks so much for joining us. 

Aaron Carroll: Thanks for having me. 

Rovner: So, I wanted to talk to you mostly about your op-ed published in The Washington Post last week. We will link to it in our show notes. It’s called: “This Phrase Was Meant To Increase Trust in Science. It backfired.” The phrase in question is “Follow the science.” Tell us why you think it backfired. 

Carroll: Well, for a couple of reasons. The biggest is that I think it to some extent conflates science and policy, and it makes it sound like that once we have science that policy naturally follows from it and that anyone who is rational will know the right answer. The problem with that is that science is sort of a set of facts, or an explanation of the world as we best understand it, but policy should take good science, and then it has to incorporate societal values, people’s preferences, what I would call utility values almost, and all the trade-offs that come with policy. And so good science should inform policy, but good science is not the same as policy. 

I provide a number of examples. One would be like, look, we have great science that shows vaccines are unsurpassed to preventing infectious disease. We also have science that shows that eating raw or undercooked eggs can cause salmonella. The first might justify vaccine mandates in schools. The second certainly doesn’t mandate banning sunny-side eggs. Just because something is true, you have to think about their differences when you come into policy. And too often we use that phrase almost as a cudgel to say: We have science, therefore this is the only policy that makes sense. And if you disagree, then you’re not following science. That’s just not the case. 

Rovner: And that’s pretty much what happened during the pandemic, wasn’t it? 

Carroll: Yeah. I mean there were so many times where we were making the best guess, because you have science, but the science isn’t terribly great and it’s not really up to date. So you have to make policy decisions from that. But different people are going to make different policies, and different groups, depending upon where they’re focusing, might make different policies. And that is OK. But we sort of fell into a trap where there could only be one voice, one truth. It really brooked no dissent, and it had to be sort of put out nationwide. And when there was pushback that the policy decisions didn’t necessarily follow from the science, everyone didn’t always react to that as well as they should have. 

Rovner: And now it’s being hung around people’s necks, whichever side they were on. 

Carroll: Yeah. 

Rovner: Even if the science has changed since then. 

Carroll: Yeah. I mean, I helped to run Indiana University’s pandemic response, and we used to do at least a weekly webinar where we would answer questions, and all the time I would say things like: This is the best answer we have right now. That’s why we’re going with this. And let me explain to you why. And these are the trade-offs. We’re trying to do the best by everyone. These are the pros. These are the cons. Let’s talk it out. And if the data change in the future, we’ll change the policy. We’re doing the best we can. But that kind of nuance, that kind of long-form answer, was too often not acceptable or not possible during the pandemic, because we wanted things to be reduced to sound bites. We wanted things reduced to easy algorithms. We wanted everyone to sort of do whatever our chosen sort of arbiter of truth said. And if people disagreed, we really accused them of disagreeing with science. And there’s a real difference between science and policy. 

Rovner: So, how do we start to win back that trust? 

Carroll: I think a couple of ways. One is, I think, we have to start listening as well as we do speaking. I think too few of us actually are willing to spend time talking with people who truly disagree with us, and that’s going to limit our ability to enact good policy. I like to point to the fact that there are change management experts who will argue that there are three reasons people resist change. They don’t understand it, they don’t like it, or they don’t like you, which is really about trust. But we treat too many things as if they only fall into that first bucket. It’s a knowledge dissemination problem. And if we just speak out facts louder and louder and more stridently, then everyone will come and listen to us. So if we just keep broadcasting facts over social media, then everyone’s going to agree with us. 

It completely ignores that there’s a section of people who are completely rational but don’t like the change, because of trade-offs. I hated wearing a mask. It fogged up my glasses completely. I would do it, but I hated it. And every time someone lectured me on how easy it was and I should just get over it, I got angry. We’ve got to be better about understanding there are trade-offs in policy, and we have to address those trade-offs. And of course there’s that huge third bucket of people that don’t trust us. That’s only going to come from slow, honest conversation with people who disagree with us. And we don’t want to do that, either. We want to shout at people over social media. We want to push people away who don’t agree with us. We want to belittle them. 

That’s a problem. In the op-ed, I talked about that, as a pediatrician, I’ve been dealing with parents that don’t want to do what I tell them is best for decades. I don’t slap ’em. You have to build trust. You have to listen to them empathetically. You have to discuss the reasons why you might want to do something or not do something. And you have to build those kinds of relationships over time. It’s slow. It can be tedious. But that’s how you get people to change their mind, not by just shouting or belittling them. And we do that too often. 

Rovner: One thing I’ve noticed over almost 40 years of doing this is that some of the best explainers of policy have been pediatricians — C. Everett Koop, David Kessler, Bill Roper, all pediatricians of one sort or another. What is it that they teach you that lets you communicate so well? 

Carroll: I trained in Seattle. People were refusing vaccines back in the ’90s, and they weren’t the same people who are refusing vaccines today. You had to learn to deal with that. I would make recommendations about how to sleep, how to eat, how to control tantrums, how to do behavior change, how to parent. And I’m competing with Grandma, and I’m competing with other relatives who have very wildly different opinions about how things should be done. And you have to learn how to deal with that, with people who just don’t agree with you right away and who aren’t swayed by data and evidence but by trust. And people get more riled up about when they’re pregnant and, I think, when they have small children, than almost any other time in their lives, about they can’t make a mistake, they’ve got to do the right thing, and they’ve got to balance competing voices who are telling them very different information. Maybe we’re just better used to it or trained to it, but a lot of this stuff that we’re arguing about now, a lot of pediatricians have been dealing with for a long time. 

Rovner: So, this administration, obviously, for anybody who’s listened to the podcast for more than five minutes knows, is not really helping matters right now, are they? 

Carroll: I mean, we’re not doing a lot of really good communication and a lot of really good listening. I think we’re seeing a lot of top-down decisions that are not perhaps based on the best data and evidence, are not as justified as well as you might want to expect, and who are dismantling or removing many of the tools that we use to produce the data and evidence that can produce sound policy. No one would argue, I think, that the NIH couldn’t have reform. No one could argue that the USPSTF [U.S. Preventive Services Task Force] is perfect and never needs to be touched. ACIP [The Advisory Committee on Immunization Practices] could be refined. I think there were decisions made about covid vaccines and boosters that produced hearty debate years ago, and lots of decisions on ways that some of these organizations work could be refined. But we don’t want to throw out the baby with the bathwater. A lot of the infrastructure that we have in place is to make sure that things are nonpartisan, that we’re relying on the best evidence, that we’re doing the best job that we can to make sure that these things are not biased or partisan in any way. 

And a lot of the steps, I think, that are being taken to wipe away a lot of this infrastructure are not going to reinforce trust. The answer isn’t to shut down discussion, which is happening too often around the country. It’s to move and lean into open dialogue. We have a meeting coming up in the next few months, Health Datapalooza, which really brings together lots of people from the current administration who should be there, plus lots of people from industry, plus researchers, plus health systems, and those who provide the care, coming together and having an open dialogue, open discussion, learning to listen to each other, and learning to realize we’re all really human beings and we need to be able to learn. Both ways is how we move forward. And unfortunately, we’re moving in a direction that tries to shut down that kind of debate and just shouting that the other side is wrong. 

Rovner: I know AcademyHealth has been pretty outspoken about the disappearing databases at HHS in particular. I mean, what could that mean for public health? And, I mean, now it’s not just databases that are being taken down but there’s a concern about data being put up that’s not necessarily trustworthy. 

Carroll: I mean, again, we can’t improve what we can’t measure, and we can’t make change if we don’t know where we’re starting from or where we need to go. And you can make an argument, I suppose, that a lot of these data would still be available without the federal government collecting it, but no one is as good or thorough or has the mandate of law to pull a lot of these data sources together in ways that people can use. And these aren’t just, like, esoteric research things. Some of these are, like, how public health officials monitor the health of their citizens. Some of these are about what clinicians might want to know to talk to their patients about what’s going on in their area, or what trends are in certain diseases, or how things work. People, clinicians, patients need these data. There are — a lot of them are mandated by law, and if we don’t have them up, people suffer. 

This isn’t, again, like we’re just punishing researchers or scientists. This is punishing people, and, again, at AcademyHealth, our mission is to promote the creation and use of data and evidence to improve health and health care for all. You can’t do that without the data, and no one can do it if they don’t trust the data. So much of this, again, is about trust, which is about transparency, which should be a nonpartisan issue. We advocated for this same kind of thing under the Biden administration when they tried to restrict Medicare data and how researchers could get and use it. And we were out in front saying: That’s not OK. People need access to this data. And that the same thing is true under the Trump administration. We want more people to have more access to the best and most trustworthy data, always. 

Rovner: Well, thank you for fighting the fight for good science and good policy. Aaron Carroll, thanks a lot. 

Carroll: Thank you. 

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

Luthra: Absolutely. My story is by Theresa Gaffney from Stat News. The headline is “Inside the American Medical Association’s Sudden Strategy Shift in Washington.” I picked this because I knew Julie and I would both get a real kick. There’s just a lot of fun in following the political trajectory of the AMA, which as we know began as this more conservative political organization, has undergone this transformation in more recent years, becoming more interested in causes, sometimes aligned with more of the political left, whether that is expanding access to health care, whether that is opposing abortion restrictions, and then had really gone quiet when we saw this big attack on a lot of medical institutions from the new administration. And this story looks at how that is starting to shift and the AMA is now trying to actually act in response to all of the things that have been happening to scientists and health care providers, and where that is coming from within the medical community and what it could mean. 

Rovner: It’s a really interesting story. And Shefali’s right. One of my hobbies is following the AMA’s political trajectory. Alice. 

Ollstein: So I have a piece in The New York Times by some KFF stalwarts, and it’s called “Why Young Americans Dread Turning 26: Health Insurance Chaos.” So, it sets up that if Congress doesn’t renew the ACA [Affordable Care Act] subsidies that are expiring later this year, people are going to face an even worse cliff when they turn 26 and they have to start buying their own insurance. But the article talks about all of the ways that cliff is already worse now before that even happens, largely because there’s just less regulation of plans, and so people are buying crappier plans that don’t adequately cover them when they actually need them and get sick, and the process, because the navigators have been defunded, and there just isn’t a lot of outreach and promotion going on under the Trump administration. 

People are very confused and overwhelmed by all of the options and are largely going without insurance. And I think what’s important from the story is you may think: Oh, this doesn’t affect me. I’m not a 26-year-old. I have my insurance. I’m fine. As we learned in the past, this impacts everybody. If young and healthy people are driven out of these markets, that impacts everybody’s costs and makes things more expensive for the rest of us. So definitely worth paying attention to. 

Rovner: Yeah, it’s a really good piece. Sarah. 

Karlin-Smith: I took a look at a piece in The New York Times by Carolyn Kitchener, “This Ohio Farm Community Is a Mecca for the” quote “‘MAHA Mom.’” And it’s about what is essentially sort of a — the story kind of describes it as the idea of the 1960s, 1970s, like, hippie farm commune but kind of MAHA [“Make America Healthy Again”] style, and maybe a bit more luxurious. And it’s essentially a look at how this community develops and operates and tries to live by some of the, quote-unquote, “MAHA principles” around how the foods you eat or grow. And it’s kind of a fascinating look as to what they’re trying to do and how they want to live their lives. 

Rovner: Yeah, it’s the new age of the New Age. Fascinating. Well, my extra credit this week is from the “Who Could Possibly Have Seen This Coming” category. It’s from ProPublica. It’s called “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman. And despite vows by Trump officials that they could cut tens of thousands of jobs at the department without harming clinical care, it turns out that the cuts are deterring clinical care workers from signing up to work at the VA [Department of Veterans Affairs] in the first place. It seems that 40% of doctors offered work at the VA in the first quarter of this year said no. That’s quadruple the rate of rejection from just the year before. And between January and June, the VA lost twice as many nurses as it hired. 

While VA officials accused ProPublica of cherry-picking numbers, I will point out that separately this week, the VA’s inspector general, in its annual report, found that every one of the VHA’s [Veterans Health Administration’s] 139 medical centers reported staff shortages, with those reporting, quote, “severe shortages” for specific jobs up 50% from the year before. So, that doesn’t sound very much like cherry-picking. 

OK. That is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our fill-in editor today, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe where you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Shefali? 

Luthra: I’m at Bluesky, @shefali. 

Rovner: Alice. 

Ollstein: On Bluesky, @alicemiranda, and still on X, @AliceOllstein. 

Rovner: Sarah. 

Karlin-Smith: Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: We’re going to take a little bit of a summer break for the rest of the month. Next week we’ll have a special episode on the 60th anniversary of Medicare and Medicaid, and the week after we’ll be dark so our hardworking staff can have some time off. We’ll be back in your feed with all the news on the Thursday after Labor Day. Until then, be healthy. 

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Emmarie Huetteman
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Emmarie Huetteman, senior editor, oversees a team of Washington reporters, as well as “Bill of the Month” and KFF Health News’ “What the Health?” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail. 

Health and Human Services Secretary Robert F. Kennedy Jr.’s announcement that the federal government will cancel nearly $500 million in mRNA research funding is unnerving not only for those who develop vaccines, but also for public health experts who see the technology behind the first covid-19 shots as the nation’s best hope to combat a future pandemic.

And President Donald Trump is demanding that major pharmaceutical companies offer many American patients the same prices available to patients overseas. It isn’t the first time he’s made such threats, and drugmakers — who scored a couple of wins against Medicare negotiations in the president’s tax and spending law — are unlikely to volunteer to drop their prices.

This week’s panelists are Emmarie Huetteman of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Sandhya Raman of CQ Roll Call, and Lauren Weber of The Washington Post.

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• Explaining the decision to cancel some mRNA vaccine funding, a priority for vaccine critics, Kennedy falsely claimed that the technology is ineffective against respiratory illnesses. Researchers have been making headway into mRNA vaccines for maladies such as bird flu and even cancer, and the Trump administration’s opposition to backing vaccine development weakens the prospects for future breakthroughs.
• Trump’s insistence that big-name drugmakers voluntarily lower their prices underscores how few tools the presidency has to deliver results on this important pocketbook issue for many Americans. Medicare’s ability to negotiate drug prices took a hit under Trump’s big tax-and-spending law, which included two provisions advocated by the pharmaceutical industry that would delay or exclude some expensive drugs from the dealmaking process.
• A year after Trump promised on the campaign trail to secure coverage of in vitro fertilization, the White House reportedly is not planning to compel insurers to pay for those pricey reproductive services — a change that would require an act of Congress and could raise costs overall.
• And with Congress back home for its August recess and a late September deadline looming, the annual government funding process is in progress — but unlikely to resolve quickly or cleanly. Senate appropriators are further along in their work than usual, but the House of Representatives has yet to release its version, which is expected to cut deeper and hit social issues like abortion harder.

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

Emmarie Huetteman: KFF Health News’ “New Medicaid Federal Work Requirements Mean Less Leeway for States,” by Katheryn Houghton and Bram Sable-Smith. 

Sarah Karlin-Smith: Slate’s “Confessions of a Welfare Queen,” by Maria Kefalas. 

Sandhya Raman: CQ Roll Call’s “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks,” by Sandhya Raman. 

Lauren Weber: The New York Times’ “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes. 

Also mentioned in this week’s podcast:

• The Washington Post’s “How RFK Jr.’s mRNA Crackdown Affects Vaccinemaking and Future Pandemics,” by Carolyn Y. Johnson and Lauren Weber.
• The AP’s “Fact Focus: Trump Says He’s Cut Drug Prices By Up to 1,500%. That’s Not Possible,” by Melissa Goldin.
• The Washington Post’s “Medicare, Medicaid Plan To Experiment with Covering Weight Loss Drugs,” by Paige Winfield Cunningham.
• The Washington Post’s “White House Has No Plan To Mandate IVF Care, Despite Campaign Pledge,” by Riley Beggin and Jeff Stein.

click to open the transcript

Transcript: Kennedy Cancels Vaccine Funding

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

Emmarie Huetteman: Hello, and welcome back to “What the Health?” I’m Emmarie Huetteman, a senior editor for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Aug. 7, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. Here we go. 

Today, we’re joined via video conference by Lauren Weber of The Washington Post. 

Lauren Weber: Hey, everybody. 

Huetteman: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning. 

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

Sarah Karlin-Smith: Hi, everybody. 

Huetteman: It’s August, and here in the nation’s capital that means Congress has flown the coop, and a lot of the federal city has gone with them. No interview this week. And you may be wondering why you’re hearing my voice instead of the incomparable Julie Rovner. Julie’s out this week having surgery to repair her broken wrist. Good news: She’s on the mend and she’ll be back in your podcast feed very soon. Get well soon, Julie. Let’s get to the news. 

On Tuesday, the Trump administration announced that the secretary of Health and Human Services, Robert F. Kennedy Jr., has canceled almost $500 million in federal grants and contracts to develop mRNA vaccines. That technology, of course, was responsible for the first covid vaccines, and researchers have been working on new ways to use mRNA, including against bird flu and even cancer. But in explaining his decision, Kennedy made false claims about mRNA vaccines, including that they do not protect against respiratory illnesses. Kennedy’s opposition to the covid vaccine, in particular, is well-documented. But before becoming health secretary, he advocated for federal officials to revoke approval for mRNA-based covid shots. 

Sarah, you’re our pharmaceutical industry expert. What will this mean for vaccine development? Without this government funding, can that research continue? 

Karlin-Smith: I think people are really concerned, particularly about the speed of vaccine development for pandemic situations. That’s a classic market failure in that companies aren’t that incentivized to work on developing products for hypothetical situations that may never come to pass, but we obviously want to be prepared for strains of the flu that can be particularly harmful and stuff. So I think that’s where people are really concerned. 

I think, in general, this is just another mark in some of the vaccine actions that have taken place since this administration took over that makes people a little more nervous about just investing in the vaccine field, whether it’s mRNA or vaccines in general. FDA has made some unusual decisions around the indications for covid vaccines moving forward. The [Centers for Disease Control and Prevention’s] whole [Advisory Committee on Immunization Practices] has changed. So I do think there’s broader concern beyond the mRNA vaccines and our need to have this technology to really prepare for a pandemic about how confident industry will be in the places they normally would invest money on their own. 

Huetteman: Lauren, you had a story yesterday about how Kennedy’s decision is intensifying concerns about our ability to fight future pandemics. Can you tell us what you’re hearing from public health experts? 

Weber: Yeah. We spoke to a number of public health experts and vaccine experts, mRNA experts, who said, Look, this is the technology that you want to be spry, to be able to alter something, to fight potentially a bird flu. It’s also used in revolutionary ways to fight maybe even cancer here in the future. There’s a lot of fear about how this could have a chilling effect, as Sarah was pointing out, on the development pipeline and what that means in a pandemic situation. 

I do think it’s important to note that just this morning, Trump was asked about this and said he was going to have a meeting on it at noon. Not sure exactly what that means, but potentially that could be something. Robert Malone, who’s an ACIP member, sent out an email trying to rally MAHA [“Make America Healthy Again”] supporters to make sure that they backed up Kennedy’s decision. 

I think it’s also important to take a step back and look at Kennedy’s past remarks on mRNA, as you alluded to. This is a man who falsely called the covid vaccine “the deadliest ever made.” He’s described it as a poison in the past. Some anti-vaccine factions of MAHA have really been pushing to try and limit access to mRNA technology. You’ve seen this also in some Republican and far-right states, that are more right. You’ve seen some legislation suggested to remove access to mRNA technology. There’s a big question among some of the folks we talked to on if this is a bit of a signal to the base. 

Karlin-Smith: I was going to say, ironically, the mRNA vaccines was probably the biggest success of the Trump administration’s first term in office. He was instrumental in spearheading the fast development of the vaccines for covid. 

Huetteman: Right, Operation Warp Speed. Interesting how far we’ve come. To be clear, this isn’t all of the government’s mRNA contracts, right? This is just a piece of the research funding? 

Karlin-Smith: This is a piece of it coming through BARDA [the Biomedical Advanced Research and Development Authority], which is particularly designed to help fill those market gaps in pandemic preparedness, but they’ve also cut other mRNA vaccine contracts previously in this administration, including a big one around bird flu, which people are concerned about right now. I’ve even seen some media reports where people, researchers in the cancer but mRNA space, were concerned about grants just being flagged just because they had the terminology. It’s not everything, but I think there’s certainly fears that this is just a step in a bigger process that is problematic. 

Huetteman: Absolutely. We’ll be keeping an eye on that. And vaccine contracts aren’t the only thing that President Trump’s team is undoing this week. Under a new federal rule, VA hospitals would no longer be able to perform abortions in cases of rape, incest, or health endangerment. You may remember that the Biden administration introduced that policy at the Department of Veterans Affairs in 2022, after the Supreme Court ended the constitutional right to an abortion. The policy has allowed veterans and their relatives to obtain abortion services even while they are stationed in states with restrictions. 

Meanwhile, lots of news to get to this week. In prescription drug news, late last week, President Donald Trump sent letters to more than a dozen drugmakers insisting that they drop their prices within 60 days. Specifically, the president demanded that pharmaceutical companies offer many American patients the same prices that drugmakers charge abroad. Over the weekend, Trump told reporters that his administration is dramatically lowering drug prices, “up to 1,500%,” he said — which, well, I think that technically means the drugmaker would pay you. 

Anyway, Trump told drugmakers that if they don’t lower drug prices, “We will deploy every tool in our arsenal.” What can the president do to force drugmakers to comply? 

Karlin-Smith: I think, in some ways, he doesn’t have as many tools in the toolbox as he probably would like to think. At least, not ones that are making the industry particularly fearful right now. He doesn’t have the power to just issue a regulation saying, “The Medicare-Medicaid reimbursement rates are tied to the rates countries are paying abroad.” That would have to be through legislation. And I think there are reasons that both Republicans and Democrats don’t really like this most-favored-nation approach to drug pricing. There is some sort of limited authority for them to do a demonstration project through CMS’ [Centers for Medicare & Medicaid Services’] Medicare-Medicaid Innovation Center. They could come up with a test of this in some kind of limited area. They tried to start implementing that [in] his last term and they got scuttled by lawsuits, so we’ll see if they have a way to avoid that problem this time. 

But the ironic thing is that when the administration issued this executive order in May calling for this most-favored-nation pricing, he set this 30-day-ish deadline of saying, OK, we’ll tell you what prices we want, you guys lower them. If not, we’re going to do rulemaking. One thing that came up when he issued this letter, these letters on Friday, giving industry another 60 days is, Well, why are they not just going through with some kind of rulemaking or next steps? It almost seemed to some people like almost a more muted threat because they haven’t done the follow-through yet or come up with what the follow-through is here.  

Huetteman: Now, where is the Medicare’s drug negotiation ability in this equation? Why isn’t the president doing more to leverage Medicare’s power to negotiate at this point? 

Weber: Well, that’s really interesting because in the “Big, Beautiful Bill,” there were two provisions that a lot of people missed that limited the ability to negotiate on some key drugs, which has been estimated to likely cost the American taxpayer and the government billions of dollars over the next couple years. 

Huetteman: Yeah, the CBO says that those changes will cost Medicare at least $5 billion in missed savings over 10 years. 

Weber: Yes, that’s what’s called effective lobbying. Essentially, what happened is some pharma companies were able to tuck in provisions that key drugs, I think it was Keytruda, I’m not sure if I’m pronouncing that right, or Keytruda, which is used to treat cancer, it’s a drug by Merck. It had $17.9 billion in U.S. sales in 2024. That’s the kind of drug that they won’t be able to negotiate prices on for a bit.  

Huetteman: Yeah, that’s right. Of course, that also means that Medicare patients will be subject to paying their percentage of those higher prices as well. On top of talking about this CBO score there, we’re talking about drug prices that real people are paying for their expensive cancer drugs right now. I guess I’m curious why Trump isn’t using the negotiation process in order to lower those drug prices? 

Raman: I would add that something that makes this more difficult is that Trump has been very back-and-forth about a lot of his opinions on different things that he’s going to do throughout the last several months in this process. Even if you look at something like how we would deal with tariffs on the pharmaceutical industry, we’ve been a little bit all over the place. I think even if he’s not demonstrating the clear idea of which way he’d want to go, it makes it a little bit harder for the regulators, whether it would be in Congress or through the FDA, to do anything, given that he’s been changing a lot what he’s hinting at wanting to do.  

Huetteman: Yeah, that’s right. Actually, Sarah, you brought up the CMS innovation option. There’s a story out about this this week. The Washington Post reports that the Trump administration is considering using that center to do a pilot project to expand access to GLP-1 drugs for weight loss purposes by allowing state Medicaid and Medicare Part D plans to cover them. 

Now, insurance premiums are slated to go way up next year. If I’m not mistaken, the cost of covering GLP-1 drugs is one reason that insurers have cited for those premium hikes. If this happens, can we expect that the cost of those drugs would strain state and federal budgets? 

Karlin-Smith: Actually, one I guess positive thing is that some GLP-1 drugs are slated to be subject to negotiation through the IRA [Inflation Reduction Act] program next year, so that there’s maybe positive news around the prices of those going down. Again, that’s obviously only for Medicare. But the problem on the back end is that, based on law, Medicare is not allowed in Part D to cover drugs for weight loss. 

The Biden administration had tried through rulemaking to make an argument that weight loss drugs and drugs that treat obesity are two different things, hearkening back to — when that law was written we really didn’t understand obesity as a disease process and all the health problems it has on your body. We thought of weight loss as more of a cosmetic thing. The Trump administration actually pulled that rule, so this would be a much more small step in the direction of trying to get coverage. The report says it would be a “voluntary demo.” 

The biggest question in my mind, which is again, knowing that these drugs, even with cheaper prices, would likely raise costs, is what is the incentive for health plans to voluntarily want to participate in this? What would the government have to do to incentivize this? Without some sort of push there for states and for Medicare Part D plans, I’m not sure the private plans are just going to pick up these products given the amount of people that would qualify for them. I think we need a lot more details from the Trump administration to know if they can actually make this feasible. 

Weber: I just find this to be such a fascinating move considering [CMS Administrator Mehmet] Oz and Kennedy have such different opinions about weight loss drugs, as does MAHA as a whole. We at The Washington Post had reported previously that Oz does have financial ties to Ozempic through his show — they had to run a sponsored ad to some extent — and also through other means. It’s fascinating to see that clearly this is going forward, despite Kennedy having said repeatedly, often, constantly that he does not want to pay for these drugs, that he thinks other interventions, healthy diet and lifestyle, should be implemented. Which Oz has also really promoted as well. So fascinating to see how this experiment plays out. I agree with Sarah; I’m not sure where the incentives are, considering the cost that this will be to see it play out. 

Huetteman: And one year after Trump promised coverage for in vitro fertilization services on the campaign trail, The Washington Post reports that the White House does not plan to require health insurers to cover IVF. The president had said that “if he were elected, the government would either pay for IVF services itself or require insurance companies to do it.” 

What’s standing in the way here? What’s involved in making something an essential health benefit? 

Raman: I think this whole process has been interesting. In February, Trump had put out an executive order directing his administration to come up ways to reduce the out-of-pocket costs for IVF. At the time, it’s pretty vague in terms of what that would entail. After the deadline passed, in part, I think a lot of people weren’t surprised because a) IVF is very expensive. And b) I think there are a lot of complicated nuances to some of his base and whether or not they fully support IVF. We had a lot of this last year, with people saying that they support it, but then also some of the folks that are more pro-life have some stipulations about not wanting embryos destroyed. It just complicated that some of the people that were talking to him about some of the other abortion-related issues were not on board with all of the IVF things. I think that has played definitely a factor in what they’re going to do with this. 

But it’s also a hard thing to do, to just make this something that — even with prescription drugs, reducing the costs of those is not simple. In order for them to make it an essential health benefit, I think, is also more complicated given the issues that we’ve been having with preventative care, and just the concerns about the [U.S. Preventive Services Task Force] getting removed and what that’ll do to different things that are covered. It’s complicated and I wouldn’t really see this changing on IVF in the near future, at least from the executive level. 

Karlin-Smith: It needs to go through Congress to be an essential health benefit. I think there’s a theme in some of the topics we’re coming up to today where Trump is clearly coming up to the limits of his bully power and his threats of negotiation. I think Martin Makary, the head of the FDA, said, “You get more bees with honey.” Well, unfortunately, sometimes it’s just not enough to attract these industries to make major changes. 

Yes, they’ve gotten some sort of minor concessions, I think. I know they would like to think they’re transformative, but I think a lot of what they’ve gotten voluntarily is pretty minor, in terms of both health impact, and also how much it harms industry in terms of, like, food dyes. Or even the insurance companies saying, Oh, sure, we’ll do better on not going crazy on prior authorization. 

I think Trump now has to actually double-down and work with policymakers on rule writing, or work with Congress. It’s more complicated, especially again, as Sandhya said, IVF is something that’s complicated for his base to support. 

Huetteman: That’s right. This all came out of the blowback about how far towards banning abortion the country was going to go under Trump. This was a way to say, We’re preserving some parts of the reproductive health that are really important to people in our base, right?  

Raman: Yet even when Congress has tried to look at any of the IVF legislation in the past, it’s fallen on party lines. There have been ones that have been more messaging on either side. I think the closest we’ve gotten is that, on the defense side, trying to consider measures there for folks with Tricare, but it’s difficult to get folks on board with things like this through Congress. 

Huetteman: Well, speaking of Congress, Congress has left the building. August recess has begun and lawmakers are back home. Say, how is that government funding coming along. Sandhya?  

Raman: I think we’re in a similar place to many years in that it’s August, they’re out. We need government funding by the end of September, and we’re nowhere close to getting that. I would say on the plus side, the Senate is further along than they usually are. Before they left, they did mark up the Labor, HHS, Education funding bill, and that was overwhelmingly bipartisan. It included some money that would be a boost for NIH [the National Institutes of Health], which I know was a big concern for a lot of folks given what was in the White House proposal. It maintains funding for some of the programs that would be cut under the White House, things like Title X, Ryan White HIV. It also has a little bit of a pushback on making sure that the agencies continue the staffing to keep up some of their statutory duties.  

But again, it’s just the Senate. The House has not put out their bill. I would expect theirs to be a bit more conservative, given that the head of the Appropriations Committee in the Senate is Susan Collins, who’s been a little bit more moderate. The House is expected to release theirs and mark up theirs right after they get back. They meant to do it before recess but got pushed back because of reconciliation and that changing their schedule. 

It depends what they say in theirs and how much difference there is. I would expect there to be a lot of differences. It seems like we’re headed toward the usual of at least some sort of temporary spending to kick it down the line. Whether or not that ends up being a year again, like we did this year, or a short-term thing, we’re not sure yet. It depends on where we are in September.  

Huetteman: Right. And possibly preceded by a lot of fighting over social issues that get thrown into the health bill, and fights over the actual funding levels, if I had to guess, based on how House lawmakers have been talking about it so far.  

Raman: Oh, no. I think just the fact that we had such a big rescissions debate this year and the fact that we might do that again, it has definitely left a sour taste for a lot of Democrats who are worried that if whatever they vote for here might just get clawed back later on down the line. That’ll be another thorn in it.  

Huetteman: Awesome. Well, thanks for that take. That’s this week’s news. Now it’s time for our extra-credits segment. That’s where we each recognize a story we read this week that we think you should read, too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device.  

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

Weber: I have a doozy of a story from The New York Times titled “‘Hot Wasps’ Found at Nuclear Facility in South Carolina,” by Emily Anthes. Yeah, it’s the stuff of nightmares. It’s all about how wasps became radioactive — four wasps’ nests near a South Carolina nuclear facility.  

Huetteman: Yikes.  

Weber: If this gave you bad dreams, it definitely did for me. Essentially, what some of the researchers have posited is that wasps could have burrowed in some sort of bad wood or wood that was contaminated or other parts of the area that are contaminated. But this idea that it sounds like something out of Chernobyl, or something like that. But this idea that in the U.S., you could have a nuclear facility that is potentially transforming some of the near-wildlife is concerning in terms of cleanup efforts, and also concerning in terms of contamination control. Clearly, there’s more that needs to be dug into there. Hopefully everyone sleeps after hearing about this.  

Huetteman: Woof, yeah. I might need to take an Ambien tonight. Sandhya, how about you go next?  

Raman: My extra credit is from me in Roll Call. It’s my last dispatch from my reporting trip in Sweden earlier this year. And it’s called “Sweden’s Push for Smokeless Products Leads Some To Wonder About Risks.” It looks a little bit at some of the public health impacts as Sweden has really tried to reduce their smoking rate to become smoke-free. The U.S. is also at a low from smoking. Some of the things that public health experts are thinking about as people shift to other products and how they’re able to message to the remaining smokers that are not willing to give that up still.  

Huetteman: Awesome. Thanks for telling us about your work there. And Sarah?  

Karlin-Smith: I looked at a story from Slate, “Confessions of a Welfare Queen: I Study Poverty for a Living, and I Never Thought I’d Need Medicaid. Then My Child Was Diagnosed With a Terminal Illness,” by Maria Kefalas. It’s a personal story from a mother whose family needed Medicaid when their young child was diagnosed with an illness that was going to severely require intense medical care and limit her lifespan. They were able to take advantage of what are known as “Katie Beckett waivers” that were instituted by Ronald Reagan to allow states to voluntarily allow higher income requirements so that people could get Medicaid and care for their children at home. The original girl it was named for was otherwise basically going to be stuck living her life, and she lived until 34, in a hospital.  

The purpose of the story is really to point out that now that the “Big, Beautiful Bill” has passed and there are $1 trillion in spending cuts to Medicaid, that these are some of the sorts of people and programs, because it is not a mandatory program, that may unfortunately be on the first for the chopping block. I think the piece does a good job of pointing out, while there’s been a lot of rhetoric around the people who are going to get hurt by this are people that are not working or somehow abusing the system, and the mother does a pretty good job of talking about how both she and her husband continue to work. Most of the families that need this program, to the extent they can, want to keep working. You just get a really human picture of the type of people that are at risk of losing services.  

Huetteman: Yeah, for sure. It’s a really illuminating story. Thanks for talking about it. My extra credit this week is from my colleagues here at KFF Health News. The headline is “New Medicaid Federal Work Requirements Mean Less Leeway for States.” It’s by Katheryn Houghton and Bram Sable-Smith. 

They report that at least 14 states are in progress designing their own work requirement programs. But now, with the passage of Trump’s law last month, which institutes federal work requirements, those states must make sure that their programs meet federal standards. In some cases, the states are actually going even further than federal requirements, my colleagues report. For instance, Arizona state law would institute a five-year lifetime limit on Medicaid coverage for “able-bodied adults.” 

OK, that’s this week’s show. Thanks as always to our producer-engineer, Francis Ying, and to Stephanie Stapleton, our editor this week. If you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on LinkedIn. Where are you guys these days? Sandhya?  

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

Huetteman: Sarah?  

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

Huetteman: And Lauren?  

Weber: I’m at X and Bluesky @laurenweberhp. Yes, the HP is for “health policy.” 

Huetteman: We’ll be back in your feed next week. Until then, be healthy. 

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

In his ongoing effort to reshape health policy, Secretary of Health and Human Services Robert F. Kennedy Jr. reportedly plans to overhaul two more government entities: the U.S. Preventive Services Task Force and the National Vaccine Injury Compensation Program. Ousting the existing members of the task force would give Kennedy a measure of control in determining the kinds of preventive care that are covered at no cost to patients in the United States. And while it’s unclear what the secretary would do to the vaccine injury program, Kennedy has made no secret of his belief that vaccines can do more harm than good.

Meanwhile, last week marked the 35th anniversary of the Americans with Disabilities Act, and President Donald Trump signed an executive order that would enable local and state governments to forcibly hospitalize some people who are homeless and struggling with mental health problems.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.

Panelists

Anna Edney
Bloomberg News

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Read Anna's stories.

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

@joannekenen.bsky.social

Read Joanne's bio.

Shefali Luthra
The 19th

@shefali.bsky.social

Read Shefali's stories.

Among the takeaways from this week’s episode:

• Less than two months after Kennedy removed all members of the Advisory Committee on Immunization Practices, he is reportedly considering a similar purge of members of the task force that recommends the preventive services insurers must cover — a list whose services, some of them controversial among Trump officials, include drugs that prevent HIV and certain cancer screenings. He is also considering changes to the federal program that compensates people who experience adverse effects from immunizations.
• This week Vinay Prasad, the Food and Drug Administration’s top vaccine official, resigned just months into his tenure. Prasad had come under attack, notably by right-wing personality Laura Loomer, and had been blasted for some agency decisions about new drugs for rare diseases — despite his work limiting the use of covid shots.
• Trump’s newly announced trade deal with the European Union includes a 15% tariff on brand-name pharmaceuticals, which would include, for example, the diabetes drug Ozempic, often used for weight loss. But it would be difficult to lower prices on brand-name drugs through tariffs; it is unlikely that drugmakers, facing higher import costs, would relocate production to the United States.
• Also, Trump’s big tax and spending law, hastened through Congress weeks ago, renders some lawfully present immigrants ineligible for Affordable Care Act subsidies. But a new KFF Health News column points out that the change would actually raise premiums for everyone else, taking more healthy people out of the insurance pool.

Also this week, Rovner interviews George Washington University health policy professor Sara Rosenbaum, one of the nation’s leading Medicaid experts, to mark Medicaid’s 60th anniversary this week.

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

Julie Rovner: KFF Health News’ “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege,” by Fred Schulte.

Anna Edney: The Washington Post’s “Morton Mintz, Post Reporter With a Muckraker Spirit, Dies at 103,” by Stefanie Dazio.

Joanne Kenen: ScienceAlert’s “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield.

Shefali Luthra: The New Yorker’s “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” by Burkhard Bilger.

Also mentioned in this week’s podcast:

• The New York Times’ “Top F.D.A. Official Resigns Under Pressure,” by Christina Jewett.
• KFF Health News’ “Lawfully Present Immigrants Help Stabilize ACA Plans. Why Does the GOP Want Them Out?” by Bernard J. Wolfson.
• The Texas Tribune’s “Texas Man Sues California Doctor in Federal Court, Testing a New Angle to Crackdown on Abortion Pills,” by Eleanor Klibanoff.

click to open the transcript

Transcript: Next on Kennedy’s List? Preventive Care and Vaccine Harm

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 31, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi. 

Rovner: Later in this episode we’ll have the second of our two-part series marking the 60th anniversary of Medicare and Medicaid, which was yesterday, for those keeping track. This week, Sara Rosenbaum of George Washington University, one of the nation’s leading Medicaid experts, takes us through the history of that program and what the next 60 years could bring. And if you want to hear more from both our Medicare and Medicaid experts, we’re going to put the full-length versions of both interviews together for a special episode later in August. But first, this week’s news. 

Before we start, I hope you’ll bear with me this week. I slipped and fell and broke my wrist. So my typing and some of my thinking skills are a little lacking at the moment. But on this week of the 35th anniversary of the Americans With Disabilities Act, which we will talk about in a few minutes, I am very grateful for all the various technological advances that are now available to those of us with disabilities, whether permanent or temporary, and which allowed the podcast to actually come to you this week. So, now, here we go. 

It was another busy week at HHS [the Department of Health and Human Services]. Secretary Robert F. Kennedy Jr., having already fired all the members of the vaccine advisory board, is reportedly now taking aim at the U.S. preventive health services task force. Now, this was not wholly unexpected. When the Trump administration switched sides on that lawsuit over the task force brought in Texas earlier this year, we assumed that RFK Jr. wanted to do something exactly like this. Right, Shefali? 

Luthra: We certainly did, because it wouldn’t have otherwise made a lot of sense to argue that they could continue to make recommendations unless, perhaps, RFK Jr. wasn’t going to listen to them. It just, once again, really bears noting that this was something many people discussed as a likely possibility, given his record, when he was nominated to be secretary. And there were some senators who suggested that perhaps he had made individual promises, commitments, to actually keep the expert panels in place. And here we are. He did not do that. 

Rovner: Yeah. And we should say he has, at least as of this moment, he has not yet fired all of the members, but certainly there are indications that he’s considering it. And obviously that was what they argued to the court, was that, Hey, it’s OK for the Senate not to confirm the members of this task force, because the secretary has control over them. So here’s the secretary suggesting that he’s going to take control over them. 

Edney: And now the senators show support for the task force. It’s just this circle that keeps on going where they need to try to bolster the backing, but the writing was on the wall when they voted to confirm him. 

Rovner: Well, apparently the secretary isn’t finished with vaccine policy, either. He’s also taking aim at the 1980s-era Vaccine Injury Compensation Program, or VICP. That’s what provides a no-fault way for people injured by vaccine side effects to get compensation for those injuries. This program was literally created to prevent the vaccine industry from going out of business in the 1980s because it was being sued into oblivion. I know that RFK Jr. said the program is, quote, “broken” and he intends to, quote, “fix it.” But does anybody have any idea what he might be planning for it? I will remind people, like, I’m shouting into the wind, that this was an act of Congress created by Congress, reformed by Congress. I don’t know whether the secretary can just take it apart on his own. 

Kenen: He can try, or leave it intact but create some kind of barriers to filing, or— 

Rovner: Actually, I think he wants to make it easier for people to get compensation. 

Kenen: He wants it easier to get compensation. We don’t know what it will do. But they keep finding workarounds or just ignoring things. So we can’t say we can or cannot do, because we don’t know what they’re going to do. But his whole health persona really is built on the fact that he believes that vaccines are damaging or dangerous and they kill more people than they save. And therefore, apparently all of us could just get a payout because we had a shot. But it’s not as much of a moneymaking business in general, not for a specific new shot, but vaccination is not as profitable as the public may perceive. Yes, the covid shots, there was some exceptional things about the speed and scale, etc.— 

Rovner: Right. Because everybody got one at the same time. 

Kenen: And they’re subsidized, etc., or some of them were. So Anna knows more about this than I do. Basically, it was designed to both protect people who were — nobody, even the strongest pro-vaccine people, nobody denies that there is such a thing as an injury. They would say it’s rare and not autism, but when it is, it is rare, but someone should get compensation and the care they need. 

Rovner: And Anna, we’re really looking at the potential for some of these vaccine makers to just say, We’re going to wash our hands of making vaccines. Right? 

Edney: Yeah, absolutely. The point of this program was to, like Joanne said, admit that there can be injury but to make it no-fault so that the vaccine makers could continue providing vaccines for the majority of people who respond well to them and to not be caught up in court battles for millions and billions of dollars all the time. And there may be some complaints, but it does seem that people, by and large, are able to get some compensation from this. And you mentioned covid vaccines. Those aren’t included in this program, so that may be something he is looking at, because they’re done through a different program, which is maybe some complaints about it or that it’s a little less likely to pay out or to give as much compensation. And so maybe a way of expanding it is to include the covid vaccines. But if it becomes that — Well, you can keep using this program, but we’re also going to make it easier to sue the vaccine makers — we’re going to see the companies be wary of being involved in providing vaccines at that point. 

Rovner: Well, in still more vaccine-related news, the controversial head of the FDA’s [Food and Drug Administration’s] vaccine division resigned unexpectedly this week. Anna, tell us why Vinay Prasad was so controversial. And why did he leave after only three months on the job? 

Edney: Yeah, this was a huge amount of drama at the FDA. So Prasad himself can be a polarizing figure. He has been at UCSF [the University of California-San Francisco] for a long time and gained prominence as someone who criticized the agency for what’s called accelerated approvals, getting certain drugs, particularly cancer drugs, quickly to patients even when they hadn’t proven necessarily that they worked. And he criticized that program. He got to the FDA. He was head of the vaccines division, which also covers biologic drugs. And under this division was a drug made by a company called Sarepta. Every one of their drugs that has come to market has had a lot of drama surrounding it because these are drugs for very, very sick, usually young boys who have Duchenne muscular dystrophy, and it’s a huge parent population that wants these drugs, even when maybe they don’t always show that they work very well. 

Well, a few kids have unfortunately died while taking these drugs in recent months, and so the FDA was looking at that, and it came out that there was another death in a clinical trial of an older gentleman, and no one knew definitely if it was related to the drug. And so once that became public, it’s not like the FDA or the company came out with it, but once it became public, the FDA kind of seemed to overcorrect and try to have the drug be paused, and then maybe take it off the market. And so Vinay Prasad was at the center of this debate. Already he was disliked by some of [President Donald] Trump’s higher-up people, particularly Laura Loomer. We may have heard her name before. 

Rovner: We have. 

Edney: She goes after some nominees, successfully in many cases. And Rick Santorum also got involved at this point. He has a daughter with a rare disease and didn’t like the way that this rare-disease drug was being treated. So essentially Prasad, who clearly for the last several years has only wanted to be at the FDA, has left after three months, was pushed out after three months. 

Rovner: Wow. It’s quite the drama. I’ll link to a story or two if you actually want to go deeper. 

Kenen: But one of the criticisms that Laura Loomer had is that he used to be a Democrat. 

Edney: Right. 

Kenen: Well, that would also apply to RFK Jr. 

Edney: Right. That’s true. 

Rovner: It would. Oh, I’m sure the drama, both at FDA and at HHS writ large, is far from over. Well, speaking of turning the clock back, President Trump issued a new executive order that would end the, quote, “housing first” policy that has driven homelessness strategy since the late 1990s. I guess this is also not a surprise. Trump complained repeatedly on the campaign trail about how homeless encampments were destroying cities. We’ve had a recent Supreme Court case on this, but this new policy seeks to not just allow but encourage localities to force at least some homeless people off the streets and into residential treatment. I imagine this is going to make for another long line of lawsuits, right? 

Kenen: Well, there’s housing first itself. It’s not without controversy. There’s a philosophical divide. Housing first means you house people and then you deal with their social and economic and physical and psychological and drug abuse, etc. Get a roof over their head and then you deal with everything else. Other people say, No, get them into treatment and stabilize them, and then you put them in housing, and they have to … Housing first has been the dominant philosophy in addressing homelessness in recent years. That’s a different debate. This is, like, put them in an institution against their will, which the courts have power to do in limited cases. There are times when a court can say, This individual doesn’t want to be hospitalized, but for their own safety they really need to be. But that’s one by one and not that common, and it’s limited. I believe it’s 30 days. I might be wrong about that. 

But this is a whole different thing. It’s a combination of this, We’re going to force them into institutional settings for treatment, whether they want it or not, combined with the Supreme Court decision of about a year ago allowing cities and local government, not just cities but governments, to forcibly clear away, to dismantle encampments, to force people out. So you have it coming from both the administration’s policies and the court decisions. This creates a whole — and housing money is being cut. Housing assistance is being cut. So you really have this tremendous shift in how we approach homelessness at a time when homelessness is high, while homelessness has been high. And nobody’s saying that there’s not a mental health component for some, but by no means all, people who are homeless. But this is not in accord with how the health and homelessness advocacy and treatment world has been approaching it. This is a significant shift. 

Rovner: And as you point out, this is a health and social service issue, too, because we are seeing money cut and money diverted that, basically this executive order will say, We’re going to give more money to localities that sort of handle this the way we want and less money to others. So I imagine this is going to have trickle-down effects for some time to come. 

Kenen: Yeah. And the clearing the encampments is going on, and we should know it’s not only a conservative state. California has done it. Other states have done it. So the idea of dismantling these — we’ve all seen these encampments — that is happening in various places in the country already, and this is sort of an extra step. It’s not only do you clear them, but this would envision forcing them into treatment, often in an institutional setting. 

Rovner: Well, meanwhile, as I mentioned at the top, this week marks the 35th anniversary of the Americans With Disabilities Act, which I also covered, by the way. Secretary Kennedy spoke at an event marking the occasion on Monday. But an awful lot of the disability community is up in arms about the cuts to Medicaid, which they say will roll back much of the progress the movement has made in the past three and a half decades, much of it for people getting in-home types of assistance. And yet the ADA was pushed hard and signed by a Republican administration, that of President George H.W. Bush. Is this yet another formerly Republican priority being kind of tossed out the window? 

Luthra: I think to your point, a lot of things that used to be bipartisan in the health policy world are not anymore. The other example is something like Title X, and it’s just we have really seen this shift of things that used to be broadly uncontroversial, because the health implications are clear, become much more so and largely become rejected by Republicans in a way that is just really, really different from what you might’ve imagined even, I don’t know, 10, 15 years ago. 

Rovner: And my favorite piece of Title X trivia: It was signed by Richard Nixon, but it was sponsored in the House by then-Rep. George H.W. Bush. So he both sponsored Title X, the Family Planning Program, and signed the ADA into law. Boy, it feels like a million years ago and not 35. 

Well, moving on to health care costs. It is tariff week in Washington — again — and not surprisingly, prescription drugs are a big part of that conversation. The trade deal that President Trump announced with the EU while he was in Scotland last weekend includes a 15% tariff on brand-name prescription drugs imported from Europe. That will include things like, I don’t know, the blockbuster weight loss drug Ozempic? Anna, how does Trump think this is going to eventually lower drug prices in the U.S.? It sounds like it’s just going to raise them. 

Edney: Yeah. I think most people agree with your sentiment that it’s going to raise them. I think a lot of this is focused on bringing drug-making back to the United States and trying to get companies to do more of that here. Whether you see that from brand-name companies seems like it could be really difficult. I know Botox is made in Ireland, and this is a facility where, because it’s essentially a toxin, a very deadly toxin if released— 

Rovner: Yes, it’s botulism. 

Edney: Right. This is a facility that is highly guarded. A colleague of mine wrote a story on it many years ago now, but you had to go underground. They’re not just moving this thing over to the United States. So I think for brand-name drugs that it’s going to be particularly difficult to lower the prices based on tariffs, or to say We’re moving production over here in any capacity. So what the thinking of how exactly this works or is beneficial will be interesting to see, because they’re also still doing — this would not apply to these — but they’re doing this national security assessment for tariffs on drugs from other places and trying to figure out if there’s a national security reason to be putting tariffs on them. For the most part, when drug quality comes into question, it’s not usually the European drugmakers that we’re concerned about. 

Rovner: And we’re still waiting to hear about the generic-drug makers in India and China, right? 

Edney: Yeah, exactly. We’re waiting to see what they’ll decide. They’re still doing their investigation, the administration is, to see what those tariffs might be from India or China, or any other countries that are making generic drugs. 

Rovner: Another story that we will continue to watch, and glad to have Anna here to continue to help us watch that. Now, it’s time for this week in what we’re still learning about the impact of the big tax and spending bill that President Trump signed on July Fourth. This week’s installment comes from my KFF Health News colleague Bernard Wolfson, whose column points out that eliminating eligibility for Affordable Care Act subsidies for immigrants who are here legally will mostly just raise premiums for everyone else by taking more healthy people out of the insurance pool. I get the administration’s insistence on not having people who are not here legally collecting benefits. We’ve talked about emergency Medicaid, but that’s a different issue. But what’s the justification for taking coverage away for people who are here because they’re refugees or victims of abuse, or those with temporary protected status? I don’t honestly understand what the point is of this. 

Kenen: There’s a stigmatization across the board as being an immigrant, right? So the administration is not embracing immigrants who are here legally. We’ve all seen reports of people who are here legally still being picked up by immigration officials. It’s very messy. Sometimes people just say, OK, we’ll save money this way, not understanding that the costs pop up someplace else in the system and it may be more expensive. So not just in terms of that individual, but if things are going untreated in communities because people aren’t seeking care, communicable diseases can also spread. So there have been attempts to blame disease outbreaks on immigration when that’s not the case. 

Rovner: Going back hundreds of years. 

Kenen: Right. Smallpox was brought here by immigrants, right? 

Rovner: Yeah. 

Kenen: Hundreds of years ago. 

Rovner: By the European immigrants. 

Kenen: Right. That’s what I— 

Rovner: And given to the Native population. 

Kenen: Right. Right. So it’s just part of an overall gestalt about immigrants and immigration, and sort of treating them as leeches, not as people who live here. 

Rovner: But I feel like both — it’s funny because this connects back to the whole tariff issue. The idea that Trump has here is to make things more “America First,” have more things made in America, and obviously more people made in America, and more Americans here to be served in America. But both of these things would take a long time. I guess the idea of not allowing legal immigrants to have benefits is to discourage people from coming here legally. One can’t see any other thing that would make that logical. And the idea of the tariffs, Anna, as you said, is to have companies build more manufacturing here. Both of those things would take a lot longer than Donald Trump is likely to be president. He doesn’t usually have a long-term view of things, and yet both of these issues are long-term issues, right? 

Edney: Yeah. I think at least for the tariffs and for — there’ve been these small announcements with certain companies where they’ll say, Well, because of Trump, we’re going to build a new plant in Indianapolis. And that plant sure isn’t, like, it’s five years away, but he can make these announcements. And Joanne, and you’re absolutely right that he obviously wants to degrade immigrants in any way that he can, but also Obamacare, right? That’s still a thing that they’re in certain ways willing to go after. 

Rovner: Good point. It’s a twofer. 

Edney: Yeah, exactly. Exactly. So if you can erode Obamacare some and have a sicker population, and people being angry that they had to pay more, but Republicans have been good at still attaching that to Democrats: Oh, Obamacare. So I don’t know, maybe that comes back around. 

Rovner: Yeah. Well, question answered. OK. Turning to abortion, the on-again, off-again Planned Parenthood funding is apparently on again, at least for now. You may recall last week a judge had allowed some of the defunding included in the budget bill to begin, but now another federal judge has said, Nope, you’ve got to keep letting Planned Parenthood collect from Medicaid for non-abortion-related services. Shefali, what comes next? 

Luthra: The case continues to go through the courts. We know that right now that is in a federal district court. It could eventually go to the appellate courts. It could eventually make its way to the Supreme Court, including the debate over whether this proceeding is allowed to take effect or not. In the meantime, I’ve been talking to a lot of clinics, and they are preparing for the real possibility that they lose their Medicaid funding. Some of them are not optimistic about the long-term legal viability of this injunction, and so they’re thinking: What will we do if we lose all of these Medicaid dollars? Will we be able to see patients in the volume that we do? Will we be able to get funds from the state? Some are in active conversations with state governments. Some are looking to private fundraising. Others are thinking about which clinics they would close and also how they would do that in a way that minimizes service loss to patients, while acknowledging that some ability to access care — whether that is abortion or STI [sexually transmitted infection] screening or contraception or cancer screening — will simply not be replaced. 

Rovner: Yeah, and I have to say, for all the million times I have said on this podcast, an administration can’t cut off Planned Parenthood from Medicaid, because it’s written into the Medicaid law, that doesn’t mean that Congress can’t cut off Planned Parenthood, because they can change the law. So I’m also a little bit wondering what the justification for Planned Parenthood being able to argue — I know that they’re arguing that they’re going after Planned Parenthood specifically, and that that’s not allowed. But certainly Congress can change the Medicaid law if it wants to. Congress wrote the Medicaid law. 

Luthra: And I think it’s worth throwing in a couple of other components as well, considering there are multiple lawsuits at play right now, not just the original from Planned Parenthood. There’s the liberal states’ attorneys general. There’s the Maine Family Planning suit, as well. But conservative states do have an avenue to block Medicaid funds going to Planned Parenthood now, if they choose. The Supreme Court gave them that opportunity in the South Carolina case earlier this year. So no matter what happens in this case, there is a very real likelihood that in many parts of the country, Planned Parenthood clinics will lose funding they are reliant on and will probably have to close many facilities. 

Rovner: Yeah. And just to reiterate, this goes back to the Title X Family Planning Program that we were talking about earlier, so it all comes full circle this week. This week we also have the latest chapter in the continuing fight between states with abortion bans and those with shield laws to try to protect doctors who are sending abortion pills through the mail into those states with abortion bans. According to The Texas Tribune, a man from Galveston is suing a doctor in California for sending his girlfriend pills to end her pregnancy. The man is being represented by Jonathan Mitchell, whose name may well be familiar to you as the originator of, most now, of Texas’s various abortion bans. The suit seeks both damages for the man who’s suing and an injunction on behalf of, quote, “all current and future fathers of unborn children in the United States.” Shefali, that feels pretty broad. 

Luthra: It certainly does feel very broad. When I read it, I really wondered: How do you decide who are future potential parents of unborn children? Is that— 

Rovner: Fathers, fathers. 

Luthra: Excuse me. Yes. Potential fathers. Even more, how — is it everyone who has sperm? I don’t know. But this is part of a really central strategy to where the anti-abortion movement is right now. They are very upset about shield law prescription and provision of abortion medication. In Texas, they are trying a bunch of things to try and block this, whether that is this particular suit, whether that is one from the attorney general that continues to move back and forth, whether that is trying to get new state laws enacted during this special session. We’ll see if that happens with all the redistricting that is going on. 

Rovner: This is all about Texas, by the way. 

Luthra: And Texas is a really important player. But we did just see a group of attorneys general around the country from conservative states just reach out to members of Congress this week and say, Can you pass some kind of law that will block shield law prescription? We’ve also seen a case out of Louisiana that is held up in court right now because it’s a criminal case. But this is just such an important goal for them, because the reason abortions haven’t gone down is because people can keep accessing care through the mail. And if they can stop that, it will have tremendous implications for people in states with abortion bans, but also in other parts of the country where maybe it’s just too much of a pain or too far to go to a clinic and you can have a doctor mail you that care. 

Rovner: Yeah. Well, clearly the abortion fights continue. We will continue to follow them. All right, that is this week’s news. Now, we’ll play excerpts of my interview with Medicaid expert Sara Rosenbaum, and then we will come back and do our extra credits. 

I am so pleased to welcome Sara Rosenbaum to the podcast. Sara is professor emerita of health law and policy at George Washington University, one of the, if not the, leading experts on Medicaid. She’s also the person who has taught me at least 80% of what I know about the program. So I am extra thrilled that she’s agreed to come be our guide. Sara, welcome. 

Sara Rosenbaum: Well, and thank you for having me. It’s such a pleasure to be on the show. 

Rovner: So let’s start at the beginning. Medicaid was kind of an afterthought to Medicare when they were both created 60 years ago. How did Medicaid come to be? 

Rosenbaum: It’s a really interesting question. This is, of course, the lore, that Medicaid was an afterthought. If you look at the original act, which had been enacted about five years before, and you read the original statutory language — which we lawyers revel in doing — you are amazed. This was not such a big afterthought. I would say that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody else had a good idea of what they were doing. They knew that they were planting the seeds for a program that ultimately would come to be the foundation of health insurance for low-income people across the United States, as well as, of course, specific categories such as people with very severe disabilities. 

Rovner: So what was the difference between Medicare and Medicaid supposed to be when they were signed into law 60 years ago? 

Rosenbaum: Yeah. So Medicaid was very much structured in the classic style of a state grants program. It has come, of course, to be so much more than that, but it was a grant to states, and states would set up state plans. This is all language that has become very familiar to us. And they would provide medical assistance, as it was called, to certain categories of poor people. And the theory was that the program would start with these people, but tucked into — the categories were cash welfare recipients — but tucked in there were a group of people known as the medically needy, in the early days. And the medically needy, I always felt, was sort of the first seeds of something much bigger, because the point was that it was a program for people who were low-income, who couldn’t afford their medical care, but didn’t get cash welfare. 

So the theory was exactly the theory that has carried the program for 60 years now. And originally the thought was that it would really — and of course, this has turned out to be the case — that that would enable people who had very serious health care costs for things that Medicare did not cover — nursing home care, home health benefits ultimately, those kinds of really big-ticket long-term care items outside of Medicare — because Medicare was really sort of like Blue Cross Blue Shield for old people like me. 

Rovner: You weren’t old at the time though? 

Rosenbaum: I was not. Right. I was just a kid. But the program was meant to replicate what folks had had during their working years, and so it was very important and very profound, but limited. 

Rovner: So Medicare’s long been the more politically popular of the two programs. 

Rosenbaum: Yes. 

Rovner: Primarily because of the political clout of older voters, which is how it was created. How was it that Medicaid became the program that grew so much? 

Rosenbaum: What would propel Medicaid forward is that, unlike Medicare, which is tied to a premium structure, right? Medicare is funded through premium payments, which is great, but premium payments are quite unique. Because they are actuarially based, they are a very tightly controlled form of financing, because you’re asking — whether it’s the government or, now, of course, private insurers that contracted the government — you’re asking them to take on a lot of financial risk, and so everybody wanted the assurance of premium structure. Well, Medicaid was not. Medicaid is a classic public health statute. It’s general revenue. And so every time something happened that required an intervention by the federal government where health care was concerned, you could just add a few pages to the Medicaid statute and end up with, voilà, a fix. And by the mid-’70s, people said, Well, what if we decoupled this category from cash welfare funding levels and just let poor children have Medicaid? And there then ensued, essentially, a decade-long effort to add poor children and pregnant women as groups in their own right to the Medicaid program. 

Rovner: I feel like in 2017, in the fight over the repeal of the Affordable Care Act, that was sort of a big change for Medicaid. I think people had finally realized that Medicaid had grown larger than— 

Rosenbaum: Yes. 

Rovner: —Medicare, that it was not just a program for the poorest of the poor, that it did all of these other things that you’re talking about, and that really a lot of, I guess, the stigma had been taken away. And yet this Congress felt comfortable — I don’t know if I’d say comfortable — but a majority of them voted to make these really deep, profound changes. What is that going to mean going forward, both to the health care system and to the political system? 

Rosenbaum: Well, I’ve spent a lot of time thinking in this post-enactment period about when was the die cast that’s had everybody spinning. And I think congressional leaders and the White House leadership understood the fatal error they’d made in 2017, which was separating the tax reforms from the spending reforms. Because, of course, we were then able to battle the spending reforms on our own turf, right?. Here, because of the decision that was made back, I’m sure, almost a year ago— 

Rovner: Literally the idea to do one “big, beautiful” bill. 

Rosenbaum: Yes. And that meant that Medicaid, along with food stamps, or SNAP [the Supplemental Nutrition Assistance Program], along with everything else, just became pay-fors. They just became offsets. And the name of the game then became beating back every attempt to deprive Congress of pay-fors to do the thing that it really wanted to do, which was tax reform. And so we were all reduced to — “we” in the sense of people who worked on social welfare policy — to bystanders in this effort to get to a trillion dollars. And therefore— 

Rovner: A trillion dollars in cuts. 

Rosenbaum: A trillion dollars in cuts, and therefore it opened the door to extraordinary things. 

Rovner: So what happens next? Does this happen? And if it happens, does it undergird or take out the underpinnings of the entire health care system? Or does Congress eventually realize what it’s done and change its mind? 

Rosenbaum: Well, I think the hope is that — some people are saying: Well, the two-year runway. It’s like two years until it becomes effective. The two-year runway is sort of going to make people forget about this, and then boom, it’ll be upon us. I don’t think so. I think the two-year runway will end up shining a huge light on the fact that states cannot implement the whole system. While we are very focused on the number of people who will lose their coverage, the states are confronting an insurmountable problem here. They’ve never had to link Medicaid to work records, and Congress did everything it could to make matters so much worse. For example, they could have just said that, We’re going to import the same requirements that apply to SNAP to Medicaid, and so if you’re getting SNAP in your working age, then you automatically enroll in Medicaid. They didn’t do that. They didn’t do that. It’s a different-enough set of eligibility criteria and exemption categories. For example, SNAP ends, I think, at about 60, and the Medicaid work requirements go all the way to 65. 

Rovner: Age 60 and 65. 

Rosenbaum: Yes, exactly. But the exemptions are different. The requirements are different. And so states — people are talking about, Oh, well, it’s just the line reporting systems. No, no, no, no. You are liable for all kinds of error rate penalties. If you just rely on SNAP, you can’t. So states have no way to deal with this. So there’s no mitigation strategy for this, and I think the hope is that Congress will call it back. 

Rovner: If it doesn’t, is this — the one sort of silver lining that I’d been sort of thinking about is, well, maybe if we tear down the health care system, we’ll have to start again and build a better one. Is it possible that we could get there, or are we just going to limp along? 

Rosenbaum: I have those thoughts often, and then I stop and think, well, those of us with health insurance could sit there and say, Yeah, maybe we just tear down the health system to start again. Meanwhile, of course, we will have millions of people without health care. So I — interestingly, the Affordable Care Act, of course, was designed not to tear down the health care system but to strengthen the health care system. But it was the brilliance of the Affordable Care Act was that it saw the holes and it sort of tried to fix them. And if we’d left it alone with everybody in this what I consider to be sort of an intermediate arrangement, we could have done exactly what you are talking about. With just about everybody in the United States covered, we could have begun to really do the serious work of moving to something more unified, better— 

Rovner: Cheaper. 

Rosenbaum: And of course, cheaper. 

Rovner: More efficient. 

Rosenbaum: More efficient. That’s right. Far easier to use. But we have decided instead to tear the Affordable Care Act apart, both the access to the marketplace by rolling back the assistance and, of course, the Medicaid reforms. 

Rovner: Well, happy birthday, Medicaid. 

Rosenbaum: Happy birthday, Medicaid. 

Rovner: Thank you so much, Sara Rosenbaum. 

Rosenbaum: Thank you for having me. It was a — it was both uplifting and sad. 

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

Kenen: The story I’m doing is in ScienceAlert: “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield. OK, I should begin with a caveat, which is I basically don’t like it when journalists hype findings. It’s something that was only in a dozen mice or something. My exception is when something is really, really sort of just interesting to learn about. Then it’s OK to report it as long as you just sort of shout: This is only in mice! We don’t know if it’s going to work in people! But it is an interesting study. 

One reason people don’t get vaccines is they’re afraid of needles. And if you could actually apply the vaccine to a dental floss pick and get it — because the line between our gums and our teeth is permeable, stuff can get in and out. That’s why we have to clean it. If you could treat a dental floss with the vaccine instead of just plain old dental floss or a needle in your arm or leg or whatever, maybe that could be a way of improving. And so these animal studies have been suggestive that this is a worthwhile course to follow. But before you go out to the drugstore with your dental floss and ask them to put the vaccine stuff on it — they’ve done it with a couple of people with dye, not with vaccine, just to sort of trace it. We are a long way away, but it was interesting enough for me to decide that we could discuss it. 

Rovner: I thought it was pretty cool. Shefali? 

Luthra: My piece also is dentistry adjacent, even dentistry directly relevant. It is from The New Yorker. It is by Burkhard Bilger. The headline is “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” This is a really fun read. He travels to this town. Los Algodones, in Mexico, is right across the border, and it is where a lot of people go to get dental work. It is much cheaper there than getting it in America. So he goes through the history of dental work, why it has been something that people really do not enjoy, the pain associated with it, how many bad dentists are out there, also the stigma and violence against dentists. And then he talks through his own personal journey of trying to figure out: Does he need this dental work? How much would it cost to get it in this Mexican town compared to getting it in the U.S.? 

He talks to a dentist there, talks to a celebrity dentist as well, and in the end decides to keep his teeth as they are, which is very beautiful to me as someone who hates going to the dentist. But it’s a really fun read to think about how expensive health care is, how often things are marketed to us that maybe we do or don’t need, and also why dentistry has really been siloed out of all other health care for basically all of our history. 

Rovner: Yeah, it really has. It’s a wonderful combination of stories. Anna. 

Edney: Mine is not dental-related. I apologize. But this is an obit in The Washington Post by Stefanie Dazio, “Morton Mintz, Post reporter with a muckraker spirit, dies at 103.” And I wanted to talk about him because he was the reporter responsible for bringing to light everything that was going on with thalidomide. He wrote a 1962 front-page Washington Post profile on Francis Kelsey, the FDA pharmacologist who essentially blocked thalidomide from getting to market in the U.S., and she faced a lot of pressure and a lot of name-calling and things to stand in the way. And he took on the story, and he did many amazing stories, so it’s just, it’s worth a read. He wrote a lot about the pharmaceutical industry as well, and so I think it’s just nice to remember him. 

Rovner: It is. I will point out he was a fellow Michigan Daily alum, a close family friend. My mother actually worked on the Michigan Daily with his younger sister and then later worked with him at The Washington Post for years, so I can attest, not just a great reporter but a really swell guy. All right, well, my extra credit is not dental-related, either. It’s another great investigation from my KFF Health News colleague Fred Schulte. It’s called, “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege.” And it’s mostly about a chain you’ve probably seen advertised called Sono Bello and how this private-equity-owned business and some others like it are being sued in scores of medical malpractice and negligence lawsuits, claiming under-trained medical professionals have caused disfiguring injuries and, in at least a dozen cases, wrongful deaths. The subtext of this story, of course, is that this is another one of those not quite med spa but not quite ambulatory surgery center categories that’s not very well regulated by either the FDA or most states. So it’s yet another good case of buyer beware when it comes to protecting your health. 

OK. That’s this week’s show. As always, thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. Extra-special thanks this week to Taylor Cook, who’s editing our Medicare and Medicaid anniversary interviews. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Shefali. 

Luthra: I am at Bluesky, @shefali. 

Rovner: Joanne. 

Kenen: Bluesky and LinkedIn, @joannekenen. 

Rovner: Anna. 

Edney: Bluesky or X, @annaedney. 

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

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The Host

Julie Rovner
KFF Health News

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Read Julie's stories.

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

Early Thursday afternoon, the House approved a budget reconciliation bill that not only would make permanent many of President Donald Trump’s 2017 tax cuts, but also impose deep cuts to Medicaid, the Affordable Care Act, and, indirectly, Medicare.

Meanwhile, those appointed by Health and Human Services Secretary Robert F. Kennedy Jr. to a key vaccine advisory panel used their first official meeting to cast doubt on a preservative that has been used in flu vaccines for decades — with studies showing no evidence of its harm in low doses.

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

Panelists

Maya Goldman
Axios

@mayagoldman_

@maya-goldman.bsky.social

Read Maya's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• This week the GOP steamrolled toward a major constriction of the nation’s social safety net, pushing through Trump’s tax and spending bill. The legislation contains significant changes to the way Medicaid is funded and delivered — in particular, through imposing the program’s first federal work requirement on many enrollees. Hospitals say the changes would be devastating, potentially resulting in the loss of services and facilities that could touch all patients, not only those on Medicaid.
• Some proposals in Trump’s bill were dropped during the Senate’s consideration, including a ban on Medicaid coverage for gender-affirming care and federal funding cuts for states that use their own Medicaid funds to cover immigrants without legal status. And for all the talk of not touching Medicare, the legislation’s repercussions for the deficit are expected to trigger spending cuts to the program that covers those over 65 and some with disabilities — potentially as soon as the next fiscal year.
• The newly reconstituted Advisory Committee on Immunization Practices met last week, and it looked pretty different from previous meetings: In addition to new members, there were fewer staffers on hand from the Centers for Disease Control and Prevention — and the notable presence of vaccine critics. The panel’s vote to reverse the recommendation of flu shots containing a mercury-based preservative — plus its plans to review the childhood vaccine schedule — hint at what’s to come.

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

Julie Rovner: The Lancet’s “Evaluating the Impact of Two Decades of USAID Interventions and Projecting the Effects of Defunding on Mortality up to 2030: A Retrospective Impact Evaluation and Forecasting Analysis,” by Daniella Medeiros Cavalcanti, et al.

Alice Miranda Ollstein: The New York Times’ “‘I Feel Like I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow.

Maya Goldman: Axios’ “New Docs Get Schooled in Old Diseases as Vax Rates Fall,” by Tina Reed.

Sarah Karlin-Smith: Wired’s “Snake Venom, Urine, and a Quest to Live Forever: Inside a Biohacking Conference Emboldened by MAHA,” by Will Bahr.

Also mentioned in this week’s episode:

• NBC News’ “Crisis Pregnancy Centers Told To Avoid Ultrasounds for Suspected Ectopic Pregnancies,” by Abigail Brooks.
• ProPublica’s “A ‘Striking’ Trend: After Texas Banned Abortion, More Women Nearly Bled to Death During Miscarriage,” by Kavitha Surana, Lizzie Presser, and Andrea Suozzo.
• The Washington Post’s “DOGE Loses Control Over Government Grants Website, Freeing Up Billions,” by Dan Diamond and Hannah Natanson.

click to open the transcript

Transcript: Trump’s Bill Reaches the Finish Line

[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 3, at 10 a.m. As always, and particularly this week, 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: Sarah Karlin-Smith at the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: No interview this week, but more than enough news, so we will get right to it. So as we sit down to tape, the House is on the cusp of passing the biggest constriction of the federal social safety net ever, part of President [Donald] Trump’s, quote, “One Big Beautiful Bill,” which is technically no longer called that, because the name was ruled out of order when it went through the Senate. In an effort to get the bill to the president’s desk by the July Fourth holiday, aka tomorrow, the House had to swallow without changes the bill that passed the Senate on Tuesday morning after Vice President JD Vance broke a 50-50 tie. And the House has been in session continuously since Wednesday morning working to do just that, with lots of arm-twisting and threatening and cajoling to walk back the complaints from both conservative Republicans, who are objecting to the trillions of dollars the bill would add to the national debt, as well as moderates objecting to the Medicaid and food stamp cuts. 

There is a whole lot to unpack here, but let’s start with Medicaid, which would take the biggest hit of the health programs in this bill — ironically, just weeks before the program’s 60th anniversary. What does this bill do to Medicaid? 

Goldman: This bill makes some huge changes to the way that Medicaid is funded and delivered in the United States. One of the biggest changes is the first federal work requirement for Medicaid, which we’ve talked about at length. 

Rovner: Pretty much every week. 

Goldman: Pretty much every week. It’s going to be — it’s sort of death by paperwork for many people. They’re not necessarily forced to lose their coverage, but there are so many paperwork hurdles and barriers to making sure that you are reporting things correctly, that CBO [the Congressional Budget Office] expects millions of people are going to lose coverage. And we know from limited experiments with work requirements in Arkansas that it does not increase employment. So, that’s the biggie. 

Rovner: The House froze provider taxes, which is what most — all states but Alaska? — use to help pay their share of Medicaid. The Senate went even further, didn’t they? 

Goldman: Yeah. Hospitals are saying that it’s going to be absolutely devastating to them. When you cut funding, cut reimbursement in that way, cut the amount of money that’s available in that way, it trickles down to the patient, ultimately. 

Karlin-Smith: Especially things like the provider tax, but even just the loss to certain health systems of Medicaid patients end up having a spiral effect where it may impact people who are on other health insurance, because these facilities will no longer have that funding to operate the way they are. Particularly some facilities talked about how the Obamacare Medicaid expansion really allowed them to expand their services and beef up. And now if they lose that population, you actually end up with risks of facilities closing. The Senate tried to provide a little bit of money to alleviate that, but I think that’s generally seen as quite small compared to the long-term effects of this bill. 

Rovner: Yeah, there’s a $50 billion rural hospital slush fund, if you will, but that’s not going to offset $930 billion in cuts to Medicaid. And it’s important — I know we keep saying this, but it’s important to say again: It’s not just the people who will lose Medicaid who will be impacted, because if these facilities close — we’re talking about hospitals and rural clinics and other facilities that depend on Medicaid — people with all kinds of insurance are going to lack access. I see lots of nods going around. 

Goldman: Yeah. One salient example that somebody told me earlier this week was, think about ER wait times. It already takes so long to get seen if you go into the ER. And when people don’t have health insurance, they’re seeking care at the ER because it’s an emergency and they waited until it was an emergency, or that’s just where they feel they can go. But this is going to increase ER wait times for everybody. 

Rovner: And also, if nursing homes or other facilities close, people get backed up in the ER because they can’t move into the hospital when they need hospital care, because the hospital can’t discharge the people who are already there. I had sort of forgotten how that the crowded ERs are often a result of things other than too many people in the ER. 

Goldman: Right. 

Rovner: They’re a result of other strains on sort of the supply chain for care. 

Goldman: There’s so many ripple effects and dominoes that are going to fall, if you will. 

Rovner: So, there were some things that were in the House bill that, as predicted, didn’t make it into the Senate bill, because the parliamentarian said they violated the budget rules for reconciliation. That included the proposed Medicaid ban on all transgender care for minors and adults, and most of the cuts to states that use their own funds to cover undocumented people. But the parliamentarian ended up kind of splitting the difference on cutting funding to Planned Parenthood, which she had ruled in 2017 Congress couldn’t do in reconciliation. Alice, what happened here? 

Ollstein: She decided that one year of cuts was OK, when they had originally sought 10. And the only reason they originally sought 10 is that’s how these bills work. It’s a 10-year budget window. That’s how you calculate things. They sort of meant it to function like a permanent defund. So, the anti-abortion movement was really divided on this outcome, where some were declaring it a big victory and some were saying: Oh, only one year. This is such a disappointment and not what we were promised blah, blah, blah. And it’ll be really interesting to see if even one year does function like a sort of permanent defund. 

On the one hand, the anti-abortion movement is worried that because it’s one year, that means they’ll have to vote on it again next year right before the midterms, when people might get more squirrelly because of the politics of it, which obviously still exist now but would be more potent then. But clinics can’t survive without funding for long. We’re already seeing Planned Parenthoods around the country close because of Title X cuts, because of other budget instability. And so once a clinic closes, even if the funding comes back later, it can’t flip a switch and turn it back on. When things close, they close, the staff moves away, etc. 

Rovner: And we should emphasize Medicaid has not been used to pay for federal abortion funding ever. 

Ollstein: Yes. Yes. 

Rovner: That’s part of the Hyde Amendment. So we’re talking about non-abortion services here. We’re talking about contraception, and STD testing and treatment, and cancer screenings, and other types of primary care that almost every Planned Parenthood provides. They don’t all provide abortion, but they all provide these other ancillary services that lots of Medicaid patients use. 

Ollstein: Right. And so this will shut down clinics in states where abortion is legal, and it’ll shut down clinics in states where abortion is illegal and these clinics only are providing those other reproductive health services, which are already in scant supply and hard to come by. There’s massive maternity care deserts, contraceptive deserts around the country, and this is set to make that worse. 

Rovner: So, while this bill was not painted as a repeal of the Affordable Care Act, unlike the 2017 version, it does do a lot to scale that law back. This has kind of flown under the radar. Maya, you wrote about this. What does this bill do to the ACA? 

Goldman: Yeah. Well, so, there were a lot of changes that Congress was seeking to codify from rule that the Trump administration has finalized that really create a lot of extra barriers to enrolling in the ACA. A lot of those did not make it into the final bill that is being voted on, but there’s still more paperwork — death by paperwork. I think there’s preenrollment verification of eligibility, things like that. And I think just in general, the ACA has created massive gains in the insurer population in the United States over the last decade and a half. And there’s estimates that show that this would wipe out three-fourths of that gain. And so that’s just staggering to see that. 

Rovner: Yeah. I think people have underestimated the impact that this could have on the ACA. Of course, we’ve talked about this also a million times. This bill does not extend the additional subsidies that were created under the Biden administration, which has basically doubled the number of people who’ve been able to afford coverage and bought it on the marketplaces. But I’ve seen estimates that more than half of the people could actually end up dropping out of ACA coverage. 

Goldman: Yeah. And I think it’s important to talk about the timelines here. A lot of the work requirements in Medicaid won’t take effect for a couple of years, but people are going to lose their enhanced subsidies in January. And so we are going to see pretty immediate effects of this. 

Rovner: And they’re shortening the enrollment time. 

Goldman: Yeah. 

Rovner: And people won’t be able to be auto-reenrolled, which is how a lot of people continue on their ACA coverage. There are a lot of little things that I think together add up to a whole lot for the ACA. 

Goldman: Right. And Trump administration ACA enrollment barriers that were finalized might not be codified in this law, but they’re still finalized. 

Rovner: Yeah. 

Goldman: And so they will take effect for 2026 coverage. 

Rovner: And while President Trump has said repeatedly that he didn’t want to touch Medicare, this bill ironically is going to do exactly that, because the amount the tax cuts add to the deficit is likely to trigger a Medicare sequester under budget rules. That means there will be automatic cuts to Medicare, probably as soon as next year. 

All right, well, that is the moving bill, the One Big Beautiful Bill. One thing that has at least stopped moving for now is the Supreme Court, at least for the moment. The justices wrapped up their formal 2024-2025 term with some pretty significant health-related cases that impact two topics we’re talking about elsewhere in this episode, abortion and vaccines. 

First, abortion. The court ruled that Medicaid patients don’t have the right to sue to enforce the section of Medicaid law that ensures free choice of provider. In this case, it frees South Carolina to kick Planned Parenthood out of its Medicaid program. Now, this isn’t about abortion. This is about, as we said, other services that Planned Parenthood provides. But, Alice, what are the ramifications of this ruling? 

Ollstein: They could be very big. A lot of states have already tried and are likely to try to cut Planned Parenthood out of their Medicaid programs. And given this federal defund, this is now going after some of their remaining supports, which is state Medicaid programs, which is a separate revenue stream. And so this will just lead to even more clinic closures. And already, this kind of sexual health care is very hard to come by in a lot of places in the country. And that is set to be even more true in the future. And this is sort of the culmination of something that the right has worked towards for a long time. And so they had just a bunch of different strategies and tactics to go after Planned Parenthood in so many ways in the courts, and there’s still more shoes to drop. There’s still court cases pending. 

There’s one in Texas that’s accusing Planned Parenthood of defrauding the state, and so that judgment could wipe them out even more. This federal legislative effort, there’s the Supreme Court case — and they’ve really been effective at just throwing everything at the wall and seeing what sticks. And enough is sticking now that the organization is really — they were able to beat back a lot of these attempts before. They were able to rally in Congress. They were able to rally at the state level to push back on a lot of this. And that wasn’t true this time. And so I don’t know what conclusion to take from that. There’s, obviously, people are very overwhelmed. There’s a lot going on. There are organizations getting hit left and right, and maybe this just got lost in the noise this time. 

Rovner: Yeah, I think that may be. Well, the other big Supreme Court decision was one we’d talked about quite a bit, the so-called Braidwood case that was challenging the ability of the CDC’s [Center for Disease Control and Prevention’s] Preventive Services Task Force from recommending services that would then be covered by health insurance. This was arguably a win for the Biden administration. The court ruled that the task force members do not need to be confirmed by the Senate. But, Sarah, this also gives Secretary [Robert F.] Kennedy [Jr.] more power to do what he will with other advisory committees, right? 

Karlin-Smith: Right. By affirming the way the U.S. Preventive Services Task Force was set up, in that the HHS [Department of Health and Human Services] secretary is ultimately the authority for appointing the task force, which then makes recommendations around what coverage requirements under the ACA. It also sort of affirms the authority of the HHS secretary here. And I think people think it has implications for other bodies like CDC’s advisory committee on vaccines as well, where the secretary has a lot of authority. 

So, I think people who really support the coverage advantages that have come through the USPSTF and Obamacare have always pushed for this outcome in this case. But given our current HHS secretary, there are some worries that it might lead to rollbacks or changes in areas of the health care paradigm that he does not support. 

Rovner: Well, let us segue to that right now. That is, of course, as you mentioned, the other major CDC advisory committee, the one on immunization practices. When we left off, Secretary Kennedy had broken his promise to Senate health committee chairman Bill Cassidy and fired all 17 members of the committee, replacing them with vaccine skeptics and a couple of outright vaccine deniers. So last week, the newly reconstituted panel held its first meeting. How’d that go? 

Karlin-Smith: It was definitely an interesting meeting, different, I think, for people who have watched ACIP [the Advisory Committee on Immunization Practices] in the past. Besides just getting rid of the members of the advisory panel, Kennedy also removed a lot of the CDC staff who work on that topic as well. So the CDC staffers who were there and doing their typical presentations were much smaller in number. And for the most part, I think they did a really good job of sticking to the tried-and-true science around these products and really having to grapple with extremely, I think, unusual questions from many of the panelists. But the agenda got shrunk quite a bit, and one of the topics was quite controversial. Basically, they decided to review the ingredient thimerosal, which was largely taken out of vaccines in the late ’90s, early 2000s, but remains in certain larger vials of flu vaccines. 

Rovner: It’s a preservative, right? You need something in a multi-dose vaccine vial to keep it from getting contaminated. 

Karlin-Smith: And they had a presentation from Lyn Redwood, who was a former leader of the Children’s Health Defense, which is a very anti-vax organization started by Robert Kennedy. The presentation was generally seen as not based in science and evidence, and there was no other presentations, and the committee voted to not really allow flu vaccines with that ingredient. 

And the impact in the U.S. here is going to be pretty small because, I think, it’s about 4% of people get vaccines through those large-quantity vials, like if you’re in a nursing home or something like that. But what people are saying, and Scott Gottlieb [Food and Drug Administration commissioner in the first Trump administration] was talking a lot about this last week, was that this is really a hint of what is to come and the types of things they are going to take aim at. And he’s particularly concerned about another, what’s called an adjuvant, which is an ingredient added to vaccines to help make them work better, that’s in a lot of childhood vaccines, that Kennedy hinted at he wanted on the agenda for this meeting. It came off the agenda, but he presumes they will circle back to it. And if companies can’t use that ingredient in their vaccines, he’s not really clear they have anything else that is as good and as safe, and could force them out of the market. 

So there were a bunch of hints of things concerning fights to come. The other big one was that they were saying they want to review the totality of the childhood vaccine schedule and the amount of vaccines kids get, which was really a red flag for people who followed the anti-vaccine movement, because anti-vaxxers have a lot of long-debunked claims that kids get too many vaccines, they get them too closer together. And scientists, again, have thoroughly debunked that, but they still push that. 

Rovner: And that was something else that Kennedy promised Cassidy he wouldn’t mess with, if I recall correctly, right? 

Karlin-Smith: You know, the nature of the agreement between Cassidy and Kennedy keeps getting more confusing to me. And I actually talked to both HHS’ secretary’s office and Cassidy’s office last week about that. And they both don’t actually agree on quite exactly what the terms were. But anyway, I looked at it in terms of the terms, like whether it’s to preserve the recommendations ACIP has made over time in the childhood schedule, whether it’s to preserve the committee members. I think it’s pretty clear that Kennedy has violated the sort of heart of the matter, which is he has gone after safe, effective vaccines and people’s access to vaccines in this country in ways that are likely to be problematic. And there are hints of more to come. He’s also cut off funding for vaccines globally. So, I don’t know. I almost just laugh thinking about what they actually agreed to, but there’s really no way Cassidy can say that Kennedy followed through on his promises. 

Rovner: Well, meanwhile, even while ACIP was meeting last week, the HHS secretary was informing the members of Gavi, that’s the Global Alliance for Vaccines and Immunizations, that he was canceling the U.S.’ scheduled billion-dollar contribution because, he said, the public-private partnership that has vaccinated more than a billion children over the past two and a half decades doesn’t take vaccine safety seriously enough. Really? 

Karlin-Smith: Yeah. Kennedy has these claims, again, that I think are, very clearly have been, debunked by experts, that Gavi is not thinking clearly about vaccine safety and offering vaccines they shouldn’t be, and the result is going to be huge gaps in what children can get around the globe to vaccines. And it comes on top of all the other cuts the U.S. has made recently to global health in terms of USAID [the U.S. Agency for International Development]. So I think these are going to be big impacts. And they may eventually trickle down to impact the U.S. in ways people don’t expect. 

If you think about a virus like covid, which continues to evolve, one of the fears that people have always had is we get a variant that is, as it evolves, that is more dangerous to people and we’re less able to protect with the vaccines we have. If you allow the virus to kind of spread through unvaccinated communities because, say you weren’t providing these vaccines abroad, that increases the risk that we get a bad variant going on. So obviously, we should be concerned, I think, just about the millions of deaths people are saying this could cause globally, but there’s also impacts to our country as well and our health. 

Rovner: I know there’s all this talk about soft-power humanitarian assistance and helping other countries, but as long as people can get on airplanes, it’s in our interest that people in other countries don’t get things that can be spread here, too, right? 

Goldman: Yeah. One very small comment that was made during the ACIP meeting this week from CDC staff was an update on the measles outbreak, which I just thought was interesting. They said that the outbreak in the South from earlier this year is mostly under control, but people are still bringing in measles from foreign countries. And so that’s very much a real, real threat. 

Rovner: Yeah. 

Ollstein: It’s the lesson that we just keep not learning again and again, which is if you allow diseases to spread anywhere, it’ll inevitably impact us here. We don’t live on an island. We have a very interconnected world. You can’t have a Well we’re going to only protect our people and nobody else mentality, because that’s just not how it works. And we’re reducing resources to vaccinate people here as well. 

Rovner: That’s right. Turning back to abortion, there was other news on that front this week. In Wisconsin, the state Supreme Court formally overturned that state’s 1849 abortion ban. That was the big issue in the Supreme Court election earlier this year. But a couple of other stories caught my eye. One is from NBC News about how crisis pregnancy centers, those anti-abortion facilities that draw women in by offering free pregnancy tests and ultrasounds, are actually advising clinics against offering ultrasounds in some cases after a clinic settled a lawsuit for misdiagnosing a woman’s ectopic pregnancy, thus endangering her life. Alice, if this is a big part of the centers’ draw with these ultrasounds, what’s going on here? 

Ollstein: I think it’s a good example. I want to stress that there’s a big variety of quality of medical care at these centers. Some have actual doctors and nurses on staff. Some don’t at all. Some offer good evidence-based care. Some do not. And I have heard from a lot of doctors that patients will come to them with ultrasounds that were incorrectly done or interpreted by crisis pregnancy centers. They were given wrong information about the gestation of their pregnancy, about the viability of their pregnancy. And so this doesn’t surprise me at all, based on what I’ve heard anecdotally. 

People should also remember that these centers are not regulated as much as health clinics are. And that goes for things like HIPAA [the Health Insurance Portability and Accountability Act] as well. They don’t have the same privacy protections for the information people share there. And so I think we should also keep in mind that women might be depending more and more on these going forward as Planned Parenthoods close, as other clinics close because of all the cuts we just talked about. These clinics are really proliferating and are trying to fill that vacuum. And so things like this should keep people questioning the quality of care they provide. 

Rovner: Yeah. And of course, layer on top of that the Medicaid cuts. There’s going to be an increased inability to get care, particularly in far-flung areas. You can sort of see how this can sort of all pile onto itself. 

Well, the other story that grabbed me this week comes from the Pulitzer Prize-winning team at ProPublica. It’s an analysis of hospital data from Texas that suggests that the state’s total abortion ban is making it more likely that women experiencing early miscarriages may not be getting timely care, and thus are more likely to need blood transfusions or experience other complications. Anti-abortion groups continue to maintain that these bans don’t impact women with pregnancy complications, which are super common, for those who don’t know, particularly early in pregnancy. But experience continues to suggest that that is not the case. 

Ollstein: Yeah. This is a follow-up to a lot of really good reporting ProPublica has done. They also showed that sepsis rates in Texas have gone way up in the wake of the abortion ban. And so anti-abortion groups like to point to the state’s report showing how many abortions are still happening in the state because of the medical emergency exceptions, and saying: See? It’s working. People are using the exceptions. And it is true that some people are, but I think that this kind of data shows that a lot of people are not. And again, if it’s with what I hear anecdotally, there’s just a lot of variety on the ground from hospital to hospital, even in the same city, interpreting the law differently. Their legal teams interpret what they can and can’t provide. It could depend on what resources they have. It could depend on whether they’re a public or private hospital, and whether they’re afraid of the state coming after them and their funding. 

And so I think this shows that one doctor could say, Yes, I do feel comfortable doing this procedure to save this woman’s life, and another doctor could say, I’m going to wait and see. And then you get the sepsis, the hemorrhage. These are very sensitive situations when even a short delay could really be life-and-death, or be long-term health consequences. People have lost the ability to have more children. We’ve seen stories about that. We’ve seen stories about people having to suffer a lot of health consequences while their doctors figure out what kind of care they can provide. 

Rovner: In the case of early miscarriage, the standard of care is to empty the uterus basically to make sure that the bleeding stops, which is either a D&C [dilation and curettage], which of course can also be an early abortion, or using the abortion pill mifepristone and misoprostol, which now apparently doctors are loath to use even in cases of miscarriage. I think that’s sort of the take-home of this story, which is a little bit scary because early miscarriage is really, really, really common. 

Ollstein: Absolutely. And this is about the hospital context, which is obviously very important, but I’m also hearing that this is an issue even for outpatient care. So if somebody is having a miscarriage, it’s not severe enough that they have to be hospitalized, but they do need this medication to help it along. And when they go to the pharmacy, their prescription says, “missed abortion” or “spontaneous abortion,” which are the technical terms for miscarriage. But a pharmacist who isn’t aware of that, isn’t used to it, it’s not something they see all the time, they see that and they freak out and they say, Oh, I don’t want to get sued, so they don’t dispense the medication. Or there are delays. They need to call and double-check. And that has been causing a lot of turmoil as well. 

Rovner: All right. Well, finally this week, Elon Musk is fighting with President Trump again over the budget reconciliation bill, but the long shadow of DOGE [the Department of Government Efficiency] still lives on in federal agencies. On the one hand, The Washington Post scooped this week that DOGE no longer has control over the Grants.gov website, which controls access to more than half a trillion dollars in federal grant funding. On the other hand, I’m still hearing that money is barely getting out and still has to get multiple approvals from political appointees before it can basically get to where it’s supposed to be going. NPR has a story this week with the ominous headline “‘Where’s Our Money?’ CDC Grant Funding Is Moving So Slowly Layoffs Are Happening.” 

I know there’s so much other news happening right now, it’s easy to overlook, but I feel like the public health and health research infrastructure are getting starved to death while the rest of us are looking at shinier objects. 

Goldman: Yeah. This the whole flood-the-zone strategy, right? There’s so many things going on that we can’t possibly keep up with all of them, but this is extremely important. I think if you talk to any research scientist that gets federal funding, they would tell you that things have not gotten back to normal. And there’s so much litigation moving through the courts that it’s going to take a really long time before this is settled, period. 

Rovner: Yeah. We did see yet another court decision this week warning that the layoffs at HHS were illegal. But a lot of these layoffs happened so long ago that these people have found other jobs or put their houses up for sale. You can’t quite put this toothpaste back in the tube. 

Goldman: Right. And also, with this particular ruling, this came from a Rhode Island federal judge, a Biden appointee, so it wasn’t very surprising. But it said that the reorganization plan of HHS was illegal. Or, not illegal, it was a temporary injunction on the reorganization plan and said HHS cannot place anyone else on administrative leave. But it doesn’t require them to rehire the employees that have been laid off, which is also interesting. 

Rovner: Yeah. Well, we will continue to monitor that. All right, that is as much as this week’s news as we have time for. 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. Sarah, you were first to choose this week. Why don’t you go first? 

Karlin-Smith: I took a look at a Wired piece from Will Bahr, “Snake Venom, Urine, and a Quest To Live Forever: Inside a Biohacking Conference Emboldened by MAHA.” And it is about a conference in Texas kind of designed to sell you products that they claim might help you live to 180 or more. A lot of what appears to be people essentially preying on people’s fears of mortality, aging, death to sell things that do not appear to be scientifically tested or validated by agencies like FDA. The founder even talks about using his own purified urine to treat his allergies. They’re microdosing snake venom. And it does seem like RFK is sort of emboldening this kind of way of thinking and behavior. 

One of the things I felt was really interesting about the story is the author can’t quite pin down what unites all of these people in their interests in this space. In many cases, they claim there are sort of — there’s not a political element to it. But since I cover the pharma industry very closely, they all seem disappointed with mainstream medical systems and the pharma industry with the U.S., and they are seeking other avenues. But it’s quite an interesting look at the types of things they are willing to try to extend their lives. 

Rovner: Yeah, it is quite the story. Maya, why don’t you go next? 

Goldman: My extra credit this week is from my Axios colleague Tina Reed. It’s called “New Docs Get Schooled in Old Diseases as Vaxx Rates Fall.” And it’s all about how medical schools are adjusting their curriculum to teach students to spend more time on measles and things that we have considered to be wiped out in the United States. And I think it just — it really goes to show that this is something that is real and that’s actually happening. People are coming to emergency rooms and hospitals with these illnesses, and young doctors need to learn about them. We already have so many things to learn in medical school that there’s certainly a trade-off there. 

Rovner: There is, indeed. And Alice, you have a related story. 

Ollstein: Yes, I do. So, this is from The New York Times. It’s called “‘I Feel I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow. And it’s about the measles outbreak that originated in Texas. But what I think it does a really good job at is, we’ve talked a lot about how people have played up the dangers of vaccines and exaggerated them and, in some cases, outright lied about them, and how that’s influencing people, fear of autism, etc., fear of these adverse reactions. But I think this piece really shows that the other side of that coin is how much some of those same voices have downplayed measles and covid. 

And so we have this situation where people are too afraid of the wrong things — vaccines — and not afraid enough of the right things — measles and these diseases. And so in the story people who are just, including people with some medical training, being shocked at how bad it is, at how healthy kids are really suffering and needing hospitalization and needing to be put on oxygen. And that really clashes with the message from this administration, which has really downplayed that and said it’s mainly hitting people who were already unhealthy or already had preexisting conditions, which is not true. It can hit other people. And so, yeah, I think it’s a very nuanced look at that. 

Rovner: Yeah, it’s a really extraordinary story. My extra credit this week is from the medical journal The Lancet. And I won’t read the entire title or its multiple authors, because that would take the rest of the podcast. But I will summarize it by noting that it finds that funding provided by the U.S. Agency for International Development, which officially closed up shop this week after being basically illegally dissolved by the Trump administration, has saved more than 90 million lives over the past two decades. And if the cuts made this year are not restored, an additional 14 million people will die who might not have otherwise. Far from the Trump administration’s claims that USAID has little to show for its work, this study suggests that the agency has had an enormous impact in reducing deaths from HIV and AIDS, from malaria and other tropical diseases, as well as those other diseases afflicting less developed nations. We’ll have to see how much if any of those services will be maintained or restored. 

OK. That’s this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. 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. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. You can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: I’m a little bit on X, mostly on Bluesky, at @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice? 

Ollstein: Mostly on Bluesky, @alicemiranda. Still a little bit on X, @AliceOllstein. 

Rovner: Maya. 

Goldman: I am on X, @mayagoldman_, and also on LinkedIn. You can just find me under my name. 

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.

After explicitly promising senators during his confirmation hearing that he would not interfere in scientific policy over which Americans should receive which vaccines, Health and Human Services Secretary Robert F. Kennedy Jr. this week fired every member of the Advisory Committee on Immunization Practices, the group of experts who help the Centers for Disease Control and Prevention make those evidence-based judgments. Kennedy then appointed new members, including vaccine skeptics, prompting alarm from the broader medical community.

Meanwhile, over at the National Institutes of Health, some 300 employees — many using their full names — sent a letter of dissent to the agency’s director, Jay Bhattacharya, saying the administration’s policies “undermine the NIH mission, waste our public resources, and harm the health of Americans and people across the globe.”

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.

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Anna Edney
Bloomberg News

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Sarah Karlin-Smith
Pink Sheet

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Read Sarah's stories.

Joanne Kenen
Johns Hopkins University and Politico

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Read Joanne's bio.

Among the takeaways from this week’s episode:

• After removing all 17 members of the vaccine advisory committee, Kennedy on Wednesday announced eight picks to replace them — several of whom lack the expertise to vet vaccine research and at least a couple who have spoken out against vaccines. Meanwhile, Sen. Bill Cassidy of Louisiana, the Republican head of the chamber’s health committee, has said little, despite the fact that Kennedy’s actions violate a promise he made to Cassidy during his confirmation hearing not to touch the vaccine panel.
• In other vaccine news, the Department of Health and Human Services has canceled private-sector contracts exploring the use of mRNA technology in developing vaccines for bird flu and HIV. The move raises concerns about the nation’s readiness against developing and potentially devastating health threats.
• Hundreds of NIH employees took the striking step of signing a letter known as the “Bethesda Declaration,” protesting Trump administration policies that they say undermine the agency’s resources and mission. It is rare for federal workers to use their own names to voice public objections to an administration, let alone President Donald Trump’s, signaling the seriousness of their concerns.
• Lawmakers have been considering adding Medicare changes to the tax-and-spend budget reconciliation legislation now before the Senate — specifically, targeting the use of what’s known as “upcoding.” Curtailing the practice, through which medical providers effectively inflate diagnoses and procedures to charge more, has bipartisan support and could increase the savings by reducing the amount the government pays for care.

Also this week, Rovner interviews Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office, to discuss how the CBO works and why it’s so controversial.

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 “Lawmakers Lobby Doctors To Keep Quiet — or Speak Up — on Medicaid Cuts in Trump’s Tax Bill,” by Daniel Payne.  

Anna Edney: KFF Health News’ “Two Patients Faced Chemo. The One Who Survived Demanded a Test To See if It Was Safe,” by Arthur Allen.  

Sarah Karlin-Smith: Wired’s “The Bleach Community Is Ready for RFK Jr. To Make Their Dreams Come True,” by David Gilbert.  

Joanne Kenen: ProPublica’s “DOGE Developed Error-Prone AI Tool To ‘Munch’ Veterans Affairs Contracts,” by Brandon Roberts, Vernal Coleman, and Eric Umansky.  

Also mentioned in this week’s podcast:

• The Hill’s “Cassidy in a Bind as RFK Jr. Blows Up Vaccine Policy,” by Nathaniel Weixel.
• JAMA Pediatrics’ “Firearm Laws and Pediatric Mortality in the US,” by Jeremy Samuel Faust, Ji Chen, and Shriya Bhat.

Click to open the transcript

Transcript: RFK Jr. Upends Vaccine Policy, After Promising He Wouldn’t

[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, June 12, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Anna Edney: Hi, everybody. 

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

Joanne Kenen: Hi, everybody. 

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

Sarah Karlin-Smith: Hello, everybody. 

Rovner: Later in this episode we’ll have my interview with Douglas Holtz-Eakin, head of the American Action Forum and former head of the Congressional Budget Office. Doug will talk about what it is that CBO actually does and why it’s the subject of so many slings and arrows. But first, this week’s news. 

The biggest health news this week is out of the Department of Health and Human Services, where Secretary Robert F. Kennedy Jr. on Monday summarily fired all 17 members of the CDC’s [Centers for Disease Control and Prevention’s] vaccine advisory committee, something he expressly promised Republican Sen. Bill Cassidy he wouldn’t do, in exchange for Cassidy’s vote to confirm him last winter. Sarah, remind us what this committee does and why it matters who’s on it? 

Karlin-Smith: So, they’re a committee that advises CDC on who should use various vaccines approved in the U.S., and their recommendations translate, assuming they’re accepted by the CDC, to whether vaccines are covered by most insurance plans and also reimbursed. There’s various laws that we have that set out, that require coverage of vaccines recommended by the ACIP [Advisory Committee on Immunization Practices] and so forth. So without ACIP recommendations, you may — vaccines could be available in the U.S. but extremely unaffordable for many people. 

Rovner: Right, because they’ll be uncovered. 

Karlin-Smith: Correct. Your insurance company may choose not to reimburse them. 

Rovner: And just to be clear, this is separate from the FDA’s [Food and Drug Administration’s] actual approval of the vaccines and the acknowledgment it’s safe and effective. Right, Anna? 

Edney: Yeah, there are two different roles here. So the FDA looks at all the safety and effectiveness data and decides whether it’s safe to come to market. And with ACIP, they are deciding whether these are things that children or adults or pregnant women, different categories of people, should be getting on a regular basis. 

Rovner: So Wednesday afternoon, Secretary Kennedy named eight replacements to the committee, including several with known anti-vaccine views. I suppose that’s what we all expected, kind of? 

Kenen: He also shrunk it, so there are fewer voices. The old panel, I believe, had 17. And the law says it has to have at least eight, and he appointed eight. As far as we know, that’s all he’s appointing. But who knows? A couple of more could straggle in. But as of now, it means there’s less viewpoints, less voices, which may or might not turn out to be a good thing. But it is a different committee in every respect. 

Edney: And I think it is a bit of what we expected in the sense that these are people who either are outright vaccine critics or, in a case or two, have actually said vaccines do horrible things to people. One of them had said before that the covid vaccine caused an AIDS-like virus in people. And there is a nurse that is part of the committee now that said her son was harmed by vaccines. And not saying that is or isn’t true — her concerns could be valid — but that she very much has worked to question vaccines. 

So I think it is the committee that we maybe would’ve expected from a sense of, I think he’s trying to bring in people who are a little bit mainstream, in the sense if you looked at where they worked or things like that, you might not say, like: Oh, Georgetown University. I get it. But they are people who have taken kind of the more of a fringe approach within maybe kind of a mainstream world. 

Karlin-Smith: I was going to say there’s also many people on the list that it’s just not even clear to me why you would look at their expertise and think, Oh, this is a committee they should serve on. One of the people is an MIT [Massachusetts Institute of Technology], essentially, like, business school professor who tangentially I think has worked on health policy to some extent. But, right, this is not somebody who has extreme expertise in vaccinology, immunology, and so forth. You have a psychiatrist whose expertise seems to be on nutrition and brain health. 

And one thing I think people don’t always appreciate about this committee at CDC is, you see them in these public meetings that happen a few times a year, but they do a lot of work behind the scenes to actually go through data and make these recommendations. And so having less people and having people that don’t actually have the expertise to do this work seems like it could cause a big problem just from that point of view. 

Edney: And that can be the issue that comes up when Kennedy has said, I don’t want anyone with any conflicts of interest. Well, we’ve talked about this. Certainly you don’t want a legit conflict of interest, but a lot of people who are going to have the expertise you need may have a perceived conflict that he doesn’t want on there. So you end up maybe with somebody who works in operations instead of on vaccines. 

Rovner: You mean maybe we’ll have people who actually have researched vaccines. 

Edney: Right. Exactly. Yeah. 

Kenen: The MIT guy is an expert in supply chains. None of us know who the best supply chain business school professor is in the world. Maybe it’s him, but it’s a very odd placement. 

Rovner: Well, so far Sen. Cassidy hasn’t said very much other than to kind of communicate that he’s not happy right now. Has anybody heard anything further? The secretary has been sort of walking up to the line of things he told the senator he wouldn’t do, but this clearly is over the line of things he told the senator he wouldn’t do. And now it’s done. 

Kenen: It’s like over the line and he set fire to it. And Cassidy has been pretty quiet. And in fact, when Kennedy testified before Cassidy — Cassidy is the chairman of the health committee — a couple of weeks ago, he gave him a really warm greeting and thanked him for coming and didn’t say: You’re a month late. I wanted you here last month. The questions were very soft. And things have only gotten more heated since then, with the dissolution of the ACIP committee and this reconstitution of it. And he’s been very quiet for somebody who publicly justified, who publicly wrestled with this, the confirmation, was the deciding vote, and then has been really soft since then — in public. 

Rovner: I sent around a story this morning to the panelists, from The Hill, which I will link to in the show notes, that quotes a political science professor in Louisiana pointing out that perhaps it would be better for Cassidy politically not to say anything, that perhaps public opinion among Republicans who will vote in a primary is more on the side of Secretary Kennedy than Sen. Cassidy, which raises some interesting questions. 

Edney: Yeah. And I think that, at least for me, I’m at the point of wondering if Cassidy didn’t know that all along, that there’s a point he was willing to go up to but a line that he is never going to have been willing to cross, and that is actually coming out against Kennedy and, therefore, [President Donald] Trump. He doesn’t want to lose his reelection. I am starting to wonder if he just hoped it wouldn’t come to this and so was able to say those things that got him to vote for Kennedy and then hope that it wouldn’t happen. 

And I think that was a lot of people. They weren’t on the line like Cassidy was, but I think a lot of people thought, Oh, nothing’s ever going to happen on this. And I think another thing I’m learning as I cover this administration and the Kennedy HHS is when they say, Don’t worry about it, look away, we’re not doing anything that big of a deal, that’s when you have to worry about it. And when they make a big deal about some policy they’re bringing up, it actually means they’re not really doing a lot on it. So I think we’re seeing that with vaccines for sure. 

Rovner: Yes, classic watch what they do not what they say. 

Kenen: But if you’re Cassidy and you already voted to impeach President Trump, which means you already have a target from the right — he’s a conservative, but it’s from the more conservative, though, the more MAGA [Make America Great Again] — if you do something mavericky, sometimes the best political line is to continue doing it. But they’ve also changed the voting rules, my understanding is, in Louisiana so that independents are — they used to be able to cross party lines in the primaries, and I believe you can’t do that anymore. So that also changed, and that’s recent, so that might have been what he thought might save him. 

Rovner: Well, it’s not just ACIP where Secretary Kennedy is insinuating himself directly into vaccine policy. HHS has also canceled a huge contract with vaccine maker Moderna, which was working on an mRNA-based bird flu vaccine, which we might well need in the near future, and they’ve also canceled trials of potential HIV vaccines. What do we know about what this HHS is doing in terms of vaccine policy? 

Karlin-Smith: The bird flu contract I think is very concerning because it seems to go along the lines of many people in this administration and Kennedy’s orbit who sometimes might seem a little bit OK with vaccines, more OK than Kennedy’s record, is they are very anti the newer mRNA technology, which we know proved very effective in saving tens of millions of lives. I was looking at some data just even the first year they rolled out after covid. So we know they work. Obviously, like all medical interventions, there are some side effects. But again, the benefits outweigh the risks. And this is the only, really, technology that we have that could really get us vaccines really quickly in a pandemic and bird flu. 

Really, the fear there is that if it were to jump to humans and really spread from human-to-human transmission — we have had some cases recently — it could be much more devastating than a pandemic like covid. And so not having the government have these relationships with companies who could produce products at a particular speed would be probably incredibly devastating, given the other technologies we have to invest in. 

Edney: I think Kennedy has also showed us that he, and spoken about this, is that he is much more interested in a cure for anything. He has talked about measles and Why can’t we just treat it better? And we’re seeing that with the HIV vaccine that won’t be going forward in the same way, is that the administration has basically said: We have the tools to deal with it if somebody gets it. We’re just not going to worry about vaccinating as much. And so I think that this is a little bit in that vein as well. 

Rovner: So the heck with prevention, basically. 

Edney: Exactly. 

Rovner: Well, in related news, some 300 employees of the National Institutes of Health, including several institute directors, this week sent an open letter of dissent to NIH Director Jay Bhattacharya that they are calling the “Bethesda Declaration.” That’s a reference to the “Great Barrington Declaration” that the NIH director helped spearhead back in 2020 that protested covid lockdowns and NIH’s handling of the science. 

The Bethesda Declaration protests policies that the signatories say, quote, “undermine the NIH mission, waste our public resources, and harm the health of Americans and people across the globe.” Here’s how one of the signers, Jenna Norton of the National Institute of Diabetes and Digestive and Kidney Diseases, put it in a YouTube video. 

Jenna Norton: And the NIH that I’m working in now is unrecognizable to me. Every day I go into the office and I wonder what ethical boundary I’m going to be asked to violate, what probably illegal action am I going to be asked to take. And it’s just soul-crushing. And that’s one of the reasons that I’m signing this letter. One of my co-signers said this, but I’m going to quote them because I thought it was so powerful: “You get another job, but you cannot get another soul.” 

Rovner: I’ve been covering NIH for a lot of years. I can’t remember pushback like this against an administration by its own scientists, even during the height of the AIDS crisis in the 1980s. How serious is this? And is it likely to have any impact on policy going forward? 

Edney: I think if you’re seeing a good amount of these signers who sign their actual names and if you’re seeing that in the government, something is very serious and there are huge concerns, I think, because, as a journalist, I try to reach people who work in the government all the time. And if they’re not in the press office, if they speak to me, which is rare, even they do not want me to use their name. They do not want to be identified in any way, because there are repercussions for that. 

And especially with this administration, I’m sure that there is some fear for people’s jobs and in some instances maybe even beyond. But I think that whether there will be any policy changes, that is a little less clear, how this administration might take that to heart or listen to what they’re saying. 

Rovner: Bhattacharya was in front of a Senate Appropriations subcommittee this week and was asked about it, but only sort of tangentially. I was a little bit surprised that — obviously, Republicans, we just talked about Sen. Cassidy, they are afraid to go up against the Trump administration’s choices for some of these jobs — but I was surprised that even some of the Democrats seemed a little bit hands-off. 

Edney: Yeah, no one ever asks the questions I want asked at hearings, I have to say. I’m always screaming. Yeah, exactly. I’m always like: No. What are you doing? 

Rovner: That’s exactly how I was, like: No, ask him this. 

Edney: Right. 

Rovner: Don’t ask him that. 

Edney: Exactly. 

Rovner: Well, moving on to the Big Budget Bill, which is my new name for it. Everybody else seems to have a different one. It’s still not clear when the Senate will actually take up its parts, particularly those related to health, but it is clear that it’s not just Medicaid and the Affordable Care Act on the table but now Medicare, too. Ironically, it feels like lawmakers could more easily squeeze savings out of Medicare without hurting beneficiaries than either Medicaid or the ACA, or is that just me being too simplistic about this whole thing? 

Kenen: The Medicare bill is targeted at upcoding, which means insurers or providers sort of describing a symptom or an illness in the most severe terms possible and they get paid more. And everybody in government is actually against that. Everybody ends up paying more. I don’t know what else the small —this has just bubbled up — but I don’t know if there’s other small print. 

This alone, if it wasn’t tied to all the politics of everything else in this bill, this is the kind of thing, if you really do a bill that attacks inflated medical bills, you could probably get bipartisan support for. But because — and, again, I don’t know what else is in, and I know that’s the top line. There may be something that I’m not aware of that is more of a poison pill. But that issue you could get bipartisan consensus on. 

But it’s folded into this horrendously contentious thing. And it’s easy to say, Oh, they’re trying to cut Medicare, which in this case maybe they’re trying to cut it in a way that is smart, but it just makes it more complicated. If they do go for it, if they do decide that this goes in there, it could create a little more wiggle room to not cut some other things quite as deeply. 

But again, they’re calling everything waste, fraud, and abuse. None of us would say there is no waste, fraud, and abuse in government or in health care. We all know there is waste, fraud, and abuse, but that doesn’t mean that what they’re cutting here is waste, fraud, and abuse in other aspects of that bill. 

Rovner: Although, as you say, I think there’s bipartisan consensus, including from Mehmet Oz, who runs Medicare, that upcoding is waste and fraud. 

Kenen: Right. But other things in the bill are being called waste, fraud, and abuse that are not, right? That there’s things in Medicaid that are not waste, fraud, and abuse. They’re just changing the rules. But I agree with you, Julie. I think that in a bill that is not so fraught, it would’ve been easier to get consensus on this particular item, assuming it’s a clean upcoding bill, if you did it in a different way. 

Rovner: And also, there’s already a bipartisan bill on pharmacy benefit managers kicking around. There are a lot of things that Congress could do on a bipartisan basis to reduce the cost of Medicare and make the program better and shore it up, and that doesn’t seem to be what’s happening, for the most part. 

Well, we continue to learn things about the House-passed bill that we didn’t know before, and one thing we learned this week that I think bears discussing comes from a new poll from our KFF polling unit that found that nearly half those who purchased Affordable Care Act coverage from the marketplaces are Republicans, including a significant percentage who identify themselves as MAGA Republicans. 

So it’s not just Republicans in the Medicaid expansion population who’d be impacted. Millions of Trump supporters could end up losing or being priced out of their ACA insurance, too, particularly in non-Medicaid-expansion states like Florida and Texas. A separate poll from Quinnipiac this week finds that only 27% of respondents think Congress should pass the big budget reconciliation bill. Could either of these things change some Republican perceptions of things in this bill, or is it just too far down the train tracks at this point? 

Karlin-Smith: We saw a few weeks ago [Sen.] Joni Ernst seemed to be really highly critical of her own supporters who were pushing back on her support for the bill. Even when Republicans failed to get rid of the ACA and [Sen.] John McCain gave it the thumbs-down, he was the one. It wasn’t like everyone else was coming to help him with that. 

And again, I think there was the same dynamic where a lot of people who, if you had asked them did they support Obamacare while it was being written in law, in early days before they saw any benefit of it, would have said no and politically align themselves with the Republican Party, and their views have come to realize, once you get a benefit, that it may actually be more desirable, perhaps, than you initially thought. 

I think it could become a problem for them, but I don’t think it’s going to be a mass group of Republicans are going to change their minds over this. 

Rovner: Or are they going to figure out that that’s why they’re losing their coverage? 

Kenen: Right. Many things in this bill, if it goes into effect, are actually after the 2026 elections. The ACA stuff is earlier. And someone correct me if I’m wrong, but I’m pretty sure it expires in time for the next enrollment season. 

Rovner: Yeah, and we’ve talked about this before. The expanded credits, which are not sort of quote-unquote— 

Kenen: No, they’re separate. 

Rovner: —“in this bill,” but it’s the expiration of those that’s going to cause— 

Kenen: In September. And so those— 

Rovner: Right. 

Kenen: —people would— 

Rovner: In December. No, at the end of the year they expire. 

Kenen: Right. So that in 2026, people getting the expanded benefit. And there’s also somewhat of a misunderstanding that that legislation opened Obamacare subsidies to people further up the eligibility roof, so more people who had more money but still couldn’t afford insurance do get subsidies. That goes away, but it cascades down. It affects lower-income people. It affects other people. It’s not just that income bracket. 

There are sort of ripple effects through the entire subsidized population. So people will lose their coverage. There’s really no dispute about that. The reason it was sunsetted is because it costs money. Congress does that a lot. If we do it for five years, we can get it on the score that we need out of the CBO. But if we do it for 10 years, we can’t. So that is not an unusual practice in Congress for Republicans and Democrats, but that happens before the election. 

It’s just whether people connect the dots and whether there are enough of them to make a difference in an election, right? Millions of people across the country. But does it change how people vote in a specific race in a state that’s already red? If it’s a very red state, it may not make people get mad, but it may not affect who gets elected to House or the Senate in 2026. 

Rovner: We will see. So Sarah, I was glad you mentioned Sen. Ernst, because last week we talked about her comment that we’re all going to die, in response to complaints at a town hall meeting about the Medicaid cuts. Well, Medicare and Medicaid chief Mehmet Oz says to Sen. Ernst, Hold my beer. Speaking on Fox Business, Oz said people should only get Medicaid if they, quote, “prove that they matter.” 

Now, this was in the context of saying that if you want Medicaid, you should work or go to school. Of course, most people on Medicaid do work or care-give for someone who can’t work or do go to school — they just have jobs that don’t come with private health insurance. I can’t help but think this is kind of a big hole in the Republican talking points that we keep seeing. These members keep suggesting that all working people or people going to school get health insurance, and that’s just not the case. 

Kenen: But it sounds good. 

Karlin-Smith: I was going to say, there are small employers that don’t have to provide coverage under the ACA. There are people that have sort of churned because they work part time or can’t quite get enough hours to qualify, and these are often lower-income people. And I think the other thing I’ve seen people, especially in the disability committee and so forth, raises — there’s an underlying rhetoric here that to get health care, you have to be deserving and to be working. 

That, I think, is starting to raise concerns, because even though they kind of say they’re not attacking that population that gets Medicaid, I think there is some concern about the language that they’re using is placing a value on people’s lives that just sort of undermines those that legitimately cannot work, for no fault of their own. 

Kenen: It’s how the Republicans have begun talking about Medicaid again. Public opinion, and KFF has had some really interesting polls on this over the last few years, really interesting changes in public attitudes toward Medicaid, much more popular. And it’s thought of even by many Republicans as a health care program, not a welfare program. What you have seen — and that’s a change. 

What you’ve seen in the last couple of months is Republican leaders, notably Speaker [Mike] Johnson, really talking about this as welfare. And it’s very reminiscent of the Reagan years, the concept of the deserving poor that goes back decades. But we haven’t heard it as much that these are the people who deserve our help and these are the lazy bums or the cheats. 

Speaker Johnson didn’t call them lazy bums and cheats, but there’s this concept of some people deserve our help and the rest of them, tough luck. They don’t deserve it. And so that’s a change in the rhetoric. And talking about waste and talking about fraud and talking about abuse is creating the impression that it’s rampant, that there’s this huge abuse, and that’s not the case. People are vetted for Medicaid and they do qualify for Medicaid. 

States have their own money and their own enrollment systems. They have every incentive to not cover people who don’t deserve to be covered. Again, none of us are saying there’s zero waste. We would never say that. None of us are saying there’s zero abuse. But it’s not like that’s the defining characteristic of Medicaid is that it’s all fraud and abuse, and that you can cut hundreds of millions of dollars out of it without anybody feeling any pain. 

Rovner: And there were a lot of Republican states that expanded Medicaid, even when they didn’t have to, that are going to feel this. That’s a whole other issue that I think we will talk about probably in the weeks to come. I want to move to DOGE [the Department of Government Efficiency]. Elon Musk is back in California, having had a very ugly breakup with President Trump and possibly a partial reconciliation. But the impact of DOGE continues across the federal government, as well as at HHS. 

The latest news is apparently hundreds of CDC employees who were told that they were being laid off who are now being told: Never mind. Come back to work. Of course, this news comes weeks after they were told they were being fired, and it’s unclear how many of them have upended their work and family lives in the interim. 

But at the same time, much of the money that’s supposed to be flowing, appropriations for the current fiscal year that were passed by Congress and signed by President Trump — apparently still being held up. What are you guys hearing about how things at HHS are or aren’t going in the wake of the DOGE cutbacks? Go ahead, Sarah. 

Karlin-Smith: It still seems like people at the federal government that I talked to are incredibly unhappy. At other agencies, as well, there have been groups of people called back to work, including at FDA. But still, I think the general sense is there’s a lot of chaos. People aren’t comfortable that their job will be there long-term. Many people even who were called back are saying they’re still looking for work other places. 

There’s just so many changes in both, I think, in their day-to-day lives and how they do their job, but then also philosophically in terms of policy and what they are allowed to do, that I think a lot of people are becoming kind of demoralized and trying to figure out: Can they do what they signed up to do in their job, or is it better just to move on? And I think there’s going to be long-term consequences for a lot of these government agencies. 

Rovner: You mean being fired and unfired and refired doesn’t make for a happy workplace? 

Karlin-Smith: I was going to say a lot of them were called back to offices that they didn’t always have to come to. They’ve lost people who have been working and never lost their jobs, have lost close colleagues, support staff they rely on to do their jobs. So it’s really complicated even if you’re in the best-case scenario, I think, at a lot of these agencies. 

Kenen: And a loss of institutional memory, too, because nobody knows everything in your office. And in an office that functions, it’s collaborative. I know this, you know that. We work together, and we come out with a better product. So that’s been eviscerated. And then — we’re all in a part of an industry that’s seen a lot of downsizing and chaos, in journalism, and the outcome is worse. When things get beaten up and battered and kicked out, things are harmed. And it’s true of any industry, since we haven’t been AI-replaced yet. 

Rovner: Yet. So it’s been a while since we had a, quote, “This Week in Private Equity in Health Care,” but this week the governor of Oregon signed into law a pretty serious ban on private equity ownership of physician practices. Apparently, this was prompted by the purchase by Optum — that’s the arm of UnitedHealth that is now the largest owner of physician practices in the U.S. — of a multi-specialty group in Eugene, Oregon, that caused significant dislocation for patients and was charged by the state with impermissibly raising prices. Hospitals are not included in Oregon’s ban, but I wonder if this is the start of a trend. Or is this a one-off in a pretty blue state, which Oregon is? 

Edney: I think that it could be. I don’t know, certainly, but I think to watch how it plays out might be quite interesting. The problem with private equity ownership of these doctors’ offices is then the doctors don’t feel that they can actually give good care. They’ve got to move people through. It’s all about how much money can they make or save so that private equity can get its reward. And so I think that people certainly are frustrated by it, as in people who get the care, also people who are doing legislating and things like that. So I wouldn’t be surprised to see some other attempts at this pop up now that we’ve seen one. 

Kenen: But Oregon is uniquely placed to get something like this through. They are a very blue state. They’ve got a history of some health reform stuff that’s progressive. I don’t think you’ll see this domino-ing through every state legislature in the short term. 

Rovner: But I will also say that even in Oregon, it took a while to get this through. There was a lot of pushback because there is concern that without private equity, maybe some of these practices are going to go belly up. This is the continuing fight about the future of the health care workforce and who’s going to underwrite it. 

Well, finally this week, I want to give a shoutout to the biggest cause of childhood death and injury that is not being currently addressed by HHS, which is gun violence. According to a new study in JAMA Pediatrics, firearms deaths among children and teens grew significantly in states that loosened gun laws following a major Supreme Court decision in 2010. And it wasn’t just accidents. The increase in deaths included homicides and suicides, too. Yet gun violence seems to have kind of disappeared from the national agenda for both parties. 

Edney: Yeah, you don’t hear as much about it. I don’t know why. I don’t know if it’s because we’re inundated every day with a million things. And currently at the moment, that just hasn’t come up again, as far as a tragedy. That often tends to bring it back to people’s front of mind. And I think that there is, on the Republican side at least, we’re seeing tax cuts for gun silencers and things like that. So I think they’re emboldened on the side of NRA [the National Rifle Association]. I don’t know if Democrats are seeing that and thinking it’s a losing battle. What else can I focus my attention on? 

Kenen: Well, it’s in the news when there’s a mass killing. Society has just sort of become inured or shut its eyes to the day to day to day to day to day. The accidents, the murders. Don’t forget, a lot of our suicide problem is guns, including older white men in rural states who are very pro-gun. Those who kill themselves, it is how they kill themselves. It’s just something we have let happen. 

Rovner: Plus, we’re now back to arguing about whether or not vaccines are worthwhile. So, a lot of the oxygen is being taken up with other issues at the moment. 

Kenen: There’s a very overcrowded bandwidth these days. Yes. 

Rovner: There is. I think that’s fair. All right, well, that is this week’s news, or as much as we could squeeze in. Now we will play my interview with Doug Holtz-Eakin, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Douglas Holtz-Eakin, president of the American Action Forum, a center-right think tank, and former head of the Congressional Budget Office during the George W. Bush administration, when Republicans also controlled both Houses of Congress. Doug, thank you so much for being here. 

Douglas Holtz-Eakin: My pleasure. Thank you. 

Rovner: I mostly asked you here to talk about CBO and what it does and why it’s so controversial. But first, tell us about the American Action Forum and what it is you do now. 

Holtz-Eakin: So the American Action Forum is, on paper, a center-right think tank, a 501(c)(3) entity that does public education on policy issues, but it’s modeled on my experiences at working at the White House twice, running the Congressional Budget Office, and I was also director of domestic and economic policy on the John McCain campaign. And in those jobs, you worked on policy issues. You did policy education, issues, options, advice, but you worked on whatever was happening that day. 

You didn’t have the luxury of saying: Yeah, that’s not what I do. Get back to me when something interests you. And you had to convey your results in English to nonspecialists. So there was a sort of a premium on the communications function, and you also had to understand the politics. On a campaign you had to make good policy good politics, and at the White House you worried about the president’s program. 

No matter who was in Congress, that was all they thought about. And in Congress, the CBO is nonpartisan by law, and so obviously you have to care about that. And I just decided I like that work, and that’s what AAF does. We do domestic and economic policy on the issues that are going on in Congress or the agencies, with an emphasis on providing material that is readable to nonspecialists so they can understand what’s going on. 

Rovner: You’re a professional policy nerd, in other words. 

Holtz-Eakin: Pretty much, yeah. 

Rovner: As am I. So I don’t mean that in any way to be derogatory. I plead guilty myself. 

Holtz-Eakin: These bills, who knew? 

Rovner: Exactly. Well, let’s talk about the CBO, which, people may or may not know, was created along with the rest of the congressional budget process overhaul in 1974. What is CBO’s actual job? What is it that CBO is tasked to do? 

Holtz-Eakin: It has two jobs. Job number one, the one we’re hearing so much about now, is to estimate the budgetary impact of pieces of legislation being considered on the floor of the House or the Senate. So they call this scoring, and it is: How much will the bill change the flow of revenues into the Treasury and the flow of spending out of the Treasury year by year over what is currently 10 years? 

And you compare that to what would happen if you didn’t pass law, which is to say, leave the laws of land on autopilot and check out what happened to the budget then. So that’s what it’s doing now, and you get a lot of disagreement on the nature of that analysis. It also spends a lot of time doing studies for members of Congress on policies that Congress may have to be looking at in the future. 

And so anticipating the needs of Congress, studying things like Social Security reforms, which are coming, or different ways to do Medicaid reform if we decide to go down that route, and things that will prepare the Congress for future debates. 

Rovner: Obviously these scores are best guesses of people who spend a lot of time studying economic models. How accurate are CBO’s estimates? 

Holtz-Eakin: They’re wrong all the time, but that’s because predicting the future is really hard, and because when CBO does its estimates, it’s not permitted by law to anticipate future actions of Congress, and Congress is always doing something. That often changes the outcome down the road. Sometimes there are just unexpected events in the world. The pandemic was not something that was in the CBO baseline in 2019. And so, obviously, the numbers changed dramatically because of that. 

And also, because CBO is not really just trying to forecast. If that was all it was being asked to do, it might get closer sometimes, but what it’s really being asked to do is to be able to compare pieces of legislation. What’s the House bill look like compared to the Senate bill? And to do that, you have to keep the point of comparison, the so-called baseline, the same for as long as you’re doing this legislation. 

In some cases, that’s quite a long time. It was over two years for the Affordable Care Act. And by the time you’re at the end, the forecast is way out of date. But for consistency, you have to hold on to it. And then people say, Oh, you got the forecast wrong. But it’s the nature of what they’re being asked to do, which is to provide consistent scores that rank things appropriately, that can interfere with the just pure forecasting aspect. 

Rovner: And basically they’re the referee. It’s hard to imagine being able to do this process without having someone who acts as a referee, right? 

Holtz-Eakin: Well, yes. And in fact, sometimes you see them rush through and ignore CBO. And generally, that’s a sign that it’s not going well, because they really should take the time to understand the consequences of what they’re up to. 

Rovner: And how does that work? CBO, people get frustrated because this stuff doesn’t happen, like, overnight. They write a bill and there should be a CBO score the next day. But it’s not just fed into an AI algorithm, right? 

Holtz-Eakin: No. That’s a great misconception about CBO. People think there’s a model. You just put it in the model. You drop the legislation and out comes the numbers. And there are some things for which we have a very good feel because they’ve been done a lot. So change the matching rate in Medicaid and see what happens to spending — been done a lot. We understand that pretty well. 

Pass a Terrorism Risk Insurance Act, where the federal government provides a backstop to the private property and casualty insurance companies in the event there’s a terrorist attack at an unknown time in the future using an unknown weapon in an unknown location — there’s no model for that. You just have to read about extreme events, look at their financial consequences, imagine how much money the insurance companies would have, when they would round up money, and how much the federal government would be on the hook for. It’s not modeling. You’re asking CBO’s professionals to make informed budgetary judgments, and we pay them for their judgment. And I think that’s poorly understood. 

Rovner: So I’ve been at this since the late 1980s. I’ve seen a lot of CBO directors, Republican and Democrats, and my impression is that, to a person, they have tried very hard to play things as much down the middle as possible. Do you guys have strategy sessions to come up with ways to be as nonpartisan as you can? 

Holtz-Eakin: The truth is you just listen to the staff. I say this and I’m not sure people will fully appreciate it: Nonpartisanship is in the DNA of CBO, and I attribute this to the very first director, Alice Rivlin, and some of her immediate successors. They were interested in establishing the budget office, which had been invented in 1974, really got up and running a couple of years later, and they wanted to establish this credibility. 

And regardless of their own political leanings, they worked hard to put in place procedures and training of the staff that emphasized: There’s a research literature out there, go look at it. What’s the consensus in that research literature? Regardless of what you might think, what is it telling you about the impact of this program or this tax or whatever it might be? Bring that back. That’s what we’re going to do. 

Now we’ve done an estimate. Let’s go out at the end of the year and look at all our baseline estimates and look at what actually happened, compare the before and after. Oh my God. We’re really off. Why? What can we learn from that? And it’s a constant repetition of that. It’s been going on for a long time now and with just outstanding results, I think. CBO is a very professional place that has a very specialized job and does it real well. 

Rovner: So obviously, lawmakers have always complained about the CBO, because you always complain about the referee, particularly if they say something you don’t like or you disagree with. I feel like the criticism has gotten more heated in the last couple of years and that there’s been more of an effort to really undermine what it is that CBO does. 

Holtz-Eakin: I don’t know if I agree with that. That comes up a lot. It is certainly more pointed. I lay a lot of this at the feet of the president, who, when he first ran, introduced a very personal style campaigning. Everything is personal. He doesn’t have abstract policy arguments. He makes it about him versus someone else and usually gives that person a nickname, like “Rocket Boy” for the leader of North Korea, and sort of diminishes the virtues and skills of his opponent, in this case. 

So he says, like, that CBO is horrible. It’s a terrible place. That is more personal. That isn’t the nature of the attacks I receive, for example. But other than that, it’s the same, right? When CBO delivers good news, Congress says, God, we did a good job. When CBO delivers bad news, they say, God, CBO is terrible. And that’s been true for a long time. 

Rovner: And I imagine it will in the future. Doug Holtz-Eakin, thank you so much for being here and explaining all this. 

Holtz-Eakin: Thank you. 

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

Karlin-Smith: I took a look at a story in Wired by David Gilbert, “The Bleach Community Is Ready for RFK Jr. To Make Their Dreams Come True.” It’s a story about Kennedy’s past references to the use of chlorine dioxide and groups of people who were pushing for this use as kind of a cure-all for almost any condition you can think of. And one thing the author of this piece picked up on is that some of the FDA warnings not to do this, because it’s incredibly dangerous and can kill you — it is not going to cure any of the ailments described — have been taken off of the agency’s website recently, which seems a bit concerning. 

Now, FDA seems to suggest they did it because it’s just a few years old and they tend to archive posts after that. But if you read what happens to people who try and use bleach — or really it’s like even more concentrated product, essentially — it would be hard for me to understand why you would want to try this. But it is incredibly concerning to see these just really dangerous, unscientifically supported cures come back and get sort of more of a platform. 

Rovner: Yes. I guess we can’t talk about gun violence because we’re talking about drinking bleach. Anna. 

Edney: So mine is from KFF Health News, by Arthur Allen. It’s “Two Patients Faced Chemo. The One Who Survived Demanded a Test To See if It Was Safe.” And I found this starts off with a woman who needed chemo, and she got it and she started getting sores in her mouth and swelling around her eyes. And eventually she died a really painful, awful death, not from the cancer but from not being able to swallow or talk. And it was from the chemo. It was a reaction to the chemo, which I didn’t realize until I read this can, is a rare side effect that can happen. 

And there is a test for it. You can tell who might respond this way to chemo. And it doesn’t necessarily mean you wouldn’t get any chemo. You would instead maybe get lower doses, maybe different days of the week, things like that to try to help you not end up like this woman. And he also was able to talk to someone who knew about this and insisted on the test. And those were some of the calibrations that they made for her treatment. So I think it’s a great piece of public service journalism. It helps a lot of people be aware. 

Rovner: Super interesting. I had no idea until I read it, either. Joanne. 

Kenen: ProPublica, Brandon Roberts, Vernal Coleman, and Eric Umansky did a story called “DOGE Developed Error-Prone AI Tool to ‘Munch’ Veterans Affairs Contract.” And they had a related story that Julie can post that actually shows the code and the AI prompts, and you do not have to be very technically sophisticated to understand that there were some problems with those prompts. Basically, they had somebody who had no government experience and no health care experience writing really bad code and bad prompts. 

And we don’t know how many of the contracts were actually canceled, as opposed to flagged for canceling. There were things that they said were worth $34 million that weren’t needed. They were actually $35,000 and essential things that really pertain to patient care, including programs to improve nursing care were targeted. They were “munched,” which is not a word I had come across. So yes, it was everything you suspected and ProPublica documented it. 

Rovner: Yeah, it’s a very vivid story. Well, my extra credit this week is from Stat, and it’s called “Lawmakers Lobby Doctors To Keep Quiet — or Speak Up — on Medicaid Cuts in Trump’s Tax Bill,” by Daniel Payne. And it’s about something called reverse lobbying, lawmakers lobbying the lobbyists — in this case, in hopes of getting them to speak out or not about the budget reconciliation bill and its possible impact. Both sides know the public trusts health groups more than they trust lawmakers at this point. 

And so Democrats are hoping doctor and hospital groups will speak out in opposition to the cuts to Medicaid and the Affordable Care Act, while Republicans hope they will at least keep quiet. And Republicans, because it’s their bill, have added some sweeteners — a long-desired pay increase for doctors in Medicare. So we will have to wait to see how this all shakes out. 

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

Edney: X or Bluesky, @annaedney. 

Rovner: Joanne 

Kenen: Bluesky or LinkedIn, @joannekenen. 

Rovner: Sarah. 

Karlin-Smith: All of the above, @SarahKarlin or @sarahkarlin-smith. 

Rovner: We’ll 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.

After narrowly passing in the House in May, President Donald Trump’s “One Big Beautiful Bill” has now arrived in the Senate, where Republicans are struggling to decide whether to pass it, change it, or — as Elon Musk, who recently stepped back from advising Trump, is demanding — kill it. 

Adding fuel to the fire, the Congressional Budget Office estimates the bill as written would increase the number of Americans without health insurance by nearly 11 million over the next decade. That number would grow to approximately 16 million should Republicans also not extend additional subsidies for the Affordable Care Act, which expire at year’s end. 

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

@jessiehellmann.bsky.social

Read Jessie's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• Even before the CBO released estimates of how many Americans stand to lose health coverage under the House-passed budget reconciliation bill, Republicans in Washington were casting doubt on the nonpartisan office’s findings — as they did during their 2017 Affordable Care Act repeal effort.
• Responding to concerns about proposed Medicaid cuts, Iowa Sen. Joni Ernst, a Republican, this week stood behind her controversial rejoinder at a town hall that “we’re all going to die.” The remark and its public response illuminated the problematic politics Republicans face in reducing benefits on which their constituents rely — and may foreshadow campaign fights to come.
• Journalists revealed that Health and Human Services Secretary Robert F. Kennedy Jr.’s report on children’s health may have been generated at least in part by artificial intelligence. The telltale signs in the report of what are called “AI hallucinations” included citations to scientific studies that don’t exist and a garbled interpretation of the findings of other research, raising further questions about the validity of the report’s recommendations.
• And the Trump administration this week revoked Biden-era guidance on the Emergency Medical Treatment and Active Labor Act. Regardless, the underlying law instructing hospitals to care for those experiencing pregnancy emergencies still applies.

Also this week, Rovner interviews KFF Health News’ Arielle Zionts, who reported and wrote the latest “Bill of the Month” feature, about a Medicaid patient who had an emergency in another state and the big bill he got for his troubles. If you have an infuriating, outrageous, or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection,” by Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts.

Alice Miranda Ollstein: Politico’s “‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector,” by Alice Miranda Ollstein.

Lauren Weber: The New York Times’ “Take the Quiz: Could You Manage as a Poor American?” by Emily Badger and Margot Sanger-Katz.

Jessie Hellmann: The New York Times’ “A DNA Technique Is Finding Women Who Left Their Babies for Dead,” by Isabelle Taft.

Also mentioned in this week’s podcast:

• NOTUS.org’s “The MAHA Report Cites Studies That Don’t Exist,” by Emily Kennard and Margaret Manto.
• The Washington Post’s “White House MAHA Report May Have Garbled Science by Using AI, Experts Say,” by Lauren Weber and Caitlin Gilbert.

click to open the transcript

Transcript: Trump’s ‘One Big Beautiful Bill’ Lands in Senate. Our 400th Episode!

[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, June 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode we’ll have my interview with my colleague Arielle Zionts, who reported and wrote the KFF Health News “Bill of the Month,” about a Medicaid patient who had a medical emergency out of state and got a really big bill to boot. But first the news. And buckle up — there is a lot of it. 

We’ll start on Capitol Hill, where the Senate is back this week and turning its attention to that “Big Beautiful” budget reconciliation bill passed by the House last month, and we’ll get to the fights over it in a moment. But first, the Congressional Budget Office on Wednesday finished its analysis of the House-passed bill, and the final verdict is in. It would reduce federal health care spending by more than a trillion dollars, with a T, over the next decade. That’s largely from Medicaid but also significantly from the Affordable Care Act. And in a separate letter from CBO Wednesday afternoon, analysts projected that 10.9 million more people would be uninsured over the next decade as a result of the bill’s provisions. 

Additionally, 5.1 million more people would lose ACA coverage as a result of the bill, in combination with letting the Biden-era enhanced subsidies expire, for a grand total of 16 million more people uninsured as a result of Congress’ action and inaction. I don’t expect that number is going to help this bill get passed in the Senate, will it? 

Ollstein: We’re seeing a lot of what we saw during the Obamacare repeal fight in that, even before this report came out, Republicans were working to discredit the CBO in the eyes of the public and sow the seeds of mistrust ahead of time so that these pretty damaging numbers wouldn’t derail the effort. They did in that case, among other things. And so they could now, despite their protestations. 

But I think they’re saying a combination of true things about the CBO, like it’s based on guesses and estimates and models and you have to predict what human behavior is going to be. Are people going to just drop coverage altogether? Are they going to do this? Are they going to do that? But these are the experts we have. This is the nonpartisan body that Congress has chosen to rely on, so you’re not really seeing them present their own credible sources and data. They’re more just saying, Don’t believe these guys. 

Rovner: Yeah, and some of these things we know. We’ve seen. We’ve talked about the work requirement a million times, that when you have work requirements in Medicaid, the people who lose coverage are not people who refuse to work. It’s people who can’t navigate the bureaucracy. And when premiums go up, which they will for the Affordable Care Act, not just because they’re letting these extra subsidies expire but because they’re going back to the way premiums were calculated before 2017. The more expensive premiums get, the fewer people sign up. So it’s not exactly rocket science figuring out that you’re going to have a lot more people without health insurance as a result of this. 

Ollstein: Honestly, it seems from the reactions so far that Republicans on the Hill are more impacted by the CBO’s deficit increase estimates than they are by the number of uninsured-people increase estimates. 

Rovner: And that frankly feels a little more inexplicable to me that the Republicans are just saying, This won’t add to the deficit. And the CBO — it’s arithmetic. It’s not higher math. It’s like if you cut taxes this much so there’s less money coming in, there’s going to be less money and a bigger deficit. I’m not a math person, but I can do that part, at least in my head. 

Jessie, you’re on the Hill. What are you seeing over in the Senate? We don’t even have really a schedule for how this is going to go yet, right? We don’t know if the committees are going to do work, if they’re just going to plunk the House bill on the floor and amend it. It’s all sort of a big question mark. 

Hellmann: Yeah, we don’t have text yet from any of the committees that have health jurisdiction. There’s been a few bills from other committees, but obviously Senate Finance has a monumental task ahead of them. They are the ones that have jurisdiction over Medicaid. Their members said that they have met dozens of times already to work out the details. The members of the Finance Committee were at the White House yesterday with President [Donald] Trump to talk about the bill. 

It doesn’t seem like they got into the nitty-gritty policy details. And the message from the president seemed to mostly be, like, Just pass this bill and don’t make any major changes to it. Which is a tall order, I think, for some of the members like [Sens.] Lisa Murkowski of Alaska and Susan Collins of Maine, and even a few others that are starting to come out and raise concerns about some of the changes that the House made, like to the way that states finance their share of Medicaid spending through the provider tax. 

Lisa Murkowski has raised concerns about how soon the work requirements would take effect, because, she was saying, Alaska doesn’t have the infrastructure right now and that would take a little bit to work out. So there are clearly still a lot of details that need to be worked out. 

Rovner: Well, I would note that Senate Republicans were already having trouble communicating about this bill even before these latest CBO numbers came out. At a town hall meeting last weekend in Iowa, where nearly 1 in 5 residents are on Medicaid, Republican Sen. Joni Ernst had an unfortunate reaction to a heckler in the audience, and, rather than apologize — well, here’s what she posted on Instagram. 

Sen. Joni Ernst: Hello, everyone. I would like to take this opportunity to sincerely apologize for a statement that I made yesterday at my town hall. See, I was in the process of answering a question that had been asked by an audience member when a woman who was extremely distraught screamed out from the back corner of the auditorium, “People are going to die!” And I made an incorrect assumption that everyone in the auditorium understood that, yes, we are all going to perish from this earth. 

So I apologize. And I’m really, really glad that I did not have to bring up the subject of the tooth fairy as well. But for those that would like to see eternal and everlasting life, I encourage you to embrace my Lord and Savior, Jesus Christ. 

Rovner: And what you can’t see, just to add some emphasis, Ernst recorded this message in a cemetery with tombstones visible behind her. I know it is early in this debate, but I feel like we might look back on this moment later like [Sen. John] McCain’s famous thumbs-down in the 2017 repeal-and-replace debate. Or is it too soon? Lauren. 

Weber: For all the messaging they’ve tried to do around Medicaid cuts, for all the messaging, We’re all going to die I cannot imagine was on the list of approved talking points. And at the end of the day, I think it gets at how uncomfortable it is to face the reality of your constituents saying, I no longer have health care. This has been true since the beginning of time. Once you roll out an entitlement program, it’s very difficult to roll it back. 

So I think that this is just a preview of how poorly this will go for elected officials, because there will be plenty of people thrown off of Medicaid who are also Republicans. That could come back to bite them in the midterms and in general, I think, could lead — combine it with the anti-DOGE [Department of Government Efficiency] fervor— I think you could have a real recipe for quite the feedback. 

Rovner: Yes, and we’re going to talk about DOGE in a second. As we all now know, Elon Musk’s time as a government employee has come to an end, and we’ll talk about his legacy in a minute. But on his way out the door, he let loose a barrage of criticism of the bill, calling it, among other things, a, quote “disgusting abomination” that will saddle Americans with, quote, “crushingly unsustainable debt.” 

So basically we have a handful of Republicans threatening to oppose the bill because it adds to the deficit, another handful of Republicans worried about the health cuts — and then what? Any ideas how this battle plays out. I think in the House they managed to get it through by just saying, Keep the ball rolling and send it to the Senate. Now the Senate, it’s going to be harder, I think, for the Senate to say, Oh, we’ll keep the ball rolling and send it back to the House. 

Ollstein: Well, and to jump off Lauren’s point, I think the political blowback is really going to be because this is insult on top of injury in terms of not only are people going to lose Medicaid, Republicans, if this passes, but they’re being told that the only people who are going to lose Medicaid are undocumented immigrants and the undeserving. So not only do you lose Medicaid because of choices made by the people you elected, but then they turn around and imply or directly say you never deserved it in the first place. That’s pretty tough. 

Rovner: And we’re all going to die. 

Ollstein: And we’re all going to die. 

Weber: Just to add onto this, I do think it’s important to note that work requirements poll very popularly among the American people. A majority of Americans here “work requirements” and say, Gee, that sounds like a commonsense solution. What the reality that we’ve talked about in this podcast many, many times is, that it ends up kicking off people for bureaucratic reasons. It’s a way to reduce the rolls. It doesn’t necessarily encourage work. 

But to the average bear, it sounds great. Yes, absolutely. Why wouldn’t we want more people working? So I do think there is some messaging there, but at the end of the day, like Alice said, like I pointed out, they have not figured out the messaging enough, and it is going to add insult to injury to imply to some of these folks that they did not deserve their health care. 

Ollstein: And what’s really baffling is they are running around saying that Medicaid is going to people who should never have been on the program in the first place, able-bodied people without children who are not too young and not too old, sort of implying that these people are enrolling against the wishes of the program’s creators. 

But Congress explicitly voted for these people to be eligible for the program. And then after the Supreme Court made it optional, all of these states, most states, voted either by a direct popular vote or through the legislature to extend Medicaid to this population. And now they’re turning around and saying they were never supposed to be on it in the first place. We didn’t get here by accident or fraud. 

Rovner: Or by executive order. 

Ollstein: Exactly. 

Rovner: Well, even before the Senate digs in, there’s still a lot of stuff that got packed into that House bill, some of it at the last minute that most people still aren’t aware of. And I’m not talking about [Rep.] Marjorie Taylor Greene and AI, although that, too, among other things. And shout out here to our podcast panelist Maya Goldman over at Axios. The bill would reduce the amount of money medical students could borrow, threatening the ability of people to train to become doctors, even while the nation is already suffering a doctor shortage. 

It would also make it harder for medical residents to pay their loans back and do a variety of other things. The idea behind this is apparently to force medical schools to lower their tuition, which would be nice, but this feels like a very indirect way of doing it. 

Weber: I just don’t think it’s very popular in an era in which we’re constantly talking about physician shortages and encouraging folks that are from minority communities or underserved communities to become primary care physicians or infectious disease physicians, to go to the communities that need them, that reflect them, to then say, Look, we’re going to cut your loans. And what that’s going to do — short of RFK [Robert F. Kennedy Jr.], who has toyed with playing with the code. So who knows? We could see. 

But as the current structure stands, here’s the deal: You have a lot of medical debt. You are incentivized to go into a more lucrative specialty. That means that you’re not going into primary care. You’re not going into infectious disease care. You’re not going to rural America, because they can’t pay you what it costs to repay all of your loans. So, I do think — and, it was interesting. I think the Guardian spoke to some of the folks from the study that said that this could change it. That study was based off of metrics from 2006, and for some reason they were like, The financial private pay loans are not really going to cut it today. 

I find it hard to believe this won’t get fixed, to be quite honest, just because I think hating on medical students is usually a losing battle in the current system. But who knows? 

Rovner: And hospitals have a lot of clout. 

Weber: Yeah. 

Rovner: Although there’s a lot of things in this bill that they would like to fix. And, I don’t know. Maybe— 

Weber: Well, and hospitals have a lot of financial incentive, because essentially they make medical residents indentured servants. So, yeah, they also would like them to have less loans. 

Rovner: As I mentioned earlier, Elon Musk has decamped from DOGE, but in his wake is a lot of disruption at the Department of Health and Human Services and not necessarily a lot of savings. Thousands of federal workers are still in limbo on administrative leave, to possibly be reinstated or possibly not, with no one doing their jobs in the meantime. Those who are still there are finding their hands tied by a raft of new rules, including the need to get a political-appointee sign-off for even the most routine tasks. 

And around the country, thousands of scientific grants and contracts have been summarily frozen or terminated for no stated cause, as the administration seeks to punish universities for a raft of supposed crimes that have nothing to do with what’s being studied. I know that it just happened, but how is DOGE going to be remembered? I imagine not for all of the efficiencies that it has wrung out of the health care system. 

Ollstein: Well, one, I wouldn’t be so sure things are over, either between Elon and the Trump administration or what the amorphous blob that is DOGE. I think that the overall slash-and-burn of government is going to continue in some form. They are trying to formalize it by sending a bill to Congress to make these cuts, that they already made without Congress’ permission, official. We’ll see where that goes, but I think that it’s not an ending. It’s just morphing into whatever its next iteration is. 

Rovner: I would note that the first rescission request that the administration has sent up formally includes getting rid of USAID [the U.S. Agency for International Development] and PEPFAR [the President’s Emergency Plan for AIDS Relief] and public broadcasting, which seems unlikely to garner a majority in both houses. 

Ollstein: Except, like I said, this is asking them to rubber-stamp something they’re already trying to do without them. Congress doesn’t like its power being infringed on, especially appropriators. They guard that power very jealously. Now, we have seen them a little quieter in this administration than maybe you would’ve thought, but I think there are some who, even if they agree on the substance of the cuts, might object to the process and just being asked to rubber-stamp it after the fact. 

Rovner: Well, meanwhile, Health and Human Services Secretary Kennedy continues to try to remake what’s left of HHS, although his big reorganization is currently blocked by a federal judge. And it turns out that his big MAHA, “Make America Healthy Again,” report may have been at least in part written by AI, which apparently became obvious when the folks at the news service NOTUS decided to do something that was never on my reporting bingo card, which is to check the footnotes in the report to see if they were real, which apparently many are not. Then, Lauren, you and your colleagues took that yet another step. So tell us about that. 

Weber: Yeah. NOTUS did a great job. They went through all the footnotes to find out that several of the studies didn’t exist, and my colleagues and I saw that and said, Hm, let’s look a little closer at these footnotes and see. And what we were able to do in speaking with AI experts is find telltale signs of AI. It’s basically a sign of artificial intelligence when things are hallucinated — which is what they call it — which is when it sounds right but isn’t completely factual, which is one of the dangers of using AI. 

And it appears that some of AI was used in the footnotes of this MAHA report, again, to, as NOTUS pointed out, create studies that don’t exist. It also kind of garbled some of the science on the other pieces of this. We found something called “oaicite,” which is a marker of OpenAI system, throughout the report. And at the end of the day, it casts a lot of questions on the report as a whole and: How exactly did it get made? What is the science behind this report? 

And even before anyone found any of these footnotes of any of this, a fair amount of these studies that this report cites to back up its thesis are a stretch. Even putting aside the fake studies and the garbled studies, I think it’s important to also note that a lot of the studies the report cites, a lot of what Kennedy does, take it a lot further than what they actually say. 

Rovner: So, this is all going well. Meanwhile, there is continuing confusion in vaccine land after Secretary Kennedy, flanked by FDA [Food and Drug Administration] Commissioner Marty Makary and NIH [National Institutes of Health] Director Jay Bhattacharya, announced in a video on X that the department would no longer recommend covid vaccines for pregnant women and healthy children, sidestepping the expert advice of the Centers for Disease Control and Prevention and its advisory committee of experts. 

The HHS officials say people who may still be at risk can discuss whether to get the vaccine with their doctors, but if the vaccines are no longer on the recommended list, then insurance is less likely to cover them and medical facilities are less likely to stock them. Paging Sen. [Bill] Cassidy, who still, as far as I can tell, hasn’t said anything about the secretary’s violation of his promise to the senator during his confirmation hearings that he wouldn’t mess with the vaccine schedule. Have we heard a peep from Sen. Cassidy about any of this? 

Ollstein: I have not, but a lot of the medical field has been very vocal and very upset. I was actually at the annual conference of the American College of Obstetricians and Gynecologists when this news broke, and they were just so confused and so upset. They had seen pregnant patients die of covid before the vaccines were available, or because there was so much misinformation and mistrust about the vaccines’ safety for pregnant people that a lot of people avoided it, and really suffered the consequences of avoiding it. 

A lot of the issue was that there were not good studies of the vaccine in pregnant people at the beginning of the rollout. There have since been, and those studies have since shown that it is safe and effective for pregnant people. But it was, in a lot of people’s minds, too late, because they already got it in their head that it was unsafe or untested. So the OB-GYNs at this conference were really, really worried about this. 

Rovner: And, confusingly, the CDC on its website amended its recommendations to leave children recommended but not pregnant women, which is kind of the opposite of, I think, what most of the medical experts were recommending. Jessie, you were about to add something. 

Hellmann: I just feel like the confusion is the point. I think Kennedy has made it a pattern now to get out ahead of an official agency decision and kind of set the narrative, even if it is completely opposite of what his agencies are recommending or are stating. He’s done this with a report that the CDC came out with autism, when he said rising autism cases aren’t because of more recognition and the CDC report said it’s a large part because of more recognition. 

He’s done this with food dyes. He said, We’re banning food dyes. And then it turns out they just asked manufacturers to stop putting food dyes into it. So I think it’s part of, he’s this figurehead of the agency and he likes to get out in front of it and just state something as fact, and that is what people are going to remember, not something on a CDC webpage that most people aren’t going to be able to find. 

Rovner: Yeah, it sounds like President Trump. It’s like, saying it is more important than doing it, in a lot of cases. So of course there’s abortion news this week, too. The Trump administration on Tuesday reversed the Biden administration guidance regarding EMTALA, the Emergency Medical Treatment and Active Labor Act. Biden officials, in the wake of the overturn of Roe v. Wade three years ago, had reminded hospitals that take Medicare and Medicaid, which is all of them, basically, that the requirement to provide emergency care includes abortion when warranted, regardless of state bans. Now, Alice, this wasn’t really unexpected. In fact, it’s happening later than I think a lot of people expected it to happen. How much impact is it going to have, beyond a giant barrage of press releases from both sides in the abortion debate? 

Ollstein: Yeah, so, OK, it’s important for people to remember that what the Biden administration, the guidance they put out was just sort of an interpretation of the underlying law. So the underlying law isn’t changing. The Biden administration was just saying: We are stressing that the underlying law means in the abortion context, in the post-Dobbs context, blah, blah, blah, blah, blah, that hospitals cannot turn away a pregnant woman who’s having a medical crisis. And if the necessary treatment to save her life or stabilize her is an abortion, then that’s what they have to do, regardless of the laws in the state. 

In a sense, nothing’s changed, because EMTALA itself is still in place, but it does send a signal that could make hospitals feel more comfortable turning people away or denying treatment, since the government is signaling that they don’t consider that a violation. Now, I will say, you’re totally right that this was expected. In the big lawsuit over this that is playing out now in Idaho, one of the state’s hospitals intervened as a plaintiff, basically in anticipation of this happening, saying, The Trump administration might not defend EMTALA in the abortion context, so we’re going to do it for them, basically, to keep this case alive. 

Rovner: And I would point out that ProPublica just won a Pulitzer for its series detailing the women who were turned away and then died because they were having pregnancy complications. So we do know that this is happening. Interestingly, the day before the administration’s announcement, the American College of Obstetricians and Gynecologists put out a new, quote, “practice advisory” on the treatment of preterm pre-labor rupture of membranes, which is one of the more common late-pregnancy complications that result in abortion, because of the risk of infection to the pregnant person. 

Reading from that guidance, quote, “the Practice Advisory affirms that ob-gyns and other clinicians must be able to intervene and, in cases of previable and periviable PPROM” — that’s the premature rupture of membranes — “provide abortion care before the patient becomes critically ill.” Meanwhile, this statement came out Wednesday from the American College of Emergency Physicians, quote, ,“Regardless of variances in the regulatory landscape from one administration to another, emergency physicians remain committed not just by law, but by their professional oath, to provide this care.” 

So on the one hand, professional organizations are speaking out more strongly than I think we’ve seen them do it before, but they’re not the ones that are in the emergency room facing potential jail time for, Do I obey the federal law or do I obey the state ban? 

Ollstein: And when I talk to doctors who are grappling with this, they say that even with the Biden administration’s interpretation of EMTALA, that didn’t solve the problem for them. It was some measure of protection and confidence. But still, exactly like you said, they’re still caught in between seemingly conflicting state and federal law. And really a lot of them, based on what they told me, were saying that the threat of the state law is more severe. It’s more immediate. 

It means being charged with a felony, being charged with a crime if they do provide the abortion, versus it’s a federal penalty, it’s not on the doctor itself. It’s on the institution. And it may or may not happen at some point. So when you have criminal charges on one side and maybe some federal regulation or an investigation on the other side, what are you going to choose? 

Rovner: And it’s hard to imagine this administration doing a lot of these investigations. They seem to be turning to other things. Well, we will watch this space, and obviously this is all still playing out in court. All right, that is this week’s news, or at least as much as we could squeeze in. Now we’ll play my “Bill of the Month” interview with Arielle Zionts, and then we’ll come back and do our extra credits. 

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

Arielle Zionts: Hi. Thanks for having me. 

Rovner: So this month’s patient has Medicaid as his health insurance, and he left his home state of Florida to visit family in South Dakota for the holidays, where he had a medical emergency. Tell us who he is and what happened that landed him in the hospital. 

Zionts: Sure. So I spoke with Hans Wirt. He was visiting family in the Black Hills. That’s where Mount Rushmore is and its beautiful outdoors. He was at a water park, following his son up and down the stairs and getting kind of winded. And at first he thought it might just be the elevation difference, because in Florida it’s like 33 feet above sea level. Here it’s above 3,000 in Rapid City. 

But then they got him back to the hotel room and he was getting a lot worse, his breathing, and then he turned pale. And his 12-year-old son is the one who called 911. And medics were like, Yep, you’re having a heart attack. And they took him to the hospital in town, and that is the only place to go. There’s just one hospital with an ER in Rapid City. 

Rovner: So the good news is that he was ultimately OK, but the bad news is that the hospital tried to stick them with the bill. How big was it? 

Zionts: It was nearly $78,000. 

Rovner: Wow. So let’s back up a bit. How did Mr. Wirt come to be on Medicaid? 

Zionts: Yeah. So it is significant that he is from Florida, because that is one of the 10 states that has not opted in to expand Medicaid. So in Florida, if you’re an adult, you can’t just be low-income. You have to also be disabled or caring for a minor child. And Hans says that’s his case. He works part time at a family business, but he also cares for his 12-year-old son, who is also on Medicaid. 

Rovner: So Medicaid patients, as we know, are not supposed to be charged even small copays for care in most cases. Is that still the case when they get care in other states? 

Zionts: So Medicaid will not pay for patient care if they are getting more of an elective or non-medically necessary kind of optional procedure or care in another state. But there are several exceptions, and one of the exceptions is if they have an emergency in another state. So federal law says that state Medicaid programs have to reimburse those hospitals if it was for emergency care. 

Rovner: And presumably a heart attack is an emergency. 

Zionts: Yes. 

Rovner: So why did the hospital try to bill him anyway? They should have billed Florida Medicaid, right? 

Zionts: So what’s interesting is while there’s a law that says the Medicaid program has to reimburse the hospital, there’s no law saying the hospital has to send the bill to Medicaid. And that was really interesting to learn. In this case, the hospital, it’s called Monument Health, and they said they only bill plans in South Dakota and four of our bordering states. So basically they said for them to bill for the Medicaid, they would have to enroll. 

And they say they don’t do that in every state, because there is a separate application process for each state. And their spokesperson described it as a burdensome process. So in this case, they billed Hans instead. 

Rovner: So what eventually happened with this bill? He presumably didn’t have $78,000 to spare. 

Zionts: Correct. Yeah. And he had told them that, and he said they only offered, Hey, you can set up a payment plan. But that would’ve still been really expensive, the monthly payments. So he reached out to KFF Health News, and I had sent my questions to the hospital, and then a few days later I get a text from Hans and he says, Hey, my balance is at zero now. He and I both eventually learned that that’s because the hospital paid for his care through a program called Charity Care. 

All nonprofit hospitals are required to have this program, which provides free or very discounted pricing for patients who are uninsured or very underinsured. And the hospital said that they screen everyone for this program before sending them to collections. But what that meant is that for months, Hans was under the impression that he was getting this bill. And he was, got a notice saying, This is your last warning before we send you to collection. 

Rovner: So, maybe they would’ve done it anyway, or maybe you gave them a nudge. 

Zionts: They say they would’ve done it anyways. 

Rovner: OK. So what’s the takeaway here? It can’t be that if you have Medicaid, you can’t travel to another state to visit family at Christmas. 

Zionts: Right. So Hans made that same joke. He said, quote, “If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state.” Obviously, he’s kidding. You can’t control when you have an emergency. So the takeaway is that you do risk being billed and that if you don’t know how to advocate yourself, you might get sent to collections. But I also learned that there’s things that you can do. 

So you could file a complaint with your state Medicaid program, and also, if you have a managed-care program, and they might have — you should ask for a caseworker, like, Hey, can you communicate with the hospital? Or you can contact an attorney. There’s free legal-aid ones. An attorney I spoke with said that she would’ve immediately sent a letter to the hospital saying, Look, you need to either register with Florida Medicaid and submit it. If not, you need to offer the Charity Care. So that’s the advice. 

Rovner: So, basically, be ready to advocate for yourself. 

Zionts: Yes. 

Rovner: OK. Arielle Zionts, thank you so much. 

Zionts: Thank you. 

Rovner: OK. We’re back, and 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. Jessie, why don’t you go first this week? 

Hellmann: My story is from The New York Times. It’s called “A [DNA] Technique Is Finding Women Who Left Their Babies for Dead,” which I don’t know how I feel about that headline, but the story was really interesting. It’s about how police departments are using DNA technology to find the mothers of infants that had been found dead years and years ago. And it gets a little bit into just the complicated situation. 

Some of these women have gone on to have families. They have successful careers. And now some of them are being charged with murder, and some who have been approached about this have unfortunately died by suicide. And it just gets into the ethics of the issue and what police and doctors, families, should be considering about the context around some of these situations, about what the circumstances were, in some cases, 40 years ago and what should be done with that. 

Rovner: Really thought-provoking story. Lauren. 

Weber: With credit to Julie, too, because she brought this up again, was brought back to a classic from The New York Times back in 2020, which is called “Take a Quiz: Could You Manage as a Poor American?” And here are the questions: I will read them for the group. 

Rovner: And I will point out that this is once again relevant. That’s why it was brought back. 

Weber: It’s once again relevant, and one of them is, “Do you have paper mail you plan to read that has been unopened for more than a week?” Yes. I’m looking at paper mail on my desk. “Have you forgotten to pay a utility bill on time?” If I didn’t set up auto pay, I probably would forget to pay a utility bill on time. “Have you received a government document in the mail that you did not understand?” Many times. “Have you missed a doctor’s appointment because you forgot you scheduled it or something came up?” 

These are the basic facts that can derail someone from having access to health care or saddle them, because they lose access to health care and don’t realize it, with massive hospital bills. And this is a lot of what we could see in the coming months if some of these Medicaid changes come through. And I just, I think I would challenge a lot of people to think seriously about how much mail they leave unopened and what that could mean for them, especially if you are living in different homes, if you are moving frequently, etc. This paperwork burden is something to definitely be considered. 

Rovner: Yeah, I think we should sort of refloat this every time we have another one of these debates. Alice. 

Ollstein: So I wanted to recommend something I wrote [“‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector”]. It was my last story before taking some time off this summer. It is about the intersection of Trump’s immigration policies and our health care system. And so this is jumping off the Supreme Court allowing the Trump administration to strip legal status from hundreds of thousands of immigrants. Again, these are people who came legally through a designated program, and they are being made undocumented by the Trump administration, with the Supreme Court’s blessing. And tens of thousands of them are health care workers. 

And so I visited an elder care facility in Northern Virginia that was set to lose 65 staff members, and I talked to the residents and the other workers about how this would affect them, and the owner. And it was just a microcosm of the damage this could have on our health sector more broadly. Elder care is especially immigrant-heavy in its workforce, and everyone there was saying there just are not the people to replace these folks. 

And not only is that the case right now, but as the baby boomer generation ages and requires care, the shortages we see now are going to be nothing compared to what we could see down the road. With the lower birth rates here, we’re just not producing enough workers to do these jobs. The piece also looks into how public health and management of infectious diseases is also being worsened by these immigration raids and crackdowns and deportations. So, would love people to take a look. 

Rovner: I’m so glad you did this story, because it’s something that I keep running up and down screaming. And you can tell us why you’re taking some time off this summer, Alice. 

Ollstein: I’m writing a book. Hopefully it will be out next year, and I can’t wait to tell everyone more about it. 

Rovner: Excellent. All right. My extra credit this week is from my KFF Health News colleagues Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts, who you just heard talking about her “Bill of the Month,” and it’s called “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection.” And that sums it up pretty well. The HHS secretary had a splashy photo op earlier this year out west, where he promised to prioritize Native American health. But while he did spare the Indian Health Service from personnel cuts, it turns out that the Native American population is also served by dozens of other HHS programs that were cut, some of them dramatically, everything from home energy assistance to programs that improve access to healthy food, to preventing overdoses. The Native community has been disproportionately hurt by the purging of DEI [diversity, equity, and inclusion] programs, because Native populations have systematically been subjected to unequal treatment over many generations. It’s a really good if somewhat infuriating story. 

OK. That is this week’s show. Before we go, if you will indulge me for a minute, this is our 400th episode of “What the Health?” We launched in 2017 during that year’s repeal-and-replace debate. I want to thank all of my panelists, current and former, for teaching me something new every single week. And everyone here at KFF Health News who makes this podcast possible. That includes not only my chief partners in crime, Francis Ying and Emmarie Huetteman, but also the copy desk and social media and web teams who do all the behind-the-scenes work that brings our podcast to you every week. And of course, big thanks to you, the listeners, who have stuck with us all these years. 

I won’t promise you 400 more episodes, but I will keep doing this as long as you keep wanting it. 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. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Jessie? 

Hellmann: @jessiehellmann on X and Bluesky, and LinkedIn. 

Rovner: Lauren. 

Weber: I’m @LaurenWeberHP on X and on Bluesky, shockingly, now. 

Rovner: Alice. 

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

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.

With only a single vote to spare, the House passed a controversial budget bill that includes billions of dollars in tax cuts for the wealthy, along with billions of dollars of cuts to Medicaid, the Affordable Care Act, and the food stamp program — most of which will affect those at the lower end of the income scale. But the bill faces an uncertain future in the Senate.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. released a report from his commission to “Make America Healthy Again” that described threats to the health of the American public — but notably included nothing on threats from tobacco, gun violence, or a lack of health insurance.

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

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Anna Edney
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Sarah Karlin-Smith
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Alice Miranda Ollstein
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Read Alice's stories.

Among the takeaways from this week’s episode:

• House Republicans passed their “big, beautiful” bill 215-214 this week, with one Republican critic voting present. But the Senate may have its own “big, beautiful” rewrite. Some conservative senators who worry about federal debt are concerned that the bill is not fully paid for and would add to the budget deficit. Others, including some red-state Republicans, say the bill’s cuts to Medicaid and food assistance go too far and would hurt low-income Americans. The bill’s cuts would represent the biggest reductions to Medicaid in the program’s 60-year history.
• Many of the bill’s Medicaid cuts would come from adding work requirements. Most people receiving Medicaid already work, but such requirements in Arkansas and Georgia showed that people often lose coverage under these rules because they have trouble documenting their work hours, including because of technological problems. The nonpartisan Congressional Budget Office estimated an earlier version of the bill would reduce the number of people with Medicaid by at least 8.6 million over a decade. The requirements also could add a burden for employers. The bill’s work requirements are relatively broad and would affect people who are 19 to 64 years old. 
• People whose Medicaid coverage is canceled also would no longer qualify for ACA subsidies for marketplace plans. Medicare also would be affected, because the bill would be expected to trigger an across-the-board sequestration cut.
• The bill also would impact abortion by effectively banning it in ACA marketplace plans, which would disrupt a compromise struck in the 2010 law. And the bill would block funding for Planned Parenthood in Medicaid, although that federal money is used for other care such as cancer screenings, not abortions. In the past, the Senate parliamentarian has said that kind of provision is not allowed under budget rules, but some Republicans want to take the unusual step of overruling the parliamentarian.
• This week, FDA leaders released covid-19 vaccine recommendations in a medical journal. They plan to limit future access to the vaccines to people 65 and older and others who are at high risk of serious illness if infected, and they want to require manufacturers to do further clinical trials to show whether the vaccines benefit healthy younger people. There are questions about whether this is legal, which products would be affected, when this would take effect, and whether it’s ethical to require these studies. 
• HHS released a report on chronic disease starting in childhood. The report doesn’t include many new findings but is noteworthy in part because of what it doesn’t discuss — gun violence, the leading cause of death for children and teens in the United States; tobacco; the lack of health insurance coverage; and socioeconomic factors that affect access to healthy food.

Also this week, Rovner interviews University of California-Davis School of Law professor and abortion historian Mary Ziegler about her new book on the past and future of the “personhood” movement aimed at granting legal rights to fetuses and embryos.

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

Julie Rovner: The Washington Post’s “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson.

Alice Miranda Ollstein: NPR’s “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago,” by Chiara Eisner.

Anna Edney: Bloomberg News’ “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug,” by Anna Edney.

Sarah Karlin-Smith: The Farmingdale Observer’s “Scientists Have Been Studying Remote Work for Four Years and Have Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier,’” by Bob Rubila.

Also mentioned in this week’s podcast:

• The New York Times’ “As Congress Debates Cutting Medicaid, a Major Study Shows It Saves Lives,” by Sarah Kliff and Margot Sanger-Katz.
• NBC News’ “Georgia Mother Says She Is Being Forced To Keep Brain-Dead Pregnant Daughter Alive Under Abortion Ban Law,” by Minyvonne Burke.
• The Washington Post’s “Trump and GOP’s Tax Bill Would Force Cuts to Medicare, CBO Says,” by Jacob Bogage and Abha Bhattarai.
• The New England Journal of Medicine’s “An Evidence-Based Approach to Covid-19 Vaccination,” by Vinay Prasad and Martin A. Makary.

click to open the transcript

Transcript: Bill With Billions in Health Program Cuts Passes House

[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, May 23, at 10 a.m. As always, and particularly this week, 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: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Sarah Karlin-Smith: Hello there. 

Rovner: Later in this episode we’ll have my interview with law professor and abortion historian Mary Ziegler, who has a new book out on the history and possible future of the “personhood” movement. But first, this week’s news. 

So, against all odds and many predictions, including my own, the House around 7 a.m. Thursday morning, after being in session all night, passed President [Donald] Trump’s One Big Beautiful Bill — that is its actual, official name — by a vote of 215-214, with one Republican voting present. Before we get into the details of the House-passed bill, what are the prospects for this budget reconciliation bill in this form in the Senate? Very different, I would think. 

Ollstein: Yeah, this is not going to come out the way it went in. Senate is already openly talking about a “‘One, Big Beautiful’ Rewrite” — that was the headline at Politico. 

And you’re going to see some of the same dynamics. You’re going to see hard-liners saying this doesn’t go far enough, this actually adds a lot to the deficit even with all of the deep cuts to government programs. And you’re going to have moderates who have a lot of people in their state who depend on Medicaid and other programs that are set to be cut who say this goes too far. And so you’re going to have that same push and pull. And the House, barely, by one vote, got this through. And so we’ll see if the Senate is able to do the same. 

Rovner: Yeah, so all eyes on [Sen.] John McCain in 2017. This year it could be all eyes on Josh Hawley, I suspect, the very conservative senator from Missouri who keeps saying “Don’t touch Medicaid.” 

But back to the House bill. We don’t have official scores yet from the Congressional Budget Office, and we won’t for a while, I suspect. But given some last-minute changes made to pacify conservatives who, as Alice pointed out, said this bill didn’t cut deeply enough, I think it’s clear that if it became law in this form, it would represent the biggest cuts to federal health programs in the 60-year history of Medicare and Medicaid. 

Those last-minute changes also took pretty square aim at the Affordable Care Act, too, so much that I think it’s safe to call this even more than a partial repeal of the health law. And Medicare does not go unscathed in this measure, either, despite repeated promises by President Trump on the campaign trail and since he took office. 

Let’s take these one at a time, starting with Medicaid. I would note that at a meeting with House Republicans on Tuesday, President Trump told them not to expletive around with Medicaid. You can go look up the exact quote yourself if you like. But apparently he’s OK with the $700 billion plus that would be cut in the bill, which Republicans say is just waste, fraud, and abuse. Where does that money come from? And would Medicaid really continue to cover everyone who’s eligible now, which is kind of what the president and moderate Republicans are promising? 

Edney: Well, it sounds like the bulk of it is coming from the work requirements that Alice mentioned earlier. And would it be able to cover them? Sure, but will it? No, in the sense that, as Alice has talked about often on this podcast, it’s basically a time tax. It’s not easy to comply with. All federal regulations, they’re not going to a website and putting in what you did for work. Particularly, if you are a freelancer or something, it can be really difficult to meet all the requirements that they’re looking for. And also, for some people, they just don’t have the ability, even the internet, to be able to do that reliably. So they’re going to save money because people are going to lose their health care. 

Rovner: I saw a lot of people referring to them this week not as work requirements anymore but as work reporting requirements. Somebody suggested it was like the equivalent of having to file your income taxes every month. It’s not just check a box and say, I worked this month. It’s producing documentation. And a lot of people have jobs that are inconsistent. They may work some hours some week and other hours the other week. And even people who work for small businesses, that would put an enormous burden on the employers to come up with all this. 

Obviously, the CBO thinks that a lot of people won’t be able to do this and therefore people are going to lose their health insurance. But Alice, as you have told us numerous times when we did this in Arkansas, it’s not that people aren’t working — it’s that people aren’t successfully reporting their work. 

Ollstein: Right. And we’ve seen this in Georgia, too, where this has been implemented, where there are many different ways that people who are working lose their insurance with this. People who don’t have good internet access struggle. People who have fluctuating work schedules, whether it’s agricultural work, tourism work, things that are more seasonal, they can’t comply with this strict monthly requirement. 

So there are numerous reports from the ground of people who should be eligible losing their coverage. And I’ll note that one of the last-minute changes the House made was moving up the start date of the requirements. And I’m hearing a lot of state officials and advocates warn that that gives states less time to set up a system where people won’t fall through the cracks. And so the predicted larger savings is in part because they imagine more people will be kicked off the program. 

Rovner: It’s also the most stringent work requirement we’ve seen. It would cover people from age 19 through age 64, like right up until you’re eligible for Medicare. And if you lose Medicaid because you fail to meet these reporting requirements, you’re no longer eligible for a subsidy to buy insurance in the ACA exchange. Is there a policy point to this? Or are they just trying to get the most people off the program so they can get the most savings? 

Edney: If you ask Republicans, they would tell you: We’re going to get people back working. We’re going to give them the pride of working — as if people don’t want that on their own. But the actual outcome is not that people end up working more. And there are cases even where they lose their health insurance and can’t work a job they already had. On the surface, and this is why it’s such a popular program, because it seems like it would get more people working. Even a large swath of Democrats support the idea when they just hear the name — of voters. But the actual outcome, that doesn’t happen. People aren’t in Medicaid because they aren’t working. 

Rovner: Right. And I get to say for the millionth time, nobody is sitting on their couch living on their Medicaid coverage. 

Edney: Right, right. 

Rovner: There’s no money that comes with Medicaid. It’s just health insurance. The health providers get paid for Medicaid and occasionally the managed-care companies. But there’s no check to the beneficiary, so there’s no way to live on your Medicaid. 

As Alice points out, most of the people who are working and have Medicaid are working at jobs, obviously, that don’t offer employer health insurance. So having, in many cases, as you say, Anna, having Medicaid is what enables you to work. 

All right, well, our podcast pals Margot Sanger-Katz and Sarah Kliff have an excellent Medicaid story out this week on a new study that looks very broadly at Medicaid and finds that it actually does improve the health of its beneficiaries. Now this seems logical, but that has been quite a talking point for Republicans for many years, that we spend all this money and it doesn’t produce better health, because we’ve had a lot of studies that have been kind of neither here nor there on this. 

Do we finally have proof that Democrats need? Because I have heard, over many years — there was a big Oregon study in 2011 that found that it helped people financially and that it helped their mental health, but there was not a lot of physical health benefit that they saw. Of course, it was a brief. It was like two years. And it takes a longer time to figure out the importance of health insurance. But I’m wondering if maybe the Democrats will finally be able to put down that talking point. I didn’t hear it, actually, as much this week as I have in years past: Why are we spending all this money on Medicaid when we don’t know whether it’s producing better health? 

Karlin-Smith: One of the interesting things I thought about this study and sort of the timing of it, post-Obamacare expansion of Medicaid and more younger people being covered, is that it seems to really show that, not only does this study show it saves lives, but it’s really helping these younger populations. 

And I think there are some theories as to why it might have been harder to show the economic cost-effectiveness benefits people were looking for before, when you had Medicaid covering populations that were already either severely ill or older. Which doesn’t mean it’s not valuable, right? To provide health coverage to somebody who’s 75 or 80, but unfortunately we have not found the everlasting secret to life yet. 

So, but I think for economists who want to be able to show this sort of, as they show in this paper, this “quality-adjusted life year” benefit, this provides some really good evidence of what that expansion of Medicaid — which is a lot of what’s being rolled back, potentially, under the reconciliation process — did, which is, helps younger people be healthier and thus, right, hopefully, ideally, live a higher quality of life, and where you need less health coverage over time, and cost the government less. 

It’s quite interesting, for people who want to go look at the graph The New York Times put in their story, of just where Medicaid fits, in terms of other sort of interventions we spend a lot of money on to help save lives. Because I was kind of surprised, given how much health insurance does cover, that it comes out on sort of the lower end, as being a pretty good bargain. 

Rovner: Yeah. Well, we don’t have time to get into everything that’s in this bill, and there is a lot. It also includes a full ban of Medicaid coverage for gender-affirming care for both minors and adults. And it cuts reimbursement to states that use their own funds to provide coverage to undocumented people. Is this a twofer for Republicans, saving money while fighting the culture wars? 

Edney: Certainly. And I was surprised to see some very liberal states on the immigration front saying: We just have to deal with this. And this really sucks, but we have to balance our budget. And if we’re not going to get those tax dollars, then we aren’t going to be able to offer health insurance to people who are undocumented, or Medicaid to people who are undocumented. 

Rovner: Yeah, California, most notably. 

Edney: Yeah, California for sure. And they found a way to do it, hit them in the pocketbook, and that that’s a way for them to win the culture war, for sure. 

Rovner: Alice, you’ve spent a lot of time looking at gender-affirming care. Were you surprised to see it banned for adults, too? Obviously the gender-affirming care for minors has been a continuing issue for a while. 

Ollstein: Yeah, I would say not surprised, because this is sort of a common pattern that we see across different things, including in the abortion space, where first policies are targeted just at minors. That often is more politically palatable. And then it gets expanded to the general population. And so I think, given the wave of state bans on care for minors that we’ve seen, I think a lot of people had been projecting that this was the trajectory. 

I think that there’s been some really good reporting from The 19th and other outlets about what an impact this would have. Trans people are disproportionately low-income and dependent on Medicaid, and so this would have really sweeping impacts on a lot of people. 

Rovner: Well, turning to the Affordable Care Act, if you thought Republicans weren’t going to try to repeal the health law this time around, you thought wrong. There are a bucket of provisions in this bill that will make the Affordable Care Act coverage both more expensive and harder to get, so much that some analysts think it could reduce enrollment by as much as half of the 24 million people who have it now. Hasn’t someone told Republicans that many of these people are their voters? 

Edney: Yeah, that’s a good question. I don’t know what the Republican strategists are telling them. But certainly they needed to save money. And so they found their loopholes and their different things that they thought they could scrape from. And maybe no one will notice? But I don’t think that’s going to happen. 

A lot of people suddenly have much higher ACA premiums because of the way they’re going to take away this ability that the insurers have had to silver-load, essentially, the way that they deal with the premium tax credits by setting some of the savings, kind of the cost sharing that they need to do, right into the silver plan, because the silver plan is where the premiums are set off of. And so they were able to offer the plans with lower premiums, essentially, but still get paid for cost-sharing reductions. So they were able to still get that money taken away from them. 

Rovner: So let me see if I can do it. It was, and this was something that Trump tried to do in 2017, that he thought was going to hurt the marketplace plans. And it ended up doing the opposite— 

Edney: Right. 

Rovner: —because it basically shifted money from the insurance companies and the beneficiaries back to the federal government, because it made the premium subsidies bigger. 

So I think the point I want to make is that we’ve been talking all year about these extra subsidies that are going to expire, and that will make premiums go up, and the Republicans did not move to extend those subsidies. But this going back to the government paying these cost-sharing reduction payments is going to basically reverse the accidental lowering of premiums that Trump did in 2017. And therefore, raise them again. 

So now we have a double whammy. We have premiums going up because the extra subsidies expire, and then we’ll have premiums going up even more because they’re going back to this original cost-sharing reduction. And yet, as we have said many times, a lot of these additional people who are now on the Affordable Care Act are people in the very red states that didn’t expand Medicaid. These are Republican voters. 

Karlin-Smith: We haven’t talked a lot about the process of how they got this bill through this week. It was incredibly fast and done literally in the dead of night. 

Ollstein: Multiple nights. 

Karlin-Smith: So you have to wonder, particularly, if you think back to the last time Republicans tried to overturn Obamacare — and they did come pretty close — eventually, I think, that unpalatableness of taking away health care from so many of their own constituents came back to really hurt them. And you do have to wonder if the jamming was in part to make more people unaware of what was happening. You’d still think there’d be political repercussions later down the line when they realize it. But I think, especially, again, just thinking back on all the years when Republicans were saying Democrats were pushing the ACA through too fast and nobody could read the bill, or their CBO scores. This was a much, much faster version of that, with a lot less debate and public transparency and so forth. 

Rovner: Yeah, they went to the Rules Committee at 1 a.m. Wednesday, so Tuesday night. The Rules Committee went until almost 9 o’clock the next evening, just consecutively. And shout out to Rules Committee chairman Virginia Foxx, who sat there for, I think, the entire time. And then they went straight from rules to the floor. 

So it’s now Wednesday night at 10 o’clock at night, and then went all the way through and voted, I think, just before 7 a.m. I’ve done a lot of all-nighters in the Capitol. I haven’t seen one that was two nights in a row like this. And I have great admiration for the people who really were up for 48 hours to push this thing through. 

Well, finally, let’s remember President Trump’s vow not to touch Medicare. Well, Medicare gets touched in this bill, too. In addition to restricting eligibility for some legal immigrants who are able to get coverage now, and making it harder for some low-income Medicare beneficiaries to get extra financial help, mostly through Medicaid, the bill as a whole is also likely to trigger a 4% Medicare sequester. Because, even all those other health cuts and food stamp cuts and other cuts don’t pay for all the huge tax breaks in the bill. Alice, you pointed that out. Is there any suggestion that this part might give people some pause, maybe when it gets to the Senate? 

Edney: I’ve heard the Senate mostly seem upset about Medicaid. And I also feel like this idea that sequestration is coming back up into our consciousness is a little bit new. Like you said, it was pushed through and it was like, Oh, wait, this is enough to trigger sequestration. I think it certainly could become a talking point, because Trump said he would not cut Medicare. I don’t think, if senators are worried about Medicaid — and I think maybe some of us were a little surprised that that is coming from some red-state senators. Medicare is a whole different thing, and in the sense of being even more wildly popular with a lot of members of Congress. 

Rovner: Yeah, I think this whole thing hasn’t, you’re right, sort of seeped into the general consciousness yet. Alice, did you want to say something? 

Ollstein: Yeah, so a couple things, a couple patterns we’ve seen. So one, there are a lot of lawmakers on the right who have been discrediting the CBO, even in advance of estimates coming out, basically disparaging their methodology and trying to convince the public that it’s not accurate. And so I think that’s both around the deficit projections as well as how many people would be uninsured under different policies. So that’s been one reaction to this. 

We’ve seen a pattern over many administrations where certain politicians are very concerned about things adding to the deficit when the opposition party is in power. And suddenly those concerns evaporate when their own party is in power and they don’t mind running up the deficit if it’s to advance policies that they want to advance. And so I think, yes, this could bother some fiscal hawks, and we saw that in the House, but I think, also, these other factors are at play. 

Rovner: Yeah, I think this has a long way to go. There’s still a lot that people, I think you’re right, have not quite realized is in there. And we will get to more of it in coming weeks, because this has a long process in the Senate. 

All right, well, segueing to abortion, the One Big Beautiful Bill also includes a couple of pretty significant abortion provisions. One would effectively ban abortion and marketplace plans for people with lower incomes. Affordable Care Act plans are not currently a big source of insurance coverage for abortion. Many states already ban abortion from coverage in these plans. But this would disrupt one of the big compromises that ultimately got the ACA passed in 2010. 

The other provision would evict Planned Parenthood from the Medicaid program, even though federal Medicaid funds don’t and never have been used for abortions. Many, many Medicaid patients use Planned Parenthood for routine medical care, including contraception and cancer screenings, and that is covered by Medicaid. 

But while I see lots of anti-abortion groups taking victory laps over this, when the House passed a similar provision in 2017 as part of its repeal bill, the Senate parliamentarian ruled that it could not go in a budget reconciliation bill, because its purpose was not, quote, “primarily budgetary.” So is this all for show? Or is there a belief that something different might happen this time? 

Ollstein: Well, I think there is more interest in ignoring or overruling the parliamentarian among Senate Republicans than there has been in the past. We’re seeing that now on an unrelated environmental issue. And so that could signal that they’re willing to do it more in the future. Of course, things like that cut both ways, and that raises the idea that the Democrats could also do that the next time they’re in power. 

Rovner: And we should say, that if you overrule the parliamentarian in reconciliation — it’s a she right now — when she says it can’t go in reconciliation, that is equivalent to getting rid of the filibuster. 

Ollstein: Correct. 

Rovner: So I mean, that’s why both parties say, We want to keep the filibuster. But the moment you say, Hey, parliamentarian, we disagree with you and we’re just going to ignore that, that has ramifications way beyond budget reconciliation legislation. 

Ollstein: That’s right. And so that’s been a line that a lot of senators have not been willing to cross, but I think you’re seeing more willingness than before. So that’s definitely something to watch on that. But I think, in terms of abortion, I think this is a real expansion of trends that were already underway, in ever-expanding the concept of what federal dollars going to abortion means. And it’s now in this very indirect way, where it’s reaching into the private insurance market, and it’s using federal funding as a cudgel to prevent groups like Planned Parenthood, and then also these private plans, from using other non-federal money to support abortions. And so it’s a real expansion beyond just you can’t use federal money to pay directly for abortions. 

Rovner: Well, meanwhile, two other reproductive-associated health stories worth mentioning. In California, a fertility clinic got bombed. The bomber apparently died in the explosion, but this is the first time I can remember a purposeful bombing to a health center that was not an abortion clinic. How significant is it to the debate, that we’re now seeing fertility clinics bombed as well? And what do we know, if anything, about why the bomber went after a fertility clinic? 

Karlin-Smith: There has been, obviously, some pressure on the right, I think, to go after fertility processes, and IVF [in vitro fertilization], and lump that in with abortion. Although, I think Trump and others have pushed back a bit on that, realizing how common and popular some of these fertility treatments are. And also it conflicts, I think, to some extent with their desire to grow the American population. 

The motives of this particular person don’t seem aligned with, I guess, the anti-abortion movement. He sort of seems more anti-natalist movement and stuff. So from that perspective, I didn’t see it as being aligned with kind of a bigger, more common political debate we’ve had recently, which is, again, does the Republican Party want to expand the anti-abortion debate even further into fertility treatments and stuff. 

Rovner: I was going to say, it certainly has drawn fertility clinics into the abortion debate, even if neither side in the abortion debate would presumably have an interest in blowing up a fertility clinic. But it is now sort of, I guess, in the general consciousness of antisocial people, if you will, that’s out there. 

The other story in the news this week is about a woman named Adriana Smith, a nurse and mother from Georgia who was nine weeks pregnant in February when she was declared brain-dead after a medical emergency. Smith has been kept alive on life support ever since, not because her family wants that but because her medical team at Emory University Hospital is worried about running afoul of Georgia’s abortion ban, which prohibits terminations after cardiac activity can be detected. Even if the mother is clinically dead? I feel like this case could have really ominous repercussions at some point. 

Ollstein: Well, I just want to point out that, yes, the state’s abortion ban is playing a role here, but this was happening while Roe v. Wade was still in place. There were cases like this. Some of it has to do with legislation around advanced directives and pregnancy. So I will point out that this is not solely a post-Dobbs phenomenon. 

Rovner: Yeah, I think it also bears watching. Well, there was lots of vaccine news this week — I’m so glad we have Anna and Sarah here — with both the HHS [Department of Health and Human Services] and FDA [Food and Drug Administration] declaring an end to recommending covid vaccines for what seems to be most of the population. Sarah, what did they do? And what does this mean? 

Karlin-Smith: So the new director of FDA’s biologics center and the FDA commissioner released a framework for approving covid shots moving forward. And basically they are saying that, because covid, the virus, shifts, and we want to try and update our vaccines at least yearly, usually, to keep up with the changing viruses, but we want to do that in a reasonable time so that by the time when you update the vaccine it’s actually available within that time — right? — FDA has allowed companies to do studies that don’t require full clinical trials anymore, because we sort of have already done those trials. We know these vaccines are safe and effective. We’re making minor tweaks to them, and they do immunogenicity studies, which are studies that basically show they mount the proper immune response. And then they approve them. 

FDA is now, seems to be, saying, We’re only going to allow those studies to approve new covid vaccine updates for people who are over 65, or under 65 and have health conditions, because they are saying, in their mind, the risk-benefit balance of offering these shots doesn’t necessarily pan out favorably for younger, healthier populations, and we should do clinical trials. 

It’s not entirely clear yet, despite them rolling out a framework, how this will actually play out. Can they relabel shots already approved? Will this only impact once companies do need to do a strain change next as the virus adapts? Did they go about doing this in a sort of legal manner? It came out through a journal kind of editorial commentary piece, not through the Federal Register or formal guidance. There’s been no notice of comment. 

So there’s a lot of questions to remain as to how this will be implemented, which products it would affect, and when. But there is a lot of concern that there may be reduced access to the products moving forward. 

Rovner: That’s because the vaccine makers aren’t going to — it’s not probably worth it financially to them — to remount all these studies. Right? 

Karlin-Smith: First off, a lot of people I’ve talked to, and this came up yesterday at a meeting FDA had, don’t believe it’s actually ethical to do some of the studies FDA is now calling for. Even though the benefits, particularly when you’re talking about boosting people who already had a primary vaccination series for covid, or some covid, is not the same as the benefits of getting an original covid vaccine series. 

There still are benefits, and there still are benefits for pretty much everybody that outweigh the risks. On average, these are extremely safe shots. We know a lot about their safety, and the balance is positive. So people are saying, once that exists, you cannot ethically test it on placebo. Even as [FDA Commissioner Marty] Makary says, Well, so many Americans are declining to take the shot, so let’s test it and see. A lot of ethicists would say it’s actually, even if people are willing to do something that may not be ideal for their health, that doesn’t mean it’s ethical to test it in a trial. 

So, I think there’s questions about, just, ethics, but also, right, whether companies would want to invest the time and money it would take to achieve and try to do them under this situation. So that is a big elephant in the room here. And I think some people feel like this is just sort of a push by Makary and his new CBER [Center for Biologics Evaluation and Research] director, essentially, to cut off vaccine access in a little bit of a sneaky way. 

Rovner: Well, I did see, also this week, was I think it was Moderna, that was going to make a combination flu covid vaccine, has decided not to. I assume that’s related to all of this? 

Karlin-Smith: Right. So Moderna had a, what people call a next-generation vaccine, which is supposed to be an improved update over the original shot, which is a bigger deal than just making a strain change. They actually think they provide a better response to protecting against the virus. And then they also added flu vaccine into it to sort of make it easier for people to get protected from both, and also provided solid data to show it would work well for flu. 

And they seem to have probably pulled their application at this point over, again, these new concerns, and what we know Novavax went through in trying to get their covid vaccine across the finish line dealing with this new administration. So I think people have their sort of alert lights up going forward as to how this administration is going to handle vaccine approvals and what that will mean for access going forward. 

Rovner: Well, in somewhat related news, we got the long-awaited report from Health and Human Services Secretary Robert F. Kennedy Jr.’s Make America Healthy Again Commission, which is supposed to lay out a blueprint for an action plan that will come later this summer. Not much in the 68-page report seems all that surprising. Some is fairly noncontroversial, calling for more study of ultra-processed foods and less screen time and more physical activity for kids. 

And some is controversial but at this point kind of predictable, calling for another look at the childhood vaccine schedule, including, as we just discussed, more placebo studies for vaccines, and also less fluoride available, except in toothpaste. Anything jump out at you guys from the report that we should keep an eye on? 

Karlin-Smith: I think one thing to think about is what it doesn’t address and doesn’t talk about. It’s not surprising the issues they call out for harming health in America, and some of them are debatable as to how much they do or don’t harm health, or whether their solutions would actually address those problems. 

But they never talk about the U.S.’ lack of a health insurance system that assures people have coverage. They don’t mention the Republican Party’s and likely president’s willingness to sign onto a major bill that’s going to impact health. They don’t really talk about the socioeconomic drivers that impact health, which I find particularly interesting when they talk about food, because, obviously, the U.S. has a lot of healthy and unhealthy food available. And a lot of people know sort of how they could make better choices, but there are these situational factors outside of, often, an individual’s control to lead to that. 

And I think the other thing that jumped out to me is, I think The Washington Post had a good line in their paragraph about just how many of the points are either overstated or misstated scientific findings. And they did a pretty good job of going through some of those. And it’s a difficult situation, I think, for the public to grapple with when you have leadership and the top echelons of our health department that is pushing so much misinformation, often very carefully, and having to weed out what is correct, where is the grains of truth, where does it go off into misinformation. 

I don’t know. I find it really hard as a journalist. And so I do worry about, again, how this all plays into public perception and misunderstanding of these topics. 

Rovner: And apparently they forgot about gun violence in all of this, which is rather notably not there. 

Ollstein: Cars and guns are the big killers. And yeah, no mention of that. 

Edney: I thought another glaring omission was tobacco. Kids are using e-cigarettes at high rates. We don’t really know much about them. And to Sarah’s point about misinformation, too, I think the hard part of being able to discern a lot of this, even as a member of the public, is everything they’ve done so far is only rhetoric. There hasn’t been actual regulation, or — this could be anything that you’re talking about. It could be food dyes. It could be “most favored nations.” We don’t know what they actually want to implement and what the potential for doing so — I think maybe on vaccines we’re seeing the most action. But as Sarah mentioned, we don’t know how that, whether it legally is going to be something that they can continue doing. 

So even with this report, it was highly anticipated, but I don’t think we got anything beyond what I probably heard Kennedy say over and over throughout the campaign and in his bid for health secretary. So I am wondering when they actually decide to move into the policymaking part of it, instead of just telling us they’re going to do something. 

Rovner: And interestingly, Secretary Kennedy was interviewed on CNN last night and walked back some of the timelines, even, including that vow that they were going to know the cause of autism by September and that they were going to have an action plan for this ready in another, I think, a hundred days. So this is going to be a hurry-up-and-wait. 

All right, well, that is as much news as we have time for in this incredibly busy week. Now we will play my interview with law professor and abortion historian Mary Ziegler, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Mary Ziegler, the Martin Luther King Jr. professor of law at the University of California-Davis. She’s also a historian of the abortion movement. And her newest book, just out, is called “Personhood: The New Civil War Over Reproduction.” 

Mary Ziegler, thanks for joining us again. 

Mary Ziegler: Thanks for having me. 

Rovner: So we’ve talked about personhood a lot on our podcast, including with you, but it means different things to different people. What’s your working definition, at least for the purpose of this book? 

Ziegler: Yeah, I’m interested in this book in the legal fight for personhood, right? Some people have religious ideas of personhood. Bioethicists have ideas of personhood. Philosophers debate personhood. But I’m really interested in the legal claim that the word “person” in the 14th Amendment, which gives us liberty and equality, applies the moment an egg is fertilized. Because it’s that legal claim that’s had a lot of knock-on effects with abortion, with IVF, and potentially even beyond. 

Rovner: So if we as a society were to accept that fetuses or embryos or zygotes were people with full constitutional rights at the moment of creation, that can impact things way beyond abortion, right? 

Ziegler: Definitely, yeah, especially if you make the moves that the anti-abortion movement, or the pro-life movement, in the United States has made, right? So one of the other things that’s probably worth saying is, if you believe the claim I laid out about fetal personhood, that doesn’t mean you necessarily think abortion should be criminalized or that IVF should be criminalized, either. 

But the people who are leading the anti-abortion movement do, in large part, right? So it would have ramifications in lots of other contexts, because there’s a conclusion not only that human life begins at fertilization and that constitutional rights begin at fertilization but that the way you honor those constitutional rights is primarily by restricting or criminalizing certain things that threaten that life, in the views of the people who advocate for it. 

Rovner: Right. And that includes IVF and forms of contraception. That’s where we sort of get to this idea that an abortion is murder or that, in this case, doing anything that harms even a zygote is murder. 

Ziegler: Yeah. And it gets us to the Adriana Smith case in Georgia, too. So there’s sort of end-of-life cases that emerge. So, it obviously would have a big impact on abortion. So it’s not wrong to think about abortion in this context. It’s just that would definitely not be the stopping point. 

Rovner: So, many people have only talked about personhood, really, since the Supreme Court overturned Roe in 2022, but the concept is a lot older than that. I started covering personhood in like 2010, I think, when a couple of states were trying to vote on it. I didn’t realize until I read your book that it goes back well beyond even that. 

Ziegler: Yeah. So I think a lot of people had that conception. And in the 2010s, there were state constitutional amendment efforts to write the idea of fetal personhood into state constitutions. And they all failed. So I think the narrative coming out of that was that you had the anti-abortion movement on the one hand, and then you had this more extreme fetal personhood movement on the other hand. 

And that narrative fundamentally is wrong. There is no one in the anti-abortion movement who’s opposed to fetal personhood. There are disagreements about how and when it can be recognized. There’s strategic disagreements. There are no substantive disagreements much to speak of on the basics of fetal personhood. 

So the idea goes all the way back to the 1960s, when states were first reforming the 19th-century criminal laws you sometimes see coming back to life as zombie laws. And initially it started as a strategic necessity, because it was very hard for the early anti-abortion movement to stop this reform wave, right? They were saying things like, Oh, abortion is going to lead to more sexual promiscuity, or, No one really needs abortion, because pregnancy is no longer dangerous. And that just wasn’t getting the job done. 

So they began to argue that no one had a choice to legalize abortion in worse circumstances, because it would violate the rights of the unborn child. What’s interesting is that argument went from being this kind of strategic expedient to being this tremendously emotionally resonant long-term thing that has lived on the American right for now like a half-century. Even in moments when, I think arguably like right now, when it’s not politically smart to be making the argument, people will continue to, because this speaks to something, I think, for a lot of people who are opposed to abortion and other things like IVF. 

Rovner: I know you’ve got access in writing this book to a lot of internal documents from people in the anti-abortion movement. I’m jealous, I have to say. Was there something there that surprised you? 

Ziegler: Yeah, I think I was somewhat surprised by how much people talked this language of personhood when they were alone, right? This was not just something for the consumption of judges, or the consumption of politicians, or sort of like a nicer way to talk about what people really wanted. This was what people said when there was no one else there. 

That didn’t mean they didn’t say other things that suggested that there were lots of other values and beliefs underlying this concept of personhood. But I think one of the important lessons of that is if you’re trying to understand people who are opposed to abortion, just assuming that everything they’re saying is just pure strategy is not helpful, right? Any more than it would be for people who support reproductive rights, to have it assume that everything they’re saying is not genuine. You just fail to understand what people are doing, I think. And I think that was probably what I was the most surprised about. 

Rovner: I was struck that you point out that personhood doesn’t have to begin and end with the criminalization of abortion. How could more acceptance of the rights of the unborn change society in perhaps less polarized ways? 

Ziegler: Yeah, one of the things that’s really striking is that there are other countries that recognize a right to life for a fetus or unborn child that don’t criminalize abortion or don’t enforce criminal abortion laws. And often what they say is that it’s not OK for the state to start with criminalization when it isn’t doing things to support pregnant women, who after all are necessary for a fetus or unborn child to survive, right? 

So there are strategies that you could use to reduce infant mortality, for example, to reduce neonatal mortality, to reduce miscarriage and stillbirth, to improve maternal health, to really eliminate some of the reasons that people who may want, all things being equal, to carry a child to term. That’s not, obviously, going to be everybody. Some people don’t want to be parents at all. 

But there are other people for whom it’s a matter of resources, or it’s a matter of overcoming racial discrimination, or it’s a matter of leaving an abusive relationship. And if governments were more committed to doing some of those things, it’s reasonable to assume that a subset of those people would carry pregnancies to term, right? 

So there are lots of ways that if a state were serious about honoring fetal life, that it could. I think one of the other things that’s striking that I realized in writing the book is that that tracks with what a subset of Americans think. You’ll find these artifacts in polls where you’ll get something like 33% of people in Pew Forum’s 2022 poll saying they thought that life and rights began at conception, but also that abortion shouldn’t be criminalized. 

So there are a subset of Americans who, whether they’re coming from a place of faith or otherwise, can hold those two beliefs at once. So I think an interesting question is, could we have a politics that accommodates that kind of belief? And at the moment the answer is probably not, but it’s interesting to imagine how that could change. 

Rovner: It’s nice to know that there is a place that we can hope to get. 

Ziegler: Yeah, exactly. 

Rovner: Mary Ziegler, thank you so much for joining us again. 

Ziegler: Thanks for having me. 

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

Karlin-Smith: I purposely chose a sort of light story from Australia, where scientists studied remote work, and the headline is “[Scientists Have Been Studying Remote Work for Four Years and Have] Reached a Very Clear Conclusion: ‘Working From Home Makes Us Happier.’” And it just goes through some of the benefits and perks people have found from working remotely, including more sleep, more time with friends and family, things like that. And it just felt like a nice, interesting read in a time where there’s a lot of heavy health news. 

Rovner: Also, scientific evidence of things that I think we all could have predicted. Anna. 

Edney: Apologies for going the other direction here, but it’s a story that I wrote this week, an investigation that I’ve been working on for a long time, “The Potential Cancer, Health Risks Lurking in One Popular OTC Drug.” So this is one, in particularly a lot of women have used. You can go in any CVS, Target, Walmart, stores like that, and buy it. Called Azo, for urinary tract infections. And all these stores sell their own generic versions as well, under phenazopyridine. 

And this drug, I was kind of shocked to learn, is not FDA-approved. There are prescription versions that are not FDA-approved, either. It’s just been around so long that it’s been grandfathered in. And that may not be a big deal, except that this one, the FDA has raised questions about whether it causes cancer and whether it needs a stronger cancer warning, because the National Cancer Institute found in 1978 that it causes tumors in rats and mice. But no other work has been done on this drug, because it hasn’t been approved. So no one’s looked at it in humans. And it masks issues that really need antibiotics and causes a host of other issues. 

There were — University of Virginia toxicologists told me they found, in the last 20 years, at least 200 suspected teen suicides where they used this drug, because of how dangerous this drug can be in any higher amounts than what’s on the box. So I went through this drug, but there are other ones on the market as well that are not approved. And there’s this whole FDA system that has allowed the OTC [over-the-counter] market to be pretty lax. 

Rovner: OK, that’s terrifying. But thank you for your work. Alice. 

Ollstein: Speaking of terrifying, I chose a piece from NPR called, “Diseases Are Spreading. The CDC Isn’t Warning the Public Like It Was Months Ago.” And this is a look at all of the ways our public health agency that is supposed to be letting us know when outbreaks are happening, and where, and how to protect ourselves, they’ve gone dark. They are not posting on social media. They are not sending out alerts. They are not sending out newsletters. And it walks through the danger of all of that happening, with interviews with people who are still on the inside and on the outside experiencing the repercussions. 

Rovner: Well, my extra credit, it helps explain why Alice’s extra credit, because it’s about all the people who were doing that who have been fired or laid off from the federal government. It’s called, “White House Officials Wanted To Put Federal Workers ‘in Trauma.’ It’s Working,” by William Wan and Hannah Natanson. 

And it’s the result of interviews with more than 30 current and former federal workers, along with the families of some who died or killed themselves. And it’s a review of documents to confirm those stories. It’s a super-depressing but beautifully told piece about the dramatic mental health impact of the federal DOGE [Department of Government Efficiency] layoffs and firings, and the impact that that’s been having on these workers, their families, and their communities. 

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 to our fill-in editor this week, Rebecca Adams, and our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging these days? Anna? 

Edney: Both of those [X and Bluesky], @annaedney. 

Rovner: Sarah. 

Karlin-Smith: Everywhere — X, Bluesky, LinkedIn, @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

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

Rovner: I am off to California next week, where we’ll be taping the podcast at the annual meeting of the Association for Health Care Journalists, which we won’t post until the following Monday. So everyone please have a great Memorial Day holiday week. And 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.

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

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

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

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Anna Edney
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Maya Goldman
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Sandhya Raman
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Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

click to open the transcript

Transcript: Cutting Medicaid Is Hard — Even for the GOP

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

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

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

Anna Edney: Hi, everybody. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

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

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

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

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

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

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

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

Goldman: Yeah. 

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

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

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

Goldman: And President Trump has said that as well. 

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

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

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

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

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

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

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

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

Edney: That’s where. 

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

Edney: Right. 

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: We’re importing other countries’— 

Edney: —prices. 

Rovner: —price limits. 

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

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

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

Goldman: If I’m remembering— 

Rovner: But I think they won. 

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

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

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

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

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

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

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

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

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

Raman: From both sides— 

Rovner: Go ahead, Sandhya. 

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

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

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

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

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

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

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

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

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

Rovner: He hasn’t yet. 

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

Rovner: Face-saving for Kennedy or for Cassidy? 

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

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

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

Lauren Sausser: Thank you. Thanks for having me. 

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

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

Rovner: And how big was the bill? 

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

Rovner: Which is a lot. 

Sausser: A lot. 

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

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

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

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

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

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

Rovner: So what eventually happened with this bill? 

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

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

Sausser: Right. 

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

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

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

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

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

Sausser: Thank you. 

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

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

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

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

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

Edney: “Creative” is a nice word. 

Rovner: Sandhya. 

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

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

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

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

Rovner: Anna. 

Edney: X and Bluesky, @annaedney. 

Rovner: Maya. 

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

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

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