Congress has mostly stood by as the Trump administration — spurred by Elon Musk and his Department of Government Efficiency, named and created by President Donald Trump  — takes a chainsaw to a broad array of government programs. But now the courts are stepping in to slow or stop some efforts that critics claim are illegal, unconstitutional, or both.

Funding freezes and contract cancellations are already having a chilling effect on health programs, such as biomedical research grants for the National Institutes of Health, humanitarian and health aid provided overseas by the U.S. Agency for International Development, and federal funding owed to community health centers and other domestic agencies.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Shefali Luthra of The 19th, and Maya Goldman of Axios.

Panelists

Among the takeaways from this week’s episode:

• Universities are reconsidering hiring and other forward-looking actions after the Trump administration imposed an abrupt, immediate cap on indirect costs, which help cover overhead and related expenses that aren’t included in federal research grants. A slowdown at research institutions could undermine the prospects for innovation generally — and the nation’s economy specifically, as the United States relies quite a bit on those jobs and the developments they produce.
• The Trump administration’s decision to apply the cap on indirect costs to not only future but also current federal grants specifically violates the terms of spending legislation passed by Congress. Meanwhile, the health impacts of the sudden shuttering of USAID are becoming clear, including concerns about how unprepared the nation could be for a health threat that emerges abroad.
• Congress still hasn’t approved a full funding package for this year, and Republicans don’t seem to be in a hurry to do more than extend the current extension — and pass a budget resolution to fund Trump’s priorities and defund his chosen targets.
• The House GOP budget resolution package released this week includes a call for $880 billion in spending cuts that is expected to hit Medicaid hard. House Republican leaders say they’re weighing imposing work requirements, but only a small percentage of Medicaid beneficiaries would be subject to that change, as most would be exempt due to disability or other reasons — or are already working. Cuts to Medicaid could have cascading consequences, including for the national problem of maternal mortality.

Also this week, Rovner interviews Mark McClellan — director of the Duke-Margolis Institute for Health Policy who led the FDA and the Centers for Medicare & Medicaid Services during the George W. Bush administration — about the impact of cutting funding to research universities. And Rovner reads the winner of the annual KFF Health News’ “health policy valentines” contest.

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

Julie Rovner: Axios’ “Nonprofit Hospital Draws Backlash for Super Bowl Ad,” by Maya Goldman. 

Shefali Luthra: Politico’s “‘Americans Can and Will Die From This’: USAID Worker Details Dangers, Chaos,” by Jonathan Martin. 

Maya Goldman: KFF Health News’ “Doctor Wanted: Small Town in Florida Offers Big Perks To Attract a Physician,” by Daniel Chang.

Jessie Hellmann: NPR’s “Trump’s Ban on Gender-Affirming Care for Young People Puts Hospitals in a Bind,” by Selena Simmons-Duffin. 

Also mentioned in this week’s podcast:

• Reuters’ “USAID Families Have Their Lives Upended by Trump Move To Shut Agency,” by Jonathan Landay and Humeyra Pamuk.
• Newsweek’s “First USAID Death as Freeze Sees Oxygen Supplies Cut Off for Refugee,” by Theo Burman.

[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, Feb. 13, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi. 

Rovner: And we welcome to the podcast our first of two new panelists you’ll be hearing in the coming weeks, Maya Goldman of Axios news. 

Maya Goldman: Hi, great to be here. 

Rovner: Later in this episode we’ll have my interview with doctor and economist Mark McClellan, former commissioner of the Food and Drug Administration and administrator of the Centers for Medicare & Medicaid Services under President George W. Bush — though not at the same time. Mark now heads a research institute at Duke University, and he will try to explain what’s happening with NIH [National Institutes of Health] grants. We also have the winner of our annual KFF Health News Health Policy Valentine Contest, but first this week’s health news. 

So by the time you hear this, Robert F. Kennedy Jr. is almost certain to have been confirmed by the Senate as the next secretary of health and human services. But even before he gets sworn in, as we have been chronicling these past few weeks, things are changing fast and furious over at HHS [the Department of Health and Human Services], and, increasingly, courts are trying to stop or at least slow some of those changes. 

The thread running through all of these, which we will talk about, is growing doubt about whether this administration will comply with those court orders or touch off a constitutional crisis. So I admit I had to make myself a chart to keep track of all of these lawsuits challenging all of the actions the administration has taken just in its first three weeks. We’ll start with what’s going on — or not — at the National Institutes of Health, where last Friday night the agency announced that, henceforth, indirect costs as part of agency grants would be capped at 15%, including for current grants. We’ll have more on this and what it might mean in my chat with Mark McClellan later in this episode. But suffice it to say that I am old enough to remember when NIH was an untouchable jewel for both Republicans and Democrats. What the heck happened here? 

Hellmann: I think Elon Musk, in his crusade to find government waste, decided to hone in on NIH next. And this has been something that the conservative think tanks have been talking about for a little bit, that they think some of these universities are just ripping off the government with these indirect costs on NIH grants. Some of the universities get up to 60% or higher on their NIH grants to cover administrative costs, staffing, stuff like that. But it’s just become a target. [President Donald] Trump also tried to do something similar in 2017, but Congress said, No, we do not want to do that, and actually put a rider in appropriations bills to stop it. And that was kind of the end of it. But it seems like the strategy in this version of the Trump administration is to do something anyway and then take it through the courts. 

Rovner: Don’t skip over that too fast. There’s actual language in the spending bill that says you can’t do this. 

Hellmann: Yeah, there just doesn’t seem to be a lot of concern about this, even from people who have historically supported NIH, and Republicans are just kind of going along with what Elon Musk has been saying about, This is wasteful. We think 15% is fair. So it’s definitely been a big shift. 

Goldman: There have been some Republicans that have spoken out, though. I think Sen. Katie Britt from Alabama was one of the first voices to — I don’t know if you could necessarily say she spoke out against it so strongly, but she said, I value the research that the universities in my state do, and I’m talking to RFK Jr. I think, well, it’s not the same kind of response that we might’ve seen seven, eight years ago. There is a little bit of pushback, which is I think different than some other health changes that we’ve seen. 

Rovner: I did notice that [Sen.] Susan Collins had a strongly worded statement in which she buried the news that she was going to vote for RFK Jr., too, as HHS secretary but also saying that Jackson Labs, big biomedical research facility in Maine, thinks this is really important. I have sort of a broader question. This usually comes up in the context of Medicare. We talk about whether or not the federal government is a good or a bad business partner. Because if they keep changing the rules, you don’t want to rely on their word if it can change. I mean it’s one thing to say, Yes, going forward we’re going to cap indirect costs of 15% and you can decide whether to take it or leave it, but they’re doing this for current grant. They’re just saying: OK, that’s it. We’re not going to pay you this money that we gave you a grant and agreed to pay you for five years. One would think that could have longer-term consequences even if this is eventually reversed. And as I just said, there is language in the spending bill that says they can’t do this. 

Luthra: The other thing that I think is worth noting is that there is this sort of uncertainty that it has created at a lot of universities, similar to what we’re seeing in basically any institution that’s been touched by some sort of very sudden funding freeze or funding cut. A lot of universities really rely on these funds, and they don’t know whether they will come back, whether they’ll be losing tens of millions of dollars each year. And they’re trying to plan their budgets, and that means in some cases I’ve heard about universities canceling existing hiring cycles because they don’t think they can necessarily afford to pay for employees that two weeks ago they thought they’d be able to. And what we have seen in other institutions, which we’ll talk about later in the podcast, is coming up here in academia as well, and this will just have vast ripple effects throughout our country and our economy, given what a big role universities play. 

Rovner: And also, in the young scientist pipeline, that’s always been a concern that, who’s going to be the next generation. If graduate students and even undergraduate students see all of this uncertainty and people being suddenly laid off, are they going to think, Well, maybe I should go learn coding or do something else? Maya, you’re nodding. 

Goldman: Yeah, I talked to somebody yesterday who said she’s hearing from students that she mentors — she’s a professor — she’s hearing from students that she mentors that they’re, like, Maybe I should just go to the private sector and make some money. Which I think is actually maybe one of the underlying goals of DOGE [the Department of Government Efficiency] and Elon Musk, to get people to go to the private sector. 

Rovner: Although as we discover, and we will talk more about this, the private sector gets a lot of money from the federal government. 

Goldman: Absolutely. 

Rovner: That’s been kind of the Republican mantra for many generations, of Let’s partner more with the private sectors. Therefore, there’s a lot of partnerships between the public and private sectors. 

Hellmann: It’s also interesting because there’s been a lot of distrust from RFK Jr. about health research done in the private sector by pharmaceutical companies. So if you’re not doing this research or funding it through NIH and you don’t trust pharmaceutical companies to do it, either, then where does that leave you? 

Rovner: Well, moving on to the broader funding freeze that the Office of Management and Budget tried to impose, then tried to rescind, but apparently didn’t in many cases. A U.S. district judge ordered the administration to resume payments, and when officials didn’t, another judge in a second lawsuit ordered the resumption in much angrier terms and led Elon Musk and Vice President JD Vance, the latter of whom is a graduate of Yale Law School, to question whether judges even have the authority to tell the executive branch what it can and can’t do. I have not been to law school, but, I don’t know, I’ve been doing this for a long time, and my perception has always been that’s courts’ jobs, to tell the executive branch and Congress what it can and can’t do. Is it not? 

Luthra: It is, and any of us who has taken civics or American history could tell you that. But I do think it’s worth noting that this actually isn’t a new talking point for, in particular, the vice president, who frequently references Andrew Jackson, the president who famously said: “The courts have made their order. Let’s see them enforce it.” And to what you alluded to earlier, Julie, that is the question about whether we find ourselves hurtling toward some kind of very serious constitutional, if not crisis, then very serious concern about whether the separation of equal powers remains tantamount. 

Rovner: I think you can call it a constitutional crisis. I mean we’re not there yet— 

Luthra: Yes, but we could be hurtling toward one. 

Rovner: Yes. I think that’s very, very fair. 

Luthra: Excellent. 

Rovner: Well, also among the early Trump actions getting shot down by federal judges are the removal of various webpages and datasets at HHS, including a two-week delay of the release of the CDC’s [Centers for Disease Control and Prevention’s] Morbidity and Mortality Weekly Report, with a couple of key studies of bird flu, which by the way continues to spread from birds to cows to people in a growing number of states, most lately Nevada. In a case filed by the liberal groups Doctors for America and Public Citizen, a judge has given HHS until this Friday to restore the websites to the state they were in before they were taken down. I checked this morning, and the CDC website still says it’s being, quote, “modified” to comply with the president’s executive orders. Is this another of those judicial orders the administration considers optional to obey? 

Goldman: I am very curious to see that. I think it’s also hard to wrap my head around exactly what was taken down and changed, because there’s just so much information on the CDC’s website, on federal health websites. So I think it’ll be really hard to know unless you’re looking on a case-by-case basis to see if something has been restored or changed. 

Rovner: I did see, I think this was in The Washington Post, a researcher who said she had a paper on using mobile vans to distribute fruit and vegetables and healthier foods in remote areas and it was taken down because it had the word “diverse” populations in it. I can’t remember whether it was back up or not. But I mean, yes, the president gets to say, We’re not going to do DEI [diversity, equality, and inclusion] again, but this is like the NIH grant. It’s one thing to say we’re not going to do this going forward, and it’s another thing to say everybody who’s ever said this is now fired, which basically they’re saying in a lot of departments. 

Luthra: And that words have very vast meanings. You mentioned diverse populations. “Biodiversity,” a scientific term that may not be used in a lot of these papers anymore, just sort of creates a real chilling effect and makes it in some cases impossible to do accurate science. 

Rovner: Yes. And if you missed it in last week’s episode, I read out part of the list of the words that can no longer be used in federally funded research. Well, outside of HHS, but still inside of health care, the fight continues over the fate of the U.S. Agency for International Development, which Elon Musk has all but obliterated. This may be an example of court relief coming too late. We’re getting stories of rotting food in warehouses with no one to deliver it, a 71-year-old refugee from Myanmar dying because the hospital that had been providing her oxygen in Thailand closed suddenly, and pregnant USAID workers suddenly finding themselves ordered to change continents while in their third trimester of pregnancy. Is there a point to this? There’s so far been no real evidence of fraud in the program. It’s only spending that the new administration doesn’t agree with. 

Luthra: I think we could go even further than spending they don’t agree with. It’s hard to see that they’ve even reviewed it. A lot of the reporting coming out shows that people who work at USAID haven’t gotten any questions from the administration about, What work are you doing? There’s been process initiated to review all the grants that they have frozen, which suggests that maybe they won’t actually do that. This seems very arbitrary, very broad, and to your point, Julie, the health implications will be and are very immediate and very sweeping and risk setting Americans, but also people across the globe, back in terms of health progress by I don’t even know how much. 

Rovner: One presumes that USAID is a target because Americans in general don’t like foreign aid. This is foreign aid. Most people haven’t heard of it. It’s an easy target, if you will, and they can sort of, like, If we can do this with USAID, then we can go on and do it with things that might be a little more politically sensitive. Is that a fair interpretation? Maya, you’re nodding. 

Goldman: Yeah. I mean I think so, but it’s also a matter of national security in a lot of ways, and foreign aid, at least global health foreign aid, is a pretty small fraction of the federal budget. But I’ve been talking to some virologists who are really worried that the collapse of U.S. involvement in global health efforts, there’s going to be viruses that mutate and then come back to the U.S., and who knows if we’ll have the public health infrastructure in our country to fight them anymore. But it’s also just a good investment to fight these viruses, prevent these viruses abroad before they even get to the U.S. 

Rovner: Yeah, it’s better to control Ebola in Africa before somebody with it gets on an airplane. 

Goldman: Exactly, yeah. And there’s also the question that we’ve been talking about on my team of the collapse of U.S. soft power in some ways. You’re leaving a vacuum for another country like China, perhaps, to come in and exert influence in other countries. And I think that you could also see that in biomedical research if NIH funding continues to be cut. 

Rovner: So moving over to Capitol Hill, we’ll talk about efforts to launch the fiscal 2026 budget process and legislate President Trump’s agenda in a moment. But first, our weekly reminder that Congress hasn’t yet finished the fiscal 2025 spending bills, even though the fiscal year began last Oct. 1. And the temporary funding that Congress passed in December runs out March 14. So the new Congress must be about to get that all tied up in a bow, right? 

Hellmann: Yeah, it doesn’t seem to be a lot of urgency about that right now. House Republicans are now pushing for a full-year CR [continuing resolution]. Some Democrats are talking about potentially using a potential shutdown as leverage as they fight back against some of these unilateral spending cuts by Elon Musk. But yeah, most of the focus right now seems to be on the budget reconciliation package that Donald Trump wants to extend his tax cuts and do border spending and things like that. And the government doesn’t shut down for a month, which is a million years in Congress time. So— 

Rovner: It’s like the opposite of dog years. But still, when you say a, quote-unquote, “full-year CR,” that’s really a seven-month CR. That’s really just, Let’s continue what we’ve been doing and move on to fight the next battle. 

Hellmann: Yeah. 

Rovner: Which of course they could have done in December, but they didn’t want to, because I think they were going to come in and do exciting things for the rest of fiscal 2025. But Congress being Congress, they’re going to kick the can down the road. And while we’re on news from Congress, as I mentioned at the top, RFK Jr. will become the next health and human services secretary any minute, if it hasn’t already happened. They are literally voting as we tape this morning. This was a huge controversy — until it wasn’t. What happened to Republicans who were so worried about his anti-vax and potentially pro-abortion-rights views? It just all kind of melted away? 

Luthra: I think what happened is what’s happened with every Cabinet nominee with the exception of Matt Gaetz, which is that the resistance from Senate Republicans is simply not there anymore. I’ve been pretty surprised personally to see some of the lawmakers who are typically considered more moderate, the Susan Collinses of the world, Lisa Murkowskis, who in Trump 1 would vote against some of these types of picks but appear to have changed their perspective this time around. There was so much attention on [Sen.] Bill Cassidy during last week’s hearings, and he made a very public conversation about whether RFK Jr.’s views on vaccines would be deeply detrimental. 

And then he came back and said, I have gotten real reassurances that everything will be fine. And all of these lawmakers are citing these private conversations they’ve had and these commitments that they say they received, and at the same time you have Democrats like [Sen.] Patty Murray saying they have never had more disturbing conversations with a nominee than they had with this particular one. And it just really shows how stark the contrast is. You have the Republican Party largely saying yes to everything Donald Trump is proposing, and Democrats may be critical in cases like this one, but without really the power to stop it. 

Rovner: As we pointed out on the podcast, Kennedy showed an almost alarming lack of knowledge about the programs that he’s going to be overseeing as secretary. I mean, not just didn’t know but apparently just didn’t bother to do the basic homework that one would assume that a Cabinet nominee would do before coming before the Senate. Perhaps he knew that it didn’t matter, that Republicans are going to basically fall in line for whoever Trump wants, because that seems to be what’s going on right now. 

Hellmann: Yeah, he was asked about Medicare and Medicaid in his first hearing and didn’t have a very good answer, and then was asked about it in his second hearing and I think somehow gave a worse answer. So it’s like he didn’t go home and do any studying on it. And maybe he has since. 

Rovner: Yeah, we will see. 

Hellmann: Hopefully. 

Rovner: All right. Well, now onto next year’s budget. It’s not hard to see why President Trump is trying to do so much using his executive power, because the Republican Congress is so far looking unlikely to do anything approaching the president’s, quote, “big, beautiful bill” anytime soon. Just a reminder that in 2017 the Republican Congress just barely got its big tax bill over the finish line before Christmas, so it took them an entire year back then. Jessie, I know you’re following this, or trying to. First, why are the House and the Senate seemingly on different tracks? If they’re going to plunge ahead with the president’s agenda, shouldn’t they be trying to do the same thing at the same time? 

Hellmann: I think Trump just wants to let both sides go at it and see who gets it done fastest and who comes up with the best outcome, kind of like pitting them against each other a little bit. But I think Senate Republicans have a lot of doubt about how quickly the House can get this done. There’s been a lot of pushback on the House side from members of the Freedom Caucus, the really conservative members who would like to see deeper spending cuts. And I think House leadership knows that that’s going to necessitate some cuts that are going to be really unpopular for some moderate Republicans in competitive districts. So I think the Senate sees a sense of urgency. Ross Vought, the OMB director, was on the Hill today basically saying they’re running out of money to do some of these immigration things that they want to do, and [Sen.] Lindsey Graham is saying: We need to be more urgent about this. We need to get this done quickly. So I think that that’s why they’re trying to move. 

Rovner: Just to be clear: The Senate is trying to do a smaller bill first with a single budget resolution, and then they’ll do the tax bill later, and the House is trying to do all of it together. Is that basically where we are in the 15-second wrap-up? 

Hellmann: Yes. 

Rovner: Well, President Trump rather famously on the campaign trail said he would not cut Social Security or Medicare benefits, and just two weeks ago he said he wouldn’t cut Medicaid, either, except for fraud and abuse. How on Earth is either chamber going to pay for $4 trillion in tax cuts without cutting Medicare, Medicaid, or Social Security? 

Goldman: I think it’s important to note that Trump said that he’s going to love and cherish Medicaid and only make changes in fraud, waste, and abuse categories. But what does that mean? We don’t really know. There are a lot of ways that that could be interpreted. So I definitely don’t think that Medicaid and, possibly, I haven’t heard chatter about Medicare, but if you apply the same logic, possibly Medicare and Social Security as well are on the table. 

Rovner: Yeah. And Medicaid, I know that certainly everybody seems to be getting all excited about Medicaid work requirements. They seem to have forgotten what we learned before, which is that most people on Medicaid already work, and if they don’t, it’s because they can’t. They’re either disabled themselves, caring for someone who’s disabled, or for other legitimate reasons cannot work. And that when you do work requirements, generally what we discovered in Arkansas is that you knock eligible people off the rolls, not because they’re not working but because they’ve not been able to properly report that they are working. So we saw lots of people who were eligible and working who were still cut — which maybe that’s the idea of how you cut Medicaid and call it waste, fraud, and abuse? 

Goldman: Definitely possible. 

Rovner: Shefali, what’s the impact of a really big cut to Medicaid, besides the fact that it would save a lot of money? 

Luthra: I think it’s something that we don’t talk about enough, because Medicaid is such a tremendous payer for so many people’s health insurance. We’ve seen really meaningful efforts to expand Medicaid’s reach in the past. Even just a few years, I’m thinking about its role in covering pregnancy, in particular. About half of all pregnancies are paid for through Medicaid. A lot of people qualify for the program specifically when they become pregnant, because the income threshold is different. And we’ve seen a lot of states extend eligibility so that you can hold on to your Medicaid for six months postpartum, the period when you’re most vulnerable, in an effort to reduce pregnancy-related mortality. And obviously insurance is not the sole silver bullet toward improving health, but it makes a very big difference. And so when we talk about cuts toward Medicaid, we talk about cuts toward very vulnerable people. We also do talk about backtracking in an effort to undo one of our most significant reproductive health problems, which is that we really trail other wealthy nations when it comes to maternal mortality, and jeopardizing Medicaid means that we could continue to do that. 

Rovner: An administration that pushes not just the pro-life position, but the pro-family position and the pro-natal, the Let’s have more children position, that seems to be something that gets lost, I think, in a lot of this fiscal discussion of, Let’s cut Medicaid to save money so we can have tax cuts. But obviously we will be talking more about this, because this is just the very beginning of it. 

All right. That is the news this week, or at least as much as we have time for. Now we will play my interview with Mark McClellan, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast health economist and doctor Mark McClellan, who is the only person to have led both the Food and Drug Administration and the Centers for Medicare & Medicaid Services, both in the George W. Bush administration. Mark now leads the Duke-Margolis Institute for Health [Policy], which conducts interdisciplinary health policy research across Duke University and its affiliated health care system. Mark, welcome to “What the Health?” 

Mark McClellan: Julie, great to be with you. That was a mouthful and nice to be talking about. There’s so much to discuss on these kinds of topics right now. 

Rovner: I know. You’re really in the right place. So I listened to a podcast that you taped all the way back in January talking about some of the policy changes you were expecting in a second Trump administration. Is it safe to say that what’s happening now over at HHS is not what you were expecting? 

McClellan: Well, maybe it’s a matter of degree and timing, but I think the Trump Version 2 here is, they said themselves, it’s different than Version 1. There are some common themes — tax cuts, deregulation — and some new themes, though, as well — “Make America Healthy Again,” bigger emphasis on finding ways to prevent chronic disease and reduce disease burden than deal frankly with a big frustration of Americans. The first Trump administration was more about repealing the ACA [Affordable Care Act]. This is a different approach here. And also the president promised not to cut Medicare benefits. But then, Julie, I think you’re referring to the third part, which may be the DOGE part, which is a more aggressive approach. As President Trump said, “I’ve learned a lot” over the last eight years. I think he and the people who are advising him have come away from that thinking they can be more aggressive if they want to get more changes done in the direction that they feel like they were elected to pursue. 

Rovner: Well, my main reason in asking you to join us today was to explain this big fight going on at the National Institutes of Health, one of the few major agencies at HHS that you have not led, at least not yet. I assume that many of the researchers you work with have NIH grants, right? 

McClellan: Yeah. So at Duke University, very heavily dependent on federal function, a big federal grant support for its research functions, lots of programs, from gene therapies to cutting-edge AI. All of the efforts to translate that from basic science to impacts on making Americans healthier depends on the NIH. 

Rovner: So how’s the grant process supposed to work? I live near NIH, and I think most people think, Oh, it all goes on there. It’s like the vast majority of it does not go on there. 

McClellan: No, the vast majority is grants that go out to academic institutions and other researchers. And that goes back to the post-World War II era when the United States was trying to figure out what kind of biomedical science policy would work best. And the decision then was we’re not going to have just government institutes run and executed under direct government oversight. We’re going to do this as a public-private partnership with the federal government providing a lot of support, especially for the basic research, what us economists call a public good. Something that benefits everybody is therefore kind of harder for an individual company to support by itself. We’re going to support private academic institutions, nonprofits, sometimes state-affiliated, and we’re going to do that through the grants themselves and also for the infrastructure that’s needed to sustain that research base and grow it out and strengthen it over time. 

Rovner: And that’s what these indirect costs are, right? 

McClellan: Yeah, the indirect costs also date back to the early days, and over time, just like everything else that where federal funding is involved, you’ve got to be careful about how to do it. So in order to do research, you not only need cutting-edge technology and equipment, the funding for the researchers who are the best trained in the world and have the most promising ideas out there, but also funding for increasingly advanced and sophisticated medical equipment, gene sequencers, advanced microscopes. 

And not only the equipment themselves, but maintaining all of this. I work with a lot of these labs and researchers in them. They are also having to spend a lot of resources and time and effort making sure that they’re handling data and samples securely and appropriately, that they’re maintaining all this equipment and the buildings and the other infrastructure supports that they need. And also making sure they’re documenting and complying with all the requirements for what you can and can’t do with federal grant money. That’s where all the overhead goes, and there’ve been, over years, a lot of agreements worked out that have a whole process for figuring out what’s an appropriate cost and what’s not that factors into the resulting overhead rates that academic institutions get for their grants. 

Rovner: So the Trump administration says that, Why should the federal government be paying these indirect costs, particularly to big institutions like Duke that have big endowments? Why can’t Duke just use its endowment to pay for these indirect costs? 

McClellan: Well, Duke does have an endowment, but most of the organizations that are conducting research don’t have an endowment that would cover the kinds of costs that we’re talking about here. We’re talking about, like, biosecure materials, sensitive patient information, very complex equipment put together at scale for major research projects. And that’s something that historically has been part of what governments do best, just like paying for the development of the good research ideas to see if they really pan out and can be advanced to be used effectively in humans. Also, the supports for those increasingly complex research projects that are needed. And the private foundations, Julie, that pay for some additional projects and things, they’re really operating off of this base publicly supported infrastructure that’s had tremendous contributions — you look at the data — tremendous contributions in terms of value for money for the research spending, including the overhead spending that goes into it. 

I should say that that’s not to say that we’ve got all this right. These programs get established and you need to keep looking at them. So do we really need as many NIH institutes as we have today? We’ve learned that a lot of underlying biological processes work across different diseases, not only different types of cancer, but say, as we’ve seen with some of the obesity drugs, obesity and cardiometabolic diseases also have implications for heart and kidney disease, maybe even cancer. Are we doing enough big moonshots on these, kind of understanding fundamental biologic processes? Are we set up to do that? And are these really the most efficient ways to set overhead to support modern technology and research where AI and cloud-based data infrastructure are a much more important part? So it’s important to keep looking at these questions, but they are important issues to deal with if you want to have effective research infrastructure. 

Rovner: What happens, though? At the moment, this is on hold. Judges ordered it stopped. I believe NIH had said they will go back to issuing grants. But if this were to happen — I mean, you’re an economist, also — this would have an enormous economic effect, and in addition to the impact that it would have just on— 

McClellan: Yeah. And I’ll leave it to the universities and the research advocates who have made a very clear case about — these are billions of dollars in funding, collectively. It would have a big impact on the biomedical research infrastructure. And I think, Julie, that’s why you’ve seen two things have happened since this proposal went out. The first was the proposals faced judicial restrictions, temporary restraining orders, both on the ground. This was a very broad decision that might not be consistent with the congressional requirements to spend money on these research priorities. But second, what they call in government regulatory speak an arbitrary and capricious government decision, one that wasn’t tied to a look at. And the NIH does have the authority to set and adjust rates, but it has a well-established set of processes for figuring out what is an appropriate rate. It can update those processes, but it has to go through the effort, essentially what the temporary restraining orders on these cases have put in place. So those are not moving forward right now. 

The other thing that’s happened has been a lot of these research advocates and others, patient groups, affected cancer patients, etc., have talked to their members of Congress, and you’ve seen a bipartisan swell of concern about this. This is not a new thing under the sun. The Trump administration in 2018 actually proposed in its legislative budget proposals to limit overhead costs. The response to that in Congress was not only continuing the NIH budget where it was, but restricting reductions in overhead rates without a due-process approach. So we’re seeing some of the same thing playing out here. 

Rovner: Last question. This is really for you. You’ve worked as a high-level HHS official in a Republican administration. What advice would you give those who are about to walk into the jobs that you once had? 

McClellan: Well, I would advise them to, and I hope would advise the administration, to help those people get there soon. So these kinds of policy approaches, some further proposals for NIH and, for that matter, FDA and CDC reforms, are on the books, but we don’t have confirmed leaders in any of those agencies right now, and also some very thin staff. Julie, often in addition to the Senate-confirmed leader of the organization, there’ll be some other senior leaders who can carry out the administration’s policy agenda, but also have a lot of experience with the agency or with the organizations that the agency is dealing with. 

And the NIH, the FDA are pretty thin on those people right now. I’d contrast that with CMS, where my other successor, Dr. [Mehmet] Oz, is not there yet. He hasn’t been confirmed, but he has a whole team of seasoned political appointees and actually some really good career appointees who have come back who are trying to implement policies effectively there. That’s what I’d really encourage, getting a team on board so we can look at these issues, find ways to do research more efficiently and effectively. Those are the kinds of goals that I think a lot of people would share. 

Rovner: Well, we will all be watching. Mark McClellan, thank you so much. 

McClellan: Great to talk with you. 

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

Hellmann: My story is from NPR. It’s called “Trump’s ban on gender-affirming care for young people puts hospitals in a bind.” It’s about an executive order basically ordering hospitals not to provide gender-affirming care if they want to continue receiving Medicare and Medicaid funding and other kinds of federal funding. Obviously, Medicare and Medicaid are huge revenue sources for hospitals, and so they really feel like they have no other option but to comply with his executive order. And the story looks at the impact that that has. Hospitals have been canceling appointments that people have already made to receive this care. And then on the other hand, you have states telling hospitals that they can’t stop providing this care if they’ve been doing it already. And it just really shows how there’s no playbook for this and hospitals and patients are left in a really tenuous position. 

Rovner: Shefali. 

Luthra: My piece is from Politico, by Jonathan Martin. The headline is “‘Americans Can and Will Die from This’: USAID Worker Details Dangers, Chaos.” And it’s a really great Q&A that he’s done with a longtime USAID worker whose name he withholds for privacy concerns. And they talk about how this employee feels and how he’s processed the past several days of USAID being virtually abandoned by the federal government. What I love about this is how frank the conversation is and how I think it does a really important job of putting a very human face on the kind of people that we have heard really criticized by Elon Musk and by Donald Trump, described as fraudsters and disloyal and criminals. 

And what we see in this piece is that the people who work for USAID and work in this industry, they could be making more money elsewhere, but they are risking their lives and often facing threats of kidnapping, of violence in their work because they think it means something and they really care about doing this work. I just hope that more people read pieces like this to understand who exactly is being hurt, workers and also the people whom they help, the lives they save every day, when we talk about the decimation of USAID that we are currently experiencing. 

Rovner: Yeah, it’s quite a moving piece. Maya. 

Goldman: My extra credit is a story published by KFF Health News on CBS’ website called “Doctor Wanted: Small town in Florida offers big perks to attract a physician.” And I think it’s important for a couple reasons. One, it’s a good reminder that while there is so much chaos happening in Washington, there are other issues that have been going on since long before the election, like health care worker shortages and primary care shortages that are still really important to pay attention to. But I also love that this takes a really big issue, provider shortages in rural areas, and humanizes it, like Shefali said, and shows a really poignant example. There’s this small town. They had one doctor for many years, and that doctor retired. And now, what do you do? It’s just, I think, a good look at that problem. 

Rovner: It is. Right, my extra credit is actually by Maya, and it’s called “Nonprofit hospital draws backlash for Super Bowl ad.” So between those ads for movies and Dunkin’ Donuts and new cars and beer was one for NYU Langone Health, a giant academic medical center in New York City. It’s not the first hospital ad to air during the Super Bowl, and it’s not even NYU’s first. But a supposedly nonprofit system dropping a cool $8 million while the long knives are out for health spending, as we’ve been discussing for the last half an hour, is maybe not the best look. I don’t know. I personally prefer the Budweiser Clydesdales. 

OK, so before we go, as promised, I am honored to announce the winner of this year’s KFF Health News Health Policy Valentine Contest. It’s from Sally Nix of North Carolina, and it goes like this. “Roses are red, our system is flawed. Surprise bills and denials leave us all feeling odd. They promise us care, yet profits come first, leaving patients to suffer and wallets to burst. But know that voices stand by your side, doctors and advocates who won’t let this slide. Love should mean coverage that’s honest and kind, not loopholes and jargon designed to blind. This Valentine’s Day, let’s champion care, and demand a system that’s honest and fair.” 

Congratulations, Sally. I hope the rest of you also have a very happy Valentine’s Day. OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always, to our producer and editor, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me occasionally at X, @jrovner, and increasingly at Bluesky, @julierovner. Where are you guys hanging on social media these days? Maya? 

Goldman: I’m on Twitter [X] and Bluesky, @Maya_Goldman_, I believe. And been a little more active on LinkedIn recently, so find me there. 

Rovner: I’m hearing that a lot. Shefali, where are you? 

Luthra: I am on Bluesky, at @shefali.bsky.social, and that’s about it. 

Rovner: Jessie? 

Hellmann: I am at X and Bluesky, @jessiehellmann. 

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

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“An Arm and a Leg” is collecting stories from listeners about what they’ve done to get the drugs they need when facing sticker shock. 

If you’ve ever faced difficult choices in order to afford your medicine, “An Arm and a Leg” would love to hear about it. If you’re interested in contributing, you can learn more and submit your stories using this form.

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there– 

So, first: Whoa. There is a LOT going on. I’m recording this on January 30th. I’m not gonna try to summarize what the Trump administration has been doing so far on health care — because by the time you hear this, I have no idea what else might have happened. 

Oh boy. We will definitely have a lot to talk about as this year goes on. And in the meantime, all the things we’ve been talking on this show … they are still happening. 

So, we’ve got a project cooking, and I need your help with it. It’s about how freaking much we pay for medicine. And what we can maybe do about it. 

This problem is something that hits a lot of us. A big recent survey asked: Have you skipped a medication in the last year because of cost? A quarter of people answered yes. 

And we know that a ton of people spend all kinds of time and energy trying to make sure they don’t have to go without meds that cost more than they can afford, or go broke paying for them. 

Looking for coupons, haggling endlessly with insurance, ordering drugs from online pharmacies — even pharmacies in other countries. And in some cases, undertaking all kinds of epic adventures. 

One of the very first episodes of this show was about Laura Derrick, of Austin Texas. And how she turned her life upside down in 2011. She had just started a new drug. 

A drug that may have saved her life. And then, almost immediately, two things happened. Thing one: Laura found out what that drug cost. 

Laura Derrick: I was covered by insurance. So this is not what I paid, but the first bill was over $55,000. 

Dan (talking to Laura): And this is for like a month supply

Laura: A month’s supply.

Dan (talking to Laura): And how much was your share of that?

Laura: Um, my share was about $20. 

Dan: And then, thing two: her husband was diagnosed with cancer. Late-stage cancer. He needed intensive treatment, which meant he couldn’t work. Which meant, he was about to lose his insurance. 

And this was before the Affordable Care Act was implemented. If you had a pre-existing condition, and you didn’t get insurance from your job, you basically couldn’t buy insurance. 

So Laura Derrick needed a job. She knew people who were eager to hire her, but there was a catch. 

Laura: My, my daughter’s last year of high school, my son’s last year of college. I left our family with my husband in cancer treatment because the only job they could offer was in Ohio. 

And it offered us an insurance policy with a zero deductible that cost $20 a month for the whole family and covered everything we needed. But it meant I had to be gone for almost a year and a half. 

Dan: That job, by the way, was with Barack Obama’s 2012 re-election campaign. Laura was determined to win — so the ACA could get implemented, so that people, including her — and her family, could get insurance without going quite as far as she did. 

But to say the least, having insurance does not mean having no problems. For some people, getting their meds — it may not mean taking a job far away from family — but fighting with insurance can become a very frustrating part-time job of its own. 

When I talked with Lillian Karabaic, in 2022, she was grinding away: trying to avoid a crushing bill for Enbrel. That’s an expensive rheumatoid arthritis drug she’d been taking for years. 

Lillian is a financial journalist, who teaches financial self-help to millennials. So, as you can imagine, she’s very organized. 

And as we talked about the adventure she was on at that point, she pulled up the time-tracking software she uses:

Lillian Karabaic: Okay, so it has been nine hours and 32 minutes in the past two weeks that I have spent on healthcare admin, which is mostly being on phone calls. 

Dan: What kicked off all those phone calls had been a rude awakening. Literally. From her phone. 

Lillian: I just got all of a sudden a text message from my specialty pharmacy saying that I have a $3,000 co-pay. That’s not a text message that anybody wants to wake up to. 

Dan: When we talked — two weeks and almost ten hours of phone calls after that text message — Lillian was … giving up on getting out of that three-thousand dollar copay. And getting to work on figuring out how to pay it. 

Lillian: But I’m kind of delaying the inevitable at least long enough to apply for a credit card that has a decent point signup bonus. So at least I can get something out of this entire situation. 

Dan: So, yes: We know how tough this can be. Has been. Is. 

I have a feeling you may know a bit about this too. Like, you may not have gotten a text message saying you owe three thousand bucks. 

But you definitely may have been in the situation of asking, “Holy crap, I’m supposed to pay THIS MUCH for my meds? What?” 

— and THIS MUCH could be thousands of dollars, or hundreds of dollars, or 60 dollars. If it’s a lot to you, it’s a lot. And that’s why I want your help: 

If you’ve been in that situation, what have you done? And what did you learn? Maybe you learned a strategy that actually worked for you. Maybe it was, “Man, I learned about a new way I’m getting screwed.” 

However things went — however they’re going: What did you learn that you want other people to know? It doesn’t have to be a big secret. Just something you’d tell a friend about if they asked. 

But I’m pretty sure there are strategies not enough people know enough about. I’m also pretty sure there are new ways we’re getting beat up.

And the more we learn about those, the more we can work together to do something about them. So I’m asking you to share all that with me. 

By the way, I know that you may not be doing this for yourself, for your own meds. You may be doing this for a family member, or maybe you’re a health care worker trying to help a patient — or patients. Or an advocate or a social worker. 

You’ve been working on this? You’ve been learning something the rest of us should know about? I wanna hear about it. I’d love it if you head over to https://armandalegshow.com/drugs/ — and tell me about it. You can keep it brief, or go long. 

That’s https://armandalegshow.com/drugs/. We’ll have a link wherever you’re finding this, and you can just click that. 

And if you HAVEN’T been on an adventure like this- – well, one: Good. I actually would love to hear about that too. I do not mind hearing good news about good people. Not everything has to be a nightmare. 

And I would love it if you passed this request around. Because probably, somebody you know has a story we should hear about. 

Please encourage them to bring that story right here. A story with a lesson or a question. Like, “Can they freaking DO that?!? Is there anything I can do about it? Is there anything SOMEBODY can do about that?” 

Over the next month or two, we’ll dig into everything you bring us. We may call you for more details. And we’ll call some experts to get answers to some of your questions. 

Then, this spring, we’ll start sharing what we learn. The place to bring it is https://armandalegshow.com/drugs/. 

We’ll have a link wherever you’re listening. Along with a link to some resources you might find helpful. Thank you SO much! 

Meanwhile, I’ll catch you in a few weeks with a new episode. Till then, take care of yourself. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it.

An Arm and a Leg February 3, 2025 Season 13, Episode 2 p.5 

An Arm and a Leg is produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show. We are distributed by KUOW, Seattle’s NPR News Station. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at armandalegshow.com/support/. 

And thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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

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Confusion continues to reign at the Department of Health and Human Services, where policies seem to be changing at a breakneck pace even before a new secretary or other senior officials are confirmed by the Senate. Some federal grantees report payments are still paused, outside communications are still canceled, and many workers are being threatened with layoffs if they don’t accept a buyout offer that some observers call legally dubious.

 Meanwhile, that new HHS secretary may soon arrive, given the Senate Finance Committee approved Robert F. Kennedy Jr.’s nomination this week on a party-line vote — including an “aye” vote from Sen. Bill Cassidy (R-La.), a doctor who had strongly condemned Kennedy’s anti-vaccine activism.

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

Panelists

Among the takeaways from this week’s episode:

• In Washington, the Trump administration’s federal funding freeze, buyout offers to scores of federal workers, and disabling of federal agency websites have left more questions than answers. A tangle of legal issues and lack of communication have only served to sow confusion around the nation and globe for health providers, researchers, and foreign aid groups — to name a few.
• As the Trump administration runs through many of the disruptive policy changes prescribed last year in the Heritage Foundation’s presidential transition playbook, Project 2025, some people are asking: Where are the Democrats? Lawmakers have taken up mostly individual efforts to question and protest the administration’s changes, but, thus far, Democrats are still pulling together a unified approach in Washington to counter the Trump administration’s break-it-to-change-it approach.
• Faced with threats to crucial federal funding, some in the health industry are falling in line with President Donald Trump’s executive orders even as they’re challenged in the courts. Notably, some hospitals have stopped providing treatment to transgender minors in Democratic-run states such as New York.
• Meanwhile, a doctor in New York is facing a criminal indictment over providing the abortion pill to a Louisiana patient. The doctor is protected by a state shield law, and the indictment escalates the interstate fight over abortion access. And a Trump order barring federal funding from being used to pay for or “promote” abortions is not only rolling back Biden-era efforts to protect abortion rights, but also going further than any modern president to restrict abortion — after Trump repeatedly said on the campaign trail that abortion policy would be left to the states.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, who reported the latest “Bill of the Month” feature about a young woman, a grandfathered health plan, and a $14,000 IUD. If you have an 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 this week that they think you should read, too: 

Julie Rovner: The New York Times’ “How R.F.K. Jr. and ‘Medical Freedom’ Rose to Power,” on “The Daily” podcast.  

Lauren Weber: CNN’s “Human Brain Samples Contain an Entire Spoon’s Worth of Nanoplastics, Study Says,” by Sandee LaMotte.  

Alice Miranda Ollstein: The Washington Post’s “Did RFK Jr. or Michelle Obama Say It About Food? Take Our Quiz,” by Lauren Weber. 

Also mentioned in this week’s podcast:

• KFF Health News’ “Trump’s Already Gone Back on His Promise To Leave Abortion to States,” by Julie Rovner.
• STAT’s “Removal of DEI Content From a Microbiology Group’s Website Shows Reach of Trump Executive Orders,” by Usha Lee McFarling.

[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, Feb. 6, at 10 a.m. As always, news happens fast and things might well have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: And Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Julie Appleby, who reported and wrote the latest “Bill of the Month” about a young woman, a grandfathered health plan, and a $14,000 IUD. It is a wild one. But first, this week’s health news. 

Now, I know a million things have happened since the Trump administration tried to freeze domestic spending and was ordered to stop by a federal judge. That happened, checks notes, last week. But I want to start there because it turns out that was far from the end of the story at the Department of Health and Human Services, and things are still far from normal. First of all, even though the funding freeze is, quote-unquote, “over,” there are still lots of reports of agencies that still can’t get paid, including Head Start programs, community health centers, and lots of nonprofits that provide domestic social services. 

We’ll get to the international stuff separately in a moment. This is potentially leaving not just people high and dry for services but staff unable to get paid, rent unable to get paid. Just to be clear, this is not supposed to be happening, right? 

Ollstein: There’s just so much confusion right now, and there is not across-the-board clarity that people can follow. And so some people are getting their funding, but they’re getting it late. Some people are not getting it at all. People are being told conflicting things. 

There are also a lot of health care providers around the country are also receiving confusing guidance about how to comply with various executive orders related to, quote-unquote, “DEI and gender.” And so they’re not clear if any program that serves lots of different people, including trans people, needs to be suspended or if anything related to serving particular, underserved minority groups needs to be suspended. There’s just so much confusion that we’re hearing, and a lot of folks are scrambling to draw down whatever funding they can now, because they don’t know what’s going to happen in the future. 

Rovner: And of course, adding to this is today is the deadline for federal workers to say whether they want to accept this strange offer allegedly from the Office of Personnel Management, which is not supposed to be sending out government-wide emails telling people that if they reply to the email with “resign,” they can have eight months of pay, even though the government is only funded at the moment through March 14. 

So, of course, all of these federal workers are getting all kinds of conflicting information about what they should do for their own situation, much less what they should do for the people they’re supposed to be serving in their jobs. 

Weber: Yeah. I think it’s important to look no further than what Elon Musk did to Twitter. He stripped it down to bare bones, and I think a lot of federal workers looking at that historical example potentially see the writing on the wall that their jobs may or may not exist. 

So they’re looking at this offer but with trepidation because, as you pointed out, how can they possibly pay the full eight months? How would that work? Is this legally possible? There’s just so much confusion swirling around, no one really has a sense of what’s up from down in terms of how this could go forward. 

Rovner: And we need to make it clear. When Elon Musk bought Twitter, he bought a company, he bought a private company. It was basically his to do with as he pleased. If he wanted to offer people buyouts — which, by the way, I think a lot of them didn’t get promised severance — he could. And if he wanted to fire people, he could. 

This is the federal government. Hundreds of thousands of civilian workers are supposed to have civil service protections. We’re not talking about political appointees. Most left on their own the day [Donald] Trump took over. These are people who were supposed to be there throughout changes in administration. 

People are just seeming to accept this at face value, that Elon Musk and his group of 19-to-25-year-olds can basically come in and fire the entire federal government at will. That’s not legal. 

Ollstein: And I’m also seeing a lot of federal worker unions telling people: Don’t fall for this. Don’t accept this “buyout.” Hold the line. They’re challenging this in court. And so again, what you both said, it’s not clear that they can fulfill this promise of funding through the fall, but it’s also not clear if any of this is legal. 

And so you have these unions and organizations pleading with federal workers not to fall for it and not to take the resignation offer. But you also have a lot of people saying, Well, if the choice is accept this or wait and just be laid off with nothing, then I’m going to accept this. And then so a lot of people are worried about their own livelihoods and thinking this is sort of a lifeboat. 

Rovner: Well, meanwhile, it’s not just funding. At the same time, webpages around the Department of Health and Human Services, mostly from the Centers for Disease Control and Prevention, the FDA [Food and Drug Administration] and the NIH [National Institutes of Health] have been disappeared. Some have been reappeared. A banner atop the main page for the CDC website says it’s, quote, “being modified to comply with President Trump’s Executive Orders.” 

And while the freeze on outside meetings and travel and grant review at NIH has been loosened, it is still ongoing. Oh, and we haven’t had a Morbidity and Mortality Weekly Report from the CDC in two weeks now. News flash: There’s an Ebola outbreak in Uganda and a herd of cattle in Nevada with a different strain of bird flu than the one that’s been going around. 

What are you guys hearing about what’s happening in these departments with their outside communications? They’re not really allowed to talk to the public yet, right? 

Weber: I think it’s just widespread confusion. It depends on the agency. It depends on your interpretation of the guidance, what you’re able to say, what you need to modify, what’s being taken down. I think, overall, a lot of folks that are on the inside are doing their best to comply and maintain their jobs, and also deal with the restrictions that seem to come and go. 

Ollstein: And I will say, like we were talking about the funding issue, the communications issue has completely been spotty, and enforcement is all over the place. For instance, yesterday we did get a report out from CDC on maternal mortality data, which we can talk about if we want. But people were not sure whether that would be released or not amid all of this, because other reports have been held up. And so it’s just all seeming from the outside to be very ad hoc right now, and there’s not, like, blanket policies that people can depend on. 

Rovner: So, Alice, you referred to this earlier, but one of those executive orders that agencies are supposed to be bringing their programs and funding in line with is aimed at eliminating any vestiges of what’s known as diversity, equity, inclusion, and accessibility in the federal government and in grant programs. 

Over at the National Science Foundation, apparently projects are suspect if they include keywords including “disability,” “female,” “historically,” “socioeconomic,” or “women,” also “minority,” “institutional,” or “excluded.” Basically, if your grant has any of those words in it, it is marked for potential cancellation. And it’s not just in government. Stat this week is reporting that the American Society for Microbiology, which is not a government agency, although it does receive some federal funding, has removed all the DEI content from its website. 

And the impact may be having unintended effects also. Eliminating all DEI jobs in federal agencies also includes people like sign language interpreters for the deaf and others who provide accommodations for workers with disabilities, which is required under — remember those? — federal laws like the Americans With Disabilities Act. Has anybody asked the White House about this or even HHS? We’re seeing reports of things happening that one assumes were not intended by these executive orders. 

Weber: There’s just so much, there’s such a flooding the zone of this, I think a lot of the federal agencies are also waiting till their new heads get into place. I think there’s a little bit of a waiting game going on here. Obviously, we saw that Robert F. Kennedy Jr.’s confirmation hearing’s advanced. 

Assumedly, sometime next week, he will likely be confirmed. I think you will see more clarification potentially. I think that’s, well, potentially, after you have some of these heads of agencies, whether that’s HHS, CDC, FDA, come into place. I think some of this was a stop, hold the line, kind of get situated. 

But the reality is, as I pointed out, Kennedy is not currently HHS head, and so there’s still a lot of waiting time. And in the meantime, there’s a lot of confusion over what the communications are. What’s allowed? What’s not allowed? What’s complying? What’s not complying? 

You saw some of that clarified when Pete Hegseth took over at DOD [the Department of Defense]. I think that some of the health agencies have just a little bit more of a waiting game, because their folks aren’t going to be confirmed for a period of time here. 

Rovner: Right. There are no Senate-confirmed agency heads at HHS yet. 

Ollstein: And I will just point out that it is a bit ironic that a big part of Kennedy’s message, as he’s sought confirmation, is being pro-data, pro-science, wanting more transparency on both. And he is saying that at a time when things are being stripped offline, decades-old databases are going down, communication is halted. And so that’s an interesting tension, and I haven’t seen members of Congress really press him on that. 

Rovner: Oh, you were anticipating my next question, which is: Where are the Democrats? 

Ollstein: There are a variety of tactics and approaches, from trying to hold press conferences and trying to enter certain federal agencies and being turned away. There are folks who are pressuring individual nominees. You’ve had Democrats pressure Kennedy to change his ethics agreement, so that he isn’t directly profiting from these anti-vax lawsuits that he was going to maintain a financial stake in. Although now it has been transferred to his son, which Sen. Elizabeth Warren and others argue is still a huge conflict of interest and doesn’t really fix the problem. There is not a unified response and message. Individual members of Congress seem to all be doing what they think is best in this moment. 

Weber: Yeah. 

Rovner: Let me ask— 

Weber: Oh, go ahead. 

Rovner: No, let me ask the question in a slightly different way. A lot of what’s happening right now was all written out in Project 2025 for those of us who read it. They are literally following the guidebook. Why weren’t the Democrats ready for any of this? They just seem frozen in place. Lauren? 

Weber: I was just going to say, Steve Bannon has publicly said, many members of the Trump administration going in have said the plan is to flood the zone. So it is a good question, Julie. If you are the opposing party, why would you not have a better plan for that? But I would just say that the Dems have seemed to be in disarray since Kamala Harris lost. They’ve been pointing a lot of fingers. I think now, one would think they would get together with some sort of unity, but they’ve yet to kind of coalesce. They’ve all been doing their own individualistic fighting back. 

We’ll continue to see how this plays out. I think flooding the zone is an effective tactic in the sense of there’s so much to respond to that they seem to not be able to get together to work on that. But we’ll have to see how this unfolds. 

Rovner: They have sent lots of sternly worded letters, as far as I can tell, that’s been — and press conferences that are scheduled like a day and a half when something happens. And then 14 other things happen between the time they schedule the press conference and the time they have it. Because that’s the strategy right now, as you say, is to flood the zone. 

Before we leave this, separately from the DEI stuff are executive orders aimed at transgender people. A judge has already blocked an effort to transfer three transgender women federal inmates to men’s facilities and to cut off their access to hormone therapy. But meanwhile, demonstrating that these orders go further than many might’ve anticipated, and I think one of you actually already mentioned this: Hospitals around the country are already cutting off treatment, including reversible treatments to transgender minors, for fear of losing all of their federal funding. 

Now, I know a lot of families moved from states with restrictive policies to states with less restrictive ones over the past couple of years. This is like what they want to do on abortion — right? — is just cut off access nationwide. 

Ollstein: I think that there are a lot of parallels with abortion in this space. I think, one, you see impacts on blue-state residents who thought they would be, quote-unquote, “safe” from these policies being effected. You’re seeing hospitals in California, you’re seeing hospitals in New York, you’re seeing hospitals in other states with their own state protections suspending services out of confusion and fear of losing federal funding, etc. I think, in both contexts, we’ve really seen over the last few years especially just how fundamentally risk-averse and cautious the health care world is. 

And when there is a gray area, they tend to lean more towards overcompliance than undercompliance. I think you’re seeing that both in the abortion space and in the trans care space right now. 

Weber: I just wanted to add, at the end of the day, hospitals are businesses. If the threat is half of your revenue from Medicaid and Medicare is cut off, they’re going to comply. That’s just a massive amount of money for a lot of these hospitals that they’d potentially be putting at risk. Not to mention the research grants that may or may not also be affected. So I think the stories that we’ve already seen trickle out, obviously, of the hospitals you mentioned in California and New York, some in D.C. and Virginia and in our backyard, is going to become very much the norm until this is sorted out more. 

Rovner: Yeah. I think what a lot of people were not expecting, Congress is basically nowhere to be seen. All of this is happening because of these executive orders, which on the one hand, yes, can reach the federal government itself. But I think people didn’t anticipate how far beyond they are reaching, basically anybody who gets federal money, which is almost everybody. The reach of this kind of executive power is, I think it’s fair to say, unprecedented. 

As someone already mentioned, Robert F. Kennedy Jr. is likely to soon become the secretary of health and human services, although he is not there yet. The Senate Finance Committee approved his nomination on a party-line vote on Tuesday. The yes votes included one from doctor and Health, Education, Labor, and Pensions Committee chairman Bill Cassidy, who serves on the Finance Committee also. Cassidy was considered the key swing vote, having sharply criticized Kennedy’s anti-vaccine advocacy. 

But Cassidy explained on the Senate floor after the Finance Committee vote that Kennedy has promised to work closely with him and not to do anything to deter Americans from getting vaccines. We have a cut of tape. 

Sen. Bill Cassidy: We need a leader at HHS who will guide President Trump’s agenda to make America healthy again. Based on Mr. Kennedy’s assurances on vaccines and his platform to positively influence Americans’ health, it is my consideration that he will get this done. 

Rovner: So what are we to make of Cassidy’s confidence that all will go well here for supporters of childhood and other vaccines? 

Weber: Is that confidence, or is that him saying he struck a deal, and these are the terms of the deal, and we’ll see how that deal turns out? Georges C. Benjamin’s told me, from the American Public Health Association, he said, Do you think that Kennedy’s going to call Cassidy every time he makes a controversial decision? And I think it’s a good question asked by the doctor over, that runs the American Public Health Association. I think at the end of the day it seems— 

Rovner: That’s what Cassidy said, though. He said that Kennedy would consult with him on all of these decisions. 

Weber: That is, I understand that’s what he said. I’m curious to see if that’s actually how that happens. Cassidy sang quite a different tune than he did in his questioning the second day of the hearings, where he said, I just really — I have a hard time believing that a 71-year-old man’s going to change his stripes. But it seemed by the time the vote came around this week that he felt that way, despite RFK Jr. really [not] giving him any sort of assurances that his position had changed on his numerous instances of falsely claiming that vaccines are linked to autism. 

Ollstein: I completely agree. And there were almost points in the hearing where Cassidy seemed to be begging Kennedy to give him something to work with, to give him some shred of a sign that he had really changed his views, and he did not get that. But clearly he was convinced by whatever assurances he got. We know because Cassidy said so, that he’s been bombarded, his office has been bombarded by phone calls. 

We know that [Vice President] JD Vance and other administration officials had been putting the screws on him in the lead-up to the vote. We’ve seen in the wake of his decision to vote for Kennedy, the public health world being really outraged and feeling that he chose his role as a politician over his role as a medical doctor. It’s also worth noting that he is up for reelection soon, would likely face a primary from the right, and so that is seen as playing into this, too. Yeah, I’ve just seen a lot of the health world really upset. I’ve seen people referring to this as “the Louisiana Purchase.” 

Rovner: I had not seen that. 

Ollstein: Feeling that he was bought off, not necessarily with money but with these pledges and promises. 

Rovner: And also, I believe he also already has a primary opponent. He’s up in the next round of elections. 

Ollstein: But we don’t know if he’s running. We don’t know if Cassidy is running for reelection, but if he does run, he will have a primary challenger. Yes. 

Rovner: Yes, that’s fair. All right. Well, leaving HHS for a moment, I want to remind our listeners that foreign policy is also health policy, which brings us to the U.S. Agency for International Development. Despite the fact that this is a congressionally created agency with an appropriated budget, Elon Musk’s “DOGE” [Department of Government Efficiency] is basically disassembling it. 

And as of the end of this week, nearly all employees will have been placed on administrative leave and those overseas being ordered home. Among the programs run by USAID is PEPFAR [the President’s Emergency Plan for AIDS Relief], the HIV/AIDS program created by President George W. Bush that’s credited with saving tens of millions of lives in Africa and other developing nations. 

Secretary of State Marco Rubio has said he’d grant exceptions for some ongoing humanitarian assistance, but the status of PEPFAR remains unclear. What, if anything, are you all hearing about all of the global health activities that had been going on? 

Ollstein: It’s hard to operate as reporters, and we are hearing from sources that it is hard for them to operate these programs, because what they’re hearing announced from the administration is not the reality they’re experiencing on the ground. And so they’re losing trust in the official announcements and guidance that they’re getting, because the frozen funds were supposed to be unfrozen, but the funds are not flowing. So there is a real fear that there is going to be a lot of tangible human suffering associated with this, millions of people losing access to the programs that keep them alive and prevent transmission. And as we know, when it comes to a transmissible disease like this, even a small pause could mean more spread and more problems down the line, even if things are restored. 

Rovner: Yeah. Lauren, are you following this at all? 

Weber: The level of confusion, I think, is amplified when you have folks in far-flung corners of the world who are dealing with life-and-death situations and have no one to reach out to. We’re talking about people that work at refugee camps. We’re talking about people that deliver nutritional aid in various countries on the brink of famine. We’re talking about folks that are now emailing people back at USAID who don’t have emails anymore. 

The scale of this is somewhat mind-boggling to those who are covering it, and as Alice said, the lack of clarity around it is pretty clear. And at the end of the day, Elon Musk has gone as far as to call the program, I believe it was, “evil”? I’ll have to check the language, but the vilification of a program that has been credited with quite a lot of impact in such a short period of time has been very complete. 

Rovner: Well, we talked about this a little bit on the domestic side. It’s not just these government workers. It’s the people who are on the ground, the contractors doing the job. And interestingly, the largest contractor for USAID is Catholic Charities, which is now faced with having to stop work and lay people off. So, again, did President Trump really think that he should be going after Catholic Charities? We’re going to find out, because that’s in fact what’s happening. 

It’s not just foreign policy. Trade policy is also health policy. Last week, President Trump announced new tariffs on goods from Mexico, Canada, and China. The big story for most of the media was the 30-day pause on the Mexican and Canadian tariffs. But the tariffs on China took effect as scheduled, and those could drive up the cost of drugs, particularly generic drugs, and many drug ingredients, which are increasingly made overseas, as well as other medical devices. I thought we were trying to reduce our reliance on China during covid, particularly for medical supplies. What happened with that? 

Weber: Well, what happened with that is it’s very expensive to build manufacturing facilities for products that don’t make people a lot of money. So no, there was not much done to really alleviate that. That was a boom-bust cycle of pandemic funding that we’re far beyond the bust. We’ve busted the bust here. So if these tariffs stay in place, many drug experts say, you could expect generic drugs to go up in the coming months. Contracts are in place that minimize probably the pocketbook hit right now, but in the coming months, that very well could change. 

Rovner: Well, meanwhile, it’s not on the front burner, but the future of abortion is still way up in the air. The big news last week came from Louisiana, where a grand jury in Baton Rouge indicted a doctor from New York for legally prescribing an abortion pill online to a Louisiana teenager. The teen’s mother is also charged with a felony. Now, the New York doctor is specifically protected by her state’s shield law, or she is supposed to be. Alice, this is the beginning of the big fight we’ve been expecting for a while, right? 

Ollstein: Well, it’s really a continuation of the big fight. We’ve seen cross-border fights. It’s an escalation, for sure. We already saw Texas bring civil charges against this very same New York doctor. And so this is a criminal charge, which is again an escalation but not a completely new attempt. And I think we’ve all been pointing out all along that, quote-unquote, “sending abortion back to the states” is not possible, because we live in an interconnected country. People travel, medications travel, and these laws are in direct conflict with one another. It’s interesting, because conservatives argue that New York providers are being allowed to meddle in and undermine the anti-abortion laws of red states, while progressives say that it’s the red states that are attempting to reach across their borders and criminalize behavior that’s legal in the place that it’s being practiced. 

It’s legal for the New York doctor sitting at her desk in New York to prescribe these medications, and they are attempting to criminalize that behavior. So this was sort of inevitable, and it will be fascinating to see how courts treat it. Of course, we have still ongoing, the same mifepristone lawsuit that now three states are leading in Texas. And so you have three other— 

Rovner: Three states that don’t include Texas. 

Ollstein: Correct. Three other GOP-led states claiming standing in a Texas court in Amarillo against mifepristone availability all over the United States. So we shall see what happens to that, but some of these cases will certainly be back on their way to the Supreme Court sooner or later. 

Rovner: Well, it’s not just in the state. I have my own column out about this week, which I will shamelessly link to in the show notes. But abortion restrictions are tightening here in Washington on the federal level as well, despite President Trump’s claim on the campaign trail that he would leave the issue to the states. This week, newly approved defense secretary Pete Hegseth, as expected, rolled back the policy instituted by President [Joe] Biden allowing members of the military time off and travel allowances to obtain abortions for themselves or a family member if they’re stationed in a banned state. 

Alice, this administration got off to a kind of slow start on abortion. We actually talked about it amongst ourselves. How are the president’s anti-abortion backers feeling about it now? 

Ollstein: They’re feeling quite good, and they’re feeling good about Kennedy, as well. He said a lot of things in his confirmation hearing that they wanted to hear, which we can walk through if we want. But I would say what’s been interesting is a lot of the stuff they’re doing, they’re doing a bit under the radar. 

So that defense policy, that didn’t get a big, splashy announcement. That was sort of quietly put out there. And like you said before, they did not do the big, splashy Day 1 executive orders that past conservative administrations have done. But Trump ran on trying to please both sides, and a lot of people who support abortion rights did vote for Trump. 

But it’s been clear, even if he’s not doing everything anti-abortion people want, he is only doing things that they want. He is not doing things that the other side wants. So he sort of ran on pleasing both sides, but it’s pretty clear which side he’s chosen. 

Rovner: Yeah, and we will. Obviously, once Kennedy gets set up at HHS, then we will talk about what’s going to go on there, because, obviously, there are many, many more shoes to fall on this particular subject. All right. Well, that’s as much news as we have time for this week. Now we will play my “Bill of the Month” interview with Julie Appleby, and then we’ll come back and do our extra credits. 

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

Julie Appleby: Thanks for having me. 

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

Appleby: This month’s patient is Callie Anderson. She’s 25, she lives in Scranton, Pennsylvania, and she went to the doctor and wanted to get off the birth control pill. So they discussed it and decided that an IUD [intrauterine device] would be right for her. So she got an appointment a couple months later and got an IUD. 

Rovner: This feels like a slam dunk, right? She has health insurance. FDA-approved contraception, including long-acting contraception like IUDs, are supposed to be covered with no patient copay under the Affordable Care Act. But that’s not what happened here. How much was the bill she got? 

Appleby: Her bill was $14,658. 

Rovner: That sounds like a lot for an IUD, even if you didn’t have insurance. Is that a lot? 

Appleby: Yes, it is a lot. The Geisinger Health System charges in this case were multiple times what the average looks like it is. For example, I spoke with Planned Parenthood, and they say it can vary depending on the type of IUD and where you live and things like that. But in general, $500 to $1,500 for an insertion is what they’re seeing. And I also looked at FAIR Health, which tracks claims, and they say, for an uninsured person, it can range from about $1,100 to $4,300, depending on where you get it. 

Rovner: So this was really an astronomically high amount. 

Appleby: That’s what one of the folks I spoke with described it, yes. 

Rovner: And why wasn’t it covered with no copay like the ACA required? 

Appleby: Very good question. There’s a type of coverage that doesn’t require plans to follow the Affordable Care Act, and these are called “grandfathered” plans. And they’re called “grandfathered” because they were in existence before March 23, 2010, which was when President Barack Obama signed the Affordable Care Act, and they’ve remained sort of substantially the same since then. So they don’t have to follow all the rules of the Affordable Care Act. And Callie Anderson’s plan — which she got through her dad because she’s 25 and she’s still on his plan, and he’s a retired police officer in Pennsylvania — that plan is grandfathered. 

Rovner: So retired police officers in Pennsylvania didn’t have coverage for FDA-approved contraception before the Affordable Care Act? 

Appleby: Yes, because it’s a grandfathered plan. And interestingly, KFF, which does an employer survey, found that about 14% of all covered workers in 2020 were on grandfathered plans. So they’re a little unusual but not that unusual. 

Rovner: Yeah. That feels like a lot to have a plan that really hasn’t substantially changed in 15 years. 

Appleby: That does seem like a lot. 

Rovner: So what’s the takeaway here for patients in this situation? 

Appleby: Experts always say it’s always best to read your benefit booklet or call your insurer before you undergo some kind of nonemergency medical procedure, just to check: Is it covered? And ask to speak with a representative. Call your insurance plan, find out how much you might owe out-of-pocket for the procedure. 

And sometimes you have to get really specific with birth control, because while birth control is covered, you might have to specify exactly what type you want. Because some insurers only cover certain brands or certain types, so it’s always best to double-check that. But that puts a lot of onus on the patient. And in this case, Callie did ask that she get prior authorization through her health system, and she thought that had been done, but it had not. 

Rovner: And what is happening with her bill? 

Appleby: What’s happening with her bill is she was offered a discount. And then she got a discount off the discount if she agreed to pay the entire amount in full, in one payment. So she ended up paying $5,236 for her IUD. 

Rovner: Still a lot. 

Appleby: Yes, still a lot of money. 

Rovner: Alas, we have plenty more Bills of the Month that we can still do. Julie Appleby, thank you so much. 

Appleby: Thank you. 

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

Weber: I pitched an article in CNN [“Human brain samples contain an entire spoon’s worth of nanoplastics, study says”] that talked about how we have a lot more plastic that is apparently residing in the cracks and crevices of our brains. Now, it’s microplastics. They’re very, very small, much smaller even than a strand of your hair. But their health impact is not known. 

And there was also some findings, not correlated, but potentially that there was more plastic, or there appeared to be more plastic, in some of the brains that were examined of folks that had dementia or Alzheimer’s. It’s unclear whether or not that’s because those brains change in size, shape, and leave reservoirs more for plastic to hide in. But as we all talk about microplastics and their health impacts, it is alarming to see that they appear to be showing up more in people’s brains. 

Rovner: I hope this is something that RFK is worried about, too. Alice. 

Ollstein: So I chose Lauren’s story [“Did RFK Jr. or Michelle Obama say it about food? Take our quiz”] at The Washington Post that is a quiz to show how much the things that RFK Jr. has been saying about the nation’s food system — you know, they sound pretty familiar. And they sound pretty familiar because they sound a hell of a lot like things Michelle Obama said when she was promoting her healthy food campaigns. 

And so it’s a quiz of: Who said it, RFK Jr. or Michelle Obama? And I will say, I got most of them right. But my strategy was that I focused on the style of speaking rather than the content, because the content is very similar but the style of speaking is not. So that’s my tip for all you out there, but it does show that— 

Rovner: Oh, cheater. 

Ollstein: —that conservatives who were outraged when Michelle Obama said these things — they thought it was a nanny state and big government telling you what to do and it’s our American right to eat french fries and all that — are now embracing this MAHA [“Make America Healthy Again”] movement that’s making very similar points. 

Rovner: Well, I took the quiz and I got most of them wrong. 

Weber: Well, Julie, that was the point. That was the point, though. 

Rovner: Yeah, exactly. All right. My extra credit this week is another podcast, the Jan. 30 episode of The New York Times’ “The Daily.” It’s called “How R.F.K. Jr. and ‘Medical Freedom’ Rose to Power.” And it’s an interview with longtime health policy and politics reporter Sheryl Gay Stolberg, who has coincidentally been working on a book on the political history of public health. In the podcast, she shares just enough of what she’s learned to make me really look forward to reading the book. But in the meantime, it’s a great half hour of how we got to where we are now in our distrust of public health. 

OK, that is this week’s show. As always, if you enjoyed 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 again to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me at X, @jrovner, and also at Bluesky, @julierovner. Where are you guys these days? Lauren? 

Weber: You know what? I did finally get a Bluesky account, so I am now on both X and Bluesky, @laurenweberhp, because I just can’t let the “hp” for “health policy” go. 

Rovner: There you go. Alice. 

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

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

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Robert F. Kennedy Jr., President Donald Trump’s nominee to lead the Department of Health and Human Services, came under sharp questioning from Democrats and some Republicans at his confirmation hearings this week before two Senate committees. Of particular interest were the doubts about Kennedy’s qualifications and past anti-vaccination positions raised by Sen. Bill Cassidy (R-La.), who is a physician — and, notably, a member of the Senate Finance Committee, which is expected to vote next week on whether to advance Kennedy’s nomination to the Senate floor.

 Meanwhile, a federal government memo temporarily freezing a lot of federal grant and loan funding touched off confusion and recriminations at the new Trump administration for its sudden, sweeping actions.

This week’s panelists are Julie Rovner of KFF Health News, Sandhya Raman of CQ Roll Call, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Among the takeaways from this week’s episode:

• During appearances before two Senate committees, Kennedy assured lawmakers he would follow science and defer to Trump’s policy preferences. But he also made mistakes that are notable for someone vying to lead the nation’s top health agency, such as confusing the Medicaid and Medicare programs.
• As Kennedy’s second hearing concluded, it was not immediately clear whether he would earn the votes needed to be confirmed by the full Senate — especially as at least one key Republican, Cassidy, seemed less than convinced. If every Democrat and independent votes against him, Kennedy could lose just a few GOP votes and still be confirmed.
• Much of the nation’s health system — alongside many, many other entities that rely on federal funding — experienced a kind of whiplash early this week, as the Trump administration’s Office of Management and Budget issued a memo freezing federal grants and loans until they could be reviewed for adherence to Trump’s priorities. A federal judge temporarily blocked the freeze from taking effect, and OMB revoked the memo — but the White House said Trump’s recent executive orders affecting funding “remain in full force and effect, and will be rigorously implemented.”
• In other Trump administration news, Trump fired a slew of inspectors general late last week — including the one who oversees HHS and the nation’s health system. And an executive order affecting health care for trans children has many parents and advocates on edge.

Also this week, Rovner interviews Nicholas Bagley, a University of Michigan law professor, who explains how the federal regulatory system is supposed to operate to make health policy.

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

Julie Rovner: 404 Media’s “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Costs Six Figures,” by Jason Koebler.

Sandhya Raman: ProPublica’s “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” by Mary Hudetz and Hannah Bassett.

Sarah Karlin-Smith: CBS News’ “Wind-Blown Bird Poop May Help Transmit Bird Flu, Minnesota’s Infectious Disease Expert Warns,” by Mackenzie Lofgren.

Also mentioned in this week’s podcast:

KFF Health News’ “Trump’s Funding ‘Pause’ Throws States, Health Industry Into Chaos,” by Phil Galewitz.

[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, Jan. 30, at 1:30 p.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 Sandhya Raman of CQ Roll call. 

Sandhya Raman: Hi, everyone. 

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

Sarah Karlin-Smith: Hi there. 

Rovner: Later in this episode, we’ll have my interview with University of Michigan law professor Nicholas Bagley, who will break down for us how the federal regulatory system is supposed to work when it comes to health. But first, how is it still January? 

We are coming to you a little later than usual today because we have been watching hearings on Capitol Hill, where Health and Human Services Secretary-designate Robert F. Kennedy Jr., who was called a “predator” in a video earlier this week posted by his cousin Caroline Kennedy, appeared for his confirmation hearings. On Wednesday, he was at the Senate Finance Committee. Earlier today, he was at the Senate Health, Education, Labor, and Pensions Committee. A reminder, only the Finance Committee actually gets to vote on whether to send this nomination to the floor. I think it’s safe to say there was a lot to chew over in these two days of hearings. But first, do we have any idea how likely he is to be confirmed by the full Senate? 

Karlin-Smith: It seems like it’s going to be close. Yesterday, I didn’t hear any notable concerns necessarily from Republicans. It seemed like all the Senate Finance Republicans didn’t have any huge issues with his nomination, although I guess I should say one of the people on that committee is the chair of the one we saw today, and he didn’t quite make his opinion known. 

And then today the Senate health committee chair, Bill Cassidy, who is a doctor, made it very clear that he is not happy with Kennedy’s views on vaccines, and that he talks about some very personal moments in his career where he experienced the death of a particular young woman who was unvaccinated and it could have been prevented if she was. And Cassidy didn’t quite indicate where he’s going, but it seems like it may be hard for Kennedy to get him to a yes, because it seemed like Cassidy was giving him a lot of chances today, and oftentimes Kennedy was kind of saying the wrong answer of what Cassidy wanted to hear on vaccinations. And there’s a few other Republicans, I think, in a similar boat there, so it’s probably going to be close, but— 

Rovner: Yeah, and of course Cassidy, who’s the chairman of the health committee, is one of the Republican votes on the Finance Committee, too. There are several members who are on both committees. It was interesting, sort of, to watch what they said yesterday compared to what they said today in terms of questioning. But certainly there don’t seem to be any Democrats who are leaning his way, which is, I mean, we saw when he was officially nominated there were a lot of Democrats, not necessarily in the Senate but around the country, who agree with some of the things he says about regulatory capture by the drug industry and the food industry and ultra-processed foods. He does say a lot of things that are of interest and agreed to by Democrats, right? 

Karlin-Smith: Yeah, there were a few people I was watching because there were some inklings again that maybe they would vote to confirm him. One was Sen. [Raphael] Warnock from Georgia, who there was no indication, again, in his remark that he had interest in supporting him. The other was [Sen.] Sheldon Whitehouse, who apparently was Kennedy’s law school roommate and friend. And again, there was no indication of support or openness, not that we actually know how he was going to vote. And then the third person actually was Sen. Bernie Sanders, who at the hearings, both days, he did express some of his interest in some of the ideas that Kennedy has espoused. But yet again, I think the things they disagree on sort of outweigh the things where they can see agreement. And I think they’re seen as so problematic that they just totally cancel out any place where they could work together. 

Rovner: Just a reminder, Cassidy is super important here because RFK Jr. can’t afford to lose more than three Republican votes, assuming all the Democrats and independents vote against him, which is not necessarily what we know. And we assume but don’t know that the three senators who voted against [now-Defense Secretary] Pete Hegseth — Sen. Lisa Murkowski, [Sen.] Susan Collins of Maine, and Sen. Mitch McConnell, who’s a polio survivor and has said things about Kennedy’s vaccine statements — we assume those are likely to be no votes. So Cassidy would be the fourth and therefore decisive one. And I think that’s why everybody’s been watching him so closely. Sandhya, I see you nodding. 

Raman: I think even if [the] health [committee] is not voting on this, he’s the head of health, he’s a doctor, and if he votes no, that gives other Republicans who might be saying yes or leaning yes cover to kind of switch if they want to. Once you have one fall, then it’s easier for others in a lot of cases. So I think that after this weekend we’ll have more information. Cassidy’d said he wanted to ask additional questions, whatever those might be, and if those, where the cards may fall. 

Rovner: Yes. I believe Cassidy’s parting words in the hearing were, You might be hearing from me this weekend. Of course, if I were Cassidy and I were thinking about voting no, I don’t think I would blast it out right now to give time for everybody to come back at him, so you could see how he might want to play his cards a little bit closer to the chest. 

Well, for those who did not sit through the hearings like we did, I will say — I went back and counted — this is my 11th HHS secretary confirmation set of hearings that I have watched. And I could say that RFK Jr. is easily the least knowledgeable nominee that I have ever seen, at least in how the Department of Health and Human Services works. At both committees he was asked pretty easy questions about Medicare and Medicaid and showed that he does not understand either program, which together cover more than a hundred million Americans. What stood out to each of you? 

Raman: I think those, definitely, especially given that he’d fumbled on that the first hearing, the fact that that comes up again from Sen. [Maggie] Hassan asking questions on that in both hearings, that he stumbles again on the issues within the CMS [Centers for Medicare & Medicaid Services] umbrella. And I think yesterday he’d had some questions about EMTALA [the Emergency Medical Treatment and Active Labor Act] and emergency pregnancies, and again he— 

Rovner: Yeah, going to ask about abortion separately in a second. 

Raman: Yeah, so I think the fact that there have been major issues within the HHS umbrella that seemed new to him doesn’t bode well for what I saw. 

Karlin-Smith: One of the things that stood out to me was that he often got caught in lies or semi-lies and stuff around some of his past statements. And again, that just seems like a failure of the various staff in the Trump organization to really prepare him to know how to handle this. Because if you have such a public record like that, you know these things are going to come up. And even there was one exchange that happened yesterday, and the same comment was brought up today with Warnock, about comments he made comparing the effects of giving people vaccines to actions of the Nazis or abusive priests. And he says, I didn’t say it. And then he sort of says, But this is what I said, which is basically the same thing. 

And then the other thing I was going to say is I’ve noticed sort of a shift, since [Donald] Trump officially won the election and was getting closer to being in office, of the drug industry, some head CEOs really being like, You know, actually, we think [President] Trump will be positive for the industry. And they seem to be kind of ignoring some of the anti-vaccine sentiment and other things, including Trump’s populist appeal on drug pricing. 

Just some of the comments of Kennedy actually surprised me. We sort of know he’s skeptical of a lot of drugs, prescription drugs, being overused in the U.S. But again, both days he made a comment suggesting there’s a study that says prescription drugs are the third-leading cause of death in the U.S., which is not correct, and having a hard time finding what study he was referencing. But the CDC [Centers for Disease Control and Prevention] does have sort of accidental and unintentional injuries as the third-leading cause of death. But that includes a lot of stuff beyond just things that may impact prescription drugs, like opioid overdose deaths. So that’s going to include every car crash in the U.S. that causes a fatality. It’s going to include drownings, a lot of things that have nothing to do with prescription drugs. And that just seems like a big thing to both get wrong as an HHS nominee and also, again, something that’s kind of concerning for people that are interested in medical research and believe there is a positive benefit to pharmaceuticals. 

Rovner: One of the things that he said a lot, which is a safe thing for a nominee to say when being questioned by senators on both sides, is that he would be in line with what the president wants. Of course, in this case, there’s a lot about Trump that we don’t know what he wants, particularly on issues that are not his very top priorities like immigration. So on health care — on Will you continue the drug negotiations that were started under the Biden administration? — he’s like, I’m going to carry out President Trump’s policies. And this is where, Sandhya, I was going to ask about abortion, because he’s obviously, and we’ve talked about this a lot, a lot of anti-abortion groups who are very suspect of him because he was a Democrat until last year and he was very much pro-abortion-rights, and now he says that he will basically do what he is told. Is that essentially how you took it? 

Raman: Yeah. And I think the interesting thing was when in some of that questioning, the way he answered wasn’t I’d had a change of heart or I had a conversation with someone that shifted my perspective or anything like that. He just said: I will do what the president says. But yes, I made those statements. There was no bridge between those. And kind of like you said, if we don’t have clarity on some of those things from Trump, it’s hard to know which way he might go, how high that could be a priority for him. 

I mean, there were certain things that we can kind of expect if he’s confirmed that he might do, just because they have been happening throughout the years under Republican administrations and some of those commitments that were kind of made. But I think this has not really been a top issue for him in general. Like what we were saying before, he wasn’t familiar with EMTALA. That has been a huge thing over the past couple years. The federal government is involved with lawsuits and into kind of upholding that law and making sure that hospitals give emergency care to pregnant women that might need an abortion. 

Rovner: And there’s a Supreme Court case pending on this. 

Raman: It’s surprising that that would be unfamiliar for him given how big of an issue that is. And I think him not being familiar is not even just an issue for Democrats. For Republicans that want that assurance, they would likely want him to be familiar so that when we have HHS implementing guidance later on, that it would go in line with how they would want to interpret EMTALA. So that was one that just really stood out to me. 

Rovner: Yeah, I think I was taken aback, just the idea that he didn’t know what it was and he didn’t even know that the Medicare program basically has the ability to enforce rules for hospitals because it gives so much money to hospitals. Of the many things that made me kind of raise my eyebrows, that made me raise my eyebrows a little bit. I think I put this on social media. Whoever prepped him for these hearings did not do a very good job, because there was some really, really basic stuff any nominee for this job should have known, for much lower jobs should have known, that he appeared not to. 

Well, that was hardly the only news this week. It’s been pretty crazy. It is still Thursday, I think. We’re going to go back a little bit to what I’m calling the “funding freeze fiasco.” When we left off last week, much of science at the Department of Health and Human Services had been “paused,” she puts in air quotes, to use the administration’s word. Meaning no outside communication, no official travel, not much purchasing, and lots of panicked scientists at National Institutes of Health, the FDA [Food and Drug Administration] and the CDC, just to name a few of the agencies. 

Well, it turns out that was just a preview. Monday night, the Office of Management and Budget, whose nominated leader, Russell Vought, has not been confirmed by the Senate yet, issued a memo calling for a halt to all federal grants and loans, with the named exceptions of Social Security and Medicare, starting at 5 p.m. Tuesday. On Tuesday morning, the White House tried to say that the freeze wasn’t supposed to affect programs that provide benefits to individuals, things like food stamps or welfare. But by midday, reports were coming out from around the country about state officials shut out of Medicare payment portals and grantees of various other health programs, including community health centers and federal family planning clinics, unable to access payment systems as well. 

Tuesday afternoon, a federal judge delayed the freeze until Monday, meaning a few days from now. But on Wednesday morning, OMB issued a memo repealing the earlier memo. Shortly after that, White House press secretary Karoline Leavitt said the freeze was actually still on for programs that may violate Trump’s executive orders trying to stop diversity, equity, and inclusion programs, as well as many programs created by the Inflation Reduction Act. A judge cited that confusion and Leavitt’s tweet and blocked the entire effort Wednesday afternoon. So where are we now? And bigger question, does the president really have the authority to just stop payment of so many federal programs? 

Raman: It’s confusing to every single person that I have talked to in different swaths of health care in that this is very unprecedented. They don’t know how to react. And that has been on different days of the week depending on which part of the timeline that we’ve been in. And a concern that I’ve heard from multiple folks has been that despite whatever is kind of written at the time, there’s the chilling effect of the confusion making something sort of overimplemented, even if it only applies to some pocket of funding or some programming. It’s just people being scared and avoiding it just so that their whole program or whole whatever doesn’t get targeted in something. And I’m not a lawyer. I can’t tell you what falls as legal or not legal. But I think that the legal experts that I’ve heard from have really questioned that they have the authority to do all of this. 

Rovner: I have a friend who works for a nongovernmental organization that works with many governmental organizations, and she said last night, “We have 13 different stop-work orders.” 

Karlin-Smith: I was going to say the other thing about the situation besides the legality of it was when they put out the initial order, it was unclear whether Medicaid was a part of it. It wasn’t specifically exempted as Medicare and Social Security were. And then the next day, all these state Medicaid portals were down and they issued this other memo that says, No, no, sorry, we didn’t mean to not accept Medicaid and SNAP [the Supplemental Nutrition Assistance Program] and these other programs that provide critical health food benefits. And it seems like part of what might have been going on is that they just don’t understand how all of this funding works and that Medicaid sort of operates through grants, right? The states get the money, and then it goes to people. And similarly with a lot of other programs, it’s not a direct payment to a person or a direct distribution of goods. 

And again, I think it’s similar to the experience of listening to RFK. It does make you wonder how much of the people that are running the government understand what the government is, what it entails, and how to operate a government appropriately and think about the consequences ahead of time. And now again, I think as Sandhya mentioned initially, maybe I think some of this confusion and chaos is just the point. They don’t care. But if they break things, it is concerning that when they’re making policy, they don’t seem to know what they’re doing. And then that federal workers feel like they have to follow these unclear policies and maybe doing almost too much because of it. And we’ve seen that maybe with some of the rollbacks of NIH spending after they froze certain spending, and they’ve allowed some of the HIV treatment distribution to go on worldwide. But the fact that people felt like they had to freeze it initially signals the policy wasn’t appropriately written or communicated or something like that. 

Rovner: Yeah, and I also saw some arguments that it was just a coincidence that all these portals were down, that they were literally down for maintenance, not because the funding was being frozen, that was just sort of an accidental thing. Although it seems very odd to take them down for maintenance in the first week of the administration. There’s a lot. So whatever happens with the broader order, and we still don’t really know, at HHS, there is still lots of upheaval going on even without any Senate-confirmed officials installed yet. Sarah, we talked a lot about what’s happening at NIH last week. What’s happening at the FDA? 

Karlin-Smith: So, in some ways, I think, from what I’ve heard, the FDA is like a little bit more protected. And I’m going to say it’s a relative thing, but drug approvals are still happening because drug approvals come from user fee funding. They’re still able to have meetings related to that. They’re still doing inspections of food facilities, manufacturing facilities, things like that that help keep people safe, even though there’s travel bans. The things that I’ve seen that seem most impactful and concerning at this point, besides just, I think, a lot of federal government workers are just a little bit nervous about their jobs and stability and so forth. 

Rovner: A little bit. 

Karlin-Smith: Yes. Right now as part of Trump’s diversity, equity, and inclusion executive order, which seemed to my read to be about really how those issues are handled in hiring and staffing, but it seems like it’s being applied very broadly, including at FDA. So a big thing is the FDA took down a lot of webpages and a key guidance document around increasing diversity in clinical trials. And that’s really important. And it’s important for minorities. It’s important for women. It wasn’t very long ago that we didn’t know a lot about how drugs worked in women vs. men because we didn’t include women. And it turns out that is a big difference sometimes. It’s things like that where key programs that I think are seen as scientifically important are in question over, again, an order that is not clear whether it’s supposed to impact that type of stuff. 

Rovner: Yeah, I noticed at the Finance Committee hearing for Kennedy yesterday, one of the senators asked him about clinical trials including more Native Americans, and he said, Oh yes, absolutely. And I thought: “Oh, I don’t think you’re supposed to say that right now. I think that’s all part of what the Trump administration is trying to get rid of.” But obviously, Sarah, as you said, Trump seems to be taking the tech phrase “Move fast and break things” very much to heart, basically doing whatever he wants and daring someone to stop him, which so far nobody really has except maybe that one judge. 

Another example of where this is happening is the World Health Organization, which Trump ordered the U.S. to leave as one of his Day 1 executive orders. But leaving the WHO is supposed to be a year-long process, and this year’s funding is supposed to be honored, yet already officials at the CDC have been ordered to stop all work with the WHO on things like Ebola and Marburg and mpox, as well as bird flu. That includes virtual as well as in-person work. Is anybody pushing back on these things? 

Raman: In a sense, if you looked at earlier this week when we were getting a lot of the pushback on the foreign-aid aspect and not for things like PEPFAR [the President’s Emergency Plan for AIDS Relief], we had even the WHO put out a statement critiquing the U.S. saying this is a bad idea. So even coming from them critiquing the actions that the U.S. is taking, even if the U.S. is kind of withdrawn. But I think this was one of the things that we kind of saw coming a lot more than some of the others, just because in the latter half of the first Trump administration there was gaining animosity towards WHO and just different things there. You could see it in Congress. It was not unexpected for them to want to amp up calls for that. 

Rovner: But my bigger question is, just throwing away some of the things that Congress has said that, Yes, if you want to pull out of the WHO, here’s how you do it, and he’s like, Nope, we’re just doing it. 

Karlin-Smith: Well, I think, and there’s sort of technicalities in how they wrote the order, but Congress does have to actually approve that or at least sign off on that. But in terms of pushback, I guess I think the sentiment I’ve seen from people is: Where are Democrats? Why are they not making a big deal about some of this stuff? Because it is so unprecedented. This is not a kind of what you typically expect in a transition. Which obviously, again, right? We transitioned from a Democratic to Republican president. There are differences in policy ideas and so forth, and they’re putting their people in charge. You sometimes maybe expect a little bit of changes, even certain types of pauses. But the scope and the potential harm and even questionable legality of some of this is different. And Democrats have been fairly quiet, and I think people are looking for that, like, Well, how do we react? And if you don’t have the leadership reacting and helping guide you, then you end up in a kind of quiet space. 

Rovner: I feel like Democrats were trying to, and they said this, that, We don’t want to be like the last Trump administration, where they reacted to every little thing. But now there seems to be the, Why are they not reacting at all? 

So I’m going to add another thing to this along some of these same lines. Trump late Friday night fired about a dozen and a half inspectors general from most of the executive departments, including several he himself had installed. Included in that group was a Health and Human Services inspector general, Christi Grimm, a career employee who had been in the IG’s office since 1999 and was in fact the acting IG during the last year of Trump’s first term in 2020. These firings of what are supposed to be nonpartisan fraud and abuse watchdogs are irregular, shall we say, because Congress passed a law requiring that a president give Congress 30 days’ notice of any IG firing and to state a cause, neither of which has happened. In fact, the Agriculture Department’s IG, Phyllis Fong, was marched out of her office after refusing to leave quietly, pointing out her termination did not follow protocol, which it did not. Is this Trump thumbing his nose at Congress or just trying to do so much so fast that nobody has time to react? 

Raman: To me, I think it’s trying to do so much so fast that people don’t have to react. Because even if you think of the HHS inspector general, what does the HHS inspector general do? A lot of oversight on Medicare and Medicaid to reduce fraud there. And that is such a big, I think, talking point for Republicans, every year in Congress, just, what are different guardrails we can add to reduce fraud. That is such a big thing for them. And to just strip that without having something else set up, it doesn’t seem in line with — I mean, I don’t know. I think that it really is part of the causing chaos. 

Rovner: Yeah. 

Karlin-Smith: I think I read last night they usually recover something in the not quite $10 billion a year or something like that. So that’s a lot of money. And we think of, again, a party, and Trump in particular, has been really focused on creating a more efficient government and reducing waste, particularly in HHS, where the primary role I think of the OIG [Office of Inspector General] and where they spend most of their time is recovering money that wasn’t properly spent. It doesn’t seem to line up with their political positions and views, and it’s just creating a lot of concern in spaces about that he’s sort of pushing the limits of the law to put his people in charge. 

Rovner: Right, because he wouldn’t want an IG who’s nonpartisan to call out fraud and waste and potential corruption from people within HHS, which is part of what the IG’s job is in all of these departments, not just HHS. So we’re going to have to watch how that plays out. Well, one thing that is pretty common to see early in a new administration is lots of executive orders, because the departments haven’t been fully staffed up yet. A lot of those executive orders this week have been aimed at transgender people. Executive orders directed an end to trans people serving in the military, seek to bar doctors from treating minors even with reversible treatments like puberty blockers, and threatened to pull federal funding from schools where teachers call students by their preferred names. Is it just me or does this feel pretty far-reaching? 

Raman: I think what part of this is, we’ve seen them kind of messaging on this issue for a while. This has been a big social issue that has been brought up. So I wouldn’t say that it is surprising that this comes up now. I think it’s part of that flood. We’re not used to having Monday, the executive order, Tuesday and Wednesday that are so broad in scope. And I think that is part of it, that it’s hard to go through it all and kind of see what are the ramifications that this could all have. I would say that the one Tuesday, the one that’s health-based, is pretty broad in that we’re seeing things that we haven’t really seen before, just because I think a lot of the expansions of gender-affirming care on the state level have been happening within the last four years, so there hasn’t really been an opportunity for if they were able to do that. 

But I think the thing that kind of sticks out is that with a lot of the trans health stuff geared at children, the age is not necessarily 18. The executive order is 19 and below, and it’s sometimes older than that in some of the states. But I think for something that’s national and just kind of what, all the rulemaking that he’s directing to not cover gender-affirming care for youth under Tricare, and just changing the provisions in the Postal Service and federal employee plans, it’s pretty wide-ranging. And I think the part that I would definitely be most curious about are the things related to the Justice Department and what they can enforce on other states, just because we do have states that have pretty progressive policies for gender-affirming care, and that folks that live in more restrictive states have kind of moved there to be able to access that for their kids, and just what they’ll be able to do on that level to tamp down on that. I think that will be a big thing to watch. 

Rovner: Well, moving on to reproductive health. Last week at this time, we were talking about how the first flurry of executive actions did not include anything about abortion. The anniversary of Roe v. Wade came and went on Wednesday, and the annual March for Life by anti-abortion forces came and went with both the president and the vice president speaking on Friday, and still nothing. And then Friday night, Trump issued the orders we’d been kind of expecting all along since Monday. Sandhya, this was kind of a return to Republican administrations past, right? 

Raman: Yeah. So he reinstated the Mexico City policy, which we’ve had every Republican administration since [President Ronald] Reagan, and it restricts the funding that we can give to foreign organizations that even if they with their other funds do anything in the abortion realms. Similar to what we’ve done with Title X in the U.S. but for foreign aid. And then I think another important piece is they in a separate document rejoined us into this document known as the Geneva Consensus Declaration, where countries kind of pledge that they’re going to be against abortion and advance women and children’s health efforts. And I think those things were pretty expected. I wasn’t expecting it to come that much later after the March for Life rather than kind of timed with that. And then the other important thing was that he rescinded two of the executive orders under [President Joe] Biden to be more in line with Hyde-level restrictions, so not using federal funding for abortion in most circumstances. 

Rovner: So then on Monday we saw things go even a little bit further. Acting Health and Human Services Secretary Dorothy Fink put out a document that looked pretty routine, except it quietly said that not only could HHS programs not pay for abortion, which they haven’t been able to because of the Hyde Amendment, but also that they could not, quote, “promote” abortion, which has been interpreted to mean talk about the procedure in anything except the most negative terms. Now, this is a big change. For decades, the Hyde Amendment that bars funding coexisted side by side with a requirement in the Title X family planning program that women with unintended pregnancies be counseled on all their options, including abortion, and be referred for abortion if they ask. This is most definitely not current law, but I guess if you’ve been following the rest of this week’s theme, that seems not to matter to this administration, right? 

Raman: Yeah. And I think also, within that same statement, she kind of said they were going to reevaluate their guidance about conscience and religious protections within the Office of Civil Rights. And that also kind of brought me back to we had a lot of rulemaking in Trump 1 related to that. And I think some of those were more directly related to abortion, gender-affirming care, things like that within that umbrella. So I would expect more on that front to also kind of come back. But yeah, I think this is another one where it’s another step more, another step more. 

Rovner: Another flood the zone and dare everybody to keep up with it. All right, one final thing this week, one of the big administration priorities we haven’t talked about is immigration. And yes, immigration is a health care issue. One of the changes the Trump administration is making is allowing ICE [Immigration and Customs Enforcement] officers to raid hospitals and other health care facilities. The reason that’s always been taboo is that you don’t want people with potentially contagious diseases to shy away from seeking medical care because they’re afraid of encountering immigration authorities, and then they end up spreading those diseases far and wide instead. Are we just going to have to learn this lesson the hard way again? 

Karlin-Smith: It seems potentially likely, and it’s at a concerning time with bird flu, avian flu circulating, and a lot of farmworkers in this country being immigrants and migrants who may or may not have legal status officially, because we need to know to actively protect everybody and figure out where the disease is spreading, what we need to do in reaction to that and keep everybody safe. We need to know if people have bird flu or don’t have bird flu. And so you want people to be comfortable getting medical care and treatment and getting tested and not feel like they’re risking being separated from their family, their livelihood, and all of that stuff. 

The other thing I thought, again, some of the rhetoric that’s used around this is sort of people are taking services from Americans and they’re not giving anything in return, and a lot of these people contribute to our tax system and stuff and don’t actually get any benefits back from that. So again, I think some of the logic around that. But it’s certainly been interesting to see hospitals figure out how they can deal with this or what they need to do to train their staff to kind of protect their patients and figure out how they comply with these policies. 

Rovner: And encourage sick people to come forward and get medical care. All right, well, that’s as much news as we have time for this week. Now we will play my interview with Nick Bagley, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Nicholas Bagley, the Thomas G. Long professor of law at the University of Michigan Law School. In addition to being an expert on all things health-law-related, in his day job Nick teaches administrative law. So I’ve asked him here to give us a refresher on how the federal regulatory process is supposed to work. Nick, thank you so much for joining us. 

Nicholas Bagley: I am thrilled to be here, and go blue. 

Rovner: Before we get to our main topic, this administration is off to a bit of a different start, if I can call it that, in terms of go fast and break things. Just how different has the start of this Trump administration been? 

Bagley: Well, in one respect, I think it’s pretty different. They’re coming out, rhetorically at least, extremely strong in a whole flurry of executive orders that say that they’re going to make enormous changes to the regulatory state. They’ve promoted this “Department of Governmental Efficiency” that Elon Musk heads. They’re making lots of claims that they’re going to cut back on all the red tape that makes it hard for Americans to get stuff done. So in that sense, it is a little bit different, a kind of shock-and-awe offensive. 

But when you drill down to details, there’s a little less there than meets the eye. So an executive order, they sound really fancy, but they’re really just gussied-up internal memoranda telling one of your subordinates to do something. And so they make big promises, and then when you drill down to the details they say, And follow through as practicable and consistent with law and make sure you take your time and talk to all the relevant stakeholders, etc., etc., etc. And so for a lot of the initiatives, we’re still waiting on details, and that’s very consistent with past administrations, because it takes a long time to make big regulatory changes. 

Rovner: So at her first briefing earlier this week, presidential press secretary Karoline Leavitt said that Trump had already repealed a number of President Biden’s regulations, and reporters I have seen use similar language. But that hasn’t really happened yet, right? 

Bagley: It hasn’t happened. And I’ve spent a lot of time trying to get across just how little these executive orders do on their own. They’re important in that they set a tone, they offer instructions, they tell us about where the president would like to go, and his subordinates will take that seriously. But the president can’t undo a regulation just by waving his pen around. There’s a process, and that process takes time. 

Rovner: What’s the difference between congressional power and executive power? I mean, President Trump seems to think that he can pretty much do anything he wants with the executive branch. That’s not really the case, right? 

Bagley: No, it’s a big misunderstanding. The executive branch is really dependent for all of its authority and all of its funding on Congress. The core of Article 2 power under the U.S. Constitution says that the president “shall take Care” that the laws are faithfully executed. That’s the president’s responsibility. And if he hasn’t been given power by Congress, he has precious few powers on his own. There’s really not much conferred in the Constitution itself. So all of the president’s awesome powers, they derive from laws that Congress can adopt and that Congress can amend and that Congress can repeal. And so this claim that he’s going to go it alone is really a claim that he’s going to work with the statutes that are on the books. And some of those statutes give him a lot of authority, and he’s going to have a lot of room to run. And others of those statutes are going to constrain him quite a bit. And we’ve seen his claims about what he wants to do, and now we’re going to have to test how much he’s going to be allowed to do. 

Rovner: Can you talk very broadly about what power the president has through rulemaking authority and what he, at least in theory, can’t do? 

Bagley: Yeah. When an agency moves to adopt a rule, a rule is something that says to the regulated community, these are the kinds of things you have to do in order to continue an operation. So if you’re a power plant, you’ve got to install this scrubber. If you’re a meat processing facility, you’ve got to abide by these safety regulations. And on and on and on. When agencies adopt those rules, there’s a law that requires them to work through a pretty intensive process. So what they’ve got to do is they’ve got to offer notice about the rule that they’re thinking of adopting. They’ve got to allow the public to comment on that rule. And then the agency has got to respond in detail to all of those comments. 

And that’s a process. It doesn’t sound that intensive, but it takes usually in the order of somewhere between one and three years to get a regulation through that process. And you can do it quicker if you really have to, but of course that takes some resources, too. So when President Trump’s press secretary says he’s gotten rid of a bunch of regulations, she’s just misstating the law. That’s not true. Now, the processes will start and many of those rules will eventually be undone, but it will take time. 

Rovner: And the same thing in terms of his doing rules. These are all about, what can he do as compared to Congress? He can’t just make up rules, right? 

Bagley: Yeah, he can’t just make up rules. There are a bunch of really important legislative constraints that are easy to forget about. The first one, and really the most important one, is the appropriations power. He can’t mint money. But the second is when he exercises power, he’s got to abide by the rules that Congress has laid out on how he exercises that power. And it turns out that Congress has never been comfortable telling the president, Go be the lord of the manner in this particular space and just rule by decree. Congress says: There’s got to be a process to make sure that all stakeholders are heard and to make sure that we get these right. And if you don’t go through the requisite process, we’ve told the courts to come in and stop you. 

And sometimes President Trump assumes that because the judiciary leans to the right, they’re going to be passive when it comes to his abuses of regulatory power, and I think is misreading how the courts think about this problem. In the first Trump administration, we saw a lot of Republican judges push back hard on sloppy regulatory choices, and I expect to see the same pattern emerge here. 

Rovner: So where do things like guidance and executive orders fit into this? He’s got power there, but not as much power as he does through the regulatory process, right? 

Bagley: That’s exactly right. So when you adopt a rule, that rule has what they call the “force of law.” It’s basically like a law even though it’s adopted by the executive branch. And that means that if you violate the rule, you can be punished for violating the rule. When you’re talking about executive orders or guidance documents, they’re kind of easy come, easy go. You can adopt them with a stroke of a pen, but they can’t actually create any new binding legal obligations. So for example, a guidance document, might hear about these sometimes, they’re just telling the world how the agency thinks about a particular rule or a particular law. It says, This is how we understand what this rule or what this law means. But that’s not binding on the courts. It’s not binding on adjudicators. It’s just the agency’s opinion. And because it’s just the agency’s opinion, it doesn’t carry that kind of weight. So if you really want to make big regulatory changes, there’s really no substitute to going through the full dress process. 

Rovner: So to add one more level of confusion to this, last year there was a very important Supreme Court case that we talked about a lot on the podcast that threw out a 40-year-old precedent known as Chevron deference that basically instructed judges to trust the expertise of federal agencies, at least in most cases. Will the elimination of Chevron make it easier or harder for the Trump administration to carry out its agenda through the regulatory process? 

Bagley: Yeah. Well, if you ask the Trump administration, they think this is great. They think it’s going to make their job easier because the United States Supreme Court is clipping the wings of these left-leaning agencies that are imposing rules willy-nilly. But actually, the truth is that losing Chevron deference is a real blow to the Trump administration’s priorities. And the reason is really simple. Chevron doctrine gave the executive branch flexibility in how it interpreted statutes. It allowed them to interpret those statutes kind of how they thought best, so long as what they offered was a reasonable interpretation. But now the courts are going to get to decide what the statutes mean. And if the Trump administration likes a particular interpretation, and the courts say, That’s not the best reading of the statute. We think the best reading of the statute is a different one, the Trump administration might have won under Chevron, but it’s going to lose under Loper Bright. And so I think they’re going to find themselves handcuffed to a much greater extent than I think they appreciate. 

Rovner: So basically, it’s going to cut both ways. 

Bagley: It’s going to cut both ways. These big changes to administrative law often have that effect. The Supreme Court, when it issues Loper Bright, what it’s saying is, We want the courts to be more important in this regulatory process. But the courts being more important means that the executive branch is a little less important, and that’s true for Democratic presidents and it’s true for Republican presidents. 

Rovner: We’re going to have to learn a lot more about health law in this coming four years. Nick Bagley, thank you so much. 

Bagley: Very happy to do it. Thank you. 

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

Raman: So I chose “Dozens of People Died in Arizona Sober Living Homes as State Officials Fumbled Medicaid Fraud Response,” and it’s by Mary Hudetz of ProPublica and Hannah Bassett of the Arizona Center for Investigative Reporting. So the story is about how at least 40 Native American residents in some sober living homes in Phoenix died when state Medicaid officials weren’t able to respond to the fraud scheme targeting Native Americans. And their investigation found that half of the deaths were happening when officials were ignoring the calls about the oversight issues that were getting reported. And the Medicaid agency even found that the fraud cost taxpayers up to like $2.5 billion. It’s a really sobering story. 

Rovner: Sarah. 

Karlin-Smith: So I took a look at a piece this week from CBS News, “Wind-blown bird poop may help transmit bird flu.” It’s about a possibility that Michael Osterholm talked about this week on his podcast, which is we have some reason to believe that bird flu may be spreading in bird poop, and it sort of can basically transmit in the air into a point where somebody, a human being including, may end up getting infected with bird flu and they didn’t have any direct contact with an animal or something like that. And so it raises concerns about the ability for it to spread much more differently. 

And also, he mentioned it raises concerns just for control of the virus, because of the way chickens are sort of housed. If they’re on farms and so forth, it would be very difficult to sort of refit their homes, if you will, to sort of prevent them from getting bird flu from outside wild birds. So if they can show this is happening, this would be kind of a big complication in our ability to track, control, and contain the virus, and of course, as they were talking about in this story, get the price of eggs down, which everyone’s very focused on. 

Rovner: That’s right. Well, my extra credit this week is from an independent news outlet called 404 Media. It’s called “Medical Device Company Tells Hospitals They’re No Longer Allowed to Fix Machine That Cost Six Figures” by Jason Koebler. It’s about a machine used in open-heart surgeries and a company that used to offer hospital maintenance staff certification classes to teach workers how to maintain and repair the machines. But now the company has decided instead to require those hospitals to purchase maintenance contracts. Hospitals are now considering not only that it’s going to cost them more but that they may have to wait longer for an authorized repair person rather than rely on their own personnel. This is part of the broader right-to-repair debate, except this one could have life-or-death consequences. 

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

Karlin-Smith: I’m mostly at Bluesky at @sarahkarlin-smith but still hanging around X a little bit and trying to post on LinkedIn, too. 

Rovner: Sandhya? 

Raman: On Bluesky and on X, @SandhyaWrites. 

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

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The “Shkreli Awards” are a kind of Oscars for the most outrageous examples of greed, fraud, and general brokenness in American health care.

The awards are named after Martin Shkreli, a former pharmaceutical executive who infamously raised the price of Daraprim, a lifesaving treatment for toxoplasmosis, from around $13 a pill to $750. The media dubbed him “the pharma bro,” and he became a symbol of brazen pharmaceutical greed.

In this episode of “An Arm and a Leg,” you’ll hear highlights from this year’s ceremony and reflections from the Lown Institute’s president, Vikas Saini.

“Showing all these stories together paints a picture of a health care system in desperate need of transformation,” Saini said at the event. “Not just because the stories are shocking, but because often what they’re depicting, like Martin Shkreli’s infamous price hike, is perfectly legal.”

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. So, awards season has already started …

Nikki Glaser, Golden Globes host: Good evening! And welcome to the 82nd Golden Globes, Ozempic’s biggest night.

Dan: OK, I did not watch the Golden Globes this year. But there is an awards show that’s made basically just for nerds like me. 

Vikas Saini (awards ceremony): Hello, everyone, and welcome to the eighth annual Shkreli Awards. 

Dan: The Shkreli Awards! Named after the “pharma bro” Martin Shkreli. Remember him? 

He became famous — infamous — in 2015, when a company he ran took over the making of an old drug called Daraprim. Old, old. Introduced in 1952, but it later became used to prevent a form of pneumonia that people with HIV can develop. 

So Martin Shkreli jacked up the price — from thirteen-and-a-half dollars a pill to seven hundred and fifty bucks. Rings a bell, right? So, who gives out awards named after that guy? 

Answer: A health care think tank called the Lown Institute. One of their big recent projects was ranking nonprofit hospitals by how much they do to “earn” their tax exemptions, for instance, by giving out charity care. The institute’s president, Dr. Vikas Saini, hosts the awards ceremony.

Vikas Saini (awards ceremony): So if this is your first time at the Shkreli Awards, this is our top 10 list of the most egregious examples of profiteering or dysfunction in health care.

Dan: I’m telling you: this is an awards show for nerds just like me. In fact, it’s also kind of a celebration of nerds kind of like me. Each of the awful stories these awards highlight was dug up and brought to light by … journalists. 

Vikas Saini (awards ceremony): So this year, the journalists behind these stories will be receiving a Shkreli Reporting Award. And I have one in my hand here.

Dan: It’s a bobble head: White guy in a black suit — Clark Kent without the glasses – and it’s in a display box that says 2024 Shkreli Award. Someday, I hope the reporting we do here earns us one of these. The ceremony was held January 7. We’ll bring you some highlights — I mean, is it a highlight when you’re giving awards for the worst things? Well, let’s just say they were some of the most entertaining stories. 

And we’ve got some reflections from a conversation I had with Dr. Saini the next day. The ceremony itself wasn’t fancy — just a Zoom presentation — but we’re gonna dress it up a little bit, so it sounds like other awards shows, with a big crowd, and a stage … 

Vikas Saini (awards ceremony): All right, so. Without further ado, let’s do the countdown. The 2024 Shkreli Awards. Brace yourselves. Here we go. 

Dan: This is An Arm and a Leg. A show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

The Shkreli Awards show is a countdown, starting with number ten. And they started with a doozy this year.

Vikas Saini (awards ceremony):Number ten. Texas Medical School allegedly neglects to notify next of kin before selling body parts of the deceased. 

Dan: NBC News reported that the University of North Texas Health Science Center in Forth Worth was getting unclaimed bodies from the county coroner, and then cutting them up and selling them — without getting anybody’s consent.

Vikas Saini (awards ceremony): The center’s business supplied the body parts to major for-profit ventures like Medtronic and Johnson Johnson. The investigation found repeated failures at the center and at the county level to contact family members who were, in fact, relatively easy to identify and reach. 

Dan: For instance, NBC talked with the family of Carl Honey, a veteran who died homeless, but was entitled to a military burial. Here’s what happened instead.

Vikas Saini (awards ceremony): Swedish medical device maker paid 341 dollars for Honey’s right leg. A Pittsburgh medical education company spent 900 dollars for his torso, and the U.S. Army paid 210 dollars for bones from his skull. It just sounds so macabre. It’s more like a Halloween story.

Dan: When NBC News told the university what they’d found — and that they’d be publishing their findings — the medical school shut down the program and fired the people who had been running it. 

But as Vikas Saini reflected when we talked, this probably wasn’t a story about a few rogue administrators. It sounded to him more like a really grisly example of how health care institutions get run. 

Vikas Saini: They set a tone at the top, that’s, we got to make our numbers. We got to make our bottom line. You know, it’s like the widget factory and, you know, how many cars did Tesla ship, and with that mentality, you set the tone.

Once you set the tone, you can’t keep track of what everybody’s doing. And the people probably thought they were doing the right thing. They’re trying to bring in some revenue.

Dan: If your job is to bring in revenue, help make the numbers, then why would you bother trying to contact next of kin and get consent before selling off somebody’s body parts? 

And this was a state medical school. As we’ll see, as you know, this theme — gotta make our numbers — runs through the whole awards ceremony and through so much of health care. 

Next on the list was another banger. 

Vikas Saini (awards ceremony): Number nine, out of the mouths of babes, a taste for tongue-tie cutting intensifies. 

Dan: I’d never heard of this, but: In some infants the little bit of tissue that connects the tongue to the floor of the mouth is a little thicker, or shorter, and that’s called a tongue tie. The New York Times reported that lactation consultants have sometimes advised new moms to have tongue-tied babies snipped, to help with nursing. 

And the Times reported that the procedure has exploded in popularity. 

Vikas Saini (awards ceremony): Despite a lack of evidence showing effectiveness, baby tongue tie cutting procedures are being touted as a cure for everything from breastfeeding difficulties to sleep apnea, scoliosis, and even constipation. 

Dan: New York Times reporters talked to one doc who said he does this procedure a hundred times a week. At 900 dollars a pop. 

Dentists also do a lot of these, and a medical-device maker named Biolase apparently was encouraging them to do more. Here’s Dr. Saini from the awards ceremony again.

Vikas Saini (awards ceremony): At an April 2024 event for pediatric dentists billed as tequila and tongue ties, representatives for the laser device company trained attendees on the procedure before doing rounds of tequila shots and margaritas. 

I should add that, you know, they had a third annual Phrenectomy Fiesta, which was advertised as “nacho average dental meeting.”

Dan: Later, Vikas Saini told me this story actually stirred some deep reflection, that goes back to the Lown Institute’s origin story, and his own. 

The institute started as the Lown Cardiovascular Research Foundation, founded in 1973 by Dr. Bernard Lown, a cardiologist who advocated for non-invasive management of heart disease — and who became Saini’s mentor. 

Vikas Saini: Dr. Lown’s motto was we do as much as possible for the patient and as little as possible to the patient.

Dan: Saini appreciates how doctors and researchers want to discover new things. But in our system, that desire gets wrapped up in the medical industry’s need to make the numbers — find new products to sell — like procedures. 

Vikas Saini: These procedures take off, especially if there’s a need or a plausible facsimile of a need in this case. And once they take off, you know, it sort of snowballs.

Dan: Tongue-tie cutting looks to him like an especially wild version of the product-development side of things. And an event like tequila and tongue ties just strikes him as a natural extension. 

Vikas Saini: This idea that the manufacturers train people in the technique, that’s not confined to this. This goes on all over the place.

Dan: We could dig up probably a trove of tongue ties and tequila shots-like events.

Vikas Saini: Yeah, yeah, yeah. Gallbladders and gimlets. 

Dan: Here’s another example of a product in search of a market. This story was dug up by Arthur Allen, a reporter with our pals at KFF Health News. And in this case, the product is a drug. 

Vikas Saini (awards ceremony): A drug company pursues high dose of profits despite risk to patients. That’s shocking. Amgen’s lung cancer drug, Lumakras … How do they make these names? Lumakras? There’s Ludacris. Lumakras… was granted accelerated FDA approval in 2021 at a daily dose of 960 milligrams.

Dan: But the company also had to test a lower dose: 240 milligrams. Which turns out to work just about as well, with a lot fewer side effects.

Vikas Saini (awards ceremony): That should be good news for patients looking to reduce the diarrhea, nausea, vomiting, and mouth sores that can occur.

Dan: One patient told KFF Health News, “After two months on that drug, I had lost 15 pounds, had sores in my mouth and down my throat, stomach stuff. It was horrible.”

So yeah, a lower dose sounds like great news. 

But not for Amgen. KFF Health News reported that by selling the higher dose, the company makes an extra 180 thousand dollars per year, per patient. So that’s what they’re doing.

At the awards ceremony, Vikas Saini said the story shows weaknesses in the FDA approval process. It’s long and expensive, but it’s not comprehensive. 

Vikas Saini (awards ceremony): There’s no way of holistically looking at how much does this cost? What are the side effects? What are the trade-offs? And what’s the strength of the evidence? We need different mechanisms and methods than just saying, “Hey, you’re approved. You can charge a thousand bucks and we’ll figure it out later.”

Dan: Before giving “final approval,” the FDA has asked Amgen for extra studies, but meanwhile, the drug is on the market, and the “FDA-approved” dose on the label is … the higher one. 

So, we’ve heard about procedures and drugs getting pushed that may… not be the best for patients. But do make money. And then there’s a story from the New York Times about folks selling products that … don’t seem to even exist.

Vikas Saini (awards ceremony): Here’s a story that’s gonna piss people off, perhaps. In 2023, a massive surge in Medicare billing for urinary catheters left patients shaking their heads. Up to 450,000 beneficiaries had bills for catheters submitted on their behalf.

Representing an 800 percent increase over previous years. Just seven suppliers were responsible for two billion dollars of these suspicious charges. 

Dan: That two billion dollars? The New York Times story says that could amount to a fifth of all Medicare spending on medical supplies for that year. That’s just seven “suppliers.” 

Vikas Saini (awards ceremony): When the New York Times looked into these suppliers, the curiously named Pretty in Pink Boutique, they found no medical business at its address, and its phone number rang a random auto body shop.

Dan: The Times found that Pretty In Pink had billed Medicare for more than a quarter-billion dollars. I said to Saini: This example seems to show, this kind of fraud — maybe you don’t even have to try that hard.​

Vikas Saini: I think it just illustrates, you know, the dollar flows through healthcare are so massive. Multiple trillions of dollars. You know, that a billion here, a billion there, it’s not even real money yet. 

Dan: So, with trillions of dollars moving around, and a LOT of people who need to hit their numbers, we get high-priced drugs that may not be worth the money and body parts sold off without anybody’s consent. Folks getting procedures they may not need. Companies billing for catheters no one seems to have gotten. 

And of course the Shkreli Awards “honored” more winners. Including a doctor accused of giving patients drugs they didn’t need — and which killed them. 

There was an insurance company that denied a claim for an air-ambulance ride for a baby — leaving the family on the hook for more than 97 thousand dollars. [That’s another one reported by our pals at KFF Health News, with NPR this time.]

And there were two stories about hospitals beholden to private equity investors. One has been accused of denying care to cancer patients and demanding payment upfront. 

The hospital denies that allegation, but NBC News found that their charity care policy had been altered in 2023 to exclude cancer treatment.

And as bad and ridiculous as all this sounds, still ahead, we’ve got top two honorees – well, dis-honorees —  and some bigger thoughts from Vikas Saini about what it all means. That’s right after this. 

An Arm and a Leg is a co-production of Public Road Productions and KFF Health News — that’s a nonprofit newsroom covering health issues in America. KFF’s reporters do amazing work — they’ve broken lots of Shkreli Award winning stories. I’m honored to work with them. 

The other private-equity story in this year’s Shkreli Awards involves a chain of hospitals, Steward Healthcare, that ended up bankrupt. The Boston Globe published a heartbreaking story with the headline, “They died in hallways. In line. Alone. Their deaths are the human cost of Steward’s financial neglect.”

The Shkreli Awards gave their number one spot to Steward’s CEO — well, now he’s the former CEO: Ralph de la Torre, who reportedly made a quarter-billion dollars over the four years leading up to the bankruptcy. 

They illustrated the story with a photo of an empty chair with a name card for de la Torre — in a Congressional hearing room. He skipped the hearing — he was reportedly on one of his yachts at the time. And got held in contempt. 

It’s a hell of a story. But if I had gotten to vote for the top spot, I would’ve gone with the company that became the runner up. 

Vikas Saini (awards ceremony): Number two, corporate healthcare behemoth exercises crushing power. So what started out as a small Minnesota health insurer is now the fourth largest business in the nation by revenue, controlling nearly 90,000 physicians and acquiring influence across the breadth and depth of the healthcare industry in the United States.

Dan: Ninety-thousand physicians. That’s more than three times as many doctors as work for the VA. 

Of course that company is UnitedHealth Group. Which also operates the country’s biggest insurance company, United HealthCare. And a BUNCH of other health care businesses. We’ve talked a lot about United on this show in the last couple of years.

And a team at STAT News — that’s a news outlet covering health, medicine and science — they did a massive series on United in 2024, documenting just how big United has grown, and how its tentacles interact.

For instance: UnitedHealth is the biggest player in Medicare Advantage — that’s the privatized version of Medicare. You’re in a United Healthcare Medicare Advantage plan, your in-network doctor is likely to work for United HealthGroup. 

STAT interviewed some of those doctors, who said they felt pressured to, one, spend less time with patients. And two … well, the second part needs a little setup: When you run a Medicare Advantage plan, you get extra money— a bonus — for insuring patients who are less healthy.

So the second thing these docs told STAT was: They felt pressured to use aggressive medical-coding tactics to make their patients look as unhealthy as possible. Which could earn that bonus for the insurance plan.

Vikas Saini (awards ceremony): According to STAT this tactic may have allowed the company to take tens of billions of dollars in additional payments from us, the taxpayers, over the past decade. UnitedHealth faces a federal lawsuit for this behavior, as well as an ongoing antitrust investigation. And of course, the company denies any wrongdoing.

Dan: When we talked, Vikas Saini said: If he were working for United, he might pursue the same kinds of strategies. That’s how you hit your numbers, keep shareholders happy. It’s the logic of so much of our healthcare system. 

It was the logic of Martin Shkreli, the guy who gives these awards their name. Shkreli did eventually spend seven years in jail. But not for jacking up the price of medicine. 

Vikas Saini: People say he went to jail and they link it to the pharma pricing thing, but he didn’t go to jail for that. He went to jail for this other thing, securities fraud. So it may be, raising the price that much was perfectly legal, and then that puts a different spin on his justification, which is he felt it was his duty to his shareholders to maximize what he could make.

Dan: By the same logic, United owes its shareholders maximum return. Grows bigger and bigger. And other players — trying to hit their numbers — they try to grow big enough to compete. 

Vikas Saini: Now, maybe someday, you know, we’ll have three behemoths duking it out. But again, the people left holding the bag and all these healthcare Godzilla-versus-King-Kong fights, the people left holding the bag are patients, communities, smaller hospitals, rural hospitals, and most of us, really.

Dan: When Godzilla and King Kong fight, they stomp on everybody.

Vikas Saini: Yeah, exactly. 

Dan: Meanwhile, United has been in the news recently, in a big way. In December, the CEO of the insurance division, Brian Thompson, was shot to death in New York. You probably heard about it.

Vikas Saini: I’d characterize my mood, or my reaction in response to that shooting to be one of alarm and urgency. The urgency is that we’ve been doing the Shkreli Awards for, you know, years, and years, and years. You know, the kind of anger and the kind of simmering resentments, they have been there for a while. And that’s what I’m alarmed about. Because we got big problems. If nothing else, it’s a flare being shot up to say there is a crisis and to call it anything less than a crisis is not real.

Dan: Vikas Saini sees this crisis as an extension of how our health care system works. Everybody hitting their numbers. And he asks, “Yeah, but, numbers of what?”

Vikas Saini: If we’re going to treat health care as a commodity and we’re going to have the magic of the marketplace solve all these problems, which some people still think is the way forward – I happen to disagree in many dimensions – but according to the logic of the marketplace, what’s the product off the assembly line?  If the product is health care activity, health care procedures, then we have the system we have, but what if the product were health? What if the product were wellness?

Dan: We don’t measure for that. He thinks again about his mentor, Bernard Lown.

Vikas Saini: He was always fond of saying that in most other businesses, the you get more efficient by doing everything faster. And he said, in health care, at least in the doctor patient relationship, you get more efficient by doing everything slower. 

Dan: Meaning, by taking time to really get to know patients. 

Vikas Saini: The quick example is, if I know someone for 10 years and they come in Friday at 4:30 with a headache, I have one response. If I’ve never met this person in my life and they come in Friday at 4:30 with a headache, I’m more likely to send them for a CT scan or see a neurologist or whatever the hell it is.

Dan: In addition — and contrast — to the Shkreli Awards, the Lown Institute gives out a Bernard Lown Award for Social Responsibility. 

It honors a “young clinician” — under the age of 45– who stands out for “bold leadership” in humanitarian work and standing up for justice. 

If you know somebody who could be a match, the deadline to nominate them for the 2025 award is January 31. 

Speaking of deadlines, we had a big one on December 31: The end of our year-end fundraising drive. 

We were racing to hit a big target: Between the Institute for Nonprofit News and a few super-generous donors, there were funds to match 30 thousand dollars in gifts.

Did we make it?

You bet we did. Or should I say, YOU did. Thank you SO much.  Because of your generosity and commitment, we’re starting out 2025 super-strong. 

Starting with: We’re bringing back the First Aid Kit newsletter, and making it WEEKLY. Starting in February. I’m super-excited.

Meanwhile, we’re starting an extremely cool partnership with KUOW, Seattle’s NPR news station. They’ll be helping more people discover this show– as a podcast. 

(No immediate plans for a broadcast version, but this is really big. In just in the first few days, we are seeing lots of new folks listening to An Arm and a Leg — and we’re literally just getting started.)

If you’re one of the folks who’s discovered this show with help from KUOW and the NPR network, welcome aboard!  I’m so glad you’re here.

We’ll be back with a new episode in a few weeks, and meanwhile, feel free to dig around in the hundred-and-some episodes we’ve published in the last six years. I think they’re all pretty good.

Catch you soon.

Till then, take care of yourself.

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The second Trump presidency launched with a bang at the Department of Health and Human Services, where a traditional pause on public communications was expanded to an effective stoppage of scientific work, as health agencies were ordered to cancel meetings, travel, and efforts on outside publications. It is unclear how long the order will stay in effect; President Donald Trump’s nominee to run the department, Robert F. Kennedy Jr., won’t go before Senate committees for his confirmation hearings until the end of the month. 

Meanwhile, starting on his first day in office, the new president issued a raft of executive orders aimed at reversing Biden administration policy — but, notably, none directly addressing abortion, which has been a traditional focus every time the White House changes parties. 

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Rachel Roubein of The Washington Post, and Rachel Cohrs Zhang of Stat.

Panelists

Among the takeaways from this week’s episode:

• The Trump administration took a very firm grip on federal agencies this week, sowing uncertainty with blanket cancellations of upcoming meetings and travel — as well as by implementing a broad pause on external communications. The cancellations reached deep into agencies’ core functions, affecting, for instance, meetings to review grant applications for federally funded research.
• Kennedy’s confirmation hearings to be Health and Human Services secretary are scheduled for Jan. 29 and 30. Yet questions remain about his nomination, including more recent revelations about conflicts of interest — such as his financial stake in ongoing litigation with Merck & Co. related to the HPV vaccine.
• Trump issued a slew of executive orders this week. (It is worth noting that executive orders largely instruct federal agencies to start making a change, rather than constituting the change themselves.) Of note on health, Trump’s orders instructed the removal of the U.S. from the World Health Organization; revoked a Biden administration order to reduce drug prices; and laid the groundwork to undermine health care for transgender people. Notably, though, none of the orders directly addressed abortion.

Also this week, Rovner interviews Rodney Whitlock, a consultant with McDermott+ and an adjunct faculty member at the George Washington University Milken Institute School of Public Health. Whitlock is a former House and Senate staffer and provides a primer on how Congress’ convoluted budget reconciliation process is supposed to work.

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

Julie Rovner: CNN’s “With Bird Flu Cases Rising, Certain Kinds of Pet Food May Be Risky for Animals — And People,” by Brenda Goodman.  

Rachel Roubein: The Washington Post’s “Antiabortion Advocates Look for Men To Report Their Partners’ Abortion,” by Caroline Kitchener.  

Rachel Cohrs Zhang: The Washington Post’s “In Florida, a Rebellion Against Fluoride Is Winning,” by Fenit Nirappil.  

Alice Ollstein: The Los Angeles Times’ “Now That You Can Return Home After the Fires, How Do You Clean Up Safely?” by Karen Garcia and Tony Briscoe. 

Also mentioned in this week’s podcast:

• The Texas Tribune’s “Longtime Planned Parenthood President Cecile Richards Dies After Battle With Brain Cancer,” by Eleanor Klibanoff.

[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, Jan. 23, at 10 a.m. As always, and particularly today, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Cohrs Zhang of Stat News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: I’ll do my best to keep the Rachels straight. Later in this episode, we’ll have my interview with longtime Hill staffer Rodney Whitlock, who will help explain budget reconciliation, which is the process by which congressional Republicans are going to try to enact most of President [Donald] Trump’s health agenda later this year. But first, the news — and it is breaking fast, as I said. 

President Donald Trump was sworn in at noon on Monday and as predicted hit the ground running with a sheaf of executive orders. Many of those have to do with health policy, and we’ll get to them in a moment. But first today, it appears the new administration is taking the tightest hold ever on the workings of the sprawling Department of Health and Human Services, creating chaos, whether on purpose or not. 

Now, every new administration puts a moratorium on what it tells the public as new political appointees integrate themselves into the everyday workings of agencies like the National Institutes of Health, the Centers for Disease Control and Prevention, and the Food and Drug Administration. But this administration has gone considerably further than ever before, literally grinding to a halt long-scheduled scientific meetings, scientific journal publications including CDC’s Morbidity and Mortality Weekly Report, and canceling travel until further notice and basically any communication with the outside world. 

What do we know about what’s happening here? Is this just the sort of government-wide external communication stoppage, or does it have to do with the administration trying to get rid of efforts at diversity, equity, and inclusion? 

Roubein: My colleagues at The Post, Dan Diamond, Lena Sun, and I dug into this on Tuesday and also Wednesday and continuing this morning, and basically our sense of it kind of early on Tuesday was that Stefanie Spear, an HHS deputy chief of staff, key [Robert F.] Kennedy [Jr.] ally, had instructed agency staff Tuesday morning to do this pause on external communications. There was then later a memo that outlined it. In general, we talked to nearly a dozen people, and some of them acknowledged that, yes, it’s expected, some review during a presidential transition so that the new incoming team can understand the vast flow of info to health agencies. But they also said they were confused by the pause’s scope, and as you mentioned, yesterday there were council meetings, travel, etc., paused, then compounded on some of that confusion. 

Rovner: Yeah, I mean, basic things like study sections, which is when they review grants. I mean, this is basically stopping a $47 billion agency, the NIH I’m talking about now, in its tracks. 

Ollstein: I think that if this continues, you’re going to see a lot of pressure on members of Congress. Even a lot of conservative Republican members of Congress have been very protective of funding for scientific research because of how many jobs it supports in their districts. I mean, we’re talking about hundreds of thousands of jobs, if not more, around the country that are contingent upon this federal funding continuing to flow. 

So I think I’m already starting to see within the scientific community calls for reaching out to members of Congress talking about how much of this investment flows to their district specifically. So we’ll see if that resonates, if these members of Congress are willing to stand up to the Trump administration on things like this. We just don’t know yet. 

Rovner: Yeah, I mean this is every research university, every research institution in the country, effectively. Again, we don’t know how long it will last. Some of it I think goes through Feb. 1, but some of it is still open-ended. 

It’s still unclear when those political appointees are actually going to get to HHS, at least at the top. The Senate Finance Committee has finally set a date for a confirmation hearing for Secretary-designate Robert F. Kennedy Jr. It’ll be next Wednesday, Jan. 29. The courtesy hearing at the Senate HELP [Health, Education, Labor, and Pensions] Committee is tentatively scheduled for the next day — only the Finance Committee actually votes on this nomination. But that nomination remains in a bit of trouble, yes? 

Cohrs Zhang: I don’t know that it’s in any more trouble this week than it was last week or last month. I think there have been more active advertising and outreach by groups that are concerned about his nomination, certainly in the public sphere. But again, these are largely Democratic-backed groups. We have seen Mike Pence’s organization doing some advertising around RFK Jr.’s lack of a— 

Rovner: His lack of a pro-life. 

Cohrs Zhang: Yeah, lack of a pro-life record. But I think as we’ve been in the hallways and talked to senators who are generally very concerned about abortion and reproductive rights and those kind of issues, they have not voiced concern about his nomination. They have met with him. They’ve had generally positive things to say. And again, I think part of it’s that they don’t want to get out ahead of themselves before these hearings. But I think there are certainly some Republican senators who do remain concerned about his views on vaccines and public health and just some of the levers that he could use on that front. And so it’s not a sure bet by any means, but I don’t know that there’s been a substantial change in the past week as to whether he gets confirmed or not. 

Rovner: One thing we did see this week were the financial disclosures, which include some interesting things. Alice, is that what you wanted to talk about? 

Ollstein: No, I— 

Rovner: Or, no, you want to mention something else? 

Ollstein: Yeah, quickly just to highlight something Rachel said, that we really have not seen widespread organized opposition to Kennedy coming from the anti-abortion movement. Mike Pence’s group is kind of out on a limb by themselves on this one. You have not seen the other big groups join them in opposing his nomination. And even though some of them do share concerns privately, they’re taking a wait-and-see approach. They want to see what he says at his hearing, like Rachel mentioned. He’s been telling Republican members of Congress what they want to hear on the abortion front, promising to do X-Y-Z to impose restrictions through different HHS policies. 

So a lot of people in the anti-abortion movement see Kennedy as someone who can be reached and influenced and isn’t a hardcore abortion rights advocate. And his record is all over the place. He’s basically taken every position possible. So it’s— 

Rovner: Like Trump. 

Ollstein: Yeah, honestly, a lot of fluidity there. And so it becomes sort of a Rorschach test where people point to the part that they want to make an argument about. 

Rovner: Any impact from some of these financial disclosures about the fact that he continues to get money from a lawsuit against Merck’s HPV vaccine, among other things? I mean, so he’s got a vested interest in that lawsuit going forward at the same time he’ll be in charge of the FDA. 

Cohrs Zhang: I think from just the feedback that we’ve heard, these agreements are very convoluted, they’re complicated, and I think that this is kind of a case that we haven’t really seen before. I think this was kind of the first disclosure of how he could try to get around some of these conflicts that he obviously has. And I think he is going to divest in a large number of those things. And the people that I’ve talked to who have served in prior administrations who are lawyers say he may have to recuse himself from some of these issues. But the ethics agreement, the wording was pretty vague. I do expect certainly some members of the Senate committees that he’s going to be appearing before to ask potentially for commitments on some of these ethical issues or to explain his position a little bit more. 

But I think what we’re seeing with the Merck and HPV vaccine is where he’s involved in referring clients to the law firm, and that’s going to stop going forward. He’ll have to divest from any case that involves United States government directly or these vaccine programs directly. But that lawsuit itself is kind of a post-program lawsuit where people have gone through, they’ve claim they’ve been injured, they’ve gone through the government program already, they’ve received their decision, and now they’re taking it further into court. So it certainly is going to be a live issue, absolutely expected to come up. But in terms of actually operating a very large agency, this Vaccine Injury Compensation Program is a, relatively, a very small part of what they do. 

Rovner: All right, well, back in the White House, as I mentioned, the new president’s executive orders issued Monday covered everything from immigration, to renaming the Gulf of Mexico as the Gulf of America, to ordering federal workers back to the office, to pulling the U.S. out of the World Health Organization. 

Now, most of these orders don’t carry the force of law. They direct federal agencies to start the process of carrying out these changes, and most could and will, and some already are, being challenged in court. But they certainly signal a dramatic change of direction the Trump administration intends to take. Let’s start with drug prices. This is an issue that Trump has been — another issue Trump has been — all over the place on. He revoked [President Joe] Biden’s executive order to have HHS look at ways to reduce out-of-pocket drug spending. That doesn’t really do anything, but does it suggest anything about whether the new administration will pursue the next round of Medicare drug price negotiations on the 15 drugs that the Biden administration named just, oh, what, a week or two ago? 

Roubein: The Biden administration, they put out very clearly, right before the change of administration, their Medicare drug negotiation list. And on a call with reporters, a lot of people asked, OK, do you expect the Trump administration to change these drugs that you have listed? And their belief is that it was pretty firm in statute the data that they needed to look at, and they didn’t expect an actual change in those drugs, which include the major weight loss drugs. So people had been really highly anticipating this second round. 

Rovner: At least Ozempic and Wegovy, that one, not all of the weight loss drugs. I don’t think I realized until I started getting into this that even if the administration doesn’t pursue the negotiations, there would still be caps on the prices of these drugs, right? I mean, that’s written into the statute. 

Cohrs Zhang: The statutory deadlines are pretty nonnegotiable. I guess there could be some lawsuits against HHS maybe for not implementing the program on schedule, but it is pretty formulaic for how these steps have to happen. I don’t know that the caps automatically go into effect if the negotiation process isn’t happening. We are kind of in uncharted territory here, testing the boundaries of the program. But I don’t know that the CMMI [Center for Medicare and Medicaid Innovation] demonstrations that we saw, I wouldn’t read that as an indicator of how they plan to proceed on negotiation, given it’s kind of like a win handed to Trump on a silver platter. So I think we’ll have to watch and stay tuned. 

Rovner: I mean, that’s sort of the mysterious part of all of this is that a lot of things that were set in motion by the Biden administration that haven’t happened yet and will happen seemed to be something that Trump could just say, “Hey, look, it happened on my watch, therefore I get credit for it.” Rachel, you’re nodding. 

Cohrs Zhang: Yes, absolutely. We’ve seen this — the Biden administration with surprise billing laws, too. That was passed under Trump and kind of was more implemented through Biden. So it’s not unheard of. This strategy happens every time. 

Rovner: Well, on the Affordable Care Act, Trump is effectively ordering the rollback of some of the things that the Biden administration did to increase enrollment, like boost outreach and lengthen enrollment periods. What else are we expecting on the ACA front, or at least administratively? I know that the big legislative push is going to be on whether or not to extend the additional subsidies that were created under the Biden administration. But do we think that Trump’s going to launch another effort, broadside, on the Affordable Care Act to make it not work, or might he just let it go this time? 

Ollstein: I think that this past week has shown that health care is not a priority for this administration. So yes, they are moving to try to roll back a lot of Biden initiatives on this front, but they aren’t really proposing anything new or anything very sweeping. And so I think, like we saw in his first administration, there is a lot they could do administratively to sort of chip away at it and make it less successful in various ways. But I think also the longer the law is in place, the more baked into the health care system it is, the more popular it’s become, the more people who are enrolled. Way more people are enrolled now, and particularly in red states, than were enrolled when he first took a whack at it in 2017. And so I think the sort of, like you said, broadside will be more difficult this time around and doesn’t seem to be on the front burner anyway. 

Roubein: I think for some of this past is prologue when obviously in 2017 Republicans did not repeal the ACA, and then the Trump administration through regulation, which took time, tried to put their stamp on it, like with changing rules to make short-term health plans more accessible. So that all is longer and it’s kind of more in the weeds, but I think that’s what we should look out for. And then the other big thing being if Congress, a Republican-controlled Congress, extends the Affordable Care Act enhanced subsidies, that’ll be a big fight for 2025. 

Rovner: And of course if they go after Medicaid, which people keep forgetting is a big piece of the Affordable Care Act, was the expansion of Medicaid. Rachel C., you wanted to say something. 

Cohrs Zhang: Yes, I just wanted to flag that Theo Merkel, who worked in the last White House and worked on a lot of these ACA rules and plans and thinks in a very sophisticated way about health care from a conservative perspective, is going back to the White House. So I think we may see some of these efforts that may not capture headlines in the same way and they may be kind of wonky, but they definitely can have a measurable effect on price transparency, on the ACA, on some of the way that these markets work. So I wouldn’t expect it to be something that Trump is talking about from a podium, but I think behind the scenes I am expecting some creative thinking on these things. 

Rovner: So speaking of things that Trump has not made a priority, he has not done anything explicitly about abortion with these executive orders. That’s a little bit surprising. And he’ll actually be in California touring the fire damage on Friday when the annual March for Life comes to D.C. And we will talk more about abortion and reproductive health shortly. But one of the executive orders, called, quote, “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government,” could have some pretty far-reaching consequences. Right, Alice? 

Ollstein: Yes, absolutely. So the order is very sweeping, and it’s basically getting rid of any federal recognition of trans or nonbinary people on all fronts. And so this will impact what documents people are able to get. It will influence what services they’ll be able to access in terms of shelters that are gender-segregated. People who are incarcerated, if they’re federally incarcerated, this gets rid of their right to gender-affirming care while incarcerated, so it’s sort of forcibly detransitioning people essentially who are in custody. Yeah, I think that this is sort of going under the radar but is going to be one of the most impactful orders they’ve done so far. 

Going back to the abortion front just for a second, I, too, thought it was very notable that they had nearly 80 Biden regulations on a list on Day 1 they were getting rid of and not a single one pertained to abortion. And I’ve been hearing from the anti-abortion community a lot of frustration and hope that he’ll still do some of these things, but he’s been the first Republican president in decades and decades to not do some of these things on Day 1 or Day 2, things like the Mexico City policy, changing the Title X program domestically. So I’m hearing from anti-abortion activists. They’re sort of asking each other How patient should we be? or How much should we push back and criticize being sort of left off the agenda? 

Rovner: Some sharp-eyed analysts also noted that the language of the executive order defines male and female as starting at conception, which in addition to being biologically not quite accurate — you cannot differentiate embryos as male or female until they are several weeks old — it also introduced the concept of personhood into the federal lexicon. Or is that reading too much into it? 

Ollstein: Yeah, I did see a lot of jokes about how under federal law everyone is a woman now because of defining sex at conception rather than at birth. I mean, we see tons of medically inaccurate language in tons of laws all the time. So it is unclear whether this is a personhood gambit or just a misunderstanding. I think obviously this is going to be challenged in court, and I’m curious if either the challengers or judges zero in on that sort of personhood-y language and try to make anything of it. 

Rovner: Well, there are a lot of judges that would like to create personhood, so I guess it depends where these things end up in court. 

Moving on to reproductive health. As I mentioned earlier, President Trump has so far been pretty mum on this issue, but the new Congress has not. Both the House and the Senate have teed up something called the Born-Alive Child Protection Act, which basically restates law that a baby born alive should receive needed medical care and that infanticide is illegal. The Senate voted yesterday, Wednesday, which was also the 52nd anniversary of the now-defunct Supreme Court ruling Roe v. Wade, and it failed to get the 60 votes needed to block a filibuster. So it’s not going to become law, at least not right now. But passing the bill was never the actual point of this exercise, right? 

Ollstein: Well, what’s fascinating is — so they’ve taken messaging votes on this exact bill multiple times before. What’s fascinating to me is that given that it is more or less a messaging vote, why they chose this policy rather than something more sweeping that the anti-abortion people would like to see, like a gestational ban or restrictions on abortion pills. This is seen as sort of the lowest rung. It is important for the anti-abortion movement and they’re touting the vote, but it is a lower ambition than some of the bills we’ve seen Congress take up in the past. 

I think it is interesting that we’re not going to get a chance to see how Trump would deal with this if it passed. I think there’s going to be a lot of interesting tensions around his promise on the campaign trail to not meddle in abortion from the federal level, whereas Congress could send him things that do that and he’ll have to make a decision either way. 

Roubein: We kind of saw the same playbook in 2023 when Republicans controlled the House and there was thinking, because that was the first year after Roe v. Wade had been overturned, that maybe they would bring up something like a 15-week ban and there was talk of that, and then they ended up not doing that and bringing up this legislation that is being voted on. And that’s been a signal to many that this is not something Republicans want to take a vote on, which is a ban it at a certain point in pregnancy. 

Rovner: Well, and I think this low-hanging fruit shows what we’ve known for a long time, which is that neither side has a filibuster-proof majority on anything that has to do with abortion, either for abortion rights or against them. I mean, this is why all the people who were complaining that the Democratic Congress should try to pass some kind of assurance of abortion rights, codify Roe v. Wade, there have never been the votes for that. 

Cohrs Zhang: They did try, and it fell short. 

Rovner: They did try, yes. They did try, and it didn’t happen, because neither side has the votes and neither side has actually had the votes since Roe v. Wade passed. In the early 1980s, the Republican Senate under President [Ronald] Reagan tried to pass constitutional amendments. They didn’t have the votes for that, either. Both sides have sort of struggled with this for decades now, and I think it looks like the struggle will continue. 

Well, speaking of the struggle continuing, in news you might’ve missed, just before leaving office last week, President Biden issued a statement recognizing the ratification of the Equal Rights Amendment. Talk about things from the 1980s. This is actually from the 1970s. This is a very long-running saga, since Virginia became the 38th state to vote to ratify the amendment in 2020. Now, Biden recognizing the amendment as law is a big deal, but not the deal that would actually make it happen, right? Or is it now a part of the Constitution? What do we know about the status of the Equal Rights Amendment? 

Ollstein: So what President Biden did doesn’t have any immediate effect. It will have to be litigated, basically. He’s putting out his theory that it is part of the Constitution, but it will take people suing under it and citing it to force courts to determine whether or not they agree. And I’ve been hearing a lot of frustration from progressives that he didn’t kick off this entire process years earlier. He could have had his solicitor general out in court arguing for this. And we know how long these court battles take, years and years and years. And so there’s a lot of frustration that he didn’t kick off that process sooner so that people could have an answer by this point, potentially. 

I talked to some folks in the White House behind the scenes who were saying: Look, the president’s view on this has had to evolve. It was influenced by the American Bar Association coming out with a statement saying they view it as ratified. They were explaining that Biden was always a supporter of the ERA but wasn’t sort of clear on what he could do and what the status of the law is. And so it is interesting that you have, in the wake of this announcement, folks on both the left and the right saying: This is theater. This doesn’t really do anything. 

Rovner: I guess what would’ve done something is, I think, that the national archivist has to publish it, which is what makes it an amendment to the Constitution, what marks it as ratified. 

Ollstein: Yes, but you have— 

Rovner: The archivist said she can’t do that, because the Justice Department has an opinion that Virginia happened too late. I mean, that’s what the fight is about. Has it, quote-unquote, “expired,” or because the period that was supposed to end was only in the preamble and not in the language of the amendment, does the amendment stand? And that’s the legal fight, right? 

Ollstein: Right. And so you have folks like Sen. [Kirsten] Gillibrand who’ve been really out in front on this saying that that is a mere technicality. The archivist works for the president. The president did her job for her was the line I was getting. And the archivist taking that particular action doesn’t really matter. It’s sort of just a technicality. Other people disagree and say that because she didn’t take that step, none of this means anything. And so, again, this will have to be hashed out in court over years, likely. 

Rovner: And just to be clear, the reason we’re talking about this in the sort of reproductive section of the podcast is that if the Equal Rights Amendment were actually part of the Constitution, it would basically create a constitutional right to abortion, yes? 

Ollstein: That is what some people argue. Again, this’ll be fought over in court for years to come. But the basic argument is, yes, if there is an amendment in the Constitution for women’s equality under law, then, some people argue, being denied the right to access abortion when men are not denied the right to access their health care services, that is an actionable discrimination. And one thing that’s interesting to me is that both progressives and conservatives view the ERA this way, and you had anti-abortion groups waging years-long campaigns against it, citing the potential for its use to expand abortion access. 

Rovner: Wow. All right, so while we are on the subject of the Supreme Court, down in Texas, Judge Matthew Kacsmaryk, he of the controversial case aimed at canceling the FDA’s approval of the abortion pill mifepristone, has officially revived the case after the Supreme Court ruled its original plaintiffs didn’t have standing to sue. Now the case will be carried forward by attorneys general of three conservative states. Now what happens? 

Roubein: This case would be prohibiting telehealth prescriptions for mifepristone, changing when people can use mifepristone in pregnancy from the current 10 weeks to the previous seven weeks. This would not be revoking the original approval in 2000 of mifepristone. 

Rovner: Which is what Judge Kacsmaryk originally said they could do and was overruled by — even the conservative 5th Circuit said, Yeah, maybe you can roll back the expansion of availability, but you can’t cancel the actual approval, although we will wait to see what the Trump administration would get, somebody installed at the FDA decides to do on that score. 

Also in Texas this week, Republican Lt. Gov. Dan Patrick I guess unexpectedly called for the state to amend its abortion ban to make clear that women with life-endangering pregnancy complications can have an abortion if needed. Alice, this has been the subject not just of debate but of a lawsuit that went to the Texas Supreme Court. How big a break is this with a leading Texas Republican? And could something actually happen during this year’s legislative session? 

Ollstein: So I mean, looking across the country, we have seen here and there Republicans coming out and saying that, The law we passed banning abortion is having consequences we did not intend. And so some have moved to add more exceptions, singling out things like ectopic pregnancies. Some have changed how people can be prosecuted under these bans, moving from affirmative defense, where we prosecute a doctor and then the doctor can exonerate themself after the fact, to having a real exception for certain medical instances. 

But we’ve seen in a lot of states, even when prominent Republicans come out and say, We need to do something — people are dying, we’ve seen things not happen and a real resistance to changing these laws from lawmakers, from anti-abortion organizations that are very influential in these different states. And so I am not sure that this is necessarily a huge breakthrough, just based on what we’ve seen in other states, because we’re also seeing at the same time calls for making a lot of these laws even stricter. And so we’re seeing both. We’re seeing both people calling for exceptions and loosening some things, and we’re seeing calls for tightening some things as well. 

Rovner: The fight rages on. Well, finally this week I want to note the passing of Cecile Richards, who was a longtime leader in the abortion rights movement, including a dozen years as head of Planned Parenthood. She was a daughter of the late Texas governor Ann Richards and the mother of former press secretary to then-Sen. Kamala Harris, Lily Adams. Even during her fight against an aggressive brain cancer, Cecile continued to try to work to advance the cause of reproductive health for women. She was respected, I think, by both sides. 

All right, that is the news for this week. Before we get to our interview, I have a quick correction. Last week I got the first name wrong of the new governor of West Virginia, which is doubly embarrassing because I have known him for more than two decades. It’s Patrick Morrisey. All right, now we will play my interview with Rodney Whitlock, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Rodney Whitlock. Rodney, who has worked as a senior staffer in both the House and the Senate, is a veteran of many, many pieces of health legislation, both large and small. He’s currently vice president at McDermott Plus, a D.C. health policy consulting firm, and one of the people I still turn to when I get confused about some piece of congressional minutia. He’s also played “What the Health?” host at various live events around Washington and done it very well. Rodney, thank you for being here as a guest. 

Rodney Whitlock: It is absolutely a pleasure to be with you, friend. I am looking forward to it. 

Rovner: So I have asked you to come help me explain as briefly as we can the congressional budget process and budget reconciliation, in particular. President Trump and congressional leaders keep talking about a, quote, “big, beautiful bill” or possibly two “big, beautiful bills” into which they would like to pour most of the president’s agenda. But there’s an entire process to go through before we get there. So let’s start at the beginning. What’s the annual budget resolution? How does it work, and why do we need it? 

Whitlock: Well, that’s an interesting question, since we haven’t had one around here forever. It’s like we have to go, “Oh, what is that again?” All right. So where we start is this, that Congress has the ability through the budget resolution process to create instructions, we call them reconciliation instructions, that allows them to make significant changes without facing a filibuster in the Senate. And so the annual budget resolution process, which produces the appropriations, etc., we’ve gotten to the point that we barely pay attention to when that occurs, because it’s not really an enforceable, or something you used to watch when you and I were much younger, as the regular process, what we would have called regular order. It only becomes interesting when they say, OK, but now we’re going to do it and we’re going to do it in unified government through budget reconciliation, which means now we’re playing with majority rules in both bodies, which allows for them to make significant changes, as we saw in ’21-’22 when Democrats are in control. Republicans tried in 2017. Democrats succeeded through the ACA in 2009-’10. So that’s where we are. 

Rovner: And just to be clear, the budget resolution is supposed to set the terms of spending both in the annual spending bills, the appropriations, and in spending that is not subject to annual appropriations, because it’s mandatory and it goes on unless Congress does something to stop it. So you don’t really need a budget resolution to do the spending bills, even though they’re supposed to set what we call the top line, the overall number, which is why the spending bills happen no matter what. But you do need a budget resolution to do reconciliation, right? 

Whitlock: That is correct. Because that allows the Senate — listen, the House has to do their job. I don’t mean to be disrespectful of the place I spent 10 years in, but I spent 11 years in the other place, so I can be disrespectful to a degree. The House, they have to do their part of it, but the game, the rules, why it matters is all about the Senate. 

Rovner: So what typically goes into a reconciliation bill as opposed to what goes into the annual spending bills? I think that’s where people get really confused. 

Whitlock: Sure. It’s especially relevant for mandatory programs and the ability to be able to make changes to mandatory programs through this special process that avoids the use of the filibuster. Generally the spending bills, at the end of the day, they come up with some agreement, although we’re still waiting for this fiscal year’s agreement, that is generally related to the appropriations bills. It doesn’t get into the mandatory side, Social Security, Medicare, Medicaid, where there’s a lot of money. And so if you want to do things there— 

Rovner: And the spending bills are not allowed to get into the mandatory side. 

Whitlock: They’re not supposed to get into them. You and I are having this wonderful conversation where we’re talking about, OK, this is how it’s supposed to happen, and then we step back and go, OK, now this is how it actually happens. So they’re not supposed to, authorizing on appropriations, blah, blah, blah. You’re not supposed to do that. But then we end up with 5,800-page bills, going, There’s a lot in here beyond just simple appropriations. So, yes, that “supposed to” thing. 

Rovner: They’re not really in the bill. They’re just catching a ride on the bill. 

Whitlock: Exactly. 

Rovner: So you’ve sort of explained why health is always a big part of a budget reconciliation bill. Because of those big programs or because it’s so much money or both? 

Whitlock: It is both. We have three monstrous mandatory programs that take up a huge chunk of our spend: Social Security, Medicare, and Medicaid. Why do we end up talking about health care? Medicare and Medicaid. And because Social Security by statute is not allowed to be used, is not allowed to be touched through reconciliation. And so that leaves you Medicare, Medicaid — health care. 

Rovner: And taxes of course, which is the big thing that gets changed through reconciliation, which they don’t have to use reconciliation for, but they do because it can’t be filibustered in the Senate, right? 

Whitlock: Correct. And the directional can vary based on who’s in charge. You can use reconciliation to increase taxes. You can use reconciliation to decrease taxes within the rules of reconciliation. 

Rovner: And those are within the parameters of the budget resolution. 

Whitlock: Correct. Which is set by the Budget Committee then goes to each floor for a vote, must be unified, must give specific instructions with specific amounts to specific committees, and each then must meet those or the whole thing falls. 

Rovner: That’s right. 

Whitlock: And so that’s why the budget resolution and that process is really important. 

Rovner: And that’s Step 1, right? Which is really three steps. House has to do a budget resolution, Senate has to do a budget resolution, and then they have to agree on a final budget resolution. 

Whitlock: Correct. And what they’re trying to do is avoid that third step by having the same one pass through both bodies, preclearance, etc., of trying to make sure they don’t have to do it twice. But certainly that’s part of the challenge they face is figuring out, and as you started in the conversation, which is: How are they going to do it? How are they setting it up? Very complicated stuff, to say the least. 

Rovner: So under regular order, you get the budget resolution. It has reconciliation instructions. It sends the committees with jurisdiction over those programs off to meet those instructions, which may, say, add several billion dollars or cut several billion dollars or do some specific things. And then that all gets bundled together and sent to each floor. Right? Do I have it right so far? 

Whitlock: That’s correct. It’s each committee has to deliver. In the House, again, doesn’t matter as much. They have to do theirs, and they want to get as close as possible. But at the end of the day, the House doesn’t have to worry about the Byrd Rule. It’s only in the Senate where the Byrd Rule has teeth and really matters. And that determines what is or is not eligible to be in a reconciliation bill. So the House will go through their process, and the House is going to try as much as they possibly can. And the House has a very vested interest. The House doesn’t want to be told by the folks in the Senate, having worked in both bodies I can speak to that, which is the House does not want to be told, Well, that’s cute of you, but you can’t do that, because the Byrd Rule. They want to do as much as they can with their own authority, not have to dance to the tune being sung by the Senate. 

Rovner: And explain what the Byrd Rule is, please. 

Whitlock: I was wondering when we were going to get to that. OK, the Byrd Rule. Essentially what happened was is that Sen. [Robert] Byrd, who was a longtime senator from West Virginia, scion of the process, he cared very much about how things were going in terms of reconciliation and how it was being used. 

In 1985, the Senate adopted a rule that basically allows you to continue with the reconciliation, but it limits how it can be used. It’s referred to as the Byrd Rule, and it was because Sen. Byrd himself felt like it was being abused. It was not being used for its intended purpose. It was being used to accomplish policy outside of that. So a rule was adopted as a six-part test, which then allows for a restriction on what you can do and a limitation on how it could be in, what meets the test. 

Rovner: Who decides what’s in or out? I mean, basically there has to be a referee to say you can put this in reconciliation or you can’t. 

Whitlock: All right, so this is complicated, but it is — effectively the way the process works is that these six-part tests, if you write a provision that goes in the reconciliation bill, down to the sentence, that it can be challenged. The technical way the challenge works is a member will stand up on the Senate floor and say, I object under the Budget Reconciliation Act of 1985, that under Section whatever whatever whatever, that this provision in Title X, Section A, of whatever bill, of the reconciliation bill, violates the Byrd Rule. Then the president pro tempore, whoever’s standing up there, my former boss, Sen. [Chuck] Grassley, or whoever is there, then says yes or no it does — does or does not. Then the Senate, if there’s an objection, has to vote. 

Now, what’s critical is to override the ruling of the chair requires 60 votes. So in a tightly controlled Senate, 53-47, which is where we are, there’s no chance it’s being overridden. Now, the step I left out there, which is important: Who actually says that? It is the Senate parliamentarian, Elizabeth MacDonough, who’s been there for the better part of 15 years. And it’s her job to listen to both sides make their arguments and determine prior to that moment where that member stands up, because they know it’s coming, which direction she would rule. She then turns to the president pro tempore and says, This is what the ruling is. The president pro tempore or the vice president repeats that. And that’s how the process goes. 

Rovner: In theory. 

Whitlock: In theory. We, the Senate have always depended upon everybody following the rules. The president pro tempore does not have to repeat what is said. That’s never happened. That is — we’ve never had — there have been challenges. Some have been overridden, some have been upheld, but we’ve never had gamesmanship where the president pro tempore ignores the ruling of the parliamentarian. We’ve had parliamentarians fired over whether or not the majority leader liked the ruling, but we’ve never had the ruling ignored. 

And so we’ll see if Republicans have to use that. We watched it to see if they would do it in ’17. We watched what the Democrats would’ve done in 2009-’10, ’21-’22. To date, everybody’s followed the rules — barely, but they have. And those rules are the Byrd Rules. 

Rovner: So what is the most important thing to know about the Byrd Rule, which is obviously what dictates what can and can’t be in this bill? 

Whitlock: Yeah. Six-part test, and some of them are very perfunctory: Can’t touch Social Security. Got to be in your jurisdiction. Has to actually save or spend money. The most important one, Rule No. 4, is produces a change and outlays the revenues, which is merely incidental to the non-budgetary components of the provision. In other words, it’s got to be more about the money than the policy. And that is the very gray-area rule where people will walk into the parliamentarian and say, OK, yeah, there are a lot of pages here, but they’re all critical to be able to achieve the savings. And the other side can say, But not that sentence and not that sentence and not that sentence, and start to pick it apart until it’s Swiss cheese, which was a lot of what happened to Republicans in 2017, such that it barely even works anymore. 

And so the fight over the Byrd Rule is typically right there on — is it about the spending or is it about the policy? And it’s not black-and-white. It is incredibly gray for us to figure out what is an answer. And it is fought out in front of the parliamentarian, and she makes the ruling. 

Rovner: And so basically, I mean, what has to be remembered is this is supposed to be a budget exercise and not a policy exercise. 

Whitlock: 100%. And that’s why, again, the Affordable Care Act could have never been written under reconciliation. The Medicare Modernization Act, which created Part D, could never have been written under reconciliation, because they were policy bills. And so you can’t do a policy bill in reconciliation. And if you come in thinking, Let me see if I can sneak a policy bill through and call it reconciliation, oh, you are in for a miserable time. Been there, done that. 

Rovner: So I’m not going to ask you to predict what’s going to be in this bill or multiple bills. You can do more than one reconciliation bill per budget resolution, but we’re not going to go there. But I will ask you to handicap how long you think this might take. I mean, it’s hardly going to be the couple-of-weeks, we’re-going-to-have-this-before-the-end-of-the-winter kind of thing. Right? 

Whitlock: Early on I felt like they were heading to a two-step process where they were going to do in the first hundred days, What could we all agree to quickly? Hold hands, get done, boom. Taxes, energy, some immigration stuff, whatever fit in, done. And then came the whole “one big, beautiful bill” concept and: Let’s do it all at once. Let’s try to throw in debt limit. Let’s try to throw in some level of deficit reduction consistent with what we would require under a debt limit agreement. And let’s do it all in one big, beautiful bill. 

Well, the former was quick, the latter is slow. And I think what we are coming to realize, and as somebody who worked both sides but certainly appreciated the Senate position, which was more often than not in my career the median position, that which what could get done, was what the Senate could get the votes for. I think right now the real concept that we’re dealing with here is what you’re going to do, how you’re going to do it, when you’re going to do it, is what the House can get done, given their very tight majority and their members who are willing to say: Nope. Perfect. I’m waiting for perfect. Everything else is my enemy. It doesn’t matter how good it is. It’s my enemy because I’m holding out for perfect. When you’ve got members willing to do that, it’s going to be a very hard slog to get there. 

And so there are things they could have moved quickly on. They’re not doing that. And so because they’ve decided to slow down the process and see if they can put things together, it’s going to take more time, because the more things you put in, the more you have to do education, the more people have to understand, the more work it is. That’s the challenge. 

Rovner: Well, this has been a very useful primer. I hope we can call on you again as the process proceeds. 

Whitlock: I’ll be here for you. I come running any time you call. 

Rovner: Rodney Whitlock, thank you so much. 

OK, we are 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. Rachel C., why don’t you go first this week? 

Cohrs Zhang: My extra credit is in The Washington Post. The headline is “In Florida, a rebellion against fluoride is winning.” And I think it’s just a great case study of what we’re going to see over the next couple of years — that, sure, there’s going to be so much attention focused on the federal level, focused on Congress, focused on HHS, but the powers of the federal government are limited on public health and some of these issues. I think fluoride and how that’s included in the water supply is a great one. And I think it is just going to be so important to watch how all these issues are playing out in state and local governments as well. 

So I think there’s just going to be this sense that local officials are emboldened by the stances that the Trump administration is taking on some of these issues. And I think it’s just a great way to make practical some of the influences of the rhetoric that we’ve seen so far before top health officials are even in office. So I thought it was really well done, and I think this is going to be a line of coverage to follow. 

Rovner: Local news more important than ever. Alice. 

Ollstein: Yeah, speaking of local news more important than ever, my piece is from the L.A. Times, which has just been doing phenomenal coverage of the fires that have devastated the area. I’m from L.A. The L.A. Times has gone through a lot, but I really want to hold up their incredible coverage of this crisis. 

And the piece I chose is by Karen Garcia and Tony Briscoe, and it’s called “Now that you can return home after the fires, how do you clean up safely?” And it’s just about how even though people are cleared to go back to the often pile of rubble that their houses have become — and obviously people are very eager to do that and want to search for anything that might have survived of their personal belongings. But this article is really warning people to take precautions when they do that, because the amount of things in the average home nowadays can be so toxic when on fire. And so things like basic cleaning products, things like synthetic fabrics and furniture. So they’re really encouraging people to wear an N95 mask, wear gloves, cover all of your skin, because some of these things can be so dangerous if inhaled or if they touch you. So I think this is a very important thing for folks in that situation to keep in mind. 

Rovner: Yes, the danger is not gone when the fire is out, basically. Rachel R. 

Roubein: My story, it’s in The Washington Post by my colleague Caroline Kitchener. The headline is “Antiabortion advocates look for men to report their partners’ abortions.” And the story shows the reach and the scope of how anti-abortion advocates have been trying to pursue ways to stop abortions, but they’ve had trouble finding efforts to fully end the practice with many women receiving pills through mail, through a handful of websites, and they’re trying to devise new strategies. 

So Caroline writes about anti-abortion advocates launching legal efforts to try and stop abortion pills from reaching women in states with bans. And how they’re doing that is increasingly turning to male sex partners of women who decided to end their pregnancies. And she writes about the strategy being filed in a lawsuit last month by Texas Attorney General Ken Paxton and that this kind of partner-focused approach will become more public next month when Texas’ largest anti-abortion organization is planning to launch ads on Facebook, etc., to reach husbands, boyfriends, sex partners of women who’ve had abortions in Texas. 

Rovner: Wow, it’s quite the eye-opening story. My extra credit this week is from CNN by Brenda Goodman, and it’s called “With bird flu cases rising, certain kinds of pet food may be risky for animals —and people.” And it’s something I never really thought about, but it seems that feeding your pets, particularly your cats, a raw diet can be as dangerous as you drinking raw milk. Raw diets are popular with lots of pet parents who don’t like processed foods and additives, but the use of raw milk, meat, and eggs can introduce bacteria and viruses like bird flu into your pet and possibly pass pathogens onto you and your family. Just something else to worry about. 

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

Ollstein: I’m on Bluesky, @alicemiranda. 

Rovner: Rachel Roubein. 

Roubein: On X, @rachel_roubein, or Bluesky, @rachelroubein. 

Rovner: Rachel C. 

Cohrs Zhang: I’m still on X, @rachelcohrs, and also hanging out more on LinkedIn these days. 

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

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Incoming President Donald Trump’s inauguration is Monday, yet the new GOP-led Congress is already rushing to work his priorities into legislation, eyeing cuts to Medicaid to pay for new tax and immigration priorities. But even in its waning days, the Biden administration continues to make big policy moves, including a possible order for tobacco companies to dramatically decrease the amount of nicotine in cigarettes. 

Meanwhile, the fires in Los Angeles are drawing new attention to the health dangers of not just smoke from organic matter, but also toxic substances released by burning plastic and other man-made materials — as well as the threat posed to both air and water quality.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Sandhya Raman of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• Republican lawmakers are weighing options to cut federal spending on Medicaid, the nearly $900-billion-a-year government program that covers 1 in 5 Americans. They could use the savings to bolster Trump priorities, such as extending the 2017 tax cuts. The GOP made splashy but unsuccessful attempts to cut Medicaid when Trump first took office and the party held a larger House majority — though the party seems more aligned with Trump today than it was then.
• Congress has gotten down to business on messaging bills: It advanced legislation this week that would ban trans athletes from girls’ school sports and, separately, a measure to detain and even deport immigrants who are living in the U.S. without legal status and have been charged with, though not convicted of, minor crimes such as shoplifting.
• The Supreme Court has agreed to hear a case later this year about the U.S. Preventive Services Task Force — an independent body of experts that issues recommendations in disease prevention and medicine. A ruling against its authority could strip coverage for key preventive health services from not just those with Affordable Care Act coverage, but also those on employer-sponsored health plans. The question stands: If not this task force, who would make the determinations about what preventive care should be covered?
• And the outgoing Biden administration issued a slew of health regulations this week, including a ban on the dye Red No. 3 in food and other ingested products, as well as an early regulation limiting the amount of nicotine in tobacco products. The incoming Trump administration could upend these and more regulations, though some do align with its policy interests.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the latest KFF Health News “Bill of the Month” feature, about a colonoscopy that came with a much larger price tag than estimated. If you have a mystifying or outrageous 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’ “Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline?” by Felice J. Freyer.

Anna Edney: Bloomberg News’ “It’s Not Just Sunscreen. Toxic Products Line the Drugstore Aisles,” by Anna Edney.

Joanne Kenen: The Atlantic’s “A Secret Way To Fight Off Stomach Bugs,” by Daniel Engber.

Sandhya Raman: Nature’s “New Obesity Definition Sidelines BMI To Focus on Health,” by Giorgia Guglielmi.

Also mentioned in this week’s podcast:

• MedPage Today’s “ABIM Revokes Certification of Another Doctor Who Made Controversial COVID Claims,” by Kristina Fiore.
• The Atlantic’s “What Happens When a Plastic City Burns,” by Zoë Schlanger.
• ProPublica’s “The Second Trump White House Could Drastically Reshape Infectious Disease Research. Here’s What’s at Stake,” by Anna Maria Barry-Jester.
• The New York Times’ “Don’t Call Kennedy a Vaccine Skeptic. Call Him What He Is: A Cynic,” by Paul A. Offit.
• The Federal Trade Commission’s “Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies.”

[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, Jan. 16, 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: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

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

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode we’ll have my interview with Harris Meyer, who reported and wrote the latest KFF Health News “Bill of the Month,” about a patient whose colonoscopy bill was a lot bigger than he expected. But first, this week’s news. 

So we are now four days from the second swearing-in of Donald Trump as president, and discussions are already picking up on Capitol Hill about rolling the new president’s entire agenda into, quote, “one big, beautiful bill,” as Trump has put it. There are lots of differences of opinions between Republicans that are still to be worked out, but one target for cost-cutting is pretty clear, and that would be Medicaid. Sandhya, we’re starting to get a picture of the possibilities of how they might want to do that. What are some of the main things that are on the table? 

Raman: So the reconciliation talks are very much underway, and we’ve made a little progress but at the same time we just didn’t also make a lot of progress. The end of, -ish, last week we got a menu of items that Republicans are kind of considering as things they would use to offset some of the things that they’d want to do through reconciliation. 

Rovner: Like continue the tax cut? 

Raman: Yes, for the tax cuts and for border security. So what we have on the House side is a lot of things that are very health-oriented. About half of that list is health-oriented, and a lot of it is Medicaid. And so some of the things they’ve been floating around are some things we saw in the first Trump administration, them trying to do. We have per-capita caps on Medicaid spending, work requirements for Medicaid, changing the federal match for Medicaid expansion, and things like changing the public charge rule to back how it was in the Trump administration. 

Rovner: Remind people what the public charge rule is. 

Raman: The public charge rule kind of limits some of the social programs for folks that are not citizens to make use of things like Medicaid, SNAP [the Supplemental Nutrition Assistance Program], and other programs like that. 

Rovner: And those are for people who are here legally? 

Raman: Yes. So this week, Tuesday, we had our first meeting from the House Energy and Commerce Republicans to look over at least the health part of that menu. And talking to both Energy and Commerce Chairman Brett Guthrie and Buddy Carter, who heads the health subcommittee, it’s just the start. Discussions were pretty good, but it’s so early. 

Carter said that he still wants to get the PBM [pharmacy benefit manager] language from last year that didn’t make it across the finish line in there. And Guthrie has said that some of the numbers that we’ve seen of how much money from Medicaid they could possibly save are really in flux because of how they interact with all of the other provisions in there. Some things are under Ways and Means jurisdictions. Some things, if you do one and not the other, the numbers would change. 

So they’re still pretty early in the process, and we don’t know if we’re going to do the “one big, beautiful bill” or kind of what the Senate wants, with two bills, and that would just kind of change what would be done earlier versus later. But we do have a little bit more of a timeline now in what they’re trying to do. 

Rovner: I feel like it’s worth remembering that they tried taking a whack out of Medicaid in 2017, when they had a much bigger Republican majority in the House, and they couldn’t get it over the finish line. What makes them think they’re going to be more successful this time? 

Raman: I think part of it is that — this is still early on. When you ask them the feedback that they’ve gotten from Republican governors — most Republican states have had Medicaid expansion at this point. We still have only the 10 holdout expansion states. So, I think, really, as we get closer, if they seem like they’re angling to include some of these in whatever vehicle we have, we’ll probably hear more. 

And I mean, if you look at this state-level already, a lot of states are kind of couching their bets with Medicaid, just thinking about how they can do things differently in case their Medicaid federal funding changes over the course of this year or next year. So, I think it really depends on what feedback they’re going to get in the coming weeks and months. 

Rovner: Joanne wanted to add something. 

Kenen: Yeah, I mean, the beauty of reconciliation if you’re the majority party, but a narrow majority, which is what’s going on now, is you’d only need 51 votes in the Senate. You don’t need 60. So on one level, that sounds like they’ve got 53. It’s a slam dunk, right? But it’s not, because reconciliation, it’s a grab bag. You put so much stuff in there, and all you need is one provision that this person won’t vote for or that person won’t vote for. 

So this seemingly simple slam dunk for a narrow-majority Senate is actually a big, complicated mess. On the other hand, compared to the first Trump administration, this is a more conservative, or a more populist, or a more approach — I mean, the ideology or worldview of the Republicans in Congress is closer to Trump than it was in 2017. 

But yeah, they failed at what they thought was going to be easy. They thought repealing the ACA [Affordable Care Act] and changing, which included a lot of Medicaid stuff, they thought it was a slam dunk. And instead, it was a year-long slog that failed. So is Medicaid going to look the way it looks right now? No, it’ll change. How much will it change is really an open question. 

Remember, there’s some things they can do through waivers. Work requirements they can do through waivers. Although in the past, the courts have blocked them. The courts have changed. We don’t know where the courts will come down. But really it’s more than a headache. It’s like a headache and a stomachache. 

Rovner: Yeah, well, so reconciliation, budget, all of this stuff is still way TBD. Still, the Republican Congress is getting off to a fast start, at least in terms of messaging legislation. The House this week passed a bill to ban transgender athletes from women’s school sports, and the Senate’s debating a House-passed bill that would allow the deportation of undocumented people who are accused but not yet convicted of violent crimes. 

In West Virginia, the new governor, who’s also a former Capitol Hill health aide, [Patrick] Morrisey, issued executive orders making it easier for parents to send their children to school without being vaccinated. Overall, it seems the Republicans are kind of coalescing around a concept known as “medical freedom,” which to me seems just like a rejection of public health in general. Or am I missing something? Is there something more to this? 

Edney: No, I think that it’s always been around, but I think that certainly this resurgence in it is coming from the fact that people didn’t trust science during the pandemic. They were fed up. Communication wasn’t handled very well, and it still isn’t handled very well. I don’t think people have figured out how to talk about these things in measured ways. 

I would recommend if someone listening hasn’t read, Dr. Paul Offit wrote an op-ed in the New York Times a few days ago on vaccination that I thought was really good because he’s like: Listen, I’m a vaccine skeptic. Like, R.F.K. Jr. [Robert F. Kennedy Jr.] is a vaccine cynic. There’s the difference, and here’s what it is. And he laid it out there. And he is a pediatrician, and he also serves on FDA’s [the Food and Drug Administration’s] advisory committee for vaccines. 

So I think that a lot of this is stemming from misinformation and miscommunication, and it resonates with people. I mean, the Republican Party picked up a lot of fans in far-left progressives by talking about this. So I think they see that as an opportunity, too. So it may not just be grassroots. It may be a little bit of an opportunity they see. 

Kenen: Anti-vaccination sentiment has been around as long as vaccines. It actually goes back to smallpox. There has always been a certain amount of fear, skepticism, whatever. It had been traditionally among Democrats and Republicans. It actually changed. It began to change two or three years before the pandemic. 

Some state legislatures — and this was the medical freedom, this was on the right — started trying to water down mandates for schools. At that point, I don’t think anything big got through. But we began to see this emergence of a deeper politicization of vaccination. And it was on the right, and it’s what we now talk about as medical freedom. 

So instead of being something that’s across the political spectrum, it is now a politicized movement, on a libertarian Government can’t tell me what to do. And we saw this during the pandemic. And neither administration, neither the Trump administration in the first year of the pandemic nor the Biden administration in the ensuing years, really managed to explain the difference between individual choice and the fact that if you get sick, you might survive but you could endanger somebody else. 

You don’t know who the person on the bus next to you is. You don’t know who the kid in your classroom is. You don’t know who you’re standing next to at the grocery store. They could be really vulnerable. And that this whole sense of “my body, my choice,” doesn’t fly when you could kill somebody else unintentionally. And that sort of has been lost, or people don’t care. 

Rovner: Yeah, I mean we’ve seen that with tobacco over how many generations. It’s like, you want to put stuff in your lungs, that’s your business. But you don’t really get the right to put stuff in other people’s lungs because you would like to smoke. 

Meanwhile, continuing with the Republican agenda, my former KFF Health News colleague Anna Maria Barry-Jester has a really good story this week about what National Institutes of Health director candidate Jay Bhattacharya might have in mind for the agency, including de-emphasizing infectious disease research and focusing more on chronic disease. 

Given that the biggest institute at NIH is already the National Cancer Institute, which focuses on a chronic disease, is this just Republicans’ way of punishing the National Institute of Allergy and Infectious Diseases that was for so long headed by the now retired Dr. Tony Fauci? 

Raman: I think in a part that is a huge driving factor, when you look at some of his comments and R.F.K. Jr.’s comments about holistic approaches to health, that really when you look at what something like NIAID does, which is so infectious-disease-driven, versus the things like with cancer and other things. 

But I think at the same time, this has kind of been bubbling up before, when we even looked to last year. Before we had any of these nominees, before we even knew the outcome of the election, we had a push within Congress from the head of the House Labor-H Appropriations subcommittee and former Energy and Commerce Chairwoman Cathy McMorris Rodgers trying to reform NIH that way. 

We didn’t get that far with it. It was included in some of the appropriations bills that didn’t go anywhere yet. But I think it’s just part of a broader discussion that there is, kind of going back to what we were saying before, some of the wanting more control of what you see, in terms of medical freedom, and that they want to know more about what’s happening. 

So I think that, regardless, we’re going to see more of this. But I think one thing that was really interesting in what she’d been writing was just the NIH is so much bigger than just NIH, you know? It’s so many of the people that are benefited by it, that are working with this grant money, are states nationwide. And it’s just the medical research is for a global understanding of medical research, and just how many of the drugs that we see come from NIH money. So even if there is a broader push for reform, that it’s very sensitive into how broad of an effect that would have. 

Rovner: And I would point out, because I live up the street from NIH, that most of what NIH does doesn’t happen on the NIH campus. It is, as you said, it’s money that goes out to every single congressional district. There’s an enormous amount of backing. 

I would also point out that, yes, NIH has gotten kind of sprawling with, I think there’s 27 institutes now. Every single one of those has been added by Congress. NIH can’t create its own institutes. Only Congress can do that. So, Congress has sort of made NIH the sprawl that it is. I think there’s been bipartisan agreement that NIH maybe needs a new look. 

I guess the question is just sort of what direction that is going to take and whether some of it is going to be punitive or whether they’re actually going to look at it in a matter of what would benefit the country, because it gets a lot of money, and that’s also been bipartisan. 

Kenen: Right. What we’re not hearing yet, or at least — and maybe Anna, who covers pharma, can tell me if I’m wrong — but we’re not — NIH also does the basic, basic, basic cellular first-step science that eventually leads to the work that drug companies do to develop drugs. They do the basic, what they call bench, science. 

I’m not hearing the drug companies speak out. The ambivalence Americans have about drug companies, which is hating the prices but liking the drugs, I haven’t heard pharma — Maybe it’s just too early. Maybe they’re weighing in quietly, and maybe Anna can tell me I’m wrong and they are and I just didn’t notice. But that’s also a huge constituency, a huge, powerful constituency. Because without the NIH, we wouldn’t have many of the drugs that keep us and our elderly relatives alive, including a lot of the gains — we haven’t cured cancer, but we’ve made gains on cancer. That wouldn’t have happened. It’s not just the premier research institute in America. It’s the premier research institute in the world, and as Julie said, a big driver economically of every single county, every medical school, every public health, you know, it has been an economic powerhouse as well as a knowledge powerhouse. 

Edney: And I wouldn’t tell you you’re wrong. I think that you’re right. I haven’t heard the pharma companies talking about it. I think they are talking about a lot of things that they want done to benefit them, and so I’m sure that they’ve made their priorities. We’ll see if this reaches sort of a boiling point, where they do end up weighing in. And I also just want to say, NIH, I know they want to focus on chronic disease. It does a lot of that. So maybe that’s not being communicated: It’s not being cut or left off the table because we’re doing this. We can do two things. We can walk and chew gum. 

Rovner: Yes, I know, and that was the point I was trying to make. It’s like, there’s an enormous amount of chronic disease research that happens from the NIH, much of it dictated by Congress already. They spend a lot of time, individual members, telling NIH what it is they should be studying, which is a whole other issue that we’ll get to another time. 

But I want to stay on the topic of drug prices, because that’s a really big question mark for the incoming administration. This week, the CEO of drugmaker Eli Lilly told a Bloomberg reporter that it will ask the Trump administration to, quote, “pause” the Medicare drug price negotiation program, which of course is just getting underway. 

Of course, that’s happening even as Lilly encourages the incoming HHS [Department of Health and Human Services] not to cancel a Biden administration decision to have Medicare begin covering its expensive new weight loss drugs. 

Meanwhile, on its way out the door, the Biden administration’s Federal Trade Commission dropped a report that found that the nation’s three largest PBMs, which together control about 80% of the U.S. prescription drug market, drove up drug prices by an estimated $7.3 billion from 2017 to 2022. 

I saw somewhere this week, and I think, Sandhya, you mentioned this, a suggestion that Republicans might try to resurrect the PBM bill that was dropped from that year-end 2024 spending bill and put it in the next spending bill that Congress is going to have to do in March. Likely? Possible? Will this report have any impact? Or is there just too much other news this week and nobody’s going to remember? 

Raman: I think it’s definitely being talked about a lot. We talked to the leadership of Energy and Commerce. It’s a priority for both of them, both for Carter and for Guthrie, because they worked so closely on it before. It was included in a bipartisan deal that we had before we got the CR [continuing resolution] that we voted into law. It just got dropped along the way. 

Rovner: When Elon Musk said the bill was too big? 

Raman: Yeah. So I think we kind of have two pathways, where both of them want to get it done regardless. I think that it might depend whether they are able to piece it away and do it as something stand-alone, which they want to get it done sooner rather than later. 

But it depends a little bit more on the leadership level, if there are savings from using that bill to be used later down the line when they get reconciliation at a later stage. So I think that’s what we’re waiting on. Would they need to put that there? Or would they be able to go forth with that now? 

Rovner: True. So, it’s a bipartisanly popular provision that also saves money, so that makes it kind of attractive to lawmakers who are putting together things that might, as Joanne would say, include spinach. 

Anna, what more broadly do you see as the outlook on drug prices? 

Edney: Well, I think the first thing I think of with that program is, it saves a lot of money if you’re giving Medicare the ability to negotiate. And so, I just wonder how that fits into this agenda if you stop it and make it more favorable towards the drugmakers. Where does that fit in with cutting spending and reducing the deficit and all of those things? 

So, I think that, maybe they have a little bit of an uphill battle in making their case on that front. All of this, for me, hinges on whether Trump really means what he says. And I think we all know that we just have to wait and see what actually happens. 

Rovner: Yeah, a lot of shrug emojis coming. 

Edney: Exactly. 

Rovner: Well, meanwhile, across the street from Capitol Hill, the Supreme Court has agreed to hear that preventive health care case out of, altogether now, Texas. The case challenges the requirements in the Affordable Care Act that insurance cover, without copay, preventive services like immunizations, cancer screenings, birth control, and, the subject of this particular case, medication to prevent HIV. 

What happens if the court rules with the plaintiffs in this case who argue that the CDC’s [Centers for Disease Control and Prevention’s] Preventive Health Services Task Force does not have the authority to determine what services should be on this list? Which of course is the entity that now determines which services should be on this list. 

Edney: Well, it sounds like, then, a lot of people don’t get their preventive care covered. As KFF wrote, there is some that would be still covered, the mammographies, but not the HIV preventative medication. Other cancer screenings included in that as well. And so, it seems to throw a wrench, I guess, sort of just asking this of the panel, that agencies then would have to go make those determinations? Does Congress have to make the determinations on what’s covered then? 

Rovner: Well, that’s of course the big question. Or, would the secretary, him or herself? Who is authorized? I think the argument is because the Preventive Health Services Task Force is not Senate-confirmed, they can’t make these decisions. 

And of course, the way it works, they don’t make these decisions. They recommend them, and then the secretary sort of ratifies them. So it’s hard to tell from this whether it really would go away, or whether Congress would have to step in, or whether the secretary could just do it. I feel like this creates as many questions as it could answers. 

Kenen: It’s a really broad array of benefits that — it’s not just the HIV PrEP preventive medicine. And I read different stories about this, and they had different lists, including some cholesterol stuff. And I don’t know, since the lists were so different, I’m not sure exactly which ones are in or which ones were out. But it’s not just HIV drugs. It’s a lot of stuff. 

So it would certainly gut something that people count on now. I mean these are free not just under an ACA plan but if you get coverage through a job, those requirements also apply. So, a lot of people would no longer have free access to a lot of what we consider preventive care. 

Rovner: We’ll be watching this case. They have not scheduled oral arguments. They just decided to take it. So, this will be a later in 2025 case. Well, the flip side of an incoming administration are all the things the outgoing administration tries to slip through on its way out of town, and this week has seen a bunch of those. 

Most of these things could be fairly easily undone by incoming officials, but not without some public pain, which sometimes is why administrations wait until the very last minute to do them, to be a little passive aggressive, or maybe in some of these cases a lot passive aggressive. Several of these last-minute changes come from the Food and Drug Administration, an agency targeted for big changes under Trump 2.0. 

In just the last 48 hours, the FDA has announced a policy that would require dramatic reductions in nicotine in cigarettes to render them, quote, “minimally addictive or nonaddictive.” It moved to ban Red Dye No. 3, a controversial additive already banned in many other countries which has been shown to cause cancer in rodents. And it proposed a major change in food labels to require them to show on the front of packaging whether the food’s sodium, sugar, and saturated fat levels are low, medium, or high. Do any of these proposals live on for more than another week? 

Edney: I think the Red No. 3 could. We know that R.F.K. Jr.’s talked about food dyes and wanting to get them out of, he specifically said, cereal, but they’re in a lot of things. So, I see that one. 

I think the industry saw that coming from far away and has been switching already, of course sometimes to another problematic, potentially, food coloring. But I don’t think this is something you’re going to see them fight super hard for to change. The nicotine is much more iffy. Big Tobacco is still a huge force, and Trump gets funding for his campaign and things from companies who have a stake in this. 

And some of that could align with this idea of not necessarily medical freedom but, sort of, we can choose what we put in our bodies. If we want to be addicted to nicotine, that’s our choice. So, the other one, the labels, I’m not sure. They’re not particularly powerful or anything. I thought they looked … When I looked at it, I was like, This is confusing and just looks like the back, but it is a little different. So, I don’t know. Maybe it survives. I’m not sure how much the industry is working on this. 

Rovner: [Sen.] Bernie Sanders of all people excoriated the food labels, saying we don’t put on cigarette packages whether the cancers they cause are low, medium, or high. Why should we do this? I mean, this is basically another effort to go after ultra-processed foods. I was surprised at how angry he was at this. 

Kenen: I think he wants them in neon. 

Rovner: I think he wants R.F.K. Jr. to have fewer ultra-processed foods available. I think that’s going to be sort of the big takeaway from all of this, I guess. 

Kenen: Right. But we also don’t understand what an ultra-processed food is, because there’s some foods that are not ultra-processed that are bad for you. And there’s some foods that do have some kind of minimal processing that, I mean, we’ve come to lump this together and I couldn’t tell you. There’s some things that are, quote, “ultra-processed” that really aren’t that processed, don’t have a lot of additives. They have something. 

So the whole categorization needs more work, both for public understanding and political understanding. There’s nobody who’s going to say that Americans have a really healthy diet and that food additives … R.F.K. Jr. has pointed out to the food additive, where the companies have to get to self-certify, Yeah, this is safe. So, is that something that he could get widespread support on? Yes, but there’s a whole lot of other things that he says that people were not going to agree with. 

Rovner: And I will remind that we not only don’t know if R.F.K. Jr. will be confirmed, but they still don’t even have a date for his confirmation hearing, because they’re still waiting on the paperwork. All right, moving on. 

As we taped this morning, there are still several fires burning in the Greater Los Angeles area. We have talked about the health effects of fire before. It’s not exactly news that fire and smoke are bad for human health, but what seems to make these fires different is that they’re not mostly trees and brush and other bits of nature that are burning but lots of toxic substances that are polluting not just the air but also the drinking water. 

Are we going to have to start thinking about fire and health in a much different way if not just remote areas but entire suburbs are now prone to burning up as a result of our changing climate? 

Edney: It will make us think of a lot of things in different ways, and particularly health care, when there’s things like high benzene levels floating in the air. We know that so much of our interior environments are made with things that contain high levels of formaldehyde, things like that. 

I think the expectation is that can create a long-term issue, but also it can in the moment create more deaths just at the time, not because it directly kills but if you already have an issue and you have a respiratory problem or a heart problem that can be exacerbated by these fires. 

Yeah, I think there’s a ton to think about. Even drinking water can be impacted more so when you have power outages and things in the areas where you’re maybe cleaning that water and then things like that. So, I think that’s going to be — masks, N95s might be coming back for a totally different reason. 

Rovner: Well, N95s are not enough. I mean, I think that was the thing that kind of jumped out at me. If you watch the news coverage of it, the reporters aren’t wearing N95s anymore. They’re wearing what looked like old-style gas masks. I mean, you need sort of the next level of masking because N95s don’t filter out some of these toxic substances that are now floating in the air. I mean, they do filter out the sort of the actual smoke from wood and whatnot, but it’s pretty scary. 

I mean, a lot more people than ever before have N95s hanging around their house, but they certainly don’t have these next-level respirators, which is what I keep hearing doctors calling for. 

Kenen: And the article you — I think it was the one that you sent around yesterday that basically that everything in our house is, our couches are basically cubes of plastic wrapped in cloth and dangerous when they’re burned. But I mean, I think that was the article that also said that some of these things that are burning produce like a cyanide kind of gas, that the firefighters can’t even be exposed. They can’t stand in front of a house with a hose for a long time. 

It could be killing or injuring firefighters. So, it also hampers — they’re not just trying to put a hose on a burning tree. 

Rovner: Yeah. A lot more things to think about, which is just what we needed. Well, turning to abortion, remember all those states last year that voted to protect abortion rights? It seems that was far from the final word. 

We are seeing court case after court case to determine which abortion restrictions can stay and which can’t as a result of passage of those ballot measures. This is happening particularly in Missouri, where Planned Parenthood clinics are still not offering the procedure after a judge invalidated some but not all of the state’s restrictions. 

This seems to be the inevitable result of what we have seen in other elections, where the same voters endorse abortion rights but then turn around and vote for candidates, including judges, who don’t. Is the gridlock here on purpose or by accident? And Sandhya, what’s going to happen? 

Raman: I don’t know that it would be on purpose. I think that these voters that vote for the candidates, if abortion is not their top issue, they’re still going to vote in the way that kind of allies with them. But then if they’re looking at other policies, they’re going to vote for these candidates. 

And Missouri, I think, is interesting because it has long been, I think, one of the test cases for so much in the abortion space, of trying out new restrictions and what will stick to the wall. And I think that we’re going to see more of these kind of long, drawn-out battles, given that the judge said that some restrictions were struck down because of the constitutional amendment but then others, like the licensing for abortion facilities, which we’ve seen for years, can stay. And that just makes it so that they can’t really operate. 

Rovner: Yeah. They have things like how wide the hallways need to be, I mean, rules that were created to deter them from offering abortions, not because they were actually needed for safety and health. 

Raman: Yeah. These rules only apply to the abortion facilities. They’re not parallel in the other types of clinics and hospitals. So it’s targeted to them. I think it is just another example of it being kind of an uphill battle for them, because now, I mean, even in the past few years we’ve seen so much more attention on state supreme court races, which I feel like a few years ago that was not something that would get national attention for one state or another. 

But, given that, as they’re kind of litigating these and seeing how can we implement the law so that these clinics can open under the constitutional amendment, it relies on them, and just how much money that is being fueled to be able to not come down on the other side so that they can kind of operate. So I think that’s something to definitely watch, as some of these states are kind of litigating these things, but it’s going to be a long, drawn-out battle, even if it’s already been several months since seven out of 10 states last year voted in favor of abortion rights. 

Rovner: Yeah, this continues, and of course, we’ll wait and see what happens at the federal level, when the Trump administration gets going. Well, finally this week, we have another entry in our recurring segment, “This Week in Medical Misinformation.” I wanted to talk about a little-noted story from the medical news site MedPage Today about the American Board of Internal Medicine pulling the board certification of a Texas cardiologist who made controversial and untrue claims about covid and the covid vaccine, including that vaccine had killed tens of thousands of people. 

What’s troublesome about this story, though, is that the ABIM wouldn’t comment on individual physicians, although it did list this particular doctor on his website as not being certified. How should specialty boards deal with doctors who express views that are, shall we say, not consistent with medical evidence? And how transparent should they be about telling patients when they sanction one of their own, which is basically what happened here? 

Kenen: Well, they did put out a statement, I think it was the New England Journal of Medicine about a year and a half ago, saying that they were going to crack down on this. I’m not sure if there’s, for any of the boards, if there’s a mechanism for telling patients, because how do you even know who all the patients or potential patients are? 

Rovner: But when I say telling patients, I mean telling the public. 

Kenen: Right. But I don’t know that any of the boards do that in any — it’s a big can of worms about decertification and how infrequently it happens. 

So ABIM did put out a statement, I think it was two years ago now, and there’s been a process for a few, but not a lot. And it doesn’t mean they don’t have a license anymore. It means they don’t have board certification. So unless the state medical board, which is really the group that pulls a license — this is saying that you’re not a board-certified whatever your specialty is under ABIM. 

But Lauren [Weber of The Washington Post], who is sometimes on the website, had a good piece a couple of months ago about how few state boards have acted to sanction doctors who say incorrect things about vaccines. And that goes back way before covid. The medical profession doesn’t do a lot of self-policing. 

Rovner: Yes, and I’ve been doing this long enough to have covered the creation of the National Practitioner Data Bank, when doctors who’d had their licenses pulled could just go to another state, and there was no way for that state to easily find out that that doctor had had his or her license revoked. 

And that was usually not for saying things but for doing things that ended up with having the doctor decreed not qualified to practice medicine anymore. So, I mean, this is an issue that goes back a long ways. 

Kenen: And you would think they would be the opposite. You would think that the state boards, when somebody is really a bad guy or a bad gal, you would think they would say, “We stop them!” Like, “We are protecting your health.” And instead, it’s been very secretive and very infrequent. 

It’s more the state licensing board. I mean, certification is important, but really the power to de-license somebody is in the state boards. 

Rovner: Yeah, well, the whole argument that professions police their own, what we’ve discovered is that professions don’t do a very good job of policing their own. But we will keep watching. All right, that is the news for this week. Now, we will play my “Bill of the Month” interview with Harris Meyer. Then we’ll come back and do our extra credits. 

I am pleased to welcome to the podcast Harris Meyer, who reported and wrote the latest KFF Health News “Bill of the Month.” Harris, welcome to “What the Health?” 

Harris Meyer: Thanks very much, Julie. Glad to be here with you. 

Rovner: So, tell us about this month’s patient — who he is, where he’s from, what kind of medical care he got. 

Meyer: OK, Julie, this is a story about high prices, confusing bills, and lack of price transparency for a very common procedure. The patient is Tom Contos, a 45-year-old health care consultant who lives in Chicago. Last spring, Tom noticed blood in his stool. He went to see his family physician at Northwestern Medicine. 

The doctor referred him for a diagnostic colonoscopy because of the bleeding and because of his family history of serious colon issues. Then in June, he went in for a colonoscopy at Northwestern Memorial Hospital, which is a big teaching hospital in downtown Chicago. 

A Northwestern gastroenterologist performed the procedure, which took less than an hour. He found and removed two polyps, which a pathologist later found were not cancerous. The gastroenterologist concluded that Tom’s rectal bleeding was due to a large hemorrhoid. 

Rovner: So, just to be clear, it’s screening colonoscopies, those for people with no symptoms, that are supposed to be free as preventive care under the Affordable Care Act. Diagnostic colonoscopies like this one can require a patient to meet deductible and copay requirements, right? That’s something important for people to know? 

Meyer: Yes. There’s a lot of confusion about this. I got a lot of comments on my Washington Post article that expressed confusion. Yes, diagnostic colonoscopies like Tom’s are done when there are symptoms like bleeding or pain. In contrast, screening colonoscopies are recommended starting at age 45, even when there are no symptoms, to prevent colon cancer or other serious conditions. 

The Affordable Care Act requires health insurers to cover screening colonoscopies at no cost to patients. But for a diagnostic colonoscopy, patients may have to pay a deductible and copayment, even though that procedure similarly can prevent colon cancer. It doesn’t— 

Rovner: It can be confusing. 

Meyer: It’s confusing, yeah. 

Rovner: So he has a procedure, which found some minor indications that were taken care of, and then, as we say, the bill came. How much was it? 

Meyer: Yeah, Northwestern’s total charge was a mind-boggling $19,000. Tom’s insurer, Aetna, had a negotiated rate with Northwestern of a still significant about $6,000. When he got his insurance explanation of benefit statement, he saw that he owed about $4,100, with the insurer paying about $2,000. 

He was bewildered because he had asked Northwestern for an estimate of how much he would owe in total and he was told that he would owe about $2,400. My outside billing expert said $4,100 is quite a high out-of-pocket bill, though not unusual for teaching hospitals. 

Rovner: And he was charged for two colonoscopies, right? 

Meyer: Yes. That was a major reason that the bill was so high. Northwestern billed him for two colonoscopies, which Tom did not understand, since he had only received one. It turns out that providers routinely bill for two procedures if the gastroenterologist removes and biopsies two polyps in two different ways during the same procedure. 

The second procedure is billed at a discounted rate. Now, this seems strange to laypeople, but this is how providers get paid for the extra work of removing two polyps rather than one. 

Rovner: Which, as you pointed out at the beginning, it’s not like this is a several-hour surgery. This is a fairly quick procedure. 

Meyer: That’s right. It’s at most an hour, often less than that. 

Rovner: So what happened eventually with the bill? 

Meyer: Well, Tom appealed the bill to Northwestern and Aetna and was told that it was correct. He had already paid about $2,400 of the nearly $4,100 he owed, but he told Northwestern that its bill was, quote-unquote, “ridiculously high” and he wasn’t going to pay the remaining $1,700 or so and that they could take him to collections. 

Northwestern said that’s what they were going to do, and Tom decided to no longer use Northwestern or its doctors in the future. 

Rovner: Although I assume he did pay the amount that they said he owed. 

Meyer: No, he said: Take me to collections. I’m not paying it. My credit is good, and — I won’t repeat some of the things that he said to them. 

Rovner: Thank you. This is a family podcast. How can others avoid falling into this trap? I mean, he got an estimate. He had an idea of what he was going to be charged, and yet he was still charged considerably more than that estimate. 

Meyer: Yeah, he’s a health care consultant, but a lot of people get confused by this process, including him taken by surprise. He only looked at the estimate after he had had the procedure but before he got the final bill. So, like a lot of people, he got confused and he didn’t proceed necessarily as efficiently as he might have. But that’s common and not surprising. 

Rovner: Even for somebody who’s basically in the health care payment business. 

Meyer: Yes, that’s correct. 

Rovner: So be vigilant. Is that basically the takeaway? 

Meyer: Well, how can you avoid falling in the same trap? Unfortunately, not easily. Patients needing a diagnostic colonoscopy should check out freestanding endoscopy centers or ambulatory surgery centers that aren’t associated with a hospital, because they can be cheaper and they can provide good quality of care. 

To price-shop ahead of time, patients can look at the hospital’s price website and their insurer’s cost estimator website to get a sense of how much a diagnostic colonoscopy could cost. They also can look up a so-called good faith estimate of the cash price, meaning the procedure could be cheaper if they pay cash, rather than going through insurance. 

Plus, there are free websites such as Turquoise Health and Fair Health for checking prices for colonoscopies and other procedures. Now, once they get a price estimate from the provider, there’s one more wrinkle. Patients should ask whether that price includes the extra services, if the gastroenterologist finds and has to remove and biopsy one or more polyps. At least 40% of colonoscopies do find polyps. 

Now, experts say it’s unfortunate that getting a diagnostic colonoscopy can be so expensive and confusing billing-wise, but don’t hesitate, because it can be a lifesaving procedure for many people. 

Rovner: All excellent advice. Harris Meyer, thank you so much. 

Meyer: Thank you, Julie. 

Rovner: OK, we are 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. Anna, why don’t you go first this week? 

Edney: I wanted to talk about one I wrote last month, and the headline is “It’s Not Just Sunscreen. Toxic Products Line the Drugstore Aisles.” I kind of wanted to put in one place talking about a lot of these contamination issues that have come up, but particularly also just show that, while the problems with products keep growing — one of them that I pointed out that’s new in this piece is dandruff shampoo containing benzene — the FDA is getting sort of slower on a lot of these things. They’re digging in, and they’re not trying to communicate to the public about the issues that have come up. They’ve had since last March of 2024 concerns brought to them about benzene and acne products. 

They’ve said nothing to the public. They just keep saying, We’re looking at it. And that’s very different from when this first kind of started happening on a larger scale, where it was like, boom, recalls. Now it’s just sort of this fight to maybe not have recalls. I don’t know what’s going on in their head. 

But there also are some issues in there with the tampons were found to contain a lot of heavy metals, FDA also slow-walking there. So I wanted to point out that piece I wrote if anybody missed it. 

Rovner: Yes. Thank you, Anna, on the “everything you thought might be safe is actually dangerous” beat. 

Edney: I’m the life of every party. 

Rovner: There you go. Joanne. 

Kenen: I’m not sure if this is an extra credit or a public service announcement, but there is a great piece in The Atlantic by Daniel Engber. Well, we all know there’s a ton of stomach bugs and norovirus going around, and it’s quite severe this year. And the headline is “A Secret Way to Fight Off Stomach Bugs,” and the answer is wash your hands with soap. 

But it’s a really well-written — it actually makes you laugh about stomach bugs. It’s a very well-written, good story. And no, for this bug, hand sanitizers don’t work. 

Rovner: Sandhya. 

Raman: My extra credit this week is called “New obesity definition sidelines BMI to focus on health,” and it’s by Giorgia Guglielmi for Nature. And it takes a look at — we had a revised definition of measuring and diagnosing obesity in the Lancet Diabetes & Endocrinology this week. 

So, instead of BMI [body mass index], which is weight- and height-linked, they’re suggesting a couple of alternatives: preclinical obesity, which is a person with extra body fat but their organs are still functioning normally, and clinical obesity, so when you have that excess body fat that it’s harming your organs. And there’s more in the piece on just different ways clinicians are looking at this globally. 

Rovner: Yeah, it’s really interesting because, obviously, every doctor says that BMI is a stupid and imprecise way to measure this, and then everybody uses BMI because, at the moment, it’s all we have. My extra credit this week is a KFF Health News story from Felice Freyer. It’s called “Can Medical Schools Funnel More Doctors into the Primary Care Pipeline?” and it’s about a problem I have been following for a while and which does not seem to be getting better. 

While the U.S. has opened lots of new medical schools over the past decade and has launched a raft of programs aimed at getting more graduating doctors to go into primary care, way too many are still pursuing specialty care instead. We have tried, as a society, free tuition and loan repayment programs, but it doesn’t seem that medical education debt is the biggest problem. 

We’ve also tried training doctors in more primary-care-centric locations, i.e. in community clinics rather than in hospitals, but that’s not made a huge dent, either. Rather, to quote one of the family medicine experts in the story: “It’s not the medical schools that are the problem; it’s the job. The job is too toxic.” 

In other words, it’s not really appealing to see too many patients for too little time and do tons of fighting with insurance companies and electronic medical records. Until we as a society start making primary care a lot more of a satisfying job, it’s not going to matter how much it pays. We’re still going to have a serious shortage. 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks again this week to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. 

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me occasionally at X, @jrovner, and increasingly at Bluesky, @julierovner.bsky.social. Where are you guys hanging out these days? Anna? 

Edney: On X, @annaedney, and then on Bluesky, @annaedney.bsky.social. 

Rovner: Joanne. 

Kenen: I’m on Bluesky, @joannekenen.bsky.social, very occasionally on X still, @JoanneKenen. 

Rovner: Sandhya. 

Raman: On X, @SandhyaWrites, and on Bluesky, @sandhyawrites.bsky.social. 

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

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The new, GOP-led, 119th Congress and President-elect Donald Trump have big legislative plans for the year — which mostly don’t include health policy. But health is likely to play an important supporting role in efforts to renew tax cuts, revise immigration policies, and alter trade — if only to help pay for some Republican initiatives.

Meanwhile, the outgoing Biden administration is racing to finish its health policy to-do list, including finalizing a policy that bars credit bureaus from including medical debt on individuals’ credit reports.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• The 119th Congress is now in session. Health care doesn’t make the list of priorities as lawmakers lay the table for the incoming Trump administration — though Republicans have floated Medicaid work requirements to cut federal spending.
• A lot of health legislation hit the cutting-room floor in December, including a bipartisan proposal targeting pharmacy benefit managers — which would have saved the federal government and patients billions of dollars. And speaking of bipartisan efforts, a congressional report from the Senate Budget Committee adds to evidence that private equity involvement in care is associated with worse outcomes for patients — notably, lawmakers’ constituents.
• As the nation bids a final farewell to former President Jimmy Carter, his global health work, in particular, is being celebrated — especially his efforts to eradicate such devastating diseases as Guinea worm disease and river blindness.
• Meanwhile, the Biden administration finalized the rule barring medical debt from appearing on credit reports. The surgeon general cautions that alcohol should come with warning labels noting cancer risk. And the new Senate Republican leader is raising abortion-related legislation to require lifesaving care for all babies born alive — yet those protections already exist.

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

Julie Rovner: The Wall Street Journal’s “UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.

Alice Miranda Ollstein: The New York Times’ “Ozempic, Lego Bricks and Hearing Aids: What Trump’s Greenland Plan Could Hit,” by Ana Swanson and Jenny Gross.

Shefali Luthra: Vox.com’s “Gigantic SUVs Are a Public Health Threat. Why Don’t We Treat Them Like One?” by David Zipper.

Lauren Weber: The Washington Post’s “Laws Restrict U.S. Shipping of Vape Products. Many Companies Do It Anyway,” by David Ovalle and Rachel Roubein.

Also mentioned in this week’s podcast:

The Senate Budget Committee’s “Profits Over Patients: The Harmful Effects of Private Equity on the U.S. Health Care System.”

[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, Jan. 9, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello hello. 

Rovner: And Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: No interview this week — way too much news to catch up on. So let us get right to it. So, welcome to the 119th Congress and, soon, to a new presidential administration. We’ll go back and recap what happened in late December shortly, but I want to start by looking ahead. What’s on the immediate agenda here in Washington for health care? Anybody? 

Ollstein: So health care is not the priority right now for the incoming administration, for the new Republican trifecta in Washington. It can make it in, because they are talking about these massive, conglomerate bills that they have criticized in the past and said that they don’t like doing that, and they would much rather vote on individual things one by one. 

But now they’re talking about cramming everything into one giant reconciliation bill early in the new administration. And there will likely be some health care components. We don’t know yet what those will be. Things that purport to save money are a lot more likely than things that purport to cost money. Although, there’s often some funny math in that. Medicaid work requirements have been floated, and so we can talk about that. We know, we’ve seen that movie before, and we know how that can go, both in terms of what it means for people’s coverage and what it means in terms of savings. 

But I think that a lot of the ambitious stuff that lawmakers tried to get through at the end of the year is now in question, as to whether it has a future or not. Because the top priorities of the new administration are more on taxes and trade and immigration and things like that and not as much on health policy. 

Rovner: Although, I would point out that that end-of-the-year rush that they got — they kept the government open, and they got the government funded — that only goes until March. I saw sort of a plaintive email yesterday from Tom Cole, the Republican chairman of the House Appropriations Committee, saying, Um, we have to start working on the next one soon. Everybody’s busy talking about this huge tax bill, reconciliation. What are we going to do about Medicaid? And it’s like, hello, the current fiscal year is not finished. They just managed to put things off. 

Lauren, you wanted to add something? 

Weber: Yeah. I just wanted to say, I feel like we’ve entered the era of marketing when it comes to these bills. You’ve got President-elect [Donald] Trump saying he wants one big, beautiful bill. That’s what he wants. He wants one big, beautiful bill. And it’s not just Trump. I mean, let’s look at the MAHA movement, the “Make America Healthy Again” movement. 

I mean, I think we’re entering an era in which bills and movements all have catchy slogans. And I mean, heck, the American public may have a better understanding, or at least know what these people are telling them is happening with this marketing, we’ll see. So I just wanted to flag that this seems to be the change over here. 

Rovner: And this is when I get to put in my other reality check, which is they keep talking about this big, beautiful reconciliation bill that they only need Republican votes for. I have to remind people every year: In order to do a reconciliation bill, first they must do a budget resolution, in both houses. That has to go to the floor, be debated, has to be reconciled between the House and the Senate, about what the budget resolution looks like. 

The whole point of what’s called “reconciliation” is that it reconciles mandatory spending to the terms of the budget resolution. It takes a long time to do a budget resolution, even when you’re rushing it through. 

Also, all these things that they’re talking about putting into this reconciliation bill are not allowed to go into budget reconciliation. It’s only about mandatory spending. It is taxes. It is Medicare and Medicaid and other mandatory spending. And it’s the debt ceiling. And those are basically all the things that can go in. Sorry, that’s the end of my lecture. 

Alice, did you want to add something? 

Ollstein: Sure. I mean, I think we’re already seeing cracks emerging in this great Republican unity that they’re trying to project. I mean, they can’t even agree yet on whether to do one big, beautiful bill or two. And the people pushing for two are pointing out that if you put all your eggs in one basket and that basket breaks and falls apart and all the eggs smash on the floor, then you don’t really have anything to show for your work. 

Which of course is a situation Congress has found itself in many times over the past several years. And so, those folks are saying it’s much less risky to break it up and have it in separate bills, so that if one goes down in flames, the other might make it through. But yes, once again, we are seeing both House vs. Senate tensions, as well as Congress vs. Trump and Trump’s advisers tensions. And I imagine that is going to be a constant for the next few years. 

Rovner: And if you thought that the House was ungovernable with its tiny Republican majority in the last Congress, it’s even tinier now. In fact, we do have Speaker Mike Johnson. He did get elected on the first ballot, but it was not easy. There were a couple of holdouts who had to take calls from the president-elect in order to change their votes. So it’s pretty tenuous there. 

Shefali, before we move on, did you want to add something? 

Luthra: No, I mean, I think what will be really interesting, as well, is to see how this emerges in all of the more fractious issues among the Republican Party. I know we’ve talked a lot about how the Republican Party is very divided on a lot of issues of reproductive health, including abortion, something Alice and I both think about all the time. And— 

Rovner: And we will get to in a few minutes. 

Luthra: We will be getting to that very soon. But it is just very clear that all of these issues, where they project unity, are pretty quickly going to fall apart when it comes to engaging with the fact that this is a very divided coalition, and a lot of the things they’re talking about doing are not very popular with voters. And so we’ll see how that affects them as well. 

Rovner: Yes. So let’s move back a little bit. When we left things in December, we were a day away from a possible government shutdown, which did not happen. But the other thing that didn’t happen was a big package with basically an entire year’s worth of bipartisan health policy work in it, everything from new transparency requirements for pharmacy benefits managers [PBMs], to renewals of programs to prepare for the next pandemic and to fight the opioid epidemic, to rolling back cuts to doctors under Medicare. Most of that didn’t make it into the final package that will keep the government running until March. 

The tiny things that did make it in were extensions of telehealth authority for Medicare and payments for community health centers and some other expiring programs — but again, only through the middle of March, which is when the rest of this funding bill expires. 

So what happens to things like the PBM bill that fell by the wayside? Do we have any reason to think that Congress is going to pick it up and pass it this year? And even if they do that Trump would sign it? Or did all of that work last year, is that all just basically for naught now? 

Ollstein: I mean, I think you could make an argument either way. You could make an argument that it has a chance because there is bipartisan support. Some of these things could save the government money and help pay for other things that the Republican majority wants to do, like cut taxes. 

Rovner: I would say the PBM bill was like $5 billion in savings, as I recall. 

Ollstein: Exactly. And it’s not like PBMs are super-popular and everyone wants to defend them right now. So you can make the argument that it has a chance because of that, but we’ve seen tons of health policies in the past that have bipartisan support that would save money also fall by the wayside, just because they are not priorities. And so, I think, you can make the optimistic or the pessimistic case on this one. 

Rovner: Go ahead, Lauren. 

Weber: I would just add, I mean, a lot of things that people were pretty upset about, in terms of smaller things, health-wise, also got cut from the bill. I mean, there was funding for 9/11 cancer funds, for those that had been exposed to toxic chemicals, first responders, and so on. A lot of outcry after that got stripped out of the bill. Understandably so, considering, basically all the advocates said: We don’t want to parade our dying first responders to Congress every year to get funds. Really, you cut this out? 

So there does seem to be some momentum to potentially add that in again. There was also hullabaloo around childhood cancer research. They ended up passing a separate smaller bill, but it did not include the full measures to really prioritize some pressure on the FDA [Food and Drug Administration] and other funding to improve childhood cancer research. And so I think you’re going to continue to see, at least from the Dems, some pointing out of these issues going forward as, I mean, childhood cancer and 9/11 first responders are pretty sympathetic characters for funding. 

Rovner: Yeah, I think it’s going to be — I think a lot of these new committee chairs, particularly in the Senate, where the Republicans are taking over, are going to have to figure their way out and try to pick up some of the pieces. One interesting thing that came through my inbox this week was a bipartisan report from the Senate Budget Committee that found, and I am quoting from the headline in the press release, “Private Equity in Health Care Shown to Harm Patients, Degrade Care and Drive Hospital Closures.” Does this suggest that Congress might try to do something on this extremely fraught subject? 

Shefali, you are smiling. I mean— 

Luthra: I’m smiling because a couple of things, and the first is that there has been a lot of discourse about private equity’s impact on health care for consumers for years. This is very interesting and important work, and it is not at all surprising. 

And the other thing that we have to remember is that Donald Trump will be president. He is ideologically very unpredictable. As an actor, he is very unpredictable. And it’s just very difficult to guess what will actually become law and getting his signature. And part of that is because, we can remember from the last time he was president, he very often would change what he believed based on the last person he spoke to. We saw this all the time with drug pricing. 

And I just think that we will see really interesting bipartisan analyses of things that could make real differences for consumers on health care, but whether they become law, whether they change people’s lives, that’s just much, much harder for us to really predict in a meaningful way. 

Rovner: Yeah, I think everything’s pretty hard to predict right now. Lauren? 

Weber: Yeah, I just wanted to add, I mean, I know, obviously hard to predict, but I think the idea that you have lawmakers issuing pretty strident releases that tie private equity to decrease patient outcomes in their specific districts is a bit of a step forward. I mean, you have [Sen. Charles] Grassley saying: Look, none of these people care about patient care. They only care about shareholders. I do think that is a shift in rhetoric, to an extent. We’ve seen a building for quite some time. We’ve all talked about private equity on this podcast. 

But I do think when you have lawmakers making that jump to, Oh, people in my district are getting worse health care because of this, I think you could see more movement. 

Rovner: Yeah, it’s something I’m going to keep an eye on. Like I said, I was surprised to see that as a bipartisan report from a committee, even though it’s the Budget Committee that doesn’t really have authority to do anything legislatively. Still, it was worth noting. 

Well, in case there wasn’t already enough news this week, here in Washington this very morning, we are bidding farewell to former President Jimmy Carter, who died at age 100 late last month. Carter was one of a long list of Democratic presidents who tried and failed to overhaul the nation’s health care system. You can Google something called “hospital cost containment” if you want to know more. He also created the Health Care Financing Administration to run Medicare and Medicaid, which got renamed the Centers for Medicare & Medicaid Services in the early 2000s. 

But Carter’s biggest health achievements came after he left office. His work through his foundation addressed, and in some cases nearly eradicated, some mostly neglected tropical diseases that mostly afflict the poorest and most marginalized people on the planet. That’s going to be one of his real major legacies, was bringing global health home. Right, Alice? 

Ollstein: Yeah, and I think that’s interesting, given the recognition of his legacy right now, around his funeral, and lying in state in the Capitol, with the Trump administration coming into office, being very against bodies like the WHO [World Health Organization] and international cooperation on health care, very vocally critical of how international cooperation happened during the covid-19 pandemic. And so I think that is going to be an interesting contrast, given what Carter was able to achieve through such cooperation. 

Rovner: Yeah. Lauren? 

Weber: Yeah, I just wanted to add, I mean, it’s a model that I think then seeped into other presidents, right? I mean, you’ve seen [former president George W.] Bush’s investment in global health, and so on. And I do think, as Alice smartly pointed out, there is, obviously, a sharp contrast. But I mean, what Carter was able to do for river blindness and Guinea worm is unprecedented. And I think what was most moving in all of the recaps of his work is that these are people that don’t have a voice. They don’t have a position of power in the country they live in. I mean, this is him using his soft power to demand action, by flying out to far-flung corners of the world, to meet with farmers who had been disabled by Guinea worm, to make sure that this didn’t happen to future generations. 

And some of these biographers have posited that’s because of his upbringing as a poor farmer in Georgia. So I think this is kind of a once-in-a-generation moment to look at this impact someone has on global health. And as Alice pointed out, I don’t know what we’ll see going forward on that. 

Rovner: It’s hard to imagine Donald Trump making eradication of Guinea worm a major priority. Well, we are also bidding farewell over the next two weeks to the Biden administration, which is using its last days to try and get as much done and trumpet as many victories as it can. We’ll start with the Affordable Care Act, where the administration just announced that with a week left to go in the official sign-up period in most states, 24 million people have now been enrolled in ACA plans. That’s up 3 million just from last year and more than double the number from 2021 when [Joe] Biden took office. 

Of course, this is likely to be the high water mark. This year marked the first that the so-called Dreamers, those people brought illegally to the U.S. as children by their parents, they could enroll, at least for now. That’s something President Trump and the Republican Congress is considered likely to end. Plus, the additional tax credits that were put in place during the pandemic expire at the end of this year, unless Congress renews them. What’s the outlook for ACA enrollment? 

Ollstein: Well, Democratic senators are starting to make a push to extend those subsidies, introducing legislation and making a big splash about it today. There’s been a lot of lobbying from the health care sector, the hospitals, all the players who don’t want to see these tax credits expire, and as well as patient advocacy groups. Really, my inbox has been flooded with things related to that and calling on Congress to extend these subsidies. 

Of course, they cost a lot of money, and the new congressional majority definitely has other things they want to spend that money on, that are not helping people buy health insurance plans as part of the Affordable Care Act. And so, I think there is likely to be a lot of wrangling and horse-trading around this. I don’t think the subsidies are necessarily toast, but I don’t think that they’re a done deal, either. 

Rovner: Yeah, I mean, I keep saying, I think everybody’s first inclination after Election Day is that they were toast, because Republican trifecta. On the other hand, when you actually dig into the numbers, the biggest increases have come in red states. 

Ollstein: Absolutely. 

Rovner: So the people who are taking advantage of these extra subsidies are people who are in Republican states and voted for Republicans and are represented by Republicans. And you’ve got to wonder whether they want to, suddenly next January, or really next October, November, when people realize: Oh my goodness, my premiums for my health insurance are going to quadruple. How did this happen? Maybe they’ll think about that when they’re putting all of these big, beautiful bills together, maybe? 

Ollstein: Yeah, we’ve started to see some comments from some Republicans. Of course, it’s the ones who have been willing to work with Democrats in the past, like Lisa Murkowski in the Senate, saying that we should look at extending these subsidies. You’re not hearing that from most Republicans by any stretch of the imagination, but I think you’re starting to hear these rumblings because, like you said, Julie, they don’t want to have a bunch of constituents lose their insurance or have their insurance get way more expensive when they’re in power. 

Rovner: Yeah, the advantage and disadvantage of the trifecta. Lauren? 

Weber: I just wanted to ask, I mean, a question for the panel. I mean, there’s all this talk about “DOGE” [the “Department of Government Efficiency”] and cutting all this money, but as you just stated, Alice, they’re likely not to get rid of these subsidies. Johnson went on the record, I think this week or last week, to say Medicare is not going to get impacted. Medicaid cuts seem to be coming, but dear God, if you don’t cut some of these other things, I don’t know how you would possibly get to the money amounts that they’re talking about, especially in health. 

Ollstein: Well, and Elon Musk has already walked back his projection of how much he’ll be able to cut, saying that $2 trillion was aspirational and hopefully they’ll get $1 trillion. And so you’re already starting to see the walk-back of some of the preelection promises on that front as they start to confront some of the realities you mentioned, Lauren. 

Rovner: Yeah, there’s nothing like the optimism of early January, when a new Congress and a new president say, We’re going to do all of this in the first hundred days. You would think that Trump of all people would know better, because he tried to repeal the Affordable Care Act in the first hundred days in 2017, and that didn’t go so well. But apparently he has a short memory, too. 

Well, speaking of things that are likely to be undone, the Consumer Financial Protection Bureau finalized its rule this week barring the use of medical debt on credit reports. It’s already been sued for exceeding its authority by two trade groups representing creditors. How important would this change be if it actually survives? 

Luthra: Something like this could be really meaningful. I remember talking to families about their efforts to buy homes and often struggling to do so because their medical debt had harmed their credit score. And the thing about medical debt is that it’s usually not planned. It is probably actually almost always not planned, because you don’t hope to fall sick. You do not try to get a devastating injury that your insurance will not fully cover the costs for. 

And this was something that had really been championed by folks in the consumer advocacy space for a very long time, well before the Biden administration. Losing it would really have implications for people across the political spectrum, especially as we are in this space where housing remains very expensive, where medical debt is a real concern, and where having it affect your credit could really put a reasonable mortgage just out of reach for a lot of Americans. 

Rovner: Well, finally, as one of his parting recommendations, outgoing Surgeon General Vivek Murthy has issued a report recommending that alcoholic beverages carrying warning labels that they can cause cancer, just like tobacco products. His report calls alcohol the third-leading preventable cause of cancer. But this doesn’t feel super-likely to happen, between the power of the alcohol industry and the distrust of science, particularly when it recommends things people probably don’t want to hear. I assume nobody here is betting on this happening anytime soon? 

Ollstein: No, you’ve already seen members of Congress for whom the alcohol and beverage industry is very economically important for their state, all the folks who represent breweries and distilleries and wineries, already speaking out and sharing concerns about this. But I think that just the surgeon general using the bully pulpit to shine a light on this, it generated a lot of news coverage. That’s important. 

It’s important for consumers to see that and be able to make choices. And you’re already seeing some trends of younger folks being more sort of sober-curious. And there’s a lot of talk about Dry January being a healthy thing to do. And a lot more bars you’re seeing offer low-alcohol or nonalcoholic options. And so I think this is something that people are slowly becoming more aware of and more concerned about, whether the government steps in or not. 

Rovner: Yeah, I think it may be like tobacco, where everybody smoked and then gradually fewer and fewer and fewer people did. Lauren, did you want to say something? 

Weber: Yeah, I mean, I’ve written a lot about food labels in the last couple of years, and, I mean, that’s just been a torturous process. So the idea that anything on alcohol would change at anything faster than a glacial pace I think is probably problematic, considering there’s a lot of lawyers in this town and there’s a lot of money in lawmakers’ pockets in this town. So just wanted to add that. 

Rovner: And alcohol’s really popular — and legal. Well, let’s turn to abortion reproductive health. All things considered, it’s actually been sort of quiet on the abortion front for the last few weeks. But there has always been news, as is predictable when Republicans take over the House, Senate, and White House at the same time. New Senate Majority Leader John Thune has announced his intention to bring up an abortion bill. In this case, not a national ban, which President-elect Trump has said he wouldn’t sign, but rather the, quote, “Born-Alive Abortion Survivors Protection Act.” What is this bill? And what would it do? And how is it different from a similar-sounding bill that Congress passed and President George W. Bush signed in 2002? 

Luthra: We were chatting about this in advance of taping the podcast, and this is really interesting for a lot of reasons. What this bill would do is, essentially, if someone gives birth, the hospital or the health care provider is required to provide all forms of lifesaving care, even if it seems like the newborn will not live. And this is relevant in a lot of places. It is relevant when, for instance, you maybe experience a very, very early delivery, in which viability is just not on the table. 

We do know that the vast majority of abortions happen well before the point when there is actually going to be something that resembles an infant being born. And so what this actually does in practice, a lot of health care providers have sounded the alarms about, is stigmatize abortion and sow more mistrust of the health care providers who perform it. And it also, in cases where someone does give birth to a child that will not live, forces doctors to provide medical interventions that maybe won’t make a difference but that will delay the opportunity or prevent the opportunity for palliative care, which is really sad. 

I mean, you give birth to a child that won’t live, and it can’t spend its few moments with some kind of comfort. Instead, it’s given medical treatments that will not really help them. This bill differs from the law signed under President Bush in that it would add penalties. But the other thing that’s worth noting is that killing infants is already illegal. We have laws that ban homicide. And so, when abortion rights supporters and legal scholars say that this kind of law would be redundant, they’re right. We already have ways to penalize killing people. But what we don’t have are national restrictions that stigmatize abortion to the extent that it will be performed less and less. 

But the other thing I think is worth noting, to your point, Julie, is that this is a big step back, especially for Senator Thune, who was on the record supporting a 15-week national abortion ban and is now not. And that helps us underscore that national abortion restrictions are very toxic and that, instead, the GOP is really trying to focus on cases where they think they might have a better chance of winning, by focusing on the very end of pregnancy, areas where they see the support for abortion rights publicly go down, and start with restrictions there, before, if they ever want to do something more sweeping, waiting a bit more time for that to be politically viable. 

Rovner: Basically, it’s a messaging bill to try and put supporters of abortion rights on the spot and say, If you won’t vote for this, then you’re for infanticide. I mean, that’s essentially what the debate’s going to be. Right, Alice? 

Ollstein: Yeah. Well, and just so folks are aware, the timing of this is around the March for Life coming up in a couple days after the inauguration. And almost every year, Republicans in Congress attempt to hold some sort of messaging vote to coincide with that big anti-abortion demonstration in Washington, D.C. 

Rovner: I would say the anti-abortion demonstration is when it is because that was the anniversary of Roe v. Wade. That’s why they come to D.C. in January. 

Ollstein: Yeah. As an aside, they considered moving it to June to mark the anniversary of Dobbs but decided to keep it in January to continue to observe the anniversary of Roe anyways. But like Shefali said, it’s interesting that, even given that this is just a messaging vote, they’re still aiming a lot lower than they have in the past and not introducing the big, sweeping anti-abortion policies that the advocacy groups on that side want to see, in terms of restrictions on abortion medication, or like in the past, 15-week bans, 20-week bans, something like that. Instead, this is sort of a niche and arguably duplicative policy that they’re putting forward. 

Rovner: Well, we will certainly watch that space. Also, over the holiday break, an OB-GYN at the University of Indiana sued the Indiana Department of Health, claiming the state’s new abortion reporting requirements violate the federal HIPAA [Health Insurance Portability and Accountability Act] patient privacy rules. Failure to follow the state law could result in potential criminal liability or loss of medical license, but federal law is supposed to preempt state law. 

Along those same lines, Senate Finance Committee Chairman, now ranking member, Ron Wyden of Oregon released a report in December, which followed up on the reporting that we’ve talked about from ProPublica, about pregnant women dying from preventable and/or treatable complications. Wyden’s staff found that doctors in states with abortion bans have been unable to get sufficient legal advice and/or guidance from their hospital officials in a timely way. 

Quoting from the report, “Doctors are playing lawyer, and lawyers are playing doctor, while pregnant women experiencing anything short of what amounts to a dire emergency are sent away and told to return to the emergency room once a preventable situation becomes life-threatening.” Is there anything on the horizon that would sort out what doctors can and can’t do in states with abortion bans? This continues to be — we keep hearing story after story after story about this. 

Ollstein: So the anti-abortion movement’s response to this is that the laws themselves do not need to be changed, and they instead are introducing these new, what they call “med ed” bills that basically order the government, in collaboration with anti-abortion groups, to develop materials that doctors and medical students will have to review, that purport to explain what is and isn’t allowed in terms of abortion care and emergency care under these restrictions. 

One state so far has implemented this, South Dakota, and they are attempting to introduce it in a bunch of other states. Now, the medical community says there’s no way a video is going to solve this. These are incredibly complex situations. You can’t cover everything that might come up. You can’t cover every condition a pregnant person could have. And they see it as sort of a CYA — if folks are familiar with “cover your behind” — move, in terms of liability and an attempt to put the onus on individual doctors who are already struggling, and to say that any of these adverse outcomes are the fault of doctors for not understanding or correctly abiding by these legal restrictions on care. 

Whereas the doctors say that: We can’t get guidance from our own employers. We can’t get adequate guidance from the state. And these really tie our hands in these very sensitive, time-sensitive, and medically sensitive situations. 

Rovner: And we’ve seen cases, I mean like in Texas, where the attorney general has threatened in writing to prosecute doctors for things that doctors say is standard medical practice. 

Ollstein: Right, so even when a doctor came forward and said, It is my medical judgment that this person needs an abortion for medical reasons, we saw the attorney general there step in and say: I am overruling your judgment. No, she does not. And so that has, based on many interviews I’ve done, and I’m sure Shefali has done, created a real chilling effect, where people are afraid of being second-guessed like that. And even short delays, where someone is trying to consult with an attorney on what to do, even a short delay can be deadly for a patient in one of those situations. 

Rovner: Well, turning to this week in medical misinformation, the big news, of course, is that Facebook is going to disband its fact-checking unit and basically adopt the anything-goes-and-if-you-don’t-like-it-correct-it-yourself system now used by X. This could have big implications for health misinformation, I would think. Even though Facebook wasn’t doing such a great job before on allowing misinformation and disinformation to spread. Is this going to have a big effect? 

Luthra: I mean, I think this is just, to some extent, a sign of Facebook shifting with the political winds, right? I mean, the fact-checking came out in part after the 2016 election when there was a lot of claims of voter fraud. There are a lot of, How did Trump get into office? They instituted fact-checking to allegedly kind of pander to people who felt like that there was a lot of misinformation spread then. Now they’re moving away from fact-checking because they feel like then it gives people the ability to reflect what the community wants. I think it’s reflecting the trend we’re seeing on X. We’ll see more Community Notes. It makes journalists’ job all the more important, to actually distill what’s true and what’s false. 

Rovner: You’re our misinformation expert. Oh, go ahead, Alice. 

Ollstein: Oh, I wanted to also flag that part of Facebook’s announcement was that they are moving some of their teams from California to Texas, because Californians are too biased to do any content moderation and Texans presumably are not. That was the frame of that announcement, basically. And so that, I’ve already seen, is raising concerns in some groups on the left, and medical groups, about access to information about kinds of care that are restricted in Texas, like abortion care, like trans care. 

Will people be able to post about those things, to post accurate things about those things on those platforms? Or will that be restricted in the future? It’s also drawing attention for that reason. 

Luthra: And if I can add one more point to what Alice mentioned, I mean, one of the very explicit areas where Mark Zuckerberg said he would like more room for disagreement and more room for discourse is on the lines of gender, and very explicitly removing restrictions on using very, quite frankly, misogynistic terms about how women should exist in our society, about LGBTQ+ people, about explicitly allowing users to call them mentally ill. 

And this has very meaningful implications for gender equality, sure, but also for health care, because we are seeing that one of the most politicized areas of health care in our country is access to health care for trans people, is access to health care for women. And it’s just very hard to not look at this and think, oh, there will be no implication for how people conceive of health care and how people conceive of those who receive this kind of health care. 

Rovner: And we should point out, which I should have at the beginning, this is not just Facebook — this is all of Meta. So this is Facebook and Instagram and Threads. It’s basically, because I know that only sort of old people like me are still on Facebook, but lots of people are on Instagram and Threads, and this is obviously going to have some pretty big implications as we go forward. 

All right, well, speaking of misinformation, one mark of responsible science is fessing up when you are wrong. And this week we have a big wrong thing to talk about. Back in November, we talked about a study that found that black plastic cooking utensils and takeout containers were dangerous because they were made from recycled electronics and were leaching amounts of fire retardants and other chemicals into your food. 

Well, it turns out that you probably still should get rid of the black plastic in your kitchen, but know that they’re not quite as dangerous as originally advertised. It turns out that the authors of the study made a math error that exaggerated the levels of toxins by a factor of 10. Still, if you don’t want to be exposed to fire retardants and other nasty stuff, you might want to cook with metal or silicone or something that is not black plastic. I do think this is important, because it does show science is an iterative process. It’s rare to see someone step up and say: Oh, oops, we got this wrong. But here, it doesn’t change our general conclusion about this. But you should know that when we make a mistake, we’re going to fix it. I mean, that seems to be very rare in this world right now. 

Ollstein: It’s so hard, because you see the act of admitting error and correcting it — that can fuel distrust. People point to that and say: See, they got that wrong. They must be getting all this other stuff wrong, too. But of course, not correcting misinformation is far worse. And so, in a time of such distrust, communication is really, really hard. And did all the people who saw the first wave of news about the black plastic also see the correction and see that it wasn’t true? How are these things framed? Were the splashy articles that were run, were they corrected? Were they retracted? It’s hard to put the toothpaste back in the tube. 

Rovner: Yeah, but science is an imperfect process. And it’s a process. It would help, I think, if people understood that science is more of a process than a, this is what is. But that’s what we’re all here for, and that’s why we all still have jobs. All right, that is the news for this week. 

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. 

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

Weber: I love this story, and I’m obviously biased, but by my colleagues David Ovalle and Rachel Roubein, on how “Laws restrict U.S. shipping of vape products. Many companies do it anyway.” Essentially, you shouldn’t be shipping flavored vapes across the country, but a bunch of companies do. And my colleagues were able to order and get their hands on quite a few of those flavored vapes. 

My favorite part is the kicker in the story, in which one company said, You’re not sanctioned to use our name in any way, when we reached out for comment after they had shipped us vapes illegally. So I thought that was quite something. But essentially, it gets at what is a flaw in this piece of the law, which is that the USPS [U.S. Postal Service] is supposed to enforce, or someone is supposed to enforce, how to stop the shipping of these vapes, but it’s not really happening. So it’s kind of a look at the best intentions may not be the reality on the ground. 

Rovner: Often. Alice. 

Ollstein: So I have a piece from the New York Times called “Ozempic, Lego Bricks and Hearing Aids: What Trump’s Greenland Plan Could Hit.” And this is coming off of Trump threatening to impose tariffs on Denmark if it refuses to allow the U.S. to take over Greenland, which has become one of Trump’s latest obsessions. 

And this piece is pointing out that tariffs on Denmark would impact a lot of things the U.S. population depends on. Specifically, the pharma giant Novo Nordisk is based there and manufactures tons of medications, including Ozempic, and other weight loss drugs and diabetes drugs in that family that are incredibly popular right now, and as well as hearing aids, other medical devices, other medications. And so this could impact consumers, if it ever were to happen, which who even knows. 

Rovner: Yes. Well, we will talk more about tariffs and the medical industry in a future podcast, but thank you for noting that. Shefali. 

Luthra: My piece is from Vox. It is by David Zipper. The headline is “Gigantic SUVs are a public health threat. Why don’t we treat them like one?” 

I think the story is so smart. I love this framing. It first lays out the evidence for why, when cars reach a certain size, they are very dangerous and much more likely to kill people. And then it gets into the conversation: Why don’t we actually treat this as a public health threat? 

And they look at the war on tobacco and the war on smoking to think through: What did it look like to take something that was so ubiquitous in our culture and actually convince the American public to shift away from it? I think this is really interesting for a lot of reasons. One is that public health is really expansive and we should think about it in an expansive way and consider all the different elements, like car size, that do affect our lives and life expectancy. 

And I also do think this ties really well to the conversation we had about the surgeon general’s alcohol warning, in that even short of policy changes, there is a lot that we can do as a society to shift the public’s understanding of health risks from things that we take for granted, and we can still move people in a direction toward being healthier and keeping our fellow Americans healthier. And that’s really interesting and important to think about. 

Rovner: Probably easier to do something about large SUVs than alcohol, but yes, I’m so glad you linked those two things. My story this week is from The Wall Street Journal. It’s called “UnitedHealth’s Army of Doctors Helped It Collect Millions More From Medicare,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty. And it’s basically the flip side of the story that Stat News has been all over, about how United has used various methods to deny care to its Medicare Advantage patients to save the insurer money. This is a story about how United is forcing the doctors who work for the company — and there are a lot of them, like 10,000 — to basically run through a checklist of potential diagnoses for every Medicare Advantage patient, to encourage doctors to make those patients seem sicker, even if they’re not, because then the company gets more money for Medicare. 

The investigation found that the, quote, “sickness scores” for patients moving from traditional Medicare to United’s Medicare Advantage increased an average of 55%, which was, quoting from the story, “roughly equivalent to every patient getting newly diagnosed with HIV … and breast cancer,” basically maximizing profits from both ends. It is quite the story, and I recommend it highly. 

OK, that’s this week’s show. I hope you feel caught up and ready for the rest of 2025. As always, if you enjoy the podcast, you could subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks, again this week, to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. 

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and increasingly at Bluesky, @julierovner.bsky.social. Where are you guys mostly these days? Alice? 

Ollstein: I am @alicemiranda on Bluesky, mostly. 

Rovner: Shefali. 

Luthra: You can find me on Bluesky, @shefali. 

Rovner: Lauren. 

Weber: Still just chilling on X, @LaurenWeberHP. 

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

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Ballard helped write that resolution. He told “An Arm and a Leg” host Dan Weissmann that he first heard about charity care after listening to an episode of the podcast.

Ballard spoke with Weissmann about organizing as a medical student, bringing the resolution to the AMA, and the optimism he feels about the fight for charity care at the hospital where he works.

Credits

Dan: Hey there– 

A few weeks ago, we put out an update about charity care. That’s the commitment by hospitals to lower or just forgive bills for folks who can’t pay them. And our story was partly about how much less charity care hospitals give out than their own policies say they should. 

And a few days later, I got an email from a listener. 

Joey: I’m Joey Ballard, and I’m an internal medicine resident. 

Dan: Joey sent me a link: The American Medical Association — or AMA, the country’s largest group representing doctors, and for a long time one of the most powerful lobbying groups in the country– had just passed a resolution supporting legislation that would require hospitals to do more. 

Joey said he was the original author of that resolution. He had proposed it as a medical student. 

And he had gotten the idea from listening to… this podcast. We talked. Joey says he’s listened to every episode, since early in med school — and he sees it as a supplement to what that curriculum provides. 

Joey: I feel like you really have to seek out other sources to understand the system and sort of what I’m actually joining and what I’m facilitating as a physician… I mean, the podcast, like, really did that, and sort of helps peel back this other layer and sort of show more what it’s like for patients that I don’t always get to see from my perspective. 

Dan: This is, I am sure you can imagine, music to my ears. 

And now, he’s pushing for more changes, closer to home — at the institution where he’s doing his residency, the University of Illinois at Chicago. I wanted to bring you a little bit of his story to close out this year. 

This is An Arm and a Leg– a show about why health care costs so freaking much and what we can maybe do about. I’m Dan Weissmann. I’m a reporter and I like a challenge so the job we’ve chosen on this show is to take one of the

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.2 

most enraging, terrifying, and depressing parts of American life and bring you something entertaining, empowering, and useful. 

This is not the only time Joey has proposed a resolution to the AMA. And it’s not his only success. 

Joey: I’ve had four that have been adopted by the AMA, which is pretty, yeah, pretty exciting. And then I’ve had over 10 for Indiana, the Indiana State Medical Association. Um, so yeah, that kept me busy for sure. 

Dan: In Joey’s first year of med school at Indiana University, IU, he joined the med-student division of Physicians for a National Health Program — a membership organization that’s been advocating for single-payer health care for almost 40 years. The med-student version is Students for a National Health Program, SNaHP for short. 

Joey: I was pretty lucky. IU is actually the largest med school in the country. In terms of enrollment. And so we had a pretty strong Snap chapter, that had a lot of great events that really piqued my interest early on. 

Dan: Joey says SNaHP encouraged students to get involved with state medical societies, to help noodge the AMA towards supporting single-payer health care. Joey jumped in. 

Joey: And then like through that, I was like, oh, like, it’s not just single payer. I can sort of use this for any kind of thing in medicine I want to highlight or bring up 

Dan: In his first years of med school, Joey had proposed four resolutions that got adopted by the Indiana State Medical Association, including one supporting policies that would prevent some people from getting kicked off Medicaid. . By early 2023, he was ready to set his sights on the AMA itself. 

Joey: and that’s when I started like reaching out to other student contacts and figure out how does this work? How do I actually do this for the AMA in the first place? 

Dan: The answer turned out to be: Posting a suggestion on a dedicated online forum for student AMA members.

An Arm and a Leg Season 12, Episode 10 December 30, 2024 p.3 

Joey: I had posted several and the charity care one was the one that by far and away got the most feedback and people reaching out to me saying that they wanted to work on it and thought it was important. 

Dan: That was almost two years ago. Next came months of online collaboration with other students — Google docs and group chats — to draft and refine the resolution itself. 

Here are a few highlights from what they came up with: 

* Requiring nonprofit hospitals to check to see if any given patient qualifies for charity care BEFORE sending them a bill. 

* Close some loopholes in the federal law: Currently, the law only requires hospitals to HAVE a charity care policy, but it doesn’t set even a minimum standard for how generous that policy has to be. And there’s no mechanism to monitor or enforce even that requirement. 

The resolution says enforcement penalties should even include the loss of tax-exempt status — which is often worth many, many millions of dollars to nonprofit hospitals. 

They worked for months, and there were lots of steps still ahead. 

A big one was a vote by AMA’s student section — November 2023. Then — seven months later — the AMA itself asked a panel called the Council on Medical Service to consider the proposal and make a report. 

And the Council made a tweak: Instead of saying the AMA should “advocate for” policies like this, the Council’s version said the AMA should “support” them. 

Joey: …Which is an important distinction in that it’s not taking active measures to actively seek out these changes or reach out to lawmakers to draft these kinds of things. 

Dan: “Support” is more like, if someone else is pushing this, they can add us to the list of supporters. 

Then in November 2024, the AMA’s house of delegates considered the committee’s report.

Guess what? Not only did they back the resolution, they changed “support” back to “advocate for.” I asked the AMA what that meant they’d actually DO next. A spokesman told me he couldn’t disclose their legislative strategy, so fair enough. 

The meeting was in Florida this year, so Joey — in the middle of residency in Chicago — wasn’t able to be there. 

Joey: these meetings that are days long, you know, different places of the country. It’s especially as like residents that like, I don’t have the time to be able to do that. 

Dan: Joey says residency doesn’t leave him as much time as med school did, to work on AMA resolutions at all. But seeing the resolution pass? That was big. 

Joey: that inspired me to be like, okay, what can I do now? It was like, I feel like I need to take a look at what my institution is doing and what we can improve from that perspective. 

Dan: He’s started working on a proposal to get his hospital, the University of Illinois at Chicago, UIC to screen all patients for charity care before sending a bill, and to swear off practices like suing patients over bills they can’t pay, and seeking to garnish their wages. He says he’s been picking up support as he goes, starting with individual colleagues and other doctors… 

Joey: …and then the big one is our union. 

Dan: Residents at UIC are unionized. Joey says he brought up his pitch at a recent union meeting. His idea is a letter to the chief medical officer, with as many signatures as possible. The union said he could add them to the list. 

Joey says he hopes to have that letter ready in a few weeks. Then what? He’s not sure. 

Joey: There’s things we talked about during the union meeting that, you know, because UIC is a public institution, that there’s a lot more ways that it’s accountable and ways that we can find out things. Which I’m sure we’ll explore. But… optimistic for now. 

Dan: And he’ll keep at it.

Joey: I do find like extreme meaning in my day to day, um, as a physician, but I feel like this advocacy work is just something that’s even in some ways like deeper, and like means more to me. 

Dan: It means so much to me to know that doctors like Joey are making this their work. And it means a lot to me personally that people like Joey are finding the work we do here useful. 

In his initial note, Joey asked me where he might look for certain pieces of data. 

I sent him what I had, and forwarded his note to a couple people. One was Eli Rushbanks, who leads research and policy at Dollar For, the folks who have taught me the most about charity care. 

And the other was Luke Messac, the doctor and historian who wrote the book on some of these issues “Your Money or Your Life: Debt Collection and American Medicine.” You might’ve heard Luke on this show when his book came out in 2023. 

They both wrote back to Joey right away. Luke also wrote to thank me for introducing him to the folks at Dollar For. 

I hope we can keep on making connections for people fighting the good fights. There’s a lot of good fights to be had. 

If you’re catching this the day we release it or the next day– it’s the END of 2024. And our year-end fundraiser is still going. 

Gifts are still being matched. And in fact, we’ve got a new stretch goal. We’ve got backers who will match up to $30,000 in gifts. 

The place to go is arm and a leg show dot com, slash support That’s arm and a leg show, dot com, slash, support. Thank you. We’ll be back in January with more new episodes. 

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss.

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. 

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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This week, KFF Health News’ “What the Health?” presents a conversation with Francis Collins, former National Institutes of Health director and White House science adviser.

Collins, the longest-serving presidentially appointed head of the nation’s crown jewel of biomedical research, spoke last month with KFF Health News’ chief Washington correspondent, Julie Rovner. He has a new book out, called “The Road to Wisdom: On Truth, Science, Faith, and Trust.”

In this interview, Collins discusses what may lie ahead for NIH in the coming Trump administration; how he and other science leaders failed to communicate to the public during the covid-19 pandemic; and his work with the group Braver Angels, which aims to facilitate conversations among people who disagree on policy issues.

[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, happy new year, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent at KFF Health News. Usually I’m joined by some of the best and smartest health reporters in Washington, but today we have a special holiday episode for you. Last month, I got the chance to chat with Francis Collins, former director of the National Institutes of Health, about a variety of subjects. Regular podcast listeners will know we used some of the excerpts of that discussion a couple of weeks ago, but today we’re bringing you the entire interview. I hope you enjoy it, and we’ll be back with all the news starting next week. So, here we go. 

I am so pleased to welcome to the podcast Dr. Francis Collins, former director of the National Institutes of Health, and former White House science adviser and former director of the National Human Genome Institute, who led the effort to map the human genome. He also has a new book out this holiday season called “The Road to Wisdom: On Truth, Science, Faith, and Trust.” 

Dr. Collins, it’s so great to have you here. 

Francis Collins: Hey, Julie, it’s great to be with you. We go way back on a lot of interesting topics in health and medical research, and let’s get into it here. 

Rovner: I want to start with some very basics because we have lots of student listeners and people who know a lot about health policy but less about science. So what is the NIH, and how does it work? 

Collins: It is the largest supporter of biomedical research in the world. The National Institutes of Health, supported by the taxpayers with money that’s allocated every year by the Congress, is the main way in which, in the United States, we support basic medical research, trying to understand the details about how life works and how sometimes things go wrong and disease happens, and then carries those discoveries forward to what you might call the translational part, take those basic findings and try to see how could they actually improve human health in the clinic. And then working with industry, make sure if there’s an idea then for an intervention of some sort that it gets tested rigorously in clinical trials and, if it works, then it’s available to everybody. 

So when you look at what’s happened over the course of many decades in terms of advances in human health, like the fact that reductions in heart attacks and strokes have happened rather dramatically, the cancer death rates are falling every year, where does that come from? An awful lot of that is because of the NIH and the thousands and thousands of people who work on this area, supported by those dollars that come from NIH, both a little bit in our own location in Bethesda, Maryland, but most of the money goes out to all those universities and institutes across the country and some outside the country. 

Rovner: Yeah, I was going to say, I happen to live right up the street from the campus in Bethesda, but I know that that’s not where most of the money goes. It goes to the rest of the country. 

Collins: Right. Eighty-five percent of the dollars are given out to people who write grant applications with their best and brightest and boldest ideas, and they get sent and reviewed by peers who have scientific expertise to be able to assess what’s most likely to make real progress happen. And then, if you get the award, you have three to five years of funding to pursue that idea and see what you can learn. Unfortunately, even though the budget for NIH has been reasonably well treated, especially in the last, oh, eight or nine years, it’s still the case that most applications that come into NIH get rejected. Only about 20% of them can be actually paid for with the current budget we have. So, sad to say, a lot of good ideas are left on the table. 

Rovner: And yet, for more than three decades now, the NIH has been kind of a bipartisan darling with strong financial support from Democrats and Republicans in both the White House and in Congress. Now we have an administration coming in that’s calling for some big changes. Could NIH honestly use some reimagining? It’s been a while. 

Collins: Oh, sure. I mean, I was privileged to be the NIH director for 12 years. I did some reimagining myself in that space. One of the first things I did when I got started was to create a whole new part of NIH called NCATS, the National Center for Advancing Translational Science, because it seemed that some of these really exciting basic science discoveries just sort of landed with a thud instead of moving forward into clinical applications. NCATS has done a lot to try to change that. So yeah, there’s always been this sense of this is the crown jewel of the federal government, but it could even be better. So let’s try to work on that. 

I hope that’s what’s going to happen in this next iteration — find things to fix. If it’s more an idea of let’s just blow the whole thing up and start over, then I’m opposed, because I think the rest of the world just has this great admiration for NIH. Many of them would say this is the most amazing engine for medical discovery that the world has ever known. Let’s certainly optimize it if we need to. But my goodness, the track record is phenomenal. And the track record is both about advances in health and it’s also about economic growth, which people are rightly concerned about as well. Every dollar that NIH gives out in a grant returns $8.38 in that return on investment to the economy within a few years. So if you wanted to just say, “Well, let’s just try to grow the economy,” and didn’t even care about health, NIH would still be one of your best bets. 

Rovner: So one of the things that Robert F. Kennedy Jr., who’s [President-elect Donald] Trump’s pick to lead HHS [the Department of Health and Human Services], has talked about is taking a break from the federal government researching infectious diseases and concentrating on chronic diseases instead. Do you think that’s a good idea for the NIH? 

Collins: Well, NIH does a lot on chronic diseases. Let’s be clear about that. Infectious disease has certainly gotten a lot of attention because of covid and the controversies around that. Although, let me also step back and say what was done during covid, the development of a vaccine in 11 months that is estimated to have saved 3.2 million lives in the U.S. alone, is one of the most amazing scientific achievements ever and shouldn’t be somehow pushed aside as if that wasn’t a big deal. That was a huge deal. But infectious diseases are still out there, and with everything that we see now with things like H5N1, there’s a lot of work that needs to be done. 

Sure, chronic diseases deserve a lot of attention, but let’s look at what’s happening there with cancer, with Alzheimer’s disease, with diabetes, with heart disease. Those are huge current investments at NIH. Could we look at them closely and ask are they being absolutely optimally spent? That’s always an appropriate question to ask, but it’s not as if this has been sort of ignored. 

Look at the project that I had something to do with starting called All of Us, which is an effort to look at all kinds of illnesses in a million people, a very diverse group, and figure out how not to just do a better job of treating chronic disease but how to prevent it. That’s an incredibly powerful resource that’s now beginning to build a lot of momentum, and there’s a place where maybe even a little bit more attention to All of Us could be helpful, because we could go faster. 

Rovner: So it’s not just either/or? 

Collins: No, it shouldn’t be either/or. And, I mean, look around your own family and the people you care about. What are the diseases that still need answers? There’s plenty of them, and they’re not all in one category or another. This is what NIH has always been charged to do. Look across the entire landscape, rare diseases as well as common diseases, infectious diseases, as well as things that are maybe caused by environment or diet. All of that has to be the purview, otherwise we’re not really serving all the people. 

Rovner: So, you’re unique in many ways, but a big one is that you’ve managed to simultaneously be a person of faith and a person of science. So often those things are at odds. Why is that so difficult for so many people? You don’t seem to have a lot of trouble with it. 

Collins: I don’t, but there’s a long history here. Maybe it helps me that I did not grow up as a person of faith. I was an atheist when I was in graduate school studying quantum mechanics, and then I went to medical school and discovered that my answers to really important questions like What’s the meaning of life? were a bit thin. Atheism didn’t help me so much, and I really felt I had to do some work to explore that and, ultimately, over a couple of years of that work, came to the conclusion that for me, both in terms of the rational arguments and also the sort of spiritual calling, that I felt that I couldn’t be an atheist anymore, and I became a Christian. 

Everybody predicted around me that my head would explode because this was going to be incompatible with my scientific loves, one of which was genetics, but it never happened. I think we have a lot of preconceived ideas about what has to be the perspective of faith or the perspective of science. When you look more closely, there’s actually more room there to figure out how these two ways of finding truth, ways of knowing, can actually inform each other. And for me, being able to have all of the questions on the table, not just the science questions or not just the faith questions but all of them that you can think through on a given Thursday, feels like a good thing, and it’s incredibly enriching. But I am sorry that not everybody sees it that way. 

Anybody listening to this that wants to look at a good dialogue about this that’s going on quite vigorously, go to the website BioLogos, B-I-O-L-O-G-O-S. A couple million people there are engaged in deep and very civil discussions about how science and faith can speak to each other in useful ways. 

Rovner: Well, that’s kind of a perfect segue because one of the things you write about in your new book is how we’ve become a society that’s distrustful, not just of science but of all expertise. How can the scientific community start to rebuild that trust that we used to have? 

Collins: Well, let’s be clear, trust in everything has been deteriorating. Institutions across the board have lost trust by various surveys that Gallup does, and that’s part of, I think, a reflection of society kind of falling into this place of skepticism and even cynicism and a likelihood to assume that anything that sounds like expertise might also be elitist and might not be good for me. This is a dangerous place to be. Society has to have institutions that are reliable and dependable and kind of create a “constitution of knowledge” that Jonathan Rauch writes about. But right now, all of that seems a bit in jeopardy. And science is just one of those sources of truth that now some people are questioning. But can I trust what science has said about something? Well, we all have to, I think, learn our own skill set, again, about how to assess information and the sources of it and whether it should be trusted. And we should not be using where we currently live, in a particular bubble, as a means of deciding whether to accept a claim or not, because there’s a lot of stuff happening in bubbles that isn’t true. 

So part of it is our own need to come back to that kind of filtering. But for scientists, I think we are very much in the space now of having to be more in the world, in the arena, and willing to listen to objections and not get defensive and come back again with thoughtful, winsome explanations about how science works and how science is self-correcting. And even though sometimes science makes mistakes, they won’t be mistakes for very long, because somebody will come along and figure out that wasn’t right and it’ll get corrected. That should be very reassuring. But oftentimes today, that information is less well understood. Maybe part of what happened during covid is that much of the science information seemed to be coming down from elitist voices like me that weren’t as close to the community as people would’ve wanted to see and maybe would’ve had more trust in. So we’ve got to diversify the sources of science communication and not have it be so much focused in just a few places. 

Rovner: Do scientists need to be more humble, if you will? I mean, more honest about there’s a lot of things we don’t know, and we’re getting new information every day, and that might change what we say? I feel like there wasn’t maybe enough of that during covid. 

Collins: I totally agree, and I talk about that in the book. I wish those times when I was shoved in front of a camera during 2020 and ’21 and asked “OK, what should the public do today to protect themselves?” that I would’ve started the answer with: “Well, there’s a lot we don’t know yet, but let me tell you the best we can do with the information we have. But don’t be surprised if a week or a month from now that information changes. This is how science works, and we’re in the process of learning about this diabolical virus, and we don’t have all the data yet.” I wish we’d said that more often. Yeah, I think all sources, if you want to be regarded as reliable, you need to have integrity. You’ve got to be honest. You’ve got to have competence. You have to have done the work. And, I’m sorry, a lot of what’s on social media does not meet that standard. 

Rovner: No, I think— 

Collins: And then you’ve got to have — and humility. Like you said, humility. I think anybody who’s basically saying, “Well, I know something about this area, so now I know something about everything” — celebrities, listen up here — that is probably not the kind of source that you want to necessarily attach yourself to. But it happens a lot. So integrity, competence, humility, use those as your standards for deciding whether to trust a particular source or an institution. 

Rovner: I know you’re active in a group called Braver Angels, which you’ve described as marriage counseling for our country, which clearly we need. 

Collins: We do. 

Rovner: Can you tell us a little bit about that? 

Collins: So, they got started eight years ago with increasing sense of the polarization, the divisiveness, and, “Wait a minute. This isn’t what we want to be. How do we bring people back together?” And they create an environment where people on opposite sides of an issue — maybe it’s gun control or immigration or public health — have to actually get together and listen to each other, for starters. No, and you’re not allowed to start shouting. You have to listen carefully to what the opposite side says about their view on this well enough that you can speak it back to them and say, “Here’s what I heard you say,” and have them say, “Yeah, that’s what I said.” We don’t do that very well. 

Right now, in those circumstances, it’s more like: “OK, they just said this. Let me plan what I’m going to say back to prove them wrong.” And you have this snappy response back and forth, and nobody actually changes their view at all. Having done a lot of these sessions with Braver Angels, I’ve learned things that I didn’t know before about how people, for instance, who felt the covid response was ham-handed in their particular local environment. Yeah, I can kind of see how it was, and ideally it would’ve been better if we’d had a more appropriate response that depended on community circumstances instead of trying to do one size fits all. Of course, it was all a crisis and we didn’t have much chance to do that, but they’ve got a point. If you’re in the heartland somewhere, all of the things that were decided, much of which seemed to be particularly relevant to the big cities, didn’t seem like it was a great fit for them. 

That’s an example of a kind of thing. And I’ve become friends with a lot of the people who initially I thought, “Well, I could never get along with that person,” but now I understand who they are. And we still disagree, and I still think they’re wrong about things and they think I’m wrong about things, but we can have that disagreement and not be disagreeable, and we can actually go to the bar afterwards and have a beer. It’s OK. We need a lot more of that. 

Rovner: Yes, we do. Well, you had a very long and decorated career. Is there one more big thing you hope to accomplish before you actually retire? I know you’re still busy in your lab. 

Collins: Busy in my lab, and I am still working on a project that I started when I was the president’s science adviser, which is an effort not to create a new solution to a disease but to get it implemented. And that is the disease called hepatitis C. And I continue to be the lead for the White House in trying to get a program underway that would find, test, treat, and cure as many of the 4 million Americans who are currently infected with this viral disease. We have a cure for this disease. It’s amazing — one pill a day, 12 weeks, 95% effective, no side effects. And yet, because many of the people who are infected are not in the best place — they might be on Medicaid, they might be uninsured, they might be in the criminal justice system, because a lot of this relates to intravenous drug use — they don’t have access. And they’re all trying to get back on their feet and they’re not going to get back on their feet if we don’t do something about this, and then end up with a terrible outcome of cirrhosis, liver cancer, and early death. 

I watched my brother-in-law die of this, and it is a horrible disease, and it’s totally preventable now. So we have a program, which I am totally confident if we can get it launched, maybe even in the next few weeks, this could save thousands and thousands of lives — and also, by the way, billions of dollars for health care that won’t be needed for all those transplants and liver cancer treatments because we’ll prevent them. 

So I am a bit obsessed about this. Maybe you’re sorry you asked if I had one more thing. This is the one more thing that I am totally devoted to getting into the end zone. 

Rovner: No, that’s super cool, and also, what a great example of something that medical research has done to help health care in the United States. 

Collins: Absolutely. We just have to do the implementation part. How hard can it be? 

Rovner: A good place to leave it for now. Dr. Francis Collins, thank you so much for joining us. I hope we can call on you again. 

Collins: Please do, Julie. It’s always great to talk to you. Thanks for everything you’re doing to spread the word about what we can do about health care. We can do a lot. 

Rovner: I hope so. Thank you. 

OK. That’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks again this week to our temporary producer, Taylor Cook, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and increasingly at Bluesky, @julierovner.bsky.social. We’ll be back in your feed next week. Until then, be healthy. 

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