Now, another proposed twist in the rules could mean that, even though Missouri pays her to do that work, she might still have to prove to the state that she’s not unemployed.

The Kansas City, Missouri, resident has cared for her disabled son, Daniel, for all 31 years of his life. A rare genetic condition called Prader-Willi syndrome, in addition to autism, left him with an intellectual disability; a constant, excessive hunger; and an inability to speak. His needs left Gallagher, an elementary school teacher by training, with little opportunity to work outside her home.

As congressional Republicans slash in federal Medicaid spending, Gallagher is among the 18.5 million Americans who could be required to prove that they work enough to keep their health insurance.

A budget bill that passed the House and Senate would require 80 hours of work or community service a month for adults who are insured through the Affordable Care Act’s Medicaid expansion program, which has allowed states to extend Medicaid coverage to more adults with low incomes. Forty states, plus Washington, D.C., have expanded their programs, additions that now cover about 20 million Americans, including Gallagher.

She enrolled in the coverage in December 2023, after she could no longer afford her private insurance. Before her husband died of cancer in 2019, the couple paid for private insurance and supported themselves on the income he earned as a master watchmaker. After his death, Gallagher was left to earn a living and find insurance on her own. At 59, she’s too young to collect her husband’s Social Security survivor benefit.

The Medicaid program that pays for in-home care for Daniel and 8,000 other Missourians with disabilities allows family members to be compensated for caregiving, but only if they’re not the legal guardian of the person they care for. So, Gallagher went to court to give up her rights to make decisions for her son and transfer authority to her parents.

“I think it’s appalling that it’s required, but it was necessary,” she said. “There was no way I could work outside of taking care of Daniel.”

Republicans have touted Medicaid work requirements both as a way to reduce federal spending on the program and as a moral imperative for Americans.

“Go out there. Do entry-level jobs. Get into the workforce. Prove that you matter. Get agency into your own life,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said in a recent interview on Fox Business.

Democrats, meanwhile, have red tape that won’t meaningfully increase employment but will cause eligible people to lose their health insurance because of administrative hurdles.

Indeed, the of Americans enrolled in Medicaid expansion are already working, caregiving, attending school, or have a disability, according to an analysis by 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News.

And while the Congressional Budget Office estimates the work requirement included in the House bill would cause to lose their insurance, only of those people are unemployed because of lack of interest in working, according to the Urban Institute, a nonprofit research group. Recent history in states that have tried work requirements suggests technical and paperwork problems have caused a substantial portion of coverage losses.

Still, the provisions are generally popular among Republican lawmakers and the public. Sen. Josh Hawley (R-Mo.), who has cutting people off from Medicaid, has signaled support for adding work requirements.

And 68% of Americans favor the requirement described in the House bill, according to a conducted by 麻豆女优. But support for work requirements dropped as low as 35% when respondents learned that most Medicaid recipients already work and could lose their coverage because of paperwork requirements.

That’s what happened in Arkansas, where 18,000 people in 2018 after the state phased in a work requirement. Thousands more were on pace to lose coverage in 2019 before a , largely over concerns about coverage losses. In discussions with focus groups, 麻豆女优 found that many Arkansas Medicaid participants did not fully understand the requirements, despite the state’s outreach efforts, and some people didn’t receive mailed notices. Others were confused because the work-reporting paperwork and separate forms to renew Medicaid coverage asked for similar information.

Many family caregivers would be exempt from the work requirements proposed in Congress, but Gallagher probably would not, since she had to relinquish guardianship of her son to be paid for the work. While the hours she already logs should be enough to satisfy the requirement, she’ll need to report them again 鈥� unless the state can identify her through its existing data. But Missouri has a history of procedural problems in the state agency that administers Medicaid.

In early 2022, for example, Missouri was taking more than 100 days on average to process applications for Medicaid expansion, a wait that prompted patients to put off needed care and was more than twice the processing time allowed by federal law.

And 79% of the more than 378,000 Missourians who lost Medicaid coverage when covid-era enrollment protections ended in 2023 did so because .

The next year, a federal judge ruled that Missourians were by the state, in part because insufficient staffing at call centers left eligible people without assistance.

“They’re historically understaffed,” Timothy McBride, a health economist at Washington University in St. Louis, said of the state agency that administers Medicaid and food assistance. “I think that’s really the underlying problem.”

McBride’s analysis of Missouri’s Medicaid recipients found that of the people enrolled in expansion in 2023 were unemployed for reasons other than caregiving, disability, attending school, or retirement. But many Missourians could lose their insurance if work requirements prompt disenrollment rates similar to Arkansas’ implementation, according to a study from the Center on Budget and Policy Priorities, a left-leaning think tank that analyzes government policies.

The estimate assumes many otherwise eligible people would still lose coverage as a result of falling through the cracks, McBride said.

Hawley, who backed the Senate bill, declined to comment for this article. The senator previously that “we can sort that out” when asked about eligible people inadvertently losing Medicaid because of work requirements.

Gallagher worries about her coverage, because she recently was diagnosed with Hashimoto’s disease, an autoimmune disorder that attacks the thyroid gland. She said she had to search for her Medicaid card to fill the prescription that followed, having barely used it in the year in a half she’s been covered.

She also worries about her son’s Medicaid. A nursing home is not a realistic option, considering his needs. His coverage doubles as Gallagher’s only source of income and also pays for other caregivers, when she can find them, who give her breaks to tend to her own health and to her aging parents.

But nearly all like those Daniel receives are optional programs that states are not required to include in their Medicaid programs. And the magnitude of the cuts being proposed have prompted fears that the optional programs could be chopped.

“It would destroy our lives,” Gallagher said. “The only income we would have would be Daniel’s Social Security.”

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President Donald Trump’s domestic policy legislation, the One Big Beautiful Bill Act that cleared the House in May and now moves to the Senate, could also be called Obamacare Repeal Lite, its critics say. In addition to causing millions of Americans to lose their coverage under Medicaid, the health program for low-income and disabled people, the measure includes the most substantial rollback of the ACA since Trump’s Republican allies that would have largely repealed President Barack Obama’s signature domestic accomplishment.

One difference today is that Republicans aren’t describing their legislation as a repeal of the ACA, after the 2017 effort cost them control of the House the following year. Instead, they say the bill would merely reduce “waste, fraud, and abuse” in Medicaid and other government health programs.

“In a way, this is their ACA repeal wish list without advertising it as Obamacare repeal,” said , an associate professor of political science at Marquette University in Milwaukee and co-author of the book “Obamacare Wars: Federalism, State Politics, and the Affordable Care Act.”

The GOP, Rocco said, learned eight years ago that the “headline of Obamacare repeal is really bad politics.”

Democrats have tried to frame Trump’s One Big Beautiful Bill Act as an assault on Americans’ health care, just as they did with the 2017 legislation.

“They are essentially repealing parts of the Affordable Care Act,” Rep. Frank Pallone Jr. (D-N.J.) said as the House debated the measure in May. “This bill will destroy the health care system of this country.”

of adults have a favorable view of the ACA, according to polling by 麻豆女优, a national health information nonprofit that includes 麻豆女优 Health News.

In contrast, about half of people polled also say there are major problems with waste, fraud, and abuse in government health programs, including Medicaid,

“We are not cutting Medicaid,” House Speaker Mike Johnson said May 25 on CNN’s “State of the Union,” describing the bill’s changes as affecting only immigrants living in the U.S. without authorization and “able-bodied workers” whom he claimed are on Medicaid but don’t work.

The program is “intended for the most vulnerable populations of Americans, which is pregnant women and young single mothers, the disabled, the elderly,” he said. “They are protected in what we’re doing because we’re preserving the resources for those who need it most.”

The 2025 legislation wouldn’t cut as deeply into health programs as the failed 2017 bill, which would have led to about 32 million Americans losing insurance coverage, the Congressional Budget Office estimated at the time. By contrast, the One Big Beautiful Bill Act, with provisions that affect Medicaid and ACA enrollees, would leave 11 million more people without health insurance by 2034, according to the , released June 4.

That number rises to about 16 million when including the Trump administration’s proposed tightening of ACA marketplace eligibility and if Congress doesn’t extend premium subsidies for Obamacare plans that were enhanced during the pandemic to help more people buy insurance on government marketplaces, the CBO says. Without congressional action, the more generous subsidies will expire at the end of the year and rise sharply.

The increased financial assistance led to a record 24 million people enrolled in ACA marketplace plans this year, and health insurance experts predict a large reduction without the enhanced subsidies.

Loss of those enhanced subsidies, coupled with other changes set in the House bill, will mean “the ACA will still be there, but it will be devastating for the program,” said , founding director of the Center for Health Policy and the Law at Georgetown University. 听听

Republicans argue that ACA subsidies are a separate issue from the One Big Beautiful Bill Act and accuse Democrats of conflating them.

The House-passed bill also makes a of ACA changes, including shortening by a month the annual open enrollment period and eliminating policies from Joe Biden’s presidency that allowed many low-income people to sign up year-round.

New paperwork hurdles the House bill creates are also expected to result in people dropping or losing ACA coverage, according to the CBO.

For example, the bill would end most automatic reenrollment, which was used by this year. Instead, most ACA enrollees would need to provide updated information, including on income and immigration status, to the federal and state ACA marketplaces every year, starting in August, well before open enrollment.

Studies show that additional administrative hurdles lead to people dropping coverage, said , a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“Not only do people drop out of the process, but it tends to be healthier, younger, lower-income folks who drop out,” she said. “That’s dumb because they go uninsured. Also, it is bad for the insurance market.”

Supporters of the provision say it’s necessary to combat fraudulent enrollment by ensuring that ACA beneficiaries still want coverage every year or that they are not being enrolled without their permission by rogue sales agents. Most of the Medicaid coverage reductions in the bill, , are due to new work requirements and directives for the 21 million adults added to the program since 2014 under an expansion authorized by the ACA.

One new requirement is that those beneficiaries prove their eligibility every six months, instead of once a year, the norm in most states.

That would add costs for states and probably lead to people who are still eligible falling off Medicaid, said Oregon Medicaid Director Emma Sandoe. Oregon has one of the most liberal continuous eligibility policies, allowing anyone age 6 or older to stay on for up to two years without reapplying.

Such policies help ensure people don’t fall off for paperwork reasons and reduce administrative burden for the state, Sandoe said. Requiring more frequent eligibility checks would “limit the ability of folks to get care and receive health services, and that is our primary goal,” Sandoe said.

The 2017 repeal effort was aimed at fulfilling Trump’s promises from his first presidential campaign. That’s not the case now. The health policy provisions of the House bill instead would help to offset the cost of extending about $4 trillion in tax cuts that skew toward wealthier Americans.

The Medicaid changes in the bill would reduce federal spending on the program by about $700 billion over 10 years. CBO has not yet issued an estimate of how much the ACA provisions would save.

a health economist at Washington University in St. Louis, said Republican efforts to make it harder for what they term “able-bodied” adults to get Medicaid is code for scaling back Obamacare.

The ACA’s Medicaid expansion has been adopted by 40 states and Washington, D.C. The House bill’s work requirement and added eligibility checks are intended to drive off Medicaid enrollees who Republicans believe never should have been on the program, McBride said. Congress approved the ACA in 2010 with no Republican votes.

Most adult Medicaid enrollees under 65 are already working, studies show. Imposing requirements that people prove they’re working, or that they’re exempt from having to work, to stay on Medicaid will lead to some people losing coverage simply because they don’t fill out paperwork, researchers say.

Manatt Health estimates that about 30% of people added to Medicaid through the ACA expansion would lose coverage, or about 7 million people, said Jocelyn Guyer, senior managing director of the consulting firm.

The bill also would make it harder for people enrolled under Medicaid expansions to get care, because it requires states to charge for some specialist services for those with incomes above which is $15,650 for an individual in 2025.

Today, copayments are rare in Medicaid, and when states charge them, they’re typically nominal, usually under $10. Studies show cost sharing in Medicaid among beneficiaries.

, a senior fellow with the conservative Manhattan Institute, acknowledged that some people will lose coverage but rejected the notion that the GOP bill amounts to a full-on assault on the ACA.

He questioned the coverage reductions forecast by the CBO, saying the agency often struggles to accurately predict how states will react to changes in law. He said that some states may make it easy for enrollees to satisfy new work requirements, reducing coverage losses.

By comparison, Pope said, the ACA repeal effort from Trump’s first term a decade ago would have ended the entire Medicaid expansion. “This bill does nothing to stop the top features of Obamacare,” Pope said.

But McBride said that while the number of people losing health insurance under the GOP bill is predicted to be less than the 2017 estimates, it would still eliminate about half the ACA’s coverage gains, which brought the U.S. uninsured rate to historical lows. “It would take us backwards,” he said.

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

Julie Rovner: The Washington Post’s “,” by William Wan and Hannah Natanson.

Alice Miranda Ollstein: NPR’s “,” by Chiara Eisner.

Anna Edney: Bloomberg News’ “,” by Anna Edney.

Sarah Karlin-Smith: The Farmingdale Observer’s “” by Bob Rubila.

Also mentioned in this week’s podcast:

• The New York Times’ “,” by Sarah Kliff and Margot Sanger-Katz.
• NBC News’ “,” by Minyvonne Burke.
• The Washington Post’s “,” by Jacob Bogage and Abha Bhattarai.
• The New England Journal of Medicine’s “,” by Vinay Prasad and Martin A. Makary.

[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.]听

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, May 23, at 10 a.m. As always, and particularly this week, news happens fast and things might have changed by the time you hear this. So, here we go.听

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

Alice Miranda Ollstein: Hello.听

Rovner: Anna Edney of Bloomberg News.听

Anna Edney: Hi, everybody.听

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

Sarah Karlin-Smith: Hello there.听

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

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

Ollstein: Yeah, this is not going to come out the way it went in. Senate is already openly talking about a “鈥極ne, Big Beautiful’ Rewrite” 鈥� that was .听

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

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

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

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

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

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

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

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

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

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

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

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

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

Edney: Right, right.听

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

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

All right, well, our podcast pals Margot Sanger-Katz and Sarah Kliff have out this week on a new study that looks very broadly at Medicaid and finds that it actually does improve the health of its beneficiaries. Now this seems logical, but that has been quite a talking point for Republicans for many years, that we spend all this money and it doesn’t produce better health, because we’ve had a lot of studies that have been kind of neither here nor there on this.听

Do we finally have proof that Democrats need? Because I have heard, over many years 鈥� there was a big Oregon study in 2011 that found that it helped people financially and that it helped their mental health, but there was not a lot of physical health benefit that they saw. Of course, it was a brief. It was like two years. And it takes a longer time to figure out the importance of health insurance. But I’m wondering if maybe the Democrats will finally be able to put down that talking point. I didn’t hear it, actually, as much this week as I have in years past: Why are we spending all this money on Medicaid when we don’t know whether it’s producing better health?听

Karlin-Smith: One of the interesting things I thought about this study and sort of the timing of it, post-Obamacare expansion of Medicaid and more younger people being covered, is that it seems to really show that, not only does this study show it saves lives, but it’s really helping these younger populations.听

And I think there are some theories as to why it might have been harder to show the economic cost-effectiveness benefits people were looking for before, when you had Medicaid covering populations that were already either severely ill or older. Which doesn’t mean it’s not valuable, right? To provide health coverage to somebody who’s 75 or 80, but unfortunately we have not found the everlasting secret to life yet.听

So, but I think for economists who want to be able to show this sort of, as they show in this paper, this “quality-adjusted life year” benefit, this provides some really good evidence of what that expansion of Medicaid 鈥� which is a lot of what’s being rolled back, potentially, under the reconciliation process 鈥� did, which is, helps younger people be healthier and thus, right, hopefully, ideally, live a higher quality of life, and where you need less health coverage over time, and cost the government less.听

It’s quite interesting, for people who want to go look at the graph The New York Times put in their story, of just where Medicaid fits, in terms of other sort of interventions we spend a lot of money on to help save lives. Because I was kind of surprised, given how much health insurance does cover, that it comes out on sort of the lower end, as being a pretty good bargain.听

Rovner: Yeah. Well, we don’t have time to get into everything that’s in this bill, and there is a lot. It also includes a full ban of Medicaid coverage for gender-affirming care for both minors and adults. And it cuts reimbursement to states that use their own funds to provide coverage to undocumented people. Is this a twofer for Republicans, saving money while fighting the culture wars?听

Edney: Certainly. And I was surprised to see some very liberal states on the immigration front saying: We just have to deal with this. And this really sucks, but we have to balance our budget. And if we’re not going to get those tax dollars, then we aren’t going to be able to offer health insurance to people who are undocumented, or Medicaid to people who are undocumented.听

Rovner: Yeah, California, most notably.听

Edney: Yeah, California for sure. And they found a way to do it, hit them in the pocketbook, and that that’s a way for them to win the culture war, for sure.听

Rovner: Alice, you’ve spent a lot of time looking at gender-affirming care. Were you surprised to see it banned for adults, too? Obviously the gender-affirming care for minors has been a continuing issue for a while.听

Ollstein: Yeah, I would say not surprised, because this is sort of a common pattern that we see across different things, including in the abortion space, where first policies are targeted just at minors. That often is more politically palatable. And then it gets expanded to the general population. And so I think, given the wave of state bans on care for minors that we’ve seen, I think a lot of people had been projecting that this was the trajectory.听

I think that there’s been some really good reporting from The 19th and other outlets about what an impact this would have. Trans people are disproportionately low-income and dependent on Medicaid, and so this would have really sweeping impacts on a lot of people.听

Rovner: Well, turning to the Affordable Care Act, if you thought Republicans weren’t going to try to repeal the health law this time around, you thought wrong. There are a bucket of provisions in this bill that will make the Affordable Care Act coverage both more expensive and harder to get, so much that some analysts think it could reduce enrollment by as much as half of the 24 million people who have it now. Hasn’t someone told Republicans that many of these people are their voters?听

Edney: Yeah, that’s a good question. I don’t know what the Republican strategists are telling them. But certainly they needed to save money. And so they found their loopholes and their different things that they thought they could scrape from. And maybe no one will notice? But I don’t think that’s going to happen.听

A lot of people suddenly have much higher ACA premiums because of the way they’re going to take away this ability that the insurers have had to silver-load, essentially, the way that they deal with the premium tax credits by setting some of the savings, kind of the cost sharing that they need to do, right into the silver plan, because the silver plan is where the premiums are set off of. And so they were able to offer the plans with lower premiums, essentially, but still get paid for cost-sharing reductions. So they were able to still get that money taken away from them.听

Rovner: So let me see if I can do it. It was, and this was something that Trump tried to do in 2017, that he thought was going to hurt the marketplace plans. And it ended up doing the opposite鈥斕�

Edney: Right.听

Rovner: 鈥攂ecause it basically shifted money from the insurance companies and the beneficiaries back to the federal government, because it made the premium subsidies bigger.听

So I think the point I want to make is that we’ve been talking all year about these extra subsidies that are going to expire, and that will make premiums go up, and the Republicans did not move to extend those subsidies. But this going back to the government paying these cost-sharing reduction payments is going to basically reverse the accidental lowering of premiums that Trump did in 2017. And therefore, raise them again.听

So now we have a double whammy. We have premiums going up because the extra subsidies expire, and then we’ll have premiums going up even more because they’re going back to this original cost-sharing reduction. And yet, as we have said many times, a lot of these additional people who are now on the Affordable Care Act are people in the very red states that didn’t expand Medicaid. These are Republican voters.听

Karlin-Smith: We haven’t talked a lot about the process of how they got this bill through this week. It was incredibly fast and done literally in the dead of night.听

Ollstein: Multiple nights.听

Karlin-Smith: So you have to wonder, particularly, if you think back to the last time Republicans tried to overturn Obamacare 鈥� and they did come pretty close 鈥� eventually, I think, that unpalatableness of taking away health care from so many of their own constituents came back to really hurt them. And you do have to wonder if the jamming was in part to make more people unaware of what was happening. You’d still think there’d be political repercussions later down the line when they realize it. But I think, especially, again, just thinking back on all the years when Republicans were saying Democrats were pushing the ACA through too fast and nobody could read the bill, or their CBO scores. This was a much, much faster version of that, with a lot less debate and public transparency and so forth.听

Rovner: Yeah, they went to the Rules Committee at 1 a.m. Wednesday, so Tuesday night. The Rules Committee went until almost 9 o’clock the next evening, just consecutively. And shout out to Rules Committee chairman Virginia Foxx, who sat there for, I think, the entire time. And then they went straight from rules to the floor.听

So it’s now Wednesday night at 10 o’clock at night, and then went all the way through and voted, I think, just before 7 a.m. I’ve done a lot of all-nighters in the Capitol. I haven’t seen one that was two nights in a row like this. And I have great admiration for the people who really were up for 48 hours to push this thing through.听

Well, finally, let’s remember President Trump’s vow not to touch Medicare. Well, in this bill, too. In addition to restricting eligibility for some legal immigrants who are able to get coverage now, and making it harder for some low-income Medicare beneficiaries to get extra financial help, mostly through Medicaid, the bill as a whole is also likely to trigger a 4% Medicare sequester. Because, even all those other health cuts and food stamp cuts and other cuts don’t pay for all the huge tax breaks in the bill. Alice, you pointed that out. Is there any suggestion that this part might give people some pause, maybe when it gets to the Senate?听

Edney: I’ve heard the Senate mostly seem upset about Medicaid. And I also feel like this idea that sequestration is coming back up into our consciousness is a little bit new. Like you said, it was pushed through and it was like, Oh, wait, this is enough to trigger sequestration. I think it certainly could become a talking point, because Trump said he would not cut Medicare. I don’t think, if senators are worried about Medicaid 鈥� and I think maybe some of us were a little surprised that that is coming from some red-state senators. Medicare is a whole different thing, and in the sense of being even more wildly popular with a lot of members of Congress.听

Rovner: Yeah, I think this whole thing hasn’t, you’re right, sort of seeped into the general consciousness yet. Alice, did you want to say something?听

Ollstein: Yeah, so a couple things, a couple patterns we’ve seen. So one, there are a lot of lawmakers on the right who have been discrediting the CBO, even in advance of estimates coming out, basically disparaging their methodology and trying to convince the public that it’s not accurate. And so I think that’s both around the deficit projections as well as how many people would be uninsured under different policies. So that’s been one reaction to this.听

We’ve seen a pattern over many administrations where certain politicians are very concerned about things adding to the deficit when the opposition party is in power. And suddenly those concerns evaporate when their own party is in power and they don’t mind running up the deficit if it’s to advance policies that they want to advance. And so I think, yes, this could bother some fiscal hawks, and we saw that in the House, but I think, also, these other factors are at play.听

Rovner: Yeah, I think this has a long way to go. There’s still a lot that people, I think you’re right, have not quite realized is in there. And we will get to more of it in coming weeks, because this has a long process in the Senate.听

All right, well, segueing to abortion, the One Big Beautiful Bill also includes a couple of pretty significant abortion provisions. One would effectively ban abortion and marketplace plans for people with lower incomes. Affordable Care Act plans are not currently a big source of insurance coverage for abortion. Many states already ban abortion from coverage in these plans. But this would disrupt one of the big compromises that ultimately got the ACA passed in 2010.听

The other provision would evict Planned Parenthood from the Medicaid program, even though federal Medicaid funds don’t and never have been used for abortions. Many, many Medicaid patients use Planned Parenthood for routine medical care, including contraception and cancer screenings, and that is covered by Medicaid.听

But while I see lots of anti-abortion groups taking victory laps over this, when the House passed a similar provision in 2017 as part of its repeal bill, the Senate parliamentarian ruled that it could not go in a budget reconciliation bill, because its purpose was not, quote, “primarily budgetary.” So is this all for show? Or is there a belief that something different might happen this time?听

Ollstein: Well, I think there is more interest in ignoring or overruling the parliamentarian among Senate Republicans than there has been in the past. We’re seeing that now on an unrelated environmental issue. And so that could signal that they’re willing to do it more in the future. Of course, things like that cut both ways, and that raises the idea that the Democrats could also do that the next time they’re in power.听

Rovner: And we should say, that if you overrule the parliamentarian in reconciliation 鈥� it’s a she right now 鈥� when she says it can’t go in reconciliation, that is equivalent to getting rid of the filibuster.听

Ollstein: Correct.听

Rovner: So I mean, that’s why both parties say, We want to keep the filibuster. But the moment you say, Hey, parliamentarian, we disagree with you and we’re just going to ignore that, that has ramifications way beyond budget reconciliation legislation.听

Ollstein: That’s right. And so that’s been a line that a lot of senators have not been willing to cross, but I think you’re seeing more willingness than before. So that’s definitely something to watch on that. But I think, in terms of abortion, I think this is a real expansion of trends that were already underway, in ever-expanding the concept of what federal dollars going to abortion means. And it’s now in this very indirect way, where it’s reaching into the private insurance market, and it’s using federal funding as a cudgel to prevent groups like Planned Parenthood, and then also these private plans, from using other non-federal money to support abortions. And so it’s a real expansion beyond just you can’t use federal money to pay directly for abortions.听

Rovner: Well, meanwhile, two other reproductive-associated health stories worth mentioning. In California, a fertility clinic got bombed. The bomber apparently died in the explosion, but this is the first time I can remember a purposeful bombing to a health center that was not an abortion clinic. How significant is it to the debate, that we’re now seeing fertility clinics bombed as well? And what do we know, if anything, about why the bomber went after a fertility clinic?听

Karlin-Smith: There has been, obviously, some pressure on the right, I think, to go after fertility processes, and IVF [in vitro fertilization], and lump that in with abortion. Although, I think Trump and others have pushed back a bit on that, realizing how common and popular some of these fertility treatments are. And also it conflicts, I think, to some extent with their desire to grow the American population.听

The motives of this particular person don’t seem aligned with, I guess, the anti-abortion movement. He sort of seems more anti-natalist movement and stuff. So from that perspective, I didn’t see it as being aligned with kind of a bigger, more common political debate we’ve had recently, which is, again, does the Republican Party want to expand the anti-abortion debate even further into fertility treatments and stuff.听

Rovner: I was going to say, it certainly has drawn fertility clinics into the abortion debate, even if neither side in the abortion debate would presumably have an interest in blowing up a fertility clinic. But it is now sort of, I guess, in the general consciousness of antisocial people, if you will, that’s out there.听

The other story in the news this week is about , a nurse and mother from Georgia who was nine weeks pregnant in February when she was declared brain-dead after a medical emergency. Smith has been kept alive on life support ever since, not because her family wants that but because her medical team at Emory University Hospital is worried about running afoul of Georgia’s abortion ban, which prohibits terminations after cardiac activity can be detected. Even if the mother is clinically dead? I feel like this case could have really ominous repercussions at some point.听

Ollstein: Well, I just want to point out that, yes, the state’s abortion ban is playing a role here, but this was happening while Roe v. Wade was still in place. There were cases like this. Some of it has to do with legislation around advanced directives and pregnancy. So I will point out that this is not solely a post-Dobbs phenomenon.听

Rovner: Yeah, I think it also bears watching. Well, there was lots of vaccine news this week 鈥� I’m so glad we have Anna and Sarah here 鈥� with both the HHS [Department of Health and Human Services] and FDA [Food and Drug Administration] declaring an end to recommending covid vaccines for what seems to be most of the population. Sarah, what did they do? And what does this mean?听

Karlin-Smith: So the new director of FDA’s biologics center and the FDA commissioner released a framework for approving covid shots moving forward. And basically they are saying that, because covid, the virus, shifts, and we want to try and update our vaccines at least yearly, usually, to keep up with the changing viruses, but we want to do that in a reasonable time so that by the time when you update the vaccine it’s actually available within that time 鈥� right? 鈥� FDA has allowed companies to do studies that don’t require full clinical trials anymore, because we sort of have already done those trials. We know these vaccines are safe and effective. We’re making minor tweaks to them, and they do immunogenicity studies, which are studies that basically show they mount the proper immune response. And then they approve them.听

FDA is now, seems to be, saying, We’re only going to allow those studies to approve new covid vaccine updates for people who are over 65, or under 65 and have health conditions, because they are saying, in their mind, the risk-benefit balance of offering these shots doesn’t necessarily pan out favorably for younger, healthier populations, and we should do clinical trials.听

It’s not entirely clear yet, despite them rolling out a framework, how this will actually play out. Can they relabel shots already approved? Will this only impact once companies do need to do a strain change next as the virus adapts? Did they go about doing this in a sort of legal manner? It came out through a journal kind of , not through the Federal Register or formal guidance. There’s been no notice of comment.听

So there’s a lot of questions to remain as to how this will be implemented, which products it would affect, and when. But there is a lot of concern that there may be reduced access to the products moving forward.听

Rovner: That’s because the vaccine makers aren’t going to 鈥� it’s not probably worth it financially to them 鈥� to remount all these studies. Right?听

Karlin-Smith: First off, a lot of people I’ve talked to, and this came up yesterday at a meeting FDA had, don’t believe it’s actually ethical to do some of the studies FDA is now calling for. Even though the benefits, particularly when you’re talking about boosting people who already had a primary vaccination series for covid, or some covid, is not the same as the benefits of getting an original covid vaccine series.听

There still are benefits, and there still are benefits for pretty much everybody that outweigh the risks. On average, these are extremely safe shots. We know a lot about their safety, and the balance is positive. So people are saying, once that exists, you cannot ethically test it on placebo. Even as [FDA Commissioner Marty] Makary says, Well, so many Americans are declining to take the shot, so let’s test it and see. A lot of ethicists would say it’s actually, even if people are willing to do something that may not be ideal for their health, that doesn’t mean it’s ethical to test it in a trial.听

So, I think there’s questions about, just, ethics, but also, right, whether companies would want to invest the time and money it would take to achieve and try to do them under this situation. So that is a big elephant in the room here. And I think some people feel like this is just sort of a push by Makary and his new CBER [Center for Biologics Evaluation and Research] director, essentially, to cut off vaccine access in a little bit of a sneaky way.听

Rovner: Well, I did see, also this week, was I think it was Moderna, that was going to make a combination flu covid vaccine, has decided not to. I assume that’s related to all of this?听

Karlin-Smith: Right. So Moderna had a, what people call a next-generation vaccine, which is supposed to be an improved update over the original shot, which is a bigger deal than just making a strain change. They actually think they provide a better response to protecting against the virus. And then they also added flu vaccine into it to sort of make it easier for people to get protected from both, and also provided solid data to show it would work well for flu.听

And they seem to have probably pulled their application at this point over, again, these new concerns, and what we know Novavax went through in trying to get their covid vaccine across the finish line dealing with this new administration. So I think people have their sort of alert lights up going forward as to how this administration is going to handle vaccine approvals and what that will mean for access going forward.听

Rovner: Well, in somewhat related news, we got the long-awaited report from Health and Human Services Secretary Robert F. Kennedy Jr.’s Make America Healthy Again Commission, which is supposed to lay out a blueprint for an action plan that will come later this summer. Not much in the 68-page report seems all that surprising. Some is fairly noncontroversial, calling for more study of ultra-processed foods and less screen time and more physical activity for kids.听

And some is controversial but at this point kind of predictable, calling for another look at the childhood vaccine schedule, including, as we just discussed, more placebo studies for vaccines, and also less fluoride available, except in toothpaste. Anything jump out at you guys from the report that we should keep an eye on?听

Karlin-Smith: I think one thing to think about is what it doesn’t address and doesn’t talk about. It’s not surprising the issues they call out for harming health in America, and some of them are debatable as to how much they do or don’t harm health, or whether their solutions would actually address those problems.听

But they never talk about the U.S.’ lack of a health insurance system that assures people have coverage. They don’t mention the Republican Party’s and likely president’s willingness to sign onto a major bill that’s going to impact health. They don’t really talk about the socioeconomic drivers that impact health, which I find particularly interesting when they talk about food, because, obviously, the U.S. has a lot of healthy and unhealthy food available. And a lot of people know sort of how they could make better choices, but there are these situational factors outside of, often, an individual’s control to lead to that.听

And I think the other thing that jumped out to me is, I think had a good line in their paragraph about just how many of the points are either overstated or misstated scientific findings. And they did a pretty good job of going through some of those. And it’s a difficult situation, I think, for the public to grapple with when you have leadership and the top echelons of our health department that is pushing so much misinformation, often very carefully, and having to weed out what is correct, where is the grains of truth, where does it go off into misinformation.听

I don’t know. I find it really hard as a journalist. And so I do worry about, again, how this all plays into public perception and misunderstanding of these topics.听

Rovner: And apparently they forgot about gun violence in all of this, which is rather notably not there.听

Ollstein: Cars and guns are the big killers. And yeah, no mention of that.听

Edney: I thought another glaring omission was tobacco. Kids are using e-cigarettes at high rates. We don’t really know much about them. And to Sarah’s point about misinformation, too, I think the hard part of being able to discern a lot of this, even as a member of the public, is everything they’ve done so far is only rhetoric. There hasn’t been actual regulation, or 鈥� this could be anything that you’re talking about. It could be food dyes. It could be “most favored nations.” We don’t know what they actually want to implement and what the potential for doing so 鈥� I think maybe on vaccines we’re seeing the most action. But as Sarah mentioned, we don’t know how that, whether it legally is going to be something that they can continue doing.听

So even with this report, it was highly anticipated, but I don’t think we got anything beyond what I probably heard Kennedy say over and over throughout the campaign and in his bid for health secretary. So I am wondering when they actually decide to move into the policymaking part of it, instead of just telling us they’re going to do something.听

Rovner: And interestingly, Secretary Kennedy was last night and walked back some of the timelines, even, including that vow that they were going to know the cause of autism by September and that they were going to have an action plan for this ready in another, I think, a hundred days. So this is going to be a hurry-up-and-wait.听

All right, well, that is as much news as we have time for in this incredibly busy week. Now we will play my interview with law professor and abortion historian Mary Ziegler, and then we will come back and do our extra credits.听

I am pleased to welcome back to the podcast Mary Ziegler, the Martin Luther King Jr. professor of law at the University of California-Davis. She’s also a historian of the abortion movement. And her newest book, just out, is called “Personhood: The New Civil War Over Reproduction.”听

Mary Ziegler, thanks for joining us again.听

Mary Ziegler: Thanks for having me.听

Rovner: So we’ve talked about personhood a lot on our podcast, including with you, but it means different things to different people. What’s your working definition, at least for the purpose of this book?听

Ziegler: Yeah, I’m interested in this book in the legal fight for personhood, right? Some people have religious ideas of personhood. Bioethicists have ideas of personhood. Philosophers debate personhood. But I’m really interested in the legal claim that the word “person” in the 14th Amendment, which gives us liberty and equality, applies the moment an egg is fertilized. Because it’s that legal claim that’s had a lot of knock-on effects with abortion, with IVF, and potentially even beyond.听

Rovner: So if we as a society were to accept that fetuses or embryos or zygotes were people with full constitutional rights at the moment of creation, that can impact things way beyond abortion, right?听

Ziegler: Definitely, yeah, especially if you make the moves that the anti-abortion movement, or the pro-life movement, in the United States has made, right? So one of the other things that’s probably worth saying is, if you believe the claim I laid out about fetal personhood, that doesn’t mean you necessarily think abortion should be criminalized or that IVF should be criminalized, either.听

But the people who are leading the anti-abortion movement do, in large part, right? So it would have ramifications in lots of other contexts, because there’s a conclusion not only that human life begins at fertilization and that constitutional rights begin at fertilization but that the way you honor those constitutional rights is primarily by restricting or criminalizing certain things that threaten that life, in the views of the people who advocate for it.听

Rovner: Right. And that includes IVF and forms of contraception. That’s where we sort of get to this idea that an abortion is murder or that, in this case, doing anything that harms even a zygote is murder.听

Ziegler: Yeah. And it gets us to the Adriana Smith case in Georgia, too. So there’s sort of end-of-life cases that emerge. So, it obviously would have a big impact on abortion. So it’s not wrong to think about abortion in this context. It’s just that would definitely not be the stopping point.听

Rovner: So, many people have only talked about personhood, really, since the Supreme Court overturned Roe in 2022, but the concept is a lot older than that. I started covering personhood in like 2010, I think, when a couple of states were trying to vote on it. I didn’t realize until I read your book that it goes back well beyond even that.听

Ziegler: Yeah. So I think a lot of people had that conception. And in the 2010s, there were state constitutional amendment efforts to write the idea of fetal personhood into state constitutions. And they all failed. So I think the narrative coming out of that was that you had the anti-abortion movement on the one hand, and then you had this more extreme fetal personhood movement on the other hand.听

And that narrative fundamentally is wrong. There is no one in the anti-abortion movement who’s opposed to fetal personhood. There are disagreements about how and when it can be recognized. There’s strategic disagreements. There are no substantive disagreements much to speak of on the basics of fetal personhood.听

So the idea goes all the way back to the 1960s, when states were first reforming the 19th-century criminal laws you sometimes see coming back to life as zombie laws. And initially it started as a strategic necessity, because it was very hard for the early anti-abortion movement to stop this reform wave, right? They were saying things like, Oh, abortion is going to lead to more sexual promiscuity, or, No one really needs abortion, because pregnancy is no longer dangerous. And that just wasn’t getting the job done.听

So they began to argue that no one had a choice to legalize abortion in worse circumstances, because it would violate the rights of the unborn child. What’s interesting is that argument went from being this kind of strategic expedient to being this tremendously emotionally resonant long-term thing that has lived on the American right for now like a half-century. Even in moments when, I think arguably like right now, when it’s not politically smart to be making the argument, people will continue to, because this speaks to something, I think, for a lot of people who are opposed to abortion and other things like IVF.听

Rovner: I know you’ve got access in writing this book to a lot of internal documents from people in the anti-abortion movement. I’m jealous, I have to say. Was there something there that surprised you?听

Ziegler: Yeah, I think I was somewhat surprised by how much people talked this language of personhood when they were alone, right? This was not just something for the consumption of judges, or the consumption of politicians, or sort of like a nicer way to talk about what people really wanted. This was what people said when there was no one else there.听

That didn’t mean they didn’t say other things that suggested that there were lots of other values and beliefs underlying this concept of personhood. But I think one of the important lessons of that is if you’re trying to understand people who are opposed to abortion, just assuming that everything they’re saying is just pure strategy is not helpful, right? Any more than it would be for people who support reproductive rights, to have it assume that everything they’re saying is not genuine. You just fail to understand what people are doing, I think. And I think that was probably what I was the most surprised about.听

Rovner: I was struck that you point out that personhood doesn’t have to begin and end with the criminalization of abortion. How could more acceptance of the rights of the unborn change society in perhaps less polarized ways?听

Ziegler: Yeah, one of the things that’s really striking is that there are other countries that recognize a right to life for a fetus or unborn child that don’t criminalize abortion or don’t enforce criminal abortion laws. And often what they say is that it’s not OK for the state to start with criminalization when it isn’t doing things to support pregnant women, who after all are necessary for a fetus or unborn child to survive, right?听

So there are strategies that you could use to reduce infant mortality, for example, to reduce neonatal mortality, to reduce miscarriage and stillbirth, to improve maternal health, to really eliminate some of the reasons that people who may want, all things being equal, to carry a child to term. That’s not, obviously, going to be everybody. Some people don’t want to be parents at all.听

But there are other people for whom it’s a matter of resources, or it’s a matter of overcoming racial discrimination, or it’s a matter of leaving an abusive relationship. And if governments were more committed to doing some of those things, it’s reasonable to assume that a subset of those people would carry pregnancies to term, right?听

So there are lots of ways that if a state were serious about honoring fetal life, that it could. I think one of the other things that’s striking that I realized in writing the book is that that tracks with what a subset of Americans think. You’ll find these artifacts in polls where you’ll get something like 33% of people in Pew Forum’s 2022 poll saying they thought that life and rights began at conception, but also that abortion shouldn’t be criminalized.听

So there are a subset of Americans who, whether they’re coming from a place of faith or otherwise, can hold those two beliefs at once. So I think an interesting question is, could we have a politics that accommodates that kind of belief? And at the moment the answer is probably not, but it’s interesting to imagine how that could change.听

Rovner: It’s nice to know that there is a place that we can hope to get.听

Ziegler: Yeah, exactly.听

Rovner: Mary Ziegler, thank you so much for joining us again.听

Ziegler: Thanks for having me.听

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

Karlin-Smith: I purposely chose a sort of light story from Australia, where scientists studied remote work, and the headline is “” And it just goes through some of the benefits and perks people have found from working remotely, including more sleep, more time with friends and family, things like that. And it just felt like a nice, interesting read in a time where there’s a lot of heavy health news.听

Rovner: Also, scientific evidence of things that I think we all could have predicted. Anna.听

Edney: Apologies for going the other direction here, but it’s a story that I wrote this week, an investigation that I’ve been working on for a long time, “.” So this is one, in particularly a lot of women have used. You can go in any CVS, Target, Walmart, stores like that, and buy it. Called Azo, for urinary tract infections. And all these stores sell their own generic versions as well, under phenazopyridine.听

And this drug, I was kind of shocked to learn, is not FDA-approved. There are prescription versions that are not FDA-approved, either. It’s just been around so long that it’s been grandfathered in. And that may not be a big deal, except that this one, the FDA has raised questions about whether it causes cancer and whether it needs a stronger cancer warning, because the National Cancer Institute found in 1978 that it causes tumors in rats and mice. But no other work has been done on this drug, because it hasn’t been approved. So no one’s looked at it in humans. And it masks issues that really need antibiotics and causes a host of other issues.听

There were 鈥� University of Virginia toxicologists told me they found, in the last 20 years, at least 200 suspected teen suicides where they used this drug, because of how dangerous this drug can be in any higher amounts than what’s on the box. So I went through this drug, but there are other ones on the market as well that are not approved. And there’s this whole FDA system that has allowed the OTC [over-the-counter] market to be pretty lax.听

Rovner: OK, that’s terrifying. But thank you for your work. Alice.听

Ollstein: Speaking of terrifying, I chose a piece from NPR called, “” And this is a look at all of the ways our public health agency that is supposed to be letting us know when outbreaks are happening, and where, and how to protect ourselves, they’ve gone dark. They are not posting on social media. They are not sending out alerts. They are not sending out newsletters. And it walks through the danger of all of that happening, with interviews with people who are still on the inside and on the outside experiencing the repercussions.听

Rovner: Well, my extra credit, it helps explain why Alice’s extra credit, because it’s about all the people who were doing that who have been fired or laid off from the federal government. It’s called, “,” by William Wan and Hannah Natanson.听

And it’s the result of interviews with more than 30 current and former federal workers, along with the families of some who died or killed themselves. And it’s a review of documents to confirm those stories. It’s a super-depressing but beautifully told piece about the dramatic mental health impact of the federal DOGE [Department of Government Efficiency] layoffs and firings, and the impact that that’s been having on these workers, their families, and their communities.听

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

Edney: Both of those [ and ], @annaedney.听

Rovner: Sarah.听

Karlin-Smith: Everywhere 鈥� , , , @SarahKarlin or @sarahkarlin-smith.听

Rovner: Alice.听

Ollstein: on X and on Bluesky.听

Rovner: I am off to California next week, where we’ll be taping the podcast at the annual meeting of the Association for Health Care Journalists, which we won’t post until the following Monday. So everyone please have a great Memorial Day holiday week. And until then, be healthy.听

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Enrollment is high because California goes beyond federal eligibility requirements, opening Medi-Cal to more low-income residents. The state also provides a broad range of benefits, such as vision, dental, and maternity care 鈥� some of which is largely paid for by federal dollars but which also affects state spending.

But lately, Medi-Cal has found itself in political crosshairs.

Democrats say the biggest threat to Medi-Cal is $880 billion in GOP budget cuts being mulled in Washington, D.C., which health experts say would require eligibility restrictions, such as work requirements, or program cuts to yield enough savings over a decade. Republicans argue that Medicaid costs have spiked due to fraud and abuse and they criticize state Democrats for making the benefit available to immigrants regardless of legal status.

In March, Gov. Gavin Newsom’s administration borrowed $3.4 billion to cover an unexpected overrun in Medi-Cal, and lawmakers in April appropriated an for the rest of the fiscal year. Although the Democratic governor , he has defended the state’s efforts to get more people covered. In 2022, California’s uninsured rate for residents under age 65 of 6.2%, according to the California Health Care Foundation.

As lawmakers debate funding for the safety net program, here’s what’s at stake for California’s largest health program.

Who’s Covered?

More than a third of Californians depend on Medi-Cal or the closely related Children’s Health Insurance Program to see a doctor, therapist, or dentist. They rely on the program to get medicine and access treatment. It can also be a lifeline for families by allowing people with disabilities and seniors to stay in their homes and providing . It also funds nursing care for seniors.

The overwhelming majority of enrollees qualify because they earn 138% or less of the federal poverty level: for an individual person or $44,367 for a family of four. While that’s low for a state where the tops $96,000, it’s far more generous than , which is 18% of the federal poverty level, or Florida’s, at 26%.

Unlike Alabama or Florida, California extends coverage to low-income adults without dependents. The state also covers more people with disabilities who work, inmates, and other residents who wouldn’t qualify for the benefit program if California lawmakers hadn’t expanded the program beyond what the federal government requires.

According to , Medi-Cal covers about 7.3 million low-income families and an additional 5 million adults, most of whom don’t have dependents. An additional million people with disabilities rely on the program.

Medi-Cal also picks up the tab for 1.4 million residents 65 and older for benefits not covered by Medicare, such as long-term care and dental, hearing, and vision care.

The majority of adult Medi-Cal recipients under 65 work, according to of March 2024 census data. In California, about 42% of nondisabled adults on Medi-Cal work full time and an additional 20% work part time. Those not employed were most commonly caring for a family member, attending school, or ill.

Just over half of Medi-Cal recipients are Latino, about 16% white, 9% Asian or Pacific Islander, and 7% Black, according to . That differs from the nation as a whole, where about 40% of people under age 65 who use Medicaid are white, 30% Hispanic, 19% Black, and 1% Indigenous people.

Where Does the Money Come From?

The federal government pays for about 60% of the Medi-Cal program. Of its nearly $175 billion budget this fiscal year, Washington, D.C., is expected to contribute .

An additional $37.6 billion comes from the state’s general fund. The final $29.5 billion comes from other sources including hospital fees, a managed-care organization tax, tobacco tax revenue, and drug rebates.

California receives 50% in matching federal dollars for core services, such as coverage to children and low-income pregnant women. But it gets a 90% match for the roughly 5 million Californians it has added to rolls under the Medicaid expansion authorized by the Affordable Care Act.

Where Does It Go?

On average, Medi-Cal costs $8,000 per recipient, but costs vary widely, according to a by the California Legislative Analyst’s Office.

For instance, people with disabilities account for 7% of enrollees but 19% of Medi-Cal’s spending, with an average annual cost of $21,626.

Meanwhile, the cost to cover seniors averages roughly $15,000. And senior enrollment, at 1.4 million, has skyrocketed, increasing 40% since 2020 as lawmakers for how many assets people 65 and older could have and still qualify for the program.

California also foots much of the bill to cover immigrants without legal status 鈥� roughly $8.4 billion of the $9.5 billion, Department of Finance program budget manager Guadalupe Manriquez said during a .

What Could Get Cut?

President Donald Trump in March said that he would not “touch Social Security, Medicare, Medicaid” but focus on getting the “fraud out of there.” However, health experts say Medicaid services would be gutted if Congress follows through on massive spending reductions to pay to extend Trump’s tax cuts.

Congressional Republicans have discussed implementing work requirements for nondisabled adults, which could affect at least in California, the most of any state, according to an analysis by the Urban Institute.

Lawmakers also could roll back the under the Affordable Care Act, also known as Obamacare, which passed in 2010 and allowed more people to qualify for Medicaid based on income. California, 39 other states, and Washington, D.C., have chosen to adopt “Medicaid expansion,” in which the federal government pays for 90% of coverage for those enrollees.

Such a move would cost California billions each year if it opted to continue coverage for the roughly 5 million additional enrollees who have gained coverage under the expansion.

Republicans could also make it tougher for states such as California to continue to draw federal aid through provider taxes such as the MCO tax, something the first Trump administration proposed but later dropped. The tax on managed care plans brings in a year and was endorsed by voters in last fall, but the federal government has been complaining for years about how states levy such taxes on insurance plans and hospitals. If it restricts how states collect these taxes, it would likely cause a funding gap in California.

If federal cuts occur, Newsom officials acknowledge, the state couldn’t absorb the cost of existing programs. Republicans are pressuring Democrats who control the legislature to end Medi-Cal coverage of residents without legal status 鈥� something neither Newsom nor Democratic legislative leaders have expressed a willingness to do.

State leaders also could be faced with cutting such as dental care and optometry, trimming services aimed at enhancing recipients’ , or reducing payments to managed care plans that cover 94% of Medi-Cal recipients.

That’s what California lawmakers did during the Great Recession, cutting reimbursement rates to providers and eliminating benefits including eye and dental care for adults. The governor at the time, Republican Arnold Schwarzenegger, went a step further, chopping $61 million from counties’ Medi-Cal funding in a budget bloodletting that he said contained "."

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Montana’s expansion, which insures roughly , is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began to reject reauthorizing the program. It also this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of 麻豆女优 Health News, an independent national newsroom that is part of the health information nonprofit 麻豆女优.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a 麻豆女优 Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

show its standard monthly reimbursement per Medicaid enrollee for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, .

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to . In February, an FGA representative of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “,” and Blase this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he said.

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Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets 鈥� a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) . That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats of the House in 2018.

In a 麻豆女优 poll last winter, two-thirds of the public to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” this impact.

“You want to make sure that preexisting coverage 鈥� conditions 鈥� are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because 鈥� with the financial help 鈥� they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying 鈥榳e’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take , with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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The 2024 campaign 鈥� particularly the one for president 鈥� has been notably vague on policy. But health issues, especially those surrounding abortion and other reproductive health care, have nonetheless played a key role. And while the Affordable Care Act has not been the focus of debate the way it was over the previous three presidential campaigns, who becomes the next president will have a major impact on the fate of the 2010 health law.

The panelists for this week’s special election preview, taped before a live audience at 麻豆女优’s offices in Washington, are Julie Rovner of 麻豆女优 Health News, Tamara Keith of NPR, Alice Miranda Ollstein of Politico, and Cynthia Cox and Ashley Kirzinger of 麻豆女优.

Panelists

Among the takeaways from this week’s episode:

• As Election Day nears, who will emerge victorious from the presidential race is anyone’s guess. Enthusiasm among Democratic women has grown with the elevation of Vice President Kamala Harris to the top of the ticket, with more saying they are likely to turn out to vote. But broadly, polling reveals a margin-of-error race 鈥� too close to call.
• Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
• While policy debates have been noticeably lacking from this presidential election, the future of Medicaid and the Affordable Care Act hinges on its outcome. Republicans want to undermine the federal funding behind Medicaid expansion, and former President Donald Trump has a record of opposition to the ACA. Potentially on the chopping block are the federal subsidies expiring next year that have transformed the ACA by boosting enrollment and lowering premium costs.
• And as misinformation and disinformation proliferate, one area of concern is the “malleable middle”: people who are uncertain of whom or what to trust and therefore especially susceptible to misleading or downright false information. Could a second Trump administration embed misinformation in federal policy? The push to soften or even eliminate school vaccination mandates shows the public health consequences of falsehood creep.

Also mentioned on this week’s podcast:

• The New York Times’ “,” by Sheryl Gay Stolberg.
• 麻豆女优 Health News’ “鈥榃hat the Health?’: SCOTUS Ruling Strips Power From Federal Health Agencies.”
• 麻豆女优’s , a program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem.

[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.]听

Emmarie Huetteman: Please put your hands together and join me in welcoming our panel and our host, Julie Rovner.听

Julie Rovner: Hello, good morning, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the very best and smartest health reporters in Washington, along with some very special guests today. We’re taping this special election episode on Thursday, October 17th, at 11:30 a.m., in front of a live audience at the Barbara Jordan Conference Center here at 麻豆女优 in downtown D.C. Say hi, audience.听

As always, news happens fast and things might have changed by the time you hear this. So, here we go.听

So I am super lucky to work at and have worked at some pretty great places and with some pretty great, smart people. And when I started to think about who I wanted to help us break down what this year’s elections might mean for health policy, it was pretty easy to assemble an all-star cast. So first, my former colleague from NPR, senior White House correspondent Tamara Keith. Tam, thanks for joining us.听

Tamara Keith: Thank you for having me.听

Rovner: Next, our regular “What the Health?” podcast panelist and my right hand all year on reproductive health issues, Alice Ollstein of Politico.听

Alice Miranda Ollstein: Hi Julie.听

Rovner: Finally, two of my incredible 麻豆女优 colleagues. Cynthia Cox is a 麻豆女优 vice president and director of the program on the ACA [Affordable Care Act] and one of the nation’s very top experts on what we know as Obamacare. Thank you, Cynthia.听

Cynthia Cox: Great to be here.听

Rovner: And finally, Ashley Kirzinger is director of survey methodology and associate director of our 麻豆女优 Public Opinion and Survey Research Program, and my favorite explainer of all things polling.听

Ashley Kirzinger: Thanks for having me.听

Rovner: So, welcome to all of you. Thanks again for being here. We’re going to chat amongst ourselves for a half hour or so, and then we will open the floor to questions. So be ready here in the room. Tam, I want to start with the big picture. What’s the state of the race as of October 17th, both for president and for Congress?听

Keith: Well, let’s start with the race for President. That’s what I cover most closely. This is what you would call a margin-of-error race, and it has been a margin-of-error race pretty much the entire time, despite some really dramatic events, like a whole new candidate and two assassination attempts and things that we don’t expect to see in our lifetimes and yet they’ve happened. And yet it is an incredibly close race. What I would say is that at this exact moment, there seems to have been a slight shift in the average of polls in the direction of former President [Donald] Trump. He is in a slightly better position than he was before and is in a somewhat more comfortable position than Vice President [Kamala] Harris.听

She has been running as an underdog the whole time, though there was a time where she didn’t feel like an underdog, and right now she is also running like an underdog and the vibes have shifted, if you will. There’s been a more dramatic shift in the vibes than there has been in the polls. And the thing that we don’t know and we won’t know until Election Day is in 2016 and 2020, the polls underestimated Trump’s support. So at this moment, Harris looks to be in a weaker position against Trump than either [Hillary] Clinton or [Joe] Biden looked to be. It turns out that the polls were underestimating Trump both of those years. But in 2022 after the Dobbs decision, the polls overestimated Republican support and underestimated Democratic support.听

So what’s happening now? We don’t know. So there you go. That is my overview, I think, of the presidential race. The campaigning has really intensified in the last week or so, like really intensified, and it’s only going to get more intense. I think Harris has gotten a bit darker in her language and descriptions. The joyful warrior has been replaced somewhat by the person warning of dire consequences for democracy. And in terms of the House and the Senate, which will matter a lot, a lot a lot, whether Trump wins or Harris wins, if Harris wins and Democrats lose the Senate, Harris may not even be able to get Cabinet members confirmed.听

So it matters a lot, and the conventional wisdom 鈥� which is as useful as it is and sometimes is not all that useful 鈥� the conventional wisdom is that something kind of unusual could happen, which is that the House could flip to Democrats and the Senate could flip to Republicans, and usually these things don’t move in opposite directions in the same year.听

Rovner: And usually the presidential candidate has coattails, but we’re not really seeing that either, are we?听

Keith: Right. In fact, it’s the reverse. Several of the Senate candidates in key swing states, the Democratic candidates are polling much better than the Republican candidates in those races and polling with greater strength than Harris has in those states. Is this a polling error, or is this the return of split-ticket voting? I don’t know.听

Rovner: Well, leads us to our polling expert. Ashley, what are the latest polls telling us, and what should we keep in mind about the limitations of polling? I feel like every year people depend a lot on the polls and every year we say, Don’t depend too much on the polls.听

Kirzinger: Well, can I just steal Tamara’s line and say I don’t know? So in really close elections, when turnout is going to matter a lot, what the polls are really good at is telling us what is motivating voters to turn out and why. And so what the polls have been telling us for a while is that the economy is top of mind for voters. Now, health care costs 鈥� we’re at 麻豆女优. So health care plays a big role in how people think about the economy, in really two big ways. The first is unexpected costs. So unexpected medical bills, health care costs, are topping the list of the public’s financial worries, things that they’re worried about, what might happen to them or their family members. And putting off care. What we’re seeing is about a quarter of the public these days are putting off care because they say they can’t afford the cost of getting that needed care.听

So that really shows the way that the financial burdens are playing heavily on the electorate. What we have seen in recent polling is Harris is doing better on the household expenses than Biden did and is better than the Democratic Party largely. And that’s really important, especially among Black women and Latina voters. We are seeing some movement among those two groups of the electorate saying that Harris is doing a better job and they trust her more on those issues. But historically, if the election is about the economy, Republican candidates do better. The party does better on economic issues among the electorate.听

What we haven’t mentioned yet is abortion, and this is the first presidential election since post-Dobbs, in the post-Dobbs era, and we don’t know how abortion policy will play in a presidential election. It hasn’t happened before, so that’s something that we’re also keeping an eye on. We know that Harris is campaigning around reproductive rights, is working among a key group of the electorate, especially younger women voters. She is seen as a genuine candidate who can talk about these issues and an advocate for reproductive rights. We’re seeing abortion rise in importance as a voting issue among young women voters, and she’s seen as more authentic on this issue than Biden was.听

Rovner: Talk about last week’s poll about young women voters.听

Kirzinger: Yeah, one of the great things that we can do in polling is, when we see big changes in the campaign, is we can go back to our polls and respondents and ask how things have changed to them. So we worked on a poll of women voters back in June. Lots have changed since June, so we went back to them in September to see how things were changing for this one group, right? So we went back to the same people and we saw increased motivation to turn out, especially among Democratic women. Republican women were about the same level of motivation. They’re more enthusiastic and satisfied about their candidate, and they’re more likely to say abortion is a major reason why they’re going to be turning out. But we still don’t know how that will play across the electorate in all the states.听

Because for most voters, a candidate’s stance on abortion policy is just one of many factors that they’re weighing when it comes to turnout. And so those are one of the things that we’re looking at as well. I will say that I’m not a forecaster, thank goodness. I’m a pollster, and polls are not good at forecasts, right? So polls are very good at giving a snapshot of the electorate at a moment in time. So two weeks out, that’s what I know from the polls. What will happen in the next two weeks, I’m not sure.听

Rovner: Well, Alice, just to pick up on that, abortion, reproductive health writ large are by far the biggest health issues in this campaign. What impact is it having on the presidential race and the congressional races and the ballot issues? It’s all kind of a clutter, isn’t it?听

Ollstein: Yeah, well, I just really want to stress what Ashley said about this being uncharted territory. So we can gather some clues from the past few years where we’ve seen these abortion rights ballot measures win decisively in very red states, in very blue states, in very purple states. But presidential election years just have a different electorate. And so, yes, it did motivate more people to turn out in those midterm and off-year elections, but that’s just not the same group of folks and it’s not the same groups the candidates need this time, necessarily. And also we know that every time abortion has been on the ballot, it has won, but the impact and how that spills over into partisan races has been a real mixed bag.听

So we saw in Michigan in 2022, it really helped Democrats. It helped Governor Gretchen Whitmer. It helped Michigan Democrats take back control of the Statehouse for the first time in decades. But that didn’t work for Democrats in all states. My colleagues and I did an analysis of a bunch of different states that had these ballot measures, and these ballot measures largely succeeded because of Republican voters who voted for the ballot initiative and voted for Republican candidates. And that might seem contradictory. You’re voting for an abortion rights measure, and you’re voting for very anti-abortion candidates. We saw that in Kentucky, for example, where a lot of people voted for (Sen.) Rand Paul, who is very anti-abortion, and for the abortion rights side of the ballot measure.听

I’ve been on the road the last few months, and I think you’re going to see a lot of that again. I just got back from Arizona, and a lot of people are planning to vote for the abortion rights measure there and for candidates who have a record of opposing abortion rights. Part of that is Donald Trump’s somewhat recent line of: I won’t do any kind of national ban. I’ll leave it to the states. A lot of people are believing that, even though Democrats are like: Don’t believe him. It’s not true. But also, like Ashley said, folks are just prioritizing other issues. And so, yes, when you look at certain slices of the electorate, like young women, abortion is a top motivating issue. But when you look at the entire electorate, it’s, like, a distant fourth after the economy and immigration and several other things.听

I found the 麻豆女优 polling really illuminating in that, yes, most people said that abortion is either just one of many factors in deciding their vote on the candidates or not a factor at all. And most people said that they would be willing to vote for a candidate who does not share their views on abortion. So I think that’s really key here. And these abortion rights ballot measures, the campaigns behind them are being really deliberate about remaining completely nonpartisan. They need to appeal to Republicans, Democrats, independents in order to pass, but that also 鈥� So their motivation is to appeal to everyone. Democrats’ motivation is to say: You have to vote for us, too. Abortion rights won’t be protected if you just pass the ballot measure. You also have to vote for Democrats up and down the ballot. Because, they argue, Trump could pursue a national ban that would override the state protections.听

Rovner: We’ve seen in the past 鈥� and this is for both of you 鈥� ballot measures as part of partisan strategies. In the early 2000s, there were anti-gay-marriage ballot measures that were intended to pull out Republicans, that were intended to drive turnout. That’s not exactly what’s happening this time, is it?听

Keith: So I was a reporter in the great state of Ohio in 2004, and there was an anti-gay-rights ballot measure on the ballot there, and it was a key part of George W. Bush’s reelection plan. And it worked. He won the state somewhat narrowly. We didn’t get the results until 5 a.m. the next day, but that’s better than we’ll likely have this time. And that was a critical part of driving Republican turnout. It’s remarkable how much has changed since then in terms of public views. It wouldn’t work in the same way this time.听

The interesting thing in Arizona, for instance, is that there’s also an anti-immigration ballot measure that’s also polling really well that was added by the legislature in sort of a rush to try to offset the expected Democratic-based turnout because of the abortion measure. But as you say, it is entirely possible that there could be a lot of Trump abortion, immigration and [House Democrat and Senate candidate] Ruben Gallego voters.听

Ollstein: Absolutely. And I met some of those voters, and one woman told me, look, she gets offended when people assume that she’s liberal because she identified as pro-choice. We don’t use that terminology in our reporting, but she identified as pro-choice, and she was saying: Look, to me, this is a very conservative value. I don’t want the government in my personal business. I believe in privacy. And so for her, that doesn’t translate over into, And therefore I am a Democrat.听

Rovner: I covered two abortion-related ballot measures in South Dakota that were two years, I think it was 2006 and 2008.听

Ollstein: They have another one this year.听

Rovner: Right. There is another one this year. But what was interesting, what I discovered in 2006 and 2008 is exactly what you were saying, that there’s a libertarian streak, particularly in the West, of people who vote Republican but who don’t believe that the government has any sort of business in your personal life, not just on abortion but on any number of other things, including guns. So this is one of those issues where there’s sort of a lot of distinction. Cynthia, this is the first time in however many elections the Affordable Care Act has not been a huge issue, but there’s an awful lot at stake for this law, depending on who gets elected, right?听

Cox: Yeah, that’s right. I mean, it’s the first time in recent memory that health care in general, aside from abortion, hasn’t really been the main topic of conversation in the race. And part of that is that the Affordable Care Act has really transformed the American health care system over the last decade or so. The uninsured rate is at a record low, and the ACA marketplaces, which had been really struggling 10 years ago, have started to not just survive but thrive. Maybe also less to dislike about the ACA, but it’s also not as much a policy election as previous elections had been. But yes, the future of the ACA still hinges on this election.听

So starting with President Trump, I think as anyone who follows health policy knows, or even politics or just turned on the TV in 2016 knows that Trump has a very, very clear history of opposing the Affordable Care Act, or Obamacare. He supported a number of efforts in Congress to try to repeal and replace the Affordable Care Act. And when those weren’t successful, he took a number of regulatory steps, joined legal challenges, and proposed in his budgets to slash funding for the Affordable Care Act and for Medicaid. But now in 2024, it’s a little bit less clear exactly where he’s going.听

I would say earlier in the 2024 presidential cycle, he made some very clear comments about saying Obamacare sucks, for example, or that Republicans should never give up on trying to repeal and replace the ACA, that the failure to do so when he was president was a low point for the party. But then he also has seemed to kind of walk that back a little bit. Now he’s saying that he would replace the ACA with something better or that he would make the ACA itself much, much better or make it cost less, but he’s not providing specifics. Of course, in the debate, he famously said that he had “concepts” of a plan, but there’s no 鈥� Nothing really specific has materialized.听

Rovner: We haven’t seen any of those concepts.听

Cox: Yes, the concept is 鈥� But we can look at his record. And so we do know that he has a very, very clear record of opposing the ACA and really taking any steps he could when he was president to try to, if not repeal and replace it, then significantly weaken it or roll it back. Harris, by contrast, is in favor of the Affordable Care Act. When she was a primary candidate in 2020, she had expressed support for more-progressive reforms like “Medicare for All” or “Medicare for More.” But since becoming vice president, especially now as the presidential candidate, she’s taken a more incremental approach.听

She’s talking about building upon the Affordable Care Act. In particular, a key aspect of her record and Biden’s is these enhanced subsidies that exist in the Affordable Care Act marketplaces. They were first, I think 鈥� They really closely mirror what Biden had run on as president in 2019, 2020, but they were passed as part of covid relief. So they were temporary, then they were extended as part of the Inflation Reduction Act but, again, temporarily. And so they’re set to expire next year, which is setting up a political showdown of sorts for Republicans and Democrats on the Hill about whether or not to extend them. And Harris would like to make these subsidies permanent because they have been responsible for really transforming the ACA marketplaces.听

The number of people signing up for coverage has doubled since Biden took office. Premium payments were cut almost in half. And so this is, I think, a key part of, now, her record, but also what she wants to see go forward. But it’s going to be an uphill battle, I think, to extend them.听

Rovner: Cynthia, to sort of build on that a little bit, as we mentioned earlier, a Democratic president won’t be able to get a lot accomplished with a Republican House and/or Senate and a Republican president won’t be able to get that much done with a Democratic House and/or Senate. What are some of the things we might expect to see if either side wins a trifecta control of the executive branch and both houses of Congress?听

Cox: So I think, there 鈥� So I guess I’ll start with Republicans. So if there is a trifecta, the key thing there to keep in mind is while there may not be a lot of appetite in Congress to try to repeal and replace the ACA, since that wasn’t really a winning issue in 2017, and since then public support for the ACA has grown. And I think also it’s worth noting that the individual mandate penalty being reduced to $0. So essentially there’s no individual mandate anymore. There’s less to hate about the law.听

Rovner: All the pay-fors are gone, too.听

Cox: Yeah the pay-fors are gone, too.听

Rovner: So the lobbyists have less to hate.听

Cox: Yes, that too. And so I don’t think there’s a ton of appetite for this, even though Trump has been saying, still, some negative comments about the ACA. That being said, if Republicans want to pass tax cuts, then they need to find savings somewhere. And so that could be any number of places, but I think it’s likely that certain health programs and other programs are off-limits. So Medicare probably wouldn’t be touched, maybe Social Security, defense, but that leaves Medicaid and the ACA subsidies.听

And so if they need savings in order to pass tax cuts, then I do think in particular Medicaid is at risk, not just rolling back the ACA’s Medicaid expansion but also likely block-granting the program or implementing per capita caps or some other form of really restricting the amount of federal dollars that are going towards Medicaid.听

Rovner: And this is kind of where we get into the Project 2025 that we’ve talked about a lot on the podcast over the course of this year, that, of course, Donald Trump has disavowed. But apparently [Senate Republican and vice presidential candidate] JD Vance has not, because he keeps mentioning pieces of it.听

Ollstein: And they’re only 鈥� They’re just one of several groups that have pitched deep cuts to health safety net programs, including Medicaid. You also have the Paragon group, where a lot of former Trump officials are putting forward health policy pitches and several others. And so I also think given the uncertainty about a trifecta, it’s also worth keeping in mind what they could do through waivers and executive actions in terms of work requirements.听

Rovner: That was my next question. I’ve had trouble explaining this. I’ve done a bunch of interviews in the last couple of weeks to explain how much more power Donald Trump would have, if he was reelected, to do things via the executive branch than a President Harris would have. So I have not come up with a good way to explain that. Please, one of you give it a shot.听

Keith: Someone else.听

Rovner: Why is it that President Trump could probably do a lot more with his executive power than a President Harris could do with hers?听

Cox: I think we can look back at the last few years and just see. What did Trump do with his executive power? What did Biden do with his executive power? And as far as the Affordable Care Act is concerned or Medicaid. But Trump, after the failure to repeal and replace the ACA, took a number of regulatory steps. For example, trying to expand short-term plans, which are not ACA-compliant, and therefore can discriminate against people with preexisting conditions, or cutting funding for certain things in the ACA, including outreach and enrollment assistance.听

And so I think there were a number 鈥� and also we’ve talked about Medicaid work requirements in the form of state waivers. And a lot of what Biden did, regulatory actions, were just rolling that back, changing that, but it’s hard to expand coverage or to provide a new program without Congress acting to authorize that spending.听

Kirzinger: I think it’s also really important to think about the public’s view of the ACA at this point in time. I mean, what the polls aren’t mixed about is that the ACA has higher favorability than Harris, Biden, Trump, any politician, right? So we have about two-thirds of the public.听

Rovner: So Nancy Pelosi was right.听

Kirzinger: I won’t go that far, but about two-thirds of the public’s now view the law favorably, and the provisions are even more popular. So while, yes, a Republican trifecta will have a lot of power, the public 鈥� they’re going to have a hard time rolling back protections for people with preexisting conditions, which have bipartisan support. They’re going to have a hard time making it no longer available for adult children under the age of 26 to be on their parents’ health insurance. All of those components of the ACA are really popular, and once people are given protections, it’s really hard to take them away.听

Cox: Although I would say that there are at least 10 ways the ACA protects people with preexisting conditions. I think on the surface it’s easy to say that you would protect people with preexisting conditions if you say that a health insurer has to offer coverage to someone with a preexisting condition. But there’s all those other ways that they say also protects preexisting conditions, and it makes coverage more comprehensive, which makes coverage more expensive.听

And so that’s why the subsidies there are key to make comprehensive coverage that protects people with preexisting conditions affordable to individuals. But if you take those subsidies away, then that coverage is out of reach for most people.听

Rovner: That’s also what JD Vance was talking about with changing risk pools. I mean, which most people, it makes your eyes glaze over, but that would be super important to the affordability of insurance, right?听

Cox: And his comment about risk pools is 鈥� I think a lot of people were trying to read something into that because it was pretty vague. But what a lot of people did think about when he made that comment was that before the Affordable Care Act, it used to be that if you were declined health insurance coverage, especially by multiple insurance companies, if you were basically uninsurable, then you could apply to what existed in many states was a high-risk pool.听

But the problem was that these high-risk pools were consistently underfunded. And in most of those high-risk pools, there were even waiting periods or exclusions on coverage for preexisting conditions or very high premiums or deductibles. So even though these were theoretically an option for coverage for people with preexisting conditions before the ACA, the lack of funding or support made it such that that coverage didn’t work very well for people who were sick.听

Ollstein: And something conservatives really want to do if they gain power is go after the Medicaid expansion. They’ve sort of set up this dichotomy of sort of the deserving and undeserving. They don’t say it in those words, but they argue that childless adults who are able-bodied don’t need this safety net the way, quote-unquote, “traditional” Medicaid enrollees do. And so they want to go after that part of the program by reducing the federal match. That’s something I would watch out for. I don’t know if they’ll be able to do that. That would require Congress, but also several states have in their laws that if the federal matches decreased, they would automatically unexpand, and that would mean coverage losses for a lot of people. That would be very politically unpopular.听

It’s worth keeping in mind that a lot of states, mainly red states, have expanded Medicaid since Republicans last tried to go after the Affordable Care Act in 2017. And so there’s just a lot more buy-in now. So it would be politically more challenging to do that. And it was already very politically challenging. They weren’t able to do it back then.听

Rovner: So I feel like one of the reasons that Trump might be able to get more done than Harris just using executive authority is the makeup of the judiciary, which has been very conservative, particularly at the Supreme Court, and we actually have some breaking news on this yesterday. Three of the states who intervened in what was originally a Texas lawsuit trying to revoke the FDA’s [Federal Drug Administration’s] approval of the abortion pill mifepristone, officially revived that lawsuit, which the Supreme Court had dismissed because the doctors who filed it initially didn’t have standing, according to the Supreme Court.听

The states want the courts to invoke the Comstock Act, an 1873 anti-vice law banning the mailing and receiving of, among other things, anything used in an abortion, to effectively ban the drug. This is one of those ways that Trump wouldn’t even have to lift a finger to bring about an abortion ban, right? I mean, he’d just have to let it happen.听

Ollstein: Right. I think so much of this election cycle has been dominated by, Would you sign a ban? And that’s just the wrong question. I mean, we’ve seen Congress unable to pass either abortion restrictions or abortion protections even when one party controls both chambers. It’s just really hard.听

Rovner: And going back 60 years.听

Ollstein: And so I think it’s way more important to look at what could happen administratively or through the courts. And so yes, lawsuits like that, that the Supreme Court punted on but didn’t totally resolve this term, could absolutely come back. A Trump administration could also direct the FDA to just unauthorize abortion pills, which are the majority of abortions that take place within the U.S.听

And so 鈥� or there’s this Comstock Act route. There’s 鈥� the Biden administration put out a memo saying, We do not think the Comstock Act applies to the mailing of abortion pills to patients. A Trump administration could put out their own memo and say, We believe the opposite. So there’s a lot that could happen. And so I really have been frustrated. All of the obsessive focus on: Would you sign a ban? Would you veto a ban? Because that is the least likely route that this would happen.听

Kirzinger: Well, and all of these court cases create an air of confusion among the public, right? And so, that also can have an effect in a way that signing a ban 鈥� I mean, if people don’t know what’s available to them in their state based on state policy or national policy.听

Ollstein: Or they’re afraid of getting arrested.听

Kirzinger: Yeah, even if it’s completely legal in their state, we’re finding that people aren’t aware of whether 鈥� what’s available to them in their state, what they can access legally or not. And so having those court cases pending creates this air of confusion among the public.听

Keith: Well, just to amplify the air of confusion, talking to Democrats who watch focus groups, they saw a lot of voters blaming President Biden for the Dobbs decision and saying: Well, why couldn’t he fix that? He’s president. At a much higher level, there is confusion about how our laws work. There’s a lot of confusion about civics, and as a result, you see blame landing in sort of unexpected places.听

Rovner: This is the vaguest presidential election I have ever covered. I’ve been doing this since 1988. We basically have both candidates refusing to answer specific questions 鈥� as a strategy, I mean, it’s not that I don’t think 鈥� I think they both would have a pretty good idea of what it is they would do, and both of them find it to their political advantage not to say.听

Keith: I think that’s absolutely right. I think that the Harris campaign, which I spend more time covering, has the view that if Trump is not going to answer questions directly and he is going to talk about “concepts” of a plan, and he’s just going to sort of, like, Well, if I was president, this wouldn’t be a problem, so I’m not going to answer your question 鈥� which is his answer to almost every question 鈥� then there’s not a lot of upside for them to get into great specifics about policy and to have think tank nerds telling them it won’t work, because there’s no upside to it.听

Cox: We’re right here.听

Panel: [Laughing]听

Rovner: So regular listeners to the podcast will know that one of my biggest personal frustrations with this campaign is the ever-increasing amount of mis- and outright disinformation in the health care realm, as we discussed at some length on last week’s podcast. You can go back and listen. This has become firmly established in public health, obviously pushed along by the divide over the covid pandemic. The New York Times last week had a by Sheryl Gay Stolberg 鈥� who’s working on a book about public health 鈥� about how some of these more fringe beliefs are getting embedded in the mainstream of the Republican Party.听

It used to be that we saw most of these kind of fringe, anti-science, anti-health beliefs were on the far right and on the far left, and that’s less the case. What could we be looking forward to on the public health front if Trump is returned to power, particularly with the help of anti-vaccine activist and now Trump endorser R.F.K. [Robert F. Kennedy] Jr.?听

Kirzinger: Oh, goodness to me. Well, so I’m going to talk about a group that I think is really important for us to focus on when we think about misinformation, and I call them the “malleable middle.” So it’s that group that once they hear misinformation or disinformation, they are unsure of whether that is true or false, right? So they’re stuck in this uncertainty of what to believe and who do they trust to get the right information. It used to be pre-pandemic that they would trust their government officials.听

We have seen declining trust in CDC [Centers for Disease Control and Prevention], all levels of public health officials. Who they still trust is their primary care providers. Unfortunately, the groups that are most susceptible to misinformation are also the groups that are less likely to have a primary care provider. So we’re not in a great scenario, where we have a group that is unsure of who to trust on information and doesn’t have someone to go to for good sources of information. I don’t have a solution.听

Cox: I also don’t have a solution.听

Rovner: No, I wasn’t 鈥� the question isn’t about a solution. The question is about, what can we expect? I mean, we’ve seen the sort of mis- and disinformation. Are we going to actually see it embedded in policy? I mean, we’ve mostly not, other than covid, which obviously now we see the big difference in some states where mask bans are banned and vaccine mandates are banned. Are we going to see childhood vaccines made voluntary for school?听

Ollstein: Well, there’s already a movement to massively broaden who can apply for an exception to those, and that’s already had some scary public health consequences. I mean, I think there are people who would absolutely push for that.听

Kirzinger: I think regardless of who wins the presidency, I think that the misinformation and disinformation is going to have an increasing role. Whether it makes it into policy will depend on who is in office and Congress and all of that. But I think that it is not something that’s going away, and I think we’re just going to continue to have to battle it. And that’s where I’m the most nervous.听

Keith: And when you talk about the trust for the media, those of us who are sitting here trying to get the truth out there, or to fact-check and debunk, trust for us is, like, in the basement, and it just keeps getting worse year after year after year. And the latest Gallup numbers have us worse than we were before, which is just, like, another institution that people are not turning to. We are in an era where some rando on YouTube who said they did their research is more trusted than what we publish.听

Rovner: And some of those randos on YouTube have millions of viewers, listeners.听

Keith: Yes, absolutely.听

Rovner: Subscribers, whatever you want to call them.听

Ollstein: One area where I’ve really seen this come forward, and it could definitely become part of policy in the future, is there’s just a lot of mis- and disinformation around transgender health care. There’s polling that show a lot of people believe what Trump and others have been saying, that, Oh, kids can come home from school and have a sex change operation. Which is obviously ridiculous. Everyone who has kids in school knows that they can’t even give them a Tylenol without parental permission. And it obviously doesn’t happen in a day, but people are like, Oh, well, I know it’s not happening at my school, but it’s sure happening somewhere. And that’s really resonating, and we’re already seeing a lot of legal restrictions on that front spilling.听

Rovner: All right, well, I’m going to open it up to the audience. Please wait to ask your question until you have a microphone, so the people who will be listening to the podcast will be able to hear your question. And please tell us who you are, and please make your question or question.听

Madeline: Hi, I’m Madeline. I am a grad student at the Milken Institute of Public Health at George Washington. My question is regarding polling. And I was just wondering, how has polling methodologies or tendencies to over-sample conservatives had on polls in the race? Are you seeing that as an issue or 鈥�?听

Kirzinger: OK. You know who’s less trusted than the media? It’s pollsters, but you can trust me. So I think what you’re seeing is there are now more polls than there have ever been, and I want to talk about legitimate scientific polls that are probability-based. They’re not letting people opt into taking the survey, and they’re making sure their samples are representative of the entire population that they’re surveying, whether it be the electorate or the American public, depending on that.听

I think what we have seen is that there have been some tendencies when people don’t like the poll results, they look at the makeup of that sample and say, oh, this poll’s too Democratic, or too conservative, has too many Trump voters. Or whatever it may be. That benefits no pollster to make their sample not look like the population that they’re aiming to represent. And so, yes, there are lots of really, really bad polls out there, but the ones that are legitimate and scientific are still striving to aim to make sure that it’s representative. The problem with election polls is we don’t know who the electorate’s going to be. We don’t know if Democrats are going to turn out more than Republicans. We don’t know if we’re going to see higher shares of rural voters than we saw in 2022.听

We don’t know. And so that’s where you really see the shifts in error happen.听

Keith: And if former President Trump’s 鈥� a big part of his strategy is turning out unlikely voters.听

Kirzinger: Yeah. We have no idea who they are.听

Rovner: Well, yeah, we saw in Georgia, their first day of in-person early voting, we had this huge upswell of voters, but we have no idea who any of those are, right? I mean, we don’t know what is necessarily turning them out.听

Kirzinger: Exactly. And historically, Democrats have been more likely to vote early and vote by mail, but that has really shifted since the pandemic. And so you see these day voting totals now, but that really doesn’t tell you anything at this point in the race.听

Rovner: Lots we still don’t know. Another question.听

Rae Woods: Hi there. Rae Woods. I’m with Advisory Board, which means that I work with health leaders who need to implement based on the policies and the politics and the results of the election that’s coming up. My question is, outside some of the big things that we’ve talked about so far today, are there some more specific, smaller policies or state-level dynamics that you think today’s health leaders will need to respond to in the next six months, the next eight months? What do health leaders need to be focused on right now based on what could change most quickly?听

Ollstein: Something I’ve been trying to shine a light on are state Supreme Courts, which the makeup of them could change dramatically this November. States have all kinds of different ways to 鈥� Some elect them on a partisan basis. Some elect them on a nonpartisan basis. Some have appointments by the governor, but then they have to run in these retention elections. But they are going to just have so much power over 鈥� I mean, I am most focused on how it can impact abortion rights, but they just have so much power on so many things.听

And given the high likelihood of divided federal government, I think just a ton of health policy is going to happen at the state level. And so I would say the electorate often overlooks those races. There’s a huge drop-off. A lot of people just vote the top of the ticket and then just leave those races blank. But yes, I think we should all be paying more attention to state Supreme Court races.听

Rovner: I think the other thing that we didn’t, that nobody mentioned we were talking about, what the next president could do, is the impact of the change to the regulatory environment and what the Supreme Court’s decision overturning Chevron is going to have on the next president. And we did a whole episode on this, so I can link back to that for those who don’t know. But basically, the Supreme Court has made it more difficult for whoever becomes president next time to change rules via their executive authority, and put more onus back on Congress. And we will see how that all plays out, but I think that’s going to be really important next year.听

Natalie Bercutt: Hi. My name is Natalie Bercutt. I’m also a master’s student at George Washington. I study health policy. I wanted to know a little bit more about, obviously, abortion rights, a huge issue on the ballot in this election, but a little bit more about IVF [in vitro fertilization], which I feel like has kind of come to the forefront a little bit more, both in state races but also candidates making comments on a national level, especially folks who have been out in the field and interacting with voters. Is that something that more people are coming out to the ballot for, or people who are maybe voting split ticket but in support of IVF, but for Republican candidate?听

Ollstein: That’s been fascinating. And so most folks know that this really exploded into the public consciousness earlier this year when the Alabama Supreme Court ruled that frozen embryos are people legally under the state’s abortion ban. And that disrupted IVF services temporarily until the state legislature swooped in. So Democrats’ argument is that because of these anti-abortion laws in lots of different states that were made possible by the Dobbs decision, lots of states could become the next Alabama. Republicans are saying: Oh, that’s ridiculous. Alabama was solved, and no other state’s going to do it. But they could.听

Rovner: Alabama could become the next Alabama.听

Ollstein: Alabama could certainly become the next Alabama. Buy tons of states have very similar language in their laws that would make that possible. Even as you see a lot of Republicans right now saying: Oh, Republicans are 鈥� We’re pro-IVF. We’re pro-family. We’re pro-babies. There are a lot of divisions on the right around IVF, including some who do want to prohibit it and others who want to restrict the way it’s most commonly practiced in the U.S., where excess embryos are created and only the most viable ones are implanted and the others are discarded.听

And so I think this will continue to be a huge fight. A lot of activists in the anti-abortion movement are really upset about how Republican candidates and officials have rushed to defend IVF and promised not to do anything to restrict it. And so I think that’s going to continue to be a huge fight no matter what happens.听

Rovner: Tam, are you seeing discussion about the threats to contraception? I know this is something that Democratic candidates are pushing, and Republican candidates are saying, Oh, no, that’s silly.听

Keith: Yeah, I think Democratic candidates are certainly talking about it. I think that because of that IVF situation in Alabama, because of concerns that it could move to contraception, I think Democrats have been able to talk about reproductive health care in a more expansive way and in a way that is perhaps more comfortable than just talking about abortion, in a way that’s more comfortable to voters that they’re talking to back when Joe Biden was running for president. Immediately when Dobbs happened, he was like, And this could affect contraception and it could affect gay rights. And Biden seemed much more comfortable in that realm. And so鈥斕�

Rovner: Yeah, Biden, who waited, I think it was a year and a half, before he said the word “abortion.”听

Keith: To say the word “abortion.” Yes.听

Rovner: There was a website: Has Biden Said Abortion Yet?听

Keith: Essentially what I’m saying is that there is this more expansive conversation about reproductive health care and reproductive freedom than there had been when Roe was in place and it was really just a debate about abortion.听

Rovner: Ashley, do people, particularly women voters, perceive that there’s a real threat to contraception?听

Kirzinger: I think what Tamara was saying about when Biden was the candidate, I do think that that was part of the larger conversation, that larger threat. And so they were more worried about IVF and contraception access during that. When you ask voters whether they’re worried about this, they’re not as worried, but they do give the Democratic Party and Harris a much stronger advantage on these issues. And so if you were to be motivated by that, you would be motivated to vote for Harris, but it really isn’t resonating with women voters and the way now that abortion, abortion access is resonating for them.听

Rovner: Basically, it won’t be resonating until they take it away.听

Kirzinger: Exactly. If, I think, the Alabama Supreme Court ruling happened yesterday, I think it would be a much bigger issue in the campaign, but all of this is timing.听

Ollstein: Well, and people really talked about a believability gap around the Dobbs decision, even though the activists who were following it closely were screaming that Roe is toast, from the moment the Supreme Court agreed to hear the case, and especially after they heard the case and people heard the tone of the arguments. And then of course the decision leaked, and even then there was a believability gap. And until it was actually gone, a lot of people just didn’t think that was possible. And I think you’re seeing that again around the idea of a national ban, and you’re seeing it around the idea of restrictions on contraception and IVF. There’s still this believability gap despite the evidence we’ve seen.听

Rovner: All right. I think we have time for one more question.听

Meg: Hi, my name’s Meg. I’m a freelance writer, and I wanted to ask you about something I’m not hearing about this election cycle, and that’s guns. Where do shootings and school shootings and gun violence fit into this conversation?听

Keith: I think that we have heard a fair bit about guns. It’s part of a laundry list, I guess you could say. In the Kamala Harris stump speech, she talks about freedom. She talks about reproductive freedom. She talks about freedom from being shot, going to the grocery store or at school. That’s where it fits into her stump speech. And certainly in terms of Trump, he is very pro–Second Amendment and has at times commented on the school shootings in ways that come across as insensitive. But for his base 鈥� and he is only running for his base 鈥� for his base, being very strongly pro–Second Amendment is critical. And I think there was even a question maybe in the Univision town hall yesterday to him about guns.听

It is not the issue in this campaign, but it is certainly an issue if we talk about how much politics have changed in a relatively short period of time. To have a Democratic nominee leaning in on restrictions on guns is a pretty big shift. When Hillary Clinton did it, it was like: Oh, gosh. She’s going there. She lost. I don’t think that’s why she lost, but certainly the NRA [National Rifle Association] spent a lot of money to help her lose. Biden, obviously an author of the assault weapons ban, was very much in that realm, and Harris has continued moving in that direction along with him, though also hilariously saying she has a Glock and she’d be willing to use it听

Ollstein: And emphasizing [Minnesota governor and Democratic vice presidential candidate Tim] Walz’s hunting.听

Keith: Oh, look, Tim Walz, he’s pheasant hunting this weekend.听

Rovner: And unlike John Kerry, he looked like he’d done it before. John Kerry rather famously went out hunting and clearly had not.听

Keith: I was at a rally in 2004 where John Kerry was wearing the jacket, the barn jacket, and the senator, the Democratic senator from Ohio hands him a shotgun, and he’s like 鈥� Ehh.听

Kirzinger: I was taken aback when Harris said that she had a Glock. I thought that was a very interesting response for a Democratic presidential candidate. I do think it is maybe part of her appeal to independent voters that, As a gun owner, I support Second Amendment rights, but with limitations. And I do think that that part of appeal, it could work for a more moderate voting block on gun rights.听

Rovner: We haven’t seen this sort of responsible gun owner faction in a long time. I mean, that was the origin of the NRA.听

Keith: But then more recently, Giffords has really taken on that mantle as, We own guns, but we want controls.听

Rovner: All right, well, I could go on for a while, but this is all the time we have. I want to thank you all for coming and helping me celebrate my birthday being a health nerd, because that’s what I do. We do have cake for those of you in the room. For those of you out in podcast land, as always, if you enjoy the podcast, you could subscribe wherever you get your podcast.听

We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our technical guru, Francis Ying, and our editor, Emmarie Huetteman, and our live-show coordinator extraordinaire, Stephanie Stapleton, and our entire live-show team. Thanks a lot. This takes a lot more work than you realize. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @麻豆女优.org, or you can still find me. I’m at X at Tam, where are you on social media?听

Keith: I’m @.听

Rovner: Alice.听

Ollstein: .听

Rovner: Cynthia.听

Cox: .听

Rovner: Ashley.听

Kirzinger: .听

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

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The 48-year-old, who works as the office manager at a nonprofit, can get emergency care through a narrow set of benefits the state makes available to immigrants without legal residency. And she has been able to get mammograms, X-rays, and blood tests at clinics that charge according to income. But it can take a long time to get such appointments, and they are often far from home.

“It’s very frustrating, because you have to have the time to go, and you can’t just lose a day of work,” says Milagro, who asked that her last name be withheld due to fear of immigration authorities.

Milagro and her husband are among the more than 700,000 immigrants ages 26-49 expected to newly qualify for full health insurance come Jan. 1. That’s when California takes the final step in opening up Medi-Cal, the state’s health care program for low-income residents, to everyone who meets eligibility requirements, regardless of their immigration status.

As I have frequently reported, getting quality care through Medi-Cal can be a challenge. But this population 鈥� often household breadwinners who can’t afford to get sick 鈥� stand to gain far better access to services such as primary and specialty care, routine dental checkups, prescription medications, inpatient hospital care, lab tests, scans, and mental health services.

New enrollees will join more than 655,000 children, young adults through age 25, and adults 50 or over who have already signed up for Medi-Cal through previous expansions to residents lacking legal authorization, according to the most recent data from the state Department of Health Care Services.

Advocates for immigrants note that people without health insurance are . “This is life-changing for people to now be able to go get regular checkups, get labs drawn, see if they might be diabetic or have high blood pressure,” says Sarah Dar, policy director in the Los Angeles office of the California Immigrant Policy Center.

Milagro says she is excited about what is coming. “I never had regular checkups when I was younger,” she says. “Now, I am more conscious of the fact that I need to take care of my health.”

Extending full Medi-Cal coverage to eligible individuals in the 26-49 age range regardless of immigration status the state $1.4 billion in the first six months and $3.4 billion a year upon full implementation.

The of just over 700,000 new enrollees is based on the number of people in the age group who are already signed up for a narrower set of benefits, known as “restricted scope” Medi-Cal, including Milagro. They will be automatically switched over to full Medi-Cal on Jan. 1. The state has begun mailing notices informing them of expanded benefits and directing them to choose a Medi-Cal health plan unless they live in a county with only one plan.

The remaining residents in the 26-49 age range covered by this expansion will be harder to reach because the state does not know who, where, or how numerous they are. Patient advocates, community groups, and county welfare offices face a number of obstacles: language barriers, wariness of governmental agencies, and fear that signing up for public benefits could jeopardize the chances for legal residency.

One challenge is to convince immigrants that being on Medi-Cal is unlikely to affect their future immigration status under the so-called . Advocates point out that California doesn’t share enrollees’ information with federal immigration authorities anyway.

But the fierce anti-immigrant sentiment that was so prevalent during the Trump administration and lingers as the nation gears up for the 2024 elections “sent a message to these communities that they should live in the shadows and are not deserving of benefits,” says Dar.

Even those already in the restricted version of Medi-Cal will be a challenge to reach if their contact information is not up to date. And they could be unaware that they were part of Medi-Cal at all. If, for example, they had a health crisis, were taken to the emergency room, and were simply asked by hospital staff to sign some paperwork to cover their treatment, they might not understand what a mailing from Medi-Cal means.

And some may fear any contact by the government. Lena Silver, director of policy and administrative advocacy at Neighborhood Legal Services of Los Angeles County, says she conducted a training session where a woman who works with day laborers said many of them were afraid to open the envelopes they’d received.

The Department of Health Care Services is spearheading an outreach campaign in 19 languages that includes ads on radio, TV, and social media.

Potentially complicating matters is the fact that the expansion of health benefits to this last 鈥� and largest 鈥� group of immigrants coincides with the so-called Medi-Cal unwinding, in which over and counting have been disenrolled, mostly due to incomplete paperwork, as pandemic-era exemptions expire.

Immigrants with restricted Medi-Cal must also demonstrate their continued income eligibility in the unwinding, which can be confusing when such a request is piled on top of notices informing them of their newly expanded benefits.

If you, a friend, or a loved one is an immigrant without legal residency, resources are available to help navigate the Medi-Cal enrollment process. on the Department of Health Care Services website () explains the expansion and contains in multiple languages detailing the new benefits that come with it.

If you need help enrolling in a Medi-Cal plan or filling out forms to demonstrate your eligibility, try the Health Consumer Alliance (, or 1-888-804-3536). Community clinics are also good sources, as are that administer Medi-Cal.

Brenda, a 33-year-old Los Angeles County resident who also asked to withhold her last name because she lacks legal immigration status, says it will be “a big old blessing” to get full Medi-Cal benefits. She arrived from Mexico as a child and has had to pay for most health care needs out of her own pocket. She rarely goes to the doctor, she hasn’t seen a dentist in three years despite toothaches, and her glasses are five years old.

Come January, she plans to be screened for breast cancer and diabetes, which runs in her family. And, she says, “I definitely want to fix my teeth. I always wanted a Colgate smile.”

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La mujer de 48 años, que trabaja como gerente administrativa en una organización sin fines de lucro, puede recibir atención de emergencia por un paquete limitado de beneficios que el estado pone a disposición de los inmigrantes sin papeles.

También ha podido tener sus mamografías, radiografías y análisis de sangre en clínicas que cobran en base a los ingresos del paciente. Sin embargo, conseguir citas lleva mucho tiempo y a menudo están lejos de su casa. “Es muy frustrante, porque tienes que tener tiempo para ir, y no puedes simplemente perder un día de trabajo”, dijo Milagro, quien pidió que no se publicara su apellido por temor a las autoridades de inmigración.

Milagro y su esposo se encuentran entre los más de 700,000 inmigrantes de entre 26 y 49 años que se espera que califiquen para el seguro de salud completo a partir del 1 de enero.

Ese día, California dará el paso final para abrir Medi-Cal, el programa de atención médica del estado para residentes con bajos ingresos, a todos los que cumplan con los requisitos de elegibilidad, independientemente de su estatus migratorio.

Como he informado con frecuencia, obtener atención de calidad a través de Medi-Cal puede ser un desafío. Pero esta población 鈥攁 menudo sostén económico del hogar que no puede permitirse enfermar鈥� podría obtener un acceso mucho mejor a servicios como atención primaria y especializada, chequeos dentales de rutina, medicamentos recetados, atención hospitalaria, análisis, pruebas de imagen, y servicios de salud mental.

Los nuevos inscritos se sumarán a más de 655,000 niños, adultos jóvenes de hasta 25 años y adultos de 50 años y más que ya se han registrado en Medi-Cal a través de expansiones anteriores para residentes sin papeles, según los datos más recientes del Departamento de Servicios de Atención Médica del estado. 听

Defensores de inmigrantes indican que las personas sin seguro médico generalmente . “Esto cambiará la vida de las personas que ahora podrán hacerse chequeos regulares, análisis, saber si pueden tener diabetes o hipertensión”, dijo Sarah Dar, directora de políticas en la oficina de Los Ángeles del California Immigrant Policy Center.

Milagro dice que está emocionada. “Nunca tuve chequeos regulares cuando era más joven”, dice. “Ahora, soy más consciente de que necesito cuidar de mi salud”.

Extender la cobertura completa de Medi-Cal a individuos elegibles de entre 26 y 49 años, independientemente de su estatus migratorio, $1.4 mil millones en los primeros seis meses y $3.4 mil millones al año con la implementación completa.

La de poco más de 700,000 nuevos inscritos se basa en el número de personas en el grupo de edad que ya están registradas para un conjunto más pequeño de beneficios, conocidos como Medi-Cal de “alcance limitado”, una de ellas, Milagro. Este grupo se transferirá automáticamente al Medi-Cal completo el 1 de enero.

El estado ha comenzado a enviar avisos informándoles de los beneficios ampliados y dirigiéndolos a elegir un plan de salud de Medi-Cal, a menos que vivan en un condado que solo tenga un plan.

Será más difícil llegar a los inmigrantes restantes en el grupo de 26 a 49 años cubiertos por esta expansión, ya que el estado no sabe quiénes son, dónde están ni cuántos son. Defensores de pacientes, grupos comunitarios y oficinas de bienestar de los condados enfrentan varios obstáculos: barreras de idioma, desconfianza en las agencias gubernamentales y el temor de que inscribirse en beneficios públicos pueda poner en peligro las posibilidades de obtener la tarjeta de residencia (green card).

Un desafío es convencer a los inmigrantes de que estar en Medi-Cal es poco probable que afecte su futuro estatus migratorio bajo la llamada .

Defensores señalan que California de todos modos no comparte la información de los inscritos con las autoridades federales de inmigración. Pero el fuerte sentimiento anti inmigrante que fue tan fuerte durante la administración Trump, y persiste mientras la nación se prepara para las elecciones de 2024, “envió un mensaje a estas comunidades de que deberían vivir en las sombras y de que no merecen beneficios”, explicó Dar.

Incluso será difícil encontrar a aquellos que ya están en la versión limitada de Medi-Cal si su información de contacto no está actualizada. Y podrían no ser incluso conscientes de que formaban parte de Medi-Cal. Si, por ejemplo, tuvieron una crisis de salud, los llevaron a la sala de emergencias y simplemente se les pidió que firmaran algunos documentos para cubrir su tratamiento, podrían no entender lo que significa recibir un correo de Medi-Cal.

Y algunos pueden temer cualquier contacto con el gobierno.

Lena Silver, directora de políticas y defensa administrativa en Neighborhood Legal Services of Los Angeles County, dijo que condujo una sesión de capacitación donde una mujer que trabaja con jornaleros dijo que muchos tenían miedo de abrir los sobres que habían recibido.

El Departamento de Servicios de Atención Médica está liderando una campaña de divulgación en 19 idiomas que incluye anuncios en radio, televisión y redes sociales.

Lo que potencialmente complica las cosas es el hecho de que la expansión de los beneficios de salud a este último (y más grande) grupo de inmigrantes coincide con la llamada cancelación de Medi-Cal, en la que más de 900,000 beneficiarios, hasta ahora, han sido eliminados del programa, principalmente debido a trámites incompletos, al expirar las exenciones por la pandemia.

Los inmigrantes con Medi-Cal limitado también deben demostrar que continúan siendo elegibles en base a sus ingresos, para evitar ser eliminados en el proceso de cancelación, lo que también puede resultar confuso cuando dicha solicitud se suma al aviso que les informa sobre sus nuevos beneficios recién ampliados.

Si tú mismo eres indocumentado, o un amigo o un ser querido, hay recursos disponibles para ayudar a navegar el proceso de inscripción en Medi-Cal. en el sitio web del Departamento de Servicios de Atención Médica () explica la expansión y tiene en varios idiomas detallando los nuevos beneficios.

Si necesitas ayuda para inscribirte en un plan de Medi-Cal o llenar formularios para demostrar tu elegibilidad, prueba con Health Consumer Alliance ( o 1-888-804-3536).

Las clínicas comunitarias también son buenas fuentes, al igual que las que administran Medi-Cal.

Brenda, residente del condado de Los Ángeles de 33 años que también pidió que no se publicara su apellido porque no tiene papeles, dijo que será “una gran bendición” obtener beneficios completos de Medi-Cal.

Brenda llegó desde México cuando era niña y ha tenido que pagar la mayoría de sus necesidades de atención médica de su propio bolsillo. Rara vez va al médico, no ha visto a un dentista en tres años a pesar de los dolores de muelas, y ha usado los mismos anteojos por cinco años.

En enero, planea hacerse una prueba de detección de cáncer de mama y diabetes, que es frecuente en su familia. Y dijo: “definitivamente quiero arreglar mis dientes. Siempre he querido una sonrisa Colgate”.

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Click here for a transcript of the episode.

The lame-duck Congress is back in Washington with a long list of bills it would like to pass and a short time to do it before Republicans take over the House majority in January. How many health-related items can be accomplished depends largely on how much money Congress agrees to spend overall, as it hashes out the annual federal spending bills.

Meanwhile, some of the remaining states that have not yet expanded the Medicaid program may be warming up to the idea, particularly North Carolina and Kansas, which have Democratic governors and Republican legislatures.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

• How much the lame-duck Congress manages to accomplish will partly hinge on whether congressional leaders opt for an omnibus spending bill 鈥� which would complete the unfinished spending bills through September 2023 鈥� versus a continuing resolution, which would simply extend what’s already on the books into sometime in the new year. Bottom line: Health priorities are competing for a pot of money, but it’s unclear how large that pot will be. Some insiders describe it as a traffic jam.
• At the top of that list are FDA reforms that didn’t make it into the prescription drug user-fee reauthorization bill that passed this year. Lawmakers fought to keep that measure “clean,” leaving the door open to tackle some leftover issues. What, if anything, will make the final cut is yet to be seen.
• Other things on the lame-duck list include reversing a 4% scheduled cut to Medicare providers’ reimbursements; weighing proposals related to pandemic preparedness; addressing Medicaid funding for U.S. territories; addressing the end of the public health emergency; and scrutinizing telehealth policy.
• Among the states that have yet to expand Medicaid under the Affordable Care Act, action is possible by those with a Democratic governor and Republican legislature 鈥� Kansas and North Carolina, in particular. Advocates are targeting such places because coverage for hundreds of thousands of people could be at risk, especially as the official end of the public health emergency looms. The financial well-being of some rural and safety-net hospitals also is in jeopardy.
• Georgia is poised to expand Medicaid eligibility somewhat, but only to people who can prove they worked or did community service for 80 hours per month. This comes after a federal judge ruled that the Biden administration’s move to cancel a Trump administration-approved waiver was “arbitrary and capricious.” The only other Medicaid work requirement that has taken effect, in Arkansas, ended up taking coverage away from thousands of people who were eligible and working, due to its complicated reporting system.
• Anti-abortion groups seem keen on finding creative ways to take aim at the so-called abortion pill, which recently became the most common method of ending pregnancy in the United States. Medication abortions are much more difficult for anti-abortion groups to target, because women do not have to go to a clinic to receive the drugs.
• One lawsuit sought to force the FDA to rescind its approval of mifepristone, dating to 2000. Anti-abortion groups say the agency didn’t have the authority to approve the drug through the “expedited” pathway it chose.
• Another strategy from anti-abortion groups claims that the use of abortion pills is contaminating wastewater and groundwater; they seek to deploy environmental laws to block the use of the drugs.
• Despite Americans’ desire to put the covid-19 pandemic in the rearview mirror, the virus may have other plans. The Biden administration wants another $10 billion before the end of the year to pay for its anti-covid campaign, although even Democrats in Congress are not pushing hard for that funding. Meanwhile, governments and social media platforms are still struggling to address covid misinformation and disinformation.

Also this week, Rovner interviews KHN’s Fred Clasen-Kelly, who reported and wrote the latest KHN-NPR “Bill of the Month,” about a mysterious mishap during minor surgery. If you have an enormous or mystifying medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “,” by Lev Facher

Alice Miranda Ollstein: ProPublica and The New York Times’ “,” by Lizzie Presser

Rachel Cohrs: The New Yorker’s “” by Ava Kofman

Sarah Karlin-Smith: The New York Times’ “,” by Shaila Dewan

Also mentioned in this week’s episode:

• Stat’s “,” by Rachel Cohrs
• Politico’s “,” by Alice Miranda Ollstein
• KHN’s “Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care,” by Markian Hawryluk

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And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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