Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.

Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
• ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
• A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes 鈥� though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
• As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Also this week, Rovner interviews 麻豆女优 Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.

Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “,” by Joedy McCreary.

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by Paul Kane.
• HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
• Politico’s “,” by Alice Miranda Ollstein.
• JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

[Editor’s note:听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:听Hello from 麻豆女优 Health News and WAMU听public听radio in Washington, D.C., and welcome to听What the Health?听I’m听Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and听I’m听joined by some of the best and smartest health reporters in Washington.听We’re听taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go.听

Today,听we are joined via video conference by Anna Edney听of听Bloomberg News.听

Anna Edney:听Hi, everyone.听

Rovner:听Alice [Miranda]听Ollstein听of Politico.听

Alice Miranda听Ollstein:听Hello.听

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

Joanne Kenen:听Hi, everybody.听

Rovner:听Later in this episode,听we’ll听have my interview with 麻豆女优 Health News’听Elisabeth Rosenthal, who reported and wrote the latest听“Bill of the Month,”听about an ER trip, a scorpion pepper, and a ghost bill. But first,听this week’s news.听Let’s听start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three听years听the Affordable Care Act’s expanded subsidies听鈥斕齮he ones that expired Jan. 1.听听

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.听听

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are听very nearly听鈥斕齣n the words of longtime Congress watcher听听鈥斕齛听[majority]听in name only, which I guess is pronounced听“MINO.”听Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise听fairly routine听labor bill.听Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the听House’s Democrats听to pass听the bill and send听it to the Senate.听But it seems that the bipartisan efforts in the Senate to get a deal are losing steam.听What’s the latest you guys are hearing?听

Ollstein:听Yeah, so it听wasn’t听a good sign when the person who has听sort of come听out as a leader of these bipartisan negotiations,听Ohio Sen.听Bernie听Moreno, at first came out听very strong听and said,听We’re听in the end zone.听We’re听very听close听to a deal.听We’re听going to have听bill听text.听And that was several days ago, and now听they’re听saying that听maybe听they’ll听have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and,听from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before.听There is听not听agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it听should听treat abortion.听

And听so听the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a听nonstarter听for most, if not all, Democrats.听So听I听don’t听know where we听go听from here.听

Rovner:听Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They听seem to听[be]听making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can听come up with听a bill that can get 60 votes in the Senate and a majority in the much more conservative House?听That is a pretty narrow needle to thread.听I听don’t听think abortion is going to be a听huge issue in听Labor,听HHS,听because听that’s听where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the听House听[is]听probably not so excited about putting all of that money back.听I’m听just wondering if there really is a deal to be had, or if听we’re听going to see for the,听you know, however many听year[s]听in a row, another continuing resolution, at least for the Department of Health and Human Services.听

Ollstein:听Well,听you’re听hearing a lot more optimism from lawmakers about the spending bill than you are about a[n]听Obamacare subsidy deal or any of the other things that听they’re听fighting about. And I would say,听on the听spending,听I think the much bigger fights听are going to be outside the health care space. I think听they’re听going to be about immigration, with everything听we’re听seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts.听On health,听yes, I think听you’ve听seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it听impacts听their districts and their voters too. So that makes sense.听

Kenen:听We’ve听also seen the Congress vote for spending that the administration听hasn’t听been spent.听So听Congress has just voted on a series of things about science funding and other听health-related听issues, including global health. But it remains to be seen whether this administration takes appropriations as law or听suggestion.听

Rovner:听So听while the effort to revive the听additional听ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago.听Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital听outpatient payments,听and continued funding for community health centers. Could that finally become law? That thing that they said,听Oh,听we’ll听pass it first thing next year, meaning 2025.听

Edney:听I think听it’s听certainly looking more likely than the subsidies that听we’ve听been talking about. But I do think听we’ve听been here before several times, not just at the end of last year听鈥斕齜ut,听like with these PBM reforms, I feel like they have certainly gotten to a point where听it’s听like,听This听is happening.听It’s听gonna听happen.听And, I mean,听it’s听been years, though, that听we’ve听been talking about pharmacy benefit manager reforms in the space of drug pricing.听So basically, you听know, from听when听[President Donald]听Trump won. And so, you know, I say this with, like, a huge amount of caution:听Maybe.听

Rovner:听Yeah, we will, but听we’ll听believe it when听鈥μ齱e get to the signing ceremony.听

Ollstein:听Exactly.听

Rovner:听Well, back to the Affordable Care Act, for which enrollment in most states听end听today.听We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies.听Sign-ups on the federal marketplace are down about听1.5听million from the end of last year’s enrollment period, and听that’s听before most people听have to听pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans.听I’m听wondering if these early numbers听鈥斕齱hich are听actually stronger听than many predicted, with fewer people听actually dropping听coverage听鈥斕齬eflect people who signed up hoping that Congress might听actually renew听the subsidies this month. Since we kept saying that was听possible.听

Ollstein:听I would bet that most people are not following the听minutiae of听what’s听happening on Capitol Hill and have no听idea听the mess听we’re听in,听and听why,听and听who’s听responsible. I would love to be wrong about that. I would听love for听everyone to be super informed.听Hopefully听they听listen听to this podcast. But you know, I think that a lot of people just听sign up听year after year and听aren’t听sure of听what’s听going on until听they’re听hit with the giant bill.听听

Rovner:听Yeah.听

Ollstein:听One thing I will point out about the emerging numbers is it does show,听at least early indications,听that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans,听that’s really working.听You’re听seeing听enrollment up听in some of those states, and so I wonder if听that’ll听encourage any others to get on board as well.听

Kenen:听But听鈥� I think what Julie said听is听it’s听鈥μ齮he follow-up is less than expected. But for the reasons Julie just听said听is that you haven’t gotten your bill yet.听So听either you听haven’t听been paying attention, or听you’re听an optimist and think听there’ll听be a solution.听So, and听people might even pay their first bill thinking that听there’ll听be a solution next month, or that听we’re听close. I mean, I would think听there’d听be drop-off soon, but there might be a steeper听cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because听they’re听not as bad as some听people听forecast听doesn’t听say that this is going to be a robust coverage year.听

Edney:听And I think,听I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up,听are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out听in other aspects?听I听think听will be听..听of the economy of jobs, like, where does that lead听us? I听think听will be something to watch out for too.听

Rovner:听And by the way, in case you’re wondering why health insurance is so expensive, we got the听, and total health expenditures grew by 7.2% from the previous year to听$5.3 trillion, or 18% of the nation’s GDP听[gross domestic product],听up from 17.7% the year before. Remember, these are the numbers for 2024,听not 2025,听but it makes听it听pretty听hard听for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because听we’re听spending more on health care.听It’s not really that complicated, right?听

Kenen:听This 17%-18% of GDP has been听pretty consistent, which听doesn’t听mean听it’s听good;听it just means听it’s听been around that level for many, many, many years. Despite all the talk about听how it’s听unsustainable,听it’s听been sustained,听with pain, but sustained.听$5.7 trillion,听even if听you’ve听been doing听this听a long time听鈥μ�

Rovner:听It’s听$5.3 trillion.听

Kenen:听$5.3 trillion.听It’s听a mind-boggling听number.听It’s听a lot of dollars!听So the ACA made insurance more听鈥斕齮he out-of-pocket cost of insurance for millions of Americans, 20-ish million听鈥斕齜ut the underlying burden we’ve not solved听the 鈥� to use the word of the moment, the听“affordability”听crisis in health听care is still with us and arguably getting worse. But like, I think听we’re听sort of numb. These numbers are just so insane, and yet you say听it’s听unsustainable, but听鈥μ齀 think it听was听Uwe’s听line, right?听

Rovner:听It was, it was a famous听Uwe听Reinhardt line.听

Kenen:听No,听it’s听sustainable, if听we’re听sustaining it at a high听鈥斕齣n听economically听鈥斕齴any price.听听

Rovner:听Right.听

Kenen:听And, like, the other thing is, like, where is the money?听Right? Everybody in health听care says they听don’t听have any money, so I听can’t听figure out who has the听$5 trillion.听

Rovner:听Yeah, well, it’s not听鈥μ齣t does not seem to be the insurance companies as much as it is,听you know, if you look at these numbers听鈥斕齛nd I’ll post a link to them听鈥斕齳ou know, it’s hospitals and drug companies and doctors and all of those who are part of the health听care industrial complex, as I like to call听it.听

Kenen:听All听of them say they听don’t听have enough.听听

Rovner:听Right.听All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate听health听committee听chairman and ardent anti-abortion听senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about听the reputed dangers of the abortion pill,听mifepristone.听Alice, like me, you watched yesterday’s hearing. What was your takeaway?听

Ollstein:听So, you know, in a sense, this was a show hearing. There听wasn’t听a bill under consideration. They听didn’t听have anyone from the administration to grill. And听so听this is just听sort of your听typical听each side听tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside听鈥斕齮hey’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill.听Their bigger goal is outlawing all abortion,听but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting.听And听so听they’re听frustrated that, you know, both听[Robert听F.]听Kennedy听[Jr.]听and听[Marty]听Makary have promised some sort of review or action on the abortion pill, and they say,听We听want to see it.听Why haven’t you done it yet?听And听so听I think that pressure听is only going to mount, and this hearing was part of that.听

Rovner:听I was fascinated by the Louisiana听attorney听general saying,听basically,听the听quiet part听out loud, which is that听we banned abortion, but because of these abortion pills, abortions are still going up in our state.听That was the first time I听think听I’d听heard an official say that. I mean that,听if you wonder why听they’re听going after the abortion pill,听that’s听why听鈥斕齜ecause they听struck down听Roe听[v. Wade]听and assumed that the number of abortions would go down, and it really has not, has it?听

Ollstein:听That’s听right. And so not only are people increasingly using pills to听terminate听pregnancies, but听they’re听increasingly getting them via telemedicine.听And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal.听You know, a lot of people just really prefer the telemedicine option,听whether because听it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons.听So听the right听鈥斕齳ou know, again, including senators like Cassidy, but also these activist groups听鈥斕齮hey’re听saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And听they’re听pretty open听about saying that.听听

Rovner:听Well, rather听convenient timing from the听, which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single听time, except once, and that once was during the first Trump administration.听Alice,听is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications?听There were,听how many, like 100,听more than 100 peer-reviewed听studies that听basically听show听this,听plus the experience of many millions of women in the United States and around the world.听

Ollstein:听Well, just like听I’m听skeptical that听there’s听any compromise that can be found on the Obamacare subsidies,听there’s听just no compromise here. You know, you have the groups that are making these arguments about the pills’听safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it听can’t听be health care if听it’s听designed to end a life, and that kind of rhetoric. And听so听the focus on the rate of complication听鈥μ齀 mean,听I’m听not saying听they’re听not genuinely concerned. They may be, but, you know, this is one of many tactics听they’re听using to try to curb access to the pills.听So听it’s听just one argument in their arsenal.听It’s听not听their,听like,听primary driving, overriding goal is, is the safety which, like you said, has been well听established听with many, many peer-reviewed studies over the last several years.听

Rovner:听So, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein:听It was one pot of money听they’re听fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last听summer,听those are still in place. And so听that’s听an order of magnitude more than this pot of听Title听X听family planning money that they just got back. So that aside,听I’ve听seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and听it’s听a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a听patient,听you can then听submit听for reimbursement. And听so听if the clinic’s not there,听it’s听not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.听听

Rovner:听Yeah.听The wheels of the courts, as we have seen, have moved very slowly.听

OK,听we’re听going to take a quick break. We will be right back.听

So听while abortion gets most of the headlines,听it’s听not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that听a majority of听justices would strike down the laws,听which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue听in recent weeks.听The House passed a bill in December, sponsored by now former Republican听congresswoman听Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide.听And the Department of Health and Human Services issued proposed regulations just before Christmas that听wouldn’t听go quite that听far, but听would have听roughly the听same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid听funding, and听would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote,听“does not meet professionally recognized standards of health care,”听and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports听team听exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors?听That’s听what this would do.听

Edney:听Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that听we’re听even talking about. And so those who are against it have done an effective job of making that听the issue. And so there听鈥μ齱ho support gender-affirming care, who have听looked into听it, would see that a lot of this is hormone treatment, things like that, to drugs听鈥μ�

Rovner:听Puberty blockers!听

Edney:听鈥μ齮hey’re taking听鈥斕齟xactly听鈥斕齛nd so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think,听too,听talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them.听So听I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like听that that’s kind of winning the day.听

Kenen:听I think,听like,听from the beginning, because, like, five or six years ago was the first time I wrote about this. The听playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now听they’re听talking about it in protecting children’s health. And,听as Anna said,听they’re听using words like mutilation. Puberty blockers are not听mutilation. Puberty听blockers are a medication that delays the onset of puberty, and it is not irreversible.听It’s听like a听brake. You take your foot off the brake,听and puberty starts.听There’s听some controversy about what age and how long, and听there’s听some听possible bone听damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now听鈥斕齧ost of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids,听cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body.听So听you know, I think it’s really important to repeat听鈥μ齮he point that Anna made, you know, 12-year-olds are not getting major surgery.听Very few minors are, and when they are,听it’s听closer听鈥� they听may be under 18,听it’s听rare. But if听you’re听under 18,听you’re听closer to 18,听it’s听later in听teens. And听it’s听not like you walk into an operating room and say, you know,听do this to me.听There’s听years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania,听in particular.听This is something that people听don’t听understand and get听very upset听about, and the inflammatory听language,听it’s听not creating understanding.听

Rovner:听We’ll听see how听this one plays听out. Finally, this week, things at the Department of Health and Human Services听continues听to be chaotic. In the latest round of听“we’re cutting you off because you don’t agree with us,”听the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees听canceling听their funding听immediately.听It’s听not entirely clear how many grants or how much money was involved, but it听appeared to be听something听in the neighborhood of听$2 billion听鈥斕齮hat’s听around a fifth of SAMHSA’s听entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then,听Wednesday night, after a furious backlash from Capitol Hill and听just about every听mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts.听Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?听听

Edney:听That is听a great question. I really听don’t听know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly,听like there was a听miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS.听

Rovner:听I听didn’t听count, but I got dozens of emails yesterday.听听

Edney:听Yeah.听

Rovner:听My entire email box was overflowing with people听basically freaking听out about these cuts听to SAMHSA. Joanne,听you wanted听to say something?听

Kenen:听I think that one of the shifts over听鈥斕齀’m not exactly sure how many years听鈥斕�7,听8,听9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue.听It’s听not that everybody thinks that.听It’s听not that every lawmaker thinks that, but we have really turned this into, we听have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the听“deaths of despair.”听Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is,听you know,听you’ve听had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes听鈥斕齭ome of the听“Opioid听Belts”听are very conservative states,听and Republican governors, you know, really saying we’ve had progress.听Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their听telephones, they听were bombarded.听听

Rovner:听Yeah.听Well, meanwhile, several听hundred听workers have听reportedly been听reinstated at the National Institute of Occupational Safety and Health听鈥斕齮hat’s听a听subagency of CDC听[the Centers for Disease Control and Prevention].听Except that those RIF听[reduction in force]听cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work?听And in news from the National Institutes of Health,听Director Jay Bhattacharya told a podcaster last week that the DEI-related听[diversity, equity, and inclusion]听grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard听Pazdur听said at the J.P.听Morgan听[Healthcare] Conference in San Francisco this week that the听firewall听between the political appointees at the agency and its career听drug reviewers has been,听quote,听“breached.”听How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots?听

Ollstein:听Not to mention听all of听this back and forth and chaos and starting and stopping is costing more,听is costing taxpayers more.听Overall spending is up. After all of the听DOGE听[Department of Government Efficiency]听and听RIFs听and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it听hasn’t听even saved the government any money, either.听

Kenen:听Like, you know, the game we played when we were kids, remember,听“Red听Light-Green听Light,”听you know, you’d听run in one direction, you run back. And if you were听8听years old, it would end with someone crying. And that’s听sort of the听way听we’re听running the government听these听days听[laughs].听The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You听can’t听even keep track. You听don’t听even know what email to use if听you’re听trying to听keep听in听touch听with them听anymore. The churn,听with what logic?听It’s, as Alice said,听just听more expensive, but it’s,听it’s听also just听鈥μ齦ike听you听can’t听get your job done.听Even if you want a smaller government, which many of conservatives and Trump people do,听you still want certain functions fulfilled.听But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring.听I mean, the American public is not against research, and the American public is not against keeping people alive.听You know, the inconsistency is pretty mind-boggling.听

Edney:听Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is听it听kind of seems听like the message as听anybody can do this part, because听it’s听all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different,听like you said, everyone wants research, but I,听Joanne, but I do think they only want certain kinds of research in this case.听So听it’s听been interesting to watch how many leaders in these agencies that are going away and not being replaced.听

Rovner:听And all the institutional memory听that’s听walking out the door. I mean,听more people听鈥斕齛nd to听Alice’s point about how this听hasn’t听saved money听鈥斕齧ore people have taken early retirement than have听been actually, you听know,听RIF’d听or fired or let go. I mean, they’ve just听鈥μ齛 lot of people听have basically, including听a lot of leaders of many of these agencies, said,听We听just听don’t听want to be here under these circumstances.听Bye.听Assuming at some point this government does want to use the Department of Health and Human Services to get things done,听there might not be the personnel around to actually effectuate it.听But we will continue to watch that space.听

OK, that’s this week’s news. Now we will play my听“Bill of the听Month”听interview with Elisabeth Rosenthal, and then we will come back and do our extra credits.听

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at听麻豆女优听Health听News and originator of our听“Bill of the Month”听series, which in its听nearly eight听years has analyzed听nearly $7 million听in dubious, infuriating,听or inflated medical charges. Libby also wrote the latest听“Bill of the听Month,”听which听we’ll听talk about in a minute. Libby, welcome back to the podcast.听

Elisabeth Rosenthal:听Thanks for having me back.听

Rovner:听So听before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated听are you that eight years on,听it’s听as relevant as it was when we began?听

Rosenthal:听We were听worried it听wouldn’t听last a year, and here we are, eight years later, still finding plenty to write about. I mean,听we’ve听had some wins.听I think we听helped contribute to the听No听Surprises听Act being passed.听There are听states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic,听it’s听the same cost. The听country’s听starting to address drug prices.听But,听you know, we听seem to be听the billing听police, and听that’s听not good.听We’ve听gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls,听they’re听like,听Oh, that was a mistake听or听Yeah,听we’re听going to write that off. And听I’m听like,听You’re听not writing that off;听that听shouldn’t听have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system听that听has听left,听as we know, you know, 100 million adult Americans with medical debt.听So听we will keep going until听it’s听solved,听I hope.听

Rovner:听Well, getting on to this month’s patient, he gives new meaning to the phrase听“It must have been something I ate.”听Tell us what it was and how he ended up in the emergency room.听

Rosenthal:听Well, Maxwell听[Kruzic]听loves eating spicy foods, but听he’s听never had a problem with it. And suddenly, one night, he had just听excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right?听So听they were all听like,听ready to go to the operating room. And then the scan came back, and it was like,听whoops,听his appendix is normal. And then,听oh, could he have kidney stones?听And听it’s听like no sign of that either. And finally, he thought, or someone asked,听Well, what did you eat last night?听And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million听[Scoville heat units], which is,听like,听through the roof, and it was a reaction to the chili peppers.听I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff.听

Rovner:听So听in the end, he was听OK.听And the story here isn’t even really about what kind of care he got, or how much it cost.听The $8,000 the hospital charged for his few hours in the ER听doesn’t听seem all that out of line compared to some of the bills听we’ve听seen.听What was most notable in this case was the fact that the bill didn’t actually come until two years later.听How much was he asked to pay two years after the hot pepper incident?听

Rosenthal:听Well, he was asked to pay a little over $2,000,听which was his coinsurance for the emergency room visit. And as he said, you know, $8,000听鈥μ齨ow we go,听well,听that’s听not bad.听I mean, all they did,听actually, was do a couple of scans and give him some IV fluids.听But听in this day and age,听you’re听like, wow, he got away听鈥� you know, from听a听“Bill of a听Month”听perspective, he got away cheap, right?听

Rovner:听But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later?听

Rosenthal:听That’s听the problem,听like,听and Maxwell听鈥斕齢e’s听a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept听thinking,听I must owe something. And he checked and he听checked听and he checked and it kept saying zero. He actually called his听insurer and听to make sure that was right. And they said,听No, no, no,听it’s听right. You owe zero. And then, you know, after like, six months, he thought,听I guess I听owe zero. But then he听didn’t听think about it, and then almost two years later, this bill arrives in the mail, and听he’s听like,听What?!听And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at听“Bill of the听Month,”听and in many cases, it’s legal, because听of听what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like,听Yeah, you know, someone was away on vacation, and someone left their job, and we听couldn’t听鈥μ齳ou know, the hospital听billed them听correctly. And the hospital said,听No, we听didn’t.听And they were just听kind of doing听the usual听back-end negotiations to figure out what a service is worth.听And when they finally agreed two years later听what should be paid,听that’s听when they sent Maxwell the bill. And the problem听is,听whether听it’s听legal really depends on your insurance contracts, and whether they allow this kind of late billing.听I do not know to this day if Maxwell’s did, because as soon as I called the insurer听and听the hospital, they were like,听Never听mind. He听doesn’t听owe听anything. And you know, as he said,听he’s听a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said,听Whoops, I forgot to bill for something, they would be like,听Forget听it!听you听know.听So听I do think this is something that needs to be addressed at a policy level, as we so often discover on听“Bill of the听Month.”听

Rovner:听So听what should you do if you get one of these ghost bills? I should say听I’m听still negotiating bills from a surgery that I had six months ago.听So听I guess I should听count听myself lucky.听

Rosenthal:听Well, I think you should check with your insurer and check with the hospital. I think more听with听your insurer听鈥斕齣f the contract says this is legal to bill.听It’s听unclear听to me,听in this case, whether it was.听The hospital was very much like,听Oh, we made a mistake;听because it took so long,听we听actually听couldn’t听bill Maxwell.听So听I think in his case, it听probably was听in the contract that this was too late to听bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude.听Well,听doesn’t听hurt to try, you know,听maybe听they’ll听pay听it. And people are afraid of bills, right? They听pay听them.听听

Rovner:听I know the feeling.听

Rosenthal:听Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations,听essentially,听on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say,听Well, we won’t pay this.听

Rovner:听And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least听modified听them?听

Rosenthal:听He said he will never eat听scorpion peppers again.听

Rovner:听Libby Rosenthal, thank you so much.听

Rosenthal:听Oh, sure.听Thanks听for having me.听

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

Edney:听Sure.听So听my extra credit is from听MedPage听Today:听“.”听I appreciated this article because it answered some questions that I had,听too,听after the sweeping change to the childhood vaccine schedule. There听was听just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will听parents听be confused? Will pediatricians听鈥斕齢ow will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA听Perspectives听that lays out, essentially, to听clinicians, you know, that they should not fear malpractice听..听issues if听they’re听going to talk about the old schedule and not adhere to the newer schedule. And听so听it lays out some of those issues.听And I thought that was really helpful.听

Rovner:听Yeah, this was a big question that I had,听too.听Alice, why don’t you go next?听

Ollstein:听Yeah, so I have a piece from ProPublica.听It’s听called听“.”听So听this is about how听there’s听been this huge push on the right to end public water fluoridation that has succeeded in a听couple听places and could spread more. And the proponents of doing that say that听it’s听fine because there are all these other sources of fluoride. You can get听a treatment听at the听dentist,听you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who听arepushing听for ending fluoridated public drinking water听are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus听all of听the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged听neurological impacts. But it also,听that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what听that’s听going to do to the nation’s teeth?听

Rovner:听Yeah,听it’s听like vaccines. The more you听talk听it听down,听the less people want to do it.听Joanne.听

Kenen:听This is听a piece by听Dhruv Khullar听in听The New Yorker called听“,”听and it was really great, because there’s certain things I think that we who听鈥斕齦ike, I don’t know how all of you watch it听鈥斕齜ut like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED听[emergency department]听have, you know, homelessness problems and can’t afford food and all that. But听Dhruv听talked听about听how it听sort听of brought that home to him, how our social safety net, the holes in it, end up in our听EDs.听And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient听a听day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER听scene.听It’s听just a very thoughtful piece about why we all love that TV show. And听it’s听not just because of听Noah Wyle.听

Rovner:听Although that helps. My extra credit this week is from听The New York Times.听It’s听called听“,” by Maxine听Joselow.听And while it’s not about HHS, it most definitely is about health.听It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost听to听human health when setting clean air rules for ozone and fine particulate matter, quoting the story:听“That would most likely lower costs听for companies while resulting in dirtier air.”听This is just another reminder that the federal government is听charged with ensuring the help of Americans from a broad array of agencies, aside from HHS听鈥斕齩r in this case, not so much.听听

OK, that’s this week’s show.听As always, thanks to our editor, Emmarie听Huetteman,听and our producer-engineer, Francis Ying.听We also had听help听this week from producer Taylor Cook.听A听reminder:听What the听Health?听is now available on WAMU platforms, the NPR app,听and wherever you get your podcasts, as well as, of course, at听kffhealthnews.org.听Also, as always, you can email us your comments or questions.听We’re听at听whatthehealth@kff.org,听or you can find me still on X听, or on Bluesky听.听Where are you folks hanging these days?听Alice.听

Ollstein:听Mostly听on听Bluesky听听and still on听X听.听

Rovner:听Joanne.听

Kenen:听I’m听mostly on听听or on听听.听

Rovner:听Anna.听

Edney:听听or听X听.听

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

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Federally recognized tribes can’t directly apply for a share of the rural health fund 鈥� only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

麻豆女优 Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma 鈥� where more than 14% of the population is Native American, a higher share than in most other states 鈥� tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

麻豆女优 Health News South Dakota correspondent Arielle Zionts contributed to this report.

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Un poste naranja y una señal de “隆Atención!” al costado de una carretera marcan el lugar donde está enterrado un cable de fibra óptica.

“Tienen necesidades de atención médica, pero carecen de las habilidades digitales necesarias”, dijo Waiters, quien trabaja como navegadora digital para una organización sin fines de lucro de Alabama. Su trabajo ha consistido en regalar computadoras y tabletas, a la vez que imparte clases sobre cómo usar internet para el trabajo y necesidades personales, como el banco y la salud. “Es como un espacio extraño”.

Esas historias ahora tienen un sabor agridulce.

Wakers forma parte de una red de navegadores digitales en todo el país, cuyo trabajo para acercar a otros al mundo digital se financió, en parte, a través de un programa federal de $2.750 millones que canceló abruptamente su financiación esta primavera.

La suspensión se produjo después de que el presidente Donald Trump publicara en su plataforma que la Ley de Equidad Digital era inconstitucional y prometiera “隆no más ayudas a la conciencia pública basadas en la raza!”.

La ley detalla exactamente el dinero, incluyendo hogares de bajos ingresos, residentes mayores, algunas personas en cárceles, estadounidenses de zonas rurales, veteranos y miembros de minorías raciales o étnicas.

Políticos, investigadores, bibliotecarios y defensores afirmaron que la desfinanciación del programa, junto con otros cambios en las iniciativas federales de banda ancha, pone en peligro los esfuerzos para ayudar a los residentes rurales y desfavorecidos a participar en la economía moderna y llevar una vida más saludable.

“Se podían ver vidas cambiando”, dijo Sam Helmick, presidente de la Asociación Americana de Bibliotecas, recordando cómo ayudaron a abuelos en Iowa a consultar recetas médicas en línea o a trabajadores despedidos de fábricas a llenar solicitudes de empleo.

La Ley de Equidad Digital forma parte de la amplia ley de infraestructura de 2021, que incluyó $65.000 millones para construir infraestructura de internet de alta velocidad y conectar a millones de personas sin acceso a internet.

Este año, el Congreso impulsó una vez más un enfoque moderno para ayudar a los estadounidenses, exigiendo a los líderes estatales que priorizaran las tecnologías nuevas y emergentes a través de su Programa de Transformación de la Salud Rural, de $50.000 millones.

Un análisis de 麻豆女优 Health News reveló que casi 3 millones de personas a lo largo del país viven en zonas con escasez de profesionales médicos y donde los servicios modernos de telesalud suelen ser inaccesibles debido a las malas conexiones a internet.

El análisis reveló que en unos 200 condados, principalmente rurales, donde persisten las zonas sin cobertura, los residentes viven con mayor riesgo de enfermedad y mueren antes, en promedio, que las personas del resto del país. El acceso a internet de alta velocidad se encuentra entre una serie de factores sociales, como la alimentación y una vivienda segura, que ayudan a las personas a llevar una vida más saludable.

“Internet proporciona esta capa adicional de resiliencia”, afirmó Christina Filipovic, quien dirige la investigación de una iniciativa del Institute for Business in the Global Context de la Universidad de Tufts. , el grupo de investigación descubrió en 2022 que el acceso a internet de alta velocidad se correlacionaba con una menor mortalidad por covid-19, especialmente en áreas metropolitanas.

Durante la pandemia de covid, los legisladores federales lanzaron un programa de subsidios financiado por la ley de infraestructura. Esta ayuda, denominada Programa de Conectividad Asequible, buscaba conectar a más personas con sus trabajos, escuelas y médicos. En 2024, el Congreso no renovó la financiación del programa de subsidios, que había inscrito a unos 23 millones de hogares de bajos ingresos.

Este año, el secretario de Comercio de Estados Unidos, Howard Lutnick, renovó y retrasó la iniciativa de construcción de la ley de infraestructura 鈥攃onocida como Programa de Equidad, Acceso e Implementación de Banda Ancha (BEAD)鈥� tras anunciar planes para reducir las cargas regulatorias. Más de 40 estados y territorios han presentado propuestas finales para extender internet de alta velocidad a zonas desatendidas bajo las nuevas directrices de la administración, según un panel del .

En mayo, la financiación de la Ley de Equidad Digital se canceló pocos días después de la publicación de Trump en Truth Social. Si bien muchos estados recibieron fondos para planificar sus programas en 2022, la siguiente ronda de financiación, destinada a que los estados y las agencias implementaran los planes, se había otorgado en gran medida, pero no distribuido.

En cambio, los reguladores federales, incluida la Administración Nacional de Telecomunicaciones e Información (NTI), la agencia federal que supervisa la implementación de la Ley de Equidad Digital, que las subvenciones serían canceladas.

Se crearon y administraron con “preferencias raciales inconstitucionales”, según la carta.

En Phoenix, Arizona, las autoridades se enteraron en enero de que la ciudad recibiría $11,8 millones para aumentar el acceso a internet y enseñar alfabetización digital, pero recibieron un correo electrónico el 20 de mayo indicando que todas las subvenciones, “excepto las destinadas a Entidades Nativas”, habían sido canceladas.

“Es una pena”, declaró la alcaldesa de Phoenix, la demócrata Kate Gallego. El dinero, afirmó, habría ayudado a 37.000 residentes a obtener acceso a internet.

En julio, los líderes demócratas de Georgia a Lutnick y al entonces administrador interino de la NTIA, Adam Cassady, reclamando la restitución de los fondos, señalando que el recorte federal ignora la intención del Congreso y vulnera la confianza pública.

La creadora de la ley, la senadora Patty Murray (demócrata por Washington), declaró durante en línea en mayo que los gobernadores republicanos de 2024 apoyaron la ley y su financiación cuando cada estado promocionó la finalización de sus planes de equidad digital requeridos y solicitó recursos.

“No puedo creer que no haya gobernadores republicanos que se unan a nosotros para luchar contra esto”, declaró Murray, y agregó que “la otra vía es a través de los tribunales”.

Los 50 estados desarrollaron planes de equidad digital luego de meses de grupos focales, encuestas y períodos de consulta pública. La directora de Equidad Digital de la NTIA, Angela Thi Bennett, durante una entrevista en agosto de 2024 con 麻豆女优 Health News, afirmó que la “participación comunitaria deliberada” de los líderes federales y estatales para brindar banda ancha a las comunidades desatendidas fue “la mayor demostración de democracia participativa que nuestro país haya visto jamás”.

No fue posible contactar con Thi Bennett para que comentara sobre este artículo. El voceru de la NTIA, Stephen Yusko, afirmó que la agencia “no podrá atender” una solicitud de entrevista con Thi Bennett y no respondió a las preguntas para este artículo.

Caroline Stratton, directora de investigación del Instituto Benton para la Banda Ancha y la Sociedad, afirmó que la financiación de la ley permitió a los estados dotar de personal a sus oficinas; identificar programas de internet de alta velocidad existentes, incluyendo los que operan en otras agencias estatales; y crear planes para subsanar las deficiencias.

“Esto motivó a la gente a investigar”, explicó Stratton, para ver si las agencias del estado ya estaban trabajando en planes de mejora de la salud y para preguntarse si el trabajo en banda ancha podría contribuir y “ayudar activamente a mejorar la situación”.

Las solicitudes de subvenciones estatales incluían objetivos para . En Mississippi, el en una iniciativa para mejorar la salud de la universidad estatal y otra agencia, explicó Stratton.

Si bien los estados debían crear programas que ayudaran a poblaciones específicas cubiertas, algunos modificaron el lenguaje o agregaron subcategorías para incluir a otras poblaciones. El incluía a inmigrantes y a personas sin hogar.

“En todos los estados, hay una pérdida”, afirmó Angela Siefer, directora ejecutiva de la Alianza Nacional para la Inclusión Digital. La organización sin fines de lucro, que recibió para colaborar con organizaciones de todo el país, pero no recibió fondos, presentó una demanda el 7 de octubre para obligar a Trump y al gobierno a distribuir el dinero.

“La brecha digital no ha terminado”, declaró Siefer.

La subvención de la organización se había planificado para apoyar a los navegadores digitales en 11 estados y territorios, incluyendo a Waiters. Su empleador, la organización sin fines de lucro Community Service Programs of West Alabama, esperaba recibir una subvención de $1,4 millones.

En los últimos dos años, Waiters dedicó horas a recorrer las carreteras rurales de Alabama para llegar a los residentes. Ha distribuido 648 dispositivos (computadoras portátiles, tabletas y tarjetas SIM) y ha ayudado a cientos de clientes mediante 117 clases de habilidades digitales de dos horas en bibliotecas, centros para personas mayores y programas de desarrollo laboral en Tuscaloosa, Alabama, y sus alrededores.

Personas de “todas las razas, edades y niveles económicos” que no “encajaban en nuestra típica categoría minoritaria” recibieron ayuda gracias a su trabajo, afirmó Waiters. Dijo que Trump y su administración deberían saber “cómo se ve realmente la situación para la gente a la que sirvo”.

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“They have health care needs, but they don’t have the digital skills,” said Waiters, who is a digital navigator for an Alabama nonprofit. Her work has involved giving away computers and tablets while also teaching classes on how to use the internet for work and personal needs, like banking and health. “It’s like a foreign space.”

Those stories are now bittersweet.

Waiters is part of a network of digital navigators across the country whose work to bring others into the digital world was, at least in part, propped up by a $2.75 billion federal program that abruptly canceled funding this spring. The halt came after President Donald Trump platform that the Digital Equity Act was unconstitutional and pledged “no more woke handouts based on race!”

The act the money should benefit, including low-income households, older residents, some incarcerated people, rural Americans, veterans, and members of racial or ethnic minority groups. Politicians, researchers, librarians, and advocates said defunding the program, along with other changes in federal broadband initiatives, jeopardizes efforts to help rural and underserved residents participate in the modern economy and lead healthier lives.

“You could see lives change,” said Sam Helmick, president of the American Library Association, recalling how they helped grandpas in Iowa check prescriptions online or laid-off factory workers fill out job applications.

The Digital Equity Act is part of the sweeping 2021 infrastructure law, which included $65 billion to build high-speed internet infrastructure and connect millions without access to the internet.

This year, Congress once again pushed for a modern approach to help Americans, mandating that state leaders prioritize new and emerging technologies through its $50 billion Rural Health Transformation Program.

A 麻豆女优 Health News analysis found that nearly 3 million people in America live in areas with shortages of medical professionals and where modern telehealth services are often inaccessible because of poor internet connections. The analysis found that in about 200 mostly rural counties where dead zones persist, residents live sicker and die earlier on average than people in the rest of the country. Access to high-speed internet is among a host of social factors, like food and safe housing, that help people lead healthier lives.

“The internet provides this extra layer of resilience,” said Christina Filipovic, who leads the research for an initiative of the Institute for Business in the Global Context at Tufts University. The research group that access to high-speed internet correlated with fewer covid deaths, particularly in metro areas.

During the covid-19 pandemic, federal lawmakers launched a subsidy program paid for by the infrastructure law. That aid, called the Affordable Connectivity Program, aimed to connect more people to their jobs, schools, and doctors. In 2024, Congress did not renew funding for the subsidy program, which had enrolled about 23 million low-income households.

This year, U.S. Commerce Secretary Howard Lutnick revamped and delayed the infrastructure law’s construction initiative 鈥� known as the Broadband Equity, Access, and Deployment Program, or BEAD 鈥� after announcing plans to . More than 40 states and territories have submitted final proposals to extend high-speed internet to underserved areas under the administration’s new guidelines, according to a .

In May, the Digital Equity Act’s funding was terminated within days of Trump’s Truth Social post. While many states in 2022 had received money to plan their programs, the next round of funding, designated for states and agencies to implement the plans, had largely been awarded but not distributed.

Instead, federal regulators 鈥� including the National Telecommunications and Information Administration, the federal agency overseeing implementation of the Digital Equity Act 鈥� that the grants would be terminated. The grants were created and administered with “unconstitutional racial preferences,” according to the letter.

In Phoenix, officials learned in January that the city was slated to get $11.8 million to increase internet access and teach digital literacy, but they received an email May 20 stating that all grants, “except for grants to Native Entities,” had been terminated. “It’s a shame,” said Phoenix Mayor Kate Gallego, a Democrat. The money, she said, would have helped 37,000 residents get internet access.

Georgia’s Democratic leaders in July to Lutnick and NTIA’s then-acting administrator, Adam Cassady, urging reinstatement of the money, noting that the federal cut ignores congressional intent and violates public trust.

The act’s creator, Sen. Patty Murray (D-Wash.), said in May that Republican governors in 2024 supported the law and its funding when each state touted completing its required digital equity plans and asked for resources.

“I cannot believe there aren’t Republican governors out there that are going to join with us to fight back on this,” Murray said, adding “the other way is through courts.”

All 50 states developed digital equity plans after months of focus groups, surveys, and public comment periods. NTIA Digital Equity Director Angela Thi Bennett, during an August 2024 interview with 麻豆女优 Health News, said the “intentional community engagement” by federal and state leaders to deliver broadband to unserved communities was “the greatest demonstration of participatory democracy our country has ever seen.”

Thi Bennett could not be reached for comment on this article. NTIA spokesperson Stephen Yusko said the agency “will not be able to accommodate” a request for an interview with Thi Bennett and did not respond to questions for this article.

Caroline Stratton, a research director at the Benton Institute for Broadband & Society, said the act’s funding allowed states to staff offices; identify existing high-speed internet programs, including those operating within other state agencies; and create plans to fill the gaps.

“This sent folks out looking,” Stratton said, to see whether agencies in the state were already working on health improvement plans and to ask whether the broadband work could contribute and “actively help move the needle.”

State grant applications included goals . In Mississippi, the of the state university and another agency’s health improvement plan, Stratton said.

While states were required to create programs that would help specific covered populations, some states modified the language or added subcategories to include other populations. included immigrants and “individuals experiencing homelessness.”

“In every state, there’s a loss,” said Angela Siefer, executive director of the National Digital Inclusion Alliance. The nonprofit, which was awarded to work with organizations nationwide but did not receive any funds, filed a lawsuit Oct. 7 seeking to force Trump and the administration to distribute the money.

“The digital divide is not over,” Siefer said.

The nonprofit’s grant had been planned to support digital navigators in 11 states and territories, including Waiters. Her employer, the nonprofit Community Service Programs of West Alabama, expected to receive a $1.4 million grant.

In the past two years, Waiters spent hours driving the roads of rural Alabama to reach residents. She has distributed 648 devices 鈥� laptops, tablets, and SIM cards 鈥� and helped hundreds of clients through 117 two-hour digital skills classes at libraries, senior centers, and workplace development programs in and around Tuscaloosa, Alabama.

People of “all races, of all ages, of all financial backgrounds” who did not “fit into our typical minority category” were helped through her work, Waiters said. Trump and his administration should know, she said, “what it actually looks like for the people I serve.”

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

Julie Rovner: ProPublica’s “,” by Brandon Roberts, Annie Waldman, and Pratheek Rebala.

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

Sarah Karlin-Smith: NPR’s “,” by Blake Farmer.

Alice Miranda Ollstein: Vox’s “,” by Dylan Scott.

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by David Ovalle and Lori Rozsa.
• The 19th’s “,” by Shefali Luthra.
• The New York Times’ “,” by Reed Abelson and Teddy Rosenbluth.

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

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

Sarah Karlin-Smith: Hi, everybody.听

Rovner: Alice Miranda Ollstein of Politico.听

Alice Miranda Ollstein: Hello.听

Rovner: And Jessie Hellmann of CQ Roll Call.听

Jessie Hellmann: Hi there.听

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And flooding the zone.听

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

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

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

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

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

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

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

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

Rovner: Next.听

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Yes, please.听

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Yikes.听

Leys: Yikes, indeed.听

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

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

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

Leys: Right.听

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

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

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

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

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

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

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

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

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

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

Rovner: True.听

Leys: We know that now.听

Rovner: And what happened with this bill?听

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

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

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

Rovner: But she won’t get rabies.听

Leys: Nope.听

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

Leys: Thank you for having me. Appreciate it.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’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it?听

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

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

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

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

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

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

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

Rovner: Jessie.听

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

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

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

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

Karlin-Smith: Kind of everywhere. At , , 鈥� @SarahKarlin or @sarahkarlin-smith.听

Rovner: Alice.听

Ollstein: Mostly on Bluesky, , and still on X, .听

Rovner: Jessie.听

Hellmann: I am on X, . I’m also on .听

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

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The Commerce Department, which runs the massive Broadband Equity, Access, and Deployment Program, in early June requiring states 鈥� some of which were ready to begin construction later this year 鈥� to solicit new bids from internet service providers.

The delay leaves millions of rural Americans stranded in places where health care is hard to access and telehealth is out of reach.

“This does monumental harm to rural America,” said , a professor of telecommunications at Penn State.

The Biden-era program, known as BEAD, was hailed when created in 2021 as a national plan to bring fast internet to all, including millions in remote rural areas.

A yearlong 麻豆女优 Health News investigation, with partner Gray Media’s InvestigateTV, found nearly 3 million people live in mostly rural counties that lack broadband as well as primary care and behavioral health care providers. In those same places, the analysis found, people live sicker and die earlier on average.

The program adopts a technology-neutral approach to “guarantee that American taxpayers obtain the greatest return on their broadband investment,” according to the June . The program previously prioritized the use of fiber-optic cable lines, but broadband experts like Ali said the new focus will make it easier for satellite-internet providers such as to win federal funds.

“We are going to connect rural America with technologies that cannot possibly meet the needs of the next generation of digital users,” Ali said. “They’re going to be missing out.”

Republicans have criticized BEAD for taking too long, and Commerce Secretary Howard Lutnick to get rid of its “woke mandates.” The revamped “Benefit of the Bargain BEAD Program,” which was released with a fact sheet titled “,” includes eliminating some labor and employment requirements and obligations to perform climate analyses on projects.

The requirement for states to do a new round of bidding with internet service providers makes it unclear whether states will be able to connect high-speed internet to all homes, said , director of policy engagement at the Benton Institute for Broadband & Society.

Garner said the changes have caused “pure chaos” in state broadband offices. More than half the states have been knocked off their original timeline to deliver broadband to homes, he said.

The change also makes the program more competitive for satellite companies and wireless providers such as Verizon and T-Mobile, Garner said.

Garner what the possible increase in low-Earth-orbit satellites would mean for rural America. He found that fiber networks are generally more expensive to build but that satellites are more costly to maintain and “much more expensive” to consumers.

Commerce Secretary Lutnick said in a June release that the new direction of the program would be efficient and deliver high-speed internet “at the right price.” The National Telecommunications and Information Administration, the Commerce Department agency overseeing BEAD, declined to release a specific amount it hopes to save with the restructuring.

The NTIA also declined to respond on the record to questions about program revisions and delays.

More than 40 states had already begun selecting companies to provide high-speed internet and fill in gaps in underserved areas, according to created to track state progress.

In late May, the website was altered and columns showing the states that had completed their work with federal regulators disappeared. Three states 鈥� Delaware, Louisiana, and Nevada 鈥� had reached the finish line and were waiting for the federal government to distribute funding.

The tracker, which 麻豆女优 Health News saved , details the steps each state made in their years-long efforts to create location-based maps and bring high-speed internet to those missing service. West Virginia had completed selection of internet service providers and a of its proposed plan shows the state was set to provide fiber connections to all homes and businesses.

Sen. Shelley Moore Capito (R-W.Va.) praised removal of some of the hurdles that delayed implementation and said she thought her state would not have to make very many changes to existing plans during a .

West Virginia’s broadband council has worked aggressively to expand in a state where 25% of counties lack high-speed internet and health providers, according to 麻豆女优 Health News’ analysis.

In Lincoln County, West Virginia, Gary Vance owns 21 acres atop a steep ridge that has no internet connection. Vance, who sat in his yard enjoying the sun on a recent day, said he doesn’t want to wait any longer.

Vance said he has various medical conditions: high blood sugar, deteriorating bones, lung problems 鈥� “all kinds of crap.” He’s worried about his family’s inability to make a phone call or connect to the internet.

“You can’t call nobody to get out if something happens,” said Vance, who also lacks running water.

麻豆女优 Health News, using data from federal and academic sources, found more than 200 counties 鈥� with large swaths in the South, Appalachia, and the remote West 鈥� lack high-speed internet, behavioral health providers, and primary care doctors who serve low-income patients on Medicaid. On average, residents in those counties experienced higher rates of diabetes, obesity, chronically high blood pressure, and cardiovascular disease.

The gaps in telephone and internet services didn’t cause the higher rates of illness, but Ali said it does not help either.

Ali, who traveled rural America for his book “,” said telehealth, education, banking, and the use of artificial intelligence all require fast download and upload speeds that cannot always be guaranteed with satellite or wireless technology.

It’s “the politics of good enough,” Ali said. “And that is always how we’ve treated rural America.”

Fiber-optic cables, installed underground or on poles, consistently provide broadband speeds that meet the Federal Communications Commission’s requirements for broadband download speed of 100 megabits per second and 20 Mbps upload speed. By contrast, a , performed by Ookla, a private research and analytics company, found that only 17.4% of Starlink satellite internet users nationwide consistently get those minimum speeds. The report also noted Starlink’s speeds were rising nationwide in the first three months of 2025.

In March, West Virginia’s Republican governor, Patrick Morrisey, to collaborate with the Trump administration on the new requirements.

Republican state Del. , who has been working with Morrisey’s office, said his goal is to eventually get fiber everywhere but said other opportunities could be available to get internet faster.

In May, the West Virginia Broadband Enhancement Council signaled it preferred fiber-optic cables to satellite for its residents and signed that noted “fiber connections offer the benefits of faster internet speeds, enhanced data security, and the increased reliability that is necessary to promote economic development and support emerging technologies.”

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Chief rural health correspondent Sarah Jane Tribble explains how millions of rural Americans live in counties with doctor shortages and where high-speed internet connections aren’t adequate to access advanced telehealth services. A 麻豆女优 Health News analysis found people in these “dead zones” live sicker and die younger on average than their peers in well-connected regions.

麻豆女优 Health News has partnered with InvestigateTV to tell the stories of residents whose health care falls into the gap. You can view the full investigation here.

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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While patients and providers say teletherapy is effective and easier to get than in-person services, experts in the field noted that teletherapy often requires a skilled mental health practitioner trained to pick up subtle communication cues.

Almost half of the roughly 4.8 million adults who visited a medical professional for mental health or substance use disorders in 2023 did so exclusively through teletherapy, according to a 麻豆女优 Health News analysis of the latest data from UCLA’s .

About 24% of adults used a combination of face-to-face and teletherapy in 2023, while roughly 23% got help exclusively in person, according to the survey of about 20,000 California households.

A of patients in the Department of Veterans Affairs health care system found a similar pattern: Fifty-five percent of mental health care continued to be provided via telemedicine, a figure that spiked after patients shifted to teletherapy by necessity during the covid-19 pandemic.

Teletherapy is certainly more convenient, allowing patients to see their therapists from the comfort of home.

“It’s actually really effective,” said , president of the . “I think part of that is that it just allows more comfortability 鈥� people are willing to work a little bit more when they’re comfortable.”

: Teletherapy patients report getting better at rates similar to those receiving in-person therapy.

“Research has basically shown that there's no difference between teletherapy versus in-person therapy 鈥� so, basically, as effective as in-person therapy,” said , a researcher at the , who recently conducted an analysis of several studies comparing teletherapy and face-to-face therapy.

But Lin said it can be difficult for a therapist to see hand motions or read body language during a video call, which could lead to therapists missing nonverbal cues about their patients’ emotional states. Lin’s most recent research, yet to be published, suggests therapy over the telephone “is less effective than video conferences” due to “more loss of information.”

And some people have trouble emotionally connecting with a therapist without seeing them in person, Lin said. Technical difficulties, not uncommon, can also interfere with clients building a therapeutic relationship.

Sacramento resident David Bain relies on teletherapy to treat his depression because mobility issues make it difficult for him to visit a therapist in person.

“It's almost to the point where I wouldn't be able to get the service if I wasn't able to get it through telehealth,” said Bain, executive director of , a nonprofit that provides support and advocacy to people with mental illness.

Bain said that his one-on-one teletherapy sessions have helped but that he’s had less success with online group therapy. He recently participated in a 10-week therapy class, but he didn’t get the connection and support he received in past in-person group settings, he said.

“There was probably me and two or three other people that were actually showing ourselves on screen,” he said. “Everyone else had their screens off.”

Teletherapy is increasingly offered through cellphone applications like and . Patients using these applications often pay a subscription fee, which insurance may partly cover, in exchange for regular sessions and contact with therapists.

, a researcher at the , co-authored published in 2023 that looked at patient reviews of eight of the most popular teletherapy apps. Many patients expressed satisfaction with their therapists, but the team also uncovered negative patterns.

Some patients did not get the therapy they paid for, often due to technical difficulties. Other patients reported their therapists acted disinterested or unprofessional, a finding Jo said could be tied to the relatively low pay therapists earn on some apps.

And several users mentioned in reviews that their therapist suddenly disappeared from the app without explanation. She said therapists in more traditional “pay-as-you-go” arrangements rarely discontinue treatment without warning.

, chief medical officer of Talkspace, said patients often can use their insurance to get therapy on the platform, at a typical cost of a $10 copay. Separately, Talkspace spokesperson Jeannine Feyen said salary for therapists has increased since Jo’s study was conducted, and that full-time Talkspace therapists make between $65,000 and $105,000 a year.

At BetterHelp, therapists earn up to $91,000 and the average patient rating last year for a live session on the platform was , spokesperson Megan Garner said. A significant majority of patients reported reliable symptom improvement or remission, she added.

The number of Californians visiting a medical professional for mental health issues rose by about 434,000, or 10%, from 2019 to 2023, UCLA data shows. It jumped by nearly 2 million, or 69%, from 2009 through 2023.

Even so, the transition from in-person therapy to teletherapy has left some behind.

The UCLA data shows that Californians living within 200% of the federal poverty level 鈥� for example, a family of four with a household income of about $60,000 or under in 2023 鈥� were less likely to use teletherapy.

The data also shows that residents in rural areas, where access to telehealth should provide a boon, weren’t using it as much as residents of urban areas.

For example, about 81% of Bay Area residents who visited a medical professional for mental health care in 2023 did so either fully or partially via teletherapy. About 62% of residents in the state’s rural, mountainous counties did the same.

Those disparities are suggestive of gaps seen in remote-work patterns: Wealthier, urban Californians are more likely to work from home than residents. By extension, Californians of greater means have more opportunities to arrange online appointments and may be more comfortable with them.

By comparison, low-income folks tend to go into the office for doctor visits, Heitzmann said.

Lower-income and rural Californians may also lack the reliable internet service necessary for good telehealth. A recent 麻豆女优 Health News analysis found millions of Americans live in places with doctor shortages and poor internet access.

Lower-income Californians also , making privacy for an intimate therapy session difficult.

Regardless, teletherapy is now dominant. And it’s not just patients who enjoy the convenience. Many therapists have ditched expensive office rents to work from home.

“Covid allowed that,” Heitzmann said. “A lot of folks really just got rid of their offices and were perfectly happy converting their home into some kind of office and doing it all day long.”

This article was produced by 麻豆女优 Health News, which publishes , an editorially independent service of the .听

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“I’m comfortable here, but I’m having health issues,” said the 68-year-old, who retired from her job as a school cook several years ago after having a stroke. “Things are failing me.”

Her trailer sits halfway up a ridge miles from town and the local health clinic. Her phone and internet are “wacky sometimes,” she said. Adkins 鈥� who is fiercely independent and calls herself a “Mountain Momma” 鈥� worries she won’t be able to call for help if service goes out, which happens often.

To Frontier Communications, the telecommunications company that owns the line to her home, Adkins says: “Please come and hook me right.”

But she might be waiting years for better service, frustrated by her internet provider and left behind by troubled federal grant programs.

A quarter of West Virginia counties 鈥� including Lincoln, where the Mud River bends its way through hollows and past cattle farms 鈥� face two barriers to health care: They lack high-speed internet and have a shortage of primary care providers and behavioral health specialists, according to a 麻豆女优 Health News analysis.

Years of Republican and Democratic administrations have tried to fix the nation’s broadband woes, through flawed attempts. Bad mapping, weak standards, and flimsy oversight have left Adkins and nearly 3 million other rural Americans in dead zones 鈥� with eroded health care services and where telehealth doesn’t reach.

Blair Levin, a former executive director of the Federal Communications Commission’s National Broadband Plan, called one rural program rollout during the first Trump administration “a disaster.”

It was launched before it was ready, he said, using unreliable federal maps and a reverse-auction process to select internet carriers. Locations went to the lowest bidder, but the agency failed to ensure winners had the knowledge and resources to build networks, said Levin, who is now an equity analyst with New Street Research.

The fund initially announced awards of $9.2 billion to build infrastructure in 49 states. By 2025, $3.3 billion of those awards were in default and, as a result, the program won’t connect 1.9 million homes and businesses, .

A $42 billion Biden-era initiative still may not help Adkins and many others shortchanged by earlier federal broadband grants. The new wave of funding, the Broadband Equity, Access, and Deployment Program, or BEAD, has an anti-waste provision and won’t provide service in places where previous grants were awarded 鈥� even if companies haven’t delivered on their commitments.

The use of federal money to get people connected is “really essential” for rural areas, said Ross DeVol, CEO and chairman of the board of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

“Internet service providers look at the economics of trying to go into some of these communities and there just isn’t enough purchasing power in their minds,” DeVol said, adding that broadband expansion is analogous to rural electrification. Without high-speed internet, “you’re simply at a distinct disadvantage,” he added. “I’ll call it economic discrimination.”

鈥業 Got Books Full’

Adkins keeps spiral-bound notebooks and calendars filled with handwritten records of phone and internet outages.

In January, while bean soup warmed on the stove, she opened a notebook: “I got books full. Hang on.”

Her finger traced the page as she recounted outages that occurred about once a month last year. Adkins said she lost connectivity twice in November, again in October, and in July, May, and March. Each time she went for days without service.

Adkins pays Frontier Communications $102.13 a month for a “bundle” that includes a connection for her house phone and wireless internet access on her cellphone. Frontier did not respond to requests for comment on Adkins’ and other customers’ service.

Adkins, a widow, spends most of her time at home and said she would do video calls with her doctors if she could. She said she still has numbness on one side of her body after the stroke. She also has high blood pressure and arthritis and uses over-the-counter pain patches when needed, such as after she carries 30-pound dog food bags into the house.

She does not own a four-wheel-drive truck and, for three weeks in January, the snow and ice were so severe she couldn’t leave. “I’m stranded up here,” she said, adding that neighbors check in: “鈥楧o you have electric? Have you got water? Are you OK?’”

The neighbors have all seen Adkins’ line. The pale-yellow cord was tied off with green plastic ties around a pole outside her trailer. As it ran down the hill, it was knotted around tree trunks and branches, frayed in places, and, finally, collapsed on the ground under gravel, snow, and ice at the bottom of the hill.

Adkins said a deer stepping on the line has interrupted her phone service.

David and Billi Belcher’s double-wide modular home sits near the top of the ridge past Adkins’ home. Inside, an old hunting dog sleeps on the floor. Belcher pointed out a window toward where he said Frontier’s cable has remained unrepaired for years: “It’s laying on the ground in the woods,” he said.

Frontier is West Virginia’s legacy carrier, controlling most of the state’s old landlines since in 2010. Twelve years later, the company won nearly $248 million to install high-speed internet to West Virginia through the Rural Digital Opportunity Fund, an initiative launched during President Donald Trump’s first term.

“Big Daddy,” as local transit driver Bruce Perry called Trump, is popular with the people of Lincoln County. About 80% of the county’s voters picked the Republican in the last election.

The Trump administration awarded Frontier money to build high-speed internet to Upper Mud River Road residents, like Adkins, . Frontier has until , to build.

But the Belchers needed better internet access for work and could afford to pay $700 for a Starlink satellite internet kit and insurance, they said. Their monthly Starlink bill is $120 鈥� a price many cannot manage, especially since Congress sunset an earlier program that helped offset the cost of high-speed plans for consumers.

Meanwhile, the latest broadband program to connect rural Americans is ensnared in Trump administration policy shifts.

The National Telecommunications and Information Administration, which administers the program, in April for states to finalize their plans during a “comprehensive review” of the program.

West Viriginia Gov. Patrick Morrisey, a Republican, would take an extension. The move, though, doesn’t make a lot of sense, said Evan Feinman, who left the agency in March after directing the broadband program for the past three years.

Calling the work already done in West Virginia an “incredible triumph,” Feinman said the state had completed the planning, mapping, and the initial selection of companies. The plan that was in place would have brought high-speed fiber lines to homes ahead of schedule and under budget, he said.

“They could be building today, and it’s just deeply disappointing that they’re not,” Feinman said.

When Feinman resigned in March, he stating that the new administration wants to take fiber away from homes and businesses and substitute it with satellite connections. The move, he said, would be more expensive for consumers and hurt rural and small-town America.

Morrisey, whose office declined to respond to requests for comment, said in his announcement that he wants to ensure West Virginia spends the money in a manner “consistent with program changes being proposed by the Trump Administration” and “evaluate a broader range of technology options.”

Commissioners from Grant County supporting fiber-optic cables rather than satellite-based connections like those provided by Elon Musk’s Starlink. Nationwide, 115 lawmakers from 28 states to federal leaders stating that changes could “delay broadband deployment by a year or more.”

For Adkins and others, the wait has been long enough.

While legislators in Washington and across the country bickered over the broadband program, Adkins went without phone and internet. By late March, she said, her 42-year-old son was increasingly worried, noting “you’re getting up in age.” He told her: “Mom, move out, get off of that hill.”

Worst-Case Scenario

A few miles from Upper Mud River Road, past the McDonald’s and across the road from the local library, Brian Vance sat in his downtown Hamlin, West Virginia, office. He said his company has been trying to “build up there for a while.”

Vance is a general manager for Armstrong Telephone and Cable, a regional telecommunications provider that competes with Frontier. He grew up in the community, and parents of a high school friend live off Upper Mud River. But he said “it’s very difficult” to build fiber along the rocky terrain to homes where “you are hoping that people will hook up, and if they don’t, well, you’ve lost a lot of money.”

A found that stringing fiber-optic lines along telephone poles would cost more than $5,000 per connection in some areas 鈥� work that would need big federal subsidies to be feasible.

Yet Vance said Armstrong cannot apply for the latest BEAD funding to help finance connections. And while he likes that the federal government is “being responsible” by not handing out two federal grants for the same area, Vance said, “we want to see people deliver on the grants they have.”

If Frontier hadn’t already gotten federal funds from the earlier Trump program, “we definitely would have applied to that area,” Vance said.

The 2022 assessment noted the community’s economy would not be sustainable without “ubiquitous broadband.”

High-speed internet brings more jobs and less poverty, said Claudia Persico, an associate professor at American University. Persico, who is also a research associate with the National Bureau of Economic Research, that found increased broadband internet leads to a reduction in the number of suicides as well as improvements in self-reported mental and physical health.

More than 30% of Lincoln County’s population reports cases of depression, according to data from the Centers for Disease Control and Prevention. The rate of opioid prescriptions dispensed in Lincoln County is down about 60% from 2014 to 2024 鈥� but still higher than the state average, according to the West Virginia Board of Pharmacy.

Twenty percent of the county’s population lives below the poverty line, and residents are also more likely than the national average to experience heart disease, diabetes, and obesity.

Lincoln Primary Care Center offers telehealth services such as electronic medical records on a patient portal and a pharmacy app, said Jill Adkins, chief quality and risk officer at Southern West Virginia Health System, which operates the clinic.

But because of limited access, only about 7% of patients use telehealth, she said.

Della Vance was a patient at the clinic but said she has never used a patient portal. If she could, Vance said, she would check records on the baby she is expecting.

“You can’t really get on if you don’t have good service and no internet,” she said. “It makes me angry, honestly.”

Vance and her husband, Isaiah, live off a gravel road that veers from Upper Mud River. There is a tall pole with black wires dangling across the road from their small home. Pointing to the cables, Isaiah Vance said he couldn’t get phone service anymore.

Verizon announced plans last year to buy Frontier . The deal, which must be approved by federal and state regulators, is expected to be completed in early 2026, according to an .

In its federal , Frontier stated that it had taken on too much debt after emerging from bankruptcy and that debt would make it difficult to finish the work of installing fiber to customers in 25 states.

In West Virginia, Frontier’s Allison Ellis , seeking approval for the merger from state regulators, that Verizon will honor the rural program commitments. The previous month, in February, Frontier with the state public service commission to keep the number of customers using copper lines and the faster fiber-optic lines confidential.

Kelly Workman, West Virginia’s broadband director, said during a November interview that her office has asked federal regulators for “greater visibility” into Frontier’s rural program construction, particularly because those locations cannot win the Biden-era infrastructure money when it's available.

“The worst-case scenario would be for any of these locations to be left behind,” Workman said.

鈥�Money Cow’

Frontier’s progress installing fiber-optic lines and its unreliable service have frustrated West Virginians for years. In to the FCC, U.S. Sen. Shelley Moore Capito (R-W.Va.) cited “the failure of Frontier to deliver on promises to federal partners” and its “mismanagement” of federal dollars, which forced the state to pay back $4.7 million because of improper use and missed deadlines.

Michael Holstine, a longtime member of the West Virginia Broadband Enhancement Council, said the company has “just used West Virginia as a money cow.” Holstine has been fighting for the construction of fiber-optic lines in Pocahontas County for years. “I really just hope I get it before I die.”

Across the state, people like Holstine and Adkins are eager for updated networks, according to interviews as well as letters released under a public records request.

Chrissy Murray, vice president of Frontier’s external communications, acknowledged that the company was “building back our community efforts” in West Virginia after a bankruptcy filing and reorganization. She said there has been a “notable decline” in consumer complaints, though she did not provide specific numbers.

Murray said Frontier built fiber-optic cables to 20% of its designated rural funds locations as of the end of 2024. It has also invested in other infrastructure projects across the state, she said in a January email, adding that the company to West Virginia University’s rural Jackson’s Mill campus.

According to , Frontier has connected 6,100 鈥� or fewer than 10% 鈥� of the more than 79,000 locations it was awarded in the Rural Digital Opportunity Fund program.

The FCC oversees the rural fund. The agency did not respond to a request for comment. Frontier expects to receive $37 million annually from the agency through 2032, .

In April, a from West Virginia residents filed as “support” for Frontier’s merger with Verizon appeared in the state regulatory docket:

“My support for this case depends on whether Verizon plans to upgrade or replace the existing Frontier infrastructure,” wrote one customer in Summers County, in the far southern corner of the state, adding, “West Virginians in my neck of the woods have been held hostage by Frontier for a generation now because no other providers exist.”

A customer from Hardy County, in the state’s northeastern corner, wrote: “This is [a] move by frontier to to [sic] escape its responsibility to continue services.”

鈥楧别别辫-搁辞辞迟别诲’

Adkins moved to Upper Mud River with her husband, Bobby, decades ago.

For years, Bobby and Ada Carol Adkins ran a “carry-out” on Upper Mud River Road. The old building is still at the rock quarry just down the hill and around the curve from where her trailer sits.

It was the type of store where locals kept a tab 鈥� which Bobby treated too much like a “charity,” Adkins said. They sold cigarettes, beer, bread, bags of chips, and some food items like potatoes and rice. “Whatever the community would want,” she said.

Then, Bobby Adkins’ “health started deteriorating and money got tighter,” Adkins said. He died at 62 years old.

Now, Adkins said, “I’m having kidney problems. I got arthritis, they’re treating me for high blood pressure.”

Her doctor has begun sending notes over the internet to refill her blood pressure medicine and, Adkins said, “I love that!”

But Adkins’ internet was out again in early April, and she can’t afford Starlink like her neighbors. Even as Adkins said she is “deep-rooted,” her son’s request is on her mind.

“I’m having health problems,” Adkins said. “He makes a lot of sense.”

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EUTAW, Ala. 鈥� Leroy Walker arrived at the county hospital short of breath. Walker, 65 and with chronic high blood pressure, was brought in by one of rural Greene County’s two working ambulances.

Nurses checked his heart activity with a portable electrocardiogram machine, took X-rays, and tucked him into Room 122 with an IV pump pushing magnesium into his arm.

“I feel better,” Walker said. Then: Beep. Beep. Beep.

The Greene County Health System, with only three doctors, has no intensive care unit or surgical services. The 20-bed hospital averages a few patients each night, many of them, like Walker, with chronic illnesses.

Greene County residents are some of the sickest in the nation, ranking near the top for rates of stroke, obesity, and high blood pressure, according to data from the federal Centers for Disease Control and Prevention.

Patients entering the hospital waiting area encounter floor tiles that are chipped and stained from years of use. A circular reception desk is abandoned, littered with flyers and advertisements.

But a less visible, more critical inequity is working against high-quality care for Walker and other patients: The hospital’s internet connection is a fraction of what experts say is sufficient. High-speed broadband is the new backbone of America’s health care system, which depends on electronic health records, high-tech wireless equipment, and telehealth access.

Greene is one of more than 200 counties with some of the nation’s worst access to not only reliable internet, but also primary care providers and behavioral health specialists, according to a 麻豆女优 Health News analysis. Despite repeated federal promises to support telehealth, these places remain disconnected.

During his first term, President Donald Trump signed promising to improve “the financial economics of rural healthcare” and touted “access to high-quality care” through telehealth. In 2021, President Joe Biden committed billions to broadband expansion.

麻豆女优 Health News found that counties without fast, reliable internet and with shortages of health care providers are mostly rural. Nearly 60% of them have no hospital, and hospitals closed in nine of the counties in the past two decades, according to data collected by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill.

Residents in these “dead zone” counties tend to live sicker and die younger than people in the rest of the United States, according to 麻豆女优 Health News’ analysis. They are places where systemic poverty and historical underinvestment are commonplace, including the remote West, Appalachia, and the rural South.

“It will always be rural areas with low population density and high poverty that are going to get attended to last,” said Stephen Katsinas, director of the Education Policy Center at the University of Alabama. “It’s vital that the money we do spend be well deployed with a thoughtful plan.”

Now, after years of federal and state planning, Biden’s $42 billion Broadband Equity Access and Deployment, or BEAD, program, which was approved with bipartisan support in 2021, is being held up, just as states 鈥� such as Delaware 鈥� were prepared to begin construction. Trump’s new Department of Commerce secretary, Howard Lutnick, has demanded “a rigorous review” of the program and called for the elimination of regulations.

Trump’s nominee to lead the federal agency overseeing the broadband program, Arielle Roth, repeatedly said during her nomination hearing in late March that she would work to get all Americans broadband “expeditiously.” But when pressed by senators, Roth declined to provide a timeline for the broadband program or confirm that states would receive promised money.

Instead, Roth said, “I look forward to reviewing those allocations and ensuring the program is compliant with the law.”

Sen. Maria Cantwell (D-Wash.), the Senate commerce committee’s ranking minority member, said she wished Roth had been more committed to delivering money the program promised.

The political wrangling in Washington is unfolding hundreds of miles from Greene County, where only about half of homes have high-speed internet and 36% of the population lives below the poverty line, according to the U.S. Census Bureau.

Walker has lived his life in Alabama’s Black Belt and once worked as a truck driver. He said his high blood pressure emerged when he was younger, but he didn’t take the medicine doctors prescribed. About 11 years ago, his kidneys failed. He now needs dialysis three times a week, he said.

While lying in the hospital bed, Walker talked about his dialysis session the day before, on his birthday. As he talked, the white sheet covering his arm slipped and revealed where the skin around his dialysis port had swollen to the size of a small grapefruit.

Room 122, where Walker rested, is sparse with a single hospital bed, a chair, and a TV mounted on the wall. He was connected to the IV pump, but no other tubes or wires were attached to him. The IV machine’s beeping echoed through the hallway outside. Staffers say they must listen for the high-pitched chirps because the internet connection at the hospital is too slow to support a modern monitoring system that would display alerts on computers at the nurses’ station.

Aaron Brooks, the hospital’s technology consultant, said financial challenges keep Greene County from buying monitoring equipment. The hospital on patient care in its most recent federal filing. Even if Greene could afford a system, it does not have the thousands of dollars to install a high-speed fiber-optic internet connection necessary to operate it, he said.

Lacking central monitoring, registered nurse Teresa Kendrick carries a portable pulse oximeter device, she said 鈥� like ones sold at drugstores that surged in popularity during the covid-19 pandemic.

Doing her job means a “continuous spot-check,” Kendrick said. Another longtime nurse described her job as “a lot of watching and checking.”

Beep. Beep.

The beeping in Room 122 persisted for more than two minutes as Walker talked. He wasn’t in pain 鈥� he was just worried about the beeping.

About 50 paces down the hall 鈥� past the pharmacy, an office, and another patient room 鈥� registered nurse Jittaun Williams sat at her station behind plexiglass. She was nearly 20 minutes past the end of her 12-hour shift and handing off to the three night-shift nurses.

They discussed plans for patients’ care, reviewing electronic records and flipping through paper charts. The nurses said the hospital’s internal and external computer systems are slow. They handwrite notes on paper charts in a patient’s room and duplicate records electronically. “Our system isn’t strong enough. There are many days you kind of sit here and wait,” Williams said.

Broadband dead zones like Greene County persist despite decades of efforts by federal lawmakers that have created a patchwork of more than 133 funding programs across 15 agencies, .

Alabama’s leaders, like others around the U.S., are actively spending federal funds from the Biden-era American Rescue Plan Act, according to public records. And Greene County Hospital is on the list of places waiting for ARPA construction, according to by the Alabama Department of Economic and Community Affairs.

“It is taking too long, but I am patient,” said Alabama state Sen. Bobby Singleton, a Democrat who represents the district that includes Greene County Hospital and two others he said lack fast-enough connectivity. Speed bumps such as a need to meet federal requirements and a “big fight” to get internet service providers to come into his rural district slowed the release of funds, Singleton said.

Alabama received its first portion of ARPA funds in June 2021, which Singleton said included money for building fiber-optic cables to anchor institutions like the hospital. Alabama’s the projects to be completed by February 2026 鈥� nearly five years after money initially flowed to the state.

Singleton said he now sees fiber lines being built in his district every day and knows the hospital is “on the map” to be connected. “This doesn’t just happen overnight,” he said.

Alabama Fiber Network, a consortium of electric cooperatives, won a total of $45.7 million in ARPA funding specifically for construction to anchor institutions in Greene and surrounding counties. James Hoffman, vice president of external affairs for AFN, said the company is ahead of schedule. It plans to offer the hospital a monthly service plan that uses fiber-optic lines by year’s end, he said.

Greene County Health System chief executive Marcia Pugh confirmed that she had talked with multiple companies but said she wasn’t sure the work would be complete in the time frame the companies predicted.

“You know, you want to believe,” Pugh said.

Beep. Beep.

Nurse Williams had finished the night-shift handoff when she heard beeps from Walker’s room.

She rushed toward the sound, accidentally ducking into Room 121 before realizing her mistake.

Once in Walker’s room, Williams pressed buttons on the IV pump. The magnesium flowing in the tube had stopped.

“You had a little bit more left in the bag, so I just turned it back on,” Williams told Walker. She smiled gently and asked if he was warm enough. Then she hand-checked his heart rate and adjusted his sheets. At the bottom of the bed, Walker’s feet hung off the mattress and Williams gently moved them and made sure they were covered.

Walker beamed. At this hospital, he said, “they care.”

As rural hospitals like Greene’s wait for fast-enough internet, nurses like Williams are “heroes every single day,” said Aaron Miri, an executive vice president and the chief digital and information officer for Baptist Health in Jacksonville, Florida.

Miri, who served under both Democratic and Republican administrations on Department of Health and Human Services technology advisory committees, said hospitals need at least a gigabit of speed 鈥� which is 1,000 megabits per second 鈥� to support electronic health records, video consultations, the transfer of scans and images, and continuous remote monitoring of patients’ heartbeats and other vital signs.

But Greene’s is less than 10% of that level, recorded on the nurses’ station computer as nearly 90 megabits per second for upload and download speeds.

It’s a “heartbreaking” situation, Miri said, “but that’s the reality of rural America.”

The Beeping Stopped

Michael Gordon, one of the hospital’s three doctors, arrived the next morning for his 24-hour shift. He paused in Room 122. Walker had been released overnight.

Not being able to monitor a cardiovascular patient’s heart rhythm, well, “that’s a problem,” Gordon said. “You want to know, 鈥楧id something really change or is that just a crazy IV machine just beeping loud and proud and nobody can hear it?’”

Despite the lack of modern technology tools, staffers do what they can to take care of patients, Pugh said. “We show the community that we care,” she said.

Pugh, who started her career as a registered nurse, arrived at the hospital in 2017. It was “a mess,” she said. The hospital was dinged four years in a row, starting in 2016, with reduced Medicare payments for readmitting patients. Pugh said that at times the hospital had not made payroll. Staff morale was low.

In 2021, federal inspectors notified Pugh of an 鈥� grounds for regulators to shut off federal payments 鈥� because of an Emergency Medical Treatment and Labor Act complaint. Among seven deficiencies inspectors cited, the hospital failed to provide a medical screening exam or stabilizing treatment and did not arrange appropriate transfer for a 23-year-old woman who arrived at the hospital in labor, according to .

Inspectors also said the hospital failed to ensure a doctor was on duty and failed to create and maintain medical records. An ambulance took the woman to another hospital, where the baby was “pronounced ,” according to the report.

Federal inspectors required the hospital to take corrective actions and in July 2021 found the hospital to be in compliance.

In 2023, federal inspectors again cited the hospital’s failure to maintain records and noted it had the “.”

Inspectors that year found that medical records for four discharged patients had been lost. The “physical record” included consent forms, physician orders, and treatment plans and was , where it had been left for two months.

Pugh declined to comment on the immediate jeopardy case. She confirmed that a lack of internet connectivity and use of paper charts played a role in federal findings, though she emphasized the charts were discharge papers rather than for patients being treated.

She said she understands why federal regulators require electronic health records but “our hospitals just aren’t the same.” Larger facilities that can “get the latest and greatest” compared with “our facilities that just don’t have the manpower or the financials to purchase it,” she said, “it’s two different things.”

Walker, like many rural Americans, relies on Medicaid, a joint state and federal insurance program for people with low incomes and disabilities. Rural hospitals in states such as Alabama that have not expanded Medicaid coverage to a wider pool of residents fare worse financially, .

During Walker’s stay, because the hospital can’t afford to modernize its systems, nurses dealt with what Pugh later called an “astronomical” number of paper forms.

Later, at Home

Walker sat on the couch in the modest brick home he shares with his sister and nephew. In a pinch, Greene County Hospital, he said, is good “for us around here. You see what I’m saying?”

Still, Walker said, he often bypasses the county hospital and drives up the road to Tuscaloosa or Birmingham, where they have kidney specialists.

“We need better,” Walker said, speaking for the 7,600 county residents. He wondered aloud what might happen if he didn’t make it to the city for specialty care.

Sometimes, Walker said, he feels “thrown away.”

“People done forgotten about me, it feels like,” he said. “They don’t want to fool with no mess like me.”

Maybe Greene County’s health care and internet will get better, Walker said, adding, “I hope so, for our sake out in a rural area.”

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