State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a �鶹Ů�� Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by �鶹Ů�� Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by �鶹Ů�� Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to �鶹Ů��. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is —­ I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to �鶹Ů�� Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” �鶹Ů�� Health News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently .

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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

USE OUR CONTENT

This story can be republished for free (details).

The enhanced premium tax credits that since 2021 have helped millions of Americans pay for insurance on the Affordable Care Act marketplaces will expire Dec. 31, despite a last-ditch effort by Democrats and some moderate Republicans in the House of Representatives to force a vote to continue them. That vote will happen, but not until Congress returns in January.

Meanwhile, the Department of Health and Human Services canceled a series of grants worth several million dollars to the American Academy of Pediatrics after the group again protested HHS Secretary Robert F. Kennedy Jr.’s changes to federal vaccine policy.

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Lizzy Lawrence of Stat, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• The House on Wednesday passed legislation containing several GOP health priorities, including policies that expand access to association health plans and lower the federal share of some Affordable Care Act exchange marketplace premiums. It did not include an extension of the expiring enhanced ACA premium tax credits — although, also on Wednesday, four Republicans signed onto a Democratic-led discharge petition forcing Congress to revisit the tax credit issue in January.
• In vaccine news, the American Academy of Pediatrics spoke out against the federal government’s recommendation of “individual decision-making” when it comes to administering the hepatitis B vaccine to newborns — and HHS then terminated multiple research grants to the AAP. Meanwhile, the Centers for Disease Control and Prevention is funding a Danish study of the hepatitis B vaccine in West Africa through which some infants will not receive a birth dose, a strategy that critics are panning as unethical.
• Also, a second round of personnel cuts at the Department of Veterans Affairs is expected to exacerbate an existing staffing shortage and further undermine care for retired service members.
• The FDA is considering rolling back labeling requirements on supplements — a “Make America Health Again”-favored industry that is already lightly regulated.
• And abortion opponents are pushing for the Environmental Protection Agency to add mifepristone to the list of dangerous chemicals the agency tracks in the nation’s water supply.

Also this week, Rovner interviews Tony Leys, who wrote the latest “Bill of the Month” feature, about an uninsured toddler’s expensive ambulance ride between hospitals.

Plus, for a special year-end “extra-credit” segment, the panelists suggest what they consider 2025’s biggest health policy themes:��

Julie Rovner: The future of the workforce in biomedical research and health care.��

Lizzy Lawrence: The politicization of science.��

Tami Luhby: The systemic impacts of cuts to the Medicaid program.��

Alice Miranda Ollstein: The resurgence of infectious diseases.��

Also mentioned in this week’s podcast:

• The Washington Post’s “.,” by Lena H. Sun and Paige Winfield Cunningham.
• MedPage Today’s “,” by Jeremy Faust.
• The Washington Post’s “,” by Meryl Kornfield, Hannah Natanson, and Lisa Rein.
• NBC News’ “,” by Berkeley Lovelace Jr.
• Politico’s “,” by Alice Miranda Ollstein and Ariel Wittenberg.
• The Washington Post’s “,” by Paige Winfield Cunningham.
• Politico’s “,” by Joanne Kenen.

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

Julie Rovner:��Hello,��from �鶹Ů�� Health News and WAMU Public Radio in Washington, D.C., and welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �鶹Ů�� Health News, and��I’m��joined by some of the best and smartest health reporters in Washington.��We’re��taping this week on Thursday,��Dec.��18,��at 10��a.m. As always, news happens fast,��and things might have changed by the time you hear this. So, here we go.��

Today, we��are joined��via video conference by Tami Luhby of CNN.��

Tami Luhby:��Hello.��

Rovner:��Alice��Ollstein��of Politico.��

Alice Miranda��Ollstein:��Hi, there.��

Rovner:��And I am pleased to welcome to the podcast panel Lizzy Lawrence of Stat��News. Lizzy, so glad��you’ll��be joining��us.��

Lizzy Lawrence:��Thanks so much for having me.��I’m��excited.��

Rovner:��Later in this episode,��we’ll��have my interview with Tony Leys, who reported and wrote the latest �鶹Ů�� Health News��“Bill of the Month”��about yet another��very expensive��ambulance ride. But first, this week’s news.��

Well, remember when House Speaker Mike Johnson complained during the government shutdown that the issue of the��additional��ACA��[Affordable Care Act]��subsidies expiring was a December problem? Well, he sure was right about that. On Wednesday, the House,��along party lines,��passed��a��bill that Republicans are calling the��“Lower Healthcare Premiums��for All��[Americans]��Act,”��which��actually doesn’t, but��we’ll��get to that in a moment. Notably,��not��part of that bill was any extension of the enhanced tax credits that now are��going��to expire at the end of this year, thus doubling or,��in some cases,��tripling what many consumers who get their coverage from the ACA marketplaces will have to pay monthly starting in January. Speaker Johnson said he was going to let Republican moderates offer an amendment to the bill to continue the��additional��subsidies with some changes, but in the end, he��didn’t.��

So, four of those Republicans,��from more purple swing districts worried about their constituents seeing their costs spike, yesterday signed on��to a Democratic-led discharge petition, thus forcing a vote on the subsidies, although not until Congress returns in January. Before we get to the potential future of the subsidies though, Tami, tell us��what’s��in that bill that just passed the House.��

Luhby:��Well, there are four main measures in it, but none of them, as you say��…��they will lower potentially some premiums for certain people, but��they’re��really a bit of a laundry list of Republican favorite provisions.��

So, one of the main ones is association health plans. They would allow more small businesses��—��and,��importantly, the self-employed��—��to band together across industries. This could lower health insurance premiums for some people, but these plans also��don’t��have to adhere to��all of��the ACA protections and benefits that are offered. So, it may attract more healthier people or be more beneficial for healthier people, but not for everyone, for sure.��

There are some PBM, pharmacy benefit manager,��reforms. They would have to provide a little more information to employers about drug prices and about the rebates they get, but it may not really have��… the experts I spoke to said��it’s��really just��tinkering around at the edges and may not be that consequential.��

Rovner:��And��it’s��not even as robust a PBM bill as Republicans and Democrats had agreed to last year��…��

Luhby:��Exactly.��

Rovner:��… that Elon Musk got struck at the last minute because the bill was too long.��

Luhby:��Exactly,��it’s��a narrower transparency. There are narrower transparency provisions. It would also,��importantly, refund the��cost-sharing��provisions. And remember, there are two types of subsidies in the Affordable Care Act. There are��the premium��subsidies, which is what everyone is talking about, the enhanced premium subsidies.��But these are cost-sharing reductions that lower-income people on the exchanges receive to actually reduce their deductibles and their copayments and coinsurance, their��out-of-pocket��expenses.��

President��[Donald]��Trump, during his first term,��in an effort to��weaken the Affordable Care Act, ended the federal funding for these cost-sharing subsidies, but the law requires that insurers continue to provide them.��So��what the insurers did was they increased the premiums of the��“silver”��plans��in order to��make up some of the difference, but those silver plans, remember, are tied to��…��the cost of those silver plans are what��determines��the premium subsidies that people get. So, basically,��by refunding or by once again funding these cost-sharing subsidies, insurers will lower the premiums for those silver plans, which will,��in turn,��lower the premium subsidies that the government��has to��pay and save the government money.��

The people in silver plans��probably won’t��be affected as much, but what happened after Trump ended the cost-sharing subsidy funding is that with these increased premium subsidies that are tied to the silver plans, a lot of people were able to buy��“gold”��plans. They were able to buy better plans for less because they got bigger premium subsidies, or they were able to buy��“bronze”��plans for��really cheap.��So basically, this��provision will end, will reduce the premium��assistance��that people get,��and��it’ll��effectively raise premium payments for people in a lot of plans, which will make it more difficult for them.��

Rovner:��Which was a wonderful explanation, by the way, of��something��that’s��super complicated.��

Luhby:��Thank you.��

Rovner:��But��I’ve��been trying to say it��basically moves��money around. It takes money that had been��…��it lowers how much the federal government will have to pay, while at the same time loading that back onto consumers.��

Luhby:��Right.��

Rovner:��So, hence my original statement that the��“Lower Premiums��for All”��Act��doesn’t��lower premiums for all. So, this is��…��

Luhby:��No, there’ll be a lot of people in gold and bronze and��“platinum”��plans who will be paying a lot more, or they’ll have to, if they’re in gold, they may have to shift to silver, which means they’ll just be paying more out-of-pocket when they actually seek care.��

And then��there’s��a fourth provision��that’s��not as consequential:��It’s��called choice plans.��It’s��to help employers give��…��it’s��to make it easier for employers to give money to people to buy coverage on the exchanges.��

Rovner:��Yeah, which��I think nobody��disagrees with. But Alice,��there’s��another even catch to the cost-sharing reductions, which is that��it’s��only for states that ban abortion or that��don’t��ban abortion. Now I��forget, which is it?��

Ollstein:��So, it’s,��yeah.��So��the great compromise of the Affordable Care Act was that��it’s��up to states whether to allow, require, or prohibit plans on the Obamacare exchanges from covering abortion. And as states do, they went in different directions, so about half ban it and about the other half, it’s��50-50 on requiring abortion coverage and just allowing it, leaving it up to individual plans. And so yes, this provision��sought��to penalize states that allowed abortion. And so, it’s expanding the definition of the Hyde Amendment from where it was before, basically saying if any federal funding is going to a plan that uses other money to pay for abortion, then that counts as funding abortion, even though the money is coming out of different buckets.��

And so, this has been a big fight on Capitol Hill this year. And as I wrote yesterday,��it’s��nowhere near being resolved. I mean, even if lawmakers were going to come together on everything else related to the subsidies, which they are not, the abortion debate was still in the way as��an impediment, including in the Senate as well.��

Rovner:��Yeah. So, what are the prospects for these��additional��subsidies? And I should go back and reiterate that what Tami and I were talking about were the original tax credits that were passed with the Affordable Care Act, not the enhanced ones, the bigger tax credits that are expiring at the end of the year. So, Republicans have now forced this vote, so we know that the House is going to vote on extending these subsidies��—��in January,��after��they’ve��expired, which is a whole issue of complication itself. But I mean, is there any prospect for a compromise here?��Might they go home and get enough pushback from constituents who are seeing their costs go up so much they’re going to have to drop their insurance that they might change their minds?��

Ollstein:��Well, Democrats and advocacy groups are trying to ramp up that pressure.��We’ve��been covering some ad campaigns and efforts. Democrats are holding town halls in Republican districts where the representatives are not holding town halls to shine a light on this.��They’re��highlighting the stories of individual, sympathetic-character folks who are having their premiums go��way up.��

So, there were press conferences just this week I saw with retirees and people who are on��Social��Security��Disability and small-business owners and single parents,��and��it’s��not hard to find these stories;��this is happening to tens of millions of people. And so,��I think this��is going to be a major, major political message going into next year. Whether��it’s��enough to make Republicans who are still so ideologically opposed to the Affordable Care Act agree on��some kind of an��extension, that remains to be seen. And we really��haven’t, despite the defection of a small handful this week in joining the Democrats on an extension��—��which was��really notable��and a sign that Speaker Johnson is not keeping his caucus in array.��But the vote hasn’t happened yet, and we’ll see if spending time back in the districts over the holidays makes people more or less willing to compromise.��It can��go either way.��

Rovner:��I saw a lot of people yesterday saying that,��Well, even if the House were to pass the clean three-year extension of the enhanced subsidies��—��which is what’s in the Democrats’��bill��—��the Senate just voted on it last week and voted it down, so it wouldn’t have any chance.��To which my response was,��“Hey, Epstein files.”��When the jailbreak happened in the House on that, the Senate voted, I believe, unanimously for it. So, things can change in the Senate. Sorry, Tami, I interrupted you;��you wanted to say something.��

Luhby:��No, I was just going to say that yes, things can certainly��change��and there have been surprises before, but this is obviously also not a new issue. I mean, the Democrats have been running ads, people have been speaking out. We have all been��writing��stories about��the cancer��survivors or cancer patients who may have to drop their coverage in the middle of their treatment because they��can’t��afford the new premiums, or��all of��these stories. So, none of this is new, but��we’ll��see.��There’s��obviously��…��what is��somewhat new��is the administration’s message on increasing affordability, and this is a huge affordability issue. So,��maybe that��will spur some change in votes or change in mindset.��

Rovner:��Well, definitely a January story too.��

Well, moving on to this week in vaccine news, the Centers for Disease Control and Prevention has made it official��—��after being blessed by the acting director of the agency, who is neither a doctor nor a public health professional��—��the U.S.��government is no longer recommending a birth dose of the hepatitis B vaccine, which by the way, has been shown to reduce chronic hepatitis B in children and teenagers by 99% since the recommendation was first issued in 1991.��

And merging two stories from this week, there’s also��news about the American Academy of Pediatrics, which has been among the most vocal medical groups protesting the vaccine schedule changes. The AAP said the hepatitis B change will��“harm children, their families, and the medical professionals who care for them.”��And in a move that seems not at all coincidental, the Department of Health and Human Services on Wednesday��terminated��seven federal grants to the AAP worth millions of dollars, for work on efforts including reducing sudden infant deaths, preventing fetal alcohol syndrome, and��identifying��autism early. According to��The Washington Post, which��, an HHS��spokesman��said the grants were canceled because they��“no longer align with the��Department’s mission or priorities.”��

First, this is not normal. Second, however,��it’s��HHS in 2025 in a microcosm, isn’t it? Either get with the program or get out. Lizzy,��you’re��nodding.��

Lawrence:��Absolutely. Yeah, I think this has become very commonplace in this administration.��And also��interestingly, yesterday, the HHS posted in the federal register that the CDC offered a $1.6 million grant to a group of Danish researchers who study in Guinea,��West Africa,��to run a placebo-controlled trial of hepatitis B vaccine for newborns. And so,��we’re��seeing an active removal of funds from the American Academy of��Pediatricians��[Pediatrics], and��then giving funds now to research. And this is a research group��actually that��RFK Jr. has cited their studies before, they study overall health effects of vaccines. And so, it will be��really interesting��to see if this is a trend that continues, if��they’re��kind of��…��we already know that HHS, the CDC’s vaccine panel,��there’s��been discussions about making our vaccine schedule closer to Denmark’s. Now��there’s��this money being given to Danish researchers who align with the way that they think about vaccines is��similar to��Kennedy and to another official at FDA,��called Tracy Beth Høeg, who is also on the CDC’s panel as the FDA representative. So,��yeah.��

Rovner:��And who is Danish, I believe.��

Lawrence:��Yes, her husband is Danish, and so she lived in Denmark for many years.��

Rovner:��I saw some scientists complain about that study in Guinea-Bissau, because they say��it’s��actually unethical��to use a placebo to study the hepatitis B vaccine because we know that it works.��So��if��you’re��giving a placebo to children,��you’re��basically exposing��them to hepatitis B.����

Lawrence:��Right.��

Ollstein:��Yeah. I saw��that��too. And a lot of folks were saying this would never be approved to be done in the U.S. And so, doing it in another country is reminding people of��colonial experiments��in��medicine that were��really unethical��and subjected people to more risks than would be allowed here. And like you said,��basically knowingly��withholding something that is safe and effective and giving someone a placebo instead.��

Another issue I saw raised was that it is not a double-blind study;��it is a single-blind study. And so, that allows for potential biases there as well.��

Lawrence:��Right. And I was also seeing that the Guinea Ministry of Health is planning to mandate a universal hep B dose in 2027.��

Rovner:��Oops.��

Lawrence:��So, that’s a crazy��…��yeah, you have babies born before that year who are not given this dose, and then after��…��so yeah, it raises all kinds of ethical concerns,��and it’s just remarkable that the government would just pull away and offer this money to them.��

Rovner:��HHS in 2025.��Specifically on the��covid��vaccine, there��were��two stories this week. One is a study in the Journal of the American Medical Association that found that pregnant women vaccinated against��covid-19 are less likely to be hospitalized, less likely to need intensive care, and less likely to deliver early, if they can track the virus, than those who are unvaccinated. And over at��,��editor Jeremy Faust,��who’s��both a doctor and a health researcher, says that FDA��vaccine��chief Vinay Prasad overstated his case when he said the agency has found at least 10 children��who’ve��died��as a result of��receiving the��covid��vaccine. Turns out the actual memo from the scientists assigned to research the topic concludes the number is somewhere between zero and seven, and five of those cases have only a 50-50 chance of being related to the vaccine. This��isn’t��great evidence for those who want to stop giving the vaccine to children and pregnant women, I would humbly suggest.��

Lawrence:��Right,��right.��Yeah, the memo that Vinay Prasad sent, which was��immediately��leaked, was remarkable in that it included no data backing up his claims.��And this is a really tricky area, when I’ve talked to scientists at the agency who focus on these issues.��I think sometimes��it’s��hard to say that there are cases that are very subjective, and so this is a discussion that needs to be handled delicately,��and��it’s��a��really severe��claim to say that this has killed 10 children. And so, that discussion needs to be shared transparently and��allow for��experts to really weigh in.��

Rovner:��Yeah. Well, another issue��that’s��going to bleed over into January. All��right,��we’re��going to take a quick break.��We will be right back.��

So��in other administration health news, it appears, at least��, that the on-again,��off-again��cuts to medical personnel at the Department of Veterans Affairs are on again. The��Post is reporting that the VA is planning to eliminate up to 35,000 doctors, nurses, and support personnel.��That’s��on top of a cut of 30,000 people earlier in 2025. Altogether,��it’s��about a 10% cut in total.��Apparently, most��of the positions are currently unfilled, but that��doesn’t��mean that��they’re��unneeded, particularly after Congress dramatically expanded��the��number of veterans eligible for health benefits by passing the PACT Act during the Biden��administration.��That’s��the bill that allowed people to claim benefits if they were exposed to toxic burn pits. What is this second round of cuts going to mean for veterans’��ability to get��timely��care from the VA? Nothing good, I imagine.��

Luhby:��Well,��I’ve��been speaking over the past year or two��to��a VA medical staffer,��who wishes to remain anonymous for obvious reasons.��And one thing they told me is that their boss, who was also a medical practitioner, took one of the retirements, and that they have to now cover their boss’��shift.��And��they’ve��asked if the boss is going to be replaced because they obviously��can’t��do two people’s jobs well, and��they’ve��been told that the boss will not be replaced.��

There’s��also,��on top of all of this,��there’s��a hiring freeze and there’s restrictions in hiring. So,��it’s��been��very difficult��for agencies, including the VA, including��the medical��personnel, to get new people. And again, the person��I’ve��spoken to said that the veterans are not getting the care, as��good care��as they were last year because this person just��can’t��do two people’s jobs. And��it’s��on the medical side, but the source also said that��it’s��throughout the hospital with the support staff and even the custodial staff. I mean, just��…��there’s��a lot of unfilled positions that are affecting overall care.����

Rovner:��I feel like a big irony here is that during the first Trump��administration, improving care at the VA and lowering the wait times was a huge priority for President Trump, not just for the administration. He talked about it all the time. And yet, here��he’s��basically undoing��everything that he did for veterans during the first administration.��

All right. Well, meanwhile,����that the FDA is considering rolling back the rule that requires dietary supplement makers to note on their labels that their products have not been reviewed by FDA for safety and efficacy. This was a compromise reached by Congress after a gigantic fight over supplements in 1994��—��I still have scars from that fight��—��following a series of illnesses and deaths due to tainted supplements a couple of years before that. The idea was to let supplements continue to be sold without direct FDA approval,��as long as��customers were informed that they were not intended to��“diagnose, treat, cure, or prevent any disease,”��a phrase that��I’m��sure��you’ve��heard many times in commercials. Of course, diet supplements are��practically an��article of faith for followers of the��“Make America Healthy Again”��movement. I would assume that this is part of RFK Jr.’s vow to loosen what he has called the��“aggressive suppression”��of vitamins and dietary supplements. Lizzy,��you’re��nodding.��

Lawrence:��Yeah, this is super interesting because this was one of the first things a year ago,��when��RFK was announced as the HHS��secretary, when people were��speculating��on what some of his priorities would be, deregulating supplements was a big one.��And so, I think this will be a really interesting space to watch and see.��And��it’s��emblematic,��too,��of the uneven view of products regulated by the FDA,��where there are some products where there’s��…��that RFK and other leaders at the FDA are super��“pro”��and��well, we��don’t��actually need��as much evidence here. And then others, like vaccines or SSRIs��[selective serotonin reuptake inhibitors], where��it seems that they��want to really raise evidence standards, which is not how the FDA is supposed to work.��It’s��supposed to be��dispassionately, with no bias, reviewing medical products.��

Rovner:��And I would point out, in case I��wasn’t��clear before, that supplements are barely regulated now. Supplements are regulated so much less than most everything else that the FDA regulates. Sorry, Alice, you wanted to say something.��

Ollstein:��Yeah. It also, I think, reveals an interesting public perception issue, where the message that a lot of people are getting is that the pharmaceutical industry is this big, bad, evil corporate thing that is out to harm you, and it has all these documented harms, whereas supplements are natural and wellness and seen as the underdog and the upstart. And I think people should remember that supplements are a huge corporate industry as well, and,��like Julie and Lizzy have been saying, regulated a lot less than pharmaceuticals. So, if��you’re��taking a prescription drug,��it’s��been tested a lot more than if��you’re��taking a supplement.��

Rovner:��Yeah, absolutely. So while most of the coverage of HHS in 2025 has been pretty critical, this week, two of our fellow podcast panelists,��Joanne Kenen��and��Paige Winfield Cunningham, have stories on how the breakout star at HHS in this first year of Trump 2.0 turns out to be Dr. Oz. Apparently being an Ivy League-trained heart surgeon with an MBA actually does give you some qualifications to run the agency that oversees Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable��Care Act.��I think I��noted way back during his confirmation hearings that he clearly already had the knack of how to deal with Congress:��flatter them and take their parochial concerns seriously.��That’s something that his boss, RFK Jr., has most certainly not mastered as of yet.��And it turns out that Dr. Oz has both leadership and policy chops. Who could have predicted this going into this year?��

Luhby:��Well, one thing��that’s��interesting is that we were all, I think, watching what Dr. Oz would do with Medicare and Medicare Advantage, because��it’s��obviously something that he had promoted on his shows.��It’s��something that the Biden��administration was trying to crack down on. And it has been interesting that he has not been giving carte blanche to the insurers. He has been cracking down on them as well. I listened to a speech that he gave before the Better Medicare Alliance, which is the group that works with Medicare Advantage insurers. And he��said basically,��“You guys have to step up,”��and so,��it’ll��be interesting to��see going forward��what��additional��measures they take. But��yeah,��he’s��certainly not bending over to the insurers.��

Rovner:��Yeah. I will say, like I said, I noticed from the beginning, from when he came to his confirmation hearing,��that somebody had briefed him well.��Apparently, according, I think��,��he’s��been talking regularly to his predecessors from both parties about how to run the agency, which surprised me a little bit. I will be interested to see how this all progresses, but if you had asked me to bet at the beginning of the year of the important people at HHS who were running these agencies who would do the consensus best job, I’m not sure I would’ve had Dr. Oz at the top of my list.��

Luhby:��Well, and one thing to also point out that was��, particularly,��is that what��we’ve��been hearing at other agencies��—��the CDC, and across the Trump��administration��—��that a lot of the political appointees are really at odds with the staff.��They’re��not communicating with the staff;��there were concerns about that after the CDC shooting over the summer. And one thing that,��obviously,��Dr. Oz is very��personable,��he knows how to reach out to an audience. And in this case, his audience is also his staff. And it was notable that Paige��detailed about��how he really is interacting a lot with the staff. And��I’m��sure��that’s��obviously helping morale and helping the mission at CMS. Also, of course,��it’s��an agency that RFK has not focused on.��

Rovner:��I say, what a shock, treating career staff with some respect,��like they know what��they’re��doing.��

All right. Well, finally, we end this year on reproductive health,��pretty much the��same way we began it, with anti-abortion groups attacking the abortion pill, mifepristone. We know that despite the fact that abortion is now illegal in roughly half the states, the number of abortions overall has not fallen, and that is because of the easy availability,��even across state lines,��of��medication��abortion. Alice,��you’ve��got quite the story this week about an unusual way to go after the pill. Tell us about it.��

Ollstein:��Yeah.��So��this is a��trend��I’ve��been covering��for the last few years, and��it’s��anti-abortion groups��trying��to use various environmental laws to achieve the ban on the pills that they want to achieve. And so,��there’s��been some various iterations of this over the years. The latest one is that groups are jumping on��a��EPA��[Environmental Protection Agency]��public comment process��that’s��going to kick off any day now. So, this is what the EPA does. Every few years, they update the list of chemicals that need to be tracked in water around the country.��So��this��is a big deal.��It costs a lot to track these chemicals.��There��can only be so many chemicals on the list. And these groups are trying to rally people around the country to demand that the EPA add mifepristone and its components to this list.��

Rovner:��This is wastewater, right? Not drinking water?��

Ollstein:��No, this is drinking water.��

Rovner:��Oh, it is drinking water.��

Ollstein:��There are other efforts to use wastewater laws to restrict abortion pills, yes.��So��we talked to scientists that say there is no evidence that mifepristone in the water supply is causing any harm whatsoever. On the other hand, there is tons of evidence of other chemicals, and so we have����talking about how if they put mifepristone on this list, it would push out another more dangerous chemical from being on that list.��

So, just to zoom out a little bit, while this��particular campaign��tactic, whatever you want to call it, may not succeed, I think��it’s��part of a bigger project to sow doubt in the public’s mind about the safety of mifepristone in��various ways.��We’ve��been seeing this all year, and for several years. But I think that this kind of gross-out factor of��there’s��abortions in the water!��Even without scientific evidence of that,��I think it��contributes to��the public��perception. And �鶹Ů�� had some polling recently showing that doubt about the safety of the pills has increased over the past few years. And so, these kinds of campaigns are working in the court of public opinion, if��not quite yet��at federal agencies.��

Rovner:��Another one we will be watching. All right, that is this week’s news. Now��we’ll��play my��“Bill of the Month”��interview with Tony Leys, and then��we’ll��come back and do our��very special��year-end extra credits.��

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

Tony Leys:��Thanks for having me, Julie.��

Rovner:��So, this month’s patient had��a very expensive��ambulance ride, alas, a story��we’ve��heard as part of this series several times. Tell us who he is and what prompted the need for an ambulance.��

Leys:��He is Darragh Yoder, a toddler from rural Ohio. He had a bacterial skin infection called��[staphylococcal]��scalded skin syndrome, which causes blisters and swelling. His mom, Elisabeth, took him to their local ER,��where doctors said he needed to be taken by ambulance to a children’s hospital in Dayton,��about 40 miles away. They put in an IV and then put him in the ambulance. His mom went��with��and said the driver��didn’t��go particularly fast or use the��siren, but��did get them there in about 40 minutes.��

Rovner:��But it��still was��an ambulance ride. So, how big was the bill?��

Leys:��$9,250.��

Rovner:��Whoa. Now, this family��doesn’t��have insurance, which��we’ll��talk about in a minute. So, it��wasn’t��an in-��or��out-of-network��thing. Was this unreasonably high compared to other ground ambulance rides of this type?��

Leys:��It’s really hard to say because the charges can be all over the place,��is��what national experts told me. But if Darragh had been on Medicaid, the ambulance company��would’ve��been paid about $610, instead of��$9,200.��

Rovner:��Whoa. So, what eventually happened with the bill?��

Leys:��The company agreed to reduce��it��about 40% to��$5,600 if the family would pay it in one lump sum. They��did,��they wound up putting it on a credit card, a no-interest credit card,��so they could pay it off overtime.��

Rovner:��Now, as we mentioned, this family��doesn’t��have insurance, but they belong to something called a��health��sharing��ministry. What is that?��

Leys:��Members pool their money together and basically agree to help each other pay bills. And they were thinking that that would cover��maybe about��three-quarters of what they owed, so��…��

Rovner:��Have they heard about that yet?��

Leys:��I have not heard.��

Rovner:��OK. So,��what’s��the takeaway here? I imagine if a doctor says your kid who has an IV attached needs to travel to another facility in an ambulance, you��shouldn’t��just bundle them into your car instead, right?��

Leys:��I sure��wouldn’t.��Yeah, no. I mean, at that point,��she felt like she had no choice. I mean, she did say if she��would’ve��just driven straight to the children’s hospital instead of stopping at the local hospital, they��would’ve��gotten there sooner than if once she stopped at the local hospital and they ordered an ambulance. So,��that’s��in retrospect what she wishes she��would’ve��done. But if��they’d��had insurance, the insurer��would’ve��presumably negotiated��a lower rate,��and they��wouldn’t��have had to do the negotiation themselves.��

Rovner:��So, they are paying this off, basically?��

Leys:��Yeah, they paid it in one lump sum, which is a stretch for them, but they felt like they had no choice.��

Rovner:��All right. Tony Leys, thank you very much.��

Leys:��Thanks for having me, Julie.��

Rovner:��OK,��we’re��back.��It’s��time for our��extra-credit��segment.��That’s��usually where we each recognize a story we read this��week��we think you should read too. But since this is our last podcast of the year, I wanted to do something a little bit different.��I’ve��asked each of our panelists to take a minute or two to��talk about what they see, not necessarily as the biggest single health story of the year, but the most important theme that��we’ll��remember 2025 for. Tami, why don’t you start us off?��

Luhby:��OK. Well, I think that Medicaid has been a big issue in 2025 and will continue to be going forward. Among the most consequential health policies enacted this year were the sweeping Medicaid changes contained in the One Big Beautiful Bill��[Act], which Congress passed over the summer. The legislation enacts historic cuts to��[the]��nation’s safety net,��with the biggest chunk coming from Medicaid, which serves low-income Americans. It would slash more than��$900 billion��from Medicaid, according to the Congressional Budget Office. About 7.5 million more people would be uninsured in 2034 due to these Medicaid provisions. And most of that spike would come from��Congress��adding work requirements to Medicaid for the first time. We know that that happened in 2018, states were trying to do��…��well, the Trump��administration allowed certain states to do that. It really only took effect in Arkansas, and about��18,000 people��lost coverage within months from the work requirements, many of whom,��the advocates say,��many people are��working,��they’re going to get caught up in red tape.��They’re��either working or��they’re��eligible for exemptions, but��they’ll��get caught up in red tape.��

So, what the Big Beautiful Bill requires is in states that have expanded Medicaid, working-age adults without disabilities or��[dependent]��children under age 14 would have to work, volunteer, or attend school or job training programs at least��80 hours��a month to remain eligible, unless they qualify for another exemption,��such as being medically frail or having substance abuse disorder. The package also limits immigrants’��eligibility for Medicaid, requires enrollees to pay some costs, and caps state and local government provider taxes, which is a key funding source for��states��and which will have ripple effects across hospitals and across states in general.��

Now,��what’s��important to note��is,��most of these provisions��haven’t��taken effect yet.��Most of them actually take effect after the midterm elections next year.��So,��they’ll��be rolling out in coming��years��and the full impact is yet to come.��

Rovner:��Alice.��

Ollstein:��So, I have chosen the resurgence of infectious diseases that we are seeing right now.��I think measles��is��really the canary in the coal mine.��Because��it’s��so infectious,��that’s��what’s��showing up first, but��it’s��not going to be the last infectious disease that the country had almost squashed out of existence that is now, as I said, resurging. And so,��I think that a lot of different policies and trends��are feeding into this. And��I think we��have the rollback of vaccine requirements at the state level, at the federal level. We have policies that deter people from seeking out testing and treatment, especially some of these anti-immigrant policies that��we’re��seeing. And then just cuts to public health and public health staff, cuts to surveillance, so��it’s��just harder to know where the outbreaks are happening and how bad they are.��It’s��hard to get reliable data on that. And��so��I think, yes,��we’re��seeing measles first, but now we are starting to see whooping��cough,��we’re��starting to see some other things, and��it’s��really troubling,��and it could have a political impact too.��

I have talked to a bunch of candidates who are running in next year’s midterms who say that they’re able to point to outbreaks right there in their state to say,��“This is the consequence of Republican health��policies, and this is why you should vote for me.”��So, I��would be keeping��an eye on that in the coming year.��

Rovner:��Lizzy.��

Lawrence:��So, my chosen theme is the politicization of science. And my focus has been on the FDA as an FDA beat reporter, but��there’s��been the politicization of science in every agency. And this is something that used to be��pretty taboo, right? I keep thinking these days about the��[Barack]��Obama HHS��secretary,��Kathleen Sebelius,��and the legal and political repercussions she faced when she vetoed an FDA decision to make��Plan B��over-the-counter. And those days seem��very far��away, because now��we’re��seeing at��the FDA speedier drug reviews being used as a bargaining chip in deals between the White House and companies in exchange for companies lowering their prices.��

At the FDA and CDC,��you’re��seeing skeptics or more political officials completely taking over operations, reopening debates on things like vaccines, antidepressants during pregnancy, RSV, monoclonal antibodies, based on thin or even��really no��or debunked evidence.��

You’re��seeing the White House just today use CMS to pull funding from hospitals that perform gender-affirming surgeries.��You’re��seeing NIH��[the National Institutes of Health]��pull funding from research studies that go against Trump��administration ideology.��So, there’s really so many examples, too many to count, of political leaders wielding in power and trying to shape science to fit their agendas in the way that they see the world.��

And then��I’d��say that has a trickle-down effect��to��the way that everyday people think about science,��and it calls everything into question and makes��…��People look to politicians and to the heads of public health agencies to tell them the truth. I mean,��maybe not��politicians, but��it seems that doctors and medical experts’��voices��are increasingly being drowned out by the political re-litigating of science that has been settled for a long time. So,��I think this��is��a very important��topic and one that��I’ll��keep watching��closely in the��next year.��

Rovner:��Yep.��So��my topic builds on Lizzy’s.��It’s��how this administration is using a combination of personnel and funding cuts and new regulations to jeopardize the future of the scientific and health��care workforce well into the future. The administration has frozen or��terminated��literally billions��of dollars in grants from the National Institutes of Health and the National Science Foundation, not just causing the shutdown of many labs, but making students who are pursuing research careers rethink their plans, including those who are well into their graduate studies. Some are even going to other countries, which are happily poaching some of our best and brightest.��

And as��we’ve��talked about so many times before in this year’s podcast, the administration also seems intent on��basically choking��off the future health��care workforce. The big budget bill includes caps on how much medical students can borrow��in��federal loans.��That’s��an effort to get medical schools to lower their tuition, but most observers think��that’s��unlikely to happen. The��Education��Department has decreed that those studying to be nurses, physician assistants, public health workers, and physical therapists are not pursuing a��“profession,”��thus also limiting how much they can borrow. And a new $100,000 visa fee��is going to make it even more difficult for hospitals and clinics, particularly those in rural areas, to hire doctors and nurses from outside the U.S., at a time when international medical workers are��literally the��only ones working in many shortage areas. These are all changes that are going to have ramifications, not just for years, but potentially for generations. So, these are all themes that we will continue to watch in��2026.��

OK, that is this week’s show and our last episode for 2025. Thank you to all of you listeners for coming with us on this wild news ride. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer-engineer, Taylor Cook. A reminder:��What the Health?��is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as,��of course, kffhealthnews.org. Also, as always, you can email us your comments or questions.��We’re��at��whatthehealth@kff.org, or you can still find me on X��, or on Bluesky��. Where are��you guys��hanging these days, Alice?��

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

Rovner:��Tami.��

Luhby:��You could find me at��.��

Rovner:��Lizzy.��

Lawrence:��You can find me at��, on LinkedIn at��, on X��, and on����—��and I forget my username, but��I’m��somewhere there.��

Rovner:��Don’t��worry about it.��OK, we will be back in your feed in January. Until then, be healthy.��

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Watts knew other missileers with similar cancers. But the connection really hit home later that same January day, when the results of a blood test revealed that Watts himself had chronic lymphocytic leukemia, a type of non-Hodgkin lymphoma.

“I don’t know if it was ironic or serendipitous or what the right word is, but there it was,” Watts said.

Within the community of U.S. service members who staff nuclear missile silos scattered across the Northern Rockies and Great Plains, suspicions had long been brewing that their workplaces were unsafe. Just months after Watts was diagnosed in 2022, Lt. Col. Danny Sebeck, a former Air Force missileer who had transferred to the U.S. Space Force, wrote a brief on a potential cancer cluster among people who served at Minuteman III launch control centers on Malmstrom Air Force Base in Montana.

Sebeck identified who served primarily from 1993 to 2011 and had been diagnosed with cancer, including himself. Of those, 11 had non-Hodgkin lymphoma; three had died. The Air Force responded swiftly to Sebeck’s findings, into cancer cases and the environment at three intercontinental ballistic missile bases and a California launch facility. The goal is to complete the research by the end of 2025.

The service has released portions of the studies as they conclude, holding online town halls and briefings to highlight its findings. But while former missileers say they are heartened by the rapid response, they remain concerned that the research, which crosses decades and includes thousands of ICBM personnel and administrative workers, may address too large a population or use statistical analyses that won’t show a connection between their illnesses and their military service.

They need that tie to expedite benefits from the Department of Veterans Affairs.

Historically, the Department of Defense has been slow to recognize potential environmental diseases. Veterans sickened by exposure to Agent Orange in Vietnam, Marines who drank contaminated water at Camp Lejeune, North Carolina, and service members who lived and worked near burn pits in Iraq and Afghanistan fought for years to have their illnesses acknowledged as related to military service.

In the case of the missileers, the Air Force already had studied potential contamination and cancer at Malmstrom in and . That research concluded that launch control centers were “safe and healthy working environments.” But with Sebeck’s presentation and the decision to pursue further investigation, Air Force Global Strike Command — the unit responsible for managing nuclear missile silos and aircraft-based nuclear weapons — said the earlier studies may not have included a large enough sampling of medical records to be comprehensive.

Sebeck, who serves as co-director of the Torchlight Initiative, an advocacy group that supports ICBM personnel and their families, told congressional Democrats that the Defense Department has not accurately tracked exposures to the community, making it difficult for veterans to prove a link and obtain VA health care and disability compensation.

“I had to go to a VA person and pull some papers,” Sebeck said, referring to the government system for recording service members’ environmental risks. “It says that I visited Poland once. It doesn’t mention that I pulled 148 alerts in a launch control center with polychlorinated biphenyls and with this contaminated air and water.”

PCBs — And the Missileers Exposed to Them

PCBs are synthetic chemicals once used in industry, including missile control electrical components such as display screens, keyboards, and circuit breakers. They have been banned for manufacture since 1979, deemed toxic and a likely carcinogen by the Environmental Protection Agency.

The Air Force’s Missile Community Cancer Study compares 14 types of common cancers in the general U.S. population and the missile community and also studies the environments at Malmstrom Air Force Base in Montana, F.E. Warren Air Force Base in Wyoming, Minot Air Force Base in North Dakota, and Vandenberg Space Force Base in California to determine whether they may have contributed to the risk of developing cancer.

The Malmstrom, Warren, and Minot bases together field 400 Minuteman III missiles, the land-based leg of the U.S. nuclear triad, which also includes submarine- and aircraft-launched nuclear weapons. The missiles are housed in silos spread across parts of Montana, North Dakota, Wyoming, Colorado, and Nebraska, staffed around the clock by missileers operating from underground, bunkerlike launch control centers.

So far, the Air Force investigation has found from cancer in the missile community compared with the general population, and it found that the death rates for four types of common cancers — non-Hodgkin lymphoma, lung, colon and rectum, and prostate cancer — were significantly lower in missileers than in the general population.

Non-Hodgkin lymphoma accounted for roughly 5.8% of all cancer deaths among people who worked in launch control centers from January 1979 to December 2020.

Early results, derived from Defense Department medical records, found elevated rates of breast and prostate cancers in the missile community, but a later analysis incorporating additional data did not support those findings. The studies also did not find increased rates of non-Hodgkin lymphoma. Air Force officials noted during a June 4 online town hall, however, that these assessments are based on roughly half the data the service expects to review for its final epidemiological reports and cautioned against drawing conclusions given the limitations.

The final incidence report will include federal and state data, including information from civilian cancer registries, and delve into subgroups and exposures, which may “provide deeper insights into the complex relationship” between serving in the missile community and cancer risk, wrote Air Force Col. Richard Speakman in a September 2024 memo on the initial epidemiology results.

Gen. Thomas Bussiere, commander of Air Force Global Strike Command, said during the June town hall that only the final results will determine whether the missile community’s cancer rates are higher than the general population’s.

Some lawmakers share the concern of missileers about the Air Force study. Following the release of a of Torchlight Initiative data that showed higher rates of non-Hodgkin lymphoma — at younger ages — among Malmstrom missileers, Rep. Don Bacon (R-Neb.) to a defense policy bill calling for the National Academies of Sciences, Engineering, and Medicine to review health and safety conditions in the facilities.

“Let’s make sure that we have some outside experts working with the Air Force studying cancer rates with our ICBM missions,” Bacon posted July 30 on the social platform X. “We want to ensure credibility and that whatever results come out, we’ve done total due diligence.”

Regarding additional studies on the working environments at the installations and a possible relationship between exposures and cancer risk, Speakman, who commands the Air Force School of Aerospace Medicine, said Malmstrom had two types of PCBs that the other two missile wing bases did not.

He added that benzene, found in cigarette smoke, vehicle exhaust, and gasoline fumes, was the largest contributor to cancer risk in reviews of the bases.

The assessment concluded that health risks to missileers is “low, but it’s not zero,” Speakman said. He said it would be appropriate to monitor the health of launch control workers.

Next Steps

Watts, whose story has been highlighted by the Torchlight Initiative, has asked the Defense Department’s inspector general to investigate — the watchdog agency referred his request to Global Strike Command — and is closely watching the Air Force research. He said the bulk of the cancer cases reported to Torchlight occurred in the 2000s, when ICBM personnel still used technology that contained PCBs, burned classified material such as treated paper and plastic coding devices indoors, and possibly were exposed to contaminated water.

“I open the door and there’s guys standing there in pressurized suits with sampling equipment,” Watts recalled. “They said, ‘We’re here to check for contaminated water.’ I look at my crew commander, and we’re standing there in cotton uniforms. I said, ‘Do you see anything wrong with this?’”

Launch control operators no longer burn code tapes indoors and the Air Force has made improvements to air circulation in the centers. Sebeck wants Congress to consider including missileers and others sickened by exposure to base contamination in the PACT Act, landmark legislation that mandates health care and benefits for veterans sickened by burn pits and other pollutants.

“It’s documented that there is a large cancer cluster in Montana, probably also in Wyoming. People act surprised, but all they have to do is go to the oncology office in Denver. I can find my missileer buddies there. We are sitting in the same chairs getting chemotherapy,” Sebeck said.

Air Force Global Strike Command spokesperson Maj. Lauren Linscott said in response to Sebeck’s remarks that the unit understands the impact of cancer on its personnel and is committed to supporting them.

“While current findings are preliminary and no conclusions can yet be drawn, we are dedicated to a rigorous, peer-reviewed, data-driven process to better understand potential health risks because the safety of our airmen is our top priority,” Linscott said.

Bills introduced in the House and Senate would address the situation. In addition to Bacon’s amendment, the Senate version of an annual defense policy bill would require a “deep cleaning” of launch control centers every five years until the sites are decommissioned as a new ICBM, the Sentinel, replaces the Minuteman IIIs.

The Air Force aims to release its final epidemiological report by the end of the year.

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

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This story can be republished for free (details).

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

Sarah Karlin-Smith: Slate’s “,” by Maria Kefalas.��

Sandhya Raman: CQ Roll Call’s “,” by Sandhya Raman.��

Lauren Weber: The New York Times’ “,” by Emily Anthes.��

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by Carolyn Y. Johnson and Lauren Weber.
• The AP’s “,” by Melissa Goldin.
• The Washington Post’s “,” by Paige Winfield Cunningham.
• The Washington Post’s “,” by Riley Beggin and Jeff Stein.

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

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

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

Lauren Weber: Hey, everybody.��

Huetteman: Sandhya Raman of CQ Roll Call.��

Sandhya Raman: Good morning.��

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

Sarah Karlin-Smith: Hi, everybody.��

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Huetteman: Yikes.����

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

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

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

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

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

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

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

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

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

Raman: I’m and Bluesky .����

Huetteman: Sarah?����

Karlin-Smith: A little bit of everywhere, but X, Bluesky, LinkedIn or .����

Huetteman: And Lauren?����

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

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

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Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. “It seems like it takes entirely too long,” he said.

Many veterans live hours from VA facilities, or they need health services that aren’t readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.

Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.

Two Republican senators have that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump’s first term.

Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn’t be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.

“My main concern is for veterans, not for the VA,” Sen. Kevin Cramer (R-N.D.) told �鶹Ů�� Health News. “I don’t believe we have an obligation to sustain the bureaucracy.”

About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.

Cramer that would allow veterans who live within 35 miles of a rural, “critical access” hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.

Cramer, who serves on the Senate Veterans’ Affairs Committee, noted his state has just one VA hospital. It’s in Fargo, on the state’s eastern border, which is more than 400 miles by car from parts of western North Dakota.

Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. “I kept thinking to myself, ‘This doesn’t make any sense at all,’” Cramer said.

Cramer said previous laws, including the , made it easier for veterans to use their benefits to cover care at community hospitals and clinics.

But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.

“We can’t let the VA itself determine whether a veteran is qualified to receive local care,” he said.

U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans’ Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department’s money to support private health care facilities.

The VA provides specialized care that responds to veterans’ needs and experiences, he argues.

“We must prevent funds from being siphoned away from veterans’ hospitals and clinics, or VA will crumble,” Takano said in a statement released by his office. “Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community.”

Some veterans’ advocacy groups have also expressed concerns.

Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn’t want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.

Retzer said it’s true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. “This is a national crisis.”

Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. “We want to ensure that the VA is the primary provider of that care,” he said.

Veterans Affairs Secretary Doug Collins to improve the community care program while maintaining the strength of the department’s hospitals and clinics. The department declined a �鶹Ů�� Health News request to interview Collins.

Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer’s bill. Lewis is a Navy veteran who uses the VA’s community care option to pay for treatment of a back injury stemming from his military service.

Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. “It’s frustrating.”

Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they’re entitled to receive locally.

“I think a lot of folks just don’t want to fight the system,” he said. “They don’t want to go through the extra hoops, and so they’ll jump in the van, and they’ll ride along.”

Rep. Mike Bost (R-Ill.), chairman of the House Veterans’ Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.

Bost helped gain for Trump’s request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that

Bost also co-sponsored that would spell out requirements for the VA to pay for community care.

Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.

Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency’s mission, including its employment of many veterans. “You just feel like you’re being taken care of by your own,” he said.

He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can’t promptly provide.

The local VA doesn’t offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.

Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.

Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn’t have to jump through so many hoops to obtain convenient care.

“After what they’ve done for us? Please,” she said.

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

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The initiative, dubbed the Million Veteran Program, is a “crown jewel of the country,” said David Shulkin, a physician who served as VA secretary during the first Trump administration. Data from the project has contributed to research on the genetics of anxiety and peripheral artery disease, for instance, and has resulted in hundreds of published papers. Researchers say the repository has the potential to help answer health questions not only specific to veterans — like who is most vulnerable to post-service mental health issues, or why they seem more prone to cancer — but also relevant to the nation as a whole.

“When the VA does research, it helps veterans, but it helps all Americans,” Shulkin said in an interview. ��

Researchers now say they fear the program is in limbo, jeopardizing the years of work it took to gather the veterans’ genetic data and other information, like surveys and blood samples.

“There’s sort of this cone of silence,” said Amy Justice, a Yale epidemiologist with a VA appointment as a staff physician. “We’ve got to make sure this survives.”

Genetic data is enormously complex, and analyzing it requires vast computing power that VA doesn’t possess. Instead, it has relied on a partnership with the Energy Department, which provides its supercomputers for research purposes.

In late April, VA Secretary Doug Collins disclosed to Sen. Richard Blumenthal, the top Democrat on the Senate Veterans’ Affairs Committee, that agreements authorizing use of the computers for the genomics project remained unsigned, with some expiring in September, according to materials shared with �鶹Ů�� Health News by congressional Democrats.

Spokespeople for the two agencies did not reply to multiple requests for comment. Other current and former employees within the agencies — who asked not to be identified, for fear of reprisal from the Trump administration — said they don’t know whether the critical agreements will be renewed.

One researcher called computing “a key ingredient” to major advances in health research, such as the discovery of new drugs.

The agreement with the Energy Department “should be extended for the next 10 years,” the researcher said.

The uncertainty has caused “incremental” damage, Justice said, pointing to some Million Veteran Program grants that have lapsed. As the year progresses, she predicted, “people are going to be feeling it a lot.”

Because of their military experience, maintaining veterans’ health poses different challenges compared with caring for civilians. The program’s examinations of genetic and clinical data allow researchers to investigate questions that have bedeviled veterans for years. As examples, Shulkin cited “how we might be able to better diagnose earlier and start thinking about effective treatments for these toxic exposures” — such as to burn pits used to dispose of trash at military outposts overseas — as well as predispositions to post-traumatic stress disorder.

“The rest of the research community isn’t likely to focus specifically” on veterans, he said. The VA community, however, has delivered discoveries of importance to the world: have won Nobel Prizes, and the agency created the first pacemaker. Its efforts also helped ignite the boom in GLP-1 weight loss drugs.

Yet turbulence has been felt throughout VA’s research enterprise. Like other government scientific agencies, it’s been buffeted by layoffs, contract cuts, and canceled research.

“There are planned trials that have not started, there are ongoing trials that have been stopped, and there are trials that have fallen apart due to staff layoffs — yes or no?” said Sen. Patty Murray (D-Wash.), pressing Collins in a May hearing of the Senate Veterans’ Affairs Committee.

The agency, which has a budget of roughly $1 billion for its research arm this fiscal year, has slashed infrastructure that supports scientific inquiry, according to documents shared with �鶹Ů�� Health News by Senate Democrats on the Veterans’ Affairs Committee. It has canceled at least 37 research-related contracts, including for genomic sequencing and for library and biostatistics services. The department has separately canceled four contracts for cancer registries for veterans, creating potential gaps in the nation’s statistics.

Job worries also consume many scientists at the VA.

According to agency estimates in May, about 4,000 of its workers are on term limits, with contracts that expire after certain periods. Many of these individuals worked not only for the VA’s research groups but also with clinical teams or local medical centers.

When the new leaders first entered the agency, they instituted a hiring freeze, current and former VA researchers told �鶹Ů�� Health News. That prevented the agency’s research offices from renewing contracts for their scientists and support staff, which in previous years had frequently been a pro forma step. Some of those individuals who had been around for decades haven’t been rehired, one former researcher told �鶹Ů�� Health News.

The freeze and the uncertainty around it led to people simply departing the agency, a current VA researcher said.

The losses, the individual said, include some people who “had years of experience and expertise that can’t be replaced.”

Preserving jobs — or some jobs — has been a congressional focus. In May, after inquiries from Sen. Jerry Moran, the Republican who chairs the Veterans’ Affairs Committee, about staffing for agency research and the Million Veteran Program, Collins wrote in a letter that he was extending the terms of research employees for 90 days and developing exemptions to the hiring freeze for the genomics project and other research initiatives.

Holding jobs is one thing — doing them is another. In June, at the annual research meeting of AcademyHealth — an organization of researchers, policymakers, and others who study how U.S. health care is delivered — some VA researchers were unable to deliver a presentation touching on psychedelics and mental health disparities and another on discrimination against LGBTQ+ patients, Aaron Carroll, the organization’s president, told �鶹Ů�� Health News.

At that conference, reflecting a trend across the federal government, researchers from the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality also dropped out of presenting. “This drop in federal participation is deeply concerning, not only for our community of researchers and practitioners but for the public, who rely on transparency, collaboration, and evidence-based policy grounded in rigorous science,” Carroll said.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message �鶹Ů�� Health News on Signal at (415) 519-8778 or .

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

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This story can be republished for free (details).

The Supreme Court this week ruled in favor of Tennessee’s law banning most gender-affirming care for minors — a law similar to those in two dozen other states.

Meanwhile, the Senate is still hoping to complete work on its version of President Donald Trump’s huge budget reconciliation bill before the July Fourth break. But deeper cuts to the Medicaid program than those included in the House-passed bill could prove difficult to swallow for moderate senators.

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

Panelists

Among the takeaways from this week’s episode:

• The Supreme Court’s ruling on gender-affirming care for transgender minors was relatively limited in its scope. The majority did not address the broader question about whether transgender individuals are protected under federal anti-discrimination laws and, as with the court’s decision overturning the constitutional right to an abortion, left states the power to determine what care trans youths may receive.
• The Senate GOP unveiled its version of the budget reconciliation bill this week. Defying expectations that senators would soften the bill’s impact on health care, the proposal would make deeper cuts to Medicaid, largely at the expense of hospitals and other providers. Republican senators say those cuts would allow them more flexibility to renew and extend many of Trump’s tax cuts.
• The Medicare trustees are out this week with a new forecast for the program that covers primarily those over age 65, predicting insolvency by 2033 — even sooner than expected. There was bipartisan support for including a crackdown on a provider practice known as upcoding in the reconciliation bill, a move that could have saved a bundle in government spending. But no substantive cuts to Medicare spending ultimately made it into the legislation.
• With the third anniversary of the Supreme Court decision overturning Roe v. Wade approaching, the movement to end abortion has largely coalesced around one goal: stopping people from accessing the abortion pill mifepristone.

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 Alexandra Berzon, Nicholas Nehamas, and Tara Siegel Bernard.����

Victoria Knight: The New York Times’ “,” by Kashmir Hill.����

Alice Miranda Ollstein: Wired’s “,” by Emily Mullin.����

Sandhya Raman: North Carolina Health News and The Charlotte Ledger’s “,” by Michelle Crouch.����

Also mentioned in this week’s podcast:

• �鶹Ů��’s “,” by Ashley Kirzinger, Lunna Lopes, Marley Presiado, Julian Montalvo III, and Mollyann Brodie.
• The Associated Press’ “,” by Kimberly Kindy and Amanda Seitz.
• The Guardian’s “,” by Aaron Glantz.

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for �鶹Ů�� Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, June 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.��

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

Alice Miranda Ollstein: Hello.��

Rovner: Sandhya Raman of CQ Roll Call.��

Sandhya Raman: Good morning.��

Rovner: And Victoria Knight of Axios News.��

Victoria Knight: Hello, everyone.��

Rovner: No interview this week but more than enough news to make up for it, so we will go right to it. It is June. That means it is time for the Supreme Court to release its biggest opinions of the term. On Wednesday, the justices upheld Tennessee’s law banning gender-affirming medical care for trans minors. And presumably that means similar laws in two dozen other states can stand as well. Alice, what does this mean in real-world terms?��

Ollstein: So, this is a blow to people’s ability to access gender-affirming care as minors, even if their parents support them transitioning. But it’s not necessarily as restrictive a ruling as it could have been. The court could have gone farther. And so supporters of access to gender-affirming care see a silver lining in that the court didn’t go far enough to rule that all laws discriminating against transgender people are fine and constitutional. A few justices more or less said that in their separate opinions, but the majority opinion just stuck with upholding this law, basically saying that it doesn’t discriminate based on gender or transgender status.��

Rovner: Which feels a little odd.��

Ollstein: Yes. So, obviously, many people have said, How can you say that laws that only apply to transgender people are not discriminatory? So, been some back-and-forth about that. But the majority opinion said, Well, we don’t have to reach this far and decide right now if laws that discriminate against transgender people are constitutional, because this law doesn’t. They said it discriminates based on diagnosis — so anyone of any gender who has the diagnosis of gender dysphoria for medications, hormones, that’s not a gender discrimination. But obviously the only people who do have those diagnoses are transgender, and so it was a logic that the dissenters, the three progressive dissenters, really ripped into.��

Rovner: And just to be clear, we’ve heard about, there are a lot of laws that ban sort of not-reversible types of treatments for minors, but you could take hormones or puberty blockers. This Tennessee law covers basically everything for trans care, right?��

Ollstein: That’s right, but only the piece about medications was challenged up to the Supreme Court, not the procedures and surgeries, which are much more rare for minors anyways. But it is important to note that some of the conservatives on the court said they would’ve gone further, and they basically said, This law does discriminate against transgender kids, and that is fine with us. And they said the court should have gone further and made that additional argument, which they did not at this time.��

Rovner: Well, I’m sure the court will get another chance sometime in the future. While we’re on the subject of gender-affirming care in the courts, in Texas on Wednesday, conservative federal district judge Matthew Kacsmaryk — that’s the same judge who unsuccessfully tried to repeal the FDA’s [Food and Drug Administration’s] approval of the abortion pill a couple of years ago — has now ruled that the Biden administration’s expansion of the HIPAA [Health Insurance Portability and Accountability Act] medical privacy rules to protect records on abortion and gender-affirming care from being used for fishing expeditions by conservative prosecutors was an overreach, and he slapped a nationwide injunction on those rules. What could this mean if it’s ultimately upheld?��

Ollstein: I kind of see this in some ways like the Trump administration getting rid of the EMTALA [Emergency Medical Treatment and Labor Act] guidance, where the underlying law is still there. This is sort of an interpretation and a guidance that was put out on top of it, saying, We interpret HIPAA, which has been around a long time, to apply in these contexts, because we’re in this brave new world where we don’t have Roe v. Wade anymore and states are seeking records from other states to try to prosecute people for circumventing abortion bans. And so, that wasn’t written into statute before, because that never happened before.��

And so the Biden administration was attempting to respond to things like that by putting out this rule, which has now been blocked nationwide. I’m sure litigation will continue. There are also efforts in the courts to challenge HIPAA more broadly. And so, I would be interested in tracking how this plays into that.��

Rovner: Yeah. There’s plenty of efforts sort of on this front. And certainly, with the advent of AI [artificial intelligence], I think that medical privacy is going to play a bigger role sort of as we go forward. All right. Moving on. While the Supreme Court is preparing to wrap up for the term, Congress is just getting revved up. Next up for the Senate is the budget reconciliation, quote, “Big Beautiful Bill,” with most of President [Donald] Trump’s agenda in it. This week, the Senate Finance Committee unveiled its changes to the House-passed bill, and rather than easing back on the Medicaid cuts, as many had expected in a chamber where just a few moderates can tank the entire bill, the Finance version makes the cuts even larger. Do we have any idea what’s going on here?��

Knight: Well, I think mostly they want to give themselves more flexibility in order to pursue some of the tax policies that President Trump really wants. And so they need more savings, basically, to be able to do that and be able to do it for a longer amount of years. And so that’s kind of what I’ve heard, is they wanted to give themselves more room to play around with the policy, see what fits where. But a lot of people were surprised because the Senate is usually more moderate on things, but in this case I think it’s partially because they specifically looked at a provision called provider taxes. It’s a way that states can help fund their Medicaid programs, and so it’s a tax levied on providers. So I think they see that as maybe — it could still affect people’s benefits, but it’s aimed at providers — and so maybe that’s part of it as well.��

Rovner: Well, of course aiming at providers is not doing them very much good, because hospitals are basically freaking out over this. Now there is talk of creating a rural hospital slush fund to maybe try to quell some of the complaints from hospitals and make some of those moderates feel better about voting for a bill that the Congressional Budget Office still says takes health insurance and food aid from the poor to give tax cuts to the rich. But if the Senate makes a slush fund big enough to really protect those hospitals, wouldn’t that just eliminate the Medicaid savings that they need to pay for those tax cuts, Victoria? That’s what you were just saying. That’s why they made the Medicaid cuts bigger.��

Knight: Yeah. I think there’s quite a few solutions that people are throwing around and proposing. Yeah, but, exactly. Depending on if they do a provider relief fund, yeah, then the savings may need to go to that. I’ve also heard — I was talking to senators last week, and some of them were like, I’d rather just go back to the House’s version. So the House’s version of the bill put a freeze on states’ ability to raise the provider tax, but the Senate version incrementally lowers the amount of provider tax they can levy over years. The House just freezes it and doesn’t allow new ones to go higher. Some senators are like: Actually, can we just do that, go back to that? And we could live with that.��

Even Sen. Josh Hawley, who has been one of the biggest vocal voices on concern for rural hospitals and concern for Medicaid cuts, he told me, Freeze would be OK with me. And so, I don’t know. I could see them maybe doing that, but we’ll see. There’s probably more negotiations going on over the weekend, and they’re also going to start the “Byrd bath” procedure, which basically determines whether provisions in the bill are related to the budget or not and can stay in the bill. And so, there’s actually gender-affirming care and abortion provisions in the bill that may get thrown out because of that. So—��

Rovner: Yeah, this is just for those who don’t follow reconciliation the way we do, the “Byrd bath,” named for the former Sen. [Robert] Byrd, who put this rule in that said, Look, if you’re going to do this big budget bill with only 50 votes, it’s got to be related to the budget. So basically, the parliamentarian makes those determinations. And what we call the “Byrd bath” is when those on both sides of a provision that’s controversial go to the parliamentarian in advance and make their case. And the parliamentarian basically tells them in private what she’s going to do — like, This can stay in, or, This will have to go out. If the parliamentarian rules it has to go out, then it needs to overcome a budget point of order that needs 60 votes. So basically, that’s why stuff gets thrown out, unless they think it’s popular enough that it could get 60 votes. And sorry, that’s my little civics lesson for the day. Finish what you were saying, Victoria.��

Knight: No, that was a perfect explanation. Thank you. But I was just saying, yeah, I think that there are still some negotiations going on for the Medicaid stuff. And where also, you have to remember, this has to go back to the House. And so it passed the House with the provider tax freeze, and that still required negotiations with some of the more moderate members of House Republicans. And some of them started expressing their concern about the Senate going further. And so they still need to — it has to go back through the House again, so they need to make these Senate moderates happy and House moderates happy. There’s also the fiscal conservatives that want deeper cuts. So there’s a lot of people within the caucus that they need to strike a balance. And so, I don’t know if this will be the final way the bill looks yet.��

Rovner: Although, I think I say this every week, we have all of these Republicans saying: I won’t vote for this bill. I won’t vote for this bill. And then they inevitably turn around and vote for this bill. Do we believe that any of these people really would tank this bill?��

Knight: That’s a great point. Yeah. Sandhya, go ahead.��

Raman: There are at least a couple that I don’t think, anything that we do, they’re not going to change their mind. There is no courting of Rep. [Thomas] Massie in the House, because he’s not going to vote for it. I feel like in the Senate it’s going to be really hard to get Rand Paul on board, just because he does not want to raise the deficit. I think the others, it’s a little bit more squishy, depends kind of what the parliamentarian pulls out. And I guess also one thing I’m thinking about is if the things they pull out are big cost-savers and they have to go back to the drawing board to generate more savings. We’ve only had a few of the things that they’ve advised on so far, but it’s not health, and we still need to see — health are the big points. So, I think—��

Rovner: Well, they haven’t started the “Byrd bath” on the Finance provisions—��

Raman: Yes, or—��

Rovner: —which is where all the health stuff is.��

Raman: Yeah.��

Knight: But that is supposed to be over the weekend. It’s supposed to start over the weekend.��

Raman: Yes.��

Rovner: Right.��

Raman: Yeah. So, I think, depending on that, we will see. Historically, we have had people kind of go back and forth. And even with the House, there were people that voted for it that then now said, Well, I actually don’t support that anymore. So I think just going back to just what the House said might not be the solution, either. They have to find some sort of in-between before their July Fourth deadline.��

Rovner: I was just going to say, so does this thing happen before July Fourth? I noticed that that Susie Wiles, the White House chief of staff said: Continue. It needs to be on the president’s desk by July Fourth. Which seems pretty nigh impossible. But I could see it getting through the Senate by July Fourth. I’m seeing some nods. Is that still the goal?��

Knight: Yeah. I think that’s the goal. That’s what Senate Majority Leader [John] Thune has been telling people. He wants to try to pass it by mid-, or I think start the process by, midweek. And then it’s going to have to go through a “vote-a-rama.” So Democrats will be able to offer a ton of amendments. It’ll probably go through the night, and that’ll last a while. And so, I saw some estimate, maybe it’ll get passed next weekend through the Senate, but that’s probably if everything goes as it’s supposed to go. So, something could mess that up.��

But, yeah, I think the factor here that has — I think everyone’s kind of been like: They’re not going to be able to do it. They’re not going to be able to do it. With the House, especially — the House is so rowdy. But then, when Trump calls people and tells them to vote for it, they do it. There’s a few, yeah, like Rand Paul and Massie — they’re basically the only ones that will not vote when Trump tells them to. But other than that — so if he wants it done, I do think he can help push to get it done.��

Rovner: Yeah. I noticed one change, as I was going through, in the Senate bill from the House bill is that they would raise the debt ceiling to $5 trillion. It’s like, that’s a pretty big number. Yeah. I’m thinking that alone is what says Rand Paul is a no. Before we move on, one more thing I feel like we can’t repeat enough: This bill doesn’t just cut Medicaid spending. It also takes aim at the Affordable Care Act and even Medicare. And a bunch of this week show that even Republicans aren’t super excited about this bill. Are Republican members of Congress going to notice this at some point? Yeah, the president is popular, but this bill certainly isn’t.��

Raman: When you look at some of the town halls that they’ve had — or tried to have — over the last couple months and then scaled back because there was a lot of pushback directly on this, the Medicaid provisions, they have to be aware. But I think if you look at that polling, if you look at the people that identify as MAGA within Republicans, it’s popular for them. It’s just more broadly less popular. So I think that’s part of it, but—��

Ollstein: I think that people are very opposed to the policies in the bill, but I also think people are very overwhelmed and distracted right now. There’s a lot going on, and so I’m not sure there will be the same national focus on this the way there was in 2017 when people really rallied in huge ways to protect the Affordable Care Act and push Congress not to overturn it. And so I think maybe that could be a factor in that outrage not manifesting as much. I also think that’s a reason they’re trying to do this quickly, that July Fourth deadline, before those protest movements have an opportunity to sort of organize and coalesce.��

Just real quickly on the rural hospital slush fund, I saw some smart people comparing it to a throwback, the high-risk pools model, in that unless you pour a ton of funding into it, it’s not going to solve the problem. And if you pour a ton of funding into it, you don’t have the savings that created the problem in the first place, the cuts. And all that is to say also, how do we define rural? A lot of suburban and urban hospitals are also really struggling currently and would be subject to close. And so now you get into the pitting members and districts against each other, because some people’s hospitals might be saved and others might be left out in the cold. And so I just think it’s going to be messy going forward.��

Rovner: I spent a good part of the late ’80s and early ’90s pulling out of bills little tiny provisions that would get tucked in to reclassify hospitals as rural so they could qualify, because there are already a lot of programs that give more money to rural hospitals to keep them open. Sorry, Victoria, we should move on, but you wanted to say one more thing?��

Knight: Oh, yeah. No. I was just going to say, going back to the unpopularity of the bill based on polling, and I think that we’ll see at least Democrats — if Republicans get this done and they have the work requirements and the other cuts to Medicaid in the bill, cuts to ACA, no renewal of premium tax credits — I think Democrats will really try to make the midterms about this, right? We already are seeing them messaging about it really hardcore, and obviously the Democrats are trying to find their way right now post-[Joe] Biden, post-[Kamala] Harris. So I think they’ll at least try to make this bill the thing and see if it’s unpopular with the general public, what Republicans did with health care on this. So we’ll see if that works for them, but I think they’re going to try.��

Rovner: Yeah, I think you’re right. Well, speaking of Medicare, we got the annual trustees report this week, and the insolvency date for Medicare’s Hospital Insurance Trust Fund has moved up to 2033. That’s three years sooner than predicted last year. Yet there’s nothing in the budget reconciliation bill that would address that, not even a potentially bipartisan effort to go after upcoding in Medicare Advantage that we thought the Finance Committee might do, that would save money for Medicare that insurers are basically overcharging the government for. What happened to the idea of going after Medicare Advantage overpayments?��

Knight: My general vibe I got from asking senators was that Trump said, We’re not touching Medicare in this bill. He did not want that to happen. And I think, again, maybe potentially thinking about the midterms, just the messaging on that, touching Medicare, it kind of always goes where they don’t want to touch Medicare, because it’s older people, but Medicaid is OK, even though it’s poor people.��

Rovner: And older people.��

Ollstein: And they are touching Medicare in the bill anyway.��

Rovner: Thank you. I know. I think that’s the part that makes my head swim. It’s like, really? There are several things that actually touch Medicare in this bill, but the thing that they could probably save a good chunk of money on and that both parties agree on is the thing that they’re not doing.��

Knight: Exactly. It was very bipartisan.��

Rovner: Yes. It was very bipartisan, and it’s not there. All right. Moving on. Elon Musk has gone back to watching his SpaceX rockets blow up on the launchpad, which feels like a fitting metaphor for what’s been left behind at the Department of Health and Human Services following some of the DOGE [Department of Government Efficiency] cuts. On Monday, a federal judge in Massachusetts ruled that billions of dollars in cuts to about 800 NIH [National Institutes of Health] research grants due to DEI [diversity, equity, and inclusion] were, quote, “arbitrary and capricious” and wrote, quote, “I’ve never seen government racial discrimination like this.” And mind you, this was a judge who was appointed by [President] Ronald Reagan. So what happens now? It’s been months since these grants were terminated, and even though the judge has ordered the funding restored, this obviously isn’t the last word, and one would expect the administration’s going to appeal, right? So these people are just supposed to hang out and wait to see if their research gets to continue?��

Raman: This has been a big thing that has come up in all of the appropriations hearings we’ve had so far this year, that even though the gist of that is to look forward at the next year’s appropriations, it’s been a big topic of just: There is funding that we as Congress have already appropriated for this. Why isn’t it getting distributed? So I think that will definitely be something that they push back up on the next ones of those. Some of the different senators have said that they’ve been looking into it and how it’s been affecting their districts. So I would say that. But I think the White House in response to that called the decision political, which I thought was interesting given, like you said, it was a Reagan appointee that said this. So it’ll definitely be something that I think will be appealed and be a major issue.��

Ollstein: Yeah, and the folks I’ve talked to who’ve been impacted by this stress that you can’t flip funding on and off like a switch and expect research to continue just fine. Once things are halted, they’re halted. And in a lot of cases, it is irreversible. Samples are thrown out. People are laid off. Labs are shut down. Even if there’s a ruling that reverses the policy, that often comes too late to make a difference. And at the same time, people are not waiting around to see how this back-and-forth plays out. People are getting actively recruited by universities and other countries saying: Hey, we’re not going to defund you suddenly. Come here. And they’re moving to the private sector. And so I think this is really going to have a long impact no matter what happens, a long tail.��

Rovner: And yet we got another reminder this week of the major advances that federally funded research can produce, with the FDA approval of a twice-a-year shot that can basically prevent HIV infection. Will this be able to make up maybe for the huge cuts to HIV programs that this administration is making?��

Raman: It’s only one drug, and we have to see what the price is, what cost—��

Rovner: So far the price is huge. I think I saw it was going to be like $14,000 a shot.��

Raman: Which means that something like PrEP [pre-exposure prophylaxis] is still going to be a lot more affordable for different groups, for states, for relief efforts. So I think that it’s a good step on the research front, but until the price comes down, the other tools in the toolbox are going to be a lot more feasible to do.��

Rovner: Yeah. So much for President Trump’s goal to end HIV. So very first-term. All right. Well, turning to abortion, it’s been almost exactly three years since the Supreme Court overturned the nationwide right to abortion in the Dobbs case. In that time we’ve seen abortion outlawed in nearly half the states but abortions overall rise due to the expanded use of abortion medication. We’ve seen doctors leaving states with bans, for fear of not being able to provide needed care for patients with pregnancy complications. And we’ve seen graduating medical students avoiding taking residencies in those states for the same reason. Alice, what’s the next front in the battle over abortion in the U.S.?��

Ollstein: It’s been one of the main fronts, even before Dobbs, but it’s just all about the pills right now. That’s really where all of the attention is. So whether that’s efforts ongoing in the courts back before our friend Kacsmaryk to try to challenge the FDA’s policies around the pills and impose restrictions nationwide, there’s efforts at the state level. There’s agitation for Congress to do something, although I think that’s the least likely option. I think it’s much more likely that it’s going to come from agency regulation or from the courts or from states. So I would put Congress last on the list of actors here. But I think that’s really it. And I think we’re also seeing the same pattern that we see in gender-affirming care battles, where there’s a lot of focus on what minors can access, what children can access, and that then expands to be a policy targeting people of any age.��

So I think it’s going to be a factor. One thing I think is going to slow down significantly are these ballot initiatives in the states. There’s only a tiny handful of states left that haven’t done it yet and have the ability to do it. A lot of states, it’s not even an option. So I would look at Idaho for next year, and Nevada. But I don’t think you’re going to see the same storm of them that you have seen the last few years. And part of that is, like I said, there’s just fewer left that have the ability. But also some people have soured on that as a tactic and feel that they haven’t gotten the bang for the buck, because those campaigns are extremely expensive, extremely resource-intensive. And there’s been frustration that, in Missouri, for instance, it’s sort of been — the will of the people has sort of been overturned by the state government, and that’s being attempted in other states as well. And so it has seemed to people like a very expensive and not reliable protection, although I’m not sure in some states what the other option would even be.��

Rovner: Of course the one thing that is happening on Capitol Hill is that the House Judiciary Committee last week voted to repeal the 1994 Freedom of Access to Clinic Entrances Act, or FACE. Now this law doesn’t just protect abortion clinics but also anti-abortion crisis pregnancy centers. This feels like maybe not the best timing for this sort of thing, especially in light of the shootings of lawmakers in Minnesota last weekend, where the shooter reportedly had in his car a list of abortion providers and abortion rights supporters. Might that slow down this FACE repeal effort?��

Ollstein: I think it already was going to be an uphill battle in the Senate and even maybe passing the full House, because even some conservatives say, Well, I don’t know if we should get rid of the FACE Act, because the FACE Act also applies to conservative crisis pregnancy centers. And lest we forget, only a few short weeks ago, an IVF [in vitro fertilization] clinic was bombed, and it would’ve applied in that situation, too. And so some conservatives are divided on whether or not to get rid of the FACE Act. And so I don’t know where it is going forward, but I think these recent instances of violence certainly are not helping the efforts, and the Trump administration has already said they’re not really going to enforce FACE against people who protest outside of abortion clinics. And so that takes some of the heat off of the conservatives who want to get rid of it. Of course, they say it shouldn’t be left for a future administration to enforce, as the Biden administration did.��

Raman: It also applies to churches, which I think if you are deeply religious that could also be a point of contention for you. But, yeah, I think just also with so much else going on and the fact that they’ve kind of slowed down on taking some of these things up for the whole chamber to vote on outside of in January, I don’t really see it coming up in the immediate future for a vote.��

Rovner: Well, at the same time, there are efforts in the other direction, although the progress on that front seems to be happening in other countries. The British Parliament this week voted to decriminalize basically all abortions in England and Wales, changing an 1861 law. And here on this side of the Atlantic, four states are petitioning the FDA to lift the remaining restrictions on the abortion pill, mifepristone, even as — Alice, as you mentioned — abortion foes argue for its approval to be revoked. You said that the abortion rights groups are shying away from these ballot measures even if they could do it. What is going to be their focus?��

Ollstein: Yeah, and I wouldn’t say they’re shying away from it. I’ve just heard a more divided view as a tactic and whether it’s worth it or not. But I do think that these court battles are really going to be where a lot is decided. That’s how we got to where we are now in the first place. And so the effort to get rid of the remaining restrictions on the abortion pill, the sort of back-and-forth tug here, that’s also been going on for years and years, and so I think we’re going to see that continue as well. And I think there’s also going to be, parallel to that, a sort of PR war. And I think we saw that recently with anti-abortion groups putting out their own not-peer-reviewed research to sort of bolster their argument that abortion pills are dangerous. And so I think you’re going to see more things like that attempting to — as one effort goes on in court, another effort in parallel in the court of public opinion to make people view abortion pills as something to fear and to want to restrict.��

Rovner: All right. Well, finally this week, a couple of stories that just kind of jumped out at me. First, the AP [Associated Press] that Medicaid officials, over the objections of some at the agency, have turned over to the Department of Homeland Security personal data on millions of Medicaid beneficiaries, including those in states that allow noncitizens to enroll even if they’re not eligible for federal matching funds, so states that use their own money to provide insurance to these people. That of course raises the prospect of DHS using that information to track down and deport said individuals. But on a broader level, one of the reasons Medicaid has been expanded for emergencies and in some cases for noncitizens is because those people live here and they get sick. And not only should they be able to get medical care because, you know, humanity, but also because they may get communicable diseases that they can spread to their citizen neighbors and co-workers. Is this sort of the classic case of cutting off your nose despite your face?��

Ollstein: I think we saw very clearly during covid and during mpox and measles, yes. What impacts one part of the population impacts the whole population, and we’re already seeing that these immigration crackdowns are deterring people, even people who are legally eligible for benefits and services staying away from that. We saw that during Trump’s first term with the public charge rule that led to people disenrolling in health programs and avoiding services. And that effect continued. There’s research out of UCLA showing that effect continued even after the Biden administration got rid of the policy. And so fear and the chilling effect can really linger and have an impact and deter people who are citizens, are legal immigrants, from using that as well. It’s a widespread impact.��

Rovner: And of course, now we see the Trump administration revoking the status of people who came here legally and basically declaring them illegal after the fact. Some of this chilling effect is reasonable for people to assume. Like the research being cut off, even if these things are ultimately reversed, there’s a lot of — depends whether you consider it damage or not — but a lot of the stuff is going to be hard. You’re not going to be able to just resume, pick up from where you were.��

Ollstein: And one concern I’ve been hearing particularly is around management of bird flu, since a lot of legal and undocumented workers work in agriculture and have a higher likelihood of being exposed. And so if they’re deterred from seeking testing, seeking treatment, that could really be dangerous for the whole population.��

Rovner: Yeah. It is all about health. It is always all about health. All right. Well, the last story this week is from The Guardian, and it’s called “.” And it’s yet another example of how purging DEI language can at least theoretically get you in trouble. It’s not clear if VA [Department of Veterans Affairs] personnel can now actually discriminate against people because of their political party or because they’re married or not married. The administration says other safeguards are still in place, but it is another example of how sweeping changes can shake people’s confidence in government programs. I imagine the idea here is to make people worried about discrimination and therefore less likely to seek care, right?��

Raman: It’s also just so unusual. I have not heard of anything like this before in anything that we’ve been reporting, where your political party is pulled into this. It just seems so out of the realm of what a provider would need to know about you to give you care. And then I could see the chilling effect in the same way, where if someone might want to be active on some issue or share their views, they might be more reluctant to do so, because they know they have to get care. And if that could affect their ability to do so, if they would have to travel farther to a different VA hospital, even if they aren’t actually denying people because of this, that chilling effect is going to be something to watch.��

Rovner: And this is, these are not sort of theoretical things. There was a case some years ago about a doctor, I think he was in Kentucky, who wouldn’t prescribe birth control to women who weren’t married. So there was reason for having these protections in there, even though they are not part of federal anti-discrimination law, which is what the Trump administration said. Why are these things in there? They’re not required, so we’re going to take them out. That’s basically what this fight is over. But it’s sort of an — I’m sure there are other places where this is happening. We just haven’t seen it yet.��

All right, well, that is this week’s news. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week?��

Knight: Sure thing. My extra credit, it’s from The New York Times. The title is, “,” by Kashmir Hill, who covers technology at The Times. I had seen screenshots of this article being shared on X a bunch last week, and I was like, “I need to read this.”��

Basically it shows that different people who, they may be going through something, they may have a lot of stress, or they may already have a mental health condition, and they start messaging ChatGPT different things, then ChatGPT can kind of feed into their own delusions and their own misaligned thinking. That’s because that’s kind of how ChatGPT is built. It’s built to be, like, they call it in the story, like a sycophant. Is that how you say it? So it kind of is supposed to react positively to what you’re saying and kind of reinforce what you’re saying. And so if you’re feeding it delusions, it will feed delusions back. And so it was really scary because real-life people were impacted by this. There was one individual who thought he was talking to — had found an entity inside of ChatGPT named Juliet, and then he thought that OpenAI killed her. And so then he ended up basically being killed by police that came to his house. It was just — yeah, there was a lot of real-life effects from talking to ChatGPT and having your own delusions reinforced. So, and so it was just an effect of ChatGPT on real-life people that I don’t know if we’ve seen illustrated in a news story yet. And so it was very illuminating, yeah.��

Rovner: Yeah. Not scary much. Sandhya.��

Raman: My extra credit was “.” It’s by Michelle Crouch for The Charlotte Ledger [and North Carolina Health News]. It’s a story about how some different ambulance patients from North Carolina are finding out that their income gets tapped for debt collection by the state’s EMS agencies, which are government entities, mostly. So the state can take through the EMS up to 10% of your monthly paycheck, or pull from your bank account higher than that, or pull from your tax refunds or lottery winnings. And it’s taking some people a little bit by surprise after they’ve tried to pay off this care and having to face this, but something that the agencies are also saying is necessary to prevent insurers from underpaying them.��

Rovner: Oh, sigh.��

Raman: Yeah.��

Rovner: The endless stream of really good stories on this subject. Alice.��

Ollstein: So I chose this piece in Wired by Emily Mullin called “,” thinking a lot about my hometown of Los Angeles, which is under heavy ICE [Immigration and Customs Enforcement] enforcement and National Guard and Marines and who knows who else. So this article is talking about the health impacts of so-called less-lethal police tactics like rubber bullets, like tear gas. And it is about how not only are they sometimes actually lethal — they can kill people and have — but also they have a lot of lingering impacts, especially tear gas. It can exacerbate respiratory problems and even cause brain damage. And so it’s being used very widely and, in some people’s view, indiscriminately right now. And there should be more attention on this, as it can impact completely innocent bystanders and press and who knows who else.��

Rovner: Yeah. There’s a long distance between nonlethal and harmless, which I think this story illustrates very well. My extra credit this week is also from The New York Times. It’s called “,” by Alexandra Berzon, Nicholas Nehamas, and Tara Siegel Bernard. It’s about how the White House basically forced Social Security officials to peddle a false narrative that said 40% of calls to the agency’s customer service lines were from scammers — they were not — how DOGE misinterpreted Social Security data and gave a 21-year-old intern access to basically everyone’s personal Social Security information, and how the administration shut down some Social Security offices to punish lawmakers who criticized the president. This is stuff we pretty much knew was happening at the time, and not just in Social Security. But The New York Times now has the receipts. It’s definitely worth reading.��

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

Raman: @SandhyaWrites and the same .��

Rovner: Alice.��

Ollstein: on Bluesky and on X.��

Rovner: Victoria.��

Knight: I am on X.��

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

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No longer. Interpreters have been noticeably absent from Trump administration press briefings, advocacy groups say. Gone, too, are the American Sign Language interpretations that used to appear on the White House’s YouTube channel. A White House webpage on accessibility, , has also ceased working.

From halting diversity programs that benefit people with disabilities to staffing cuts at the Department of Veterans Affairs, the Trump administration has taken a slew of actions that harm those with impairments or chronic health conditions. Decades of hard-fought gains risk being undone by cuts to federal programs, freezes on research funding, and a White House ban on practices that support diversity.

Advocacy groups are pushing back, setting the stage for years of lawsuits and pitched health policy battles. Some leaders at organizations that serve disabled people are loath to publicly criticize the White House actions because of concerns their groups could become targeted by the administration, especially if they rely on federal funding or grants.

“The silencing of opposition is quite chilling,” said Michael Rembis, director of the Center for Disability Studies at State University of New York-Buffalo. “The denial of disabled people’s humanity and their voice, as well as the actions against disabled people in terms of the removal or evisceration of core infrastructure, are directly related to the ableist language being used by the administration. It is all part of a larger fear and loathing of people who are unlike themselves.”

The White House position is that the Trump-Vance administration values the contributions of government employees with disabilities and believes they should be recognized and rewarded based on the merit of their work. The White House did not provide on-the-record comments or details about its current views on government employees with disabilities.

During Trump’s first term, , he supported people with disabilities by investing millions in home- and community-based services and launching a government-wide task force focused on expanding employment for Americans with disabilities. He also issued an executive order owed by American veterans who are completely and permanently disabled.

But Trump 2.0 seems to be a different story.

The administration’s March 27 restructuring announcement for HHS, which includes a significant downsizing of the workforce, would dismantle the Administration for Community Living and integrate its services into other parts of the agency. Within a week, when HHS staff cuts were announced, that federal office took a mortal hit. The community living administration has focused on ensuring that seniors and people with disabilities can stay in their homes and communities as they age, and it has given $85 million to centers that help people live independently, among other investments. The funding, which came from stimulus legislation that Trump , enabled the centers to provide individuals with prepared meals, personal care items, and help with housing.

This development has left the disability community reeling.

“What America needs now is a coordinated federal effort to make it easier for families to care for older adults and combat chronic disease,” Sarita A. Mohanty, president and chief executive of the Scan Foundation, a senior advocacy group, said in a statement. “HHS’s Administration for Community Living is the only dedicated government agency that helps older adults age in their home and in their community, which is what people say they want.”

Canceling the Culture of DEI

From the get-go, Trump signed that directed the erasure of diversity, equity, and inclusion, which dealt a major setback to the disabled rights movement.

The ramifications have been sweeping. Some federal webpages that provided information on HIV vanished, and the administration cut grants related to HIV and AIDS. Staffers at HHS’ U.S. Office of Infectious Disease and HIV/AIDS Policy also lost their jobs.

The Social Security Administration ceased funding the , which conducted research addressing DEI in Social Security, retirement, and disability policies. Funding had supported such work as a study on to finding work for this population and helping disabled children who receive Social Security transition to adulthood.

The crackdown on DEI also halted or endangered disability-related research at the National Institutes of Health. That, on top of a proposed cap on related research costs that would slash $5.5 billion annually in NIH funding, has imperiled the work. A judge issued a nationwide preliminary injunction blocking the proposed cuts.

includes for children with intellectual challenges and a study of muscular development that aims to help people with muscular dystrophy.

, which aims to improve the lives of older LGBTQ+ people, is among the disability-aid organizations that have had federal funding cut or halted or are worried their grants could be revoked. About a third of SAGE’s funding comes from the federal government.

Donna Sue Johnson, a licensed clinical social worker with post-traumatic stress disorder in New Rochelle, New York, says she relies on SAGE’s socialization services. The 68-year-old said she’s concerned by the DEI executive order and the discontinuation of grants, and she’s also worried cuts to veterans’ services and to Medicaid will harm the disabled community.

“This administration is very myopic,” said Johnson, a former U.S. Army officer. “My rights are being jeopardized as a veteran, a lesbian, and being disabled. They want to make you invisible.”

As another matter of concern, she pointed to Trump’s signaled support for the House-passed GOP budget measure that would likely lead to billions of dollars in cuts from Medicaid, a federal-state health program for people with disabilities and low incomes.

Messaging From the Top

These policy and programmatic decisions reflect a bias that starts with Trump, according to some disability rights groups. They say the president has a history of public, derogatory comments about the people for whom they advocate.

As evidence, they point to an episode in 2015 when Trump appeared at a rally. Then-candidate Trump flailed his hands around in an apparent imitation of the reporter’s physical movements. Trump he was not mocking the reporter. He is also reported to have said “no one wants to see that” when referring to disabled veterans appearing at his events.

More recently, Trump suggested a January midair collision between an American Airlines jet and an Army Black Hawk helicopter outside Washington, D.C., could be partially attributed to an alleged Biden-era focus on at the Federal Aviation Administration.

There is no evidence a focus on diversity in hiring was related to the accident that killed all 67 people on both aircraft.

The administration’s creation of a commission to focus on issues such as the role of antidepressants and nutrition on autism, attention-deficit/hyperactivity disorder, and other chronic diseases also sends a troubling message, some advocates say.

“The memo establishing the Make America Healthy Again commission sees people with disabilities and other chronic illnesses as a danger to the American way of life,” said Maria Town, president and chief executive of the American Association of People with Disabilities, describing what disability rights advocates consider to be the White House’s prevailing view.

Rollbacks to programs that help people with disabilities aren’t occurring only as new policies. The administration is also taking direct actions at specific agencies.

Trump fired two of the three Democratic commissioners who serve on the Equal Employment Opportunity Commission, a five-member panel that acts on violations of federal laws that ban disability bias and other types of discrimination in the workplace. Now, , the commission can’t approve certain cases or issue new guidance.

The hobbling of the commission comes amid an filed with the EEOC. The 88,531 new such cases in fiscal 2024 reflected a 9% jump from fiscal 2023.

Efforts to downsize the federal government are also having a . The federal government has long enjoyed a strong reputation for hiring and accommodating people with disabilities, and nearly 1 in 10 federal workers are disabled compared with about 7% of workers in the U.S. overall.

In addition, people with disabilities can be appointed to federal jobs under a program that streamlines their hiring. It comes with a probationary status of up to two years compared with one year for most other federal employees. In cutting staff, the administration has targeted federal employees on probation, which disproportionately hurts the disabled because they’re more likely to have longer probationary periods.

Some advocacy groups are calling on the administration to restore services for disabled people.

The National Association for the Deaf, for example, of the White House press conference interpreters. Hundreds of people took to such as Facebook to post about the lack of interpreters, commenting, for example, that “we don’t matter and never will” and “I hope accessibility returns.”

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But once he returns to the White House in January, Trump can make abortions difficult — or illegal —across the United States without Congress taking action at all.

The president-elect will have a variety of tools to restrict reproductive rights in general and abortion rights in particular, both directly from 1600 Pennsylvania Ave. and from the executive agencies he’ll oversee. They include strategies he used during his first term, but also new ones that emerged in the wake of the Supreme Court’s overturn of Roe v. Wade in 2022.

The Trump transition team did not respond to a request for comment on this topic.

By far the most sweeping thing Trump could do without Congress would be to order the Justice Department to , an 1873 anti-vice law that bars the mailing of “obscene matter and articles used to produce abortion.”

While Roe was in effect, the law was presumed unconstitutional, but many legal scholars say it could be resurrected. “And it is so broad that it would ban abortion nationwide from the beginning of a pregnancy without exception. Procedural abortion, pills, everything,” Greer Donley, an associate professor and abortion policy researcher at the University of Pittsburgh Law School, said on �鶹Ů�� Health News’ “What the Health?” podcast early this year.

Even if he does not turn to Comstock, Trump is expected to quickly reimpose restrictions embraced by every GOP president for the past four decades. When Trump took office in 2017, he reinstituted the “” (also known as the “global gag rule”), a Ronald Reagan-era rule that banned U.S. aid to international organizations that support abortion rights. He also pulled U.S. funding for the . Both actions were undone when President Joe Biden took office in 2021.

Those aren’t the only policies Trump could resurrect. Others that Trump imposed and Biden overturned include:

• Barring providers who perform abortions and entities that provide referrals for abortion (such as Planned Parenthood) from the federal family planning program, Title X. The Trump administration in 2019; Biden formally in 2021.
• Banning the use of human fetal tissue in research funded by the National Institutes of Health. The Trump administration in 2019; the Biden administration in 2021.
• Requiring health plans under the Affordable Care Act to collect separate premiums if they offer coverage for abortion. The was .
• Allowing health providers to refuse to offer any service that violates their conscience. The — a revision of one originally implemented by President George W. Bush — had already been blocked by several appeals courts before being rescinded and rewritten by the Biden administration. The was issued in January.

Anti-abortion groups say those changes are the minimum they expect. “The commonsense policies of President Trump’s first term become the baseline for the second, along with reversing Biden-Harris administration’s unprecedented violation of longstanding federal laws,” Marjorie Dannenfelser, president of Susan B. Anthony Pro-Life America, said in a statement to �鶹Ů�� Health News.

Dannenfelser was referring to the expectation that Trump will overturn actions that Biden took toward protecting abortion rights after the Supreme Court’s decision. Some included:

• Providing that who live in states with abortion bans be permitted to take leave and travel to other states for reproductive health care.
• Allowing to provide abortion counseling and, in limited circumstances, abortions to veterans and VA beneficiaries, regardless of the laws in the state where the facility is located.
• Expanding the .
• Clarifying that the requires hospitals to provide abortions to women with pregnancy complications that threaten their health, not just their life regardless of state law.

Even easier than formal changes of policy, though, Trump could simply order the Justice Department to drop several cases being heard in federal court in which the federal government is effectively arguing to preserve abortion rights. Those cases include:

• FDA v. The Alliance for Hippocratic Medicine. This case out of Texas . The Supreme Court in June ruled that the original plaintiffs lacked standing to sue, but attorneys general in three states (Missouri, Idaho, and Kansas) have stepped in as plaintiffs. The case has been revived at the U.S. District Court for the Northern District of Texas.
• Texas v. Becerra. In this case, the state of Texas is suing the Department of Health and Human Services, charging that the Biden administration’s interpretation of a law requiring emergency abortions to protect the health of the pregnant woman oversteps its authority. The in October, but that left the possibility that the court would have to step in later — depending on the outcome of a similar case from Idaho that the justices sent back to the Court of Appeals.

Whether Trump will take any or all of these actions is anyone’s guess. Whether he can take these actions, however, is unquestioned.

HealthBent, a regular feature of �鶹Ů�� Health News, offers insight into and analysis of policies and politics from �鶹Ů�� Health News chief Washington correspondent Julie Rovner, who has covered health care for more than 30 years.

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

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It was the latest in a drumbeat of health issues that she traces to the first months of 2020, when dozens of veterans died at the Soldiers’ Home in Holyoke, in one of the country’s at a long-term nursing facility. Ragoonanan has worked at the home for nearly 30 years. Now, she said, the sights, sounds, and smells there trigger her trauma. Among her ailments, she lists panic attacks, brain fog, and other symptoms of post-traumatic stress disorder, .

Scrutiny of the outbreak prompted the state to change the facility’s name to the , replace its leadership, sponsor a of the premises, and agree to a $56 million settlement for veterans and families. But the front-line caregivers have received little relief as they grapple with the outbreak’s toll.

“I am retraumatized all the time,” Ragoonanan said, sitting on her back porch before her evening shift. “How am I supposed to move forward?”

Covid killed more than 3,600 U.S. health care workers in the first year of the pandemic. It left many more with physical and mental illnesses — and a gutting sense of abandonment.

What workers experienced has been detailed in state investigations, surveys of nurses, and published studies. These found that many health care workers weren’t given masks in 2020. Many got covid and worked while sick. More than a dozen lawsuits filed on behalf of residents or workers at nursing facilities detail such experiences. And others allege that accommodations weren’t made for workers facing depression and PTSD triggered by their pandemic duties. Some of the lawsuits have been dismissed, and others are pending.

Health care workers and unions reported risky conditions to state and federal agencies. But the federal Occupational Safety and Health Administration had fewer inspectors in 2020 to investigate complaints than at any point in a half-century. It investigated only about that were filed officially, and just 4% of more than 16,000 informal reports made by phone or email.

Nursing assistants, health aides, and other lower-wage health care workers were particularly vulnerable during outbreaks, and many remain burdened now. About 80% of lower-wage workers who provide are women, and these workers are more likely to be immigrants, to be people of color, and to live in poverty than doctors or nurses.

Some of these a person’s covid risk. They also help explain why these workers had limited power to avoid or protest hazardous conditions, said Eric Frumin, formerly the safety and health director for the Strategic Organizing Center, a coalition of labor unions.

He also cited decreasing membership in unions, which negotiate for higher wages and safer workplaces. One-third of the U.S. labor force was , but the level has fallen to 10% in recent years.

Like essential workers in meatpacking plants and warehouses, nursing assistants were at risk because of their status, Frumin said: “The powerlessness of workers in this country condemns them to be treated as disposable.”

In interviews, essential workers in various industries told �鶹Ů�� Health News they felt duped by a system that asked them to risk their lives in the nation’s moment of need but that now offers little assistance for harm incurred in the line of duty.

“The state doesn’t care. The justice system doesn’t care. Nobody cares,” Ragoonanan said. “All of us have to go right back to work where this started, so that’s a double whammy.”

‘A War Zone’

The plight of health care workers is a problem for the United States as the population ages and the threat of future pandemics looms. called their burnout “an urgent public health issue” leading to diminished care for patients. That’s on top of a predicted shortage of more than 3.2 million lower-wage health care workers by 2026, according to the .

The veterans home in Holyoke illustrates how labor conditions can jeopardize the health of employees. The facility is not unique, but its situation has been vividly described in a state investigative report and in a report from a joint oversight committee of the Massachusetts Legislature.

The Soldiers’ Home made headlines in March 2020 when got a tip about refrigerator trucks packed with the bodies of dead veterans outside the facility. About 80 residents died within a few months.

The placed blame on the home’s leadership, starting with Superintendent Bennett Walsh. “Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report said. He resigned under pressure at the end of 2020.

Investigators said that “at least 80 staff members” tested positive for covid, citing “at least in part” the management’s “failure to provide and require the use of proper protective equipment,” even restricting the use of masks. They included a disciplinary letter sent to one nursing assistant who had donned a mask as he cared for a sick veteran overnight in March. “Your actions are disruptive, extremely inappropriate,” it said.

To avoid hiring more caretakers, the home’s leadership combined infected and uninfected veterans in the same unit, fueling the spread of the virus, the report found. It said veterans didn’t receive sufficient hydration or pain-relief drugs as they approached death, and it included testimonies from employees who described the situation as “total pandemonium,” “a nightmare,” and “a war zone.”

Because his wife was immunocompromised, Walsh didn’t enter the care units during this period, according to his lawyer’s statement in a deposition obtained by �鶹Ů�� Health News. “He never observed the merged unit,” it said.

In contrast, nursing assistants told �鶹Ů�� Health News that they worked overtime, even with covid, because they were afraid of being fired if they stayed home. “I kept telling my supervisor, ‘I am very, very sick,’” said Sophia Darkowaa, a nursing assistant who said she now suffers from PTSD and symptoms of long covid. “I had like four people die in my arms while I was sick.”

Nursing assistants recounted how overwhelmed and devastated they felt by the pace of death among veterans whom they had known for years — years of helping them dress, shave, and shower, and of listening to their memories of war.

“They were in pain. They were hollering. They were calling on God for help,” Ragoonanan said. “They were vomiting, their teeth showing. They’re pooping on themselves, pooping on your shoes.”

Nursing assistant Kwesi Ablordeppey said the veterans were like family to him. “One night I put five of them in body bags,” he said. “That will never leave my mind.”

Four years have passed, but he said he still has trouble sleeping and sometimes cries in his bedroom after work. “I wipe the tears away so that my kids don’t know.”

High Demands, Low Autonomy

A third of health care workers reported symptoms of PTSD related to the pandemic, according to covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer’s. It can lead to substance use and self-harm.

Since covid began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. “More than I have ever received in my career,” she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.

Another factor contributing to these workers’ trauma is “moral injury,” a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among in the pandemic who weren’t given ample resources to provide care.

“Folks who don’t make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful,” said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. “They also have fewer resources to cope with that stress,” she added.

People in lower income brackets have to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.

Such memories can feel as intense as the original event. “If there’s not a change in circumstances, it can be really, really, really hard for the brain and nervous system to recalibrate,” van Dernoot Lipsky said. Rather than focusing on self-care alone, she pushes for policies to ensure adequate staffing at health facilities and accommodations for mental health issues.

In 2021, Massachusetts legislators acknowledged the plight of the Soldiers’ Home residents and staff in a joint saying the events would “impact their well-being for many years.”

But only veterans have received compensation. “Their sacrifices for our freedom should never be forgotten or taken for granted,” the state’s veterans services director, Jon Santiago, said at an event announcing a memorial for veterans who died in the Soldiers’ Home outbreak. The state’s $56 million settlement followed a class-action lawsuit brought by about 80 veterans who were sickened by covid and a roughly equal number of families of veterans who died.

The state’s attorney general also brought criminal charges against Walsh and the home’s former medical director, David Clinton, in connection with their handling of the crisis. The two averted a trial and possible jail time this March by changing their not-guilty pleas, instead acknowledging that the facts of the case were sufficient to warrant a guilty finding.

An attorney representing Walsh and Clinton, Michael Jennings, declined to comment on queries from �鶹Ů�� Health News. He instead referred to legal proceedings in March, in which Jennings argued that “many nursing homes proved inadequate in the nascent days of the pandemic” and that “criminalizing blame will do nothing to prevent further tragedy.”

Nursing assistants sued the home’s leadership, too. The lawsuit alleged that, in addition to their symptoms of long covid, what the aides witnessed “left them emotionally traumatized, and they continue to suffer from post-traumatic stress disorder.”

The case was dismissed before trial, with courts ruling that the caretakers could have simply left their jobs. “Plaintiff could have resigned his employment at any time,” Judge Mark Mastroianni wrote, referring to Ablordeppey, the nursing assistants’ named representative in the case.

But the choice was never that simple, said Erica Brody, a lawyer who represented the nursing assistants. “What makes this so heartbreaking is that they couldn’t have quit, because they needed this job to provide for their families.”

‘Help Us To Retire’

Brody didn’t know of any cases in which staff at long-term nursing facilities successfully held their employers accountable for labor conditions in covid outbreaks that left them with mental and physical ailments. �鶹Ů�� Health News pored through lawsuits and called about a dozen lawyers but could not identify any such cases in which workers prevailed.

A Massachusetts chapter of the Service Employees International Union, SEIU Local 888, is looking outside the justice system for help. It has pushed for a bill — proposed last year by Judith García, a Democratic state representative — to allow workers at the state veterans home in Holyoke, along with its sister facility in Chelsea, to receive their retirement benefits five to 10 years earlier than usual. The bill’s fate will be decided in December.

Retirement benefits for Massachusetts state employees amount to 80% of a person’s salary. Workers qualify at different times, depending on the job. Police officers get theirs at age 55. Nursing assistants qualify once the sum of their time working at a government facility and their age comes to around 100 years. The state stalls the clock if these workers take off more than their allotted days for sickness or vacation.

Several nursing assistants at the Holyoke veterans home exceeded their allotments because of long-lasting covid symptoms, post-traumatic stress, and, in Ragoonanan’s case, a brain aneurysm. Even five years would make a difference, Ragoonanan said, because, at age 56, she fears her life is being shortened. “Help us to retire,” she said, staring at the slippers covering her swollen feet. “We have bad PTSD. We’re crying, contemplating suicide.”

I got my funeral dress out because the way everybody was dying, I knew I was going to die.

Debra Ragoonanan

Certain careers are linked with shorter life spans. Similarly, economists have shown that, on average, people with lower incomes in the United States than those with more. Nearly 60% of long-term care workers are among the bottom earners in the country, paid less than $30,000 — or about $15 per hour — in 2018, according to analyses by the Department of and , a health policy research, polling, and news organization that includes �鶹Ů�� Health News.

Fair pay was among the solutions listed in the surgeon general’s report on burnout. Another was “hazard compensation during public health emergencies.”

If employers offer disability benefits, that generally entails a pay cut. Nursing assistants at the Holyoke veterans home said it would halve their wages, a loss they couldn’t afford.

“Low-wage workers are in an impossible position, because they’re scraping by with their full salaries,” said John Magner, SEIU Local 888’s legal director.

Despite some public displays of gratitude for health care workers early in the pandemic, essential workers haven’t received the financial support given to veterans or to emergency personnel who risked their lives to save others in the aftermath of 9/11. Talk show host Jon Stewart, for example, has lobbied for this group for over a decade, successfully pushing Congress to compensate them for their sacrifices.

“People need to understand how high the stakes are,” van Dernoot Lipsky said. “It’s so important that society doesn’t put this on individual workers and then walk away.”

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