[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 麻豆女优 Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, April 2, 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: And Sandhya Raman, now at Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

Rovner: Later in this episode, we’ll have my interview with 麻豆女优 Health News’ Elisabeth Rosenthal, who reported and wrote the last two 麻豆女优 Health News “Bills of the Month.” One is about a patient who got caught in the crossfire over prices between insurers and drug companies. The other is about a woman who, and this is not an April Fools’ joke, got her insurance canceled for failing to pay a bill for 1 cent. But first, this week’s news. 

So Congress is on spring break, but when they come back, health policy will be waiting. A new Gallup poll out this week found 61% of those surveyed said they worry about the availability and affordability of health care, quote, “a great deal.” That was 10 percentage points more than the economy, inflation, and the federal budget deficit, and it topped a list of 15 domestic concerns. And while we are still waiting for final enrollment numbers for Affordable Care Act plans, we do know that the share of people paying more than $500 a month for their coverage doubled from last year to 2026. Yet Axios this week is reporting that Republicans are considering still more cuts to the Affordable Care Act to potentially pay for a $200 billion war supplemental. What exactly are they thinking? And it’s looking more like Republicans are going to try for another budget reconciliation bill this spring. Isn’t that, right, Jessie? 

Hellmann: House Budget chair Jodey Arrington has kind of been pushing this idea really hard of going after what he says is fraud in mandatory programs like Medicare and Medicaid. He’s also talked about funding cost-sharing reductions, which is an idea that slipped out of the last reconciliation bill, and it’s a wonky kind of idea 鈥� 

Rovner: But I think the best way to explain it is that it will raise premiums for many people. That’s how I’ve just been doing it.  

Hellmann: Yeah, exactly. 

Rovner: Let’s not get into the details. 

Hellmann: It would reduce spending for the federal government but wouldn’t really help people who buy insurance on the marketplace. He hasn’t been very specific. He’s also talked about, like, site-neutral policies in Medicare, but it’s hard to see how all of this could make a serious dent in a $200 billion Iran supplemental. There’s also a new development. I think President [Donald] Trump threw a wrench in things yesterday when he said he wanted the reconciliation bill to focus on border spending and immigration spending to cover a three-year period, and now Senate Majority Leader John Thune is saying that there’s probably not room for much else in the bill. So, unclear what the path forward is for all of that. 

Rovner: Yeah, and of course, that was part of the deal to free up the Department of Homeland Security’s budget in the appropriation. It’s all one sort of big, tied-up mess at this point. Alice, I see you’re nodding. 

Ollstein: Yeah. I mean, what often happens with these reconciliation bills is it starts out with a tight focus and everyone’s unified, and then, because it can often be the only legislative train leaving the station, everybody gets desperate to get their pet issue on board, and then the more and more things get piled onto it, then they start losing votes, and people start disagreeing more. And so I think even though this is still in the ideas phase, you’re already seeing some signs of that happening. And when it comes to health care, it can be particularly fraught. And of course, you have lawmakers, especially in the House, with wildly different needs. Some of them need to fend off a primary from the right, and so they want to be as conservative as possible. Some are fighting to hang on in swing districts, and so they want to be more moderate. And these things are in conflict. And so these proposals to cut health spending, even more than the massive amount that was cut last year, are already, you know, raising some red flags among some moderate Republican members. And it’s very possible the whole thing falls apart. 

Rovner: Well, along those lines, we’re supposed to get the president’s budget on Friday, which is only two months late. It was due in February. And while I haven’t seen much on it, Jessie, your colleagues at Roll Call are reporting that the budget will seek a 20% cut to the National Institutes of Health. That’s only half the cut that the administration proposed last year. But given that Congress actually boosted the agency’s budget slightly this year, that feels kind of unlikely. 

Hellmann: Yeah, I don’t think that the appropriators are likely to go along with this. They have really strong advocates, and Sen. Susan Collins, who’s chair of the Senate Appropriations Committee. And, like you said, they rejected cuts last year. Kind of surprised. Twenty percent is not as deep as the Trump administration went last year. I was actually kind of surprised it wasn’t a bigger proposed cut. But either way, I don’t think Congress is going to go along with that.  

Rovner: Meanwhile, I saw a late headline that FDA is looking to hire back people after DOGE [Department of Government Efficiency] cut thousands of people last year. Sandhya, HHS [Department of Health and Human Services] is just in this sort of personnel churn at this point, isn’t it? 

Raman: Yeah, I think that HHS is kind of getting bit in the foot from, you know, we’ve had so many of these layoffs, and we’ve also had a lot of people just flee the various agencies over the past year because of some of this instability and all of these changes. And as we’re getting closer and closer to, you know, deadlines of things that they need to get done, they’re realizing that they do need more personnel to get some of those things done, as we’ve been passing deadlines. So I don’t think it’s something that’s unique to just FDA. But I think the way to solve this 鈥� it’s not an overnight thing for the federal government to staff up. It’s a longer process, but it’s really showing in a lot of areas right now. 

Rovner: Yeah, I would say this is not like TSA [Transportation Security Administration], where you can, you know, hire new people and train them up in a couple of months. These are 鈥� many of them scientists who’ve got years and years of training and experience at doing some of these jobs that, you know, the federal government is ordered to do by legislation. 

Raman: Yeah, those statutes are things that, you know, if they don’t meet those deadlines, those are things that are going to be challenged, and just further tie things up in litigation. And we already see so many of those right now that are making things more complicated.  

Rovner: Well, in news that is not from Congress or the administration, the Supreme Court this week said Colorado could not ban licensed mental health professionals from using so-called conversion therapy aimed at LGBTQ individuals, at least not on minors. What’s the practical impact here? It goes well beyond Colorado, I would think. 

Ollstein: Interesting, because a lot of people think of this as regulating health care, restricting providers from providing health care that is not helpful and maybe actively harmful to the health of the patients. 

Rovner: And that’s 鈥� I would say that’s been a state 鈥� 

Ollstein: Power. 

Rovner: 鈥� power. For generations.  

Ollstein: Absolutely. Right, I mean, you don’t want people selling sketchy snake oil pills on the street, etc. So many people view this as akin to that. But it has morphed in the hands of conservative courts into a free speech issue, and that, you know, these laws are restricting the speech of mental health workers who are against people transitioning. And so, yes, it definitely has national implications. And of course, we are in a national wave right now of both state and federal entities, you know, moving in the direction of rolling back trans rights in the health care space and beyond. 

Rovner: Yeah. In related news, regarding Colorado and minors and gender,  that Children’s Hospital Colorado has not yet resumed providing gender-affirming care for transgender youth. That’s despite a federal judge in Oregon having struck down an HHS declaration that would have punished hospitals for providing such services. Apparently, the hospital in Colorado is concerned that the judge’s ruling doesn’t provide it with enough legal cover for them to resume that care. I’m wondering, is this the administration’s strategy here to get organizations to do what they want, even if they might lack the legal authority to do it? Just by making them worry that they might come after them? 

Raman: I think the chilling effect is definitely a big part of this broader issue. I mean, we’ve seen it in other issues in the past, but just that if there is this worry that it’s a) going to stop on the provider side, new folks taking part in providing care, and also just it’s going to make patients, even if there are opportunities, even less likely to want to go because of the fears there. I mean, it goes broader than that. We’ve had FTC [Federal Trade Commission] complaints, where they have gone and investigated different places that provide gender-affirming care or endorse it. So I think it’s broader than this, and really part of that chilling effect.  

Rovner: And Alice, as you were saying, I mean, the subject of transgender rights, or lack thereof, remains a political hot topic. The Idaho Legislature this week passed a bill that now goes to the governor that would require teachers and doctors to out transgender minors to their parents. Parents could sue teachers, doctors, and child care providers who, quote, “facilitate the social transformation of the minor student.” That includes using pronouns or titles that don’t align with their sex at birth. I don’t know about teachers, but that definitely seems to violate patient privacy when it comes to doctors, right? 

Ollstein: There’s definitely patient privacy issues there. I also think, you know, it’s interesting that this kind of nonmedical transitioning is now coming under attack. Because, you know, you would think that there would be some support for letting a kid, you know, go by a different name for a few weeks, test it out, see how it feels. Maybe it’s a phase, then they discover that they don’t want to actually pursue taking medications and going through a medical transition. But this is sort of shutting down that avenue as well. You can’t even change your appearance, change how you present in the world, at a time when kids are really trying to figure out who they are. So I think the broad acceptance of hostility to medical transitioning for youth is now spilling over into this kind of social transitioning, and I wonder if we’re going to see more of that in the future. 

Rovner: Yeah, I feel like we started with minors shouldn’t have surgery. They shouldn’t do anything that’s not easily reversible. And now we’ve gotten down to, in the Idaho law, there’s actually mention of nicknames. You can’t 鈥� a kid can’t change his or her nickname. It feels like we’ve sort of reduced this way, way, way down. 

Ollstein: And I think we’ve seen these laws, laws related to bathrooms. We’ve seen these have negative impacts on people who are not trans at all, people who just are a tomboy or not looking like people’s stereotypes of what different genders may look like. And so there’s a lot of policing of people who are not trans in any way. You know, there’s media reports of people being confronted by law enforcement for going into a bathroom that does align with their biological sex. And so it’s important to keep in mind that these laws have an effect that’s much broader than just the very small percentage of people who do consider themselves trans. 

Rovner: Yeah, it’s kind of the opposite of not being woke. All right, we’re going to take a quick break. We will be right back.  

So while we’ve had lots of news out of the Department of Health and Human Services the past few weeks, it’s been mostly public health-related. But there’s a lot going on in the Medicare and Medicaid programs too. Item A: Stat News is reporting that HHS is studying whether to make the private Medicare Advantage program the default for seniors when they qualify for Medicare. Right now, you get the traditional fee-for-service plan that allows you to go to any doctor or hospital that accepts Medicare, which is most of them. You have to affirmatively opt into Medicare Advantage, which often provides extra benefits but also much narrower networks. What would it mean to make Medicare Advantage the default, that people would go into private plans instead of the government plan, unless they affirmatively opted for the traditional fee-for-service? 

Hellmann: Someone’s experience with 鈥� can vary greatly between being on traditional Medicare and Medicare Advantage. If you’re in Medicare Advantage, you could be exposed to narrow networks. You can only see certain doctors that are covered by your plan. You can be exposed to higher cost sharing. A lot of people are kind of fine with their plans until they have a medical issue and need to go to the hospital or they need skilled nursing care. So making this the default could definitely be a challenge for some people, especially people that have complex health needs. Some people on the early side of their Medicare eligibility are fine with Medicare Advantage, and then they get older and they’re not fine with it anymore. So it’s interesting that the administration would kind of float this idea because they’ve been critical of Medicare Advantage. 

Rovner: Thank you. That’s exactly what I was thinking. 

Hellmann: Yeah, they’ve talked about the federal government pays these plans too much, and it’s not for better quality in a lot of cases, and they’ve talked about reforms in that area. So I was a little surprised to see that. 

Rovner: Yeah, Republicans have been super ambivalent. I mean, Medicare Advantage was their creation. They overpaid them at the beginning when they, you know, sort of redid the program in 2003. And they purposely overpaid them to get people into Medicare Advantage. And then the Democrats pointed out that this is wasting money because we’re overpaying them. And now the Republicans seem to have joined a lot of their 鈥� at least some Republicans 鈥� seem to have joined a lot of the Democrats in saying, Yes, we’re overpaying them. We’re paying them too much. And you know, they talk about the big, powerful insurance companies, and yet they’re now floating this idea to make Medicare Advantage the default. So pick a side, guys. 

All right, well, in other Medicare news, the Electronic Frontier Foundation is suing Medicare officials to learn more about the pilot program that’s using artificial intelligence to oversee prior authorization requests in the traditional Medicare fee-for-service program. The idea here is to cut down on, quote, “low-value services,” things that doctors might be prescribing that aren’t either particularly necessary or shown to actually work. But the fear, of course, is that needed care for patients will be delayed or denied, which is what we’ve seen with prior authorization in Medicare Advantage. This is the perennial push-pull of our health care system, right? If you do everything that doctors say, it’s going to be too expensive, and if you second-guess them, it’s going to be, you know, it might turn out to be too constraining. 

Hellmann: Well, I was just going to say this is another issue that was kind of a little surprising to me, because there’s been so much criticism of the use of prior authorization and Medicare Advantage. And CMS [Centers for Medicare & Medicaid Services] looked at that and said, Oh, what if we did it in traditional Medicare? Like it was never going to go over well politically, and I think there are even some Republican members of Congress who are not in support of this, but they haven’t really made a huge stink about it. Yeah, this wasn’t something I really expected to see. 

Rovner: Yeah, we’ll see how this one plays out too. Well, meanwhile, regarding Medicaid, two really good stories this week from my 麻豆女优 Health News colleagues Phil Galewitz, Rachana Pradhan, and Samantha Liss.  found that efforts in multiple states to find enrollees who were not eligible for the program due to their immigration status turned up very few violators. While  the hundreds of millions of dollars states and the federal government are spending to set up computer programs to track Medicaid’s new work requirement, despite the fact that we already know that most people on Medicaid either already work or they are exempt from the requirements under the new law. Is it just me, or are we spending lots of time and effort on both of these policies that are going to have not a very big return?  

Ollstein: Well, that’s what we’ve seen in the few states that have gone ahead and attempted this before, that it costs a lot, and you insure fewer people. And that’s not because those people got great jobs with great health care. You insure fewer people, and the level of employment does not meaningfully change. 

Rovner: I would say you insure fewer people who may well still be eligible. They just get caught in the bureaucratic red tape of all of this. 

Ollstein: Exactly. These tech systems that are being set up are challenging to navigate, if people even have a means to do it, if they even have a smartphone or a computer or access to Wi-Fi. There are not that many physical offices they can go to to work it out if they need to. And some of those are very far from where they live. And so you see some of these tech vendors, you know, are set to make off very well out of this system, and people who need the care not so much. And then, of course, you know, it’s not just the patients who will feel the impact. You have these hospitals around the country that are on the brink of closure. And if they have people who used to be insured 鈥� they used to be able to bill and get reimbursed for their services, suddenly they’re uninsured 鈥� and they’re coming in for emergency care that they can’t pay for, that the hospital has to throw out-of-pocket for, that puts the strain that some of these facilities can barely cope with. And so you’re seeing a lot of state hospital associations sounding the alarm as well. 

Raman: I would also say the timing is interesting. You know, we spent so much time and energy last year going through the reconciliation process to tighten these areas, to get in the work requirements, to reduce immigrant eligibility for Medicaid. And then, you know, as they’re gearing up to possibly do this again, to defer their crackdown on health care as part of that, instead of it saving money 鈥� that it’s not having as much of an effect and costing so much, in the case of the work requirements, where we’re not expected to see the return of it. 

Rovner: Yeah, that may be, although I guess the return is that people will not have insurance anymore, and so the federal government, the states, won’t be spending money for their medical care. They’ll be spending money on other things. All right, of course, there’s more news from HHS than just Medicare and Medicaid this week. We also have a lot of news about the Make America Healthy Again movement, which is a sentence that 2023 me would definitely not recognize.  about a new poll that finds the MAHA vote isn’t necessarily locked in with Republicans. Tell us about it. 

Ollstein: Yeah, that’s right. So Politico did our own polling on this, because we hadn’t really seen good data out there on who identifies as MAHA and what do they even believe about the different parties and about different issues. And so we found that, OK, yes, most people associate MAHA with the Republican Party 鈥� most, but not all. But a lot of voters who identify as MAHA, and a lot of voters who voted for Trump in 2024 don’t think that the Trump administration has done a good job making America healthy again. And they rank the Democratic Party above the Republican Party on a lot of their top priority issues, like standing up to influence from the food industry and the pharmaceutical industry. They rank Democrats as caring more about health. So, you know, we found this very fascinating, and it supports what we’ve been hearing anecdotally, where Democratic candidates, a handful of them, and Democratic electoral groups, are really seeing a lot of opportunity to go after MAHA voters and win them over for this November. And you know, we should remember that even if you don’t see a big swing of people voting for Democrats, even if MAHA voters are disillusioned and stay home, that alone could decide races. You know, midterms are decided by very narrow margins. 

Rovner: Well, two other really interesting MAHA takes this week. . It’s about the tension in and among medical groups, about how to deal with HHS Secretary [Robert F.] Kennedy [Jr.] and the MAHA movement. The American Medical Association seems to be trying to play nice, at least on things it agrees with the secretary about, lest it risk things like its giant contract to supply the CPT billing codes to Medicare. On the other hand, the American Academy of Pediatrics and the American College of Physicians have been more confrontational to the point of going to court. The other story, from  pushing MAHA. One thing I noticed is that all of the teens in the story seem to suffer from physical problems that are not well understood by the mainstream medical community, and so they turned online to seek advice instead, which is understandable in each individual case. But then they turn around and try to influence others. And you can see how easily misinformation can spread. It makes me not so much wonder 鈥� it makes me see how, oh, this is how this stuff sort of gets out there, because you see so much 鈥� and Alice, this goes back to what you were saying about MAHA is not a movement that’s allied with one particular political party. It’s more of sort of a mindset that doesn’t trust expertise. 

Ollstein: I think it spans people who identify as Democrats, identify as Republicans. And, you know, we’re not really interested in politics until the rise of Robert F Kennedy Jr., and so I think it does show a lot of malleability. And there is a fight for this, for this cohort right now, on the airwaves, on the internet, etc.  

Rovner: And, as The New York Times pointed out, you know, we’ve thought of this as being sort of a young men cohort. It’s now also a young woman cohort, too. So there’s lots of people out there to go and get, for these people who are pursuing votes.  

Well, turning to reproductive health, we have a couple of follow-ups to things we covered earlier. The big one is Title X, the federal family planning program, whose grants were set to end as of April 1. Sandhya, it looks like the federal government is going to fund the program after all? 

Raman: Yeah, the family planning grantees in this space have been on edge for so long, you know, waiting to see would they finally just issue the grant applications. And then it was such a short timeline for them to get them done. And then everyone that I talked to in the lead-up was expecting some sort of delay, just because it was such a short timeframe before they were set to run out of money. And so I think that they were all pleasantly surprised that HHS was able to turn things around when they confirmed that the money is going to go out the day before the deadline. It does take a couple of days to go through the process and get that done. But I think the new worry now is also that in the statements that the White House and HHS have made is just that they are still at work on getting Title X rulemaking out so that a lot of these groups would be ineligible if they also provide abortions. Or we also don’t know what will be in the rule 鈥� if it will be broader than what was under the last Trump administration, if it encompasses other restrictions. So a little bit of both there.  

Rovner: Yeah. And I also was gonna say, I mean, we know that anti-abortion groups are unhappy with the administration, so this would be one place where they could presumably throw them a bone, yes? 

Ollstein: So people on both sides have been a little mystified why we haven’t seen a new Title X rule yet. They were expecting that near the beginning of last year, especially if the administration was just planning to reimpose his 2019 version, that would be pretty straightforward and simple. And yet, here we are, more than a year into the administration, and we haven’t really seen this yet. The administration did confirm to me 鈥� we put this in our newsletter 鈥� that a new rule is coming. And they said it will align with pro-life values. And the White House’s comments to some conservative media outlets were very explicit that this will be the last time Planned Parenthood can get funding. Now I wonder if that statement will come back to bite them in court, because the rule previously was very careful not to name Planned Parenthood or name any specific organization. It just imposed criteria that applied to a lot of Planned Parenthood facilities, and in order to make them ineligible for Title X funding. And so I wonder if that will help Planned Parenthood sue later on. But we’ll put a pin in that and come back to it. But we have confirmed that some sort of new rule is coming, but we don’t know when, and we don’t know what it would entail. There’s a lot of speculation that this could go way beyond an attempt to kick Planned Parenthood out. There’s speculation it could involve restrictions on particular forms of birth control. There’s speculation that it could entail restrictions on gender-affirming care. There’s speculation that it could involve rules around parental consent, stricter parental consent requirements, which are currently something that’s not part of Title X. And so we just don’t know, you know, in order to mollify the anti-abortion groups that are upset, they are saying, Don’t worry, new rule is coming. But again, we don’t know when, and we don’t know what’s going to be in it. 

Rovner: Well, we’ll be here when it happens. Another topic we’ve talked about at some length is crisis pregnancy centers, which are anti-abortion organizations that sometimes offer some medical services.  who was told after an ultrasound at a crisis pregnancy center that she had a normal pregnancy, and three days later, ended up in emergency surgery because the pregnancy was not normal, but rather ectopic 鈥� in other words, implanted in her fallopian tube rather than her uterus, which could have been fatal if not caught. This is not the first such case, but it again raises this question of whether these centers should be treated as medical facilities, which we’ve talked about many states do.  

Raman: And I think a lot of the rationale that people have for trying to do some of these mandatory ultrasounds, you know, encouraging people to go to this is because the talking point is that you don’t know if you have an ectopic pregnancy, you don’t have another complication, so you should go here to instead of just taking a medication abortion. So 鈥� we’re coming full circle here, where this is also not helping the case, if you’re not finding the full information there. So I think that was an interesting point to me 鈥�  

Rovner: Yeah, it’s going on both sides basically. It is fraught, and we will continue to cover it. 

All right, that is this week’s news. Now we’ll play my interview with Elisabeth Rosenthal at 麻豆女优 Health News, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast 麻豆女优 Health News’ Elisabeth Rosenthal, who reported and wrote the last two “Bills of the Month.” Libby, thanks for coming back. 

Elisabeth Rosenthal: Thanks for having me.  

Rovner: So let’s start with our drug copay card patient. Before we get into the particulars, what’s a drug copay card? 

Rosenthal: Well, copay cards, or copayment programs, are things that the drug companies give patients. You know, when it says you could pay as little as $0, where they pay your copayment, which is usually pretty big 鈥� when you see a copay card, it means the price is big, and they’ll bill your insurance for the rest. So for patients, it sounds like a good deal, and it is a good deal when they work. 

Rovner: So tell us about this patient, and what drug did he need that cost so much that he required a copay card? 

Rosenthal: Well, the funny thing is 鈥� his name is Jayant Mishra, and he has a psoriatic arthritis. And the doctor told him, you know, there’s this drug called Otezla that would really help you. And he was, he was a little cautious, because he knew it could be expensive, so he did wait a few months, and his symptoms, his joint pain, in particular, got worse. He was like, OK, I’ll start it. So he started it the first month, and it worked really well.  

Rovner: “It” the drug, or “it” the copay card, or both? 

Rosenthal: Both seemed to work very well. So the copay card covered his copay of over $5,000 and he was like, Oh, this is great. And then what happened was, the next month, he tried to fill it, and it was like, Wait, the copay card didn’t work! And really what happens is copay cards, they are often limited in time and in the amount of money that’s on them. So depending on how much the copay is, they can run out, basically expire. You used all the money, and you have a drug that you’ve used that is working really well for you, and then suddenly you’re hit with a big bill. So they kind of get people addicted to drugs, which they then can’t afford.  

Rovner: And what happened in this case was the insurance company charged more than expected, right? 

Rosenthal: Well, Otezla, you know, there’s so many things about this, and many “Bill of the Month” stories that, you know, are eye-rollers. Otezla 鈥� there are biosimilars that were approved by the FDA in 鈥� 2021? 鈥� which everyone’s talking about, faster approval of biosimilars. Well, this was approved, but the drugmaker filed multiple suits and patent infringement, and so in the U.S., it won’t be on the market, the biosimilar, until 2028, so that’s a problem too. 

Rovner: So if you want this drug, it’s going to be expensive. 

Rosenthal: It’s going to be expensive. And the other problem is copay cards. Insurers used to say, OK, that will count towards your deductible, right? So you didn’t really feel it, right? Because you got a $5,000 copay card, and you had a $5,000 deductible if you had a high-deductible plan. And everything was good. Now, insurers kind of said, Whoa, we’re not sure we like these things. So yeah, you can use them, but it won’t count towards your deductibles. So they’re not nearly as useful as they might have been in the past. But patients are really stuck, because these are really expensive drugs that most people couldn’t afford without copay cards. 

Rovner: So what eventually happened to this patient, and how can other people avoid falling into the copay card trap? 

Rosenthal: So basically, because he had used up the amount on the copay card, which was $9,400 for the year, by the second month, he tried for the third month to kind of ration his drugs to take half as much, and his symptoms came back. And then the lucky thing for him was then it was January, right, copay cards are usually done for the year. So he got a new copay card for another $9,400 and he was good for January, and he paid with his health savings account for the first month’s copay, with the copay card the second month, with the copay card and his health savings account. And when this went to press, he wasn’t sure how he was going to pay for the rest of the year. And for him, it’s not a huge problem, because he has a very well-funded health savings account, which few of us do, but he was really up in the air for the rest of the year when we wrote about this. 

Rovner: So sort of moral of this story, be careful if you want to take an expensive drug, and the theory that when the drugmaker promises, Oh, you can have this for as little as $0 copay. 

Rosenthal: Well, I think it’s you have to understand what a particular card does. You have to understand what’s the limit on how much is on the copay card. You have to understand how many months it’s good for. You have to understand, from your insurer’s point of view, if that will count as your deductible or not. And then, man, you know, you’re kind of on your own, right? Sometimes your copay card will work great for you, and at other times it will work for a shorter amount of time. And you got to figure out what to do. I think the third, bigger lesson is getting biosimilars, which are these very expensive drugs approved, is not really the big problem in our country. The problem is the patent thickets that surround so many of these drugs that prevent them from getting to the patients who need them.  

Rovner: In other words, you can make a copy of this drug, but you might not be able to get it onto the market.  

Rosenthal: Right. You can make a copy this drug 鈥� it [a generic] was approved in 2021 鈥� but that won’t help patients until 2028, which is really terrible. You know, it’s available in other countries, but not here. 

Rovner: So moving on, our March patient had insurance through the Affordable Care Act exchange and was benefiting from one of those zero-premium plans until she got caught in a literally Kafkaesque mess over a 1-cent bill that turned into a 5-cent bill. Who is she and what happened here? 

Rosenthal: Yeah, her name in this wonderful, terrible story is Lorena Alvarado Hill. And what happened here is she was on one of these $0 insurance plans through the Obamacare exchanges with that great subsidy, the Biden-era subsidy, and she and her mother were on the same plan, and her mother went on to Medicare, turned 65. So Lorena didn’t need the family coverage and told the insurer that. And the insurance, of course, automatically recalculates your subsidy, and her premium went from being zero to 1 cent. Now, no human would make that, you know, would say, Oh, that makes sense. And to Lorena, it didn’t really make sense either. She was like, I’m not sure how to pay 1 cent, like, will it work on my credit card? And some of the bills said, you know, you understand that this could impact the continuation of your insurance, but, you know, she was like, 1 cent, I don’t think so. And then she kept going to doctors, and the insurance still worked, and then at some point, four months later, she got a letter in November saying, Oh, your insurance was canceled in July, and you owe money for all these bills. 

Rovner: And what happened with this case? 

Rosenthal: Well, you know, like many of our “Bill of the Month” patients, I celebrate them for being real fighters, because her bill, since her premium was 1 cent a month, went from 1 cent to 2 cents to 3 cents to 4 cents to 5 cents, when they sent her the note saying your insurance has been canceled for the last four months. And what turns out, which is really interesting, is this is a known glitch in the way the subsidies were calculated, were administered. There’s a recalculation of subsidies every time there’s a life event, a kid goes off the plan, you change jobs, get married, you get divorced. So the recalculation happens automatically. And the Biden administration, understanding that this glitch could exist, they gave the insurers the option not to cancel insurance if the amount owed was less than $10. And there were apparently 180,000 people caught in this situation where their insurance could have been canceled for under $10 of a recalculated premium. The Trump administration revoked that rule because their feeling was, you owe something, you pay something. So it’s part of their “stamp out fraud and abuse,” and this was, in their view, abuse of a system when people didn’t pay what they owed.  

Rovner: One cent. 

Rosenthal: One cent, right. So what happened with her is, you know, a good bill-paying citizen sending her daughter to college with loans. She wrote her insurers, she wrote to the state, she wrote to everyone. And as a last resort, of course, someone said, Well, there’s this thing called Bill of the Month you could write to. So when we looked into this, at first HealthFirst, which was her insurer in Florida, said, Oh, she’s not insured through us. And I was like, Yeah, because you canceled her insurance. And then I gave them her insurance number, and they said, Well, yes, according to law, we did the right thing. She didn’t pay, so it was canceled. Somehow, through all of this, word got back to the hospital and the insurer, and they worked together, and her bills were suddenly zero on her portal. So that’s the good news for Lorena Alvarado Hill. It doesn’t really help all those other people whose insurance may have been canceled for premiums that were under $10. 

Rovner: So, basically, if you get a bill for 5 cents, you should pay it. 

Rosenthal: Yeah, you know, it was funny when this story went up, many people were sympathetic, but other commenters said, Well, she should have just paid $1 because you can pay that. And maybe there was a way to pay 1 cent. And I’m kind of with her, like, if I got a bill for 1 cent, life is busy. This is a woman who is a teacher’s aide and works on weekends at a store to help pay for her daughter’s college. Life is busy. You just can’t sweat over 1-cent bills and spend a lot of time figuring out how to pay them. And I guess the lesson is, what’s the worst that can happen in a very dysfunctional system where so much is automated now? The worst that can happen is always really bad. Your insurance could be canceled. 

Rovner: So basically, stay on top of it, I guess, is the message for both of these stories this month. Elisabeth Rosenthal, thank you so much. 

Rosenthal: Thanks, Julie, for having me. 

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

Hellmann: My story is from The Texas Tribune, from a group of reporters who I can’t name individually. There’s too many of them. But it is  in Texas after the governor issued an executive order a few years ago requiring that hospitals check patients’ citizenship. So the story found that hospital visits by undocumented people dropped by about a third, and the story also got into how this is bleeding into other types of health care at other facilities, free vaccine clinics are not being attended as widely anymore. People aren’t attending their preventive care appointments, like cancer screenings or prenatal care checkups. Some of these other health facilities are required to check citizenship status, but it’s definitely a chilling effect over the broader health care landscape in Texas. 

Rovner: Yeah. There have been a lot of good stories about that. Sandhya. 

Raman: My extra credit is from Science, and it’s by Jocelyn Kaiser, and the story is “.” In her story, she talks about how last year, you know, the administration cut a lot of staff at the Agency for Healthcare Research and Quality. They’ve canceled all of the open grants, but Congress still appropriated $345 million for the agency this year, and so supporters kind of want to revive what should be going on at the agency, which hasn’t been issuing any of the grants since the start of the fiscal year, and just kind of make progress on some of the things that this agency does do, like running the U.S. Preventive Services Task Force, which has been, you know, something that has been talked about this year. So thought it was an interesting piece.  

Rovner: Yeah, I’m old enough to remember when AHRQ was bipartisan. Alice. 

Ollstein: So a very harrowing story in The New York Times titled “.” And I will say, since this piece ran, we have seen that an oil shipment from Russia is going through to the island, but I don’t think that will be sufficient to completely wipe away all of the upsetting conditions that this piece really gets into, what is happening as a result of the ramped-up U.S. embargo and blockade of the island. People can’t get food, they can’t get medicine, they can’t get electricity, and that is having a devastating effect on health care. The Cuban health care system has been really miraculous over the years, just the pride of the government. It has meant, prior to this blockade, that their life expectancy was better than ours, and a lot of their outcomes were better. And so this has been really devastating. There’s, you know, harrowing scenes of people on ventilators having to be hand-pumped when the electricity cuts out, babies in incubators, you know, losing power. You know, people having to skip medications, etc. And so this is really shining a light on a foreign policy situation that this administration is behind. 

Rovner: Yeah, that’s really been an under-covered story, too, I think, you know, right off our shores. My extra credit this week is one I simply could not resist. It’s from New York Magazine, and it’s called “,” by Helaine Olen. And as the headline rather vividly points out, we are witnessing the rise of pet medical tourism, along with human medical tourism, which has been a thing for a couple of decades now. It seems that veterinary medicine is getting nearly as expensive as human medicine, and that one way to find cheaper care is to cross the border, which is obviously easier if you live near the border. I’m not sure how much cheaper veterinary care is in Canada, but as the owner of two corgis, I may have to do some investigating of my own.  

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

Raman: On  and on  . 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

Rovner: Jessie. 

Hellmann: I’m on LinkedIn under Jessie Hellmann and on X . 

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

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

Dan: Hey there. About a dozen years ago, Nicole Wipp was trying to spend less time running her law firm and more time with her son, who was in preschool. ?It was a work in progress. 

And then she started feeling鈥� a little off. ?Tired. Out of breath. Her doctor thought it was stress.

Nicole didn’t think so, but she soldiered on. And got worse. For months. Until one day鈥� when she told her husband she just couldn’t get off the couch 鈥� he was like, you’re going to urgent care. An x-ray showed her whole left lung totally blacked out.?

 Next stop, emergency room. 

Nicole Wipp: They put a huge needle and shoved it into my back and drew out two liters. Imagine a whole two-liter of pop 鈥� I’m from Michigan, so I say pop 鈥� from your body. They draw a whole two-liter of liquid. And I felt so much better immediately. I was like, wow, I can breathe. Like, wow, this is so cool. But, um, it was sort of horrifying.

Dan: Nicole says she eventually got diagnosed with a rare lung condition

Nicole Wipp: It’s called lymphangioleiomyomatosis 鈥� LAMB for short.

Dan: But not before she’d spent a month in hospitals 鈥� hospitals, plural 鈥� and had multiple expensive surgeries.

Nicole Wipp: Minimum 鈥� my husband and I tried to like tally it all up, like look at all the bills afterward 鈥� and it was, minimum, a half a million dollars. 

Dan: Which, because her husband’s job at the time provided good health insurance, didn’t break them.

Nicole’s condition hasn’t bothered her for years. But it’s not cured. It’s incurable.

And yet. This year, Nicole and her husband didn’t sign up for health insurance.

For more than 20 million people on Obamacare plans, the price of health insurance changed dramatically this year. Premiums skyrocketed just as subsidies got sharply reduced. 

Some people faced horrifically stark new circumstances: 

People who needed insurance to cover ongoing treatment: for cancer, for diabetes 鈥� treatment they literally could not live without 鈥� saw premiums jump by thousands of dollars a month, more than they could possibly afford.

And millions more got stuck taking gambles. Making messy, unsatisfying choices. 

Our partners at 麻豆女优 Health News have been talking with lots of those people. 

They introduced us to Nicole. She and her husband could have paid for health insurance. But when rates went up, they did the math and decided not to. They’re generally healthy, and honestly have more financial cushion than most people. 

If they need medical care 鈥� ordinary medical care, anyway鈥� they think they’ll be better off just paying cash. 

But they know they’re gambling: that 2026 won’t be the year Nicole’s condition flares up, or that some other catastrophe hits.

Our pals at 麻豆女优 Health News also introduced us to this man:

Noah Hulsman: My name’s Noah Hulsman. I own and operate Home Skateboard Shop here in Louisville, Kentucky.

Dan: It’s Louisville’s only skateboard shop. It’s kind of a family business, kind of a community center, kind of a place Noah’s spent most of his 37 years. 

Noah’s still paying for insurance 鈥� paying for  protection against catastrophe. But because all he can afford this year is a bare-bones plan, he doesn’t have a way to pay for ordinary medical care. Which he could actually really use. 

Noah Hulsman: So I’m kind of in a position right now鈥� I need my left shoulder looked at, but I have an $8,400 deductible. Yeah.

Dan:  We’ll get into that 鈥� it sucks. But first: I really want you to hear about this skateboard shop.

Noah Hulsman: When I tell the story, it almost seems like a movie or something. Like, somebody made this up.

Dan: Let’s go. 

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

Here’s how Noah ended up a skater for life.

Noah Hulsman: So my grandmother, she opened up a skateboard shop in 1988 here in Louisville. It was called Skateboards Unlimited. She had a little skate park also behind it called Ottoman Skate Park.

Dan: Noah’s grandmother was not a skater. She’d been a nurse 鈥� but she had five kids, and Noah says she ended up more of a stay-at-home mom.

Noah Hulsman: And then with all the commotion that was always occurring, with all the friends in and outta the house, with having five kids and all these skateboarders that just started popping up, she just decided, you know what? Let’s like have a place for you all to go.

Dan: She opened Skateboards Unlimited 鈥� and a skate park behind it.

When her youngest son finished high school 鈥� and moved to the West Coast as a professional skateboarder 鈥� it was the end of an era. And the beginning of another. 

Noah’s grandma closed up Skateboards Unlimited. 

Noah Hulsman: And uh, that’s when one of her employees was like, you know what? We gotta keep having a skate shop. 

Dan: They called it Home Skate Shop. Noah became a regular customer, eventually an employee. And 鈥� ten years ago, when he was 27, 鈥� he took over the business. 

Noah is as invested as anybody could possibly be.

Noah Hulsman: It’s everything. It’s my whole life. Yeah.

Dan: It’s doing OK. There were a few rocky years early on 鈥� Noah says he qualified for Medicaid. But things actually picked up when the pandemic started.

Noah Hulsman: Skateboarding was one of the only things that you do by yourself. You’re doing it outside. If I would’ve been able to get a hold of more product, we would’ve, we would’ve killed it.

Dan: Noah got an Obamacare plan, and he even bought a building 鈥� he leases out a couple of apartments, runs an air bnb in a third one, and says he breaks even on it, right now..

Noah Hulsman: They say, you know, real estate is a long term game.

Dan: Noah’s a long-term kind of guy.

\He and his girlfriend have been together for 16 years 鈥� even while she was away at veterinary school.

Noah Hulsman: She just finished up at Auburn this past year and moved back home and yeah, it’s been awesome.

Dan: Now they live together 鈥� with their four cats 鈥� in an apartment less than a mile from where his grandma started her skate shop.

But it’s not a cushy living. Noah says he takes odd jobs and gives skateboarding lessons to make ends meet.

Noah Hulsman: Every single day is a hustle. There is no day, like you can’t get sick, you can’t be鈥�  no downtime. If you take vacations, you’re still working from your phone, you’re checking in on the shop.

Dan: Noah says his income 鈥� all in 鈥� has been holding steady at around $33,000 a year. Last year, with a subsidy, he was able to get a gold plan for about a hundred and five dollars a month.

For 2026 鈥� with premiums jacked up and subsidies cranked down 鈥� that gold plan would have cost him an extra $500 a month. That’s $6000 a year. Way more than he could afford.

Instead, he picked a Bronze plan. It leaves him paying pretty much exactly the same every month as he did last year, but it covers so much less.

Noah Hulsman: I don’t even know why I’m paying that. It’s useless really, unless I get into a car accident and I have $10,000 worth of bills.

Dan: Or a skateboarding accident. Or a serious illness. Anything.

He’s holding onto the plan as a backstop against a worst-case scenario, against ending up with more debt than he could ever pay back.

But having a backstop is not the same as having access to medical care.

A few months ago, Noah says his left shoulder started bothering him. He says it doesn’t stop him from day-to-day stuff, running the shop. But it does impose limits. 

Noah Hulsman: It’s those like quick movements. It’s those like blast-off times like when I’m popping on my skateboard or when I’m like turning a certain like front side and like throwing all my weight that way. 

Dan: His bronze plan 鈥� with its $8400 deductible 鈥� means he can’t afford to get it checked out.

Noah Hulsman: To go through, okay first you have to go see primary care, then they gotta do the x-ray. Then once you see the x-ray, oh, we can’t tell anything from the x-ray. Yeah, we know because it’s ligaments and tendons and muscles and things like, I’m not a doctor, but I’ve been through this a few times. So, okay, we’re gonna get you the MRI. All right. Here’s the MRI. None of that’s gonna be covered.

Dan: It sounds like thousands of dollars to Noah 鈥� to me too, really. And that’s before getting it treated, which could mean surgery.

Noah doesn’t have thousands of dollars lying around. If he did, he would’ve paid up for the gold plan. 

So he’s avoiding tricks that could irritate the shoulder,

Noah Hulsman:  I can still skateboard. I just have to choose what tricks or what obstacles. I don’t have like the freedom that I had when I used to ride my skateboard.

Dan: He’s hoping he can nurse the injury along till next year, when he thinks he could afford better insurance. 

Noah Hulsman: What I’m kind of planning on doing is my, my shop vehicle is about to be paid off next year or like at, at the, I think it’s like middle of next year. And that payment is basically what that gold plan payment is.

Dan: Yeah, yeah,

Noah Hulsman: That’s what’s probably gonna happen. That’s my new car payment. New shoulder payment.

Dan: Man, that super sucks. I mean, grimly hilarious 

Noah Hulsman: Yeah. Yeah. I mean, if this, you have to just laugh at how ridiculous the world is these days. There’s, I mean, if you just take it serious, doom and gloom all the time, it’s going to, you’re not gonna make it. You gotta just laugh these days. It’s so ridiculous.

Dan: It is. Noah is far from alone. A Gallup poll taken in late 2025 found that more than a quarter of all Americans had postponed surgery or medical treatment because of cost.

Being insured and having access to medical care 鈥� for lots of people, they haven’t been the same for a long time.

This year, especially for people using Obamacare, that’s accelerating. 

We don’t know yet how many people made choices like Noah’s, and moved to plans that cover less, in order to have a monthly payment they could kind of afford.

Federal numbers won’t be out for a while. But an analyst named Charles Gaba ran some preliminary numbers from a few states.

He found that the number of people in Silver and Gold and Platinum plans was down significantly. And the number of people in Bronze plans, the cheapest, was up dramatically.

And we do know that at least a million people have dropped Obamacare. Some have dropped insurance altogether. Including, of course, Nicole Wipp.

We’re coming back to her story, just ahead. 

This episode of An Arm and a Leg is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom reporting on health issues in America. The reporters at 麻豆女优 Health News do amazing work 鈥� win all kinds of awards every year. And in a little while, you’ll meet the 麻豆女优 reporter who introduced me to Noah Hulsman and Nicole Wipp.

Dan: Before Nicole Wipp knew that her Obamacare rates would be going up, she knew she was pissed at what she calls the insurance industrial complex. 

Nicole Wipp: So my son. Just for example, we took him鈥� called in advance, 鈥榙o you take our insurance?’ Took him to get basic well child vaccines. Well, next thing I know, I got a bill for $4,000. I called them up and was like, what is this? 

Dan: She says that was early 2025, and she’s been fighting ever since. 

Nicole Wipp: They’ve cut it down to like 1200, but I’m like, no, no, no, no, no. It should be a hundred percent covered under our insurance, So that’s the thing is like, why would I participate in this?

Dan: And at least since her half-a-million-dollar medical adventure Nicole Wipp has been pretty determined to live life on her own terms.

Even before her illness, she had already been trying to spend less time running her law practice and more time with her family.

Then, after the illness, she more than doubled down on that. On her website, she says she went from working 80 hours a week to working just five days a month.

That’s the website for a new business she started after her recovery: a consulting and coaching practice that offers to help people achieve financial success on their own terms. 

Nicole Wipp: Financial success for me is very much not just about money, it’s really more about quality of life and having enough money to have that quality of life.

Dan: So, for instance, about four years after her illness, Nicole’s family moved from Michigan to Hawaii.

Nicole Wipp: We said, we want to live in Hawaii because we wanna have a quality of life. And of course, living in Hawaii is not cheap. It’s one of the most expensive places in the United States to live.

Dan: But that’s what they wanted. And they made it work. 

And then their son got into polo. Like, with horses. Which is harder to do in Hawaii鈥� to do seriously, competitively 鈥� without a lot of traveling to the mainland. So they moved again, to South Carolina.

Nicole Wipp: And we did, by the way, when we moved back to the mainland, FedExed four horses from Hawaii

Dan: Oh my God.

Nicole Wipp: I know, and like when you say, all these things, it sounds insane, right? It is insane. 

Dan: Since then, she says they’ve picked up another four horses.

Nicole Wipp: Now we have a total of eight, which is a lot, a lot by the way. Um, and so, you know, I say it out loud and I’m like, oh, I’m not proud of this, to be honest with you. But, but we have also though made other choices like we live in a smaller home than we would otherwise, so that we can do that.

Dan: And that home is in a part of South Carolina where houses aren’t super- expensive. So Nicole says the mortgage on their house is less than the $1400 they would’ve been paying if they’d kept their insurance this year. 

The expensive horses, the less-expensive home鈥�

Nicole Wipp:  Like these are choices that we’ve made as a family that I understand very much that most people would never make these choices, but we’re doing it in as responsible of a fashion as we possibly can.

Dan: A few years ago, her husband changed careers鈥� no more job-based health coverage. They started buying insurance on the Obamacare exchange.

But by mid-2025, it started looking like that insurance could get a lot more expensive. Not because they’d lose a subsidy 鈥� they hadn’t qualified for a subsidy to start with. 

But if subsidies went away, she figured rates would go way up.  

Nicole Wipp: I started bringing it up to my husband. Like, I don’t know what this is gonna look like. I’m very worried about it. And we may be in a situation where we need to make a choice 

Dan: Could they contemplate doing without insurance?

Nicole Wipp: And so we had probably, you know, 20 conversations, at least, about it.

Dan: Before making a decision 鈥� even before 2026 rates got posted 鈥� Nicole and her husband started taking some steps. She scheduled a colonoscopy, and went to the dermatologist for a skin check. Her husband got some tests too.

If they didn’t have insurance next year, those tests wouldn’t be covered. And if any tests came back with scary results, insurance would be more important.

Obamacare premiums for 2026 got published. Their family’s rate would go up by about 50 percent. 

Nicole Wipp: Once the numbers came out, I was like, I just don’t know if this makes sense.?But we were like, okay, we need to gather more information. We need to think about it some more. 

Dan: Their tests had come back OK. And they felt fine. Maybe they wouldn’t need any medical care in 2026, or not much. But maybe they would. How might they pay the bills? They kept talking. And they identified some ideas.

For one thing, Nicole found some money socked away in a health savings account from her husband’s old job. 

Nicole Wipp: It’s not a lot, but it was like, oh, that’s a nice little cushion. Like we could use that if we needed it. 

Dan: Nicole figured, if they were paying cash, she’d be in a good position to negotiate with providers for discounts. 

Nicole Wipp: Because I’m a lawyer and I’ve been around the block on these things, so I had a lot of faith that I could negotiate a bill.

Dan: And she had other ideas for finding deals. 

Nicole Wipp: I was like, you know, depending on what the situation is, we could fly to another country, receive healthcare quality healthcare. It still would be less. And I am not above doing that.

Dan: And if all of that required more cash than they had lying around, Nicole figured, they still had options. 

Nicole Wipp: We have certain assets that in an extreme emergency we could sell 鈥� I mean, because it’s not just the horses. We have horse trailers and like, you know, there’s a lot that goes along with all of that that isn’t just the horses by the way.

Dan: None of which made the decision easy. Nicole says she and her husband didn’t fully decide until the actual deadline came for signing up. Even then, they knew they were gonna keep their son insured.

Nicole Wipp: I would be in my opinion, not responsible as a mom, so鈥� because he does play a very dangerous sport.

Dan: But for the adults, they weighed the risks, and decided to gamble.

Nicole Wipp: If I take that money and invest it instead of putting, I don’t know, am I gonna be out further ahead? I will if I don’t have a massive emergency and a half a million dollar illness. Um, right? And so it’s a gamble, like, right? All of this is a gamble, but it was a gamble that I was like, I just don’t want to participate in this any longer because this is not workable for almost anybody, but it certainly isn’t workable for me anymore mentally or emotionally.

Dan: Not workable for almost anybody. 

[Music transition]

Renu Rayasam: I mean, I also think about this as a reporter. We have these individual stories. What do they mean? First of all, why is this system like this and what does it mean for everyone?

Dan: That’s Renu Rayasam. She’s a senior correspondent with our partners at 麻豆女优 Health News. She introduced me to Nicole and to Noah. She and her colleagues have been talking with dozens of people about the choices they’ve been forced to make about insurance this year.

?And thinking about what those individual stories mean has led Renu to some big reflections. 

Renu Rayasam: I think sometimes in the US you take for granted the way things are. Just you don’t, you don’t realize there is another way, you know? There is another way! And um, and that’s where everybody has health insurance and those costs are better spread out. 

Dan: Renu is speaking in part from experience. She spent a half-dozen years living in Germany. We talked about her experience鈥� and how it affects the way she sees stories like Nicole’s and Noah’s. 

Renu Rayasam: ?Well first of all, it was kind of amazing to like never get a medical bill. Like that was like, like so mind blowing that you just, like, you go to the doctor and you never get a bill. 

Dan: Not because the government pays for health care. But because the government requires everybody to have health insurance. 

Renu Rayasam:  People pay premiums. ?You have to pay into the system. And it’s not necessarily cheap either.??But then on the back end, you’re never worried about, oh, my shoulders hurt, I have to get this MRI and I’m gonna get a bill.

Dan: ?Most people pay a government-set rate 鈥� about 15 percent of their income. Most insurance funds are non-profit. Everything’s highly regulated, and everybody gets the same benefits. Here, things are 鈥� more chaotic. Less predictable. People have to make hard choices鈥� and those choices feed back into the chaos. 

Renu Rayasam: So if somebody like Nicole opts out of health insurance, they’re not paying into this system and the people who are paying into the system are people who need care. And so that makes health insurance more expensive generally. 

Dan: Because insurers set their rates based on how much they expect to pay out. When healthy people bail, the rates go up. And when rates go up, healthy people bail. They reinforce each other. It’s what experts call a death spiral.

As some of those experts told Renu, a version of that happened over the last year. ?It wasn’t a coincidence that insurers jacked up prices when subsidies were on the chopping block. 

Renu Rayasam: Part of the reason that insurers raised their prices was because they expected people to drop plans and that fewer people would be paying their premiums and be paying into the system.

Dan: And people like Nicole and Noah ended up with lousy choices to make. 

Noah chose to keep paying for insurance as a backstop against absolute financial catastrophe 鈥� even though the insurance he can afford doesn’t give him access to medical care he needs. 

Nicole and her husband think they’ve got the resources to pay for ordinary medical care. Even maybe a big medical deal 鈥� as long as there was time to hop on a plane and get to a country where they could afford treatment.

But they’re not protected against the worst. Nicole knows bankruptcy is a real possibility. 

Nicole Wipp: We don’t have a guarantee. And it still weighs on me every day that I made this choice because it feels fraught. Do I regret it? No, not at the moment. I don’t. Will I regret it? I hope not.

Dan: Hmm.

Nicole Wipp: I don’t know though.

Dan: Yeah, you’re not like, I did it. I’m free, you know, this is the best. It’s like, no, you’re not free of it.

Nicole Wipp: No, I don’t feel free at all.

Dan: I wish I had a snappier ending to this story. We are more stuck than ever 鈥� all of us 鈥� making messy choices, hoping for the best. So I’m gonna give Noah the last word here. 

He’s taking his own advice: Taking things as they come, recognizing what’s ridiculous, and aiming to hang in there for the long term.

Noah Hulsman: ?Hopefully we, you know, get enough equity in this building that once it’s time to pass the skateboard shop on, maybe sell the building and hopefully that’s when we get to maybe cash out and go to the beach. 

Dan: Wow. 

Noah Hulsman: ?Maybe. Or maybe I’ll just get to pay off my medical debt that I’ve accrued over however many years at that point.

Dan: We’ll be back in a few weeks with a new episode. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta 鈥� and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

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

 Zach Dyer is senior audio producer at 麻豆女优 Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

Julie Rovner: Hello from 麻豆女优 Health News and WAMU public radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 22, 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 Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: Sheryl Gay Stolberg of The New York Times. 

Sheryl Gay Stolberg: Hello, Julie. Glad to be here. 

Rovner: And Paige Winfield Cunningham of The Washington Post. 

Paige Winfield Cunningham: Hey, Julie. 

Rovner: Later in this episode, we’ll have my interview with Dr. Ezekiel Emanuel, whose new book, Eat Your Ice Cream, is both a takedown of the wellness industrial complex and a kinder, gentler way to live a more pleasant and meaningful life. But first, this week’s news. 

So, and I don’t want to jinx this, it looks like Congress might pass a spending bill for the Department of Health and Human Services that will become law 鈥� meaning not a continuing resolution 鈥� for the first time in years. And attached to that spending bill, scheduled for a vote in the House today, is a compromise health extenders deal that was dropped from the final spending bill in 2024 and which we’ll talk about in a minute. But first, the HHS appropriations bill. Sandhya, what are some of the highlights? 

Raman: So I think overall we just see a little bit of a slight increase for HHS compared to last year. Some agencies get a little bit of a bump: NIH [the National Institutes of Health], SAMHSA [the Substance Abuse and Mental Health Services Administration], HRSA [the Health Resources and Services Administration], Administration for Community Living. CDC [the Centers for Disease Control and Prevention] is kind of the same as last year. But then we do see some cuts in some places. Something that was getting watched a little bit was refugee and entrant assistance, given some of the different national news related to refugees and immigrants, and so that’s getting cut by about a billion. And some of the back-and-forth there is, some conservatives wanted more than that, some Democrats didn’t want that to be cut. I think the big thing in health care that we were waiting on on this was whether or not they would prohibit NIH forward funding, which is something the administration has been pushing for, just giving out a lump sum for grants through NIH rather than over a multiyear period. And the concern the Democrats had on that was that if you’re doing the lump sum all at first, fewer groups would get money for research. And so there is a prohibition on that, on doing the forward funding. 

Rovner: But just to be clear, the president, the administration, had asked for deep, deep cuts to the Department of Health and Human Services, and Congress is basically saying: Yep. Nope. 

Raman: Yeah. I think even if you look at what the House had proposed last year, they had cut a lot of programs, or proposed to cut a lot of, and that was not there. I think a lot of times, what we’ve seen is that even in Trump 1, there’d be a lot more proposed cuts in their proposal, when the White House puts out their blueprint, and then Congress comes to more of a medium point, kind of similar to previous years. So I think that was something that a lot of the health groups had celebrated, that they weren’t going to get the steep cuts that they thought could be part of the process. 

Rovner: Of course, the big question here is: Does the administration actually spend this money? We saw in 2025 them refusing to spend money, cutting grants, cutting off entire universities. And this is money that Congress had appropriated and that the administration is supposed to spend. Are they going to do it this time, is Congress? Have they put anything in this bill to ensure that the administration is going to do it this time? 

Raman: There’s a little bit here and there on some of that. I don’t think there’s quite the sweeping things that some Democrats would have wanted to prevent some of that. Just last week, we had the back-and-forth with SAMHSA grants getting pulled and then unpulled. And so there’s a little language related to that in there, just because that was such a big 24-hour issue. And then education funding is coupled with HHS, and there there is specific language saying you can’t transfer the money that would be for education into another department to dismantle it. So鈥� 

Rovner: And, I would say, and basically, you can’t cut the Department of Education unless Congress says you can. 

Raman: Yeah. So there’s some things in there that are like that, but to get appropriations done, it has to be a bipartisan thing to get that to the finish line. So no one is going to get everything they wanted, not even President [Donald] Trump. 

Rovner: Yes, and I will point out that they are not there yet. The House has to pass this. The Senate has to pass this when they come back next week. We’ve got, apparently, a gigantic snowstorm coming towards Washington, D.C. So it’s moving in the right direction, but it’s not there yet. All right. Now onto the health package that’s catching a ride on this spending bill. What’s in it? And how close is it to the package that got stripped from the 2024 bill after Elon Musk tweeted that the bill was too many pages long? 

Raman: I think it’s fairly similar. We have a lot of the same PBM [pharmacy benefit manager] language that we had when that got dismantled, and a lot of these same kind of extenders that we see from time to time whenever we get an appropriations deal, extending things that are pretty bipartisan but just never have a place to ride elsewhere 鈥� National Health Service Corps, Special Diabetes Program, things like that. I think that since this time we haven’t had that pushback, we don’t have Elon Musk weighing in and kind of pulling the strings in the way that we did before, these have been very bipartisan provisions that both chambers have been saying that they want to get this done, they want to get this done as soon as possible, even in the beginning of last year. So I don’t sense that something’s really going to derail language targeting PBMs and stuff like that. 

Rovner: I would say the big piece of this is the deal that Congress came up with in 2024 to require more transparency on the part of these pharmacy benefit managers that everybody on both sides is accusing of pocketing some of the savings that they’re getting from drug companies and therefore making drug prices more expensive for employers and consumers. 

Raman: So I think that this has been such a priority that this is their shot to get it done. And it seems like as long as nothing derails appropriations in the next day and a half, then this is their chance to do that. 

Rovner: So what’s not in either of these packages are most of the pieces of the legislation that President Trump called for last week in his self-titled Great Healthcare Plan, with the PBM provisions being a major exception. What else is in Trump’s plan? And what are the prospects for passing it in pretty much any form this year? 

Winfield Cunningham: I would say not great. Yeah. A couple of things that struck me about this plan, which I would note was one page long: This is very Trumpy. Trump obviously loves, he’s a lot more into hauling pharmaceutical CEOs into the White House to make deals than he is crafting detailed policy. Because if you’re actually trying to do health care reform, this is not the way that you would do it. What you would do is actually spend a lot of time on the Hill seeing what Republicans can sign onto, and working with staff to craft detailed policies and etc., etc. But, yeah, so most of this stuff 鈥� yet I guess another big thing that struck me was a lot of this actually goes after insurers. There are some things in here that drugmakers don’t like, but Trump goes so far as to propose bypassing insurers entirely and sending money to people. And of course he doesn’t detail how that would work. And then there’s a lot of stuff in here about transparency by insurers. I would note the Affordable Care Act had some insurer transparency provisions already. 

So I think what this plan, if we want to call it a plan, reflects is just Trump’s desire to have something that he can call a “great” health care plan that he’s promised for a long time and which he’s going to talk a lot about. But yeah, I don’t think we’re going to see Republicans in Congress do much on this. Yeah, with the exception of the PBMs, which is pretty notable, and I think actually represents a really big win for the pharmaceutical industry, which has obviously felt under fire in this administration and has struck these deals with the White House, which they really don’t like. But they had been threatened that the administration would go further in trying to do this “most favored nation” price caps. And so it’s interesting because insurers are kind of Trump’s new target. That’s what I kind of read in this. And of course I would mention today that major insurers are testifying on the Hill because they’re under fire for raising insurance premiums. 

Rovner: Although, as we’ve noted many times, they’re raising insurance premiums because the cost of health care is going up. Yes, Sheryl. 

Stolberg: Julie, I think the political context of the Great Healthcare Plan, the so-called Great Healthcare Plan, is important. First of all, Republicans have had trouble for decades coming up with some kind of health plan, even before the Affordable Care Act was passed and signed into law in 2010. They weren’t able to do it then. President Trump famously said “nobody knew” that health care was “so complicated.” He’s in a situation now where Republicans have stripped many Americans of their health insurance by letting the extended Obamacare credits expire, and we’re going into a midterm election season in which his party and he have promised repeatedly that they were going to come up with a plan. He said he had a concept of a plan. I think this plan, so to speak, is not even a concept of a plan, and its primary provision actually lifts from what Sen. [Bill] Cassidy was promoting, which was to steer money away from insurance companies and toward consumers. Trump kind of latched onto that. He doesn’t say that explicitly in this 325-word proposal, but it seems clear to me that that is his idea, and that is just not a workable idea. 

He wants, they want, to move money into health savings accounts. I cracked up my elbow earlier this year. I had surgery to repair it. I saw the bill. The bill was $122,000. I am very blessed to have good health insurance through my company. There is no way that the government is going to steer that kind of money into a health savings account for an uninsured person. These are accounts that are meant to be sort of supplemental to spend on relatively small expenditures. And if you are an uninsured person, there is really no way that you can cover yourself. And that’s basically what this so-called “great” American health care plan is proposing, which I suspect, if most Americans really looked at it, they would say, is not so great. 

Rovner: Yeah. I also, I broke my wrist this summer. I also had surgery, although I had outpatient surgery, and it cost $30,000. So it’s, yeah, health care is really expensive, which, as I said, is why insurance premiums are going up. So, this week marks a year since the start of Trump 2.0, and it would take us the rest of the year to detail all that has changed in health policy. But I did want to hit a few themes, some of which you’ve started to talk about, Sheryl. One is the administration’s effort to basically end the federal public health structure as we know it. The Centers for Disease Control and Prevention in Atlanta has basically been taken over by political appointees, most of them without health experience or expertise. Sheryl, you’re our public health expert here. What does it mean for public health to be basically ceded back to the states? 

Stolberg: Well, I think this is kind of a novel experiment here. The core of the CDC is its infectious disease programs. Now, over the decades, since the 1970s, the CDC has greatly expanded its remit to cover things like chronic disease and gun violence prevention and auto safety, etc. But its core is infectious disease. And we know that infectious disease knows no borders. So what we risk having here is a patchwork of state-by-state vaccine recommendations, where some states will follow the CDC’s recommendations, presumably those that are red states. This was never political before. And we’re seeing some states, like blue states like New York and Massachusetts and other New England states, kind of coming together to put forth their own vaccine recommendations. I think this has implications for what vaccines will be covered and what vaccines will be offered by the Vaccines for Children Program, which was created by [President] Bill Clinton to cover poor kids and make sure they get vaccinated. I don’t think we know how that’s going to play out. 

I saw [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] yesterday in Harrisburg, Pennsylvania, and he insisted that he’s not taking any vaccines away from anyone. If you want your vaccines, you can get them. But the truth is that for decades, the American public and the medical establishment have relied on the CDC to provide guidance. The CDC doesn’t mandate anything, but it provides really important guidance to the country, and the agency is crippled now. Its guidance is not going to be followed. And I think we’re in uncharted territory here. We’re already seeing measles is on the rise. The country’s about to lose its measles elimination status, which we acquired in 2000. Whooping cough is on the rise. 

Rovner: Basically things we know we can prevent with vaccines. 

Stolberg: Exactly, exactly. 

Winfield Cunningham: One of the things I keep thinking about is, Kennedy says over and over again that if you’re a mom, you should do your own research. And it seems like a lot of the effects here is stepping away from this broad recommendation to now this patchwork of recommendations. So when you go to your pediatrician, you might hear guidance based on AAP’s [the American Academy of Pediatrics’] guidance, for example. States are doing different things. And as a parent, when you go to your pediatrician, it all of a sudden, I think, becomes a lot more confusing, especially if you’re someone who maybe already has a little bit of hesitancy about vaccines. 

I was in with our pediatrician last week and asked her what they’re seeing, and people are coming in with a lot more questions. And interestingly, they actually are changing their policy for mandatory vaccines. They actually had required every patient to be up to date by age 2 with the CDC-recommended vaccines. Now those vaccines that are under shared clinical decision-making, they’re no longer going to require those. And it’s not, and they’re going to continue to recommend them, but I think they’re concerned that patients are going to come in and they’re saying: Hey, the CDC doesn’t necessarily recommend these now. I’m worried about them. So it’s put pediatricians in a difficult place. But, yeah, it’s, as a parent, you’re having to make a million decisions about your children, and this just kind of makes that more complicated and confusing, potentially, for parents. 

Rovner: And takes time away from doctors who would like to counsel about other things, too. 

Stolberg: I just want to add one thing about that. Kennedy says do your own research. And if you read the package inserts on a vaccine, you’re going to see that vaccines have side effects, just like any drug. But that information needs context around it, and the parents who are weighing those side effects need also to be told about the risk of the diseases that those vaccines are intended to prevent. And my kids are grown. I’m wondering how pediatricians are having that conversation, or if they’re having that conversation, in talking to parents about: These are the risks of the vaccine. But should your child get measles, these are the risks. Before vaccination was widespread for measles, 450 kids died on average every year. Many more were hospitalized. So I think those conversations need to be had. 

Winfield Cunningham: And I think it’s hard for pediatricians sometimes to illustrate that, because we’re so far removed from people having examples or knowing anyone who had these. 

Rovner: Not anymore. 

Winfield Cunningham: Not anymore. But largely, right? I have a lot of parent friends, and I don’t know a child who’s had measles. Our pediatrician was telling me that when she was in medical school, it was still common for pediatric hospitals to be filled with babies with rotavirus. She said you could smell it down the hallway. And now, actually, the people in medical school, they’re not experiencing that, because of widespread vaccination. 

Rovner: All right. Well, the second big thing I want to hit on is, as Sheryl already mentioned, people losing their health insurance. Last summer’s big budget bill would cut nearly a trillion dollars from the Medicaid program and make it more difficult for people to maintain their coverage through the Affordable Care Act. Republicans refusing to extend the expanded Affordable Care Act subsidies from the Biden era is already prompting people to drop coverage that they can no longer afford. What does it mean to the health care system as a whole that the number of Americans without health insurance is going to begin to rise again? 

Raman: I think it’s a multipronged thing. There are some aspects of these things that might not be felt immediately, that might be later this year or early next year as different provisions of the [One] Big Beautiful Bill kind of come into play 鈥� work requirements, things like that that might affect how many people have insurance. But also, I think it kind of goes back to some of the things that Sheryl and Paige were saying about, just, if fewer people are vaccinated, it increases the risks for everyone. And if fewer people have health insurance, regardless of what they have, it also makes it more difficult. If people are not getting treated for things, they get exacerbated into more serious conditions. So I think there are a lot of issues at play. Some of them have just, we’re kind of waiting to see how the effects are.  

You know, people that may have skipped out on ACA insurance this year, maybe they haven’t needed to go to the doctor yet. We’re in the first month. People might not go every month. But that doesn’t mean they’re not going to be hit with something big, even tomorrow, next month, month after that. And so I think all of these things kind of compound together to make it a lot more difficult of a situation, and just a lot of the complexities, I think it’s kind of in both of them where you’re not sure. Oh, is this renewed? Is this not renewed? It’s, I think, a lot more difficult for the average person to follow this national conversation as much as people that are really plugged in, so that by the time that it trickles down to them, it’s like: Can I sign up for health insurance still? Are the costs high? Am I still eligible? It gets more and more confusing. And then people who might be eligible might kind of be scared away with some of that chilling effect. 

Stolberg: I should say, I think emergency rooms will also bear the brunt of the reduction in insurance, because without, people who don’t have health insurance will forgo going to the doctor until their [conditions are] unable to be ignored. And then they will wind up in the emergency room. 

Rovner: And then those, I was going to say, and then those emergency rooms will end up passing the bills that they can’t pay鈥� 

Stolberg: Exactly. 

Rovner: 鈥攐nto others who can, or in鈥� 

Stolberg: Exactly. It will drive up costs鈥� 

Rovner: Paige, started鈥� 

Stolberg: 鈥攊n the end. 

Winfield Cunningham: I think a lot of this is going to become clearer over the next couple of months. We still don’t really know the effects of those extra subsidies expiring. I was actually surprised to see that the ACA marketplace enrollment figures they released, I believe last week, were not actually that much lower than last year. But people aren’t kicked off their plan until they haven’t paid their premium for three months. So I think we need to wait until April or so to see how many people were, say, auto-enrolled in a plan which they can no longer afford, and now they’re kicked off. And maybe it’s fewer people than we think. Maybe it’s more people than we think. But I think we just don’t know that yet, and we’re going to have to wait for a couple months to see. 

Rovner: Yeah, I think you’re exactly right. I had the same reaction to seeing those numbers. Like, Wow, those are pretty high. And then it’s like, yeah, but those aren’t necessarily people who’ve had to pay their bills yet. Those are just the people who I think may have signed up hoping that Congress was going to do something. So, yeah, we will have to see how many people, I think it’s called “effectuated enrollment,” and we won’t get those numbers for a little while. 

Well, finally, dismantling the federal research enterprise. As I said, we’ve talked about this a lot, but I didn’t want to let it sort of go unstated. This administration appears to like to keep people guessing by cutting and then restoring research grants, refusing to spend congressionally appropriated funding until they’re ordered to do it by the court, and firing or laying off workers only to call them back weeks or months later. All that makes it difficult or impossible for researchers and universities to plan their projects and personnel needs. Combined with new limits on federal student loans for a lot of graduate students, are we at risk of losing the next generation of researchers? We’re already talking about seeing people moving to Europe to continue their research. 

Stolberg: Yes. I think the answer to that is an unequivocal yes. I am hearing from scientists who are having trouble filling their postdoctoral slots. Or young scientists. It’s really the next generation, right? People who are here already and who have families are trying as best they can to sort of stick it out, or maybe they’ll go into industry if they have to leave academia because they’ve lost their grant funding, or if they’ve left NIH. But it really is the next generation of researchers. I hate to draw this comparison, but we did see during World War II, the United States absorbed a lot of European researchers. This is how we got Albert Einstein, right? So I don’t know that we’ll see necessarily a reversal of that, of scientists fleeing, but we might see more young people choosing not to go into academic biomedicine. 

Rovner: And we’re already seeing, it’s not just Europe. It’s China and India鈥� 

Stolberg: Yeah. Right. 

Rovner: 鈥攐ffering packages. 

Stolberg: And they’re recruiting. Those countries are recruiting. Yeah, they’re recruiting young scientists, especially China.  

Rovner: Yeah. 

Stolberg: And that’s a good point. David Kessler, the former FDA [Food and Drug Administration] commissioner, has argued that this is really a national security threat for the country. China is a main adversary of the United States, certainly of President Trump. And if we’re at risk of losing highly qualified biomedical researchers to China, then we are giving them an advantage. 

Rovner: Yeah, something else we will keep an eye on, I think, for the rest of the year. OK, we’re going to take a quick break. We will be right back. 

Meanwhile, back to this week’s news. The American Academy of Pediatrics is leading a coalition of public health groups that are suing to reverse the changes to the childhood vaccine schedule made by the CDC earlier this month. The suit claims that the administration violated portions of the law that oversees federal advisory committees that require membership on those panels to be, quote, “fairly balanced,” and not, quote, “inappropriately influenced.” Among other things, the lawsuit asked the court to ban the CDC’s Advisory Committee on Immunization Practices from further meetings. That would basically stop any further changes to the vaccine schedule, I assume? 

Raman: At the end of the day, what ACIP does is just a recommendation to CDC, and they can choose whether or not to go with that recommendation. So I’m not really sure what would happen next, but it is kind of a whack-a-mole situation where just because you stop this does not mean that changes above that aren’t going to happen. 

Stolberg: Yeah. The Advisory Committee on Immunization Practices is just that. It’s an advisory committee. So this lawsuit takes issue with appointments to that committee and also complains that the committee was not consulted before the decision was made public to change the vaccine recommendations. I’m not exactly sure what the legal authority is for that. There’s apparently a federal law requiring federal advisory committees to be, quote, “fairly balanced” and not “inappropriately influenced.” But this isn’t 鈥� it’s an executive action 鈥� right? 鈥� to appoint committee members. It comes out of the executive branch. So I don’t know of any situation in the past where the judiciary has weighed in and said, You can appoint these people or not these people, or You have to redo a committee. So it’s hard to predict what the courts will say about this. 

Rovner: Meanwhile, it’s not just the ACIP that HHS Secretary RFK Jr. is taking aim at. Following his remaking of that advisory committee, he’s now fired some of the members of a separate panel, the Advisory Commission on Childhood Vaccines, which oversees the federal Vaccine Injury Compensation Program, which Kennedy has said he also wants to revamp. That’s the program that compensates patients who can demonstrate injury from side effects of vaccines. How big a deal could this be if he’s going to go after the vaccine compensation program?  

Stolberg: Julie, this is a big deal, and I’ll tell you why. That committee sets what is known as the table of vaccines. Which injuries does the federal government compensate for? And the federal government does not compensate for autism as a vaccine injury. And I have no evidence of this, but if I were betting, that is where Kennedy wants to go. He does not like the 1986 law that created the National Vaccine Injury Compensation Program because it offered liability protection to pharmaceutical companies. He wants to strip away the liability protection, but as I understand it, he does not want to do away with the law. He does not want to do away with the compensation program. So he may be trying to lay the foundation for the compensation program to be more expansive and cover injuries or allow claims for injuries that are not currently considered vaccine injuries, like autism. 

Rovner: Which of course would collapse the program because it’s paid for by an excise tax on vaccines. That was the original deal back in 1986. The vaccine manufacturers said: We’ll pay you this tax, from which you, the federal government, will determine who gets compensated. And in exchange, you’ll relieve us of this liability, because we’re getting sued to death. And if you don’t do this, we’re going to stop making vaccines entirely. That was the origin of this back in 1986. And I was there. I covered it. 

Stolberg: Yeah, exactly. I have read a lot of this history, and the CDC was really over a barrel. The companies were writing to CDC, saying, We’re going to pull the plug on our vaccines. And the CDC was worried that American kids were going to go without lifesaving vaccines because companies were going to quit making them. So they pushed this bill. [President Ronald] Reagan didn’t like it. He signed it into law anyway. And it’s created this program, which is actually imperfect. A lot of people who actually legitimately have vaccine-injured children have trouble getting compensated through this program., and I think many people on all sides of this issue would say that it does need to be overhauled. But it will be interesting to see who Kennedy picks for those committee slots. 

Rovner: Yeah, I think we’re going to learn a lot more about it. We’re going to learn a lot more about it this year. Well, finally, in vaccine land this week, Texas attorney general and U.S. Senate candidate Ken Paxton on Wednesday announced what his office is calling a, quote, “wide sweeping investigation into unlawful financial incentives related to childhood vaccine recommendations.” His statement says that there is a, quote, “multi-level, multi-industry scheme that has illegally incentivized medical providers to recommend childhood vaccines that are not proven to be safe or necessary.” Actually, one of the reasons that Congress created the Vaccines for Children Program back in the 1990s, Sheryl, as you mentioned earlier, is because most pediatricians lost money on giving vaccines. And today, many people can’t even get vaccines from their doctors, because it’s too expensive for the doctors to stock them. What does Paxton think he might find here? 

Stolberg: This is like stump the panelists. No one knows. 

Rovner: I see a lot of people’s鈥� 

Raman: I’m not sure what he thinks he might find, but I do think that he is one of the attorneys general that is generally on the forefront of trying things, to throw spaghetti at the wall and see if it sticks on a variety of issues. So it might be the sort of thing where if he finds something, then it could be kind of a jumping point for other conservative attorneys general. And of course just that he’s primarying Sen. John Cornyn for Senate, so if it raises his profile for more folks. But I’m not sure if there’s a specific thing that he’s looking for. 

Rovner: So he’s trying to curry favor with the anti-vaxxers in Texas, of which we know there are a lot. 

Raman: That would be my best read. 

Stolberg: Austin is, actually, the state capital in Austin is a hot spot for anti-vaccine activism. Andrew Wakefield, who wrote the 1998 Lancet article that’s been retracted, is in Austin. Del Bigtree, who runs the Informed Consent Action Network, is in Austin. There’s a group that I have  called Texans for Vaccine Choice that is one of the early parent-driven groups seeking to roll back vaccine mandates, is based in Austin. So there’s a lot of sentiment there that Ken Paxton might be trying to appeal to. 

Rovner: See? You’ve answered my question. Thank you. All right, that is this week’s news. Before we get to my interview with Dr. Zeke Emanuel, a couple of corrections from last week. First, I misspoke when I said House Republicans were becoming a minority in name only. Of course, I meant they were becoming a majority in name only. I also incorrectly said the lawsuit that helped get the Title X family planning money flowing back to clinics was filed by Planned Parenthood. It was actually filed by the ACLU [American Civil Liberties Union] on behalf of the National Family Planning and Reproductive Health Association. Apologies to all. OK, now we will play my interview with Dr. Zeke Emanuel about his new wellness book, and then we’ll come back and do our extra credits. 

I am so pleased to welcome back to the podcast Dr. Ezekiel Emanuel. Zeke is an oncologist and bioethicist by training and currently serves as vice provost for global initiatives and professor of medical ethics and health policy at the University of Pennsylvania. He formerly worked at the National Institutes of Health before he helped write and implement the Affordable Care Act while his brother Rahm was serving as President [Barack] Obama’s White House chief of staff. Zeke’s latest book, Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life, is out now. Zeke, welcome back to What the Health? 

Ezekiel Emanuel: Oh, it’s my great honor and pleasure. 

Rovner: So I feel like the subtitle of this book could be How to Keep Yourself Healthy Without Making Yourself Crazy or Broke and that it’s a not so thinly veiled attack on what many of us refer to as the “wellness industrial complex.” What’s gone wrong with the wellness movement? Isn’t it good for us to pursue wellness? 

Emanuel: It is good for us to pursue wellness. I think that there are probably three things that are seriously wrong with the movement. The first one is that they make wellness an obsession that you have to focus all your energy on, which is totally wrong. Wellness should be a habit that sort of works in the background while you focus on the really important things of life. I think the second thing is they tend to overcomplicate things. Part of that is they’ve got to send out an email every day or every other day. They’ve got to do a video, a podcast, what have you. And so they make it complicated so that they have something to report on. And the third thing is they make it oversimple. They’re reductionist. They talk about diet and exercise and sleep, and leave out other very, very important parts of wellness, maybe the most important part of wellness, which is your social interactions. And almost all these experts ignore it. 

And the last thing I would say 鈥� I guess I have four points 鈥� the last thing I would say is they have huge conflicts of interest. The wellness industrial complex is between $1- and $2 trillion a year, depending on what you want to include in that bucket, which means that there’s lots of people chasing lots of money trying to sell you lots of crazy items. So there’s money to be had and Them thar hills and people make all sorts of exaggerations. I want to emphasize for your listeners, I’m selling nothing, absolutely nothing. 

Rovner: I will say, I went to your book party. I’ve been to a lot of book parties over the years. Yours is the first one where I actually was not expected to buy the book. You actually gave the book away. 

Emanuel: Yeah, I can’t stand that. Oh, I hate that. 

Rovner: I would say, I assume you were making a point with that. I also ate the ice cream, which was very good. 

Emanuel: Yes. 

Rovner: I feel like your underlying message here is that it’s not enough to make yourself biologically healthy 鈥� you have to do things that make you happy, too. Is that a fair interpretation? 

Emanuel: Yes, that’s a very fair interpretation. Look, if you’re going to do wellness right, you’re going to be doing it for years and decades of your life. You cannot will yourself to do something for decades. You can will yourself to do something for a few weeks and a few months, but then, unless it becomes a habit that you actually enjoy, you’re simply not going to continue to do it. And so if you want to eat well, you want to exercise, you want to have social interactions, you actually have to make them something that’s pleasurable for your life, something that you find meaningful, even. That’s, again, I think something that’s seriously missing from a lot of these wellness influencers, because they make a lot of wellness about self-denial, about: You should deprive yourself. You should fast. Maybe you should fast. That’s OK if you can do it and you can work it into your schedule. Actually today is one of my fast days, so I am working it into my schedule. But that’s not for everyone, and it’s not essential to wellness and living a long and happy life. 

Rovner: So what are your six simple rules, in two minutes or less? 

Emanuel: The first one is: Don’t be a schmuck. Don’t take unreasonable risks. Don’t climb Mount Everest. Don’t go BASE jumping. Don’t smoke. Don’t do a lot of other stupid things. The second is: Engage people. A rich social life is the most important thing for a long, healthy, and happy life, and having close friends who you get together with regularly, talk to every week, have dinners with, acquaintances, very, very important. And then casually talking to people who you happen to interact with, either when you get your coffee, you go to the grocery store, you go to the restaurant, you hop in an Uber or a cab. Those are very important social interactions that we tend to ignore and tend to downplay. The third rule is: Keep your mind mentally sharp. And there are important aspects of that. Don’t retire. Take on new cognitive challenges. 

The fourth is: Eat well, and make sure you get rid of the unhealthy eating part and eat important, non-processed items. The fifth is: Exercise. Do the three kinds of exercise: aerobic exercise, strength training, and balance and flexibility with yoga. And the last one is: Sleep well. It’s the one you cannot will yourself to begin doing. You can only sort of prep the bedroom and then hope it happens. 

Rovner: So this whole thing didn’t really need to be book length, but you spent a lot of time reviewing the literature on various aspects of health and wellness, like, you know, a scientist would. Are you trying to make a point here about the current state of science and how the public views it? 

Emanuel: I am. I am a data-driven guy. I like data. I think when you have more than 3 million people that have been surveyed and followed in terms of social interactions and their impact on your wellness and your physical health, that’s worth noting, and it’s worth noting what those studies come to. And they all come to the same basic thing, which is you can reduce your risk of death and mortality in the subsequent six, 10, 12 years, depending upon the study, by about 20% to 30% by greater social interaction, more robust friendships. That’s a pretty impressive number, if you ask me. So I’m trying to emphasize the data and get people to understand and be motivated by the data. And I think I’m pretty clear about moments when I, say, interpret the data differently than a lot of other people do, because I think that’s part of science. 

So, for example, the PSA [prostate-specific antigen] test. Most guidelines say you should get a PSA test. I’m against the PSA test because, yes, it will reduce your risk of dying from prostate cancer, but it does not reduce your overall mortality. I think I don’t much care what’s written on my death certificate. I care about the length and wellness of my life, and the PSA isn’t going to affect that. But others disagree, and then I’m very frank about those kind of disagreements. 

Rovner: So in 2014 you rather famously wrote an Atlantic article called “.” Has writing this book changed your mind about this? And I will say, I’m only a year younger than you, so I have a stake in this, too. 

Emanuel: No, writing this book didn’t change my mind. It did change some things that I do. I will say, what really changed my mind, to the extent that anything changed my mind, was covid and the idea of getting vaccines after 75, I think, is a good thing, especially if whatever’s going around is targeting older people. It seems easy to protect yourself, whether from the flu or something like covid, with a vaccine. So that, I have changed my mind. Researching this book made me put a little more emphasis on, for example, strength training, which I had not done a whole lot of, directly. I’d done it because I ride a bicycle and I strengthen my lower half, my quads and my hamstrings and my gluteal muscles, but I hadn’t really focused on the upper body. 

Rovner: You should do Pilates. It’s great. 

Emanuel: Noted. 

Rovner: Zeke Emanuel. It is always fun to chat with you. And congratulations on the book. 

Emanuel: Thank you, Julie. This has been wonderful and very rapid-fire, more rapid-fire than anyone, because you get right to the heart of things. 

Rovner: Well, we have a lot more that we’re going to talk about this week. Thank you, Zeke. 

Emanuel: Take care, Julie. Bye-bye. 

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

Raman: My extra credit is called “,”and it’s by Judd Legum for Popular Information, his newsletter. And I thought this was really interesting, because, I think, for me, I look very much at HHS and major health agencies, but his piece kind of looks at how ICE [Immigration and Customs Enforcement] has not been paying third-party providers for medical care for detainees since October and that ICE, last week, the agency kind of quietly announced that it would not be processing any of the claims for medical care until April of 2026. And so doctors are instructed to kind of hold on that. And that’s kind of a downward spiral of providers denying services to detainees because they know they’re not going to get paid for a while. And so I thought this was a really interesting piece looking at that. 

Rovner: Yes, indeed. And kind of scary. Paige. 

Winfield Cunningham: Yeah, mine is a piece in Politico called “,” and it’s by Amanda Chu. And this really caught my eye because it was a look at how RFK’s demonization of food and pharma is motivating trial lawyers representing consumers who are saying they’ve been harmed by these products 鈥� one example, of course, is the lawsuit against the maker of Tylenol 鈥� and how this really kind of goes against where Republicans have usually been, against trial lawyers representing consumers who say they’ve been harmed by big, bad companies. And so, yeah, it was a really interesting look at that and just at how RFK’s kind of populist, pro-consumer streak has fueled all of this. 

Rovner: The world indeed turned upside down. Sheryl. 

Stolberg: So my extra credit is from Rolling Stone. The headline is “,” and it’s by Katherine Eban. She’s a terrific journalist. And this is about the study in Guinea-Bissau. When CDC pulled back its recommendation for children to be vaccinated at birth against hepatitis B, HHS gave this grant to these Danish researchers to conduct this study in Guinea-Bissau, which would compare vaccinated infants to unvaccinated infants. And there was a huge howl of protest. This study would never be done in this country. The idea of withholding a vaccine from an infant that has been proven to be safe and effective is highly unethical. It evokes memories of the Tuskegee study, in which government doctors withheld treatment for syphilis. So there was this huge uproar, and it turns out that the researchers who got the grant are these Danish statisticians who have a really questionable research history. And the story documents, through emails, how they got basically this no-bid grant by coordinating with some of Kennedy’s allies from his movement, from his vaccine advocacy days. And it was kind of an inside deal, basically. So I just think that this study has generated a lot a lot of complaints. I should say that the researchers have amended the protocol, and now I think they’re going to give shots to one group at age 6 weeks. But still, it’s a very problematic study, and the story exposes how it came to be. 

Rovner: Yeah, it is quite the story. Well, I also have an immigration story. It’s from my former colleague Liz Szabo at the University of Minnesota’s Center for Infectious Disease Research and Policy, and it’s called “.” And it’s not just undocumented people avoiding medical care, as Liz details. U.S. citizens with serious health needs are also scared of getting caught up in the ICE dragnet that’s now all around the city. And ICE officials have even been entering hospitals and other health facilities 鈥� which in previous years they had not been allowed to do. In the dead of winter in Minneapolis, with a particularly severe flu year, this is threatening to become a health crisis as well as an immigration crisis. 

OK, that’s this week’s show. Before we go, it’s almost February. That means our annual 麻豆女优 Health News Health Policy Valentine contest is open. Please send us your clever, heartfelt, or hilarious tributes to the policies that shape health care. I will post a link to the formal announcement in the show notes. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcast, 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 find me still on X, , or on Bluesky, . Where are you folks hanging these days? Sandhya. 

Raman:  and , @SandhyaWrites. 

Rovner: Sheryl 

Stolberg: I’m  and , @SherylNYT. 

Rovner: Paige. 

Winfield Cunningham: I’m on X, , and Bluesky, . 

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

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

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

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

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

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

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

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

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

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

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

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

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

Rovner: Yeah, we will, but we’ll believe it when 鈥� we get to the signing ceremony. 

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

Kenen: No, it’s sustainable, if we’re sustaining it at a high 鈥� in economically 鈥� zany price.  

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer 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, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

[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 麻豆女优 Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, April 2, 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: And Sandhya Raman, now at Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

Rovner: Later in this episode, we’ll have my interview with 麻豆女优 Health News’ Elisabeth Rosenthal, who reported and wrote the last two 麻豆女优 Health News “Bills of the Month.” One is about a patient who got caught in the crossfire over prices between insurers and drug companies. The other is about a woman who, and this is not an April Fools’ joke, got her insurance canceled for failing to pay a bill for 1 cent. But first, this week’s news. 

So Congress is on spring break, but when they come back, health policy will be waiting. A new Gallup poll out this week found 61% of those surveyed said they worry about the availability and affordability of health care, quote, “a great deal.” That was 10 percentage points more than the economy, inflation, and the federal budget deficit, and it topped a list of 15 domestic concerns. And while we are still waiting for final enrollment numbers for Affordable Care Act plans, we do know that the share of people paying more than $500 a month for their coverage doubled from last year to 2026. Yet Axios this week is reporting that Republicans are considering still more cuts to the Affordable Care Act to potentially pay for a $200 billion war supplemental. What exactly are they thinking? And it’s looking more like Republicans are going to try for another budget reconciliation bill this spring. Isn’t that, right, Jessie? 

Hellmann: House Budget chair Jodey Arrington has kind of been pushing this idea really hard of going after what he says is fraud in mandatory programs like Medicare and Medicaid. He’s also talked about funding cost-sharing reductions, which is an idea that slipped out of the last reconciliation bill, and it’s a wonky kind of idea 鈥� 

Rovner: But I think the best way to explain it is that it will raise premiums for many people. That’s how I’ve just been doing it.  

Hellmann: Yeah, exactly. 

Rovner: Let’s not get into the details. 

Hellmann: It would reduce spending for the federal government but wouldn’t really help people who buy insurance on the marketplace. He hasn’t been very specific. He’s also talked about, like, site-neutral policies in Medicare, but it’s hard to see how all of this could make a serious dent in a $200 billion Iran supplemental. There’s also a new development. I think President [Donald] Trump threw a wrench in things yesterday when he said he wanted the reconciliation bill to focus on border spending and immigration spending to cover a three-year period, and now Senate Majority Leader John Thune is saying that there’s probably not room for much else in the bill. So, unclear what the path forward is for all of that. 

Rovner: Yeah, and of course, that was part of the deal to free up the Department of Homeland Security’s budget in the appropriation. It’s all one sort of big, tied-up mess at this point. Alice, I see you’re nodding. 

Ollstein: Yeah. I mean, what often happens with these reconciliation bills is it starts out with a tight focus and everyone’s unified, and then, because it can often be the only legislative train leaving the station, everybody gets desperate to get their pet issue on board, and then the more and more things get piled onto it, then they start losing votes, and people start disagreeing more. And so I think even though this is still in the ideas phase, you’re already seeing some signs of that happening. And when it comes to health care, it can be particularly fraught. And of course, you have lawmakers, especially in the House, with wildly different needs. Some of them need to fend off a primary from the right, and so they want to be as conservative as possible. Some are fighting to hang on in swing districts, and so they want to be more moderate. And these things are in conflict. And so these proposals to cut health spending, even more than the massive amount that was cut last year, are already, you know, raising some red flags among some moderate Republican members. And it’s very possible the whole thing falls apart. 

Rovner: Well, along those lines, we’re supposed to get the president’s budget on Friday, which is only two months late. It was due in February. And while I haven’t seen much on it, Jessie, your colleagues at Roll Call are reporting that the budget will seek a 20% cut to the National Institutes of Health. That’s only half the cut that the administration proposed last year. But given that Congress actually boosted the agency’s budget slightly this year, that feels kind of unlikely. 

Hellmann: Yeah, I don’t think that the appropriators are likely to go along with this. They have really strong advocates, and Sen. Susan Collins, who’s chair of the Senate Appropriations Committee. And, like you said, they rejected cuts last year. Kind of surprised. Twenty percent is not as deep as the Trump administration went last year. I was actually kind of surprised it wasn’t a bigger proposed cut. But either way, I don’t think Congress is going to go along with that.  

Rovner: Meanwhile, I saw a late headline that FDA is looking to hire back people after DOGE [Department of Government Efficiency] cut thousands of people last year. Sandhya, HHS [Department of Health and Human Services] is just in this sort of personnel churn at this point, isn’t it? 

Raman: Yeah, I think that HHS is kind of getting bit in the foot from, you know, we’ve had so many of these layoffs, and we’ve also had a lot of people just flee the various agencies over the past year because of some of this instability and all of these changes. And as we’re getting closer and closer to, you know, deadlines of things that they need to get done, they’re realizing that they do need more personnel to get some of those things done, as we’ve been passing deadlines. So I don’t think it’s something that’s unique to just FDA. But I think the way to solve this 鈥� it’s not an overnight thing for the federal government to staff up. It’s a longer process, but it’s really showing in a lot of areas right now. 

Rovner: Yeah, I would say this is not like TSA [Transportation Security Administration], where you can, you know, hire new people and train them up in a couple of months. These are 鈥� many of them scientists who’ve got years and years of training and experience at doing some of these jobs that, you know, the federal government is ordered to do by legislation. 

Raman: Yeah, those statutes are things that, you know, if they don’t meet those deadlines, those are things that are going to be challenged, and just further tie things up in litigation. And we already see so many of those right now that are making things more complicated.  

Rovner: Well, in news that is not from Congress or the administration, the Supreme Court this week said Colorado could not ban licensed mental health professionals from using so-called conversion therapy aimed at LGBTQ individuals, at least not on minors. What’s the practical impact here? It goes well beyond Colorado, I would think. 

Ollstein: Interesting, because a lot of people think of this as regulating health care, restricting providers from providing health care that is not helpful and maybe actively harmful to the health of the patients. 

Rovner: And that’s 鈥� I would say that’s been a state 鈥� 

Ollstein: Power. 

Rovner: 鈥� power. For generations.  

Ollstein: Absolutely. Right, I mean, you don’t want people selling sketchy snake oil pills on the street, etc. So many people view this as akin to that. But it has morphed in the hands of conservative courts into a free speech issue, and that, you know, these laws are restricting the speech of mental health workers who are against people transitioning. And so, yes, it definitely has national implications. And of course, we are in a national wave right now of both state and federal entities, you know, moving in the direction of rolling back trans rights in the health care space and beyond. 

Rovner: Yeah. In related news, regarding Colorado and minors and gender,  that Children’s Hospital Colorado has not yet resumed providing gender-affirming care for transgender youth. That’s despite a federal judge in Oregon having struck down an HHS declaration that would have punished hospitals for providing such services. Apparently, the hospital in Colorado is concerned that the judge’s ruling doesn’t provide it with enough legal cover for them to resume that care. I’m wondering, is this the administration’s strategy here to get organizations to do what they want, even if they might lack the legal authority to do it? Just by making them worry that they might come after them? 

Raman: I think the chilling effect is definitely a big part of this broader issue. I mean, we’ve seen it in other issues in the past, but just that if there is this worry that it’s a) going to stop on the provider side, new folks taking part in providing care, and also just it’s going to make patients, even if there are opportunities, even less likely to want to go because of the fears there. I mean, it goes broader than that. We’ve had FTC [Federal Trade Commission] complaints, where they have gone and investigated different places that provide gender-affirming care or endorse it. So I think it’s broader than this, and really part of that chilling effect.  

Rovner: And Alice, as you were saying, I mean, the subject of transgender rights, or lack thereof, remains a political hot topic. The Idaho Legislature this week passed a bill that now goes to the governor that would require teachers and doctors to out transgender minors to their parents. Parents could sue teachers, doctors, and child care providers who, quote, “facilitate the social transformation of the minor student.” That includes using pronouns or titles that don’t align with their sex at birth. I don’t know about teachers, but that definitely seems to violate patient privacy when it comes to doctors, right? 

Ollstein: There’s definitely patient privacy issues there. I also think, you know, it’s interesting that this kind of nonmedical transitioning is now coming under attack. Because, you know, you would think that there would be some support for letting a kid, you know, go by a different name for a few weeks, test it out, see how it feels. Maybe it’s a phase, then they discover that they don’t want to actually pursue taking medications and going through a medical transition. But this is sort of shutting down that avenue as well. You can’t even change your appearance, change how you present in the world, at a time when kids are really trying to figure out who they are. So I think the broad acceptance of hostility to medical transitioning for youth is now spilling over into this kind of social transitioning, and I wonder if we’re going to see more of that in the future. 

Rovner: Yeah, I feel like we started with minors shouldn’t have surgery. They shouldn’t do anything that’s not easily reversible. And now we’ve gotten down to, in the Idaho law, there’s actually mention of nicknames. You can’t 鈥� a kid can’t change his or her nickname. It feels like we’ve sort of reduced this way, way, way down. 

Ollstein: And I think we’ve seen these laws, laws related to bathrooms. We’ve seen these have negative impacts on people who are not trans at all, people who just are a tomboy or not looking like people’s stereotypes of what different genders may look like. And so there’s a lot of policing of people who are not trans in any way. You know, there’s media reports of people being confronted by law enforcement for going into a bathroom that does align with their biological sex. And so it’s important to keep in mind that these laws have an effect that’s much broader than just the very small percentage of people who do consider themselves trans. 

Rovner: Yeah, it’s kind of the opposite of not being woke. All right, we’re going to take a quick break. We will be right back.  

So while we’ve had lots of news out of the Department of Health and Human Services the past few weeks, it’s been mostly public health-related. But there’s a lot going on in the Medicare and Medicaid programs too. Item A: Stat News is reporting that HHS is studying whether to make the private Medicare Advantage program the default for seniors when they qualify for Medicare. Right now, you get the traditional fee-for-service plan that allows you to go to any doctor or hospital that accepts Medicare, which is most of them. You have to affirmatively opt into Medicare Advantage, which often provides extra benefits but also much narrower networks. What would it mean to make Medicare Advantage the default, that people would go into private plans instead of the government plan, unless they affirmatively opted for the traditional fee-for-service? 

Hellmann: Someone’s experience with 鈥� can vary greatly between being on traditional Medicare and Medicare Advantage. If you’re in Medicare Advantage, you could be exposed to narrow networks. You can only see certain doctors that are covered by your plan. You can be exposed to higher cost sharing. A lot of people are kind of fine with their plans until they have a medical issue and need to go to the hospital or they need skilled nursing care. So making this the default could definitely be a challenge for some people, especially people that have complex health needs. Some people on the early side of their Medicare eligibility are fine with Medicare Advantage, and then they get older and they’re not fine with it anymore. So it’s interesting that the administration would kind of float this idea because they’ve been critical of Medicare Advantage. 

Rovner: Thank you. That’s exactly what I was thinking. 

Hellmann: Yeah, they’ve talked about the federal government pays these plans too much, and it’s not for better quality in a lot of cases, and they’ve talked about reforms in that area. So I was a little surprised to see that. 

Rovner: Yeah, Republicans have been super ambivalent. I mean, Medicare Advantage was their creation. They overpaid them at the beginning when they, you know, sort of redid the program in 2003. And they purposely overpaid them to get people into Medicare Advantage. And then the Democrats pointed out that this is wasting money because we’re overpaying them. And now the Republicans seem to have joined a lot of their 鈥� at least some Republicans 鈥� seem to have joined a lot of the Democrats in saying, Yes, we’re overpaying them. We’re paying them too much. And you know, they talk about the big, powerful insurance companies, and yet they’re now floating this idea to make Medicare Advantage the default. So pick a side, guys. 

All right, well, in other Medicare news, the Electronic Frontier Foundation is suing Medicare officials to learn more about the pilot program that’s using artificial intelligence to oversee prior authorization requests in the traditional Medicare fee-for-service program. The idea here is to cut down on, quote, “low-value services,” things that doctors might be prescribing that aren’t either particularly necessary or shown to actually work. But the fear, of course, is that needed care for patients will be delayed or denied, which is what we’ve seen with prior authorization in Medicare Advantage. This is the perennial push-pull of our health care system, right? If you do everything that doctors say, it’s going to be too expensive, and if you second-guess them, it’s going to be, you know, it might turn out to be too constraining. 

Hellmann: Well, I was just going to say this is another issue that was kind of a little surprising to me, because there’s been so much criticism of the use of prior authorization and Medicare Advantage. And CMS [Centers for Medicare & Medicaid Services] looked at that and said, Oh, what if we did it in traditional Medicare? Like it was never going to go over well politically, and I think there are even some Republican members of Congress who are not in support of this, but they haven’t really made a huge stink about it. Yeah, this wasn’t something I really expected to see. 

Rovner: Yeah, we’ll see how this one plays out too. Well, meanwhile, regarding Medicaid, two really good stories this week from my 麻豆女优 Health News colleagues Phil Galewitz, Rachana Pradhan, and Samantha Liss.  found that efforts in multiple states to find enrollees who were not eligible for the program due to their immigration status turned up very few violators. While  the hundreds of millions of dollars states and the federal government are spending to set up computer programs to track Medicaid’s new work requirement, despite the fact that we already know that most people on Medicaid either already work or they are exempt from the requirements under the new law. Is it just me, or are we spending lots of time and effort on both of these policies that are going to have not a very big return?  

Ollstein: Well, that’s what we’ve seen in the few states that have gone ahead and attempted this before, that it costs a lot, and you insure fewer people. And that’s not because those people got great jobs with great health care. You insure fewer people, and the level of employment does not meaningfully change. 

Rovner: I would say you insure fewer people who may well still be eligible. They just get caught in the bureaucratic red tape of all of this. 

Ollstein: Exactly. These tech systems that are being set up are challenging to navigate, if people even have a means to do it, if they even have a smartphone or a computer or access to Wi-Fi. There are not that many physical offices they can go to to work it out if they need to. And some of those are very far from where they live. And so you see some of these tech vendors, you know, are set to make off very well out of this system, and people who need the care not so much. And then, of course, you know, it’s not just the patients who will feel the impact. You have these hospitals around the country that are on the brink of closure. And if they have people who used to be insured 鈥� they used to be able to bill and get reimbursed for their services, suddenly they’re uninsured 鈥� and they’re coming in for emergency care that they can’t pay for, that the hospital has to throw out-of-pocket for, that puts the strain that some of these facilities can barely cope with. And so you’re seeing a lot of state hospital associations sounding the alarm as well. 

Raman: I would also say the timing is interesting. You know, we spent so much time and energy last year going through the reconciliation process to tighten these areas, to get in the work requirements, to reduce immigrant eligibility for Medicaid. And then, you know, as they’re gearing up to possibly do this again, to defer their crackdown on health care as part of that, instead of it saving money 鈥� that it’s not having as much of an effect and costing so much, in the case of the work requirements, where we’re not expected to see the return of it. 

Rovner: Yeah, that may be, although I guess the return is that people will not have insurance anymore, and so the federal government, the states, won’t be spending money for their medical care. They’ll be spending money on other things. All right, of course, there’s more news from HHS than just Medicare and Medicaid this week. We also have a lot of news about the Make America Healthy Again movement, which is a sentence that 2023 me would definitely not recognize.  about a new poll that finds the MAHA vote isn’t necessarily locked in with Republicans. Tell us about it. 

Ollstein: Yeah, that’s right. So Politico did our own polling on this, because we hadn’t really seen good data out there on who identifies as MAHA and what do they even believe about the different parties and about different issues. And so we found that, OK, yes, most people associate MAHA with the Republican Party 鈥� most, but not all. But a lot of voters who identify as MAHA, and a lot of voters who voted for Trump in 2024 don’t think that the Trump administration has done a good job making America healthy again. And they rank the Democratic Party above the Republican Party on a lot of their top priority issues, like standing up to influence from the food industry and the pharmaceutical industry. They rank Democrats as caring more about health. So, you know, we found this very fascinating, and it supports what we’ve been hearing anecdotally, where Democratic candidates, a handful of them, and Democratic electoral groups, are really seeing a lot of opportunity to go after MAHA voters and win them over for this November. And you know, we should remember that even if you don’t see a big swing of people voting for Democrats, even if MAHA voters are disillusioned and stay home, that alone could decide races. You know, midterms are decided by very narrow margins. 

Rovner: Well, two other really interesting MAHA takes this week. . It’s about the tension in and among medical groups, about how to deal with HHS Secretary [Robert F.] Kennedy [Jr.] and the MAHA movement. The American Medical Association seems to be trying to play nice, at least on things it agrees with the secretary about, lest it risk things like its giant contract to supply the CPT billing codes to Medicare. On the other hand, the American Academy of Pediatrics and the American College of Physicians have been more confrontational to the point of going to court. The other story, from  pushing MAHA. One thing I noticed is that all of the teens in the story seem to suffer from physical problems that are not well understood by the mainstream medical community, and so they turned online to seek advice instead, which is understandable in each individual case. But then they turn around and try to influence others. And you can see how easily misinformation can spread. It makes me not so much wonder 鈥� it makes me see how, oh, this is how this stuff sort of gets out there, because you see so much 鈥� and Alice, this goes back to what you were saying about MAHA is not a movement that’s allied with one particular political party. It’s more of sort of a mindset that doesn’t trust expertise. 

Ollstein: I think it spans people who identify as Democrats, identify as Republicans. And, you know, we’re not really interested in politics until the rise of Robert F Kennedy Jr., and so I think it does show a lot of malleability. And there is a fight for this, for this cohort right now, on the airwaves, on the internet, etc.  

Rovner: And, as The New York Times pointed out, you know, we’ve thought of this as being sort of a young men cohort. It’s now also a young woman cohort, too. So there’s lots of people out there to go and get, for these people who are pursuing votes.  

Well, turning to reproductive health, we have a couple of follow-ups to things we covered earlier. The big one is Title X, the federal family planning program, whose grants were set to end as of April 1. Sandhya, it looks like the federal government is going to fund the program after all? 

Raman: Yeah, the family planning grantees in this space have been on edge for so long, you know, waiting to see would they finally just issue the grant applications. And then it was such a short timeline for them to get them done. And then everyone that I talked to in the lead-up was expecting some sort of delay, just because it was such a short timeframe before they were set to run out of money. And so I think that they were all pleasantly surprised that HHS was able to turn things around when they confirmed that the money is going to go out the day before the deadline. It does take a couple of days to go through the process and get that done. But I think the new worry now is also that in the statements that the White House and HHS have made is just that they are still at work on getting Title X rulemaking out so that a lot of these groups would be ineligible if they also provide abortions. Or we also don’t know what will be in the rule 鈥� if it will be broader than what was under the last Trump administration, if it encompasses other restrictions. So a little bit of both there.  

Rovner: Yeah. And I also was gonna say, I mean, we know that anti-abortion groups are unhappy with the administration, so this would be one place where they could presumably throw them a bone, yes? 

Ollstein: So people on both sides have been a little mystified why we haven’t seen a new Title X rule yet. They were expecting that near the beginning of last year, especially if the administration was just planning to reimpose his 2019 version, that would be pretty straightforward and simple. And yet, here we are, more than a year into the administration, and we haven’t really seen this yet. The administration did confirm to me 鈥� we put this in our newsletter 鈥� that a new rule is coming. And they said it will align with pro-life values. And the White House’s comments to some conservative media outlets were very explicit that this will be the last time Planned Parenthood can get funding. Now I wonder if that statement will come back to bite them in court, because the rule previously was very careful not to name Planned Parenthood or name any specific organization. It just imposed criteria that applied to a lot of Planned Parenthood facilities, and in order to make them ineligible for Title X funding. And so I wonder if that will help Planned Parenthood sue later on. But we’ll put a pin in that and come back to it. But we have confirmed that some sort of new rule is coming, but we don’t know when, and we don’t know what it would entail. There’s a lot of speculation that this could go way beyond an attempt to kick Planned Parenthood out. There’s speculation it could involve restrictions on particular forms of birth control. There’s speculation that it could entail restrictions on gender-affirming care. There’s speculation that it could involve rules around parental consent, stricter parental consent requirements, which are currently something that’s not part of Title X. And so we just don’t know, you know, in order to mollify the anti-abortion groups that are upset, they are saying, Don’t worry, new rule is coming. But again, we don’t know when, and we don’t know what’s going to be in it. 

Rovner: Well, we’ll be here when it happens. Another topic we’ve talked about at some length is crisis pregnancy centers, which are anti-abortion organizations that sometimes offer some medical services.  who was told after an ultrasound at a crisis pregnancy center that she had a normal pregnancy, and three days later, ended up in emergency surgery because the pregnancy was not normal, but rather ectopic 鈥� in other words, implanted in her fallopian tube rather than her uterus, which could have been fatal if not caught. This is not the first such case, but it again raises this question of whether these centers should be treated as medical facilities, which we’ve talked about many states do.  

Raman: And I think a lot of the rationale that people have for trying to do some of these mandatory ultrasounds, you know, encouraging people to go to this is because the talking point is that you don’t know if you have an ectopic pregnancy, you don’t have another complication, so you should go here to instead of just taking a medication abortion. So 鈥� we’re coming full circle here, where this is also not helping the case, if you’re not finding the full information there. So I think that was an interesting point to me 鈥�  

Rovner: Yeah, it’s going on both sides basically. It is fraught, and we will continue to cover it. 

All right, that is this week’s news. Now we’ll play my interview with Elisabeth Rosenthal at 麻豆女优 Health News, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast 麻豆女优 Health News’ Elisabeth Rosenthal, who reported and wrote the last two “Bills of the Month.” Libby, thanks for coming back. 

Elisabeth Rosenthal: Thanks for having me.  

Rovner: So let’s start with our drug copay card patient. Before we get into the particulars, what’s a drug copay card? 

Rosenthal: Well, copay cards, or copayment programs, are things that the drug companies give patients. You know, when it says you could pay as little as $0, where they pay your copayment, which is usually pretty big 鈥� when you see a copay card, it means the price is big, and they’ll bill your insurance for the rest. So for patients, it sounds like a good deal, and it is a good deal when they work. 

Rovner: So tell us about this patient, and what drug did he need that cost so much that he required a copay card? 

Rosenthal: Well, the funny thing is 鈥� his name is Jayant Mishra, and he has a psoriatic arthritis. And the doctor told him, you know, there’s this drug called Otezla that would really help you. And he was, he was a little cautious, because he knew it could be expensive, so he did wait a few months, and his symptoms, his joint pain, in particular, got worse. He was like, OK, I’ll start it. So he started it the first month, and it worked really well.  

Rovner: “It” the drug, or “it” the copay card, or both? 

Rosenthal: Both seemed to work very well. So the copay card covered his copay of over $5,000 and he was like, Oh, this is great. And then what happened was, the next month, he tried to fill it, and it was like, Wait, the copay card didn’t work! And really what happens is copay cards, they are often limited in time and in the amount of money that’s on them. So depending on how much the copay is, they can run out, basically expire. You used all the money, and you have a drug that you’ve used that is working really well for you, and then suddenly you’re hit with a big bill. So they kind of get people addicted to drugs, which they then can’t afford.  

Rovner: And what happened in this case was the insurance company charged more than expected, right? 

Rosenthal: Well, Otezla, you know, there’s so many things about this, and many “Bill of the Month” stories that, you know, are eye-rollers. Otezla 鈥� there are biosimilars that were approved by the FDA in 鈥� 2021? 鈥� which everyone’s talking about, faster approval of biosimilars. Well, this was approved, but the drugmaker filed multiple suits and patent infringement, and so in the U.S., it won’t be on the market, the biosimilar, until 2028, so that’s a problem too. 

Rovner: So if you want this drug, it’s going to be expensive. 

Rosenthal: It’s going to be expensive. And the other problem is copay cards. Insurers used to say, OK, that will count towards your deductible, right? So you didn’t really feel it, right? Because you got a $5,000 copay card, and you had a $5,000 deductible if you had a high-deductible plan. And everything was good. Now, insurers kind of said, Whoa, we’re not sure we like these things. So yeah, you can use them, but it won’t count towards your deductibles. So they’re not nearly as useful as they might have been in the past. But patients are really stuck, because these are really expensive drugs that most people couldn’t afford without copay cards. 

Rovner: So what eventually happened to this patient, and how can other people avoid falling into the copay card trap? 

Rosenthal: So basically, because he had used up the amount on the copay card, which was $9,400 for the year, by the second month, he tried for the third month to kind of ration his drugs to take half as much, and his symptoms came back. And then the lucky thing for him was then it was January, right, copay cards are usually done for the year. So he got a new copay card for another $9,400 and he was good for January, and he paid with his health savings account for the first month’s copay, with the copay card the second month, with the copay card and his health savings account. And when this went to press, he wasn’t sure how he was going to pay for the rest of the year. And for him, it’s not a huge problem, because he has a very well-funded health savings account, which few of us do, but he was really up in the air for the rest of the year when we wrote about this. 

Rovner: So sort of moral of this story, be careful if you want to take an expensive drug, and the theory that when the drugmaker promises, Oh, you can have this for as little as $0 copay. 

Rosenthal: Well, I think it’s you have to understand what a particular card does. You have to understand what’s the limit on how much is on the copay card. You have to understand how many months it’s good for. You have to understand, from your insurer’s point of view, if that will count as your deductible or not. And then, man, you know, you’re kind of on your own, right? Sometimes your copay card will work great for you, and at other times it will work for a shorter amount of time. And you got to figure out what to do. I think the third, bigger lesson is getting biosimilars, which are these very expensive drugs approved, is not really the big problem in our country. The problem is the patent thickets that surround so many of these drugs that prevent them from getting to the patients who need them.  

Rovner: In other words, you can make a copy of this drug, but you might not be able to get it onto the market.  

Rosenthal: Right. You can make a copy this drug 鈥� it [a generic] was approved in 2021 鈥� but that won’t help patients until 2028, which is really terrible. You know, it’s available in other countries, but not here. 

Rovner: So moving on, our March patient had insurance through the Affordable Care Act exchange and was benefiting from one of those zero-premium plans until she got caught in a literally Kafkaesque mess over a 1-cent bill that turned into a 5-cent bill. Who is she and what happened here? 

Rosenthal: Yeah, her name in this wonderful, terrible story is Lorena Alvarado Hill. And what happened here is she was on one of these $0 insurance plans through the Obamacare exchanges with that great subsidy, the Biden-era subsidy, and she and her mother were on the same plan, and her mother went on to Medicare, turned 65. So Lorena didn’t need the family coverage and told the insurer that. And the insurance, of course, automatically recalculates your subsidy, and her premium went from being zero to 1 cent. Now, no human would make that, you know, would say, Oh, that makes sense. And to Lorena, it didn’t really make sense either. She was like, I’m not sure how to pay 1 cent, like, will it work on my credit card? And some of the bills said, you know, you understand that this could impact the continuation of your insurance, but, you know, she was like, 1 cent, I don’t think so. And then she kept going to doctors, and the insurance still worked, and then at some point, four months later, she got a letter in November saying, Oh, your insurance was canceled in July, and you owe money for all these bills. 

Rovner: And what happened with this case? 

Rosenthal: Well, you know, like many of our “Bill of the Month” patients, I celebrate them for being real fighters, because her bill, since her premium was 1 cent a month, went from 1 cent to 2 cents to 3 cents to 4 cents to 5 cents, when they sent her the note saying your insurance has been canceled for the last four months. And what turns out, which is really interesting, is this is a known glitch in the way the subsidies were calculated, were administered. There’s a recalculation of subsidies every time there’s a life event, a kid goes off the plan, you change jobs, get married, you get divorced. So the recalculation happens automatically. And the Biden administration, understanding that this glitch could exist, they gave the insurers the option not to cancel insurance if the amount owed was less than $10. And there were apparently 180,000 people caught in this situation where their insurance could have been canceled for under $10 of a recalculated premium. The Trump administration revoked that rule because their feeling was, you owe something, you pay something. So it’s part of their “stamp out fraud and abuse,” and this was, in their view, abuse of a system when people didn’t pay what they owed.  

Rovner: One cent. 

Rosenthal: One cent, right. So what happened with her is, you know, a good bill-paying citizen sending her daughter to college with loans. She wrote her insurers, she wrote to the state, she wrote to everyone. And as a last resort, of course, someone said, Well, there’s this thing called Bill of the Month you could write to. So when we looked into this, at first HealthFirst, which was her insurer in Florida, said, Oh, she’s not insured through us. And I was like, Yeah, because you canceled her insurance. And then I gave them her insurance number, and they said, Well, yes, according to law, we did the right thing. She didn’t pay, so it was canceled. Somehow, through all of this, word got back to the hospital and the insurer, and they worked together, and her bills were suddenly zero on her portal. So that’s the good news for Lorena Alvarado Hill. It doesn’t really help all those other people whose insurance may have been canceled for premiums that were under $10. 

Rovner: So, basically, if you get a bill for 5 cents, you should pay it. 

Rosenthal: Yeah, you know, it was funny when this story went up, many people were sympathetic, but other commenters said, Well, she should have just paid $1 because you can pay that. And maybe there was a way to pay 1 cent. And I’m kind of with her, like, if I got a bill for 1 cent, life is busy. This is a woman who is a teacher’s aide and works on weekends at a store to help pay for her daughter’s college. Life is busy. You just can’t sweat over 1-cent bills and spend a lot of time figuring out how to pay them. And I guess the lesson is, what’s the worst that can happen in a very dysfunctional system where so much is automated now? The worst that can happen is always really bad. Your insurance could be canceled. 

Rovner: So basically, stay on top of it, I guess, is the message for both of these stories this month. Elisabeth Rosenthal, thank you so much. 

Rosenthal: Thanks, Julie, for having me. 

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

Hellmann: My story is from The Texas Tribune, from a group of reporters who I can’t name individually. There’s too many of them. But it is  in Texas after the governor issued an executive order a few years ago requiring that hospitals check patients’ citizenship. So the story found that hospital visits by undocumented people dropped by about a third, and the story also got into how this is bleeding into other types of health care at other facilities, free vaccine clinics are not being attended as widely anymore. People aren’t attending their preventive care appointments, like cancer screenings or prenatal care checkups. Some of these other health facilities are required to check citizenship status, but it’s definitely a chilling effect over the broader health care landscape in Texas. 

Rovner: Yeah. There have been a lot of good stories about that. Sandhya. 

Raman: My extra credit is from Science, and it’s by Jocelyn Kaiser, and the story is “.” In her story, she talks about how last year, you know, the administration cut a lot of staff at the Agency for Healthcare Research and Quality. They’ve canceled all of the open grants, but Congress still appropriated $345 million for the agency this year, and so supporters kind of want to revive what should be going on at the agency, which hasn’t been issuing any of the grants since the start of the fiscal year, and just kind of make progress on some of the things that this agency does do, like running the U.S. Preventive Services Task Force, which has been, you know, something that has been talked about this year. So thought it was an interesting piece.  

Rovner: Yeah, I’m old enough to remember when AHRQ was bipartisan. Alice. 

Ollstein: So a very harrowing story in The New York Times titled “.” And I will say, since this piece ran, we have seen that an oil shipment from Russia is going through to the island, but I don’t think that will be sufficient to completely wipe away all of the upsetting conditions that this piece really gets into, what is happening as a result of the ramped-up U.S. embargo and blockade of the island. People can’t get food, they can’t get medicine, they can’t get electricity, and that is having a devastating effect on health care. The Cuban health care system has been really miraculous over the years, just the pride of the government. It has meant, prior to this blockade, that their life expectancy was better than ours, and a lot of their outcomes were better. And so this has been really devastating. There’s, you know, harrowing scenes of people on ventilators having to be hand-pumped when the electricity cuts out, babies in incubators, you know, losing power. You know, people having to skip medications, etc. And so this is really shining a light on a foreign policy situation that this administration is behind. 

Rovner: Yeah, that’s really been an under-covered story, too, I think, you know, right off our shores. My extra credit this week is one I simply could not resist. It’s from New York Magazine, and it’s called “,” by Helaine Olen. And as the headline rather vividly points out, we are witnessing the rise of pet medical tourism, along with human medical tourism, which has been a thing for a couple of decades now. It seems that veterinary medicine is getting nearly as expensive as human medicine, and that one way to find cheaper care is to cross the border, which is obviously easier if you live near the border. I’m not sure how much cheaper veterinary care is in Canada, but as the owner of two corgis, I may have to do some investigating of my own.  

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

Raman: On  and on  . 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

Rovner: Jessie. 

Hellmann: I’m on LinkedIn under Jessie Hellmann and on X . 

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

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

Dan: Hey there. About a dozen years ago, Nicole Wipp was trying to spend less time running her law firm and more time with her son, who was in preschool. ?It was a work in progress. 

And then she started feeling鈥� a little off. ?Tired. Out of breath. Her doctor thought it was stress.

Nicole didn’t think so, but she soldiered on. And got worse. For months. Until one day鈥� when she told her husband she just couldn’t get off the couch 鈥� he was like, you’re going to urgent care. An x-ray showed her whole left lung totally blacked out.?

 Next stop, emergency room. 

Nicole Wipp: They put a huge needle and shoved it into my back and drew out two liters. Imagine a whole two-liter of pop 鈥� I’m from Michigan, so I say pop 鈥� from your body. They draw a whole two-liter of liquid. And I felt so much better immediately. I was like, wow, I can breathe. Like, wow, this is so cool. But, um, it was sort of horrifying.

Dan: Nicole says she eventually got diagnosed with a rare lung condition

Nicole Wipp: It’s called lymphangioleiomyomatosis 鈥� LAMB for short.

Dan: But not before she’d spent a month in hospitals 鈥� hospitals, plural 鈥� and had multiple expensive surgeries.

Nicole Wipp: Minimum 鈥� my husband and I tried to like tally it all up, like look at all the bills afterward 鈥� and it was, minimum, a half a million dollars. 

Dan: Which, because her husband’s job at the time provided good health insurance, didn’t break them.

Nicole’s condition hasn’t bothered her for years. But it’s not cured. It’s incurable.

And yet. This year, Nicole and her husband didn’t sign up for health insurance.

For more than 20 million people on Obamacare plans, the price of health insurance changed dramatically this year. Premiums skyrocketed just as subsidies got sharply reduced. 

Some people faced horrifically stark new circumstances: 

People who needed insurance to cover ongoing treatment: for cancer, for diabetes 鈥� treatment they literally could not live without 鈥� saw premiums jump by thousands of dollars a month, more than they could possibly afford.

And millions more got stuck taking gambles. Making messy, unsatisfying choices. 

Our partners at 麻豆女优 Health News have been talking with lots of those people. 

They introduced us to Nicole. She and her husband could have paid for health insurance. But when rates went up, they did the math and decided not to. They’re generally healthy, and honestly have more financial cushion than most people. 

If they need medical care 鈥� ordinary medical care, anyway鈥� they think they’ll be better off just paying cash. 

But they know they’re gambling: that 2026 won’t be the year Nicole’s condition flares up, or that some other catastrophe hits.

Our pals at 麻豆女优 Health News also introduced us to this man:

Noah Hulsman: My name’s Noah Hulsman. I own and operate Home Skateboard Shop here in Louisville, Kentucky.

Dan: It’s Louisville’s only skateboard shop. It’s kind of a family business, kind of a community center, kind of a place Noah’s spent most of his 37 years. 

Noah’s still paying for insurance 鈥� paying for  protection against catastrophe. But because all he can afford this year is a bare-bones plan, he doesn’t have a way to pay for ordinary medical care. Which he could actually really use. 

Noah Hulsman: So I’m kind of in a position right now鈥� I need my left shoulder looked at, but I have an $8,400 deductible. Yeah.

Dan:  We’ll get into that 鈥� it sucks. But first: I really want you to hear about this skateboard shop.

Noah Hulsman: When I tell the story, it almost seems like a movie or something. Like, somebody made this up.

Dan: Let’s go. 

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

Here’s how Noah ended up a skater for life.

Noah Hulsman: So my grandmother, she opened up a skateboard shop in 1988 here in Louisville. It was called Skateboards Unlimited. She had a little skate park also behind it called Ottoman Skate Park.

Dan: Noah’s grandmother was not a skater. She’d been a nurse 鈥� but she had five kids, and Noah says she ended up more of a stay-at-home mom.

Noah Hulsman: And then with all the commotion that was always occurring, with all the friends in and outta the house, with having five kids and all these skateboarders that just started popping up, she just decided, you know what? Let’s like have a place for you all to go.

Dan: She opened Skateboards Unlimited 鈥� and a skate park behind it.

When her youngest son finished high school 鈥� and moved to the West Coast as a professional skateboarder 鈥� it was the end of an era. And the beginning of another. 

Noah’s grandma closed up Skateboards Unlimited. 

Noah Hulsman: And uh, that’s when one of her employees was like, you know what? We gotta keep having a skate shop. 

Dan: They called it Home Skate Shop. Noah became a regular customer, eventually an employee. And 鈥� ten years ago, when he was 27, 鈥� he took over the business. 

Noah is as invested as anybody could possibly be.

Noah Hulsman: It’s everything. It’s my whole life. Yeah.

Dan: It’s doing OK. There were a few rocky years early on 鈥� Noah says he qualified for Medicaid. But things actually picked up when the pandemic started.

Noah Hulsman: Skateboarding was one of the only things that you do by yourself. You’re doing it outside. If I would’ve been able to get a hold of more product, we would’ve, we would’ve killed it.

Dan: Noah got an Obamacare plan, and he even bought a building 鈥� he leases out a couple of apartments, runs an air bnb in a third one, and says he breaks even on it, right now..

Noah Hulsman: They say, you know, real estate is a long term game.

Dan: Noah’s a long-term kind of guy.

\He and his girlfriend have been together for 16 years 鈥� even while she was away at veterinary school.

Noah Hulsman: She just finished up at Auburn this past year and moved back home and yeah, it’s been awesome.

Dan: Now they live together 鈥� with their four cats 鈥� in an apartment less than a mile from where his grandma started her skate shop.

But it’s not a cushy living. Noah says he takes odd jobs and gives skateboarding lessons to make ends meet.

Noah Hulsman: Every single day is a hustle. There is no day, like you can’t get sick, you can’t be鈥�  no downtime. If you take vacations, you’re still working from your phone, you’re checking in on the shop.

Dan: Noah says his income 鈥� all in 鈥� has been holding steady at around $33,000 a year. Last year, with a subsidy, he was able to get a gold plan for about a hundred and five dollars a month.

For 2026 鈥� with premiums jacked up and subsidies cranked down 鈥� that gold plan would have cost him an extra $500 a month. That’s $6000 a year. Way more than he could afford.

Instead, he picked a Bronze plan. It leaves him paying pretty much exactly the same every month as he did last year, but it covers so much less.

Noah Hulsman: I don’t even know why I’m paying that. It’s useless really, unless I get into a car accident and I have $10,000 worth of bills.

Dan: Or a skateboarding accident. Or a serious illness. Anything.

He’s holding onto the plan as a backstop against a worst-case scenario, against ending up with more debt than he could ever pay back.

But having a backstop is not the same as having access to medical care.

A few months ago, Noah says his left shoulder started bothering him. He says it doesn’t stop him from day-to-day stuff, running the shop. But it does impose limits. 

Noah Hulsman: It’s those like quick movements. It’s those like blast-off times like when I’m popping on my skateboard or when I’m like turning a certain like front side and like throwing all my weight that way. 

Dan: His bronze plan 鈥� with its $8400 deductible 鈥� means he can’t afford to get it checked out.

Noah Hulsman: To go through, okay first you have to go see primary care, then they gotta do the x-ray. Then once you see the x-ray, oh, we can’t tell anything from the x-ray. Yeah, we know because it’s ligaments and tendons and muscles and things like, I’m not a doctor, but I’ve been through this a few times. So, okay, we’re gonna get you the MRI. All right. Here’s the MRI. None of that’s gonna be covered.

Dan: It sounds like thousands of dollars to Noah 鈥� to me too, really. And that’s before getting it treated, which could mean surgery.

Noah doesn’t have thousands of dollars lying around. If he did, he would’ve paid up for the gold plan. 

So he’s avoiding tricks that could irritate the shoulder,

Noah Hulsman:  I can still skateboard. I just have to choose what tricks or what obstacles. I don’t have like the freedom that I had when I used to ride my skateboard.

Dan: He’s hoping he can nurse the injury along till next year, when he thinks he could afford better insurance. 

Noah Hulsman: What I’m kind of planning on doing is my, my shop vehicle is about to be paid off next year or like at, at the, I think it’s like middle of next year. And that payment is basically what that gold plan payment is.

Dan: Yeah, yeah,

Noah Hulsman: That’s what’s probably gonna happen. That’s my new car payment. New shoulder payment.

Dan: Man, that super sucks. I mean, grimly hilarious 

Noah Hulsman: Yeah. Yeah. I mean, if this, you have to just laugh at how ridiculous the world is these days. There’s, I mean, if you just take it serious, doom and gloom all the time, it’s going to, you’re not gonna make it. You gotta just laugh these days. It’s so ridiculous.

Dan: It is. Noah is far from alone. A Gallup poll taken in late 2025 found that more than a quarter of all Americans had postponed surgery or medical treatment because of cost.

Being insured and having access to medical care 鈥� for lots of people, they haven’t been the same for a long time.

This year, especially for people using Obamacare, that’s accelerating. 

We don’t know yet how many people made choices like Noah’s, and moved to plans that cover less, in order to have a monthly payment they could kind of afford.

Federal numbers won’t be out for a while. But an analyst named Charles Gaba ran some preliminary numbers from a few states.

He found that the number of people in Silver and Gold and Platinum plans was down significantly. And the number of people in Bronze plans, the cheapest, was up dramatically.

And we do know that at least a million people have dropped Obamacare. Some have dropped insurance altogether. Including, of course, Nicole Wipp.

We’re coming back to her story, just ahead. 

This episode of An Arm and a Leg is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom reporting on health issues in America. The reporters at 麻豆女优 Health News do amazing work 鈥� win all kinds of awards every year. And in a little while, you’ll meet the 麻豆女优 reporter who introduced me to Noah Hulsman and Nicole Wipp.

Dan: Before Nicole Wipp knew that her Obamacare rates would be going up, she knew she was pissed at what she calls the insurance industrial complex. 

Nicole Wipp: So my son. Just for example, we took him鈥� called in advance, 鈥榙o you take our insurance?’ Took him to get basic well child vaccines. Well, next thing I know, I got a bill for $4,000. I called them up and was like, what is this? 

Dan: She says that was early 2025, and she’s been fighting ever since. 

Nicole Wipp: They’ve cut it down to like 1200, but I’m like, no, no, no, no, no. It should be a hundred percent covered under our insurance, So that’s the thing is like, why would I participate in this?

Dan: And at least since her half-a-million-dollar medical adventure Nicole Wipp has been pretty determined to live life on her own terms.

Even before her illness, she had already been trying to spend less time running her law practice and more time with her family.

Then, after the illness, she more than doubled down on that. On her website, she says she went from working 80 hours a week to working just five days a month.

That’s the website for a new business she started after her recovery: a consulting and coaching practice that offers to help people achieve financial success on their own terms. 

Nicole Wipp: Financial success for me is very much not just about money, it’s really more about quality of life and having enough money to have that quality of life.

Dan: So, for instance, about four years after her illness, Nicole’s family moved from Michigan to Hawaii.

Nicole Wipp: We said, we want to live in Hawaii because we wanna have a quality of life. And of course, living in Hawaii is not cheap. It’s one of the most expensive places in the United States to live.

Dan: But that’s what they wanted. And they made it work. 

And then their son got into polo. Like, with horses. Which is harder to do in Hawaii鈥� to do seriously, competitively 鈥� without a lot of traveling to the mainland. So they moved again, to South Carolina.

Nicole Wipp: And we did, by the way, when we moved back to the mainland, FedExed four horses from Hawaii

Dan: Oh my God.

Nicole Wipp: I know, and like when you say, all these things, it sounds insane, right? It is insane. 

Dan: Since then, she says they’ve picked up another four horses.

Nicole Wipp: Now we have a total of eight, which is a lot, a lot by the way. Um, and so, you know, I say it out loud and I’m like, oh, I’m not proud of this, to be honest with you. But, but we have also though made other choices like we live in a smaller home than we would otherwise, so that we can do that.

Dan: And that home is in a part of South Carolina where houses aren’t super- expensive. So Nicole says the mortgage on their house is less than the $1400 they would’ve been paying if they’d kept their insurance this year. 

The expensive horses, the less-expensive home鈥�

Nicole Wipp:  Like these are choices that we’ve made as a family that I understand very much that most people would never make these choices, but we’re doing it in as responsible of a fashion as we possibly can.

Dan: A few years ago, her husband changed careers鈥� no more job-based health coverage. They started buying insurance on the Obamacare exchange.

But by mid-2025, it started looking like that insurance could get a lot more expensive. Not because they’d lose a subsidy 鈥� they hadn’t qualified for a subsidy to start with. 

But if subsidies went away, she figured rates would go way up.  

Nicole Wipp: I started bringing it up to my husband. Like, I don’t know what this is gonna look like. I’m very worried about it. And we may be in a situation where we need to make a choice 

Dan: Could they contemplate doing without insurance?

Nicole Wipp: And so we had probably, you know, 20 conversations, at least, about it.

Dan: Before making a decision 鈥� even before 2026 rates got posted 鈥� Nicole and her husband started taking some steps. She scheduled a colonoscopy, and went to the dermatologist for a skin check. Her husband got some tests too.

If they didn’t have insurance next year, those tests wouldn’t be covered. And if any tests came back with scary results, insurance would be more important.

Obamacare premiums for 2026 got published. Their family’s rate would go up by about 50 percent. 

Nicole Wipp: Once the numbers came out, I was like, I just don’t know if this makes sense.?But we were like, okay, we need to gather more information. We need to think about it some more. 

Dan: Their tests had come back OK. And they felt fine. Maybe they wouldn’t need any medical care in 2026, or not much. But maybe they would. How might they pay the bills? They kept talking. And they identified some ideas.

For one thing, Nicole found some money socked away in a health savings account from her husband’s old job. 

Nicole Wipp: It’s not a lot, but it was like, oh, that’s a nice little cushion. Like we could use that if we needed it. 

Dan: Nicole figured, if they were paying cash, she’d be in a good position to negotiate with providers for discounts. 

Nicole Wipp: Because I’m a lawyer and I’ve been around the block on these things, so I had a lot of faith that I could negotiate a bill.

Dan: And she had other ideas for finding deals. 

Nicole Wipp: I was like, you know, depending on what the situation is, we could fly to another country, receive healthcare quality healthcare. It still would be less. And I am not above doing that.

Dan: And if all of that required more cash than they had lying around, Nicole figured, they still had options. 

Nicole Wipp: We have certain assets that in an extreme emergency we could sell 鈥� I mean, because it’s not just the horses. We have horse trailers and like, you know, there’s a lot that goes along with all of that that isn’t just the horses by the way.

Dan: None of which made the decision easy. Nicole says she and her husband didn’t fully decide until the actual deadline came for signing up. Even then, they knew they were gonna keep their son insured.

Nicole Wipp: I would be in my opinion, not responsible as a mom, so鈥� because he does play a very dangerous sport.

Dan: But for the adults, they weighed the risks, and decided to gamble.

Nicole Wipp: If I take that money and invest it instead of putting, I don’t know, am I gonna be out further ahead? I will if I don’t have a massive emergency and a half a million dollar illness. Um, right? And so it’s a gamble, like, right? All of this is a gamble, but it was a gamble that I was like, I just don’t want to participate in this any longer because this is not workable for almost anybody, but it certainly isn’t workable for me anymore mentally or emotionally.

Dan: Not workable for almost anybody. 

[Music transition]

Renu Rayasam: I mean, I also think about this as a reporter. We have these individual stories. What do they mean? First of all, why is this system like this and what does it mean for everyone?

Dan: That’s Renu Rayasam. She’s a senior correspondent with our partners at 麻豆女优 Health News. She introduced me to Nicole and to Noah. She and her colleagues have been talking with dozens of people about the choices they’ve been forced to make about insurance this year.

?And thinking about what those individual stories mean has led Renu to some big reflections. 

Renu Rayasam: I think sometimes in the US you take for granted the way things are. Just you don’t, you don’t realize there is another way, you know? There is another way! And um, and that’s where everybody has health insurance and those costs are better spread out. 

Dan: Renu is speaking in part from experience. She spent a half-dozen years living in Germany. We talked about her experience鈥� and how it affects the way she sees stories like Nicole’s and Noah’s. 

Renu Rayasam: ?Well first of all, it was kind of amazing to like never get a medical bill. Like that was like, like so mind blowing that you just, like, you go to the doctor and you never get a bill. 

Dan: Not because the government pays for health care. But because the government requires everybody to have health insurance. 

Renu Rayasam:  People pay premiums. ?You have to pay into the system. And it’s not necessarily cheap either.??But then on the back end, you’re never worried about, oh, my shoulders hurt, I have to get this MRI and I’m gonna get a bill.

Dan: ?Most people pay a government-set rate 鈥� about 15 percent of their income. Most insurance funds are non-profit. Everything’s highly regulated, and everybody gets the same benefits. Here, things are 鈥� more chaotic. Less predictable. People have to make hard choices鈥� and those choices feed back into the chaos. 

Renu Rayasam: So if somebody like Nicole opts out of health insurance, they’re not paying into this system and the people who are paying into the system are people who need care. And so that makes health insurance more expensive generally. 

Dan: Because insurers set their rates based on how much they expect to pay out. When healthy people bail, the rates go up. And when rates go up, healthy people bail. They reinforce each other. It’s what experts call a death spiral.

As some of those experts told Renu, a version of that happened over the last year. ?It wasn’t a coincidence that insurers jacked up prices when subsidies were on the chopping block. 

Renu Rayasam: Part of the reason that insurers raised their prices was because they expected people to drop plans and that fewer people would be paying their premiums and be paying into the system.

Dan: And people like Nicole and Noah ended up with lousy choices to make. 

Noah chose to keep paying for insurance as a backstop against absolute financial catastrophe 鈥� even though the insurance he can afford doesn’t give him access to medical care he needs. 

Nicole and her husband think they’ve got the resources to pay for ordinary medical care. Even maybe a big medical deal 鈥� as long as there was time to hop on a plane and get to a country where they could afford treatment.

But they’re not protected against the worst. Nicole knows bankruptcy is a real possibility. 

Nicole Wipp: We don’t have a guarantee. And it still weighs on me every day that I made this choice because it feels fraught. Do I regret it? No, not at the moment. I don’t. Will I regret it? I hope not.

Dan: Hmm.

Nicole Wipp: I don’t know though.

Dan: Yeah, you’re not like, I did it. I’m free, you know, this is the best. It’s like, no, you’re not free of it.

Nicole Wipp: No, I don’t feel free at all.

Dan: I wish I had a snappier ending to this story. We are more stuck than ever 鈥� all of us 鈥� making messy choices, hoping for the best. So I’m gonna give Noah the last word here. 

He’s taking his own advice: Taking things as they come, recognizing what’s ridiculous, and aiming to hang in there for the long term.

Noah Hulsman: ?Hopefully we, you know, get enough equity in this building that once it’s time to pass the skateboard shop on, maybe sell the building and hopefully that’s when we get to maybe cash out and go to the beach. 

Dan: Wow. 

Noah Hulsman: ?Maybe. Or maybe I’ll just get to pay off my medical debt that I’ve accrued over however many years at that point.

Dan: We’ll be back in a few weeks with a new episode. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta 鈥� and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

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

 Zach Dyer is senior audio producer at 麻豆女优 Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

Julie Rovner: Hello from 麻豆女优 Health News and WAMU public radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 22, 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 Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: Sheryl Gay Stolberg of The New York Times. 

Sheryl Gay Stolberg: Hello, Julie. Glad to be here. 

Rovner: And Paige Winfield Cunningham of The Washington Post. 

Paige Winfield Cunningham: Hey, Julie. 

Rovner: Later in this episode, we’ll have my interview with Dr. Ezekiel Emanuel, whose new book, Eat Your Ice Cream, is both a takedown of the wellness industrial complex and a kinder, gentler way to live a more pleasant and meaningful life. But first, this week’s news. 

So, and I don’t want to jinx this, it looks like Congress might pass a spending bill for the Department of Health and Human Services that will become law 鈥� meaning not a continuing resolution 鈥� for the first time in years. And attached to that spending bill, scheduled for a vote in the House today, is a compromise health extenders deal that was dropped from the final spending bill in 2024 and which we’ll talk about in a minute. But first, the HHS appropriations bill. Sandhya, what are some of the highlights? 

Raman: So I think overall we just see a little bit of a slight increase for HHS compared to last year. Some agencies get a little bit of a bump: NIH [the National Institutes of Health], SAMHSA [the Substance Abuse and Mental Health Services Administration], HRSA [the Health Resources and Services Administration], Administration for Community Living. CDC [the Centers for Disease Control and Prevention] is kind of the same as last year. But then we do see some cuts in some places. Something that was getting watched a little bit was refugee and entrant assistance, given some of the different national news related to refugees and immigrants, and so that’s getting cut by about a billion. And some of the back-and-forth there is, some conservatives wanted more than that, some Democrats didn’t want that to be cut. I think the big thing in health care that we were waiting on on this was whether or not they would prohibit NIH forward funding, which is something the administration has been pushing for, just giving out a lump sum for grants through NIH rather than over a multiyear period. And the concern the Democrats had on that was that if you’re doing the lump sum all at first, fewer groups would get money for research. And so there is a prohibition on that, on doing the forward funding. 

Rovner: But just to be clear, the president, the administration, had asked for deep, deep cuts to the Department of Health and Human Services, and Congress is basically saying: Yep. Nope. 

Raman: Yeah. I think even if you look at what the House had proposed last year, they had cut a lot of programs, or proposed to cut a lot of, and that was not there. I think a lot of times, what we’ve seen is that even in Trump 1, there’d be a lot more proposed cuts in their proposal, when the White House puts out their blueprint, and then Congress comes to more of a medium point, kind of similar to previous years. So I think that was something that a lot of the health groups had celebrated, that they weren’t going to get the steep cuts that they thought could be part of the process. 

Rovner: Of course, the big question here is: Does the administration actually spend this money? We saw in 2025 them refusing to spend money, cutting grants, cutting off entire universities. And this is money that Congress had appropriated and that the administration is supposed to spend. Are they going to do it this time, is Congress? Have they put anything in this bill to ensure that the administration is going to do it this time? 

Raman: There’s a little bit here and there on some of that. I don’t think there’s quite the sweeping things that some Democrats would have wanted to prevent some of that. Just last week, we had the back-and-forth with SAMHSA grants getting pulled and then unpulled. And so there’s a little language related to that in there, just because that was such a big 24-hour issue. And then education funding is coupled with HHS, and there there is specific language saying you can’t transfer the money that would be for education into another department to dismantle it. So鈥� 

Rovner: And, I would say, and basically, you can’t cut the Department of Education unless Congress says you can. 

Raman: Yeah. So there’s some things in there that are like that, but to get appropriations done, it has to be a bipartisan thing to get that to the finish line. So no one is going to get everything they wanted, not even President [Donald] Trump. 

Rovner: Yes, and I will point out that they are not there yet. The House has to pass this. The Senate has to pass this when they come back next week. We’ve got, apparently, a gigantic snowstorm coming towards Washington, D.C. So it’s moving in the right direction, but it’s not there yet. All right. Now onto the health package that’s catching a ride on this spending bill. What’s in it? And how close is it to the package that got stripped from the 2024 bill after Elon Musk tweeted that the bill was too many pages long? 

Raman: I think it’s fairly similar. We have a lot of the same PBM [pharmacy benefit manager] language that we had when that got dismantled, and a lot of these same kind of extenders that we see from time to time whenever we get an appropriations deal, extending things that are pretty bipartisan but just never have a place to ride elsewhere 鈥� National Health Service Corps, Special Diabetes Program, things like that. I think that since this time we haven’t had that pushback, we don’t have Elon Musk weighing in and kind of pulling the strings in the way that we did before, these have been very bipartisan provisions that both chambers have been saying that they want to get this done, they want to get this done as soon as possible, even in the beginning of last year. So I don’t sense that something’s really going to derail language targeting PBMs and stuff like that. 

Rovner: I would say the big piece of this is the deal that Congress came up with in 2024 to require more transparency on the part of these pharmacy benefit managers that everybody on both sides is accusing of pocketing some of the savings that they’re getting from drug companies and therefore making drug prices more expensive for employers and consumers. 

Raman: So I think that this has been such a priority that this is their shot to get it done. And it seems like as long as nothing derails appropriations in the next day and a half, then this is their chance to do that. 

Rovner: So what’s not in either of these packages are most of the pieces of the legislation that President Trump called for last week in his self-titled Great Healthcare Plan, with the PBM provisions being a major exception. What else is in Trump’s plan? And what are the prospects for passing it in pretty much any form this year? 

Winfield Cunningham: I would say not great. Yeah. A couple of things that struck me about this plan, which I would note was one page long: This is very Trumpy. Trump obviously loves, he’s a lot more into hauling pharmaceutical CEOs into the White House to make deals than he is crafting detailed policy. Because if you’re actually trying to do health care reform, this is not the way that you would do it. What you would do is actually spend a lot of time on the Hill seeing what Republicans can sign onto, and working with staff to craft detailed policies and etc., etc. But, yeah, so most of this stuff 鈥� yet I guess another big thing that struck me was a lot of this actually goes after insurers. There are some things in here that drugmakers don’t like, but Trump goes so far as to propose bypassing insurers entirely and sending money to people. And of course he doesn’t detail how that would work. And then there’s a lot of stuff in here about transparency by insurers. I would note the Affordable Care Act had some insurer transparency provisions already. 

So I think what this plan, if we want to call it a plan, reflects is just Trump’s desire to have something that he can call a “great” health care plan that he’s promised for a long time and which he’s going to talk a lot about. But yeah, I don’t think we’re going to see Republicans in Congress do much on this. Yeah, with the exception of the PBMs, which is pretty notable, and I think actually represents a really big win for the pharmaceutical industry, which has obviously felt under fire in this administration and has struck these deals with the White House, which they really don’t like. But they had been threatened that the administration would go further in trying to do this “most favored nation” price caps. And so it’s interesting because insurers are kind of Trump’s new target. That’s what I kind of read in this. And of course I would mention today that major insurers are testifying on the Hill because they’re under fire for raising insurance premiums. 

Rovner: Although, as we’ve noted many times, they’re raising insurance premiums because the cost of health care is going up. Yes, Sheryl. 

Stolberg: Julie, I think the political context of the Great Healthcare Plan, the so-called Great Healthcare Plan, is important. First of all, Republicans have had trouble for decades coming up with some kind of health plan, even before the Affordable Care Act was passed and signed into law in 2010. They weren’t able to do it then. President Trump famously said “nobody knew” that health care was “so complicated.” He’s in a situation now where Republicans have stripped many Americans of their health insurance by letting the extended Obamacare credits expire, and we’re going into a midterm election season in which his party and he have promised repeatedly that they were going to come up with a plan. He said he had a concept of a plan. I think this plan, so to speak, is not even a concept of a plan, and its primary provision actually lifts from what Sen. [Bill] Cassidy was promoting, which was to steer money away from insurance companies and toward consumers. Trump kind of latched onto that. He doesn’t say that explicitly in this 325-word proposal, but it seems clear to me that that is his idea, and that is just not a workable idea. 

He wants, they want, to move money into health savings accounts. I cracked up my elbow earlier this year. I had surgery to repair it. I saw the bill. The bill was $122,000. I am very blessed to have good health insurance through my company. There is no way that the government is going to steer that kind of money into a health savings account for an uninsured person. These are accounts that are meant to be sort of supplemental to spend on relatively small expenditures. And if you are an uninsured person, there is really no way that you can cover yourself. And that’s basically what this so-called “great” American health care plan is proposing, which I suspect, if most Americans really looked at it, they would say, is not so great. 

Rovner: Yeah. I also, I broke my wrist this summer. I also had surgery, although I had outpatient surgery, and it cost $30,000. So it’s, yeah, health care is really expensive, which, as I said, is why insurance premiums are going up. So, this week marks a year since the start of Trump 2.0, and it would take us the rest of the year to detail all that has changed in health policy. But I did want to hit a few themes, some of which you’ve started to talk about, Sheryl. One is the administration’s effort to basically end the federal public health structure as we know it. The Centers for Disease Control and Prevention in Atlanta has basically been taken over by political appointees, most of them without health experience or expertise. Sheryl, you’re our public health expert here. What does it mean for public health to be basically ceded back to the states? 

Stolberg: Well, I think this is kind of a novel experiment here. The core of the CDC is its infectious disease programs. Now, over the decades, since the 1970s, the CDC has greatly expanded its remit to cover things like chronic disease and gun violence prevention and auto safety, etc. But its core is infectious disease. And we know that infectious disease knows no borders. So what we risk having here is a patchwork of state-by-state vaccine recommendations, where some states will follow the CDC’s recommendations, presumably those that are red states. This was never political before. And we’re seeing some states, like blue states like New York and Massachusetts and other New England states, kind of coming together to put forth their own vaccine recommendations. I think this has implications for what vaccines will be covered and what vaccines will be offered by the Vaccines for Children Program, which was created by [President] Bill Clinton to cover poor kids and make sure they get vaccinated. I don’t think we know how that’s going to play out. 

I saw [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] yesterday in Harrisburg, Pennsylvania, and he insisted that he’s not taking any vaccines away from anyone. If you want your vaccines, you can get them. But the truth is that for decades, the American public and the medical establishment have relied on the CDC to provide guidance. The CDC doesn’t mandate anything, but it provides really important guidance to the country, and the agency is crippled now. Its guidance is not going to be followed. And I think we’re in uncharted territory here. We’re already seeing measles is on the rise. The country’s about to lose its measles elimination status, which we acquired in 2000. Whooping cough is on the rise. 

Rovner: Basically things we know we can prevent with vaccines. 

Stolberg: Exactly, exactly. 

Winfield Cunningham: One of the things I keep thinking about is, Kennedy says over and over again that if you’re a mom, you should do your own research. And it seems like a lot of the effects here is stepping away from this broad recommendation to now this patchwork of recommendations. So when you go to your pediatrician, you might hear guidance based on AAP’s [the American Academy of Pediatrics’] guidance, for example. States are doing different things. And as a parent, when you go to your pediatrician, it all of a sudden, I think, becomes a lot more confusing, especially if you’re someone who maybe already has a little bit of hesitancy about vaccines. 

I was in with our pediatrician last week and asked her what they’re seeing, and people are coming in with a lot more questions. And interestingly, they actually are changing their policy for mandatory vaccines. They actually had required every patient to be up to date by age 2 with the CDC-recommended vaccines. Now those vaccines that are under shared clinical decision-making, they’re no longer going to require those. And it’s not, and they’re going to continue to recommend them, but I think they’re concerned that patients are going to come in and they’re saying: Hey, the CDC doesn’t necessarily recommend these now. I’m worried about them. So it’s put pediatricians in a difficult place. But, yeah, it’s, as a parent, you’re having to make a million decisions about your children, and this just kind of makes that more complicated and confusing, potentially, for parents. 

Rovner: And takes time away from doctors who would like to counsel about other things, too. 

Stolberg: I just want to add one thing about that. Kennedy says do your own research. And if you read the package inserts on a vaccine, you’re going to see that vaccines have side effects, just like any drug. But that information needs context around it, and the parents who are weighing those side effects need also to be told about the risk of the diseases that those vaccines are intended to prevent. And my kids are grown. I’m wondering how pediatricians are having that conversation, or if they’re having that conversation, in talking to parents about: These are the risks of the vaccine. But should your child get measles, these are the risks. Before vaccination was widespread for measles, 450 kids died on average every year. Many more were hospitalized. So I think those conversations need to be had. 

Winfield Cunningham: And I think it’s hard for pediatricians sometimes to illustrate that, because we’re so far removed from people having examples or knowing anyone who had these. 

Rovner: Not anymore. 

Winfield Cunningham: Not anymore. But largely, right? I have a lot of parent friends, and I don’t know a child who’s had measles. Our pediatrician was telling me that when she was in medical school, it was still common for pediatric hospitals to be filled with babies with rotavirus. She said you could smell it down the hallway. And now, actually, the people in medical school, they’re not experiencing that, because of widespread vaccination. 

Rovner: All right. Well, the second big thing I want to hit on is, as Sheryl already mentioned, people losing their health insurance. Last summer’s big budget bill would cut nearly a trillion dollars from the Medicaid program and make it more difficult for people to maintain their coverage through the Affordable Care Act. Republicans refusing to extend the expanded Affordable Care Act subsidies from the Biden era is already prompting people to drop coverage that they can no longer afford. What does it mean to the health care system as a whole that the number of Americans without health insurance is going to begin to rise again? 

Raman: I think it’s a multipronged thing. There are some aspects of these things that might not be felt immediately, that might be later this year or early next year as different provisions of the [One] Big Beautiful Bill kind of come into play 鈥� work requirements, things like that that might affect how many people have insurance. But also, I think it kind of goes back to some of the things that Sheryl and Paige were saying about, just, if fewer people are vaccinated, it increases the risks for everyone. And if fewer people have health insurance, regardless of what they have, it also makes it more difficult. If people are not getting treated for things, they get exacerbated into more serious conditions. So I think there are a lot of issues at play. Some of them have just, we’re kind of waiting to see how the effects are.  

You know, people that may have skipped out on ACA insurance this year, maybe they haven’t needed to go to the doctor yet. We’re in the first month. People might not go every month. But that doesn’t mean they’re not going to be hit with something big, even tomorrow, next month, month after that. And so I think all of these things kind of compound together to make it a lot more difficult of a situation, and just a lot of the complexities, I think it’s kind of in both of them where you’re not sure. Oh, is this renewed? Is this not renewed? It’s, I think, a lot more difficult for the average person to follow this national conversation as much as people that are really plugged in, so that by the time that it trickles down to them, it’s like: Can I sign up for health insurance still? Are the costs high? Am I still eligible? It gets more and more confusing. And then people who might be eligible might kind of be scared away with some of that chilling effect. 

Stolberg: I should say, I think emergency rooms will also bear the brunt of the reduction in insurance, because without, people who don’t have health insurance will forgo going to the doctor until their [conditions are] unable to be ignored. And then they will wind up in the emergency room. 

Rovner: And then those, I was going to say, and then those emergency rooms will end up passing the bills that they can’t pay鈥� 

Stolberg: Exactly. 

Rovner: 鈥攐nto others who can, or in鈥� 

Stolberg: Exactly. It will drive up costs鈥� 

Rovner: Paige, started鈥� 

Stolberg: 鈥攊n the end. 

Winfield Cunningham: I think a lot of this is going to become clearer over the next couple of months. We still don’t really know the effects of those extra subsidies expiring. I was actually surprised to see that the ACA marketplace enrollment figures they released, I believe last week, were not actually that much lower than last year. But people aren’t kicked off their plan until they haven’t paid their premium for three months. So I think we need to wait until April or so to see how many people were, say, auto-enrolled in a plan which they can no longer afford, and now they’re kicked off. And maybe it’s fewer people than we think. Maybe it’s more people than we think. But I think we just don’t know that yet, and we’re going to have to wait for a couple months to see. 

Rovner: Yeah, I think you’re exactly right. I had the same reaction to seeing those numbers. Like, Wow, those are pretty high. And then it’s like, yeah, but those aren’t necessarily people who’ve had to pay their bills yet. Those are just the people who I think may have signed up hoping that Congress was going to do something. So, yeah, we will have to see how many people, I think it’s called “effectuated enrollment,” and we won’t get those numbers for a little while. 

Well, finally, dismantling the federal research enterprise. As I said, we’ve talked about this a lot, but I didn’t want to let it sort of go unstated. This administration appears to like to keep people guessing by cutting and then restoring research grants, refusing to spend congressionally appropriated funding until they’re ordered to do it by the court, and firing or laying off workers only to call them back weeks or months later. All that makes it difficult or impossible for researchers and universities to plan their projects and personnel needs. Combined with new limits on federal student loans for a lot of graduate students, are we at risk of losing the next generation of researchers? We’re already talking about seeing people moving to Europe to continue their research. 

Stolberg: Yes. I think the answer to that is an unequivocal yes. I am hearing from scientists who are having trouble filling their postdoctoral slots. Or young scientists. It’s really the next generation, right? People who are here already and who have families are trying as best they can to sort of stick it out, or maybe they’ll go into industry if they have to leave academia because they’ve lost their grant funding, or if they’ve left NIH. But it really is the next generation of researchers. I hate to draw this comparison, but we did see during World War II, the United States absorbed a lot of European researchers. This is how we got Albert Einstein, right? So I don’t know that we’ll see necessarily a reversal of that, of scientists fleeing, but we might see more young people choosing not to go into academic biomedicine. 

Rovner: And we’re already seeing, it’s not just Europe. It’s China and India鈥� 

Stolberg: Yeah. Right. 

Rovner: 鈥攐ffering packages. 

Stolberg: And they’re recruiting. Those countries are recruiting. Yeah, they’re recruiting young scientists, especially China.  

Rovner: Yeah. 

Stolberg: And that’s a good point. David Kessler, the former FDA [Food and Drug Administration] commissioner, has argued that this is really a national security threat for the country. China is a main adversary of the United States, certainly of President Trump. And if we’re at risk of losing highly qualified biomedical researchers to China, then we are giving them an advantage. 

Rovner: Yeah, something else we will keep an eye on, I think, for the rest of the year. OK, we’re going to take a quick break. We will be right back. 

Meanwhile, back to this week’s news. The American Academy of Pediatrics is leading a coalition of public health groups that are suing to reverse the changes to the childhood vaccine schedule made by the CDC earlier this month. The suit claims that the administration violated portions of the law that oversees federal advisory committees that require membership on those panels to be, quote, “fairly balanced,” and not, quote, “inappropriately influenced.” Among other things, the lawsuit asked the court to ban the CDC’s Advisory Committee on Immunization Practices from further meetings. That would basically stop any further changes to the vaccine schedule, I assume? 

Raman: At the end of the day, what ACIP does is just a recommendation to CDC, and they can choose whether or not to go with that recommendation. So I’m not really sure what would happen next, but it is kind of a whack-a-mole situation where just because you stop this does not mean that changes above that aren’t going to happen. 

Stolberg: Yeah. The Advisory Committee on Immunization Practices is just that. It’s an advisory committee. So this lawsuit takes issue with appointments to that committee and also complains that the committee was not consulted before the decision was made public to change the vaccine recommendations. I’m not exactly sure what the legal authority is for that. There’s apparently a federal law requiring federal advisory committees to be, quote, “fairly balanced” and not “inappropriately influenced.” But this isn’t 鈥� it’s an executive action 鈥� right? 鈥� to appoint committee members. It comes out of the executive branch. So I don’t know of any situation in the past where the judiciary has weighed in and said, You can appoint these people or not these people, or You have to redo a committee. So it’s hard to predict what the courts will say about this. 

Rovner: Meanwhile, it’s not just the ACIP that HHS Secretary RFK Jr. is taking aim at. Following his remaking of that advisory committee, he’s now fired some of the members of a separate panel, the Advisory Commission on Childhood Vaccines, which oversees the federal Vaccine Injury Compensation Program, which Kennedy has said he also wants to revamp. That’s the program that compensates patients who can demonstrate injury from side effects of vaccines. How big a deal could this be if he’s going to go after the vaccine compensation program?  

Stolberg: Julie, this is a big deal, and I’ll tell you why. That committee sets what is known as the table of vaccines. Which injuries does the federal government compensate for? And the federal government does not compensate for autism as a vaccine injury. And I have no evidence of this, but if I were betting, that is where Kennedy wants to go. He does not like the 1986 law that created the National Vaccine Injury Compensation Program because it offered liability protection to pharmaceutical companies. He wants to strip away the liability protection, but as I understand it, he does not want to do away with the law. He does not want to do away with the compensation program. So he may be trying to lay the foundation for the compensation program to be more expansive and cover injuries or allow claims for injuries that are not currently considered vaccine injuries, like autism. 

Rovner: Which of course would collapse the program because it’s paid for by an excise tax on vaccines. That was the original deal back in 1986. The vaccine manufacturers said: We’ll pay you this tax, from which you, the federal government, will determine who gets compensated. And in exchange, you’ll relieve us of this liability, because we’re getting sued to death. And if you don’t do this, we’re going to stop making vaccines entirely. That was the origin of this back in 1986. And I was there. I covered it. 

Stolberg: Yeah, exactly. I have read a lot of this history, and the CDC was really over a barrel. The companies were writing to CDC, saying, We’re going to pull the plug on our vaccines. And the CDC was worried that American kids were going to go without lifesaving vaccines because companies were going to quit making them. So they pushed this bill. [President Ronald] Reagan didn’t like it. He signed it into law anyway. And it’s created this program, which is actually imperfect. A lot of people who actually legitimately have vaccine-injured children have trouble getting compensated through this program., and I think many people on all sides of this issue would say that it does need to be overhauled. But it will be interesting to see who Kennedy picks for those committee slots. 

Rovner: Yeah, I think we’re going to learn a lot more about it. We’re going to learn a lot more about it this year. Well, finally, in vaccine land this week, Texas attorney general and U.S. Senate candidate Ken Paxton on Wednesday announced what his office is calling a, quote, “wide sweeping investigation into unlawful financial incentives related to childhood vaccine recommendations.” His statement says that there is a, quote, “multi-level, multi-industry scheme that has illegally incentivized medical providers to recommend childhood vaccines that are not proven to be safe or necessary.” Actually, one of the reasons that Congress created the Vaccines for Children Program back in the 1990s, Sheryl, as you mentioned earlier, is because most pediatricians lost money on giving vaccines. And today, many people can’t even get vaccines from their doctors, because it’s too expensive for the doctors to stock them. What does Paxton think he might find here? 

Stolberg: This is like stump the panelists. No one knows. 

Rovner: I see a lot of people’s鈥� 

Raman: I’m not sure what he thinks he might find, but I do think that he is one of the attorneys general that is generally on the forefront of trying things, to throw spaghetti at the wall and see if it sticks on a variety of issues. So it might be the sort of thing where if he finds something, then it could be kind of a jumping point for other conservative attorneys general. And of course just that he’s primarying Sen. John Cornyn for Senate, so if it raises his profile for more folks. But I’m not sure if there’s a specific thing that he’s looking for. 

Rovner: So he’s trying to curry favor with the anti-vaxxers in Texas, of which we know there are a lot. 

Raman: That would be my best read. 

Stolberg: Austin is, actually, the state capital in Austin is a hot spot for anti-vaccine activism. Andrew Wakefield, who wrote the 1998 Lancet article that’s been retracted, is in Austin. Del Bigtree, who runs the Informed Consent Action Network, is in Austin. There’s a group that I have  called Texans for Vaccine Choice that is one of the early parent-driven groups seeking to roll back vaccine mandates, is based in Austin. So there’s a lot of sentiment there that Ken Paxton might be trying to appeal to. 

Rovner: See? You’ve answered my question. Thank you. All right, that is this week’s news. Before we get to my interview with Dr. Zeke Emanuel, a couple of corrections from last week. First, I misspoke when I said House Republicans were becoming a minority in name only. Of course, I meant they were becoming a majority in name only. I also incorrectly said the lawsuit that helped get the Title X family planning money flowing back to clinics was filed by Planned Parenthood. It was actually filed by the ACLU [American Civil Liberties Union] on behalf of the National Family Planning and Reproductive Health Association. Apologies to all. OK, now we will play my interview with Dr. Zeke Emanuel about his new wellness book, and then we’ll come back and do our extra credits. 

I am so pleased to welcome back to the podcast Dr. Ezekiel Emanuel. Zeke is an oncologist and bioethicist by training and currently serves as vice provost for global initiatives and professor of medical ethics and health policy at the University of Pennsylvania. He formerly worked at the National Institutes of Health before he helped write and implement the Affordable Care Act while his brother Rahm was serving as President [Barack] Obama’s White House chief of staff. Zeke’s latest book, Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life, is out now. Zeke, welcome back to What the Health? 

Ezekiel Emanuel: Oh, it’s my great honor and pleasure. 

Rovner: So I feel like the subtitle of this book could be How to Keep Yourself Healthy Without Making Yourself Crazy or Broke and that it’s a not so thinly veiled attack on what many of us refer to as the “wellness industrial complex.” What’s gone wrong with the wellness movement? Isn’t it good for us to pursue wellness? 

Emanuel: It is good for us to pursue wellness. I think that there are probably three things that are seriously wrong with the movement. The first one is that they make wellness an obsession that you have to focus all your energy on, which is totally wrong. Wellness should be a habit that sort of works in the background while you focus on the really important things of life. I think the second thing is they tend to overcomplicate things. Part of that is they’ve got to send out an email every day or every other day. They’ve got to do a video, a podcast, what have you. And so they make it complicated so that they have something to report on. And the third thing is they make it oversimple. They’re reductionist. They talk about diet and exercise and sleep, and leave out other very, very important parts of wellness, maybe the most important part of wellness, which is your social interactions. And almost all these experts ignore it. 

And the last thing I would say 鈥� I guess I have four points 鈥� the last thing I would say is they have huge conflicts of interest. The wellness industrial complex is between $1- and $2 trillion a year, depending on what you want to include in that bucket, which means that there’s lots of people chasing lots of money trying to sell you lots of crazy items. So there’s money to be had and Them thar hills and people make all sorts of exaggerations. I want to emphasize for your listeners, I’m selling nothing, absolutely nothing. 

Rovner: I will say, I went to your book party. I’ve been to a lot of book parties over the years. Yours is the first one where I actually was not expected to buy the book. You actually gave the book away. 

Emanuel: Yeah, I can’t stand that. Oh, I hate that. 

Rovner: I would say, I assume you were making a point with that. I also ate the ice cream, which was very good. 

Emanuel: Yes. 

Rovner: I feel like your underlying message here is that it’s not enough to make yourself biologically healthy 鈥� you have to do things that make you happy, too. Is that a fair interpretation? 

Emanuel: Yes, that’s a very fair interpretation. Look, if you’re going to do wellness right, you’re going to be doing it for years and decades of your life. You cannot will yourself to do something for decades. You can will yourself to do something for a few weeks and a few months, but then, unless it becomes a habit that you actually enjoy, you’re simply not going to continue to do it. And so if you want to eat well, you want to exercise, you want to have social interactions, you actually have to make them something that’s pleasurable for your life, something that you find meaningful, even. That’s, again, I think something that’s seriously missing from a lot of these wellness influencers, because they make a lot of wellness about self-denial, about: You should deprive yourself. You should fast. Maybe you should fast. That’s OK if you can do it and you can work it into your schedule. Actually today is one of my fast days, so I am working it into my schedule. But that’s not for everyone, and it’s not essential to wellness and living a long and happy life. 

Rovner: So what are your six simple rules, in two minutes or less? 

Emanuel: The first one is: Don’t be a schmuck. Don’t take unreasonable risks. Don’t climb Mount Everest. Don’t go BASE jumping. Don’t smoke. Don’t do a lot of other stupid things. The second is: Engage people. A rich social life is the most important thing for a long, healthy, and happy life, and having close friends who you get together with regularly, talk to every week, have dinners with, acquaintances, very, very important. And then casually talking to people who you happen to interact with, either when you get your coffee, you go to the grocery store, you go to the restaurant, you hop in an Uber or a cab. Those are very important social interactions that we tend to ignore and tend to downplay. The third rule is: Keep your mind mentally sharp. And there are important aspects of that. Don’t retire. Take on new cognitive challenges. 

The fourth is: Eat well, and make sure you get rid of the unhealthy eating part and eat important, non-processed items. The fifth is: Exercise. Do the three kinds of exercise: aerobic exercise, strength training, and balance and flexibility with yoga. And the last one is: Sleep well. It’s the one you cannot will yourself to begin doing. You can only sort of prep the bedroom and then hope it happens. 

Rovner: So this whole thing didn’t really need to be book length, but you spent a lot of time reviewing the literature on various aspects of health and wellness, like, you know, a scientist would. Are you trying to make a point here about the current state of science and how the public views it? 

Emanuel: I am. I am a data-driven guy. I like data. I think when you have more than 3 million people that have been surveyed and followed in terms of social interactions and their impact on your wellness and your physical health, that’s worth noting, and it’s worth noting what those studies come to. And they all come to the same basic thing, which is you can reduce your risk of death and mortality in the subsequent six, 10, 12 years, depending upon the study, by about 20% to 30% by greater social interaction, more robust friendships. That’s a pretty impressive number, if you ask me. So I’m trying to emphasize the data and get people to understand and be motivated by the data. And I think I’m pretty clear about moments when I, say, interpret the data differently than a lot of other people do, because I think that’s part of science. 

So, for example, the PSA [prostate-specific antigen] test. Most guidelines say you should get a PSA test. I’m against the PSA test because, yes, it will reduce your risk of dying from prostate cancer, but it does not reduce your overall mortality. I think I don’t much care what’s written on my death certificate. I care about the length and wellness of my life, and the PSA isn’t going to affect that. But others disagree, and then I’m very frank about those kind of disagreements. 

Rovner: So in 2014 you rather famously wrote an Atlantic article called “.” Has writing this book changed your mind about this? And I will say, I’m only a year younger than you, so I have a stake in this, too. 

Emanuel: No, writing this book didn’t change my mind. It did change some things that I do. I will say, what really changed my mind, to the extent that anything changed my mind, was covid and the idea of getting vaccines after 75, I think, is a good thing, especially if whatever’s going around is targeting older people. It seems easy to protect yourself, whether from the flu or something like covid, with a vaccine. So that, I have changed my mind. Researching this book made me put a little more emphasis on, for example, strength training, which I had not done a whole lot of, directly. I’d done it because I ride a bicycle and I strengthen my lower half, my quads and my hamstrings and my gluteal muscles, but I hadn’t really focused on the upper body. 

Rovner: You should do Pilates. It’s great. 

Emanuel: Noted. 

Rovner: Zeke Emanuel. It is always fun to chat with you. And congratulations on the book. 

Emanuel: Thank you, Julie. This has been wonderful and very rapid-fire, more rapid-fire than anyone, because you get right to the heart of things. 

Rovner: Well, we have a lot more that we’re going to talk about this week. Thank you, Zeke. 

Emanuel: Take care, Julie. Bye-bye. 

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

Raman: My extra credit is called “,”and it’s by Judd Legum for Popular Information, his newsletter. And I thought this was really interesting, because, I think, for me, I look very much at HHS and major health agencies, but his piece kind of looks at how ICE [Immigration and Customs Enforcement] has not been paying third-party providers for medical care for detainees since October and that ICE, last week, the agency kind of quietly announced that it would not be processing any of the claims for medical care until April of 2026. And so doctors are instructed to kind of hold on that. And that’s kind of a downward spiral of providers denying services to detainees because they know they’re not going to get paid for a while. And so I thought this was a really interesting piece looking at that. 

Rovner: Yes, indeed. And kind of scary. Paige. 

Winfield Cunningham: Yeah, mine is a piece in Politico called “,” and it’s by Amanda Chu. And this really caught my eye because it was a look at how RFK’s demonization of food and pharma is motivating trial lawyers representing consumers who are saying they’ve been harmed by these products 鈥� one example, of course, is the lawsuit against the maker of Tylenol 鈥� and how this really kind of goes against where Republicans have usually been, against trial lawyers representing consumers who say they’ve been harmed by big, bad companies. And so, yeah, it was a really interesting look at that and just at how RFK’s kind of populist, pro-consumer streak has fueled all of this. 

Rovner: The world indeed turned upside down. Sheryl. 

Stolberg: So my extra credit is from Rolling Stone. The headline is “,” and it’s by Katherine Eban. She’s a terrific journalist. And this is about the study in Guinea-Bissau. When CDC pulled back its recommendation for children to be vaccinated at birth against hepatitis B, HHS gave this grant to these Danish researchers to conduct this study in Guinea-Bissau, which would compare vaccinated infants to unvaccinated infants. And there was a huge howl of protest. This study would never be done in this country. The idea of withholding a vaccine from an infant that has been proven to be safe and effective is highly unethical. It evokes memories of the Tuskegee study, in which government doctors withheld treatment for syphilis. So there was this huge uproar, and it turns out that the researchers who got the grant are these Danish statisticians who have a really questionable research history. And the story documents, through emails, how they got basically this no-bid grant by coordinating with some of Kennedy’s allies from his movement, from his vaccine advocacy days. And it was kind of an inside deal, basically. So I just think that this study has generated a lot a lot of complaints. I should say that the researchers have amended the protocol, and now I think they’re going to give shots to one group at age 6 weeks. But still, it’s a very problematic study, and the story exposes how it came to be. 

Rovner: Yeah, it is quite the story. Well, I also have an immigration story. It’s from my former colleague Liz Szabo at the University of Minnesota’s Center for Infectious Disease Research and Policy, and it’s called “.” And it’s not just undocumented people avoiding medical care, as Liz details. U.S. citizens with serious health needs are also scared of getting caught up in the ICE dragnet that’s now all around the city. And ICE officials have even been entering hospitals and other health facilities 鈥� which in previous years they had not been allowed to do. In the dead of winter in Minneapolis, with a particularly severe flu year, this is threatening to become a health crisis as well as an immigration crisis. 

OK, that’s this week’s show. Before we go, it’s almost February. That means our annual 麻豆女优 Health News Health Policy Valentine contest is open. Please send us your clever, heartfelt, or hilarious tributes to the policies that shape health care. I will post a link to the formal announcement in the show notes. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcast, 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 find me still on X, , or on Bluesky, . Where are you folks hanging these days? Sandhya. 

Raman:  and , @SandhyaWrites. 

Rovner: Sheryl 

Stolberg: I’m  and , @SherylNYT. 

Rovner: Paige. 

Winfield Cunningham: I’m on X, , and Bluesky, . 

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

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

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

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

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

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

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

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

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

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

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

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

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

Rovner: Yeah, we will, but we’ll believe it when 鈥� we get to the signing ceremony. 

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

Kenen: No, it’s sustainable, if we’re sustaining it at a high 鈥� in economically 鈥� zany price.  

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer 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, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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