[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, Nov. 20, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via video conference by Paige Winfield Cunningham of The Washington Post. 

Paige Winfield Cunningham: Hi, Julie. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: 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 Avik Roy, longtime Republican health care adviser and chair of the Foundation for Research on Equal Opportunity. But first, this week’s news. 

So, Democrats may not have “won the shutdown,” but they definitely got health reform back on the national agenda. The last time we had such a full-scale health debate was in 2017, which didn’t end particularly well for Republicans. For a while, it looked like there might be enough Republicans who were worried about 鈥� oh, I don’t know 鈥� their voters seeing their ACA [Affordable Care Act] insurance made effectively unaffordable that there might be a compromise in the offing. But now it seems that ship has sailed, and the two sides have retreated to their respective corners. That certainly seemed to be the case at the Senate Finance Committee hearing on Wednesday, where Republicans and Democrats basically talked past each other for three hours. Am I missing something? Is there some glimmer of hope here that I’m not seeing that when they have this vote in a couple of weeks, the Republicans are all going to say, Yeah, let’s extend those subsidies? 

Winfield Cunningham: It’s funny, Julie, I was thinking, was it last weekend, I think, that Trump tweeted about we need to bypass the insurers and send the money directly to consumers? And for a couple of days, there was all this buzz around Is this going to be yet another chance for Republicans to do something big on health care? And the whole time I was thinking: Was anybody around in 2017? This isn’t going to go anywhere. And especially, you could sort of predict this just because calls to redirect the subsidies 鈥� which are a core part of the ACA 鈥� away from the marketplaces, also a core part of the ACA 鈥� directly into tax-free savings accounts obviously [were] always going to be a no-go with Democrats. So the idea that this was kind of what Republicans were talking about, this isn’t even in the realm of possibilities that could be a bipartisan agreement on health care. 

There seems for a little while to be a semi-earnest effort in the Senate to come up with some kind of bipartisan plan. I know I spoke with folks for Sen. [Jeanne] Shaheen [D-N.H.] earlier this week who say they’ve been talking to 10 to 12 Republican offices who say they’re interested in some kind of deal and extending the subsidies. But honestly, when you start stacking up all of the barriers that would be in the way of getting a deal, one of them is abortion funding. I mean, this seems 鈥� 

Rovner: We’ll get to that later. Don’t jump the gun on that. 

Winfield Cunningham: But that’s a huge one. And then also, just the inability, and just how far apart the parties are on talking about health care affordability and how you manage to bring down costs for people. It’s just really hard to see this going anywhere. So, my prediction is that we see Republicans kind of coalesce around their own thing. Democrats coalesce around their own thing. And ultimately, we don’t see an extension of the subsidies. 

Rovner: What happens in January, though, when people actually start coming to town hall meetings and saying: Hey, we had to give up our health insurance because it was going up $4,000 a month? Might this build when these cuts actually occur in January? 

Kenen: The Republicans have floated health savings accounts for actually a couple of decades now. 

Rovner: Since the 1990s. 

Kenen: Right, that’s decades. 

Rovner: The first pilot project was in HIPAA [Health Insurance Portability and Accountability Act] in 1996. 

Kenen: And it is not what people want. I mean, it is what some people want in conjunction with an HSA alone. There are plans that are a combination of 鈥� in the exchange it would be a “bronze” 鈥� but this is not what the American people have. … They have not been saying: Please, take away my health care, and give me a couple of thousand bucks instead. That’s not what we’re hearing, or my health insurance, I should say, and take away. 

Rovner: That’s the point. Also, I’m seeing all these Republicans now saying we should not be giving money to the big, rich, bloated insurance companies, who we do know are unpopular instead 鈥� 

Kenen: Except for Medicare Advantage. 

Rovner: Thank you for finishing my sentence. So, finish my sentence for me, Joanne. 

Kenen: Medicare Advantage, which has bipartisan support now 鈥� not without some qualifications and criticism 鈥� Medicare Advantage is here. Many Democrats use it, and many Democratic lawmakers support it. But Medicare Advantage is private insurers who are being paid more than government-traditional Medicare to pay for people’s health care. So it is not a coherent, well-thought-out ideologically, or technically, or politically savvy plan that is going to solve the Republicans’ problems on Jan. 1, Jan. 2, Jan. 3, and you name the date after that. People who got subsidies for health care insurance are going to lose them, and many of them are [President Donald] Trump voters. And that’s a reality, period. 

Rovner: Paige, I know you’ve been looking into this pretty closely. Is there anything new here? I mean, it does seem that giving people money to go out and bargain on their own has been the Republican mantra, I know, since the 1990s. They’ve had all this time. Where is the plan? 

Winfield Cunningham: Let’s just think about the numbers here on HSA. So, I think the average subsidy [that] the average marketplace consumer gets is around $6,500. OK, that’s fine 鈥� great 鈥� if you’re healthy. If you’re sick 鈥� if you have diabetes, or you have cancer 鈥� say you have $6,500 in your account, [and] you don’t have health insurance, that’s not going to come anywhere close to the cost that you need to cover your cost of care. So this whole conversation isn’t about the healthy people, right? The conversation is about the sick people who bring up the costs, who need the insurance, who can’t afford the care. And HSAs and FSAs [flexible spending accounts] 鈥� especially HSAs, though 鈥� I think are largely used by wealthier people, healthier people, and it is a way to maybe put a couple extra hundred bucks in your pocket to pay for health care. It is not a sweeping long-term solution to making sure that people can afford the cost of care. 

Rovner: Right. It’s a great way to pay for your eyeglasses and your dental care, maybe, if you don’t need a lot of dental care. 

Kenen: It’s not just sick people. It’s also pregnancy. It’s also people who are healthy until they get sick. You can 鈥� 

Rovner: I keep saying this: I fell and broke my wrist, and it cost $30,000. $6,500 would not have begun to put a dent in it. Sorry, Shefali. You wanted to say something? 

Luthra: No, I was just going to say to Joanne’s point about pregnancy and your point about breaking bones: Some of the people who are most vulnerable in this kind of situation [are] families. Maybe you give birth, something the administration really talks about supporting. Maybe, I don’t know, you use fertility treatment. Maybe you have two kids. One gets the flu; one breaks a bone. These are not expenses you anticipated. And the very core of this pronatalist, conservative ideology of supporting families, helping it become easier to raise children, becomes a lot harder when you don’t have affordable health insurance. 

Kenen: I mean, there are some. [Louisiana Republican Sen. Bill] Cassidy’s plan is a little different. Democrats are still not going to love it. It is money in your pocket of a health savings account or a flexible spending account 鈥� I keep reading different details of what it is 鈥� combined with some kind of health insurance so that the exposure is not infinite, but it’s also not nothing. It’s not the same as Trump’s plan. There’s more protection for people in his version. But we haven’t really seen what his version looks like in detail. I keep reading about all these proposals, and I can’t figure out exactly what they look like because I don’t think they know yet. 

Rovner: Right, I don’t think they’ve been put on paper yet. 

Winfield Cunningham: Well, yeah, I asked Cassidy’s office for details earlier this week, and they didn’t respond. I don’t know if they’re waiting to see what polls well among colleagues. But I was going to say: On the politics, I’m never great on political analysis because I feel like I’m always wrong. But I would say [the] last time Republicans tried to go after ACA in 2017, Democrats really successfully leveraged that in the following year. They talked about trying to go after protections for preexisting conditions. And you’ve already seen, I think, [that] the DCCC [Democratic Congressional Campaign Committee] already put out some ads on the subsidies. So, this is going to be a huge, huge point for Democrats. They’re going to be talking about this nonstop next year. So, I imagine it would hurt Republicans. 

I’d also add, I think that Democrats sometimes have more to lose on health care than Republicans only because health care is not a top issue for Republican voters in the way that it is for Democratic voters. So, sometimes, Republicans can make missteps, and then their voters are more forgiving of it than maybe they would be of Democrats. 

Rovner: Although we’ll see, because as we keep saying, there’s a lot of Republicans in a lot of these states that have been using these extra subsidies. When they go away, they’re going to be really ticked off. 

Kenen: Could I just say one last thing? And we’ve said this again, we’ve said this repeatedly, but it is worth bearing, repeating is: Congress usually gives people benefits. Taking away benefits is not really a politically savvy approach. And then, yes, Medicaid isn’t until after the election, after the 2026 elections. But there’s going to be repercussions from the Medicaid law that [are] also going to be felt in the near term in terms of how are hospitals preparing, and responding, and cutting back, and what’s available in communities, and debates in their state legislatures about how they fill budget holes, and what services will be cut. This is turning into a health care year on both the ACA health costs and affordability and the impact of Medicaid that usually helps Democrats. But we are living in a time of intense short attention spans. We’re not living in … the parallels don’t always apply to the current situation, but it’s a Democratic issue. 

Rovner: Yeah. Well, continuing on my theme of maybe Democrats didn’t really lose the shutdown despite what many of them said, I’m kind of surprised at all the things that did get into the continuing resolution that passed last week and reopened the government. Democrats got all the federal workers back pay, which, despite being the law, was not a given. They got the federal worker firings during the shutdown reversed with a promise of no more RIFs [reductions in force] until at least the end of the next CR at the end of January. Because the CR also included full-year funding for the Department of Agriculture, they also got SNAP [Supplemental Nutrition Assistance Program] fully funded through next September. 

But two other really nerdy things were tucked into the bill that could turn into a big deal. One is the explicit rejection of a proposal to cut in half the budget of the Government Accountability Office, GAO, and preserving the right of the GAO’s head, the comptroller general, to sue the administration for violating the Impoundment Act, which is what protects Congress’ power of the purse. This is really the fight over the funding bills, right? We’ve got the Trump administration saying, Congress, we don’t actually care what you do in these spending bills. We’re going to decide how to spend this money. 鈥� which is not what the Constitution says. 

Kenen: But the Congress has its objective. I mean as the administration 鈥� 

Rovner: The GAO has, and they’re suing. 

Kenen: Right. But at the end of the day, what’s happening in the courts is not really changing behavior all that much, so it’s still 鈥� 

Rovner: Because it hasn’t all been resolved yet. 

Kenen: It’s a TBD [to be determined]. I think we’ll know more after the tariffs ruling. But when they do suffer a defeat in court, they just sort of find another way around. Even if they do something, the court says they just find another way of doing what they wanted to accomplish. 

Rovner: Yes, which we have seen. And apparently they did. I saw a story this week that they were trying to put in a provision that would stop what we call the pocket rescissions. Right now, the administration can say, We don’t want to spend this money, and then Congress votes on whether or not to agree with the administration. But if they do it at the end of the fiscal year, it’s too late. And that’s called a pocket rescission. There was some language to stop that, which also appears on its face to be illegal. And apparently Russell Vought of OMB [Office of Management and Budget] complained, and it was taken out of the bill before it was passed. So that fight [is] going to still continue. 

Well, there’s another even more nerdy provision that resets something called the PAYGO [pay-as-you-go] scorecard to zero. Among other things, this cancels the required cuts to Medicare that would’ve been the result of the Republicans failing to offset the cost of the tax cuts in last summer’s big budget bill. You may have heard Democrats referring to these cuts and thought they meant Medicaid, thought they were misspeaking. They were not. There actually was a half-a-billion-dollar cut to Medicare that was in the offing. But canceling this kind of cuts both ways because it takes away a talking point for Democrats, right? 

Kenen: Yes, but I don’t know that that one’s going to matter so much in six, 10, 12 months. Because also, we’re used to them not doing the cuts to Medicare that they’ve said. I mean, they walk to the very edge of the plank and jump back into the boat over and over again since 2012 at least, probably before that. So I don’t know that that has the staying power. It’s hard. Like the word sequester, unfortunately we understand it, but a lot of people think it’s a jury. I mean cuts that didn’t happen 鈥� 

Rovner: Right, and cuts that are not going to happen. We’ll see how long it takes the Democrats to wipe the Medicare cuts out of their talking points, which they now have to do because that was in the bill. Well, meanwhile, even with the government back open, the chaos continues at Robert F. Kennedy Jr.’s Department of Health and Human Services, where just this morning we’ve seen a change to the CDC [Centers for Disease Control and Prevention] website suggesting that vaccines might cause autism. They do not. And a new large-scale study showing that fluoride in typical doses doesn’t lower kids’ IQs, which is the exact opposite of what RFK Jr. has been saying. Paige and Shefali, you’re following this report on transgender care, which is another sort of big controversial issue over at HHS. 

Winfield Cunningham: Yeah. So what we saw yesterday was basically the final release of this report, which was ordered up by Trump via executive order earlier this year. And they had released an initial draft last spring, but at that time, they didn’t release the names of the authors on the report, nor did it have any peer reviewers. And that was the focus of a lot of the criticism of the report 鈥� that there wasn’t transparency there to see who was actually reviewing all of this evidence around gender-transition care for kids. So, we saw the names of the nine authors were released yesterday, as well as about eight peer reviewers. This also, not shockingly, did not engender a lot of wide confidence in the medical community about this report. And the authors of the report all have prior histories of criticizing how gender-transition care is delivered in the U.S. And critics have pointed to that saying: Well, the report’s not legitimate because basically the people were handpicked by the administration to deliver a particular conclusion. 

And so I’ve been talking to some of the authors. They are of course defensive. They say, Look at the research. Look at the report. The report does skew very critical of transition care and recommends counseling first, which is something that some of the leading medical organizations are pushing back against. So, I don’t know where all this is going to go. I think the debate [is] going to continue, but certainly we’re going to see the administration use this report to try to undergird its arguments for a dramatic crackdown on transition care. They’re actually working on two rules at CMS [Centers for Medicare & Medicaid Services] right now which would penalize hospitals for providing transition care for kids. Those rules are being reviewed I think by the White House right now, but we’re probably going to see those finalized sometime next year. 

Luthra: I think some really important context for us to consider here 鈥� in this conversation as well as what the actual reality of health care looks like for trans youth 鈥� and in particular, the thing that really stands out to me as we look at this report and look at these criticisms that these authors are levying, is that already, for young people who are getting gender-affirming care, it’s a very involved process. There aren’t a lot of providers who offer this to begin with. There is a lot of counseling. The idea that young people are getting these gender-affirming surgeries at a young age without any sort of long-thought, long conversation just isn’t really borne out by evidence. There is a lot of conversation, a lot of counseling. A lot of youth start with things that are reversible. You start with maybe something that doesn’t have that same level of permanence before ensuring that this is something that people truly do want. And I think that’s really important. 

The other thing that really sits with me in this conversation 鈥� which I think this is a conversation that has been really built up by a lot of social conservatives who are looking for a new target after they sort of lost the war on gay marriage 鈥� is that young people are sort of a starting point. And we’ve already seen a lot of efforts in some states to expand restrictions on gender-affirming care 鈥� not only for young people, but for people of all ages who are trans. It reminds me a lot, actually, of the conversation around abortion, where you began with restrictions for young people as a pathway to restricting it writ large. And I think we have to be really aware of that context when we look at how this political and policy fight unfolds. 

Rovner: Yeah, there’s also a lot less of this care you’re saying. It is hard to get. There’s less available than there was at the start of the year. We’ve seen so many of these universities and hospitals knuckle under and say, We just don’t want to be part of this because they’re threatening to take away all of our funding. There’s a new study in JAMA Internal Medicine this week that found that HHS cuts from earlier this year disrupted more than 400 clinical trials, and treatment for more than 74,000 patients who were participating in those trials. Most impacted, according to the report, were trials on infectious diseases and prevention. But a second study chronicled the deep cuts to gender-affirming care. So, it’s not even how it’s being delivered, it’s if it’s being delivered at this point, right? 

Luthra: The people who are getting this health care have gone through a lot of hoops to get this care already. They have shown a real … desire is the wrong word. They have worked very, very hard to get here in a way that you don’t do if this isn’t something you have thought about a lot. 

Rovner: It’s not like quitting smoking. 

Winfield Cunningham: But I also add, this isn’t a conversation that’s only happening in the U.S. This is happening around the world. You have seen a huge surge of young people seeking this care. So it’s kind of a relatively new thing. And in a way, just in terms of the number of people, and you’ve seen. … I think New Zealand actually this week announced that they’re putting new restrictions on puberty blockers for young people. You’ve also seen similar things in the U.K. [United Kingdom] and the Netherlands. And they’ve also conducted reviews, just raising questions around how much evidence we have around the long-term benefits or harms of giving these treatments to kids. So I think it’s an important conversation for researchers to be having. And I think it’s unfortunate it’s gotten so politicized, because this is, to Shefali’s point, really important for a lot of children in the U.S. and around the world. And yeah, it’s really important for researchers to have a really clear picture of the best way to help them. 

Rovner: Yeah, I was going to say this is one of those things that’s both a culture war issue, and a legitimate medical scientific issue that we’re looking at.  

Well, meanwhile, it’s not just policy that’s a little chaotic at HHS. According to The Wall Street Journal, the secretary reportedly considered sidelining FDA [Food and Drug Administration] Commissioner Marty Makary because of his inability to control infighting between some of his division directors. Yet it feels like FDA is kind of the least of Kennedy’s worries right now. Also ongoing are fights between supporters of MAGA, the Make America Great Again movement, and MAHA, the Make America Healthy Again movement, over who should be in charge of health policy. Is this just usual infighting, or is this sort of new and different and [at] a more significant level than we often see? 

Kenen: I’m not sure we know yet, because some of this stuff is boiling up pretty quickly. But we’re seeing all sorts of splits and fractures on the Republican side that we have not been accustomed to seeing. Trump is very good at unifying his party, and papering over things, and changing the subject. He’s a very, very gifted controller of narrative. And the fact that we’re seeing policy splits as well as the [Jeffrey] Epstein scandal, and all sorts of other things, it’s not one crack. There’s a bunch. And crack might be too strong a word 鈥� we don’t know yet 鈥� but we’re seeing more dissent, and more disagreement bubbling over in public than we had before. 

Rovner: Yes, and that’s what’s so unusual to me. Have these people had long knives out for each other? Absolutely. Have we seen big front-page stories about it? Not so much. 

Kenen: And it’s heightened since the New Jersey and Virginia races. It’s more blame-gaming going around. So I think we’re seeing a slightly different internal landscape among Republicans, as we just said, it’s apparent how much these health care versus public health versus vaccine versus MAHA versus MAGA, these … how much they splinter and stay splintered. It’s interesting to watch right now. I mean, Kennedy hasn’t been that engaged on the health policy side, the insurance fight, the HSAs, FSAs, subsidies. That’s not where his public energy is. 

Rovner: He’s left that to Dr. [Mehmet] Oz mostly. 

Kenen: Right. And we know what’s important to him. There’s a long list of changes he wants to make on that side. So, I think it’s interesting. I think it’s significant. I don’t know what it’s going to look like in a month. 

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

OK. We’re back. Well, there is also news, finally, this week on the reproductive health front, as you tried to jump the gun, Paige. Circling back for a minute to the impending vote on extending the enhanced ACA subsidies, abortion turns out to be a big obstacle to any potential compromise, even if there was one to be had. This shouldn’t really be surprising. Abortion very nearly scuttled the passage of the ACA itself in 2010 鈥� 

Luthra: At the very last minute. 

Rovner: At the very last minute. And anti-abortion forces still think the law is too lenient, even though it’s a lot more restrictive than abortion-rights backers had wanted and fought for. Shefali, are Republicans really going to refuse to stop premium increases for voters just to please the anti-abortion movement? 

Luthra: I don’t see why not. It seems like this is … I mean, really, though, the anti-abortion movement in some ways took a pretty big loss getting Trump as the Republican president. This is someone who does not really want to capitalize on the post-ops momentum with a national ban. And so they’re looking where they can to try and restrict abortion through other means 鈥� whether that meant the Planned Parenthood defunding, whether that means trying to get this mifepristone reviewed, or if it means trying to enact more restrictions through ACA subsidies. It really seems like kind of a no-brainer. If you can’t get this win for a very important constituency from the president, you do what you can everywhere else to try and get it, or get at least what you can. 

Rovner: OK. Paige, now you get to say what you wanted to say before. 

Winfield Cunningham: Well, no, I guess I was just going to say again, I’ve just been thinking a lot about 2017 and how health reform never seems to go forward. But yeah, this is a perennial issue. It’s all about the Hyde [Amendment] language and anti-abortion folks, and Republicans have always been very resentful of how the debate about the ACA went about. And they are upset because they think these plans are that taxpayer dollars are still going to abortions, et cetera, et cetera. And actually, I was thinking with this HSA idea of rerouting the subsidies to the HSAs, the problem would actually be even more pronounced, because they’re going to demand that you attach then abortion restrictions to money that people have in their own accounts that they’re supposed to be using for health care. And that just seems like even more of a no-go with Democrats. I think all of us knew this was a big obstacle, but it takes a little bit of time for people on [Capitol] Hill to figure this out, but I think it’s becoming more and more clear that this is just a really massive barrier. 

Rovner: Yeah, it is. All right, well the abortion fight also continues in the states. South Carolina lawmakers this week held a hearing on what would’ve been the strictest abortion ban in the country, allowing judges to send women who have abortions to prison, and potentially restricting IVF [in vitro fertilization] and some forms of birth control. Apparently, that bill went a little too far, even for some Republicans on the subcommittee. The bill failed to advance, at least for now. Are we likely to see more laws like this, though, as states try to top one another in pleasing what the anti-abortion forces want? 

Luthra: I think we will. This is a really long-standing and deep debate in the state-based anti-abortion movement, and in particular the debates over contraception, the debates over IVF, and especially around whether you send someone who gets an abortion to prison, whether they’re held criminally liable. And there is a very extreme movement; they call themselves abortion abolitionists. They are introducing bills and growing numbers every year, trying to build up support. Even some of the pretty conservative abortion opponents say, Oh, those people are too extreme for me. But they’re gaining influence. And I see this as a conversation and a debate that the anti-abortion movement only continues to have, especially as this is something that progresses on the state level and not necessarily the federal one. 

Winfield Cunningham: I do wonder, though, how much more room there is for state bans, because you saw this huge surge in red states placing bans after Dobbs [Dobbs v. Jackson Women’s Health Organization]. At this point, I think around 17 or so states have almost-complete bans on abortion. So in a way, I think there’s been a lot of work done there. And I think the opportunity that the anti-abortion folks see is at the federal level, but of course they’re running into top appointees 鈥� Kennedy, some of the others at HHS, who, for them, this is really not a priority 鈥� and it doesn’t sound like anti-abortion folks would love to see them roll back access to mifepristone, for example. I’m not convinced that’s going to happen anytime soon because the folks pulling the levers there aren’t necessarily in the camp. 

Rovner: Yeah, apparently one of the reasons that people aren’t angry with Marty Makary at FDA is because he appears to be slow-walking this mifepristone study, and he approved, even though he had to, another generic of the medication. So, I know that that’s also part of this. 

Luthra: If I can add one more thing, Julie? 

Rovner: Yes, please. 

Luthra: Frankly, a really good litmus test for where states are heading is coming in only a few weeks when Texas’ new abortion law takes effect. And this is one of the most ambitious efforts to stop telehealth and shield law provision of abortion. And this is an area where state-based abortion opponents are very frustrated, because they see it as breaking or fundamentally incapacitating their abortion bans when people can still get medication through the mail from doctors who have not been successfully prosecuted for doing so. And so, when this law takes effect, it enables civil lawsuits against people who make medication abortion available in Texas. I think we will see: Are there civil suits filed by abortion opponents, for instance. Is there any really concerted effort to use this new tool to stop telehealth? And if so, does that spread to other states? Especially since Texas has for so long been a real pioneer in abortion restrictions and making it even harder to get. 

Rovner: Yeah, where Texas goes, so go the rest of the red states. 

All right, that is all the time we have for the news this week. Now we will play my interview with Republican health expert Avik Roy, and then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Avik Roy here in person in our studio at 麻豆女优. Avik is co-founder and chairman of the Foundation for Research on Equal Opportunity, which studies and recommends social policies for the half of the population that earns less than the U.S. median. But he’s also a longtime health policy wonk and health adviser to Republicans, including several Republican presidential candidates over the years. And full disclosure, he is, like me, a fellow Michigan Wolverines fan. 

Avik Roy: Go, Blue. 

Rovner: Avik, welcome to “What the Health?” 

Roy: Great to see you, Julie. 

Rovner: So, how did you come to health policy? It was a bit of a winding road, wasn’t it? 

Roy: Yeah, I kind of fell into it. I was working as a health care investor, actually, at Bain Capital and a couple of other places like that, as a health care investor. In 2008, [Barack] Obama gets elected and starts to talk about what we now call the Affordable Care Act, or Obamacare. And I wasn’t reading anything I agreed with. At that time, you had Ezra Klein, then at The Washington Post, and you had Jonathan Cohn at The New Republic. You had that group of young bloggers who are writing, Hey, there’s this brilliant MIT economist named Jonathan Gruber, and he’s got it all figured out, and everything’s going to work great, and premiums are going to go down. And Obama himself promised that premiums for the average family of four would decline by $2,500 per year. That’s what he campaigned on in 2008. Then on the conservative side, you had a lot of people writing things like, It’s big government. It’s unconstitutional. It’s welfare. 

And I found these arguments kind of like empty calories, because for the average American who’s struggling to afford health insurance and health care, I just don’t see how that person is going to respond to that kind of argument. They’re going to be like, Look, if one side is telling me they’re going to reduce my premiums by $2,500 per family per year, and the other side is just saying, ignore this all because it’s big government, which side is the average person going to choose? They’re going to choose a side that’s going to try to reduce their health care bills. And my point of view was not aligned with either of those positions. My point of view was actually: Health care bills are going to continue to increase, and the design of the ACA has a number of flaws that are not being called out because the conservative critics just weren’t digging into the technical design 鈥� the architecture of the bill. And even though I’m not as eminent as Jonathan Gruber, I did go to MIT. And so I maybe felt a little more willing to engage in that debate. 

Rovner: And you’re a doctor. 

Roy: Well, I went to med school. I never practiced, don’t have a license. 

Rovner: But you have, at least, the medical education. So you have a good bit of background in this. I want to think broadly. Every other developed country has some sort of national health insurance scheme. Most of them are hybrids of public and private. Some of them more public; some of them more private. Why hasn’t the U.S. been able to solve this problem that every other developed country has? 

Roy: We actually do a lot of work on this at the Foundation for Research on Equal Opportunity. We have a whole annual research product we put out called the World Index of Healthcare Innovation, where we compare 32 countries around the world with the highest GDP [gross domestic product] per capita that have a population over 5 million on quality, choice, science and technology, and fiscal sustainability. So, a number of other people do these kinds of comparisons, but our study is different for two reasons. One, we don’t just look at OECD [Organization for Economic Co-operation and Development] countries, which is typically where most academics get their data. We look at countries that are outside the OECD, particularly in Asia. And we also again score countries not merely on health outcomes and equity-type measures, but we also look at things like fiscal sustainability, which we think matters for long-term equity, and science and technology. One of the defenses of the American system that you always hear is, Well, yes, our system is so expensive, but we’re also the innovation center of the world, and you can’t have one without the other. 

So, one thing that we wanted to study was: Is that really true? Can you have innovation at a U.S.-like level but with a universal system that covers everybody and has good quality? And the system that has ranked No. 1 in our study every year is Switzerland. The reason that’s really interesting is because there’s a misconception, both on the left and the right, that to achieve universal health insurance you have to have a single-payer system. And that’s not actually true. There are plenty of countries 鈥� they are a minority of the industrialized countries, but it’s a robust and significant minority 鈥� that have achieved universal coverage using private insurance, not necessarily a single-payer, government-run insurer. And Switzerland is, in our view, the best example of that because Switzerland is a place where there’s an innovative pharmaceutical and biotech, and med devices ecosystem. They have universal coverage. It’s basically like Medicare Advantage for all, or Obamacare for all. It’s a universal individual market where the market is regulated and subsidized, but it works. 

Rovner: I would say big subsidies. I’ve been to Switzerland. I’ve studied the Swiss health care system. 

Roy: Big subsidies. It depends on your vantage point. Relative to the American system, the subsidies are actually quite low. So what Switzerland spends subsidizing health care is about 45% of what the U.S. spends per capita subsidizing health care. We actually subsidize health care per capita more than any other country in the world, because the cost of health care is so high in America that the cost of subsidizing health care is so high. 

Rovner: Which was going to be my second point about Switzerland is that it’s way more regulated than a lot of Republicans think. 

Roy: Well, it’s about as regulated as Medicare Advantage, or the ACA plans in terms of the insurance plan to sign. There are other things 鈥� and we don’t have to spend all of our time on Switzerland here 鈥� but you ask the question, it’s like, Why can’t we do this in America? That was your original question, and there’s a number of reasons for that. One is path dependence. With any health care system, once you’ve established it, it’s hard to change. The one thing I’ll say that we did in the mid-20th century that really put us on this path was when we excluded from taxation employer-sponsored insurance, because in World War II there were wage and price controls. Employers figured out how to get around that by offering employer-sponsored insurance that wasn’t regulated by wage and price controls. And then after the war, [Dwight D.] Eisenhower said, Yeah, let’s not tax those insurance policies because they seem to be important for people. 

And it was kind of an offhanded decision. No one really knew that that was going to be this big thing. But sure enough 鈥� 80 years later, or 70 years later 鈥� here we are. And I would argue that’s the biggest driver of health care inflation, because we don’t merely have third-party payment for health care. Every country has third-party payment for health care. But we have third-party payment of third-party payment of health care. We have ninth-party payment of health care basically. And no wonder that no one has any sense of why everything is so expensive. But that’s the core driver. And unfortunately, Medicare, in particular, built on that system. When the Medicare law was passed in 1965, a key element of Medicare was to build upon and drive the benefits based on the traditional Blue Cross employer-based plan, which had by that point already ballooned into something resembling what we have now. 

Rovner: So why has health care been such a low priority for Republicans? I always hear, Well, Republicans don’t really work on this because it’s not important to their voters. That can’t possibly be true anymore. 

Roy: I think everything you said is just right. I think that historically, Republicans didn’t feel that it was relevant to their voters. And their voters weren’t really pushing for it because their voters were 鈥� relative to the median constituent 鈥� perhaps more likely to be employed, or more likely to be on Medicare 鈥� and therefore didn’t feel like they had to worry about affordability. But affordability, as everybody at 麻豆女优 knows, and the audience that listens to your program knows, affordability is a big deal for everyone. Premiums in the employer-sponsored market have gone up, and people don’t necessarily notice that. But they notice that their paychecks have been flat. They notice their deductibles going up, and their copays going up, and that’s been a big problem both in the ACA markets, and the employer market. 

But affordability is a big deal. And now that the Trump GOP has become more of a working man and woman’s party 鈥� and you see it in all the exit polls that if you actually look at who’s voting for Democrats and who’s voting for Republicans in presidential election years 鈥� the Republican electorate is now a bit more lower-income than the Democratic constituency, which has a lot more of those college grads, and grad school grads. I think you’re starting to see more of that populist concern about the affordability of health care, but there’s still an enormous amount of intellectual catch-up to get there. And I think because of this experience of studying the international health care world, I’ve been much more optimistic about the ability to achieve universal coverage in a way that’s friendly to free marketeers, people who believe in private-sector competition. 

Whereas I think the traditional Republican view, which you kind of alluded to earlier 鈥� and I ran into this a lot in the 2017 repeal-and-replace debate 鈥� was it’s not the federal government’s job to ensure that everybody has affordable health insurance. That’s what I heard from a lot of the kind of old-line Republicans and Republican staffers in the 2010s. It’s not the federal government’s job to guarantee affordable health insurance for people. That should be up to ordinary people to make enough money to afford health insurance. And I disagree with that very strongly. And the reason I disagree with that very strongly is because it was the federal government that screwed it up in the first place. It was the tax exclusion for employer-sponsored insurance, and then some of the things around the design of Medicare that drive all the health care inflation that we’ve seen over the last 80 years. 

So the federal government created the mess, and it is the federal government’s job to clean up the mess. And I guess you could say a big purpose of my work is to try to convince more Republicans to agree with me on that. 

Rovner: So why has it been so hard for Republicans to come together on anything? The Democrats have big divisions, too, on health care. They have a big chunk of Democrats who would like “Medicare for All,” and another chunk of Democrats who would like to build on the existing system. Republicans presumably have the same kinds of divisions, just in the other direction, and yet we almost never see Republican proposals, and we do see Democratic proposals. 

Roy: Well, I will quibble with you a little bit, Julie, in that there are Republican proposals. They don’t always get the same amount of media coverage that the Democratic proposals get. There is a bill that’s been introduced in both the House and the Senate, based on our work at FREOPP, called the Fair Care Act, which would achieve voluntary universal coverage. It wouldn’t force anyone to buy coverage, but everyone who wants to buy health insurance would be guaranteed to have an affordable option. It would reduce the deficit, increase coverage by about 9 to 10 million, and also reduce federal spending. It would reduce taxes, and reduce federal spending, because it would reduce the underlying cost of health care. 

Rovner: How? 

Roy: By, in particular, tackling the power of hospital monopolies, and being more aggressive about high drug prices. And it would also means-test the subsidies. And by means-testing, I don’t just mean means-testing Medicare, which is often what people talk about, but also means-testing the employer tax break for health insurance, for example, and really having 鈥� 

Rovner: So more like Switzerland. 

Roy: Exactly. So all these random digressions that I’ve been coming 鈥� there is actually a coherent idea here that I’m trying to get to, and I thank you for reminding me on that. 

Rovner: Well, we’re back in the thick of it. Avik Roy, hope we can have you back again. 

Roy: Thanks, Julie. I’d love it. 

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

Winfield Cunningham: Sure. Yeah. Well, I was really struck by this story in The Wall Street Journal called “.” And this was just a really, really intensive look at some of the struggles faced by Medicaid patients when they go to their plan, they look up doctors, they try to get appointments, but it turns out that a lot of the doctors listed in the directories for these Medicaid plans don’t see patients anymore, or they’re far away. And there’s a real mismatch here between the providers’ insurer networks’ claim to offer and what is actually available to people. And of course, a lot of Medicaid patients live in medically underserved areas. So I just thought this article, they had actually looked at some patients that live near St. Louis, my hometown, and how difficult it was for them to find a timely appointment with a specialist. I just thought it was a really good, intensive look at some of the real challenges here in the Medicaid program. 

Rovner: Yeah, provider directories are sort of an underappreciated huge problem in the entire health care system. Joanne? 

Kenen: This is a piece from ProPublica,  by Nat Lash, with pretty cool graphics by Chris Alcantara. And basically, they’re arguing that the USDA [United States Department of Agriculture] for three and others prior to Trump 鈥� it’s not just a Trump administration policy 鈥� has been emphasizing sanitation, and what they call biosecurity practices to stop bird flu entering. They blame it on sort of bad control, like the farms let bad stuff in. And in fact, there’s increasing evidence 鈥� and ProPublica worked with researchers and experts on climate and wind patterns and everything 鈥� that it’s airborne. That it’s coming in on wind and dust. That it’s not just what’s tracked on the floor. It’s on the feathers. And that the whole approach is therefore inadequate. And also the USDA has refused to do vaccination, which many European countries are doing. So the combination of underemphasizing the role of wind and air current, and the reluctance has to do with import policies and the economy of poultry and eggs, is really putting us at greater risk. 

Rovner: Yeah, very scary story. Shefali? 

Luthra: My piece is from ProPublica. It is by Kavitha Surana and Lizzie Presser. It is called  The story really wrecked me. It’s really important journalism. It is a story about one woman, in particular, but then gets into the fact that there are many cases like this of people who are pregnant, have medical conditions that make their pregnancy very high risk. So their health is threatened but not their lives. And as such, they don’t qualify for an exception under an abortion ban like Texas’. And the woman in this story, Tierra Walker, died. She already had a kid who now does not have his mom because she couldn’t get an abortion. 

And I think what this story really gets at is a few important things. One is that the exceptions that states have passed don’t account for the fact that pregnancy can make your health really at risk, even if there’s not something really dramatic like sepsis. It is just simply all the other things that make you at greater risk of dying. The other thing that’s really important is that all these doctors who treated her never suggested an abortion. That’s important because it underscores that years later, there is still a lot of fear for health care providers operating in these states that is very obvious that being pregnant was a risk for this patient. And there was a conversation that she could have had with her medical provider, a choice that she and her family could have made about her circumstances and what was best for her. Doctors didn’t feel safe having that conversation because of state laws. And now she’s dead. 

Rovner: And yeah, this is a continuation of a ProPublica series that won a Pulitzer this year. So they’ve been tracking this through several states and lots of patients, unfortunately. 

All right, my extra credit this week is from CNBC. It’s by Scott Zamost, Paige Tortorelli, and Melissa Lee. It’s called  and it’s a lovely take on how the U.S. health system has become such a mess that employers can now hire third-party companies who pay for patients to take all-expense paid trips to the Bahamas or the Cayman Islands to buy expensive prescription drugs at a price that still saves enough money from what’s charged in the U.S. to pay for the trip. There’s just one catch, though. While it’s not illegal to go to another country to get your own medication, some of these third parties also import drugs themselves, and that is illegal. For the umpteenth time, if the U.S regulated drug prices the way all these other countries do, drugs here would be a lot less expensive. Although I will say, I have been to both the Bahamas and to the Caymans, and they are both lovely. 

OK, that is this week’s show. Thanks as always 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, 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 on X , or on Bluesky . Where are you guys hanging around these days? Shefali? 

Luthra: I’m on Bluesky . 

Rovner: Paige? 

Winfield Cunningham: I am on X . 

Rovner: Joanne? 

Kenen: I’m either at  or  @JoanneKenen. 

Rovner: We’ll be back in your feed early next week for the Thanksgiving holiday. 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, starting this week, from 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, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again. 

Winfield Cunningham: Hi, Julie. It’s great to be back. 

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving. 

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either. 

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America. 

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that. 

Rovner: Well, of course, and SNAP isn’t an HHS program. 

Goldman: Exactly. Exactly. 

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find? 

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan 鈥� which, of course, is what, we know 鈥� that’s what the subsidies are pegged to 鈥� is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it. 

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand. 

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …  

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks. 

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain. 

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely 鈥� because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced 鈥� and now they have no cap. 

Rovner: I think 8.5% of their income, actually, under the enhanced premiums. 

Winfield Cunningham: Under the enhanced. OK. 

Rovner: It’s going to go back to 10%. 

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%. 

Rovner: 400%. 

Winfield Cunningham: Right. Yeah. Yeah. 

Rovner: That’s right. 

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it. 

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies. 

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue. 

Winfield Cunningham: This is very true. 

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something. 

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So 鈥� 

Rovner: Yeah. Although it is 鈥� 

Goldman: Obviously, that’s a lot of what ifs, but 鈥� 

Rovner: 鈥� only the death spiral that goes back to prior to covid, which 鈥� it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA. 

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers 鈥� will be subject to the full force of the premium increases because they won’t have any subsidies. 

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.  

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further 鈥� this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought 鈥� yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget 鈥� states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought? 

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that 鈥� I don’t know what health systems have said about this particular move, to be honest 鈥� but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is. 

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant. 

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC? 

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this. 

Rovner: Yeah. I’ve seen numbers as low as 60,000. 

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels. 

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years. 

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics. 

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades 鈥� focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that. 

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic. 

Ollstein: Exactly. 

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My 麻豆女优 Health News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes? 

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects. 

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head. 

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary. 

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division 鈥� that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo 鈥� to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way 鈥� even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.? 

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data. 

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the 鈥� give credence to this idea that 鈥� I see you nodding, Maya 鈥� that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain. 

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch. 

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So 鈥� 

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications. 

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do. 

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line. 

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, . Is contraception going to become the next health care service that’s only available in blue states, Alice? 

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services. 

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two. 

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something? 

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate. 

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods? 

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want. 

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but 鈥� 

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight. 

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week? 

Goldman: Sure. So this story is from 麻豆女优 Health News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked. 

Rovner: Yeah, it is a public health issue, an interesting one. Alice? 

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah. 

Rovner: Yeah. A combination of a lot of different factors in that story. 

Ollstein: Definitely. 

Rovner: Paige? 

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague. 

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my 麻豆女优 Health News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.  

OK. That is this week’s show. Thanks this week 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 else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, , or on Bluesky, . Where are you folks hanging these days? Maya? 

Goldman: I am on X as and I’m also on . 

Rovner: Alice? 

Ollstein: on Bluesky and on X.  

Rovner: Paige? 

Winfield Cunningham: I am still on X. 

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