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鈥�

We are kicking off a new series here 鈥� We’re calling it An Arm and a Leg 101.

We’ve spent years of reporting on two huge questions: Why does health care cost so freaking much? And what can we maybe do about it?

We’ve been chasing answers one story, one question at a time.

Now, we’re pulling together some of what we’ve learned. Digging a little deeper, going a little broader.

Starting with why so many drugs cost so much.

One of the first questions I ever asked 鈥� one of our first stories 鈥� was: How can insulin be so expensive? Wasn’t it discovered in the early 20th century? Shouldn’t it be a generic drug by now?

You know, cheap? 

And part of the answer I got was: Insulin has been transformed since the early 20th century. A lot.

A medical researcher named Jing Luo told me: Today’s insulins are a long way from what we had a hundred years ago.

Jing Luo: They’ve been really modified at a molecular level. It’s cool stuff. It’s super cool stuff. And you know, there are multiple Nobel prizes in physiology and medicine that have made this happen.

Dan: And all that super-cool stuff, those amazing discoveries, got patented.

Meaning: The patent-holders鈥� the pharma companies 鈥� got a monopoly on those amazing discoveries.

The pharma companies claimed patents 鈥� and monopolies鈥� on a bunch of other things too. Not all of them amazing.

But each new patent can mean another delay for a generic version coming to market.

Jing Luo: Companies can stack dozens of patents on top of each other to try to thwart generic competition because they can say, look, we’ve got three patents on the active ingredient. We’ve got patents on the medical uses of the active ingredient. We’ve got patents on the non-active excipient associated with this ingredient. We’ve got multiple patents on the devices, and so you who are trying to enter this space will sue you for patent infringement on all of them.

Dan: A patent guarantees you at least a 20-year monopoly. Drugs can generally get an extra five. 

And these extra patents 鈥� secondary patents 鈥揷an keep you protected LONGER. If you don’t file them at the same time as the original: 

To talk about a drug that’s in the news right now. The original patent on the active ingredient in Wegovy and Ozempic actually expired this year.. The extra five years extends it to the early 2030s. 

But dozens of extra patents 鈥� secondary patents, filed later 鈥� mean that here in the U.S., we might not see cheaper generic versions until 2042. Or later.

And as Jing Luo told me: This strategy isn’t a secret. It’s an industry cornerstone. 

Jing Luo: When you listen to these like CEOs of pharma companies being interviewed at CNBC, you know, they’d be like, well, what about generic competition for this product? And they’ll just keep saying, no, no, no. We’ve got this really robust patent portfolio. We can withstand any challenge. We’re gonna tie this up in courts forever and don’t worry about it.We’re gonna continue this gravy boat for a long, long time. That’s the way they reinsure investors.

Dan: A robust patent portfolio. ?Or what researchers and advocates call a patent thicket.

They say quality matters less than quantity. 

The numbers are wild. 

, the 10 best-selling drugs for 2021 鈥� drugs for cancer, HIV, arthritis 鈥� were protected by a combined total of seven hundred and forty-two patents. With hundreds more “pending.”

When these add-on patents get challenged in court, they actually get tossed out more often than primary patents..

But lawsuits cost money. A robust patent portfolio 鈥� a patent thicket 鈥� means generic companies would need to be ready to file a LOT of them.

So, we wanted to know: How did all this happen? How did these games get started?

It turns out, there is one guy who can tell you the story from the beginning, for better and for worse. Who helped shape it. Made millions of dollars from it. Saw its flaws. And has spent most of the last 30 years trying to fix them. Hie’s a lawyer named Al Engelberg, and he’s 86 years old.

Alfred Engelberg: I tell people all the time, I live in a world, a pharma world where half the people think I’m dead and the other half wish I was.  

Dan: Al Engelberg’s story is the story  of generic drugs in America. And it’s a wild ride. 

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 something entertaining, empowering, and useful.

?Al Engelberg’s parents fled Nazi Germany in the late 1930s.

He was born here, less than a year after they arrived. They had nothing.

And  here’s where they made their new life. 

Retro news reel: We are flying over a well-known eastern city. That is remarkable because manufacturing is almost non-existent. A city whose principle business is the entertainment of millions. Atlantic city, often called the vacation capital of the nation

Dan: Al likes to say he learned most of what he knows about practicing law on the Atlantic City boardwalk, by the time he was 16. 

Alfred Engelberg: We grew up very, very fast there. I started working when I was about nine or 10 and, and there were lots of opportunities on the boardwalk. 

Dan: His first “job” was crawling around under the boardwalk, looking for loose change.

Alfred Engelberg: But I went on to work at hotdog stands and at an illegal bingo game for the local mob.

Dan: And in every job, Atlantic City drove home its major lesson: Cheating 鈥� hustling 鈥� is something you’ve gotta expect. 

At this illegal bingo parlor, Al’s job was walking between tables, doling out bingo cards for a dime apiece. The bosses hired college kids to walk behind kids like Al, to keep him honest.

Alfred Engelberg: I mean, these guys are running an illegal game, but they still need to count, and they still inherently don’t trust anybody. 

Dan: Which was correct. Al says the college kids had their own hustle: They’d have him set aside a dollar or two before turning in his dimes 鈥� split that dollar with him fifty-fifty 鈥� and tell the bosses Al’s count was fine.

Alfred Engelberg: And everybody knowing that the counts were wildly inaccurate anyway 鈥榗ause the little old ladies were, were stealing cards. Everybody in the room had their own thing going, you know, from the customers on.

Dan: After Al made it out of Atlantic City, his unique on-the-job education continued. He studied chemical engineering at Drexel, then took a job as a patent examiner while going to law school at night.

And at that job, he learned: The patent system was ripe for hustling.

Partly because most of his colleagues weren’t necessarily giving the job their all. 

Like him, most patent examiners were working their way through law school. And they were sneaking time to study on the job.

Alfred Engelberg: We used to be able to cut our notes down so they fit in these file drawers with the patents. And we would be reading your notes and if your boss came by, you would just drop a patent on top of the notes.

Dan: You could say it was Atlantic City all over again. Everybody in the job is sneaking something for themselves 鈥� in this case, time.

And Al Engelberg could see that, even if his colleagues gave it their all, they were too green to do their job well. 

A patent examiner’s job 鈥� deciding whether a proposed invention deserves a monopoly (which at that time was 17 years) 鈥� means deciding whether the idea for that invention would be obvious to “a person of ordinary skill in that field.”

Alfred Engelberg: And most of the examiners had never worked in that field and had absolutely no idea. And this is the big leagues. You’re granting somebody a monopoly for 17 years, and it seemed ridiculous on its face.

Dan: Al cut his own path at the patent office. He’d worked his way through engineering school, in manufacturing plants, he saw what people of ordinary skill in that field solve problems every day. So he specialized in examining patents he actually knew something about.

That got him promoted, then it got him recruited by a corporate lawyer.. After the company paid his way through the rest of law school, he jumped to the Justice Department. 

He was ambitious鈥� he wanted experience junior lawyers don’t usually get 鈥� like trying cases of his own.

After a few years doing just that, he took a job with a small law firm in New York City in 1968.

Alfred Engelberg: I came to New York to private practice at the age of 30 and I was ready to go. I mean, I was ready to, to tear the world apart and I did.

Dan: Patents were still a specialty. Then, in 1973, he gets a call that leads to his first generic drug case.

Generic drugs were not a hot market at the time.

Alfred Engelberg: ?The generic drug industry in 1970s was essentially, a half a dozen, privately owned family businesses, mostly in the metropolitan New York area. And most of the drugs that they were selling were drugs that were approved before 1962. 

Dan: Yeah. 1962 is when the FDA made it harder to get a new drug approved 鈥� you had to go through long clinical trials to show that your drug was safe and effective. 

Even if your drug was a generic version of an existing drug. Those little companies didn’t have the capital to run those trials, so they were stuck selling those old drugs.

Not much of a business. Maybe 20 percent of prescriptions were for generic drugs.

So when Al Engelberg got a call for his first generic drug case, that was the context. And the case itself did not sound promising. For one thing:

Alfred Engelberg: The call wasn’t even from the client. It was from a bank. The client was bankrupt. 

Dan: The client was bankrupt. This bankrupt client, Premo Pharmaceuticals, was getting sued for patent infringement. The bank was willing to put up ten thousand dollars for a defense. Nowhere near enough to actually try a case. Oh, and鈥�

Alfred Engelberg: From what they told me, the information they gave me, we didn’t have a very good defense.

Dan: But Al Engelberg saw an opening. He could see that his opponents have weaknesses too.

Alfred Engelberg: The patent owners were in a very strange position. If they won, they got nothing because we were already bankrupt. Two, they were gonna have to spend the legal fees to win.

Dan: Win against a young lawyer named Al Engelberg who already had a rep as a tough opponent. So they could lose.

Alfred Engelberg: And if they lost, they would lose millions and millions of dollars in business because there wouldn’t be a patent. And they’d have competition from generic drugs.

Dan: And meanwhile, Al Engelberg is also sizing up the judge. He knows the guy doesn’t love patents.

So Al shows up to the first conference and he bluffs. 

Alfred Engelberg: I said to the judge, oh, your Honor, you know, it’s another one of those patents. They’re all invalid. And I said, we don’t need very much discovery. We’re, we’ll be ready to go to trial in a few months. Just set a trial date.

Dan: The other side walks out beside themselves.

And within a couple of weeks they call Al to say: Hey, how about this? You guys just acknowledge our patent is OK, and we’ll give you the money we would’ve spent litigating. Call it 400,000 bucks?

Alfred Engelberg: I called the client and said, how’s $400,000? He said, are you kidding?

Dan: They didn’t just get out of trouble 鈥� they got out of bankruptcy, with $400,000 in their pockets. Because Al Engelberg knew how to size up a situation.   

Alfred Engelberg: You don’t learn that in law school. That’s not what they teach.

Dan: Word gets  around about that case, and pretty soon everybody in the generic drug world is calling him.

It’s a small world, but by the end of the 1970s, there may be room for it to start getting bigger. 

People are starting to notice: Drugs are expensive. Maybe there should be more cheap generics. 

Some generic drug companies form an association and start lobbying: Make it easier to get generic drugs to market without having to go through all those trials.

The brand-name drugmakers push back: They say it takes so long to run the trials and get their drugs approved, they don’t get enough time to make money before those patents expire.

In 1983, Democratic Representative Henry Waxman steps in to broker a compromise, with Republican Senator Orrin Hatch.

And Mr. Engelberg goes to Washington. To run strategy for the generic drugmakers. 

Alfred Engelberg: In a lot of ways , that’s where my Atlantic City training really helped me at the end of the day

Dan: There were a lot of people, with a lot of interests. A lot of angles. ?He starts commuting from New York to Washington DC a couple times a week 鈥� for months and months, more than a year.

And Al Engelberg says: This time, it wasn’t just about winning a case.

Alfred Engelberg: I was in the back of a cab the way I remember, with the senior partner of the law firm. And he says to me, why are you breaking your ass going to Washington two or three times? Why don’t you send an associate? You know, it’s just like, it’s just another case. And I said. I said, are you kidding? I said, you know, how many lawyers ever get to do what I’m doing right now? To be at the table influencing what may be a major law that’s gonna have major consequences is, is like something I never thought my whole life I’d be doing.

Dan: A kid from Atlantic City was exactly the right person to try to balance all the angles, negotiate a compromise. It took more than a year. It almost didn’t happen. But then it did. Congress passed the bill, and President Ronald Reagan got in front of cameras to sign it.

Ronald Reagan: Let me turn my attention to the real reason we’re here this afternoon, signing into law the Drug Price Competition and Patent Term Restoration Act of 1984. 

Dan: better known as Hatch-Waxman.

Hatch Waxman had three basic components:

One: Brand drugmakers got a few extra years on their patents.

Two: Generic drugmakers got a pathway to get FDA approval.

And three 鈥揟he new law laid out rules for a generic drugmaker when they wanted to CHALLENGE an existing patent. 

Negotiating that third part was the part where Al Engelberg’s education on the Atlantic City boardwalk, and the U.S. patent office, and the generic drug industry came together: The result would make him millions and millions of dollars 鈥� and blow a giant hole into the grand bargain he had worked so hard to bring about.

That’s coming right up.

This episode of An arm and a Leg is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom covering health issues in America. The folks at 麻豆女优 Health News are amazing journalists 鈥� their work wins all kinds of awards, every year. We are honored to work with them.

So. The brand-name drug makers and the generic drug makers struck a deal. That deal was good for them. Both sides got something big out of it. The public was supposed to get something out of it too.

And, to be fair, we did: Remember, back then, maybe one out of five prescriptions was for a generic drug. Now it’s nine out of ten.

But we pay more than ever for drugs. Mostly for branded, patent-protected drugs. And the biggest, most-important, most profitable drugs get locked behind patent thickets.

How did that happen? 

Well, to understand that, it helps to know what Al Engelberg got out of the whole bargain.

Al had been there at the bargaining table, on behalf of the generics. 

One day, during those negotiations, he was in the office with Henry Waxman’s lead counsel, a guy named Bill Corr, when Corr got a call from someone on the other side.

Corr starts pointing at the phone, pointing to Al 鈥� indicating: This guy is talking about you.

When Corr gets off the phone he says: That guy’s not sure about this deal where bad patents could be challenged. He’s suspicious about where you might take this. Like, are you just gonna set up a bounty-hunting operation, to get patents declared invalid?

And Corr said, Al, would you do that? 

Alfred Engelberg: And I said, you know, Bill, until this moment, I’ve never given it any thought, but it’s a hell of a good idea. Maybe I’ll look at it. 

Dan: And he did. Starting almost as soon as Hatch-Waxman became law.

Alfred Engelberg: And we sat in the rose garden, September 23rd, 1984, watched Reagan sign the bill. And in December of that year, I sat down at my kitchen table with a yellow pad and I laid out a strategy.

Dan: If you were gonna set up a bounty-hunting operation, how would you do it?

Al Engelberg knew a lot of patents were garbage. Knew it from his time in the patent office, knew it from practicing law. And he knew how much money a successful patent challenge could be worth.

The way Hatch-Waxman worked: If a generic drug company challenged a patent and won, they would get six months before any OTHER generic drugmakers could get a crack at the market.

So their only competition would be the brand. If a pill cost two cents to make, and the brand was selling for a dollar a pill 鈥� that’s 98 cents of profit for every pill.

You’re the only competitor? You could charge 75 cents a pill and get 73 cents of profit. On a hit drug, you could make millions and millions 鈥� just in those six months. 

Al’s idea was this: Partner up with a generic drugmaker. Go find cases鈥� drugs with weak patents. Win ’em. 

And split those millions in potential profits fifty-fifty. 

Al pitched a generic drugmaker 鈥� they were ready to go 鈥� and brought the deal to his law firm. .

Alfred Engelberg: As it turned out, my partners weren’t interested in having me do this. They tried to talk me out of it.

Dan: But they couldn’t. So he left. Went out on his own. All on his own.

Alfred Engelberg: I never hired a single soul, not even a secretary. And I couldn’t type. I still can’t type.

Dan: But he hunted and pecked his way through brief after brief. He bought an early portable computer 鈥� it weighed thirty pounds 鈥� and lugged it around in the back of his car. For ten years.

Alfred Engelberg: It was stupid. I almost killed myself. But, it worked out okay.

Dan: Yeah. Turns out Al was really good at finding the problems with drug patents.

In one of his first cases, Al Engelberg personally made more than 70 million dollars. Others settled: A few million here, a few million there鈥� it adds up.

And then鈥�

Alfred Engelberg: It got to be the mid nineties, and I was working on a case called Buspar. 

Dan: The Buspar case ended up a big winner for Al Engelberg and his generic drug partners. 

But it had consequences that went way beyond a single case. And led to big losses for the public.. Here’s how it went.  

Alfred Engelberg: Buspar was an anti-anxiety drug. And by all accounts not a very good one.

Dan: But Bristol Meyers Squibb invested in big advertising and marketing campaigns.

Speaker 5: I feel anxious. I can’t concentrate. 

Speaker 6: I’m so irritable. If you. You suffer from excessive worry. It can feel like a mountain of anxiety. 

Speaker 5: I’ll never get it all done. I’m overwhelmed. 

Speaker 6: But a prescription medication called buspar can help.

Dan: And all that marketing did its job. By the mid-1990s, Buspar was making more than 200 million dollars a year for Bristol.

Alfred Engelberg: The only problem for them was that the drug was not new. 

Dan: The active ingredient was well-known in medical literature as a tranquilizer. Nobody had bothered to market it.

So Bristol Myers Squibb filed a patent on it, claiming it had discovered a new use for this well-known tranquilizer: Treating anxiety.

Al Engelberg says when he read the patent application, he could barely believe it: What do tranquilizers do if not鈥� treat anxiety?

It’s like saying: There’s this stuff called sugar. We’re gonna take out a patent on using it as a sweetener.

This looked like a case for a guy from Atlantic City. 

Alfred Engelberg: I did something that lawyers don’t. That’s just the way I was built. 

I filed a motion with the court and basically said, we don’t need any evidence.

You just have to read the patent. If you believe it’s true, the patent’s invalid. Just, you know, all you need is a dictionary basically.

Dan: Al says Bristol was eager to settle. 

Alfred Engelberg: We get into a settlement discussion and we keep saying, no, no, no, no.

Dan: Al’s partners had done the math: They figured they stood to make a hundred million dollars or more once they won. So when the other side offered 25 million, no was the easy answer.

Alfred Engelberg: We said, why are we gonna take this? You know, it’s crazy. There’s a reward here we know what it is. We’re gonna get it eventually.

Dan: Al sits down with a lawyer from the other side, a guy he knows, explains how he sees the math.

And soon the other side comes through with a much bigger offer: 72 million dollars 鈥� almost three times as much. 

Alfred Engelberg: And I’m sitting there like, what are you crazy? But then think about it from their point of view. 

Dan: Paying 72 million dollars is nothing, compared to what Bristol stands to gain if this lawsuit goes away. 

With their monopoly, Bristol Meyer Squibb is making more than 200 million dollars a year on Buspar. And unless somebody else lines up to do what Al Engelberg had done, expect to keep that monopoly for years.

Charging whatever they want. Two dollars a pill, three dollars a pill. Which Al Engelberg says is exactly what happened.

In fact, they kept that monopoly for like five years. 

Alfred Engelberg: As it turned out, nobody came behind us. And so, they had that monopoly until 2000. So they got five years of 2 billion, in gross profits. 

Dan: They made out.

Alfred Engelberg:  For the cost of $75 million. And you know, the public got screwed ’cause they are continuing to pay, you know, $2 a pill or $3 a pill for a drug that eventually ends up being available for 20 or 30 cents. Um, so that’s, that’s how it works.

Dan: That’s how it works. The branded company and the generic company both make out great. Cheaper generic versions of a drug get delayed. 

That amazing payday for Al Engelberg and his partners at the generic drug company turned into a model a template for the kind of deal that every generic drug company would want in on.

It got a nickname: Pay for delay.

Alfred Engelberg: That spread through the industry like wildfire, those numbers, you know, you don’t make those numbers half a cent at a time on, on pills,

Dan: Lawsuits were way more profitable.

But Al Engelberg wasn’t filing them.

A year or so after the Buspar case settled, sparking the Pay for Delay gold rush, he retired. He had plenty of money and nothing to prove.

And in retirement, he started evaluating what he’d accomplished, for better and for worse.

For better, generic drugs had more than doubled their share of the market since Hatch-Waxman took effect.

For worse, he could see two places where 鈥� despite all of his Atlantic City training 鈥� he had missed a couple of angles in negotiating Hatch-Waxman. 

One was: this whole pay-for-delay scheme. Turned out, in balancing incentives for brands and generic makers, he’d left open this perverse incentive that left the public out. 

And the second was a loophole  that Hatch-Waxman had left open.: 

It created a process where players like Al and his generic partners could challenge patents on drugs like Buspar, that they thought didn’t deserve protected monopolies. It removed some friction for those attacks. 

The drug companies developed a way to add more friction:  stacking extra patents 鈥� secondary patents 鈥� on every drug.

Developing patent thickets.

Even if a secondary patent is trivial  鈥� and lots of them do get tossed out 鈥� challenging it means a court fight. And that costs money.

Alfred Engelberg: It caused the big drug companies to just get more and more patents. Because why not? You know, there was nothing standing in the way.

Dan: I mean, nobody knows better than Al Engelberg: Patent examiners don’t exactly stand in the way. 

And those patent thickets and pay for delay, they feed on each other. 

Alfred Engelberg: The economics of the business, caused these kinds of settlements to reach epic proportions. So the generic companies would, challenge these secondary patents and, the drug companies would pay them off.

Dan: In 1999 he published an article in a scholarly journal arguing that Hatch-Waxman needed a reboot. Even the six-month head start for a successful challenge could probably go. 

And ever since 鈥� for more than twenty-five years 鈥� he’s poured millions of dollars into efforts to tighten the rules. Funding research. A public-information campaign from Consumer Reports. Even a center for IP law at his alma mater, NYU.

It hasn’t always gone his way. 

Pay for delay has gotten much bigger since Al Engelberg wrote his first article calling for reform: He wrote in 1999 that about two dozen patent challenges had been filed.

Now he estimates that number at twelve thousand.

Alfred Engelberg: I can’t tell you how many tens of billions of dollars in legal fees that is. It’s one of the fastest growing and and steadiest industries for big law.

Dan: A Hatch-Waxman litigation forum on LinkedIn has more than fourteen thousand members.

And Hatch-Waxman doesn’t cover many of today’s the top-selling drugs鈥� the biggest moneymakers. They belong to a class called “biologics.”

That includes famously-expensive rheumatoid arthritis drugs like Humira and Enbrel 鈥� and insulin. 

Biologics weren’t a category forty years ago when Hatch-Waxman got negotiated. Congress passed a new law to deal with them in 2010 鈥� ?the Biologics Price Competition and Innovation Act.

Al Engelberg is not a fan of that law.

Alfred Engelberg: Whatever mistakes were made in Hatch Waxman, they were multiplied by 10 and deliberately in the biologics law

Dan: He says the all but encourages patent thickets. And doesn’t provide a pathway to challenge them.

He says it reminds him of some of his early days practicing law.

Alfred Engelberg: Back in the seventies, we used to have small startup clients in the computer field, and they would get letters from IBM. It says, we are ready to inform you that you may be infringing one or more of the following patents. And there was a 10 page list of patents attached. And the startup would come to us and say, you know, what should we do? And we would say, find another line of work, you know, what are you gonna do?

Dan: But he has not given up. In 2025, he published a book: Breaking the Medicine Monopolies.

It tells the story of his career 鈥� and lays out his prescriptions for fixing the problem.

He doesn’t JUST focus on plugging the holes in Hatch-Waxman and the biologics law.

Alfred Engelberg: You know, we don’t actually need a generic drug industry. We need generic drug pricing. 

Dan: He’s got proposals for an increased government role in negotiating and regulating prices 鈥� and more than that.

He argues that a 1980 law allows the government to commisssion generic versions of drugs that were developed using public research dollars.

He also says the FDA rules that protect secondary patents on drugs 鈥� that allow patent thicketing 鈥� are based on a completely wrong interpretation of Hatch-Waxman.

And tells us he’s working up a challenge, with help from AI tools like Claude. 

He’s 86 years old. And he doesn’t seem inclined to stop.

Alfred Engelberg: It so changed my life and I did so well by it, I thought, how can I not take on this problem? Who’s gonna do it if I don’t do it?

Dan: He’s got the time. Money’s no object. And he knows the territory as well as anybody. He helped create it. 

Alfred Engelberg: So it’s, it’s my obligation really. It’s that sort of Jewish guilt. What can I tell you? I’m paying back for the bingo game.

Dan: So we’ve gone back more than fifty years on the question: Why aren’t there more generic drugs? We’ve learned why we’ve got the ones we have, and what stands in the way of getting more.

And that is just in time. Because this spring the U.S. Supreme Court will hear arguments in a case that could restrict the generic drug pipeline even further. It could have major implications.

And understanding what they are requires all of the 101 we’ve covered here. We’ll have that story for you in a few weeks. Til then, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta, with help from Dan Weissmann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. 

This series 鈥� An Arm and a Leg 101 鈥� is made possible in part by support from Arnold Ventures. 

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 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 reporters covering Washington. We are taping this week on Thursday, March 12, 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 Shefali Luthra of the 19th. 

Shefali Luthra: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: And Joanne Kenen at 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 Andy Schneider of Georgetown University, who will try to explain how the federal government’s fraud crackdown on blue-state Medicaid programs is something completely different from any fraud-fighting effort we’ve seen before. But first, this week’s news 鈥� and some of last week’s. 

Let’s start at the Department of Health and Human Services, where I think it’s safe to say Secretary Robert F Kennedy Jr. is not having a great week. The secretary reportedly had to have his rotator cuff surgically repaired on Tuesday. It’s not clear if he injured it during one of his famous video workouts. But it is clear, at least according to  from the University of Pennsylvania’s Annenberg Center, that the American public is not buying what he’s selling when it comes to policy. According to the survey, public trust in HHS agencies, which already took a dive during the pandemic, has fallen even more since Kennedy took over the department. Although, interestingly, public trust in career HHS officials is higher than it is for their political leaders. And trust in outside professional health organizations, places like the American Heart Association and the American Academy of Pediatrics, is higher than for any of the government entities. 

Perhaps related to that is another piece of HHS news from this week. The FDA [Food and Drug Administration] approved a label change for the drug leucovorin, which Secretary Kennedy last fall very aggressively touted as a potential treatment for autism. But the drug wasn’t approved to treat autism. Rather, the label changes to treat a rare genetic condition. Kennedy bragged about leucovorin, by the way, at the same press conference that President [Donald] Trump urged pregnant women not to take Tylenol, which has not been shown to contribute to the rise in autism. Maybe it’s fair to say the public is paying attention to the news and that helps explain the results of this Annenberg Center survey? 

Luthra: Maybe. I was just thinking, we do know that Tylenol prescriptions for people who are pregnant did go down, right? There’s research that shows, after that press conference, behaviors did change. And so to your point, it’s clear there is a lot of confusion, and confusion maybe breeds mistrust. But I don’t know that we can necessarily say that American voters and the public at large are very obviously informed as much as they are perhaps disenchanted by things that seem as if they were told would restore trust and make things clearer and in fact have not done so. 

Rovner: That’s a fair assessment. Anna. 

Edney: Yeah, I think there’s a lot of overpromising and underdelivering, and that can kind of create this issue where this administration 鈥� and RFK Jr. has been doing this as well 鈥� kind of is making these decisions from the top, rather than having these normal conversations with the career scientists and things like that, where the public can kind of follow along on why the scientific decisions are being made if they so choose to, or at least have an idea that there was a discussion out there. And that’s not happening. So that’s not something that’s creating a lot of trust. I think people are seeing that as unscientific and chaotic. 

Rovner: I was particularly interested in one of the findings in the survey, is that Dr. Fauci, Dr. Tony Fauci, who was sort of the bête noire of the pandemic, has a higher approval rating than either RFK Jr. or some of his top deputies. Joanne, I see you nodding. 

Kenen: Yeah that was so stri鈥� I mean, it’s still not high. It was, I believe it was 鈥� I’m looking for my note 鈥� but I think was 54%, which is not great. But it was better than Dr. [Mehmet] Oz [head of the Centers for Medicare & Medicaid Services]. It was better than Kennedy. It was better than a bunch of people. So, but it also shows that half the country still doesn’t trust him. It was a really interesting survey, but the gaps in trust in credible science are still significant. What was interesting is the declining trust in our government officials in health care, but there’s still, nationally, the U.S. population, there’s still a lot of skepticism of science and public health. Maybe not as bad as it was, but still pretty bad. 

Luthra: And Julie, you alluded to these famous push-up and workout videos. And part of what you’re getting at 鈥� right? 鈥� is that the communications that we see are targeted toward a not necessarily very large audience. It is these people who are hyper-online, in particular internet spaces and communities, and that’s somewhat divorced from most people and how they live their lives. And when you focus your message and you’re campaigning on this very particular slice, it’s just a lot easier to lose sight of where people are and what they want from their government and what they will actually appreciate. 

Rovner: It’s true. The online America is very separate from the rest of America, which is a whole lot bigger. Well鈥� 

Kenen: And there’s also the young people who probably aren’t in these surveys who, teenagers, who are getting a lot of information on TikTok about supplements and raw milk. And the young men and the teenage boys and the supplements is a big deal, and that’s online. And also we have been seeing for a while, but I think it’s probably creeping up, the recommendations about psychedelics. So there’s all this stuff out there that isn’t going to be picked up by that poll. But yes, it was an interesting poll. 

Rovner: All right. Well, meanwhile over at the Food and Drug Administration, in-again out-again in-again vaccine chief Vinay Prasad is apparently out again, or will be as of later this spring. I feel like Prasad’s very rocky tenure has been kind of a microcosm for the difficulties this administration has had working with career scientists at FDA and elsewhere, at HHS. Anna, what made him so controversial? 

Edney: Well, I think, Prasad was an FDA critic before he came to the agency. And so essentially, when he was out in public, particularly during covid, but there were even criticisms he had before that. He was criticizing these career scientists at the agency. And so he got there, and the way he appeared to operate was that he knew best and he didn’t need to talk to any of these people that had been there, some for decades, and that was getting him in a lot of trouble. But he was being defended and protected by FDA Commissioner Martin Makary, and he really supported Prasad, and he called him a genius and wanted him to stay on. So the first time Prasad left, he convinced him to come back. And now this time, I think, things maybe just went a bridge too far when there was sort of this behind-the-scenes but very public fight with a company trying to make a rare-disease drug. And this is something that, particularly, several senators really, really hate, is when the FDA is getting in the way of a rare-disease drug getting to market, because they don’t think that that’s something the agency should be trying to do unless the drug is maybe wholly unsafe. But they think anyone should be able to try it. And so when this exploded and FDA officials were and HHS officials were behind the scenes, but very publicly, calling this company a liar, it was just a bridge too far. 

Rovner: Well, and he, this was, this incredibly unusual  in which he tried to not be quoted by name, but kind of hard when the head of the agency, or the head of the center at FDA is basically trashing a company, trying to do it on background. Was that kind of the last straw? 

Edney: Yeah, I think so. And sort of an aside on that. I’m curious how that phone call even was allowed to be set up and called. Because, it’s not like he did it on his own. There were, there was an infrastructure around him that helped him set that up. So I’m curious about why that even went down, but I think that was definitely what pushed him out the door. You know, this company wanted to get this drug approved. The FDA had said, No, not unless you do this extremely difficult trial, which the company said would require drilling holes in people’s heads, for what they were trying to get approved, and that it would be a placebo, essentially, for some of those patients, even when you get a hole drilled in your head, and this could be a 10-hour sham surgery, is what the company said. And then Prasad comes out and says: No, they’re lying. That definitely could be a half-hour. No big deal. And I just think that there were senators frustrated with this, the White House not wanting to see another thing blow up over rare-disease drugs, because that has, there have been a lot of issues at FDA under his tenure, of just drugs not being able to get to market. Or having issues with vaccines that have been years in development not being able to get even reviewed, and then that being reversed. So it was just, that was kind of the last straw. 

Rovner: And of course President Trump himself has been a big proponent of this whole Right to Try effort, that it should be easier for people with, particularly with terminal diseases to be able to try drugs that may or may not help. Joanne, you want to add something. 

Kenen: Also wasn’t he still, Prasad, still living in California and running up really huge travel bills and鈥� 

Rovner: Yes. 

Kenen: 鈥攏ot being at the FDA very much, at a time when everybody else has been forced to come back to work? So, but I do confess that I keep looking at my phone to check if he’s still out or is he already back again. 

Rovner: Right. 

Kenen: I’m really not totally convinced that this is the end of Prasad, but yeah. 

Rovner: Yeah, I was not kidding when I said on-again off-again on-again off-again. All right. Well, moving over to the National Institutes of Health, which also has a director that’s doing more than one job in more than one place. I know there’s so much news that it’s hard to keep track of it all, but I do think it’s important to continue to follow things that look to be settled, like funding for the NIH, which Congress actually increased in the spending bill that passed at the end of January. To that end, a shout-out to our podcast panelist Sandhya Raman, formerly of CQ, now at Bloomberg, for  grant funding that still pays for most of the nation’s basic biomedical research is still being held up. This is months after it was ordered resumed by courts and appropriated by Congress. 

Shout-out as well to my 麻豆女优 Health News colleagues Rachana Pradhan and Katheryn Houghton for their project on the people and research projects that have been disrupted by all the cuts at NIH, as well as new bureaucratic hurdles put in place. I feel like if there weren’t so much else going on, what’s happening at basically the economic and health engine of NIH would be getting much, much, much more attention, particularly because of the continuing brain drain with researchers moving to other countries and students choosing different careers rather than becoming researchers. I wonder if this sort of drip, drip, drip at NIH is going to turn into a very long-term hole that’s going to be very difficult to fill. A lot of these things have years- if not decades-long runways. These great scientific achievements start somewhere, and it looks like they’re just sort of pulling out the whole starting part. 

Kenen: It’s already affecting the pipeline. In graduate schools, many schools fund their PhD candidates, and it’s NIH money, or partly NIH money. It’s different 鈥� I’m not an expert in every single school’s support systems for PhD candidates, but I do know that the pipeline has been shrunken in some fields at some schools, and that’s been reported on widely. And there’s been a lot of coverage about years and years of research. You can’t just restart a multiyear, complicated clinical trial or research project. Once you stop it, you’re losing everything to date, right? You can’t just sort of say, Oh, I’ll put it on hold for a couple of years and resume it. You can’t do that. So we’ve already reached some kind of a critical point. It’s just a matter of how much worse it gets, or whether the ship begins to stabilize in any way going forward. But there’s already damage. 

Rovner: I say, are you guys as surprised as I am, though, that this isn’t 鈥� the NIH has been this sort of bipartisan jewel that everybody has supported over the decades that I’ve been covering it, and now it’s basically being dismantled in front of our eyes, and nobody’s saying very much about it. 

Kenen: It’s also an engine of economic growth. You see different ROI [return on investment] numbers when you look at NIH, but I think the lowest number you hear is two and a half dollars of benefit for every dollar we invest. And I’ve seen reports up to $7. I don’t know what the magic number is, but this is an engine of economic growth in the United States. This is basic biomedical research that the private sector or the academic sector cannot do. It has to come from the government. And I don’t think any of us have really gotten our heads around 鈥� why harm the NIH when it is bipartisan, it is economically successful, and it has humanitarian value. It’s the basis. The drug companies develop the drug and bring it to the market. But that basic, basic, earlier what’s called bench science, that’s funded by the NIH. 

Rovner: I know. It’s a mystery. Well, adding to RFK Jr.’s bad week are the growing divisions within his base, the Make America Healthy Again movement. While the White House, seeing that the public doesn’t really support MAHA’s anti-vaccine positions, is trying to get HHS to tone it down, there was a major MAHA meetup just blocks from the White House this week, with sessions urging a complete end to the childhood vaccine schedule and the removal of all vaccines from the market, quote, until they can be proven “safe and effective.” By the way, most of them have been already. Meanwhile, lots of MAHA followers are still angry that the White House is supporting the continuing production of glyphosate, the weed killer sold commercially as Roundup. Democrats, , are trying to exploit the divisions in the MAHA movement, which leads to the question: Will MAHA be a net plus or a net minus for this fall’s midterm elections? On the one hand, I think Trump appointed Kennedy because he was hoping that the MAHA movement would be a boost to turnout. On the other hand, MAHA seems pretty split right now. 

Edney: Well, I think that’s the million-dollar question, is which way they’re going to swing if they swing at all. And it’s hard to say right now, because I think they are angry at certain aspects of things this administration is doing, the two things you mentioned, on Roundup and on vaccines, kind of telling RFK to kind of talk a little bit less about those. But will they be able to then vote for Democrats instead? I think, it’s only March, so it’s so difficult to say what will happen between now and then. I think there’s still things that the health secretary could do on food that he’s talked about, that could draw attention away from that anger, that might make many of them happy. I think there were some things he kind of started doing early in his term that hasn’t been talked about as much. And also, I think there’s still the prospect of Casey Means becoming surgeon general 鈥� or not 鈥� out there, and that’s kind of a big piece of this. If she is to get into the administration, and that is sort of up in the air right now, then that could kind of give them something else to focus on, because she is a large part of this playbook of the MAHA movement. 

Rovner: That’s right. And we are waiting to see sort of if she can get the votes even to get out of committee, much less get to the floor, see whether we’re going to have, as some are saying, the first surgeon general who does not have an active license to practice medicine. Shefali, you wanted to add something. 

Luthra: No, I just think we’ve talked about this before on the podcast, that the food stuff is much more popular than the vaccine stuff. The vaccine components of MAHA remain very unpopular. It’s difficult to really see or say sort of what the White House can do on food in a sustained, focused way, without going off-script, that is also popular. But I think to Anna’s point, it’s just so hard to say to what extent this ultimately matters in November, because there are just so many concerns right now. People can’t afford their health insurance, and gas prices are going up. And I just think we have to wait and see to what extent people are voting based on food policy. 

Rovner: Yeah, well, we will see. All right, we’re going to take a quick break. We will be right back. 

OK, turning to another Trump administration priority, fighting fraud. This week, the administration accused another Democratic-led state, New York, of not policing Medicaid fraud forcefully enough. This comes after the Centers for Medicare & Medicaid Services said it will withhold hundreds of millions of dollars from Minnesota, which our guest, Andy Schneider, will talk about at more length. Minnesota, by the way, last week sued the federal government over its Medicaid efforts. So that fight will continue for a while. But it’s not just blue states, and it’s not just Medicaid. In something I didn’t have on my bingo card, this administration is also going after fraud in the Medicare Advantage program, which has long been a Republican darling. 

Last week, CMS banned the Medicare Advantage plan operated by Elevance Health, which has nearly 2 million Medicare patients currently enrolled, from adding any new enrollees starting March 31, for what the agency described as, quote, “substantial and persistent noncompliance with Medicare Advantage risk adjustment data.” And on Tuesday, the congressional Joint Economic Committee reported that overpayments to those Medicare Advantage plans raised premiums by an estimated $200 per Medicare enrollee annually 鈥� and that’s all Medicare enrollees, not just those in the private Medicare Advantage plans. Is this the end of the honeymoon for Medicare Advantage? Joanne, you were there with me when Republicans were pushing this. 

Kenen: I’ve been surprised, as you have, Julie, because basically Medicare Advantage has been the darling, and it is popular with people. It’s grown and grown and grown, not because the government forced people in. It has good marketing and some benefits for the younger, healthier post-65 population, gyms and things like that. But 鈥� and vision and dental, which are a big deal. But we’ve also seen a backlash, in some ways, because there’s the prior authorization issues in Medicare Advantage have gotten a lot of attention the last couple of years. But not just am I surprised by sort of the swing that we’re hearing about generally. I’m surprised by Dr. Oz, because when he ran for Senate a couple years ago in Pennsylvania, and much of his public persona has been really, really, really gung-ho, pro Medicare Advantage. 

And yet, some of you were at or, like me, watched the live stream of 鈥� he did a very interesting, thoughtful, and, I’ve mentioned this at least one time before, hourlong conversation with a lot of Q&A at the Aspen Institute here in D.C. a couple of months ago. And one of the questions was someone said: Dr. Oz, you’ve just turned 65. Are you doing Medicare Advantage, or are you doing traditional Medicare? And the expected answer for me was, well, I knew that he’s on government insurance now. So he, you have to, at 65 you have to go into Medicare Advanta鈥� Medicare A, whether you 鈥� that’s automatic. That’s the hospital part. But you have the choice. But if you’re still working and getting insurance or government 鈥� he’s on a government plan. He doesn’t have to do that. But he actually, and he pointed that out, but the next sentence really surprised me, because he said: I don’t know. My wife and I are still talking about that. And I thought that was A) a very honest answer. He didn’t have to even say. But it was also, it just was interesting to me that after all that Rah-rah Medicare Advantage we were hearing about, his own personal choice was, Not sure if that one’s right for me. 厂辞&苍产蝉辫;鈥�&苍产蝉辫;

Rovner: I was going to say, I feel like the Republicans are sort of twisting right now between Medicare Advantage, which they’ve always pushed 鈥� they want to privatize Medicare because they don’t like government health insurance 鈥� and then there’s the current populist push against big insurance companies, because, of course, all those Medicare Advantage plans belong to those big insurance companies that Republicans are suddenly saying are too big and getting too much money. So they’re sort of caught between trying to have it both ways. I’ll be interested to see how they come down. One of the things that did strike me, though, even before Dr. Oz sort of started his little crusade against Medicare Advantage, was, I think it was at Kennedy’s confirmation hearing that Sen. Bill Cassidy was suddenly questioning Medicare Advantage. That was, I think, the first Republican I saw to like, Oh. That made me raise my eyebrows. And I think since then, I’ve kind of seen why. 

Kenen: The populist talk against insurance companies, not giving money to insurance companies, is part of the Republican 鈥� and, specifically, President Trump’s 鈥� desire to not extend the ACA, the Affordable Care Act, enhanced subsidies. That was the basic: Well, we’re not going to do this, because we’re just throwing money at these insurance companies. And we don’t want to do that. We want to empower the patients. That was the, I’m not, and the missing piece of that argument is: Yes, the ACA subsidies go to insurance companies. However, all of us are benefiting in some way or other from government policies that benefit insurance companies. The tax breaks our employers get. The tax breaks we get for our insurance. And then the biggie, of course, is Medicare Advantage. 

We are paying Medicare Advantage more than we are paying traditional Medicare. So Medicare Advantage is private insurance companies, and the government has been just sending them lots and lots of money for years. So I’m not sure it’s 鈥� this Medicare Advantage thing is just bubbling up, and we’re not really sure how this plays out. But I think that the rhetoric against insurance companies is the rhetoric against the ACA. 

Rovner: Oh, it is. 

Kenen: Rather that hasn’t yet been connected to the Medicare Advantage. I think they’re, yes, we all know they’re connected. But I think the political debate, it’s not Medicare Advantage is bad because insurance companies are bad. It’s the ACA is bad because it enriches insurance companies. There’s a different ideological parade going down the road. 

Rovner: I was going to say, it’s important to remember at the beginning of Medicare Advantage, which was a Republican proposal back in 2003, they purposely overpaid it. They gave it more money because they know that when they give them more money, the insurance companies are required to return some of that money to beneficiaries in the form of these extra benefits. That’s why there are gym memberships and dental and vision and hearing coverage in these Medicare Advantage plans. It does make them popular, so people sign up. And that was sort of Republicans’ intent at the beginning. It was to sort of not so much push people into it but entice people into it. 

Kenen:&苍产蝉辫;础苍诲&苍产蝉辫;迟丑别苍鈥�&苍产蝉辫;

Rovner: And then maybe cut it back later. 

Kenen: No, but it’s exceeded expectations. 

Rovner: Absolutely. 

Kenen: The number of people going into Medicare Advantage has been really high, higher than people expected. And it’s also hard to get out, depending on what state you live in. It’s not impossible, but it’s costly and difficult, except for a few, I think it’s seven or eight states make it pretty easy. But also remember that the earlier version of what we now call Medicare Advantage was 鈥� which was the ’90s, right Julie? 鈥� I think the Medicare Part C, and that failed. 厂辞&苍产蝉辫;鈥�&苍产蝉辫;

Rovner: Well after, that failed because they cut it when they were 鈥� 

Kenen: Right. Right. 

Rovner: They cut all the funding when they were balancing the budget 鈥� 

Kenen: Right.  

Rovner:&苍产蝉辫;鈥�&苍产蝉辫;颈苍&苍产蝉辫;1997.&苍产蝉辫;

Kenen: But that gave them the excu鈥� right. 

Rovner: They made it fail. 

Kenen: That gave them an excuse to give them more money later that, when they revived it, renamed it, and launched it in 2003 legislation, that initial push to give them a ton of money, because they could say, Well, we didn’t give them enough money, and that’s why they fa鈥�. There are all sorts of political things going on that weren’t strictly money. But yeah, it was part of the narrative of Why we have to give them more money, is They need it. 

Rovner: Yeah. Anyway, we’ll also watch that space. Well, finally, this week, there’s news on the reproductive health front, because there’s always news on the reproductive health front. Shefali, Wyoming has become the latest state to enact a so-called heartbeat ban, barring abortions when cardiac activity can be detected. That’s often around six weeks, which is before many people are even aware of being pregnant. I thought the Wyoming Supreme Court said just this past January that its constitution prevents abortion bans. So what’s up here? 

Luthra: They did, in fact, say that, and so we are seeing this law taken to court. It was actually added in a court filing to a preexisting case challenging other abortion restrictions in the state. I’m sure that’s going to play out for quite some time. But what’s interesting about the Wyoming Constitution 鈥� right? 鈥� is that it protects the right to make health care decisions, in an effort to sort of fight against the ACA. That was this conservative approach that now has come to really benefit abortion rights supporters as well. But what I think this underscores is that even as we are seeing fairly little abortion policy in Washington, at least in a meaningful way, a lot is still happening on the state level. That really is where the bulk of action is, whether you see that in Wyoming, in Missouri, where they’re trying to undo the abortion rights protections there, and just鈥� 

Rovner: The ones that passed by voters. 

Luthra: Exactly. And so what we’re really thinking about is anti-abortion activists are not really that confident in the president’s desire, interest, ability, what have you, to get their agenda items done. And for now, they are really focusing on the states, and that is where their interest, I think, will only remain, at least until the primary for the next presidential race begins in earnest. 

Rovner: Well, Shefali, I also want to ask you about  this week on just how many things ripple out economically from abortion restrictions. Now it’s having an impact on rent prices? Please explain. 

Luthra: I thought this was so interesting. It was this NBER [National Bureau of Economic Research] paper that came out this week, and they looked at comparably trending rental markets in states with abortion bans and those without them. And what they saw was that after the Dobbs decision, rental prices declined relative to places without bans, compared to those in those that had them. And this is really interesting. It just sort of continues. Rental prices went down, and also vacancies went up. And what the researchers say is this is a very, very dramatic and clear relationship, and it illustrates that people, when they have a choice, are considering abortion rights in terms of where they want to live. And anecdotally, we know that, because we’ve seen residents make choices about where they will practice. We’ve seen doctors decide where they will live. We have seen people move. Companies offer relocation benefits if people want them. And this is more data that illustrates that actually that affects the economy of communities, and it really underscores that where we live just simply will look different based on things like abortion rights and abortion policy and other of these things that are treated as social but really do affect people’s economic behaviors. 

Rovner: And as we pointed out before, it’s not just about quote-unquote “abortion,” because when doctors choose not to live in a certain place, it’s other types of health care. It’s all health care. And we know that doctors tend to marry or partner with other doctors. So sometimes if an OB GYN doesn’t want to move to a certain place, then that OB-GYN’s partner, who may be some completely other type of doctor, isn’t going to move there either. So we are starting to see some of these geographical shifts going on. 

Luthra: And one point actually that the researcher made that I thought was so interesting was that abortion policy, it can be emblematic, in and of itself, a reason people choose not to live somewhere, but people may also be making these decisions because of what it represents. Do I look at an abortion policy and say, Oh, this reflects social values or gender beliefs? Or does it also suggest maybe more anti-LGBTQ+ laws? And all of that can create a picture that is broader than simply abortion or not, and determine where and how people want to live their lives. 

Rovner: It’s a really interesting story. We will link to it. All right, that is this week’s news. Now I’ll play my interview with Andy Schneider of Georgetown University, and then we will be back to do our extra credits. 

Rovner: I am pleased to welcome to the podcast Andy Schneider, a research professor of the practice at the Georgetown University McCourt School of Public Policy. And he spent many years on Capitol Hill helping write and shape Medicaid law as a top aide to California Democratic congressman Henry Waxman 鈥� and many hours explaining it to me. I have asked him here to help untangle the Medicaid fraud fight now taking place between the federal government and, at least so far, mostly Democratic-led states. Andy, thanks for being here. 

Andy Schneider: Thanks for having me, Julie. 

Rovner: So, it’s not like fraud in Medicaid 鈥� and other health programs, for that matter 鈥� is anything new. Who are the major perpetrators of health care fraud? It’s not usually the patients, is it? 

Schneider: No, it’s usually some bad-actor providers or bad-actor businesspeople. 

Rovner: So how are fraud-fighting efforts at both the federal and state level, since Medicaid funding is shared, supposed to work? How does the federal government and the state government sort of try and make fraud as minimal as possible? Since presumably they’re never going to get rid of it. 

Schneider: Unfortunately, I don’t think you’re ever going to get rid of it in Medicaid or Medicare or private insurance or in other walks of life. There are bad actors out there. They’re going to try to take advantage. So you need your defenses up. So the short of this is, Medicaid is administered on a day-to-day basis by the states. The federal government pays for a majority of it and oversees how the states run their programs. In that context, the state Medicaid agency and the state fraud control unit have a primary role in identifying where there might be fraud, investigating, and then, in appropriate cases, prosecuting. The federal government also has a role, however. Depending on the scope of the fraud, it could involve the FBI. It could involve the Office of Inspector General at the Department of Health and Human Services. So there’s both federal and state presence, but the primary responsibilities were the states’. 

Rovner: We know that Minnesota has been experiencing a Medicaid fraud problem, because both the state and the federal government have been working on it for more than a year now. What is the Trump administration doing in Minnesota? And why is this different from what the federal government has traditionally done when it’s trying to ensure that states are appropriately trying to minimize fraud? 

Schneider: Well, usually the vice president of the United States does not get up at a White House press conference and announce he and the Centers for Medicare & Medicaid Services are withholding $260 million in federal funds, called a deferral. That is highly, highly unusual. And normally the head of the Centers for Medicare & Medicaid Services does not go and make videos in the state before something like this is announced. So I would say that this is way out of the ordinary, and I think it has to do with some animus in the administration towards Gov. [Tim] Walz and his administration. 

Rovner: Right. Gov. Walz, for those who don’t remember, was the vice presidential candidate in 2024 running against President Trump, who did win, in fact. But there have been two different efforts to withhold Medicaid money for Minnesota, right? 

Schneider: Yeah. Now you’re into the Medicaid weeds, but since you asked the question, I’ll take you there. So in January, the administra鈥� the Center for Medicare & Medicaid Services 鈥� we’ll call them CMS here 鈥� they announced they were going to withhold about $2 billion a year going forward, not looking back but going forward, in matching funds that the federal government would otherwise pay to the state of Minnesota for the services that it was providing to its over 1 million beneficiaries. In February at this White House press conference, what the vice president announced was withholding temporarily 鈥� we’ll see how temporary it is 鈥� but withholding temporarily $260 million in federal Medicaid matching funds that applied to state spending that’s already occurred, happened in the past, happened in the quarter ending Sept. 30, 2025. So both the past expenditures and future expenditures are targets for these CMS actions. 

Rovner: So what happens if the federal government actually doesn’t pay the state this money? I assume more than people who are committing fraud would be impacted. 

Schneider: Well, let’s be clear. The amounts of money here, there’s no relationship between those and however much fraud is going on in Minnesota. And there has been fraud against Medicaid in Minnesota. Everybody’s clear about that. The state is clear about it. The feds are clear about it. But $2 billion going forward in a year, $1 billion going, looking backwards, $260 million times four 鈥� there’s no relationship between those amounts, right? Should they come to pass 鈥攁nd all of this is still in process 鈥� should those amounts come to pass, you’re looking at, depending on who’s doing the estimates, between 7 and 18% of the amount of money the federal government pays, helps the state with, each year in Medicaid. That’s just an enormous hole for a state to fill, and it doesn’t have many good options. It can cut eligibility. It can cut services. It can cut reimbursement rates. Filling in that hole with state revenues, that’s going to be a real stretch. 

Rovner: So it’s not just Minnesota. Now the administration says it is seeing concerning things going on in New York and has launched a probe there. Is there any indication that this administration is going after states that are not run by Democrats? 

Schneider: So the only letters that we’ve seen from the administration have been to California, New York, and Maine. There may be other letters out there. We only access the public record. So so far, based on what we know, it’s just been Democratically run states. 

Rovner: As long as I’ve been covering this, which is now a long time, fraud-fighting has been pretty bipartisan. It’s been something that Congress has worked on, Democrats and Republicans in Congress, Democrats and Republicans in the states. What’s the danger of politicizing fraud-fighting, which is what certainly seems to be going on right now? 

Schneider: Yeah, that’s a terrific point. So it always has been bipartisan, because money is green. It’s not red. It’s not blue. It’s green. And trying to keep bad actors from ripping it off from Medicaid or Medicare has always been a bipartisan undertaking. The reason that’s important, particularly in a program like Medicaid, where the federal government and the state have to talk to one another when they are flagging potential fraud, when they’re investigating it, when they’re prosecuting it, you don’t want the agencies tripping all over one another. You want them sharing information as necessary, etc. When that gets politicized, it’s very bad for the results and for the effective operation of the program. 

Rovner: Well we will keep watching this space, and we’ll have you back to explain it more. Andy Schneider, thank you very much. 

Schneider: Julie Rovner, thank you very much. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will 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. Mine is in The Wall Street Journal. It’s [“”]. This is a look at the booming business of providing therapy to children with autism. And that’s particularly been big in the Medicaid program. And I don’t want to give away too much, because there are just so many jaw-dropping details in this. So I guess the reporters were able to kind of go through the data and billing records in a way that showed some of these companies and what they were doing and how they were becoming millionaires, people who had never done anything in autism before. So if you enjoy a sort of jaw-dropping read, I think you should take a look at it. 

Rovner: Yeah, jaw-dropping is definitely the right description. Joanne. 

Kenen: So I sort of rummaged around the internet to the less widely read sources, and I came across this great story from the Idaho Capital Sun by Laura Guido. It has a long headline. Reminder that 988 is the mental health crisis line and suicide help. The headline is: “” The story is that a 15-year-old boy named Jace Woods called two years ago 鈥� so this still hasn’t been fixed after two years 鈥� and they cut him off. They sort of gently cut him off. But they can’t talk to these kids who have, who are in crisis, without parental consent. They do a quick assessment. If they think someone’s life is immediately in danger right then and there, they can stay on. But a kid who’s what they call suicidal ideation, seriously depressed and at risk, and knows he’s at risk or she’s at risk, and made this phone call, they don’t talk to them unless they think it’s imminent. So it also affects, these parental, it affects sexual health and STDs and abortion and whole lot of other things. 

Rovner: That’s what it was for. 

Kenen: That was the initial reason, but it got bigger. So a kid who calls in a crisis can get no help at all. And even in those emergency situations where they can stay on the line and try to get emergency help if they do think a kid’s in imminent danger, they’re not allowed to make a follow-up call to make sure they’re OK. So this kid has been trying for two years. There’s a state lawmaker. They’re refining a law. They say it’s, they’re refining a bill. They say it’s going to go through. But really this, talk about unintended consequences. We have a national mental health crisis, particularly acute for teens. This is not solving any problems. 

Rovner: It is not. Shefali. 

Luthra: My story is in The New York Times. It is by Apoorva Mandavilli. The headline is “.” And it’s just a good story about what is happening with the Ryan White AIDS Drug Assistance Programs, which people use to get their HIV medications paid for or for free. They get insurance support. And these are really important. Funding has been pretty flat for quite some time because they’re funded by Congress. And what the story gets into is that with growing financial pressure on these programs, there is more-expensive drugs, there are more-expensive insurance premiums, more people might be losing Medicaid. States are having to make very difficult choices, and they are cutting benefits. They are changing who is eligible, because it’s getting more expensive and there is more need and there is no support coming. And I wasn’t really on top of this and did not know what was going on, and I just thought it was interesting and a very useful look at some of the consequences of the policy choices that are making all of these health programs more expensive and health care, in general, harder to afford. 

Rovner: My extra credit this week is from The Marshall Project. It’s called “.” It’s by Shannon Heffernan and Jesse Bogan and Anna Flagg. It answers the question that I’ve been wondering about since the whole immigration crackdown began, which is: What happens to the people who are snatched off the streets or out of their cars or homes, flown to a distant state, and then someone says: Oops, sorry. You can go. How do you get home from Texas or Louisiana to Minnesota or Massachusetts? Authorities don’t give you plane or even bus tickets to get back to where you were picked up, even though that’s where most of those being released are required to go to report back to immigration authorities. It turns out there’s a small network of charities that is helping. But as the story details pretty vividly, the harm to these families doesn’t end when their detention does./ 

OK. That’s 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, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, , or on Bluesky, . Where are you guys hanging these days? Shefali? 

Luthra: I am at Bluesky, . 

Rovner: Anna. 

Edney:  and , @annaedney. 

Rovner: Joanne. 

Kenen: A little bit of  and more on , @joannekenen. 

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, Feb. 12, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Lizzy Lawrence of Stat News. 

Lizzy Lawrence: Hi.  

Rovner: And up early to join us from California, my 麻豆女优 Health News colleague Jackie Fortiér. Welcome, Jackie.  

Jackie Fortiér: Hey, everyone. 

Rovner: No interview this week, but plenty of news. So let’s jump right in. We will start this week at the Food and Drug Administration, where things are 鈥� why don’t we call it 鈥� newsmaking. The biggest FDA story that broke this week was controversial vaccine chief Vinay Prasad outright rejecting an application for a new flu vaccine from Moderna, maker of the mRNA covid vaccine that so many anti-vaxxers have criticized. Lizzy, you . Congratulations. What happened exactly? And why is this such a big deal beyond the flu vaccine? 

Lawrence: This is a big deal because to refuse to file is a pretty rare occurrence in general, because in general the FDA and industry like to have agreed-upon standards for clinical trials before companies embark on them and pour millions of dollars into them. So that was surprising. And then鈥� 

Rovner: And refuse to file means that they said that they’ve got the application and said: Yeah, we’re not accepting that. We’re not going to review this. Right? 

Lawrence: Yes, yes. And Prasad wrote that the grounds for this was that it wasn’t an adequate, controlled trial. Well, Moderna is saying that actually the FDA greenlit this trial back under the Biden administration in 2024. They acknowledged that there was basically a control vaccine that the FDA say they would prefer that Moderna use for the older population. But they said, however, it’s acceptable if you don’t do that. 

Rovner: And I want to make sure I understand this. The complication here is that this is supposed to be a better vaccine for older people, but right now there’s vaccines for older people that start at age 65 and this is a vaccine that’s supposed to start at age 50, right? So it was unclear who they were going to test it against, whether it was going to be the 50-to-64s or the 65s and older. Because there isn’t a vaccine right now that’s approved for 50 and up, right? 

Lawrence: Exactly, exactly. So it was there’s the high-dose vaccine, which is recommended for the above-65s, but that is not recommended for the 50-to-64, which is part of why Moderna didn’t use that high-dose vaccine, because the population that they were studying was broader than this over-65s. So anyway, so yeah, so refusing to file is already rare, and then for there to be an overriding refuse to file, where the, I was told, basically, while there may have been individuals who agreed with Dr. Prasad’s assessment, the review team, every discipline, thought that it was reviewable. And the head of vaccines wrote a memo explaining why he thought it was viable, so that the career staff kind of documented their thoughts here. It’s not clear whether this will be made public ever, but one would hope, with radical transparency, but we’ll see. Despite that, Dr. Prasad still refused to review Moderna’s application. 

Rovner: So obviously it’s a big deal for the flu vaccine, but it’s a big deal beyond this. Moderna’s CEO was on cable news this morning, said that, as you said, after consulting with the FDA officials about the trial, they spent a billion dollars on this trial. How do we expect companies to invest in new medicines like this if the FDA is basically acting on vibes? 

Lawrence: I don’t know. Yeah. And it’s interesting. It doesn’t seem like there’s a ton of sympathy from this administration. Even back last year, [FDA] Commissioner [Marty] Makary tweeted something 鈥� this was when they were limiting, wanted to require more data for covid vaccines for the under-65 crowd. And I think he said something like: Our goal is not to save companies money. That’s not something we 鈥� which of course that isn’t. The FDA’s goal is to promote public health. But it’s definitely a change in tune. I think that in the past, the FDA has understood that you’re really only going to get innovation if you have clear, consistent guidance and that it’s a really worst-case scenario for a company to spend a billion dollars on a clinical trial and then there’s nothing to show for it and nothing for it to benefit patients, either. So. 

Rovner: Is this over? What happens now? 

Lawrence: So now Moderna has requested a meeting to challenge this decision, and now there begins a kind of negotiation. It might be possible that the FDA would, in fact, would review at least the 50-to-64 cohort, because they don’t have any objections there, seemingly. But we’ll have to see. On a call yesterday, a senior FDA official talked about Moderna kind of coming to the agency with humility and acknowledging that the FDA had recommended this high-dose vaccine. And so I don’t know. I think companies are definitely 鈥� it’s a lesson that they’re, especially if you’re in the vaccine space, you have to tread very carefully. 

Rovner: Yeah. And I would think others in the drug space, too. It’s not just 鈥� that’s the point of this 鈥� it’s not just vaccines. Alice, you wanted to say something. 

Ollstein: Oh, yeah. Not only the monetary investment, which we’ve touched on a bunch, but companies spend years. So it’s the time investment as well. And why would you dedicate years of effort to something that you’re not sure if a political appointee is going to swoop in and override career scientific officials’ assessment, if you can’t trust the regulatory system to work as it’s always worked. There really is just a lot of risk there, and you might see people not making these submissions on all kinds of fronts. Of course, this is coming as we’ve had a really bad flu season. I’ve had people in my life get really sick and say it’s been really, really bad. So the prospect of having something that works better to prevent, or even just make it milder, not coming to fruition is rough. 

Rovner: Yeah. And this year, as we know, this year’s flu vaccine was not very well matched to the strains that ended up circulating. And that’s kind of the point of this Moderna vaccine, this mRNA vaccine, is that they say it would be much faster for them to match strains to what’s going around. If it works as the clinical trials suggest it would actually be a better flu vaccine than we have now. 

Well, meanwhile, cases of measles are also continuing to multiply, as they do when people aren’t vaccinated, and not just in the places we’ve talked about, like Texas and South Carolina, but also all around us here in the nation’s capital, apparently, as a result of people traveling here for the anti-abortion March for Life in January. There have been more than 730 confirmed cases of measles in the U.S. already this year. That’s four times more than have been typical for a full year, and it’s not yet the middle of February. Yet that doesn’t seem to be deterring the administration from its anti-vaccine activities. So now, the American Medical Association and the University of Minnesota Vaccine Integrity Project have announced they’ll convene a parallel group of experts to make vaccine recommendations, basically saying they are done following the Centers for Disease Control and Prevention. This has been brewing for a while. Right, Lizzy? 

Lawrence: Yes. As soon as the secretary fired all of the experts who served on the advisory panel to the CDC on vaccines, I think there’s been unease. And now, as you said, there’s an active parallel public health establishment that’s trying to spread credible information and provide an alternative resource, because it’s clear that HHS [the Department of Health and Human Services] has become compromised when it comes to vaccine recommendations. And yet, you’re seeing the spread of infectious diseases right now. 

Fortiér: Having kind of this rival court is not surprising, because they’ve refused to participate in any of the Advisory Committee on Immunization Practices meetings for months and months. I do wonder if this will maybe change some of the tone. We do have an upcoming ACIP meeting in February. Normally we would have a agenda out by now. Before Secretary [Robert F.] Kennedy [Jr.] we would have them weeks in advance, and we haven’t seen one yet, so we’re really not totally sure what they’re going to be talking about. But Dr. [Mehmet] Oz did say this week that he finally advised people 鈥� he’s the CMS [Centers for Medicare & Medicaid Services] director鈥� to take the vaccine. And there’s been over 933 cases in just South Carolina during this outbreak that started last October. And so when I talk to people on the ground who are treating folks in South Carolina and have been treating them for months, and they’ve been doing vaccine clinics and things like that, they were just so fed up with Dr. Oz and the administration, because they partially blame them for these various outbreaks. And I had one of them tell me, like, well, it’s like a band-aid on a bullet hole. Like, now they’re finally encouraging people to get vaccinated when we could have had this months ago. 

Rovner: And, of course, the CDC doesn’t have a director at the moment, because the Senate-approved director was summarily fired and/or quit, not clear which, after refusing to basically rubber-stamp the immunization panel’s recommendations that had not been made at the time. So the American Academy of Pediatrics is suing to stop this February ACIP meeting. I did not hear what the last decision was on that, but I know that there’s still a lot of movement around here. I guess the big worry is: Who should the public trust now? Is it going to be this sort of grouping of medical societies led by the AMA, or the CDC, which people and doctors are used to following the advice of? 

Ollstein: And there’s all these state alliances forming to do the same thing. And so I think, yeah, the more competing recommendations the average person hears, the more they just sort of throw their hands up and say: I don’t even know who to trust anymore. I’m not listening to any of these people. And the trust that’s eroded in the federal government, that’s going to be really hard to recuperate in the future. You can’t just flip a switch and say: OK, it’s a different government. We trust them again. Once those seeds of doubt are planted in people’s minds, it’s really hard to unearth. And so, if not permanent damage, all of this is doing at least very long-term damage to the idea of expertise and authoritative information. 

Rovner: And science, which this administration insists it wants to follow. Well, turning to FDA-related “MAHA” [“Make America Healthy Again”] news, the agency said last week it would relax enforcement of its food additive regulations to make it easier for manufacturers to say they’re not using artificial dyes. Now this was a huge deal when the agency announced the phaseout of artificial coloring. Looking at you, fancy-colored Froot Loops. Now the administration says it’s going to allow foodmakers to say they’re not using artificial colors as long as they’re not using petroleum-based dyes. Apparently, natural dyes are OK. But even that is controversial, and it appears that this whole effort really relies on manufacturers’ willingness to comply rather than, you know, actual regulation, which is kind of what the FDA does for a living. It’s a regulatory agency. 

Ollstein: Well, every time the word “natural” comes up, I always laugh because there is no definition of that. And there are plenty of things that are natural that could kill you or hurt you very badly. And there are plenty of things that are synthetically manufactured that are helpful and fine for you. And so it has this veneer of safety, veneer of health with no actual substance. So my red flags go up whenever I hear that word, and I think everyone should be skeptical. 

Rovner: But it goes with RFK Jr.’s quest now that you should, quote, “eat real food.” 

Lawrence: Right. Yeah. I was going to say same with “chemical.” I feel like, “chemical” abortion drug, “chemical.” And it’s like, a lot of things are chemicals. That’s not鈥� 

Ollstein: Yeah, like in your own body, naturally. 

Lawrence: Yeah. 

Ollstein: You have chemicals. 

Lawrence: We are chemicals. 

Ollstein: We are chemicals. 

Rovner: You guys are all too young to remember the Dow Chemical advertising line “Better Living Through Chemistry,” which at the time, in the ’60s and ’70s, was true. There was, there 鈥� we’ve had a lot of better living through chemistry. And some of it has turned out to be maybe not so good for us, but a lot of it has turned out to be pretty darn good for us. 

Well, finally, in FDA land, Commissioner Marty Makary this week met with anti-abortion senators about that ongoing review of the abortion pill mifepristone, which senators want the FDA to remove from the market. Alice, how’d that meeting go? 

Ollstein: Not great for the FDA, from what I was told. I got on the phone with Sen. Josh Hawley after it, and he was extremely frustrated. He said he didn’t get answers to any of the questions he’s been sending in public letters to the FDA for months and now asking in this briefing behind closed doors that they held on Capitol Hill this week. He said he didn’t get answers about what the timeline is for this review of the abortion pill mifepristone, what the review consists of, whether it’s even begun, really, whether it’s even underway. And so he is sort of concluding that this is not going anywhere, and he wants Congress to step in and take action. Now, Congress has tried to step in and take action before. They’ve tried to put restrictions on mifepristone in the FDA funding bill. That didn’t pass. So I don’t know if this is even plausible in this environment where Congress can’t really pass much of anything anymore. 

But Hawley is not just another Republican senator. He is very intertwined with the anti-abortion movement. His wife is an extremely prominent anti-abortion lawyer who’s led a lot of the major cases trying to restrict or ban mifepristone. They founded their own anti-abortion advocacy group. And so it really shows that the tensions, clashes, whatever we want to call them, between the anti-abortion movement and the Trump administration, so after backing the Trump administration for years and years, they’re really getting fed up. And they’re fed up that even after they achieved their grand goal of overturning Roe v. Wade, there are actually more abortions happening now than before, and that’s largely through these pills and people’s ability to get them. And so they’re getting increasingly impatient with the Trump administration, who has been sort of stringing them along and saying: Yeah, we’re working on it. We’re working on it. But they want to see results. Now, of course, if there were some sort of restrictions imposed, that could have a big political effect. And so a lot of Republicans are very torn about that. But not Sen. Hawley. Sen. Hawley wants to see it.  

Rovner: That’s right. Well, moving to what I call FDA-adjacent news, one of the many thorny issues that FDA has been dealing with is the compounding of those very popular and very pricey obesity drugs. When the drugs were in shortage, it was legal for compounders to make their own copies. But now the shortage for both of the leading medications 鈥� semaglutide, made by Novo Nordisk, and tirzepatide, made by Eli Lilly 鈥� is over, and those cheaper copycats were supposed to be pulled from the market. So it was a bit of a surprise when the company Hims, one of those direct-to-consumer drug sites, announced the unveiling of a semaglutide tablet just weeks after the first such drug was approved by the FDA, by Novo Nordisk. The FDA promptly referred the company to the Justice Department for possible violation of federal drug laws, after which Hims said, Oh, maybe we won’t start selling the drug after all. Oh, and Novo is suing for patent infringement. But I would think that the war over the “fat” drugs, as President [Donald] Trump likes to call them, is likely to lower prices just as effectively as government regulation might. Or am I misreading that? Lizzy, this has been quite the sideshow, if you will. 

Lawrence: Yeah. It might. I think that the compounding, the FDA’s crackdown on Hims was very interesting to me because I think before the commissioner had come into his role, there was some speculation. He had worked for a telehealth company that prescribed compounded drugs. And there’s also, I think compounders have tried to tap into a little bit of the MAHA medical freedom aspect. But clearly that’s not been the case, at least at the FDA. They are clearly very upset about this and mean business, and I think it’s tying into their crackdown on direct-to-consumer drug advertising as well. But as far as price, yeah. I think the deals that Trump has managed to strike with the companies could actually be reducing price for patients. I think we’ll have to see. I know there’s obviously drug pricing programs as well that they could pursue. So, yeah, we’ll have to see.  

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

OK. We’re back. And speaking of President Trump, there’s also drug news this week that’s not directly related to the FDA. That’s the official unveiling of TrumpRx, the website the president says will lower drug prices like no one’s “ever seen before.” That’s a direct quote, by the way. Except it turns out that’s not quite the case. First, these discounts are only for people who are paying out-of-pocket, not those with insurance, which makes them valuable mostly for people who have no coverage or people who take drugs that insurance often doesn’t cover, like those for obesity or infertility. Yet of the 43 drugs so far that are promoted on the TrumpRx website, about half already have cheaper generic copies available through sites like GoodRx and Mark Cuban’s Cost Plus Drugs. And really, the website just points people to already existing manufacturer websites that were already offering those lower prices. So what is the point of TrumpRx? 

Lawrence: Great question. Yeah. This administration has been very focused on, obviously, media and wins and attaching President Trump’s name to things. So it accomplishes that goal. Maybe it does raise awareness for these other sites that already exist. But that’s a theme of a lot of the movement on health care so far, has been 鈥� there’s been a lot of chaos, and then there’s also sometimes things that they announce as like a grand, brand-new, no-one’s-ever-thought-of-it-before policy, but then there are already, of course, existing programs or avenues for that. 

Rovner: And to be fair, Trump has jawboned down some prices, including some prices for the obesity drugs, by basically dragging in the CEOs of these companies and saying, You will lower prices. 

Lawrence: Yeah, yeah. The dealmaking has been effective. And I think the question is: Will this last beyond his administration? Will there be a legacy there? 

Ollstein: I think there’s also some danger in overpromising, because he’s out there saying things that don’t comport with how math works. He’s basically suggesting prices will come down so many percents that we’ll be getting paid to take drugs, because that’s what more than 100% is. And people who are hearing that, voters who are hearing that, if they aren’t seeing that show up in their bills, if they’re not actually seeing those drastic, drastic drops that they’re being promised by the president, are they going to get upset? And is that going to impact how they vote? So yes, there has been some, on the margins, improvements, but when you’re out there promising 600% reductions and not delivering, there’s a risk to that. 

Rovner: Jackie, you wanted to add something. 

Fortiér: Well, I was going to say, I think it’s also confusing for a lot of people, from a consumer perspective, because you log on and I think people, they hear these huge promises, like Alice is talking about, and then they think that they can, necessarily, buy the drugs through there and immediately get them shipped, what these third parties like Hims and Weight Watchers are doing a lot of with the GLP-1s. And that’s not how this works. You still have another step of getting a prescription and then going to the pharmacy and using these to potentially get discounts and lower prices, in the same way that these have been available from pharmaceutical manufacturers and other things like GoodRx for years. But it’s that disconnect between, even if you can get a discount, actually getting the discount and crediting the Trump administration for that that I think is going to be really difficult for a lot of voters to make that connection in the way that the administration wants them to. 

Rovner: And this was ever the case with rebates 鈥� for other consumer products, not just talking about drugs. We’ll give you a $15 rebate, but you have to fill out 87 forms and send it to this place and get it exactly right, do it before the end date, and we’ll send you back $15. Because they count on most people not being able or willing to follow all of the various steps. So instead of giving everybody the discounted price, they make you really basically work for your discount, which is a consumer thing, but it’s pretty popular in the drug space as well. Rather than just lowering prices, they’re going to say, We will give you a discount, but you’re going to have to do this, that, and the other thing in order to get it. 

Fortiér: Right. But when you’re president and you want credit for it, it’s going to be a little more 鈥� it’s harder in order to make that connection. Sorry. 

Rovner: Yes, that’s true. That is a good point. All right, moving on. We have talked a lot about consolidation in the health care industry, particularly companies like UnitedHealthcare, which used to be just an insurer, now owns its own PBM [pharmacy benefit manager], its own claims processing company, and thousands of medical practices around the country. Well, now an extremely unlikely pair in the Senate, Massachusetts Democrat Elizabeth Warren and Missouri Republican Josh Hawley, have joined to introduce something called the Break Up Big Medicine Act, which would basically outlaw so-called vertical integration, like that of United and, to a somewhat lesser extent, Cigna and CVS Health, which owns Aetna, the insurer. Some are referring to this as the health version of the 1932 Glass-Steagall Act, which separated commercial from investment banking 鈥� and, side note, whose repeal in 1999 is considered a major factor setting off the financial crisis of 2008. But that was a risk thing. It was done to prevent another stock market crash like the one in 1929. This is a cost thing. This is to go after high health care costs. Could it work? Could it pass? And is this the beginning of the next big thing in health reform? 

Lawrence: Perhaps. Yeah. Last year, I worked with my colleagues on  kind of examining UnitedHealth Group and the effects of consolidation on doctors and patients. And at the time, I think, there were some vocal lawmakers on either side of the aisle who were criticizing this, especially in the wake of the murder of the UnitedHealth CEO, and which had a surprising 鈥� the public sort of had this reaction and to鈥� 

Rovner: Not in United’s favor. 

Lawrence: Not in United’s favor. And so I think that there is, this is a political issue that affects everyone, Republican and Democrat, the, well, cost in general, but I think there’s a lot of resentment and anger, and it seems like that is bringing together these unlikely and pretty powerful senators. I’m not an expert on the Hill. I don’t know if this has a chance. Especially, it’s targeting massive, powerful companies with hands in every part of the health care system. So it’s something that you would imagine the entire health care industry would fight against. But, yeah, I don’t know. 

Rovner: And I will point out that Sen. Josh Hawley, in addition to all his anti-abortion activities, last year, when Congress was debating the Medicaid cuts, kept vowing not to vote for those Medicaid cuts. So he’s 鈥� which, of course, in the end, he did 鈥� but he’s been sort of on the consumer side of health care for a while now. It’s just this is not brand new to him. 

Lawrence: Right. And I’m not sure how many other Republican senators would follow him down this path. But it’s definitely a noteworthy development, and curious to see where it goes. 

Rovner: Yeah, I’m curious to see sort of if the populist part of health care costs sort of rises to the fore. We’ll have to, we will have to watch that space. Well, finally this week, more on the impact of the Trump administration’s immigration crackdowns and health. My 麻豆女优 Health News colleague Amy Maxmen has  about health professionals in the U.S. Public Health Service Commissioned Corps actually resigning rather than accepting postings to Guantánamo Bay, Cuba, where some immigrants are being detained in prisons that used to hold al-Qaida suspects. Another  by Claudia Boyd-Barrett describes how when people detained by ICE [Immigration and Customs Enforcement] end up in the hospital, often their immediate families and their lawyers aren’t even allowed to know where. And remember, last week we talked about cases of measles in some immigration detention facilities. Well, now there are two confirmed cases of tuberculosis at the ICE facility at Fort Bliss in El Paso, Texas. I’m thinking maybe the health part of this is starting to kind of get to people as much as the whole depriving-civil-liberties part. 

Fortiér: Yeah, and there’s also been cases of covid-19, which makes sense. You’re going to have respiratory viruses as you get hundreds of people grouped together. That makes sense. A judge in California a couple days ago ordered that there had to be adequate health provided to detainees in one specific California 鈥� it was a prison and now it’s an ICE detainee facility. That’s specific to there, but it’s 鈥� more and more senators, I think, are also looking at this and pointing out that they’re just not providing the health facilities that people need. And especially ongoing care 鈥� a lot of folks need diabetes treatment, and that treatment just isn’t really happening in many cases. 

Rovner: Yeah, we’ve talked about this at some length, over many weeks, that people in detention are not getting health care, even though it is required, that we keep hearing stories about people not getting needed health care. I didn’t know until I read this story that people who actually end up being hospitalized, that their family members are not allowed to know. That’s allegedly, well, it is because of security, because the idea is that if somebody who’s in detention is in a hospital, you don’t necessarily want bad people knowing that and being able to come to the hospital. But these are people often who are, as we have documented at length, do not have criminal records, and it’s hard to find out where they are. Alice, you wanted to add something. 

Ollstein: Yeah. So there was a recent GAO [Government Accountability Office] report about this, and it found that people were not getting evaluated when they entered a facility to see if they were medically vulnerable and at risk of having a really bad episode or emergency, and that even children, pregnant women, vulnerable populations weren’t getting that initial evaluation, which then led to problems down the road. And it also said that people upon their release 鈥� either deportation or release within the United States if that’s what a court ordered 鈥� they weren’t being given their medical records, their prescriptions. And so the continuity of care was disrupted. And it’s important to note that that GAO report was about a few years ago under the Biden administration. So this isn’t new. These problems aren’t new, but they’re getting much worse, because the number of people detained is at record levels and so everything’s just getting multiplied. 

Rovner: Yeah, it is. Well, we will keep watching that space. OK, that’s this week’s news. Before we get to our extra credits, I am pleased to present the winner of our annual 麻豆女优 Health News Health Policy Valentine contest. It’s from [Andrew Carleen] of Massachusetts, based on a story about Medicare Advantage overpayments. And it goes like this: “I thought it was love. My heart felt spring-loaded. Turns out our relationship was significantly upcoded.” Congratulations, and happy Valentine’s Day to all. 

OK, 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. Alice, why don’t you start us off this week? 

Ollstein: Sure. So I have a kind of fun story [“”] from my co-worker Amanda Chu about how the Oura ring has taken over D.C. They have been heavily lobbying the Trump administration and Congress to prevent tough regulations. Basically, there’s a debate about whether it should be regulated as a medical device or not. 

Rovner: Tell us again what it does. 

Ollstein: It’s a ring you wear on your finger that monitors different health metrics. And so the Trump administration MAHA movement has gone all in on this. They love it. The Pentagon has a huge contract with them. Other government agencies are looking at it, too. I think it’s interesting because it is this very sort of conservative mindset of individual responsibility in health care and, oh, if you could just track your own metrics and do the right things. That’s an approach that is sort of counter to the idea of public health and government protecting your health through policy. 

Rovner: And we know HHS Secretary Kennedy is a big fan of wearables. 

Ollstein: Exactly, and this is one of the most popular ones right now. And so this story does a good job digging into all the lobbying and also into concerns about data privacy and pointing out that these technologies are moving much faster than government can regulate them. And that is leaving some lawmakers really concerned about who could have access to this data. 

Rovner: Jackie. 

Fortiér: Mine is by Ariana Hendrix. She’s a writer based in Norway. It’s entitled “.” It was published in Stat. And she writes eloquently about being a parent in Norway and knowing that her children wouldn’t go to day care until they were about 16 months old, because Norway has paid parental leave. And she points out, beyond the vaccine debate there’s a bigger issue, that the U.S. lacks universal health care and federal paid parental leave. So changes in infant vaccines in the U.S. have a large effect, because babies in the U.S. often go to day care, when they’re around a lot of other kids when they’re just a few weeks old. So she points to the, in January, the infant RSV [respiratory syncytial virus] vaccine was moved to the high-risk category of shots, so now it isn’t routinely recommended for all babies in the U.S. And RSV, of course, is the most common cause of hospitalizations for infants, and that’s due to the fact that they’re exposed to the virus in day care a lot earlier than other children in other countries like Norway and Denmark whose vaccine schedules U.S. officials are now kind of trying to emulate. So she does a really great job of laying out how families face greater health and financial risks in the U.S. without the same safety net that other countries have. 

Rovner: Or just the same social policies that other countries have. 

Fortiér: Yeah, it reminded me鈥� 

Rovner: It’s hard to, right, it’s hard to import another country’s 鈥� part of another country’s 鈥� policies without importing all of them. It is really good story. Lizzy. 

Lawrence: Yeah. So my piece is by Rachana Pradhan and 麻豆女优 Health News, and it’s about the “” And I thought this piece was very interesting, just because in general I’ve been fascinated by 鈥� politicization of medicine isn’t new 鈥� but just like right-wing-coded products and left-wing-coded products. And in this piece, Rachana talks about NIH [National Institutes of Health] Director Jay Bhattacharya kind of talking about how, It’s the people’s NIH and if a lot of people are using it, well, we want to investigate it. So she just, she does a really good job of kind of unpacking why this is problematic, that they’re kind of just choosing a random medication and there’s not really any scientific reason to be investing in it as much as they are. And she got a response from NIH after the fact as well, kind of where they were trying to defend this decision to pour this much investment. And so, yeah, I think it’s just a really interesting development in NIH land. 

Rovner: It is. My extra credit this week is from ProPublica, by Mica Rosenberg, and it’s called “.” It’s about what immigration detention looks like from the point of view of children being held at a family facility in Dilley, Texas. That’s the one where the two cases of measles were diagnosed earlier this winter. The story includes some pretty wrenching letters and video calls from kids who were living elsewhere in the U.S., while their parents were mostly working within the immigration system. And these kids had been ripped from their daily lives, their other parents and siblings in some cases, their schools and their classmates, and in many cases, from hope itself. Wrote one 14-year-old from Hicksville, New York, quote: “Since I got to this Center all you will feel is sadness and mostly depression.” It really is a must-read story. 

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, 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 on X, , or on Bluesky, . Where are you folks hanging these days? Jackie. 

Fortiér: Bluesky mainly, . 

Rovner: Alice. 

Ollstein: Mainly on Bluesky, , and still on X, . 

Rovner: Lizzy. 

Lawrence: On X, . On Bluesky, . 

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鈥�

We are kicking off a new series here 鈥� We’re calling it An Arm and a Leg 101.

We’ve spent years of reporting on two huge questions: Why does health care cost so freaking much? And what can we maybe do about it?

We’ve been chasing answers one story, one question at a time.

Now, we’re pulling together some of what we’ve learned. Digging a little deeper, going a little broader.

Starting with why so many drugs cost so much.

One of the first questions I ever asked 鈥� one of our first stories 鈥� was: How can insulin be so expensive? Wasn’t it discovered in the early 20th century? Shouldn’t it be a generic drug by now?

You know, cheap? 

And part of the answer I got was: Insulin has been transformed since the early 20th century. A lot.

A medical researcher named Jing Luo told me: Today’s insulins are a long way from what we had a hundred years ago.

Jing Luo: They’ve been really modified at a molecular level. It’s cool stuff. It’s super cool stuff. And you know, there are multiple Nobel prizes in physiology and medicine that have made this happen.

Dan: And all that super-cool stuff, those amazing discoveries, got patented.

Meaning: The patent-holders鈥� the pharma companies 鈥� got a monopoly on those amazing discoveries.

The pharma companies claimed patents 鈥� and monopolies鈥� on a bunch of other things too. Not all of them amazing.

But each new patent can mean another delay for a generic version coming to market.

Jing Luo: Companies can stack dozens of patents on top of each other to try to thwart generic competition because they can say, look, we’ve got three patents on the active ingredient. We’ve got patents on the medical uses of the active ingredient. We’ve got patents on the non-active excipient associated with this ingredient. We’ve got multiple patents on the devices, and so you who are trying to enter this space will sue you for patent infringement on all of them.

Dan: A patent guarantees you at least a 20-year monopoly. Drugs can generally get an extra five. 

And these extra patents 鈥� secondary patents 鈥揷an keep you protected LONGER. If you don’t file them at the same time as the original: 

To talk about a drug that’s in the news right now. The original patent on the active ingredient in Wegovy and Ozempic actually expired this year.. The extra five years extends it to the early 2030s. 

But dozens of extra patents 鈥� secondary patents, filed later 鈥� mean that here in the U.S., we might not see cheaper generic versions until 2042. Or later.

And as Jing Luo told me: This strategy isn’t a secret. It’s an industry cornerstone. 

Jing Luo: When you listen to these like CEOs of pharma companies being interviewed at CNBC, you know, they’d be like, well, what about generic competition for this product? And they’ll just keep saying, no, no, no. We’ve got this really robust patent portfolio. We can withstand any challenge. We’re gonna tie this up in courts forever and don’t worry about it.We’re gonna continue this gravy boat for a long, long time. That’s the way they reinsure investors.

Dan: A robust patent portfolio. ?Or what researchers and advocates call a patent thicket.

They say quality matters less than quantity. 

The numbers are wild. 

, the 10 best-selling drugs for 2021 鈥� drugs for cancer, HIV, arthritis 鈥� were protected by a combined total of seven hundred and forty-two patents. With hundreds more “pending.”

When these add-on patents get challenged in court, they actually get tossed out more often than primary patents..

But lawsuits cost money. A robust patent portfolio 鈥� a patent thicket 鈥� means generic companies would need to be ready to file a LOT of them.

So, we wanted to know: How did all this happen? How did these games get started?

It turns out, there is one guy who can tell you the story from the beginning, for better and for worse. Who helped shape it. Made millions of dollars from it. Saw its flaws. And has spent most of the last 30 years trying to fix them. Hie’s a lawyer named Al Engelberg, and he’s 86 years old.

Alfred Engelberg: I tell people all the time, I live in a world, a pharma world where half the people think I’m dead and the other half wish I was.  

Dan: Al Engelberg’s story is the story  of generic drugs in America. And it’s a wild ride. 

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 something entertaining, empowering, and useful.

?Al Engelberg’s parents fled Nazi Germany in the late 1930s.

He was born here, less than a year after they arrived. They had nothing.

And  here’s where they made their new life. 

Retro news reel: We are flying over a well-known eastern city. That is remarkable because manufacturing is almost non-existent. A city whose principle business is the entertainment of millions. Atlantic city, often called the vacation capital of the nation

Dan: Al likes to say he learned most of what he knows about practicing law on the Atlantic City boardwalk, by the time he was 16. 

Alfred Engelberg: We grew up very, very fast there. I started working when I was about nine or 10 and, and there were lots of opportunities on the boardwalk. 

Dan: His first “job” was crawling around under the boardwalk, looking for loose change.

Alfred Engelberg: But I went on to work at hotdog stands and at an illegal bingo game for the local mob.

Dan: And in every job, Atlantic City drove home its major lesson: Cheating 鈥� hustling 鈥� is something you’ve gotta expect. 

At this illegal bingo parlor, Al’s job was walking between tables, doling out bingo cards for a dime apiece. The bosses hired college kids to walk behind kids like Al, to keep him honest.

Alfred Engelberg: I mean, these guys are running an illegal game, but they still need to count, and they still inherently don’t trust anybody. 

Dan: Which was correct. Al says the college kids had their own hustle: They’d have him set aside a dollar or two before turning in his dimes 鈥� split that dollar with him fifty-fifty 鈥� and tell the bosses Al’s count was fine.

Alfred Engelberg: And everybody knowing that the counts were wildly inaccurate anyway 鈥榗ause the little old ladies were, were stealing cards. Everybody in the room had their own thing going, you know, from the customers on.

Dan: After Al made it out of Atlantic City, his unique on-the-job education continued. He studied chemical engineering at Drexel, then took a job as a patent examiner while going to law school at night.

And at that job, he learned: The patent system was ripe for hustling.

Partly because most of his colleagues weren’t necessarily giving the job their all. 

Like him, most patent examiners were working their way through law school. And they were sneaking time to study on the job.

Alfred Engelberg: We used to be able to cut our notes down so they fit in these file drawers with the patents. And we would be reading your notes and if your boss came by, you would just drop a patent on top of the notes.

Dan: You could say it was Atlantic City all over again. Everybody in the job is sneaking something for themselves 鈥� in this case, time.

And Al Engelberg could see that, even if his colleagues gave it their all, they were too green to do their job well. 

A patent examiner’s job 鈥� deciding whether a proposed invention deserves a monopoly (which at that time was 17 years) 鈥� means deciding whether the idea for that invention would be obvious to “a person of ordinary skill in that field.”

Alfred Engelberg: And most of the examiners had never worked in that field and had absolutely no idea. And this is the big leagues. You’re granting somebody a monopoly for 17 years, and it seemed ridiculous on its face.

Dan: Al cut his own path at the patent office. He’d worked his way through engineering school, in manufacturing plants, he saw what people of ordinary skill in that field solve problems every day. So he specialized in examining patents he actually knew something about.

That got him promoted, then it got him recruited by a corporate lawyer.. After the company paid his way through the rest of law school, he jumped to the Justice Department. 

He was ambitious鈥� he wanted experience junior lawyers don’t usually get 鈥� like trying cases of his own.

After a few years doing just that, he took a job with a small law firm in New York City in 1968.

Alfred Engelberg: I came to New York to private practice at the age of 30 and I was ready to go. I mean, I was ready to, to tear the world apart and I did.

Dan: Patents were still a specialty. Then, in 1973, he gets a call that leads to his first generic drug case.

Generic drugs were not a hot market at the time.

Alfred Engelberg: ?The generic drug industry in 1970s was essentially, a half a dozen, privately owned family businesses, mostly in the metropolitan New York area. And most of the drugs that they were selling were drugs that were approved before 1962. 

Dan: Yeah. 1962 is when the FDA made it harder to get a new drug approved 鈥� you had to go through long clinical trials to show that your drug was safe and effective. 

Even if your drug was a generic version of an existing drug. Those little companies didn’t have the capital to run those trials, so they were stuck selling those old drugs.

Not much of a business. Maybe 20 percent of prescriptions were for generic drugs.

So when Al Engelberg got a call for his first generic drug case, that was the context. And the case itself did not sound promising. For one thing:

Alfred Engelberg: The call wasn’t even from the client. It was from a bank. The client was bankrupt. 

Dan: The client was bankrupt. This bankrupt client, Premo Pharmaceuticals, was getting sued for patent infringement. The bank was willing to put up ten thousand dollars for a defense. Nowhere near enough to actually try a case. Oh, and鈥�

Alfred Engelberg: From what they told me, the information they gave me, we didn’t have a very good defense.

Dan: But Al Engelberg saw an opening. He could see that his opponents have weaknesses too.

Alfred Engelberg: The patent owners were in a very strange position. If they won, they got nothing because we were already bankrupt. Two, they were gonna have to spend the legal fees to win.

Dan: Win against a young lawyer named Al Engelberg who already had a rep as a tough opponent. So they could lose.

Alfred Engelberg: And if they lost, they would lose millions and millions of dollars in business because there wouldn’t be a patent. And they’d have competition from generic drugs.

Dan: And meanwhile, Al Engelberg is also sizing up the judge. He knows the guy doesn’t love patents.

So Al shows up to the first conference and he bluffs. 

Alfred Engelberg: I said to the judge, oh, your Honor, you know, it’s another one of those patents. They’re all invalid. And I said, we don’t need very much discovery. We’re, we’ll be ready to go to trial in a few months. Just set a trial date.

Dan: The other side walks out beside themselves.

And within a couple of weeks they call Al to say: Hey, how about this? You guys just acknowledge our patent is OK, and we’ll give you the money we would’ve spent litigating. Call it 400,000 bucks?

Alfred Engelberg: I called the client and said, how’s $400,000? He said, are you kidding?

Dan: They didn’t just get out of trouble 鈥� they got out of bankruptcy, with $400,000 in their pockets. Because Al Engelberg knew how to size up a situation.   

Alfred Engelberg: You don’t learn that in law school. That’s not what they teach.

Dan: Word gets  around about that case, and pretty soon everybody in the generic drug world is calling him.

It’s a small world, but by the end of the 1970s, there may be room for it to start getting bigger. 

People are starting to notice: Drugs are expensive. Maybe there should be more cheap generics. 

Some generic drug companies form an association and start lobbying: Make it easier to get generic drugs to market without having to go through all those trials.

The brand-name drugmakers push back: They say it takes so long to run the trials and get their drugs approved, they don’t get enough time to make money before those patents expire.

In 1983, Democratic Representative Henry Waxman steps in to broker a compromise, with Republican Senator Orrin Hatch.

And Mr. Engelberg goes to Washington. To run strategy for the generic drugmakers. 

Alfred Engelberg: In a lot of ways , that’s where my Atlantic City training really helped me at the end of the day

Dan: There were a lot of people, with a lot of interests. A lot of angles. ?He starts commuting from New York to Washington DC a couple times a week 鈥� for months and months, more than a year.

And Al Engelberg says: This time, it wasn’t just about winning a case.

Alfred Engelberg: I was in the back of a cab the way I remember, with the senior partner of the law firm. And he says to me, why are you breaking your ass going to Washington two or three times? Why don’t you send an associate? You know, it’s just like, it’s just another case. And I said. I said, are you kidding? I said, you know, how many lawyers ever get to do what I’m doing right now? To be at the table influencing what may be a major law that’s gonna have major consequences is, is like something I never thought my whole life I’d be doing.

Dan: A kid from Atlantic City was exactly the right person to try to balance all the angles, negotiate a compromise. It took more than a year. It almost didn’t happen. But then it did. Congress passed the bill, and President Ronald Reagan got in front of cameras to sign it.

Ronald Reagan: Let me turn my attention to the real reason we’re here this afternoon, signing into law the Drug Price Competition and Patent Term Restoration Act of 1984. 

Dan: better known as Hatch-Waxman.

Hatch Waxman had three basic components:

One: Brand drugmakers got a few extra years on their patents.

Two: Generic drugmakers got a pathway to get FDA approval.

And three 鈥揟he new law laid out rules for a generic drugmaker when they wanted to CHALLENGE an existing patent. 

Negotiating that third part was the part where Al Engelberg’s education on the Atlantic City boardwalk, and the U.S. patent office, and the generic drug industry came together: The result would make him millions and millions of dollars 鈥� and blow a giant hole into the grand bargain he had worked so hard to bring about.

That’s coming right up.

This episode of An arm and a Leg is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom covering health issues in America. The folks at 麻豆女优 Health News are amazing journalists 鈥� their work wins all kinds of awards, every year. We are honored to work with them.

So. The brand-name drug makers and the generic drug makers struck a deal. That deal was good for them. Both sides got something big out of it. The public was supposed to get something out of it too.

And, to be fair, we did: Remember, back then, maybe one out of five prescriptions was for a generic drug. Now it’s nine out of ten.

But we pay more than ever for drugs. Mostly for branded, patent-protected drugs. And the biggest, most-important, most profitable drugs get locked behind patent thickets.

How did that happen? 

Well, to understand that, it helps to know what Al Engelberg got out of the whole bargain.

Al had been there at the bargaining table, on behalf of the generics. 

One day, during those negotiations, he was in the office with Henry Waxman’s lead counsel, a guy named Bill Corr, when Corr got a call from someone on the other side.

Corr starts pointing at the phone, pointing to Al 鈥� indicating: This guy is talking about you.

When Corr gets off the phone he says: That guy’s not sure about this deal where bad patents could be challenged. He’s suspicious about where you might take this. Like, are you just gonna set up a bounty-hunting operation, to get patents declared invalid?

And Corr said, Al, would you do that? 

Alfred Engelberg: And I said, you know, Bill, until this moment, I’ve never given it any thought, but it’s a hell of a good idea. Maybe I’ll look at it. 

Dan: And he did. Starting almost as soon as Hatch-Waxman became law.

Alfred Engelberg: And we sat in the rose garden, September 23rd, 1984, watched Reagan sign the bill. And in December of that year, I sat down at my kitchen table with a yellow pad and I laid out a strategy.

Dan: If you were gonna set up a bounty-hunting operation, how would you do it?

Al Engelberg knew a lot of patents were garbage. Knew it from his time in the patent office, knew it from practicing law. And he knew how much money a successful patent challenge could be worth.

The way Hatch-Waxman worked: If a generic drug company challenged a patent and won, they would get six months before any OTHER generic drugmakers could get a crack at the market.

So their only competition would be the brand. If a pill cost two cents to make, and the brand was selling for a dollar a pill 鈥� that’s 98 cents of profit for every pill.

You’re the only competitor? You could charge 75 cents a pill and get 73 cents of profit. On a hit drug, you could make millions and millions 鈥� just in those six months. 

Al’s idea was this: Partner up with a generic drugmaker. Go find cases鈥� drugs with weak patents. Win ’em. 

And split those millions in potential profits fifty-fifty. 

Al pitched a generic drugmaker 鈥� they were ready to go 鈥� and brought the deal to his law firm. .

Alfred Engelberg: As it turned out, my partners weren’t interested in having me do this. They tried to talk me out of it.

Dan: But they couldn’t. So he left. Went out on his own. All on his own.

Alfred Engelberg: I never hired a single soul, not even a secretary. And I couldn’t type. I still can’t type.

Dan: But he hunted and pecked his way through brief after brief. He bought an early portable computer 鈥� it weighed thirty pounds 鈥� and lugged it around in the back of his car. For ten years.

Alfred Engelberg: It was stupid. I almost killed myself. But, it worked out okay.

Dan: Yeah. Turns out Al was really good at finding the problems with drug patents.

In one of his first cases, Al Engelberg personally made more than 70 million dollars. Others settled: A few million here, a few million there鈥� it adds up.

And then鈥�

Alfred Engelberg: It got to be the mid nineties, and I was working on a case called Buspar. 

Dan: The Buspar case ended up a big winner for Al Engelberg and his generic drug partners. 

But it had consequences that went way beyond a single case. And led to big losses for the public.. Here’s how it went.  

Alfred Engelberg: Buspar was an anti-anxiety drug. And by all accounts not a very good one.

Dan: But Bristol Meyers Squibb invested in big advertising and marketing campaigns.

Speaker 5: I feel anxious. I can’t concentrate. 

Speaker 6: I’m so irritable. If you. You suffer from excessive worry. It can feel like a mountain of anxiety. 

Speaker 5: I’ll never get it all done. I’m overwhelmed. 

Speaker 6: But a prescription medication called buspar can help.

Dan: And all that marketing did its job. By the mid-1990s, Buspar was making more than 200 million dollars a year for Bristol.

Alfred Engelberg: The only problem for them was that the drug was not new. 

Dan: The active ingredient was well-known in medical literature as a tranquilizer. Nobody had bothered to market it.

So Bristol Myers Squibb filed a patent on it, claiming it had discovered a new use for this well-known tranquilizer: Treating anxiety.

Al Engelberg says when he read the patent application, he could barely believe it: What do tranquilizers do if not鈥� treat anxiety?

It’s like saying: There’s this stuff called sugar. We’re gonna take out a patent on using it as a sweetener.

This looked like a case for a guy from Atlantic City. 

Alfred Engelberg: I did something that lawyers don’t. That’s just the way I was built. 

I filed a motion with the court and basically said, we don’t need any evidence.

You just have to read the patent. If you believe it’s true, the patent’s invalid. Just, you know, all you need is a dictionary basically.

Dan: Al says Bristol was eager to settle. 

Alfred Engelberg: We get into a settlement discussion and we keep saying, no, no, no, no.

Dan: Al’s partners had done the math: They figured they stood to make a hundred million dollars or more once they won. So when the other side offered 25 million, no was the easy answer.

Alfred Engelberg: We said, why are we gonna take this? You know, it’s crazy. There’s a reward here we know what it is. We’re gonna get it eventually.

Dan: Al sits down with a lawyer from the other side, a guy he knows, explains how he sees the math.

And soon the other side comes through with a much bigger offer: 72 million dollars 鈥� almost three times as much. 

Alfred Engelberg: And I’m sitting there like, what are you crazy? But then think about it from their point of view. 

Dan: Paying 72 million dollars is nothing, compared to what Bristol stands to gain if this lawsuit goes away. 

With their monopoly, Bristol Meyer Squibb is making more than 200 million dollars a year on Buspar. And unless somebody else lines up to do what Al Engelberg had done, expect to keep that monopoly for years.

Charging whatever they want. Two dollars a pill, three dollars a pill. Which Al Engelberg says is exactly what happened.

In fact, they kept that monopoly for like five years. 

Alfred Engelberg: As it turned out, nobody came behind us. And so, they had that monopoly until 2000. So they got five years of 2 billion, in gross profits. 

Dan: They made out.

Alfred Engelberg:  For the cost of $75 million. And you know, the public got screwed ’cause they are continuing to pay, you know, $2 a pill or $3 a pill for a drug that eventually ends up being available for 20 or 30 cents. Um, so that’s, that’s how it works.

Dan: That’s how it works. The branded company and the generic company both make out great. Cheaper generic versions of a drug get delayed. 

That amazing payday for Al Engelberg and his partners at the generic drug company turned into a model a template for the kind of deal that every generic drug company would want in on.

It got a nickname: Pay for delay.

Alfred Engelberg: That spread through the industry like wildfire, those numbers, you know, you don’t make those numbers half a cent at a time on, on pills,

Dan: Lawsuits were way more profitable.

But Al Engelberg wasn’t filing them.

A year or so after the Buspar case settled, sparking the Pay for Delay gold rush, he retired. He had plenty of money and nothing to prove.

And in retirement, he started evaluating what he’d accomplished, for better and for worse.

For better, generic drugs had more than doubled their share of the market since Hatch-Waxman took effect.

For worse, he could see two places where 鈥� despite all of his Atlantic City training 鈥� he had missed a couple of angles in negotiating Hatch-Waxman. 

One was: this whole pay-for-delay scheme. Turned out, in balancing incentives for brands and generic makers, he’d left open this perverse incentive that left the public out. 

And the second was a loophole  that Hatch-Waxman had left open.: 

It created a process where players like Al and his generic partners could challenge patents on drugs like Buspar, that they thought didn’t deserve protected monopolies. It removed some friction for those attacks. 

The drug companies developed a way to add more friction:  stacking extra patents 鈥� secondary patents 鈥� on every drug.

Developing patent thickets.

Even if a secondary patent is trivial  鈥� and lots of them do get tossed out 鈥� challenging it means a court fight. And that costs money.

Alfred Engelberg: It caused the big drug companies to just get more and more patents. Because why not? You know, there was nothing standing in the way.

Dan: I mean, nobody knows better than Al Engelberg: Patent examiners don’t exactly stand in the way. 

And those patent thickets and pay for delay, they feed on each other. 

Alfred Engelberg: The economics of the business, caused these kinds of settlements to reach epic proportions. So the generic companies would, challenge these secondary patents and, the drug companies would pay them off.

Dan: In 1999 he published an article in a scholarly journal arguing that Hatch-Waxman needed a reboot. Even the six-month head start for a successful challenge could probably go. 

And ever since 鈥� for more than twenty-five years 鈥� he’s poured millions of dollars into efforts to tighten the rules. Funding research. A public-information campaign from Consumer Reports. Even a center for IP law at his alma mater, NYU.

It hasn’t always gone his way. 

Pay for delay has gotten much bigger since Al Engelberg wrote his first article calling for reform: He wrote in 1999 that about two dozen patent challenges had been filed.

Now he estimates that number at twelve thousand.

Alfred Engelberg: I can’t tell you how many tens of billions of dollars in legal fees that is. It’s one of the fastest growing and and steadiest industries for big law.

Dan: A Hatch-Waxman litigation forum on LinkedIn has more than fourteen thousand members.

And Hatch-Waxman doesn’t cover many of today’s the top-selling drugs鈥� the biggest moneymakers. They belong to a class called “biologics.”

That includes famously-expensive rheumatoid arthritis drugs like Humira and Enbrel 鈥� and insulin. 

Biologics weren’t a category forty years ago when Hatch-Waxman got negotiated. Congress passed a new law to deal with them in 2010 鈥� ?the Biologics Price Competition and Innovation Act.

Al Engelberg is not a fan of that law.

Alfred Engelberg: Whatever mistakes were made in Hatch Waxman, they were multiplied by 10 and deliberately in the biologics law

Dan: He says the all but encourages patent thickets. And doesn’t provide a pathway to challenge them.

He says it reminds him of some of his early days practicing law.

Alfred Engelberg: Back in the seventies, we used to have small startup clients in the computer field, and they would get letters from IBM. It says, we are ready to inform you that you may be infringing one or more of the following patents. And there was a 10 page list of patents attached. And the startup would come to us and say, you know, what should we do? And we would say, find another line of work, you know, what are you gonna do?

Dan: But he has not given up. In 2025, he published a book: Breaking the Medicine Monopolies.

It tells the story of his career 鈥� and lays out his prescriptions for fixing the problem.

He doesn’t JUST focus on plugging the holes in Hatch-Waxman and the biologics law.

Alfred Engelberg: You know, we don’t actually need a generic drug industry. We need generic drug pricing. 

Dan: He’s got proposals for an increased government role in negotiating and regulating prices 鈥� and more than that.

He argues that a 1980 law allows the government to commisssion generic versions of drugs that were developed using public research dollars.

He also says the FDA rules that protect secondary patents on drugs 鈥� that allow patent thicketing 鈥� are based on a completely wrong interpretation of Hatch-Waxman.

And tells us he’s working up a challenge, with help from AI tools like Claude. 

He’s 86 years old. And he doesn’t seem inclined to stop.

Alfred Engelberg: It so changed my life and I did so well by it, I thought, how can I not take on this problem? Who’s gonna do it if I don’t do it?

Dan: He’s got the time. Money’s no object. And he knows the territory as well as anybody. He helped create it. 

Alfred Engelberg: So it’s, it’s my obligation really. It’s that sort of Jewish guilt. What can I tell you? I’m paying back for the bingo game.

Dan: So we’ve gone back more than fifty years on the question: Why aren’t there more generic drugs? We’ve learned why we’ve got the ones we have, and what stands in the way of getting more.

And that is just in time. Because this spring the U.S. Supreme Court will hear arguments in a case that could restrict the generic drug pipeline even further. It could have major implications.

And understanding what they are requires all of the 101 we’ve covered here. We’ll have that story for you in a few weeks. Til then, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta, with help from Dan Weissmann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. 

This series 鈥� An Arm and a Leg 101 鈥� is made possible in part by support from Arnold Ventures. 

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 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 reporters covering Washington. We are taping this week on Thursday, March 12, 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 Shefali Luthra of the 19th. 

Shefali Luthra: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: And Joanne Kenen at 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 Andy Schneider of Georgetown University, who will try to explain how the federal government’s fraud crackdown on blue-state Medicaid programs is something completely different from any fraud-fighting effort we’ve seen before. But first, this week’s news 鈥� and some of last week’s. 

Let’s start at the Department of Health and Human Services, where I think it’s safe to say Secretary Robert F Kennedy Jr. is not having a great week. The secretary reportedly had to have his rotator cuff surgically repaired on Tuesday. It’s not clear if he injured it during one of his famous video workouts. But it is clear, at least according to  from the University of Pennsylvania’s Annenberg Center, that the American public is not buying what he’s selling when it comes to policy. According to the survey, public trust in HHS agencies, which already took a dive during the pandemic, has fallen even more since Kennedy took over the department. Although, interestingly, public trust in career HHS officials is higher than it is for their political leaders. And trust in outside professional health organizations, places like the American Heart Association and the American Academy of Pediatrics, is higher than for any of the government entities. 

Perhaps related to that is another piece of HHS news from this week. The FDA [Food and Drug Administration] approved a label change for the drug leucovorin, which Secretary Kennedy last fall very aggressively touted as a potential treatment for autism. But the drug wasn’t approved to treat autism. Rather, the label changes to treat a rare genetic condition. Kennedy bragged about leucovorin, by the way, at the same press conference that President [Donald] Trump urged pregnant women not to take Tylenol, which has not been shown to contribute to the rise in autism. Maybe it’s fair to say the public is paying attention to the news and that helps explain the results of this Annenberg Center survey? 

Luthra: Maybe. I was just thinking, we do know that Tylenol prescriptions for people who are pregnant did go down, right? There’s research that shows, after that press conference, behaviors did change. And so to your point, it’s clear there is a lot of confusion, and confusion maybe breeds mistrust. But I don’t know that we can necessarily say that American voters and the public at large are very obviously informed as much as they are perhaps disenchanted by things that seem as if they were told would restore trust and make things clearer and in fact have not done so. 

Rovner: That’s a fair assessment. Anna. 

Edney: Yeah, I think there’s a lot of overpromising and underdelivering, and that can kind of create this issue where this administration 鈥� and RFK Jr. has been doing this as well 鈥� kind of is making these decisions from the top, rather than having these normal conversations with the career scientists and things like that, where the public can kind of follow along on why the scientific decisions are being made if they so choose to, or at least have an idea that there was a discussion out there. And that’s not happening. So that’s not something that’s creating a lot of trust. I think people are seeing that as unscientific and chaotic. 

Rovner: I was particularly interested in one of the findings in the survey, is that Dr. Fauci, Dr. Tony Fauci, who was sort of the bête noire of the pandemic, has a higher approval rating than either RFK Jr. or some of his top deputies. Joanne, I see you nodding. 

Kenen: Yeah that was so stri鈥� I mean, it’s still not high. It was, I believe it was 鈥� I’m looking for my note 鈥� but I think was 54%, which is not great. But it was better than Dr. [Mehmet] Oz [head of the Centers for Medicare & Medicaid Services]. It was better than Kennedy. It was better than a bunch of people. So, but it also shows that half the country still doesn’t trust him. It was a really interesting survey, but the gaps in trust in credible science are still significant. What was interesting is the declining trust in our government officials in health care, but there’s still, nationally, the U.S. population, there’s still a lot of skepticism of science and public health. Maybe not as bad as it was, but still pretty bad. 

Luthra: And Julie, you alluded to these famous push-up and workout videos. And part of what you’re getting at 鈥� right? 鈥� is that the communications that we see are targeted toward a not necessarily very large audience. It is these people who are hyper-online, in particular internet spaces and communities, and that’s somewhat divorced from most people and how they live their lives. And when you focus your message and you’re campaigning on this very particular slice, it’s just a lot easier to lose sight of where people are and what they want from their government and what they will actually appreciate. 

Rovner: It’s true. The online America is very separate from the rest of America, which is a whole lot bigger. Well鈥� 

Kenen: And there’s also the young people who probably aren’t in these surveys who, teenagers, who are getting a lot of information on TikTok about supplements and raw milk. And the young men and the teenage boys and the supplements is a big deal, and that’s online. And also we have been seeing for a while, but I think it’s probably creeping up, the recommendations about psychedelics. So there’s all this stuff out there that isn’t going to be picked up by that poll. But yes, it was an interesting poll. 

Rovner: All right. Well, meanwhile over at the Food and Drug Administration, in-again out-again in-again vaccine chief Vinay Prasad is apparently out again, or will be as of later this spring. I feel like Prasad’s very rocky tenure has been kind of a microcosm for the difficulties this administration has had working with career scientists at FDA and elsewhere, at HHS. Anna, what made him so controversial? 

Edney: Well, I think, Prasad was an FDA critic before he came to the agency. And so essentially, when he was out in public, particularly during covid, but there were even criticisms he had before that. He was criticizing these career scientists at the agency. And so he got there, and the way he appeared to operate was that he knew best and he didn’t need to talk to any of these people that had been there, some for decades, and that was getting him in a lot of trouble. But he was being defended and protected by FDA Commissioner Martin Makary, and he really supported Prasad, and he called him a genius and wanted him to stay on. So the first time Prasad left, he convinced him to come back. And now this time, I think, things maybe just went a bridge too far when there was sort of this behind-the-scenes but very public fight with a company trying to make a rare-disease drug. And this is something that, particularly, several senators really, really hate, is when the FDA is getting in the way of a rare-disease drug getting to market, because they don’t think that that’s something the agency should be trying to do unless the drug is maybe wholly unsafe. But they think anyone should be able to try it. And so when this exploded and FDA officials were and HHS officials were behind the scenes, but very publicly, calling this company a liar, it was just a bridge too far. 

Rovner: Well, and he, this was, this incredibly unusual  in which he tried to not be quoted by name, but kind of hard when the head of the agency, or the head of the center at FDA is basically trashing a company, trying to do it on background. Was that kind of the last straw? 

Edney: Yeah, I think so. And sort of an aside on that. I’m curious how that phone call even was allowed to be set up and called. Because, it’s not like he did it on his own. There were, there was an infrastructure around him that helped him set that up. So I’m curious about why that even went down, but I think that was definitely what pushed him out the door. You know, this company wanted to get this drug approved. The FDA had said, No, not unless you do this extremely difficult trial, which the company said would require drilling holes in people’s heads, for what they were trying to get approved, and that it would be a placebo, essentially, for some of those patients, even when you get a hole drilled in your head, and this could be a 10-hour sham surgery, is what the company said. And then Prasad comes out and says: No, they’re lying. That definitely could be a half-hour. No big deal. And I just think that there were senators frustrated with this, the White House not wanting to see another thing blow up over rare-disease drugs, because that has, there have been a lot of issues at FDA under his tenure, of just drugs not being able to get to market. Or having issues with vaccines that have been years in development not being able to get even reviewed, and then that being reversed. So it was just, that was kind of the last straw. 

Rovner: And of course President Trump himself has been a big proponent of this whole Right to Try effort, that it should be easier for people with, particularly with terminal diseases to be able to try drugs that may or may not help. Joanne, you want to add something. 

Kenen: Also wasn’t he still, Prasad, still living in California and running up really huge travel bills and鈥� 

Rovner: Yes. 

Kenen: 鈥攏ot being at the FDA very much, at a time when everybody else has been forced to come back to work? So, but I do confess that I keep looking at my phone to check if he’s still out or is he already back again. 

Rovner: Right. 

Kenen: I’m really not totally convinced that this is the end of Prasad, but yeah. 

Rovner: Yeah, I was not kidding when I said on-again off-again on-again off-again. All right. Well, moving over to the National Institutes of Health, which also has a director that’s doing more than one job in more than one place. I know there’s so much news that it’s hard to keep track of it all, but I do think it’s important to continue to follow things that look to be settled, like funding for the NIH, which Congress actually increased in the spending bill that passed at the end of January. To that end, a shout-out to our podcast panelist Sandhya Raman, formerly of CQ, now at Bloomberg, for  grant funding that still pays for most of the nation’s basic biomedical research is still being held up. This is months after it was ordered resumed by courts and appropriated by Congress. 

Shout-out as well to my 麻豆女优 Health News colleagues Rachana Pradhan and Katheryn Houghton for their project on the people and research projects that have been disrupted by all the cuts at NIH, as well as new bureaucratic hurdles put in place. I feel like if there weren’t so much else going on, what’s happening at basically the economic and health engine of NIH would be getting much, much, much more attention, particularly because of the continuing brain drain with researchers moving to other countries and students choosing different careers rather than becoming researchers. I wonder if this sort of drip, drip, drip at NIH is going to turn into a very long-term hole that’s going to be very difficult to fill. A lot of these things have years- if not decades-long runways. These great scientific achievements start somewhere, and it looks like they’re just sort of pulling out the whole starting part. 

Kenen: It’s already affecting the pipeline. In graduate schools, many schools fund their PhD candidates, and it’s NIH money, or partly NIH money. It’s different 鈥� I’m not an expert in every single school’s support systems for PhD candidates, but I do know that the pipeline has been shrunken in some fields at some schools, and that’s been reported on widely. And there’s been a lot of coverage about years and years of research. You can’t just restart a multiyear, complicated clinical trial or research project. Once you stop it, you’re losing everything to date, right? You can’t just sort of say, Oh, I’ll put it on hold for a couple of years and resume it. You can’t do that. So we’ve already reached some kind of a critical point. It’s just a matter of how much worse it gets, or whether the ship begins to stabilize in any way going forward. But there’s already damage. 

Rovner: I say, are you guys as surprised as I am, though, that this isn’t 鈥� the NIH has been this sort of bipartisan jewel that everybody has supported over the decades that I’ve been covering it, and now it’s basically being dismantled in front of our eyes, and nobody’s saying very much about it. 

Kenen: It’s also an engine of economic growth. You see different ROI [return on investment] numbers when you look at NIH, but I think the lowest number you hear is two and a half dollars of benefit for every dollar we invest. And I’ve seen reports up to $7. I don’t know what the magic number is, but this is an engine of economic growth in the United States. This is basic biomedical research that the private sector or the academic sector cannot do. It has to come from the government. And I don’t think any of us have really gotten our heads around 鈥� why harm the NIH when it is bipartisan, it is economically successful, and it has humanitarian value. It’s the basis. The drug companies develop the drug and bring it to the market. But that basic, basic, earlier what’s called bench science, that’s funded by the NIH. 

Rovner: I know. It’s a mystery. Well, adding to RFK Jr.’s bad week are the growing divisions within his base, the Make America Healthy Again movement. While the White House, seeing that the public doesn’t really support MAHA’s anti-vaccine positions, is trying to get HHS to tone it down, there was a major MAHA meetup just blocks from the White House this week, with sessions urging a complete end to the childhood vaccine schedule and the removal of all vaccines from the market, quote, until they can be proven “safe and effective.” By the way, most of them have been already. Meanwhile, lots of MAHA followers are still angry that the White House is supporting the continuing production of glyphosate, the weed killer sold commercially as Roundup. Democrats, , are trying to exploit the divisions in the MAHA movement, which leads to the question: Will MAHA be a net plus or a net minus for this fall’s midterm elections? On the one hand, I think Trump appointed Kennedy because he was hoping that the MAHA movement would be a boost to turnout. On the other hand, MAHA seems pretty split right now. 

Edney: Well, I think that’s the million-dollar question, is which way they’re going to swing if they swing at all. And it’s hard to say right now, because I think they are angry at certain aspects of things this administration is doing, the two things you mentioned, on Roundup and on vaccines, kind of telling RFK to kind of talk a little bit less about those. But will they be able to then vote for Democrats instead? I think, it’s only March, so it’s so difficult to say what will happen between now and then. I think there’s still things that the health secretary could do on food that he’s talked about, that could draw attention away from that anger, that might make many of them happy. I think there were some things he kind of started doing early in his term that hasn’t been talked about as much. And also, I think there’s still the prospect of Casey Means becoming surgeon general 鈥� or not 鈥� out there, and that’s kind of a big piece of this. If she is to get into the administration, and that is sort of up in the air right now, then that could kind of give them something else to focus on, because she is a large part of this playbook of the MAHA movement. 

Rovner: That’s right. And we are waiting to see sort of if she can get the votes even to get out of committee, much less get to the floor, see whether we’re going to have, as some are saying, the first surgeon general who does not have an active license to practice medicine. Shefali, you wanted to add something. 

Luthra: No, I just think we’ve talked about this before on the podcast, that the food stuff is much more popular than the vaccine stuff. The vaccine components of MAHA remain very unpopular. It’s difficult to really see or say sort of what the White House can do on food in a sustained, focused way, without going off-script, that is also popular. But I think to Anna’s point, it’s just so hard to say to what extent this ultimately matters in November, because there are just so many concerns right now. People can’t afford their health insurance, and gas prices are going up. And I just think we have to wait and see to what extent people are voting based on food policy. 

Rovner: Yeah, well, we will see. All right, we’re going to take a quick break. We will be right back. 

OK, turning to another Trump administration priority, fighting fraud. This week, the administration accused another Democratic-led state, New York, of not policing Medicaid fraud forcefully enough. This comes after the Centers for Medicare & Medicaid Services said it will withhold hundreds of millions of dollars from Minnesota, which our guest, Andy Schneider, will talk about at more length. Minnesota, by the way, last week sued the federal government over its Medicaid efforts. So that fight will continue for a while. But it’s not just blue states, and it’s not just Medicaid. In something I didn’t have on my bingo card, this administration is also going after fraud in the Medicare Advantage program, which has long been a Republican darling. 

Last week, CMS banned the Medicare Advantage plan operated by Elevance Health, which has nearly 2 million Medicare patients currently enrolled, from adding any new enrollees starting March 31, for what the agency described as, quote, “substantial and persistent noncompliance with Medicare Advantage risk adjustment data.” And on Tuesday, the congressional Joint Economic Committee reported that overpayments to those Medicare Advantage plans raised premiums by an estimated $200 per Medicare enrollee annually 鈥� and that’s all Medicare enrollees, not just those in the private Medicare Advantage plans. Is this the end of the honeymoon for Medicare Advantage? Joanne, you were there with me when Republicans were pushing this. 

Kenen: I’ve been surprised, as you have, Julie, because basically Medicare Advantage has been the darling, and it is popular with people. It’s grown and grown and grown, not because the government forced people in. It has good marketing and some benefits for the younger, healthier post-65 population, gyms and things like that. But 鈥� and vision and dental, which are a big deal. But we’ve also seen a backlash, in some ways, because there’s the prior authorization issues in Medicare Advantage have gotten a lot of attention the last couple of years. But not just am I surprised by sort of the swing that we’re hearing about generally. I’m surprised by Dr. Oz, because when he ran for Senate a couple years ago in Pennsylvania, and much of his public persona has been really, really, really gung-ho, pro Medicare Advantage. 

And yet, some of you were at or, like me, watched the live stream of 鈥� he did a very interesting, thoughtful, and, I’ve mentioned this at least one time before, hourlong conversation with a lot of Q&A at the Aspen Institute here in D.C. a couple of months ago. And one of the questions was someone said: Dr. Oz, you’ve just turned 65. Are you doing Medicare Advantage, or are you doing traditional Medicare? And the expected answer for me was, well, I knew that he’s on government insurance now. So he, you have to, at 65 you have to go into Medicare Advanta鈥� Medicare A, whether you 鈥� that’s automatic. That’s the hospital part. But you have the choice. But if you’re still working and getting insurance or government 鈥� he’s on a government plan. He doesn’t have to do that. But he actually, and he pointed that out, but the next sentence really surprised me, because he said: I don’t know. My wife and I are still talking about that. And I thought that was A) a very honest answer. He didn’t have to even say. But it was also, it just was interesting to me that after all that Rah-rah Medicare Advantage we were hearing about, his own personal choice was, Not sure if that one’s right for me. 厂辞&苍产蝉辫;鈥�&苍产蝉辫;

Rovner: I was going to say, I feel like the Republicans are sort of twisting right now between Medicare Advantage, which they’ve always pushed 鈥� they want to privatize Medicare because they don’t like government health insurance 鈥� and then there’s the current populist push against big insurance companies, because, of course, all those Medicare Advantage plans belong to those big insurance companies that Republicans are suddenly saying are too big and getting too much money. So they’re sort of caught between trying to have it both ways. I’ll be interested to see how they come down. One of the things that did strike me, though, even before Dr. Oz sort of started his little crusade against Medicare Advantage, was, I think it was at Kennedy’s confirmation hearing that Sen. Bill Cassidy was suddenly questioning Medicare Advantage. That was, I think, the first Republican I saw to like, Oh. That made me raise my eyebrows. And I think since then, I’ve kind of seen why. 

Kenen: The populist talk against insurance companies, not giving money to insurance companies, is part of the Republican 鈥� and, specifically, President Trump’s 鈥� desire to not extend the ACA, the Affordable Care Act, enhanced subsidies. That was the basic: Well, we’re not going to do this, because we’re just throwing money at these insurance companies. And we don’t want to do that. We want to empower the patients. That was the, I’m not, and the missing piece of that argument is: Yes, the ACA subsidies go to insurance companies. However, all of us are benefiting in some way or other from government policies that benefit insurance companies. The tax breaks our employers get. The tax breaks we get for our insurance. And then the biggie, of course, is Medicare Advantage. 

We are paying Medicare Advantage more than we are paying traditional Medicare. So Medicare Advantage is private insurance companies, and the government has been just sending them lots and lots of money for years. So I’m not sure it’s 鈥� this Medicare Advantage thing is just bubbling up, and we’re not really sure how this plays out. But I think that the rhetoric against insurance companies is the rhetoric against the ACA. 

Rovner: Oh, it is. 

Kenen: Rather that hasn’t yet been connected to the Medicare Advantage. I think they’re, yes, we all know they’re connected. But I think the political debate, it’s not Medicare Advantage is bad because insurance companies are bad. It’s the ACA is bad because it enriches insurance companies. There’s a different ideological parade going down the road. 

Rovner: I was going to say, it’s important to remember at the beginning of Medicare Advantage, which was a Republican proposal back in 2003, they purposely overpaid it. They gave it more money because they know that when they give them more money, the insurance companies are required to return some of that money to beneficiaries in the form of these extra benefits. That’s why there are gym memberships and dental and vision and hearing coverage in these Medicare Advantage plans. It does make them popular, so people sign up. And that was sort of Republicans’ intent at the beginning. It was to sort of not so much push people into it but entice people into it. 

Kenen:&苍产蝉辫;础苍诲&苍产蝉辫;迟丑别苍鈥�&苍产蝉辫;

Rovner: And then maybe cut it back later. 

Kenen: No, but it’s exceeded expectations. 

Rovner: Absolutely. 

Kenen: The number of people going into Medicare Advantage has been really high, higher than people expected. And it’s also hard to get out, depending on what state you live in. It’s not impossible, but it’s costly and difficult, except for a few, I think it’s seven or eight states make it pretty easy. But also remember that the earlier version of what we now call Medicare Advantage was 鈥� which was the ’90s, right Julie? 鈥� I think the Medicare Part C, and that failed. 厂辞&苍产蝉辫;鈥�&苍产蝉辫;

Rovner: Well after, that failed because they cut it when they were 鈥� 

Kenen: Right. Right. 

Rovner: They cut all the funding when they were balancing the budget 鈥� 

Kenen: Right.  

Rovner:&苍产蝉辫;鈥�&苍产蝉辫;颈苍&苍产蝉辫;1997.&苍产蝉辫;

Kenen: But that gave them the excu鈥� right. 

Rovner: They made it fail. 

Kenen: That gave them an excuse to give them more money later that, when they revived it, renamed it, and launched it in 2003 legislation, that initial push to give them a ton of money, because they could say, Well, we didn’t give them enough money, and that’s why they fa鈥�. There are all sorts of political things going on that weren’t strictly money. But yeah, it was part of the narrative of Why we have to give them more money, is They need it. 

Rovner: Yeah. Anyway, we’ll also watch that space. Well, finally, this week, there’s news on the reproductive health front, because there’s always news on the reproductive health front. Shefali, Wyoming has become the latest state to enact a so-called heartbeat ban, barring abortions when cardiac activity can be detected. That’s often around six weeks, which is before many people are even aware of being pregnant. I thought the Wyoming Supreme Court said just this past January that its constitution prevents abortion bans. So what’s up here? 

Luthra: They did, in fact, say that, and so we are seeing this law taken to court. It was actually added in a court filing to a preexisting case challenging other abortion restrictions in the state. I’m sure that’s going to play out for quite some time. But what’s interesting about the Wyoming Constitution 鈥� right? 鈥� is that it protects the right to make health care decisions, in an effort to sort of fight against the ACA. That was this conservative approach that now has come to really benefit abortion rights supporters as well. But what I think this underscores is that even as we are seeing fairly little abortion policy in Washington, at least in a meaningful way, a lot is still happening on the state level. That really is where the bulk of action is, whether you see that in Wyoming, in Missouri, where they’re trying to undo the abortion rights protections there, and just鈥� 

Rovner: The ones that passed by voters. 

Luthra: Exactly. And so what we’re really thinking about is anti-abortion activists are not really that confident in the president’s desire, interest, ability, what have you, to get their agenda items done. And for now, they are really focusing on the states, and that is where their interest, I think, will only remain, at least until the primary for the next presidential race begins in earnest. 

Rovner: Well, Shefali, I also want to ask you about  this week on just how many things ripple out economically from abortion restrictions. Now it’s having an impact on rent prices? Please explain. 

Luthra: I thought this was so interesting. It was this NBER [National Bureau of Economic Research] paper that came out this week, and they looked at comparably trending rental markets in states with abortion bans and those without them. And what they saw was that after the Dobbs decision, rental prices declined relative to places without bans, compared to those in those that had them. And this is really interesting. It just sort of continues. Rental prices went down, and also vacancies went up. And what the researchers say is this is a very, very dramatic and clear relationship, and it illustrates that people, when they have a choice, are considering abortion rights in terms of where they want to live. And anecdotally, we know that, because we’ve seen residents make choices about where they will practice. We’ve seen doctors decide where they will live. We have seen people move. Companies offer relocation benefits if people want them. And this is more data that illustrates that actually that affects the economy of communities, and it really underscores that where we live just simply will look different based on things like abortion rights and abortion policy and other of these things that are treated as social but really do affect people’s economic behaviors. 

Rovner: And as we pointed out before, it’s not just about quote-unquote “abortion,” because when doctors choose not to live in a certain place, it’s other types of health care. It’s all health care. And we know that doctors tend to marry or partner with other doctors. So sometimes if an OB GYN doesn’t want to move to a certain place, then that OB-GYN’s partner, who may be some completely other type of doctor, isn’t going to move there either. So we are starting to see some of these geographical shifts going on. 

Luthra: And one point actually that the researcher made that I thought was so interesting was that abortion policy, it can be emblematic, in and of itself, a reason people choose not to live somewhere, but people may also be making these decisions because of what it represents. Do I look at an abortion policy and say, Oh, this reflects social values or gender beliefs? Or does it also suggest maybe more anti-LGBTQ+ laws? And all of that can create a picture that is broader than simply abortion or not, and determine where and how people want to live their lives. 

Rovner: It’s a really interesting story. We will link to it. All right, that is this week’s news. Now I’ll play my interview with Andy Schneider of Georgetown University, and then we will be back to do our extra credits. 

Rovner: I am pleased to welcome to the podcast Andy Schneider, a research professor of the practice at the Georgetown University McCourt School of Public Policy. And he spent many years on Capitol Hill helping write and shape Medicaid law as a top aide to California Democratic congressman Henry Waxman 鈥� and many hours explaining it to me. I have asked him here to help untangle the Medicaid fraud fight now taking place between the federal government and, at least so far, mostly Democratic-led states. Andy, thanks for being here. 

Andy Schneider: Thanks for having me, Julie. 

Rovner: So, it’s not like fraud in Medicaid 鈥� and other health programs, for that matter 鈥� is anything new. Who are the major perpetrators of health care fraud? It’s not usually the patients, is it? 

Schneider: No, it’s usually some bad-actor providers or bad-actor businesspeople. 

Rovner: So how are fraud-fighting efforts at both the federal and state level, since Medicaid funding is shared, supposed to work? How does the federal government and the state government sort of try and make fraud as minimal as possible? Since presumably they’re never going to get rid of it. 

Schneider: Unfortunately, I don’t think you’re ever going to get rid of it in Medicaid or Medicare or private insurance or in other walks of life. There are bad actors out there. They’re going to try to take advantage. So you need your defenses up. So the short of this is, Medicaid is administered on a day-to-day basis by the states. The federal government pays for a majority of it and oversees how the states run their programs. In that context, the state Medicaid agency and the state fraud control unit have a primary role in identifying where there might be fraud, investigating, and then, in appropriate cases, prosecuting. The federal government also has a role, however. Depending on the scope of the fraud, it could involve the FBI. It could involve the Office of Inspector General at the Department of Health and Human Services. So there’s both federal and state presence, but the primary responsibilities were the states’. 

Rovner: We know that Minnesota has been experiencing a Medicaid fraud problem, because both the state and the federal government have been working on it for more than a year now. What is the Trump administration doing in Minnesota? And why is this different from what the federal government has traditionally done when it’s trying to ensure that states are appropriately trying to minimize fraud? 

Schneider: Well, usually the vice president of the United States does not get up at a White House press conference and announce he and the Centers for Medicare & Medicaid Services are withholding $260 million in federal funds, called a deferral. That is highly, highly unusual. And normally the head of the Centers for Medicare & Medicaid Services does not go and make videos in the state before something like this is announced. So I would say that this is way out of the ordinary, and I think it has to do with some animus in the administration towards Gov. [Tim] Walz and his administration. 

Rovner: Right. Gov. Walz, for those who don’t remember, was the vice presidential candidate in 2024 running against President Trump, who did win, in fact. But there have been two different efforts to withhold Medicaid money for Minnesota, right? 

Schneider: Yeah. Now you’re into the Medicaid weeds, but since you asked the question, I’ll take you there. So in January, the administra鈥� the Center for Medicare & Medicaid Services 鈥� we’ll call them CMS here 鈥� they announced they were going to withhold about $2 billion a year going forward, not looking back but going forward, in matching funds that the federal government would otherwise pay to the state of Minnesota for the services that it was providing to its over 1 million beneficiaries. In February at this White House press conference, what the vice president announced was withholding temporarily 鈥� we’ll see how temporary it is 鈥� but withholding temporarily $260 million in federal Medicaid matching funds that applied to state spending that’s already occurred, happened in the past, happened in the quarter ending Sept. 30, 2025. So both the past expenditures and future expenditures are targets for these CMS actions. 

Rovner: So what happens if the federal government actually doesn’t pay the state this money? I assume more than people who are committing fraud would be impacted. 

Schneider: Well, let’s be clear. The amounts of money here, there’s no relationship between those and however much fraud is going on in Minnesota. And there has been fraud against Medicaid in Minnesota. Everybody’s clear about that. The state is clear about it. The feds are clear about it. But $2 billion going forward in a year, $1 billion going, looking backwards, $260 million times four 鈥� there’s no relationship between those amounts, right? Should they come to pass 鈥攁nd all of this is still in process 鈥� should those amounts come to pass, you’re looking at, depending on who’s doing the estimates, between 7 and 18% of the amount of money the federal government pays, helps the state with, each year in Medicaid. That’s just an enormous hole for a state to fill, and it doesn’t have many good options. It can cut eligibility. It can cut services. It can cut reimbursement rates. Filling in that hole with state revenues, that’s going to be a real stretch. 

Rovner: So it’s not just Minnesota. Now the administration says it is seeing concerning things going on in New York and has launched a probe there. Is there any indication that this administration is going after states that are not run by Democrats? 

Schneider: So the only letters that we’ve seen from the administration have been to California, New York, and Maine. There may be other letters out there. We only access the public record. So so far, based on what we know, it’s just been Democratically run states. 

Rovner: As long as I’ve been covering this, which is now a long time, fraud-fighting has been pretty bipartisan. It’s been something that Congress has worked on, Democrats and Republicans in Congress, Democrats and Republicans in the states. What’s the danger of politicizing fraud-fighting, which is what certainly seems to be going on right now? 

Schneider: Yeah, that’s a terrific point. So it always has been bipartisan, because money is green. It’s not red. It’s not blue. It’s green. And trying to keep bad actors from ripping it off from Medicaid or Medicare has always been a bipartisan undertaking. The reason that’s important, particularly in a program like Medicaid, where the federal government and the state have to talk to one another when they are flagging potential fraud, when they’re investigating it, when they’re prosecuting it, you don’t want the agencies tripping all over one another. You want them sharing information as necessary, etc. When that gets politicized, it’s very bad for the results and for the effective operation of the program. 

Rovner: Well we will keep watching this space, and we’ll have you back to explain it more. Andy Schneider, thank you very much. 

Schneider: Julie Rovner, thank you very much. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will 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. Mine is in The Wall Street Journal. It’s [“”]. This is a look at the booming business of providing therapy to children with autism. And that’s particularly been big in the Medicaid program. And I don’t want to give away too much, because there are just so many jaw-dropping details in this. So I guess the reporters were able to kind of go through the data and billing records in a way that showed some of these companies and what they were doing and how they were becoming millionaires, people who had never done anything in autism before. So if you enjoy a sort of jaw-dropping read, I think you should take a look at it. 

Rovner: Yeah, jaw-dropping is definitely the right description. Joanne. 

Kenen: So I sort of rummaged around the internet to the less widely read sources, and I came across this great story from the Idaho Capital Sun by Laura Guido. It has a long headline. Reminder that 988 is the mental health crisis line and suicide help. The headline is: “” The story is that a 15-year-old boy named Jace Woods called two years ago 鈥� so this still hasn’t been fixed after two years 鈥� and they cut him off. They sort of gently cut him off. But they can’t talk to these kids who have, who are in crisis, without parental consent. They do a quick assessment. If they think someone’s life is immediately in danger right then and there, they can stay on. But a kid who’s what they call suicidal ideation, seriously depressed and at risk, and knows he’s at risk or she’s at risk, and made this phone call, they don’t talk to them unless they think it’s imminent. So it also affects, these parental, it affects sexual health and STDs and abortion and whole lot of other things. 

Rovner: That’s what it was for. 

Kenen: That was the initial reason, but it got bigger. So a kid who calls in a crisis can get no help at all. And even in those emergency situations where they can stay on the line and try to get emergency help if they do think a kid’s in imminent danger, they’re not allowed to make a follow-up call to make sure they’re OK. So this kid has been trying for two years. There’s a state lawmaker. They’re refining a law. They say it’s, they’re refining a bill. They say it’s going to go through. But really this, talk about unintended consequences. We have a national mental health crisis, particularly acute for teens. This is not solving any problems. 

Rovner: It is not. Shefali. 

Luthra: My story is in The New York Times. It is by Apoorva Mandavilli. The headline is “.” And it’s just a good story about what is happening with the Ryan White AIDS Drug Assistance Programs, which people use to get their HIV medications paid for or for free. They get insurance support. And these are really important. Funding has been pretty flat for quite some time because they’re funded by Congress. And what the story gets into is that with growing financial pressure on these programs, there is more-expensive drugs, there are more-expensive insurance premiums, more people might be losing Medicaid. States are having to make very difficult choices, and they are cutting benefits. They are changing who is eligible, because it’s getting more expensive and there is more need and there is no support coming. And I wasn’t really on top of this and did not know what was going on, and I just thought it was interesting and a very useful look at some of the consequences of the policy choices that are making all of these health programs more expensive and health care, in general, harder to afford. 

Rovner: My extra credit this week is from The Marshall Project. It’s called “.” It’s by Shannon Heffernan and Jesse Bogan and Anna Flagg. It answers the question that I’ve been wondering about since the whole immigration crackdown began, which is: What happens to the people who are snatched off the streets or out of their cars or homes, flown to a distant state, and then someone says: Oops, sorry. You can go. How do you get home from Texas or Louisiana to Minnesota or Massachusetts? Authorities don’t give you plane or even bus tickets to get back to where you were picked up, even though that’s where most of those being released are required to go to report back to immigration authorities. It turns out there’s a small network of charities that is helping. But as the story details pretty vividly, the harm to these families doesn’t end when their detention does./ 

OK. That’s 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, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, , or on Bluesky, . Where are you guys hanging these days? Shefali? 

Luthra: I am at Bluesky, . 

Rovner: Anna. 

Edney:  and , @annaedney. 

Rovner: Joanne. 

Kenen: A little bit of  and more on , @joannekenen. 

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, Feb. 12, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Lizzy Lawrence of Stat News. 

Lizzy Lawrence: Hi.  

Rovner: And up early to join us from California, my 麻豆女优 Health News colleague Jackie Fortiér. Welcome, Jackie.  

Jackie Fortiér: Hey, everyone. 

Rovner: No interview this week, but plenty of news. So let’s jump right in. We will start this week at the Food and Drug Administration, where things are 鈥� why don’t we call it 鈥� newsmaking. The biggest FDA story that broke this week was controversial vaccine chief Vinay Prasad outright rejecting an application for a new flu vaccine from Moderna, maker of the mRNA covid vaccine that so many anti-vaxxers have criticized. Lizzy, you . Congratulations. What happened exactly? And why is this such a big deal beyond the flu vaccine? 

Lawrence: This is a big deal because to refuse to file is a pretty rare occurrence in general, because in general the FDA and industry like to have agreed-upon standards for clinical trials before companies embark on them and pour millions of dollars into them. So that was surprising. And then鈥� 

Rovner: And refuse to file means that they said that they’ve got the application and said: Yeah, we’re not accepting that. We’re not going to review this. Right? 

Lawrence: Yes, yes. And Prasad wrote that the grounds for this was that it wasn’t an adequate, controlled trial. Well, Moderna is saying that actually the FDA greenlit this trial back under the Biden administration in 2024. They acknowledged that there was basically a control vaccine that the FDA say they would prefer that Moderna use for the older population. But they said, however, it’s acceptable if you don’t do that. 

Rovner: And I want to make sure I understand this. The complication here is that this is supposed to be a better vaccine for older people, but right now there’s vaccines for older people that start at age 65 and this is a vaccine that’s supposed to start at age 50, right? So it was unclear who they were going to test it against, whether it was going to be the 50-to-64s or the 65s and older. Because there isn’t a vaccine right now that’s approved for 50 and up, right? 

Lawrence: Exactly, exactly. So it was there’s the high-dose vaccine, which is recommended for the above-65s, but that is not recommended for the 50-to-64, which is part of why Moderna didn’t use that high-dose vaccine, because the population that they were studying was broader than this over-65s. So anyway, so yeah, so refusing to file is already rare, and then for there to be an overriding refuse to file, where the, I was told, basically, while there may have been individuals who agreed with Dr. Prasad’s assessment, the review team, every discipline, thought that it was reviewable. And the head of vaccines wrote a memo explaining why he thought it was viable, so that the career staff kind of documented their thoughts here. It’s not clear whether this will be made public ever, but one would hope, with radical transparency, but we’ll see. Despite that, Dr. Prasad still refused to review Moderna’s application. 

Rovner: So obviously it’s a big deal for the flu vaccine, but it’s a big deal beyond this. Moderna’s CEO was on cable news this morning, said that, as you said, after consulting with the FDA officials about the trial, they spent a billion dollars on this trial. How do we expect companies to invest in new medicines like this if the FDA is basically acting on vibes? 

Lawrence: I don’t know. Yeah. And it’s interesting. It doesn’t seem like there’s a ton of sympathy from this administration. Even back last year, [FDA] Commissioner [Marty] Makary tweeted something 鈥� this was when they were limiting, wanted to require more data for covid vaccines for the under-65 crowd. And I think he said something like: Our goal is not to save companies money. That’s not something we 鈥� which of course that isn’t. The FDA’s goal is to promote public health. But it’s definitely a change in tune. I think that in the past, the FDA has understood that you’re really only going to get innovation if you have clear, consistent guidance and that it’s a really worst-case scenario for a company to spend a billion dollars on a clinical trial and then there’s nothing to show for it and nothing for it to benefit patients, either. So. 

Rovner: Is this over? What happens now? 

Lawrence: So now Moderna has requested a meeting to challenge this decision, and now there begins a kind of negotiation. It might be possible that the FDA would, in fact, would review at least the 50-to-64 cohort, because they don’t have any objections there, seemingly. But we’ll have to see. On a call yesterday, a senior FDA official talked about Moderna kind of coming to the agency with humility and acknowledging that the FDA had recommended this high-dose vaccine. And so I don’t know. I think companies are definitely 鈥� it’s a lesson that they’re, especially if you’re in the vaccine space, you have to tread very carefully. 

Rovner: Yeah. And I would think others in the drug space, too. It’s not just 鈥� that’s the point of this 鈥� it’s not just vaccines. Alice, you wanted to say something. 

Ollstein: Oh, yeah. Not only the monetary investment, which we’ve touched on a bunch, but companies spend years. So it’s the time investment as well. And why would you dedicate years of effort to something that you’re not sure if a political appointee is going to swoop in and override career scientific officials’ assessment, if you can’t trust the regulatory system to work as it’s always worked. There really is just a lot of risk there, and you might see people not making these submissions on all kinds of fronts. Of course, this is coming as we’ve had a really bad flu season. I’ve had people in my life get really sick and say it’s been really, really bad. So the prospect of having something that works better to prevent, or even just make it milder, not coming to fruition is rough. 

Rovner: Yeah. And this year, as we know, this year’s flu vaccine was not very well matched to the strains that ended up circulating. And that’s kind of the point of this Moderna vaccine, this mRNA vaccine, is that they say it would be much faster for them to match strains to what’s going around. If it works as the clinical trials suggest it would actually be a better flu vaccine than we have now. 

Well, meanwhile, cases of measles are also continuing to multiply, as they do when people aren’t vaccinated, and not just in the places we’ve talked about, like Texas and South Carolina, but also all around us here in the nation’s capital, apparently, as a result of people traveling here for the anti-abortion March for Life in January. There have been more than 730 confirmed cases of measles in the U.S. already this year. That’s four times more than have been typical for a full year, and it’s not yet the middle of February. Yet that doesn’t seem to be deterring the administration from its anti-vaccine activities. So now, the American Medical Association and the University of Minnesota Vaccine Integrity Project have announced they’ll convene a parallel group of experts to make vaccine recommendations, basically saying they are done following the Centers for Disease Control and Prevention. This has been brewing for a while. Right, Lizzy? 

Lawrence: Yes. As soon as the secretary fired all of the experts who served on the advisory panel to the CDC on vaccines, I think there’s been unease. And now, as you said, there’s an active parallel public health establishment that’s trying to spread credible information and provide an alternative resource, because it’s clear that HHS [the Department of Health and Human Services] has become compromised when it comes to vaccine recommendations. And yet, you’re seeing the spread of infectious diseases right now. 

Fortiér: Having kind of this rival court is not surprising, because they’ve refused to participate in any of the Advisory Committee on Immunization Practices meetings for months and months. I do wonder if this will maybe change some of the tone. We do have an upcoming ACIP meeting in February. Normally we would have a agenda out by now. Before Secretary [Robert F.] Kennedy [Jr.] we would have them weeks in advance, and we haven’t seen one yet, so we’re really not totally sure what they’re going to be talking about. But Dr. [Mehmet] Oz did say this week that he finally advised people 鈥� he’s the CMS [Centers for Medicare & Medicaid Services] director鈥� to take the vaccine. And there’s been over 933 cases in just South Carolina during this outbreak that started last October. And so when I talk to people on the ground who are treating folks in South Carolina and have been treating them for months, and they’ve been doing vaccine clinics and things like that, they were just so fed up with Dr. Oz and the administration, because they partially blame them for these various outbreaks. And I had one of them tell me, like, well, it’s like a band-aid on a bullet hole. Like, now they’re finally encouraging people to get vaccinated when we could have had this months ago. 

Rovner: And, of course, the CDC doesn’t have a director at the moment, because the Senate-approved director was summarily fired and/or quit, not clear which, after refusing to basically rubber-stamp the immunization panel’s recommendations that had not been made at the time. So the American Academy of Pediatrics is suing to stop this February ACIP meeting. I did not hear what the last decision was on that, but I know that there’s still a lot of movement around here. I guess the big worry is: Who should the public trust now? Is it going to be this sort of grouping of medical societies led by the AMA, or the CDC, which people and doctors are used to following the advice of? 

Ollstein: And there’s all these state alliances forming to do the same thing. And so I think, yeah, the more competing recommendations the average person hears, the more they just sort of throw their hands up and say: I don’t even know who to trust anymore. I’m not listening to any of these people. And the trust that’s eroded in the federal government, that’s going to be really hard to recuperate in the future. You can’t just flip a switch and say: OK, it’s a different government. We trust them again. Once those seeds of doubt are planted in people’s minds, it’s really hard to unearth. And so, if not permanent damage, all of this is doing at least very long-term damage to the idea of expertise and authoritative information. 

Rovner: And science, which this administration insists it wants to follow. Well, turning to FDA-related “MAHA” [“Make America Healthy Again”] news, the agency said last week it would relax enforcement of its food additive regulations to make it easier for manufacturers to say they’re not using artificial dyes. Now this was a huge deal when the agency announced the phaseout of artificial coloring. Looking at you, fancy-colored Froot Loops. Now the administration says it’s going to allow foodmakers to say they’re not using artificial colors as long as they’re not using petroleum-based dyes. Apparently, natural dyes are OK. But even that is controversial, and it appears that this whole effort really relies on manufacturers’ willingness to comply rather than, you know, actual regulation, which is kind of what the FDA does for a living. It’s a regulatory agency. 

Ollstein: Well, every time the word “natural” comes up, I always laugh because there is no definition of that. And there are plenty of things that are natural that could kill you or hurt you very badly. And there are plenty of things that are synthetically manufactured that are helpful and fine for you. And so it has this veneer of safety, veneer of health with no actual substance. So my red flags go up whenever I hear that word, and I think everyone should be skeptical. 

Rovner: But it goes with RFK Jr.’s quest now that you should, quote, “eat real food.” 

Lawrence: Right. Yeah. I was going to say same with “chemical.” I feel like, “chemical” abortion drug, “chemical.” And it’s like, a lot of things are chemicals. That’s not鈥� 

Ollstein: Yeah, like in your own body, naturally. 

Lawrence: Yeah. 

Ollstein: You have chemicals. 

Lawrence: We are chemicals. 

Ollstein: We are chemicals. 

Rovner: You guys are all too young to remember the Dow Chemical advertising line “Better Living Through Chemistry,” which at the time, in the ’60s and ’70s, was true. There was, there 鈥� we’ve had a lot of better living through chemistry. And some of it has turned out to be maybe not so good for us, but a lot of it has turned out to be pretty darn good for us. 

Well, finally, in FDA land, Commissioner Marty Makary this week met with anti-abortion senators about that ongoing review of the abortion pill mifepristone, which senators want the FDA to remove from the market. Alice, how’d that meeting go? 

Ollstein: Not great for the FDA, from what I was told. I got on the phone with Sen. Josh Hawley after it, and he was extremely frustrated. He said he didn’t get answers to any of the questions he’s been sending in public letters to the FDA for months and now asking in this briefing behind closed doors that they held on Capitol Hill this week. He said he didn’t get answers about what the timeline is for this review of the abortion pill mifepristone, what the review consists of, whether it’s even begun, really, whether it’s even underway. And so he is sort of concluding that this is not going anywhere, and he wants Congress to step in and take action. Now, Congress has tried to step in and take action before. They’ve tried to put restrictions on mifepristone in the FDA funding bill. That didn’t pass. So I don’t know if this is even plausible in this environment where Congress can’t really pass much of anything anymore. 

But Hawley is not just another Republican senator. He is very intertwined with the anti-abortion movement. His wife is an extremely prominent anti-abortion lawyer who’s led a lot of the major cases trying to restrict or ban mifepristone. They founded their own anti-abortion advocacy group. And so it really shows that the tensions, clashes, whatever we want to call them, between the anti-abortion movement and the Trump administration, so after backing the Trump administration for years and years, they’re really getting fed up. And they’re fed up that even after they achieved their grand goal of overturning Roe v. Wade, there are actually more abortions happening now than before, and that’s largely through these pills and people’s ability to get them. And so they’re getting increasingly impatient with the Trump administration, who has been sort of stringing them along and saying: Yeah, we’re working on it. We’re working on it. But they want to see results. Now, of course, if there were some sort of restrictions imposed, that could have a big political effect. And so a lot of Republicans are very torn about that. But not Sen. Hawley. Sen. Hawley wants to see it.  

Rovner: That’s right. Well, moving to what I call FDA-adjacent news, one of the many thorny issues that FDA has been dealing with is the compounding of those very popular and very pricey obesity drugs. When the drugs were in shortage, it was legal for compounders to make their own copies. But now the shortage for both of the leading medications 鈥� semaglutide, made by Novo Nordisk, and tirzepatide, made by Eli Lilly 鈥� is over, and those cheaper copycats were supposed to be pulled from the market. So it was a bit of a surprise when the company Hims, one of those direct-to-consumer drug sites, announced the unveiling of a semaglutide tablet just weeks after the first such drug was approved by the FDA, by Novo Nordisk. The FDA promptly referred the company to the Justice Department for possible violation of federal drug laws, after which Hims said, Oh, maybe we won’t start selling the drug after all. Oh, and Novo is suing for patent infringement. But I would think that the war over the “fat” drugs, as President [Donald] Trump likes to call them, is likely to lower prices just as effectively as government regulation might. Or am I misreading that? Lizzy, this has been quite the sideshow, if you will. 

Lawrence: Yeah. It might. I think that the compounding, the FDA’s crackdown on Hims was very interesting to me because I think before the commissioner had come into his role, there was some speculation. He had worked for a telehealth company that prescribed compounded drugs. And there’s also, I think compounders have tried to tap into a little bit of the MAHA medical freedom aspect. But clearly that’s not been the case, at least at the FDA. They are clearly very upset about this and mean business, and I think it’s tying into their crackdown on direct-to-consumer drug advertising as well. But as far as price, yeah. I think the deals that Trump has managed to strike with the companies could actually be reducing price for patients. I think we’ll have to see. I know there’s obviously drug pricing programs as well that they could pursue. So, yeah, we’ll have to see.  

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

OK. We’re back. And speaking of President Trump, there’s also drug news this week that’s not directly related to the FDA. That’s the official unveiling of TrumpRx, the website the president says will lower drug prices like no one’s “ever seen before.” That’s a direct quote, by the way. Except it turns out that’s not quite the case. First, these discounts are only for people who are paying out-of-pocket, not those with insurance, which makes them valuable mostly for people who have no coverage or people who take drugs that insurance often doesn’t cover, like those for obesity or infertility. Yet of the 43 drugs so far that are promoted on the TrumpRx website, about half already have cheaper generic copies available through sites like GoodRx and Mark Cuban’s Cost Plus Drugs. And really, the website just points people to already existing manufacturer websites that were already offering those lower prices. So what is the point of TrumpRx? 

Lawrence: Great question. Yeah. This administration has been very focused on, obviously, media and wins and attaching President Trump’s name to things. So it accomplishes that goal. Maybe it does raise awareness for these other sites that already exist. But that’s a theme of a lot of the movement on health care so far, has been 鈥� there’s been a lot of chaos, and then there’s also sometimes things that they announce as like a grand, brand-new, no-one’s-ever-thought-of-it-before policy, but then there are already, of course, existing programs or avenues for that. 

Rovner: And to be fair, Trump has jawboned down some prices, including some prices for the obesity drugs, by basically dragging in the CEOs of these companies and saying, You will lower prices. 

Lawrence: Yeah, yeah. The dealmaking has been effective. And I think the question is: Will this last beyond his administration? Will there be a legacy there? 

Ollstein: I think there’s also some danger in overpromising, because he’s out there saying things that don’t comport with how math works. He’s basically suggesting prices will come down so many percents that we’ll be getting paid to take drugs, because that’s what more than 100% is. And people who are hearing that, voters who are hearing that, if they aren’t seeing that show up in their bills, if they’re not actually seeing those drastic, drastic drops that they’re being promised by the president, are they going to get upset? And is that going to impact how they vote? So yes, there has been some, on the margins, improvements, but when you’re out there promising 600% reductions and not delivering, there’s a risk to that. 

Rovner: Jackie, you wanted to add something. 

Fortiér: Well, I was going to say, I think it’s also confusing for a lot of people, from a consumer perspective, because you log on and I think people, they hear these huge promises, like Alice is talking about, and then they think that they can, necessarily, buy the drugs through there and immediately get them shipped, what these third parties like Hims and Weight Watchers are doing a lot of with the GLP-1s. And that’s not how this works. You still have another step of getting a prescription and then going to the pharmacy and using these to potentially get discounts and lower prices, in the same way that these have been available from pharmaceutical manufacturers and other things like GoodRx for years. But it’s that disconnect between, even if you can get a discount, actually getting the discount and crediting the Trump administration for that that I think is going to be really difficult for a lot of voters to make that connection in the way that the administration wants them to. 

Rovner: And this was ever the case with rebates 鈥� for other consumer products, not just talking about drugs. We’ll give you a $15 rebate, but you have to fill out 87 forms and send it to this place and get it exactly right, do it before the end date, and we’ll send you back $15. Because they count on most people not being able or willing to follow all of the various steps. So instead of giving everybody the discounted price, they make you really basically work for your discount, which is a consumer thing, but it’s pretty popular in the drug space as well. Rather than just lowering prices, they’re going to say, We will give you a discount, but you’re going to have to do this, that, and the other thing in order to get it. 

Fortiér: Right. But when you’re president and you want credit for it, it’s going to be a little more 鈥� it’s harder in order to make that connection. Sorry. 

Rovner: Yes, that’s true. That is a good point. All right, moving on. We have talked a lot about consolidation in the health care industry, particularly companies like UnitedHealthcare, which used to be just an insurer, now owns its own PBM [pharmacy benefit manager], its own claims processing company, and thousands of medical practices around the country. Well, now an extremely unlikely pair in the Senate, Massachusetts Democrat Elizabeth Warren and Missouri Republican Josh Hawley, have joined to introduce something called the Break Up Big Medicine Act, which would basically outlaw so-called vertical integration, like that of United and, to a somewhat lesser extent, Cigna and CVS Health, which owns Aetna, the insurer. Some are referring to this as the health version of the 1932 Glass-Steagall Act, which separated commercial from investment banking 鈥� and, side note, whose repeal in 1999 is considered a major factor setting off the financial crisis of 2008. But that was a risk thing. It was done to prevent another stock market crash like the one in 1929. This is a cost thing. This is to go after high health care costs. Could it work? Could it pass? And is this the beginning of the next big thing in health reform? 

Lawrence: Perhaps. Yeah. Last year, I worked with my colleagues on  kind of examining UnitedHealth Group and the effects of consolidation on doctors and patients. And at the time, I think, there were some vocal lawmakers on either side of the aisle who were criticizing this, especially in the wake of the murder of the UnitedHealth CEO, and which had a surprising 鈥� the public sort of had this reaction and to鈥� 

Rovner: Not in United’s favor. 

Lawrence: Not in United’s favor. And so I think that there is, this is a political issue that affects everyone, Republican and Democrat, the, well, cost in general, but I think there’s a lot of resentment and anger, and it seems like that is bringing together these unlikely and pretty powerful senators. I’m not an expert on the Hill. I don’t know if this has a chance. Especially, it’s targeting massive, powerful companies with hands in every part of the health care system. So it’s something that you would imagine the entire health care industry would fight against. But, yeah, I don’t know. 

Rovner: And I will point out that Sen. Josh Hawley, in addition to all his anti-abortion activities, last year, when Congress was debating the Medicaid cuts, kept vowing not to vote for those Medicaid cuts. So he’s 鈥� which, of course, in the end, he did 鈥� but he’s been sort of on the consumer side of health care for a while now. It’s just this is not brand new to him. 

Lawrence: Right. And I’m not sure how many other Republican senators would follow him down this path. But it’s definitely a noteworthy development, and curious to see where it goes. 

Rovner: Yeah, I’m curious to see sort of if the populist part of health care costs sort of rises to the fore. We’ll have to, we will have to watch that space. Well, finally this week, more on the impact of the Trump administration’s immigration crackdowns and health. My 麻豆女优 Health News colleague Amy Maxmen has  about health professionals in the U.S. Public Health Service Commissioned Corps actually resigning rather than accepting postings to Guantánamo Bay, Cuba, where some immigrants are being detained in prisons that used to hold al-Qaida suspects. Another  by Claudia Boyd-Barrett describes how when people detained by ICE [Immigration and Customs Enforcement] end up in the hospital, often their immediate families and their lawyers aren’t even allowed to know where. And remember, last week we talked about cases of measles in some immigration detention facilities. Well, now there are two confirmed cases of tuberculosis at the ICE facility at Fort Bliss in El Paso, Texas. I’m thinking maybe the health part of this is starting to kind of get to people as much as the whole depriving-civil-liberties part. 

Fortiér: Yeah, and there’s also been cases of covid-19, which makes sense. You’re going to have respiratory viruses as you get hundreds of people grouped together. That makes sense. A judge in California a couple days ago ordered that there had to be adequate health provided to detainees in one specific California 鈥� it was a prison and now it’s an ICE detainee facility. That’s specific to there, but it’s 鈥� more and more senators, I think, are also looking at this and pointing out that they’re just not providing the health facilities that people need. And especially ongoing care 鈥� a lot of folks need diabetes treatment, and that treatment just isn’t really happening in many cases. 

Rovner: Yeah, we’ve talked about this at some length, over many weeks, that people in detention are not getting health care, even though it is required, that we keep hearing stories about people not getting needed health care. I didn’t know until I read this story that people who actually end up being hospitalized, that their family members are not allowed to know. That’s allegedly, well, it is because of security, because the idea is that if somebody who’s in detention is in a hospital, you don’t necessarily want bad people knowing that and being able to come to the hospital. But these are people often who are, as we have documented at length, do not have criminal records, and it’s hard to find out where they are. Alice, you wanted to add something. 

Ollstein: Yeah. So there was a recent GAO [Government Accountability Office] report about this, and it found that people were not getting evaluated when they entered a facility to see if they were medically vulnerable and at risk of having a really bad episode or emergency, and that even children, pregnant women, vulnerable populations weren’t getting that initial evaluation, which then led to problems down the road. And it also said that people upon their release 鈥� either deportation or release within the United States if that’s what a court ordered 鈥� they weren’t being given their medical records, their prescriptions. And so the continuity of care was disrupted. And it’s important to note that that GAO report was about a few years ago under the Biden administration. So this isn’t new. These problems aren’t new, but they’re getting much worse, because the number of people detained is at record levels and so everything’s just getting multiplied. 

Rovner: Yeah, it is. Well, we will keep watching that space. OK, that’s this week’s news. Before we get to our extra credits, I am pleased to present the winner of our annual 麻豆女优 Health News Health Policy Valentine contest. It’s from [Andrew Carleen] of Massachusetts, based on a story about Medicare Advantage overpayments. And it goes like this: “I thought it was love. My heart felt spring-loaded. Turns out our relationship was significantly upcoded.” Congratulations, and happy Valentine’s Day to all. 

OK, 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. Alice, why don’t you start us off this week? 

Ollstein: Sure. So I have a kind of fun story [“”] from my co-worker Amanda Chu about how the Oura ring has taken over D.C. They have been heavily lobbying the Trump administration and Congress to prevent tough regulations. Basically, there’s a debate about whether it should be regulated as a medical device or not. 

Rovner: Tell us again what it does. 

Ollstein: It’s a ring you wear on your finger that monitors different health metrics. And so the Trump administration MAHA movement has gone all in on this. They love it. The Pentagon has a huge contract with them. Other government agencies are looking at it, too. I think it’s interesting because it is this very sort of conservative mindset of individual responsibility in health care and, oh, if you could just track your own metrics and do the right things. That’s an approach that is sort of counter to the idea of public health and government protecting your health through policy. 

Rovner: And we know HHS Secretary Kennedy is a big fan of wearables. 

Ollstein: Exactly, and this is one of the most popular ones right now. And so this story does a good job digging into all the lobbying and also into concerns about data privacy and pointing out that these technologies are moving much faster than government can regulate them. And that is leaving some lawmakers really concerned about who could have access to this data. 

Rovner: Jackie. 

Fortiér: Mine is by Ariana Hendrix. She’s a writer based in Norway. It’s entitled “.” It was published in Stat. And she writes eloquently about being a parent in Norway and knowing that her children wouldn’t go to day care until they were about 16 months old, because Norway has paid parental leave. And she points out, beyond the vaccine debate there’s a bigger issue, that the U.S. lacks universal health care and federal paid parental leave. So changes in infant vaccines in the U.S. have a large effect, because babies in the U.S. often go to day care, when they’re around a lot of other kids when they’re just a few weeks old. So she points to the, in January, the infant RSV [respiratory syncytial virus] vaccine was moved to the high-risk category of shots, so now it isn’t routinely recommended for all babies in the U.S. And RSV, of course, is the most common cause of hospitalizations for infants, and that’s due to the fact that they’re exposed to the virus in day care a lot earlier than other children in other countries like Norway and Denmark whose vaccine schedules U.S. officials are now kind of trying to emulate. So she does a really great job of laying out how families face greater health and financial risks in the U.S. without the same safety net that other countries have. 

Rovner: Or just the same social policies that other countries have. 

Fortiér: Yeah, it reminded me鈥� 

Rovner: It’s hard to, right, it’s hard to import another country’s 鈥� part of another country’s 鈥� policies without importing all of them. It is really good story. Lizzy. 

Lawrence: Yeah. So my piece is by Rachana Pradhan and 麻豆女优 Health News, and it’s about the “” And I thought this piece was very interesting, just because in general I’ve been fascinated by 鈥� politicization of medicine isn’t new 鈥� but just like right-wing-coded products and left-wing-coded products. And in this piece, Rachana talks about NIH [National Institutes of Health] Director Jay Bhattacharya kind of talking about how, It’s the people’s NIH and if a lot of people are using it, well, we want to investigate it. So she just, she does a really good job of kind of unpacking why this is problematic, that they’re kind of just choosing a random medication and there’s not really any scientific reason to be investing in it as much as they are. And she got a response from NIH after the fact as well, kind of where they were trying to defend this decision to pour this much investment. And so, yeah, I think it’s just a really interesting development in NIH land. 

Rovner: It is. My extra credit this week is from ProPublica, by Mica Rosenberg, and it’s called “.” It’s about what immigration detention looks like from the point of view of children being held at a family facility in Dilley, Texas. That’s the one where the two cases of measles were diagnosed earlier this winter. The story includes some pretty wrenching letters and video calls from kids who were living elsewhere in the U.S., while their parents were mostly working within the immigration system. And these kids had been ripped from their daily lives, their other parents and siblings in some cases, their schools and their classmates, and in many cases, from hope itself. Wrote one 14-year-old from Hicksville, New York, quote: “Since I got to this Center all you will feel is sadness and mostly depression.” It really is a must-read story. 

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, 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 on X, , or on Bluesky, . Where are you folks hanging these days? Jackie. 

Fortiér: Bluesky mainly, . 

Rovner: Alice. 

Ollstein: Mainly on Bluesky, , and still on X, . 

Rovner: Lizzy. 

Lawrence: On X, . On Bluesky, . 

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