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

Julie Rovner: Hello, from 麻豆女优 Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, April 2, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: And Sandhya Raman, now at Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

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

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

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

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

Hellmann: Yeah, exactly. 

Rovner: Let’s not get into the details. 

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Power. 

Rovner: 鈥� power. For generations.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And what happened with this case? 

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

Rovner: One cent. 

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

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

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

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

Rosenthal: Thanks, Julie, for having me. 

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

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

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

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

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

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

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

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

Raman: On  and on  . 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

Rovner: Jessie. 

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

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

[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’re taping this week on Thursday, March 26, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via video conference by Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Lizzy Lawrence of Stat News. 

Lizzy Lawrence: Hello. 

Rovner: Later in this episode we’ll have my interview with Katie Keith of Georgetown University about the state of the Affordable Care Act as it turns 16 鈥� old enough to drive in most states. But first, this week’s news. 

So, it has been another busy week at the Department of Health and Human Services. Last week, a federal judge in Massachusetts blocked the department’s vaccine policy, ruling it had violated federal administrative procedures regarding advisory committees. This week, a federal judge in Portland, Oregon, ruled the department also didn’t follow the required process to block federal reimbursement for transgender-related medical treatment. The case was brought by 21 Democratic-led states. Where does this leave the hot-button issue of care for transgender teens? Shefali, you’ve been following this. 

Luthra: I mean, I think it’s still really up in the air. A lot of this depends on how hospitals now respond 鈥� whether they feel confident in the court’s decision, having staying power enough to actually resume offering services. Because a lot of them stopped. And so that’s something we’re still waiting to actually see how this plays out in practice. Obviously, it’s very symbolic, very legally meaningful, but whether this will translate into changes in practical health care access, I think, is an open question still. 

Rovner: Yeah, we will definitely have to see how this one plays out 鈥� and, obviously, if and when the administration appeals it. Well, speaking of that vaccine ruling from last week 鈥� which, apparently, the administration has not yet appealed, but is going to 鈥� one of the most contentious members of that very contentious Advisory Committee on Immunization Practices has resigned. Dr. Robert Malone, a physician and biochemist, said he didn’t want to be part of the “drama,” air quotes. But he caused a lot of the drama, didn’t he? 

Cohrs Zhang: He has been pretty outspoken, and I think he isn’t like a Washington person necessarily 鈥� isn’t somebody who’s used to, like, being on a public stage and having your social media posts appear in large publications. So I think it’s questionable, like, whether he had a position to resign from. I think his nomination was stayed, too. But I think it is 鈥� the back-and-forth, I think, there is a good point that this limbo can be frustrating for people when meetings are canceled at the last minute, and people have travel plans, and it does 鈥� just changes the calculus for kind of making it worth it to serve on one of these advisory committees. 

Rovner: And I’m not sure whether we mentioned it last week, but the judge’s ruling not only said that the people were incorrectly appointed to ACIP, but it also stayed any meetings of the advisory committee until there is further court action, until basically, the case is done or it’s overruled by a higher court. So 鈥� vaccine policy definitely is in limbo.  

Well, meanwhile, yesterday was the deadline for the administration to nominate someone to head the Centers for Disease Control and Prevention since Susan Monarez was abruptly dismissed, let go, resigned, whatever, late last summer. Now that that deadline has passed, it means that acting Director Jay Bhattacharya, who had added that title to his day job as head of the National Institutes of Health, can no longer remain acting director of CDC. Apparently, though he’s going to sort of remain in charge, according to HHS spokespeople, with some authorities reverting to [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.]. What’s taking so long to find a CDC director?  

To quote D.C. cardiologist and frequent cable TV health policy commentator , “The problem here is that there’s no candidate who’s qualified, MAHA acceptable, and Senate confirmable. Those job requirements are mutually exclusive.” That feels kind of accurate to me. Is that actually the problem? Rachel, I see you smiling. 

Cohrs Zhang: Yeah. I think it is tough to find somebody who checks all of those boxes. And though it has been 210 days since the clock has started, I would just point out that there has been a significant leadership shake-up at HHS, like among the people who are kind of running this search, and they came in, you know, not that long ago. It’s only been, you know, a month and a half or so. So I think there certainly have been some new faces in the room who might have different opinions. But I think it isn’t a good look for them to miss this deadline when they have this much notice. But I think there’s also, like, legal experts that I’ve spoken with don’t think that there’s going to be a huge day-to-day impact on the operations of the CDC. It kind of reminds me of that office where there’s, like, an “assistant to the regional manager vibe” going on, where, like, Dr. Bhattacharya is now acting in the capacity of CDC director, even though he isn’t acting CDC director anymore. So, I think I don’t know that it’ll have a huge day-to-day impact, but it is kind of hanging over HHS at this point, as they are already struggling with the surgeon general nomination, to get that through the Senate. So it just creates this backlog of nominations. 

Rovner: I’ve assumed they’ve floated some names, let us say, one of which is Ernie Fletcher, the former governor of Kentucky, also a former member of the House Energy and Commerce health subcommittee, with some certainly medical chops, if not public health chops. I think the head of the health department in Mississippi. There was one other who I’ve forgotten, who it is among the names that have been floated 鈥� 

Cohrs Zhang: Joseph Marine. He’s a cardiologist at Johns Hopkins, who has 鈥� is kind of like in the kind of Vinay Prasad world of critics of the FDA and, like, CDC’s covid booster strategy. 

Rovner: And yet, apparently, none of them could pass, I guess, all three tests. Do we think it might still be one of them? Or do we think there are other names that are yet to come? 

Cohrs Zhang: Our understanding is that there are other candidates whose names have not become public, and I think there’s also a possibility they don’t choose any of these candidates and just drag it on for a while because, at this point, like, I don’t know what the rush is, now that the deadline is passed. 

Lawrence: Yeah, is there another deadline to miss? 

Cohrs Zhang: I don’t think so. 

Lawrence: I think this was the only one. 

Cohrs Zhang: This was the big one that they now have. It’s vacant, but it was vacant before as well. Like, I think, earlier in the administration, when Susan Monarez was nominated. 

Rovner: But she, well 鈥� that’s right, she was the “acting,” and then once she was nominated, she couldn’t be the acting anymore. 

Cohrs Zhang: Yeah. 

Rovner: So I guess it was vacant while she was being considered. 

Cohrs Zhang: It was. So it’s not an unprecedented situation, even in this administration. It’s just not a good look, I guess. And I think there is value in having a leader that can interface with the White House and with different leaders, and just having a direction for the agency, especially because it’s in Atlanta, it’s a little bit more removed from the everyday goings-on at HHS in general. So I think there’s definitely a desire for some stability over there. 

Rovner: And we have measles spreading in lots more states. I mean, every time I 鈥� open up my news feeds, it’s like, oh, now we have measles, you know, in Utah, I think, in Montana. Washtenaw County, Michigan, had its first measles case recently. So this is something that the CDC should be on top of, and yet there is no one on top of the CDC. Well, Rachel, you already alluded to this, but it is also apparently hard to find a surgeon general who’s both acceptable to MAHA and Senate confirmable, which is my way of saying that the Casey Means nomination still appears to lack the votes to move out of the Senate, Health, Education, Labor & Pensions Committee. Do we have any latest update on that? 

Cohrs Zhang: I think the latest update, I mean, my colleagues at Bloomberg Government just kind of had an update this week that they’re still not to “yes” 鈥� like, there are some key senators that still haven’t announced their positions publicly. So I think a lot of the same things that we’ve been hearing 鈥� like Sens. Susan Collins and Lisa Murkowski and Bill Cassidy obviously have not stated their positions publicly on the nomination. Sen. Thom Tillis, who you know is kind of in a lame-duck scenario and doesn’t really have anything to lose, has, you know, said he’s not really made a decision. So I think they’re kind of in this weird limbo where they, like, don’t have the votes to advance her, but they also have not made a decision to pull the nomination at this time. So either, I think, they have to push harder on some of these senators, and I think senators see this as a leverage point that I don’t know that a lot of 鈥� that all of the complaints are about Dr. Means specifically, but anytime that there is frustration with the wider department, then this is an opportunity for senators to have their voice heard, to 鈥� potentially extract some concessions. And so there’s a question right now, are they going to change course again for this position, or are they going to, you know, sit down at the bargaining table and really cut some deals to advance her nomination? I just don’t think we know the answer to that yet. 

Rovner: Yeah, it’s worth reminding that, frequently, nominations get held up for reasons that are totally disconnected from the person involved. We went 鈥� I should go back and look this up 鈥� we went, like, four years in two different administrations without a confirmed head of the Centers for Medicare & Medicaid Services because members of Congress were angry about other things, not because of any of the people who had actually been nominated to fill that position. But in this case, it does seem to be, I think, both Casey Means and, you know, her connection to MAHA, and the fact that among those who haven’t declared their positions yet, it’s the chairman of the committee, Bill Cassidy, who’s in this very tight primary to keep his seat. So we will keep on that one.  

Also, meanwhile, HHS continues to push its Make America Healthy Again priority. Secretary Kennedy hinted on the Joe Rogan podcast last month that the FDA will soon take unspecified action to make customized peptides easier to obtain from compounding pharmacies. These mini-proteins are part of a biohacking trend that many MAHA adherents say can benefit health, despite their not having been shown to be safe and effective in the normal FDA approval process. The FDA has also formally pulled a proposed rule that would have banned teens from using tanning beds. We know that the secretary is a fan of tanning salons, even though that has been shown to cause potential health problems, like skin cancer. Lizzy, is Kennedy just going to push as much MAHA as he can until the courts or the White House stops him? 

Lawrence: I guess so. I mean, we do have this new structure at HHS now that’s trying to 鈥� clearly 鈥� there are warring factions with the MAHA agenda and the White House really trying to focus more on affordability and less on 鈥� vaccine scrutiny and the medical freedom movement that is really popular among Kennedy’s supporters. 鈥� I’m very curious about what’s going to happen with peptides, because it’s a sign of Kennedy’s regulatory philosophy, where there’s some products that are good and some that are bad. It’s very atypical, of course, for 鈥� 

Rovner: And that he gets to decide rather than the scientists, because he doesn’t trust the scientists. 

Lawrence: Right. Right. But there has been, I mean, the FDA has kind of been pretty severe on GLP-1 compounders Hims & Hers, so it’ll be interesting to see, you know, how much Kennedy is able to exert his will here, and how much FDA regulators will be able to push back and make their voices heard. 

Rovner: My favorite piece of FDA trivia this week is that FDA is posting the jobs that are about to be vacant at the vaccine center, and one of the things that it actually says in the job description is that you don’t have to be immunized. I don’t know if that’s a signal or what. 

Lawrence: Yeah, I think it said no telework, which Vinay Prasad famously was teleworking from San Francisco. So, yeah, I don’t know. But this was, I think it was for his deputy, although I’m sure, I mean, they do need a CBER [Center for Biologics Evaluation and Research] director as well. 

Rovner: Yeah, there’s a lot of openings right now at HHS. All right, we’re gonna take a quick break. We will be right back. 

So Monday was the 16th anniversary of the signing of the Affordable Care Act, which we will hear more about in my interview with Katie Keith. But I wanted to highlight a story by my 麻豆女优 Health News colleague Sam Whitehead about older Americans nearing Medicare eligibility putting off preventive and other care until they qualify for federal coverage that will let them afford it. For those who listened to my interview last week with Drew Altman, this hearkens back to one of the big problems with our health system. There are so many quote-unquote “savings” that are actually just cost-shifting, and often that cost-shifting raises costs overall. In this case, because those older people can no longer afford their insurance or their deductibles, they put off care until it becomes more expensive to treat. At that point, because they’re on Medicare, the federal taxpayer will foot a bill that’s even bigger than the bill that would have been paid by the insurance company. So the savings taxpayers gained by Congress cutting back the Affordable Care Act subsidies are lost on the Medicare end. Is this cost-shifting the inevitable outcome of addressing everything in our health care system except the actual prices of medical care? 

Cohrs Zhang: I think it’s just another example of how people’s behavior responds to these weird incentives. And I think we’re seeing this problem, certainly among early retirees, exacerbated by the expiration of the Affordable Care Act subsidies that we’ve talked about very often on this podcast, because it affects these higher earners, and it can dramatically increase costs for coverage. And I think people just hope that they can hold on. But again, these statutory deadlines that lawmakers make up sometimes, not with a lot of forethought or rational reasoning, they have consequences. And obviously, the Medicare program continues to pay beyond age 65 as well. And I think it’s just another symptom of what the administration talks about when they talk about emphasizing, you know, preventative care and addressing chronic conditions 鈥� like, that is a real problem. And, yeah, I think we’re going to see these problems in this population continue to get worse as more people forgo care, as it becomes more expensive on the individual markets. 

Luthra: I think you also make a good point, though, Julie, because the increase in costs and cost sharing is not limited to people with marketplace plans, right? Also, people with employer-sponsored health care are seeing their out-of-pocket costs go up. Employers are seeing what they pay for insurance go up as well. And there absolutely is something to be said about it’s been 16 years since the Affordable Care Act passed, we haven’t really had meaningful intervention on the key source of health care prices, right? Hospitals, providers, physicians. And it does seem, just thinking about where the public is and the politics are, that there is possibly appetite around this. You see a lot of talk about affordability, but a lot of this feels, at least as an observer, very focused on insurance, which makes sense. Insurance is a very easy villain to cast. But I think you’ve raised a really good point: that addressing these really potent burdens on individuals and eventually on the public just requires something more systemic and more serious if we actually want to yield better outcomes. 

Rovner: Yeah, there’s just, there’s so much passing the hat that, you know, I don’t want to do this, so you have to do this. You know, inevitably, people need health care. Somebody has to pay for it. And I think that’s sort of the bottom line that nobody really seems to want to address. 

Well, the other theme of 2026 that I feel like I keep repeating is what funding cutbacks and other changes are doing to the future of the nation’s biomedical and medical workforces. Last week was Match Day. That’s when graduating medical school seniors find out if and where they will do their residency training. One big headline from this year’s match is that the percentage of non-U.S. citizen graduates of foreign medical schools matching to a U.S. residency position fell to a five-year low of 56.4%. That compares to a 93.5% matching rate for U.S. citizen graduates of U.S. medical schools. Why does that matter? Well, a quarter of the U.S. physician workforce are immigrants, and they are disproportionately represented, both in lower-paid primary care specialties, particularly in rural areas, both of which U.S. doctors tend to find less desirable. This would seem to be the result of a combination of new fees for visas for foreign professionals that we’ve talked about, a general reduction in visa approvals, and some people likely not wanting to even come to the U.S. to practice. But that rural health fund that Republicans say will revitalize rural health care doesn’t seem like it’s really going to work without an adequate number of doctors and nurses, I would humbly suggest. 

Lawrence: Yeah, absolutely. I mean, it’s patients that suffer, right? I mean, you need the people doing the work. And so I think that the impacts will start being felt sooner rather than later. That is something that hopefully people will start to feel the pain from. 

Rovner: I feel like when people think about the immigrant workforce, they think about lower-skilled, lower-paid jobs that immigrants do, and they don’t think about the fact that some of the most highly skilled, highly paid jobs that we have, like being doctors, are actually filled by immigrants, and that if we cut that back, we’re just going to exacerbate shortages that we already know we have. 

Luthra: And training doctors takes, famously, a very long time. And so if you are disincentivizing people from coming here to practice, cutting off this key source of supply, it’s not as if you can immediately go out and say, Here, let’s find some new people and make them doctors. It will take years to make that tenable, make that attractive, and make that a reality. And it just seems, to Lizzy’s point, that even in the scenario where that was possible 鈥� which I would be somewhat doubtful; medicine is a hard and difficult career; it’s not like you can make someone want to do that overnight 鈥� patients will absolutely see the consequences. I don’t know if it’s enough to change how people think about immigration policy and ways in which we recruit and engage with immigrant workers, but it’s absolutely something that should be part of our discussion. 

Rovner: Yeah, and I think it’s been left out. Well, meanwhile, over at the National Institutes of Health, a , Lizzy, found that more than a quarter have laid off laboratory workers. More than 2 in 5 have canceled research, and two-thirds have counseled students to consider careers outside of academic research. A separate study published this week found that women and early-career scientists have been disproportionately affected by the NIH cuts, even though most of the money goes to men and to later-career scientists. As I keep saying, this isn’t just about the future of science. Biomedical research is a huge piece of the U.S. economy. Earlier this month, the group United for Medical Research , finding that every dollar invested produced $2.57 for the economy. Concerned members of Congress from both parties last week at an appropriations hearing got NIH Director Jay Bhattacharya to again promise to push all the money that they appropriated out the door. But it’s not clear whether it’s going to continue to compromise the future workforce. I feel like, you know, we talk about all these missing people and nomination stuff, but we’re not really talking a lot about what’s going on at the National Institutes of Health, which is a, you know, almost $50 billion-a-year enterprise. 

Lawrence: Right. In some labs, the damage has already been done. You know, even if Dr. Bhattacharya [follows through], try spending all the money that has been appropriated. There are young researchers that have been shut out and people that have had to choose alternative career paths. And I think this is one of those things that’s difficult politically or, you know, in the public consciousness, because it is hard to see the immediate impacts it’s measured. And I think my colleague Jonathan wrote [that] breakthroughs are not discovered things, you know. So it’s hard to know what is being missed. But the immediate impact of the workforce and not missing this whole generation of scientists that has decided to go to another country or go to do something else, those impacts will be felt for years to come. 

Rovner: Yeah, this is another one where you can’t just turn the spigot back on and have it immediately refill.  

Finally, this week, there is always reproductive health news. This week, we got the Alan Guttmacher Institute’s  for the year 2025, which both sides of the debate consider the most accurate, and it found that for the second year in a row, the number of abortions in the U.S. remained relatively stable, despite the fact that it’s outlawed or seriously restricted in nearly half the states. Of course, that’s because of the use of telehealth, which abortion opponents are furiously trying to get stopped, either by the FDA itself or by Congress. Last week, anti-abortion Sen. Josh Hawley of Missouri introduced legislation that would basically rescind approval for the abortion pill mifepristone. But that legislation is apparently giving some Republicans in the Senate heartburn, as they really don’t want to engage this issue before the midterms. And, apparently, the Trump administration doesn’t either, given what we know about the FDA saying that they’re still studying this. On the other hand, Republicans can’t afford to lose the backing of the anti-abortion activists either. They put lots of time, effort, and money into turning out votes, particularly in times like midterms. How big a controversy is this becoming, Shefali? 

Luthra: This is a huge controversy, and it’s so interesting to watch this play out. When I saw Sen. Hawley’s bill, I mean, that stood out to me as positioning for 2028. He clearly wants to be a favorite among the anti-abortion movement heading into a future presidential primary. But at the same time, this is teasing out really potent and powerful dynamics among the anti-abortion movement and Republican lawmakers, exactly what you said. Republican lawmakers know this is not popular. They do not want to talk about abortion, an issue at which they are at a huge disadvantage with the public. Susan B Anthony List and other such organizations are trying to make the argument that if they are taken for granted, as they feel as if they are, that will result in an enthusiasm gap. Right? People will not turn out. They will not go door-knocking, they won’t deploy their tremendous resources to get victories in a lot of these contested, particularly Senate and House, races. And obviously, the president cares a lot about the midterms. He’s very concerned about what happens when Democrats take control of Congress. But I think what Republicans are wagering, and it’s a fair thought, is that where would anti-abortion activists go? Are they going to go to Democrats, who largely support abortion rights? And a lot of them seem confident that they would rather risk some people staying home and, overall, not alienating a very large sector of the American public that does not support restrictions on abortion nationwide, especially those that many are concerned are not in keeping with the actual science. 

Rovner: Yeah, I think the White House, as you said, would like to make this not front and center, let’s put it that way, for the midterms. But yeah, and just to be clear, I mean, Sen. Hawley introduced this bill. It can’t pass. There’s no way it gets 60 votes in the Senate. I’d be surprised if it could get 50 votes in the Senate. So he’s obviously doing this just to turn up the heat on his colleagues, many of whom are not very happy about that. 

Luthra: And anti-abortion activists are already thinking about 2028. They are, in fact, talking to people like Sen. Hawley, like the vice president, like Marco Rubio, trying to figure out who will actually be their champion in a post-Trump landscape. And so far, what I’m hearing, is that they are very optimistic that anyone else could be better for them than the president is because they are just so dissatisfied with how little they’ve gotten. 

Rovner: Although they did get the overturn of Roe v. Wade. 

Luthra: That’s true. 

Rovner: But you know, it goes back to sort of my original thought for this week, which is that the number of abortions isn’t going down because of the relatively easy availability of abortion pills by mail. Well, speaking of which, in a somewhat related story, a woman in Georgia has been charged with murder for taking abortion pills later in pregnancy than it’s been approved for, and delivering a live fetus who subsequently died. But the judge in the case has already suggested the prosecutors have a giant hill to climb to convict her and set her bail at $1. Are we going to see our first murder trial of a woman for inducing her own abortion? We’ve been sort of flirting with this possibility for a while. 

Luthra: It seems possible. I think it’s a really good question, and this moment certainly feels like a possible Rubicon, because going after people who get abortions is just so toxic for the anti-abortion movement. They have promised they would not go after people who are pregnant, who get abortions. And this is exactly what they are doing. And I think what really stands out to me about this case is so much of it depends on individual prosecutors and individual judges. You have the law enforcement officials who decided to make this a case, and they’re actually using, not the abortion law, even though the language in the case, right, really resonates, reflects with the law in Georgia’s six-week ban. Excuse me, with the language in Georgia’s six-week ban. But then you have a judge who says this is very suspect. And what feels so significant is that your rights and your protection under abortion laws depend not only on what state you live in, but who happens to be the local prosecutor, the local cop, the local judge, and that’s just a level of micro-precision that I think a lot of Americans would be very surprised to realize they live under. 

Rovner: Yeah, absolutely. We should point out that the woman has been charged but not yet indicted, because many, many people are watching this case very, very carefully. And we will too. 

All right, that is this week’s news. Now I’ll play my interview with Katie Keith of Georgetown University Law Center, and then we’ll come back with our extra credits. 

I am pleased to welcome back to the podcast Katie Keith. Katie is the founding director of the Center for Health Policy and the Law at the Georgetown University Law Center and a contributing editor at Health Affairs, where she keeps all of us up to date on the latest health policy, legal happenings. Katie, thanks for joining us again. It’s been a minute. 

Katie Keith: Yeah. Thanks for having me, Julie, and happy ACA anniversary. 

Rovner: So you are my go-to for all things Affordable Care Act, which is why I wanted you this week in particular, when the health law turned 16. How would you describe the state of the ACA today? 

Keith: Yeah, it’s a great question. So, the ACA remains a hugely important source of coverage for millions of people who do not have access to job-based coverage. I am thinking of farmers, and self-employed people, and small-business owners. And you know, in 2025, more than 24 million people relied on the marketplaces all across the country for this coverage. So it remains a hugely important place where people get their health insurance. And we are already starting to see real erosion in the gains made under the Biden administration as a result of, I think, three primary changes that were made in 2025. So the first would be Congress’ failure to extend the enhanced premium tax credits, which you have covered a ton, Julie and the team, as having a huge impact there. The second is the changes from the One Big Beautiful Bill Act. And then the third is some of the administrative changes made by the Trump administration that we’re already seeing. So we don’t yet have full data to understand the impact of all three of those things yet. We’re still waiting. But the preliminary data shows that already enrollments down by more than a million people. I’m expecting that to drop further. There was some 麻豆女优 survey data out last week that about 1 in 10 people are going uninsured from the marketplace already, and that’s not even, doesn’t even account for all the people who are paying more but getting less, which their survey data shows is about, you know, 3 in 10 folks. So you know what makes all of this really, really tough, as you and I have discussed before, is, I think, 2025, was really a peak year. We saw peak enrollment at the ACA. We saw peak popularity of the law, which has been more popular than not ever since 2017, when Republicans in Congress tried to repeal it the first time. And 鈥� but now it feels like we’re sort of on this precipice for 2026, watching what’s going to happen with the data into this really important source of coverage for so many people. 

Rovner: And 鈥� there’s been so much news that I think it’s been hard for people to absorb. You know, in 2017, when Republicans tried to repeal the Affordable Care Act, they said that, We’re trying to repeal the Affordable Care Act. Well, the 2025 you know, “Big, Beautiful Bill,” they didn’t call it a repeal, but it had pretty much the same impact, right? 

Keith: It had a quite significant impact. And I think a lot, like, you know, there was so much coverage about how Democrats in Congress and the White House learned, in doing the Affordable Care Act, learned from the failed effort of the Clinton health reform in the ’90s. I think similarly here you saw Republicans in Congress, in the White House, learn from the failed effort in 2017 to be successful here. And so you’re exactly right. You did not hear any talk of “repeal and replace,” by any stretch of the imagination. I think in 2017 Republicans were judged harshly 鈥� and appropriately so, in my opinion 鈥� by the “replace” portion of what, you know, what they were going to do, and it just wasn’t there. And so you did not see that kind of framing this time around. Instead, it really is an attempt to do death by a thousand paper cuts and impose administrative burdens and a real focus on kind of who 鈥� you can’t see me, but air quotes, you know 鈥� who “deserves” coverage and a focus on immigrant populations. So 鈥� those changes, when you layer all of them on 鈥� changes to Medicaid coverage, Medicaid financing, paperwork burdens, all across all these different programs 鈥� you know, the One Big Beautiful Bill Act, it really does erect new barriers that fundamentally change how Medicaid and the Affordable Care Act will work for people. And so it’s not repealed. I think those programs will still be there, but they will look very different than how they have and, you know, the CBO [Congressional Budget Office] at the time, the coverage losses almost 鈥� they look quite close to, you know, the skinny repeal that we all remember in the middle of the morning 鈥� early, like, late night, Sen. John McCain with his thumbs down. The coverage losses were almost the same, and you’ve got the CBO now saying, estimating about 35 million uninsured people by 2028, which, you know, is not 鈥� it’s just erasing, I think, not all, but a lot of the gains we’ve made over the past 15, now 16, years under the Affordable Care Act. 

Rovner: And now the Trump administration is proposing still more changes to the law, right? 

Keith: Yep, that’s right. They’re continuing, I think, a lot of the same. There’s several changes that, you know, go back to the first Trump administration that they’re trying to reimpose. Others are sort of new ideas. I’m thinking some of the same ideas are some of the paperwork burdens. So really, in some cases, building off of what has been pushed in Congress. What’s maybe new this time around for 2027 that they’re pushing is a significant expansion of catastrophic plans. So huge, huge, high-deductible plans that, you know, really don’t cover much until you hit tens of thousands of dollars in out-of-pocket costs. You get your preventive services and three primary care visits, but that’s it. You’re on the hook for anything else you might need until you hit these really catastrophic costs. They’re punting to the states on core things like network adequacy. You know, again, some of it’s sort of new. Some of it’s a throwback to the first Trump administration, so not as surprising. And then on the legislative front, I don’t know what the prospects are, but you do continue to see President [Donald] Trump call for, you know, health savings account expansions. We think, I think, you know, the idea is to send people money to buy coverage, rather than send the money to the insurers, which I think folks have interpreted as health savings accounts. There’s a continued focus on funding cost-sharing reductions, but that issue continues to be snarled by abortion restrictions across the country. So that’s something that continues to be discussed, but I don’t know if it will ever happen. And you know anything else that’s kind of under the so-called Great Healthcare Plan that the White House has put out. 

Rovner: You mentioned that 2025 was the peak not just of enrollment but of popularity. And we have seen in poll after poll that the changes that the Trump administration and Congress is making are not popular with the public, including the vast majority of independents and many, many Republicans as well. Is there any chance that Congress and President Trump might relent on some of these changes between now and the midterms? We did see a bunch of Republicans, you know, break with the rest of the party to try to extend the, you know, the enhanced premiums. Do you see any signs that they’re weakening or are we off onto other things entirely right now? 

Keith: It’s a great question. I think you probably need a different analyst to ask that question to. I don’t think my crystal ball covers those types of predictions. But to your point, Julie, I thought that if there would have been time for a compromise and sort of a path forward, it would have been around the enhanced premium tax credits. And it was remarkable, you know, given what the history of this law has been and the politics surrounding it, to see 17 Republicans join all Democrats in the House to vote for a clean three-year extension of the premium tax credits. But no, I think especially thinking about where those enhanced tax credits have had the most benefit, it is states like Georgia, Florida, Texas, and I thought that maybe would, could have moved the needle if there was a needle to be moved. So I, it seems like there’s much more focus on prescription drugs and other issues, but anything can happen. So I guess we’ll all stay tuned. 

Rovner: Well, we’ll do this again for the 17th anniversary. Katie Keith, thank you so much. 

Keith: Thanks, Julie. 

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

Lawrence: Sure. So my extra credit is by Nick [Nicholas] Florko, former Stat-ian, in The Atlantic, “” I immediately read this piece, because this is something that’s been driving me kind of crazy. Just seeing 鈥� if you’ve missed it 鈥� there have been 鈥� HHS has been posting AI-generated videos of Secretary Kennedy wrestling a Twinkie, wearing waterproof jeans, all of these things. And this has been, this is not unique to HHS 鈥� [the] White House in general has really embraced AI slop as a genre, and I can’t look away. And so I thought Nick did a good job just acknowledging how crazy this is, and then also what goes unsaid in these videos. I think I personally am just very curious if this resonates with people, or if it’s kind of disconcerting for the average American seeing these videos like, Oh, my government is making AI slop. Like I, you know, social media strategy is so important, so maybe for some people are really liking this. But yeah, I’m just kind of curious about public sentiment. 

Rovner: I know I would say, you know, the National Park Service and the Consumer Product Safety Commission have been sort of famous for their very cutesy social media posts, but not quite to this extent. I mean, it’s one thing to be cheeky and funny. This is sort of beyond cheeky and funny. I agree with you. I have no idea how this is going over the public, but they keep doing it. It’s a really good story. Rachel. 

Cohrs Zhang: Mine is a story in The Boston Globe, and the headline is “” by Tal Kopan. And this was a really good profile of Tony Lyons, who is Robert F. Kennedy Jr.’s book publisher, and he’s kind of had the role of institutionalizing all the political energy behind RFK Jr. and trying to make this into a more enduring political force. So I think he is, like, mostly a behind-the-scenes guy, not really like a D.C. fixture, more of like a New York book publishing figure. But I think his efforts and what they’re using, all the money they’re raising for, I think, is a really important thing to watch in the midterms, and like, whether they can actually leverage this beyond a Trump administration, or beyond however long Secretary Kennedy will be in his position. So I think it was just a good overview of all the tentacles of institutional MAHA that are trying to, you know, find their footing here, potentially for the long term.  

Rovner: I had never heard of him, so I was glad to read this story. Shefali. 

Luthra: My story is from NPR. It is by Tara Haelle. The headline is “.” Story says exactly what it promises, that if you have an infant, babies under 6 months, then getting a covid vaccine while you are pregnant will actually protect your baby, which is great because there is no vaccine for infants that young. I love this because it’s a good reminder of something that we were starting to see, and now it just really underscores that this is true, and in the midst of so much conversation around vaccines and safety and effectiveness, it’s a reminder that really, really good research can show us that it is a very good idea to take this vaccine, especially if you are pregnant. 

Rovner: More fodder for the argument, I guess. All right, my extra credit this week is a clever story from Stat’s John Wilkerson called “.” And, spoiler, that loophole is that one way companies can avoid running afoul of their promise not to charge other countries less for their products than they charge U.S. patients is for them to simply delay launching those drugs in those other countries that have price controls. Already, most drugs are launched in the U.S. first, and apparently some of the companies that have done deals with the administration limited their promises to three years, anyway. That way they can charge U.S. consumers however much they think the market will bear before they take their smaller profits overseas. Like I said, clever. Maybe that’s why so many companies were ready to do those deals. 

All right, that is this week’s show. As always, thanks to our editor, Emmarie Huetteman; our producer-engineer, Francis Ying; and our interview producer, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, 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 folks hanging these days? Shefali? 

Luthra: I am on Bluesky . 

Rovner: Rachel. 

Cohrs Zhang: On X , or . 

Rovner: Lizzy. 

Lawrence: I’m on X  and  and . 

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

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

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

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

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

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

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

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

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

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

Julie Rovner: Hello, from 麻豆女优 Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, April 2, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

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

Alice Miranda Ollstein: Hello. 

Rovner: Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: And Sandhya Raman, now at Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

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

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

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

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

Hellmann: Yeah, exactly. 

Rovner: Let’s not get into the details. 

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Power. 

Rovner: 鈥� power. For generations.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: And what happened with this case? 

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

Rovner: One cent. 

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

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

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

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

Rosenthal: Thanks, Julie, for having me. 

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

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

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

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

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

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

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

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

Raman: On  and on  . 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

Rovner: Jessie. 

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

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

[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’re taping this week on Thursday, March 26, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via video conference by Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Lizzy Lawrence of Stat News. 

Lizzy Lawrence: Hello. 

Rovner: Later in this episode we’ll have my interview with Katie Keith of Georgetown University about the state of the Affordable Care Act as it turns 16 鈥� old enough to drive in most states. But first, this week’s news. 

So, it has been another busy week at the Department of Health and Human Services. Last week, a federal judge in Massachusetts blocked the department’s vaccine policy, ruling it had violated federal administrative procedures regarding advisory committees. This week, a federal judge in Portland, Oregon, ruled the department also didn’t follow the required process to block federal reimbursement for transgender-related medical treatment. The case was brought by 21 Democratic-led states. Where does this leave the hot-button issue of care for transgender teens? Shefali, you’ve been following this. 

Luthra: I mean, I think it’s still really up in the air. A lot of this depends on how hospitals now respond 鈥� whether they feel confident in the court’s decision, having staying power enough to actually resume offering services. Because a lot of them stopped. And so that’s something we’re still waiting to actually see how this plays out in practice. Obviously, it’s very symbolic, very legally meaningful, but whether this will translate into changes in practical health care access, I think, is an open question still. 

Rovner: Yeah, we will definitely have to see how this one plays out 鈥� and, obviously, if and when the administration appeals it. Well, speaking of that vaccine ruling from last week 鈥� which, apparently, the administration has not yet appealed, but is going to 鈥� one of the most contentious members of that very contentious Advisory Committee on Immunization Practices has resigned. Dr. Robert Malone, a physician and biochemist, said he didn’t want to be part of the “drama,” air quotes. But he caused a lot of the drama, didn’t he? 

Cohrs Zhang: He has been pretty outspoken, and I think he isn’t like a Washington person necessarily 鈥� isn’t somebody who’s used to, like, being on a public stage and having your social media posts appear in large publications. So I think it’s questionable, like, whether he had a position to resign from. I think his nomination was stayed, too. But I think it is 鈥� the back-and-forth, I think, there is a good point that this limbo can be frustrating for people when meetings are canceled at the last minute, and people have travel plans, and it does 鈥� just changes the calculus for kind of making it worth it to serve on one of these advisory committees. 

Rovner: And I’m not sure whether we mentioned it last week, but the judge’s ruling not only said that the people were incorrectly appointed to ACIP, but it also stayed any meetings of the advisory committee until there is further court action, until basically, the case is done or it’s overruled by a higher court. So 鈥� vaccine policy definitely is in limbo.  

Well, meanwhile, yesterday was the deadline for the administration to nominate someone to head the Centers for Disease Control and Prevention since Susan Monarez was abruptly dismissed, let go, resigned, whatever, late last summer. Now that that deadline has passed, it means that acting Director Jay Bhattacharya, who had added that title to his day job as head of the National Institutes of Health, can no longer remain acting director of CDC. Apparently, though he’s going to sort of remain in charge, according to HHS spokespeople, with some authorities reverting to [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.]. What’s taking so long to find a CDC director?  

To quote D.C. cardiologist and frequent cable TV health policy commentator , “The problem here is that there’s no candidate who’s qualified, MAHA acceptable, and Senate confirmable. Those job requirements are mutually exclusive.” That feels kind of accurate to me. Is that actually the problem? Rachel, I see you smiling. 

Cohrs Zhang: Yeah. I think it is tough to find somebody who checks all of those boxes. And though it has been 210 days since the clock has started, I would just point out that there has been a significant leadership shake-up at HHS, like among the people who are kind of running this search, and they came in, you know, not that long ago. It’s only been, you know, a month and a half or so. So I think there certainly have been some new faces in the room who might have different opinions. But I think it isn’t a good look for them to miss this deadline when they have this much notice. But I think there’s also, like, legal experts that I’ve spoken with don’t think that there’s going to be a huge day-to-day impact on the operations of the CDC. It kind of reminds me of that office where there’s, like, an “assistant to the regional manager vibe” going on, where, like, Dr. Bhattacharya is now acting in the capacity of CDC director, even though he isn’t acting CDC director anymore. So, I think I don’t know that it’ll have a huge day-to-day impact, but it is kind of hanging over HHS at this point, as they are already struggling with the surgeon general nomination, to get that through the Senate. So it just creates this backlog of nominations. 

Rovner: I’ve assumed they’ve floated some names, let us say, one of which is Ernie Fletcher, the former governor of Kentucky, also a former member of the House Energy and Commerce health subcommittee, with some certainly medical chops, if not public health chops. I think the head of the health department in Mississippi. There was one other who I’ve forgotten, who it is among the names that have been floated 鈥� 

Cohrs Zhang: Joseph Marine. He’s a cardiologist at Johns Hopkins, who has 鈥� is kind of like in the kind of Vinay Prasad world of critics of the FDA and, like, CDC’s covid booster strategy. 

Rovner: And yet, apparently, none of them could pass, I guess, all three tests. Do we think it might still be one of them? Or do we think there are other names that are yet to come? 

Cohrs Zhang: Our understanding is that there are other candidates whose names have not become public, and I think there’s also a possibility they don’t choose any of these candidates and just drag it on for a while because, at this point, like, I don’t know what the rush is, now that the deadline is passed. 

Lawrence: Yeah, is there another deadline to miss? 

Cohrs Zhang: I don’t think so. 

Lawrence: I think this was the only one. 

Cohrs Zhang: This was the big one that they now have. It’s vacant, but it was vacant before as well. Like, I think, earlier in the administration, when Susan Monarez was nominated. 

Rovner: But she, well 鈥� that’s right, she was the “acting,” and then once she was nominated, she couldn’t be the acting anymore. 

Cohrs Zhang: Yeah. 

Rovner: So I guess it was vacant while she was being considered. 

Cohrs Zhang: It was. So it’s not an unprecedented situation, even in this administration. It’s just not a good look, I guess. And I think there is value in having a leader that can interface with the White House and with different leaders, and just having a direction for the agency, especially because it’s in Atlanta, it’s a little bit more removed from the everyday goings-on at HHS in general. So I think there’s definitely a desire for some stability over there. 

Rovner: And we have measles spreading in lots more states. I mean, every time I 鈥� open up my news feeds, it’s like, oh, now we have measles, you know, in Utah, I think, in Montana. Washtenaw County, Michigan, had its first measles case recently. So this is something that the CDC should be on top of, and yet there is no one on top of the CDC. Well, Rachel, you already alluded to this, but it is also apparently hard to find a surgeon general who’s both acceptable to MAHA and Senate confirmable, which is my way of saying that the Casey Means nomination still appears to lack the votes to move out of the Senate, Health, Education, Labor & Pensions Committee. Do we have any latest update on that? 

Cohrs Zhang: I think the latest update, I mean, my colleagues at Bloomberg Government just kind of had an update this week that they’re still not to “yes” 鈥� like, there are some key senators that still haven’t announced their positions publicly. So I think a lot of the same things that we’ve been hearing 鈥� like Sens. Susan Collins and Lisa Murkowski and Bill Cassidy obviously have not stated their positions publicly on the nomination. Sen. Thom Tillis, who you know is kind of in a lame-duck scenario and doesn’t really have anything to lose, has, you know, said he’s not really made a decision. So I think they’re kind of in this weird limbo where they, like, don’t have the votes to advance her, but they also have not made a decision to pull the nomination at this time. So either, I think, they have to push harder on some of these senators, and I think senators see this as a leverage point that I don’t know that a lot of 鈥� that all of the complaints are about Dr. Means specifically, but anytime that there is frustration with the wider department, then this is an opportunity for senators to have their voice heard, to 鈥� potentially extract some concessions. And so there’s a question right now, are they going to change course again for this position, or are they going to, you know, sit down at the bargaining table and really cut some deals to advance her nomination? I just don’t think we know the answer to that yet. 

Rovner: Yeah, it’s worth reminding that, frequently, nominations get held up for reasons that are totally disconnected from the person involved. We went 鈥� I should go back and look this up 鈥� we went, like, four years in two different administrations without a confirmed head of the Centers for Medicare & Medicaid Services because members of Congress were angry about other things, not because of any of the people who had actually been nominated to fill that position. But in this case, it does seem to be, I think, both Casey Means and, you know, her connection to MAHA, and the fact that among those who haven’t declared their positions yet, it’s the chairman of the committee, Bill Cassidy, who’s in this very tight primary to keep his seat. So we will keep on that one.  

Also, meanwhile, HHS continues to push its Make America Healthy Again priority. Secretary Kennedy hinted on the Joe Rogan podcast last month that the FDA will soon take unspecified action to make customized peptides easier to obtain from compounding pharmacies. These mini-proteins are part of a biohacking trend that many MAHA adherents say can benefit health, despite their not having been shown to be safe and effective in the normal FDA approval process. The FDA has also formally pulled a proposed rule that would have banned teens from using tanning beds. We know that the secretary is a fan of tanning salons, even though that has been shown to cause potential health problems, like skin cancer. Lizzy, is Kennedy just going to push as much MAHA as he can until the courts or the White House stops him? 

Lawrence: I guess so. I mean, we do have this new structure at HHS now that’s trying to 鈥� clearly 鈥� there are warring factions with the MAHA agenda and the White House really trying to focus more on affordability and less on 鈥� vaccine scrutiny and the medical freedom movement that is really popular among Kennedy’s supporters. 鈥� I’m very curious about what’s going to happen with peptides, because it’s a sign of Kennedy’s regulatory philosophy, where there’s some products that are good and some that are bad. It’s very atypical, of course, for 鈥� 

Rovner: And that he gets to decide rather than the scientists, because he doesn’t trust the scientists. 

Lawrence: Right. Right. But there has been, I mean, the FDA has kind of been pretty severe on GLP-1 compounders Hims & Hers, so it’ll be interesting to see, you know, how much Kennedy is able to exert his will here, and how much FDA regulators will be able to push back and make their voices heard. 

Rovner: My favorite piece of FDA trivia this week is that FDA is posting the jobs that are about to be vacant at the vaccine center, and one of the things that it actually says in the job description is that you don’t have to be immunized. I don’t know if that’s a signal or what. 

Lawrence: Yeah, I think it said no telework, which Vinay Prasad famously was teleworking from San Francisco. So, yeah, I don’t know. But this was, I think it was for his deputy, although I’m sure, I mean, they do need a CBER [Center for Biologics Evaluation and Research] director as well. 

Rovner: Yeah, there’s a lot of openings right now at HHS. All right, we’re gonna take a quick break. We will be right back. 

So Monday was the 16th anniversary of the signing of the Affordable Care Act, which we will hear more about in my interview with Katie Keith. But I wanted to highlight a story by my 麻豆女优 Health News colleague Sam Whitehead about older Americans nearing Medicare eligibility putting off preventive and other care until they qualify for federal coverage that will let them afford it. For those who listened to my interview last week with Drew Altman, this hearkens back to one of the big problems with our health system. There are so many quote-unquote “savings” that are actually just cost-shifting, and often that cost-shifting raises costs overall. In this case, because those older people can no longer afford their insurance or their deductibles, they put off care until it becomes more expensive to treat. At that point, because they’re on Medicare, the federal taxpayer will foot a bill that’s even bigger than the bill that would have been paid by the insurance company. So the savings taxpayers gained by Congress cutting back the Affordable Care Act subsidies are lost on the Medicare end. Is this cost-shifting the inevitable outcome of addressing everything in our health care system except the actual prices of medical care? 

Cohrs Zhang: I think it’s just another example of how people’s behavior responds to these weird incentives. And I think we’re seeing this problem, certainly among early retirees, exacerbated by the expiration of the Affordable Care Act subsidies that we’ve talked about very often on this podcast, because it affects these higher earners, and it can dramatically increase costs for coverage. And I think people just hope that they can hold on. But again, these statutory deadlines that lawmakers make up sometimes, not with a lot of forethought or rational reasoning, they have consequences. And obviously, the Medicare program continues to pay beyond age 65 as well. And I think it’s just another symptom of what the administration talks about when they talk about emphasizing, you know, preventative care and addressing chronic conditions 鈥� like, that is a real problem. And, yeah, I think we’re going to see these problems in this population continue to get worse as more people forgo care, as it becomes more expensive on the individual markets. 

Luthra: I think you also make a good point, though, Julie, because the increase in costs and cost sharing is not limited to people with marketplace plans, right? Also, people with employer-sponsored health care are seeing their out-of-pocket costs go up. Employers are seeing what they pay for insurance go up as well. And there absolutely is something to be said about it’s been 16 years since the Affordable Care Act passed, we haven’t really had meaningful intervention on the key source of health care prices, right? Hospitals, providers, physicians. And it does seem, just thinking about where the public is and the politics are, that there is possibly appetite around this. You see a lot of talk about affordability, but a lot of this feels, at least as an observer, very focused on insurance, which makes sense. Insurance is a very easy villain to cast. But I think you’ve raised a really good point: that addressing these really potent burdens on individuals and eventually on the public just requires something more systemic and more serious if we actually want to yield better outcomes. 

Rovner: Yeah, there’s just, there’s so much passing the hat that, you know, I don’t want to do this, so you have to do this. You know, inevitably, people need health care. Somebody has to pay for it. And I think that’s sort of the bottom line that nobody really seems to want to address. 

Well, the other theme of 2026 that I feel like I keep repeating is what funding cutbacks and other changes are doing to the future of the nation’s biomedical and medical workforces. Last week was Match Day. That’s when graduating medical school seniors find out if and where they will do their residency training. One big headline from this year’s match is that the percentage of non-U.S. citizen graduates of foreign medical schools matching to a U.S. residency position fell to a five-year low of 56.4%. That compares to a 93.5% matching rate for U.S. citizen graduates of U.S. medical schools. Why does that matter? Well, a quarter of the U.S. physician workforce are immigrants, and they are disproportionately represented, both in lower-paid primary care specialties, particularly in rural areas, both of which U.S. doctors tend to find less desirable. This would seem to be the result of a combination of new fees for visas for foreign professionals that we’ve talked about, a general reduction in visa approvals, and some people likely not wanting to even come to the U.S. to practice. But that rural health fund that Republicans say will revitalize rural health care doesn’t seem like it’s really going to work without an adequate number of doctors and nurses, I would humbly suggest. 

Lawrence: Yeah, absolutely. I mean, it’s patients that suffer, right? I mean, you need the people doing the work. And so I think that the impacts will start being felt sooner rather than later. That is something that hopefully people will start to feel the pain from. 

Rovner: I feel like when people think about the immigrant workforce, they think about lower-skilled, lower-paid jobs that immigrants do, and they don’t think about the fact that some of the most highly skilled, highly paid jobs that we have, like being doctors, are actually filled by immigrants, and that if we cut that back, we’re just going to exacerbate shortages that we already know we have. 

Luthra: And training doctors takes, famously, a very long time. And so if you are disincentivizing people from coming here to practice, cutting off this key source of supply, it’s not as if you can immediately go out and say, Here, let’s find some new people and make them doctors. It will take years to make that tenable, make that attractive, and make that a reality. And it just seems, to Lizzy’s point, that even in the scenario where that was possible 鈥� which I would be somewhat doubtful; medicine is a hard and difficult career; it’s not like you can make someone want to do that overnight 鈥� patients will absolutely see the consequences. I don’t know if it’s enough to change how people think about immigration policy and ways in which we recruit and engage with immigrant workers, but it’s absolutely something that should be part of our discussion. 

Rovner: Yeah, and I think it’s been left out. Well, meanwhile, over at the National Institutes of Health, a , Lizzy, found that more than a quarter have laid off laboratory workers. More than 2 in 5 have canceled research, and two-thirds have counseled students to consider careers outside of academic research. A separate study published this week found that women and early-career scientists have been disproportionately affected by the NIH cuts, even though most of the money goes to men and to later-career scientists. As I keep saying, this isn’t just about the future of science. Biomedical research is a huge piece of the U.S. economy. Earlier this month, the group United for Medical Research , finding that every dollar invested produced $2.57 for the economy. Concerned members of Congress from both parties last week at an appropriations hearing got NIH Director Jay Bhattacharya to again promise to push all the money that they appropriated out the door. But it’s not clear whether it’s going to continue to compromise the future workforce. I feel like, you know, we talk about all these missing people and nomination stuff, but we’re not really talking a lot about what’s going on at the National Institutes of Health, which is a, you know, almost $50 billion-a-year enterprise. 

Lawrence: Right. In some labs, the damage has already been done. You know, even if Dr. Bhattacharya [follows through], try spending all the money that has been appropriated. There are young researchers that have been shut out and people that have had to choose alternative career paths. And I think this is one of those things that’s difficult politically or, you know, in the public consciousness, because it is hard to see the immediate impacts it’s measured. And I think my colleague Jonathan wrote [that] breakthroughs are not discovered things, you know. So it’s hard to know what is being missed. But the immediate impact of the workforce and not missing this whole generation of scientists that has decided to go to another country or go to do something else, those impacts will be felt for years to come. 

Rovner: Yeah, this is another one where you can’t just turn the spigot back on and have it immediately refill.  

Finally, this week, there is always reproductive health news. This week, we got the Alan Guttmacher Institute’s  for the year 2025, which both sides of the debate consider the most accurate, and it found that for the second year in a row, the number of abortions in the U.S. remained relatively stable, despite the fact that it’s outlawed or seriously restricted in nearly half the states. Of course, that’s because of the use of telehealth, which abortion opponents are furiously trying to get stopped, either by the FDA itself or by Congress. Last week, anti-abortion Sen. Josh Hawley of Missouri introduced legislation that would basically rescind approval for the abortion pill mifepristone. But that legislation is apparently giving some Republicans in the Senate heartburn, as they really don’t want to engage this issue before the midterms. And, apparently, the Trump administration doesn’t either, given what we know about the FDA saying that they’re still studying this. On the other hand, Republicans can’t afford to lose the backing of the anti-abortion activists either. They put lots of time, effort, and money into turning out votes, particularly in times like midterms. How big a controversy is this becoming, Shefali? 

Luthra: This is a huge controversy, and it’s so interesting to watch this play out. When I saw Sen. Hawley’s bill, I mean, that stood out to me as positioning for 2028. He clearly wants to be a favorite among the anti-abortion movement heading into a future presidential primary. But at the same time, this is teasing out really potent and powerful dynamics among the anti-abortion movement and Republican lawmakers, exactly what you said. Republican lawmakers know this is not popular. They do not want to talk about abortion, an issue at which they are at a huge disadvantage with the public. Susan B Anthony List and other such organizations are trying to make the argument that if they are taken for granted, as they feel as if they are, that will result in an enthusiasm gap. Right? People will not turn out. They will not go door-knocking, they won’t deploy their tremendous resources to get victories in a lot of these contested, particularly Senate and House, races. And obviously, the president cares a lot about the midterms. He’s very concerned about what happens when Democrats take control of Congress. But I think what Republicans are wagering, and it’s a fair thought, is that where would anti-abortion activists go? Are they going to go to Democrats, who largely support abortion rights? And a lot of them seem confident that they would rather risk some people staying home and, overall, not alienating a very large sector of the American public that does not support restrictions on abortion nationwide, especially those that many are concerned are not in keeping with the actual science. 

Rovner: Yeah, I think the White House, as you said, would like to make this not front and center, let’s put it that way, for the midterms. But yeah, and just to be clear, I mean, Sen. Hawley introduced this bill. It can’t pass. There’s no way it gets 60 votes in the Senate. I’d be surprised if it could get 50 votes in the Senate. So he’s obviously doing this just to turn up the heat on his colleagues, many of whom are not very happy about that. 

Luthra: And anti-abortion activists are already thinking about 2028. They are, in fact, talking to people like Sen. Hawley, like the vice president, like Marco Rubio, trying to figure out who will actually be their champion in a post-Trump landscape. And so far, what I’m hearing, is that they are very optimistic that anyone else could be better for them than the president is because they are just so dissatisfied with how little they’ve gotten. 

Rovner: Although they did get the overturn of Roe v. Wade. 

Luthra: That’s true. 

Rovner: But you know, it goes back to sort of my original thought for this week, which is that the number of abortions isn’t going down because of the relatively easy availability of abortion pills by mail. Well, speaking of which, in a somewhat related story, a woman in Georgia has been charged with murder for taking abortion pills later in pregnancy than it’s been approved for, and delivering a live fetus who subsequently died. But the judge in the case has already suggested the prosecutors have a giant hill to climb to convict her and set her bail at $1. Are we going to see our first murder trial of a woman for inducing her own abortion? We’ve been sort of flirting with this possibility for a while. 

Luthra: It seems possible. I think it’s a really good question, and this moment certainly feels like a possible Rubicon, because going after people who get abortions is just so toxic for the anti-abortion movement. They have promised they would not go after people who are pregnant, who get abortions. And this is exactly what they are doing. And I think what really stands out to me about this case is so much of it depends on individual prosecutors and individual judges. You have the law enforcement officials who decided to make this a case, and they’re actually using, not the abortion law, even though the language in the case, right, really resonates, reflects with the law in Georgia’s six-week ban. Excuse me, with the language in Georgia’s six-week ban. But then you have a judge who says this is very suspect. And what feels so significant is that your rights and your protection under abortion laws depend not only on what state you live in, but who happens to be the local prosecutor, the local cop, the local judge, and that’s just a level of micro-precision that I think a lot of Americans would be very surprised to realize they live under. 

Rovner: Yeah, absolutely. We should point out that the woman has been charged but not yet indicted, because many, many people are watching this case very, very carefully. And we will too. 

All right, that is this week’s news. Now I’ll play my interview with Katie Keith of Georgetown University Law Center, and then we’ll come back with our extra credits. 

I am pleased to welcome back to the podcast Katie Keith. Katie is the founding director of the Center for Health Policy and the Law at the Georgetown University Law Center and a contributing editor at Health Affairs, where she keeps all of us up to date on the latest health policy, legal happenings. Katie, thanks for joining us again. It’s been a minute. 

Katie Keith: Yeah. Thanks for having me, Julie, and happy ACA anniversary. 

Rovner: So you are my go-to for all things Affordable Care Act, which is why I wanted you this week in particular, when the health law turned 16. How would you describe the state of the ACA today? 

Keith: Yeah, it’s a great question. So, the ACA remains a hugely important source of coverage for millions of people who do not have access to job-based coverage. I am thinking of farmers, and self-employed people, and small-business owners. And you know, in 2025, more than 24 million people relied on the marketplaces all across the country for this coverage. So it remains a hugely important place where people get their health insurance. And we are already starting to see real erosion in the gains made under the Biden administration as a result of, I think, three primary changes that were made in 2025. So the first would be Congress’ failure to extend the enhanced premium tax credits, which you have covered a ton, Julie and the team, as having a huge impact there. The second is the changes from the One Big Beautiful Bill Act. And then the third is some of the administrative changes made by the Trump administration that we’re already seeing. So we don’t yet have full data to understand the impact of all three of those things yet. We’re still waiting. But the preliminary data shows that already enrollments down by more than a million people. I’m expecting that to drop further. There was some 麻豆女优 survey data out last week that about 1 in 10 people are going uninsured from the marketplace already, and that’s not even, doesn’t even account for all the people who are paying more but getting less, which their survey data shows is about, you know, 3 in 10 folks. So you know what makes all of this really, really tough, as you and I have discussed before, is, I think, 2025, was really a peak year. We saw peak enrollment at the ACA. We saw peak popularity of the law, which has been more popular than not ever since 2017, when Republicans in Congress tried to repeal it the first time. And 鈥� but now it feels like we’re sort of on this precipice for 2026, watching what’s going to happen with the data into this really important source of coverage for so many people. 

Rovner: And 鈥� there’s been so much news that I think it’s been hard for people to absorb. You know, in 2017, when Republicans tried to repeal the Affordable Care Act, they said that, We’re trying to repeal the Affordable Care Act. Well, the 2025 you know, “Big, Beautiful Bill,” they didn’t call it a repeal, but it had pretty much the same impact, right? 

Keith: It had a quite significant impact. And I think a lot, like, you know, there was so much coverage about how Democrats in Congress and the White House learned, in doing the Affordable Care Act, learned from the failed effort of the Clinton health reform in the ’90s. I think similarly here you saw Republicans in Congress, in the White House, learn from the failed effort in 2017 to be successful here. And so you’re exactly right. You did not hear any talk of “repeal and replace,” by any stretch of the imagination. I think in 2017 Republicans were judged harshly 鈥� and appropriately so, in my opinion 鈥� by the “replace” portion of what, you know, what they were going to do, and it just wasn’t there. And so you did not see that kind of framing this time around. Instead, it really is an attempt to do death by a thousand paper cuts and impose administrative burdens and a real focus on kind of who 鈥� you can’t see me, but air quotes, you know 鈥� who “deserves” coverage and a focus on immigrant populations. So 鈥� those changes, when you layer all of them on 鈥� changes to Medicaid coverage, Medicaid financing, paperwork burdens, all across all these different programs 鈥� you know, the One Big Beautiful Bill Act, it really does erect new barriers that fundamentally change how Medicaid and the Affordable Care Act will work for people. And so it’s not repealed. I think those programs will still be there, but they will look very different than how they have and, you know, the CBO [Congressional Budget Office] at the time, the coverage losses almost 鈥� they look quite close to, you know, the skinny repeal that we all remember in the middle of the morning 鈥� early, like, late night, Sen. John McCain with his thumbs down. The coverage losses were almost the same, and you’ve got the CBO now saying, estimating about 35 million uninsured people by 2028, which, you know, is not 鈥� it’s just erasing, I think, not all, but a lot of the gains we’ve made over the past 15, now 16, years under the Affordable Care Act. 

Rovner: And now the Trump administration is proposing still more changes to the law, right? 

Keith: Yep, that’s right. They’re continuing, I think, a lot of the same. There’s several changes that, you know, go back to the first Trump administration that they’re trying to reimpose. Others are sort of new ideas. I’m thinking some of the same ideas are some of the paperwork burdens. So really, in some cases, building off of what has been pushed in Congress. What’s maybe new this time around for 2027 that they’re pushing is a significant expansion of catastrophic plans. So huge, huge, high-deductible plans that, you know, really don’t cover much until you hit tens of thousands of dollars in out-of-pocket costs. You get your preventive services and three primary care visits, but that’s it. You’re on the hook for anything else you might need until you hit these really catastrophic costs. They’re punting to the states on core things like network adequacy. You know, again, some of it’s sort of new. Some of it’s a throwback to the first Trump administration, so not as surprising. And then on the legislative front, I don’t know what the prospects are, but you do continue to see President [Donald] Trump call for, you know, health savings account expansions. We think, I think, you know, the idea is to send people money to buy coverage, rather than send the money to the insurers, which I think folks have interpreted as health savings accounts. There’s a continued focus on funding cost-sharing reductions, but that issue continues to be snarled by abortion restrictions across the country. So that’s something that continues to be discussed, but I don’t know if it will ever happen. And you know anything else that’s kind of under the so-called Great Healthcare Plan that the White House has put out. 

Rovner: You mentioned that 2025 was the peak not just of enrollment but of popularity. And we have seen in poll after poll that the changes that the Trump administration and Congress is making are not popular with the public, including the vast majority of independents and many, many Republicans as well. Is there any chance that Congress and President Trump might relent on some of these changes between now and the midterms? We did see a bunch of Republicans, you know, break with the rest of the party to try to extend the, you know, the enhanced premiums. Do you see any signs that they’re weakening or are we off onto other things entirely right now? 

Keith: It’s a great question. I think you probably need a different analyst to ask that question to. I don’t think my crystal ball covers those types of predictions. But to your point, Julie, I thought that if there would have been time for a compromise and sort of a path forward, it would have been around the enhanced premium tax credits. And it was remarkable, you know, given what the history of this law has been and the politics surrounding it, to see 17 Republicans join all Democrats in the House to vote for a clean three-year extension of the premium tax credits. But no, I think especially thinking about where those enhanced tax credits have had the most benefit, it is states like Georgia, Florida, Texas, and I thought that maybe would, could have moved the needle if there was a needle to be moved. So I, it seems like there’s much more focus on prescription drugs and other issues, but anything can happen. So I guess we’ll all stay tuned. 

Rovner: Well, we’ll do this again for the 17th anniversary. Katie Keith, thank you so much. 

Keith: Thanks, Julie. 

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

Lawrence: Sure. So my extra credit is by Nick [Nicholas] Florko, former Stat-ian, in The Atlantic, “” I immediately read this piece, because this is something that’s been driving me kind of crazy. Just seeing 鈥� if you’ve missed it 鈥� there have been 鈥� HHS has been posting AI-generated videos of Secretary Kennedy wrestling a Twinkie, wearing waterproof jeans, all of these things. And this has been, this is not unique to HHS 鈥� [the] White House in general has really embraced AI slop as a genre, and I can’t look away. And so I thought Nick did a good job just acknowledging how crazy this is, and then also what goes unsaid in these videos. I think I personally am just very curious if this resonates with people, or if it’s kind of disconcerting for the average American seeing these videos like, Oh, my government is making AI slop. Like I, you know, social media strategy is so important, so maybe for some people are really liking this. But yeah, I’m just kind of curious about public sentiment. 

Rovner: I know I would say, you know, the National Park Service and the Consumer Product Safety Commission have been sort of famous for their very cutesy social media posts, but not quite to this extent. I mean, it’s one thing to be cheeky and funny. This is sort of beyond cheeky and funny. I agree with you. I have no idea how this is going over the public, but they keep doing it. It’s a really good story. Rachel. 

Cohrs Zhang: Mine is a story in The Boston Globe, and the headline is “” by Tal Kopan. And this was a really good profile of Tony Lyons, who is Robert F. Kennedy Jr.’s book publisher, and he’s kind of had the role of institutionalizing all the political energy behind RFK Jr. and trying to make this into a more enduring political force. So I think he is, like, mostly a behind-the-scenes guy, not really like a D.C. fixture, more of like a New York book publishing figure. But I think his efforts and what they’re using, all the money they’re raising for, I think, is a really important thing to watch in the midterms, and like, whether they can actually leverage this beyond a Trump administration, or beyond however long Secretary Kennedy will be in his position. So I think it was just a good overview of all the tentacles of institutional MAHA that are trying to, you know, find their footing here, potentially for the long term.  

Rovner: I had never heard of him, so I was glad to read this story. Shefali. 

Luthra: My story is from NPR. It is by Tara Haelle. The headline is “.” Story says exactly what it promises, that if you have an infant, babies under 6 months, then getting a covid vaccine while you are pregnant will actually protect your baby, which is great because there is no vaccine for infants that young. I love this because it’s a good reminder of something that we were starting to see, and now it just really underscores that this is true, and in the midst of so much conversation around vaccines and safety and effectiveness, it’s a reminder that really, really good research can show us that it is a very good idea to take this vaccine, especially if you are pregnant. 

Rovner: More fodder for the argument, I guess. All right, my extra credit this week is a clever story from Stat’s John Wilkerson called “.” And, spoiler, that loophole is that one way companies can avoid running afoul of their promise not to charge other countries less for their products than they charge U.S. patients is for them to simply delay launching those drugs in those other countries that have price controls. Already, most drugs are launched in the U.S. first, and apparently some of the companies that have done deals with the administration limited their promises to three years, anyway. That way they can charge U.S. consumers however much they think the market will bear before they take their smaller profits overseas. Like I said, clever. Maybe that’s why so many companies were ready to do those deals. 

All right, that is this week’s show. As always, thanks to our editor, Emmarie Huetteman; our producer-engineer, Francis Ying; and our interview producer, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, 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 folks hanging these days? Shefali? 

Luthra: I am on Bluesky . 

Rovner: Rachel. 

Cohrs Zhang: On X , or . 

Rovner: Lizzy. 

Lawrence: I’m on X  and  and . 

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

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

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

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

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

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

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

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

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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