The Host
Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.
Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.
This week’s panelists are Julie Rovner of ýҕl Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.
Panelists
Among the takeaways from this week’s episode:
- Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
- ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
- A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
- As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.
Also this week, Rovner interviews ýҕl Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The New York Times’ “,” by Maxine Joselow.
Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.
Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.
Anna Edney: MedPage Today’s “,” by Joedy McCreary.
Also mentioned in this week’s podcast:
- The Washington Post’s “,” by Paul Kane.
- HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
- Politico’s “,” by Alice Miranda Ollstein.
- JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.
[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 ýҕl Health News and WAMUpublicradio in Washington, D.C., and welcome toWhat the Health?I’mJulie Rovner, chief Washington correspondent for ýҕl Health News, andI’mjoined by some of the best and smartest health reporters in Washington.We’retaping 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 EdneyofBloomberg News.
Anna Edney:Hi, everyone.
Rovner:Alice [Miranda]Ollsteinof Politico.
Alice MirandaOllstein:Hello.
Rovner:AndJoanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen:Hi, everybody.
Rovner:Later in this episode,we’llhave my interview with ýҕl 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’sstart 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 threeyearsthe Affordable Care Act’s expanded subsidies—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 arevery nearly—in the words of longtime Congress watcher—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 otherwisefairly routinelabor 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 theHouse’s Democratsto passthe bill and sendit 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 itwasn’ta good sign when the person who hassort of comeout as a leader of these bipartisan negotiations,Ohio Sen.BernieMoreno, at first came outvery strongand said,We’rein the end zone.We’reverycloseto a deal.We’regoing to havebilltext.And that was several days ago, and nowthey’resaying thatmaybethey’llhave 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 isnotagreement on how Obamacare currently treats abortion, and thus there can be no agreement on how itshouldtreat abortion.
Andsothe 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 anonstarterfor most, if not all, Democrats.SoIdon’tknow where wegofrom 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. Theyseem 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 cancome up witha 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.Idon’tthink abortion is going to be ahuge issue inLabor,HHS,becausethat’swhere 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 theHouse[is]probably not so excited about putting all of that money back.I’mjust wondering if there really is a deal to be had, or ifwe’regoing to see for the,you know, however manyyear[s]in a row, another continuing resolution, at least for the Department of Health and Human Services.
Ollstein:Well,you’rehearing 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 thatthey’refighting about. And I would say,on thespending,I think the much bigger fightsare going to be outside the health care space. I thinkthey’regoing to be about immigration, with everythingwe’reseeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts.On health,yes, I thinkyou’veseen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, itimpactstheir districts and their voters too. So that makes sense.
Kenen:We’vealso seen the Congress vote for spending that the administrationhasn’tbeen spent.SoCongress has just voted on a series of things about science funding and otherhealth-relatedissues, including global health. But it remains to be seen whether this administration takes appropriations as law orsuggestion.
Rovner:Sowhile the effort to revive theadditionalACA 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 hospitaloutpatient payments,and continued funding for community health centers. Could that finally become law? That thing that they said,Oh,we’llpass it first thing next year, meaning 2025.
Edney:I thinkit’scertainly looking more likely than the subsidies thatwe’vebeen talking about. But I do thinkwe’vebeen here before several times, not just at the end of last year—but,like with these PBM reforms, I feel like they have certainly gotten to a point whereit’slike,Thisis happening.It’sgonnahappen.And, I mean,it’sbeen years, though, thatwe’vebeen talking about pharmacy benefit manager reforms in the space of drug pricing.So basically, youknow, fromwhen[President Donald]Trump won. And so, you know, I say this with, like, a huge amount of caution:Maybe.
Rovner:Yeah, we will, butwe’llbelieve it when…we get to the signing ceremony.
Ollstein:Exactly.
Rovner:Well, back to the Affordable Care Act, for which enrollment in most statesendtoday.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 about1.5million from the end of last year’s enrollment period, andthat’sbefore most peoplehave topay 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’mwondering if these early numbers—which areactually strongerthan many predicted, with fewer peopleactually droppingcoverage—reflect people who signed up hoping that Congress mightactually renewthe subsidies this month. Since we kept saying that waspossible.
Ollstein:I would bet that most people are not following theminutiae ofwhat’shappening on Capitol Hill and have noideathe messwe’rein,andwhy,andwho’sresponsible. I would love to be wrong about that. I wouldlove foreveryone to be super informed.Hopefullytheylistento this podcast. But you know, I think that a lot of people justsign upyear after year andaren’tsure ofwhat’sgoing on untilthey’rehit 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’reseeingenrollment upin some of those states, and so I wonder ifthat’llencourage any others to get on board as well.
Kenen:But… I think what Julie saidisit’s…the follow-up is less than expected. But for the reasons Julie justsaidis that you haven’t gotten your bill yet.Soeither youhaven’tbeen paying attention, oryou’rean optimist and thinkthere’llbe a solution.So, andpeople might even pay their first bill thinking thatthere’llbe a solution next month, or thatwe’reclose. I mean, I would thinkthere’dbe drop-off soon, but there might be a steepercliff 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 becausethey’renot as bad as somepeopleforecastdoesn’tsay 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 outin other aspects?Ithinkwill be..of the economy of jobs, like, where does that leadus? Ithinkwill 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 makesitprettyhardfor Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive becausewe’respending more on health care.It’s not really that complicated, right?
Kenen:This 17%-18% of GDP has beenpretty consistent, whichdoesn’tmeanit’sgood;it just meansit’sbeen around that level for many, many, many years. Despite all the talk abouthow it’sunsustainable,it’sbeen sustained,with pain, but sustained.$5.7 trillion,even ifyou’vebeen doingthisa long time…
Rovner:It’s$5.3 trillion.
Kenen:$5.3 trillion.It’sa mind-bogglingnumber.It’sa lot of dollars!So the ACA made insurance more—the out-of-pocket cost of insurance for millions of Americans, 20-ish million—but the underlying burden we’ve not solvedthe — to use the word of the moment, the“affordability”crisis in healthcare is still with us and arguably getting worse. But like, I thinkwe’resort of numb. These numbers are just so insane, and yet you sayit’sunsustainable, but…I think itwasUwe’sline, right?
Rovner:It was, it was a famousUweReinhardt line.
Kenen:No,it’ssustainable, ifwe’resustaining it at a high—ineconomically—zany price.
Rovner:Right.
Kenen:And, like, the other thing is, like, where is the money?Right? Everybody in healthcare says theydon’thave any money, so Ican’tfigure out who has the$5 trillion.
Rovner:Yeah, well, it’s not…it does not seem to be the insurance companies as much as it is,you know, if you look at these numbers—and I’ll post a link to them—you know, it’s hospitals and drug companies and doctors and all of those who are part of the healthcare industrial complex, as I like to callit.
Kenen:Allof them say theydon’thave 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 Senatehealthcommitteechairman and ardent anti-abortionsenator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead aboutthe 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. Therewasn’ta bill under consideration. Theydidn’thave anyone from the administration to grill. Andsothis is justsort of yourtypicaleach sidetries 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—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.Andsothey’refrustrated that, you know, both[RobertF.]Kennedy[Jr.]and[Marty]Makary have promised some sort of review or action on the abortion pill, and they say,Wewant to see it.Why haven’t you done it yet?AndsoI think that pressureis only going to mount, and this hearing was part of that.
Rovner:I was fascinated by the Louisianaattorneygeneral saying,basically,thequiet partout loud, which is thatwe banned abortion, but because of these abortion pills, abortions are still going up in our state.That was the first time IthinkI’dheard an official say that. I mean that,if you wonder whythey’regoing after the abortion pill,that’swhy—because theystruck downRoe[v. Wade]and assumed that the number of abortions would go down, and it really has not, has it?
Ollstein:That’sright. And so not only are people increasingly using pills toterminatepregnancies, butthey’reincreasingly 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 becauseit’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons.Sothe right—you know, again, including senators like Cassidy, but also these activist groups—they’resaying, 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. Andthey’repretty openabout saying that.
Rovner:Well, ratherconvenient 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 singletime, 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-reviewedstudies thatbasicallyshowthis,plus the experience of many millions of women in the United States and around the world.
Ollstein:Well, just likeI’mskeptical thatthere’sany compromise that can be found on the Obamacare subsidies,there’sjust 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 itcan’tbe health care ifit’sdesigned to end a life, and that kind of rhetoric. Andsothe focus on the rate of complication…I mean,I’mnot sayingthey’renot genuinely concerned. They may be, but, you know, this is one of many tacticsthey’reusing to try to curb access to the pills.Soit’sjust one argument in their arsenal.It’snottheir,like,primary driving, overriding goal is, is the safety which, like you said, has been wellestablishedwith many, many peer-reviewed studies over the last several years.
Rovner: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 moneythey’refighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over lastsummer,those are still in place. And sothat’san order of magnitude more than this pot ofTitleXfamily planning money that they just got back. So that aside,I’veseen 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, andit’sa 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 apatient,you can thensubmitfor reimbursement. Andsoif the clinic’s not there,it’snot 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’regoing to take a quick break. We will be right back.
Sowhile abortion gets most of the headlines,it’snot 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 thata majority ofjustices 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 issuein recent weeks.The House passed a bill in December, sponsored by now former RepublicancongresswomanMarjorie 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 thatwouldn’tgo quite thatfar, butwould haveroughly thesame effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaidfunding, andwould 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 sportsteamexclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors?That’swhat 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 thatwe’reeven talking about. And so those who are against it have done an effective job of making thatthe issue. And so there…who support gender-affirming care, who havelooked intoit, would see that a lot of this is hormone treatment, things like that, to drugs…
Rovner:Puberty blockers!
Edney:…they’re taking—exactly—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.SoI 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 likethat 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. Theplaybook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and nowthey’retalking about it in protecting children’s health. And,as Anna said,they’reusing words like mutilation. Puberty blockers are notmutilation. Pubertyblockers are a medication that delays the onset of puberty, and it is not irreversible.It’slike abrake. You take your foot off the brake,and puberty starts.There’ssome controversy about what age and how long, andthere’ssomepossible bonedamage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now—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.Soyou know, I think it’s really important to repeat…the point that Anna made, you know, 12-year-olds are not getting major surgery.Very few minors are, and when they are,it’scloser… theymay be under 18,it’srare. But ifyou’reunder 18,you’recloser to 18,it’slater inteens. Andit’snot like you walk into an operating room and say, you know,do this to me.There’syears 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 peopledon’tunderstand and getvery upsetabout, and the inflammatorylanguage,it’snot creating understanding.
Rovner:We’llsee howthis one playsout. Finally, this week, things at the Department of Health and Human Servicescontinuesto 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 granteescancelingtheir fundingimmediately.It’snot entirely clear how many grants or how much money was involved, but itappeared to besomethingin the neighborhood of$2 billion—that’saround a fifth of SAMHSA’sentire 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 andjust about everymental 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 isa great question. I reallydon’tknow 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 amiscalculation 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:Ididn’tcount, but I got dozens of emails yesterday.
Edney:Yeah.
Rovner:My entire email box was overflowing with peoplebasically freakingout about these cutsto SAMHSA. Joanne,you wantedto say something?
Kenen:I think that one of the shifts over—I’m not exactly sure how many years—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’snot that everybody thinks that.It’snot that every lawmaker thinks that, but we have really turned this into, wehave 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’vehad 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—some of the“OpioidBelts”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 theirtelephones, theywere bombarded.
Rovner:Yeah.Well, meanwhile, severalhundredworkers havereportedly beenreinstated at the National Institute of Occupational Safety and Health—that’sasubagency 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 RichardPazdursaid at the J.P.Morgan[Healthcare] Conference in San Francisco this week that thefirewallbetween the political appointees at the agency and its careerdrug 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 mentionall ofthis back and forth and chaos and starting and stopping is costing more,is costing taxpayers more.Overall spending is up. After all of theDOGE[Department of Government Efficiency]andRIFsand 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 ithasn’teven saved the government any money, either.
Kenen:Like, you know, the game we played when we were kids, remember,“RedLight-GreenLight,”you know, you’drun in one direction, you run back. And if you were8years old, it would end with someone crying. And that’ssort of thewaywe’rerunning the governmentthesedays[laughs].The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. Youcan’teven keep track. Youdon’teven know what email to use ifyou’retrying tokeepintouchwith themanymore. The churn,with what logic?It’s, as Alice said,justmore expensive, but it’s,it’salso just…likeyoucan’tget 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, isitkind of seemslike the message asanybody can do this part, becauseit’sall 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.Soit’sbeen interesting to watch how many leaders in these agencies that are going away and not being replaced.
Rovner:And all the institutional memorythat’swalking out the door. I mean,more people—and toAlice’s point about how thishasn’tsaved money—more people have taken early retirement than havebeen actually, youknow,RIF’dor fired or let go. I mean, they’ve just…a lot of peoplehave basically, includinga lot of leaders of many of these agencies, said,Wejustdon’twant 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 theMonth”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 atKFFHealthNews and originator of our“Bill of the Month”series, which in itsnearly eightyears has analyzednearly $7 millionin dubious, infuriating,or inflated medical charges. Libby also wrote the latest“Bill of theMonth,”whichwe’lltalk about in a minute. Libby, welcome back to the podcast.
Elisabeth Rosenthal:Thanks for having me back.
Rovner:Sobefore we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustratedare you that eight years on,it’sas relevant as it was when we began?
Rosenthal:We wereworried itwouldn’tlast a year, and here we are, eight years later, still finding plenty to write about. I mean,we’vehad some wins.I think wehelped contribute to theNoSurprisesAct being passed.There arestates 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’sthe same cost. Thecountry’sstarting to address drug prices.But,you know, weseem to bethe billingpolice, andthat’snot good.We’vegotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls,they’relike,Oh, that was a mistakeorYeah,we’regoing to write that off. AndI’mlike,You’renot writing that off;thatshouldn’thave 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 systemthathasleft,as we know, you know, 100 million adult Americans with medical debt.Sowe will keep going untilit’ssolved,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, buthe’snever had a problem with it. And suddenly, one night, he had justexcruciating, 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?Sothey were alllike,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?Andit’slike 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:Soin the end, he wasOK.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 ERdoesn’tseem all that out of line compared to some of the billswe’veseen.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…now we go,well,that’snot bad.I mean, all they did,actually, was do a couple of scans and give him some IV fluids.Butin this day and age,you’relike, wow, he got away— you know, froma“Bill of aMonth”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’sthe problem,like,and Maxwell—he’sa pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he keptthinking,I must owe something. And he checked and hecheckedand he checked and it kept saying zero. He actually called hisinsurer andto make sure that was right. And they said,No, no, no,it’sright. You owe zero. And then, you know, after like, six months, he thought,I guess Iowe zero. But then hedidn’tthink about it, and then almost two years later, this bill arrives in the mail, andhe’slike,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 theMonth,”and in many cases, it’s legal, becauseofwhat 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 wecouldn’t…you know, the hospitalbilled themcorrectly. And the hospital said,No, wedidn’t.And they were justkind of doingthe usualback-end negotiations to figure out what a service is worth.And when they finally agreed two years laterwhat should be paid,that’swhen they sent Maxwell the bill. And the problemis,whetherit’slegal 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 insurerandthe hospital, they were like,Nevermind. Hedoesn’toweanything. And you know, as he said,he’sa 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,Forgetit!youknow.SoI do think this is something that needs to be addressed at a policy level, as we so often discover on“Bill of theMonth.”
Rovner:Sowhat should you do if you get one of these ghost bills? I should sayI’mstill negotiating bills from a surgery that I had six months ago.SoI guess I shouldcountmyself lucky.
Rosenthal:Well, I think you should check with your insurer and check with the hospital. I think morewithyour insurer—if the contract says this is legal to bill.It’sunclearto me,in this case, whether it was.The hospital was very much like,Oh, we made a mistake;because it took so long,weactuallycouldn’tbill Maxwell.SoI think in his case, itprobably wasin the contract that this was too late tobill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude.Well,doesn’thurt to try, you know,maybethey’llpayit. And people are afraid of bills, right? Theypaythem.
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 leastmodifiedthem?
Rosenthal:He said he will never eatscorpion peppers again.
Rovner:Libby Rosenthal, thank you so much.
Rosenthal:Oh, sure.Thanksfor having me.
Rovner:OK,we’reback, and nowit’stime for ourextra-creditsegment.That’swhere we each recognize a story we read thisweekwe think you should read,too.Don’tworry 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.Somy extra credit is fromMedPageToday:“.”I appreciated this article because it answered some questions that I had,too,after the sweeping change to the childhood vaccine schedule. Therewasjust a lot of discussions I had about, you know, well, what does this really mean on the ground? And willparentsbe confused? Will pediatricians—how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMAPerspectivesthat lays out, essentially, toclinicians, you know, that they should not fear malpractice..issues ifthey’regoing to talk about the old schedule and not adhere to the newer schedule. Andsoit 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’scalled“.”Sothis is about howthere’sbeen this huge push on the right to end public water fluoridation that has succeeded in acoupleplaces and could spread more. And the proponents of doing that say thatit’sfine because there are all these other sources of fluoride. You can geta treatmentat thedentist,you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people whoarepushingfor ending fluoridated public drinking waterare also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plusall ofthe just rhetoric about fluoride, which is very misleading. It misrepresents studies about its allegedneurological impacts. But it also,that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, whatthat’sgoing to do to the nation’s teeth?
Rovner:Yeah,it’slike vaccines. The more youtalkitdown,the less people want to do it.Joanne.
Kenen:This isa piece byDhruv KhullarinThe New Yorker called“,”and it was really great, because there’s certain things I think that we who—like, I don’t know how all of you watch it—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. ButDhruvtalkedabouthow itsortof brought that home to him, how our social safety net, the holes in it, end up in ourEDs.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 patientaday. But he talked about compassion and how that is rediscovered in this frenetic ED/ERscene.It’sjust a very thoughtful piece about why we all love that TV show. Andit’snot just because ofNoah Wyle.
Rovner:Although that helps. My extra credit this week is fromThe New York Times.It’scalled“,” by MaxineJoselow.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 costtohuman health when setting clean air rules for ozone and fine particulate matter, quoting the story:“That would most likely lower costsfor companies while resulting in dirtier air.”This is just another reminder that the federal government ischarged with ensuring the help of Americans from a broad array of agencies, aside from HHS—or in this case, not so much.
OK, that’s this week’s show.As always, thanks to our editor, EmmarieHuetteman,and our producer-engineer, Francis Ying.We also hadhelpthis week from producer Taylor Cook.Areminder:What theHealth?is now available on WAMU platforms, the NPR app,and wherever you get your podcasts, as well as, of course, atkffhealthnews.org.Also, as always, you can email us your comments or questions.We’reatwhatthehealth@kff.org,or you can find me still on X, or on Bluesky.Where are you folks hanging these days?Alice.
Ollstein:MostlyonBlueskyand still onX.
Rovner:Joanne.
Kenen:I’mmostly onor on.
Rovner:Anna.
Edney:orX.
Rovner:We will be backin your feed next week. Until then, be healthy.
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