While lawmakers continue to disagree on a way forward, keeps the issue front and center, it would be understandable to think these are the only taxpayer-funded health insurance subsidies in the U.S. system.

But .

“The vast majority of people with health insurance for it, from Medicaid to Medicare to the ACA to employer-sponsored insurance,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes �������ýҕ�l Health News.

These broad taxpayer supports are rarely discussed, though, as they apply to work-based coverage. So, let’s take a look.

Adding Up the Tax Breaks

of the more than on Medicare, the second-largest program in the federal budget behind Social Security, comes from general federal funds. The rest comes from payroll taxes and the monthly premiums paid by enrollees, who number .

Medicaid — the nation’s largest health insurer, covering more than 70 million low-income people — costs annually. It’s jointly financed by the federal government (65%) and states (35%).

For both programs, expenses are partially funded with taxpayer dollars. A less obvious form of federal support comes through employer-sponsored health coverage. Here, the impact on the federal bottom line is less visible, as hundreds of billions of dollars never reach the U.S. Treasury because it takes the form of tax breaks for employers and workers.

“It’s a world apart from Medicare, Medicaid, and Obamacare — from the government writing checks to people,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Job-based insurance provides coverage for under age 65. (By comparison, about 23 million people enrolled in Affordable Care Act plans for this year, generally because they don’t have job-based insurance. Extending the enhanced ACA subsidies that expired at the end of 2025 over a decade, or roughly $35 billion annually.)

In fact, contributions to employer-sponsored health plans are the single-largest “exclusion” — a tax policy that allows certain income to be exempt from taxes — in the federal budget. For this fiscal year, the , according to the Joint Committee on Taxation and the Congressional Budget Office.

The money employers spend to offer health coverage to their employees can be written off as a business expense. And workers who receive this benefit don’t have to pay income or payroll taxes on its value.

or even thousands of dollars a year for workers. The amount varies, with the biggest breaks going to those with the most expensive health plans and those whose wages put them in the upper tax brackets. Contributions to health savings accounts related to health insurance.

But the exclusion can be a difficult concept for insured workers to wrap their heads around, as most employees still contribute a portion of their pay to health coverage.

Even though they’re not taxed on that, “it doesn’t necessarily feel like a subsidy to people,” Levitt said. “They do feel like they’re paying.”

Baked Into the Tax System

The tax treatment evolved along with work-based health insurance policies in the U.S., fueled during World War II, when wage and price controls spurred interest in offering health coverage to lure workers. It was enacted into tax law in 1954.

Backers, which often include labor unions and employers, say it encourages companies to offer health insurance, as most large companies do. Because of the cost, smaller companies are less likely to do so, even with the tax incentive. Also, for workers, getting $1 of health care coverage is worth more than an extra dollar in wages, which would be taxed and, thus, worth less.

Opponents of the tax break, however, note the lost revenue to the Treasury and that the tax exclusion, according to some economists, leads employers and workers to choose the most generous — and expensive — health insurance offered, which they say drives up health care spending. The tax break benefits wealthier workers more than those in lower-income tax brackets, and economists also say the amounts employers pay for health insurance might otherwise be spent on boosting workers’ wages.

While there is currently no pending legislation to modify the tax break, the growing federal deficit has some the policy will change. Benefit experts say the outcome would vary.

“It’s not clear that it would wind up in increased wages for everyone,” said KFF’s Levitt. “Some workers have more negotiating leverage than others.”

to cap or eliminate the exclusion have all failed.

“It’s had a bipartisan target on its back for 40 years,” said Paul Fronstin, a director at the Employee Benefit Research Institute, a private, nonprofit, nonpartisan organization.

Any change, however, “would raise some revenue, but it’s also a tax increase for workers,” Fronstin noted. “What would that mean, if their taxes go up? Do wages go up because they’re not getting the same tax breaks? There will be winners and losers in that equation.”

Still, because job-based coverage is the way so many Americans get health insurance, some policy experts warn that eliminating or even lowering the exclusion could remove an incentive for employers to offer coverage. While some employers would likely keep offering coverage even without the tax break — because it is a benefit that helps attract and retain workers — it is a huge expense, so others might drop it. Average family premiums cost an employer nearly $27,000 last year, .

“These are businesses, which weigh the costs of offering insurance, which have gone up dramatically,” said Elizabeth Mitchell, CEO of the , an organization of large public and private employers that offer health insurance to their workers. “If there’s not some sort of tax incentive, I would expect them to revisit whether they would bear those costs.”

Cannon, of the Cato Institute, considers the tax policy bad because it takes choice away from workers, who might rather have increased wages, even if they are taxed. Those additional wages, he argues, could then be invested in tax-advantaged health savings accounts, used to pay medical costs.

Under the current tax break approach, “you are effectively saying let the employer control a huge chunk of your earnings and enroll in the plan the employer chooses,” he argues.

Employers counter by saying they are better able to negotiate higher-quality, lower-cost health insurance packages than individuals could on their own.

Mitchell, at the employer group, said, “It is challenging for an enormous employer to negotiate fair prices with the large consolidated systems. So it’s hard to imagine how an individual would be able to navigate our current system.”

She also disputes arguments that the tax break leads to higher health care prices, driven by overly generous employer plans that lead insured workers to use more health services.

“That’s a tired economic theory that doesn’t apply in health care,” she said. “People don’t shop for health care because they want more of it. They use health care because they need it. It’s fundamentally different.”

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Loretta Forbes realized she would have to drop her plan after her monthly ACA marketplace premiums jumped tenfold in 2026. So the 56-year-old, who lives outside Nashville, Tennessee, started rationing her rheumatoid arthritis medications. Her husband, Jim, gave up on his fledgling handyman business and started looking for a job with insurance coverage.

And when Nicole Wipp learned the monthly premium for her family’s ACA plan would be more than their mortgage payment, she and her husband decided to drop their family plan and buy coverage only for their 15-year-old son.

After crunching the numbers, Wipp, 54, a self-employed lawyer in Aiken, South Carolina, said she and her family made the tough call.

“We decided that, ultimately, it would be better for us to gamble.”

Despite a contentious back-and-forth and the longest government shutdown in history last fall, the GOP-led Congress allowed enhanced ACA subsidies, which had helped millions of Americans cover all or part of their marketplace premiums since 2021, to expire on Dec. 31. With the loss of the subsidies and health care costs already surging, more middle-income people face tough decisions about their health coverage this year.

Hulsman, Forbes, and Wipp don’t qualify for Medicaid, the public insurance program for those with low incomes or disabilities. But like many others, they are being squeezed by the increasing costs of groceries, housing, and other necessities. Rising monthly health insurance premiums, along with copayments, high deductibles, and other out-of-pocket medical costs, can often push families like these to the brink.

More than 80% of Americans said their cost of living has increased in the past year, according to from that includes �������ýҕ�l Health News. Health care costs ranked at the top of their concerns, with about two-thirds saying that they are somewhat or very worried about affording health care — more than said the same about other necessities, such as food and housing, the poll found., director of private coverage at the health consumer group Families USA. “This is an especially critical time for Congress to do something.”

Most Republican lawmakers have refused to renew the enhanced subsidies. Most of the public says that inaction by Congress was the “wrong thing,” according to the KFF poll. Instead, GOP lawmakers have advocated for an expansion of health savings accounts and for more plans with lower premiums and steeper deductibles and copays that don’t reduce overall costs.

President Donald Trump released in January with few details about how to lower out-of-pocket costs for millions of Americans. The One Big Beautiful Bill Act, which he signed in July, is expected to leave millions uninsured over the next decade as it reduces federal health spending by nearly $1 trillion, mostly from Medicaid.

Already about 1.2 million fewer people have signed up for plans for this year under the ACA, also known as Obamacare, according to . Health policy analysts expect more people to stop making payments and drop coverage in the coming months. ACA marketplace insurers have said that they are charging 4 percentage points more in 2026 because they expect healthier people to drop plans as enhanced tax credits expire, leaving more sick and high-cost patients.

Rising costs and lack of congressional action are forcing many to make “untenable choices,” said , executive director and co-founder of the Center for Children and Families at Georgetown University.

“People are faced with absorbing this huge financial and health risk,” she said.

Forbes, the woman with rheumatoid arthritis near Nashville, had been on an ACA marketplace plan since 2018. But this year she and her husband, Jim, dropped their coverage after learning the monthly premium would jump from $250 to $2,500 because the enhanced subsidies expired. Jim, 59, gave up his handyman business and began searching for a job with health insurance.

“We were like: ‘OK, we can’t breathe. We’re gonna tap out,’” said Forbes, who was diagnosed with cervical cancer in 2021. Last year she lost her job at a retirement facility because she couldn’t work after she had a hysterectomy.

A day before their ACA coverage lapsed, her husband got a job offer at a property management company that provides health coverage. In January, they learned that Forbes was approved for Medicare because of her disability. The $155 monthly premium is automatically deducted from her disability check, she said.

Forbes’ Medicare plan starts in February, just in time for her next cancer screening.

“You cannot imagine what a relief it is to know I will have care,” Forbes said.

Even those who are insured face drastically higher out-of-pocket costs. This year, health insurers’ premiums for ACA marketplace plans , the result of higher hospital costs, the popularity of pricey GLP-1 drugs for obesity and diabetes, and the threat of tariffs, according to KFF. Nearly 4 in 10 adults said they were skipping or postponing necessary care because of costs, showed.

Hulsman, the Louisville shop owner, said he takes home about $33,000 a year from his business. Last year he paid about $105 a month for a gold plan on the marketplace, with a $750 deductible. This year, with the loss of the enhanced subsidy, Hulsman is paying the same monthly premium for a “bronze” plan, but with a deductible of $8,450, which he must pay out-of-pocket before his insurer starts paying for care. On average, deductibles for bronze plans are more than four times those of gold plans, according to .

Hulsman didn’t consider dropping health insurance, because Kentucky has limited . But he said he’ll try to get an estimate if he needs to go to a doctor. And he’s worried that a major accident could wipe out his skate shop. He won’t be able to buy inventory or pay shop bills if he has to meet his full deductible, he said.

“I’m just riding the line right now,” the skateboarder said. “One slip and it’s gonna be uncomfortable.”

In South Carolina, Wipp dragged her family to get routine vaccinations on New Year’s Eve — the last day that she and her husband had health coverage.

This year’s monthly premium for a bare-bones bronze family plan would have cost them $1,400, up from $900 last year. They would still have faced high copays for doctor visits and need to meet a deductible of more than $10,000. Instead, they’re paying around $200 to cover just her son.

Wipp, who has a rare condition that causes cysts and other growths to form in the lungs, said she and her husband plan to pay out-of-pocket this year for any initial preventive care. Their second source of money, for larger medical expenses, is an old health savings account. But she said that account doesn’t have enough to cover a major accident or illness. And Wipp can’t add to the account while she is uninsured.

“The third source would be, I don’t know,” Wipp said. “The fourth is bankruptcy.”

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Loretta Forbes se dio cuenta de que tendría que dejar su plan después de que sus primas mensuales del mercado de seguros de ACA se multiplicaran por diez en 2026. Así que esta mujer de 56 años, que vive en las afueras de Nashville, Tennessee, empezó a racionar sus medicamentos para la artritis reumatoide. Su esposo, Jim, abandonó su negocio de reparaciones domésticas que recién comenzaba para buscar un trabajo que ofreciera cobertura médica.

Y cuando Nicole Wipp se enteró de que la prima mensual de su plan familiar de ACA sería más alta que el pago de su hipoteca, ella y su esposo decidieron cancelarlo y comprar cobertura únicamente para su hijo de 15 años.

Después de hacer cuentas, Wipp, abogada independiente de 54 años en Aiken, Carolina del Sur, dijo que su familia tomó una decisión difícil.

“Decidimos que, al final, nuestra única salida era arriesgarnos”.

A pesar de las intensas discusiones y del cierre del gobierno más largo en la historia ocurrido el otoño pasado, el Congreso liderado por el Partido Republicano permitió que los subsidios mejorados de ACA expiraran el pasado 31 de diciembre.

Desde 2021, estos subsidios habían ayudado a millones de personas a cubrir total o parcialmente sus primas en el mercado de seguros. Con su pérdida y el aumento ya existente en los costos de la atención médica, cada vez más personas de ingresos medios enfrentan decisiones imposibles sobre su cobertura este año.

Hulsman, Forbes y Wipp no califican para Medicaid, el programa público de salud para personas con ingresos bajos o que viven con discapacidades. Pero como muchos otros, se han visto afectados por el aumento de los precios de alimentos, vivienda y otras necesidades básicas. Las primas mensuales cada vez más altas, junto con copagos, deducibles elevados y otros gastos médicos de su bolsillo, suelen llevar a familias como estas al borde de la desesperación.

Más del 80% de los estadounidenses dijeron que su costo de vida aumentó el último año, según realizada por , una dedicada a la información sobre salud que incluye a �������ýҕ�l Health News.

Los costos de atención médica encabezaron la lista de preocupaciones: alrededor de dos tercios dijeron que les preocupa algo o mucho poder pagarla: más que lo que dijeron sobre otros bienes básicos como alimentos o vivienda.

“Las primas están volviéndose realmente inasequibles para muchas personas. El costo tanto de la atención médica como de otras necesidades básicas está subiendo”, dijo , directora de cobertura privada en el grupo de consumidores de salud Families USA. “Este es un momento especialmente crítico para que el Congreso actúe”.

La mayoría de los legisladores republicanos se ha negado a renovar los subsidios mejorados. Según la encuesta de KFF, la mayoría de la población considera que la inacción del Congreso fue “una decisión equivocada”. En cambio, los legisladores republicanos han promovido la expansión de las cuentas de ahorro de salud y planes con primas más bajas, pero con deducibles y copagos más altos, que no bajan los costos generales.

El presidente Donald Trump publicó en enero con pocos detalles sobre cómo reducir los gastos de bolsillo de millones de personas. La ley conocida como One Big Beautiful Bill Act, que el presidente firmó en julio, se espera que deje sin seguro a millones durante la próxima década, al reducir el gasto federal en salud en casi $1.000 millones, principalmente a través de recortes a Medicaid.

Según , este año cerca de 1,2 millones de personas menos se inscribieron en planes de ACA, también conocida como Obamacare. Analistas de políticas de salud esperan que más personas dejen de pagar sus primas y cancelen su cobertura en los próximos meses.

Las aseguradoras del mercado de ACA han informado que están cobrando 4 puntos porcentuales más en 2026 porque anticipan que las personas más saludables abandonarán sus planes luego del fin de los subsidios mejorados, dejando en el sistema a pacientes más enfermos y costosos.

El aumento de los costos y la falta de acción del Congreso obligan a muchos a tomar “decisiones insostenibles”, dijo , directora ejecutiva y cofundadora del Centro para Niños y Familias de la Universidad Georgetown.

“Las personas enfrentan un enorme riesgo financiero y de salud”, agregó.

Forbes, la mujer con artritis reumatoide cerca de Nashville, tenía un plan del mercado de ACA desde 2018. Pero este año ella y su esposo, Jim, cancelaron su cobertura después de enterarse de que la prima mensual subiría de $250 a $2.500, debido a la expiración de los subsidios. Jim, de 59 años, dejó su negocio de reparaciones domésticas y empezó a buscar un empleo que ofrezca seguro médico.

“Fue como decir: ‘OK, no podemos respirar. Tenemos que rendirnos’”, contó Forbes, quien fue diagnosticada con cáncer de cuello uterino en 2021. El año pasado perdió su empleo en un centro para personas jubiladas porque no pudo seguir trabajando tras una histerectomía.

Un día antes de que venciera su cobertura de ACA, su esposo recibió una oferta de trabajo en una empresa de administración de propiedades que ofrece seguro médico. En enero, se enteraron de que Forbes fue aprobada para recibir Medicare debido a su discapacidad. Dijo que los $155 mensuales de prima se descuentan automáticamente de su cheque de discapacidad.

El plan de Medicare de Forbes comienza en febrero, justo a tiempo para su próximo examen de detección de cáncer.

“No se imaginan el alivio que siento al saber que tendré atención médica”, dijo Forbes.

Incluso quienes tienen seguro médico enfrentan gastos de bolsillo mucho más altos.

Este año, las primas de los planes del mercado de ACA debido al alza en los costos hospitalarios, la popularidad de medicamentos costosos como los GLP-1 para la obesidad y la diabetes, y la amenaza de aranceles, según KFF. Casi 4 de cada 10 adultos dijeron que iban a renunciar o a retrasar la atención médica necesaria por los costos, según .

Hulsman, el dueño de la tienda en Louisville, dijo que gana unos $33.000 al año con su negocio. El año pasado pagaba unos $105 al mes por un plan “Oro” del mercado, con un deducible de $750. Este año, sin el subsidio mejorado, Hulsman paga lo mismo por un plan “Bronce”, pero con un deducible de $8.450, que debe cubrir completamente antes de que la aseguradora empiece a pagar.

En promedio, los deducibles de los planes “Bronce” son más de cuatro veces más altos que los de los planes “Oro”, según un .

Hulsman ni siquiera consideró dejar de tener seguro médico, ya que Kentucky ofrece . Pero dijo que intentará conocer el precio antes de ir al médico. Y le preocupa que un accidente grave pueda llevar a la quiebra a su tienda de patinetas. Si tiene que cubrir todo el deducible, no podrá comprar inventario ni pagar las cuentas del negocio.

“En este momento estoy aguantando como puedo”, dijo el skater. “Un tropiezo y la cosa se pone fea”.

En Carolina del Sur, Wipp llevó a su familia a vacunarse el 31 de diciembre, el último día en que ella y su esposo tenían cobertura médica.

La prima mensual este año para un plan familiar básico “Bronce” les habría costado $1.400, frente a $900 el año pasado. Aun así, habrían tenido copagos altos para visitas médicas y un deducible de más de $10.000. En cambio, están pagando unos $200 por la cobertura de su hijo.

Wipp, quien tiene una enfermedad poco común que causa quistes y otros crecimientos en los pulmones, dijo que ella y su esposo planean pagar de su bolsillo este año cualquier atención preventiva inicial. Su segunda fuente de dinero para gastos médicos mayores es una antigua cuenta de ahorro de salud. Pero dijo que esa cuenta no tiene suficiente dinero para cubrir un accidente o enfermedad grave.

Y no puede seguir contribuyendo a esa cuenta mientras no tenga seguro.

“La tercera fuente de dinero sería… no sé”, dijo Wipp. “La cuarta es la bancarrota”.

¿Tienes dificultades para pagar tu seguro médico? ¿Has decidido renunciar a la cobertura? Haz clic��aquí��para contactar a �������ýҕ�l Health News y compartir tu historia.

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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 �������ýҕ�l 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 �������ýҕ�l 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 �������ýҕ�l Health News and WAMU��public��radio in Washington, D.C., and welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �������ýҕ�l 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 �������ýҕ�l 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��—��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��—��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 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��—��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��…��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��—��which are��actually stronger��than many predicted, with fewer people��actually dropping��coverage��—��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��… I think what Julie said��is��it’s��…��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��…��

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��—��the out-of-pocket cost of insurance for millions of Americans, 20-ish million��—��but the underlying burden we’ve not solved��the — 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��…��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��—��in��economically��—��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��…��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 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��—��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��—��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��—��you know, again, including senators like Cassidy, but also these activist groups��—��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��…��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.��

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 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��…��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��…����

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.��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��—��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��…��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��… 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��—��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��—��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’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��—��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��—��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��…��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��—��and to��Alice’s point about how this��hasn’t��saved money��—��more people have taken early retirement than have��been actually, you��know,��RIF’d��or fired or let go. I mean, they’ve just��…��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��KFF��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��…��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��— 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��—��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��…��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��—��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��—��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��—��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. 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��—��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.��

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It’s feeding time for the animals on this property outside Nashville, Tennessee. An albino raccoon named Cricket reaches through the wires of its cage to grab an animal cracker, an appetizer treat right before the evening meal.

“Cricket is blind,” said Robert Sory, who is trying to open a nonprofit animal sanctuary along with his wife, Emily. “A lot of our animals come to us with issues.”

The menagerie in Thompson’s Station includes Russian foxes, African porcupines, emus, bobcats, and some well-fed goats.

The Sorys are passionate about their pets and seem to put the animals’ needs before their own.

Both Robert and Emily started 2026 without health insurance.

Robert had been covered through a marketplace plan subsidized through the Affordable Care Act. His share of the monthly premiums was $0. When he looked up the rates for 2026, he saw that a barebones “bronze”-level plan would cost him at least $70 a month. He decided to forgo coverage altogether.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” he said. “It’s not affordable.”

Dumping Coverage

Marketplace plans from the Affordable Care Act no longer feel very affordable to many people, because Congress did not extend a package of enhanced subsidies that expired at the end of 2025. Last week, the House did pass legislation to extend the��expired subsidies, and negotiations have moved to the Senate. Without a deal, an estimated will go without coverage this year.

But even without a health plan, people will still need medical care. Many, like the Sorys, have been thinking through their plan B to maintain their health.

The Sorys both lost jobs in November, within days of each other. Robert worked as a farmhand. Emily worked at a staffing firm and lost her insurance along with her position.

“It’s a horrible, horrible market right now. Really tough,” she said.

The first time she had to pay out-of-pocket for her three monthly prescriptions, the cost was $184.

“To equate that to kind of how we think about it, you’re talking about 350 pounds of food for these animals,” Robert said. He pointed to his bobcats, who eat only meat.

Workarounds for the Newly Uninsured

To keep kibble in the food bowls, the Sorys are prepping for an uninsured future. They see the same psychiatrist and met with him to make a plan. He was willing to work with them by charging $125 per visit. They’ll have to go every three months to keep their prescriptions current.

And if other medical problems emerge? They’re hoping for the best.

“I’m not somebody who gets sick super often, thank God,” Robert said. “And if I do, generally I go to an emergency room where they’re going to bill me later.” Robert said he would arrange a repayment plan for bills like that.

Emily has costly health conditions and has already taken on substantial medical debt. “It’s just sitting there, and I’ve racked up money,” she said. “But I’ve had to go to the doctor.”

Donated Drugs and Sliding Scales

Hospitals and clinics are of newly uninsured patients. They’re also concerned that people won’t know about alternative ways to get medical care.

“We don’t have marketing dollars, so you’re not going to see big billboards or radio ads,” said , CEO of in Nashville. It’s one of the country’s 1,400 federally qualified health centers, also called FQHCs.

FQHCs are by the federal government. Although they do not usually offer free care, their fees tend to be lower or on a sliding scale.

Uninsured people who get care receive a bill, Beard said, “but the bill will be based on their ability to pay.”

FQHCs often have on-site pharmacies, and some offer prescription medications free of charge through a partnership with the , a Nashville-based nonprofit.

Many hospital pharmacies also partner with the nonprofit, which has donated by pharmaceutical companies to 277 sites in 38 states. must make the medicine available free of charge to people without insurance who have annual incomes below 300% of the federal poverty limit.

The organization primarily sources medications for chronic conditions such as high blood pressure, diabetes, and mental health. Demand is expected to outstrip supply in the new year, according to .

“We’re projecting and engaging with our manufacturers and asking them, ‘Are you willing to help support, for this future status that we are anticipating?’” he said. “By and large,” he said, pharmaceutical companies have said they’re willing to step up.

“It’s a continuous conversation that we’re having,” Cornwell said.

A Medicaid ‘Gap’ in 10 States

Hospitals will also have to find a way to care for more patients who cannot pay. Industry groups such as the have been vocal about the threat to hospitals’ financial health and have urged Congress to extend the enhanced subsidies, which take the form of tax credits.

The impact might be most acute in states like Tennessee that have not expanded Medicaid to cover people who work but do not have job-based insurance and cannot afford it on their own.

Ten states have chosen not to expand Medicaid to uninsured, low-income adults — an optional provision of the ACA that is mainly paid for by federal funds.

This Medicaid “gap” is , at the high end of the spectrum, by as much as 65% in Mississippi and by 50% in South Carolina, according to the Urban Institute.

As Emily Sory pets a Russian fox, she admits she is keenly aware that she will soon become part of this growing population. After all, her last job involved health care staffing. Her mother is a nurse.

“I understand the system. And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad,” she said. “But at the same time, I don’t have the money to pay it.”

This article is from a partnership that includes��,��, and �������ýҕ�l Health News.

�������ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Congress returned from its holiday break to the same question it faced in December: whether to extend covid-era premium subsidies for health plans sold under the Affordable Care Act. The expanded subsidies expired at the end of 2025, leaving more than 20 million Americans facing dramatically higher out-of-pocket costs for insurance.

Meanwhile, the Robert F. Kennedy Jr.-led Department of Health and Human Services announced an overhaul of the federal vaccine schedule for children, reducing the number of diseases for which vaccines are recommended from 17 to 11.

This week’s panelists are Julie Rovner of �������ýҕ�l Health News, Sarah Karlin-Smith of Pink Sheet, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• The conservative movement to end abortion access nationwide has ensnared a last-ditch effort in Congress to help millions afford their health plans. As lawmakers consider a compromise to revive enhanced federal tax credits for ACA plans, some Republicans are arguing that the tax credits should be barred from subsidizing any plan that covers abortion care — even though the federal dollars would not be used to pay for abortions anyway. That change would force some states to choose between dropping their requirements for insurance coverage for abortion care or forgoing that federal assistance.
• President Donald Trump this week urged Republicans in Congress to be “flexible” about abortion restrictions. Meanwhile, his health policies so far are not yielding notable benefits for Americans, with most of the savings from his high-profile pharmaceutical deals going to the federal and state Medicaid programs. And the $50 billion federal funding boost for rural health — intended to counterbalance nearly $1 trillion in expected Medicaid spending cuts — is unlikely to make a meaningful dent, in no small part because rural facilities are barred from using the money for general expenses.
• While Kennedy announced an overhaul of federal recommendations for childhood vaccines, the action’s impact on vaccination rates and insurance coverage will depend in large part on how various states react, since states are the ones that impose mandates — such as for school enrollment — and regulate some insurers. Nonetheless, it is likely to result in a patchwork of state policies, which is problematic for public health efforts.
• Federal health officials also unveiled new nutritional guidelines, turning the decades-old food pyramid upside down. Some of the recommendations adhere to scientific findings, such as cutting added sugar from one’s diet. Others are more controversial, particularly the suggestion that Americans should eat more red meat and the softening of guidelines on saturated fats.

Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:

Julie Rovner: �������ýҕ�l Health News’ “Advertisements Promising Patients a ‘Dream Body’ With Minimal Risk Get Little Scrutiny,” by Fred Schulte.��

Alice Miranda Ollstein: SFGate’s “,” by Lester Black and Stephen Council.����

Sarah Karlin-Smith: ProPublica’s “” by Anna Maria Barry-Jester and Brett Murphy.����

Lauren Weber: The Washington Post’s “,” by Rachel Roubein, Lena H. Sun, and Lauren Weber.����

Also mentioned in this week’s podcast:

• NBC News’ “” by Berkeley Lovelace Jr.
• Stat’s “,” by Isabella Cueto and Sarah Todd.
• The Washington Post’s “,” by Lauren Weber, Caitlin Gilbert, Dylan Moriarty, and Joshua Lott.
• The Guardian’s “,” by Carter Sherman.

[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 �������ýҕ�l Health News and WAMU Public Radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for �������ýҕ�l 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. 8, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.

We are joined via videoconference by Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hi.

Rovner: And Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: No interview this week, but tons of news to catch up on, so let us get right to it. So, we start 2026 in health care the same way we ended 2025, with a fight over expiring subsidies for the Affordable Care Act. By the time you hear this, the House will likely have approved a Democratic-sponsored bill to reinstate for three years the expanded ACA subsidies that were in effect from 2021 through the end of 2025.

That vote was made possible by four Republicans crossing party lines in December to sign a discharge petition that forces a floor vote, over the objection to the House leadership. Interestingly, a preliminary vote on the bill on Wednesday drew not just the four moderate Republicans who signed the original discharge petition but five more, for a total of nine. The consensus of political reporters is that the bill is DOA [dead on arrival] in the Senate, which voted an identical proposal down in early December.

But I’m wondering how much heat Republicans were exposed to over the break by constituents whose out-of-pocket costs for insurance were doubling or more, and whether that might change the forecast somewhat. What are you guys hearing?

Weber: So, it seems that there are still some big hurdles to cross. And based on what senators told my colleagues over the past couple days, there’s not even an agreement on what current law is and does, and thus, they can’t agree on how it should change. And so, I’m talking specifically about the still-unresolved abortion issue.

This is the question of whether plans that cover abortion should receive any federal subsidy, even if those subsidies do not directly pay for an abortion. The Republicans are arguing that it’s an indirect subsidy, even though these are going into separate accounts. So, one of the Republican senators who is trying to craft a deal — that’s Bernie Moreno of Ohio — he was saying that they still don’t agree whether, under current law, federal funding is going to abortion.

So, it’s like you don’t even have a shared reality that senators are operating under, and that makes it really hard to come up with a proposal. They say they’re going to have text by Monday, but we’ll see if that actually happens.

Rovner: Yeah. Well, before we get too deeply into the abortion issue, which we will do in a minute, I want to talk a little bit more about that. I won’t even call it an emerging compromise. I’ll call it a potential compromise in the Senate.

Ollstein: Some bullet points were shared.

Rovner: Some bullet points. We know what the bullet points are. They would extend the additional subsidies for two more years, not three, with a couple of changes, including capping income eligibility for those subsidies at 700% of poverty up from 400% that it reverted back to on Jan. 1. It would also replace zero-premium plans with $5-per-month plans. That’s to crack down on brokers who fraudulently sign up people who don’t even know they have insurance so the brokers can collect commissions. And it would allow people to choose whether their enhanced subsidies should go into Republican-favored health savings accounts or directly toward their premiums.

Assuming — and this is obviously a big assumption — they could get past this abortion issue, what are the chances for a compromise that looks something like this? I mean, it sounds like something that could satisfy both Democrats and Republicans, particularly Republicans who are feeling pressured by their own constituents who’ve now seen there — are either dropping their insurance or seeing their out-of-pocket cost just goes wild.

Ollstein: I’ve heard some criticism from the Democratic side about getting rid of zero-premium plans specifically. They’re saying the Republicans want to run on affordability and helping out people who are struggling. How does eliminating the ability to get a zero-premium plan align with that?

And so I expect there will be some clashes over that. But I also think, again, senators aren’t even agreeing on what the current reality is, and that applies there, too. There have been all of these allegations of widespread fraud, and some experts and lawmakers have been pointing out that just because someone who is enrolled doesn’t actually use their benefits, that doesn’t necessarily mean there’s fraud going on.

It does seem like there is some fraud going on. You mentioned the perverse incentives for brokers, but a lot of this is circumstantial evidence rather than direct evidence.

Rovner: Also, one of the ironies here is that if you have somebody who’s healthy, who signs up for health insurance and doesn’t use it, that’s a good thing for the risk pool. You don’t want only sick people.

Ollstein: It helps everyone.

Rovner: There’s a lot of things making my head explode. Well, one of the things that Alice, I know, is making your head explode, too, is this disagreement about reality about abortion. And I would point out that President [Donald] Trump spoke to the retreat of the House Republicans this week and urged some flexibility, put that in air quotes, on this Hyde Amendment issue. Alice, remind us why this is an issue here. Doesn’t the Affordable Care Act already ban federal funding of abortion just like all other federal programs?

Ollstein: Yes. Yes, it does. So basically, this is part of a larger project on the right to expand the definition of Hyde.

Rovner: We should probably go back to the very beginning of what is …

Ollstein: Yes.

Rovner: … the Hyde Amendment because it only applies to annual appropriations, and that’s why it’s been important. I will let you take it from there.

Ollstein: Sure, sure. So, this is a budget rider that dates back to the 1970s that says that there can be no federal funding of abortion, except in a few instances, of there’s a risk to the mother’s life, and rape and incest. And so that has been renewed over and over under administrations of both parties, under Congress majorities of both parties.

And now, what they’re fighting over is, already federal funding that goes to these plans in the form of these subsidies, it does not go to pay for abortion directly. But conservatives are now arguing that if it goes to a plan that covers abortion using other funding, then that functions as an indirect subsidy. This is the same argument they’ve made about Title X, where any federal funding going to a program that uses other funding to pay for abortion, they now consider that sort of an indirect subsidy, even though it’s coming out of different buckets of money.

And so, what they’re pushing for is basically a nationwide restriction on any plan that gets a federal subsidy paying for abortion. So, this would have the most impact in the states where all plans on the ACA market are required to cover abortion, in states like California, New York, and Massachusetts, big states with many, many millions of people. And so that would have a huge impact and force those plans to either drop abortion coverage or forgo the federal subsidy. So, that would have a really big impact.

And Democrats say this is not necessary. There’s already restrictions that prevent federal funding to go to pay for abortion. And that is what the senators and everyone can’t agree on right now.

Rovner: That’s right. And that’s a big fund. Well, we’ll see where that goes. In the meantime, what the president was talking about when he called for flexibility on Hyde was actually health care writ large.

This clearly reflects what we know the president’s pollster has been telling him: that Republicans are currently at a distinct public disadvantage when it comes to health care, and not just the Affordable Care Act. Trump says that Republicans should, again, air quotes, try to “own” the health care issue. And he has spent a good bit of his first year working on health issues. At least he’s been talking about them a lot, but it turns out that his s are not mostly being felt by consumers here in the U.S.

The savings he’s negotiated are mostly going to the state and federal Medicare and Medicaid programs, as well as to people willing and able to pay out-of-pocket for their prescription drugs. And while the administration is making much of its December announcement about the first distribution of rural health funding that was authorized in last summer’s budget bill, that $50 billion in funding won’t make much of a dent compared to the nearly $1 trillion in cuts that were created for Medicaid in that same bill. So, my question from all of this is: Can Republicans use things like this to own the health care issue or at least cut into Democrats’ advantage between now and the midterms?

Weber: Well, I think it depends on what they end up doing with it. He brought up in that same meeting with legislators wanting to own IVF [in vitro fertilization], which is something he floated during his campaign that got a lot of shock from [the] conservative Republican base. So, what does he mean? What is he saying on that? We don’t have particulars.

Bottom line is, voters don’t necessarily know the in-the-weeds policy. So, if he gets out there and says enough things, who knows that they can own the health care issue? But I would say for now that it is solely in the Democrats’ camp and is helping lead them with an advantage for midterms for now.

Rovner: Sarah, he keeps saying on drug prices that he’s done all this stuff, and he has done a lot of stuff, but it hasn’t had a big dent in what people pay for their drugs, right?

Karlin-Smith: Right. And I think the one reason drug pricing has been a popular health policy topic for politicians to focus on is because people really can feel it directly compared to how they feel other health costs. And so, I think that there’s only a certain amount of time where people will just accept Trump saying, Oh, we’re saving you money, without them actually seeing it on the back end. And the problem right now is these most-favored-nation deals where he’s struck privately with a lot of drug companies to get Medicaid, really mostly at this point, in theory lower prices.

It’s not clear how much money it’s actually going to save Medicaid because Medicaid actually gets some of the best deals that the U.S. gets. Most people on Medicaid actually don’t really directly pay copays for most of their products, either. The other problem is they’ve then rolled out a number of other drug-pricing models to try and pair this concept, again, of getting the prices a lot of other countries get for drugs in the U.S., but they then exempted all these companies they’ve struck these private deals with.

So, it’s not really clear who is left in terms of drug companies and drug products. Then you might get cheaper prices under some of these other demonstrations, which by their nature, these are demonstration pilot programs that are not going to reach every Medicare beneficiary they’re pushing for. So, I think it’s going to be a big problem because many people are not actually going to see savings.

For people that have a decent amount of income and can afford some of these direct-to-consumer products where health insurers have often been denying it — like the weight loss, common popular weight loss drugs — some people may feel a little benefit there. But if you’re somebody who’s underinsured or uninsured, even if there’s really good discounts on a direct-to-consumer buying market, you’re probably also still not going to be able to afford these weight loss drugs.

Rovner: Yes, Lauren.

Weber: Just to go back to the rural health fund disbursement, I just have so many thoughts on this, because I mean, at the end of the day, rural hospitals are also the equivalent of rural jobs programs for rural America. And typically, rural hospitals fall in red America. And so, this attempt to prop them up, it sounds flashy, right? I mean, it’s billions of dollars. But when you break it down by the 50 states, it’s hundreds of millions, like tops like $281 million depending on the state.

That’s not going to cover the deficit that the bill has created for those folks. And I understand that it’s meant by the administration to be a flashy way of, Oh, we’re supporting rural health care, but the crushing Medicaid cuts that these rural hospitals are going to face, when they already operate on such thin margins, will be devastating. I mean, it will be devastating for already health care deserts that we already see, and this money is not going to be enough to stop the blood flow there in rural America.

Rovner: And Alice, you guys at Politico pointed out that even this $50 billion was not exactly distributed based on need, right? It was distributed based on deals.

Ollstein: Yes. And to build on Lauren’s point, not only is it not enough to make up for the Medicaid cuts, but there are restrictions. States can only use a little fraction of the money to keep these rural hospitals’ lights on, basically. The money is supposed to be for these transformative projects. It’s very tech focused. It’s very, Let’s try these pilot programs and completely revamp the way rural health care is delivered. Meanwhile, there are all these rural hospitals on the brink of closure, and states aren’t allowed to spend a lot of the money on just paying the salaries of the people who work there, paying for keeping the buildings in good shape. And so, we could see benefit from this money, but we could also, in the meantime, see a bunch more rural hospitals close, as they have been. And once they close, it’s really hard to come back.

And so, to your point, the way the money was distributed is getting a lot of criticism from all around the country because, one, a lot of it was split evenly between states regardless of the size of their population. And so, you saw, for instance, Alaska get more than California despite having a tiny, tiny sliver of its population. And I had people arguing with me online saying, Well, what about the rural population? Yes, California has a huge rural population. It’s not just LA and San Francisco. So, even if you only count the rural population, it’s much, much, much bigger than Alaska.

Also, there were these policy incentives in the program where states that adopted Trump-administration-friendly policies — like restrictions on what people can buy with SNAP [Supplemental Nutrition Assistance Program], on implementing the presidential fitness test, on deregulating short-term insurance plans, which Democrats have criticized and called junk plans — these would get the states more money if they adopted these policies. So, we’ve been digging into that and digging into the struggles on the state level on that front.

Rovner: All right. Well, that’s the rural health news. We’re going to take a quick break. We will be right back.

So, the other big news out of HHS [the Department of Health and Human Services] was on the vaccine front where Secretary Robert F. Kennedy Jr. made unilaterally a major change to the federal government’s childhood vaccine schedule, reducing the number of diseases with explicit vaccine recommendations from 17 to 11. No longer recommended for all children will be vaccines to protect against flu, covid, rotavirus, hepatitis A, and the germs that cause meningitis. Sarah, you’re the mom here on this panel today. How is this schedule change actually going to affect parents and children and doctors?

Karlin-Smith: I think a lot of it is going to depend [on] how the pediatrician health community reacts to this, because there’s been a lot of pushback from the medical public health community that this is not an appropriate or scientifically based change. So, doctors may still guide parents to hopefully making the decision to get these vaccines, but parents who may be a little hesitant, maybe feel more comfortable backing out.

Despite sometimes the rhetoric you hear from this administration, states are really the ones that end up creating policies that end up with actual mandates for people to get vaccinated for school and so forth. So, states may build off this and change their mandates, and that may impact access, but they may also not. So, people may still have to, for school purposes, get some of these shots as well.

Rovner: And I should point out that the American Academy of Pediatrics is fighting this, I would say tooth and nail, but also in court. I mean, they’re actually suing, saying that Kennedy didn’t even have the authority to make this change without going through a much more detailed regulatory process.

So, the administration says that all the vaccines currently on the schedule will remain, quote, “covered by insurance,” but I’m not positive that’s necessarily going to be the case in the long term, right? Isn’t mandatory insurance coverage linked to the recommendations of the CDC [Centers for Disease Control and Prevention]? And if these are no longer actually recommended, are they no longer required to be covered?

I know the insurance industry, we’ve talked about this, has said that they’re going to continue to cover all the vaccines at least through 2026. But I’m wondering about the legality. I tried to track this back, but I couldn’t find it all the way.

Ollstein: We could see a patchwork because a lot of states are moving to change their own laws about insurance coverage and have it be based on something other than these federal recommendations. I think that obviously patchworks are challenging when you’re talking about infectious diseases, which do not respect state or national boundaries, but Sarah can say more.

Rovner: Go ahead, Sarah.

Karlin-Smith: Yeah. To build on Alice’s comment, and the thing that gets really confusing really fast always with U.S. health care is states can regulate certain insurance plans and states cannot regulate certain insurance plans, the ERISA [Employee Retirement Income Security Act] plans. So, you could end up, even if states want to mandate coverage, depending on the type of health care coverage you get in your state, you may live in that state, work in that state, and you’re not going to get covered. So, that adds to the patchwork and always adds to the confusion when trying to explain that issue to people.

But the administration has claimed basically because the vaccines, they’re no longer universally recommended — they’re moving to what’s called the shared decision-making recommendation, where people are supposed to consult with their doctor and figure out whether these vaccines are appropriate for them and their children — that that still, under the way laws and regulations are written, requires the mandatory coverage for health care and no copays and so forth.

And I’ve talked to people who’ve looked at this, and there is precedent for that with other vaccines. I think there’s some concerns, however, that that could be challenged by people in court who don’t want these vaccines to be covered. There’s also concern when it comes to like the HPV [human papillomavirus] vaccine, which they’re now only recommending one shot of instead of two.

In that case, because they’ve really fully eliminated the recommendation for a second shot, if somebody felt like they wanted that two-series shot, I don’t think that would be covered. And the other question is, while they didn’t use the CDC’s Advisory Committee on Immunization Practices to make these changes for the most part. And they are largely advisory, but they do have certain legal authority when it comes to vaccines for children’s program, and their legal authority from Congress very much relates to the coverage and reimbursement. So, it’ll be interesting to see, again, if this all aligns.

Rovner: And we should point out that the Vaccines for Children Program, which many people have never heard of, is actually responsible for vaccinating something like half of all children in the United States. It’s a huge program that’s just basically invisible but really, really important.

Karlin-Smith: Right. And so, I think there’s going to be legal questions that they didn’t vote on those reimbursement questions here.

Rovner: Yeah. There’s a lot that’s going to have to be sorted out here. Well, one of the arguments that HHS officials are making is that they compared the U.S. vaccine schedule to that of, quote, “peer nations” like Denmark, but those peer nations have something the U.S. does not: universal health insurance. That can make a really big difference in vaccine uptake and in just the prevalence of disease, right?

Karlin-Smith: Yeah. And so, one thing that people have tried to look at and explain in recent days is the U.S. isn’t actually that different from most of its peers. Denmark, some have made the case, is actually the outlier. And if you look at Germany, Japan, Canada, Australia, the amount of pathogens, viruses the U.S. is vaccinating against is actually much more in line with most of the peer population. And then when you have a country like Denmark, which has universal health insurance …

Rovner: And a very small population.

Karlin-Smith: Right. I mean, it’s very different, but they’ve made in some cases the calculus that if we don’t vaccinate for rotavirus, and we are able to treat the however many kids each year will need to be hospitalized and treated, and you have a certain comfort — I don’t think that most parents would like the idea of knowing your kid is going to get sick and need to be hospitalized maybe or treated — but there’s a lot more comfort that they would get care, and quick care, and would do better there. But they certainly are not, and there’s data to show, [they] don’t do as well as the U.S. does in terms of the amount of people that get some of these diseases.

The other thing with some of the vaccines I noted that like some of these comparison countries don’t cover is they’re newer and they’re still more expensive. So, sometimes one of the reasons these countries are choosing not to recommend them more broadly is because they’re making decisions based on the fact that they have universal health care — the taxpayers pay for it — and then deciding that at this point, the pricing is not affordable. They’re not making a decision saying if the cost was zero, that the risk-benefit calculus isn’t favorable for people.

Rovner: Right. And it’s all about the risk-benefit calculus. So, one thing we know is that the rise in vaccine hesitancy is leading to outbreaks of previously rare diseases in the U.S., including measles and pertussis, or whooping cough. Lauren, you’ve got a really cool story this week with a tool that can help people figure out if they and their families are at risk. So, tell us about it.

Weber: Yeah. My colleagues at The Washington Post, including Caitlin Gilbert, and I set out last year to tell people across the country what their . And so, we requested records from all 50 states and were able to get school-based records for about, I think, 36 of them and county-based records for vaccination records for 44 states. So, we have a nifty tool where you can look up in your local community what your vaccination rates are.

But taking a step back, what we found in our reporting is that before the pandemic, rates weren’t looking that great. Only half of the country was making 95% vaccination against measles, which is herd immunity. After the pandemic, that dropped to 28%.

And what we found in digging in a lot deeper is that schools, which were once considered kind of this bulwark against infectious disease, because they’re the ones who would enforce whether or not you needed your shots to attend school, are somewhat stepping away from that responsibility in the politically charged environment that is America today. I spoke to a superintendent in Minnesota, which has seen a large drop in vaccination for measles, who said, Look, I’m a record keeper. It’s not my job to promote a medical decision.

And you see that attitude across the country in school nurses and so on where maybe they’re not being empowered by their superintendent or principal to draw the line, or they’re valuing the child going to school over getting vaccinated. And so, there’s a lot of talk about at the state level that we have these mandates for vaccination, but if they’re not enforced and there’s no mechanism to enforce them, our investigation found that you had these slipping rates.

And a lot of folks are really concerned. Because look to South Carolina. You have hundreds of kids quarantined and missing school; you have hundreds of people infected. And, in general, measles cases were at their highest in 33 years last year. So, we have this rise of infectious disease amid an administration headed by a man who has disparaged vaccines for years and is working to roll back policy around them.

Rovner: Is there any talk from Capitol Hill on … we’ve talked so much about Sen. Bill Cassidy [R-La.], who’s a doctor, who was the deciding vote for RFK Jr. and said that he got RFK Jr. to promise not to change the vaccine schedule, which he just did. But it’s not just Cassidy. There’s 534 other members of Congress. Is anybody pushing back on any of this?

Weber: I mean, Cassidy tweeted after the vaccine change that he was appalled. I’m a physician. My job is to protect children. This is a problem. At the end of the day, the person who runs HHS is a man who has repeatedly linked the rising number of vaccines, which are rising because we have more vaccines that can fight more pathogens, to chronic conditions that experts say is not based in evidence.

And so, no, I do not see a massive Capitol Hill pushback. I mean, you have frustration and irritation, but I don’t see Cassidy hauling Kennedy in for a hearing. Hasn’t happened yet, really, besides those couple that were mandated. So, we’ll see how this continues to play out.

But the reality is amid all of this talk of vaccine schedules, the people on the front lines of this are these school nurses or pediatricians who are met with a wave of parents who are so confused. I talked to so many pediatricians who said, Look, we refer to the AAP, the American Academy of Pediatrics, but it’s really hard when the president and the head of the health system is saying something different to convince parents that may be confused. And oftentimes, if you’re confused, it’s easier to not take action, to not get your child vaccinated than to do so. And…

Rovner: And because pediatricians don’t already have enough to do.

Weber: Right. Many are scared that these trends that we identified in our investigation will continue to worsen in the years to come.

Rovner: Well, also this week we got the new food pyramid recommendations from HHS and the Department of Agriculture. Food, obviously another big priority for RFK Jr., who, as we know, is a fan of red meat and whole-fat dairy. Unlike the vaccine schedule, though, the changes to the food pyramid appear, at least at first blush, to hew to fairly consensus opinions in the nutrition world that whole foods are better than processed foods, protein is good, added sugar and refined carbohydrates are bad.

Still, when you get into the details, there are some things that are likely to cause nutrition scientists, some, shall we say, indigestion. What are some of the more controversial recommendations here other than Dr. [Mehmet] Oz saying in Wednesday’s press briefing that you might not want to drink alcohol for breakfast?

Ollstein: So, the alcohol piece has gotten pushback because it’s weakening the previous recommendation that really no amount of alcohol is safe. We talked before about a report about alcohol as a carcinogen that was buried last year, a government report that had been worked on for years that was supposed to come out that got buried by the Trump administration. And so that I think is reflected in these new recommendations. And I saw a lot of conservatives celebrating this and saying, Happy hour’s back, everyone! But look, there’s real science that shows the dangers of even moderate alcohol consumption, and that’s getting sidelined here.

Rovner: The previous recommendations were that, I would say the previous recommendations were like no more than one drink a day for women and two for men, and they took that away? I think that was the actual change here.

Ollstein: There was a push to say that no amount is safe, basically, that even small amounts are potentially harmful to health.

Rovner: And that didn’t happen.

Ollstein: Correct, correct. The other concern I was hearing is about the emphasis on red meat when that is something that Americans eat too much of already.

Rovner: Although I know there’s an irony here that I think the new recommendations state, you still shouldn’t have more than 10% of your calories from saturated fat. But saturated fat isn’t nearly as bad as we used to think it was, Sarah. I see you nodding.

Karlin-Smith: Yeah. I think the saturated fat and the focus on the sources of fat and protein is one of the biggest controversies here because there is lots of research and evidence that saturated fat can lead to heart disease and other medical complications. And people have long been pushed toward plant-based proteins, leaner proteins, and the role of dairy, and whether you should be doing high-fat dairy as well.

And there’s been some good reporting from Stat and others of recent days that there was a lot of who was making these recommendations around their relationships with these various industries. They tried to avoid contradicting the science too much in how they made their push for more red meat and more saturated fat. But it’s probably another area where, if you read it in full, you’re going to get confused and you may not end up making the right decisions because some of the recommendations there are kind of contradictory.

Rovner: Although we’ll point out that the difference between the nutrition guidelines and the vaccine schedule is very large because the new nutrition guidelines are just that. They’re guidelines. They do determine what gets served in school lunches and things like that, but it’s not quite nearly of the level that the vaccine schedule is.

Well, finally this week, turning to reproductive health, the Wyoming Supreme Court struck down two abortion bans, kind of remarkable for one of the reddest states in the nation. Interestingly, one of the reasons the bans were struck down is because the state tried to thwart the Affordable Care Act back in 2012. Alice, explain what these two things have to do with each other.

Ollstein: Yes. So, the state adopted some laws saying that people have the right to make their own health care decisions, and that was squarely aimed at the Affordable Care Act. However, the judges found that it also applied to the right to have an abortion.

Rovner: Oops.

Ollstein: They said, Based on the text of this law, it doesn’t matter what you meant it to say. It matters what it actually says. And we find that it applies here.

That’s actually not the only state where that’s happened over the past few years. There have been other conservative states that have inadvertently protected the right to abortion through these right-to-control-your-own-health care provisions. So, I think we’ve seen over the past few years that state constitutions can be more protective of abortion than the federal Constitution in certain circumstances. But I think it’s also notable that Wyoming had one of the first laws specifically banning abortion pills, and that was also struck down.

So, nothing changes in practice, because these laws were already enjoined and were not being enforced, but it is a big deal. And it could lead to more efforts to hold the ballot referendums that we’ve seen over the past few years. There are set to be a few more this fall, but there could be even more following decisions like this in the courts.

Rovner: Yeah. Along those lines, there’s a really interesting piece in The Guardian that suggests that , but not so much for Republicans, most of whom still consider it a deal breaker for a candidate not to agree with them. What happened to all that enthusiasm for abortion rights that we saw in 2023 and 2024 to some extent?

Ollstein: Look, there’s a lot going on right now. So, it may be that just other issues are overshadowing this. And also, it’s a long way to go before the elections. We do not know what’s going to happen.

If various court cases lead to a big change, another big change in abortion access, this could rear its head once again. As we’ve discussed many times, this is not really ever over or settled.

Rovner: All right. Well, it is January. All right. That is this week’s news, or at least as much as we had time for.

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

Weber: Yeah. I have to shout out another investigation my colleagues and I completed led by Rachel Roubein and Lena Sun and I. [“”] We dug into the first year of Kennedy in office. In interviews with nearly a hundred folks and documents, we uncovered some of his previously undisclosed shaping of vaccine policy. We got ahold of an email in which a top aide asked to replace the membership of ACIP and reconsider the universal hep B vaccine recommendation and revisit the use of multidose flu shot vials. We also analyzed how while Kennedy has talked about food twice as much as vaccines while in office, one of his advisers, Del Bigtree, told us, Look, food is more popular with the American mom. And I think some of these revelations shape and put into context what we’re seeing now, which is this culmination of changing the vaccine schedule and continued policy to upend public health infrastructure in this country.

Rovner: That’s a really good piece. Alice.

Ollstein: So, I have a very depressing piece out of San Francisco called, “” This is yet another death of a young person after heavily using some of these LLMs [large language models] for advice. Some of the chat logs show that he was able to very easily circumvent the protections that were put in place.

ChatGPT is not supposed to give people advice on using drugs recreationally, but that is very easily circumvented by pretending it’s a hypothetical question or various other means. And this article does a good job showing that it’s really a garbage-in-garbage-out scenario. ChatGPT is drawing from the entire internet. And so somebody’s dumb post on Reddit by a person who has a substance abuse issue, for instance, could be informing what advice the bot gives you. And so I think this is especially important to keep in mind as, just this week, ChatGPT is launching, making a big push, launching a whole health-care-focused chatbot and encouraging millions of people to use it.

And so this article … quotes experts who argue that it’s not possible to prevent this bad advice from getting in there, just because these chatbots are trained on huge volumes of text from the entire internet. It’s not possible to weed out things like this. And so I think that’s important to keep in mind.

Rovner: So, what could possibly go wrong? Sarah.

Karlin-Smith: I took a look at some ProPublica pieces on the impact of the U.S.’ USAID cuts [“”]. One of the stories that I looked at was “” It’s just a really deep dive into the decisions that these political leaders made to cut off aid and support for various countries. This one, in particular, was looking at South Sudan, even though they were warned that they would make certain disease outbreaks and other humanitarian situations worse. And it just goes through the hardship of that, as well as the fact that Trump administration officials were making claims throughout this time, once there was pushback, that they were going to not cut off certain life-supporting aid and so forth. And that was not actually the case. They did cut it off, and they did it in ways that were extremely abrupt and fast, that there could not be any safety valve or stopgap to prevent the harm that occurred.

Rovner: Yeah. It’s quite the series and really heavy but really good. My extra credit this week comes from my colleague Fred Schulte, who’s moved on from uncovering malfeasance in Medicare Advantage to uncovering malfeasance in cosmetic surgery. This one is called “Advertisements Promising Patients a ‘Dream Body’ With Minimal Risk Get Little Scrutiny.”

And if you’ve ever been tempted by one of those body-sculpting commercials promising quick results, little pain, and an immediate return to your daily routine, you really need to read this story first. It includes a long list of patients who either died of complications of allegedly minimally invasive techniques or who ended up in the hospital and with scars that have yet to heal. Many of the lawsuits filed in these cases are still in process, but it is definitely “buyer beware.”

OK, that is this week’s show. Hope you feel at least a little bit caught up. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer engineer, Zach Dyer.

A reminder, What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X, , or on Bluesky, . Where are you folks hanging these days? Lauren.

Weber: I am on X, , and same thing on these days.

Rovner: Sarah?

Karlin-Smith: Mostly and at @sarahkarlin-smith.

Rovner: Alice.

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

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

Credits

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USE OUR CONTENT

This story can be republished for free (details).

The enhanced premium tax credits that since 2021 have helped millions of Americans pay for insurance on the Affordable Care Act marketplaces will expire Dec. 31, despite a last-ditch effort by Democrats and some moderate Republicans in the House of Representatives to force a vote to continue them. That vote will happen, but not until Congress returns in January.

Meanwhile, the Department of Health and Human Services canceled a series of grants worth several million dollars to the American Academy of Pediatrics after the group again protested HHS Secretary Robert F. Kennedy Jr.’s changes to federal vaccine policy.

This week’s panelists are Julie Rovner of �������ýҕ�l Health News, Lizzy Lawrence of Stat, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• The House on Wednesday passed legislation containing several GOP health priorities, including policies that expand access to association health plans and lower the federal share of some Affordable Care Act exchange marketplace premiums. It did not include an extension of the expiring enhanced ACA premium tax credits — although, also on Wednesday, four Republicans signed onto a Democratic-led discharge petition forcing Congress to revisit the tax credit issue in January.
• In vaccine news, the American Academy of Pediatrics spoke out against the federal government’s recommendation of “individual decision-making” when it comes to administering the hepatitis B vaccine to newborns — and HHS then terminated multiple research grants to the AAP. Meanwhile, the Centers for Disease Control and Prevention is funding a Danish study of the hepatitis B vaccine in West Africa through which some infants will not receive a birth dose, a strategy that critics are panning as unethical.
• Also, a second round of personnel cuts at the Department of Veterans Affairs is expected to exacerbate an existing staffing shortage and further undermine care for retired service members.
• The FDA is considering rolling back labeling requirements on supplements — a “Make America Health Again”-favored industry that is already lightly regulated.
• And abortion opponents are pushing for the Environmental Protection Agency to add mifepristone to the list of dangerous chemicals the agency tracks in the nation’s water supply.

Also this week, Rovner interviews Tony Leys, who wrote the latest “Bill of the Month” feature, about an uninsured toddler’s expensive ambulance ride between hospitals.

Plus, for a special year-end “extra-credit” segment, the panelists suggest what they consider 2025’s biggest health policy themes:��

Julie Rovner: The future of the workforce in biomedical research and health care.��

Lizzy Lawrence: The politicization of science.��

Tami Luhby: The systemic impacts of cuts to the Medicaid program.��

Alice Miranda Ollstein: The resurgence of infectious diseases.��

Also mentioned in this week’s podcast:

• The Washington Post’s “.,” by Lena H. Sun and Paige Winfield Cunningham.
• MedPage Today’s “,” by Jeremy Faust.
• The Washington Post’s “,” by Meryl Kornfield, Hannah Natanson, and Lisa Rein.
• NBC News’ “,” by Berkeley Lovelace Jr.
• Politico’s “,” by Alice Miranda Ollstein and Ariel Wittenberg.
• The Washington Post’s “,” by Paige Winfield Cunningham.
• Politico’s “,” by Joanne Kenen.

[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 �������ýҕ�l Health News and WAMU Public Radio in Washington, D.C., and welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �������ýҕ�l Health News, and��I’m��joined by some of the best and smartest health reporters in Washington.��We’re��taping this week on Thursday,��Dec.��18,��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 Tami Luhby of CNN.��

Tami Luhby:��Hello.��

Rovner:��Alice��Ollstein��of Politico.��

Alice Miranda��Ollstein:��Hi, there.��

Rovner:��And I am pleased to welcome to the podcast panel Lizzy Lawrence of Stat��News. Lizzy, so glad��you’ll��be joining��us.��

Lizzy Lawrence:��Thanks so much for having me.��I’m��excited.��

Rovner:��Later in this episode,��we’ll��have my interview with Tony Leys, who reported and wrote the latest �������ýҕ�l Health News��“Bill of the Month”��about yet another��very expensive��ambulance ride. But first, this week’s news.��

Well, remember when House Speaker Mike Johnson complained during the government shutdown that the issue of the��additional��ACA��[Affordable Care Act]��subsidies expiring was a December problem? Well, he sure was right about that. On Wednesday, the House,��along party lines,��passed��a��bill that Republicans are calling the��“Lower Healthcare Premiums��for All��[Americans]��Act,”��which��actually doesn’t, but��we’ll��get to that in a moment. Notably,��not��part of that bill was any extension of the enhanced tax credits that now are��going��to expire at the end of this year, thus doubling or,��in some cases,��tripling what many consumers who get their coverage from the ACA marketplaces will have to pay monthly starting in January. Speaker Johnson said he was going to let Republican moderates offer an amendment to the bill to continue the��additional��subsidies with some changes, but in the end, he��didn’t.��

So, four of those Republicans,��from more purple swing districts worried about their constituents seeing their costs spike, yesterday signed on��to a Democratic-led discharge petition, thus forcing a vote on the subsidies, although not until Congress returns in January. Before we get to the potential future of the subsidies though, Tami, tell us��what’s��in that bill that just passed the House.��

Luhby:��Well, there are four main measures in it, but none of them, as you say��…��they will lower potentially some premiums for certain people, but��they’re��really a bit of a laundry list of Republican favorite provisions.��

So, one of the main ones is association health plans. They would allow more small businesses��—��and,��importantly, the self-employed��—��to band together across industries. This could lower health insurance premiums for some people, but these plans also��don’t��have to adhere to��all of��the ACA protections and benefits that are offered. So, it may attract more healthier people or be more beneficial for healthier people, but not for everyone, for sure.��

There are some PBM, pharmacy benefit manager,��reforms. They would have to provide a little more information to employers about drug prices and about the rebates they get, but it may not really have��… the experts I spoke to said��it’s��really just��tinkering around at the edges and may not be that consequential.��

Rovner:��And��it’s��not even as robust a PBM bill as Republicans and Democrats had agreed to last year��…��

Luhby:��Exactly.��

Rovner:��… that Elon Musk got struck at the last minute because the bill was too long.��

Luhby:��Exactly,��it’s��a narrower transparency. There are narrower transparency provisions. It would also,��importantly, refund the��cost-sharing��provisions. And remember, there are two types of subsidies in the Affordable Care Act. There are��the premium��subsidies, which is what everyone is talking about, the enhanced premium subsidies.��But these are cost-sharing reductions that lower-income people on the exchanges receive to actually reduce their deductibles and their copayments and coinsurance, their��out-of-pocket��expenses.��

President��[Donald]��Trump, during his first term,��in an effort to��weaken the Affordable Care Act, ended the federal funding for these cost-sharing subsidies, but the law requires that insurers continue to provide them.��So��what the insurers did was they increased the premiums of the��“silver”��plans��in order to��make up some of the difference, but those silver plans, remember, are tied to��…��the cost of those silver plans are what��determines��the premium subsidies that people get. So, basically,��by refunding or by once again funding these cost-sharing subsidies, insurers will lower the premiums for those silver plans, which will,��in turn,��lower the premium subsidies that the government��has to��pay and save the government money.��

The people in silver plans��probably won’t��be affected as much, but what happened after Trump ended the cost-sharing subsidy funding is that with these increased premium subsidies that are tied to the silver plans, a lot of people were able to buy��“gold”��plans. They were able to buy better plans for less because they got bigger premium subsidies, or they were able to buy��“bronze”��plans for��really cheap.��So basically, this��provision will end, will reduce the premium��assistance��that people get,��and��it’ll��effectively raise premium payments for people in a lot of plans, which will make it more difficult for them.��

Rovner:��Which was a wonderful explanation, by the way, of��something��that’s��super complicated.��

Luhby:��Thank you.��

Rovner:��But��I’ve��been trying to say it��basically moves��money around. It takes money that had been��…��it lowers how much the federal government will have to pay, while at the same time loading that back onto consumers.��

Luhby:��Right.��

Rovner:��So, hence my original statement that the��“Lower Premiums��for All”��Act��doesn’t��lower premiums for all. So, this is��…��

Luhby:��No, there’ll be a lot of people in gold and bronze and��“platinum”��plans who will be paying a lot more, or they’ll have to, if they’re in gold, they may have to shift to silver, which means they’ll just be paying more out-of-pocket when they actually seek care.��

And then��there’s��a fourth provision��that’s��not as consequential:��It’s��called choice plans.��It’s��to help employers give��…��it’s��to make it easier for employers to give money to people to buy coverage on the exchanges.��

Rovner:��Yeah, which��I think nobody��disagrees with. But Alice,��there’s��another even catch to the cost-sharing reductions, which is that��it’s��only for states that ban abortion or that��don’t��ban abortion. Now I��forget, which is it?��

Ollstein:��So, it’s,��yeah.��So��the great compromise of the Affordable Care Act was that��it’s��up to states whether to allow, require, or prohibit plans on the Obamacare exchanges from covering abortion. And as states do, they went in different directions, so about half ban it and about the other half, it’s��50-50 on requiring abortion coverage and just allowing it, leaving it up to individual plans. And so yes, this provision��sought��to penalize states that allowed abortion. And so, it’s expanding the definition of the Hyde Amendment from where it was before, basically saying if any federal funding is going to a plan that uses other money to pay for abortion, then that counts as funding abortion, even though the money is coming out of different buckets.��

And so, this has been a big fight on Capitol Hill this year. And as I wrote yesterday,��it’s��nowhere near being resolved. I mean, even if lawmakers were going to come together on everything else related to the subsidies, which they are not, the abortion debate was still in the way as��an impediment, including in the Senate as well.��

Rovner:��Yeah. So, what are the prospects for these��additional��subsidies? And I should go back and reiterate that what Tami and I were talking about were the original tax credits that were passed with the Affordable Care Act, not the enhanced ones, the bigger tax credits that are expiring at the end of the year. So, Republicans have now forced this vote, so we know that the House is going to vote on extending these subsidies��—��in January,��after��they’ve��expired, which is a whole issue of complication itself. But I mean, is there any prospect for a compromise here?��Might they go home and get enough pushback from constituents who are seeing their costs go up so much they’re going to have to drop their insurance that they might change their minds?��

Ollstein:��Well, Democrats and advocacy groups are trying to ramp up that pressure.��We’ve��been covering some ad campaigns and efforts. Democrats are holding town halls in Republican districts where the representatives are not holding town halls to shine a light on this.��They’re��highlighting the stories of individual, sympathetic-character folks who are having their premiums go��way up.��

So, there were press conferences just this week I saw with retirees and people who are on��Social��Security��Disability and small-business owners and single parents,��and��it’s��not hard to find these stories;��this is happening to tens of millions of people. And so,��I think this��is going to be a major, major political message going into next year. Whether��it’s��enough to make Republicans who are still so ideologically opposed to the Affordable Care Act agree on��some kind of an��extension, that remains to be seen. And we really��haven’t, despite the defection of a small handful this week in joining the Democrats on an extension��—��which was��really notable��and a sign that Speaker Johnson is not keeping his caucus in array.��But the vote hasn’t happened yet, and we’ll see if spending time back in the districts over the holidays makes people more or less willing to compromise.��It can��go either way.��

Rovner:��I saw a lot of people yesterday saying that,��Well, even if the House were to pass the clean three-year extension of the enhanced subsidies��—��which is what’s in the Democrats’��bill��—��the Senate just voted on it last week and voted it down, so it wouldn’t have any chance.��To which my response was,��“Hey, Epstein files.”��When the jailbreak happened in the House on that, the Senate voted, I believe, unanimously for it. So, things can change in the Senate. Sorry, Tami, I interrupted you;��you wanted to say something.��

Luhby:��No, I was just going to say that yes, things can certainly��change��and there have been surprises before, but this is obviously also not a new issue. I mean, the Democrats have been running ads, people have been speaking out. We have all been��writing��stories about��the cancer��survivors or cancer patients who may have to drop their coverage in the middle of their treatment because they��can’t��afford the new premiums, or��all of��these stories. So, none of this is new, but��we’ll��see.��There’s��obviously��…��what is��somewhat new��is the administration’s message on increasing affordability, and this is a huge affordability issue. So,��maybe that��will spur some change in votes or change in mindset.��

Rovner:��Well, definitely a January story too.��

Well, moving on to this week in vaccine news, the Centers for Disease Control and Prevention has made it official��—��after being blessed by the acting director of the agency, who is neither a doctor nor a public health professional��—��the U.S.��government is no longer recommending a birth dose of the hepatitis B vaccine, which by the way, has been shown to reduce chronic hepatitis B in children and teenagers by 99% since the recommendation was first issued in 1991.��

And merging two stories from this week, there’s also��news about the American Academy of Pediatrics, which has been among the most vocal medical groups protesting the vaccine schedule changes. The AAP said the hepatitis B change will��“harm children, their families, and the medical professionals who care for them.”��And in a move that seems not at all coincidental, the Department of Health and Human Services on Wednesday��terminated��seven federal grants to the AAP worth millions of dollars, for work on efforts including reducing sudden infant deaths, preventing fetal alcohol syndrome, and��identifying��autism early. According to��The Washington Post, which��, an HHS��spokesman��said the grants were canceled because they��“no longer align with the��Department’s mission or priorities.”��

First, this is not normal. Second, however,��it’s��HHS in 2025 in a microcosm, isn’t it? Either get with the program or get out. Lizzy,��you’re��nodding.��

Lawrence:��Absolutely. Yeah, I think this has become very commonplace in this administration.��And also��interestingly, yesterday, the HHS posted in the federal register that the CDC offered a $1.6 million grant to a group of Danish researchers who study in Guinea,��West Africa,��to run a placebo-controlled trial of hepatitis B vaccine for newborns. And so,��we’re��seeing an active removal of funds from the American Academy of��Pediatricians��[Pediatrics], and��then giving funds now to research. And this is a research group��actually that��RFK Jr. has cited their studies before, they study overall health effects of vaccines. And so, it will be��really interesting��to see if this is a trend that continues, if��they’re��kind of��…��we already know that HHS, the CDC’s vaccine panel,��there’s��been discussions about making our vaccine schedule closer to Denmark’s. Now��there’s��this money being given to Danish researchers who align with the way that they think about vaccines is��similar to��Kennedy and to another official at FDA,��called Tracy Beth Høeg, who is also on the CDC’s panel as the FDA representative. So,��yeah.��

Rovner:��And who is Danish, I believe.��

Lawrence:��Yes, her husband is Danish, and so she lived in Denmark for many years.��

Rovner:��I saw some scientists complain about that study in Guinea-Bissau, because they say��it’s��actually unethical��to use a placebo to study the hepatitis B vaccine because we know that it works.��So��if��you’re��giving a placebo to children,��you’re��basically exposing��them to hepatitis B.����

Lawrence:��Right.��

Ollstein:��Yeah. I saw��that��too. And a lot of folks were saying this would never be approved to be done in the U.S. And so, doing it in another country is reminding people of��colonial experiments��in��medicine that were��really unethical��and subjected people to more risks than would be allowed here. And like you said,��basically knowingly��withholding something that is safe and effective and giving someone a placebo instead.��

Another issue I saw raised was that it is not a double-blind study;��it is a single-blind study. And so, that allows for potential biases there as well.��

Lawrence:��Right. And I was also seeing that the Guinea Ministry of Health is planning to mandate a universal hep B dose in 2027.��

Rovner:��Oops.��

Lawrence:��So, that’s a crazy��…��yeah, you have babies born before that year who are not given this dose, and then after��…��so yeah, it raises all kinds of ethical concerns,��and it’s just remarkable that the government would just pull away and offer this money to them.��

Rovner:��HHS in 2025.��Specifically on the��covid��vaccine, there��were��two stories this week. One is a study in the Journal of the American Medical Association that found that pregnant women vaccinated against��covid-19 are less likely to be hospitalized, less likely to need intensive care, and less likely to deliver early, if they can track the virus, than those who are unvaccinated. And over at��,��editor Jeremy Faust,��who’s��both a doctor and a health researcher, says that FDA��vaccine��chief Vinay Prasad overstated his case when he said the agency has found at least 10 children��who’ve��died��as a result of��receiving the��covid��vaccine. Turns out the actual memo from the scientists assigned to research the topic concludes the number is somewhere between zero and seven, and five of those cases have only a 50-50 chance of being related to the vaccine. This��isn’t��great evidence for those who want to stop giving the vaccine to children and pregnant women, I would humbly suggest.��

Lawrence:��Right,��right.��Yeah, the memo that Vinay Prasad sent, which was��immediately��leaked, was remarkable in that it included no data backing up his claims.��And this is a really tricky area, when I’ve talked to scientists at the agency who focus on these issues.��I think sometimes��it’s��hard to say that there are cases that are very subjective, and so this is a discussion that needs to be handled delicately,��and��it’s��a��really severe��claim to say that this has killed 10 children. And so, that discussion needs to be shared transparently and��allow for��experts to really weigh in.��

Rovner:��Yeah. Well, another issue��that’s��going to bleed over into January. All��right,��we’re��going to take a quick break.��We will be right back.��

So��in other administration health news, it appears, at least��, that the on-again,��off-again��cuts to medical personnel at the Department of Veterans Affairs are on again. The��Post is reporting that the VA is planning to eliminate up to 35,000 doctors, nurses, and support personnel.��That’s��on top of a cut of 30,000 people earlier in 2025. Altogether,��it’s��about a 10% cut in total.��Apparently, most��of the positions are currently unfilled, but that��doesn’t��mean that��they’re��unneeded, particularly after Congress dramatically expanded��the��number of veterans eligible for health benefits by passing the PACT Act during the Biden��administration.��That’s��the bill that allowed people to claim benefits if they were exposed to toxic burn pits. What is this second round of cuts going to mean for veterans’��ability to get��timely��care from the VA? Nothing good, I imagine.��

Luhby:��Well,��I’ve��been speaking over the past year or two��to��a VA medical staffer,��who wishes to remain anonymous for obvious reasons.��And one thing they told me is that their boss, who was also a medical practitioner, took one of the retirements, and that they have to now cover their boss’��shift.��And��they’ve��asked if the boss is going to be replaced because they obviously��can’t��do two people’s jobs well, and��they’ve��been told that the boss will not be replaced.��

There’s��also,��on top of all of this,��there’s��a hiring freeze and there’s restrictions in hiring. So,��it’s��been��very difficult��for agencies, including the VA, including��the medical��personnel, to get new people. And again, the person��I’ve��spoken to said that the veterans are not getting the care, as��good care��as they were last year because this person just��can’t��do two people’s jobs. And��it’s��on the medical side, but the source also said that��it’s��throughout the hospital with the support staff and even the custodial staff. I mean, just��…��there’s��a lot of unfilled positions that are affecting overall care.����

Rovner:��I feel like a big irony here is that during the first Trump��administration, improving care at the VA and lowering the wait times was a huge priority for President Trump, not just for the administration. He talked about it all the time. And yet, here��he’s��basically undoing��everything that he did for veterans during the first administration.��

All right. Well, meanwhile,����that the FDA is considering rolling back the rule that requires dietary supplement makers to note on their labels that their products have not been reviewed by FDA for safety and efficacy. This was a compromise reached by Congress after a gigantic fight over supplements in 1994��—��I still have scars from that fight��—��following a series of illnesses and deaths due to tainted supplements a couple of years before that. The idea was to let supplements continue to be sold without direct FDA approval,��as long as��customers were informed that they were not intended to��“diagnose, treat, cure, or prevent any disease,”��a phrase that��I’m��sure��you’ve��heard many times in commercials. Of course, diet supplements are��practically an��article of faith for followers of the��“Make America Healthy Again”��movement. I would assume that this is part of RFK Jr.’s vow to loosen what he has called the��“aggressive suppression”��of vitamins and dietary supplements. Lizzy,��you’re��nodding.��

Lawrence:��Yeah, this is super interesting because this was one of the first things a year ago,��when��RFK was announced as the HHS��secretary, when people were��speculating��on what some of his priorities would be, deregulating supplements was a big one.��And so, I think this will be a really interesting space to watch and see.��And��it’s��emblematic,��too,��of the uneven view of products regulated by the FDA,��where there are some products where there’s��…��that RFK and other leaders at the FDA are super��“pro”��and��well, we��don’t��actually need��as much evidence here. And then others, like vaccines or SSRIs��[selective serotonin reuptake inhibitors], where��it seems that they��want to really raise evidence standards, which is not how the FDA is supposed to work.��It’s��supposed to be��dispassionately, with no bias, reviewing medical products.��

Rovner:��And I would point out, in case I��wasn’t��clear before, that supplements are barely regulated now. Supplements are regulated so much less than most everything else that the FDA regulates. Sorry, Alice, you wanted to say something.��

Ollstein:��Yeah. It also, I think, reveals an interesting public perception issue, where the message that a lot of people are getting is that the pharmaceutical industry is this big, bad, evil corporate thing that is out to harm you, and it has all these documented harms, whereas supplements are natural and wellness and seen as the underdog and the upstart. And I think people should remember that supplements are a huge corporate industry as well, and,��like Julie and Lizzy have been saying, regulated a lot less than pharmaceuticals. So, if��you’re��taking a prescription drug,��it’s��been tested a lot more than if��you’re��taking a supplement.��

Rovner:��Yeah, absolutely. So while most of the coverage of HHS in 2025 has been pretty critical, this week, two of our fellow podcast panelists,��Joanne Kenen��and��Paige Winfield Cunningham, have stories on how the breakout star at HHS in this first year of Trump 2.0 turns out to be Dr. Oz. Apparently being an Ivy League-trained heart surgeon with an MBA actually does give you some qualifications to run the agency that oversees Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable��Care Act.��I think I��noted way back during his confirmation hearings that he clearly already had the knack of how to deal with Congress:��flatter them and take their parochial concerns seriously.��That’s something that his boss, RFK Jr., has most certainly not mastered as of yet.��And it turns out that Dr. Oz has both leadership and policy chops. Who could have predicted this going into this year?��

Luhby:��Well, one thing��that’s��interesting is that we were all, I think, watching what Dr. Oz would do with Medicare and Medicare Advantage, because��it’s��obviously something that he had promoted on his shows.��It’s��something that the Biden��administration was trying to crack down on. And it has been interesting that he has not been giving carte blanche to the insurers. He has been cracking down on them as well. I listened to a speech that he gave before the Better Medicare Alliance, which is the group that works with Medicare Advantage insurers. And he��said basically,��“You guys have to step up,”��and so,��it’ll��be interesting to��see going forward��what��additional��measures they take. But��yeah,��he’s��certainly not bending over to the insurers.��

Rovner:��Yeah. I will say, like I said, I noticed from the beginning, from when he came to his confirmation hearing,��that somebody had briefed him well.��Apparently, according, I think��,��he’s��been talking regularly to his predecessors from both parties about how to run the agency, which surprised me a little bit. I will be interested to see how this all progresses, but if you had asked me to bet at the beginning of the year of the important people at HHS who were running these agencies who would do the consensus best job, I’m not sure I would’ve had Dr. Oz at the top of my list.��

Luhby:��Well, and one thing to also point out that was��, particularly,��is that what��we’ve��been hearing at other agencies��—��the CDC, and across the Trump��administration��—��that a lot of the political appointees are really at odds with the staff.��They’re��not communicating with the staff;��there were concerns about that after the CDC shooting over the summer. And one thing that,��obviously,��Dr. Oz is very��personable,��he knows how to reach out to an audience. And in this case, his audience is also his staff. And it was notable that Paige��detailed about��how he really is interacting a lot with the staff. And��I’m��sure��that’s��obviously helping morale and helping the mission at CMS. Also, of course,��it’s��an agency that RFK has not focused on.��

Rovner:��I say, what a shock, treating career staff with some respect,��like they know what��they’re��doing.��

All right. Well, finally, we end this year on reproductive health,��pretty much the��same way we began it, with anti-abortion groups attacking the abortion pill, mifepristone. We know that despite the fact that abortion is now illegal in roughly half the states, the number of abortions overall has not fallen, and that is because of the easy availability,��even across state lines,��of��medication��abortion. Alice,��you’ve��got quite the story this week about an unusual way to go after the pill. Tell us about it.��

Ollstein:��Yeah.��So��this is a��trend��I’ve��been covering��for the last few years, and��it’s��anti-abortion groups��trying��to use various environmental laws to achieve the ban on the pills that they want to achieve. And so,��there’s��been some various iterations of this over the years. The latest one is that groups are jumping on��a��EPA��[Environmental Protection Agency]��public comment process��that’s��going to kick off any day now. So, this is what the EPA does. Every few years, they update the list of chemicals that need to be tracked in water around the country.��So��this��is a big deal.��It costs a lot to track these chemicals.��There��can only be so many chemicals on the list. And these groups are trying to rally people around the country to demand that the EPA add mifepristone and its components to this list.��

Rovner:��This is wastewater, right? Not drinking water?��

Ollstein:��No, this is drinking water.��

Rovner:��Oh, it is drinking water.��

Ollstein:��There are other efforts to use wastewater laws to restrict abortion pills, yes.��So��we talked to scientists that say there is no evidence that mifepristone in the water supply is causing any harm whatsoever. On the other hand, there is tons of evidence of other chemicals, and so we have����talking about how if they put mifepristone on this list, it would push out another more dangerous chemical from being on that list.��

So, just to zoom out a little bit, while this��particular campaign��tactic, whatever you want to call it, may not succeed, I think��it’s��part of a bigger project to sow doubt in the public’s mind about the safety of mifepristone in��various ways.��We’ve��been seeing this all year, and for several years. But I think that this kind of gross-out factor of��there’s��abortions in the water!��Even without scientific evidence of that,��I think it��contributes to��the public��perception. And KFF had some polling recently showing that doubt about the safety of the pills has increased over the past few years. And so, these kinds of campaigns are working in the court of public opinion, if��not quite yet��at federal agencies.��

Rovner:��Another one we will be watching. All right, that is this week’s news. Now��we’ll��play my��“Bill of the Month”��interview with Tony Leys, and then��we’ll��come back and do our��very special��year-end extra credits.��

I am pleased to welcome back to the podcast �������ýҕ�l Health News’��Tony Leys, who reported and wrote the latest �������ýҕ�l Health News��“Bill of the��Month.”��Tony, welcome back.��

Tony Leys:��Thanks for having me, Julie.��

Rovner:��So, this month’s patient had��a very expensive��ambulance ride, alas, a story��we’ve��heard as part of this series several times. Tell us who he is and what prompted the need for an ambulance.��

Leys:��He is Darragh Yoder, a toddler from rural Ohio. He had a bacterial skin infection called��[staphylococcal]��scalded skin syndrome, which causes blisters and swelling. His mom, Elisabeth, took him to their local ER,��where doctors said he needed to be taken by ambulance to a children’s hospital in Dayton,��about 40 miles away. They put in an IV and then put him in the ambulance. His mom went��with��and said the driver��didn’t��go particularly fast or use the��siren, but��did get them there in about 40 minutes.��

Rovner:��But it��still was��an ambulance ride. So, how big was the bill?��

Leys:��$9,250.��

Rovner:��Whoa. Now, this family��doesn’t��have insurance, which��we’ll��talk about in a minute. So, it��wasn’t��an in-��or��out-of-network��thing. Was this unreasonably high compared to other ground ambulance rides of this type?��

Leys:��It’s really hard to say because the charges can be all over the place,��is��what national experts told me. But if Darragh had been on Medicaid, the ambulance company��would’ve��been paid about $610, instead of��$9,200.��

Rovner:��Whoa. So, what eventually happened with the bill?��

Leys:��The company agreed to reduce��it��about 40% to��$5,600 if the family would pay it in one lump sum. They��did,��they wound up putting it on a credit card, a no-interest credit card,��so they could pay it off overtime.��

Rovner:��Now, as we mentioned, this family��doesn’t��have insurance, but they belong to something called a��health��sharing��ministry. What is that?��

Leys:��Members pool their money together and basically agree to help each other pay bills. And they were thinking that that would cover��maybe about��three-quarters of what they owed, so��…��

Rovner:��Have they heard about that yet?��

Leys:��I have not heard.��

Rovner:��OK. So,��what’s��the takeaway here? I imagine if a doctor says your kid who has an IV attached needs to travel to another facility in an ambulance, you��shouldn’t��just bundle them into your car instead, right?��

Leys:��I sure��wouldn’t.��Yeah, no. I mean, at that point,��she felt like she had no choice. I mean, she did say if she��would’ve��just driven straight to the children’s hospital instead of stopping at the local hospital, they��would’ve��gotten there sooner than if once she stopped at the local hospital and they ordered an ambulance. So,��that’s��in retrospect what she wishes she��would’ve��done. But if��they’d��had insurance, the insurer��would’ve��presumably negotiated��a lower rate,��and they��wouldn’t��have had to do the negotiation themselves.��

Rovner:��So, they are paying this off, basically?��

Leys:��Yeah, they paid it in one lump sum, which is a stretch for them, but they felt like they had no choice.��

Rovner:��All right. Tony Leys, thank you very much.��

Leys:��Thanks for having me, Julie.��

Rovner:��OK,��we’re��back.��It’s��time for our��extra-credit��segment.��That’s��usually where we each recognize a story we read this��week��we think you should read too. But since this is our last podcast of the year, I wanted to do something a little bit different.��I’ve��asked each of our panelists to take a minute or two to��talk about what they see, not necessarily as the biggest single health story of the year, but the most important theme that��we’ll��remember 2025 for. Tami, why don’t you start us off?��

Luhby:��OK. Well, I think that Medicaid has been a big issue in 2025 and will continue to be going forward. Among the most consequential health policies enacted this year were the sweeping Medicaid changes contained in the One Big Beautiful Bill��[Act], which Congress passed over the summer. The legislation enacts historic cuts to��[the]��nation’s safety net,��with the biggest chunk coming from Medicaid, which serves low-income Americans. It would slash more than��$900 billion��from Medicaid, according to the Congressional Budget Office. About 7.5 million more people would be uninsured in 2034 due to these Medicaid provisions. And most of that spike would come from��Congress��adding work requirements to Medicaid for the first time. We know that that happened in 2018, states were trying to do��…��well, the Trump��administration allowed certain states to do that. It really only took effect in Arkansas, and about��18,000 people��lost coverage within months from the work requirements, many of whom,��the advocates say,��many people are��working,��they’re going to get caught up in red tape.��They’re��either working or��they’re��eligible for exemptions, but��they’ll��get caught up in red tape.��

So, what the Big Beautiful Bill requires is in states that have expanded Medicaid, working-age adults without disabilities or��[dependent]��children under age 14 would have to work, volunteer, or attend school or job training programs at least��80 hours��a month to remain eligible, unless they qualify for another exemption,��such as being medically frail or having substance abuse disorder. The package also limits immigrants’��eligibility for Medicaid, requires enrollees to pay some costs, and caps state and local government provider taxes, which is a key funding source for��states��and which will have ripple effects across hospitals and across states in general.��

Now,��what’s��important to note��is,��most of these provisions��haven’t��taken effect yet.��Most of them actually take effect after the midterm elections next year.��So,��they’ll��be rolling out in coming��years��and the full impact is yet to come.��

Rovner:��Alice.��

Ollstein:��So, I have chosen the resurgence of infectious diseases that we are seeing right now.��I think measles��is��really the canary in the coal mine.��Because��it’s��so infectious,��that’s��what’s��showing up first, but��it’s��not going to be the last infectious disease that the country had almost squashed out of existence that is now, as I said, resurging. And so,��I think that a lot of different policies and trends��are feeding into this. And��I think we��have the rollback of vaccine requirements at the state level, at the federal level. We have policies that deter people from seeking out testing and treatment, especially some of these anti-immigrant policies that��we’re��seeing. And then just cuts to public health and public health staff, cuts to surveillance, so��it’s��just harder to know where the outbreaks are happening and how bad they are.��It’s��hard to get reliable data on that. And��so��I think, yes,��we’re��seeing measles first, but now we are starting to see whooping��cough,��we’re��starting to see some other things, and��it’s��really troubling,��and it could have a political impact too.��

I have talked to a bunch of candidates who are running in next year’s midterms who say that they’re able to point to outbreaks right there in their state to say,��“This is the consequence of Republican health��policies, and this is why you should vote for me.”��So, I��would be keeping��an eye on that in the coming year.��

Rovner:��Lizzy.��

Lawrence:��So, my chosen theme is the politicization of science. And my focus has been on the FDA as an FDA beat reporter, but��there’s��been the politicization of science in every agency. And this is something that used to be��pretty taboo, right? I keep thinking these days about the��[Barack]��Obama HHS��secretary,��Kathleen Sebelius,��and the legal and political repercussions she faced when she vetoed an FDA decision to make��Plan B��over-the-counter. And those days seem��very far��away, because now��we’re��seeing at��the FDA speedier drug reviews being used as a bargaining chip in deals between the White House and companies in exchange for companies lowering their prices.��

At the FDA and CDC,��you’re��seeing skeptics or more political officials completely taking over operations, reopening debates on things like vaccines, antidepressants during pregnancy, RSV, monoclonal antibodies, based on thin or even��really no��or debunked evidence.��

You’re��seeing the White House just today use CMS to pull funding from hospitals that perform gender-affirming surgeries.��You’re��seeing NIH��[the National Institutes of Health]��pull funding from research studies that go against Trump��administration ideology.��So, there’s really so many examples, too many to count, of political leaders wielding in power and trying to shape science to fit their agendas in the way that they see the world.��

And then��I’d��say that has a trickle-down effect��to��the way that everyday people think about science,��and it calls everything into question and makes��…��People look to politicians and to the heads of public health agencies to tell them the truth. I mean,��maybe not��politicians, but��it seems that doctors and medical experts’��voices��are increasingly being drowned out by the political re-litigating of science that has been settled for a long time. So,��I think this��is��a very important��topic and one that��I’ll��keep watching��closely in the��next year.��

Rovner:��Yep.��So��my topic builds on Lizzy’s.��It’s��how this administration is using a combination of personnel and funding cuts and new regulations to jeopardize the future of the scientific and health��care workforce well into the future. The administration has frozen or��terminated��literally billions��of dollars in grants from the National Institutes of Health and the National Science Foundation, not just causing the shutdown of many labs, but making students who are pursuing research careers rethink their plans, including those who are well into their graduate studies. Some are even going to other countries, which are happily poaching some of our best and brightest.��

And as��we’ve��talked about so many times before in this year’s podcast, the administration also seems intent on��basically choking��off the future health��care workforce. The big budget bill includes caps on how much medical students can borrow��in��federal loans.��That’s��an effort to get medical schools to lower their tuition, but most observers think��that’s��unlikely to happen. The��Education��Department has decreed that those studying to be nurses, physician assistants, public health workers, and physical therapists are not pursuing a��“profession,”��thus also limiting how much they can borrow. And a new $100,000 visa fee��is going to make it even more difficult for hospitals and clinics, particularly those in rural areas, to hire doctors and nurses from outside the U.S., at a time when international medical workers are��literally the��only ones working in many shortage areas. These are all changes that are going to have ramifications, not just for years, but potentially for generations. So, these are all themes that we will continue to watch in��2026.��

OK, that is this week’s show and our last episode for 2025. Thank you to all of you listeners for coming with us on this wild news ride. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer-engineer, 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 guys��hanging these days, Alice?��

Ollstein:��Mostly on Bluesky��, and still on X��.��

Rovner:��Tami.��

Luhby:��You could find me at��.��

Rovner:��Lizzy.��

Lawrence:��You can find me at��, on LinkedIn at��, on X��, and on����—��and I forget my username, but��I’m��somewhere there.��

Rovner:��Don’t��worry about it.��OK, we will be back in your feed in January. Until then, be healthy.��

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California, Massachusetts, Connecticut, and have set caps on health care spending in a bid to rein in the intense financial pressure felt by many families, individuals, and employers who every year face increases in premiums, deductibles, and other health-related expenses.

Hospitals and other health care providers are citing Republicans’ One Big Beautiful Bill Act, signed by President Donald Trump in July, as one more reason to challenge those limits.

The law is expected to reduce federal Medicaid spending by over a decade, which mathematically should help the overall health care system meet the caps. But the law is also expected to increase the number of uninsured Americans, mostly Medicaid beneficiaries, by an estimated . Health care analysts predict hospitals and other providers will raise prices to cover the double whammy of lost Medicaid revenue and the cost of caring for an influx of newly uninsured patients.

Whether regulators in some states will allow providers to justify higher prices and exceed the spending caps is unclear. Only can penalize providers financially if they fail to meet targets.

“Are we going to say, ‘That’s OK’? Or are we going to say, ‘Well, you exceeded the target. We’re still going to penalize you for that’?” said Richard Pan, a former state lawmaker and a member of the California Office of Health Care Affordability’s board. “That has not yet been decided.”

The California Hospital Association, the industry’s main state lobbying group, in October asking a state court to strike down the spending caps, which it argued fail to account for all the cost pressures hospitals face. Those pressures, it said, include an aging, sicker population; the of labor; expensive advances in medical technology; large capital outlays on required seismic retrofitting; and changes in federal policy, including the One Big Beautiful Bill Act. The hospital group’s lawsuit also asserted that the state affordability office, by hastily imposing ill-considered cost-cutting targets, was undermining its other key mission of improving health care access, quality, and equity.

California’s affordability office last year set a five-year target to cap statewide spending growth, starting at 3.5% in 2025 and declining to 3% by 2029. The annual caps apply to a wide range of health care entities, including hospitals, medical groups, insurers, and other payers.

Earlier this year, it imposed much lower spending growth caps — starting at 1.8% in 2026 and declining to 1.6% by 2029 — for .

“The spending caps set by politically appointed bureaucrats could force cuts that result in many Californians traveling farther for care, facing longer emergency room wait times, experiencing more overcrowding, and losing access to critical services,” Carmela Coyle, the hospital association’s president and CEO, said in an October press release.

The California attorney general’s office, which will represent the affordability agency, has not yet filed a response to the hospital group’s complaint and did not respond to a request for comment.

Hospitals’ Pushback

California is not the only state taking a close look at hospital prices, which are widely considered a of health care costs.

“States, armed with information that points to payments to hospitals as a driver of what is way beyond affordable commercial premiums, have begun to take increasingly targeted actions focused on commercial hospital prices,” said Michael Bailit, founder of the Needham, Massachusetts-based consultancy , which has advised multiple states, including California, on ways to tame health care spending. “It is not surprising that the hospital industry is going to oppose such state actions.”��

In its lawsuit, the California Hospital Association said the affordability office’s own report showed that pharmaceutical and insurance companies are largely responsible for high costs.

Hospitals in some states with cost growth limits, including and , have expressed objections similar to the ones raised in the California lawsuit. They could follow their counterparts in California if their lawsuit succeeds, said Peter Lee, who led California’s Affordable Care Act marketplace, Covered California, for and is now a at Stanford Medicine’s Clinical Excellence Research Center.

Lee said the work of California’s affordability office and similar agencies in other states is just about the only systemwide effort being made to cut health care costs. They are basically saying, “‘Look, health care is taking money away from education, it is taking money away from the environment, it is taking money away from everything in the public sector, and in the private sector it is taking money away from wages,’” he said. “‘We don’t know how you, the health system, are going to do it, but it is your job not just to provide quality but to lower costs. Here’s the target.’”

To be sure, achieving the cost savings that California and those other states are seeking is no easy lift. It will ultimately require persuading large, financially powerful players that compete fiercely for health care dollars to adopt a different mindset and begin cooperating to reduce costs instead. And that, in many cases, will mean lower revenue.

But the status quo, as many people know all too well, means continued financial pain for millions.

In early 2020, Estevan Rodriguez, a bartender at California’s Monterey Beach Hotel, had surgery for a staph infection in his leg. The bill came to nearly $168,000. His insurance paid most of it, but he still owed $5,665, which took him two years to pay, more than $200 every month. “It may not be a lot to some people, but it was a lot to me,” Rodriguez said.

He said he dropped his Hulu subscription, switched to a lower-cost cellphone, and got cheaper car insurance. He started going to food banks rather than the grocery store, he said, and had a lot less time with his kids, because he was constantly working to pay off the hospital bill.

, where Rodriguez had his surgery, is one of the seven hospitals identified by California’s affordability office as high-cost. A attributed high hospital prices in Monterey County to a lack of market competition “rather than higher operating costs or superior quality of care.”

The Monterey hospital referred a request for comment about its “high-cost” designation to the California Hospital Association. CHA spokesperson Jan Emerson-Shea declined to comment beyond the language of the lawsuit and Coyle’s press release statement.

Reduced Competition

Health care analysts worry the One Big Beautiful Bill Act will reduce market competition even further by stressing already weak hospitals, leading some to shut services, merge with larger health systems, or close. One study estimates are at risk of closing nationwide.

Less competition, in addition to fewer Medicaid dollars and an increase in uninsured patients, will only strengthen the incentive of health systems with the requisite market clout to raise their commercial prices, increasing premiums for employers and individuals.

“We think commercial prices will continue to increase as health care providers, and hospitals in particular, will seek to preserve or increase their revenue,” said Rachel Block, a program officer at the Milbank Memorial Fund, a foundation that focuses on health equity.

That in turn could pose a challenge to state affordability regulators tasked with overseeing compliance with growth targets for health care spending.

California’s affordability office is required to consider mitigating factors, including changes in federal and state laws. But some of its board members have expressed skepticism about letting hospitals offset Medicaid losses with higher commercial prices.

“There’s a lot of talk about using HR 1 and other federal policies as an excuse to raise prices on commercial payers,” Ian Lewis, an affordability office board member and policy director for UNITE HERE Local 2, a hospitality workers union in the Bay Area, said at the agency’s , referring to the One Big Beautiful Bill. “There’s no more blood to be squeezed from this stone.”

�������ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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�������ýҕ�l Health News Washington health policy reporter Amanda Seitz discussed the cost of insurance on Illinois Public Media’s The 21st Show on Dec. 10.

�������ýҕ�l Health News Nevada correspondent Jazmin Orozco Rodriguez discussed Native Americans and the Rural Health Transformation Program on The Daily Yonder’s The Yonder Report on Dec. 3.

• Read Orozco Rodriguez’s “Republicans Left Tribes Out of Their $50B Rural Fund. Now It’s Up to States To Share.”

�������ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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But this time there’s an extra complication. Though it’s the middle of open enrollment, lawmakers are still debating whether to extend the subsidies that have given consumers extra help paying their health insurance premiums in recent years.

The circumstances have led to deep consumer concerns about higher costs and fears of political fallout among some Republican lawmakers.

According to released in December, about half of current enrollees who are registered to vote said that if their overall health care expenses — copays, deductibles, and premiums — increased by $1,000 next year, it would have a “major impact” on whether they vote in next year’s midterm elections or which party’s candidate they support.

For those caught in the middle — including consumers and leaders of the , that run their own ACA marketplaces — the lack of action on Capitol Hill has led to uncertainty about what to do.

“Before I sign up, I will wait and see what happens,” said poll participant Daniela Perez, a 34-year-old education consultant in Chicago who says her current plan will increase to $1,200 a month from about $180 this year without an extension of the tax credits. “I’m not super hopeful. Seems like everything is in gridlock.”

In Washington, as part of the deal to end the recent government shutdown, a Senate vote was held Dec. 11 on a proposal to extend the subsidies. Another option, which was advanced by Republicans and included funding health savings accounts, was also considered. Neither reached the 60-vote mark necessary for passage.

On the House side, Speaker Mike Johnson plans to bring to the floor a narrow legislative package designed to “tackle the real drivers of health care costs.” It would include expanded access to association health plans and appropriations for cost-sharing reduction payments to stabilize the individual market and lower premiums. It would also increase transparency requirements for pharmacy benefit managers. Like the bill put forward by Republicans in the Senate it would not extend the ACA’s enhanced subsidies. Lawmakers are likely to vote on such an extension at some point.

In general, Democrats want to extend the life of the more generous subsidies, created in response to the covid pandemic. Those are set to expire at the end of the year. Republicans are split, with many balking at the cost of a straightforward extension, as well as the policy and political implications that might come with a vote to buttress Obamacare, which many have long viewed as public enemy No. 1.

And a few back various proposals that would extend the tax subsidies, fearing that failing to do so will result in political fallout in next year’s midterm elections.

The result is that differing policy positions are being of the aisle and in .

The White House, though supportive of HSAs in principle, its choice among the various Capitol Hill plans.

Meanwhile, the clock is ticking for shoppers. People needed to choose their ACA plan before Dec. 15 for coverage to begin Jan. 1. Open enrollment continues in most states until Jan. 15 for coverage beginning Feb. 1.

The marketplaces, too, must have contingency plans in case Congress intervenes. These adjustments could take days or weeks.

“We have a plan on the shelf” to go update the website, including notifying consumers of any changes, said Audrey Morse Gasteier, executive director of the Massachusetts Health Connector, a state-based ACA insurance marketplace.

Still, not many working days remain on Congress’ 2025 calendar, and “in many ways, it feels like they are farther apart than they were even a few months ago,” said Jessica Altman, executive director of Covered California, that state’s ACA marketplace.

Waiting for Numbers

Both Altman and Gasteier said it’s still too early to tell how final enrollment tallies will come out, but already there are indications of how sign-ups will compare with last year’s record high of about 24 million.

The Centers for Medicare & Medicaid Services figures from about the first month of open enrollment, showing 949,450 new sign-ups — people who did not have ACA coverage this year — across the federal and state marketplaces. That’s down a bit from approximately the same period last year, when new enrollees by early December.

Up slightly, however, are returning customers who have already selected a plan for next year. That stands at about 4.8 million, according to CMS, compared with about 4.4 million at this time last year.

That initial finding — lower new enrollments but quicker action by some already covered — may reflect that “people who come back early in the enrollment period are those who need the coverage because they have a chronic condition or need something done,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms. “So they are more motivated in the front half.”

And the final number of federal marketplace enrollments takes time to shake out. “The rubber meets the road when people have to pay the first premium,” Corlette said. “With the federal marketplace, we won’t know that for some time.”

Some states have also released information from the first few weeks, with the caveat that many people may wait until mid-December or later to make coverage decisions. Affordability has emerged as a pressure point.

, in the first six weeks of open enrollment there was a 16% decrease in people signing up for the first time compared with last year, according to data posted by Pennie, the state’s ACA insurance marketplace. For every one of those new enrollments, 1.5 existing customers canceled, Pennie reported.

There were some indicators that income is a factor: Most of those canceling earned 150% to 200% of , or $23,475 to $31,300 for a single adult.

Most states automatically reenroll existing customers into the same or similar coverage for the following year. Letters and other notifications are sent to consumers, who then can let the coverage continue or go online during the open enrollment period to change their plan or cancel it.

California reported a through Dec. 6. And Altman said she’s also seeing some other changes.

She said more people are opting for “bronze”-level plans, which have lower premium payments than “silver” or “gold” plans but also higher deductibles — the amount people have to pay before most insurance coverage kicks in.

Nationally, the will be $7,476 next year, while silver plans carry an average $5,304 deductible, according to KFF, a health information nonprofit that includes �������ýҕ�l Health News.

“That people are being forced to opt for plans with really high deductibles is a warning sign,” Altman said.

In Massachusetts, consumer calls to the state’s marketplace in the first month were up 7% over last year, Gasteier said.

Additionally, “our call centers are getting heartbreaking phone calls from people about how they can’t understand how they can possibly remain in coverage,” she said.

Detailing the Difference

If the enhanced tax credits expire, Obamacare subsidies will revert to pre-pandemic levels.

Households will pay a percentage of their income toward the premium, and a tax credit subsidy will cover the remainder, with the payment generally made directly to the insurer.

The enhanced subsidies reduced the amount of household income people had to pay toward their own coverage, with the lowest-income people paying nothing. Also, there was no upper limit on income to qualify — a particular point of criticism from Republicans. Still, in reality, some high earners don’t get a subsidy, because their premiums without it are less than what they are required to contribute.

Next year, without the more generous subsidies, those in the lowest income brackets will pay at toward their premiums, with the highest earners paying nearly 10%. No subsidies would be available for people earning more than four times the federal poverty level, which comes to $62,600 for an individual or $84,600 for a couple.

For those now shopping for coverage, that cap means a sharp increase in coverage costs. Not only have insurers raised premiums, but now that group’s subsidies have been cut entirely.

“They said, based on our salary, we don’t qualify,” said Debra Nweke, who, at 64, is retired, while her husband, 62, still works. They live in Southern California and are looking at coverage going from $1,000 a month this year to $2,400 monthly next year if they stay in the same ACA plan. “How can you have health insurance that is more than your rent?”

said in early December that Republicans want to find a solution that will lower health care costs, but not one with “people who are making unlimited amounts of money being able to qualify for government subsidies.” He also objected to granting free coverage to those at the lower end of the income scale.

Even those getting subsidies say they are feeling the pinch.

“Our prices are going up, but even at that, I don’t have any other options,” said Andrew Schwarz, a 38-year-old preacher in Bowie, Texas, who gets ACA coverage for himself and his wife. His three children are on a state health insurance program because the family qualifies as low-income. Both Schwarz and Nweke took part in the KFF poll.

Schwarz’s coverage is going from $40 a month this year to $150 monthly next year, partly because he chose a plan with a lower deductible than some of the other options.

Schwarz said that while the health system overall has many problems, Obamacare has worked out for his family. They’ll just have to take the additional cost out of somewhere else in the family budget, he said.

�������ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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