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

Julie Rovner: Hello, from �������ýҕ�l Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for �������ýҕ�l Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Aug. 27, at 10:30 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 Margot Sanger-Katz of The New York Times. 

Margot Sanger-Katz: Hello, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello! 

Rovner: And Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Later in this episode, we’ll have my interview with Dean Rosen about his time working for Kansas Republican Sen. Nancy Landon Kassebaum, who died last week at the age of 94, and how she represented a type of lawmaker we don’t see that much anymore. But first, this week’s news. So we’re taking the next week off for a needed break for our entire team, which makes this the last podcast of the technical summer. And I thought I’d do something just a little bit different. I’m going to break the discussion up into what I’m calling “The Themes of the Summer” — things we’ve talked about nearly every week. I hope it gives some of you the realization that I get from putting this together every week, that we’re looking less at a long list of separate events and items and more at pieces of a much larger picture that we don’t often see. 

So, theme No. 1 this week is declining health coverage. When Republicans passed their big budget bill last summer, they thought they were being clever by backdating most of the Medicaid cuts so they wouldn’t happen before the 2026 midterms. Well, the problem for them is that states and health systems are already making their own cuts in anticipation of those federal cuts to come, and people are already starting to feel them. This week’s evidence is from a Stat News piece called “,” and it includes ways that access is shrinking overall, particularly in heavily rural states like Maine and Louisiana, as the number of people without insurance goes up and the money from the government goes down. Is it really possible that Republicans didn’t see this coming? Or did they really believe they could take a trillion dollars out of the nation’s healthcare system and not have people notice? 

Sanger-Katz: I think that many of them were not paying very close attention. I think it may be accurate to say that they were indifferent to this possibility and are, in fact, surprised now to see the way that it is working out. I just, you know, for context, this bill that made these very large cuts to Medicaid and some smaller cuts to Obamacare funding was part of this huge package that included, you know, major tax cuts and tax reforms that were a big priority for Republicans, changes to energy policy, changes to other social welfare programs, changes to education policy, and, you know, they called it the One Big Beautiful Bill. And I think the bigness of it is easy to forget, in retrospect. But I think for a lot of lawmakers, they were really focused on the parts of the bill that they really cared about. For many of them, it was the tax part of the package. And the president and their leadership repeatedly told them not to worry about the Medicaid changes, characterized them as not being cuts. And I think, you know, a good, responsible lawmaker ought to do some diligence about that. But I think that many of them maybe took their eye off of the healthcare parts of the bill, were focused more on these other parts of the bill, and now are really starting to see what is happening in their home states as these policies are starting to roll out. 

Roubein: And I also think it’s true that, like, some of the full impacts, as I think Daniel Payne pointed out in his Stat piece, won’t be felt for years to come, particularly as the Medicaid work requirements do kick in next year. So once there are more concrete human faces and examples, that tends to come to more the forefront and, like, you know, the political mind. So yes, those changes a lot of them are not fully going into effect till after the midterms. 

Rovner: I do think that one thing that lawmakers really didn’t appreciate was how much this might impact not just people who would be losing coverage, but people who would be losing access. I mean, people who still have coverage, but, you know, if a hospital can’t keep its door open, or a clinic can’t keep its door open, or a doctor can’t, you know, keep the practice going, that’s going to impact people with insurance as well as people who are losing their insurance. I mean, that’s, I think, that’s part of why this piece went to explore some of these more rural places, where people are going to feel this first. Shefali, I see you nodding. 

Luthra: Yeah, one thing I’ve been thinking about a lot is you do hear Republicans, especially someone like [Maine Sen.] Susan Collins, really trying to tout the rural health fund that was part of this, right, and that was meant to, at least rhetorically, offset these massive healthcare cuts. Obviously, you look at math, you look at numbers, and one doesn’t really undo the other. But …  

Rovner: Yeah, the rural health fund is, what, $150 billion of $1 trillion … ? 

Sanger-Katz: $50 billion, I think. 

Rovner: Or, oh, it was even less. 

Luthra: And so, yeah. I mean, I think what maybe people didn’t fully appreciate is that voters are less compelled, perhaps, by [lawmakers] saying I voted for this funding, and more compelled by what they see happening around them, which is these massive cuts resulting in major changes to what is often the biggest employer, what is often the only source of healthcare for miles, something that is very intimate, very much of the community. And that’s why this is just such a potent issue, especially in a lot of these really close Senate races now. 

Roubein: I mean, we’ve seen in the past how rural healthcare can impact politics. With Medicaid expansion, Republicans were really, really, really against it, and then you saw some begin to change their mind — North Carolina being a notable example, and just all of the ballot measures in red states — Oklahoma, for instance. 

Rovner: Idaho. 

Sanger-Katz: I think it’s worth just pointing out how much is still to come. I think a lot of what we’re seeing right now is hospitals and other healthcare organizations that were kind of in a difficult financial situation going into this change in policy. They’re looking around, they’re already in the red, and they see they’re not going to get more money in the future; they’re going to get less money. And so I think a lot of them are accelerating changes that they were hoping to stave off. But the real cuts in almost all cases have not come yet. So, you know, the work requirements, as Rachel noted, are going to reduce the number of people who are covered by Medicaid. So that means that a lot of these healthcare organizations are going to have to absorb uncompensated care that was previously paid for. But then, further down the road, there are actually much larger cuts that are coming to state Medicaid budgets that are done in these kind of complicated, a little bit obscure, formulaic ways. But there are these reductions on how much the state can directly pay hospitals for care. There are reductions in how much states can raise through Medicaid taxes that then get transferred back. And there, I think, have been very valid criticisms of these funding mechanisms for Medicaid. They are this kind of Rube Goldberg complicated ways of financing the program, but they’ve been around for decades, and these healthcare organizations and these state budgets have really been built on the foundation of these funding streams. And so, as that money starts to go away, I think, then we may see even larger impacts because, again, the things that are happening now are healthcare organizations looking down the road and thinking, Ooh, it’s going to get messy. Maybe I should start adjusting now. But down the road, it will start getting messy for them, and I think there are going to be potentially some much harder choices for some of these organizations. 

Rovner: Well, continuing along that theme, , we talked earlier this summer about a new rule from the Centers for Medicare & Medicaid Services to enforce the administration’s ban on the use of the Medicaid or CHIP [Children’s Health Insurance] Program to pay for gender-affirming care for minors. But it seems that the mechanism CMS is using could open the door to denying coverage for other drugs too, or at least some uses of other drugs. Now, this isn’t in the Stat story, but, Shefali, when I read it, I wondered if one goal here is to cut back on the use of drugs like misoprostol, which is used for a lot of things, but also for medication abortion. 

Luthra: That’s a really good question, and I think one that we still don’t really know. And obviously, a lot of states’ Medicaid doesn’t cover abortion to begin with. That really only happens in states that have actively made an effort. But, I mean, misoprostol is not only used for abortion; it is used for miscarriage management. And I think it’s just something really important for us to keep in mind what happens when you see these sorts of approaches to just, like, carving out individual forms of healthcare. And obviously, it’s very interesting as well because drugs used for gender-affirming care are also used for other things. RFK [Robert F. Kennedy] Jr. really loves hormone therapy for many people, just not trans people. And so I think there’s just a lot of questions that we don’t really have answers to about just how sweeping the implications of something like this could be. 

Rovner: Yeah, we will see as it goes. Well, it’s not just Medicaid. that CMS is clawing back billions of dollars in Affordable Care Act premium subsidies from insurers who have allegedly phantom enrollees, people with zero premium plans who don’t file claims. And while that is a known problem, a lot of those people might be actual enrollees who just haven’t needed their insurance yet, as in young, healthy folks who have health insurance just in case, or because their parents told them that they should, and, by the way, they could get a plan with a zero premium. And stripping these people from the rolls is likely to boost premiums overall by making risk pools sicker, in general. I feel like this administration might not be familiar with the bizarre and sometimes illogical way the health insurance market works? 

Sanger-Katz: I think there’s a delicate balance going on here, where if there are people who are enrolled in these plans who are fake, are not real people, do not know that they have insurance, never plan to use their insurance, you know, that is a waste of federal dollars to subsidize those premiums and just give that money to insurance companies. But I don’t think that there’s very strong evidence that there are a lot of these people. And I also think that the mere fact that someone has not used their health insurance yet, in a year, is not by itself evidence that they are a fake person or that their enrollment is fraudulent. As you said, Julie, there are a lot of reasons why people in this market may not have used their insurance. You know, a lot of the people who have become newly enrolled are relatively young and healthy. That is good for the risk pool, but it may mean they don’t have a lot of healthcare needs. There’s also, just because of the nature of the individual market, you know, one expert pointed out to me, there’s just a lot of churn. You know, someone loses their job, they sign up for a plan, then they get a different plan, or, you know, people who are in this market may only be in this market for a short period of time, and that may also explain why there’s a higher share of them who don’t make any claims, because they haven’t sort of gotten through the whole year, they haven’t had a healthcare need yet. So I think deciding to just disenroll people on this basis does risk disenrolling people who are legitimately insured, who are not phantoms, and who are not committing any kind of fraud. To the degree that there is fraudulent enrollment, and I think there’s evidence that there’s some of it, there are, you know, I think that is a valid concern, and I think the federal government is certainly within its rights to try to address that and make sure that these federal tax subsidies are being appropriately spent. 

Rovner: Yeah, I think “delicate balance” is exactly the right word. I mean, that’s, you know, with the work requirements too. I mean, the idea is to make sure that people are doing things. But if you make the administrative requirements so burdensome, then you’re going to throw off people who are legitimately enrolled. 

Moving on to the next theme of the summer: the resurgence of measles, and the continuing fight over vaccine policy. Until this week, the Trump administration had boasted that while measles cases have been rising pretty precipitously — they’re at the highest level in more than three decades — the U.S. was actually doing better than most other countries with outbreaks, and besides, no one had died of measles yet this year. Well, that worked until Tuesday, when the Pennsylvania Department of Health announced two measles-related deaths in Lancaster County — although we have few details other than that both people were unvaccinated and one was an infant. The announcement touched off a rather nasty war of words between Pennsylvania governor (and possible 2028 presidential candidate) Democrat Josh Shapiro and HHS Secretary Robert F. Kennedy Jr., who said that the state was not cooperating with federal health officials, and maybe the people didn’t actually die of measles after all. This isn’t really going to get more people vaccinated, I would suggest — this just sort of fighting back and forth, right? 

Luthra: It’s a good question. It certainly doesn’t help. I think one thing I was thinking about this morning, and this is not measles-specific, but there’s a really great New Yorker piece from this week looking at the actual vaccine data over the past year and a half, and obviously people are affected by public rhetoric, but the declines in vaccination are not as big as one might have feared when RFK Jr. was initially nominated and really made a point of highlighting anti-vaccine beliefs. And so obviously, like, this is, the fact that people are dying is very bad. The fact that they’re sowing confusion … 

Rovner: The fact that people are getting measles is very bad! 

Luthra: Yes, it’s very, very bad. It’s not, none of it is good. But that was actually really striking to me that amidst all of this, like, really terrible news, there is a bright spot, which is that things could be a lot worse. That is something that I hadn’t thought about. 

Roubein: I mean, if, I think … I’ve been thinking about this today, like, if you kind of step back from the really high-level view, I think Americans who are watching this are confused. They are not sure who to trust. There are, you know, Republicans are saying one thing, Kennedy allies are saying one thing, the Department of Health [and Human Services] and Gov. Shapiro, Democrats are saying another thing. You’re seeing a, you know, a war of words between, like, Republican and Democratic county commissioners on this, you know, just from a public health messaging standpoint. 

Rovner: Yeah, it has not been a great job of communication all the way around. I think there, I mean, there are even, you know, public health defenders who are saying, Why don’t we know more about these two deaths yet? There’s been not a lot of information, and that has, of course, as we saw, you know, during covid, the more noninformation you have, the more people try to fill in their own information, whether it’s true or not.  

Well, even before the Pennsylvania news, we had a somewhat excruciating pair of appearances on CBS’ Sunday show Face the Nation this week. First, CMS Administrator Dr. [Mehmet] Oz needed three separate tries to be able to say that, no, President [Donald] Trump was incorrect when he said in his Oval Office vaccine event that the measles, mumps, rubella combination shot was lethal. Spoiler: It is not. Then Florida Republican congressman Byron Donalds, who’s now the Republican candidate for governor, said the measles outbreak there has been caused by illegal immigration rather than residents not getting their children vaccinated. What happened to the idea we heard last winter that being anti-vax wasn’t good politics? I think this speaks to what you were just saying, Shefali. You know, I think in January and February we thought that Republicans were going to sort of leave this alone and focus on other things. 

Sanger-Katz: Well, I think one thing that we’ve learned recently is that while a lot of the president’s advisers and political staff, I think, were concerned that an anti-vaccine message was damaging, what we’ve seen is that the president himself sincerely has anti-vaccine views and has been saying them out in public. And so I think it does put other Republican political figures in a difficult bind, and certainly puts folks like Dr. Oz, who work in the administration, in a difficult place. Whatever his genuine views are, whatever his political advisers and his public health advisers are telling him, he works for President Trump, and President Trump has made it pretty clear what he thinks. And so I think that’s why we are now seeing this kind of new round of muddled messaging around vaccines, when I do think for a little while there was kind of a pullback on the most overt anti-vaccine rhetoric, and, you know, we saw RFK talking less about it, for example, in public. Now, I think we’re in a little bit of a new phase, where the president is leading the way back. 

Roubein: Yeah, I mean, I think that’s exactly right, and I mean, Trump has, you know, privately questioned why his administration had yet to release new vaccine recommendations, , with Lena [H. Sun] and my colleague Dan [Diamond]. And that’s, you know, some of what, a lot of what drove the executive order that we saw from just a few weeks ago to reduce the childhood vaccine schedule. Trump says he wants to break up the MMR shot. That’s not something that is currently available, but, you know, he has driven that by pushing some of his advisers. 

Rovner: Yeah, absolutely. Well, meanwhile, demonstrating just how expensive it is to track, trace, and quarantine people after a confirmed case of measles. One Denver outbreak that ended up being just 10 cases still cost state and local agencies nearly a half a million dollars, almost 7,000 hours of work from 189 staff members, not to mention 91 people being quarantined and 500 days of school being missed. We may call public health invisible when it works, but it is certainly not cheap. 

Roubein: Yeah, I mean we don’t talk about the economics of it very often. I mean, public health officials always say that they are underfunded, but just, in general, the talk of the economics here is generally not a huge part of the conversation. 

Sanger-Katz: And measles is just such a difficult disease to contain because it is so contagious. It is one of the most contagious infectious diseases out there. And so that means that any person who has measles just has the potential to spread it to so many people. And I think that really strains these traditional public health approaches of trying to track, trace, and quarantine because you have to find so many contacts. 

Rovner: Yeah, just a reminder, I mean, measles can linger in the air after the infected person has left for, I think it’s like, two hours. So it’s, you know, anybody who’s been in a place where somebody with measles has been is potentially at risk if they’re not vaccinated. 

Sanger-Katz: I mean, we remember how hard this was with covid. Of course, in the early days, no one was vaccinated, so there were more people who were susceptible to covid. But measles is substantially more contagious even than covid. 

Rovner: Yeah. Well, as yet, as the debate continues to rage over vaccines, the evidence continues to pile up that vaccines are actually, on balance, a very good thing. Just this week, we have two more studies. of 4 million teens and young adults that found that those who received that controversial mRNA-based covid vaccine were less likely than those who just got covid to develop myocarditis or other heart problems. That was something that people were worried about with young people getting this vaccine. appears to confirm that the shingles vaccine, Shingrix, appears to not only have a protective effect against dementia, something we reported earlier this year, but also against cardiovascular disease. How do we get to a place where vaccines have become controversial again? I assume, I mean, I want to go back, Margot, to what you were saying that it does seem that President Trump himself has anti-vax views that I think we didn’t appreciate until this year. I mean, I think most of us thought that this was all being driven by RFK Jr., who’d obviously made a career of being anti-vax. But when he backed off, we saw the president basically fill right in, and that’s kind of where we are? 

Sanger-Katz: And I also think this is a reminder to us, both of these studies and others that have come out recently, that, you know, vaccines have some risks. They do. But infectious disease can be really dangerous for people, and it can have lingering and downstream effects that are not obvious. It’s not just that you get sick in the moment that you get sick, but having that disease affects your body in ways that may show up much later. And I think some of these longer-term studies that are following people — you know, not just in the weeks and months after they get a vaccine, but what happens years later to their heart or to other major organ systems —really shows that preventing people from getting serious illness is good for their long-term health. 

Rovner: Yeah. 

Roubein: And I mean, Secretary Kennedy, just to go back to last year, he did drive changes. He fired CDC’s [the Centers for Disease Control and Prevention’s] vaccine advisers, who had made changes to vaccines. The health department did release a new childhood, slimmed-down childhood immunization schedule earlier this year. A lot of those changes, though, have been on hold from a federal judge. 

Rovner: Yeah, he also fired the head of the CDC, who refused to rubber-stamp his vaccine changes. So, he was busy before he got sort of unbusy with this. All right, we are going to take a quick break. We will be right back. 

OK, our next theme of the summer are the continued cutbacks by the Trump administration to federal health programs, including some of those that have been specifically funded by Congress. First up is a story from �������ýҕ�l Health News this week about how, at the same time President Trump can’t stop talking about the increasing rates of autism and what a problem it is, the administration is scaling back enforcement of civil rights protections for people with autism, research into the education needs of people with all sorts of disabilities, and even data collection efforts. So, on the one hand, the president keeps pressuring RFK Jr. to find a definite cause of autism, but at the same time, this administration is doing less to help those who are already diagnosed? 

Luthra: I think what I find really interesting every time we talk about this is the really, really long tail of funding cuts, because this is something on, like, a broad macro scale that began at the beginning of this administration, right? Just massive funding cuts and freezes across the board and have continued. And because of the way grant-making works, because of the way research works, we keep seeing the consequences. We keep getting more people reporting, “Oh, my funding didn’t come,” or “This was held up,” or “This project I was working on no longer can.” And what I think is also really interesting is we see how slow the ability to respond is because of the long tail of funding cuts. I mean, courts take a long time, finding new funding when you suddenly lose yours actually is very difficult. And this is something that we’re just going to keep coming back to. We are going to be seeing the consequences of these funding cuts for months and years, as we’ve been talking, but also for much longer as the consequences in terms of research, of cures developed or not developed, becomes even more clear. 

Rovner: Yeah, although sometimes I think it’s going to be hard to connect the dots to get from, you know, from you cut this so this didn’t happen. It’s almost going to be like proving a negative at some point. 

Well, another big theme this summer has been drug prices, particularly prices for those expensive GLP-1 weight loss drugs. As part of the administration’s push to make those drugs less expensive for the end users, CMS offered states the option to participate in its direct negotiations with the drug manufacturers if they would offer them through their Medicaid programs. Only, , so far only one state has taken up the offer, and more states are actually cutting back on their GLP-1 coverage through Medicaid that they have been offering because it’s been such a financial strain on their programs. Several state officials told Politico that they worry about the long-term financial sustainability of the program. I know it’s also a worry for the Medicare GLP-1 program, which is basically at this point a year-and-a-half-long pilot for drugs that, as far as we know, need to be taken indefinitely. Is it fair to say that the president has not really been able to keep his promise to make these drugs cheaper and much more widely available, or that if he has, people may end up getting them yanked out from underneath of them? 

Sanger-Katz: I think it’s complicated. I think it’s hard to know how much credit the president should get. But I will say that the prices for these drugs — the kind of cash-pay prices, that he was able to negotiate allegedly, and that he was able to announce certainly a few months ago — were substantially lower than what individuals and insurers, including some public insurers, were paying for those drugs. So we are now seeing a kind of cash price for the main anti-obesity drugs that is much more affordable than it had been in the past. I think some of that was driven by market pressures and would have happened regardless of the president’s intervention. But I think certainly his pushing these companies, his threatening of these companies, his cajoling of these companies probably maybe did induce them to sort of do it at the same time, to do it faster, and to do it more prominently. 

Rovner: Well, some of it already had happened, before he got in. The self-pay cost had already gone down because so many insurers had stopped covering it. 

Sanger-Katz: It had gone down, but it then went down again.  

Rovner: It did. 

Sanger-Katz: The prices that are available now that the president announced are lower than what we had seen in the past, and they are a major discount even compared to the previously lowered prices that had been public. So I think that is a real thing. Whether or not those prices were meaningfully lower than the price that the Medicaid programs in states were already paying is a little bit of an unanswered question. But my understanding from talking to some Medicaid officials is that Medicaid was already getting very similar prices, even before the president announced these discounts. And that’s because Medicaid has, by law, gets the best price for drugs. They get discounts that are not available to other purchasers. And Medicaid budgets are quite tight. You know, as we were just discussing, all of these state Medicaid programs are facing very substantial cuts that are coming down as the rollout of the big tax-and-spending bill is implemented. And the states that went early and did cover GLP-1 drugs for obesity, I think that they saw that interest and uptake really exceeded their expectations. There were a lot of people in the Medicaid population who stood to benefit from these drugs, and that when so many of them enrolled at once and started taking these drugs at once, it did create, I think, an unanticipated budget strain. So I think states are in a difficult position. This pilot is offering them this cash price for their Medicaid programs, and I think a lot of them are looking at that, and they’re saying, “Well, this is, like, a good price. It’s not that much better than what we could have gotten before, and we weren’t doing it before because we didn’t think that we could afford it.” And so I think those circumstances really haven’t changed. It will be interesting to see what happens over time. It does seem like there is huge potential public health benefit for Medicaid populations if these programs can find a way to cover these drugs. You know, the evidence about the health benefits of these drugs for people who have obesity are just really tremendous, and we’re seeing them over numerous, different health conditions and body systems. And, you know, in my own reporting on North Carolina’s Medicaid program, which was one of the early ones to cover these drugs, you know, I just talked to a lot of people who were really excited about having this opportunity to take this drug. People who had really struggled with their weight and related illnesses, and, you know, were glad that the state was offering it to them. And now, you know, North Carolina has had, is one of the states that’s had to roll back. 

Rovner: Yep. All right. Well, finally, this week, a word about Dolly Parton, possibly the only person in America who was pretty literally loved by everyone. The country and pop music superstar and actress who was known for her genuine kindness and generosity was, in fact, also an important healthcare philanthropist. A lot of people probably remember she gave a million dollars to Vanderbilt University in 2020 to help develop the aforementioned mRNA-based covid vaccine. What people might not remember is that she also used her own money to fund pediatric infectious disease research, underwrite a women’s healthcare center in the East Tennessee county where she was raised, and help train pediatric health professionals. There are celebrities who lend their name and their time and sometimes their money to causes to help burnish their personal PR, and then there are those who clearly do it because they want to give back. I think it’s fair to say that Dolly Parton was one of the latter, and I think she’s going to really be remembered for a lot of the work that she did on bringing healthcare to more people, right? 

Luthra: Yeah, yeah. It’s very sad. 

Rovner: It is. And healthcare owes her a debt. All right, that is this week’s news. Now we’ll play my interview with Dean Rosen, and we’ll come back and do our extra credits. 

I am pleased to welcome to the podcast Dean Rosen. Dean is a partner at Mehlman Consulting, where he landed after a long career on both sides of Capitol Hill, during which he helped shape some of the most important health legislation of the 1990s and early 2000s, including President George W. Bush’s HIV/AIDS program, PEPFAR; the Medicare prescription drug law; and the 1997 Balanced Budget Act. But before all those things, Dean was the top health aide to Sen. Nancy Landon Kassebaum, the Kansas Republican who passed away last week at the age of 94. After Republicans took over Congress in the wave election of 1994, Kassebaum chaired the then-Senate Labor and Human Resources Committee, now the HELP [Health, Education, Labor, and Pensions] Committee, and stewarded the surprisingly difficult path to law of what was originally a very bipartisan bill, the Health Insurance Portability and Accountability Act of 1996, or HIPAA. Dean Rosen, welcome. 

Dean Rosen: Thanks, Julie. I’m honored to be here, and I’m a longtime fan of What the Health? — so this is a real great opportunity. Excited to be with you. 

Rovner: Great. So, HIPAA, which was known at the time as Kassebaum-Kennedy for its bipartisan Senate sponsors — your boss and the late Edward M. Kennedy, a Democrat of Massachusetts — is today mostly known for its medical records confidentiality provisions. But that’s not how it started out, right? It was really an effort to do something bipartisan in the wake of the failed Bill Clinton very partisan health plan. Talk about how it kind of came to be. 

Rosen: Yeah, that’s exactly right. It sort of started in the Senate and then moved to the House and then moved to a traditional conference committee, which we don’t seem to do very much of, either, anymore these days. But when it started off, it really did start, as you said, as a health insurance portability bill, and just a really, in some ways, minimalist solutions-oriented legislative proposal that was designed to try to get at what was really, I think, the core concern, or one of the core concerns, at the time, which was people’s ability to get and maintain health insurance if they had preexisting conditions.  

And really what happened was the Clinton plan had kind of imploded spectacularly, as you know, despite the fact that there were huge Democratic majorities in the House and the Senate — not filibuster-proof, but close in the Senate — and the Democrats just couldn’t … get it done. And they couldn’t get any Republican support. They couldn’t get enough Democratic support. And then in the 1994 election, something unexpected happened. I guess polling was a little less sophisticated at the time, but you had the “Republican Revolution” led by [who] was to be Speaker [Newt] Gingrich in the House, and you had the Senate — which had changed hands before, but the House, which had not changed hands and had been in Democratic control for 40 years — switch, and Republicans were ascendant. Bill Clinton was still president. I think probably some of the fact that there was such a gain of seats had something to do with the failure of health reform. And Republicans were getting ready to move a very aggressive deregulatory agenda. And Ted Kennedy, who was a liberal lion of the Senate, who you know was a champion of universal coverage and other liberal causes, moved from the majority side of the dais and having the gavel at the Senate Labor Committee, now the HELP Committee, to the minority side. And Sen. Kassebaum, who had hired me just a few months before that, all of a sudden became the first woman to chair a major committee in the Senate, a standing committee in the Senate. And really, what started it, was that Sen. Kennedy and his team came over and met with us, and somewhat surprisingly, said, “Hey, I know I’m for universal coverage, but I’m willing to do something that’s much more modest,” and shared with Sen. Kassebaum and me and the team a chart that they had put together showing where, not had there been disagreement, but where actually there had been agreement among the major plans, ranging from the most liberal, the Clinton plan, to some of the most conservative plans. And the heart of that, Julie, was health insurance portability, preexisting condition protections at access, and that was the bill that started off in the Senate, and that’s the one that gained traction and passed until we got to the House. 

Rovner: So, Sen. Kassebaum was one of those legislators who actually believed in passing laws, even if it meant compromising — so you only achieved a few of your goals at a time. Why are there so few people like that on either side anymore? 

Rosen: Yeah, well, you know, I think I would say also about HIPAA that it … she was an incrementalist. I think she was one of the reasons … she was considered a moderate Republican in the day, and I think now even more moderate. But she was at her heart a conservative in the sense of she believed that the best legislating was done sort of inch by inch, step by step, as opposed to in one bill. And you sort of saw that proof come to be when the Clinton plan failed, because it tried to really do everything in the healthcare system; it was huge. I think to your question: Today, it’s harder because there’s just less overlap, and the incentives are such that, you know, as one current member of Congress, very senior, told me a couple years ago, if you’re a Republican, you’re looking over your right shoulder. If you’re a Democrat, you’re looking over your left shoulder. And I think that the venerable, you know, Cook Political Report says that in this election, there are only truly 18 toss-up seats in the House out of 435. And so, what it means is that, you know, 5% of the country is going to decide who controls the House ultimately, and the incentives are not to put together bipartisan bills, big or small, healthcare or not healthcare. But the incentive is, frankly, to play to your base, particularly in a midterm election. Now, that’s not always the case. You do have examples of bipartisanship, but I think it’s harder because of those incentives, which we’ve seen become more and more true as politics has changed, and, frankly, as the country’s changed. 

Rovner: You wrote a really lovely tribute to the senator about going to the White House for the signing of HIPAA by Bill Clinton, which I think just showed sort of the generosity of spirit of Sen. Kassebaum. Tell us about it? 

Rosen: Yeah, so, you know, after Nancy passed away, there’s a group of us who’ve been keeping up through chat over the years, and her family, actually granddaughter and stepdaughter, had informed us all before they informed the press over the weekend that she had passed away. And I suddenly was sitting there over the weekend and realizing, Julie, that it had been — she had died 30 years to the day since HIPAA was signed by Bill Clinton. And, you know, to your point of bipartisanship, that bill passed the House with only two dissenting votes and the Senate unanimously. So not only was it bipartisan, but it passed unanimously. 

So we went over to the White House — to kind of tell a little bit of the story — I’d never been to the White House before. This was, like, my first job on Capitol Hill. I was much younger then, and — obviously — and the senator made sure I was on the invitation list. And this was, you know, Sen. Kassebaum was not really known as a legislator who was someone who passed, you know, tons of major bills. This was really, if you read all the obituaries, the health insurance portability law is one of the two bills they mention — the other one being a general aviation bill, and her work internationally, which was significant around apartheid. But they mention this health insurance bill as her signature achievement. So we go to the White House. It’s a hot August day, and as I said, I realized that she died 30 years to the day after this bill was signed. And I was reflecting on the fact of something that I never really shared publicly before, that at the signing ceremony, it’s traditional — as you know, you’ve probably been to many, many, many of these — that the presidents will sign these bills, they’ll use multiple pens, as Bill Clinton did, and he handed one of the pens to Sen. Kennedy, and he handed another one to Sen. Kassebaum — we’re standing over each of his shoulders. And we’re walking out of the Rose Garden, and Sen. Kassebaum came over to me, and it was just the two of us, and she said, “Here, I want you to have the pen. You wrote the bill.” And, you know, I guess as a staff person you do, but I didn’t think of it that way. I thought of the fact that she was giving away to me really one of the most tangible symbols of her signature bill, and I said, “I can’t take this. This is your bill. This is one of your crowning achievements. You worked so hard to get this done.” And she insisted that I keep it.  

And as I said in the piece that I wrote, you know, it struck me that that was just essential Nancy Kassebaum, that not only in the legislation could she find ways to work with Ted Kennedy, who, she said, in subsequent interviews, coming from Kansas — and folks will appreciate this with Wicked being out — that I think a lot of Kansans thought that Ted Kennedy was the Wicked Witch of the East. But working with Ted Kennedy to get something passed into law, and then coming over to me with no ceremony, with no one around, with no political advantage, and just saying, “Here, I’d like to give you credit, as opposed to taking credit for myself,” I think said a lot about her character, and I shared that story with her family, and they gave me permission to share it publicly. I think it just goes to her character and who she was, which, as I said, I think is, much more important than the legislative achievement, was just the kind of person that it takes to get things like that done in Washington today, and, frankly, in Washington then. 

Rovner: Any chance we’re going to get back to seeing those kinds of legislators on Capitol Hill? We’re both in this for the long run. 

Rosen: Yeah, you know, I have to say, you know, I prefer to be somebody, Julie, who looks forward. I mean, you know, you can look back and wring your hands and be pessimistic. But, you know, I came to Washington as a [Ronald] Reagan Republican, and Reagan always said that he felt like American optimism was the heart of the country, and that our best days were ahead. And I really do feel optimistic about the country. We’ve survived a lot over the last 250 years, and you’ve got examples of bipartisan legislation. You’ve got, you know, Dr. [John] Joyce and [Rep. Greg] Murphy, and [Rep. Kim] Schrier, a bipartisan bill in the House that takes on the difficult and expensive issue of Medicare physician reform. You’ve got a bill by Sen. [Chuck] Grassley and [Catherine] Cortez Masto and others in the Senate that got introduced a couple weeks ago on fraud and abuse at a time when that issue could be really political. 

So to me, I do see people of goodwill in both parties who want to get things done. I think we’ve got to recognize, as we talked about a moment ago, that the broader incentives in our country and in our political environment and in our institutions are pulling people apart. And I think it is going to take people of goodwill to find things to do where they can compromise without losing their principles and find ways to make progress. And I do see hopeful signs of that. You know, I’m not sure we’re going to get back to the day where there’s tremendous overlap and a huge number of moderates in either party, but I think it makes it even more important that people of goodwill who come to Washington as citizen legislators and want to solve things find ways to do that. And in this divided government, where we’ve seen 12 change elections of the last 14 and extremely narrow historic margins, it’s going to take both sides to get things done. 

Rovner: We will keep watching, Dean Rosen. Thank you so much. 

Rosen: Thanks, Julie. Thanks for having me. 

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

Roubein: My extra credit is from The New York Times. The headline is “,” by Noah Daly and Andrew Jacobs. And the story is about how Americans are traveling abroad, often to Latin America, for psychedelics, a form of medical tourism, and the authors write that this could carry substantial risks. There’s no official tally of injuries, deaths, or adverse events at the overseas psychedelic clinics. But The New York Times interviewed more than two dozen patients and researchers, who cited just a litany of troubling episodes. Basically, the field of psychedelics is in its infancy, so researchers have found this sort of patchwork of standards and rules. And, just for context, here in the United States, the FDA hasn’t approved a psychedelic as of yet, but the idea has really gained traction in recent years for mental health conditions, but particularly, this spring, when President Trump signed an executive order that was aimed at accelerating research into the drugs and also fast-tracking federal reviews of psychedelic medicines. But advocates for these drugs do have concerns about adverse events at overseas clinics because they don’t want it to, you know, kind of spark a backlash that could hamper this trajectory. The Times did speak to a practitioner who said that his prescribing practices were informed by a patient’s self-reported medical history. But I thought this was a really interesting look at what’s happening overbroad given there’s been so much chatter about psychedelics in the United States. 

Rovner: Something else to worry about. Margot. 

Sanger-Katz: I wanted to recommend an article in Stat from Anil Oza. Headline is “.” And this story outlines that a number of people who had submitted comments on a rule about science funding suddenly found their comments removed from the public record. And it appears that the reason is because they were making reference to Russell Vought, the OMB [Office of Management and Budget] head, who, you know, was behind this rule. He has a child with cystic fibrosis who has benefited from a [National Institutes of Health] NIH-funded drug, and I think a lot of them were making reference to that as part of a personal plea for him not to implement this policy. But it’s a little bit puzzling why OMB removed them, on what basis. They haven’t been transparent about it, and there have been basically no explanations. And I think, you know, Secretary Kennedy, during his confirmation hearings, talked about radical transparency in the HHS process and policymaking. And I think this is one of many examples where that really hasn’t happened. There has been a reluctance, I think, by HHS to go through notice-and-comment rulemaking in situations where it is not necessary. There has been a reluctance sometimes to answer questions from the public, from reporters, and I do think that the kind of deletion without explanation of these comments is part of that broader pattern. There is obviously this personal sensitivity here that is part of it, and there may be some valid reason why this public official’s child should not be in the federal record. But it would be nice if someone would explain. 

Rovner: Yeah, and also props not just to Stat, but to the people who actually have been tracking these comments and noticed that they were taken down. Shefali. 

Luthra: All right. My story is from LJ Dawson. It is a collaboration between �������ýҕ�l Health News and The Washington Post. The headline is “.” This story combines many of my interests, like European vacations, Greece, and fertility treatment. And I think it’s a really, really, like, interesting and useful look into just how expensive this can be for Americans, especially if insurance doesn’t cover it, and the lengths to which people go to become pregnant. And the family that the story follows, they live in Florida. They could only get pregnant through IVF [in vitro fertilization]. They were quoted close to $40,000 for a round, and they were like, This is nowhere near what we can afford. They realized it was much cheaper to travel to Greece, to literally go on vacation in Greece and get IVF done there. And this is a thing that people genuinely do. Like, I know many people who have looked into the costs of IVF in different European countries, including Scandinavian ones. And I think it’s just a really helpful, dramatic look at what happens when people really, really would benefit from a medical treatment for achieving their fertility goals, their reproductive goals, etc., but it is simply not affordable. And I think this is also interesting because there has been so much chatter about making IVF more affordable, but, in fact, it is more expensive than ever and more in demand than ever because people are having children later, more likely to need fertility treatment, and we don’t really have a good solution yet in sight. 

Rovner: No, except that our system is way too expensive. Well, you may have noticed that in my themes of the summer, I left out the unusual spate of foodborne illnesses. Well, fear not. My extra credit this week is also from The Washington Post. It’s by Tamar Haspel. It’s called “.” And it makes a pretty good case that lettuce and its leafy green cousins are not only the foods most likely to result in foodborne illness, but it’s also not got much to offer nutritionally. It doesn’t store very well, and the land that we use to cultivate it could be better used for, well, better food. I have to say, I stopped buying lettuce a long time ago, mostly because it doesn’t keep very well, and I live by myself. And while I do eat plenty of salad, it’s mostly cucumbers, peppers, and tomatoes. Now, you guys all do you, but I can just say that I haven’t contracted cyclospora this summer. 

All right, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer this week, 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? Shefali. 

Luthra: I’m on Bluesky . 

Rovner: Margot. 

Sanger-Katz: I am all the places , and on Signal at sangerkatz.01. 

Rovner: Rachel. 

Roubein: Several places: on X, ; Bluesky, ; ; Signal; etc. 

Rovner: As I mentioned at the top, we’re taking next week off. You should too, if you can. It’s going to be a busy fall. We will be back in your feed on Sept. 10. Until then, be healthy.