[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 Ñî¹óåú´«Ã½Ò•îl Health News and, starting this week, from WAMU public radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again. 

Winfield Cunningham: Hi, Julie. It’s great to be back. 

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving. 

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either. 

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America. 

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that. 

Rovner: Well, of course, and SNAP isn’t an HHS program. 

Goldman: Exactly. Exactly. 

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find? 

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan — which, of course, is what, we know … that’s what the subsidies are pegged to — is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it. 

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand. 

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …  

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks. 

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain. 

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely — because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced … and now they have no cap. 

Rovner: I think 8.5% of their income, actually, under the enhanced premiums. 

Winfield Cunningham: Under the enhanced. OK. 

Rovner: It’s going to go back to 10%. 

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%. 

Rovner: 400%. 

Winfield Cunningham: Right. Yeah. Yeah. 

Rovner: That’s right. 

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it. 

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies. 

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue. 

Winfield Cunningham: This is very true. 

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something. 

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So … 

Rovner: Yeah. Although it is … 

Goldman: Obviously, that’s a lot of what ifs, but … 

Rovner: … only the death spiral that goes back to prior to covid, which — it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA. 

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers — will be subject to the full force of the premium increases because they won’t have any subsidies. 

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.  

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further — this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought — yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget — states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought? 

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that — I don’t know what health systems have said about this particular move, to be honest — but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is. 

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant. 

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC? 

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this. 

Rovner: Yeah. I’ve seen numbers as low as 60,000. 

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels. 

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years. 

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics. 

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades — focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that. 

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic. 

Ollstein: Exactly. 

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My Ñî¹óåú´«Ã½Ò•îl Health News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes? 

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects. 

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head. 

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary. 

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division — that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo — to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way — even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.? 

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data. 

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the … give credence to this idea that — I see you nodding, Maya — that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain. 

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch. 

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So … 

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications. 

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do. 

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line. 

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, . Is contraception going to become the next health care service that’s only available in blue states, Alice? 

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services. 

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two. 

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something? 

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate. 

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods? 

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want. 

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but … 

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight. 

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. 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’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week? 

Goldman: Sure. So this story is from Ñî¹óåú´«Ã½Ò•îl Health News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked. 

Rovner: Yeah, it is a public health issue, an interesting one. Alice? 

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah. 

Rovner: Yeah. A combination of a lot of different factors in that story. 

Ollstein: Definitely. 

Rovner: Paige? 

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague. 

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my Ñî¹óåú´«Ã½Ò•îl Health News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.  

OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, , or on Bluesky, . Where are you folks hanging these days? Maya? 

Goldman: I am on X as and I’m also on . 

Rovner: Alice? 

Ollstein: on Bluesky and on X.  

Rovner: Paige? 

Winfield Cunningham: I am still on X. 

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

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

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Hello, everyone. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: No interview this week, but more than enough news. So we will get right to it. 

We’re going to start on Capitol Hill, where in the very wee hours of Thursday morning, the Senate approved the $9 billion package of rescissions of money already appropriated. It was largely for foreign aid and the Corporation for Public Broadcasting, which oversees NPR and PBS. Now, this bill represents pennies compared to the entire federal budget and even to the total of dollars that are appropriated every year, but it’s still a big deal because it’s basically Congress ceding more of its spending power back to the president. And even this small package was controversial. Before even bringing it to the floor, senators took out the rescission of funds for PEPFAR [the President’s Emergency Plan for AIDS Relief], the bipartisanly popular international AIDS/HIV program begun under President George W. Bush. So now it has to go back to the House, and the clock on this whole process runs out on Friday. Sandhya, what’s likely to happen next? 

Raman: I think that the House has been more amenable. They got this through quicker, but if you look— 

Rovner: By one vote. 

Raman: Yeah. But I think if you look at what else has been happening in the House this week that isn’t in the health sphere, they’ve been having issues getting other things done, because of some pushback from the Freedom Caucus, who’s been kind of stalling the votes and having them to go back. And other things that should have been smoother are taking a lot longer and having a lot more issues. So it’s more difficult to say without seeing how all of that plays out, if those folks are going to make a stink again about something here because some of this money was taken out. It’s a work in progress this week in the House. 

Rovner: Yeah, that’s a very kind way to put it. The House has basically been stalled for the last 24 hours over, as you say, many things, completely unrelated, but there is actually a clock ticking on this. They had 45 days from when the administration sent up this rescission request, and we’re now on Day 43 because Congress is the world’s largest group of high school students that never do anything until the last minute. So Democrats warned that this bill represents yet another dangerous precedent. They reached a bipartisan agreement on this year of spending bills in the spring, and this basically rolls at least some of that back using a straight party-line vote. What does this bode for the rest of Congress’ appropriations work for the fiscal year that starts in just a couple of months? 

Raman: I think that the sense has been that once this goes through, I think a lot of people have just been assuming that it’ll take time but that things will get passed on rescissions. It really puts a damper on the bipartisan appropriations process, and it’s going to make it a lot harder to get people to come to the table. So earlier this week we had the chair of the Appropriations Committee and the chair of the Labor, HHS [Health and Human Services], Education subcommittee in the House say that the health appropriations they were going to do next week for the House are going to get pushed back until September because they’re not ready. And I think that health is also one of the hardest ones to get through. There’s a lot more controversial stuff. It’s setting us up to go, kind of like usual at this point, for another CR [continuing resolution], because it’s going to be a really short timeline before the end of the fiscal year. But if you look at some— 

Rovner: Every year they say they’re going to do the spending bills separately, and every year they don’t. 

Raman: Yeah, and I think if you look at how they’ve been approaching some of the things that have been generally a little bit less controversial and how much pushback and how much more difficulties they’ve been having with that, even this week, I think that it’s going to be much more difficult to get that done. And the rescissions, pulling back on Congress’ power of the purse, is not going to make that any easier. 

Rovner: I think what people don’t appreciate, and I don’t think I appreciated it either until this came up, is that the rescissions process is part of the budget act, which is one of these things that Congress can do on an expedited basis in the Senate with just a straight majority. But the regular appropriations bills, unlike the budget reconciliation bill that we just did, need 60 votes. They can be filibustered. So the only way to get appropriations done is on a bipartisan basis, and yet they’re using this rather partisan process to take back some of the deal that they made. The Democrats keep saying it, and everybody’s like, Oh, process, process. But that actually could be a gigantic roadblock, to stopping everything in its tracks, right? 

Raman: I really think so. And if you look at who are the two Republicans in the Senate that voted against the rescissions, one of them is the Senate Appropriations chair, Susan Collins. And throughout this, one of her main concerns was when we still had the PEPFAR in there. But it just takes back her power as the highest-ranking appropriator in the Senate to do it through this process, especially when she wasn’t in favor of the rescissions package. 

So it’s going to make things, I think, a lot more complicated, and one of her concerns throughout has just been that there wasn’t enough information. She was pulling out examples of rescissions in the past and how it was kind of a different process. They were really briefed on why this was necessary. And it was just different now. So I think what happens with appropriations and how long it’ll take this year is going to be interesting to watch. 

Rovner: And it’s worth remembering that it’s when the appropriations don’t happen that the government shuts down. So, but that doesn’t happen until October. Well, separately we learned that — oh, go ahead, Joanne. 

Kenen: There’s also sort of a whole new wrinkle, is that rescissions is, if you’re a Republican and you don’t like something and you end up, to avoid a government shutdown or whatever reason, you end up having to vote for a bill, you just have the president put out a statement saying, If this goes through, I’m going to cut it afterwards. And then the Republican who doesn’t like it can give a floor speech saying, I’m voting for it because I like this in it and I know that the president’s going to take care of that. It really — appropriations is always messy, but there’s this whole unknown. The constitutional balance of who does what in the American government is shifting. And at the end of the day, the only thing we do know after both the first term and what’s happened so far even more so in the second term, is what [President Donald] Trump wants, Trump tends to get. 

So, Labor-H [the appropriations for Labor, HHS, Education and related agencies], like Sandhya just pointed out, the health bill is one of the hardest because there’s so much culture-war stuff in it. But, although, the Supreme Court has put some of that off the table. But I just don’t know how things play out in the current dynamic, which is unprecedented. 

Rovner: And of course, Labor-HHS also has the Department of Education in it. 

Kenen: The former Department of Education. 

Rovner: To say, which is in the process of being dismantled. So that’s going to make that even more controversial this year. Moving back to the present, separately we learned this week that the administration plans to spend hundreds of thousands of dollars of taxpayer money to destroy stocks of food and contraceptives and other medical devices rather than distribute them through some of the international aid programs that they’re canceling. Now, in the case of an estimated 500 tons of high-energy biscuits bought by USAID [the U.S. Agency for International Development] at the end of the Biden administration, you can almost understand it because they’re literally about to expire next week. According to The Atlantic, which first reported , this is only a small part of 60,000 metric tons of food already purchased from U.S. farmers and sitting in warehouses around the world, where the personnel who’d be in charge of distributing them would’ve been fired or transferred or called back to the U.S. 

At the same time, there are apparently also plans to destroy an estimated $12 million worth of HIV prevention supplies and contraceptives originally purchased as part of foreign aid programs rather than turn them over or even sell them to other countries or nonprofits. This feels like maybe the not most efficient use of taxpayer dollars? 

Luthra: I think this is something we’ve talked about before, but it really bears repeating. As a media ecosphere, we’ve sort of moved on from the really rapid dismantling of USAID. And it was not only without precedent. It was incredibly wasteful with the sudden way it was done, all of these things that were already purchased no longer able to be used, leases literally broken. And people had to pay more to break leases for offices set up in other countries, all these sorts of things that really could have already been used because they had been paid for. And instead, the money is simply lost. 

And I think the important thing for us to remember here is not only the immense waste financially to taxpayers but the real trust that has been lost, because these were promises made, things purchased, programs initiated, and when other countries see us pulling back in such a, again, I keep saying wasteful, but truly wasteful manner, it’s just really hard to ever imagine that the U.S. will be a reliable partner moving forward. 

Rovner: Yeah, absolutely. I understand the food thing to some extent because the food’s going to expire, but the medical supplies that could be distributed by somebody else? I’m still sort of searching for why that would make any sense in any universe, but yeah I guess this is the continuation of, We’re going to get rid of this aid and pretend that it never happened. 

Well, meanwhile, it’s only been a couple of weeks, but we’re starting to see the politics of that big Trump tax and spending measure play out. One big question is: Why didn’t Republicans listen to the usually very powerful hospital industry that usually gets its way but did not this time? And relatedly, will those Republicans who voted with Trump but against those powerful hospital interests do an about-face between now and when these Medicaid cuts are supposed to take effect? We’ve already seen Sen. Josh Hawley, the Republican from Missouri who loudly proclaimed his opposition to those Medicaid cuts before he voted for them anyway, introduce legislation to rescind them. So is this the new normal? I think, Joanne, you were sort of alluding to this, that you can now sort of vote for something and then immediately say: Didn’t mean to vote for that. Let’s undo it. 

Kenen: You could even do it before you vote for it, if they play it right. If Congress passes these things, we’re not going to pay attention. We’re already in that moment. But also, when I was working on a Medicaid piece, the magazine piece like four or five months ago, one of the most cynical people I know in Washington told me, he said, Oh, they’ll pass these huge cuts because they need the budget score to get the taxes through, and then they’ll start repealing it. And it seemed so cynical at the time, only he might’ve been right. 

So I don’t think they’re going to cut all of it. Republicans ideologically want a smaller Medicaid program. They want less spending. They want work requirements. You’re not going to see the whole thing go away. Could you see some retroactive tinkering or postponement or something? Yeah, you could. It’s too soon to know. Hospitals are the biggest employer in many, many congressional districts. This is a power— 

Rovner: Most of them. 

Kenen: Most, yeah. I don’t think it’s quite all, but like a lot. It’s the biggest single employer, and Medicaid is a big part of their income. And they still by law have to stabilize people who come in sick, and there’s emergency care and all sorts of other things, right? They do charity care. They do uninsured people. They do all sorts. They still treat people under certain circumstances even when they can’t pay. But right now, the threat of a primary opponent is more powerful than the threat of your local hospital being mad at you and harming health care access in your community. So much in the Republican world revolves around not getting the president mad enough that he threatens to get you beaten in a primary. We’ve seen that time and again already. 

Rovner: Right. And I will also say there’s precedent for this, for passing something and then unpassing it. Joanne and I covered in 19— 

Kenen: But it wasn’t the plan. 

Rovner: Yeah, I know. But remember, back in 1997 when they passed the Balanced Budget Act, every year for the next — was it three or four years? They did what we came to call “give back” bills. 

Kenen: Or punting, right? 

Rovner: Yeah, where they basically undid, they unspooled, some of those cuts, mostly because they’d cut more deeply than they’d intended to. And then we know with the Affordable Care Act, I’ve said this several times, they passed all of these financing mechanisms for it and then one by one repealed them. 

Kenen: And the individual mandate — I mean everything- 

Rovner: And the individual mandate, right. 

Kenen: They kept the dessert and they gave away everything. They undid everything that paid for the dessert, basically. 

Rovner: Right. Right. 

Kenen: And so it was the Cadillac — because people don’t remember anymore — the Cadillac tax, the insurance tax, the device tax. They all were like, One at a time! And they were repealed because lobbying works. 

Rovner: The tanning tax just went. 

Kenen: Right, right. So that dynamic existed, passing something unpopular and then redoing it, but the dynamic now really just comes — basically this is Donald Trump’s town. He has had a remarkable success in not only getting Congress to do what he wants but getting Congress to surrender some of its own powers, which have been around since Congress began. This is the way our government was set up. So there’s a very, very different dynamic, and it’s still unpredictable. None of us thought that the biggest crisis would be the [Jeffrey] Epstein case, right? Which is not a health story, and we don’t have to spend any time on it except to acknowledge— 

Rovner: Please. 

Kenen: —that there’s stuff going on in the background that people who had been extremely loyal to the president are now mad. And we don’t know how long. He’s very good at neutralizing things, too. He’s blaming it on the Democrats. 

But there is a different dynamic. Congress has less power because Congress gave up some of its power. Are they going to want to reassert themselves? There is no sign of it right now, but who knows what happens. I thought they would cut Medicaid. I thought they would do work requirements. I thought they would let the enhanced ACA subsidies expire. But I did not think the cuts would go this deep and this extensive — really transformationally pretty historic cuts. 

Rovner: Shefali, you wanted to say something? 

Kenen: Not pretty historic cuts, very historic cuts. Unprecedented. 

Luthra: I was thinking Joanne made such a good point about how, for all of the talk now about trying to mitigate that backlash, a lot of this is in line ideologically with what Republicans want. They do want a smaller Medicaid program. And I think a really interesting and still open question is whether they are willing and able to actually create policy that does reverse some of these cuts or not, and even if they do, if it’s sufficient to change voters’ perception, because we know that these cuts are very unpopular. Democrats are talking about them a lot. Hospitals are talking about them a lot. And just the failed attempt to repeal the ACA led to the 2018 midterms. And I think there is a real chance that this is the dominant topic when we head into next year’s elections. And it’s hard to say if Josh Hawley putting out a bill can undo that damage, so—. 

Rovner: Well, I’m so glad you mentioned that, because The Washington Post has a about a clinic closing in rural Nebraska, with its owners publicly blaming the impending Medicaid cuts. Yet its Trump-supporting patients are just not buying it. Now in 2010, Republicans managed to hang the Affordable Care Act around Democrats’ necks well before the vast majority of the changes took place. Are Democrats going to be able to do that now? There’s a lot of people saying, Oh, well, they’re not going to be able to blame this on the Republicans, because most of it won’t have happened yet. This is really going to be a who-manages-to-push-their-narrative, right? 

Kenen: This really striking thing about that story is that the people who were losing access, they’re not losing their Medicaid yet, but they’re losing access to the only clinic within several — they have to drive hours now to get medical care. And when they were told this was because the Republican Congress and President Trump, they said, Oh no, it can’t be. First of all, a lot of people just don’t pay attention to the news. We know that. And then if you’re paying attention to news that never says anything negative about the president, that blames everything on Joe Biden no matter — if it rains yesterday, it was his fault, right? 

So the sort of gap between — there are certain things that are matters of opinion and interpretation, and there are certain things that are matters of fact, but those facts are not getting through. And we do not know whether the Democrats will be able to get them through, because the resistance, it’s almost magical, right? My clinic closed because of a Republican Medicaid bill? Oh no, it’s hospital greed. They just don’t want to treat us anymore. They just, it doesn’t compute, because it doesn’t fit into what they have been reading and hearing, to the extent that they read and hear. 

Rovner: Sandhya, you want to add something? 

Raman: The one thing that as I’ve been asking around on Capitol Hill about the Hawley bill — and there was one from Sen. Rand Paul, and a House counterpart, from [Rep.] Greg Steube, does sort of the opposite — it wants to move up the timeline for one of the provisions. So one important thing to consider is neither of these bills have had a lot of buy-in from other members of Congress. They’ve been introduced, but the people that I’ve talked to have said, I’m not sure. 

And I think something interesting that Sen. Thom Tillis had said was: If Republicans had a problem with what some of the impacts would be, then why were they denying that there would be an effect on rural health or some of those things to begin with? And I think a lot of it will take some time to judge to see if people will move the needle, but if we’re going to change any of these deadlines through not reconciliation, you need 60 votes in the Senate and you’ll need Democrats on board as well as Republicans. And I think one interesting thing to watch there is that I think some of the Democrats are also looking at this in a political way. If there’s a Republican that has a bill that is trying to tamp down some of the effects of their signature reconciliation law, do they want to help them and sign on to that bill or kind of illustrate the effects of the bill before the midterms or whatever? 

Rovner: A lot more politics to come. 

Raman: Yeah. Yeah. 

Rovner: Meanwhile, over at HHS [the Department of Health and Human Services], there is also plenty of news. Many of the workers who’ve been basically in limbo since April when a judge temporarily halted the Trump administration’s efforts to downsize have now been formally let go after the Supreme Court last week lifted that injunction. What are we hearing about how things are going over at HHS? We’ve talked sort of every week about this sort of continuing chaos. I assume that the hammer falling is not helping. It’s not adding to things settling down. 

Kenen: No. And then Secretary [Robert F.] Kennedy [Jr.] just fired two top aides because — no one knows exactly the full story but it’s — and I certainly do not know the full story. But what I have read is that the personality conflict with his top aide — and that happens in offices, and he’s not the first person in the history of HHS to have people who don’t get along with one another. But it’s just more unsettled stuff in an agency already in flux, because now in addition to all these people being let go in all sorts of programs and programs being rolled back, you also have some leadership chaos at the top. 

Rovner: Well, meanwhile, HHS Secretary Kennedy took office with vows to eliminate the financial influence of Big Pharma, Big Food, and other industries with potential conflicts of interests. But shoutout here to my Ñî¹óåú´«Ã½Ò•îl Health News colleague Stephanie Armour, who has a story this week about how the new vested interests at HHS are the wellness industry. Kennedy and four top advisers, three of whom have been hired into the department, wrote Stephanie, quote, “earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a Ñî¹óåú´«Ã½Ò•îl Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS. That total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data is not publicly available.” Have we basically just traded one form of regulatory capture for another form of regulatory capture? 

Kenen: And one isn’t covered by insurance. Some of it is, but there’s a lot of stuff in the, quote, “wellness” industry that providers and so forth, certain services are covered if there’s licensed people and an evidence base for them, but a lot of it isn’t. And these providers charge a lot of money out-of-pocket, too. 

Rovner: And they make a lot of money. This is a totally — unlike Big Pharma, Big Food, and Big Medicine, which is regulated, Big Wellness is largely not regulated. 

Kenen: I think Stephanie — that was a really good piece — and I think Stephanie said it was, what, $6.3 trillion industry? Was that— 

Rovner: Yeah, it’s huge. 

Kenen: Am I remembering that number right? It’s largely unregulated. Many of the products have never gone through any review for safety or efficacy. And insurance doesn’t cover a lot of it. It doesn’t mean it’s all bad. There are certain things that are helpful, but as an industry overall, it leaves something for us to worry about. 

Rovner: Well, in HHS-adjacent breaking news that could turn out to be nothing or something really big, an appeals court in Richmond on Tuesday ruled 2-1 that West Virginia may in fact limit access to the abortion pill, even though it’s approved by the FDA [Food and Drug Administration]. It’s the first time a federal appeals court has basically said that states can effectively override the FDA’s nationwide drug approval authority. And it’s the question that the Supreme Court has already ducked once, in that case out of Texas last year where the justices ruled that the doctors who were suing didn’t have standing, so they didn’t have to get to that question. But, Shefali, this has implications well beyond abortion, right? 

Luthra: Oh, absolutely. We are seeing efforts across the country to restrict access to certain medications that are FDA-approved. Abortion pills are the obvious one, but, of course, we can think about gender-affirming care. We can think about access to all sorts of other therapeutics and even vaccines that are now sort of coming under political fire. And if FDA approval means less than state restrictions, as we are seeing in this case, as we very possibly could see as these kinds of arguments and challenges make their way to the Supreme Court. The case you alluded to earlier with the doctors who didn’t have standing is still alive, just with different plaintiffs now. And so these questions will probably come back. There are just such vast ramifications for any kind of medication that could be politicized, and it’s something that industry at large has been very worried about since this abortion pill became such a big question. And it is something that this decision is not going to alleviate. 

Rovner: Yes. Speaking of Big Pharma, they’re completely freaked out by this possibility because it does have implications for every FDA-approved drug. 

Luthra: And they invest so much money in trying to get products that have FDA approval. There’s a real promise that with this global gold standard, you will be able to keep a drug on the market and really make a lot of money on it. There’s also obviously concerns for birth control, which we aren’t seeing legally restricted in the same way as abortion yet, but it is something that is so deeply subject to politics and culture-war issues that that’s something that we could see coming down the line if trends continue the way they are. 

Rovner: Well, we will watch that space. Moving on. Wednesday was the third anniversary of the federal 988 federal crisis line, which has so far served an estimated 16 million people with mental health crises via call, text, or chat. An estimated 10% of those calls were routed through a special service for LGBTQ+ youth, which is being cut off today by the Trump administration, which accused the program, run by the Trevor Project, as, quote, “radical gender ideology.” Now, LGBTQ+ youth are among those at the highest risk for suicide, which is exactly what the 988 program was created to prevent. Yet there’s been very little coverage of this. I had to actually go searching to find out exactly what happened here. Is this just kind of another day in the Trump administration? 

Raman: I think a lot of it stems back to some of those initial executive orders related to gender ideology and DEI [diversity, equity, and inclusion] and things like that. The Trump administration’s kind of argument is that it shouldn’t be siloed. It should be all general. There shouldn’t be sort of special treatment, even though we do have specialized services for veterans who call in to these services and things. But I— 

Rovner: Although that was only saved when members of Congress complained. 

Raman: Yeah. But I do think that when we have so much happening in this space focused on LGBTQ issues, it’s easier for things to get missed. I think the one thing that I did notice was that California announced yesterday that they were going to step up to do a partnership with the Trevor Project to at least — the LGBTQ youth calling from California to any of those local 988 centers would be reaching people that have been trained a little bit more in cultural competency and dealing with LGBTQ youth. But that’s not going to be all the states and it’s going to take time. Yeah. 

Rovner: Yeah, we’re going to continue to see this cobbled together state by state. It feels like increasingly what services are available to you are going to be very much dependent on where you live. That’s always been true, but it feels like it’s getting more and more and more true. Shefali, I see you nodding. 

Luthra: Something you alluded to that I think bears making explicit is public health interventions are typically targeted toward people who are in greater danger or are at greater risk. That’s not discrimination — that’s public health efficiency. And suggesting that we shouldn’t have resources targeted toward people at higher risk of suicide is counter to what public health experts have been arguing for a very long time. And that’s just something that I think really bears noting and keeping in mind as we see what the impact of this is moving forward. 

Rovner: Yeah, I think that’s a very good point. Thank you. 

Well, speaking of popular things that are going away, a federal judge appointed by President Trump last week struck down the last-minute Biden administration rule from the Consumer Financial Protection Bureau that tried to bar medical debt from appearing on credit reports. This had been hailed as a major step for the 100 million Americans with medical debt, which is not exactly the same as buying a car or a TV that you really can’t afford. People don’t go into medical debt saying, Oh, I think I’m going to go run up a big medical bill that I can’t pay. But this strikes me as yet another way this administration is basically inflicting punishment on its own voters. Yes? 

Kenen: Yes, except we just don’t know. Some red states are so red that you don’t need every voter. We don’t know who actually votes, and we don’t know whether people make these connections, right? What we were talking about before with Medicaid — do they understand that this is something that President Trump not just urged but basically ordered Congress to do? So do people pay attention? How many people even know if their medical debt is or is not on their credit report? They know they have the medical debt, but I’m not sure everybody understands all the implication, particularly if you’re used to being in debt. You may be somebody who’s lost a job or couldn’t pay your mortgage or couldn’t pay your rent. Some of the people who have medical debt have so many other financial — not all — that it’s just part of a debt soup and it’s just one more ingredient. 

So how it plays out and how it’s perceived? It’s part of this unpredictable mix. Trump is openly talking about gerrymandering more, and so it won’t matter what voters do, because they’ll have more Republican seats. That’s just something he’s floating. We don’t know whether it’ll actually happen, but he floated it in public, so— 

Rovner: So much of this is flooding the zone, that people — there’s so much happening that people have no idea who’s responsible for what. There’s always the pollster question: Is your life better or worse than it was last year? Or four years ago, whatever. And I think that when you do so much so fast, it’s pretty hard to affix blame to anybody. 

Raman: And most people aren’t single-issue voters. They’re not going to the polls saying, My medical debt is back on my credit report. There’s so many other things, even if with the last election, health care was not the number one issue for most voters. So it’s difficult to say if it will be the top issue for the next election or the next one after that. 

And I guess just piggybacking that a lot of the times when there’s these big changes, they don’t take effect for a while. So it’s easier to rationalize, Oh, it may have been this person or that person or the senator then, or who was president at a different time, just because of how long it takes to see the effects in your daily life. 

Rovner: Politics is messy. All right, well, this is as much time for the news as we have this week? 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’ll put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week? 

Luthra: Sure. My piece is from The New York Times, by Apoorva Mandavilli. The headline is “” And she takes a look at when the head of the OMB [Office of Management and Budget] told the Senate that PEPFAR had spent almost $10 million advising Russian doctors on abortions and gender analysis. And she goes through and says this isn’t true. PEPFAR hasn’t been in Russia. They cannot fund abortions. And she talks with people who were there and can say this simply isn’t true and this is very easy to disprove. And I like this piece because it’s just a reminder that a lot of things are being said about government spending that are not true. And it is a public service to remind readers that they are very easily disproven. 

Rovner: Yeah, and to go ahead and do that. Sandhya. 

Raman: My extra credit is “,” and it’s from Cecilia Nowell for The Nation, my co-fellow through AHCJ [the Association of Health Care Journalists] this year. Cecilia went to Kiruna, which is an Arctic village in Sweden, to look at how they’re using mifepristone for abortions up to 22 weeks in pregnancy, compared to up to 10 weeks in the U.S. And it’s a really interesting look at how they’re navigating rural access to abortion in very remote areas. Almost all abortions in Sweden are done through medication abortion, and while the majority here are in the 60% versus high 90s. So just interesting how they’re taking their approach there as rural access is limited here. 

Rovner: Really interesting story. Joanne. 

Kenen: This is a piece in The New Yorker by Dhruv Khullar, and it’s “” And what I found interesting, we’ve been hearing about: Can AI do this? It’s sort of been in the air since AI came around. But what was so interesting about this article is there’s a nonprofit that is actually doing it, and they have this sort of whole sort of hierarchy of why a drug may be promising and why a disease may be a good target. And then the AI look at genetics and diseases, and they have four or five factors they look at. And then there’s this just sort of hierarchy of which are the ones we can make accessible. 

So A, it’s actually happening. B, it has promise. It’s not a panacea, but there’s promise. And C, it’s being done by a nonprofit. It’s not a cocktail for an individual patient. It’s trying to figure out: What are the smartest drugs to be looking at and what can they treat? And they give examples of people who have gone into remission from rare diseases. And also it says there are 18,000 diseases and only 9,000 have treatment. So this is huge, right? Rare diseases may only affect a few people, but there are lots of rare diseases. So cumulatively some of the people they strike are young. So for someone who doesn’t always read about AI, I found this one interesting. 

Rovner: Also, we read somebody’s story about how AI is terrible for this, that, and the other thing. It is very promising for an awful lot of things. 

Kenen: No. Right. 

Rovner: There’s a reason that everybody’s looking at it. 

All right, my extra credit this week is also from The New York Times. It’s called “,” by David Enrich, who’s The Times’ deputy investigations editor and, notably, author of a book on attacks on press freedoms. That’s because the story chronicles how UnitedHealth, the mega health company we have talked about a lot on this show, is taking a cue from President Trump and increasingly taking its critics to court, in part by claiming that critical reporting about the company risks inciting further violence like the Midtown Manhattan murder of United executive Brian Thompson last year. 

I hasten to add, this isn’t a matter of publications making stuff up. United, as we have pointed out, is a subject of myriad civil and criminal investigations into potential Medicare fraud as well as antitrust violations. This is still another chapter unfolding in the big United story. 

OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us to review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, , or on Bluesky, . Where are you folks hanging these days? Shefali? 

Raman: I’m at Bluesky, . 

Rovner: Sandhya. 

Raman: I’m and , @SandhyaWrites. 

Rovner: Joanne? 

Kenen: I’m mostly at Bluesky, , and I’ve been posting things more on , and there are more health people hanging out there. 

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

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

Julie Rovner: Hello and welcome back to “What The Health.” I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl 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. 16, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

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 Harris Meyer, who reported and wrote the latest Ñî¹óåú´«Ã½Ò•îl Health News “Bill of the Month,” about a patient whose colonoscopy bill was a lot bigger than he expected. But first, this week’s news. 

So we are now four days from the second swearing-in of Donald Trump as president, and discussions are already picking up on Capitol Hill about rolling the new president’s entire agenda into, quote, “one big, beautiful bill,” as Trump has put it. There are lots of differences of opinions between Republicans that are still to be worked out, but one target for cost-cutting is pretty clear, and that would be Medicaid. Sandhya, we’re starting to get a picture of the possibilities of how they might want to do that. What are some of the main things that are on the table? 

Raman: So the reconciliation talks are very much underway, and we’ve made a little progress but at the same time we just didn’t also make a lot of progress. The end of, -ish, last week we got a menu of items that Republicans are kind of considering as things they would use to offset some of the things that they’d want to do through reconciliation. 

Rovner: Like continue the tax cut? 

Raman: Yes, for the tax cuts and for border security. So what we have on the House side is a lot of things that are very health-oriented. About half of that list is health-oriented, and a lot of it is Medicaid. And so some of the things they’ve been floating around are some things we saw in the first Trump administration, them trying to do. We have per-capita caps on Medicaid spending, work requirements for Medicaid, changing the federal match for Medicaid expansion, and things like changing the public charge rule to back how it was in the Trump administration. 

Rovner: Remind people what the public charge rule is. 

Raman: The public charge rule kind of limits some of the social programs for folks that are not citizens to make use of things like Medicaid, SNAP [the Supplemental Nutrition Assistance Program], and other programs like that. 

Rovner: And those are for people who are here legally? 

Raman: Yes. So this week, Tuesday, we had our first meeting from the House Energy and Commerce Republicans to look over at least the health part of that menu. And talking to both Energy and Commerce Chairman Brett Guthrie and Buddy Carter, who heads the health subcommittee, it’s just the start. Discussions were pretty good, but it’s so early. 

Carter said that he still wants to get the PBM [pharmacy benefit manager] language from last year that didn’t make it across the finish line in there. And Guthrie has said that some of the numbers that we’ve seen of how much money from Medicaid they could possibly save are really in flux because of how they interact with all of the other provisions in there. Some things are under Ways and Means jurisdictions. Some things, if you do one and not the other, the numbers would change. 

So they’re still pretty early in the process, and we don’t know if we’re going to do the “one big, beautiful bill” or kind of what the Senate wants, with two bills, and that would just kind of change what would be done earlier versus later. But we do have a little bit more of a timeline now in what they’re trying to do. 

Rovner: I feel like it’s worth remembering that they tried taking a whack out of Medicaid in 2017, when they had a much bigger Republican majority in the House, and they couldn’t get it over the finish line. What makes them think they’re going to be more successful this time? 

Raman: I think part of it is that — this is still early on. When you ask them the feedback that they’ve gotten from Republican governors — most Republican states have had Medicaid expansion at this point. We still have only the 10 holdout expansion states. So, I think, really, as we get closer, if they seem like they’re angling to include some of these in whatever vehicle we have, we’ll probably hear more. 

And I mean, if you look at this state-level already, a lot of states are kind of couching their bets with Medicaid, just thinking about how they can do things differently in case their Medicaid federal funding changes over the course of this year or next year. So, I think it really depends on what feedback they’re going to get in the coming weeks and months. 

Rovner: Joanne wanted to add something. 

Kenen: Yeah, I mean, the beauty of reconciliation if you’re the majority party, but a narrow majority, which is what’s going on now, is you’d only need 51 votes in the Senate. You don’t need 60. So on one level, that sounds like they’ve got 53. It’s a slam dunk, right? But it’s not, because reconciliation, it’s a grab bag. You put so much stuff in there, and all you need is one provision that this person won’t vote for or that person won’t vote for. 

So this seemingly simple slam dunk for a narrow-majority Senate is actually a big, complicated mess. On the other hand, compared to the first Trump administration, this is a more conservative, or a more populist, or a more approach — I mean, the ideology or worldview of the Republicans in Congress is closer to Trump than it was in 2017. 

But yeah, they failed at what they thought was going to be easy. They thought repealing the ACA [Affordable Care Act] and changing, which included a lot of Medicaid stuff, they thought it was a slam dunk. And instead, it was a year-long slog that failed. So is Medicaid going to look the way it looks right now? No, it’ll change. How much will it change is really an open question. 

Remember, there’s some things they can do through waivers. Work requirements they can do through waivers. Although in the past, the courts have blocked them. The courts have changed. We don’t know where the courts will come down. But really it’s more than a headache. It’s like a headache and a stomachache. 

Rovner: Yeah, well, so reconciliation, budget, all of this stuff is still way TBD. Still, the Republican Congress is getting off to a fast start, at least in terms of messaging legislation. The House this week passed a bill to ban transgender athletes from women’s school sports, and the Senate’s debating a House-passed bill that would allow the deportation of undocumented people who are accused but not yet convicted of violent crimes. 

In West Virginia, the new governor, who’s also a former Capitol Hill health aide, [Patrick] Morrisey, issued executive orders making it easier for parents to send their children to school without being vaccinated. Overall, it seems the Republicans are kind of coalescing around a concept known as “medical freedom,” which to me seems just like a rejection of public health in general. Or am I missing something? Is there something more to this? 

Edney: No, I think that it’s always been around, but I think that certainly this resurgence in it is coming from the fact that people didn’t trust science during the pandemic. They were fed up. Communication wasn’t handled very well, and it still isn’t handled very well. I don’t think people have figured out how to talk about these things in measured ways. 

I would recommend if someone listening hasn’t read, Dr. Paul Offit wrote in the New York Times a few days ago on vaccination that I thought was really good because he’s like: Listen, I’m a vaccine skeptic. Like, R.F.K. Jr. [Robert F. Kennedy Jr.] is a vaccine cynic. There’s the difference, and here’s what it is. And he laid it out there. And he is a pediatrician, and he also serves on FDA’s [the Food and Drug Administration’s] advisory committee for vaccines. 

So I think that a lot of this is stemming from misinformation and miscommunication, and it resonates with people. I mean, the Republican Party picked up a lot of fans in far-left progressives by talking about this. So I think they see that as an opportunity, too. So it may not just be grassroots. It may be a little bit of an opportunity they see. 

Kenen: Anti-vaccination sentiment has been around as long as vaccines. It actually goes back to smallpox. There has always been a certain amount of fear, skepticism, whatever. It had been traditionally among Democrats and Republicans. It actually changed. It began to change two or three years before the pandemic. 

Some state legislatures — and this was the medical freedom, this was on the right — started trying to water down mandates for schools. At that point, I don’t think anything big got through. But we began to see this emergence of a deeper politicization of vaccination. And it was on the right, and it’s what we now talk about as medical freedom. 

So instead of being something that’s across the political spectrum, it is now a politicized movement, on a libertarian Government can’t tell me what to do. And we saw this during the pandemic. And neither administration, neither the Trump administration in the first year of the pandemic nor the Biden administration in the ensuing years, really managed to explain the difference between individual choice and the fact that if you get sick, you might survive but you could endanger somebody else. 

You don’t know who the person on the bus next to you is. You don’t know who the kid in your classroom is. You don’t know who you’re standing next to at the grocery store. They could be really vulnerable. And that this whole sense of “my body, my choice,” doesn’t fly when you could kill somebody else unintentionally. And that sort of has been lost, or people don’t care. 

Rovner: Yeah, I mean we’ve seen that with tobacco over how many generations. It’s like, you want to put stuff in your lungs, that’s your business. But you don’t really get the right to put stuff in other people’s lungs because you would like to smoke. 

Meanwhile, continuing with the Republican agenda, my former Ñî¹óåú´«Ã½Ò•îl Health News colleague Anna Maria Barry-Jester has this week about what National Institutes of Health director candidate Jay Bhattacharya might have in mind for the agency, including de-emphasizing infectious disease research and focusing more on chronic disease. 

Given that the biggest institute at NIH is already the National Cancer Institute, which focuses on a chronic disease, is this just Republicans’ way of punishing the National Institute of Allergy and Infectious Diseases that was for so long headed by the now retired Dr. Tony Fauci? 

Raman: I think in a part that is a huge driving factor, when you look at some of his comments and R.F.K. Jr.’s comments about holistic approaches to health, that really when you look at what something like NIAID does, which is so infectious-disease-driven, versus the things like with cancer and other things. 

But I think at the same time, this has kind of been bubbling up before, when we even looked to last year. Before we had any of these nominees, before we even knew the outcome of the election, we had a push within Congress from the head of the House Labor-H Appropriations subcommittee and former Energy and Commerce Chairwoman Cathy McMorris Rodgers trying to reform NIH that way. 

We didn’t get that far with it. It was included in some of the appropriations bills that didn’t go anywhere yet. But I think it’s just part of a broader discussion that there is, kind of going back to what we were saying before, some of the wanting more control of what you see, in terms of medical freedom, and that they want to know more about what’s happening. 

So I think that, regardless, we’re going to see more of this. But I think one thing that was really interesting in what she’d been writing was just the NIH is so much bigger than just NIH, you know? It’s so many of the people that are benefited by it, that are working with this grant money, are states nationwide. And it’s just the medical research is for a global understanding of medical research, and just how many of the drugs that we see come from NIH money. So even if there is a broader push for reform, that it’s very sensitive into how broad of an effect that would have. 

Rovner: And I would point out, because I live up the street from NIH, that most of what NIH does doesn’t happen on the NIH campus. It is, as you said, it’s money that goes out to every single congressional district. There’s an enormous amount of backing. 

I would also point out that, yes, NIH has gotten kind of sprawling with, I think there’s 27 institutes now. Every single one of those has been added by Congress. NIH can’t create its own institutes. Only Congress can do that. So, Congress has sort of made NIH the sprawl that it is. I think there’s been bipartisan agreement that NIH maybe needs a new look. 

I guess the question is just sort of what direction that is going to take and whether some of it is going to be punitive or whether they’re actually going to look at it in a matter of what would benefit the country, because it gets a lot of money, and that’s also been bipartisan. 

Kenen: Right. What we’re not hearing yet, or at least — and maybe Anna, who covers pharma, can tell me if I’m wrong — but we’re not — NIH also does the basic, basic, basic cellular first-step science that eventually leads to the work that drug companies do to develop drugs. They do the basic, what they call bench, science. 

I’m not hearing the drug companies speak out. The ambivalence Americans have about drug companies, which is hating the prices but liking the drugs, I haven’t heard pharma — Maybe it’s just too early. Maybe they’re weighing in quietly, and maybe Anna can tell me I’m wrong and they are and I just didn’t notice. But that’s also a huge constituency, a huge, powerful constituency. Because without the NIH, we wouldn’t have many of the drugs that keep us and our elderly relatives alive, including a lot of the gains — we haven’t cured cancer, but we’ve made gains on cancer. That wouldn’t have happened. It’s not just the premier research institute in America. It’s the premier research institute in the world, and as Julie said, a big driver economically of every single county, every medical school, every public health, you know, it has been an economic powerhouse as well as a knowledge powerhouse. 

Edney: And I wouldn’t tell you you’re wrong. I think that you’re right. I haven’t heard the pharma companies talking about it. I think they are talking about a lot of things that they want done to benefit them, and so I’m sure that they’ve made their priorities. We’ll see if this reaches sort of a boiling point, where they do end up weighing in. And I also just want to say, NIH, I know they want to focus on chronic disease. It does a lot of that. So maybe that’s not being communicated: It’s not being cut or left off the table because we’re doing this. We can do two things. We can walk and chew gum. 

Rovner: Yes, I know, and that was the point I was trying to make. It’s like, there’s an enormous amount of chronic disease research that happens from the NIH, much of it dictated by Congress already. They spend a lot of time, individual members, telling NIH what it is they should be studying, which is a whole other issue that we’ll get to another time. 

But I want to stay on the topic of drug prices, because that’s a really big question mark for the incoming administration. This week, the CEO of drugmaker Eli Lilly told a Bloomberg reporter that it will ask the Trump administration to, quote, “pause” the Medicare drug price negotiation program, which of course is just getting underway. 

Of course, that’s happening even as Lilly encourages the incoming HHS [Department of Health and Human Services] not to cancel a Biden administration decision to have Medicare begin covering its expensive new weight loss drugs. 

Meanwhile, on its way out the door, the Biden administration’s Federal Trade Commission that found that the nation’s three largest PBMs, which together control about 80% of the U.S. prescription drug market, drove up drug prices by an estimated $7.3 billion from 2017 to 2022. 

I saw somewhere this week, and I think, Sandhya, you mentioned this, a suggestion that Republicans might try to resurrect the PBM bill that was dropped from that year-end 2024 spending bill and put it in the next spending bill that Congress is going to have to do in March. Likely? Possible? Will this report have any impact? Or is there just too much other news this week and nobody’s going to remember? 

Raman: I think it’s definitely being talked about a lot. We talked to the leadership of Energy and Commerce. It’s a priority for both of them, both for Carter and for Guthrie, because they worked so closely on it before. It was included in a bipartisan deal that we had before we got the CR [continuing resolution] that we voted into law. It just got dropped along the way. 

Rovner: When Elon Musk said the bill was too big? 

Raman: Yeah. So I think we kind of have two pathways, where both of them want to get it done regardless. I think that it might depend whether they are able to piece it away and do it as something stand-alone, which they want to get it done sooner rather than later. 

But it depends a little bit more on the leadership level, if there are savings from using that bill to be used later down the line when they get reconciliation at a later stage. So I think that’s what we’re waiting on. Would they need to put that there? Or would they be able to go forth with that now? 

Rovner: True. So, it’s a bipartisanly popular provision that also saves money, so that makes it kind of attractive to lawmakers who are putting together things that might, as Joanne would say, include spinach. 

Anna, what more broadly do you see as the outlook on drug prices? 

Edney: Well, I think the first thing I think of with that program is, it saves a lot of money if you’re giving Medicare the ability to negotiate. And so, I just wonder how that fits into this agenda if you stop it and make it more favorable towards the drugmakers. Where does that fit in with cutting spending and reducing the deficit and all of those things? 

So, I think that, maybe they have a little bit of an uphill battle in making their case on that front. All of this, for me, hinges on whether Trump really means what he says. And I think we all know that we just have to wait and see what actually happens. 

Rovner: Yeah, a lot of shrug emojis coming. 

Edney: Exactly. 

Rovner: Well, meanwhile, across the street from Capitol Hill, the Supreme Court has agreed to hear that preventive health care case out of, altogether now, Texas. The case challenges the requirements in the Affordable Care Act that insurance cover, without copay, preventive services like immunizations, cancer screenings, birth control, and, the subject of this particular case, medication to prevent HIV. 

What happens if the court rules with the plaintiffs in this case who argue that the CDC’s [Centers for Disease Control and Prevention’s] Preventive Health Services Task Force does not have the authority to determine what services should be on this list? Which of course is the entity that now determines which services should be on this list. 

Edney: Well, it sounds like, then, a lot of people don’t get their preventive care covered. As KFF wrote, there is some that would be still covered, the mammographies, but not the HIV preventative medication. Other cancer screenings included in that as well. And so, it seems to throw a wrench, I guess, sort of just asking this of the panel, that agencies then would have to go make those determinations? Does Congress have to make the determinations on what’s covered then? 

Rovner: Well, that’s of course the big question. Or, would the secretary, him or herself? Who is authorized? I think the argument is because the Preventive Health Services Task Force is not Senate-confirmed, they can’t make these decisions. 

And of course, the way it works, they don’t make these decisions. They recommend them, and then the secretary sort of ratifies them. So it’s hard to tell from this whether it really would go away, or whether Congress would have to step in, or whether the secretary could just do it. I feel like this creates as many questions as it could answers. 

Kenen: It’s a really broad array of benefits that — it’s not just the HIV PrEP preventive medicine. And I read different stories about this, and they had different lists, including some cholesterol stuff. And I don’t know, since the lists were so different, I’m not sure exactly which ones are in or which ones were out. But it’s not just HIV drugs. It’s a lot of stuff. 

So it would certainly gut something that people count on now. I mean these are free not just under an ACA plan but if you get coverage through a job, those requirements also apply. So, a lot of people would no longer have free access to a lot of what we consider preventive care. 

Rovner: We’ll be watching this case. They have not scheduled oral arguments. They just decided to take it. So, this will be a later in 2025 case. Well, the flip side of an incoming administration are all the things the outgoing administration tries to slip through on its way out of town, and this week has seen a bunch of those. 

Most of these things could be fairly easily undone by incoming officials, but not without some public pain, which sometimes is why administrations wait until the very last minute to do them, to be a little passive aggressive, or maybe in some of these cases a lot passive aggressive. Several of these last-minute changes come from the Food and Drug Administration, an agency targeted for big changes under Trump 2.0. 

In just the last 48 hours, the FDA has announced a policy that would require dramatic reductions in nicotine in cigarettes to render them, quote, “minimally addictive or nonaddictive.” It moved to ban Red Dye No. 3, a controversial additive already banned in many other countries which has been shown to cause cancer in rodents. And it proposed a major change in food labels to require them to show on the front of packaging whether the food’s sodium, sugar, and saturated fat levels are low, medium, or high. Do any of these proposals live on for more than another week? 

Edney: I think the Red No. 3 could. We know that R.F.K. Jr.’s talked about food dyes and wanting to get them out of, he specifically said, cereal, but they’re in a lot of things. So, I see that one. 

I think the industry saw that coming from far away and has been switching already, of course sometimes to another problematic, potentially, food coloring. But I don’t think this is something you’re going to see them fight super hard for to change. The nicotine is much more iffy. Big Tobacco is still a huge force, and Trump gets funding for his campaign and things from companies who have a stake in this. 

And some of that could align with this idea of not necessarily medical freedom but, sort of, we can choose what we put in our bodies. If we want to be addicted to nicotine, that’s our choice. So, the other one, the labels, I’m not sure. They’re not particularly powerful or anything. I thought they looked … When I looked at it, I was like, This is confusing and just looks like the back, but it is a little different. So, I don’t know. Maybe it survives. I’m not sure how much the industry is working on this. 

Rovner: [Sen.] Bernie Sanders of all people excoriated the food labels, saying we don’t put on cigarette packages whether the cancers they cause are low, medium, or high. Why should we do this? I mean, this is basically another effort to go after ultra-processed foods. I was surprised at how angry he was at this. 

Kenen: I think he wants them in neon. 

Rovner: I think he wants R.F.K. Jr. to have fewer ultra-processed foods available. I think that’s going to be sort of the big takeaway from all of this, I guess. 

Kenen: Right. But we also don’t understand what an ultra-processed food is, because there’s some foods that are not ultra-processed that are bad for you. And there’s some foods that do have some kind of minimal processing that, I mean, we’ve come to lump this together and I couldn’t tell you. There’s some things that are, quote, “ultra-processed” that really aren’t that processed, don’t have a lot of additives. They have something. 

So the whole categorization needs more work, both for public understanding and political understanding. There’s nobody who’s going to say that Americans have a really healthy diet and that food additives … R.F.K. Jr. has pointed out to the food additive, where the companies have to get to self-certify, Yeah, this is safe. So, is that something that he could get widespread support on? Yes, but there’s a whole lot of other things that he says that people were not going to agree with. 

Rovner: And I will remind that we not only don’t know if R.F.K. Jr. will be confirmed, but they still don’t even have a date for his confirmation hearing, because they’re still waiting on the paperwork. All right, moving on. 

As we taped this morning, there are still several fires burning in the Greater Los Angeles area. We have talked about the health effects of fire before. It’s not exactly news that fire and smoke are bad for human health, but what seems to make these fires different is that they’re not mostly trees and brush and other bits of nature that are burning but lots of toxic substances that are polluting not just the air but also the drinking water. 

Are we going to have to start thinking about fire and health in a much different way if not just remote areas but entire suburbs are now prone to burning up as a result of our changing climate? 

Edney: It will make us think of a lot of things in different ways, and particularly health care, when there’s things like high benzene levels floating in the air. We know that so much of our interior environments are made with things that contain high levels of formaldehyde, things like that. 

I think the expectation is that can create a long-term issue, but also it can in the moment create more deaths just at the time, not because it directly kills but if you already have an issue and you have a respiratory problem or a heart problem that can be exacerbated by these fires. 

Yeah, I think there’s a ton to think about. Even drinking water can be impacted more so when you have power outages and things in the areas where you’re maybe cleaning that water and then things like that. So, I think that’s going to be — masks, N95s might be coming back for a totally different reason. 

Rovner: Well, N95s are not enough. I mean, I think that was the thing that kind of jumped out at me. If you watch the news coverage of it, the reporters aren’t wearing N95s anymore. They’re wearing what looked like old-style gas masks. I mean, you need sort of the next level of masking because N95s don’t filter out some of these toxic substances that are now floating in the air. I mean, they do filter out the sort of the actual smoke from wood and whatnot, but it’s pretty scary. 

I mean, a lot more people than ever before have N95s hanging around their house, but they certainly don’t have these next-level respirators, which is what I keep hearing doctors calling for. 

Kenen: And you — I think it was the one that you sent around yesterday that basically that everything in our house is, our couches are basically cubes of plastic wrapped in cloth and dangerous when they’re burned. But I mean, I think that was the article that also said that some of these things that are burning produce like a cyanide kind of gas, that the firefighters can’t even be exposed. They can’t stand in front of a house with a hose for a long time. 

It could be killing or injuring firefighters. So, it also hampers — they’re not just trying to put a hose on a burning tree. 

Rovner: Yeah. A lot more things to think about, which is just what we needed. Well, turning to abortion, remember all those states last year that voted to protect abortion rights? It seems that was far from the final word. 

We are seeing court case after court case to determine which abortion restrictions can stay and which can’t as a result of passage of those ballot measures. This is happening particularly in Missouri, where Planned Parenthood clinics are still not offering the procedure after a judge invalidated some but not all of the state’s restrictions. 

This seems to be the inevitable result of what we have seen in other elections, where the same voters endorse abortion rights but then turn around and vote for candidates, including judges, who don’t. Is the gridlock here on purpose or by accident? And Sandhya, what’s going to happen? 

Raman: I don’t know that it would be on purpose. I think that these voters that vote for the candidates, if abortion is not their top issue, they’re still going to vote in the way that kind of allies with them. But then if they’re looking at other policies, they’re going to vote for these candidates. 

And Missouri, I think, is interesting because it has long been, I think, one of the test cases for so much in the abortion space, of trying out new restrictions and what will stick to the wall. And I think that we’re going to see more of these kind of long, drawn-out battles, given that the judge said that some restrictions were struck down because of the constitutional amendment but then others, like the licensing for abortion facilities, which we’ve seen for years, can stay. And that just makes it so that they can’t really operate. 

Rovner: Yeah. They have things like how wide the hallways need to be, I mean, rules that were created to deter them from offering abortions, not because they were actually needed for safety and health. 

Raman: Yeah. These rules only apply to the abortion facilities. They’re not parallel in the other types of clinics and hospitals. So it’s targeted to them. I think it is just another example of it being kind of an uphill battle for them, because now, I mean, even in the past few years we’ve seen so much more attention on state supreme court races, which I feel like a few years ago that was not something that would get national attention for one state or another. 

But, given that, as they’re kind of litigating these and seeing how can we implement the law so that these clinics can open under the constitutional amendment, it relies on them, and just how much money that is being fueled to be able to not come down on the other side so that they can kind of operate. So I think that’s something to definitely watch, as some of these states are kind of litigating these things, but it’s going to be a long, drawn-out battle, even if it’s already been several months since seven out of 10 states last year voted in favor of abortion rights. 

Rovner: Yeah, this continues, and of course, we’ll wait and see what happens at the federal level, when the Trump administration gets going. Well, finally this week, we have another entry in our recurring segment, “This Week in Medical Misinformation.” I wanted to talk about from the medical news site MedPage Today about the American Board of Internal Medicine pulling the board certification of a Texas cardiologist who made controversial and untrue claims about covid and the covid vaccine, including that vaccine had killed tens of thousands of people. 

What’s troublesome about this story, though, is that the ABIM wouldn’t comment on individual physicians, although it did list this particular doctor on his website as not being certified. How should specialty boards deal with doctors who express views that are, shall we say, not consistent with medical evidence? And how transparent should they be about telling patients when they sanction one of their own, which is basically what happened here? 

Kenen: Well, they did put out a statement, I think it was the New England Journal of Medicine about a year and a half ago, saying that they were going to crack down on this. I’m not sure if there’s, for any of the boards, if there’s a mechanism for telling patients, because how do you even know who all the patients or potential patients are? 

Rovner: But when I say telling patients, I mean telling the public. 

Kenen: Right. But I don’t know that any of the boards do that in any — it’s a big can of worms about decertification and how infrequently it happens. 

So ABIM did put out a statement, I think it was two years ago now, and there’s been a process for a few, but not a lot. And it doesn’t mean they don’t have a license anymore. It means they don’t have board certification. So unless the state medical board, which is really the group that pulls a license — this is saying that you’re not a board-certified whatever your specialty is under ABIM. 

But Lauren [Weber of The Washington Post], who is sometimes on the website, had a good piece a couple of months ago about how few state boards have acted to sanction doctors who say incorrect things about vaccines. And that goes back way before covid. The medical profession doesn’t do a lot of self-policing. 

Rovner: Yes, and I’ve been doing this long enough to have covered the creation of the National Practitioner Data Bank, when doctors who’d had their licenses pulled could just go to another state, and there was no way for that state to easily find out that that doctor had had his or her license revoked. 

And that was usually not for saying things but for doing things that ended up with having the doctor decreed not qualified to practice medicine anymore. So, I mean, this is an issue that goes back a long ways. 

Kenen: And you would think they would be the opposite. You would think that the state boards, when somebody is really a bad guy or a bad gal, you would think they would say, “We stop them!” Like, “We are protecting your health.” And instead, it’s been very secretive and very infrequent. 

It’s more the state licensing board. I mean, certification is important, but really the power to de-license somebody is in the state boards. 

Rovner: Yeah, well, the whole argument that professions police their own, what we’ve discovered is that professions don’t do a very good job of policing their own. But we will keep watching. All right, that is the news for this week. Now, we will play my “Bill of the Month” interview with Harris Meyer. Then we’ll come back and do our extra credits. 

I am pleased to welcome to the podcast Harris Meyer, who reported and wrote the latest Ñî¹óåú´«Ã½Ò•îl Health News “Bill of the Month.” Harris, welcome to “What the Health?” 

Harris Meyer: Thanks very much, Julie. Glad to be here with you. 

Rovner: So, tell us about this month’s patient — who he is, where he’s from, what kind of medical care he got. 

Meyer: OK, Julie, this is a story about high prices, confusing bills, and lack of price transparency for a very common procedure. The patient is Tom Contos, a 45-year-old health care consultant who lives in Chicago. Last spring, Tom noticed blood in his stool. He went to see his family physician at Northwestern Medicine. 

The doctor referred him for a diagnostic colonoscopy because of the bleeding and because of his family history of serious colon issues. Then in June, he went in for a colonoscopy at Northwestern Memorial Hospital, which is a big teaching hospital in downtown Chicago. 

A Northwestern gastroenterologist performed the procedure, which took less than an hour. He found and removed two polyps, which a pathologist later found were not cancerous. The gastroenterologist concluded that Tom’s rectal bleeding was due to a large hemorrhoid. 

Rovner: So, just to be clear, it’s screening colonoscopies, those for people with no symptoms, that are supposed to be free as preventive care under the Affordable Care Act. Diagnostic colonoscopies like this one can require a patient to meet deductible and copay requirements, right? That’s something important for people to know? 

Meyer: Yes. There’s a lot of confusion about this. I got a lot of comments on my Washington Post article that expressed confusion. Yes, diagnostic colonoscopies like Tom’s are done when there are symptoms like bleeding or pain. In contrast, screening colonoscopies are recommended starting at age 45, even when there are no symptoms, to prevent colon cancer or other serious conditions. 

The Affordable Care Act requires health insurers to cover screening colonoscopies at no cost to patients. But for a diagnostic colonoscopy, patients may have to pay a deductible and copayment, even though that procedure similarly can prevent colon cancer. It doesn’t— 

Rovner: It can be confusing. 

Meyer: It’s confusing, yeah. 

Rovner: So he has a procedure, which found some minor indications that were taken care of, and then, as we say, the bill came. How much was it? 

Meyer: Yeah, Northwestern’s total charge was a mind-boggling $19,000. Tom’s insurer, Aetna, had a negotiated rate with Northwestern of a still significant about $6,000. When he got his insurance explanation of benefit statement, he saw that he owed about $4,100, with the insurer paying about $2,000. 

He was bewildered because he had asked Northwestern for an estimate of how much he would owe in total and he was told that he would owe about $2,400. My outside billing expert said $4,100 is quite a high out-of-pocket bill, though not unusual for teaching hospitals. 

Rovner: And he was charged for two colonoscopies, right? 

Meyer: Yes. That was a major reason that the bill was so high. Northwestern billed him for two colonoscopies, which Tom did not understand, since he had only received one. It turns out that providers routinely bill for two procedures if the gastroenterologist removes and biopsies two polyps in two different ways during the same procedure. 

The second procedure is billed at a discounted rate. Now, this seems strange to laypeople, but this is how providers get paid for the extra work of removing two polyps rather than one. 

Rovner: Which, as you pointed out at the beginning, it’s not like this is a several-hour surgery. This is a fairly quick procedure. 

Meyer: That’s right. It’s at most an hour, often less than that. 

Rovner: So what happened eventually with the bill? 

Meyer: Well, Tom appealed the bill to Northwestern and Aetna and was told that it was correct. He had already paid about $2,400 of the nearly $4,100 he owed, but he told Northwestern that its bill was, quote-unquote, “ridiculously high” and he wasn’t going to pay the remaining $1,700 or so and that they could take him to collections. 

Northwestern said that’s what they were going to do, and Tom decided to no longer use Northwestern or its doctors in the future. 

Rovner: Although I assume he did pay the amount that they said he owed. 

Meyer: No, he said: Take me to collections. I’m not paying it. My credit is good, and — I won’t repeat some of the things that he said to them. 

Rovner: Thank you. This is a family podcast. How can others avoid falling into this trap? I mean, he got an estimate. He had an idea of what he was going to be charged, and yet he was still charged considerably more than that estimate. 

Meyer: Yeah, he’s a health care consultant, but a lot of people get confused by this process, including him taken by surprise. He only looked at the estimate after he had had the procedure but before he got the final bill. So, like a lot of people, he got confused and he didn’t proceed necessarily as efficiently as he might have. But that’s common and not surprising. 

Rovner: Even for somebody who’s basically in the health care payment business. 

Meyer: Yes, that’s correct. 

Rovner: So be vigilant. Is that basically the takeaway? 

Meyer: Well, how can you avoid falling in the same trap? Unfortunately, not easily. Patients needing a diagnostic colonoscopy should check out freestanding endoscopy centers or ambulatory surgery centers that aren’t associated with a hospital, because they can be cheaper and they can provide good quality of care. 

To price-shop ahead of time, patients can look at the hospital’s price website and their insurer’s cost estimator website to get a sense of how much a diagnostic colonoscopy could cost. They also can look up a so-called good faith estimate of the cash price, meaning the procedure could be cheaper if they pay cash, rather than going through insurance. 

Plus, there are free websites such as and for checking prices for colonoscopies and other procedures. Now, once they get a price estimate from the provider, there’s one more wrinkle. Patients should ask whether that price includes the extra services, if the gastroenterologist finds and has to remove and biopsy one or more polyps. At least 40% of colonoscopies do find polyps. 

Now, experts say it’s unfortunate that getting a diagnostic colonoscopy can be so expensive and confusing billing-wise, but don’t hesitate, because it can be a lifesaving procedure for many people. 

Rovner: All excellent advice. Harris Meyer, thank you so much. 

Meyer: Thank you, Julie. 

Rovner: OK, we are back, and 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 put the links in our show notes on your phone or other mobile device. Anna, why don’t you go first this week? 

Edney: I wanted to talk about one I wrote last month, and the headline is “.” I kind of wanted to put in one place talking about a lot of these contamination issues that have come up, but particularly also just show that, while the problems with products keep growing — one of them that I pointed out that’s new in this piece is dandruff shampoo containing benzene — the FDA is getting sort of slower on a lot of these things. They’re digging in, and they’re not trying to communicate to the public about the issues that have come up. They’ve had since last March of 2024 concerns brought to them about benzene and acne products. 

They’ve said nothing to the public. They just keep saying, We’re looking at it. And that’s very different from when this first kind of started happening on a larger scale, where it was like, boom, recalls. Now it’s just sort of this fight to maybe not have recalls. I don’t know what’s going on in their head. 

But there also are some issues in there with the tampons were found to contain a lot of heavy metals, FDA also slow-walking there. So I wanted to point out that piece I wrote if anybody missed it. 

Rovner: Yes. Thank you, Anna, on the “everything you thought might be safe is actually dangerous” beat. 

Edney: I’m the life of every party. 

Rovner: There you go. Joanne. 

Kenen: I’m not sure if this is an extra credit or a public service announcement, but there is a great piece in The Atlantic by Daniel Engber. Well, we all know there’s a ton of stomach bugs and norovirus going around, and it’s quite severe this year. And the headline is “,” and the answer is wash your hands with soap. 

But it’s a really well-written — it actually makes you laugh about stomach bugs. It’s a very well-written, good story. And no, for this bug, hand sanitizers don’t work. 

Rovner: Sandhya. 

Raman: My extra credit this week is called “,” and it’s by Giorgia Guglielmi for Nature. And it takes a look at — we had a revised definition of measuring and diagnosing obesity in the Lancet Diabetes & Endocrinology this week. 

So, instead of BMI [body mass index], which is weight- and height-linked, they’re suggesting a couple of alternatives: preclinical obesity, which is a person with extra body fat but their organs are still functioning normally, and clinical obesity, so when you have that excess body fat that it’s harming your organs. And there’s more in the piece on just different ways clinicians are looking at this globally. 

Rovner: Yeah, it’s really interesting because, obviously, every doctor says that BMI is a stupid and imprecise way to measure this, and then everybody uses BMI because, at the moment, it’s all we have. My extra credit this week is a Ñî¹óåú´«Ã½Ò•îl Health News story from Felice Freyer. It’s called “Can Medical Schools Funnel More Doctors into the Primary Care Pipeline?” and it’s about a problem I have been following for a while and which does not seem to be getting better. 

While the U.S. has opened lots of new medical schools over the past decade and has launched a raft of programs aimed at getting more graduating doctors to go into primary care, way too many are still pursuing specialty care instead. We have tried, as a society, free tuition and loan repayment programs, but it doesn’t seem that medical education debt is the biggest problem. 

We’ve also tried training doctors in more primary-care-centric locations, i.e. in community clinics rather than in hospitals, but that’s not made a huge dent, either. Rather, to quote one of the family medicine experts in the story: “It’s not the medical schools that are the problem; it’s the job. The job is too toxic.” 

In other words, it’s not really appealing to see too many patients for too little time and do tons of fighting with insurance companies and electronic medical records. Until we as a society start making primary care a lot more of a satisfying job, it’s not going to matter how much it pays. We’re still going to have a serious shortage. 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks again this week to our temporary production team, Taylor Cook and Lonnie Ro, as well as our editor, Emmarie Huetteman. 

As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me occasionally at X, , and increasingly at Bluesky, . Where are you guys hanging out these days? Anna? 

Edney: On X, , and then on Bluesky, . 

Rovner: Joanne. 

Kenen: I’m on Bluesky, , very occasionally on X still, . 

Rovner: Sandhya. 

Raman: On X, , and on Bluesky, . 

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