[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.] 

Mary Agnes Carey: Hello from Ñî¹óåú´«Ã½Ò•îl Health News and WAMU radio in Washington, D.C. Welcome to What the Health? I’m Mary Agnes Carey, managing editor of Ñî¹óåú´«Ã½Ò•îl Health News, filling in for Julie Rovner this week. And as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Friday, April 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’re joined via videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Joanne Kenen: Hi, everybody. 

Carey: And my Ñî¹óåú´«Ã½Ò•îl Health News colleague Emmarie Huetteman. 

Emmarie Huetteman: Hey there. 

Carey: Later in this episode, we’ll play Julie’s interview with immigration attorney Michelle Canero about the impact the Trump administration’s immigration policies are having on the medical workforce. But first, this week’s news — and there is plenty of it. 

On Thursday, President [Donald] Trump nominated Dr. Erica Schwartz to lead the Centers for Disease Control and Prevention. Schwartz, a vaccine supporter, served as a deputy surgeon general in President Trump’s first term, and during the coronavirus pandemic she ran the federal government’s drive-through testing program. She’s also a Navy officer and a retired rear admiral in the Commissioned Corps of the U.S. Public Health Service. Her appointment requires Senate confirmation. President Trump also announced other changes to the agency’s top leadership: Sean Slovenski, a health care industry executive, as the agency’s deputy director and chief operating officer; Dr. Jennifer Shuford, health commissioner for Texas, as deputy director and chief medical officer, and Dr. Sara Brenner, who briefly served as acting commissioner of the FDA [Food and Drug Administration], as a senior counselor to Department of Health and Human Services Secretary Robert F Kennedy Jr. So we’ve discussed previously on the podcast several times that the CDC has lacked a permanent director for most of the president’s second term. Will Dr. Schwartz, if confirmed, and the other members of this new leadership team make the difference? 

Huetteman: I think that we’ve seen a CDC that’s been in a protracted period of turmoil, and this is going to be an opportunity for maybe a shift in that. Dr. Schwartz would actually be the agency’s fourth leader in a little more than a year, and we’ve talked on the podcast about how naming someone who could fit the bill to lead the CDC was a difficult task facing the Trump administration. They needed someone who could support the MAHA [Make America Healthy Again] agenda while not embracing some of the more anti-vaccine views, and that person needed to be able to win Senate confirmation, which isn’t a given, even with this Republican-controlled Senate. 

Edney: And I think we’ve seen that there have been some people already in the MAHA coalition that have come out and been upset about this pick. So I think what that shows is a calculated decision by the administration to, kind of, as they’ve been doing for this year, is kind of not focus on the vaccine part of Secretary Kennedy’s agenda and to, as Emmarie said, try to get someone that can get through Senate confirmation. We’ve already seen the surgeon general nominee be held up in the Senate because she was not as strong on vaccines as I think some would have liked to see when she had her confirmation hearing. 

Kenen: So this happened late yesterday, and I’ve been traveling this week, but I did have a chance to talk to some public health people about her, and there was sort of this audible sigh of relief. The Senate is a very unpredictable place, and we live in very unpredictable times. At this point, my initial gut reaction is she’s got a pretty good chance of confirmation. The other thing, I think some of the other appointees, there’s a little bit more concern about, but what really matters is who is the face of the CDC, and she would be the face of the CDC. She would be in charge, and people like her. Also, this is an administration that has not had a lot of minorities, and she will be, she’s a Black woman. respected in her field. And that also is going to — she needs to be able to speak to all Americans about their health, and I think that people welcome that as well, both her credentials and her life experience. So, yeah, I think that MAHA is sort of in this funny moment now, because clearly Kennedy isn’t doing everything that people wanted or expected. And so we’ll sort of see how the — I think if he had his ideal CDC director, this, we can probably surmise that this would not, she would not be the first on his list. But there’s a certain amount of adaptation going on at the moment. So I think many, many people will be relieved to see somebody get through, confirmed pretty quickly. People can get held up for things that have absolutely nothing to do with the CDC or public health. The Senate has all sorts of peculiarities. But I think there’s probably going to be a desire to get this done pretty quickly. 

Carey: All right. Well, we’ll see what happens, and we will go back to the MAHA folks a little bit later in the podcast. But right now I want to shift to Capitol Hill. Thursday was a very big day on the Hill for HHS Secretary Kennedy. He kicked off a series of appearances before Congress. This week he’s testifying before three House committees before he heads over to the Senate next week. This is the first time that the secretary has visited some of these House panels, and while the purpose of the latest congressional visit is to talk about President Trump’s HHS budget request, this also was the first time that a lot of lawmakers ever had an opportunity to talk to Kennedy, and what they asked him sometimes deviated, maybe quite a bit, from that subject of federal funding. The topics included Medicaid fraud, measles outbreaks, the birth-dose recommendation for the hepatitis B vaccine, peptides, unaccompanied minors, and more — actually, much more when you look at the hearings from yesterday, and I’m sure that will also happen with today’s session. What stood out to you about Kennedy’s testimony this week? 

Edney: I think it was the mix of questions, and you sort of alluded to this, but they wanted, the members of Congress wanted to talk about so many things. And I feel like in the earlier hearing, which was in the House Ways and Means Committee, that it was, there was a lot of focus in the beginning on fraud, and that sort of surprised me, and then we saw maybe one or two questions on vaccines. And so I thought the mix of questions, the things that members were interested in, were really interesting. And it did — there were some fiery moments, but for his first time on the Hill in a while, for such a controversial Cabinet member, I thought they were pretty tame. 

Kenen: Yeah, I watched a fair amount of the morning. I did not see the afternoon, but I read about the afternoon, and I totally agree with Anna’s take. This administration and Kennedy did what this administration has been doing. They blame all problems on [former president Joe] Biden and the prior administration. And to be fair, Democrats, when they’re in power, they, I don’t think they do it quite to this extreme, but Democrats spend, when they have the chance, they blame things on Republicans. So that’s sort of Washington as usual. The emphasis on fraud has been a hallmark of this administration, particularly in health and social services. And you’ve seen, of course, in the way they’ve gone after blue states in particular. And a lot of their justification for the changes in Medicaid that are coming in the coming year are supposedly because of massive fraud and they’re cracking down. It was not dominated by vaccines, and I was watching Kennedy’s face really carefully. When he was asked about the first child to die of measles in Texas last year, and a Democrat asked him could the vaccine have saved her life, and you could sort of see him just, you just sort of watch his facial expressions, and he knew he had to say this, and he came out with the word “possibly,” and, which is a change. And then in the afternoon — where I did not, as I said, I did not watch the afternoon, but I read about it — he was much more certain. He was much stronger about the measles vaccine and said it’s, the measles vaccine, is safer than measles, which is a big signal shift there. 

Huetteman: It’s true, although I will point out, though, that he did stand by the decision to remove the recommendation for the birth dose of the hepatitis B vaccine when he was pressed on that. So it was, I agree it was a softening, I’d say. At least it wasn’t a dramatic turnaround from what he’d said or not said in the past. But for him, it was at least a softening. 

Kenen: In the hepatitis B recommendation, he said that the biggest threat to infection was at, through birth, at, through the mother, and if you test the mother, the baby is not at risk. And that’s partially true, and that is a significant factor to eliminate risk. It doesn’t — it minimizes risk. It does not eliminate risk. Babies can and have been infected in the first weeks of life in other ways. The recommendation was not to totally eliminate that vaccine. It was to postpone it. But there’s, public health, still believe that, in general, many public health leaders would still say that the vaccine at birth is the better way of doing it. 

Carey: The focus was, theoretically, on the budget request from the administration. Did the secretary shed any light on those priorities or their impacts? I was taken, I think in the afternoon hearing I read about various lawmakers, including Rosa DeLauro from Connecticut, who sort of just said: A CDC cut of 30%? We’re not gonna do that. And there were also some Republican members who jumped in to sort of say, I don’t think we’re going to do the cuts you envision. But did the secretary defend them? Did he bring any new clarity to them? 

Edney: I don’t feel like I gained any new clarity on it. I think to bring it back to Budget 101, I guess, is like when the president, when the administration, sends down their budget, I think a lot of people already assume it’s dead on arrival. And maybe even though Kennedy is there to talk about the budget, it does become this broader hearing, because they don’t get him on the Hill that often and people go there to talk about all kinds of things, and I think that he probably knew that he didn’t have to defend it in the same way, because it’s not going to happen. 

Carey: Sure. As they say, the president proposes and Congress disposes. But Joanne, you want to jump in? 

Kenen: Yeah, there’s something significant about this administration, which is Congress has repeatedly authorized more money for various health programs and science programs, and the administration doesn’t spend it, so that there’s a different dynamic. Traditionally, yes, Congress — the president proposes, Congress legislates, and then people go off and spend money. That’s what people like to do. And in this case, when Congress has, in a bipartisan way, differed with the administration and restored funding, it hasn’t all gone, those dollars haven’t gone out the door. So the entire sort of checks-and-balances system has been askew in terms of funding. I agree with everybody here. I do not think that Congress is going to accept these extreme cuts across the board in health care and health policy, in public health and science and NIH [the National Institutes of Health] and everything, but I don’t know what they’re actually going to spend at the end of the day. 

Carey: Emmarie, you wanted to jump in. 

Huetteman: Yeah, there was one striking exchange to me where the secretary acknowledged he wasn’t happy with the cuts that were proposed. I think those were his words. But he pretty quickly added, and neither is President Trump, and he framed it as a matter of making hard decisions when faced with federal budget shortfalls. 

Carey: All right. Well, we’ll keep watching this as it moves through Congress. Also during yesterday’s House Ways and Means hearing, some Democrats took issue with past statements from Secretary Kennedy and President Trump that linked Tylenol use during pregnancy to autism in children. released this week in JAMA Pediatrics found that the use of Tylenol by women during pregnancy was not associated with autism in their children. This nationwide study from Denmark followed more than one and a half million kids born between 1997 and 2002, including more than 31,000 who were exposed to Tylenol in the womb. in another medical journal examining community water fluoridation exposure from childhood to age 80 found no impact on IQ or brain function. Kennedy has claimed that fluoride in water has led to IQ loss in children. These studies clearly debunk medical claims that have gotten a lot of attention. Will these findings have an impact now? 

Kenen: I think we’ve seen over and over and over again that there are people who are very deeply wedded to certain beliefs, and new science, new research, does not deter them from those beliefs. We also see some people who are sort of in the middle, who are uncertain, and new findings can shift their beliefs, right? And then, of course, there’s a lot of — these are not new studies. I mean these are new studies but they are not the first of their kind. The reason we’ve been using fluoride for, what, 60 years now in the water. Tylenol has been around a long time. So is it going to change everybody’s belief? No. Is it going to perhaps slow the push to ban fluoridation? Perhaps. But I just don’t think we know, because we’re sort of on these dual-reality tracks regarding a lot of science in this country, where once people sort of buy into disinformation, they’re very, it’s very hard to change — or misinformation — it’s hard to change people’s minds. 

Edney: I do think, on the Tylenol front — I absolutely agree with what Joanne said overall. And I think on the Tylenol front that it’s possible that this study will give pediatricians something to give and talk about with parents that are asking. I think there still is some confusion among some people. It’s not a huge, I don’t think, widespread thing, but I think there are some new parents who are wondering. And if you are able to take this study that is published in 2026 — it just happened, it was after Trump made his statements — I think maybe that would give them something to talk about with their patients. 

Kenen: I agree with Anna. I think the Tylenol one is easier to change than some of the fluoridation stuff going on, partly because so many of us — and we should just say, it’s not just the Tylenol, the brand. It’s acetaminophen, which I’ve never pronounced right. I think those of us who have been pregnant, we’ve taken that in our life before and we don’t think of it as a big, dangerous, heavy prescription drug. I think we’ve, it’s something we feel comfortable with. And I think there’s also the counterinformation, which is, a fever in a pregnant woman can, a pregnant person can be dangerous to the fetus. So I think that one’s a little — and I don’t, also, I don’t think it’s as deep-rooted. The fluoridation stuff goes back decades, and the Tylenol thing is sort of new. And it might be, I’m not sure that the course of these arguments — I think that Tylenol is easier to counter than some other things, because partly just we do feel safe with it. 

Carey: All right. We’re going to take a quick break. We’ll be right back. 

We’re back and talking about how the Trump administration is managing the voters behind the Make America Healthy Again, or MAHA, movement, which helped President Trump win the 2024 election. My colleagues Stephanie Armour and Maia Rosenfeld wrote about the administration’s recent decision to give coke oven plants in the U.S. a one-year exemption from tougher environmental standards. And that was a move that angered some MAHA activists who wondered if the GOP is more beholden to industry than the MAHA agenda. President Trump, HHS Secretary Kennedy, and other top administration officials met recently at the White House with a group of MAHA leaders to calm concerns that the administration is moving too slowly on food policy changes, and they are concerned about the president’s recent support of the pesticide glyphosate. According to press reports, the MAHA folks seem to feel their concerns were heard during that session. But is this ongoing conflict between the president and this key political constituency, will it be one that keeps brewing as the midterm elections approach? 

Edney: Yes, 100%. I think it will continue to brew. I think that meeting was thrown together so quickly that some members of the MAHA movement who were invited couldn’t even make it. So it wasn’t exactly a long-planned, seemingly deep desire to fix everything. But it was, as you’ve said, an effort to kind of hear them out and make them feel heard. No one that I’ve talked to has said everything is fixed now. It’s more of a to-be-determined We will see what the administration will do moving forward, if they will listen to any of our plans — which we will not share with you, by the way — to make us happy. And I think that that’s going to continue. There’s a rally planned in front of the Supreme Court on glyphosate later this month where a lot of those people will be, and so I think that they’re upset and they’re stirring up, that concern is only going to get stirred up more. 

Carey: Emmarie. 

Huetteman: It’s a small thing, but our fellow podcast panelist Sheryl Stolberg at The New York Times during this White House meeting where President Trump was meeting with MAHA leaders, one of the leaders made a joke about how this is not a group that’s going to be, quote, “Team Diet Coke,” and the president apparently took that as a cue to press that Diet Coke button he famously has on his desk and summon a server who apparently brought him a Diet Coke. Supporters of MAHA have been clear that they want not just for the Trump administration to promote policies supporting priorities like healthy eating and removing food dyes, but also they want them to rein in or end policies they don’t support. And that weed-killer executive order, that really was a big example of that. The MAHA constituency made it clear that they felt betrayed by that order, and they’re going to have to do some work to walk that back. 

Carey: We’ll also see how, with their concerns about the new CDC director nominee, which they’re already voicing, we’ll see how that plays out. 

Kenen: No, I just think that we are, as we mentioned at the beginning, we’re seeing cracks, right? We’re seeing — none of us are privy to any conversations that President Trump has had privately with Secretary Kennedy. But his, Secretary Kennedy’s, public statements have been a little different than they were a few months ago. There’s certainly been reports that he’s been told to soft-pedal vaccines and talk about some of the things that there’s more unanimity across ideological and party lines. Healthier food — there’s debate about how to, whether, there’s debate about how Kennedy defines healthier food. But in general, should we eat healthier? Yes, we should eat healthier. Should our kids get more exercise? Yes, our kids should get more exercise. Do we have too much chronic disease? Yes, we have too much chronic disease. So they’re sort of this, trying to move a little bit more, sort of this sort of top line, very hazier agreement. But at the same time, the people who are sort of really the core of MAHA, as Kennedy has sort of created it or led it, there’s cracks there. 

Carey: All right, we’ll see. We’ll see where that goes. But let’s go ahead and move on to ACA enrollment. A found that 1 in 7 people who signed up for an Affordable Care Act plan failed to pay their first month’s premium. The analysis from Wakely consulting group found that nationally around 14% of those who enrolled in ACA plans didn’t pay their first bill for January coverage. Now we know the elimination of the enhanced ACA tax credits and higher premium costs led to lower enrollment in the ACA exchanges, with sign-ups for 2026 falling to 23 million from 24 million a year ago. But how do you interpret this finding that 14% of enrollees didn’t pay their January premium? Is it a sign of more trouble ahead? 

Edney: I think it could be a sign of more trouble ahead. Some — what we’re seeing is sticker shock. And there may be some people who are trying to deal with that and won’t be able to as the months go on. And so, yeah, I think it could mean that even more drop out, and that means more people lose coverage and are uninsured. 

Kenen: I think there was sort of a general, initial, misleading sigh of relief when in December, when the enrollment figures, the drop wasn’t as bad as some feared. But at the same time, people said: Wait a minute. This doesn’t really count. Signing up isn’t the same thing as staying covered. The drop in January was significant, we now know. And I agree with Anna. I think we don’t know how many more people will decide they can’t afford it. Or we don’t know whether the big drop is January. Probably a lot of it is, because you get that first bill. But can, will more people drop? Probably. We have no way of knowing how many. And it also depends on the economy, right? If more people lose jobs, right now it’s still pretty, kind of still pretty stable, but we don’t know what’s ahead. We don’t know what’s going to happen with the war. We don’t know many, many, many — we don’t know anything. So the future is mysterious. I would expect it to drop more. I don’t think, I don’t know whether this is the big drop or February will be just as bad. I suspect January will be the biggest. But who knows? It depends on other outside factors. 

Huetteman: We’re also seeing a drop-off in the kind of coverage that people are choosing. That analysis that you referenced, Mac, showed that there was a 17% drop in silver plan membership, with most of those folks switching to bronze plans, which, in other words, that means they switch to plans that have lower monthly premiums but they have higher deductibles. And that means that when you get sick, you owe more, in some cases much more, before your insurance starts picking up the tab. And I think really what this means is people are more exposed to the high charges for medical services, bigger bills when you get sick. I think that 

Kenen: I think that the Republicans were seen as having pushed back a lot of the health impacts of the so-called One Big Beautiful Bill and that it would be after the election. And I and others wrote: No, no, no, no, no. We’re going to see this playing out before the election. This is a really big political red flag, right? This is a lot more people becoming uninsured, which makes other people worried about their insurance and stability. So I think this is definitely going to — it may not be. There are other things going on in the world. Health care may not be the dominant theme in this year’s election. But yes, this is going to be, the off-year elections are going to be health care elections, like almost every one else has been for— 

Carey: Oh yeah. 

Kenen: —since the Garden of Eden, right? 

Carey: Absolutely, it’s a perennial. All right, we’ll keep our eye on that. That’s this week’s news. Now we’re going to play Julie’s interview with immigration attorney Michelle can arrow, and then we’ll be back with our extra credits. 

Julie Rovner: I am pleased to welcome to the podcast Michelle Canero. Michelle is an immigration attorney from Miami and a member of the board of Immigrants’ List, a bipartisan political action committee focused on immigration reform. Michelle, thanks for joining us. 

Michelle Canero: Thank you for having me. 

Rovner: So, we’ve talked a lot about immigration policy on this podcast over the past year, but I want to look at the big picture. How important to the U.S. health care system are people who originally come from other countries? 

Canero: I think the statistics speak for themselves. One in three residency positions can’t be filled by American graduates alone. That means 33% of these residency positions are being filled by immigrant workers. Twenty-seven percent of physicians are foreign-born. Twenty percent of hospital workers are immigrants. And, at least in Florida, a large percentage of our home health care workers happen to be immigrants. And we depend on this population heavily in the health care sector. 

Rovner: Now, we talk a lot about the Trump administration’s crackdown on illegal immigration, but we talk a little bit less about their sort of messing with the legal immigration system. And there’s a lot going on there, isn’t there? 

Canero: There is. And I think that the campaign talking points were illegal immigration but what we’re actually seeing is a little more sinister. I think that the goal of leadership at the head of DHS [the Department of Homeland Security] and DOS [the State Department], or really Stephen Miller, is pushing something called reverse migration, which is really not about limiting illegal immigration but reducing the immigrant population in the United States. And I think that’s where the real concern is and why you’re seeing these policies that directly affect legal immigrants. 

Rovner: We talk a lot about doctors and nurses and skilled, the top skilled, medical professionals who make up a large chunk of the United States health care workforce. We don’t talk as much about the sort of midlevel professional workers and the support staff. They’re also overwhelmingly immigrant, aren’t they? 

Canero: Yeah, and whether it’s your IT- and technical-knowledge-based workers in hospitals who facilitate all the technology — we rely on an immigrant workforce for a lot of the technology sector. And then you’ve got research professionals. A lot of clinical researchers, medical researchers, are foreign-born. So it’s not just about the doctors. It’s also the critical staff that keep the hospitals operating. And I’m from Florida. For us, it’s the home health care workers. We have an aging population, and a large percentage of the home health care workers, particularly in Florida, happen to be Haitians on TPS [temporary protected status] or people with asylum work authorizations. And when we lose that, our aging population is left with no resources, because that’s not something AI or technology can fix. You can’t turn someone over in a bed with a robot yet, and we’re probably decades away from that. 

Rovner: So what’s the last year been like for you and your clients? 

Canero: I think it’s a lot of uncertainty. A lot of these policies are percolating, and we’re assuming that they’ll be resolved in litigation, but the damage is being done in real time. So we’re seeing hospitals turning away from hiring foreign workers, because of the H-1B penalty now. The suspension of J-1 processing created backlogs. These visa bans that affect 75 countries on certain visas and 39 countries on others. You’ve got thousands of health care workers that are stuck outside the U.S. So what’s happening, really, is that hospitals and medical providers are just shutting down, and they’re cutting back services, and that means that there are less available services and resources for the same population and the same demand. People are waiting longer for doctor’s appointments. People are finding that they’re not able to get to the specialist that they need to get to in time. And so for us as practitioners, I think, we’re trying to navigate as best we can, but we’re just seeing a lot of people, employers that traditionally would rely on our services, give up and foreign workers looking to go elsewhere. 

Rovner: I noticed during the annual residency match in March that it worked out, I think, fairly well for most graduating medical students. But the big sort of sore thumb that stuck out were international medical graduates. That’s going to impact the pipeline going forward, isn’t it? 

Canero: From what I understand, it takes like seven to 15 years to get to that level, and we just don’t have the student body to meet the demand of residency positions. From my understanding, there’s a gap between American graduates and the demand for residents that’s usually filled by foreign workers. And if we don’t have those foreign workers, those residency positions just don’t get filled. And that becomes more expensive for hospitals, and that transfers to our medical bills. 

Rovner: And people assume that, Oh well this doesn’t impact me. But it really impacts all patients, doesn’t it? And I would think particularly those in rural areas, which are less desirable for U.S.-born and -trained medical professionals and tend to be overrepresented by immigrants. 

Canero: Yeah, I think a lot of the J-1 doctors and H-1B doctors are what facilitate, are working at, our veterans hospitals and our rural medical facilities. And what’s ending up happening is the very same people that this administration touts to support their interests are being forced to travel farther for specialists, right? If there isn’t an endocrinologist in your area, you may have to drive 100 miles to go see that specialist, and you may forgo necessary medical care because of the inconvenience or the cost. And I think that’s hitting at our health. 

Rovner: So you’re on the board of Immigrants’ List, which is working to change things politically. What’s one change that could really make a big difference in what we’re starting to see in terms of immigration and the health care workforce? 

Canero: Well, asking Congress to actually do something. It’s been a problem for decades. So I don’t really know, but I think there’s a couple of things, whether it’s just policymakers supporting our fight against some of these illegal policy changes in courts, organizations supporting us with amicus briefs. For example, there’s a lot of lawsuits challenging these visa bans and these adjudicative holds and the H-1B fine. The more support that the plaintiffs in the litigation get, the more likely we are to resolve that through the court system. And then I hope that there’s enough pressure from hospitals and organizations that have real dollars that impact these elected officials to get them to start seeing, Hey, we need to pass reasonable immigration reform to address some of the loopholes that this administration is using to cause chaos in the system, right? They’re able to do this because we have a gap. We allow them to terminate TPS. We don’t have a structure to ensure that a community that’s been on TPS for 20 years gets grandfathered into some sort of more stable visa. We don’t have a system that precludes the administration from just putting a hold or a visa ban on nationalities. So it’s something that Congress is going to have to step up and do something about. 

Rovner: What worries you most about sort of what’s going on with the immigration system and health care? What keeps you up at night? Obviously you, I know you work on more than just health care. 

Canero: I think my concern is that the American people aren’t seeing what’s happening, or they’re sort of turning a blind eye to it, and by the time it starts to actually impact them and they start asking, Wait, wait, wait. Why is this happening? I don’t understand, it’s going to be too late. Because it’s not hitting their pocket, because it’s not their suffering at this point, they’re not standing up and saying, Hey, this needs to stop, at the level that we need, opposition, to make it stop. And by the time it does hit their pocket and it does affect them directly, I think, it’ll be a little too late. I think people will be scared off from coming here, people that we needed will be gone, and to reverse the system is going to take decades. 

Rovner: Michelle Canero, thanks again. 

Canero: No, you’re very welcome. Thank you for your time. 

Carey: OK, we’re back. Now it’s time for our extra-credit segment, and that’s where we each recognize a story we read this week and we think that you should read it, too. Don’t worry if you miss it. We’ll post the links in our show notes. Joanne, why don’t you start us off this week? 

Kenen: Well, this is by Teddy Rosenbluth in The New York Times. The headline is “” This is one of those stories where you know exactly how it’s going to end in the first paragraph, and yet it was so compellingly and beautifully written that you kept reading until the last word. It is, as the headline suggested, a young man who is an expert on AI and cognitive science named Ben Riley discovered that his father had been lying about a controllable, treatable form of leukemia. He had denied treatment, he’d refused treatment, he had ignored his oncologist because he was relying on AI. And as we all know, AI has its up moments and its down moments. And he was getting incorrect information, distrusted the diagnosis, refused treatment, getting sicker and sicker and sicker as the oncologist and the family got increasingly desperate. And the son, Ben Riley, had, like, skills. He knew how to find scientific evidence, and his father just would not believe it. And by the time his father finally consented to treatment, it was too late, and he did die. And his father was a neuroscientist, a retired neuroscientist, but he found a neuroscience rabbit hole. 

Carey: That’s amazing. Anna, what’s your extra credit? 

Edney: Mine, I’m highlighting a story that I wrote in Bloomberg called “.” And this is, I wanted to dive into this policy that the FDA had implemented. The commissioner has long talked about and felt that perimenopausal and menopausal women were not getting access to the treatments that maybe they really needed, because there had been sort of this two-decade-old study that had showed there were some safety issues regarding breast cancer and cardiovascular disease, but the issue being that those studies had looked at older forms of the medication and also at women who were much older than those who might benefit from taking it. And so they, the agency, asked the companies to remove those warning labels, at least the strongest ones. And what we’ve seen, why — I wanted to dive into the numbers specifically. Bloomberg has some prescription data that was able to help me out here and just look at when this started rising. You could see that the prescriptions started going up around 2021. I feel like a lot of influencers, a lot of celebrities, were talking about this. And then in 2024 to 2025 when the FDA started talking about this, it really just goes, the prescription numbers just go straight up on the scale. And so there were about 32 million prescriptions written last year, which is a huge increase. And I just dove into some of this, some of the companies, what kind of drugs there are out there, and talked to some women who are benefiting but also, because of this pop, experiencing shortages, because the companies aren’t quite keeping up with the products. 

Carey: Wow, that sounds like an outstanding deep dive. Thank you. Emmarie. 

Huetteman: Yeah, my extra credit is from my colleague at Ñî¹óåú´«Ã½Ò•îl Health News who covers health technology. That’s Darius Tahir. The headline is “Your New Therapist: Chatty, Leaky, and Hardly Human.” The story looks at the proliferation of AI chatbot apps that offer mental health and emotional support, particularly the ones that market themselves as, quote-unquote, “therapy apps.” Darius counted 45 such apps in Apple’s App Store last month, and he uncovered in some cases that safety and privacy concerns existed, such as minimal age protections. Fifteen of the apps that he looked at said they could be downloaded by users who were only 4 years old. His story also explored the tension between the risks of sharing sensitive data and the interests of app developers and collecting that data for business purposes. It’s a good read. All right, 

Carey: All right. Thanks so much. My extra credit is from Politico, and it’s written by Alice Miranda Olstein, and she’s a frequent guest here on What the Health? The headline is, quote, “,” close quote. The headline kind of says it all. Alice writes that Nebraska is racing to implement Medicaid work requirements by May 1, and that’s eight months ahead of the national deadline that was set by the One Big Beautiful Bill Act. Nebraska state officials plan to do this without hiring additional staff, even as other health departments in other states prepare to bring in dozens, if not hundreds, of new employees. Alice writes that advocates for people on Medicaid fear that this rush timeline and lack of new staff will cause many problems for Medicaid beneficiaries who are just trying to meet those new work requirements. 

All right. That’s this week’s show. Thank you so much for listening. Thanks, as always, to our editor and panelist Emmarie Huetteman, to this week’s producer and engineer, Taylor Cook, and to my KFF colleague Richard Ho, who provided technical assistance. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us with your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, . Joanne, where can people find you these days? 

Kenen: and , @joannekenen. 

Carey: OK. Anna? 

Edney: and and , @annaedney. 

Carey: And Emmarie. 

Huetteman: You can find me on . 

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

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

Julie Rovner: Hello, 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 24, 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 videoconference by Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And my Ñî¹óåú´«Ã½Ò•îl Health News colleague Julie Appleby. 

Julie Appleby: Hi. 

Rovner: Later in this episode we’ll have the first of a two-part series marking the 60th anniversary of Medicare and Medicaid, which is July 30. Medicare historian and University of North Carolina professor Jonathan Oberlander takes us on a brief tour of the history of Medicare. Next week we’ll do the same with Medicaid. But first, this week’s news. 

So, we have talked a lot about the changes to Medicaid as a result of the Trump tax and spending law, but there are big changes coming to the Affordable Care Act, too, which is why I have asked my colleague Julie Appleby to join us this week. Julie, what can people who buy insurance from the ACA marketplaces expect for 2026? 

Appleby: Well, there’s a lot of changes. Let’s talk about premiums first, OK? So there’s a couple of things going on with premiums. It’s kind of a double whammy. So, on the one hand, insurers are asking for higher premiums next year to cover different things. So in the summer they put out their rates for the following year. So there’s been a lot of uncertainty this year, so that’s playing into it as well. But what they’re asking for is some money for rising medical and labor costs, the usual culprits, drug costs going up, that kind of thing. But they’re tacking on some extra percentages to deal with some of the policy changes advanced by the Trump administration and the Republican-controlled Congress. And one key factor is the uncertainty over whether Congress is going to extend those more generous covid-era tax subsidies. So we’re looking at premiums going up, and the ask right now, what they’re asking for, the median ask, is 15%, which is a lot higher. Last year when KFF did the same survey, it was 7%. So we’re getting premium increase requests of a fairly substantial amount. In fact, they say it’s about the highest in five years.  

And then on top of that, it’s still not clear what’s going to happen with those more generous subsidies. And if the more generous subsidies go away, if Congress does not reinstate them, there’ll be costs from that, and people could be paying maybe 75% more than they’re paying this year. And we could talk some more about that. But that’s kind of the double whammy we’re looking at, rising premiums and the potential that these more generous subsidies won’t be extended by Congress. 

Rovner: So there were some things that were specifically in that tax and spending bill that drive up premiums for the ACA, right? Besides not extending the additional subsidies. 

Appleby: Well, that’s the biggest piece of it, but yes. They’re tacking on about 4% of that 15% medium increase is related to the uncertainty. Well, they’re assuming that the tax credits will expire. It was not in the bill. Congress could still act. They have until the end of the year. They could extend those subsidies. So that’s about 4%. But one of the things that people haven’t really been talking about are tariffs, and some of the insurers are asking for 3% because they expect drug costs to go up. So there’s those things that are going on. And then there’s just sort of the uncertainty going forward for insurers about what’s going to happen with enrollment as a result of both these premium increases, and then looking a little bit further down the line, there are some changes in the tax and spending bill and some rules that are going to substantially reduce enrollment. 

So insurers are worried that the people who are going to sign up for coverage are the ones who are most motivated, and those are probably going to be the people who have some health problems. And the folks who aren’t as motivated are going to look at the prices and maybe the additional red tape and will drop out and leave them with a sicker and more expensive pool to cover. So all of that is factoring in with these premium rate increases that they’re trying to put together. Now remember, a lot of these insurers put in these premium increase requests before they knew the outcome of the tax and spending legislation. They could still modify them. 

Rovner: And Jessie, as Julie said, there’s still a chance that Republicans will change their minds on the increased subsidies and tack them onto something. And there’s a big bipartisan health bill on drug prices and other expiring programs that still could get done before the end of the year? Yes? 

Hellmann: There have been discussions about a bipartisan health bill, though the main author of it, Sen. Bill Cassidy, himself even seems kind of skeptical. I talked to him this week, and he’s like, It might happen, it might not. But there are a bunch of other health extenders that Congress will need to get to, like telehealth, some Medicare and Medicaid payment things. So there’s definitely something to attach it to. Republicans are not friendly to the ACA. As you mentioned, they made a bunch of changes to it in this tax and spending bill. So I think the people I talk to think it’s a long shot that they’re going to pass billions of dollars in a subsidy extension in this bill. Though there are Republicans who do care about this issue, like Sen. Lisa Murkowski of Alaska. She’s kind of been sounding the alarm on this. She thinks that Congress needs to do something to mitigate which could be very big premium increases for people. So there is some pressure there, but it doesn’t seem like the people who should be thinking about this right now have started thinking about it much yet. 

Rovner: One presumes they’ll start thinking about it when they start seeing these actual premium increases. I sound like a broken record, but we keep saying, the people who these premium increases are going to hit the hardest are voters in red states. 

Appleby: Last year, in 2024, 56% of ACA enrollees lived in Republican congressional districts and 76% were in states won by President [Donald] Trump. So I’ve got to think they’re thinking about it. When I did the reporting , I spoke with a couple of folks, and they said that some people in Congress are looking at maybe they can mess around or maybe they can do something with the subsidies that’s not keeping them as they are but might deal with a piece of it. For example, there is something called a subsidy cliff. So if you make more than 400% of the federal poverty level, you used to not get any subsidies. That would come back if they don’t extend this. And so 400% of the federal poverty level, you make a dollar more, you don’t get a subsidy. So this year — and this year will be the numbers that next year’s rates are based on — $62,600 for one person is 400% of the federal poverty level and $84,600 for a couple. So people are going to start getting, if they don’t extend the tax credits, they’re going to start getting notification about how much they owe for premiums next year. 

And this is going to be one of the first effects that people are going to see from all these changes in Washington, the tax and spending bill and the other things, when they get these premiums for January. And if they make even a dollar over that, they’re not going to get any subsidy at all. So what I’m told by some of my sources is that maybe they’re thinking about raising that cliff, maybe keeping the cliff but maybe moving it up a little bit to 500% or 600%. But it’s totally unclear. Like you all are saying, nothing may happen. We may go through Dec. 31 and nothing happens, but I’m hearing that they are maybe talking a little bit about that. 

Rovner: Alice. 

Ollstein: Yeah. And there’s a couple interesting dynamics that I think could influence the politics of this and what Congress feels motivated to do or not do. So, like Julie was saying, this would hit in January. And a lot of the stuff in the bill they just passed is designed to not hit until the midterms, but this would hit before the midterms. And so that’s got to be on their minds. And then, like you were saying, not only would this hit Republican voters the hardest, but a reason that’s more true today than it was the last time they took a round at the Affordable Care Act in 2017 is because all of these red states have expanded since then. You have a lot more enrollment, even in states that didn’t expand, and so, like we mentioned, are going to have a lot of Republican voters who get hit and have this sticker shock. And the party in power in Congress and the White House could be to blame. 

Rovner: Yeah. One of the things in 2017, there were, what, 12 million people who were buying coverage on the marketplaces. And now there’s 24 million people who are buying coverage on the marketplaces. So it’s a lot more people, just plain, in addition to a lot more people who are likely in some of these red states. So we will follow this closely. 

Meanwhile, the fallout continues as people find out more about the new tax and spending law. The Congressional Budget Office is out with on the bill as enacted. It’s now estimating that 10 million more people will be uninsured in 2034 as a result of the new law. That’s down from the 11.8 million estimate of the original Senate bill. That’s because the parliamentarian bounced the provisions that would’ve punished states using their own money to cover undocumented people. That was not allowed to be considered under the reconciliation procedure. 

We also have a brand-new poll from my colleagues here at KFF that find that more people know about the law than did before it passed, and it’s still unpopular. We’ll to those numbers so you can see just how unpopular it is. As we’ve discussed, lots of Republican senators and House members expressed concern about the impact the Medicaid cuts could have on rural hospitals in particular. So much so that a $50 billion fund was eventually added to the bill to offset roughly $155 billion in rural Medicaid cuts. Even more confusing, that $50 billion is likely to be distributed before some of the cuts begin — as you were just saying, Alice — and not necessarily to just rural areas. So is this $50 billion fund really just a big lobbying bonanza? 

Ollstein: Well, it’s certainly designed to function as softening the blow. But these are different things. The hospital could be propped up and stay open, but if no one has Medicaid to go there, that’s still a problem. And the money is sort of acknowledging that a bunch of people are going to lose their coverage, because it’s meant to give the hospital something to use for uncompensated care for people who have no coverage and come to the ER. But that still means that people who lost their insurance because of other provisions in the bill, they might not be going to their preventive care appointments that would avoid them having to go to the emergency room in the first place, which costs all of us more in the long run. So there’s a lot of skepticism about the efficacy of this. 

Rovner: Jessie, are you seeing the lobbying already begin for who’s going to get this $50 billion? 

Hellmann: Yeah, because the legislation leaves a lot of how the money will be handed out to the HHS [Department of Health and Human Services] secretary, and so that’s something that they’re going to start thinking about. It reminds me a lot of the provider relief fund that was set up during covid. And that didn’t go very well. There were lots of complaints that providers were getting the funding that didn’t need the funding, and the small safety net hospitals weren’t getting enough of the funding. So I’m wondering if they’re going to revisit how that went and try to learn any lessons from it. And then at the same time, like Alice said, this just isn’t a lot of money. It’s not going to offset some of the pain to rural providers that the bill has caused. 

Rovner: Yeah. Well, another piece that we will be watching. Meanwhile, the cuts to SNAP [Supplemental Nutrition Assistance Program] food benefits conflict with another stated goal of this administration, improving health by getting people to eat healthier food. Except, as we know, healthier food is often more expensive. Other than not letting people buy soda and candy with their SNAP cards, has the administration tried to address this contradiction at all? I’m seeing a lot of blank stares. I’m assuming that the answer to that is no. We’re hearing so much about food and unhealthy food, and we’re getting rid of seed oils and we’re getting rid of dyes, but at the same time, it’s the biggest cut ever to nutrition assistance, and yet nobody’s really talking about it, right? 

Appleby: Sounds like, I think, the states are really worried, obviously, because they’re going to have to make up the difference if they can. And so what other programs are they going to cut? So I’m sure they are talking with folks in Congress, but I don’t know how much leverage they’re going to have. Do you guys have any idea whether the states, is there anything else that they can do to try to get some of this funding? 

Rovner: There’s no — I’ve seen no indication. As we said, there’s already some buyer’s remorse on the health side. Last week we talked about [Sen.] Josh Hawley introducing legislation to restore some of the Medicaid cuts that he just voted for, but I haven’t seen anybody talking about restoring any of these nutrition assistance cuts or any of the other cuts, right? 

Appleby: Right. And from what I’ve read, the SNAP cuts won’t fully take effect until after the midterm elections. So maybe we’re just not hearing about it as much because it hasn’t really hit home yet. People are still trying to figure out: What does all this mean? 

Rovner: Well, one thing that has hit home yet, I’ve wanted for a while to highlight what some of the changes to immigration policy are going to mean for health care. It’s not just ending legal status for people who came and have lived in the U.S. legally for years, or reinterpreting, again, the 1996 welfare law to declare ineligible for Medicaid and other programs many legal immigrants who are not yet permanent residents but who have been getting benefits because they had been made legally eligible for them by Congress and the president. One of the big changes to policy came to light last week when it was revealed that immigration officials are now being given access to Medicaid enrollment information, including people’s physical addresses. Why is this such a big deal? Alice, you’ve been following this whole immigration and health care issue, right? 

Ollstein: Yes. Experts are warning that this is very dangerous from a public health perspective. If you deter people from physically wanting to visit a clinic or a doctor out of fear of ICE [Immigration and Customs Enforcement] enforcement there, which we’ve already seen — we’ve already seen ICE try to barge into hospitals and seize people. And so fear of that is keeping people away from their appointments. That makes it harder to manage chronic illnesses. That makes it harder to manage infectious diseases, which obviously impacts the whole community and the whole society. We all bear those costs. We live in an interconnected world. What impacts part of the population impacts the rest of the population. 

And so what you mentioned about the Medicaid data, as well, deters people who are perfectly eligible, who are not undocumented, who have legal status, who are eligible for Medicaid. It deters them from enrolling, which again deters people from using that health care and keeping their conditions in check. And so there’s a lot of concern about how this could play out and how long the effect could last, because there are studies showing that policies from the first Trump administration were still deterring immigrants from enrolling even after they were lifted by the Biden administration. 

Rovner: And we should point out that this whole address thing is a big issue because, as you say, there, maybe, there are a lot of families where there are people who live there who are perfectly, as you say, perfectly eligible. You’re not eligible for Medicaid if you’re not here legally. But they may live in a family, in a household with people who are not here with documentation, and they’re afraid now that if they have their addresses, that ICE is going to come knocking at their door to get, if not them, then their relatives or people who are staying with them. 

Appleby: Yeah. And I think it’s also affecting employment. So nursing homes are already saying that they’re losing some people who are losing their protected status or this or that. So they’re losing employees. Some of them are reporting, from what I’ve read, that they are getting fewer applicants for jobs. This is going to make it even tougher. Many of them already have staffing issues, and the nursing home industry has said, Hey, how come we’re not getting any special consideration? Like maybe some of the farmers or other places are supposedly getting, but I don’t know if that’s actually happening. But why aren’t they being considered and why are they losing some of their workers who are here under protected status, which they’re going to lose? And some of them may also be undocumented — I don’t know. But that’s just the nursing homes. Think of all the people around the country who need help in their homes, and maybe they’re taking care of elderly parents and they hire people, and some of those people may not be documented. And that’s a vast number of folks that we’re never going to hear about, but if they start losing their caregivers as well, I think that’s going to be a big impact as we go forward. 

Rovner: And it’s also skilled health workers who are here on visas who are immigrants. 

Appleby: Right. 

Rovner: In rural areas in particular, doctors and nurses are usually people who have been recruited from other countries because there are not enough people or not health professionals living in those rural areas. The knock-on effect of this, I think, is bigger than anybody has really sort of looked at yet. 

Ollstein: Absolutely. States have even been debating and in some cases passing legislation to make it easier for foreign medical workers to come practice here, making it so that they don’t have to redo their residency if they already did their residency somewhere abroad, things like that, because there’s such shortages right now, especially in primary care and maternal care and a lot of different areas. 

Rovner: Yeah. This is another area that I think we’re only just beginning to see the impact of. Well, there is also news this week in Trump administration cuts that are not from the budget bill. from the Congressional Budget Office that’s separate from the latest budget reconciliation estimate, analysts said that the Trump administration’s proposed cuts to the budgets of the National Institutes of Health and the Food and Drug Administration could reduce the number of new drugs coming to market. That would not only mean fewer new treatments and cures but also a hit to the economy. And apparently it doesn’t even take into account the uncertainty that’s making many researchers consider offers to decamp to Canada or Europe or other countries. There’s a real multiplier effect here on what’s a big part of U.S. innovation. 

Hellmann: I’ve been talking to people on the Hill about this who traditionally have been big supporters of the NIH and authorizing and appropriating increases for the NIH every year. And they are still kind of playing a little coy. The White House is suggesting a budget cut at the NIH of 40%, which would be massive. It’s so massive that the CBO report was like: We cannot estimate the impact of this. We’re going to estimate a smaller hypothetical. Because they just can’t. 

And so I think it’ll be interesting to see how it plays out in the appropriations process. You do have senators who are more publicly concerned about it, like Sen. Susan Collins of Maine, who obviously is on the Appropriations Committee. So we might see a situation where Congress ignores the budget request. That usually happens, but these are weird times. And so I think there are questions about, even if they do, if Congress does proceed as normal and appropriate the money that they typically do for NIH, what is the administration going to do with it? They’ve already signaled that they’re fine not spending money that has been appropriated by Congress. And so I think that there’s a big question about that. 

Rovner: At some point, this has to come to a head. We’ve been — as I say, I feel like a broken record on this. We talk about it a lot, that this is money that’s been appropriated by Congress and signed by the president and that we keep hearing that people, particularly at NIH, are not being allowed, for one reason or another, to send out. This is technically illegal impoundment. And at some point it comes to a head. We know that Russ Vought, the head of the Office of Management Budget, thinks that the anti-impoundment law is illegal and that he can just ignore it. And that’s a lot of what’s happening right now. I’m still surprised that it’s the end of July and Congress is going out for the August recess — and Jessie, I know you’re talking to people and they’re playing coy — that they haven’t jumped up and down yet. The NIH in particular has been such a bipartisanly supported entity. If you’ve ever been around the campus in Bethesda, all of the buildings are named after various appropriators of both parties. This is something that is really dear to Congress, and yet they are just basically sitting there holding their tongues. At some point, won’t it stop? 

Hellmann: I think maybe they’re hoping to say something through whatever legislation that they come out with, whatever spending legislation. But, yeah, they’re not being very forceful about it. And I think people are obviously just very afraid of making the Trump administration angry. Lisa Murkowski of Alaska has said this, like she kind of fears the repercussions of making the president mad. And he’s on this spending-cut spree. So I definitely expected more anger, especially the bipartisan history of the NIH has lasted so long. It’s kind of a weird thing to see happen. 

Rovner: Yeah. Of all the things that I didn’t expect to see happen this year, that has to be the thing that I most didn’t expect to see happen this year, which was basically an administration just stopping funding research and Congress basically sitting back and letting it happen. It is still sort of boggling to my mind. Well, we also learned this week about hospitals stopping gender-affirming care of all kinds for minors, under increasing pressure from the administration. And we’re not just talking about red states anymore. Children’s hospitals in California and here in Washington, D.C., have now announced they won’t be offering the care anymore. Wasn’t it just a few months ago when people were moving from red states to blue states to get their kids care? Now what are they going to be able to do? 

Ollstein: I think a lot of what we’re seeing play out in the gender-affirming care fight, it reminds me of the abortion rights fight. There are a lot of themes about the formal health care system being very, very risk-averse. And so rather than test the limits of the law, rather than continuing to provide services while things are still pingponging back and forth in courts, which is the case, they’re saying, just out of caution, We’re just going to stop altogether. And that is cutting off a lot of families from care that they were relying on. And there’s a lot of concern about the physical and mental health impacts on — again, this is very small compared to the general population of trans kids — but it’s going to hit a lot of people. And yeah, like you said, this is happening in blue states as well. There’s sort of nowhere for them to go. 

Rovner: Yeah. We’re going to see how this one also plays out. Well, turning to abortion, we talked last week about how a federal appeals court upheld a West Virginia law aimed at banning the abortion pill mifepristone. And I wondered why we weren’t hearing more from the drug industry about the dangers of state-by-state undermining of the FDA. And lo and behold, here come the drugmakers. In comments letters to the FDA, more than 50 biotech leaders and investors are urging the agency to disregard a controversial study from the anti-abortion think tank the Ethics and Public Policy Center that officials are citing as a reason to reopen consideration of the drug’s approval. Alice, remind us what this study is and why people are so upset about it. 

Ollstein: So it’s not a study, first of all. Even its supporters in the anti-abortion movement admitted, in private in a Zoom meeting that I obtained access to, that it is not a study. This is an analysis that they created. They are not disclosing the dataset that it is based on. It did not go through peer review. And so they are citing their own sort of white-paper analysis put out by an explicitly anti-abortion think tank to argue that abortion pills are more dangerous than previously known or that the FDA has previously acknowledged. There’s been a lot of fact checks and debunks of some of their main points that we’ve been through on this podcast also before. The Washington Post did if people want to look that up. But suffice it to say that that has not deterred members of Congress from citing this and to pressure the FDA. 

And now you have the FDA sort of promising to do a review. If you look at the exact wording of what [FDA Commissioner Marty] Makary said, I’m not sure. He said something like, Like we monitor the safety of all drugs, we’re going to blah, blah, blah. And so it’s unclear if there’s anything specific going on. But the threat that there could be, like you said, is really shaking up the drugmaking industry. And you’re hearing a lot of the same alarms that we heard from the pharmaceutical industry when this was before the Supreme Court, when they were afraid the Supreme Court would second-guess the FDA’s judgment and reimpose restrictions on mifepristone. And they’re saying, Look, if we can’t count on this being a process that just takes place based on the science and not politics and not courts coming in 25 years later and saying actually no, then why would we invest so much money in developing drugs if we can’t even count on the rules being fair and staying the same? 

Rovner: Yeah. We will see how this goes. I was surprised, though. We know that that Texas case that the Supreme Court managed to not reach the point of, because the plaintiffs didn’t have standing, is still alive elsewhere. But I didn’t realize that this other case was still sort of chugging along. So we’ll see when the Supreme Court gets another bite at it. Meanwhile, the fight over funding for Planned Parenthood — whose Medicaid eligibility, at least for one year, was canceled by the new budget law — continues in court. This week a judge in Massachusetts gave the group a partial win by blocking the defunding for some smaller clinics and those that don’t perform abortions, but that ruling replaced a more blanket delay on the defunding. So many clinics are now having their funding stopped while the court fight continues. Alice, what’s the impact here of these Planned Parenthood clinics closing down? It’s not just abortion that we’re talking about. In fact, it’s not even primarily abortion that we’re talking about. 

Ollstein: Absolutely. So this is one, it’s set to hit a lot of clinics in states where abortion is legal. And so these are the clinics that are serving a lot of people traveling from red states. And so there’s already an issue with wait times, and this is set to make it worse. But that’s just for abortion. Like you said, this is also set to hit a bunch of clinics in states where abortion is illegal and where these clinics are only providing other services, like birth control, like STI [sexually transmitted infection] testing. And at the same time we’re having a lot of other funding frozen, and so this could really be tough for some of these areas where there aren’t a lot of providers, and especially there are not a lot of providers who accept Medicaid. 

Rovner: Meanwhile, a number of states are passing conscience laws that let health professionals opt out of things like doing abortions or providing gender-affirming care if they violate their beliefs. Well, in Tennessee now we have a story of a pregnant woman who says her doctor refused to provide her with prenatal care, because she’s not married to her partner of 15 years. She said at a congressional town hall that her doctor said her marital status violated his Christian beliefs, and he’s apparently protected by the new Tennessee state law called the Medical Ethics Defense Act. I’ve heard of doctors refusing to prescribe birth control for unmarried women, but this is a new one to me, and I’ve been doing this for a very long time. Are these just unintended consequences of these things that maybe state lawmakers didn’t think a lot about? Or are they OK with doctors saying, We’re not going to provide you with prenatal care if you’re pregnant and not married? 

Ollstein: So one, as we just said, we’re in a situation where there is such a shortage of providers and such a shortage of providers who accept certain coverage that being turned away by one place, you might not be able to get an appointment somewhere else, depending where you live. And so this isn’t just an issue of, Oh, well, just don’t go to that doctor who believes that. People have very limited choices in a lot of circumstances. But I— 

Rovner: Apparently this woman in Tennessee said she’s having to go to Virginia to get her prenatal care. 

Ollstein: Well, exactly. Yeah. Exactly. This isn’t like people have tons of options. And also this is an example of a slippery slope, of if you allow people to be able to refuse service for this reason, for that reason, what else could happen? And some states have more legal protections for things like marital status, and some do not. And so it’s worth thinking through what could be sort of the next wave. 

Rovner: Well, we’re certainly going to see what the outcome of this could be. Well, before we end our news segment this week, I want to give a shoutout to tennis legend Venus Williams, who at age 45 won a singles match at a professional tournament here in Washington this week and said in her post-match interview that she came back to playing because she needed the pro tour’s health insurance to take care of several chronic conditions that she has. So see, even rich athletes need their health insurance. All right. That is this week’s news. Now we will play my interview with Medicare historian Jonathan Oberlander, and then we will come back and do our extra credits. 

I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. Jon, welcome to “What the Health?” 

Jonathan Oberlander: Great to see you, Julie. 

Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here? 

Oberlander: Wow. So let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete. And the problem is, as you know very well, they haven’t been added to all that much. And here we have a population, and all of us know as we get older, we generally don’t get healthier. I wish it was true, but it’s not. Older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else. And that may be an individual private plan that they purchase called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare. 

Some low-income Medicare beneficiaries have Medicaid as well as Medicare and they are dual-eligible. Some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure— 

Rovner: We’ll get to. 

Oberlander: —we’ll have a lot to say. So the bottom line, though, is Medicare has grown. It has, what, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace. 

Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve? 

Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call a single-payer, federal-government-run program for everybody, they trimmed their ambitions down to, initially, just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition and the American Medical Association and charges of socialized medicine, all things that are really throwing a wrench into plans for national health insurance. It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enact it. And there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of, how do you enact government health insurance in the United States? You pick a more sympathetic population. 

Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age, and that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65, before Medicare, was around 50%. Not 15 but five zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage. 

Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by? 

Oberlander: So in terms of populations in 1972, Medicare added coverage for persons who have end-stage renal disease, so people who need dialysis no matter what the age. It’s a lifesaving technology. They can qualify for Medicare. It didn’t really make sense to add it to Medicare — it’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance. For a couple of years they qualify for Medicare as well and are a very important part in the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody. 

In terms of benefits, the benefit package has been remarkably stable, for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited. 

Rovner: So Medicare is also the biggest payer in the nation’s health care system and for decades set the standard in how private insurance covered and paid for health care. So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion? 

Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all, through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans and it’s changed Medicare politics. 

I don’t think Medicare Advantage is going anywhere. I think the question is, how big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is — given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government, and it’s losing a lot of money on Medicare Advantage, and it’s never saved money — is there going to come a point where they actually clamp down? There’ve been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore. So I think it’s an open question about, how big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two. 

Rovner: Thank you so much. 

Oberlander: Oh, thanks for having me. It was great to see you. 

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

Appleby: Yeah. I found this story on NPR quite interesting. It’s maybe something that a lot of us have thought about, but it just added a lot of numbers to the question of how many chemicals are in our beauty products — basically, the makeup we use, the lotions, our hairspray, the stuff that happens at the salon, that kind of thing. And it’s called “.” And it was written by Rachel Treisman. Basically it says that the average American adult uses about 12 personal care products a day, resulting in exposure to about 168 chemicals, which can include things like formaldehyde, mercury, asbestos, etc., etc. OK, so that’s interesting. But it also talks about how the European Union has banned more than 2,000 chemicals, basically, but the FDA puts limits on only about a dozen. 

So this has caused four Democratic lawmakers to introduce a package of legislation, actually they’re calling the Safer Beauty Bill Package, and it’s four bills. And basically one of them would ban two entire classes of chemicals, phthalates and formaldehyde-releasing chemicals. And it also calls for some other things as well, which they say hasn’t been done and needs to be looked at. So I just thought it was an interesting thing that pulled together a lot of data from various sources and talked about this package of bills and whether or not it might make a difference in terms of looking at some of these chemicals in the products we use all the time and requiring a little bit more transparency about that. It’s a step. I don’t know if it’s going to resolve everybody’s concerns about this, but I just thought it was an interesting little piece looking at that topic. 

Rovner: It’s worth remembering that the FDA’s governing statute is actually called the Food, Drug, and Cosmetic Act. 

Appleby: That’s right. 

Rovner: The cosmetics often gets very short shrift in that whole thing. Alice, why don’t you go next? 

Ollstein: Yeah. So I have a piece from The Associated Press. It’s called “.” And so this really gets at something we’ve been talking about on the podcast, where the administration is really fixated on a few kind of superficial food health things like colored dyes in food and frying something in beef tallow instead of vegetable oil. But something fried in beef tallow is still unhealthy. Froot Loops without the color dye are still unhealthy. And these meals that he is promoting as a service for Medicare and Medicaid enrollees are unhealthy. So this article is about how they do have chemical additives, they are high in sodium and sugar and saturated fats, and so it’s not in sort of keeping with the overall MAHA [Make America Healthy Again] message. But in a way it kind of is. 

Rovner: From the oops file. Jessie. 

Hellmann: My extra credit is from my colleague Ariel Cohen at Roll Call. It’s called “.” She did a story about something that kind of, I think, flew under the radar this week. The Trump administration is starting to make good on its promise to look at SSRIs [selective serotonin reuptake inhibitors], and the panel was very much full of skeptics of SSRIs who sought to undermine the confidence in using them while pregnant. And Marty Makary himself, FDA commissioner, claimed it could cause birth defects and other fetal harm. That was a statement that was echoed by many of the panelists. There was only one panelist who talked about the benefits of SSRIs in pregnant people who need them, the risks of postpartum depression to both the mom and the baby. And so I think this is definitely something to keep an eye on, is it looks like they’re going to keep looking more at this and raising questions about SSRIs without having much of a nuanced conversation about it. 

Rovner: Yeah. I did see something from ACOG, from the American College of Obstetricians and Gynecologists, this week pushing back very hard on the anti-SSRI-during-pregnancy push. So we’ll see how that one goes, too. My extra credit this week is from my Ñî¹óåú´«Ã½Ò•îl Health News colleague Katheryn Houghton, and it’s called “” And it’s about something that didn’t really come up during the whole Medicaid debate, the fact that if Republicans really want people to go to work, well, then maybe they shouldn’t take away their health insurance if they get a small raise or a few extra hours. The subject of this story, only identified as James, technically makes about $50 a week too much to stay on Medicaid, but he otherwise can’t afford his six prescription medications and he can’t afford the care that he needs through even a subsidized Affordable Care Act plan, or his employer’s plan, either. 

The point of the ACA was to make coverage seamless so that as you earn more, you can still afford coverage even if you’re not on Medicaid anymore. But obviously that isn’t happening for everyone. Quoting from the story: “‘I don’t want to be a fraud. I don’t want to die,’ James said. ‘Those shouldn’t be the only two options.’” Yet for a lot of people they are. It’s not great, and it’s not something that’s currently being addressed by policymakers. 

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 a review. That helps other people find us, too. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, , or on Bluesky, . Where are you folks hanging on social media these days? Jessie? 

Hellmann: I’m @jessiehellmann on and . 

Rovner: Alice. 

Ollstein: on X and on Bluesky. 

Rovner: Julie. 

Appleby: on X. 

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

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

Mary Agnes Carey: Hello from Ñî¹óåú´«Ã½Ò•îl Health News and WAMU radio in Washington, D.C. Welcome to What the Health? I’m Mary Agnes Carey, managing editor of Ñî¹óåú´«Ã½Ò•îl Health News, filling in for Julie Rovner this week. And as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Friday, April 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’re joined via videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Joanne Kenen: Hi, everybody. 

Carey: And my Ñî¹óåú´«Ã½Ò•îl Health News colleague Emmarie Huetteman. 

Emmarie Huetteman: Hey there. 

Carey: Later in this episode, we’ll play Julie’s interview with immigration attorney Michelle Canero about the impact the Trump administration’s immigration policies are having on the medical workforce. But first, this week’s news — and there is plenty of it. 

On Thursday, President [Donald] Trump nominated Dr. Erica Schwartz to lead the Centers for Disease Control and Prevention. Schwartz, a vaccine supporter, served as a deputy surgeon general in President Trump’s first term, and during the coronavirus pandemic she ran the federal government’s drive-through testing program. She’s also a Navy officer and a retired rear admiral in the Commissioned Corps of the U.S. Public Health Service. Her appointment requires Senate confirmation. President Trump also announced other changes to the agency’s top leadership: Sean Slovenski, a health care industry executive, as the agency’s deputy director and chief operating officer; Dr. Jennifer Shuford, health commissioner for Texas, as deputy director and chief medical officer, and Dr. Sara Brenner, who briefly served as acting commissioner of the FDA [Food and Drug Administration], as a senior counselor to Department of Health and Human Services Secretary Robert F Kennedy Jr. So we’ve discussed previously on the podcast several times that the CDC has lacked a permanent director for most of the president’s second term. Will Dr. Schwartz, if confirmed, and the other members of this new leadership team make the difference? 

Huetteman: I think that we’ve seen a CDC that’s been in a protracted period of turmoil, and this is going to be an opportunity for maybe a shift in that. Dr. Schwartz would actually be the agency’s fourth leader in a little more than a year, and we’ve talked on the podcast about how naming someone who could fit the bill to lead the CDC was a difficult task facing the Trump administration. They needed someone who could support the MAHA [Make America Healthy Again] agenda while not embracing some of the more anti-vaccine views, and that person needed to be able to win Senate confirmation, which isn’t a given, even with this Republican-controlled Senate. 

Edney: And I think we’ve seen that there have been some people already in the MAHA coalition that have come out and been upset about this pick. So I think what that shows is a calculated decision by the administration to, kind of, as they’ve been doing for this year, is kind of not focus on the vaccine part of Secretary Kennedy’s agenda and to, as Emmarie said, try to get someone that can get through Senate confirmation. We’ve already seen the surgeon general nominee be held up in the Senate because she was not as strong on vaccines as I think some would have liked to see when she had her confirmation hearing. 

Kenen: So this happened late yesterday, and I’ve been traveling this week, but I did have a chance to talk to some public health people about her, and there was sort of this audible sigh of relief. The Senate is a very unpredictable place, and we live in very unpredictable times. At this point, my initial gut reaction is she’s got a pretty good chance of confirmation. The other thing, I think some of the other appointees, there’s a little bit more concern about, but what really matters is who is the face of the CDC, and she would be the face of the CDC. She would be in charge, and people like her. Also, this is an administration that has not had a lot of minorities, and she will be, she’s a Black woman. respected in her field. And that also is going to — she needs to be able to speak to all Americans about their health, and I think that people welcome that as well, both her credentials and her life experience. So, yeah, I think that MAHA is sort of in this funny moment now, because clearly Kennedy isn’t doing everything that people wanted or expected. And so we’ll sort of see how the — I think if he had his ideal CDC director, this, we can probably surmise that this would not, she would not be the first on his list. But there’s a certain amount of adaptation going on at the moment. So I think many, many people will be relieved to see somebody get through, confirmed pretty quickly. People can get held up for things that have absolutely nothing to do with the CDC or public health. The Senate has all sorts of peculiarities. But I think there’s probably going to be a desire to get this done pretty quickly. 

Carey: All right. Well, we’ll see what happens, and we will go back to the MAHA folks a little bit later in the podcast. But right now I want to shift to Capitol Hill. Thursday was a very big day on the Hill for HHS Secretary Kennedy. He kicked off a series of appearances before Congress. This week he’s testifying before three House committees before he heads over to the Senate next week. This is the first time that the secretary has visited some of these House panels, and while the purpose of the latest congressional visit is to talk about President Trump’s HHS budget request, this also was the first time that a lot of lawmakers ever had an opportunity to talk to Kennedy, and what they asked him sometimes deviated, maybe quite a bit, from that subject of federal funding. The topics included Medicaid fraud, measles outbreaks, the birth-dose recommendation for the hepatitis B vaccine, peptides, unaccompanied minors, and more — actually, much more when you look at the hearings from yesterday, and I’m sure that will also happen with today’s session. What stood out to you about Kennedy’s testimony this week? 

Edney: I think it was the mix of questions, and you sort of alluded to this, but they wanted, the members of Congress wanted to talk about so many things. And I feel like in the earlier hearing, which was in the House Ways and Means Committee, that it was, there was a lot of focus in the beginning on fraud, and that sort of surprised me, and then we saw maybe one or two questions on vaccines. And so I thought the mix of questions, the things that members were interested in, were really interesting. And it did — there were some fiery moments, but for his first time on the Hill in a while, for such a controversial Cabinet member, I thought they were pretty tame. 

Kenen: Yeah, I watched a fair amount of the morning. I did not see the afternoon, but I read about the afternoon, and I totally agree with Anna’s take. This administration and Kennedy did what this administration has been doing. They blame all problems on [former president Joe] Biden and the prior administration. And to be fair, Democrats, when they’re in power, they, I don’t think they do it quite to this extreme, but Democrats spend, when they have the chance, they blame things on Republicans. So that’s sort of Washington as usual. The emphasis on fraud has been a hallmark of this administration, particularly in health and social services. And you’ve seen, of course, in the way they’ve gone after blue states in particular. And a lot of their justification for the changes in Medicaid that are coming in the coming year are supposedly because of massive fraud and they’re cracking down. It was not dominated by vaccines, and I was watching Kennedy’s face really carefully. When he was asked about the first child to die of measles in Texas last year, and a Democrat asked him could the vaccine have saved her life, and you could sort of see him just, you just sort of watch his facial expressions, and he knew he had to say this, and he came out with the word “possibly,” and, which is a change. And then in the afternoon — where I did not, as I said, I did not watch the afternoon, but I read about it — he was much more certain. He was much stronger about the measles vaccine and said it’s, the measles vaccine, is safer than measles, which is a big signal shift there. 

Huetteman: It’s true, although I will point out, though, that he did stand by the decision to remove the recommendation for the birth dose of the hepatitis B vaccine when he was pressed on that. So it was, I agree it was a softening, I’d say. At least it wasn’t a dramatic turnaround from what he’d said or not said in the past. But for him, it was at least a softening. 

Kenen: In the hepatitis B recommendation, he said that the biggest threat to infection was at, through birth, at, through the mother, and if you test the mother, the baby is not at risk. And that’s partially true, and that is a significant factor to eliminate risk. It doesn’t — it minimizes risk. It does not eliminate risk. Babies can and have been infected in the first weeks of life in other ways. The recommendation was not to totally eliminate that vaccine. It was to postpone it. But there’s, public health, still believe that, in general, many public health leaders would still say that the vaccine at birth is the better way of doing it. 

Carey: The focus was, theoretically, on the budget request from the administration. Did the secretary shed any light on those priorities or their impacts? I was taken, I think in the afternoon hearing I read about various lawmakers, including Rosa DeLauro from Connecticut, who sort of just said: A CDC cut of 30%? We’re not gonna do that. And there were also some Republican members who jumped in to sort of say, I don’t think we’re going to do the cuts you envision. But did the secretary defend them? Did he bring any new clarity to them? 

Edney: I don’t feel like I gained any new clarity on it. I think to bring it back to Budget 101, I guess, is like when the president, when the administration, sends down their budget, I think a lot of people already assume it’s dead on arrival. And maybe even though Kennedy is there to talk about the budget, it does become this broader hearing, because they don’t get him on the Hill that often and people go there to talk about all kinds of things, and I think that he probably knew that he didn’t have to defend it in the same way, because it’s not going to happen. 

Carey: Sure. As they say, the president proposes and Congress disposes. But Joanne, you want to jump in? 

Kenen: Yeah, there’s something significant about this administration, which is Congress has repeatedly authorized more money for various health programs and science programs, and the administration doesn’t spend it, so that there’s a different dynamic. Traditionally, yes, Congress — the president proposes, Congress legislates, and then people go off and spend money. That’s what people like to do. And in this case, when Congress has, in a bipartisan way, differed with the administration and restored funding, it hasn’t all gone, those dollars haven’t gone out the door. So the entire sort of checks-and-balances system has been askew in terms of funding. I agree with everybody here. I do not think that Congress is going to accept these extreme cuts across the board in health care and health policy, in public health and science and NIH [the National Institutes of Health] and everything, but I don’t know what they’re actually going to spend at the end of the day. 

Carey: Emmarie, you wanted to jump in. 

Huetteman: Yeah, there was one striking exchange to me where the secretary acknowledged he wasn’t happy with the cuts that were proposed. I think those were his words. But he pretty quickly added, and neither is President Trump, and he framed it as a matter of making hard decisions when faced with federal budget shortfalls. 

Carey: All right. Well, we’ll keep watching this as it moves through Congress. Also during yesterday’s House Ways and Means hearing, some Democrats took issue with past statements from Secretary Kennedy and President Trump that linked Tylenol use during pregnancy to autism in children. released this week in JAMA Pediatrics found that the use of Tylenol by women during pregnancy was not associated with autism in their children. This nationwide study from Denmark followed more than one and a half million kids born between 1997 and 2002, including more than 31,000 who were exposed to Tylenol in the womb. in another medical journal examining community water fluoridation exposure from childhood to age 80 found no impact on IQ or brain function. Kennedy has claimed that fluoride in water has led to IQ loss in children. These studies clearly debunk medical claims that have gotten a lot of attention. Will these findings have an impact now? 

Kenen: I think we’ve seen over and over and over again that there are people who are very deeply wedded to certain beliefs, and new science, new research, does not deter them from those beliefs. We also see some people who are sort of in the middle, who are uncertain, and new findings can shift their beliefs, right? And then, of course, there’s a lot of — these are not new studies. I mean these are new studies but they are not the first of their kind. The reason we’ve been using fluoride for, what, 60 years now in the water. Tylenol has been around a long time. So is it going to change everybody’s belief? No. Is it going to perhaps slow the push to ban fluoridation? Perhaps. But I just don’t think we know, because we’re sort of on these dual-reality tracks regarding a lot of science in this country, where once people sort of buy into disinformation, they’re very, it’s very hard to change — or misinformation — it’s hard to change people’s minds. 

Edney: I do think, on the Tylenol front — I absolutely agree with what Joanne said overall. And I think on the Tylenol front that it’s possible that this study will give pediatricians something to give and talk about with parents that are asking. I think there still is some confusion among some people. It’s not a huge, I don’t think, widespread thing, but I think there are some new parents who are wondering. And if you are able to take this study that is published in 2026 — it just happened, it was after Trump made his statements — I think maybe that would give them something to talk about with their patients. 

Kenen: I agree with Anna. I think the Tylenol one is easier to change than some of the fluoridation stuff going on, partly because so many of us — and we should just say, it’s not just the Tylenol, the brand. It’s acetaminophen, which I’ve never pronounced right. I think those of us who have been pregnant, we’ve taken that in our life before and we don’t think of it as a big, dangerous, heavy prescription drug. I think we’ve, it’s something we feel comfortable with. And I think there’s also the counterinformation, which is, a fever in a pregnant woman can, a pregnant person can be dangerous to the fetus. So I think that one’s a little — and I don’t, also, I don’t think it’s as deep-rooted. The fluoridation stuff goes back decades, and the Tylenol thing is sort of new. And it might be, I’m not sure that the course of these arguments — I think that Tylenol is easier to counter than some other things, because partly just we do feel safe with it. 

Carey: All right. We’re going to take a quick break. We’ll be right back. 

We’re back and talking about how the Trump administration is managing the voters behind the Make America Healthy Again, or MAHA, movement, which helped President Trump win the 2024 election. My colleagues Stephanie Armour and Maia Rosenfeld wrote about the administration’s recent decision to give coke oven plants in the U.S. a one-year exemption from tougher environmental standards. And that was a move that angered some MAHA activists who wondered if the GOP is more beholden to industry than the MAHA agenda. President Trump, HHS Secretary Kennedy, and other top administration officials met recently at the White House with a group of MAHA leaders to calm concerns that the administration is moving too slowly on food policy changes, and they are concerned about the president’s recent support of the pesticide glyphosate. According to press reports, the MAHA folks seem to feel their concerns were heard during that session. But is this ongoing conflict between the president and this key political constituency, will it be one that keeps brewing as the midterm elections approach? 

Edney: Yes, 100%. I think it will continue to brew. I think that meeting was thrown together so quickly that some members of the MAHA movement who were invited couldn’t even make it. So it wasn’t exactly a long-planned, seemingly deep desire to fix everything. But it was, as you’ve said, an effort to kind of hear them out and make them feel heard. No one that I’ve talked to has said everything is fixed now. It’s more of a to-be-determined We will see what the administration will do moving forward, if they will listen to any of our plans — which we will not share with you, by the way — to make us happy. And I think that that’s going to continue. There’s a rally planned in front of the Supreme Court on glyphosate later this month where a lot of those people will be, and so I think that they’re upset and they’re stirring up, that concern is only going to get stirred up more. 

Carey: Emmarie. 

Huetteman: It’s a small thing, but our fellow podcast panelist Sheryl Stolberg at The New York Times during this White House meeting where President Trump was meeting with MAHA leaders, one of the leaders made a joke about how this is not a group that’s going to be, quote, “Team Diet Coke,” and the president apparently took that as a cue to press that Diet Coke button he famously has on his desk and summon a server who apparently brought him a Diet Coke. Supporters of MAHA have been clear that they want not just for the Trump administration to promote policies supporting priorities like healthy eating and removing food dyes, but also they want them to rein in or end policies they don’t support. And that weed-killer executive order, that really was a big example of that. The MAHA constituency made it clear that they felt betrayed by that order, and they’re going to have to do some work to walk that back. 

Carey: We’ll also see how, with their concerns about the new CDC director nominee, which they’re already voicing, we’ll see how that plays out. 

Kenen: No, I just think that we are, as we mentioned at the beginning, we’re seeing cracks, right? We’re seeing — none of us are privy to any conversations that President Trump has had privately with Secretary Kennedy. But his, Secretary Kennedy’s, public statements have been a little different than they were a few months ago. There’s certainly been reports that he’s been told to soft-pedal vaccines and talk about some of the things that there’s more unanimity across ideological and party lines. Healthier food — there’s debate about how to, whether, there’s debate about how Kennedy defines healthier food. But in general, should we eat healthier? Yes, we should eat healthier. Should our kids get more exercise? Yes, our kids should get more exercise. Do we have too much chronic disease? Yes, we have too much chronic disease. So they’re sort of this, trying to move a little bit more, sort of this sort of top line, very hazier agreement. But at the same time, the people who are sort of really the core of MAHA, as Kennedy has sort of created it or led it, there’s cracks there. 

Carey: All right, we’ll see. We’ll see where that goes. But let’s go ahead and move on to ACA enrollment. A found that 1 in 7 people who signed up for an Affordable Care Act plan failed to pay their first month’s premium. The analysis from Wakely consulting group found that nationally around 14% of those who enrolled in ACA plans didn’t pay their first bill for January coverage. Now we know the elimination of the enhanced ACA tax credits and higher premium costs led to lower enrollment in the ACA exchanges, with sign-ups for 2026 falling to 23 million from 24 million a year ago. But how do you interpret this finding that 14% of enrollees didn’t pay their January premium? Is it a sign of more trouble ahead? 

Edney: I think it could be a sign of more trouble ahead. Some — what we’re seeing is sticker shock. And there may be some people who are trying to deal with that and won’t be able to as the months go on. And so, yeah, I think it could mean that even more drop out, and that means more people lose coverage and are uninsured. 

Kenen: I think there was sort of a general, initial, misleading sigh of relief when in December, when the enrollment figures, the drop wasn’t as bad as some feared. But at the same time, people said: Wait a minute. This doesn’t really count. Signing up isn’t the same thing as staying covered. The drop in January was significant, we now know. And I agree with Anna. I think we don’t know how many more people will decide they can’t afford it. Or we don’t know whether the big drop is January. Probably a lot of it is, because you get that first bill. But can, will more people drop? Probably. We have no way of knowing how many. And it also depends on the economy, right? If more people lose jobs, right now it’s still pretty, kind of still pretty stable, but we don’t know what’s ahead. We don’t know what’s going to happen with the war. We don’t know many, many, many — we don’t know anything. So the future is mysterious. I would expect it to drop more. I don’t think, I don’t know whether this is the big drop or February will be just as bad. I suspect January will be the biggest. But who knows? It depends on other outside factors. 

Huetteman: We’re also seeing a drop-off in the kind of coverage that people are choosing. That analysis that you referenced, Mac, showed that there was a 17% drop in silver plan membership, with most of those folks switching to bronze plans, which, in other words, that means they switch to plans that have lower monthly premiums but they have higher deductibles. And that means that when you get sick, you owe more, in some cases much more, before your insurance starts picking up the tab. And I think really what this means is people are more exposed to the high charges for medical services, bigger bills when you get sick. I think that 

Kenen: I think that the Republicans were seen as having pushed back a lot of the health impacts of the so-called One Big Beautiful Bill and that it would be after the election. And I and others wrote: No, no, no, no, no. We’re going to see this playing out before the election. This is a really big political red flag, right? This is a lot more people becoming uninsured, which makes other people worried about their insurance and stability. So I think this is definitely going to — it may not be. There are other things going on in the world. Health care may not be the dominant theme in this year’s election. But yes, this is going to be, the off-year elections are going to be health care elections, like almost every one else has been for— 

Carey: Oh yeah. 

Kenen: —since the Garden of Eden, right? 

Carey: Absolutely, it’s a perennial. All right, we’ll keep our eye on that. That’s this week’s news. Now we’re going to play Julie’s interview with immigration attorney Michelle can arrow, and then we’ll be back with our extra credits. 

Julie Rovner: I am pleased to welcome to the podcast Michelle Canero. Michelle is an immigration attorney from Miami and a member of the board of Immigrants’ List, a bipartisan political action committee focused on immigration reform. Michelle, thanks for joining us. 

Michelle Canero: Thank you for having me. 

Rovner: So, we’ve talked a lot about immigration policy on this podcast over the past year, but I want to look at the big picture. How important to the U.S. health care system are people who originally come from other countries? 

Canero: I think the statistics speak for themselves. One in three residency positions can’t be filled by American graduates alone. That means 33% of these residency positions are being filled by immigrant workers. Twenty-seven percent of physicians are foreign-born. Twenty percent of hospital workers are immigrants. And, at least in Florida, a large percentage of our home health care workers happen to be immigrants. And we depend on this population heavily in the health care sector. 

Rovner: Now, we talk a lot about the Trump administration’s crackdown on illegal immigration, but we talk a little bit less about their sort of messing with the legal immigration system. And there’s a lot going on there, isn’t there? 

Canero: There is. And I think that the campaign talking points were illegal immigration but what we’re actually seeing is a little more sinister. I think that the goal of leadership at the head of DHS [the Department of Homeland Security] and DOS [the State Department], or really Stephen Miller, is pushing something called reverse migration, which is really not about limiting illegal immigration but reducing the immigrant population in the United States. And I think that’s where the real concern is and why you’re seeing these policies that directly affect legal immigrants. 

Rovner: We talk a lot about doctors and nurses and skilled, the top skilled, medical professionals who make up a large chunk of the United States health care workforce. We don’t talk as much about the sort of midlevel professional workers and the support staff. They’re also overwhelmingly immigrant, aren’t they? 

Canero: Yeah, and whether it’s your IT- and technical-knowledge-based workers in hospitals who facilitate all the technology — we rely on an immigrant workforce for a lot of the technology sector. And then you’ve got research professionals. A lot of clinical researchers, medical researchers, are foreign-born. So it’s not just about the doctors. It’s also the critical staff that keep the hospitals operating. And I’m from Florida. For us, it’s the home health care workers. We have an aging population, and a large percentage of the home health care workers, particularly in Florida, happen to be Haitians on TPS [temporary protected status] or people with asylum work authorizations. And when we lose that, our aging population is left with no resources, because that’s not something AI or technology can fix. You can’t turn someone over in a bed with a robot yet, and we’re probably decades away from that. 

Rovner: So what’s the last year been like for you and your clients? 

Canero: I think it’s a lot of uncertainty. A lot of these policies are percolating, and we’re assuming that they’ll be resolved in litigation, but the damage is being done in real time. So we’re seeing hospitals turning away from hiring foreign workers, because of the H-1B penalty now. The suspension of J-1 processing created backlogs. These visa bans that affect 75 countries on certain visas and 39 countries on others. You’ve got thousands of health care workers that are stuck outside the U.S. So what’s happening, really, is that hospitals and medical providers are just shutting down, and they’re cutting back services, and that means that there are less available services and resources for the same population and the same demand. People are waiting longer for doctor’s appointments. People are finding that they’re not able to get to the specialist that they need to get to in time. And so for us as practitioners, I think, we’re trying to navigate as best we can, but we’re just seeing a lot of people, employers that traditionally would rely on our services, give up and foreign workers looking to go elsewhere. 

Rovner: I noticed during the annual residency match in March that it worked out, I think, fairly well for most graduating medical students. But the big sort of sore thumb that stuck out were international medical graduates. That’s going to impact the pipeline going forward, isn’t it? 

Canero: From what I understand, it takes like seven to 15 years to get to that level, and we just don’t have the student body to meet the demand of residency positions. From my understanding, there’s a gap between American graduates and the demand for residents that’s usually filled by foreign workers. And if we don’t have those foreign workers, those residency positions just don’t get filled. And that becomes more expensive for hospitals, and that transfers to our medical bills. 

Rovner: And people assume that, Oh well this doesn’t impact me. But it really impacts all patients, doesn’t it? And I would think particularly those in rural areas, which are less desirable for U.S.-born and -trained medical professionals and tend to be overrepresented by immigrants. 

Canero: Yeah, I think a lot of the J-1 doctors and H-1B doctors are what facilitate, are working at, our veterans hospitals and our rural medical facilities. And what’s ending up happening is the very same people that this administration touts to support their interests are being forced to travel farther for specialists, right? If there isn’t an endocrinologist in your area, you may have to drive 100 miles to go see that specialist, and you may forgo necessary medical care because of the inconvenience or the cost. And I think that’s hitting at our health. 

Rovner: So you’re on the board of Immigrants’ List, which is working to change things politically. What’s one change that could really make a big difference in what we’re starting to see in terms of immigration and the health care workforce? 

Canero: Well, asking Congress to actually do something. It’s been a problem for decades. So I don’t really know, but I think there’s a couple of things, whether it’s just policymakers supporting our fight against some of these illegal policy changes in courts, organizations supporting us with amicus briefs. For example, there’s a lot of lawsuits challenging these visa bans and these adjudicative holds and the H-1B fine. The more support that the plaintiffs in the litigation get, the more likely we are to resolve that through the court system. And then I hope that there’s enough pressure from hospitals and organizations that have real dollars that impact these elected officials to get them to start seeing, Hey, we need to pass reasonable immigration reform to address some of the loopholes that this administration is using to cause chaos in the system, right? They’re able to do this because we have a gap. We allow them to terminate TPS. We don’t have a structure to ensure that a community that’s been on TPS for 20 years gets grandfathered into some sort of more stable visa. We don’t have a system that precludes the administration from just putting a hold or a visa ban on nationalities. So it’s something that Congress is going to have to step up and do something about. 

Rovner: What worries you most about sort of what’s going on with the immigration system and health care? What keeps you up at night? Obviously you, I know you work on more than just health care. 

Canero: I think my concern is that the American people aren’t seeing what’s happening, or they’re sort of turning a blind eye to it, and by the time it starts to actually impact them and they start asking, Wait, wait, wait. Why is this happening? I don’t understand, it’s going to be too late. Because it’s not hitting their pocket, because it’s not their suffering at this point, they’re not standing up and saying, Hey, this needs to stop, at the level that we need, opposition, to make it stop. And by the time it does hit their pocket and it does affect them directly, I think, it’ll be a little too late. I think people will be scared off from coming here, people that we needed will be gone, and to reverse the system is going to take decades. 

Rovner: Michelle Canero, thanks again. 

Canero: No, you’re very welcome. Thank you for your time. 

Carey: OK, we’re back. Now it’s time for our extra-credit segment, and that’s where we each recognize a story we read this week and we think that you should read it, too. Don’t worry if you miss it. We’ll post the links in our show notes. Joanne, why don’t you start us off this week? 

Kenen: Well, this is by Teddy Rosenbluth in The New York Times. The headline is “” This is one of those stories where you know exactly how it’s going to end in the first paragraph, and yet it was so compellingly and beautifully written that you kept reading until the last word. It is, as the headline suggested, a young man who is an expert on AI and cognitive science named Ben Riley discovered that his father had been lying about a controllable, treatable form of leukemia. He had denied treatment, he’d refused treatment, he had ignored his oncologist because he was relying on AI. And as we all know, AI has its up moments and its down moments. And he was getting incorrect information, distrusted the diagnosis, refused treatment, getting sicker and sicker and sicker as the oncologist and the family got increasingly desperate. And the son, Ben Riley, had, like, skills. He knew how to find scientific evidence, and his father just would not believe it. And by the time his father finally consented to treatment, it was too late, and he did die. And his father was a neuroscientist, a retired neuroscientist, but he found a neuroscience rabbit hole. 

Carey: That’s amazing. Anna, what’s your extra credit? 

Edney: Mine, I’m highlighting a story that I wrote in Bloomberg called “.” And this is, I wanted to dive into this policy that the FDA had implemented. The commissioner has long talked about and felt that perimenopausal and menopausal women were not getting access to the treatments that maybe they really needed, because there had been sort of this two-decade-old study that had showed there were some safety issues regarding breast cancer and cardiovascular disease, but the issue being that those studies had looked at older forms of the medication and also at women who were much older than those who might benefit from taking it. And so they, the agency, asked the companies to remove those warning labels, at least the strongest ones. And what we’ve seen, why — I wanted to dive into the numbers specifically. Bloomberg has some prescription data that was able to help me out here and just look at when this started rising. You could see that the prescriptions started going up around 2021. I feel like a lot of influencers, a lot of celebrities, were talking about this. And then in 2024 to 2025 when the FDA started talking about this, it really just goes, the prescription numbers just go straight up on the scale. And so there were about 32 million prescriptions written last year, which is a huge increase. And I just dove into some of this, some of the companies, what kind of drugs there are out there, and talked to some women who are benefiting but also, because of this pop, experiencing shortages, because the companies aren’t quite keeping up with the products. 

Carey: Wow, that sounds like an outstanding deep dive. Thank you. Emmarie. 

Huetteman: Yeah, my extra credit is from my colleague at Ñî¹óåú´«Ã½Ò•îl Health News who covers health technology. That’s Darius Tahir. The headline is “Your New Therapist: Chatty, Leaky, and Hardly Human.” The story looks at the proliferation of AI chatbot apps that offer mental health and emotional support, particularly the ones that market themselves as, quote-unquote, “therapy apps.” Darius counted 45 such apps in Apple’s App Store last month, and he uncovered in some cases that safety and privacy concerns existed, such as minimal age protections. Fifteen of the apps that he looked at said they could be downloaded by users who were only 4 years old. His story also explored the tension between the risks of sharing sensitive data and the interests of app developers and collecting that data for business purposes. It’s a good read. All right, 

Carey: All right. Thanks so much. My extra credit is from Politico, and it’s written by Alice Miranda Olstein, and she’s a frequent guest here on What the Health? The headline is, quote, “,” close quote. The headline kind of says it all. Alice writes that Nebraska is racing to implement Medicaid work requirements by May 1, and that’s eight months ahead of the national deadline that was set by the One Big Beautiful Bill Act. Nebraska state officials plan to do this without hiring additional staff, even as other health departments in other states prepare to bring in dozens, if not hundreds, of new employees. Alice writes that advocates for people on Medicaid fear that this rush timeline and lack of new staff will cause many problems for Medicaid beneficiaries who are just trying to meet those new work requirements. 

All right. That’s this week’s show. Thank you so much for listening. Thanks, as always, to our editor and panelist Emmarie Huetteman, to this week’s producer and engineer, Taylor Cook, and to my KFF colleague Richard Ho, who provided technical assistance. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us with your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, . Joanne, where can people find you these days? 

Kenen: and , @joannekenen. 

Carey: OK. Anna? 

Edney: and and , @annaedney. 

Carey: And Emmarie. 

Huetteman: You can find me on . 

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

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

Julie Rovner: Hello, 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 24, 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 videoconference by Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And my Ñî¹óåú´«Ã½Ò•îl Health News colleague Julie Appleby. 

Julie Appleby: Hi. 

Rovner: Later in this episode we’ll have the first of a two-part series marking the 60th anniversary of Medicare and Medicaid, which is July 30. Medicare historian and University of North Carolina professor Jonathan Oberlander takes us on a brief tour of the history of Medicare. Next week we’ll do the same with Medicaid. But first, this week’s news. 

So, we have talked a lot about the changes to Medicaid as a result of the Trump tax and spending law, but there are big changes coming to the Affordable Care Act, too, which is why I have asked my colleague Julie Appleby to join us this week. Julie, what can people who buy insurance from the ACA marketplaces expect for 2026? 

Appleby: Well, there’s a lot of changes. Let’s talk about premiums first, OK? So there’s a couple of things going on with premiums. It’s kind of a double whammy. So, on the one hand, insurers are asking for higher premiums next year to cover different things. So in the summer they put out their rates for the following year. So there’s been a lot of uncertainty this year, so that’s playing into it as well. But what they’re asking for is some money for rising medical and labor costs, the usual culprits, drug costs going up, that kind of thing. But they’re tacking on some extra percentages to deal with some of the policy changes advanced by the Trump administration and the Republican-controlled Congress. And one key factor is the uncertainty over whether Congress is going to extend those more generous covid-era tax subsidies. So we’re looking at premiums going up, and the ask right now, what they’re asking for, the median ask, is 15%, which is a lot higher. Last year when KFF did the same survey, it was 7%. So we’re getting premium increase requests of a fairly substantial amount. In fact, they say it’s about the highest in five years.  

And then on top of that, it’s still not clear what’s going to happen with those more generous subsidies. And if the more generous subsidies go away, if Congress does not reinstate them, there’ll be costs from that, and people could be paying maybe 75% more than they’re paying this year. And we could talk some more about that. But that’s kind of the double whammy we’re looking at, rising premiums and the potential that these more generous subsidies won’t be extended by Congress. 

Rovner: So there were some things that were specifically in that tax and spending bill that drive up premiums for the ACA, right? Besides not extending the additional subsidies. 

Appleby: Well, that’s the biggest piece of it, but yes. They’re tacking on about 4% of that 15% medium increase is related to the uncertainty. Well, they’re assuming that the tax credits will expire. It was not in the bill. Congress could still act. They have until the end of the year. They could extend those subsidies. So that’s about 4%. But one of the things that people haven’t really been talking about are tariffs, and some of the insurers are asking for 3% because they expect drug costs to go up. So there’s those things that are going on. And then there’s just sort of the uncertainty going forward for insurers about what’s going to happen with enrollment as a result of both these premium increases, and then looking a little bit further down the line, there are some changes in the tax and spending bill and some rules that are going to substantially reduce enrollment. 

So insurers are worried that the people who are going to sign up for coverage are the ones who are most motivated, and those are probably going to be the people who have some health problems. And the folks who aren’t as motivated are going to look at the prices and maybe the additional red tape and will drop out and leave them with a sicker and more expensive pool to cover. So all of that is factoring in with these premium rate increases that they’re trying to put together. Now remember, a lot of these insurers put in these premium increase requests before they knew the outcome of the tax and spending legislation. They could still modify them. 

Rovner: And Jessie, as Julie said, there’s still a chance that Republicans will change their minds on the increased subsidies and tack them onto something. And there’s a big bipartisan health bill on drug prices and other expiring programs that still could get done before the end of the year? Yes? 

Hellmann: There have been discussions about a bipartisan health bill, though the main author of it, Sen. Bill Cassidy, himself even seems kind of skeptical. I talked to him this week, and he’s like, It might happen, it might not. But there are a bunch of other health extenders that Congress will need to get to, like telehealth, some Medicare and Medicaid payment things. So there’s definitely something to attach it to. Republicans are not friendly to the ACA. As you mentioned, they made a bunch of changes to it in this tax and spending bill. So I think the people I talk to think it’s a long shot that they’re going to pass billions of dollars in a subsidy extension in this bill. Though there are Republicans who do care about this issue, like Sen. Lisa Murkowski of Alaska. She’s kind of been sounding the alarm on this. She thinks that Congress needs to do something to mitigate which could be very big premium increases for people. So there is some pressure there, but it doesn’t seem like the people who should be thinking about this right now have started thinking about it much yet. 

Rovner: One presumes they’ll start thinking about it when they start seeing these actual premium increases. I sound like a broken record, but we keep saying, the people who these premium increases are going to hit the hardest are voters in red states. 

Appleby: Last year, in 2024, 56% of ACA enrollees lived in Republican congressional districts and 76% were in states won by President [Donald] Trump. So I’ve got to think they’re thinking about it. When I did the reporting , I spoke with a couple of folks, and they said that some people in Congress are looking at maybe they can mess around or maybe they can do something with the subsidies that’s not keeping them as they are but might deal with a piece of it. For example, there is something called a subsidy cliff. So if you make more than 400% of the federal poverty level, you used to not get any subsidies. That would come back if they don’t extend this. And so 400% of the federal poverty level, you make a dollar more, you don’t get a subsidy. So this year — and this year will be the numbers that next year’s rates are based on — $62,600 for one person is 400% of the federal poverty level and $84,600 for a couple. So people are going to start getting, if they don’t extend the tax credits, they’re going to start getting notification about how much they owe for premiums next year. 

And this is going to be one of the first effects that people are going to see from all these changes in Washington, the tax and spending bill and the other things, when they get these premiums for January. And if they make even a dollar over that, they’re not going to get any subsidy at all. So what I’m told by some of my sources is that maybe they’re thinking about raising that cliff, maybe keeping the cliff but maybe moving it up a little bit to 500% or 600%. But it’s totally unclear. Like you all are saying, nothing may happen. We may go through Dec. 31 and nothing happens, but I’m hearing that they are maybe talking a little bit about that. 

Rovner: Alice. 

Ollstein: Yeah. And there’s a couple interesting dynamics that I think could influence the politics of this and what Congress feels motivated to do or not do. So, like Julie was saying, this would hit in January. And a lot of the stuff in the bill they just passed is designed to not hit until the midterms, but this would hit before the midterms. And so that’s got to be on their minds. And then, like you were saying, not only would this hit Republican voters the hardest, but a reason that’s more true today than it was the last time they took a round at the Affordable Care Act in 2017 is because all of these red states have expanded since then. You have a lot more enrollment, even in states that didn’t expand, and so, like we mentioned, are going to have a lot of Republican voters who get hit and have this sticker shock. And the party in power in Congress and the White House could be to blame. 

Rovner: Yeah. One of the things in 2017, there were, what, 12 million people who were buying coverage on the marketplaces. And now there’s 24 million people who are buying coverage on the marketplaces. So it’s a lot more people, just plain, in addition to a lot more people who are likely in some of these red states. So we will follow this closely. 

Meanwhile, the fallout continues as people find out more about the new tax and spending law. The Congressional Budget Office is out with on the bill as enacted. It’s now estimating that 10 million more people will be uninsured in 2034 as a result of the new law. That’s down from the 11.8 million estimate of the original Senate bill. That’s because the parliamentarian bounced the provisions that would’ve punished states using their own money to cover undocumented people. That was not allowed to be considered under the reconciliation procedure. 

We also have a brand-new poll from my colleagues here at KFF that find that more people know about the law than did before it passed, and it’s still unpopular. We’ll to those numbers so you can see just how unpopular it is. As we’ve discussed, lots of Republican senators and House members expressed concern about the impact the Medicaid cuts could have on rural hospitals in particular. So much so that a $50 billion fund was eventually added to the bill to offset roughly $155 billion in rural Medicaid cuts. Even more confusing, that $50 billion is likely to be distributed before some of the cuts begin — as you were just saying, Alice — and not necessarily to just rural areas. So is this $50 billion fund really just a big lobbying bonanza? 

Ollstein: Well, it’s certainly designed to function as softening the blow. But these are different things. The hospital could be propped up and stay open, but if no one has Medicaid to go there, that’s still a problem. And the money is sort of acknowledging that a bunch of people are going to lose their coverage, because it’s meant to give the hospital something to use for uncompensated care for people who have no coverage and come to the ER. But that still means that people who lost their insurance because of other provisions in the bill, they might not be going to their preventive care appointments that would avoid them having to go to the emergency room in the first place, which costs all of us more in the long run. So there’s a lot of skepticism about the efficacy of this. 

Rovner: Jessie, are you seeing the lobbying already begin for who’s going to get this $50 billion? 

Hellmann: Yeah, because the legislation leaves a lot of how the money will be handed out to the HHS [Department of Health and Human Services] secretary, and so that’s something that they’re going to start thinking about. It reminds me a lot of the provider relief fund that was set up during covid. And that didn’t go very well. There were lots of complaints that providers were getting the funding that didn’t need the funding, and the small safety net hospitals weren’t getting enough of the funding. So I’m wondering if they’re going to revisit how that went and try to learn any lessons from it. And then at the same time, like Alice said, this just isn’t a lot of money. It’s not going to offset some of the pain to rural providers that the bill has caused. 

Rovner: Yeah. Well, another piece that we will be watching. Meanwhile, the cuts to SNAP [Supplemental Nutrition Assistance Program] food benefits conflict with another stated goal of this administration, improving health by getting people to eat healthier food. Except, as we know, healthier food is often more expensive. Other than not letting people buy soda and candy with their SNAP cards, has the administration tried to address this contradiction at all? I’m seeing a lot of blank stares. I’m assuming that the answer to that is no. We’re hearing so much about food and unhealthy food, and we’re getting rid of seed oils and we’re getting rid of dyes, but at the same time, it’s the biggest cut ever to nutrition assistance, and yet nobody’s really talking about it, right? 

Appleby: Sounds like, I think, the states are really worried, obviously, because they’re going to have to make up the difference if they can. And so what other programs are they going to cut? So I’m sure they are talking with folks in Congress, but I don’t know how much leverage they’re going to have. Do you guys have any idea whether the states, is there anything else that they can do to try to get some of this funding? 

Rovner: There’s no — I’ve seen no indication. As we said, there’s already some buyer’s remorse on the health side. Last week we talked about [Sen.] Josh Hawley introducing legislation to restore some of the Medicaid cuts that he just voted for, but I haven’t seen anybody talking about restoring any of these nutrition assistance cuts or any of the other cuts, right? 

Appleby: Right. And from what I’ve read, the SNAP cuts won’t fully take effect until after the midterm elections. So maybe we’re just not hearing about it as much because it hasn’t really hit home yet. People are still trying to figure out: What does all this mean? 

Rovner: Well, one thing that has hit home yet, I’ve wanted for a while to highlight what some of the changes to immigration policy are going to mean for health care. It’s not just ending legal status for people who came and have lived in the U.S. legally for years, or reinterpreting, again, the 1996 welfare law to declare ineligible for Medicaid and other programs many legal immigrants who are not yet permanent residents but who have been getting benefits because they had been made legally eligible for them by Congress and the president. One of the big changes to policy came to light last week when it was revealed that immigration officials are now being given access to Medicaid enrollment information, including people’s physical addresses. Why is this such a big deal? Alice, you’ve been following this whole immigration and health care issue, right? 

Ollstein: Yes. Experts are warning that this is very dangerous from a public health perspective. If you deter people from physically wanting to visit a clinic or a doctor out of fear of ICE [Immigration and Customs Enforcement] enforcement there, which we’ve already seen — we’ve already seen ICE try to barge into hospitals and seize people. And so fear of that is keeping people away from their appointments. That makes it harder to manage chronic illnesses. That makes it harder to manage infectious diseases, which obviously impacts the whole community and the whole society. We all bear those costs. We live in an interconnected world. What impacts part of the population impacts the rest of the population. 

And so what you mentioned about the Medicaid data, as well, deters people who are perfectly eligible, who are not undocumented, who have legal status, who are eligible for Medicaid. It deters them from enrolling, which again deters people from using that health care and keeping their conditions in check. And so there’s a lot of concern about how this could play out and how long the effect could last, because there are studies showing that policies from the first Trump administration were still deterring immigrants from enrolling even after they were lifted by the Biden administration. 

Rovner: And we should point out that this whole address thing is a big issue because, as you say, there, maybe, there are a lot of families where there are people who live there who are perfectly, as you say, perfectly eligible. You’re not eligible for Medicaid if you’re not here legally. But they may live in a family, in a household with people who are not here with documentation, and they’re afraid now that if they have their addresses, that ICE is going to come knocking at their door to get, if not them, then their relatives or people who are staying with them. 

Appleby: Yeah. And I think it’s also affecting employment. So nursing homes are already saying that they’re losing some people who are losing their protected status or this or that. So they’re losing employees. Some of them are reporting, from what I’ve read, that they are getting fewer applicants for jobs. This is going to make it even tougher. Many of them already have staffing issues, and the nursing home industry has said, Hey, how come we’re not getting any special consideration? Like maybe some of the farmers or other places are supposedly getting, but I don’t know if that’s actually happening. But why aren’t they being considered and why are they losing some of their workers who are here under protected status, which they’re going to lose? And some of them may also be undocumented — I don’t know. But that’s just the nursing homes. Think of all the people around the country who need help in their homes, and maybe they’re taking care of elderly parents and they hire people, and some of those people may not be documented. And that’s a vast number of folks that we’re never going to hear about, but if they start losing their caregivers as well, I think that’s going to be a big impact as we go forward. 

Rovner: And it’s also skilled health workers who are here on visas who are immigrants. 

Appleby: Right. 

Rovner: In rural areas in particular, doctors and nurses are usually people who have been recruited from other countries because there are not enough people or not health professionals living in those rural areas. The knock-on effect of this, I think, is bigger than anybody has really sort of looked at yet. 

Ollstein: Absolutely. States have even been debating and in some cases passing legislation to make it easier for foreign medical workers to come practice here, making it so that they don’t have to redo their residency if they already did their residency somewhere abroad, things like that, because there’s such shortages right now, especially in primary care and maternal care and a lot of different areas. 

Rovner: Yeah. This is another area that I think we’re only just beginning to see the impact of. Well, there is also news this week in Trump administration cuts that are not from the budget bill. from the Congressional Budget Office that’s separate from the latest budget reconciliation estimate, analysts said that the Trump administration’s proposed cuts to the budgets of the National Institutes of Health and the Food and Drug Administration could reduce the number of new drugs coming to market. That would not only mean fewer new treatments and cures but also a hit to the economy. And apparently it doesn’t even take into account the uncertainty that’s making many researchers consider offers to decamp to Canada or Europe or other countries. There’s a real multiplier effect here on what’s a big part of U.S. innovation. 

Hellmann: I’ve been talking to people on the Hill about this who traditionally have been big supporters of the NIH and authorizing and appropriating increases for the NIH every year. And they are still kind of playing a little coy. The White House is suggesting a budget cut at the NIH of 40%, which would be massive. It’s so massive that the CBO report was like: We cannot estimate the impact of this. We’re going to estimate a smaller hypothetical. Because they just can’t. 

And so I think it’ll be interesting to see how it plays out in the appropriations process. You do have senators who are more publicly concerned about it, like Sen. Susan Collins of Maine, who obviously is on the Appropriations Committee. So we might see a situation where Congress ignores the budget request. That usually happens, but these are weird times. And so I think there are questions about, even if they do, if Congress does proceed as normal and appropriate the money that they typically do for NIH, what is the administration going to do with it? They’ve already signaled that they’re fine not spending money that has been appropriated by Congress. And so I think that there’s a big question about that. 

Rovner: At some point, this has to come to a head. We’ve been — as I say, I feel like a broken record on this. We talk about it a lot, that this is money that’s been appropriated by Congress and signed by the president and that we keep hearing that people, particularly at NIH, are not being allowed, for one reason or another, to send out. This is technically illegal impoundment. And at some point it comes to a head. We know that Russ Vought, the head of the Office of Management Budget, thinks that the anti-impoundment law is illegal and that he can just ignore it. And that’s a lot of what’s happening right now. I’m still surprised that it’s the end of July and Congress is going out for the August recess — and Jessie, I know you’re talking to people and they’re playing coy — that they haven’t jumped up and down yet. The NIH in particular has been such a bipartisanly supported entity. If you’ve ever been around the campus in Bethesda, all of the buildings are named after various appropriators of both parties. This is something that is really dear to Congress, and yet they are just basically sitting there holding their tongues. At some point, won’t it stop? 

Hellmann: I think maybe they’re hoping to say something through whatever legislation that they come out with, whatever spending legislation. But, yeah, they’re not being very forceful about it. And I think people are obviously just very afraid of making the Trump administration angry. Lisa Murkowski of Alaska has said this, like she kind of fears the repercussions of making the president mad. And he’s on this spending-cut spree. So I definitely expected more anger, especially the bipartisan history of the NIH has lasted so long. It’s kind of a weird thing to see happen. 

Rovner: Yeah. Of all the things that I didn’t expect to see happen this year, that has to be the thing that I most didn’t expect to see happen this year, which was basically an administration just stopping funding research and Congress basically sitting back and letting it happen. It is still sort of boggling to my mind. Well, we also learned this week about hospitals stopping gender-affirming care of all kinds for minors, under increasing pressure from the administration. And we’re not just talking about red states anymore. Children’s hospitals in California and here in Washington, D.C., have now announced they won’t be offering the care anymore. Wasn’t it just a few months ago when people were moving from red states to blue states to get their kids care? Now what are they going to be able to do? 

Ollstein: I think a lot of what we’re seeing play out in the gender-affirming care fight, it reminds me of the abortion rights fight. There are a lot of themes about the formal health care system being very, very risk-averse. And so rather than test the limits of the law, rather than continuing to provide services while things are still pingponging back and forth in courts, which is the case, they’re saying, just out of caution, We’re just going to stop altogether. And that is cutting off a lot of families from care that they were relying on. And there’s a lot of concern about the physical and mental health impacts on — again, this is very small compared to the general population of trans kids — but it’s going to hit a lot of people. And yeah, like you said, this is happening in blue states as well. There’s sort of nowhere for them to go. 

Rovner: Yeah. We’re going to see how this one also plays out. Well, turning to abortion, we talked last week about how a federal appeals court upheld a West Virginia law aimed at banning the abortion pill mifepristone. And I wondered why we weren’t hearing more from the drug industry about the dangers of state-by-state undermining of the FDA. And lo and behold, here come the drugmakers. In comments letters to the FDA, more than 50 biotech leaders and investors are urging the agency to disregard a controversial study from the anti-abortion think tank the Ethics and Public Policy Center that officials are citing as a reason to reopen consideration of the drug’s approval. Alice, remind us what this study is and why people are so upset about it. 

Ollstein: So it’s not a study, first of all. Even its supporters in the anti-abortion movement admitted, in private in a Zoom meeting that I obtained access to, that it is not a study. This is an analysis that they created. They are not disclosing the dataset that it is based on. It did not go through peer review. And so they are citing their own sort of white-paper analysis put out by an explicitly anti-abortion think tank to argue that abortion pills are more dangerous than previously known or that the FDA has previously acknowledged. There’s been a lot of fact checks and debunks of some of their main points that we’ve been through on this podcast also before. The Washington Post did if people want to look that up. But suffice it to say that that has not deterred members of Congress from citing this and to pressure the FDA. 

And now you have the FDA sort of promising to do a review. If you look at the exact wording of what [FDA Commissioner Marty] Makary said, I’m not sure. He said something like, Like we monitor the safety of all drugs, we’re going to blah, blah, blah. And so it’s unclear if there’s anything specific going on. But the threat that there could be, like you said, is really shaking up the drugmaking industry. And you’re hearing a lot of the same alarms that we heard from the pharmaceutical industry when this was before the Supreme Court, when they were afraid the Supreme Court would second-guess the FDA’s judgment and reimpose restrictions on mifepristone. And they’re saying, Look, if we can’t count on this being a process that just takes place based on the science and not politics and not courts coming in 25 years later and saying actually no, then why would we invest so much money in developing drugs if we can’t even count on the rules being fair and staying the same? 

Rovner: Yeah. We will see how this goes. I was surprised, though. We know that that Texas case that the Supreme Court managed to not reach the point of, because the plaintiffs didn’t have standing, is still alive elsewhere. But I didn’t realize that this other case was still sort of chugging along. So we’ll see when the Supreme Court gets another bite at it. Meanwhile, the fight over funding for Planned Parenthood — whose Medicaid eligibility, at least for one year, was canceled by the new budget law — continues in court. This week a judge in Massachusetts gave the group a partial win by blocking the defunding for some smaller clinics and those that don’t perform abortions, but that ruling replaced a more blanket delay on the defunding. So many clinics are now having their funding stopped while the court fight continues. Alice, what’s the impact here of these Planned Parenthood clinics closing down? It’s not just abortion that we’re talking about. In fact, it’s not even primarily abortion that we’re talking about. 

Ollstein: Absolutely. So this is one, it’s set to hit a lot of clinics in states where abortion is legal. And so these are the clinics that are serving a lot of people traveling from red states. And so there’s already an issue with wait times, and this is set to make it worse. But that’s just for abortion. Like you said, this is also set to hit a bunch of clinics in states where abortion is illegal and where these clinics are only providing other services, like birth control, like STI [sexually transmitted infection] testing. And at the same time we’re having a lot of other funding frozen, and so this could really be tough for some of these areas where there aren’t a lot of providers, and especially there are not a lot of providers who accept Medicaid. 

Rovner: Meanwhile, a number of states are passing conscience laws that let health professionals opt out of things like doing abortions or providing gender-affirming care if they violate their beliefs. Well, in Tennessee now we have a story of a pregnant woman who says her doctor refused to provide her with prenatal care, because she’s not married to her partner of 15 years. She said at a congressional town hall that her doctor said her marital status violated his Christian beliefs, and he’s apparently protected by the new Tennessee state law called the Medical Ethics Defense Act. I’ve heard of doctors refusing to prescribe birth control for unmarried women, but this is a new one to me, and I’ve been doing this for a very long time. Are these just unintended consequences of these things that maybe state lawmakers didn’t think a lot about? Or are they OK with doctors saying, We’re not going to provide you with prenatal care if you’re pregnant and not married? 

Ollstein: So one, as we just said, we’re in a situation where there is such a shortage of providers and such a shortage of providers who accept certain coverage that being turned away by one place, you might not be able to get an appointment somewhere else, depending where you live. And so this isn’t just an issue of, Oh, well, just don’t go to that doctor who believes that. People have very limited choices in a lot of circumstances. But I— 

Rovner: Apparently this woman in Tennessee said she’s having to go to Virginia to get her prenatal care. 

Ollstein: Well, exactly. Yeah. Exactly. This isn’t like people have tons of options. And also this is an example of a slippery slope, of if you allow people to be able to refuse service for this reason, for that reason, what else could happen? And some states have more legal protections for things like marital status, and some do not. And so it’s worth thinking through what could be sort of the next wave. 

Rovner: Well, we’re certainly going to see what the outcome of this could be. Well, before we end our news segment this week, I want to give a shoutout to tennis legend Venus Williams, who at age 45 won a singles match at a professional tournament here in Washington this week and said in her post-match interview that she came back to playing because she needed the pro tour’s health insurance to take care of several chronic conditions that she has. So see, even rich athletes need their health insurance. All right. That is this week’s news. Now we will play my interview with Medicare historian Jonathan Oberlander, and then we will come back and do our extra credits. 

I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. Jon, welcome to “What the Health?” 

Jonathan Oberlander: Great to see you, Julie. 

Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here? 

Oberlander: Wow. So let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete. And the problem is, as you know very well, they haven’t been added to all that much. And here we have a population, and all of us know as we get older, we generally don’t get healthier. I wish it was true, but it’s not. Older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else. And that may be an individual private plan that they purchase called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare. 

Some low-income Medicare beneficiaries have Medicaid as well as Medicare and they are dual-eligible. Some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure— 

Rovner: We’ll get to. 

Oberlander: —we’ll have a lot to say. So the bottom line, though, is Medicare has grown. It has, what, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace. 

Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve? 

Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call a single-payer, federal-government-run program for everybody, they trimmed their ambitions down to, initially, just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition and the American Medical Association and charges of socialized medicine, all things that are really throwing a wrench into plans for national health insurance. It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enact it. And there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of, how do you enact government health insurance in the United States? You pick a more sympathetic population. 

Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age, and that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65, before Medicare, was around 50%. Not 15 but five zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage. 

Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by? 

Oberlander: So in terms of populations in 1972, Medicare added coverage for persons who have end-stage renal disease, so people who need dialysis no matter what the age. It’s a lifesaving technology. They can qualify for Medicare. It didn’t really make sense to add it to Medicare — it’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance. For a couple of years they qualify for Medicare as well and are a very important part in the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody. 

In terms of benefits, the benefit package has been remarkably stable, for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited. 

Rovner: So Medicare is also the biggest payer in the nation’s health care system and for decades set the standard in how private insurance covered and paid for health care. So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion? 

Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all, through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans and it’s changed Medicare politics. 

I don’t think Medicare Advantage is going anywhere. I think the question is, how big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is — given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government, and it’s losing a lot of money on Medicare Advantage, and it’s never saved money — is there going to come a point where they actually clamp down? There’ve been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore. So I think it’s an open question about, how big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two. 

Rovner: Thank you so much. 

Oberlander: Oh, thanks for having me. It was great to see you. 

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

Appleby: Yeah. I found this story on NPR quite interesting. It’s maybe something that a lot of us have thought about, but it just added a lot of numbers to the question of how many chemicals are in our beauty products — basically, the makeup we use, the lotions, our hairspray, the stuff that happens at the salon, that kind of thing. And it’s called “.” And it was written by Rachel Treisman. Basically it says that the average American adult uses about 12 personal care products a day, resulting in exposure to about 168 chemicals, which can include things like formaldehyde, mercury, asbestos, etc., etc. OK, so that’s interesting. But it also talks about how the European Union has banned more than 2,000 chemicals, basically, but the FDA puts limits on only about a dozen. 

So this has caused four Democratic lawmakers to introduce a package of legislation, actually they’re calling the Safer Beauty Bill Package, and it’s four bills. And basically one of them would ban two entire classes of chemicals, phthalates and formaldehyde-releasing chemicals. And it also calls for some other things as well, which they say hasn’t been done and needs to be looked at. So I just thought it was an interesting thing that pulled together a lot of data from various sources and talked about this package of bills and whether or not it might make a difference in terms of looking at some of these chemicals in the products we use all the time and requiring a little bit more transparency about that. It’s a step. I don’t know if it’s going to resolve everybody’s concerns about this, but I just thought it was an interesting little piece looking at that topic. 

Rovner: It’s worth remembering that the FDA’s governing statute is actually called the Food, Drug, and Cosmetic Act. 

Appleby: That’s right. 

Rovner: The cosmetics often gets very short shrift in that whole thing. Alice, why don’t you go next? 

Ollstein: Yeah. So I have a piece from The Associated Press. It’s called “.” And so this really gets at something we’ve been talking about on the podcast, where the administration is really fixated on a few kind of superficial food health things like colored dyes in food and frying something in beef tallow instead of vegetable oil. But something fried in beef tallow is still unhealthy. Froot Loops without the color dye are still unhealthy. And these meals that he is promoting as a service for Medicare and Medicaid enrollees are unhealthy. So this article is about how they do have chemical additives, they are high in sodium and sugar and saturated fats, and so it’s not in sort of keeping with the overall MAHA [Make America Healthy Again] message. But in a way it kind of is. 

Rovner: From the oops file. Jessie. 

Hellmann: My extra credit is from my colleague Ariel Cohen at Roll Call. It’s called “.” She did a story about something that kind of, I think, flew under the radar this week. The Trump administration is starting to make good on its promise to look at SSRIs [selective serotonin reuptake inhibitors], and the panel was very much full of skeptics of SSRIs who sought to undermine the confidence in using them while pregnant. And Marty Makary himself, FDA commissioner, claimed it could cause birth defects and other fetal harm. That was a statement that was echoed by many of the panelists. There was only one panelist who talked about the benefits of SSRIs in pregnant people who need them, the risks of postpartum depression to both the mom and the baby. And so I think this is definitely something to keep an eye on, is it looks like they’re going to keep looking more at this and raising questions about SSRIs without having much of a nuanced conversation about it. 

Rovner: Yeah. I did see something from ACOG, from the American College of Obstetricians and Gynecologists, this week pushing back very hard on the anti-SSRI-during-pregnancy push. So we’ll see how that one goes, too. My extra credit this week is from my Ñî¹óåú´«Ã½Ò•îl Health News colleague Katheryn Houghton, and it’s called “” And it’s about something that didn’t really come up during the whole Medicaid debate, the fact that if Republicans really want people to go to work, well, then maybe they shouldn’t take away their health insurance if they get a small raise or a few extra hours. The subject of this story, only identified as James, technically makes about $50 a week too much to stay on Medicaid, but he otherwise can’t afford his six prescription medications and he can’t afford the care that he needs through even a subsidized Affordable Care Act plan, or his employer’s plan, either. 

The point of the ACA was to make coverage seamless so that as you earn more, you can still afford coverage even if you’re not on Medicaid anymore. But obviously that isn’t happening for everyone. Quoting from the story: “‘I don’t want to be a fraud. I don’t want to die,’ James said. ‘Those shouldn’t be the only two options.’” Yet for a lot of people they are. It’s not great, and it’s not something that’s currently being addressed by policymakers. 

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 a review. That helps other people find us, too. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, , or on Bluesky, . Where are you folks hanging on social media these days? Jessie? 

Hellmann: I’m @jessiehellmann on and . 

Rovner: Alice. 

Ollstein: on X and on Bluesky. 

Rovner: Julie. 

Appleby: on X. 

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