The lawsuit, settled on confidential terms last year, blamed not only the managers of City Creek Post-Acute and Assisted Living but also the building’s owner, a real estate investment trust, or REIT.

In the year Darby died, City Creek paid CareTrust REIT more than $1 million in rent, while the Sacramento, California, nursing home ran a deficit, court records show.

Federal tax rules ban REITs from running health care facilities, but CareTrust was not an absentee landlord either, according to internal records filed in the case. It chose the nursing home’s management company and required through the lease that the home keep at least 80% of beds occupied. CareTrust granularly tracked how well the home kept to its financial plan, down to the money spent monthly on nurses and food, the records said. And the documents showed that the real estate company kept tabs on government safety inspection findings and Medicare quality ratings.

Both CareTrust and the nursing home operator denied liability for Darby’s death. CareTrust officials said in court papers that it is not involved in day-to-day nursing home decisions or patient care, and that it monitors facilities to ensure nothing jeopardizes rent payments. In a written statement, CareTrust Corporate Counsel Joseph Layne told ���ϳԹ��� News: “We are the property owners, not the operators.”

Landlords With Influence

Over the past decade, real estate investment trusts have bought thousands of buildings that house nursing homes, hospitals, assisted living facilities, and medical offices. A ���ϳԹ��� News examination of court filings and corporate records shows that these landlords have more influence than the health care facilities publicly acknowledge.

The documents reveal REITs often select the management who oversee the operations and leave them in place even when they are aware of threadbare staffing, floundering governance, repeated safety violations, or other problems that hamper quality of care. A California jury in March awarded $92 million in punitive damages against a former REIT over the death of a 100-year-old resident with dementia who froze to death outside her assisted living facility.

“The REITs are in charge,” said Laraclay Parker, one of the lawyers who represent Darby’s daughter.

Absence of Oversight

Despite their ubiquity, REITs remain invisible to state and federal health regulators. Hospitals and nursing homes are not required to disclose rent payments or landlord identities in the annual reports they submit to Medicare.

Under President Donald Trump, the Centers for Medicare & Medicaid Services a Biden-era requirement that nursing homes . Catherine Howden, a CMS spokesperson, said in a statement that the agency does not regulate facilities based on their tax status or corporate form and instead focuses on the quality of the care they provide.

REITs now of the nation’s senior housing, which includes assisted living, memory care, and independent living, according to an industry analysis. REITs also hold investments in nursing homes. Publicly traded REITs that focus on health care are now worth nearly a quarter of a trillion dollars, according to Nareit, an industry association.

While one research study found REIT investments were associated with , another concluded that after being bought by REITs, nursing homes frequently with less skilled nurses and aides. A concluded that health inspection results were worse after REIT investment.

Researchers also found that investor-owned hospital chains that sold buildings to REITs were or go bankrupt, with Steward Health Care. Often, private equity investors kept the sale proceeds as profits while the hospitals were burdened with new rent costs. “There were no improvements in clinical outcomes,” said Thomas Tsai, an associate professor at the Harvard T.H. Chan School of Public Health.

REITs are required to distribute most of their income and don’t have to pay the 21% federal corporate income tax on it. There is a catch: A REIT that “directly or indirectly operates or manages” a health care facility for five years. Typically, a REIT leases the property to another company that runs the nursing home or assisted living facility and maintains its tax break. Nareit said health care REITs distributed more than $7 billion in dividends in 2024.

Michael Stroyeck, head of health care analysis at Green Street, a real estate research company, said “there’s definitely a symbiotic relationship” between REITs and facility managers because they have the same goals. He said he has seen REITs replace operators that are having difficulties or go bankrupt.

John Kane, a senior vice president at the American Health Care Association and the National Center for Assisted Living, an industry group that represents nursing homes, said in a statement: “Given government funding often falls short, REITs have been valuable partners in helping to invest in long term care without influencing daily operations.”

Low Staffing at a Chain

Strawberry Fields REIT, which like CareTrust trades on the New York Stock Exchange, owns or controls the buildings of 131 nursing home facilities. The nursing home operations inside 66 of those facilities are owned by Moishe Gubin, Strawberry Fields’ chief executive, and Michael Blisko, one of its directors, according to Strawberry Fields’ for last year.

Gubin and Blisko also jointly own , which manages their nursing homes; Blisko is Infinity’s CEO. On average, Infinity-affiliated nursing homes provided an hour and a quarter less nursing care per resident per day than the national average of four hours, a ���ϳԹ��� News analysis of federal records found.

Infinity and several of its nursing homes have recently settled 30 death and injury lawsuits in Cook County, Illinois, totaling more than $4 million, said Margaret Battersby Black, a Chicago lawyer. A jury last year awarded $12 million in a lawsuit brought against Infinity and one of its Chicago nursing homes over the 2023 death of Shirley Adams. A retired candy factory worker, Adams died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to the lawsuit.

“She had wounds that no one could explain,” one of her adult children, Leslie Adams, testified at trial. Medicare its lowest quality rating, one star out of five.

Paul Connery, a lawyer for Adams’ family, said they are still trying to collect on the judgment against the nursing home and management company, which now totals $17 million with interest and attorney fees.

“If I get caught speeding and I went to court, they issue me a ticket and I’ve got a fine to pay,” Adams said in an interview. “How are they able to still continue to move on with business like nothing has happened?”

In a phone interview and an email, Gubin said Strawberry Fields, Infinity, and the nursing homes are all legally distinct and that he has not played an active role in Infinity in more than a decade. He said nursing homes get sued all the time but that the verdict against Lakeview is so large that it will force the home to declare bankruptcy or shut down.

“The whole thing is unfortunate,” Gubin said by phone. “For 15 years they were a perfectly good guardian” and “a well-run building,” he said. “You wouldn’t think it was fair to be judged on your worst day.”

Blisko and an Infinity lawyer did not respond to requests for comment.

Strawberry Fields, which owns 10 assisted living facilities and two long-term care hospitals in addition to the nursing homes, earned net income last year of from $155 million in rent, a 21% profit margin, securities filings show. Gubin said those weren’t excessive returns.

A $110 Million Verdict

Traditionally, REIT leases make the operating companies responsible for paying property taxes, insurance premiums, and maintenance costs. In 2008, Congress gave health care REITs a new option to make money: On top of collecting rents, they could set up subsidiaries and take profits directly from health care businesses. They still must have independent management overseeing care decisions. Many REITs have embraced the role even though the subsidiaries must pay corporate taxes and risk losing money if the businesses do poorly.

Colony Capital was a REIT that through layers of shell corporations owned both the building and the operation of Greenhaven Estates, a Sacramento assisted living and memory care facility. In 2018 Greenhaven paid Colony $1.4 million in rent, nearly a third of its $4.5 million in revenue that year, according to financial records filed in court.

Greenhaven also was on the verge of losing its license, according to a revocation notice filed in November 2018 by the California Department of Social Services. Greenhaven had racked up years of health violations, including from letting untrained workers administer medications, lacking enough employees to care for people with dementia, and neglecting a resident who smeared feces over his body, bed, floor, and bathroom, the notice said.

In February 2019, a few weeks after celebrating her 100th birthday, Mildred Hernandez, a resident with Alzheimer’s, wandered out of Greenhaven in the middle of the night. Her assisted living wing had no exit door alarms even though it housed several residents with dementia, court records showed. Berta Lepe, one of Greenhaven’s caregivers, found Hernandez under a bush, wearing only a shirt and underwear. The temperature was in the 30s.

“She was talking, but I couldn’t understand what she was saying,” Lepe testified at trial over a lawsuit from Hernandez’s family. Hernandez died of hypothermia a few hours later, according to her death certificate.

Frontier Management, the company that Colony had hired to manage Greenhaven, denied liability and settled the lawsuit on undisclosed terms.

Since the lawsuit, Colony has changed its name to DigitalBridge, which no longer owns Greenhaven and gave up its REIT status. At trial earlier this year, DigitalBridge said resident care was the responsibility of Frontier and that Colony “encouraged” Frontier to address problems. Richard Welch, a former Colony executive, testified that replacing management is disruptive. “I viewed it as a last resort,” he said.

In March, a jury awarded Hernandez’s family $110 million: $10 million in compensatory damages, $92 million in punitive damages against DigitalBridge, and $8 million in punitive damages against Formation Capital, an asset management company.

“REIT money is very detached from knowing about or caring about patient or resident outcomes, because it’s not in their business model,” Ed Dudensing, a lawyer for the family, said in an interview. “Their allegiance is to their investors.”

DigitalBridge has asked the judge to delay finalizing the judgment while its legal challenges to the lawsuit and the verdict are evaluated. A DigitalBridge attorney and a corporate spokesperson did not respond to requests for comment, a Formation attorney declined comment, and a Frontier attorney and a spokesperson did not respond to a request for comment.

‘Wet From Head to Toe’

When CareTrust bought City Creek Post-Acute and Assisted Living in 2019, the Sacramento nursing home where Pearlene Darby lived had a one-star Medicare rating and was losing money. CareTrust leased the building to a management company called Kalesta Healthcare Group based on the business plan Kalesta submitted.

While CareTrust was not the operator, it held periodic phone calls with Kalesta, which provided “a full update of what’s happening at the facility,” including changes in leadership, financial progress, and health inspection survey results, according to deposition testimony by Ryan Williams, a Kalesta co-founder.

According to a state inspection report, in 2020, the year Darby died, City Creek left a resident in soiled linens “wet from head to toe lying in bed” for more than eight hours. During a different visit, a health inspector cited the home after watching a nurse put a dirty diaper back onto a resident after caring for a wound. “It was just a small stool and it is far from where the wound is,” the nurse told the inspector, according to the report.

James Callister, CareTrust’s chief investment officer, said in his deposition that CareTrust officials “review results of regulatory surveys provided to us by the tenant. We review the five-star rating.” He said, “We evaluate results of care, but we do not evaluate types of care given or how or when, no.”

Darby had been living in City Creek since 2011 after a stroke left her in a wheelchair. She needed help getting in and out of bed. From September through November 2020, Darby lost 30 pounds, her family’s lawsuit alleged. During those months, employees dropped her three times as one worker rather than the required two operated the mechanical lift, the lawsuit said.

The suit alleged City Creek failed to reposition her every two hours in bed or her wheelchair, which is the clinical standard for people at risk of bedsores, and to promptly order devices to protect her skin.

In November, the nursing home sent Darby to the hospital. A blood test found bacteria had entered her bloodstream from her feces’ touching open skin wounds, according to the lawsuit. The hospital diagnosed her with sepsis. A surgeon said she needed an operation to redirect fecal waste from her intestines but concluded she wasn’t medically stable enough for surgery, the suit said.

Darby began receiving comfort care measures and was sent back to City Creek. She died two weeks later. In court filings, CareTrust and Kalesta denied the allegations.

In a phone interview, Williams, the Kalesta co-founder, said Darby’s death occurred during the most challenging point of the covid pandemic, when California rules required any nurses testing positive for the virus to be sent home and nurses were quitting out of fear for their health. “It was the most herculean of professional efforts to secure enough staff,” he said.

While expressing sympathy for Darby and her family, he said it was “unconscionable” that personal injury lawyers sued nursing homes over care failures during “the worst of times.”

In court, CareTrust petitioned Judge Richard Miadich to dismiss it from the lawsuit before trial. “This case does not concern a property condition,” CareTrust’s lawyers wrote. “CareTrust is simply a landlord.” But the judge ruled last year a jury should decide whether CareTrust “exercised actual control over City Creek.”

The case was settled out of court a few months later. All parties declined to reveal the settlement terms.

A 67% Profit

As recently as November 2023 — four years after its acquisition — City Creek earned one star from Medicare. It was cited for failing to have the minimum nursing home staffing required by California law during five of 24 randomly selected days in 2022, according to an inspection report. Williams said in the interview that Kalesta had increased spending on nursing over the course of its ownership, including boosting wages, but that it takes a year or two to turn around a troubled nursing home. He said the home’s star rating in 2023 was dragged down by its poor inspection history from before Kalesta took over.

City Creek’s rating has climbed in the past two years, and it now has the top overall rating of five, according to Medicare. Medicare rates City Creek’s current staffing levels as average. That’s better than most nursing homes in more than 200 buildings CareTrust bought before 2025, according to a ���ϳԹ��� News analysis of federal data. On average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours.

In its statement to ���ϳԹ��� News, CareTrust’s counsel Layne said the REIT worked to “identify quality operators as tenants,” and that the homes the REIT rents out have more nurses and aides than the minimum required for nursing homes by their state governments. “The operators are licensed by state regulators and retain sole responsibility for operations,” the statement said.

CareTrust, which now owns more than 500 senior housing and nursing home buildings, reported net income last year of $320 million from in rents and other revenue — a 67% profit margin. By comparison, HCA Healthcare, one of the nation’s largest for-profit hospital and health care chains, for last year.

Lesley Ann Clement, one of Darby’s lawyers, said cases like hers show the nursing home industry is wrong to complain it lacks financial resources for more staffing.

“There’s plenty of money,” Clement said. “They’re just not spending it on patient care.”

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

USE OUR CONTENT

This story can be republished for free (details).

President Donald Trump this week nominated a former deputy surgeon general who has expressed support for vaccines to lead the Centers for Disease Control and Prevention. Considered a more traditional fit for the job, Erica Schwartz would be the agency’s fourth leader in roughly a year, should she be confirmed by the Senate.��

And Health and Human Services Secretary Robert F. Kennedy Jr. appeared on Capitol Hill this week in the first of several hearings discussing Trump’s budget request for the department. But the topics up for discussion deviated quite a bit from the subject of federal funding, with lawmakers raising issues of Medicaid fraud, measles outbreaks, the hepatitis B vaccine, peptides, unaccompanied minors, and much, much more.��

This week’s panelists are Mary Agnes Carey of ���ϳԹ��� News, Anna Edney of Bloomberg News, Emmarie Huetteman of ���ϳԹ��� News, and Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine.

Panelists

Among the takeaways from this week’s episode:

• Trump on Thursday named four officials to the CDC’s leadership team. Schwartz, whom he picked as director, is a physician and Navy officer who served as a deputy surgeon general during Trump’s first term. She has voiced support for vaccines and played a key role in the covid-19 pandemic response.
• RFK Jr. testified before three committees of the House of Representatives this week on the president’s budget request for HHS. While the hearings touched on a wide variety of topics, notable moments included a slight softening of Kennedy’s stance on the measles vaccine, including the acknowledgment that being immunized is safer than having measles — although he also stood by the decision to remove the recommendation for the newborn dose of the hepatitis B vaccine.
• New studies on the use of acetaminophen during pregnancy and the effects of water fluoridation on cognitive function refute Trump administration claims. And a White House meeting that brought together Trump, Kennedy, and other leaders of the Make America Healthy Again movement aimed to soothe concerns among supporters — yet there’s reason to believe the overture won’t completely mend fences between the Trump administration and the MAHA constituency ahead of the midterm elections.

Also this week, ���ϳԹ��� News’ Julie Rovner interviews Michelle Canero, an immigration attorney, about how the Trump administration’s policies affect the medical workforce.

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

 Mary Agnes Carey: Politico’s “,” by Alice Miranda Ollstein.

Joanne Kenen: The New York Times’ “,” by Teddy Rosenbluth.

Anna Edney: Bloomberg’s “,” by Anna Edney.

Emmarie Huetteman: ���ϳԹ��� News’ “Your New Therapist: Chatty, Leaky, and Hardly Human,” by Darius Tahir.

Also mentioned in this week’s podcast:

• JAMA Pediatrics’ “,” by Kira Philipsen Prahm, Pingnan Chen, Line Rode, et al.
• Proceedings of the National Academy of Sciences’ “,” by John Robert Warren, Gina Rumore, Kamil Sicinski, and Michal Engelman.
• ���ϳԹ��� News’ “Pennsylvania Town Faces Fallout From Trump’s Environmental Rule Rollback,” by Stephanie Armour and Maia Rosenfeld.
• The New York Times’ “,” by Sheryl Gay Stolberg.
• Wakely Consulting Group’s “,” by Michelle Anderson, Chia Yi Chin, and Michael Cohen.

[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 ���ϳԹ��� News and WAMU radio in Washington, D.C. Welcome to What the Health? I’m Mary Agnes Carey, managing editor of ���ϳԹ��� 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 ���ϳԹ��� 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 ���ϳԹ��� 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.

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But seven months later, findings from five states shared with ���ϳԹ��� News show that the reviews have uncovered little evidence of a widespread problem.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers health care costs for people with low incomes and disabilities, and the closely related Children’s Health Insurance Program. Both programs are administered by states.

Spokespeople from Pennsylvania’s and Colorado’s Medicaid agencies said, as of March, the states had found no one who needed to be terminated from Medicaid. That was after checking a combined 79,000 names.

Texas has reviewed records of more than 28,000 Medicaid enrollees at the Trump administration’s request and terminated coverage for 77 of them, according to Jennifer Ruffcorn, a spokesperson for the Texas Department of Human Services.

Ohio has checked 65,000 Medicaid enrollees, of which 260 people were disenrolled from the program, said Stephanie O’Grady, a spokesperson for the Ohio Department of Medicaid.

In Utah, 42 of the 8,000 enrollees identified by the Trump administration had their Medicaid coverage terminated, said Becky Wickstrom, a spokesperson for the state’s Department of Workforce Services.

In announcing the reviews, Health and Human Services Secretary Robert F. Kennedy Jr. said: “We are tightening oversight of enrollment to safeguard taxpayer dollars and guarantee that these vital programs serve only those who are truly eligible under the law.”

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, said the reviews ordered by the federal Centers for Medicare & Medicaid Services were unneeded because states check immigration status when people sign up.

“It is entirely predictable that all of these burdensome reviews that the federal government is forcing upon states would yield no pay dirt,” Cuello said. “The states had already done the reviews once, and CMS was just making them reverify the same information they had already checked. Making states go through the same bureaucratic process twice is incredibly wasteful and inefficient.”

CMS spokesperson Chris Krepich said in a statement to ���ϳԹ��� News that the ongoing checks are verifying eligibility “for certain enrollees whose status could not be confirmed through federal data sources.”

“CMS provides states with regular reports for follow-up review, and states are responsible for independently verifying eligibility and taking appropriate action consistent with federal requirements,” he said.

But the findings shared with ���ϳԹ��� News also suggest that many of the enrollees whose eligibility the Trump administration said it could not confirm are indeed U.S. citizens. O’Grady said Ohio found that, of the 65,000 names referred by the federal government, the state already had information on 53,000 confirming them as citizens and an additional 11,000 showing appropriate immigration status for Medicaid.

Caseworkers then worked on the remaining 1,000 names to review their information or reach out for more details, she said.

CMS did not answer questions about the findings from the states sampled by ���ϳԹ��� News or provide information about responses it received from all 50 states and the District of Columbia, which were instructed to perform verification checks.

The agency also did not respond to a question about whether it’s forwarding the names of those whose Medicaid coverage was terminated to federal immigration officials.

In June, advisers to Kennedy ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, prompting a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against residents living in the U.S. without authorization.

A federal judge that Immigration and Customs Enforcement workers could access information only about people in the country unlawfully in the Medicaid databases of the states that sued.

CMS continues to send states lists of names at least every few months, though state officials say the numbers have declined since the first batch last summer.

People without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces. Medicaid does reimburse hospitals for providing emergency care to people without legal status if they meet income and other program requirements.

Seven states and the District of Columbia provide health coverage regardless of immigration status, funding the programs with their own money.

In March 2025, CMS began financial reviews of those programs. “CMS has identified over $1.8 billion in federal funds that are being recouped through voluntary returns and deferrals of future federal Medicaid payments,” Krepich said. He did not answer how much has been collected so far or from which states.

Medicaid’s overall spending topped $900 billion in fiscal year 2024.

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

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Bostic learned of a federal program designed to help people who suffer rare vaccine reactions.

The Vaccine Injury Compensation Program was created in 1986 after a flood of vaccine injury lawsuits drove drugmakers from the market. Congress aimed to offer a faster and more generous path to compensation for people injured by vaccines, while shielding manufacturers from liability. The VICP, commonly known as vaccine court, is taxpayer-funded. The government pays any award to claimants as well as attorneys fees.

Bostic filed a claim in 2022 for compensation to cover her son’s spiraling medical bills. She then contacted the Carlson Law Firm, which referred her to Arizona-based attorney Andrew Downing — who now serves as a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

Downing declined to comment and HHS did not respond to requests for comment for this article.

Downing, who has represented hundreds of plaintiffs in vaccine court in Washington, D.C., signed on to take their case, according to reviewed by ���ϳԹ��� News. They agreed Downing would pursue the claim before the VICP.

Bostic shared documents and medical records as he requested them. Months passed as she waited for news on her son’s case.

After several months of making court filings, Downing told her it was time to opt out of the vaccine program and sue the drugmaker. When she refused to opt out, he withdrew from the case.

The government paid Downing $445 an hour for representing Bostic, for program attorneys with his experience, according to court records.

Three years later, Bostic said, she hasn’t received a dime for her son’s injury. Thomas, now 18, endures debilitating pain that doctors say may never go away.

Rather than help them work through the program, Bostic feels that Downing steered them away from it and toward a lawsuit against the manufacturer. The VICP ultimately dismissed her case.

Bostic was furious that the court paid Downing anything.

“Y’all could’ve gave that to me for my son,” she said. “How dare y’all.”

In Business With Washington

In June, Kennedy’s HHS also awarded Downing’s law firm, Brueckner Spitler Shelts, a to consult on an overhaul of the VICP. The contract has grown to $410,000. Downing is the only attorney listed on the firm’s website who has practiced in vaccine court.

Kennedy has routinely questioned vaccine safety and saying it shields drug companies from some liability “.” As a personal injury lawyer, Kennedy previously spearheaded civil litigation against vaccine maker Merck.

Downing and about a dozen other lawyers have transferred hundreds of clients from the vaccine program to civil suits, where the financial rewards — for patients and their lawyers — could run far higher, according to a ���ϳԹ��� News analysis of court records and program data. They’ve collected millions of taxpayer dollars in attorneys fees from vaccine court while launching precisely what it was designed to avoid: lawsuits against vaccine manufacturers.

This shift in legal strategy has fueled Kennedy’s crusade against Merck, and it could end up hurting some vaccine-injured clients, several experts said.

University of California Law-San Francisco professor Dorit Reiss has studied vaccine court for over a decade and has tracked the rise of anti-vaccine forces in American politics. She said VICP attorneys who are also suing vaccine makers have “incentives to direct more people” to lawsuits, “when it might not be in their best interest.”

A Delicate Balance

Kennedy has criticized the VICP as a barrier to accountability. But for Bostic, vaccine court offered an opportunity to hold the government to its promise of caring for casualties of widespread immunization.

Like any medication, vaccines can have side effects. Serious reactions to routine shots are rare, but for the unlucky few who bear this burden, the government promises recourse through its administrative program.

Vaccine court aims to strike a balance between protecting public health and helping individuals who may pay its price. The no-fault program allows claimants with vaccine-related injuries to get help without showing that the vaccine maker did anything wrong, even when the evidence doesn’t meet courtroom standards.

The program has made more than 12,500 awards, totaling roughly $5 billion in compensation. Historically, nearly half of claims have been resolved with some kind of award.

If patients aren’t satisfied with the outcome or don’t get a ruling within 240 days, they may leave the administrative program and sue the vaccine maker in civil court. Plaintiffs could potentially win larger awards. Lawyers could obtain higher fees, which they can’t in vaccine court.

But winning a civil suit is far more difficult, in part because plaintiffs have a greater burden of showing the vaccine caused their injury and that the maker was at fault. Since the VICP was created, no vaccine injury lawsuit has won a judgment in regular court, records show.

That hasn’t stopped some lawyers from trying. After the requisite 240 days, they have transferred hundreds of VICP claims into civil litigation against HPV vaccine manufacturer Merck, the ���ϳԹ��� News analysis found.

The lawyers who represented those claims include Downing and other VICP attorneys with ties to Kennedy, court records show. Those include Kennedy advisers and people who work in the law office of his longtime personal lawyer Aaron Siri or with Children’s Health Defense, the anti-vaccine outfit Kennedy founded, as well as a former Kennedy co-counsel in suits against Merck over its HPV vaccine, Gardasil.

Downing, whose describes him as “one of the preeminent litigation attorneys in the Court of Federal Claims,” has not won an HPV vaccine injury claim in the past five years, records show. Vaccine court did compensate dozens of HPV vaccine claims in that time, but most — including nearly all of Downing’s — were withdrawn upon reaching the opt-out period.

VICP data and court records show that over the past five years, Downing and other lawyers withdrew roughly 400 Gardasil claims from vaccine court before a ruling was issued. The plaintiffs received nothing from the program. Hundreds of these cases joined the litigation against Merck, according to court records.

Once the opt-out period arrived in Bostic’s case, Downing informed her that he was preparing to withdraw her son’s claim and move the case back to the original law firm for a lawsuit against Merck.

“That,” he wrote in an email, “was the plan all along.”

Fighting for Compensation

Thomas, who hopes to enroll in community college and become a computer programmer, has intermittent numbness in his fingers and stabbing sensations in his arm nearly every day. The pain often radiates across his back or up his neck, and he’s developed migraines. Once an active kid who dreamed of playing basketball professionally, he now spends his time playing video games and trying to sleep during lulls in his pain.

Bostic’s claim on behalf of her son made him one of about 1,000 people who have filed with vaccine court for HPV vaccine injuries. More than 200 have received compensation — just over one for every million shots given. Court records show program awards were typically $50,000 to $100,000, with some also covering past medical bills or future health care expenses.

Richard Hughes IV, a health care attorney and former pharmaceutical executive who teaches vaccine law at George Washington University Law School, reviewed Thomas’ records and said cases like his were exactly what the vaccine program was designed to address.

“That just seems straightforward,” Hughes said of Thomas’ claim. “That should have gotten compensated.”

Bostic wanted the federal agencies that had approved and recommended Gardasil to answer for her son’s injuries. The single mother hoped compensation from the program would allow Thomas to see specialists including neurologists, afford natural treatments, and enroll in physical therapy.

“He would have had the best of the best health care,” she said.

When Downing took their case, Bostic said, he told her during a phone call that vaccine court’s $250,000 limit on pain and suffering was too low for her son’s injury. Bostic said Downing advised she could get more money by suing Merck, though that could take longer.

“I said, ‘No, that will take years. My son needs help now,’” Bostic recalled.

Bostic said she told Downing she wanted a fund set up for Thomas’ health care as soon as possible.

In the following weeks, Bostic sent paperwork to Downing’s office but had difficulty getting in touch with him, email and text messages show. Downing’s show a gap in his work on the case from late September until mid-November.

In November 2022, Downing emailed Bostic, “The opt out date for K.T.’s case is set for April 23, 2023. At that point, we will be in a position to opt K.T.’s case out of the Vaccine Program and move the case back over to the Carlson Law Firm for handling in the Merck litigation.”

Bostic said she was confused at the time by that language. But she remembers being emphatic in a follow-up phone call with Downing, repeatedly telling him she would not opt out.

After that, Bostic said, she didn’t hear from Downing for months despite calling his office and leaving messages with secretaries.

Downing’s billing records show that he and his paralegals spent fewer than nine hours on Bostic’s case in that stretch. This included time spent requesting, reviewing, and filing medical records, as well as drafting and filing extension requests. The billing records did not include any communication with Bostic during that time.

The court granted each of Downing’s extension requests, pushing back the deadline a month at a time.

In April 2023, Downing sent Bostic an email noting that 240 days had passed, so he could drop their government claim and they could sue Merck.

“Gardasil cases do not receive very fair treatment in the Vaccine Program,” Downing wrote, adding that he would withdraw as her attorney if Bostic stayed in the program.

Bostic chose to stick with vaccine court, later telling the vaccine court judge by email that she’d advised her attorney “I was not trying to become a millionaire.”

That exchange of emails in April is when Bostic said she learned Downing was already representing plaintiffs in lawsuits over Gardasil. The litigation encompassed hundreds of other patients who — most of them under Downing’s counsel — had filed VICP claims in recent years.

Running out the 240-day clock, critics say, is allowed but subverts the program’s intent.

Some legal experts criticize the way Downing handled Bostic’s case.

“They trusted him to file the VICP case,” Reiss said. “It’s his job to zealously advocate for his clients. In this case, his clients want to go through VICP. It’s his job to fight for them in VICP, not to wait for 240 days.”

When Downing joined HHS as a senior adviser to Kennedy, court records show, he handed off his remaining vaccine court cases to other attorneys in firms involved in the litigation against Merck.

A New Approach

The vaccine program has long faced criticism for giving claimants too little, too late. Even VICP advocates see the need for reform, with eight officials deciding a growing , driving up wait times. The cap on pain and suffering payments has not changed since 1986. But the court can award further compensation like a fund for lifetime medical care that can reach millions.

Most vaccine-injured individuals are better off in the administrative program than in civil litigation, legal experts said.

Renée Gentry, director of GWU’s Vaccine Injury Litigation Clinic and a founding member of the Vaccine Injured Petitioners Bar Association, has represented hundreds of families alleging vaccine injuries. Most of them, she said, aren’t focused on big payouts; rather, they “want their kid taken care of or they want to be taken care of.”

For claims that often fail in vaccine court, however, Gentry said a lawsuit may be the best option. According to Gentry, HPV vaccine claims like Thomas’ are particularly challenging to win in the VICP.

“If you’re not going to win, then you want those clients to have at least an opportunity at something,” she said.

For Mark Sadaka, a prominent vaccine court lawyer representing some claims in Merck litigation, sending clients to regular court is a last resort.

Sadaka said certain Gardasil injury claimants, such as those alleging mental rather than physical harm, might be better off in litigation. But by sticking it out in the VICP, Sadaka has won HPV vaccine injury claims that were the first of their kind, including for narcolepsy, alopecia, and even a deadly arrhythmia.

“He’s going to get taken care of for the rest of his life,” Sadaka said of his client who won compensation for narcolepsy in 2023. “And he doesn’t have to pay me anything.”

Sadaka, like all program lawyers, gets an hourly rate from the VICP. He said that he could make much more money representing the same claims in traditional litigation, since he could get a cut of any awards.

“It’s a better thing for me to file in regular court and get a higher fee, but for the client, sometimes it makes sense, sometimes it doesn’t,” Sadaka said. “My role is to explain both sides in gross detail for them and give them as much information as possible so they can make an informed decision.”

According to Sadaka, some lawyers in the VICP automatically advise their clients to leave vaccine court and file a lawsuit.

“If they can extract settlements, they’re going to be very happy to put that money in their pockets,” Hughes noted.

Winning a lawsuit or reaching a major settlement could also spell trouble for nationwide vaccine access, replaying the events that gave rise to vaccine court in the 1980s.

Some vaccine lawyers and policymakers believe Kennedy and his colleagues might welcome a return to those days.

“If they can bring down the system, that’s a feather in their cap,” Hughes said.

Lawyers cannot win contingency fees in vaccine court. They get paid for time spent on reasonable claims whether they win or lose. Downing made more than $1 million representing clients before the VICP in recent years, according to court records.

A shows that since fiscal year 2020, the program has paid scores of attorneys about $280 million — including over $43 million for cases they did not win.

In each of the last two fiscal years, lawyers got roughly $9 million for VICP claims in which their clients got nothing. That was more than the program had ever previously paid to attorneys for unsuccessful claims, according to vaccine court data.

‘Learning How To Cope’

After discovering her attorney would not pursue VICP compensation for her son, Bostic decided to advocate for Thomas herself.

“Please help me,” she wrote in a letter to the court.

VICP staff gave Bostic extra time to find a new lawyer and gather records.

The following months proved difficult for the family. Bostic was hospitalized with a life-threatening condition. Her mother’s health declined. She was laid off and lost her family’s health insurance.

By the time Bostic could take Thomas to a pediatric neurologist to get medical records for his VICP case, she said, the doctor had moved hours away to Orlando.

Bostic repeatedly missed deadlines and failed to communicate with program staff as required, court records show. Emails, docket entries, and letters suggest she may have misunderstood some court orders and not received others.

When Thomas’ medical records remained incomplete for another year, the presiding official dismissed Bostic’s claim, writing that while he had sympathy for what she and her son had endured, “the case cannot be allowed to remain pending indefinitely.”

Thomas said he can no longer play basketball with friends. He can’t even help his mother carry groceries into the house.

“I got to live with this, and there’s pain,” he said.

Bostic now works from home as a bank fraud analyst. With an income just above the cutoff for government assistance, she puts in overtime in hopes of affording health insurance for Thomas and her six other children.

“People are asking, ‘How’s your son doing?’” Bostic said. “I normally say, ‘Still the same. We just learning how to cope with it.’”

Methodology

The ���ϳԹ��� News analysis began with court records for cases in the U.S. Court of Federal Claims, which includes vaccine court. We first identified all cases since 2006 (when the HPV vaccine was introduced) in which the “nature of suit” field explicitly mentioned human papillomavirus, or in which “nature of suit” was categorized as “other” vaccine injury/death and the case text included the word “papillomavirus.” The latter made up about 10% of identified cases, mostly claims filed before the HPV vaccine was added to the program or claims involving multiple vaccines. We cross-referenced the number of cases with data from VICP reports to verify completeness.

After identifying the relevant vaccine court cases, we pulled these claims’ filing and closing dates and took the difference to find the number of days that each case spent in vaccine court. To estimate total attorneys fees awarded for these claims, we added the fee amounts recorded in dozens of the VICP rulings and derived a minimum estimate based on the number of such cases.

We then searched federal court records for litigation over Merck’s HPV vaccine, Gardasil, and pulled the names of the plaintiffs and attorneys involved. To gauge the scale of claims diverted from the VICP to litigation, we searched for each attorney in the Gardasil-related vaccine court cases and searched for the last name of each plaintiff in the titles of those cases.

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“It’s just the cost of doing business with our borders being somewhat porous for global and international travel,” Abraham said. “We have these communities that choose to be unvaccinated. That’s their personal freedom.”

Infections from other countries, however, accounted for only of measles cases detected since Jan. 20, 2025, the official start of the deadly measles outbreak in West Texas, which spread to other states and Mexico. The rest were acquired domestically. This marks a change since the U.S. eliminated measles in 2000. Measles occasionally popped up in the U.S. from people infected abroad, but the cases rarely sparked outbreaks, because of extremely high rates of vaccination. Two doses of the measles, mumps, and rubella vaccine strongly prevent infection and halt the virus’s spread.

To maintain its measles elimination status, the U.S. must prove that the virus has not circulated continuously in the nation for a year, between Jan. 20, 2025, and Jan. 20, 2026. To answer the question, scientists are examining whether the major outbreaks in South Carolina, Utah, Arizona, and Texas were linked.

Health officials confirmed that the main measles virus strain in each of these outbreaks is D8-9171. But because this strain also occurs in Canada and Mexico, CDC scientists are now analyzing the entire genomes of measles viruses — about 16,000 genetic letters long — to see whether those in the United States are more closely related to one another than to those in other countries.

The CDC expects to complete its studies within a couple of months and make the data public. Then the Pan American Health Organization, which oversees the Americas in partnership with the World Health Organization, will decide whether the U.S. will lose its measles elimination status. And that would mean that potentially deadly, and preventable measles outbreaks could become common again.

“When you hear somebody like Abraham say ‘the cost of doing business,’ how can you be more callous,” said pediatrician and vaccine specialist Paul Offit, in an hosted by the health blog on Jan. 20. “Three people died of measles last year in this country,” Offit added. “We eliminated this virus in the year 2000 — eliminated it. Eliminated circulation of the most contagious human infection. That was something to be proud of.”

Abraham said vaccination remains the most effective way to prevent measles but that parents must have the freedom to decide whether to vaccinate their children. Several states have loosened school vaccine requirements since 2020, and vaccine rates . A record rate of kindergartners, representing about obtained vaccine exemptions for the 2024-25 school year.

Information on vaccines has been muddied by Health and Human Services Secretary Robert F. Kennedy Jr., who previously founded an anti-vaccine organization. He has undermined vaccines throughout his tenure. On national television, he has repeated scientifically debunked rumors that vaccines may cause autism, .

Jennifer Nuzzo, director of the Pandemic Center at Brown University, disparaged the Trump administration’s focus on finding genetic technicalities that may spare the country’s measles-free status. “This is the wrong thing to pay attention to. Our attention has to be on stopping the outbreaks,” she said.

“If we keep our status, it should be because we have stopped the spread of measles,” she said. “It’s like they’re trying to be graded on a curve.”

The Trump administration impeded the CDC’s ability to assist West Texas during the first critical weeks of its outbreak and slowed the release of federal emergency funds, according to ���ϳԹ��� News investigations. However, the agency stepped up its activity last year, providing local health departments with measles vaccines, communication materials, and testing. Abraham said HHS would give South Carolina $1.5 million to respond to its outbreak, which began nearly four months ago and had reached 646 cases as of Jan. 20.

If the CDC’s genomic analyses show that last year’s outbreaks resulted from separate introductions from abroad, political appointees will probably credit Kennedy for saving the country’s status, said Demetre Daskalakis, a former director of the CDC’s national immunization center, who resigned in protest of Kennedy’s actions in August.

And if studies suggest the outbreaks are linked, Daskalakis predicted, the administration will cast doubt on the findings and downplay the reversal of the country’s status: “They’ll say, who cares.”

Indeed, at the briefing, Abraham told a that a reversal in the nation’s status would not be significant: “Losing elimination status does not mean that the measles would be widespread.”

Data shows otherwise. Case counts last year were the highest since 1991, before the government enacted vaccine policies to ensure that all children could be protected with measles immunization.

Lauren Sausser contributed reporting.

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They wrote that the claims and policy changes in the memo from Vinay Prasad, the head of the FDA’s Center for Biologics Evaluation and Research, pose “a threat to evidence-based vaccine policy and public health security” and break sharply from long-standing scientific norms.

What is unfolding inside the FDA is not a narrow dispute over covid vaccines. It is an attempt, according to critics and vaccine scientists, to rewrite the rules governing the entire U.S. vaccine system — how risks are weighed, how benefits are proved, and how quickly lifesaving shots reach the public. Former agency leaders warn that if these changes take hold, the consequences could be lasting: fewer vaccines, slower updates, weakened public trust, and more preventable outbreaks.

Prasad made clear he sees the moment as corrective. “Never again will the US FDA commissioner have to himself find deaths in children for staff to identify it,” he wrote, telling employees the agency’s mission, and its “worldview,” would change.

Prasad’s email reopened old arguments about covid vaccines, using what is generally considered weak and misleading science in the peer-reviewed research community. He claimed that FDA staff had found “at least 10” deaths in children that happened “after and because of” covid vaccination, using reports from the .

The VAERS system is notoriously crowdsourced, meaning anyone can contribute, and scientists say it serves only as a clearinghouse for reports. For example, a person could file a report saying that after getting a flu shot, their hair turned purple. Though that report would remain in the database until it was reviewed, it cannot prove the cause of medical events. But Prasad argued that the true number of deaths was likely higher because many cases go unreported.

On Substack, that Prasad used incomplete information and that a Dec. 5 internal FDA memo set the pediatric death toll from covid shots somewhere between zero and seven. Department of Health and Human Services spokesperson Emily Hilliard wrote, “The FDA’s investigation into deaths caused by Covid vaccines is still ongoing and there’s no final count yet of those deaths.”

Prasad also accused the FDA and the Centers for Disease Control and Prevention of downplaying the risk of heart inflammation, called myocarditis, in young men; criticized the agency for approving shots for teenagers; and suggested that school and workplace vaccine mandates may have “harmed more children than we saved,” adding that “we do not know if we saved lives on balance.”

By comparison, died of covid itself since the pandemic began, the CDC reported.

Based on his erroneous and misleading claims about covid vaccines, Prasad proposed a major overhaul of how vaccines are approved. He said the FDA should stop relying on immune markers to establish the efficacy of shots, such as antibody levels, and instead require large placebo-controlled randomized trials that track hospitalizations and deaths before approving most new vaccines.

Many immunologists and vaccine experts say it’s unethical to test vaccines known to be effective against disease with a control group that would receive a placebo, exposing them to infection.

“There is a rock-solid principle in bioethics that it is unethical to test any drug or vaccine against a placebo if it is known to be safe and effective. The reason is that such placebo-controlled trials would effectively deny patients access to a vaccine that could prevent a dangerous infectious disease,” said Lawrence Gostin, a professor of global health law at Georgetown University.

Prasad called the current flu vaccine system an “evidence-based catastrophe,” questioned the approval of vaccines for pregnant women based on immune response alone, and raised concerns about giving multiple vaccines at once. He told staff to rewrite FDA guidelines to match his new “worldview” and said anyone who disagreed with his “core principles” should resign.

The former FDA leaders expressed alarm in the NEJM article. They said Prasad is exploiting public frustration over the federal response to covid to spark doubt about the entire childhood vaccine system, which could undo decades of success in protecting children from deadly diseases.

“This is really different. And it’s really dangerous. And people will be hurt, particularly by the vaccine decisions,” former FDA commissioner Robert Califf said in an interview. He also warned that Prasad’s proposed policies — which he noted echo positions on vaccines held by Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist — could shake the entire vaccine market.

“The goal of RFK seems to be to make it impossible for vaccines to be available in the U.S.,” he said. If the proposals advance, he added, “it won’t be a viable business.”

Hilliard pushed back sharply on those concerns, writing: “The American people deserve evidence-based science. Prasad’s email lays out a philosophical framework that points us toward that higher standard. We will soon release documents laying out that framework and data confirming how the COVID vaccine resulted in children’s deaths that previous leadership failed to properly investigate.”

For generations, the childhood vaccine program has depended on clear rules, strong safety systems, and public trust. Experts say Prasad’s ideas, based on claims they argue are not supported by real evidence, could make it much harder to test, approve, and deliver vaccines to families.

Fueling Parental Doubt

Prasad’s memo indicates he considers VAERS reports as proof that vaccines caused children’s deaths. The system, though, is designed to be only an “” for potential safety issues with vaccines that can be investigated further.

“VAERS signals should never be taken as proof of true vaccine risks without careful, confirmatory studies,” said Katherine Yih, an epidemiologist and longtime investigator with the Vaccine Safety Datalink, a CDC program.

Doing so, scientists say, directly feeds public fear at a time when many parents are already unsure whom to trust.

“Causation requires converging evidence, not just one report or coincidence,” said Robert Hopkins, medical director of the National Foundation for Infectious Diseases.

Prasad’s framework, however, treats uncertainty as a reason to halt development entirely.

Experts fear this doubt won’t stay limited to covid vaccines. Once parents start to question the FDA’s honesty, they may begin doubting long-standing vaccines for measles, polio, or whooping cough — shots that have protected children for decades.

“Science must be transparent,” Gostin said. If families believe the FDA is misusing data or silencing experts, confidence in the entire vaccine system can collapse, he said. “There’s a public narrative that people have lost trust in science, but that’s not true. The vast majority want the FDA to make decisions based on the best scientific evidence. Once they believe that the agency is marginalizing scientists and cherry-picking evidence, their trust will plummet.”

Delicate Vaccine Pipeline

Prasad’s new framework will likely make it far harder for companies to produce or update vaccines. The 12 former FDA commissioners warned that requiring clinical trials for all new or updated shots would slow vaccine improvements and leave people unprotected. His plan, they wrote, “would impede the ability to update vaccines in a timely fashion, especially for respiratory viruses.”

For fast-changing viruses like flu and covid, this could be disastrous. There’s simply not enough time to run full clinical trials every time a virus mutates.

There are also major business effects. Vaccine development is costly, and companies may decide the U.S. is no longer worth the risk. If companies slow down or leave the market, families could face shortages, fewer innovations, and fewer protections for their kids.

‘Checks and Balances’

Science depends on open and public debate. Prasad’s memo warned his employees against it. In addition to demanding that FDA staff members who disagree with him resign, he said their disputes should stay private and called leaks “unethical” and “illegal.”

Susan Ellenberg, a former director of the FDA’s Office of Biostatistics and Epidemiology, warned that Prasad risks destroying the process that makes science credible. “If disagreement is treated as disloyalty, you lose the only mechanism that keeps science honest,” she said.

Without strong internal debate, safety reviews become weaker. “You lose the checks and balances that make vaccine safety science credible,” said Kathryn Edwards, a pediatric infectious disease specialist at Vanderbilt University Medical Center who served on the Clinical Immunization Safety Assessment Network during the covid pandemic.

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

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

Lizzy Lawrence: The politicization of science.��

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

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

Also mentioned in this week’s podcast:

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

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

Julie Rovner:��Hello,��from ���ϳԹ��� News and WAMU Public Radio in Washington, D.C., and welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for ���ϳԹ��� News, and��I’m��joined by some of the best and smartest health reporters in Washington.��We’re��taping this week on Thursday,��Dec.��18,��at 10��a.m. As always, news happens fast,��and things might have changed by the time you hear this. So, here we go.��

Today, we��are joined��via video conference by Tami Luhby of CNN.��

Tami Luhby:��Hello.��

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

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

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

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

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

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

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

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

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

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

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

Luhby:��Exactly.��

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

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

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

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

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

Luhby:��Thank you.��

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

Luhby:��Right.��

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lawrence:��Right.��

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

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

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

Rovner:��Oops.��

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner:��Oh, it is drinking water.��

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

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

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

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

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

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

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

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

Leys:��$9,250.��

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

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

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

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

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

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

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

Leys:��I have not heard.��

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

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

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

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

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

Leys:��Thanks for having me, Julie.��

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

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

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

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

Rovner:��Alice.��

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

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

Rovner:��Lizzy.��

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

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

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

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

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

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

OK, that is this week’s show and our last episode for 2025. Thank you to all of you listeners for coming with us on this wild news ride. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer-engineer, Taylor Cook. A reminder:��What the Health?��is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as,��of course, kffhealthnews.org. Also, as always, you can email us your comments or questions.��We’re��at��whatthehealth@kff.org, or you can still find me on X��, or on Bluesky��. Where are��you guys��hanging these days, Alice?��

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

Rovner:��Tami.��

Luhby:��You could find me at��.��

Rovner:��Lizzy.��

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

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

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This story can be republished for free (details).

Congress is running out of time to avert a huge increase in health care premium payments for millions of Americans who buy insurance through the Affordable Care Act marketplaces. Dec. 15 is the deadline to sign up for coverage that begins Jan. 1, and some consumers are waiting to see whether the credits will be extended, enabling them to afford coverage next year.

Meanwhile, a federal vaccine advisory panel handpicked by Health and Human Services Secretary Robert F. Kennedy Jr. voted last week to end the universal recommendation for a hepatitis B vaccine dose at birth. It’s just the start of what are expected to be major changes in childhood vaccine recommendations overall.

This week’s panelists are Julie Rovner of ���ϳԹ��� News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sheryl Gay Stolberg of The New York Times.

Panelists

Among the takeaways from this week’s episode:

• As of Thursday morning, the Senate was preparing to vote on competing health proposals, neither of which was expected to pass: one, from Democrats, that would extend the enhanced ACA premium tax credits and a second, from Republicans, that would instead add money to health savings accounts for some ACA enrollees. With the credits set to expire and time running out to sign up for plans, it is likely that coverage will be unaffordable for some Americans, leaving them uninsured.
• The Advisory Committee on Immunization Practices’ decision to end its recommendation that newborns be immunized against hepatitis B is a major development in the federal government’s shift away from promoting vaccines. While the panel coalesced around the claim that babies are most likely to contract hepatitis B from their mothers, the reality is that the virus can live on household items, posing a threat of chronic disease and death to unvaccinated children.
• In reproductive health news, House Speaker Mike Johnson removed insurance coverage of fertility treatment for service members from the National Defense Authorization Act before the legislation’s passage, and anti-abortion groups are calling for the firing of Food and Drug Administration head Marty Makary over reports he is slow-walking policy changes on medication abortion.

Also this week, Rovner interviews Georgetown University professor Linda Blumberg about what the GOP’s health plans have in common.

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

Julie Rovner: The Washington Post’s “,” by David Ovalle.����

Anna Edney: Bloomberg News’ “,” by Anna Edney.����

Sheryl Gay Stolberg: The New York Times’ “,” by Katie J.M. Baker.

Maya Goldman: ProPublica’s “,” by Aliyya Swaby.

Also mentioned in this week’s podcast:

• Politico’s “,” by Alice Miranda Ollstein, Ruth Reader, and Liz Crampton.
• The New York Times’ “,” by Sheryl Gay Stolberg and Christina Jewett.
• Bloomberg News’ “,” by Charles Gorrivan, Riley Griffin, and Rachel Cohrs Zhang.
• The Associated Press’ “,” by Ali Swenson and Nicky Forster.

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

Julie Rovner:��Hello from ���ϳԹ��� News and WAMU Public Radio in Washington, D.C.��Welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for ���ϳԹ��� News, and��I’m��joined by some of the best and smartest health reporters in Washington.��We’re��taping this week on Thursday,��Dec.��11,��at 10��a.m. As always, news happens fast,��and things might have changed by the time you hear this. So here we go. Today, we are joined via video conference by��Anna��Edney��of Bloomberg News.��

Anna��Edney:��Hi,��Julie.��

Rovner:��Maya Goldman of Axios News.��

Goldman:��Great to be here.��

Rovner:��And��I’m��pleased to welcome to the podcast panel my friend and longtime health reporting colleague, Sheryl Gay Stolberg��of��The New York Times. Sheryl, so glad to have you��join��us.��

Stolberg:��I’m��so glad to be here, Julie.��

Rovner:��So,��later in this episode,��we’ll��have my interview with Linda Blumberg of Georgetown University. Linda has spent years analyzing Republican proposals to fix health��care and has some interesting observations to share. But first, this week’s news.��

We will start again with the continuing saga of the expiring enhanced tax credits for the Affordable Care Act.��Starting Jan.��1, millions of people who get their insurance from the Obamacare marketplaces will face huge increases in what they have to pay in premiums.��Some will find those increases so big��they’ll��have no choice but to drop their insurance altogether. And next Monday, Dec.��15,��is the deadline for people to sign up for coverage that starts in January. So,��the Senate is set to vote today on two different options. The first, backed by all the��chamber’s Democrats, calls for a straight,��three-year extension of the enhanced payments that were first implemented in 2021.��Those extra payments made insurance so much more affordable that enrollment��basically doubled��from about��12 million people��in the��marketplaces to about 24 million. That bill,��though,��is unlikely to achieve the 60-vote majority it would need to advance. The Senate is also scheduled to consider a Republican alternative,��sponsored by Finance Committee��Chairman��Mike Crapo of Idaho and Health Committee Chair Bill Cassidy��of Louisiana. It��wouldn’t��extend the enhanced tax credits at all. Instead, it would provide either $1,000 or $1,500 for a tax-preferred health savings account that individuals could��use for��routine health expenses to be coupled with��a high-deductible insurance��policy.��“High-deductible”��meaning��many thousands of dollars.��It’s��not��expected to achieve 60 votes either.��So,��assuming��both of these��plans fail to��muster��the��needed 60 votes, where does that leave us?��

Edney:��I think that��leaves us looking for what the next turn of the key will be. I mean, will they be able to come to some��agreement on extending the tax credits��—��likely��—��or the subsidies��—��likely after.��Like you said, enrollment has been underway,��and people are enrolling even though they��don’t��really know what the fate of these will be. So,��it’ll��be interesting to see how the marketplace reacts given what happens.��But I don’t think there’s a��really clear��idea yet, except that everyone thinks that something might start moving once these votes are dispensed with.��

Stolberg:��I think what��happens is that a lot of Americans are going to lose their health insurance.��We know that the number of Americans insured on the Obamacare��exchange is more than double after the enactment of these extended tax credits in 2021.��I think there��were 11 million;��now there are 24 million. And people, as you said in the outset,��have to��decide now. And��maybe they’ll��sign up now.��But if they lose these credits,��I think that a lot of folks��are going to suddenly find themselves without insurance coverage. And I think politically for Republicans, that is going to be a big problem going into next year’s midterms.��They know this, and that’s why they’re scrambling to come up with some kind of alternative that does not have Obamacare in its name.��But we also know that the alternatives that��they’re��proposing��won’t��go��very far��in terms of offsetting��out-of-pocket��costs for people who are struggling to pay for health��care.��

Rovner:��Things are starting to bubble up in the��House,��too. I mean,��we’ve��seen this.��… We knew we were going to have this Senate vote, which is everybody protected by everyone to be a show vote, but now Republicans in the House are getting skittish as well.��

Goldman:��Yeah, absolutely. And��we’ve��seen a��couple��different��proposals in the House. So,��there are some moderates that are Republican moderates that are proposing��a��straight,��two-year extension. I think, like Anna said,��we’ll��see what happens after the Senate votes today,��if��that brings people to the table or not. I think one thing that struck me this week is��The Associated Press reported that����are��actually slightly��ahead of where they were at this time last year.��But of course, that��doesn’t��mean that��that’s��going to result in more overall enrollment. There��is still a lot that needs to be ironed out there.��One thing that��I’m��wondering is:��Is health coverage just something that people are��biting��the bullet��on at this point? And they’re like,��Well, I know it’s��really expensive, but I still need to have health insurance.��And is that going to��…��even if people do drop off,��we’re��so far away, politically speaking, from the November elections, that,��is that��actually going��to resonate still? I��don’t��know.��

Rovner:��Yeah. I mean, one of the things that��… I saw that AP story,��too,��that enrollment is��actually higher��than it was last year at this time.��But you��have to��worry if��there’s��going to be what they call the death spiral,��where only the people who need insurance the most sign up. You��have to��wonder whether these are the people who would sign up no matter what. And��it’s��the healthier people for whom��it’s��a bigger question mark��—��whether they��actually need��the health��insurance at this much higher price��—��who are��probably waiting��right now. If��you’re��sick,��you’re��probably going��to sign up no matter what. So,��in some ways, I wondered if that was more of a warning signal than anything else.��

Goldman:��That’s��a great point.��

Stolberg:��I think the death spiral��is a real concern, especially with the plan that Cassidy and Crapo are putting forward. It would drive people into either catastrophic plans or��“bronze”��plans, which are lower costs, but��high-deductible. And the people who are going to get into those plans are healthy people. That is going to deprive the��risk��pools for sick people of the��healthy. And we know what happens when the��risk��pools become imbalanced like that.��Then insurance costs really skyrocket for the people who need it most.��

Rovner:��Yeah. Now, even if Republicans do decide they want to sue for peace, if you will, there are a lot of other obstacles to a bipartisan deal.��We’ve��talked��about abortion.��But it looks��like there are other things that Republicans want to do that Democrats are not going to want to accept.��

Stolberg:��Such as ending support for IVF��[in vitro fertilization]��coverage like they did in the��defense��bill��this week?��

Rovner:��Yeah, which��we’ll��get to in a little while.��

Stolberg:��OK.��

Rovner:��Yeah. I mean, I could see a bipartisan deal.��I’m��just dubious partly��—��and��we’ve��said this, I think, every week for the last five or six weeks��—��that Republicans��won’t��vote for an extension without permanent abortion restrictions,��and Democrats��won’t��vote for an extension with permanent abortion restrictions. But I know that some of these Republican bills also would deprive legal immigrants. There are anti-fraud provisions, some of which might be supported by Democrats, some of which might be seen as so onerous that they would prevent legitimate people from legitimately signing up.��Does anybody��actually see��a bipartisan deal happening?��I guess how scared do Republicans��have to��get before��they’re��willing to do something that the Democrats would agree to?��

Stolberg:��I��don’t��see a bipartisan bill happening in time. I mean, Cassidy said at this hearing last week, literally pleading with his��colleagues saying,��We��can talk about grand plans,��Bernie��[Sanders, I-Vermont]��can talk about��“Medicare for All,”��and we can talk about this, but we got to do something in three weeks.��Well, now��it’s��two weeks,��and��they’re��not going to come to some compromise, especially not one involving abortion or undocumented immigrants by Christmas.��It’s��not going to happen.��

Rovner:��Yeah. Congress loves to give itself deadlines and then not meet them.��

Goldman:��Absolutely. And��I think we��have Republicans with their grand plans,��and you��can’t��implement a full HSA��[health savings account]��expansion in the time that��they’ve��allotted.��That’s��just not��practicable.��

Rovner:��Yeah.��I think this��is a war of talking points at this point. All right. Well, the ACA may be this week’s news, but I��don’t��want to��miss out on��the vaccine news from late last week after we taped. As��predicted, HHS Secretary RFK Jr.’s��[Health and Human Services Secretary Robert F. Kennedy Jr.]��handpicked CDC��[Centers for Disease Control and Prevention]��advisory committee on vaccine practices voted to roll back the universal recommendation for a first dose of the hepatitis B vaccine for infants,��right after birth. Instead, the panel recommended making the vaccine the subject of��“individual-based��decision-making.”��What’s��the difference between that and��actually recommending��the vaccine?��Is this a really big change?��Anna, Sheryl,��you guys��have been watching this closely.��

Edney:��Yeah, I think that��it’s��a big change��in the sense that it can be��pretty confusing��for parents.��And it injects this idea of the vaccine��possibly being��harmful��—��although��that’s��not something��that’s��seen in the data��—��and also��that��maybe it’s��just not that big of a deal, which is the problem of the success of the vaccine is the vaccine works. Hepatitis B cases in newborns go down,��and people think,��Oh, well, we��don’t��really have to worry about this anymore.��But��that’s just��not the case. Obviously, as��we’ve��seen with other diseases of late, these things can come back.��

And��so��I think��it’s��not going to change��at the moment, at least, necessarily insurance coverage for having the vaccine, but it does leave open this door that,��Well,��maybe you��should talk to your doctor, see if��it’s��really the best thing.��And��there’s��just a lot coming at you as a new parent or a parent with a new child on the way,��and a lot of medical advice to wade through,��and things like that. So,��this adds an extra piece to that for which a lot of the medical societies and doctors, Sen.��Cassidy included, have said,��This��isn’t��something that��we’ve��had a big question mark on.��It’s been��actually really,��really helpful��in the health of children.��

Rovner:��Yeah. Hepatitis B cases in children and teens have gone down 99%.��

Stolberg:��That’s��right,��since 1991.��I was going to say, I think this is a��really big��deal.��And it’s a��really big��deal for a couple of reasons.��One,��it’s��not��science-based.��There’s��no evidence that delaying the vaccine makes it any safer for children.��Two, it’s a��really big��deal because of the debate that Kennedy and his allies have created around what was once not given any thought.��And��it’s��also a big deal because,��as doctors will tell you, in theory, one could argue, as Kennedy and his group do, that this is a disease��that’s��transmitted sexually,��or��it’s��transmitted through intravenous drug use. And for infants, the real risk is mother-to-child transmission. Well,��first of all,��that’s��not entirely true. The virus can last and live on household items like��scissors,��or��tables,��or whatever. We know that newborns are the ones that are most at risk.��

And we also know that the best time to capture or vaccinate a newborn is when��they’re��there in the hospital,��and they have access to medical professionals who can administer the vaccine. And unlike countries like Denmark, which follow��up their babies, our babies��don’t��get that kind of follow-up. And��so��the likelihood is that kids will not get vaccinated when��they’re��older. Parents will forget about it,��and they will have missed that critical opportunity to be protected against an infection that can cause chronic liver disease and death.��

Goldman:��Yeah. And there was a lot of discussion during the meeting on,��Oh, well, we need to do a better job of screening the mothers for hepatitis B,��and you should still get the newborn vaccine if you test positive, et cetera, et cetera.��But that’s not ACIP’s��[Advisory Committee on Immunization Practices]��job to say that we should be screening mothers,��so they��don’t��have any authority there to enforce that. And a CDC staff member said,��We’re��working on that.��But,��like Sheryl said, we��don’t��have the same��kind of system that they have in other countries,��where you can get those follow-up appointments,��and get women in for prenatal care that they need.��And��so��I agree,��it’s��going to be a huge, huge issue.��

Rovner:��Yeah. Well, speaking of those other countries,��later on��Friday after the meeting,��in news that some might have missed, President��[Donald]��Trump issued an executive order basically telling RFK Jr. that he can do anything he wants with the childhood vaccine schedule because he should compare it to our��“peer��nations.”��Sheryl, you had a big story last week about��. What are they?��

Stolberg:��Well, what I reported with my colleague Christina Jewett is that Kennedy has been on this two-decade crusade to really upend American vaccine policy.��Ultimately,��he��would like to end all mandates for childhood vaccination.��That’s��not within his purview.��That’s��in the purview of the states.��But he wants to revisit the entire childhood vaccine schedule. And you can��see in��what he has done by installing his allies, some of whom presented at this ACIP meeting last��week,��he’s��put them in key places. People like Mark��Blaxill, who is a parent of a child with autism, who was a founder of a group called Safe Minds, which was an advocacy group. Mark��Blaxill��now works for��the CDC.��He’s��a smart,��Harvard-educated��businessman, not a doctor, but he presented on hepatitis B. We saw Aaron Siri, Kennedy’s lawyer,��presenting on the childhood vaccine schedule.��

This is a committee that is supposed to be��comprised��of medical experts��—��people who are physicians��who’ve��administered care. And what we are seeing is Kennedy installing these people and others,��sprinkling them throughout the department,��or bringing them in,��to carry out his vision. And he was��very clear��about that vision in an interview with me. I mean, he��firmly believes, as he said��—��he was careful��—��he said that autism has gone up over these past decades,��and��it’s��the same time as the childhood vaccines have become��…��we’ve��had more widespread use of vaccines.��We’ve��also had more widespread drinking of pumpkin spice lattes,��as Kennedy’s critics note, but Kennedy has said��vaccines must be a potential culprit.��I thought��that��was��very interesting��that he put that word in��—��potential. It was a wiggle word. But frankly, what he thinks is that vaccines are responsible,��and he has said as much in other interviews.��

Rovner:��And yet, while this is going on at this��very high��level,��we’re��now having a huge and growing measles outbreak in South Carolina,��in addition to the one that��we’ve��already had in Texas.��This is really having an impact on parents’��willingness to have their children vaccinated. I mean, that,��I think at this point,��cannot be denied just by��the evidence.��

Edney:��Yeah. Fewer parents are getting their kids vaccinated for school.��They’re��getting more waivers and things like that,��too. So,��we do see that this is��definitely giving��parents who��maybe had��concerns,��or��have felt some kinship with the MAHA��[Make America Healthy Again]��movement as��it’s��grown, the��ability to do what they feel is right, less so following��the science.��

Stolberg:��Peter Hotez, who is at Baylor University, told me that he was not surprised when there was a��measles outbreak in Texas, and��in particular in��that part of West Texas, because vaccination rates in that corner of the state had been dropping precipitously in the years prior to the outbreak. And he said he could see it coming.��

Goldman:��I think��it’s��also,��it’s��not just people that are very in line with the MAHA movement at this point. I think if��you’re��not paying as close of attention as we are, the messages that��you’re��seeing are,��Vaccines are bad. We need to��look into��vaccines. I��don’t��know, should I get a vaccine? Should I give my children vaccines?��And I think��that’s��really taking hold.��

Rovner:��Another story that��we’re��going to follow��into��2026. All��right,��we’re��going to take a quick break. We will be right back.����

Turning to reproductive health, the last big bill Congress is trying to finish before leaving for the year is the National Defense Authorization��[Act]. And for the second year in a row, House Speaker Mike Johnson has ordered the removal of a provision passed by both the House and the Senate that would provide military��personnel��the same fertility coverage that other federal employees and members of Congress get. Right now, fertility treatments like IVF are only covered for those in the military who have service-related injuries or illnesses. I thought this was a priority for President Trump. At least he keeps saying that it is.��

Stolberg:��I think this��is daylight between Trump and Mike Johnson,��clearly.��

Rovner:��I have to say, I was surprised.��Since when��can the speaker just take something out of a bill that was passed by both the House and the Senate?��

Stolberg:��Also, not to mention that members of Congress have this coverage.��

Rovner:��That’s right, which they only got��fairly recently.��I’m��surprised that there’s, I would say, less��pushback. There obviously is��pushback. There��are people who are��really furious��about this, but��in the manner of how things work in��Congress,��this is��literally the��second time��he’s��done it. And his spokespeople admit that he did it. And he says,��Well, I only want this if��it’s��done ethically.��And a reminder,��he’s��from Louisiana, which is the state that has current restrictions on the destruction of excess embryos from IVF��that’s��made IVF difficult to obtain in that state.��It’s��one person exerting his will over the rest of the Congress.��

Stolberg:��Yeah. I think��that’s��the most interesting thing about it is the daylight between Johnson and Trump��and also��Kennedy on this��issue.��Because while Trump and Kennedy profess to be anti-abortion,��it’s��not really a top-of-mind issue for either one of them.��But it is for Johnson. And I guess I��can’t��imagine Trump vetoing the��defense bill, so��I guess this��is going to go through.��

Rovner:��Yeah, without it. Again.��Well, speaking of who it’s a priority for, much��[to]��the frustration and anger of the anti-abortion movement, a new report finds that the percentage of medication abortions using telehealth continues to grow, including those from states with shield laws that protect prescribers to states that have abortion bans, to patients in those states that have abortion bans, which��underlines a story from your colleagues at Bloomberg, Anna,��suggesting that FDA commissioner Marty Makary is����of the abortion pill that was promised to anti-abortion lawmakers, that he’s apparently slow walking that until perhaps after the midterms.��

I hasten to add that HHS��spokesman��Andrew Nixon denies the studies being deliberately delayed. But just the story has angered anti-abortion forces so much��[that]��they’re��now calling for Makary’s firing. And Missouri Republican Sen.��Josh Hawley,��who’s��been at the forefront of the fight against the abortion��pill, and I believe the person who got the promise for this study,��has called the allegations unacceptable and is demanding answers by this Monday. Combined with��what’s��going on with the carousel of center directors at the FDA, how much longer can Makary last under this continuing onslaught?��

Edney:��Yeah, what I was thinking of when you were talking about this story is this is just one in a tiny slice of all the things that��seem to be��coming at Makary and going��wrong,��and��calling into question his ability to manage the FDA. I think specifically��—��you were just mentioning this with abortion, Sheryl��—��that��it’s��not top of mind for Trump or RFK. So,��I’m��not sure that this is the thing that does him in unless Sen.��Hawley or something breaks on that end.��Maybe there��are some senators who will be upset enough as more, or��if,��more details come out.��

I think that��definitely Makary��appears to be fighting for his job.��I think there have been some��great stories��in��The Washington Post and��The Wall Street Journal talking about these discussions at the White House every few weeks,��where��should we keep doing this? Do we need to think of��maybe putting��someone different in leadership?��He’s��still there.��And so,��it seems that RFK is backing him��pretty publicly.��Obviously,��that can change at a moment’s notice.��So,��something to keep a��really close��eye on.��

Goldman:��Something that we’ve been talking about on my team related to that is that it’s going to be��really hard��to get anyone else approved through the Senate for any of these positions.��And they can install an acting director, but there are limits to how long that can last. And��so��I think that that is maybe partially helping with some job security for a lot of these people at these high levels.��

Stolberg:��I think it would be��very hard��to get someone else installed given the broken promises that Kennedy has made to Cassidy.��They’re��going to be very wary.��And also, Makary is in the arc,��or the spectrum,��of people who could fill that job.��He’s��actually��kind��of��moderate, if you will.��And I talked to someone close to Kennedy who said that Kennedy still has confidence in him. So,��his ouster,��I think,��would require the White��House bigfooting��Kennedy. And��I’m��not sure��that��that would happen.��

Rovner:��And they have, as��we’ve��noticed, other things to deal with right now.��Finally��this week, remember that��$50 billion��Congress��included for��rural health in last summer’s big budget bill to offset the��nearly��$1 trillion��in cuts to Medicaid?��Well, now the Trump administration is effectively telling states that if they want to claim a share of that money, they need to make changes that align with other����—��things like barring people from using food stamps for junk food,��or legalizing��short-term��insurance plans that many states worry could destabilize the individual insurance market. Now, I��wouldn’t��call this outright coercion, but I remember that the Supreme Court��basically did��just that when they ruled that the ACA’s Medicaid expansion had to be voluntary. Is this really going to fly,��that the Trump administration could say,��You��can’t��have this money unless you do other things that we want you to do?��

Goldman:��If��I’m��remembering correctly, all states that have all��right��to��applications will get a baseline of money,��and states can get more money for certain things that they apply for. And��so��I think that��maybe that��makes this a little different. But I think states will be��very upset��if they��don’t��get the money that they��want,��that they are asking for. And��it’ll��be interesting to see if there is legal action on the back��end,��too.��

Rovner:��Yeah. I mean, clearly this��$50 billion��for rural health is not enough to even begin to make up for the cuts that are coming to Medicaid. So,��we’re��talking about��small amounts��of money.��It’s��just,��I��don’t��remember seeing conditions that were quite this blatant. And��you’re��right, Maya, it’s��not��all of��the money, but it is some segment of the money. But for them to just literally come out and say,��We’re��going to give you money if you do what we want.��I would think at some point Congress gets to say,��Hey, not what we had in mind.��

Stolberg:��But Congress��won’t��say it. Not this Congress.��

Rovner:��Yeah, not this Congress. So��maybe a��future Congress. All right. Well, that is this week’s news. Now, we will play my interview with Linda Blumberg of Georgetown University, and then we will come back and do our extra credits.����

I am pleased to��welcome to��the podcast Linda Blumberg.��Linda is a research professor at Georgetown University and an institute fellow in the Health Policy Division of the Urban Institute, and one of my go-to people whenever I have a��really complicated��question about health policy.��Linda, welcome to��What��the Health?��

Linda��Blumberg:��Thanks so much for having me here.��

Rovner:��So,��to the unpracticed eye, it looks like Republicans in the House and Senate are just now��coming up with��all these new and different health plans. But,��in fact, most of them are variations on what Republicans have been pushing, not just for years, but for decades in some cases.��Is there anything��really new,��or is this just a long list of golden oldies?��

Blumberg:��I think this��is��basically a��list of things that have been brought out before. Now, they��have to��present them and talk about them in the context of the Affordable Care Act, which they��didn’t��have to do many years ago.��They’re��working around in terms of what��they’re��impacting on��the Affordable Care Act,��and how these other pieces would fit in with what they want to do there. But��they’re��essentially the��same things��they’ve��been talking about for a long time.��

Rovner:��So,��you’ve��been analyzing these plans for years now.��And while they may look different on the surface, you say they all have one thing in common:��that they work to segment rather than pool risk. Can you explain that in��layman’s terms?��

Blumberg:��Sure. When I talk about segmenting health��care risk, what I’m talking about is policies,��or strategies that place more of the financial responsibility of paying for medical care on the people who need that care when they need it, or on those who are most likely to need medical care.��That is the opposite of pooling risk more broadly, which��actually takes��health��care costs and spreads them to a greater extent across people, both healthy and sick.��

Rovner:��So basically,��protecting��sick people, which is the idea of health insurance in general, right?��

Blumberg:��Well, from my perspective, yes. The situation is because there is��—��what we in economics call��— a��very skewed distribution of health��care spending, that means that in any particular year, at any��particular moment in time, most people are pretty healthy and don’t use much medical care,��and the great bulk of health��care spending falls on a small percentage of the population. And so,��when��you’re��only looking in the short term, when��you’re��not looking broadly across time,��or across somebody’s life, then people who, when you segment health��care risk, you��can create savings for people when��they’re��super healthy. The problem is that it increases the cost even more when they are not healthy,��and none of us are healthy forever.��

Rovner:��And just to be clear, the percentage of people who use��the majority of��health��care is really,��really tiny, isn’t it?��

Blumberg:��Yeah. So,��for example, there is a rule of thumb that around the top 5% of health��care spenders account for��basically half��of all health��care spending, and the bottom half of spenders account for less than 3% of health��care spending. But that is at a particular moment in time,��again. And��I think the problem��is when we think about health��care spending as��Who’s��going to��win?��Who’s��going to lose?��in terms of money,��right now,��at a particular moment in time.��Instead of thinking about what happens to us over the course of our lifetime, which is,��then,��when we spread the costs much more broadly,��we’re��more protected. We have access to adequate affordable health��care under broad-based pooling of health��care��risk. When we segment it,��we’re��really making people much more��vulnerable��to not being able to get the care they need when they need it.��

Rovner:��And how do things like health savings accounts,��and giving consumers more power to go out and negotiate on their own, how do those��actually segment��risk?��

Blumberg:��So,��the more you take the dollars that are being spent on health��care and remove it from the health insurance pool��—��the amount of money that is going to pay for claims through health insurance,����whether it’s public or private insurance��—��the more you take it out of the insurance pool and you put it on the individuals, the more we’re separating the risks and putting heavier costs on people when they need care. So,��a health savings account gives us some��cash,��or��allows us to put some cash into an account to use when��we’re needing��care. But it also comes with health insurance plans that are much��higher��deductibles and much larger out-of-pocket costs.��

And��so��what we see in practice is that the people who have these��accounts, they��tend to not��…��First of all, they tend to be much wealthier people��because��they’re��tax advantages��for wealthy people, not for people who are��[of]��much more modest means. And when they go to get care,��there’s��usually not that much money in the account to help them pay for these much larger deductibles and out-of-pocket costs. And��so��they’re��paying for��a lot more when they need��the care. The insurance kicks in at a much higher level of��spend. And��so��the��financial burden, even though��they’ve��paid lower premiums when they need��the care, the financial hit is on the individual.��

Rovner:��So why shouldn’t we put higher-risk people in a different pool? Since, as you point out, most people are healthy most of the time. That would reduce costs for more people than it would raise costs for.��Right?��

Blumberg:��Well, it would,��at a particular moment in time, but the problem is we don’t stay healthy��all of��the time.��And so,��I’m��not born with a stamp on my head that says,��You’re��going to be a low spender,��and so��you’re��going to be better off over here.��All I need is a broken leg. All I need is somebody in my family to develop diabetes. God��forbid,��a kid gets hit by a��car,��or��develops a brain tumor. Stuff happens from��out of the blue. And then,��if��that’s��the case, if��I’m��in a situation that could really make it so that I��can’t��access,��or my loved ones��can’t��access,��the care that they need when they need it.��And by the way, as��we age, everybody tends to use��more and more��care.��

So,��you can save money at a moment of time by segmenting risk in these ways, but if you do it,��you’re��putting so many people at risk for not being able to get adequate care when they need it. And because of that skewed distribution of health��care spending,��it’s��a situation where what you save when��you’re��healthy from segmenting risk is��really pretty��small compared��to the extra amount you��have to��spend for pooling risk. Because if you take these dollars,��and you spread them over everybody, then the increment that you��have to��spend��in order to��make sure��you’re��protected,��and everybody else is protected when they need medical care,��is not that big.��

Rovner:��Is there some ideological��reason why��Republicans��seem to be��coalescing around these risk-segmentation ideas?��

Blumberg:��I’m��not a psychologist, so the motivation escapes me.��Because I do think people are better off over the course of their lifetimes when we spread risk broadly.��I think part of the issue��is the other philosophical difference between conservatives and more progressive policymakers is the idea of income distribution. And the truth of the matter is that��really wealthy��people, if they get sick and have a high-deductible plan,��or they have a much��more narrow��set of benefits that are being offered to them, they have wealth that can take them a long way to get to buy medical care. They can pay for the broken limb.��They can pay for��various different��medications.��

If they have��a very serious��illness,��or injury��that’s��longer lasting, they may not��—��even wealthy people��—��may not be able to cover the costs,��or it may really have��a big impact��on them.��But by and large, wealthy��people��are able to��insulate��themselves to some degree, even��with very��pared-down coverage. Whereas somebody��who’s��middle-income, who’s��lower-income,��who’s��not super wealthy, is not going to be able to access that care. So,��if your focus is on protecting the assets of those with a lot of wealth, this is��a positive��in that regard.��

Rovner:��So how does this ongoing debate about these enhanced premium subsidies play into this whole thing?��

Blumberg:��When��we’re��talking about the enhanced premium tax credits, which seem to be,��by the end of this week,��will��be going by the��wayside,��those are��actually pooling��mechanisms,��too. And I think it’s important for people to understand that financial assistance for lower-��and middle-income people, one of the great things that it does��—��as a secondary effect of just giving those people insurance coverage��—��is it brings a lot more healthier people into the pool. People who are healthy, young, who��wouldn’t��have been able to afford health insurance coverage before,��and so would have��remained��uninsured and did before these credits were in place. It brings them into the pool. It lowers the average medical expenses��of people insured.��And by pooling risk in that way, it��actually lowers��the premium.��Because as the average cost of the individuals enrolled goes down, the premiums go down,��too.��

And so one of the things besides these other strategies,��which would tend to segment risk further, as we talked about, the strategy that they are denying��—��which is continuing these enhanced subsidies��—��is also going to further segment risk because it’s going to push healthier people out of the pool that can’t afford it anymore. Same with, by the way, the��people who are immigrants but are residing here legally, who are no longer going to be able to access assistance to buy coverage in the marketplaces as they have been for the last number of years, they also tend to be people who use less medical care on average. And so those immigrants being in our insurance pools are��actually helping��to subsidize American citizens who are less healthy. And��so��by saying,��Listen,��we’re��not going to let you in.��We’re��not going to give you subsidies to make it affordable for you to come in.��We’re��actually pushing��the average cost of the health insurance coverage upward for no good reason, honestly.��

Rovner:��Linda Blumberg, thanks very much.��

Blumberg:��My pleasure. Good to see you.��

Rovner:��OK,��we’re��back.��It’s��time for our��extra-credit��segment.��That’s��where we each recognize the story we read this��week��we think you should read,��too.��Don’t��worry��if you miss it;��we will put the links in our show notes on your phone or other mobile device. Anna, you have a story written by you this week. Why don’t you go first?��

Edney:��Yeah, thank you. I had a��story��just published today.��It’s��in Bloomberg:��“.”��And I took a deep look at this issue of preterm infant��formula.��So,��for��preemies��that are born��really early, there’s this big debate right now on whether formula is harming them,��or whether it’s something else that’s causing one a day,��essentially,��to die from this awful disease, necrotizing enterocolitis.��And��so��Abbott is struggling because they don’t make a lot of money��off of��this formula, but they’re being sued for billions and billions of dollars.��So��they really want Congress, any agency, the White House, whoever, to intervene in some way.��

They’re��throwing everything at the wall to see what can stick. And I’ll just say one tidbit that I��found that��was��really interesting.��There’s��a lot of debate. There was an NIH��[National Institutes of Health]��report on this disease recently that moved in Abbott’s favor a little bit. I did learn through my reporting that the report was ghostwritten by a company that does a lot of work with��Abbott,��and��lists them as a client. So��that’s��an interesting conflict of interest there,��maybe a��hook to get��you guys��to go read it. Thanks.��

Rovner:��Oops.��I’m��definitely going��to go read it.��Maya, why don’t you go next?��

Goldman:��Yeah,��I’m��excited to read that, Anna.��

Edney:��Thank you.��

Goldman:��My extra credit this week is from ProPublica.��It’s��by Aliyya Swaby and��it’s��called��“”��There are a lot of details in the story, but��I think the headline��tells you the gist of it. But what stuck out to me about this is I think in health journalism and health policy, we��often talk about the safety net as if��it’s��magic and going to catch everyone, or at least I find myself slipping into that mindset sometimes. And I think��it’s��really important��to��look into��how people on the ground are��actually experiencing��these services. And��it’s��also a reminder, unfortunately, that there are bad actors everywhere.��

Rovner:��Alas. Sheryl.��

Stolberg:��So,��my extra credit this week is��actually more��of a science��policy story than a health��policy story, but it is a fascinating yarn.��It’s��titled��“.”��It’s��in The New York Times by my colleague Katie J.M. Baker. And this is the story of two Chinese virologists who were married,��and the woman came to believe that��covid��was a bioweapon created in a lab,��and that the Chinese government had purposefully grown this virus and released it to set off the pandemic. And this doctor fell under the sway of people like Steve Bannon, Trump’s ally, and an exiled��Chinese billionaire who had reason to want to blame the Chinese government,��and who brought her to the United States, placed her in a series of safe houses once she arrived,��and arranged for her to meet some of Trump’s top advisers.��

And she has now gone underground,��and her husband��actually moved��to the United States to try to find her. And��she’s��basically in��hiding.��She’s��cut off contact with her family.��And it’s heartbreaking,��and poignant,��and also,��from my perspective, revelatory about just the politics that have come to define our debates around science and health in the wake of the pandemic.��

Rovner:��Yeah, it is quite the story. All right. My extra credit this week is from��The Washington Post.��It’s��called����by David Ovalle. And��we’ve��talked about this issue before. These fees were��mainly aimed��at tech companies,��who are the biggest users of the H1B visa program, but this new $100,000 fee is already preventing particularly rural practitioners from bringing medical professionals to places in the United States that Americans just��don’t��want to practice. This story centers on an overworked kidney disease practice in North Carolina��that’s��still waiting on a U.S.-trained doctor that it hired months ago,��who is stuck in India.��We’ve��already talked about how the Medicaid cuts are going to hit rural areas particularly hard. This fee to bring in international medical professionals sounds like��it’s��making that even worse.����

OK, that is this week’s show.��Thanks to our editor, Emmarie Huetteman,��and our producer-engineer,��Taylor Cook. A��reminder:��What��the Health?��is now available on WAMU platforms, the NPR app, and wherever you get your podcast, as well as,��of course,��kffhealthnews.org. Also, as always, you can email��us��your comments or questions.��We’re��at whatthehealth@kff.org, or you can find me still on X����or on Bluesky��. Where are you folks hanging these days, Maya?��

Goldman:��I am on X����and on LinkedIn under my name.��

Rovner:��Anna?��

Edney:����or����@AnnaEdney,and��LinkedIn as well.��

Rovner:��Sheryl.��

Stolberg:��And��I’m��on����and����@sherylnyt,��and LinkedIn under my own name.��

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

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More children would be hospitalized because of this preventable disease. Some would lose their hearing. Some would die. Measles is also expensive. A — not yet published in a scientific journal — estimates that the public health response to outbreaks with only a couple of cases costs about $244,000. When a patient requires hospital care, costs average $58,600 per case. The study’s estimates suggest that an outbreak the size of the one in West Texas earlier this year, with 762 cases and 99 hospitalizations, costs about $12.6 million.

America’s status hinges on whether the country’s main outbreaks this year stemmed from the big one in West Texas that officially began Jan. 20. If these outbreaks are linked, and go on through Jan. 20 of next year, the U.S. will no longer be among nations that have banished the disease.

“A lot of people worked very hard for a very long time to achieve elimination — years of figuring out how to make vaccines available, get good vaccine coverage, and have a rapid response to outbreaks to limit their spread,” said Paul Rota, a microbiologist who recently retired from a nearly 40-year career at the Centers for Disease Control and Prevention.

Instead of acting fast to prevent a measles comeback, Robert F. Kennedy Jr., a lawyer who founded an anti-vaccine organization before taking the helm at the Department of Health and Human Services, has undermined the ability of public health officials to prevent and contain outbreaks by eroding trust in vaccines. The measles vaccine is safe and effective: Only confirmed U.S. cases of measles this year have been in people who had received two doses.

Kennedy has fired experts on the vaccine advisory committee to the CDC and has said, without evidence, that vaccines may cause autism, brain swelling, and death. On Nov. 19, scientific information on a CDC webpage about vaccines and autism was replaced with false claims. Kennedy that he ordered the change.

“Do we want to go back into a prevaccine era where 500 kids die of measles each year?” asked Demetre Daskalakis, a former director of the CDC’s national immunization center, who resigned in protest of Kennedy’s actions in August. He and other scientists said the Trump administration appears to be occupied more with downplaying the resurgence of measles than with curbing the disease.

HHS spokesperson Andrew Nixon said in a statement that vaccination remains the most effective tool for preventing measles and that the “CDC and state and local health agencies continue to work together to assess transmission patterns and ensure an effective public health response.”

Looking for Links

CDC scientists are indeed tracking measles, alongside researchers at health departments and universities. To learn whether outbreaks are linked, they’re looking at the genomes of measles viruses, which contain all their genetic information. Genomic analyses could help reveal the origin of outbreaks and their true size, and alert officials to undetected spread.

Scientists have conducted genomic analyses of HIV, the flu, and covid for years, but it’s new for measles because the virus hasn’t been much of a problem in the U.S. for decades, said Samuel Scarpino, a public health specialist at Northeastern University in Boston. “It’s important to get a surveillance network into place so that we could scale up rapidly if and when we need it,” he said.

“We are working with the CDC and other states to determine whether what we’re seeing is one large outbreak with continued spread from state to state,” said Kelly Oakeson, a genomics researcher at the Utah Department of Health and Human Services.

At first glance, the ongoing outbreak in and , with 258 cases as of Dec. 1, seems linked to the one in Texas because they’re caused by the same strain of measles, D8-9171. But this strain is also spreading throughout Canada and Mexico, which means the outbreaks could have been sparked separately from people infected abroad. If that happened, this technicality could spare the U.S. from losing its status, Rota said. Being measles-free means the virus isn’t circulating in a country continuously year-round.

Canada lost its measles-elimination status in November because authorities couldn’t prove that various outbreaks from the D8-9171 strain were unrelated, said Daniel Salas, executive manager of the comprehensive immunization program at the Pan American Health Organization. The group, which works with the World Health Organization, includes health officials from countries in North, South, and Central America, and the Caribbean. It makes a call on measles elimination based on reports from scientists in the countries it represents. led by the CDC. A straightforward way to figure out how large an outbreak is would be through surveys, but that’s complicated when communities don’t trust public health workers.

“In a collaborative setting, we could administer questionnaires asking if anyone in a household had a rash and other measles symptoms,” Pavia said, “but the same issues that make it difficult to get people to quarantine and vaccinate make this hard.”

Instead, Pavia and other researchers are analyzing genomes. A lot of variation suggests an outbreak spread for weeks or months before it was detected, infecting many more people than known.

A less intrusive mode of surveillance is through wastewater. This year, the CDC and state health departments have launched efforts to test sewage from households and buildings for measles viruses that infected people shed. A found that this could function as an early warning system, alerting public health authorities to an outbreak before people show up in hospitals.

The quiet research of CDC scientists stands in stark contrast to its dearth of public-facing actions. The CDC hasn’t held a single press briefing on measles since President Donald Trump took office, and its last publication on measles in the agency’s Morbidity and Mortality Weekly Report was in April.

Rather than act fast to limit the size of the Texas outbreak, the Trump administration impeded the CDC’s ability to communicate quickly with Texas officials and slowed the release of federal emergency funds, according to investigations by ���ϳԹ��� News. Meanwhile Kennedy on vaccines .

Daskalakis said that as the outbreak in Texas worsened, his CDC team was met by silence when they asked to brief Kennedy and other HHS officials.

“Objectively they weren’t helping with the Texas outbreak, so if we lose elimination, maybe they’ll say, ‘Who cares,’” Daskalakis said.

Nixon, the HHS spokesperson, said Kennedy responded strongly to the Texas outbreak by directing the CDC to help provide measles vaccines and medications to communities, expediting measles testing, and advising doctors and health officials. The U.S. retains its elimination status because there’s no evidence of continuous transmission for 12 months, he added.

“Preliminary genomic analysis suggests the Utah and Arizona cases are not directly linked to Texas,” the CDC’s acting director, Deputy HHS Secretary Jim O’Neill, .

Given Kennedy’s distortions of data on vitamin A, Tylenol, and autism, Daskalakis said the Trump administration may insist that outbreaks aren’t linked or that PAHO is wrong.

“It will be quite a stain on the Kennedy regime if he is the health secretary in the year we lose elimination status,” he said. “I think they will do everything they can to cast doubt on the scientific findings, even if it means throwing scientists under the bus.”

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“I don’t think people should be taking medical advice from me,” Kennedy Democratic congressman in May.

Kennedy once expressed different views — for example, about the need to proselytize about exercise. As he , he wants to use the “bully pulpit” to “obliterate the delicacy” with which Americans discuss fitness and explain that “suffering” is virtuous.

“We need to establish an ethic that you’re not a good parent unless your kids are doing some kind of physical activity,” Kennedy told the podcaster in September 2024.

The Department of Health and Human Services is tasked with communicating information to protect and improve the health and well-being of every American. It provides reminders about vaccinations and screenings; alerts about which food is unsafe; and useful, everyday tips about subjects such as sunscreen and, yes, exercise.

Under Kennedy’s watch, though, HHS has compromised once-fruitful campaigns promoting immunizations and other preventive health measures. On Instagram, the agency often emphasizes Kennedy’s personal causes, his pet projects, or even the secretary himself. Former agency employees say communications have a more political edge, with “Make America Healthy Again” frequently featured in press releases.

Interviews with over 20 former and current agency employees provide a look inside a health department where personality and politics steer what is said to the public. ���ϳԹ��� News granted many of these people anonymity because they fear retribution.

One sign of change is what is no longer, or soon will not be, amplified — for instance, acclaimed anti-smoking campaigns making a dent in one of Kennedy’s priorities, chronic disease.

Another sign is what gets celebrated. On the official HHS Instagram account this year, out were posts saluting Juneteenth and Father’s Day. In, under Kennedy, were posts and .

Commenting on such changes, HHS spokesperson Andrew Nixon said in an email that “DEI is gone, thanks to the Trump administration.”

Some elected officials are pointedly not promoting Kennedy as a source of health care information. Regarding the secretary’s announcement citing unproven links between Tylenol and autism, Senate Majority Leader John Thune told MSNBC that, “if I were a woman, I’d be talking to my doctor and not taking, you know, advice from RFK or any other government bureaucrat, for that matter.” (Thune’s office did not respond to a request for comment.)

At since January show trust in Kennedy as a medical adviser is low. , from The Economist and YouGov, barely over a quarter of respondents said they trusted Kennedy “a lot” or “somewhat.”

The department’s online messaging looks “a lot more like propaganda than it does public health,” said Kevin Griffis, who worked in communications at the CDC under President Joe Biden .

Transition to a New Administration

The new administration inaugurated dramatic changes. Upon arrival, political appointees froze the health agency’s outside communications on a broader scale than in previous changeovers, halting everything from routine webpage updates to meetings with grant recipients. The pause created logistical snafus: For example, one CDC employee described being forced to cancel, and later rebook, advertising campaigns — at greater cost to taxpayers.

Even before the gag order was lifted in the spring, the tone and direction of HHS’ public communications had shifted.

According to data shared by iSpot.tv, a market research firm that tracks television advertising, at least four HHS ads about vaccines ended within two weeks of Trump’s inauguration.

“Flu campaigns were halted,” during a season in which a died from influenza, Deb Houry, who had resigned as the CDC’s chief medical officer, said in a Sept. 17 congressional hearing.

Instead of urging people to get vaccinated, HHS officials contemplated more-ambivalent messaging, said Griffis, then the CDC’s director of communications. According to Griffis, other former agency employees, and communications reviewed by ���ϳԹ��� News, Nixon contemplated a campaign that would put more emphasis on vaccine risks. It would “be promoting, quote-unquote, ‘informed choice,’” Griffis said.

Nixon called the claim “categorically false.” Still, the department continues to push anti-vaccine messaging. In November, the CDC to assert the false claim that vaccines may cause autism.

Messaging related to tobacco control has been pulled back, according to Brian King, an executive at the Campaign for Tobacco-Free Kids, as well as multiple current and former CDC employees. Layoffs, administrative leaves, and funding turmoil have drained offices at the CDC and the FDA focused on educating people about the risks of smoking and vaping, King said.

Four current and former CDC employees told ���ϳԹ��� News that “Tips From Former Smokers,” a campaign credited with helping approximately a million people quit smoking, is in danger. Ordinarily, a contract for the next year’s campaign would have been signed by now. But, as of Nov. 21, there was no contractor, the current and former employees said.

Nixon did not respond to a question from ���ϳԹ��� News regarding plans for the program.

“We’re currently in an apocalypse for national tobacco education campaigns in this country,” King said.

Kennedy’s HHS has a different focus for its education campaigns, including the “Take Back Your Health” campaign, for which the department this year to produce “viral” and “edgy” content to urge Americans to exercise.

An earlier version of the campaign’s solicitation asked for partners to boost wearables, such as gadgets that track steps or glucose levels — reflecting a for every American to be wearing such a device within four years.

The source of funds for the exercise campaign? In the spring, leadership of multiple agencies discussed using funding for the CDC’s Tips From Former Smokers campaign, employees from those agencies said. By the fall, the smoking program hadn’t spent all its funds, the current and former CDC employees said.

Nixon did not respond to questions about the source of funding for the exercise campaign.

Food Fight

At the FDA, former employees said they noticed new types of political interference as Trump officials took the reins, sometimes making subtle tweaks to public communications, sometimes changing wholesale what messages went out. The interventions into messaging — what was said, but also what went unsaid — proved problematic, they said.

Early this year, multiple employees told ���ϳԹ��� News, Nixon gave agency employees a quick deadline to gather a list of all policy initiatives underway on infant formula. That was then branded “,” as if it were a new push by a new administration.

Marianna Naum, a former acting director of external communications and consumer education at the FDA, said she supports parts of the Trump administration’s agenda. But she said she disagreed with how it handled Operation Stork Speed. “It felt like they were trying to put out information so they can say: ‘Look at the great work. Look how fast we did it,’” she said.

Nixon called the account “false” without elaborating. ���ϳԹ��� News spoke with three other employees with the same recollections of the origins of Operation Stork Speed.

“Things that didn’t fit within their agenda, they were downplayed,” Naum said.

For example, she said, Trump political appointees resisted a proposed press release noting agency approval of cell-cultured pork — that is, pork grown in a lab. Similar products have raised the ire of ranchers and farmers working in typically GOP-friendly industries. States such as Florida have .

The agency ultimately issued . But a review of the agency’s archives showed it hasn’t put out press releases about two later approvals of cell-cultured meat.

Wide-ranging layoffs have also hit the FDA’s food office hard, leaving fewer people to make sure news gets distributed properly and promptly. Former employees say notices about recalled foods aren’t circulated as widely as they used to be, meaning fewer eyeballs on alerts about contaminated , , and the like.

Nixon did not respond to questions about changes in food recalls. Overall, Nixon answered nine of 53 questions posed by ���ϳԹ��� News.

Pushing Politics

Televised HHS public service campaigns earned nearly 7.3 billion fewer impressions in the first half of 2025 versus the same period in 2022, according to iSpot data, with the drop being concentrated in pro-vaccine messaging. Other types of ads, such as those covering substance use and mental health, also fell. Data from the marketing intelligence firm Sensor Tower shows similar drops in HHS ad spending online.

With many of the longtime professionals laid off and new political appointees in place atop the hierarchy, a new communications strategy — bearing the hallmarks of Kennedy’s personality — is being built, said the current and former HHS employees, plus public health officials interviewed by ���ϳԹ��� News.

Whereas in 2024, the agency would mostly post public health resources such as the 988 suicide hotline on its Instagram page, its feed in 2025 features more of the health secretary himself. Through the end of August, according to a ���ϳԹ��� News review, 77 of its 101 posts featured Kennedy — often fishing, biking, or doing pullups, as well as pitching his policies.

By contrast, only 146 of the agency’s 754 posts last year, or about 20%, featured Xavier Becerra, Kennedy’s predecessor.

In 2024, on Instagram, the agency promoted Medicare and individual insurance open enrollment; in 2025, the agency has not.

In 2024, the agency’s Instagram feed included some politicking as Biden ran for reelection, but the posts were less frequent and often indirect — for instance, touting a policy enacted under Biden’s signature legislation, the Inflation Reduction Act, but without mentioning the name of the bill or its connection to the president.

In 2025, sloganeering is a frequent feature of the agency’s Kennedy-era Instagram. Through the end of August, “Make America Healthy Again” or variants of the catchphrase featured in at least 48% of posts.

Amid the layoffs, the agency made a notable addition to its team. It hired a state legislative spokesperson as a “rapid response” coordinator, a role that employees from previous administrations couldn’t recall previously existing at HHS.

“Like other Trump administration agencies, HHS is continuously rebutting fake news for the benefit of the public,” Nixon said when asked about the role.

On the day Houry and Susan Monarez, the CDC leader ousted in late August, testified before senators about Kennedy’s leadership, the agency’s X feed posted clips belittling the former officials. The department also derisively rebuts unfavorable news coverage.

“It’s very interesting to watch the memeification of the United States and critical global health infrastructure,” said McKenzie Wilson, an HHS spokesperson under Biden. “The entire purpose of this agency is to inform the public about safety, emergencies as they happen.”

‘Clear, Powerful Messages From Bobby’

Kennedy’s , released in September, proposes public awareness campaigns on subjects such as illegal vaping and fluoride levels in water, while reassuring Americans that the regulatory system for pesticides is “robust.”

Those priorities reflect — and are amplified by — cadres of activists outside government. Since the summer, HHS officials have appeared on Zoom calls with aligned advocacy groups, trying to drum up support for Kennedy’s agenda.

— on which, according to host Tony Lyons, activists “representing over 250 million followers on social media” were registered — famous names such as motivational speaker Tony Robbins gave pep talks about how to influence elected officials and the public.

“Each week, you’re gonna get clear, powerful messages from Bobby, from HHS, from their team,” Robbins said. “And your mission is to amplify it, to make it your own, to speak from your soul, to be bold, to be relentless, to be loving, to be loud, you know, because this is how we make the change.”

The communications strategy captivates the public, but it also confuses it.

Anne Zink, formerly the chief medical officer for Alaska, said she thought Kennedy’s messaging was some of the catchiest of any HHS director.

But, she said, in her work as an emergency physician, she’s seen the consequences of his health department’s policies on her puzzled patients. Patients question vaccines. Children show up with gastrointestinal symptoms Zink says she suspects are related to raw milk consumption.

“I increasingly see people say, ‘I just don’t know what to trust, because I just hear all sorts of things out there,’” she said.

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