[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 ºÚÁϳԹÏÍø News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, June 4, at 10:30 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. Today, we are joined via video conference by Margot Sanger-Katz of The New York Times. 

Margot Sanger-Katz: Hello, everybody. 

Rovner: Alice Miranda Olstein of Politico. 

Alice Miranda Ollstein: Hi, there. 

Rovner: And we welcome to our podcast panel this week Liz Essley Whyte of The Wall Street Journal. Happy to have you join us. 

Liz Essley Whyte: Thanks for having me, Julie. 

Rovner: Later in this episode, we’ll have my interview with my colleague Lauren Sausser, who wrote the latest ºÚÁϳԹÏÍø News “Bill of the Month.” It’s about a woman with a temporary memory problem who probably wishes she could forget about a $59,000 hospital bill. But first, this week’s news. 

So, it’s been almost a full year since President [Donald] Trump signed the big budget bill that would reduce Medicaid spending by nearly a trillion dollars over the next decade, and this week we got the much-anticipated regulation outlining what states have to do in order to implement the new Medicaid work requirements for low-income adults on the program by next Jan. 1. And it’s safe to say that these rules â€” which are interim final rules, by the way, so that means they technically take effect immediately â€” are not what states were expecting. I want to break this down in pieces, but first, let’s talk about what a heavy lift this was going to be for the 43 states that are required to put these rules into effect.  before the rules came out, right? 

Ollstein: Yes, this is being pitched as a massive money saver, that was how it was framed. It’s being scored that way in the original bill in order to pay for a bunch of other things: tax cuts, etc. 

Rovner: I would say it is a money saver for the federal government, right? 

Ollstein: Well, that is the promise, that it will save money by reducing the number of people covered by Medicaid. And so proponents of this frame it as cracking down on waste, fraud, and abuse, arguing that the only people who are going to get booted off of Medicaid are the people who deserve to be booted off of Medicaid, because in this piece of it they’re not working or volunteering or going to school or caring for a sick relative. We looked at, yes, this is aimed at saving federal money, but it is currently costing states millions or tens of millions of dollars to implement. It is extremely expensive to implement. States are having to hire a lot of people, they’re having to create, you know, brand-new tech systems that, or upgrade their old tech systems that they didn’t have before. And a lot of state officials told us that this is coming at really the worst time for them. They’re already losing other federal funding, they are really struggling, they’re having to make lots of cuts to social services. And so there just isn’t a lot of extra money to go around. And yet they have to spend all this money to implement these rules. And, especially, Democratic officials were telling us that, Look, we wouldn’t mind having to invest this money if it were going to lead to covering more people or offering people better, more comprehensive coverage. But they really resent having to spend this money in order to cover fewer people in the future.  

Rovner: So, let’s get to the rules themselves. As I like to explain, there are two big things that states are going to have to do here: first, to determine which Medicaid recipients are exempt from that community engagement requirement â€” to work, volunteer, or attend school 80 hours per month â€” and second, to determine if those who are not exempt are actually meeting the requirements. And these new rules make both of those harder for states, right, Margot? 

Sanger-Katz: Yeah, I think it’s been like this huge freak-out among states over these last few weeks, because there were a lot of rumors flying around, but I think there was just this concern, like, Whoa, if they make major changes right now, it’s going to be even harder for us to implement. And for states that were, as Alice said, some of these blue states that were trying to minimize the coverage losses under the Medicaid work requirement, I think they were worried, Well, they’re only going to make it stricter; they’re only going to make it harsher. Why would they be changing things now? And so, , it turns out that is, in fact, what they did, that there were a number of policy choices where they decided to apply a stricter standard than what states had been told before this week. 

So what are the biggest examples of this? I think there are two. One is that the work requirement doesn’t apply to everyone. The Republicans in Congress basically said we want people, adults without young children and without disabilities, to be engaged in their communities â€” to work, volunteer, go to school a minimum number of hours each month if they want to stay eligible for Medicaid. But we understand that there are certain people who are going to have trouble doing that, and so we want to have exceptions for those people. So not everyone has to do the work requirement, a bunch of people don’t have to. And the biggest category of this was a category that Congress called “medical frailty.” The idea was these are people who have medical problems that, like, might make it hard for them to work, or who might really suffer if they lost their health insurance. So, depending on who you talk to, that was what Congress was trying to protect with that exception. And what CMS [the Centers for Medicare & Medicaid Services] had been telling states over these last few months is: Put together a list of diagnoses of serious illnesses, and you can data match, you know, you have people in your Medicaid system already. OK, if they had cancer, if they have HIV, if they have Parkinson’s disease, that’s a serious illness. Those people are medically frail. You can just automatically exempt them, and then you don’t have to check their work hours. 

Rovner: That’s what Nebraska is already doing, right? Because they’re one of the states that have started this early. 

Sanger-Katz: Correct. Yeah, so Nebraska is already live with its work requirement. And, again, Nebraska, even more so than these other states, got tons of guidance from CMS, because they were so excited to go first, and they wanted to do everything right. They wanted to be a good example. And I think CMS wanted them to demonstrate, OK, you can like do this policy. Yeah, they had a list, I think they had like 300 pages of diagnostic codes, you know, like all these diseases. If you have these diseases, we’re gonna exempt you, then you don’t have to demonstrate work hours. If you don’t, OK, like, then you’re gonna have to prove that you’re working or volunteering or going to school. 

So what the rule said is, like, that’s not good enough. It is not good enough to have cancer â€” that in order to be exempted from having to demonstrate that you are working, you have to prove that you have cancer, and that your cancer is creating a problem that would make it hard for you to work. And the rule creates a standard where states are going to have to evaluate not just what diseases people have, which might be easy to do using medical records, for at least people who are already enrolled and who have been getting medical care, but instead that they have to make something like a disability determination, which is something that the states were really not ready for, that they don’t really have the staff to do or the training to do, and that cannot be easily automated on the back end right now. I think there’s not an easy way for them to go into the medical record and decide whether or not someone’s illness is serious enough that it would impair their ability to work. And the language that they use in the rule, the standard, is not actually really like the standard in other programs that have work requirements, so the states have no experience with the standard.  

And, as it turns out, doctors don’t really have any experience with this standard either. So, you know, when you are making a workman’s comp claim, for example, like the doctors have forms, there’s a system, they understand what it means to be too sick to work because of an injury that would preclude you from workman’s comp. And in SNAP [Supplemental Nutrition Assistance Program], it turns out, there’s also a standard if you’re unable to work, you could get out of the work requirements. But that is slightly different. And so I think there is this real concern by states that they just like actually don’t know how to do this. There might be some AI [artificial intelligence] solution where they’re data mining in the medical records and trying to figure out if they have these codes, and these codes, like, maybe there’s a way to prove that someone is sick enough. What most people that I’ve talked to said is that basically this is going to be a system that’s largely going to be achieved with doctors’ notes. Doctors have to be willing to do this thing that they’ve never done before, and they’re, you know, having to sign that someone can’t work, and that’s going to be a lot of frictions in that process. And then there’s going to have to be a caseworker on the other end who is going to have to look at those doctors’ notes and is going to have to read them and decide whether the doctor has specified the impairment such that it is in compliance with the work requirement. 

So this is just a lot of like administrative headache. I think there are reasonable arguments for wanting to have this standard given what Congress’ intent was, that they wanted to have a work requirement. The point was they wanted people who could work to work, and they wanted people to be exempted who could not work. I think not everyone in Congress agrees with that, but I think some of them do. But I think the reality of how you actually do this in real life is much, much more complicated than that. There is no, like, godlike state that can just see how sick you are and can make these determinations. And so I think that states are really worried about this. They’re worried about how they’re going to get in compliance with this, they’re worried about all the changes they’re going to have to make to the systems that they’ve already built. And I think that a lot of advocates for people with Medicaid, and a lot of disease groups, advocates for people with serious illnesses, are very worried that many, many more people are going to lose coverage, and particularly people who are medically frail. You know, if you think about, say, a person with HIV, they may be in treatment and getting their medicines, and they might even have undetectable levels of HIV in their blood, and they are perfectly capable of working right now. But if they lose their health insurance and they lose their access to their prescription drugs, they fall out of treatment, their health condition could worsen pretty substantially. And I think we can all think of lots of other diseases that are like that. I think cancer is a good example. You know, some people are living with cancer, and it’s kind of like a chronic disease, but it’s because they’re getting regular care. If they lose their treatment&²Ô²ú²õ±è;…&²Ô²ú²õ±è;they lose their treatment for many other diseases we can think of that are like this. Depression, you know, certain kinds of mental health problems, if people fall out of treatment, that actually could impair their ability to work, and that causality could run in the opposite direction. So, I think this is a big change. 

And then the other change that they made is more technical, but it was like, how are people going to prove various things under this law? And a lot of states were just expecting people would be able to sign a statement and say, I am caring for a disabled relative&²Ô²ú²õ±è;…&²Ô²ú²õ±è;you can trust me, I’m signing under penalty of perjury. This is what I’m doing. Or I volunteered 12 hours last month, you know, I’m just going to sign this under penalty of perjury. Because there’s not a good way to check. 

Rovner: And for the first year, that’s OK, right? They’re taking these attestations&²Ô²ú²õ±è;…&²Ô²ú²õ±è;

Sanger-Katz: For the first year, they’re going to allow it. And then after the first year, they’re going to allow it for medical frailty only â€” once. So if you sign up for Medicaid in 2028 and you claim that you’re too sick to work, you can sign a form that says that, but then, within the next six months, before you renew your coverage, you’re going to have to come back with some kind of medical record with some kind of doctor’s note that proves it. So you know these are some pretty big changes, and Trump administration officials said, you know, our view is this is consistent with [what] the law is for, which is to ensure that people are working and are engaged in their communities if they’re capable of doing it. They also said that this prohibition on people just signing statements is a way to avoid fraud, because why wouldn’t people just sign a statement saying that they didn’t have to do this work requirement if they could? But I think this is going to have real implications in the real world. It’s going to create a huge administrative headache for states. It’s probably going to impair a lot of people from getting coverage who would have otherwise been covered if CMS had stayed the course with what it had been telling states before. 

Rovner: So, I know my inbox is full of reactions from groups across the medical spectrum. Alice and Liz, I assume you guys are hearing lots of feedback about this, too. 

Ollstein: Absolutely. I mean, just like Margot said, there just isn’t really a good way to do this, trying to automate it and base it on medical claims, like 1) States don’t have that built yet, the different systems don’t, quote unquote, “talk to each other” in that way. But also, you know, just because someone used a certain number or kind of health services in a year doesn’t necessarily tell you whether they can work or not. You know, lots of people who are too sick to work maybe haven’t had the medical services, and someone who had a lot of medical services maybe can work fine. But then again, leaving it up to individual doctors who are not trained to make this determination, who don’t have the time to have a bunch of extra appointments just to do this, and who are more used to doing this for â€” Margot gave a few examples, but something some doctors brought up to me was like short-term disability, like evaluating, like, this is the number of weeks someone needs to recover from X surgery. So like that’s a determination a doctor feels qualified to make. Whether someone can work any job, I mean, that’s just not really something they can confidently say. I mean, working a job in a factory is not the same as working an email job, and what kind of jobs are available in this person’s area? It’s just a huge mess. 

Rovner: So, is there any chance the administration is going to back off? There is public comment being taken now until, I think, July. Or will Congress perhaps step in and say this is not what we intended, or does somebody get to sue here? I mean, or this is what’s called an interim, I’m saying, an interim final rule, so it’s not set in concrete yet. 

Sanger-Katz: I mean, I would not be at all surprised if we see lawsuits, but I think we’ll see something else happen first, which is: The law says the states have to get ready to go by&²Ô²ú²õ±è;…&²Ô²ú²õ±è;Dec. 31, 2026, to be ready to go live in January. But it says if they encounter a hardship, if they’ve been making good-faith effort towards getting ready for the work requirement, and they’ve encountered some hardship, and they, like, can’t make the deadline, they can apply for a waiver, basically a two-year extension from CMS. The Trump administration has been extremely clear to states about this all the way along, basically saying, You are not going to get these, we are not going to grant them, like, you know, maybe if there’s like a volcano that goes off in your state and the entire mainframe that holds your Medicaid enrollment system is melted, like, we’ll talk. But I think a lot of states now, especially some of these blue states that are really concerned about this stuff, I think that they are going to apply now, which they might not have done before. And I think if they are denied, I could see some lawsuits around that waiver process to just say, Look, like, you just changed the rules very late. There’s no practical way that we can get this done in time. We have been proceeding in good faith, and, you know, we need more time. So, I think that there could be litigation. I also think they did have this temporary policy for 2027 around self-attestation, which I think does help states get out of some of these, like, really tricky technical issues in the first year. I don’t know, like maybe there could be some further extension of that. But I don’t know. I’m curious, Alice, what, or Liz, what you think. But I am not holding out much expectation that Congress is going to make major changes here. 

Ollstein: Well, and because of the January deadline, making changes could solve one problem and create another. Because states already feel like they don’t have enough time, and they already feel like the rules of the game are being changed in the middle of the game. You know, what they had been spending months preparing for now has to change because of this guidance. If it changes yet again, and they have even less time to adapt and make a new change&²Ô²ú²õ±è;…&²Ô²ú²õ±è;like you said, they’re making hires, they’re trying to make contracts based on this, and so even as advocacy groups, and even states ask for additional changes, additional changes could make it even harder to implement in time. 

Rovner: All right, well, let us move on, because there’s lots more news. Speaking of new regulations, a proposed rule from the Office of Management and Budget would basically make all grant funding from the U.S. Treasury subject to political appointee approval. Currently, most grant-level awards are determined by career scientists and peer reviewers, who make decisions based on scientific merit. Under this new policy, grants would have to, quote, “demonstrably advance the president’s policy agenda.” At the same time, the new 400-page document includes many new rules for grant recipients, including universities and other entities, including limiting their ability to engage in so-called issue advocacy and allowing the revocation of grant funds if recipients take actions that are not deemed by administration political officials to be in, quote, “the public interest.” Now, all this isn’t totally new. Office of Management and Budget Director Russell Vought has been talking about this literally for years. It was laid out in Project 2025 as well as in several executive orders that have been issued by President Trump, which is why I think it’s getting relatively little attention, given the pretty earth-shaking changes that it envisions. Still, putting it out in an actual proposed regulation raises the stakes here, doesn’t it? 

Whyte: Yeah, I would echo that. This has been on Russ Vought’s radar for many years. If you talk to folks, you know, who know him and know his thinking, this all comes down to this thinking about the executive branch and its role in the Constitution, and how there shouldn’t really be independent agencies or branches of the executive branch that aren’t doing what the president wants. And so that is manifested in this regulation that says you can’t promote anti-American values, contribute to illegal immigration, things like that, that are policy priorities of this administration, and a new filter that’s going to be applied to all federal grant-making, once this is finalized. And it’s a distillation of that theory about the executive branch that is now coming out in practice. 

Rovner: Although going back to what we were just talking about with the Medicaid work requirements, I mean, the idea of having to have a political appointee involved at this extremely micro level in the hundreds of thousands of grants that the federal government issues every year. I mean, some of it is the ideology, but some of it is just the logistics. I know that this has been part of the problem of getting money out the door at the National Institutes of Health â€” is that normally money that just sort of flowed when it was approved by career workers now has to wait for the approval of a political appointee, and there are not enough political appointees to approve all of these things, and people aren’t getting their money. So, I mean, this is a logistical logjam, as well as an ideological one, right? 

Sanger-Katz: And we’ve seen some evidence of this. The Department of Homeland Security has had an informal policy like this, where the director was personally approving any expenditure, I think, more than 100 â€”now, I’m forgetting. 

Rovner: $100,000, yeah, I think it was. 

Sanger-Katz: There was some threshold, and it did lead to this huge backlog, because you know this is a busy person who has a lot of other things to do. And it was leading to a lot of money not getting spent that had been authorized by the staff members who thought it was appropriate. And I think there’s also potential for corruption with this kind of system, where you have these bottlenecks where very few people are making all the decisions about where money goes, because then there is an obvious focus on where you send your lobbying efforts to try to get favorable outcomes in contracting and in grant-making. 

Whyte: Yeah, the concern from the science and public health organizations is that the merit of the scientific grant will no longer matter, that how good the science is won’t be the chief thing. 

Rovner: Yeah, that this is all about, you know, promoting the president’s agenda. I’m just wondering what Republicans will feel about this when Democrats, you know, take back the administration and try to do the same thing. 

Whyte: I think that’s exactly the concern that a lot of conservatives on the Hill have, which is, you know, all of this is fine and well, but you’re not going to like it when the tables turn. 

Rovner: Yeah, that was â€” that’s what I said, you know, when the Affordable Care Act passed, I said, there’s an awful lot of places where it says the secretary shall, or the secretary may, or the secretary will. I said, you know, the secretary’s not always going to be somebody who supports this. That&²Ô²ú²õ±è;…&²Ô²ú²õ±è;turned out to be a correct prediction.  

Moving on, the idea of this administration playing down its vaccine skepticism was so last month. Last Friday, President Trump issued an executive order basically endorsing Health and Human Services Secretary [Robert F.] Kennedy [Jr.]’s revamp of the childhood vaccine schedule, and ordering the CDC [Centers for Disease Control and Prevention] to review it and, quote, “take any appropriate steps to update said schedule.” What happened to “This isn’t popular, so we’re not going to push it,” or is doing this on a Friday afternoon how the administration is trying to placate the MAHA [Make America Healthy Again] movement, but not really make big headlines here? I also â€” this is another story that I think kind of flew below the radar. 

Whyte: Yeah, it’s funny because HHS can’t really say anything about this executive order due to their litigation ongoing, and so it’s just kind of out there. But it’s totally unclear to everybody why or what it’s expected to do, given that the court has put everything regarding the Advisory Committee on Immunization Practices on hold, and there currently is no ACIP. So what exactly the White House was intending with this remains pretty opaque, I think. 

Rovner: Like a lot of things, although I have started to, you know, like, pay attention on Friday afternoons again. Meanwhile, our podcast colleague  about how the anti-vax movement is trying to achieve its goal through the courts by arguing that vaccine mandates that lack religious exemptions are unconstitutional. And one of those cases is likely to reach the Supreme Court at some point in the not-too-distant future. What would it mean to public health if the court were to actually strike down the ability of states to impose vaccine mandates, which is one of the possible outcomes here? Or, as the groups claim, is this just about getting the five states that don’t have religious exemptions from vaccines into alignment with the rest of the states? 

Sanger-Katz: I think there is pretty strong evidence from the studies of state policies over the years that having really limited exemptions on mandatory vaccination really increases the number of kids who get vaccinated, that the more ways there are to kind of wiggle out of the requirement, the more parents will choose one of those options. And the narrower the exceptions, the fewer will. So, there are clearly some parents who really, really care about this issue and who do qualify for one of these exemptions. But I think there’s a larger number of parents who are maybe ambivalent or have kind of weakly held preferences not to vaccinate; if they’re not really being forced to do it, they won’t do it. If they are really being forced to go through a lot of administrative burden to prove that they need an exception, then they tend to vaccinate. And so I think this is an exception that almost every state already has, but I think that the evidence is relatively clear that opening up more exceptions in those states that don’t have them now, probably on the margin, will lead to fewer kids getting vaccinated in those states. 

Whyte: Yeah, the five states that don’t allow religious exemptions to vaccine mandates are West Virginia, California, New York, Connecticut, and Maine. So that would be, you know, an immediate effect there. But then I think we can expect from a Supreme Court precedent, if one is set, that other states, state legislatures, local school districts would perhaps expand the religious exemptions they have now, or make them easier. We’ve seen that how much friction there is when you get a religious exemption really matters. So, like, do you have to just sign a form, click a box, or do you have to go meet with someone and prove that you, you know, have sincerely held beliefs on this matter? And those kind of friction points matter a lot too. 

Rovner: Yeah, I just, I couldn’t help thinking, as I was reading this story, about going back to the Dobbs case, the abortion case, which was not originally intended or filed as one that was going to overturn Roe, and makes me wonder what the Supreme Court might do, even if the question that’s raised is, you know, about these religious exemptions, could they go on and overturn â€” I think that precedent was from 1905 that said that states can have vaccine mandates â€” and wondering whether a) that’s possible, and b) that’s likely. 

Sanger-Katz: It’s always hard to predict what the Supreme Court is going to do. 

Rovner: Always. 

Sanger-Katz: It’s really up to them. They’re an idiosyncratic group of people who get the final say on a lot of things. 

Whyte: I thought it was interesting, Lauren’s story was great, and one of the things it pointed out is that what the Supreme Court did is specifically give instructions to this lower court to go back and look at this question about religious exemptions for vaccine mandates using a case that happened in Maryland, where the Supreme Court found that the school district could not mandate that kids participate in lessons with LGBTQ content that would conflict with their parents’ religious beliefs. So in other words, the families had a religious right to not have to participate into that in school. And the Supreme Court is asking, is there a similar right that a family would have to not have to participate in vaccination to attend school? So that’ll be an interesting question, and it could, as we said, you know, have big impacts across the states and how school districts handle vaccine mandates for kindergartners. 

Rovner: Although I think this will take a while to play out. And before we leave the subject of vaccines, an update to our discussion from a couple of weeks back about the global vaccine alliance known as Gavi, which the U.S. owes some $600 million appropriated by Congress. That’s money that’s been held up by HHS Secretary RFK Jr. At a hearing of the Senate Foreign Relations Committee on Tuesday, Secretary of State Marco Rubio said his agency, which has historically been in charge of Gavi for the U.S. government, said that it is, quote, “sort of at a stage where we are going to re-engage. We need to drive this to an outcome.” Was that his polite way of saying that he plans to give Gavi the money that Congress allocated to it, and RFK Jr.’s concerns be damned? 

Whyte: I think a lot of people are reading it that way. You know, the State Department has a very practical view on these things. I also thought the way that Rubio phrased how they were giving Secretary Kennedy a large amount of deference because of his strongly held views on this matter was a very interesting insight into how the Cabinet works and how Trump has instructed his top officials to work together. And I think part of the problem here is that they’re just running into the practicalities of not having an Ebola vaccine. And so the State Department is going to have to do what it feels must be done. 

Rovner: Yeah, it was just a little peek behind the curtain of this intra-agency squabble that’s going on. We’ll wait and see if that happens. 

Whyte: I should say that they don’t have a vaccine for this newest outbreak that is going on. They, you know, the older Ebola vaccine, it was not appropriate to treat this one or to prevent this. 

Rovner: All right. We’re going to take a quick break. We will be right back. 

All right. Our theme this week seems to be federal rulemaking. So, here’s another one. The Trump administration has issued final rules attempting to fix the arbitration system created in the, quote, “No Surprises Act” â€” that it is safe to say has not worked as it was designed by Congress. Margot, remind us what went haywire with the process that’s actually in practice [to] dramatically increase what providers get paid, and will these new rules make it all better?  

Sanger-Katz: So this is a system supposed to solve the problem of surprise medical billing when you, say, go to the emergency room and some doctor treats you, and it turns out that that doctor didn’t take your insurance and sends you a huge bill. So the law did away with that, basically said no one is allowed to send you a huge bill in that situation, and then it created a system on the back end for the insurance company and the doctor to kind of fight it out and figure out what the doctor was going to get paid if they didn’t have a contract with that insurance company. And the expectation of Congress was that this is a system that would be used fairly rarely, that most of the time this would be negotiated between the parties; they would just decide on a price and work it out, but every once in a while there would be a rare case where they would need to litigate their dispute. And it would go, they set up this arbitration system where a neutral arbiter, usually a lawyer, but not always, would hear arguments from each side and decide who had the more reasonable position, and would have to choose between the two bids. They couldn’t negotiate any further, but, you know, the doctor would say, This was a very complicated case, I deserve $10,000. And the insurance company would say, No, no, no, like, normally for this kind of visit we pay $500. And the arbitrator would have to decide which is more reasonable: $10,000 or $500. 

What’s happened, I think, to the surprise of a lot of people, is that instead of 17,000 of these cases going to arbitration, which is what CMS expected when the law passed, more than a million are going through a year. There has just been an explosion of cases coming through the system. Lots and lots of medical disputes are now being decided using this process, and the doctors are winning almost all of the time. I think in the last quarter for which there is data, 88% of these arbitration claims are being decided in favor of doctors. And because of that, the doctors, in many cases, have started getting more aggressive in what they ask for. Because they keep winning, there is not really an incentive to say that price is normally $500. They’re much more likely now to ask for $10,000 than early on in the system, where maybe they were asking for $1,000. And so we’re seeing some really eye-popping awards. Not all of them; there are a fair number of awards that are, you know, within a reasonable number of multiples of what the normal price is. But there are an increasing number where doctors are just getting huge, huge, huge increases over what you would expect. And my colleague Sarah Kliff and I wrote a story a few weeks ago about a plastic surgeon in New York and New Jersey who was routinely collecting fees of hundreds of thousands of dollars for breast reduction surgeries that he had previously accepted payments of around $10,000 from the same insurer prior to this law going into place. So big problems. Lots of complaints from insurers, as you can imagine, and also from employers who, in many cases, are actually paying the bills for their workers’ health insurance directly, because they have these self-insured ERISA [Employee Retirement Income Security Act of 1974] plans. 

This rule that just came out is not getting at the real, like, meat of the system, how the arbitration works, and what&²Ô²ú²õ±è;…&²Ô²ú²õ±è;how the arbitrators make their decisions. But it’s dealing with, like, a lot of, like, technical issues about, you know, how do you submit paperwork? What kind of information do you provide? Is it all in one computer system? How can you make sure that you have identified the right insurance company? And what are the administrative fees that you pay when you want to initiate one of these claims? And so this is a very hot issue. I wrote this one story, and, like, everyone is just really worked up about it. The doctors are really worked up about it, the insurers are really worked up about it, the arbitrators are really worked, you know, everyone feels strongly about this law, and whether it’s going well or not well, or what changes or they want or don’t want. Everybody loved this rule. As far as I can tell, there have been, like, basically no complaints about this rule. The one complaint I’ve seen is that they lowered the fee to file a new case, and so I think people who feel like there are too many of these cases would like it to be a little harder to file a new case. But, in general, it seems like these were expected, helpful, technical upgrades that are just going to make the process work a little bit more smoothly and deal with some of the annoying administrative headaches. 

Rovner: But not address the deeper problem. 

Sanger-Katz: The bigger issues, I think, really do require the involvement of Congress. If Congress wants to revisit the law and change the way that this overall system is structured, they’re probably going to have to write new legislation. And I’m not sure how large the appetite is for that right now. 

Rovner: Yeah, I’m not going to hold my breath on that one. All right, that’s as much news as we have time for this week. Now, we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast ºÚÁϳԹÏÍø News’ Lauren Sausser, who reported and wrote the latest “Bill of the Month.” Hi, Lauren. 

Lauren Sausser: Hi. 

Rovner: So, this month’s patient got caught in one of those fights between the insurance company and the hospital, and, of course, it turned out to be harder to untangle it than it should have been. Tell us who she was, what happened to her, what kind of care she needed. 

Sausser: Sure, so Jan Anderson is a 65-year-old woman who splits her time between Arizona and Washington state. And Jan was hiking with her husband about a year ago in Arizona. They were in Sedona. And later that afternoon â€” it might have even been pushing into early evening â€” she started repeating herself. So she asked her husband, Did we hike today? And he said, Yes, we hiked. And then a few seconds later she asked the exact same question, Did we hike today? And it was clear almost immediately that Jan needed to be seen. So her husband drove her to a freestanding ER in the Sedona area, and that facility assessed her but was not equipped to deal with patients who might be experiencing stroke. They didn’t know what was happening with Jan at this point, so she was airlifted to a hospital in the Phoenix area, where she was admitted. And they ran a bunch of different tests and images, and it turns out she wasn’t having a stroke, she was having, she was experiencing an episode of something that’s called temporary [transient] global amnesia â€” which, the good news is, is benign, and as the name suggests, temporary. But her hospital bill ended up being quite a lot, even though it was less of an emergency than they originally thought. 

Rovner: Well, of course, that’s what they always tell you: If you’re having symptoms, you should go to the emergency room. So, she did have insurance, right? So, why did the hospital in Phoenix think that she didn’t? And how much was the bill? 

Sausser: OK, so the total bill was $59,181. That’s just for the care she received at the hospital in the Phoenix area. She did have insurance. She was insured through Molina [Healthcare], and it was a plan that she had purchased through the federal healthcare.gov marketplace. For some reason, though, her insurance information was not transferred from that freestanding ER in Sedona to the facility where she was airlifted in the Phoenix area. So it was a mistake, but that second facility billed her as if she was a self-pay patient with no health insurance. 

Rovner: Now, once the hospital did figure out that she had insurance, why did the insurance company then still reject the claim? 

Sausser: It took a while to get some answers on this, but eventually Jan learned that Molina was not going to cover the cost of that care she received in Phoenix, because the Phoenix hospital had not sought prior authorization for her to be admitted. Now, under the federal No Surprises Act, emergency services are supposed to be paid for in-network without prior authorization. In this case, the insurer was saying Yes, we do cover emergency services without prior authorization, but in this case her care team was recommending that she be admitted. And the insurer argued that the insurance company needed to be notified before that happened. 

Rovner: So, I know I ask this question all the time: Why didn’t the No Surprises bill [Act] get the patient out of the middle of this obvious insurance company hospital dispute?  

Sausser: This&²Ô²ú²õ±è;…&²Ô²ú²õ±è;in this case, the No Surprises Act kind of worked. Jan received a bill pretty early on saying she owed about $15,000 of that $59,000 total charge. After she told the hospital that she did indeed have coverage, that bill was suspended. There was no one technically knocking on her door pressuring her to pay any amount of the charges she had accumulated in the Phoenix hospital. But every time she would log on to her patient portal, she would see these outstanding charges. The hospital didn’t understand why the insurance company wouldn’t pay. The insurance company was saying she needed to have had prior authorization, and these charges just weren’t disappearing, and so eventually she started reaching out to insurance commissioners, lawmakers, trying to get someone to pay attention, because she was worried at some point she might owe the hospital $59,000. She couldn’t get these charges resolved, and didn’t understand why. 

Rovner: And what eventually happened? 

Sausser: Well, she eventually contacted us. And, as is often the case when journalists get involved with these health insurance issues, the ball started moving. So Molina started talking to the hospital in the Phoenix area, the Phoenix-area hospital has assured Jan that she will not be billed for any of the $59,000. Even if Molina doesn’t pay, the hospital has assured her that they will write off the balance and that she will not be billed. Jan has asked for that assurance in writing. As of the last time I spoke to her, she hasn’t gotten that, but she has been told she will not have to pay any of it. 

Rovner: So, what’s the takeaway here? I mean, it sounds like, you know, she did everything right, and it seems to be resolved. 

Sausser: It seems to be resolved, although the last I heard the $59,000 in charges haven’t necessarily gone away. I spoke with a patient billing expert about this, and the advice that she gave in a situation like this, you know, when you have a hospital stay, you get all sorts of paperwork in the mail afterward. You get paperwork from the insurer, you get paperwork from the provider. This billing expert recommends that you look at the patient responsibility portion of your explanation of benefits. Now that’s a document that you will get from your insurance company. It should list the charges that the hospital has billed, but it should also list the portion of those charges that the patient is responsible for. In Jan’s case, her explanation of benefits clearly stated that she was not responsible for any of it. Now, that didn’t mean that those $59,000 in charges was automatically disappearing, as this story shows. More than a year later, it’s still not resolved. But it shows you that the insurance company is saying you are not responsible for this bill, in this case. The billing expert that I spoke to recommended that the patient mail or email the explanation of benefits from the insurer to the hospital and show that the patient responsibility is zero, in order to get that balance cleared.  

Rovner: We’ll see if this happens. Lauren Sausser, thank you so much. 

Sausser: Of course, thanks for having me. 

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

Ollstein: Yeah, I have a very interesting piece from The New York Times by Simar Bajaj, and it’s called “.” And it is about the trend we’re seeing under the MAHA movement, largely, you know, expressed by Secretary Kennedy, back towards putting a lot of focus on personal responsibility, personal lifestyle choices, and less focus on policy and environmental factors. And it’s, you know, digging into the history of that on a few different fronts, both with, you know, infectious diseases, but also with things like obesity. And it is talking about basically how we’re seeing a return to a system that didn’t really work before, which is, you know, basically browbeating and shaming people into healthier behaviors that did not work in the past. And yet we are sort of attempting to revive that, and part of that is a reaction to the fact that trying to move away from that also hasn’t seemed to work either. So it really explores these, the different history of these approaches in public health. 

Rovner: That’s why public health will continue to be studied. Margot. 

Sanger-Katz: I want to suggest an article in ProPublica from Alec MacGillis called “.” I’ve been interested in the public health problem of gun deaths for many years, and I have to admit that Alec in the story has tackled an issue that I just wasn’t watching. I think it’s, like, one of these other things that has a little bit slipped beneath the radar, because the Trump administration makes so much news. But they, through the ATF [Bureau of Alcohol, Tobacco, Firearms and Explosives], which regulates firearms and firearms dealers, has really loosened up a lot of the restrictions that the Biden administration had put in place to try to prevent the trafficking of illegal guns onto the streets of American cities, where a lot of crime happens. And the story sort of looks at those policy changes and what it means for gun dealers and for people who buy guns. And I think it is too soon to tell whether these policy changes will have an effect on violence and gun deaths on the streets. I think it takes, in many cases, a long time for illegal guns to kind of get out there and be used for crimes. But we have been in this period of really merciful reduction in the crime rate and the murder rate in many American cities for the last few years, and I do think that Alec raises the question that if we are seeing more guns on the streets of the future, whether those declines can be sustained.  

Rovner: Liz. 

Whyte: My choice is from my colleagues Anna Wilde Mathews and Christopher Weaver at The Wall Street Journal, and it’s entitled “.” And it’s a really great look at how there are all these providers that have really exploited this new and growing segment of therapy for kids with autism, which is obviously a growing diagnosis, such that you have, you know, this mom in New Jersey who hears that she can get a no-out-of-pocket-cost treatment for her son and has someone come a few days a week, three or four hours of therapy, and winds up with a bill for more than $900,000, which is obviously a nightmare. So we had previously looked, The Wall Street Journal had, [at] Medicaid billing abuse with these autism therapy services, and found that it was a huge issue. And then this is a look at kind of the private insurance sector, where all these providers are charging private insurance a lot, and when an insurer says, No, we’re not going to pay that, some of these bills end up falling on the families, which is really tragic. About 40 large employers, covering 3.5 million people, their expenses for autism therapy doubled from 2021 to 2025, to $108 million. The Wall Street Journal looked at a bill that was $30,000 for one kid to get autism therapy for one day; it’s actually quite insane. So, kudos to my colleagues for writing about this.  

Sanger-Katz: Can I share one fact from this article that really struck me? 

Rovner: Sure. 

Sanger-Katz: One of the things that these reporters did that I thought was so smart is they documented the growth in the autism services workforce. So, the number of people who are providing this kind of behavioral therapy to children with autism is now larger than the workforce of the U.S. Postal Service. That’s according to a tweet from Derek Thompson, who compared the numbers. But it is kind of astonishing, the growth, not just in the Medicaid spending, not just in private insurance spending, not just in some of these unjustifiable bills that individuals have faced, but also that this is now a huge part of the American workforce is serving in this specific industry right now.  

Rovner: And if this story sounds familiar, it’s because we had a different autism therapy abuse story last week as one of our extra credits. It was written by Margot here, and Sarah Kliff. Yeah, a burgeoning source for reporters to plumb. My extra credit this week is a joint investigation between my colleagues here at ºÚÁϳԹÏÍø News and the AP. It’s called “Festering Infections to Untreated Cancer: ICE Detainees Describe Medical Neglect Across US.” The team of six reporters and analysts dug through court records to document that hundreds of immigration detainees in 33 states have filed suit, charging that they were denied adequate medical care. Quoting from the story, “Requests for help went unanswered for weeks, blood sugars rose, infections festered, cancers remained untreated, detainees collapsed and had seizures.” And there’s not even anyone to complain to. Officially, the administration shut down the office of the Immigration Detention Ombudsman earlier this year. The story is really infuriating and worth reading in its entirety. 

OK, that is this week’s news. Thanks to our editor this week, Stephanie Stapleton, and our producer-engineer, Francis Ying. We also had production help this week from 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: I am on Bluesky , and on X . 

Rovner: Liz. 

Whyte: I am , and on X , and Signal: JournoLiz.80. 

Rovner: Margot. 

Sanger-Katz: I am @sangerkatz at , and on Signal. If you want to send me tips, I’m @sangerkatz.01. 

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

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

Julie Rovner: Hello from KFF Health News and WAMU public radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, May 14, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via videoconference by Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everybody. 

Rovner: And Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi. 

Rovner: Later in this episode, we’ll have my interview with Wisconsin Democratic Sen. Tammy Baldwin. But first, this week’s news. 

Well, as we foreshadowed last week, Marty Makary’s tenure as commissioner of the Food and Drug Administration has come to an end. It’s not entirely clear whether he was fired or whether he resigned or whether he was forced to resign, but what is clear is that his 13-month tenure at the helm of the agency that regulates $1 of every $5 worth of consumer products in the U.S. was chaotic, to say the least. Quoting from the excellent  on his exit, “He had upset advocates for vaping and rare-disease patients, antiabortion groups, and some drug-industry leaders â€” as well as other officials in the administration.” Rachel, you’ve been following this story very closely and breaking a lot of news on it. Who didn’t Marty Makary piss off? And tell us more about that Wall Street Journal ticktock of his last few days, since it’s your “extra credit” this week. 

Cohrs Zhang: It is my extra credit. Truly nothing scares me more than seeing Josh Dawsey’s byline on a story on my beat. So I think the tension with Dr. Makary had been going on for months. I think there was kind of an effort that bubbled up, kind of last fall, in November, about â€” that raised some questions about his future and just his ability to cooperate. But he was able to keep his job at that point in time. But I think there have been a lot of changes at HHS [the Department of Health and Human Services] this calendar year, and I think there’s been an effort to kind of stabilize things, start to get people in place for some of these other positions, at surgeon general and at CDC [the Centers for Disease Control and Prevention]. And once those personnel searches started wrapping up, I think it shifted the focus back, I think, to FDA a little bit more, and there’s a lot of drama coming out of there. 

And I think there is certainly a desire from the White House to get wins out of their agencies to tout, and especially ahead of the midterms, they just want people to be on message and to not have distractions. And I think the FDA, under Dr. Makary’s tenure, just continued to produce distractions. And there was personnel issues. There were certain policy issues that he was not necessarily aligned with the White House on. But there’s also just internal dynamics. When you’re leading an organization, you’re coming in after DOGE [the Department of Government Efficiency], it takes a lot of work to build trust back with career staff who saw their bosses fired, their colleagues retiring. It’s â€” there was so much turnover. 

Rovner: And I was going to say, FDA took a big hit from DOGE, didn’t it? 

Cohrs Zhang: It did take a big hit. 

Rovner: This was before Makary came in. 

Cohrs Zhang: Yes, technically before he came in. But I think we’ve seen other agencies â€” certainly not the level of turnover we saw at FDA â€” but try to build bridges and speak positively about career staff and really make an effort to value their expertise and bring them in the room. And I think we just didn’t really see that at the FDA. I think there was just mistrust and genuinely a view that we hear in public sometimes that career staff, or the “deep state,” weren’t supportive of the administration’s goals. And I think ultimately just the culture becomes toxic enough, and it’s just a difficult work environment for people doing really important work. 

Rovner: And people, the stakeholders at FDA, are really important people, many of them. 

Rachel Cohrs Zhang: They are. It cuts across so many different industries, like tobacco, food, medical devices, drugs, Big Pharma, small biotech. Truly, it’s a tough job to balance all the stakeholder interest. But I think if there had been a sense that he was really taking on industry and pursuing needed reforms, I think that would have been OK. But I think it was just communication issues, unpredictability. It’s just investors, companies don’t like unpredictability. They don’t like surprises, especially kind of a regulator that usually is pretty â€” has a lot of continuity from one administration to another. 

Julie Rovner: Well, it seems like the last straw, as we discussed last week, was this fight over vaping â€” in particular, fruit-flavored vapes, which might help adults quit more-dangerous tobacco products but also might attract children to start vaping. Makary was against the fruit-flavored vapes. [President Donald] Trump had promised the vaping industry during the 2024 campaign that he would protect them. Is there going to be more fallout from this whole vaping fight? I did see that a top HHS spokesman quit this week, also citing approval of the fruit-flavored vapes. But there’s more to that story, too. Right, Rachel? 

Cohrs Zhang: Yeah, I think personnel issues are really hard to cover, and the context that I would want to provide is that these resignations, both of Dr. Makary and the , Rich Danker, were not resignations where these individuals had the possibility of a long and robust career at these agencies. I think they both kind of reached the end of the line. And certainly, are there policy disagreements that occurred about fruity-flavored vapes? Absolutely, yes. But those dynamics have been ongoing for a long time. I think it’s also important to point out that the agency did approve these before the exit of both of these officials. And I think there’s just, the timeline, it’s a little complicated. Personnel issues are complicated, but I think, again, the Wall Street Journal story by Liz [Essley Whyte] and Josh did a really good job of trying to get that 360 view and kind of explain it in a fair and balanced way as to how that all went down. 

Rovner: So the question that this keeps leaving in my mind is: How is tobacco not a bigger piece of MAHA? If we’re going to “Make America Healthy Again,” isn’t the first thing we want to do is get people to stop using tobacco products? Why is this out in this sort of little island by itself, when [Health and Human Services Secretary] RFK [Robert F. Kennedy] Jr. is beating up on pretty much everything else? 

Cohrs Zhang: That is an interesting point. Calley Means at the White House also did a conversation with Harvard this morning and just kind of mentioned that they’re not trying to ban anything in the administration. That was kind of the talking point they were using: We’re not banning cigarettes. We’re not banning ultraprocessed food. We’re just trying to educate people on what’s good or bad for you. So that’s kind of the line they’re taking. 

Rovner: So it’s like vaccines? It’s like everything should be up to your choice about what you put in your body? 

Weber: I just wanted to add that, Julie, I feel like you’re asking a question of the MAHA movement the MAHA movement is unable to answer, which is: What is the MAHA movement? If we care so much about chronic disease, why aren’t we looking at one of the things that kills people a lot, which is tobacco? So, which leads also, and we’ll get to it later, to my extra credit, which is on Stat’s excellent series on alcohol, which the administration is also not really looking at. So I think when MAHA talks about these underlying pillars of combating the chronic disease epidemic, that’s all great. But what are they defining as the chronic disease epidemic? Because a lot of their attention has been focused on vaccines, which scientists have very clearly stated are not causing the chronic disease epidemic. So, we’ll see how this continues to unfold. 

Rovner: And reversing the food pyramid, to emphasize things that science has shown do contribute to chronic disease, like lots of animal products. So it’s a little bit curious, let us say. Well, the person who is now installed to replace Dr. Makary, at least on an interim basis, isn’t even a doctor. He’s a former corporate lawyer at the firm Jones Day and a hunting partner of Donald Trump Jr.’s. What else do we know about Kyle Diamantas, who’s been heading up FDA’s food division? 

Ollstein: So the anti-abortion groups that were demanding Makary’s ouster, some of them, over accusations that Makary was not doing enough to restrict access to abortion pills, are already worried about the acting replacement because records surfaced showing that he represented Planned Parenthood as a private attorney a decade ago, and so â€” 

Rovner: In a real estate case, right? 

Ollstein: In a real estate case, in a dispute between a clinic and its landlord. So clearly this was a concern, because within hours of his appointment as acting FDA leader, he was on the phone with anti-abortion groups, and he’s been talking to them on Tuesday, on Wednesday, on Thursday, different groups, trying to reassure them that he personally opposes abortion and will work with them going forward. But I think if he is nominated to lead the agency on a more permanent basis, that could potentially become a flash point. 

Rovner: And of course, we do know, Rachel, I think you were breaking this morning that the idea of him replacing Makary on a more permanent basis is already not going over very well in the Senate. 

Cohrs Zhang: Yeah, I think Sen. Bill Cassidy made some comments about Kyle. And I think there is absolutely a permanent search. I am not under the impression that they are planning to nominate Kyle Diamantas to be the permanent leader. I think they are searching for somebody with more robust expertise. But I think he’s just made a lot of allies. He’s been a pretty predictable and rational actor in the FDA. He got promoted earlier this year to be an adviser. He’s been doing public appearances, conferences, and on podcasts and television. So I think they just see him as a kind of a steady hand to guide the agency and not cause a lot of drama going into the midterms, because there’s a big backup of nominations in the Senate. So this could drag on for a while. 

Rovner: Right. That is my next question. Who is likely to get this job permanently? And, wow, the nominations are stacking up at the Senate HELP [Health, Education, Labor, and Pensions] Committee, where chairman and troubled Trump ally Bill Cassidy now has to oversee the confirmations of a new FDA commissioner, a new CDC director, and a surgeon general. And Cassidy himself is facing a primary election this weekend in which the president has endorsed one of his opponents. Awkward much? 

Cohrs Zhang: Yeah, it’s an interesting test of some of this proof of concept. Secretary Kennedy’s political operation has backed congresswoman Julia Letlow and so has the president. So there are these bigger macro issues of loyalty to the president and kind of where the Republican Party is headed. But there is a distinct healthcare flavor to this, given Sen. Cassidy’s influence over health policy in the Senate, and also just the involvement of a sitting Cabinet secretary’s political operation, which is pretty unusual, especially countering a sitting senator from his own party. So, yeah. It’ll be interesting to watch on Saturday. 

Rovner: Lauren, you want to add something. 

Weber: I want to call out again that Trump and RFK and Calley Means went pretty scorched-earth on Cassidy when they pulled Casey Means out, too. It’s not just that Trump has opposed him. It’s that this is like blow-everything-up-on-the-field oppose Bill Cassidy. So it is very curious to hear how this goes over, considering that Cassidy was the vote that got RFK his secretary post. So the weekend will be one to watch. 

Rovner: Yeah, it will. Well, the other big story from last week that continues this week is also FDA-related. It’s the fate of the abortion pill mifepristone and whether it will continue to be available via telehealth prescribing. The Supreme Court last week put a temporary hold on a 5th Circuit Court of Appeals ruling that would have rolled back the tele-prescribing option. We were supposed to get a decision on whether or not that appeals court ruling would take effect by the end of the day Monday. But, as we so often say in Washington, that did not happen. Alice, where are we with this case? 

Ollstein: We’re in a real hurry-up-and-wait situation. I had all my pre-writes ready to go on Monday, and I still have them ready to go for today. Look, the Supreme Court could punt again. They could say we need even more time. That’s happened before. They could say that the nationwide restrictions that the 5th Circuit put into effect that would cut off telehealth access to abortion pills and mail delivery of abortion pills and reinstate a prior rule saying patients can only get the drugs in person from a doctor, they could let that go into effect. Or they could say, Look, we’re going to maintain the status quo for now while this case makes its way through the courts. Those are sort of the three options. There could be a secret fourth thing. This is the Supreme Court. They kind of do what they want. One possibility is some parties in the case have asked the Supreme Court to leapfrog the 5th Circuit and just deal with this themselves once and for all. So that could happen, or they could send it back down to the 5th Circuit. 

We can sort of take some clues from what they did when a different case challenging abortion pills came before them in 2023, which is: They maintained the status quo. They maintained nationwide telehealth access while sending the case back to the 5th Circuit. And then it eventually came back to the Supreme Court, and they eventually sort of dodged the heart of the issue and decided it based on standing. That could happen again here, too. We have no idea. But this is really a major case because if these nationwide restrictions on telehealth go into effect, it’ll be really the biggest rollback of access since Roe v. Wade was overturned in 2022. And it will really go after access in blue states with protections on the books for abortion access in a way that people in those states really haven’t experienced before now, which could have very big political as well as healthcare implications. 

Rovner: And which those states have also sued. 

Ollstein: Yes. Yes, yes, yes. 

Rovner: The blue states. So there’s more to come. What role if any did the anti-abortion movement have in Dr. Makary’s losing his job? As we discussed last week, they blamed him for the FDA’s slow-walking of a review of mifepristone safety, even though it’s pretty clear that that delay came from the White House, not from Makary himself. And I know there was a White House meeting just last Friday with anti-abortion groups, just as the Makary-is-on-his-way-out rumors began to fly in earnest. Connected? 

Ollstein: So the administration is definitely trying to reassure the anti-abortion movement and keep them in their good graces leading up to the midterms. But that’s not entirely been successful. The anti-abortion groups are still upset. They still want to see these policy actions. They want the FDA or the DOJ [Department of Justice] or the EPA [Environmental Protection Agency] or some agency to do something to cut off access to abortion pills. They have not gotten that yet. They’re also really upset that the current ban on Planned Parenthood receiving Medicaid funding is set to expire in July, and it’s not totally clear Congress is going to manage to extend that defunding provision at all or in time for its expiration. And so these are two big priorities of theirs that they are very upset about. And so it’s not clear that all of this access that the administration is extending to them in these meetings and these phone calls, if that’s not followed up by concrete policy action, they’re not going to be satisfied. They’re going to keep complaining, loudly, as we’ve already seen this week. 

Rovner: Well, meanwhile the Trump administration used Mother’s Day this week to unveil a new regulation aimed at making it easier for employers to offer IVF [in vitro fertilization] coverage to their workers, though not making it free, as Trump had promised on the campaign trail in 2024. And at a maternal health event on Monday in the White House, administration officials continued to press their pro-natal push for more people to procreate. Here’s how [Centers for] Medicare & Medicaid [Services] chief Dr. Mehmet Oz put it at the event. 

Mehmet Oz: One in 3 Americans are under-babied. What does under-babied mean? That means that you either don’t have any children or you have less children than you would normally want to have. 

Rovner: Um, OK then. This event also featured the unveiling of a new federal website, moms.gov, which HHS says is a, quote, “user-friendly, one-stop digital hub providing new and expectant mothers with essential resources.” But it also links users to an anti-abortion group site that collects lots of sensitive personal information that can apparently be used any way the group, Heartbeat International, sees fit. Alice, this has prompted some concern in the reproductive health community. Has it not? 

Ollstein: It has, and it’s also a good example of how the administration is both working to appeal to anti-abortion activists while also continuing to piss them off, disappoint them. And so there was just a lot of mixed reaction to the unveiling of this website, because the anti-abortion folks were thrilled that it was steering people, using government resources to steer people to these often faith-based, anti-abortion crisis pregnancy centers. But at the same time, it was promoting IVF, which many of them oppose. They see it as akin to abortion. They — some see it as even worse than abortion, because it’s creating all these embryos and discarding them. And so it’s this real sort of push and pull where they’re not happy and, as you mentioned, the pro-abortion-rights camp is really not happy, either. 

Rovner: So we will have more of this as we go forward. All right, we’re going to take a quick break. We will be right back. 

So back in February â€”I looked this up â€” we talked about the Trump administration threatening to withhold millions of dollars appropriated to the global childhood vaccine group called Gavi, because it wouldn’t promise to phase out the use of the preservative thimerosal, which, by the way, has long since been cleared of accusations that it causes autism. The U.S., which helped create Gavi, now owes it $600 million â€” $300 million each for the last fiscal year and the current fiscal year. And last week, a bipartisan group of senators, led by Senate Appropriations Chairwoman Susan Collins of Maine, sent a letter to Secretary of State Marco Rubio asking him to, you know, spend the money that Congress appropriated. Now, Gavi says it has specific reasons for using vaccines with preservatives, because it mostly operates in poor countries, where refrigeration can be spotty, and it has to make the best use of limited funds. My bigger question is: How does the secretary of Health and Human Services get to stop the State Department from spending money appropriated by Congress? 

Weber: I think that’s a great question, Julie. At the end of the day, Kennedy, for years â€” this is not something he came up with overnight. This is something he’s been harping on for years. He wrote a book about thimerosal. He has linked it to autism, which is a claim that has been disproven by scientists and even folks at his own agency, before his handpicked advisory committee voted to get rid of it, in a decision that now is on ice with the federal court. But he also has railed against the sending of these vaccines abroad for years. I’ve listened to him talk about it. He really dislikes Bill Gates for his involvement in some of this. And so on. So it was a personal issue for him that he’s held tightly. I’m not sure how you get ahold of State Department funds, but I’m not sure of a lot of things these days. So, here we are. 

Rovner: Neither is Congress, apparently. We will watch the Gavi space, too. Well, meanwhile, we are also still watching this hantavirus outbreak that apparently came from Dutch tourists in Argentina, who caught it and spread it on a cruise ship in the Atlantic. So far, there are nine confirmed cases and two more people showing symptoms. Public health experts, including what’s left of the Centers for Disease Control and Prevention here in the U.S., seem fairly united in the view that while this is an odd outbreak, since hantavirus rarely spreads from person to person, they’re still not super worried about it morphing into another pandemic. But it does underscore just how unprepared the U.S. is should another outbreak of this or something else prove more dangerous, now that the nation has basically cut public health capacity to the bone, cut ties with international public health organizations like the World Health Organization, and defunded much of the federal public health infrastructure. Although, I have to add, there is at least a little bit of karma in watching all these officials who rose to prominence criticizing the nation’s covid response trying to respond to a public health emergency of their own. What are you guys watching for? Lauren, you must be on this one. 

Weber: Yeah, no, I had  earlier in the week about: What’s it like to be in the Nebraska national quarantine unit? Which it was kind of fascinating to me. So basically there’s this whole setup in the middle of the country â€” and as a Midwesterner, I obviously love a Midwest shout-out â€” where they repatriated all these people off the cruise ship and sent them to Nebraska. And you end up, basically, if you’re in the quarantine unit, in what’s essentially a souped-up hotel room. There’s an exercise bike. Apparently, the staff is very nice. But you can’t leave, really, unless â€” there is some talk about letting some of the people that seem to really have no symptoms potentially leave to stay at home, but it’s a little unclear what’s happening there. Staff comes in in protected masks. And you don’t get to see people for a while, so that’s kind of a tough go after you were on a cruise ship sailing the world. That really went awry. So â€” 

Rovner: And it’s a long incubation period for this particular strain of hantavirus. 

Weber: It’s a long â€” 42 days! That’s a long time to be stuck in a room. But again, officials â€” as you said, Julie, I think which was smart to point out â€” have said this is not covid. This does have very low risk of spreading to the general public. I do think there is some question about this question of prolonged contact and what that means â€” it seems like it’s being debated a little bit about how exactly this spreads and how exactly many people may end up coming down with it â€” that we’ll have to continue to watch as well. 

Rovner: And of course, we’re already seeing people online, like, selling more ivermectin. And, this sort of thing does bring out the less-than-scrupulous actors in public health, shall we say? 

Weber: Nothing like a crisis. But, in general, I think it’s a good reminder. As you pointed out, we’re watching the contrarians run the ship. I was fascinated. In the Oval Office, basically, RFK Jr. said there’s nothing to worry about, Nothing to see here kind of thing. And that is, it’s interesting, the public health messaging, which has varied from person to person in the administration, because they have litigated how covid was messaged for such a long time. Now, again, this is not covid. But it’s very fascinating to see players that had such strong opinions deal with some of the same terms, like “quarantine,” “6-feet isolation,” the uncertainty of what’s happening, and, again, deal with it in a backdrop of: We’ve withdrawn from the WHO. There have been CDC cuts. And what happens now? 

Rovner: Yeah, and also the fact, and we talked about this a little bit last week, that the U.S. didn’t even know that some of the people who were exposed had already gotten off the ship and gone home. And those people are not in quarantine in Nebraska. Those people are apparently being watched by their individual state health departments. So the coordination effort here was not great, either. 

Weber: Well, it does sound like the CDC was on the horn with state health officials. But yeah, I mean, some of these people kind of flew into the wind, so to speak, and they haven’t found everyone. But that said, you know, I talked to the Virginia state health official who was like, Look, we’re in talks with the patient in Virginia who&²Ô²ú²õ±è;…&²Ô²ú²õ±è;they check in for daily monitoring of temperature checks and so on. The California state health official that I listened to said, Look, these people that we’re watching were either a row behind or a row in front of, or two seats next to, for at least 15 minutes a suspected ill passenger on a plane. That’s why we’re watching them. And that’s interesting to me, too, because that speaks to the level: Is that prolonged contact? What does prolonged contact mean? is my underlying question I continue to ask. So we’ll have to continue to see what we learn more on this front. 

Rovner: Well, at very least, they’re getting an idea that covid was not so easy to deal with â€” these people who’ve been criticizing the covid response. OK, that is this week’s news. Now we’ll play my interview with Sen. Tammy Baldwin of Wisconsin, and then we’ll come back and do our extra credits. 

I am so pleased to welcome to the podcast U.S. Sen. Tammy Baldwin, Democrat of Wisconsin. Sen. Baldwin is a senior member of both the Health, Education, Labor, and Pensions Committee and the Senate Appropriations Committee, where she’s the top Democrat on the subcommittee that funds the Department of Health and Human Services. Sen. Baldwin, thank you so much for joining us. 

Sen. Tammy Baldwin: Thank you for having me. 

Rovner: So we spend a lot of time on the podcast talking about health issues that are divisive, and often divisive by party, but one feel-good story of the past few months comes from a study showing that the new 988 suicide prevention hotline has, in fact, reduced youth suicides. That was a very bipartisan effort in Congress that you were, I know, a big part of. How satisfying has it been to see that succeed, and is there a chance that you could repeat that work on other health issues, or was this kind of a one-off? 

Baldwin: Look, I knew when we wrote the bill to establish the 988 hotline that it was going to save lives. But to have this study showing that there was 10% to 11% reduction in youth suicide and attributable to this 988 hotline â€” it’s heartwarming to know that this work matters. And it was very bipartisan legislation to establish the 988 hotline. You know, we’ve long had a mental health crisis suicide prevention hotline. It was a 10-digit number that no one would remember at a time of crisis and need. And so now people remember it and can use it, and it’s also modern in that you can also chat or text as well as call. And with the young generation, sometimes that’s their preferred way of reaching out and communicating. But again, heartwarming to hear what I always believed would be true about 988 â€” that it is saving lives and people are using it. 

Rovner: I know that as much of a success as this has been, you’ve been critical of HHS Secretary RFK Jr. for eliminating the part of the hotline that provided a separate option for LGBTQ+ youth. What’s the status of your effort to get that restored? 

Baldwin: Yeah, and I’ll focus on that. And there’s some other concerns that I have about the way in which we support 988. But let me start with that. There are certain populations in the United States that have higher rates of suicide. I think we all immediately think of our military veterans. And so when you call the 988 hotline, one of the first screening questions is: “Are you a military veteran? Press 1.” And if you are, you have the option then of getting your call or inquiry responded to by somebody in the VA [Department of Veterans Affairs] system who, I might say, has walked in your boots before and understands the experiences that you might have had while serving in the military. Another population with a very high rate of suicide is LGBTQ youth, and so the “Press 3” option made sure that youth who were in the LGBTQ community and reaching out for help in crisis were getting their calls and texts responded to by somebody who was specially trained and understood their situation. And you know, again, it promotes use of the line because you don’t think when you call that you’re likely to be judged. And by the way, the study that showed this was having a very positive impact on reducing suicide said that 1 in 10 calls to the 988 hotline, people utilize the “Press 3” option. But what happened there is the Trump administration last year abruptly ended the service and defended that by saying, Well, we want to treat everyone the same. We don’t want to discriminate. Well, they kept the “Press 1” option for veterans, and understanding that specialized response for veterans would be important to keep, but they eliminated the service “Press 3” for LGBTQ youth. Very unfortunate. But fortunately, there was a bipartisan pushback to that â€”on two fronts for that, one successful and the other still in progress. We wanted to make sure that the administration restored the “Press 3” option and restored the contracts with nonprofits that are able to provide the response to those calls. And that was written into our appropriations law for the fiscal year 2026. Now we’re chasing down the administration and Secretary Kennedy, saying, It’s in the law. Let’s get it done. It hasn’t happened yet, but we have his public commitment to make sure it does. And so we’re pressing him for expeditious restoration of the “Press 3” option. That said, we also want to make this permanent law. And so I have a bill that is bipartisan with Sen. Lisa Murkowski that would write into statute that a “Press 3” option has to exist and so that it doesn’t become political football in the future. 

Rovner: Well, I’m so glad you mentioned things that have been written into the appropriations law, because one of the continuing issues that we’ve chronicled over this last year has been this administration just refusing to spend money as appropriated by Congress. Now, I’ve been covering Congress in general â€” and the Labor-HHS appropriation, in particular â€” for four decades now, and a 25-year-old or 35-year-old me could not imagine appropriators standing for any administration, ignoring their power of the purse, which this one seems to be doing. Why has there been so little pushback, and is that going to change? 

Baldwin: Yeah, in answer to your question, I want to say that in this most recently passed bill that Donald Trump signed into law, we had to put guardrails that we’ve never had to put into our appropriations laws before to enforce our spending bills. And those laws have made it clear that we expect that they must spend what we have appropriated, and not just, you know, all of it at the end of the fiscal year, but in a timely manner throughout the year. And we also are more specific about staffing requirements, because we saw last year these incredible numbers of people fired, RIF’d, as well as really heavy pressure to get people to sign up to early retirements, etc., but just a big push to get people out of the agencies. And so we had to write into the appropriations law that they have to maintain staffing sufficient for their mission. And I can give you any number of examples where people needed to reach out to divisions within the CDC, for example, and no one was there. 

Rovner: Is there going to be more pushback, do you think, if the administration tries this year to avoid spending money in the way that they tried to avoid spending money last year â€” and, as you kind of mentioned, dumped a lot of money out the door at the very end of the fiscal year? 

Baldwin: Yeah, so one of the areas in which they did that in a significant way was NIH [the National Institutes of Health]. We saw thousands fewer grants awarded last fiscal year, and we’re very worried that they would continue to act in that vein. And part of that battle is still ongoing. There’s something â€” we’re going to get in the weeds here for a second â€” but there’s something they call forward funding, where instead of just annually funding one year of grant research activity, you actually fund multiyear grants all at once up-front. And the administration has wanted to move into doing that more and more and more, but if you have a finite number of dollars, that simply means fewer grants will be awarded each year. And the way I liken it, if you’re thinking about NIH and curing cancer or finding a better treatment for Alzheimer’s, these are more shots on goal. We need to not just invest in a few research endeavors to try to cure cancer, to try to treat Alzheimer’s, to deal with all of the things that NIH is trying to advance, you have to have as many shots on goal as you can. And so this forward funding is really tying up a lot of resources in fewer and fewer research endeavors. 

Rovner: And that â€” which leads me to my last question, which is&²Ô²ú²õ±è;…&²Ô²ú²õ±è;concerns the other thing we’ve talked about a lot, is that future health care and research worker pipeline having fewer grants means fewer jobs for students and PhDs. And this administration has also made it more difficult for medical students and other health profession students to take out loans by capping the loan amount. How big a concern is this? And what can you do from your posts, either on the HELP Committee or on the Appropriations Committee, to make sure that there is a future workforce for healthcare and research? 

Baldwin: Yes. Well, especially in research, I was proud to&²Ô²ú²õ±è;…&²Ô²ú²õ±è;lead bipartisan legislation called the Next Generation Researchers Act that passed many years ago but is definitely in threat under this administration. I represent the state of Wisconsin. We have a couple of academic research centers that are exceptional. And I remember visiting on so many occasions and seeing these bright postdocs looking forward to their opportunity to advance treatments and cures for devastating illnesses and learn about the basic mechanisms of biology. And knowing each year that the average age of the first-time grant awardee is getting older and older and older, and the opportunities for a career in research â€” which is such an investment by the individual to their education and postdoc work â€” their opportunities are shrinking and shrinking. And some are leaving research and going into private industry. Some are leaving the country and are actually being lured by other nations who want to take advantage of this neglect here in the United States. This is something we’ve got to turn around. And forward funding is one of the things that is making it harder, but also the lack of commitment to just increasing the overall research enterprise in the United States, which is something we are known for globally. You have to keep up with it. Costs increase, and so you can’t just flat-fund, that means less. You can’t forward-fund, that means less. So we’re going to have some bipartisan pushback, but we also are going to have a very limited amount of resources to deal with, especially â€” just to drop a big topic at the very end here â€” especially with a Defense Department that is seeking $1.5 trillion in funding â€” that, just the math doesn’t work out. 

Rovner: Well, we will be watching the appropriations process closely as it moves forward. 

Baldwin: Yes, indeed. 

Rovner: Sen. Baldwin, thank you so much for joining us. 

Baldwin: Thank you for having me. 

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

Weber: Yeah, I wanted to highlight Stat’s series, the first of which is titled “,” by Lev Facher and Isabella Cueto. And it’s just a fabulous step-back look at how this administration, in particular, which would seem to be primed to look into alcohol as an addiction, considering that Trump himself is a teetotaler and RFK Jr. has publicly spoken about his recovery from addiction to alcohol, is not seizing the moment. And this is happening at a time that ER visits for alcohol are going up, and that alcohol does, speaking of chronic diseases, contribute to quite a large amount of American healthcare costs. And it’s a real bracing look at an issue that, you know, oftentimes people don’t want to look at in this way, as alcohol is such an inherent part of America’s social fabric. So kudos to them for the look. 

Rovner: Yeah, I would point out that both alcohol and tobacco are, you know, two of those vices that have been bipartisan over the years. Republicans and Democrats in Congress have worked on, but this administration seems to be sort of downplaying both of them. Alice. 

Ollstein: Yes, I have a piece by my colleague Katherine Tully-McManus titled “.” Now we’ve been hearing a lot about the threats to medical privacy with everything being in these electronic records, and, you know, being shared from company to company. And turns out, even being a member of Congress does not protect you from this brave new world that we live in. And there was a data breach this week that lawmakers were informed of, and potentially their prescription history was unveiled. And so that is information I am sure they do not want out there. So it just really shows that if even they can be at risk, then, you know, what’s going to happen to the rest of us? 

Rovner: Yeah, that was some story. And I would add that TMZ is looking for members of Congress who smoke weed. That’s a separate story. Not my extra credit. My extra credit this week is from ProPublica. It’s called “,” by Rob Davis. It’s about a state law that gave Oregon officials the power to stop mergers and acquisitions that were deemed not in the best interest of patients. The idea was to, if not stop them, then at least slow the consolidation push that was cutting access and driving up healthcare costs â€” except it hasn’t worked, at least not yet. Quoting from the story: “Of the nine healthcare deals for which regulators have done follow-up reviews, at least three had outcomes the law was meant to forestall.” As always, complicated healthcare problems defy simple solutions, but I assume they’ll keep trying. 

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever 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? Lauren. 

Weber: I am still on X  and the same thing on . 

Rovner: Rachel. 

Cohrs Zhang: I’m on X  and on . 

Rovner: Alice. 

Ollstein: I am  on Bluesky and  on X. 

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