[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 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, May 7, 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 Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Sandhya Raman of Bloomberg Law. 

Sandhya Raman: Good morning, everyone. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: Later in this episode, we’ll have my interview with Andrew Jones, who reported and wrote the latest KFF Health News “Bill of the Month,” about an emergency room bill for what turned out not to be an emergency but could have been. But first, as always, this week’s news. 

Let’s start this week with the continuing fight over the abortion pill mifepristone. Last month, it appeared that the court fight over the pill was put on the back burner. That was after the Trump administration, to the consternation of abortion opponents, asked a federal district court judge to postpone proceedings while it finished a new safety review of the pill by the Food and Drug Administration. Well, the state of Louisiana, which had brought the suit to roll back the pill’s availability, wasn’t satisfied with that, and appealed the delay to the 5th Circuit Court of Appeals. Last Friday, right before dinner, a three-judge appeals court panel ruled in favor of Louisiana and basically ordered a rollback of abortion pill availability to the rules that were in place before 2021. That’s when doctors had to literally hand the pill to patients, meaning no telehealth and no pharmacy distribution. Shefali, you’re one of our abortion experts. Pick up the story from there. What happened over the weekend, and where are we now? 

Luthra: Over the weekend, there was a lot of confusion. I spent a lot of time talking to abortion providers and people who track abortion law quite closely. And providers were prepared to switch regimens, if they had to, to change to what’s misoprostol-only â€” using larger doses of the other drug in medication abortions, which is safe, is effective â€” is less safe, less effective? â€” but still good, though not gold standard. Meanwhile, we saw an appeal from the manufacturers of medication abortion to the Supreme Court. They also saw a stay from the 5th Circuit. While they might get some more time to figure things out, they never heard from the 5th Circuit. But then, on Monday, the Supreme Court weighed in and said, We are blocking this 5th Circuit ruling for a week. You have a few days â€” so, until Thursday, today actually â€” to submit arguments from both sides. And then, by the end of the day Monday, they are supposed to say whether this stay will be extended, whether they will be ruling, whether they might take up this case. And there’s a lot that could happen, right? They could try and make a ruling now, they could send this back to the lower courts. They could say, We want to hear arguments before this term ends, which would be at the end of June. They could say, We want to hear arguments on this in the fall, right before the midterm elections. But what they do could have real significance for whether mifepristone is available by telehealth, and, as a result, how people in states with abortion bans â€” but also where abortion is legal â€” get abortions. Because telehealth abortion is increasingly popular. One in 4 abortions are done by telehealth. About half of those are for people in states with bans, but half of them are for people in states where abortion is legal and protected. But going to a clinic and getting a pill handed to you is simply much more inconvenient and often impractical or not really possible, compared to having it mailed to you â€” if you have child care, if you can’t get off work, if you live really far from a clinic. And so access to this gold-standard regimen of abortion care is now possibly going to be very much in limbo for all these people across the country. 

I don’t know if we have seen much to indicate that this is going to be a campaign issue. We haven’t really heard as much chatter from Democrats as one might expect. But it is possible that if this becomes more of a live issue, if the Supreme Court makes those restrictions more permanent, or if they, in fact, do take this case up in a manner of timing that would be very influential, that this could, in fact, become a meaningful campaign issue, because most voters don’t like abortion restrictions, especially national ones. 

Rovner: Yeah, among the people who are sort of put in a difficult situation here is the Trump administration. The anti-abortion movement clearly wants more action on this issue. Trump was pretty clear, even on the campaign trail in 2024, that he doesn’t want to further restrict abortion; he’s already getting hammered for not following through on his promise to make in vitro fertilization more available. And now anti-abortion groups are planning to put not just money but their large volunteer power up against those candidates who won’t vow to take more aggressive federal action. How angry are they? And what impact could that have on the midterms, where Republicans are already on defense? 

Luthra: They are furious with the Trump administration. I mean, you have the head of SBA Pro-Life America : Trump is the problem. That’s quite blatant for what is ostensibly a close ally to the White House, an organization that has tried to influence policy, that has hoped for those influences to be translated into actual policy. It’s clear that they’ve given up on that. And many of them were very, very frustrated that the administration took on this purported review of mifepristone and kept saying, We will have more information for you later, probably after the elections. And that they, in fact, argued against Louisiana in the courts, and they defended their policy of having mifepristone available for now. And so I think what you’re seeing politically is this real possibility of schisms in the conservative movement. The people who oppose abortion and, right, are an important part of that base, but also, Trump may be unpopular nationally, but he still carries a lot of influence in a large part of the Republican Party. We just saw that in the primaries in Indiana this week. And so I think we really don’t know who wins. Do anti-abortion voters simply stay home? Do they say, Well, this is still our best option. It’s the Republican Party. And also, in the meantime, how much does the movement start thinking instead about trying to pick a possible successor to Trump? And a lot of them really are focusing now on the midterms, but also on 2028. And so do they just say, Well, we’re done with this. We’re not going to win and move on. Or is there something that they might be able to get if they keep threatening to withhold money and voter influence? Open question. I think we’ll see. 

Rovner: Jessie, Sandhya, you guys are on the Hill. I mean, you know, there’s been a lot written this week: Oh, Democrats haven’t said anything about this. I think this came as a bit of a surprise. I think we, most of us, thought that this was going to be kind of back-burnered until after the election. Do you see Democrats picking this up and running with it at some point? It has, it has been, it’s been an effective political issue, but maybe not so much in terms of votes, right?  

Hellmann: I don’t know if Democrats really saw much gain from focusing on abortion in the last round of elections, which feels like such a weird way to talk about it. But they might think that other campaign issues, like the affordability issue, healthcare costs, more generally, might be more of an issue that they want to hit on&²Ô²ú²õ±è;…&²Ô²ú²õ±è;especially after the ACA tax credits expired. But we might see more from them as this issue continues to play out in the courts. 

Rovner: And I’m just wondering if, you know, if Republicans start&²Ô²ú²õ±è;…&²Ô²ú²õ±è;I mean, we’ve seen people like Bill Cassidy, the chairman of the HELP [Senate Committee on Health, Education, Labor and Pensions] Committee, who’s been very outspoken, you know, and has long anti-abortion bona fides, I mean, going back pretty much his whole career. But it’s interesting that he’s been hammering on this. I’ve seen Republicans on the Hill hammering on this in a way that separates them from the president, which is a little bit surprising. It makes me wonder if Democrats are going to try to exploit that difference or not, or if they can figure out how, or if just, as you say, affordability is so much a bigger issue right now. 

Hellmann: I think the Bill Cassidy race is really interesting. He’s in a heated primary against Julia Letlow, and he seems to think that this mifepristone issue is going to be, like, a wedge issue in that race. He’s the chairman of the HELP Committee, so he spends so much time talking about this. Even when HHS [Department of Health and Human Services] Secretary RFK [Robert F. Kennedy] Jr. was on the Hill a few weeks ago, this is one of the first things that he asked him about, and he didn’t even get to the vaccine issue until later. But I think that maybe in those more conservative primaries, it could be an issue. But then it’ll be interesting to see how he’ll talk about it later on, if he does win that primary. 

Luthra: I think one thing to note about the Cassidy primary that I’m really surprised by â€” and I think speaks to the complicated state of things, and maybe the fact that people thought this was a resolved issue â€” is he talks about it a lot on the Hill. If you go through his TV ads that he is running in this very close primary, they’re not about abortion. He has not had a single TV ad about abortion, and it is largely instead about trying to assert his bona fides as a true partner to Donald Trump. And I think that’s really interesting because, again, as we’ve discussed, Trump is not really interested in this issue, and Louisiana primary voters certainly are. But there’s a calculation, right? Do you want to situate yourself as the partner to the president, or do you want to talk about abortion? And maybe you can do both, but maybe it’s actually really difficult to do both of those things. 

Rovner: Well, one thing I haven’t seen mentioned in this latest round of debate over abortion is the potential impact on the rest of the drug industry. Once again, justices are being asked to step in and override the presumably evidence-based findings of the Food and Drug Administration. The last time we got this close to a Supreme Court ruling on an FDA approval of mifepristone was in 2024, when the justices were able to punt by pointing out that the doctors group that brought the suit didn’t have standing. But it doesn’t look like that’s as viable an out this time, because it’s the state that’s suing. Why haven’t we heard more from drugmakers, who we know are freaking out about not being able to rely on FDA decisions to make, you know, business plans worth billions of dollars? 

Raman: I think we will. I think it really depends on what we see in the next week, in terms of is this getting escalated, that the Supreme Court would hold arguments, or where we are? If I think back to 2024, I feel like a lot of more of the involvement from the pharmaceutical industry â€” when they were speaking out more, holding briefings, maybe submitting those briefs â€” was when we got to the Supreme Court stage. So I think it’s a matter of time. And right now it’s, you know, kind of figuring out their options and what they’re going to do. But a ruling could have a huge impact on so many other drugs. So I doubt that they’d be quiet as we get further along. 

Rovner: Yes, I would expect, I mean, we’re going to see a flurry of briefs by the end of the day today, and I would expect that the drug industry would be among those who are going to be filing those briefs. So we will know more. 

Luthra: In fact, we actually already have a brief from PhRMA [. 

Rovner: Oh good. 

Luthra: It came in either last night or this morning, and it says exactly what you’d say, that they are concerned that pharmaceutical development will suffer if Louisiana wins, that this is really problematic for drug research and development. And we are seeing some op-eds from biotech CEOs, etc., in places like Stat just highlighting that they are very concerned about the ramifications for the industry. So I think so I’m just totally right, like, as this case picks up steam, that chorus will get louder and louder, because this is just too consequential for the industry to not talk about. 

Rovner: Right, this is about much, much more than abortion. All right. Well, speaking of the FDA, Commissioner Marty Makary’s job is, quote, “on thin ice” — that was, were the exact words used in stories from Bloomberg, NOTUS, and The Wall Street Journal, all in the past few days. On the one hand, we’ve heard these rumors before, as things at FDA have been chaotic, to say the least, but this week’s flurry of rumors appears to be over Makary’s overruling of FDA scientists who recommended approval of mango- and blueberry-flavored vapes. Makary was reportedly concerned about attracting children to vaping by approving fruit flavors. This has been a long-standing argument. While the scientists who recommended approval wanted to help adults actually quit smoking, which is demonstrably worse for their health than vaping. As it turns out, the flavored vapes were approved on Tuesday, apparently after President Trump intervened personally by calling Makary. So this raises two questions. First, is this more politicization of FDA policy? It certainly looks like it, even if the ultimate decision here was what the FDA scientists actually wanted. 

Raman: I mean, if you look back to when President Trump was on the campaign trail, he did talk about wanting to save vaping and how that was a big issue for certain voters and stuff. So it has been something that’s been in the back burner. These kind of approvals and authorizations take a very long time. And they’ve, you know, a lot of folks have been complaining for a long time about how long some of these things take. They can be backlogged for years. And we had very different opinions with some of the appointees during the Biden administration about how to handle flavored nicotine and tobacco products. I do think that the short turnaround between some of those conversations over the weekend and then suddenly this getting authorized is a little unusual, but it’s kind of hard to say where they were in the process before that, if they were dotting the i’s, crossing the t’s, or if this shoved things forward a lot more. So it’s hard to tell, but I think it really does build into your earlier point about how folks are just not sure for how long that he remains as FDA commissioner. I mean, there have been things building for months, but it really has heated up in the last couple weeks or so. And I think something that raises for me there is just if he does get out at some point soon, that would make another thing that the Senate has to get through and, you know, find agreement on which could get even more complicated if, depending on what happens with&²Ô²ú²õ±è;…&²Ô²ú²õ±è;

Rovner: â€¦ with the abortion case. 

Raman: Yeah, and Cassidy’s race! 

Rovner: Oh, Cassidy’s primary! That’s right. Yes. 

Raman: Yeah. So I think there’s a lot of interconnected things that will be really interesting to watch here as this plays out. 

Rovner: Well, there’s also, before we get off of this, there’s a broader question here about harm reduction. Sandhya, we just talked about this a few weeks ago, after the federal government said it would stop paying for test strips to detect fentanyl and other potentially fatal substances added to illicit drugs. So harm reduction is bad when it comes to fentanyl strips, but good for flavored vapes? 

Raman: I think we’ve had a lot of conflicting messaging on this. Flavored vapes, I guess, are a little bit more complicated, because you could be an adult and just go straight into flavored vapes, and it is a little bit more complicated than that. 

Rovner: And it is a legal product. 

Raman: Yes, it is a legal product. You know, it’s regulated very differently. But I think, since you did bring up harm reduction, the interesting thing there that has been happening is just that there’s been so much differences of opinion, despite that guidance. You know, we had the Office of National Drug Control Policy this week put out their drug control strategy plan for the year, and that had language in favor of the testing strip. So we’ve had a lot of conflicting messages between different parts of the administration over the same issue, which is really confusing folks on the ground. 

Rovner: It is. Well, in other news from the FDA this week,  that the agency blocked the publication of several studies that found very few serious side effects from vaccines for covid-19 and shingles. This included top FDA officials ordering the withdrawal of studies that had already been accepted by medical journals. This is far from the first that we’ve heard of this sort of thing from the FDA and from the Centers for Disease Control and Prevention. But it does increase the doubts that this administration is, quote, “following the science,” does it not? 

Raman: I mean, we saw the same kind of reaction in terms of why this happened from HHS, you know, saying that the studies were making really broad claims, and they were not supported by whatever the underlying data that they had was. I think that this and the CDC vaccine study getting pulled are both highly unusual, but the fact that they’re both happening in a short period of time, you know, kind of increases that. I think it’ll be interesting, you know, we saw with the CDC study that it ended up getting leaked, and then people were able to look at it and make their own conclusions. What happens with this? But having these studies about vaccine efficacy being pulled when the administration is trying to pull back on their vaccine messaging is, like, a less salient issue for the midterms is interesting. So I’m curious what happens next there. 

Rovner: Yeah, me too. OK, we’re going to take a quick break. We will be right back. 

OK, we’re back, and of course, we have more personnel news. Last Thursday, just after we taped, thank you very much, President Trump pulled the nomination of Casey Means to become the next surgeon general after it had become clear she did not have the votes to even move out of committee. In her place, the president nominated Dr. Nicole Saphier, a Fox News contributor who did finish her medical residency and is a practicing radiologist specializing in breast imaging, and â€” apparently this is now a requirement for a high job at the Department of Health and Human Services â€” she’s a podcast host. Just this week, there’s been a  that were critical of some of the health stances taken by President Trump and HHS Secretary RFK Jr. But I imagine that might actually help her nomination, which has generally been pretty well received, by making her look like she’s at least as interested in accurate medical advice as she is in currying favor. Or am I misreading this? 

Raman: I don’t know that the tweets are going to have a huge effect either way, when there’s so many other things going on. And I feel like it’s so interesting that her book from, you know, long before this administration, was called Make America Healthy Again. So it seems like if anyone is committed to this movement, it would be someone with a book titled that six years ago. 

Rovner: Although she’s not really a MAHA person, right? 

Raman: Yeah, yeah. But it just is such a funny coincidence. But I think that right after they pulled the Means nomination, it was interesting â€” kind of goes back to what Jessie said was that â€” we had the president; we had her brother, Calley Means; and then we had Secretary Kennedy as well digging in on Cassidy and blaming him for that nomination falling through. But they did back the new nominee. So it’s interesting what is going to happen there. But just how political just getting this across is, even though there weren’t other votes in the Senate to get Casey across the finish line. 

Rovner: Yeah. Shefali, you were going to add something? 

Luthra: Oh, I just think that the tweets, I mean, they are really striking, and I think you’ve hit on something that is a fascinating tension. This is someone who has criticized the president’s talking points around Tylenol in pregnancy; who has said that, you know, maybe there is not a link between Tylenol and pregnancy and autism. Maybe I don’t want to be told just tough it out when I am in pain. She also, fascinatingly, is quite anti-abortion, and has talked about that a lot as well. And I think there’s just a lot of really complicated worldviews that she brings. And on the one hand, like, maybe some of that ends up being appealing to lawmakers because, as we’ve discussed many times on this podcast, the stances that are more anti-vax, anti-medicine, anti-science are not necessarily that popular with voters, and lawmakers are reacting to that. That’s why it’s been so difficult to confirm a surgeon general nominee. And maybe this finally changes that. Maybe deleting those tweets does suggest that someone would rather remain in good standing with the president. I don’t think we really know until&²Ô²ú²õ±è;…&²Ô²ú²õ±è;if she gets the job and then see what happens. But it is really fascinating to see the third person picked, where there’s still an unfilled position, possibly being someone a bit more aligned with some things that are, in fact, conventionally accepted medicine. 

Rovner: Well, we will see. And of course, this is&²Ô²ú²õ±è;…&²Ô²ú²õ±è;yet another nomination that has to go through Bill Cassidy’s HELP Committee. And regardless of what happens in his primary, even if he loses his primary, he’s going to be the chairman of that committee until the end of this year. So we will have to see. 

All right. Moving on to the Affordable Care Act, we have more evidence this week about the impact of last year’s big budget bill and the expiration of those covid-era additional premium subsidies that they’re having on enrollment.  that analysts and state officials are expecting a drop of about 20%, dropping from 24 million in 2025 to about 19 million. Insurance company Cigna announced last week that it’s dropping out of the ACA marketplace. It currently sells in 11 states. And hospitals are reporting their first-quarter results that are already experiencing the fallout â€” from lower admissions to more uncompensated care. That includes not just people who’ve dropped insurance, but people who had to buy insurance with higher deductibles that they may not be able to pay. Republicans in the Trump administration have tried to downplay the reductions, but as the year wears on and the results get more obvious, aren’t they going to have to have some counterargument to this? 

Hellmann: A 20% decrease in enrollment could be really bad for the marketplaces, especially if the people who are leaving are healthy. It’s going to lead to a sicker risk pool, which is going to possibly lead to higher premiums in the future. So you would think that the administration would have to respond to that. But they have also showed that they’re not really a friend to the ACA, and the first Trump administration also did a lot of things to undermine it. So I’m not sure that they’re going to try to find a way to fix these problems. And they also had a recent marketplace rule that some experts actually think could weaken the health of the marketplaces even more.  

Rovner: Yeah&²Ô²ú²õ±è;…&²Ô²ú²õ±è;I know the Republicans&²Ô²ú²õ±è;…&²Ô²ú²õ±è;one of the big Republican talking points is that a lot of these people were what they call phantom enrollees. They didn’t even know they were enrolled. They didn’t file any claims. But, as you point out, a lot of people have insurance and don’t file any claims because they are healthy. Those are kind of the people that the insurers want. Obviously, not phantom people who don’t know they’re enrolled. That’s fraud. But people who&²Ô²ú²õ±è;…&²Ô²ú²õ±è;have insurance and don’t use it are a good thing for the insurance industry. Shefali, you’re nodding. 

Luthra: No, I was just thinking about all the years I’ve had health insurance and didn’t file a claim. Like, of course you would want that. That’s awesome. It doesn’t mean I wasn’t covered. It meant that I relied on the peace of mind of having health insurance. And I would be very sad if I started filing claims for insurance and suddenly all the healthy people were gone. That would be terrible. 

Rovner: Yeah, we will â€¦ again, I think we’re going to get more evidence as the year wears on, and this is going to become a big, I think, campaign issue, obviously. 

Well, I want to talk about global health, at least briefly. A lot of people are watching that Dutch-flagged cruise ship with passengers sickened and some dying of hantavirus. Now, hantavirus is not normally spread person-to-person, but it is fairly clear that that’s what’s happening in this case, and it appears the outbreak is being fairly effectively handled by the World Health Organization. But of course, the U.S. left the WHO when Trump returned to office, so the U.S. is not only not helping with this, it’s out of the loop, even though there are more than a dozen Americans who’ve been on board, and reportedly seven who could have been exposed to this who have disembarked and already returned to the U.S. This is kind of why the U.S. was part of the WHO, right? When you have an international incident like this? 

Raman: Yeah, and I was just listening in to [an] infectious disease briefing this morning, where they were detailing how this situation is unusual. Usually, at this point in a crisis like this, we would have had more communication from the CDC, from the NIH [National Institutes of Health], just about the state of play, different briefings, or just going and helping with the situation. And we haven’t seen that, and just how striking that is right now. 

Rovner: And of course, I mean, so many people are having PTSD [post-traumatic stress disorder] from covid, and remembering, you know, cruise ships with people with covid. Public health experts say that’s not going to happen here with hantavirus. It’s just this one strain of hantavirus that spreads person to person. It’s hard to spread it. But with so little trust in science and so much misinformation, you got to wonder whether even this incident that shouldn’t cause a panic might anyway. 

Raman: Yeah, I think that has been kind of the concern is that this is something that the experts are worried about, and they’d like to learn more about, because there is a new case that they can learn from, to provide more public health information. But to not panic over this, just because the things that you said: This is not likely to cause another major pandemic in the same way as covid. 

Rovner: Well. Finally, this week, HHS Secretary RFK Jr. has struck out on another cause. Now he wants to get people off of their antidepressants. At a MAHA meeting on Monday, he unveiled a series of steps for doing that, from encouraging non-drug interventions for mental health conditions, to paying doctors to counsel patients for how to taper off the medications. He says he doesn’t want to tell people to stop taking their drugs, which can be lifesaving in many cases, although he’s also said he doesn’t want people not to be allowed to take vaccines, too. So where is this headed? Is this â€¦ this is a big, I guess, some MAHA people think people are overmedicated with antidepressants and ADHD [] drugs. 

Raman: I think it has a lot of the same playbook that we’ve seen with vaccines. He’s talked about over-medicalization as an issue for a while now. It was in the last MAHA report about a year ago, and even before that, he’s brought it up. My sense from attending that event this week was not that they were really looking at changing prescription guidelines, but I guess it’s hard to tell where we’ll see further along down the line. But it was more of just like an exploratory stage, you know, training physicians about different things related to tapering and things like that. But sometimes that’s the start of things changing down the line, and it is interest[ing], that kind of brings back his focus to very much the psychiatric drugs, the ADHD, depression, anxiety, and just wanting to lessen the medications there. So. 

Rovner: I can’t help but wonder if, because he’s been told to back off of the vaccine issue, because it doesn’t play that well with the public, that he’s going to pick this up as his next crusade.  

Raman: There was a huge emphasis on informed consent, which is, I feel, another big talking point with vaccine. So there is a lot of similarities in how it’s approached. So, I would look for more of those kind of clues there. 

Luthra: I think it’s also worth noting, even if this is early rhetoric that we know from research that rhetoric does influence prescribing behavior. We saw that study that showed after the “don’t take Tylenol when you’re pregnant” kerfluffle, prescriptions of Tylenol went down for people who are pregnant. And this is not really the first time RFK has talked about SSRIs, specifically. He’s talked about them with regard to pregnancy, in particular, and that’s already a very stigmatized, very fraught time for people, even though the consensus is, if you are depressed, stay on your medications. And I think this is something absolutely worth keeping an eye on, even if this is largely rhetorical, discouraging use of medications. Does that translate into changes, especially around something that is fraught and is often stigmatized and misunderstood, like antidepressants, which, as you mentioned, Julie, are lifesaving and very important for people with severe depression. 

Rovner: Indeed, and for people with severe anxiety. All right, that’s this week’s news. Now we’ll play my “Bill of the Month” interview with Andrew Jones, and then we’ll come back with our extra credits. 

I am pleased to welcome to the podcast KFF Health News’ Andrew Jones, who reported and wrote the latest “Bill of the Month.” Andrew, welcome. 

Andrew Jones: Thank you so much for having me. 

Rovner: So tell us about this month’s patient â€” who she is, where she’s from, and what happened that landed her in the emergency room. 

Jones: Silvana Toska. She’s from Davidson, North Carolina. It’s just north of Charlotte. She’s a professor of political science there, and a mom of two. And while she was outdoor at an event last fall, she got bit by an insect, and she ended up with such a bad systemic allergic reaction that she got anaphylaxis. What anaphylaxis means is that her lungs began to be difficult to breathe. And so she broke out in hives, and she immediately decides, with her husband, to go to an urgent care, where she gets treated with two doses of epinephrine. And then the doctor says you need to be under watch for a couple of hours, so you need to go to the ER, which is kind of where our story starts. 

Rovner: So she doesn’t drive off to the ER, she goes in an ambulance to the ER, right? 

Jones: That’s correct. Yeah. They put her in the back of an ambulance, and they ship her off to the ER. Her husband and her two kids follow. 

Rovner: So by the time she got to the ER, she was already feeling better from the medication that they gave her at the urgent care. That’s what’s in an EpiPen, right? 

Jones: That’s correct, yeah. 

Rovner: The epinephrine. So what happened when she got to the ER? 

Jones: So, not a whole lot, actually. Like you said, she’s feeling fine at that point. A doctor comes in. The doctor sees her for less than five minutes, asks her about her condition, does a quick checkup, doesn’t actually make physical contact with her, which I thought was very interesting. And then the doctor steps out. And she basically spends an hour and a half doing nothing, trying to keep her kids entertained. And she gets a dose of Pepcid to keep the allergic reaction at bay. But after the doctor came in again, just to say that she could leave, she left, and it was an incredibly uneventful ER visit. 

Rovner: And then, as we say, the bill came. So how much is the ER charge for her couple of hours of follow-up&²Ô²ú²õ±è;…&²Ô²ú²õ±è;at which not very much happened? 

Jones: Yeah. So that empty hour and a half, essentially, for that time, she was charged $6,746.50. And at the end of the day, she was responsible for a $150 copay and $3,100.24 â€” a bill that she got on Christmas Day that year. 

Rovner: Awesome. So what was the justification for such a big bill for such â€” I won’t say “little care,” but what seemed to be little care? 

Jones: Yeah, well, she was actually charged for something that wasn’t little. It was called “critical care.” She was coded for critical care, her time there was. And the experts that I spoke to said that while Toska had every right to think that it was an outrageous price to charge, it was probably an appropriate charge for the situation, those codes were. And that’s partly because of a coding system that really isn’t hyper-specific to individual cases. Toska needed to be in the ER setting because of the anaphylaxis. It can return and cause a critical situation. And while she was coded based on what might have happened, rather than what did happen, it ended up not working in her favor as far as the bill went. And so people all over the U.S. experience this. Another expert I spoke to said that people are brought on that train of care when they arrive to the ER. There’s really no way to get off once it starts moving. And you don’t know what it’s going&²Ô²ú²õ±è;…&²Ô²ú²õ±è;what the dreaded bill is going to be once it stops. And there definitely could be reform in the way that U.S. healthcare system does ER coding, although there would have to be some, you know, pretty titanic changes for that to happen. But I’ll say that if listeners ever find themselves concerned about a bill, they should definitely call their insurance company, ask if there was an attempt to negotiate, and they should call the hospital to check the accuracy of the coding. Toska did do both of those things and, unfortunately, nothing changed. But I can say that that was the right thing to do. There was some great back-and-forth. There was a letter that explained why they did that and, ultimately, what happened to her comes down to a coding system that did not work in her favor. And she told me that recently she experienced another allergic reaction, but instead of going to the ER, she just took some Benadryl instead. 

Rovner: And you know, I guess the takeaway here is that when a medical professional tells you to go to the ER, it’s not usually because they’re going to make money from sending you to the ER. It’s because something could happen that you should be in the ER for it. I guess that’s sort of why we have medical insurance, right? 

Jones: Absolutely, absolutely. Yeah. I mean, she really had no other choice. It was the right thing for her to do. But again, because of a coding system that wasn’t specific to her situation, it ended up â€” I see, you know, testimonies all the time from people who see this very outrageous bill for a little care. Toska is the first time I’ve seen a bill where there was essentially no care that she could see. And so I think it’s fair for her to have this discussion in her mind and with her family, and here in this article about: Is our coding system fair? But ultimately, when a provider says you need to go to the ER to make sure that you know your situation is taken care of, that’s what you have to do. 

Rovner: Andrew Jones, thank you very much. 

Jones: Julie, thank you. 

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 links in our show notes on your phone or other mobile device. Jessie, why don’t you go first this week? 

Hellmann: My extra credit is from Nature. It’s titled “.” They [Max Kozlov, Alexandra Witze, and Dan Garisto] did an analysis showing that more than 100 independent advisory panels have been terminated. These are panels that advise agencies on biomedical environmental policy and other types of health policy. They’re typically staffed by researchers and other experts from outside of the government. And now so many of these groups are being canceled, there’s concern that this could result in less transparency and more of agencies making decisions within their own ranks. And then they also found that groups that are still in existence are meeting less and less. They’re not issuing public reports. An example of this that we all know about is the Advisory Committee on Immunization Practices, which is tied up in a big legal dispute right now. And the White House defended all of this, is saying that these panels are a waste of taxpayer dollars that don’t meaningfully inform policymaking. So I thought that was a good read on something that doesn’t get a ton of attention. 

Rovner: Yeah. Well&²Ô²ú²õ±è;…&²Ô²ú²õ±è;of course, these panels are intended to bring in the public to make public policy. That’s kind of why they’re there. They’ve always been sort of a bipartisan thing. Anyway, really interesting story. Sandhya. 

Raman: So my extra credit is from The Cut, and it’s called “,” and it’s by Juno DeMelo. And this was a story that, you know, they talked to a lot of pediatricians about how their jobs have changed given the increasing vaccine skepticism. And some of these pediatricians are talking about having to really sell to their patients and their families why pediatric vaccines are necessary, or just devoting a lot more time, having a longer appointment just to explain why this is necessary. Sometimes it takes multiple appointments, which is just different with what they’ve had to do from the past. And, you know, the fatigue from having to go into all the science, instead of just presuming the child will get the vaccine and being able to discuss other things â€” safety and signs to watch and growth, and all of that. And so I think it was a good look at some of the things that drilled down on that. 

Rovner: Yeah, it was. These policy changes have impacts way down the line. Shefali. 

Luthra: My story is from ProPublica. It is by Duaa Eldeib. The headline is “.” It’s about families opting out of vitamin K shots, which are useful for blood clotting for newborns, and babies dying. And I think the story is remarkable for several reasons. It’s really got remarkable examples, and we see who these children are who are dying. We know how old they are, we know the color of their hair. We know what their symptoms were and what happened to them. There isn’t government data tracking vitamin K shots and whether they are rejected, but the story does a really good job painting a picture anyway. It has interviews with hospitals who have seen more and more parents saying we don’t want this because we are concerned. And it contextualizes this within the rising anti-establishment approach to medicine, more skepticism around well-researched and appropriate interventions. There is data showing how many children die from this spontaneous bleeding that can often happen if you’re deficient in vitamin K. And together, it uses those different points to create a picture of a troubling and avoidable public health trend that’s resulting in kids dying. 

Rovner: Yeah, more fallout from the anti-vax movement. My extra credit this week is from my KFF Health News colleague Stephanie Armour, and it’s called “HHS’ Healthy Food Agenda Puts Hospitals on Notice About Patients’ Meals.” It’s a story about something that we’ve talked about before in the podcast, the new HHS policy that threatens hospitals’ Medicare and Medicaid reimbursement for facilities that don’t conform to last year’s new dietary guidelines. But there’s some pretty vivid detail here about how those guidelines actually fail to address the needs of many hospitalized patients who may be limited in their ability to eat or drink and might actually need Jell-O or ginger ale or Ensure, all of which are now at least theoretically banned. And the administration is also asking patients to report hospitals that are violating the new rules. Again, another thing that was not on my 2026 bingo card. 

All right, 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 . Sandhya, where are you hanging these days? 

Raman: I’m on  and on  @SandhyaWrites. 

Rovner: Jessie. 

Hellmann:  on  and  and also on . 

Rovner: Shefali. 

Luthra: On Bluesky . 

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

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

Julie Rovner: Hello from ºÚÁϳԹÏÍø News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, 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, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with ºÚÁϳԹÏÍø News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly â€” in the words of longtime Congress watcher  â€” a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year â€” but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when&²Ô²ú²õ±è;…&²Ô²ú²õ±è;we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers â€” which are actually stronger than many predicted, with fewer people actually dropping coverage â€” reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But â€¦ I think what Julie said is it’s&²Ô²ú²õ±è;…&²Ô²ú²õ±è;the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time&²Ô²ú²õ±è;…&²Ô²ú²õ±è;

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more â€” the out-of-pocket cost of insurance for millions of Americans, 20-ish million â€” but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but&²Ô²ú²õ±è;…&²Ô²ú²õ±è;I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high â€” in economically â€” zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not&²Ô²ú²õ±è;…&²Ô²ú²õ±è;it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers â€” and I’ll post a link to them â€” you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside â€” they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why â€” because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right â€” you know, again, including senators like Cassidy, but also these activist groups â€” they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication&²Ô²ú²õ±è;…&²Ô²ú²õ±è;I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

¸é´Ç±¹²Ô±ð°ù:ÌýSo, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

OK, we’re going to take a quick break. We will be right back. 

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there&²Ô²ú²õ±è;…&²Ô²ú²õ±è;who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs&²Ô²ú²õ±è;…&²Ô²ú²õ±è; 

Rovner: Puberty blockers! 

Edney:&²Ô²ú²õ±è;…&²Ô²ú²õ±è;they’re taking â€” exactly â€” and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now â€” most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat&²Ô²ú²õ±è;…&²Ô²ú²õ±è;the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer â€¦ they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion â€” that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over â€” I’m not exactly sure how many years â€” 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes â€” some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health â€” that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just&²Ô²ú²õ±è;…&²Ô²ú²õ±è;like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people â€” and to Alice’s point about how this hasn’t saved money â€” more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just&²Ô²ú²õ±è;…&²Ô²ú²õ±è;a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000&²Ô²ú²õ±è;…&²Ô²ú²õ±è;now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away â€” you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell â€” he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t&²Ô²ú²õ±è;…&²Ô²ú²õ±è;you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer â€” if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians â€” how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who â€” like, I don’t know how all of you watch it â€” but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS â€” or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer 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, at 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? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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