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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 31, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi. 

Rovner: Later in this episode we’ll have the second of our two-part series marking the 60th anniversary of Medicare and Medicaid, which was yesterday, for those keeping track. This week, Sara Rosenbaum of George Washington University, one of the nation’s leading Medicaid experts, takes us through the history of that program and what the next 60 years could bring. And if you want to hear more from both our Medicare and Medicaid experts, we’re going to put the full-length versions of both interviews together for a special episode later in August. But first, this week’s news. 

Before we start, I hope you’ll bear with me this week. I slipped and fell and broke my wrist. So my typing and some of my thinking skills are a little lacking at the moment. But on this week of the 35th anniversary of the Americans With Disabilities Act, which we will talk about in a few minutes, I am very grateful for all the various technological advances that are now available to those of us with disabilities, whether permanent or temporary, and which allowed the podcast to actually come to you this week. So, now, here we go. 

It was another busy week at HHS [the Department of Health and Human Services]. Secretary Robert F. Kennedy Jr., having already fired all the members of the vaccine advisory board, is reportedly now taking aim at the U.S. preventive health services task force. Now, this was not wholly unexpected. When the Trump administration switched sides on that lawsuit over the task force brought in Texas earlier this year, we assumed that RFK Jr. wanted to do something exactly like this. Right, Shefali? 

Luthra: We certainly did, because it wouldn’t have otherwise made a lot of sense to argue that they could continue to make recommendations unless, perhaps, RFK Jr. wasn’t going to listen to them. It just, once again, really bears noting that this was something many people discussed as a likely possibility, given his record, when he was nominated to be secretary. And there were some senators who suggested that perhaps he had made individual promises, commitments, to actually keep the expert panels in place. And here we are. He did not do that. 

Rovner: Yeah. And we should say he has, at least as of this moment, he has not yet fired all of the members, but certainly there are indications that he’s considering it. And obviously that was what they argued to the court, was that, Hey, it’s OK for the Senate not to confirm the members of this task force, because the secretary has control over them. So here’s the secretary suggesting that he’s going to take control over them. 

Edney: And now the senators show support for the task force. It’s just this circle that keeps on going where they need to try to bolster the backing, but the writing was on the wall when they voted to confirm him. 

Rovner: Well, apparently the secretary isn’t finished with vaccine policy, either. He’s also taking aim at the 1980s-era Vaccine Injury Compensation Program, or VICP. That’s what provides a no-fault way for people injured by vaccine side effects to get compensation for those injuries. This program was literally created to prevent the vaccine industry from going out of business in the 1980s because it was being sued into oblivion. I know that RFK Jr. said the program is, quote, “broken” and he intends to, quote, “fix it.” But does anybody have any idea what he might be planning for it? I will remind people, like, I’m shouting into the wind, that this was an act of Congress created by Congress, reformed by Congress. I don’t know whether the secretary can just take it apart on his own. 

Kenen: He can try, or leave it intact but create some kind of barriers to filing, or— 

Rovner: Actually, I think he wants to make it easier for people to get compensation. 

Kenen: He wants it easier to get compensation. We don’t know what it will do. But they keep finding workarounds or just ignoring things. So we can’t say we can or cannot do, because we don’t know what they’re going to do. But his whole health persona really is built on the fact that he believes that vaccines are damaging or dangerous and they kill more people than they save. And therefore, apparently all of us could just get a payout because we had a shot. But it’s not as much of a moneymaking business in general, not for a specific new shot, but vaccination is not as profitable as the public may perceive. Yes, the covid shots, there was some exceptional things about the speed and scale, etc.— 

Rovner: Right. Because everybody got one at the same time. 

Kenen: And they’re subsidized, etc., or some of them were. So Anna knows more about this than I do. Basically, it was designed to both protect people who were — nobody, even the strongest pro-vaccine people, nobody denies that there is such a thing as an injury. They would say it’s rare and not autism, but when it is, it is rare, but someone should get compensation and the care they need. 

Rovner: And Anna, we’re really looking at the potential for some of these vaccine makers to just say, We’re going to wash our hands of making vaccines. Right? 

Edney: Yeah, absolutely. The point of this program was to, like Joanne said, admit that there can be injury but to make it no-fault so that the vaccine makers could continue providing vaccines for the majority of people who respond well to them and to not be caught up in court battles for millions and billions of dollars all the time. And there may be some complaints, but it does seem that people, by and large, are able to get some compensation from this. And you mentioned covid vaccines. Those aren’t included in this program, so that may be something he is looking at, because they’re done through a different program, which is maybe some complaints about it or that it’s a little less likely to pay out or to give as much compensation. And so maybe a way of expanding it is to include the covid vaccines. But if it becomes that — Well, you can keep using this program, but we’re also going to make it easier to sue the vaccine makers — we’re going to see the companies be wary of being involved in providing vaccines at that point. 

Rovner: Well, in still more vaccine-related news, the controversial head of the FDA’s [Food and Drug Administration’s] vaccine division resigned unexpectedly this week. Anna, tell us why Vinay Prasad was so controversial. And why did he leave after only three months on the job? 

Edney: Yeah, this was a huge amount of drama at the FDA. So Prasad himself can be a polarizing figure. He has been at UCSF [the University of California-San Francisco] for a long time and gained prominence as someone who criticized the agency for what’s called accelerated approvals, getting certain drugs, particularly cancer drugs, quickly to patients even when they hadn’t proven necessarily that they worked. And he criticized that program. He got to the FDA. He was head of the vaccines division, which also covers biologic drugs. And under this division was a drug made by a company called Sarepta. Every one of their drugs that has come to market has had a lot of drama surrounding it because these are drugs for very, very sick, usually young boys who have Duchenne muscular dystrophy, and it’s a huge parent population that wants these drugs, even when maybe they don’t always show that they work very well. 

Well, a few kids have unfortunately died while taking these drugs in recent months, and so the FDA was looking at that, and it came out that there was another death in a clinical trial of an older gentleman, and no one knew definitely if it was related to the drug. And so once that became public, it’s not like the FDA or the company came out with it, but once it became public, the FDA kind of seemed to overcorrect and try to have the drug be paused, and then maybe take it off the market. And so Vinay Prasad was at the center of this debate. Already he was disliked by some of [President Donald] Trump’s higher-up people, particularly Laura Loomer. We may have heard her name before. 

Rovner: We have. 

Edney: She goes after some nominees, successfully in many cases. And Rick Santorum also got involved at this point. He has a daughter with a rare disease and didn’t like the way that this rare-disease drug was being treated. So essentially Prasad, who clearly for the last several years has only wanted to be at the FDA, has left after three months, was pushed out after three months. 

Rovner: Wow. It’s quite the drama. I’ll link to or two if you actually want to go deeper. 

Kenen: But one of the criticisms that Laura Loomer had is that he used to be a Democrat. 

Edney: Right. 

Kenen: Well, that would also apply to RFK Jr. 

Edney: Right. That’s true. 

Rovner: It would. Oh, I’m sure the drama, both at FDA and at HHS writ large, is far from over. Well, speaking of turning the clock back, President Trump issued a new executive order that would end the, quote, “housing first” policy that has driven homelessness strategy since the late 1990s. I guess this is also not a surprise. Trump complained repeatedly on the campaign trail about how homeless encampments were destroying cities. We’ve had a recent Supreme Court case on this, but this new policy seeks to not just allow but encourage localities to force at least some homeless people off the streets and into residential treatment. I imagine this is going to make for another long line of lawsuits, right? 

Kenen: Well, there’s housing first itself. It’s not without controversy. There’s a philosophical divide. Housing first means you house people and then you deal with their social and economic and physical and psychological and drug abuse, etc. Get a roof over their head and then you deal with everything else. Other people say, No, get them into treatment and stabilize them, and then you put them in housing, and they have to … Housing first has been the dominant philosophy in addressing homelessness in recent years. That’s a different debate. This is, like, put them in an institution against their will, which the courts have power to do in limited cases. There are times when a court can say, This individual doesn’t want to be hospitalized, but for their own safety they really need to be. But that’s one by one and not that common, and it’s limited. I believe it’s 30 days. I might be wrong about that. 

But this is a whole different thing. It’s a combination of this, We’re going to force them into institutional settings for treatment, whether they want it or not, combined with the Supreme Court decision of about a year ago allowing cities and local government, not just cities but governments, to forcibly clear away, to dismantle encampments, to force people out. So you have it coming from both the administration’s policies and the court decisions. This creates a whole — and housing money is being cut. Housing assistance is being cut. So you really have this tremendous shift in how we approach homelessness at a time when homelessness is high, while homelessness has been high. And nobody’s saying that there’s not a mental health component for some, but by no means all, people who are homeless. But this is not in accord with how the health and homelessness advocacy and treatment world has been approaching it. This is a significant shift. 

Rovner: And as you point out, this is a health and social service issue, too, because we are seeing money cut and money diverted that, basically this executive order will say, We’re going to give more money to localities that sort of handle this the way we want and less money to others. So I imagine this is going to have trickle-down effects for some time to come. 

Kenen: Yeah. And the clearing the encampments is going on, and we should know it’s not only a conservative state. California has done it. Other states have done it. So the idea of dismantling these — we’ve all seen these encampments — that is happening in various places in the country already, and this is sort of an extra step. It’s not only do you clear them, but this would envision forcing them into treatment, often in an institutional setting. 

Rovner: Well, meanwhile, as I mentioned at the top, this week marks the 35th anniversary of the Americans With Disabilities Act, which I also covered, by the way. Secretary Kennedy spoke at an event marking the occasion on Monday. But an awful lot of the disability community is up in arms about the cuts to Medicaid, which they say will roll back much of the progress the movement has made in the past three and a half decades, much of it for people getting in-home types of assistance. And yet the ADA was pushed hard and signed by a Republican administration, that of President George H.W. Bush. Is this yet another formerly Republican priority being kind of tossed out the window? 

Luthra: I think to your point, a lot of things that used to be bipartisan in the health policy world are not anymore. The other example is something like Title X, and it’s just we have really seen this shift of things that used to be broadly uncontroversial, because the health implications are clear, become much more so and largely become rejected by Republicans in a way that is just really, really different from what you might’ve imagined even, I don’t know, 10, 15 years ago. 

Rovner: And my favorite piece of Title X trivia: It was signed by Richard Nixon, but it was sponsored in the House by then-Rep. George H.W. Bush. So he both sponsored Title X, the Family Planning Program, and signed the ADA into law. Boy, it feels like a million years ago and not 35. 

Well, moving on to health care costs. It is tariff week in Washington — again — and not surprisingly, prescription drugs are a big part of that conversation. The trade deal that President Trump announced with the EU while he was in Scotland last weekend includes a 15% tariff on brand-name prescription drugs imported from Europe. That will include things like, I don’t know, the blockbuster weight loss drug Ozempic? Anna, how does Trump think this is going to eventually lower drug prices in the U.S.? It sounds like it’s just going to raise them. 

Edney: Yeah. I think most people agree with your sentiment that it’s going to raise them. I think a lot of this is focused on bringing drug-making back to the United States and trying to get companies to do more of that here. Whether you see that from brand-name companies seems like it could be really difficult. I know Botox is made in Ireland, and this is a facility where, because it’s essentially a toxin, a very deadly toxin if released— 

Rovner: Yes, it’s botulism. 

Edney: Right. This is a facility that is highly guarded. A colleague of mine wrote a story on it many years ago now, but you had to go underground. They’re not just moving this thing over to the United States. So I think for brand-name drugs that it’s going to be particularly difficult to lower the prices based on tariffs, or to say We’re moving production over here in any capacity. So what the thinking of how exactly this works or is beneficial will be interesting to see, because they’re also still doing — this would not apply to these — but they’re doing this national security assessment for tariffs on drugs from other places and trying to figure out if there’s a national security reason to be putting tariffs on them. For the most part, when drug quality comes into question, it’s not usually the European drugmakers that we’re concerned about. 

Rovner: And we’re still waiting to hear about the generic-drug makers in India and China, right? 

Edney: Yeah, exactly. We’re waiting to see what they’ll decide. They’re still doing their investigation, the administration is, to see what those tariffs might be from India or China, or any other countries that are making generic drugs. 

Rovner: Another story that we will continue to watch, and glad to have Anna here to continue to help us watch that. Now, it’s time for this week in what we’re still learning about the impact of the big tax and spending bill that President Trump signed on July Fourth. This week’s installment comes from my ºÚÁϳԹÏÍø News colleague Bernard Wolfson, whose column points out that eliminating eligibility for Affordable Care Act subsidies for immigrants who are here legally will mostly just raise premiums for everyone else by taking more healthy people out of the insurance pool. I get the administration’s insistence on not having people who are not here legally collecting benefits. We’ve talked about emergency Medicaid, but that’s a different issue. But what’s the justification for taking coverage away for people who are here because they’re refugees or victims of abuse, or those with temporary protected status? I don’t honestly understand what the point is of this. 

Kenen: There’s a stigmatization across the board as being an immigrant, right? So the administration is not embracing immigrants who are here legally. We’ve all seen reports of people who are here legally still being picked up by immigration officials. It’s very messy. Sometimes people just say, OK, we’ll save money this way, not understanding that the costs pop up someplace else in the system and it may be more expensive. So not just in terms of that individual, but if things are going untreated in communities because people aren’t seeking care, communicable diseases can also spread. So there have been attempts to blame disease outbreaks on immigration when that’s not the case. 

Rovner: Going back hundreds of years. 

Kenen: Right. Smallpox was brought here by immigrants, right? 

Rovner: Yeah. 

Kenen: Hundreds of years ago. 

Rovner: By the European immigrants. 

Kenen: Right. That’s what I— 

Rovner: And given to the Native population. 

Kenen: Right. Right. So it’s just part of an overall gestalt about immigrants and immigration, and sort of treating them as leeches, not as people who live here. 

Rovner: But I feel like both — it’s funny because this connects back to the whole tariff issue. The idea that Trump has here is to make things more “America First,” have more things made in America, and obviously more people made in America, and more Americans here to be served in America. But both of these things would take a long time. I guess the idea of not allowing legal immigrants to have benefits is to discourage people from coming here legally. One can’t see any other thing that would make that logical. And the idea of the tariffs, Anna, as you said, is to have companies build more manufacturing here. Both of those things would take a lot longer than Donald Trump is likely to be president. He doesn’t usually have a long-term view of things, and yet both of these issues are long-term issues, right? 

Edney: Yeah. I think at least for the tariffs and for — there’ve been these small announcements with certain companies where they’ll say, Well, because of Trump, we’re going to build a new plant in Indianapolis. And that plant sure isn’t, like, it’s five years away, but he can make these announcements. And Joanne, and you’re absolutely right that he obviously wants to degrade immigrants in any way that he can, but also Obamacare, right? That’s still a thing that they’re in certain ways willing to go after. 

Rovner: Good point. It’s a twofer. 

Edney: Yeah, exactly. Exactly. So if you can erode Obamacare some and have a sicker population, and people being angry that they had to pay more, but Republicans have been good at still attaching that to Democrats: Oh, Obamacare. So I don’t know, maybe that comes back around. 

Rovner: Yeah. Well, question answered. OK. Turning to abortion, the on-again, off-again Planned Parenthood funding is apparently on again, at least for now. You may recall last week a judge had allowed some of the defunding included in the budget bill to begin, but now another federal judge has said, Nope, you’ve got to keep letting Planned Parenthood collect from Medicaid for non-abortion-related services. Shefali, what comes next? 

Luthra: The case continues to go through the courts. We know that right now that is in a federal district court. It could eventually go to the appellate courts. It could eventually make its way to the Supreme Court, including the debate over whether this proceeding is allowed to take effect or not. In the meantime, I’ve been talking to a lot of clinics, and they are preparing for the real possibility that they lose their Medicaid funding. Some of them are not optimistic about the long-term legal viability of this injunction, and so they’re thinking: What will we do if we lose all of these Medicaid dollars? Will we be able to see patients in the volume that we do? Will we be able to get funds from the state? Some are in active conversations with state governments. Some are looking to private fundraising. Others are thinking about which clinics they would close and also how they would do that in a way that minimizes service loss to patients, while acknowledging that some ability to access care — whether that is abortion or STI [sexually transmitted infection] screening or contraception or cancer screening — will simply not be replaced. 

Rovner: Yeah, and I have to say, for all the million times I have said on this podcast, an administration can’t cut off Planned Parenthood from Medicaid, because it’s written into the Medicaid law, that doesn’t mean that Congress can’t cut off Planned Parenthood, because they can change the law. So I’m also a little bit wondering what the justification for Planned Parenthood being able to argue — I know that they’re arguing that they’re going after Planned Parenthood specifically, and that that’s not allowed. But certainly Congress can change the Medicaid law if it wants to. Congress wrote the Medicaid law. 

Luthra: And I think it’s worth throwing in a couple of other components as well, considering there are multiple lawsuits at play right now, not just the original from Planned Parenthood. There’s the liberal states’ attorneys general. There’s the Maine Family Planning suit, as well. But conservative states do have an avenue to block Medicaid funds going to Planned Parenthood now, if they choose. The Supreme Court gave them that opportunity in the South Carolina case earlier this year. So no matter what happens in this case, there is a very real likelihood that in many parts of the country, Planned Parenthood clinics will lose funding they are reliant on and will probably have to close many facilities. 

Rovner: Yeah. And just to reiterate, this goes back to the Title X Family Planning Program that we were talking about earlier, so it all comes full circle this week. This week we also have the latest chapter in the continuing fight between states with abortion bans and those with shield laws to try to protect doctors who are sending abortion pills through the mail into those states with abortion bans. According to , a man from Galveston is suing a doctor in California for sending his girlfriend pills to end her pregnancy. The man is being represented by Jonathan Mitchell, whose name may well be familiar to you as the originator of, most now, of Texas’s various abortion bans. The suit seeks both damages for the man who’s suing and an injunction on behalf of, quote, “all current and future fathers of unborn children in the United States.” Shefali, that feels pretty broad. 

Luthra: It certainly does feel very broad. When I read it, I really wondered: How do you decide who are future potential parents of unborn children? Is that— 

Rovner: Fathers, fathers. 

Luthra: Excuse me. Yes. Potential fathers. Even more, how — is it everyone who has sperm? I don’t know. But this is part of a really central strategy to where the anti-abortion movement is right now. They are very upset about shield law prescription and provision of abortion medication. In Texas, they are trying a bunch of things to try and block this, whether that is this particular suit, whether that is one from the attorney general that continues to move back and forth, whether that is trying to get new state laws enacted during this special session. We’ll see if that happens with all the redistricting that is going on. 

Rovner: This is all about Texas, by the way. 

Luthra: And Texas is a really important player. But we did just see a group of attorneys general around the country from conservative states just reach out to members of Congress this week and say, Can you pass some kind of law that will block shield law prescription? We’ve also seen a case out of Louisiana that is held up in court right now because it’s a criminal case. But this is just such an important goal for them, because the reason abortions haven’t gone down is because people can keep accessing care through the mail. And if they can stop that, it will have tremendous implications for people in states with abortion bans, but also in other parts of the country where maybe it’s just too much of a pain or too far to go to a clinic and you can have a doctor mail you that care. 

Rovner: Yeah. Well, clearly the abortion fights continue. We will continue to follow them. All right, that is this week’s news. Now, we’ll play excerpts of my interview with Medicaid expert Sara Rosenbaum, and then we will come back and do our extra credits. 

I am so pleased to welcome Sara Rosenbaum to the podcast. Sara is professor emerita of health law and policy at George Washington University, one of the, if not the, leading experts on Medicaid. She’s also the person who has taught me at least 80% of what I know about the program. So I am extra thrilled that she’s agreed to come be our guide. Sara, welcome. 

Sara Rosenbaum: Well, and thank you for having me. It’s such a pleasure to be on the show. 

Rovner: So let’s start at the beginning. Medicaid was kind of an afterthought to Medicare when they were both created 60 years ago. How did Medicaid come to be? 

Rosenbaum: It’s a really interesting question. This is, of course, the lore, that Medicaid was an afterthought. If you look at the original act, which had been enacted about five years before, and you read the original statutory language — which we lawyers revel in doing — you are amazed. This was not such a big afterthought. I would say that Wilbur Cohen and Wilbur Mills and Lyndon Johnson and everybody else had a good idea of what they were doing. They knew that they were planting the seeds for a program that ultimately would come to be the foundation of health insurance for low-income people across the United States, as well as, of course, specific categories such as people with very severe disabilities. 

Rovner: So what was the difference between Medicare and Medicaid supposed to be when they were signed into law 60 years ago? 

Rosenbaum: Yeah. So Medicaid was very much structured in the classic style of a state grants program. It has come, of course, to be so much more than that, but it was a grant to states, and states would set up state plans. This is all language that has become very familiar to us. And they would provide medical assistance, as it was called, to certain categories of poor people. And the theory was that the program would start with these people, but tucked into — the categories were cash welfare recipients — but tucked in there were a group of people known as the medically needy, in the early days. And the medically needy, I always felt, was sort of the first seeds of something much bigger, because the point was that it was a program for people who were low-income, who couldn’t afford their medical care, but didn’t get cash welfare. 

So the theory was exactly the theory that has carried the program for 60 years now. And originally the thought was that it would really — and of course, this has turned out to be the case — that that would enable people who had very serious health care costs for things that Medicare did not cover — nursing home care, home health benefits ultimately, those kinds of really big-ticket long-term care items outside of Medicare — because Medicare was really sort of like Blue Cross Blue Shield for old people like me. 

Rovner: You weren’t old at the time though? 

Rosenbaum: I was not. Right. I was just a kid. But the program was meant to replicate what folks had had during their working years, and so it was very important and very profound, but limited. 

Rovner: So Medicare’s long been the more politically popular of the two programs. 

Rosenbaum: Yes. 

Rovner: Primarily because of the political clout of older voters, which is how it was created. How was it that Medicaid became the program that grew so much? 

Rosenbaum: What would propel Medicaid forward is that, unlike Medicare, which is tied to a premium structure, right? Medicare is funded through premium payments, which is great, but premium payments are quite unique. Because they are actuarially based, they are a very tightly controlled form of financing, because you’re asking — whether it’s the government or, now, of course, private insurers that contracted the government — you’re asking them to take on a lot of financial risk, and so everybody wanted the assurance of premium structure. Well, Medicaid was not. Medicaid is a classic public health statute. It’s general revenue. And so every time something happened that required an intervention by the federal government where health care was concerned, you could just add a few pages to the Medicaid statute and end up with, voilà, a fix. And by the mid-’70s, people said, Well, what if we decoupled this category from cash welfare funding levels and just let poor children have Medicaid? And there then ensued, essentially, a decade-long effort to add poor children and pregnant women as groups in their own right to the Medicaid program. 

Rovner: I feel like in 2017, in the fight over the repeal of the Affordable Care Act, that was sort of a big change for Medicaid. I think people had finally realized that Medicaid had grown larger than— 

Rosenbaum: Yes. 

Rovner: —Medicare, that it was not just a program for the poorest of the poor, that it did all of these other things that you’re talking about, and that really a lot of, I guess, the stigma had been taken away. And yet this Congress felt comfortable — I don’t know if I’d say comfortable — but a majority of them voted to make these really deep, profound changes. What is that going to mean going forward, both to the health care system and to the political system? 

Rosenbaum: Well, I’ve spent a lot of time thinking in this post-enactment period about when was the die cast that’s had everybody spinning. And I think congressional leaders and the White House leadership understood the fatal error they’d made in 2017, which was separating the tax reforms from the spending reforms. Because, of course, we were then able to battle the spending reforms on our own turf, right?. Here, because of the decision that was made back, I’m sure, almost a year ago— 

Rovner: Literally the idea to do one “big, beautiful” bill. 

Rosenbaum: Yes. And that meant that Medicaid, along with food stamps, or SNAP [the Supplemental Nutrition Assistance Program], along with everything else, just became pay-fors. They just became offsets. And the name of the game then became beating back every attempt to deprive Congress of pay-fors to do the thing that it really wanted to do, which was tax reform. And so we were all reduced to — “we” in the sense of people who worked on social welfare policy — to bystanders in this effort to get to a trillion dollars. And therefore— 

Rovner: A trillion dollars in cuts. 

Rosenbaum: A trillion dollars in cuts, and therefore it opened the door to extraordinary things. 

Rovner: So what happens next? Does this happen? And if it happens, does it undergird or take out the underpinnings of the entire health care system? Or does Congress eventually realize what it’s done and change its mind? 

Rosenbaum: Well, I think the hope is that — some people are saying: Well, the two-year runway. It’s like two years until it becomes effective. The two-year runway is sort of going to make people forget about this, and then boom, it’ll be upon us. I don’t think so. I think the two-year runway will end up shining a huge light on the fact that states cannot implement the whole system. While we are very focused on the number of people who will lose their coverage, the states are confronting an insurmountable problem here. They’ve never had to link Medicaid to work records, and Congress did everything it could to make matters so much worse. For example, they could have just said that, We’re going to import the same requirements that apply to SNAP to Medicaid, and so if you’re getting SNAP in your working age, then you automatically enroll in Medicaid. They didn’t do that. They didn’t do that. It’s a different-enough set of eligibility criteria and exemption categories. For example, SNAP ends, I think, at about 60, and the Medicaid work requirements go all the way to 65. 

Rovner: Age 60 and 65. 

Rosenbaum: Yes, exactly. But the exemptions are different. The requirements are different. And so states — people are talking about, Oh, well, it’s just the line reporting systems. No, no, no, no. You are liable for all kinds of error rate penalties. If you just rely on SNAP, you can’t. So states have no way to deal with this. So there’s no mitigation strategy for this, and I think the hope is that Congress will call it back. 

Rovner: If it doesn’t, is this — the one sort of silver lining that I’d been sort of thinking about is, well, maybe if we tear down the health care system, we’ll have to start again and build a better one. Is it possible that we could get there, or are we just going to limp along? 

Rosenbaum: I have those thoughts often, and then I stop and think, well, those of us with health insurance could sit there and say, Yeah, maybe we just tear down the health system to start again. Meanwhile, of course, we will have millions of people without health care. So I — interestingly, the Affordable Care Act, of course, was designed not to tear down the health care system but to strengthen the health care system. But it was the brilliance of the Affordable Care Act was that it saw the holes and it sort of tried to fix them. And if we’d left it alone with everybody in this what I consider to be sort of an intermediate arrangement, we could have done exactly what you are talking about. With just about everybody in the United States covered, we could have begun to really do the serious work of moving to something more unified, better— 

Rovner: Cheaper. 

Rosenbaum: And of course, cheaper. 

Rovner: More efficient. 

Rosenbaum: More efficient. That’s right. Far easier to use. But we have decided instead to tear the Affordable Care Act apart, both the access to the marketplace by rolling back the assistance and, of course, the Medicaid reforms. 

Rovner: Well, happy birthday, Medicaid. 

Rosenbaum: Happy birthday, Medicaid. 

Rovner: Thank you so much, Sara Rosenbaum. 

Rosenbaum: Thank you for having me. It was a — it was both uplifting and sad. 

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

Kenen: The story I’m doing is in ScienceAlert: “,” by David Nield. OK, I should begin with a caveat, which is I basically don’t like it when journalists hype findings. It’s something that was only in a dozen mice or something. My exception is when something is really, really sort of just interesting to learn about. Then it’s OK to report it as long as you just sort of shout: This is only in mice! We don’t know if it’s going to work in people! But it is an interesting study. 

One reason people don’t get vaccines is they’re afraid of needles. And if you could actually apply the vaccine to a dental floss pick and get it — because the line between our gums and our teeth is permeable, stuff can get in and out. That’s why we have to clean it. If you could treat a dental floss with the vaccine instead of just plain old dental floss or a needle in your arm or leg or whatever, maybe that could be a way of improving. And so these animal studies have been suggestive that this is a worthwhile course to follow. But before you go out to the drugstore with your dental floss and ask them to put the vaccine stuff on it — they’ve done it with a couple of people with dye, not with vaccine, just to sort of trace it. We are a long way away, but it was interesting enough for me to decide that we could discuss it. 

Rovner: I thought it was pretty cool. Shefali? 

Luthra: My piece also is dentistry adjacent, even dentistry directly relevant. It is from The New Yorker. It is by Burkhard Bilger. The headline is “” This is a really fun read. He travels to this town. Los Algodones, in Mexico, is right across the border, and it is where a lot of people go to get dental work. It is much cheaper there than getting it in America. So he goes through the history of dental work, why it has been something that people really do not enjoy, the pain associated with it, how many bad dentists are out there, also the stigma and violence against dentists. And then he talks through his own personal journey of trying to figure out: Does he need this dental work? How much would it cost to get it in this Mexican town compared to getting it in the U.S.? 

He talks to a dentist there, talks to a celebrity dentist as well, and in the end decides to keep his teeth as they are, which is very beautiful to me as someone who hates going to the dentist. But it’s a really fun read to think about how expensive health care is, how often things are marketed to us that maybe we do or don’t need, and also why dentistry has really been siloed out of all other health care for basically all of our history. 

Rovner: Yeah, it really has. It’s a wonderful combination of stories. Anna. 

Edney: Mine is not dental-related. I apologize. But this is an obit in The Washington Post by Stefanie Dazio, “.” And I wanted to talk about him because he was the reporter responsible for bringing to light everything that was going on with thalidomide. He wrote a 1962 front-page Washington Post profile on Francis Kelsey, the FDA pharmacologist who essentially blocked thalidomide from getting to market in the U.S., and she faced a lot of pressure and a lot of name-calling and things to stand in the way. And he took on the story, and he did many amazing stories, so it’s just, it’s worth a read. He wrote a lot about the pharmaceutical industry as well, and so I think it’s just nice to remember him. 

Rovner: It is. I will point out he was a fellow Michigan Daily alum, a close family friend. My mother actually worked on the Michigan Daily with his younger sister and then later worked with him at The Washington Post for years, so I can attest, not just a great reporter but a really swell guy. All right, well, my extra credit is not dental-related, either. It’s another great investigation from my ºÚÁϳԹÏÍø News colleague Fred Schulte. It’s called, “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege.” And it’s mostly about a chain you’ve probably seen advertised called Sono Bello and how this private-equity-owned business and some others like it are being sued in scores of medical malpractice and negligence lawsuits, claiming under-trained medical professionals have caused disfiguring injuries and, in at least a dozen cases, wrongful deaths. The subtext of this story, of course, is that this is another one of those not quite med spa but not quite ambulatory surgery center categories that’s not very well regulated by either the FDA or most states. So it’s yet another good case of buyer beware when it comes to protecting your health. 

OK. That’s this week’s show. As always, thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. Extra-special thanks this week to Taylor Cook, who’s editing our Medicare and Medicaid anniversary interviews. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. 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 folks hanging these days? Shefali. 

Luthra: I am at Bluesky, . 

Rovner: Joanne. 

Kenen: and , @joannekenen. 

Rovner: Anna. 

Edney: or , @annaedney. 

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 and welcome back 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, July 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

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

Sandhya Raman: Hello, everyone. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

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

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

Rovner: By one vote. 

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

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

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

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

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

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

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

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

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

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

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

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

Kenen: The former Department of Education. 

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

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

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

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

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

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

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

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

Rovner: Most of them. 

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

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

Kenen: But it wasn’t the plan. 

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

Kenen: Or punting, right? 

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

Kenen: And the individual mandate — I mean everything- 

Rovner: And the individual mandate, right. 

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

Rovner: Right. Right. 

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

Rovner: The tanning tax just went. 

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

Rovner: Please. 

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

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

Rovner: Shefali, you wanted to say something? 

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

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

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

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

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

Rovner: Sandhya, you want to add something? 

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

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

Rovner: A lot more politics to come. 

Raman: Yeah. Yeah. 

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

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

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

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

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

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

Rovner: Yeah, it’s huge. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Politics is messy. All right, well, this is as much time for the news as we have this week? Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week? 

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

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

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

Rovner: Really interesting story. Joanne. 

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

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

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

Kenen: No. Right. 

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

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

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

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

Raman: I’m at Bluesky, . 

Rovner: Sandhya. 

Raman: I’m and , @SandhyaWrites. 

Rovner: Joanne? 

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

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