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

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, April 23, 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 Sheryl Gay Stolberg of The New York Times. 

Sheryl Gay Stolberg: Hi, Julie. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And we welcome back to the podcast my former ºÚÁϳԹÏÍø News colleague Victoria Knight, now at Bloomberg. 

Victoria Knight: Hi, everyone. Happy to be back. 

Rovner: Later in this episode, we’ll have the latest installment of our “How Would You Fix It?” series. This week with David Blumenthal, a physician, health policy expert, author, and former Obama administration official. He literally wrote the book on the history of presidents and health reform through George W. Bush, and he has a brand-new book on the last three presidents and their health care policies. But first, this week’s news.  

So, Health and Human Services Secretary Robert F Kennedy Jr. on Wednesday completed his tour of Capitol Hill, having appeared before seven separate House and Senate committees in four days of hearings. Ostensibly, Kennedy’s appearances were to answer questions about President [Donald] Trump’s budget proposal for the Department of Health and Human Services. But, as usual, there were lots of other topics as well, as this was the first time the secretary appeared before some of these panels, and the first time some of these members of Congress got to question him in person ever. Victoria, you sat through all of the hearings, right? Or at least all the hearings this week. What was your big takeaway? I guess, not as many fireworks as some of us might have been expecting? 

Knight: Yeah, definitely not as many fireworks. I mean, I think that it’s pretty clear Kennedy has gotten a mandate in some way from the administration to watch his rhetoric, basically, especially his vaccine rhetoric. And we even, at Bloomberg, we’ve had reporting directly saying that he’s â€¦&²Ô²ú²õ±è;there’s an internal memo that said, you know, he’d keep his messaging on chronic diseases and nutrition and health care affordability, you know, more palatable topics. So I think he definitely tried to stick to that messaging. But there were points where the Kennedy that has for years been anti-vaccine came back through. And so we saw that in certain lines of questioning. And also he really wasn’t able to justify the cuts. He was there on the Hill to testify about the HHS budget, which President Trump proposed putting in still significant cuts to HHS. It wasn’t as deep as proposed last year. But there wasn’t really any good justification that Kennedy provided, except that the U.S. is in a lot of debt, and they need to, we need to reduce it. But he kept being, like, The programs are still good. We need to do these programs.  

Rovner: I’m amused, because this, you know, goes back forever of when Cabinet secretaries come up to justify cuts to their departments that they clearly don’t want to make, and they’re not allowed to say, But it wasn’t my idea.  

Knight: Well, and also that they know Congress will reject it. And so it’s, it’s kind of all fake anyways. All these congressional appropriators are like, Yeah, this is not happening. 

Rovner: Yeah. Hence the reason why they get to talk about other things. I will say one thing that I noticed is that he was less rude to these committees than he had been in previous appearances on Capitol Hill.  

Stolberg: Really? 

Rovner: Yeah.  

Stolberg: I sat through all seven of them. Julie. I thought he was pretty rude. 

Rovner: I guess it’s all in how you look at it. I thought he wasn’t. Yes, he was definitely still rude, but I really thought there were times when he had now sort of taken the briefing that you get, which is to try and agree with something that a member of Congress says, and says, I will work with you, which he hasn’t done before. He’d just been combative before.  

Stolberg: That maybe is true, but he has a habit of addressing members of Congress by their first name, which is a serious violation of protocol. And he was rebuked in the House last week for doing that with Frank Pallone, the Democrat of New Jersey. He did apologize for that, which I thought was interesting. But that did not stop him from also accusing senators of, Democrats, of making stuff up, grandstanding, and, you know, fake indignation. And, you know, he yells at them. And then at one point, Diana Harshbarger, the Republican in the House that was chairing the committee, said to him, she just said, I think it’d be best if everybody would just simmer down.  

Rovner: Yeah, there were definitely moments.  

Stolberg: And I would add to what Alice [Victoria] said, I do think that the big takeaway was that vaccines really still dominate his tenure. That is the defining issue of his tenure. [Sen. Bill] Cassidy yesterday was very pointed in correcting Kennedy when Kennedy cited a study that he said showed that advances in or reductions in deaths from an infectious disease were largely due to hygiene and sanitation, which is actually true in the first half of the 20th century, before vaccines were introduced. And the second line in that study, which Kennedy did not cite, was that, you know, vaccines had made an incredible difference and were extremely important. And Cassidy had somebody look up that study in the middle of the hearing and came back to Kennedy and said, This is what you didn’t say. You took it out of context.  

Rovner: Yeah, I was actually very impressed, because first Cassidy couldn’t find the study, and then â€¦&²Ô²ú²õ±è;

Stolberg: I knew the study because I had cited it before. 

Rovner: I had a feeling you probably knew it. I was trying to find it, and I couldn’t find it. So I was glad that they did.  

Stolberg: It’s in the Journal of Pediatrics in 2000 by an author named Guyer, not David Geier, but G-U-Y-E-R. You can look it up.  

Rovner: We could. I will  in the show notes. OK. 

Knight: I did want to mention also, I do think Cassidy did press Kennedy on vaccines. Certainly, everyone was watching that very closely because of his hesitation last year to vote for Kennedy, and really talking about struggling with the vote, and extracting all these commitments from Kennedy, ostensibly to vote for him, for HHS secretary. Cassidy did not mention any of those, like Kennedy violating any of those commitments, which he clearly has. He was supposed to be in frequent contact with the HELP [Health, Education, Labor & Pensions Committee] chair, go up to the Hill quarterly. He hadn’t been to the â€” Kennedy had not been to the Hill since September. In some of the committees, he hadn’t been there since last year, the last budget proposal. So Cassidy also did not mention these childhood vaccine recommendation overhaul that Kennedy did, which is a huge deal. And he did not mention the Advisory Committee on Immunization Practices being completely overhauled as well, and all those members being fired, which are two things Cassidy said he extracted commitments from Kennedy on. So I just want to make that point. Yes. 

Stolberg: One quick on that. After the hearing, I asked Cassidy, “Do you think Kennedy has lived up to his promises to you?” And he looked at me and he said, “We’ll talk later.” 

Rovner: I would say, Alice, you wrote a separate story about the fix in which Chairman Cassidy finds himself. He’s being challenged in a primary by a Republican congresswoman endorsed by the Make America Healthy Again PAC. I thought Cassidy was actually more restrained than I expected him to be in yesterday’s hearings. Although I think I guess it was our colleagues at The [Washington] Post who thought he was pretty combative. I mean, what did you take away from the Cassidy-Kennedy relationship? 

Ollstein: Yeah, definitely. I mean, one thing I noticed with both Cassidy and a few other Republicans is one of the few topics where they feel comfortable really going after Kennedy and the Trump administration more broadly is abortion. They think that the administration has not done enough to restrict access to abortion pills, and so they felt more comfortable hammering Kennedy on that issue. You saw Cassidy do that. You saw [Sen. Steve] Daines and a couple of other very anti-abortion senators raise that. And I think that’s an area where they feel like they’re more aligned with the sort of activist GOP base than the administration is. And so whatever blowback they would get for questioning the administration is outweighed by their anti-abortion bona fides. So â€¦&²Ô²ú²õ±è;

Rovner: Although I would say, I will interrupt before you finish and say I thought it was interesting that the members kept doing that because I thought most of it was for show, because we knew early on, because he’s been to all of these committees, that Kennedy was not going to talk about the FDA study on the abortion pill because there’s pending litigation, which is an easy out. But they made, they all made their little speeches, and they knew exactly what he was going to say.  

Ollstein: Oh, absolutely, absolutely. I mean, they want to be seen fighting on the issue, for sure. I’ve talked to a lot of anti-abortion activists who say, you know, Look, the Trump administration keeps saying we got to go through the process with the study. We got to go through the process with the courts. We got to check all the boxes. And the anti-abortion activists point out, you know â€” correctly, I think â€” that the administration has been very willing to break with protocol, and even, you know, legal procedure on a bunch of other issues, and they’re saying â€¦&²Ô²ú²õ±è;

Rovner: Which we’ll get to in a moment.  

Ollstein: â€¦&²Ô²ú²õ±è;Why not us? Why are they so careful when it comes to our issue when, clearly, they do whatever they want on other issues? And so, I mean, that is a fair point, and I think it’s going to be a continuing frustration. The  is the influence of the Make America Healthy Again, MAHA, as a political force. We’re going to really get a key test of that in Cassidy’s primary that’s coming up in just a few weeks. MAHA has put a big target on him and wants to knock him out. And my colleague and I took a really critical look at their influence in the race, and it’s sort of not living up to the hype, I would say. MAHA is not making a big impact financially in the race, and they are not making a big impact, really, in messaging. They haven’t succeeded in putting MAHA issues â€” like vaccines, like healthy food, chemicals in the environment â€” they haven’t made those the top issues in this race. It’s sort of the same bread-and-butter, cost-of-living Republican red meat stuff that you’re seeing in other states. And so, I think, you know, we talked to a lot of people, you know, close to the situation, who said, even if Cassidy loses, it’s not going to be because of MAHA. And so I don’t know if that makes him more willing to tangle with RFK in these hearings or not.  

Rovner: I did think, I thought that it was politics that made him lead with abortion, though, because he â€¦&²Ô²ú²õ±è;I mean, Louisiana, as we know, is one of the most anti-abortion of all the anti-abortion states. He’s been a longtime anti-abortion crusader. This is not a new position for him, and he’s got this primary, so he would like to bring out his supporters. I mean â€¦&²Ô²ú²õ±è;I saw that. It’s like, oh, aha, politically, that makes sense, even though he knew that Kennedy wasn’t going to respond to the question.  

Aside from the secretary’s continuing denial of the accusation that he is anti-vax, there was, in fact, considerable anti-vaccine-related news this week. First, over at the Defense Department, where Secretary Pete Hegseth has decreed that annual flu shots will no longer be required for active-duty and reserve military members. This is, according to Hegseth, “because your body, your faith, and your convictions are not negotiable.” Now, flu vaccines have routinely been given to members of the military since just after World War II for the fairly obvious reason that viral infections pass easily among people who are living together in close quarters, like, you know, members of the military. And vaccine requirements in the military, in general, date back to the Revolutionary War, when George Washington ordered troops to submit to the then fairly new smallpox vaccine. Sheryl, you’re our public health historian at the table. Has there ever been a time when the balance between personal liberty and public health has been tilted so heavily towards personal liberty as it is right now?  

Stolberg: I don’t think so. We’ve had anti-vaccine activism in the United States for as long as we’ve had vaccines. And especially at the turn of the 20th century, around the time when smallpox was kind of racing through Boston and other cities, there was a big anti-vaccine push. You might remember, in 1905, the Supreme Court ruled that states could mandate vaccination to protect the public health, and that was in a case brought by a pastor in Cambridge, Massachusetts, who didn’t want to get vaccinated for smallpox. And then we had the ’60s, when, you know, vaccines were new, and public health people were touting them, and there was a big embrace of vaccination. So it’s very interesting to see what Hegseth has done. And what came up yesterday in the HELP Committee hearing, where [Sen.] Patty Murray reminded Kennedy that during the Great Influenza of 1918, the flu was very indiscriminate, and a lot of soldiers were killed. It did not strike only young people and old people. It struck down people in the prime of their life, many, many in the military. And she said that, you know, this was an issue for readiness. And Kennedy was like, You think the flu is going to kill people? Like, the flu is not going to kill people. And it seemed obvious to me that he did not really understand that influenza is not the same all the time, that the virus mutates, and it very well could mutate into a pandemic strain. And he himself is pushing for a universal influenza vaccine, which has been kind of like the dream of public health people, so we could guard against, you know, all types of flu strains. 

Rovner: And not have to redo the vaccine every year. 

Stolberg: Right. So, in short answer to your question, I think certainly not in the last 50 or even 100 years have we seen the ascendancy of the medical freedom movement and the argument that individual liberty takes precedence over the health of the community. 

Rovner: Yeah. Alice, you wanted to add something. 

Ollstein: Yeah. I’ve also seen a lot of people pointing out that it’s not like this is an across-the-board embrace of individual liberty. I mean, if you’re in the military, you still can’t grow a beard if you’re a man, even if you have a skin condition where shaving really hurts and is bad for your skin. You don’t have the personal medical freedom to transition from male to female, or female to male. You don’t even have the personal freedom to wear what you want, to have the hairstyle you want, and so this is really just about vaccines. And, like Sheryl said, you know, really could threaten military readiness. There have been several wars in the past where more soldiers died of disease than died of violent combat impacts. So this is a very interesting carve-out that has a lot of people worried. 

Rovner: Also on the vaccine front at HHS, NIH [National Institutes of Health] Director Jay Bhattacharya, who was actually acting in his role as acting director of the Centers for Disease Control and Prevention, has reportedly canceled publication of a study that found the covid vaccine dramatically reduced hospitalizations and emergency department visits. Bhattacharya,  and The New York Times, complained that the study’s methodology was flawed. But CDC officials say not only is it the same methodology used in the past, but it’s also basically unheard of for a study approved by CDC’s own scientists not to be published in the agency’s “Morbidity and Mortality Weekly Report” once it reached the stage that this study had reached. Is there any conclusion to be drawn here? Other than that the study’s results contradict the administration’s position that the covid vaccine is not helpful.  

Stolberg: Raises a question about radical transparency, that’s for sure. Secretary Kennedy came into office promising radical transparency. This doesn’t seem radically transparent.  

Rovner: No. Kennedy keeps saying â€” and he said how many times during these hearings? â€” that he’s trying to restore trust in the science agencies. And this does not strike a lot of people as a way to restore trust when something is canceled because you don’t like the results. Victoria, did you want to add something?  

Knight: Yeah, I mean, I think that’s a great point. He just said multiple times throughout all these hearings, especially when Democrats were questioning him on vaccines, that I’m willing to look at studies, I’m willing to look at data, I’m willing to review everything, if you’re bringing up maybe things he allegedly said he had not seen before, data or whatever. So yeah, exactly this goes exactly against that. You would think if there’s a study showing something, he’d be willing to view it. If that was his philosophy. 

Rovner: We would see. All right. Well, meanwhile, President Trump continues to make his health policy out of the White House. Last Saturday, he summoned his top health officials, plus popular podcaster Joe Rogan, to the Oval Office to sign an executive order to facilitate research into and to fast-track FDA review of some previously banned psychedelic substances, including ibogaine and LSD, which are legally considered to have no medicinal uses. This is actually not all that controversial. It’s part of an ongoing push from researchers who say that some of these substances might well be useful for treating things like severe depression, PTSD, and even opioid dependence. But what made this so unusual is that it was apparently pushed to fruition in just a matter of days by a text from Joe Rogan to President Trump. So what message does this send about the so-called gold-standard science being the only thing that counts in this administration, when a podcaster with a big following that the president wants can spring loose a major policy shift in less than a week? 

Stolberg: So I have a theory about this, actually. Well, first, it is highly unusual that Trump would step in on this, right? Like it’s not the ordinary course of science that the president issues these executive orders. But Casey Means, who is President Trump’s nominee for surgeon general, has advocated the use of psilocybin, and so has Secretary Kennedy, for that matter. But this is one of the things that is kind of stalling her nomination. [Sen.] Susan Collins has raised concerns about this. I guess I just kind of wonder if Trump is trying to put his imprimatur on this research, maybe as a backhanded way to give her a boost? Or maybe I’m just too Machiavellian, and maybe it’s just that Joe Rogan texted him, and he was like, Yeah, that’s a good idea. 

Rovner: And it was, in fairness, it was already in the works. 

Stolberg: Yeah. And, I mean, there is a lot of legitimate scientific reasons to do this kind of research. 

Rovner: And, I will say, I mean, I’ve studied this, and I believe breaking just today, they’re, you know, rescheduling marijuana. Again, all of these technical changes are to make it easier to do the research. Part of the problem has been that because these substances were scheduled as having no medicinal uses, you couldn’t get them to do the research. So one of the things that this does is make it easier. To have Joe Rogan in the Oval Office on a Saturday morning struck me as, like, OK, this is a little strange. 

Knight: But isn’t that how this administration works? Right? I mean, I think that, just in general, there’s a lot of influencer types that â€” I would say, Joe Rogan, podcaster, influencer type â€” that just have influence in this White House because they have forged a connection with Trump. And so, if they say something to him, he will take that into account and change policy sometimes. 

Rovner: And he wants the young male demographic, which Joe Rogan very much represents. All right, we’re going to take a quick break. We will be right back.  

OK, we are back. And turning to the Affordable Care Act, despite reassurances from Trump administration officials that the lapse of the Biden-era additional premium tax credits didn’t result in a big drop in coverage, we’re getting more data suggesting that is not the case. A new report this week from the group representing the 21 states that run their own marketplaces show[s] about 900,000 enrollees dropped coverage in the first three months of this year. Compared to last year, disenrollments are up 24%. Hardest hit, not surprisingly, are older enrollees between the age 55 and 64. Their premiums are higher to begin with, so the loss of additional subsidies hits them harder. Meanwhile, even people who have managed to keep coverage are paying more, as many dropped the more generous “gold” and “silver” plans, for those with higher deductibles but lower premiums. And those deductibles are often eye-popping indeed â€” not just $1,000 or $1,500 a year, but often more than five figures. I know I say this roughly every other week, but I’m surprised this isn’t making more of an impact in the national conversation. I mean, you know, I keep seeing people who say I’m having to drop my insurance or, you know, I have insurance and I can’t afford to use it because my deductible is $10,000. I know it sort of swept into this whole “affordability” thing, but I thought this might have come up more during seven hearings with the secretary of HHS.  

Knight: I mean, I think it’s partly because there is just so much happening in the world right now that everything else is getting pushed aside in a way, if it’s not related to the Iran war or gas prices or things like that. But I do think, I mean, we’ll see, but Democrats, once we were starting to get â€” you know, we just started to get some of this data about ACA enrollment and how it’s changing now that the premium tax credit, enhanced premium tax credits, were not extended by Congress, we’re just now starting to get some of the data. So I think as we see more data, and then we’ll see even more of that going into the summer, I think Democrats, at least, will be hitting this really hard on the campaign trail, and maybe that will permeate and become part of more of the national conversation. We’ll see, but they’re at least gonna message on it, certainly.  

Rovner: Yeah, I think, you know, one of the things that’s important to remember is that the administration, it’s telling the truth when it says, you know, most people were still enrolled in January, because a lot of those people got auto-enrolled. And it takes several months of not paying your premiums before you can actually get kicked off your insurance. So in fact, we’re only just starting to see how many people. 

Ollstein: This is just the beginning. And the fact that we’re already seeing such coverage losses means that there’s going to be more. And I think it’s going to have a political impact in certain contexts. I mean, there was a report just about the big drop in enrollment in Georgia, and Georgia is a major swing state with some major races coming up, and so I expect it to have a big impact there. And so I think, rather than being like a dominant national message, I think in certain places where you’re really seeing the strain. I’ll also point out that it’s not just about people becoming completely uninsured. There’s also a big shift from people being in more comprehensive health care plans to people moving into skimpy, high-deductible health care plans. And that’s going to have a lot of ripple effects going forward as well, and going to lead to a lot of struggle. And so I think it contributes to the overall sense that people are really in financial dire straits and can’t afford basic daily life.  

Stolberg: We’re going to see that, coupled with a lot of Democrats talking, as they did during the hearings, about cuts to Medicaid. Kennedy insists that we’re not cutting Medicaid, but if you talk to any rural hospital executive around the country, they will tell you that they are crumbling under the loss of Medicaid reimbursements. And I think that those, the Medicaid and also the ACA enrollments, will emerge as powerful issues for Democrats.  

Rovner: Kennedy was repeating the age-old argument that’s always made that if the amount of money to Medicaid goes up, it can’t be a cut, even though that doesn’t keep up with inflation or enrollment or the number of people. Yeah, so, I mean, it’s like â€¦&²Ô²ú²õ±è;if you’re paying more, if your mortgage goes up and you’re paying more for it and it goes up more than you’re paying, than you’re able to pay, then that’s really a cut in your income. So it’s a perennial argument that we do see.  

Stolberg: It’s Washington accounting.  

Rovner: Yeah. Finally, this week, there is news on the reproductive health front. In Pennsylvania, a state appellate court ruled that a 1982 ban on the use of public funds to pay for abortion violates that state’s Equal Rights Amendment. Now this case could still be appealed to the state Supreme Court, but this is a pretty significant ruling for a very purple swing state, right, Alice? And it could lead to state-funded Medicaid coverage for abortion, if it’s upheld. 

Ollstein: That’s right. And I will say there was a major state Supreme Court race last year, and it was all about abortion rights â€” that was, like, the dominating issue in it. And the progressives prevailed on that message. I think you’re really seeing, like you said, a very mixed state, a very purple state, really being swayed in the direction of supporting abortion rights. And we’ve seen that in a lot of states, you know, since Dobbs â€” states you might not expect to go in that direction. And I think it’s going to continue to dominate state Supreme Court races as an issue. You’re seeing that right now with Georgia. I would advise folks to keep an eye on that. There’s a very pro-abortion rights message for those candidates in that race. â€¦&²Ô²ú²õ±è;But this is specifically the issue of Medicaid coverage of abortion, I think, is going to keep coming up over and over as well, because it’s really getting at the question of, yes, you can have legal access to abortion on paper, but if you can’t afford it, is it really accessible? So this could open up access to a lot of low-income people that would not maybe be able to afford it otherwise.  

Rovner: And for the people who are wondering, Wait a minute, I thought Medicaid coverage of abortion is banned â€” it’s federal Medicaid coverage of abortion is banned. States may use their own money if they wish to pay for abortion, and many bluer states do. That’s the question at hand here.  

Meanwhile, in South Carolina, lawmakers are advancing a ban on abortion that’s so strict it would subject women who have abortions to punishment, although not as severe as the punishment for those who perform abortions. I thought this was a basic tenet of the anti-abortion movement, that the women who have abortions are also victims and shouldn’t be punished. Is that changing?  

Ollstein: It’s been a very loud debate recently. You have different wings of the anti-abortion movement who are clashing on this, and many are watching the total number of abortions in the U.S. go up since Dobbs, and say this incremental strategy where we shield women who have abortions from prosecution and only go after the doctors. Some of the hard-liners feel that that’s not working, and so they have to try something else in order to actually have the chilling effect that they want to have and deter people from even attempting to get abortions. And then you have a lot of the more mainstream groups who really are against that strategy, and say that, you know, this will just drive voters into the arms of Democrats if we look like we’re the quote-unquote “war on women” that we’ve been accused of waging all these years. And so it’s a very active debate right now.  

Stolberg: I was going to say, do you remember when Trump was running in 2015 and he said that he thought women should be punished for having abortions? And there was a big firestorm over it from the anti-abortion movement. And he basically shut up on that. 

Rovner: Yes, I do remember that.  

Stolberg: So â€¦&²Ô²ú²õ±è;you can see how things have evolved. Of course, that was, you know, when Roe was still into effect. Then we got Dobbs, and, as Alice said, things are changing.  

Rovner: Yes, things are changing. All right. Well, that is this week’s news, or at least as much as we have time for. Now we will play my “How Would You Fix It?” interview with David Blumenthal, and then we’ll come back and do our extra credits. 

I am pleased to welcome to “How Would You Fix It?” David Blumenthal, a true Renaissance man of health policy. When I first met David in the 1980s, he was teaching at Harvard Medical School, doctoring in Boston, and writing about health policy. Since then, he has served as president of the health policy research organization The Commonwealth Fund, and, before that, as national coordinator for health information technology in the Obama administration. In his “spare time,” air quotes, David has written countless journal and other articles and several books, most notably, with political scientist James Morone, The Heart of Power: Health and Politics in the Oval Office, which chronicles presidential health policies from Teddy Roosevelt through George W Bush. Now he and Morone are out with a follow-up book called Whiplash: From the Battle for Obamacare to the War on Science, which covers the rather eventful last three administrations in health care. David Blumenthal, thank you so much for joining us. 

David Blumenthal: Oh, it’s my pleasure. What a great introduction. Thank you so much for that. 

Rovner: So, if it’s Congress that makes the laws, why is it that the president is so pivotal when it comes to health policy? 

Blumenthal: Well, people forget that there is only one official in the United States who is elected by all the people, and that is the president. That gives him â€” or someday her, we hope â€” a legitimacy, a symbolic authority, and an ability to rise above the din of Washington conversation to reach the American people and to build support or mobilize opposition to whatever an enterprising congressman or senator has in mind. Those same congressmen and senators really crave direction, most of them, from the president to know what that official’s priorities are, so they can line up behind it. They also want to know what the president might veto before they put a lot of effort into things. So all those things are reasons why presidents have a level of authority which is often underappreciated, especially in health care, where the day-to-day conversation often focuses on what a senator or a congressman or a committee chairman is saying. But in the end, unless the president is behind something important, it’s not going to happen in the Congress. 

Rovner: And pretty much everything major in health care has had a president spearheading it, hasn’t it? 

Blumenthal: Exactly. Some that have succeeded, like Medicare and Medicaid, Lyndon Johnson’s proposals, and some that have not, like the Clinton health plan. And then, of course, the Affordable Care Act, which was uniquely the product of President Barack Obama’s sponsorship, passion, enduring commitment, with a lot of help from Nancy Pelosi. 

Rovner: Can you talk a little bit about tinkering versus major reforms, and what you’ve learned from studying the last dozen or so major health reform debates? I know just in the 40 years I’ve been doing this, you know federal government has gone back and forth between We should try to do something big; no, we can’t do something big, so we should try to do something small; no, it doesn’t work if we do something small, we should try to do something big. It’s just been this constant swaying. 

Blumenthal: Well, one of the stories that we tell in both of our books is the story of the dance that has gone on over the ages between proponents of major health care reform and opponents. And this has typically been Democratic proponents and Republican opponents. And the story is this: Somebody in the Democratic Party proposes a massive health care reform proposal, and the Republicans scream socialism, government control, death panels, whatever, and propose an alternative that is smaller, more about free markets, more about the private sector, more about competition. The Democratic proposal goes down in flames, and then 20 years later, the Democrats come back and propose what the Republicans proposed the first time. Then the Republicans say socialism, government control, more limited government, more free market, more private sector. Same thing happens. It goes and goes and goes. What we saw with the Affordable Care Act was that the effort to get anything meaningful in the way of coverage, with a less governmentally oriented program, had run out its rope. There was just nowhere else for conservatives to go, which is why we got the Heritage Foundation proposing what Gov. Mitt Romney and Ted Kennedy accepted in Massachusetts as the basis for health care reform. So I think what happened was that â€” and this, I think, you saw mostly in the repeal-and-replace failure â€” the Republicans could not come up with anything that was more incremental, less comprehensive, and still made a difference for people’s insurance, especially on the issue of preexisting conditions. 

Rovner: They were OK with the repeal, just not with the replace. 

Blumenthal: Exactly, which is a story that we tell, in detail, in Whiplash. So incremental reform is the way Americans do business. We’ve now incremented our way to a four-legged stool that can achieve universal coverage. We have employer-sponsored insurance, which, of course, is subsidized by the government. We have Medicare, which is the third rail of health care politics. We have Medicaid, which can be expanded if states and the federal government choose, and we have the Affordable Care Act. And together, those got us, during the last years of the Biden administration, to 93% coverage of Americans. We have the tools to increment our way now to universal coverage, and that just seems â€¦ to be the way Americans want to do business, at least in health care. 

Rovner: How does that politicization of not just health insurance coverage but everything that surrounds health and health care becoming red or blue â€” how’s that going to impact the next big health debate? 

Blumenthal: Well, it’s red-blue. It’s also â€¦&²Ô²ú²õ±è;has racial overtones. It also has xenophobic overtones, with attitudes toward immigration. All these things now run straight through health care. I think there’s a difference between the psychology of opposition to vaccination and suspicion of the NIH and the people who come into play when it comes to the cost-control issue. Cost control is a bread-and-butter issue. Vaccination is about personal freedom, the sanctity of bodies, the freedom to say no. It has a different overtone and undertone to it. I think that the controversy over cost will be viewed much more as a traditional interest-group struggle, rather than as a red-blue struggle. And I think there’ll be some people from the Republican Party who will get to the point where their constituents are saying, We may have health insurance, but it’s not worth a damn because our deductibles are too high and our copayments are too high. We got to do something. And I think there’s a chance for a bipartisan solution on that score. 

Rovner: So we’re calling this series “How Would You Fix It?” How would you fix it if you could wave a wand and put aside all of the politics that I know you now know so well. But if you could do one or two things to make our health system function better, what would it be? 

Blumenthal: Well, you know, we, in writing the book, we spent some time with President Obama, who said, you know, I would have loved to have had “Medicare for All,” but I knew that was impossible. So we now have this Rube Goldberg apparatus providing us coverage, and I think we’re stuck with that. So what I would do first is make the Affordable Care Act as generous as it should have been and got to be after the Inflation Reduction Act. And I think if we did that and worked our way around the Supreme Court’s prohibition about requiring Medicaid expansion, which we almost did in the IRA â€” it’s little-known, but there was an alternative to expanding Medicaid that would have made it a federal program, added to the state program, and not be â€¦ go crosswise with the Supreme Court. That, plus â€¦&²Ô²ú²õ±è;so that would be just sort of make do everything we can to make coverage as universal as it could be. And then add to that a set of incremental changes that would reduce the cost of care. That would involve, I think, more regulation of private insurance to reduce the complexity of benefits and the complexity of billing. The Netherlands and Germany run their health systems through private insurance. They just standardize what the private companies offer. We could do that. In fact, the Affordable Care Act begins that process, especially in marketplaces like California, where private insurers are heavily regulated. 

The second is we need to break up the monopolies that have formed at the local level in the health care provider system, where you have virtually no competition based on price or anything else. We need to change the way we pay for care much more aggressively. Artificial intelligence has enormous potential to reduce administrative costs, but it also has an enormous potential to run them up. If the incentives in the system are not fixed, the incentives in the fee-for-service system will lead to using AI to maximize billing. 

Rovner: Which we’ve already seen. 

Blumenthal: Right, and not reduce administrative expenses. And so we need to give providers and other powerful interests an incentive to use AI to make the health care system work better, rather than to make it generate more revenue. So I think those are some of the things that we’ll need to do. So, build on what we have, the four-legged stool, the foundation for universal coverage we already have, and begin to take on the cost of care through changes that are, for which there are precedents elsewhere in the world, but which until now, we’ve been unwilling to take on. 

Rovner: David Blumenthal, we’ll see how this all plays out. Thank you so much. 

Blumenthal: Thank you, Julie. 

Rovner: OK, we’re back. 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. Victoria, why don’t you start us off this week? 

Knight: Sure thing. My story for extra credit is in The New York Times, and the title is “,” by Sarah Kliff and Margot Sanger-Katz, Sheryl’s colleagues. So this is a really interesting look at the ramifications of the 2020 No Surprises Act that was passed by Congress. And the whole point of this act was to protect patients from surprise medical bills. Because, you know, it still happens nowadays, but this law helps it. Basically, sometimes patients go to an out-of-network doctor, they might get stuck with a really, really high bill, and it’s really difficult for them to pay. So Congress wanted to do something about it. They did, and now, basically, insurers and doctors have to go to an arbitrator if there is a conflict about the price of the bill, if it’s an out-of-network bill. This article really had a lot of great data points on how it seems arbitrators are really favoring doctors in these decision-making and awarding doctors with these really high amounts of money for these medical procedures. So basically, the doctors offer an amount of money that the medical procedure should cost, and the insurers offer one, and the arbitrator just picks one of the two prices. And so doctors are really getting awarded way more. â€¦&²Ô²ú²õ±è;Some doctors are profiting off of this by certain types of procedures, such as breast reduction that was mentioned in the title. And so it was really fascinating. And a few lawmakers were interviewed, and they were like, Well, we didn’t really think about that happening, but at least patients are protected. I don’t know if Congress will do anything about it, but it’s a new twist in our health care system.  

Rovner: Yeah, I love this story because there’s been complaints about the arbitration system pretty much since the law passed. And I think it takes, you know, a story like this for everybody to say, Oh, my goodness, is that what’s happening? Alice, why don’t you go next? 

Ollstein: Yes, I have a[n] analysis from The Washington Post. It’s called “,” and it’s looking at these science and research grants from the National Institutes of Health, and even though Congress has largely protected that funding and approved increases, even where the White House pushed for decreases, that money is not going out, and it’s really not going out to certain researchers researching certain topics, chief among them things that impact women’s health. And this is partially, as the article gets into, a result of this war on what’s viewed as DEI [diversity, equity, and inclusion]. And so research into conditions that primarily or solely impact women, like endometriosis, are seen as DEI and are therefore getting cut. And so it really gets into the toll that’s taking on these labs around the country that are, you know, potentially discovering breakthroughs, but are now in limbo and having to lay people off and has big consequences.  

Rovner: Another story that made me angry. Sheryl, you have one of Alice’s stories as your extra credit. 

Stolberg: I do. So this is from Politico by Alice and her colleague, Amanda Friedman: “.” And the reason I like this story is because it’s about Casey Means, and in how this â€” there’s a wave of attacks coming against her, kind of under the radar from the right, from abortion opponents, including the policy arm of the Southern Baptist Convention, and also people who, as we mentioned before, are perhaps raised questions about her embrace of psychedelics. And I think that what happens with Casey Means is really kind of a symbol, or it’s like a microcosm of what is going to happen with the MAHA movement. And yesterday, after the hearing, I asked Sen. Cassidy, who is kind of sitting on Casey Means’ confirmation, “When are we going to see a vote on Casey Means?” And he said, “No comment.” So I just think that this is something to watch, and I applaud Alice and her colleague for pointing out this kind of below-the-radar campaign to hold her up.  

Rovner: Yeah, really, really good story. All right. My extra credit, also from one of our podcast panelists, Rachel Roubein at The Washington Post. It’s called “.” And I love this story because it’s one of those “what seems simple is anything but” policy stories. What seems simple here is the idea that food stamps shouldn’t be used to pay for unhealthy food like candy and soda. But who determines what’s healthy and how is that decided? Thanks to a big pilot program from the Trump administration, two dozen states have received permission to make changes to the food and drink that’s eligible to be paid for using SNAP [Supplemental Nutrition Assistance Program] benefits, and 10 states have now implemented restrictions. But it’s a lot harder than just saying you can’t buy soda and candy. In some states, Gatorade and even Pedialyte are ineligible, even though those are often given to nurse sick kids. In Iowa, KitKat and Twix bars are eligible because they’re made with flour and so they’re not technically candy. Some SNAP rules are so arbitrary that â€” and this is not part of Rachel’s story because it just happened â€” a bipartisan group of U.S. senators on Wednesday introduced the “Hot Rotisserie Chicken Act” to make sure that Costco’s famous $4.99 roasted bird remains available to those getting federal food assistance. We will watch to see if that flies. Sorry. Not really sorry. 

Rovner: OK, that is this week’s show. 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 Twitter , or on Bluesky . Where are you folks these days? Sheryl?  

Stolberg: I’m at @SherylNYTon , formerly Twitter, and . 

Rovner: Victoria. 

Knight: I’m  on X. 

Rovner: Alice. 

Ollstein:  on Bluesky and  on Twitter [X]. 

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.] 

Mary Agnes Carey: Hello from ºÚÁϳԹÏÍø News and WAMU radio in Washington, D.C. Welcome to What the Health? I’m Mary Agnes Carey, managing editor of ºÚÁϳԹÏÍø News, filling in for Julie Rovner this week. And as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Friday, April 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. 

Today we’re joined via videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

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

Joanne Kenen: Hi, everybody. 

Carey: And my ºÚÁϳԹÏÍø News colleague Emmarie Huetteman. 

Emmarie Huetteman: Hey there. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Carey: Emmarie, you wanted to jump in. 

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

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

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

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

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

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

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

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

Carey: Emmarie. 

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

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

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

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

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

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

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

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

Carey: Oh yeah. 

Kenen: —since the Garden of Eden, right? 

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

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

Michelle Canero: Thank you for having me. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Michelle Canero, thanks again. 

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

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

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

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

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

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

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

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

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

Kenen: and , @joannekenen. 

Carey: OK. Anna? 

Edney: and and , @annaedney. 

Carey: And Emmarie. 

Huetteman: You can find me on . 

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