And presto: You’ve got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.

The Trump administration and congressional Republicans have just checked that achievement off their list.

They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.

Among the many provisions, there’s this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.

Wait. What?

I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It’s an echo of the federal immigration raids in Los Angeles and elsewhere.

“It’s creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. “For those who believe health care is a human right, this is like excluding that population from something that should be a given.”

In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.

It’s not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.

The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And “Dreamers” will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.

The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.

Supporters of the policy changes enshrined in the CMS rule and budget law think it’s high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.

“It’s about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program,” says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.

But Blase doesn’t have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.

Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. “If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered,” she says.

Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California’s 1.9 million enrollees. That’s because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.

Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.

Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.

The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.

And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.

Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.

“Who are the people who are going to decide to go through hours and hours of onerous paperwork?” says Morse Gasteier. “They’re people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks.”

California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect “unreasonable barriers to coverage.” California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.

“The Trump administration claims that their final rule will prevent fraud,” Bonta said. “It’s obvious what this is really about. It’s yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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The Host

Julie Rovner
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Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Much of the hubbub in health care this year has been focused on Medicaid, which faces dramatically reduced federal funding as the result of the huge budget bill signed by President Donald Trump earlier this month. But now the attention is turning to the Affordable Care Act, which is facing some big changes that could cost many consumers their health coverage as soon as 2026.

Meanwhile, changes to immigration policy under Trump could have an outsize impact on the nation’s health care system, both by exacerbating shortages of health workers and by eliminating insurance coverage that helps keep some hospitals and clinics afloat.

This week’s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Jessie Hellmann of CQ Roll Call, and Alice Miranda Ollstein of Politico.

Panelists

Julie Appleby
KFF Health News

@julie_appleby

Read Julie's stories.

Jessie Hellmann
CQ Roll Call

@jessiehellmann

@jessiehellmann.bsky.social

Read Jessie's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• Many Americans can expect their health insurance premiums to rise next year, but those rate hikes could be even bigger for the millions who rely on ACA health plans. To afford such plans, most consumers rely on enhanced federal government subsidies, which are set to expire — and GOP lawmakers seem loath to extend them, even though many of their constituents could lose their insurance as a result.
• Congress included a $50 billion fund for rural health care in Trump’s new law, aiming to cushion the blow of Medicaid cuts. But the fund is expected to fall short, especially as many people lose their health insurance and clinics, hospitals, and health systems are left to cover their bills.
• Abortion opponents continue to claim the abortion pill mifepristone is unsafe, more recently by citing a problematic analysis — and some lawmakers are using it to pressure federal officials to take another look at the drug’s approval. Meanwhile, many Planned Parenthood clinics are bracing for an end to federal funding, stripping money not only from busy clinics where abortion is legal but also from clinics that provide only contraception, testing for sexually transmitted infections, and other non-abortion care in states where the procedure is banned.
• And as more states implement laws enabling doctors to opt out of treatments that violate their morals, a pregnant woman in Tennessee says her doctor refused to provide prenatal care, because she is unmarried.

Also this week, Rovner interviews Jonathan Oberlander, a Medicare historian and University of North Carolina health policy professor, to mark Medicare’s 60th anniversary later this month.

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

Julie Rovner: KFF Health News’ “Republicans Call Medicaid Rife with Fraudsters. This Man Sees No Choice but To Break the Rules,” by Katheryn Houghton.  

Julie Appleby: NPR’s “Many Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That,” by Rachel Treisman.  

Jessie Hellmann: Roll Call’s “Kennedy’s Mental Health Drug Skepticism Lands at FDA Panel,” by Ariel Cohen.  

Alice Miranda Ollstein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and Jonel Aleccia.  

Also mentioned in this week’s podcast:

• KFF Health News’ “Insurers and Customers Brace for Double Whammy to Obamacare Premiums,” by Julie Appleby.
• The Congressional Budget Office’s “Estimated Budgetary Effects of Public Law 119-21, to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline.”
• The CBO’s “How Changes to Funding for the NIH and Changes in the FDA’s Review Times Would Affect the Development of New Drugs.”
• KFF’s “KFF Health Tracking Poll: Public Views on Recent Tax and Budget Legislation,” by Grace Sparks, Shannon Schumacher, Julian Montalvo III, Ashley Kirzinger, and Liz Hamel.
• The Washington Post’s “Digging Into the Math of a Study Attacking the Safety of the Abortion Pill,” by Glenn Kessler.

click to open the transcript

Transcript: Here Come the ACA Premium Hikes

[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 KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 24, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And my KFF Health News colleague Julie Appleby. 

Julie Appleby: Hi. 

Rovner: Later in this episode we’ll have the first of a two-part series marking the 60th anniversary of Medicare and Medicaid, which is July 30. Medicare historian and University of North Carolina professor Jonathan Oberlander takes us on a brief tour of the history of Medicare. Next week we’ll do the same with Medicaid. But first, this week’s news. 

So, we have talked a lot about the changes to Medicaid as a result of the Trump tax and spending law, but there are big changes coming to the Affordable Care Act, too, which is why I have asked my colleague Julie Appleby to join us this week. Julie, what can people who buy insurance from the ACA marketplaces expect for 2026? 

Appleby: Well, there’s a lot of changes. Let’s talk about premiums first, OK? So there’s a couple of things going on with premiums. It’s kind of a double whammy. So, on the one hand, insurers are asking for higher premiums next year to cover different things. So in the summer they put out their rates for the following year. So there’s been a lot of uncertainty this year, so that’s playing into it as well. But what they’re asking for is some money for rising medical and labor costs, the usual culprits, drug costs going up, that kind of thing. But they’re tacking on some extra percentages to deal with some of the policy changes advanced by the Trump administration and the Republican-controlled Congress. And one key factor is the uncertainty over whether Congress is going to extend those more generous covid-era tax subsidies. So we’re looking at premiums going up, and the ask right now, what they’re asking for, the median ask, is 15%, which is a lot higher. Last year when KFF did the same survey, it was 7%. So we’re getting premium increase requests of a fairly substantial amount. In fact, they say it’s about the highest in five years.  

And then on top of that, it’s still not clear what’s going to happen with those more generous subsidies. And if the more generous subsidies go away, if Congress does not reinstate them, there’ll be costs from that, and people could be paying maybe 75% more than they’re paying this year. And we could talk some more about that. But that’s kind of the double whammy we’re looking at, rising premiums and the potential that these more generous subsidies won’t be extended by Congress. 

Rovner: So there were some things that were specifically in that tax and spending bill that drive up premiums for the ACA, right? Besides not extending the additional subsidies. 

Appleby: Well, that’s the biggest piece of it, but yes. They’re tacking on about 4% of that 15% medium increase is related to the uncertainty. Well, they’re assuming that the tax credits will expire. It was not in the bill. Congress could still act. They have until the end of the year. They could extend those subsidies. So that’s about 4%. But one of the things that people haven’t really been talking about are tariffs, and some of the insurers are asking for 3% because they expect drug costs to go up. So there’s those things that are going on. And then there’s just sort of the uncertainty going forward for insurers about what’s going to happen with enrollment as a result of both these premium increases, and then looking a little bit further down the line, there are some changes in the tax and spending bill and some rules that are going to substantially reduce enrollment. 

So insurers are worried that the people who are going to sign up for coverage are the ones who are most motivated, and those are probably going to be the people who have some health problems. And the folks who aren’t as motivated are going to look at the prices and maybe the additional red tape and will drop out and leave them with a sicker and more expensive pool to cover. So all of that is factoring in with these premium rate increases that they’re trying to put together. Now remember, a lot of these insurers put in these premium increase requests before they knew the outcome of the tax and spending legislation. They could still modify them. 

Rovner: And Jessie, as Julie said, there’s still a chance that Republicans will change their minds on the increased subsidies and tack them onto something. And there’s a big bipartisan health bill on drug prices and other expiring programs that still could get done before the end of the year? Yes? 

Hellmann: There have been discussions about a bipartisan health bill, though the main author of it, Sen. Bill Cassidy, himself even seems kind of skeptical. I talked to him this week, and he’s like, It might happen, it might not. But there are a bunch of other health extenders that Congress will need to get to, like telehealth, some Medicare and Medicaid payment things. So there’s definitely something to attach it to. Republicans are not friendly to the ACA. As you mentioned, they made a bunch of changes to it in this tax and spending bill. So I think the people I talk to think it’s a long shot that they’re going to pass billions of dollars in a subsidy extension in this bill. Though there are Republicans who do care about this issue, like Sen. Lisa Murkowski of Alaska. She’s kind of been sounding the alarm on this. She thinks that Congress needs to do something to mitigate which could be very big premium increases for people. So there is some pressure there, but it doesn’t seem like the people who should be thinking about this right now have started thinking about it much yet. 

Rovner: One presumes they’ll start thinking about it when they start seeing these actual premium increases. I sound like a broken record, but we keep saying, the people who these premium increases are going to hit the hardest are voters in red states. 

Appleby: Last year, in 2024, 56% of ACA enrollees lived in Republican congressional districts and 76% were in states won by President [Donald] Trump. So I’ve got to think they’re thinking about it. When I did the reporting on this story, I spoke with a couple of folks, and they said that some people in Congress are looking at maybe they can mess around or maybe they can do something with the subsidies that’s not keeping them as they are but might deal with a piece of it. For example, there is something called a subsidy cliff. So if you make more than 400% of the federal poverty level, you used to not get any subsidies. That would come back if they don’t extend this. And so 400% of the federal poverty level, you make a dollar more, you don’t get a subsidy. So this year — and this year will be the numbers that next year’s rates are based on — $62,600 for one person is 400% of the federal poverty level and $84,600 for a couple. So people are going to start getting, if they don’t extend the tax credits, they’re going to start getting notification about how much they owe for premiums next year. 

And this is going to be one of the first effects that people are going to see from all these changes in Washington, the tax and spending bill and the other things, when they get these premiums for January. And if they make even a dollar over that, they’re not going to get any subsidy at all. So what I’m told by some of my sources is that maybe they’re thinking about raising that cliff, maybe keeping the cliff but maybe moving it up a little bit to 500% or 600%. But it’s totally unclear. Like you all are saying, nothing may happen. We may go through Dec. 31 and nothing happens, but I’m hearing that they are maybe talking a little bit about that. 

Rovner: Alice. 

Ollstein: Yeah. And there’s a couple interesting dynamics that I think could influence the politics of this and what Congress feels motivated to do or not do. So, like Julie was saying, this would hit in January. And a lot of the stuff in the bill they just passed is designed to not hit until the midterms, but this would hit before the midterms. And so that’s got to be on their minds. And then, like you were saying, not only would this hit Republican voters the hardest, but a reason that’s more true today than it was the last time they took a round at the Affordable Care Act in 2017 is because all of these red states have expanded since then. You have a lot more enrollment, even in states that didn’t expand, and so, like we mentioned, are going to have a lot of Republican voters who get hit and have this sticker shock. And the party in power in Congress and the White House could be to blame. 

Rovner: Yeah. One of the things in 2017, there were, what, 12 million people who were buying coverage on the marketplaces. And now there’s 24 million people who are buying coverage on the marketplaces. So it’s a lot more people, just plain, in addition to a lot more people who are likely in some of these red states. So we will follow this closely. 

Meanwhile, the fallout continues as people find out more about the new tax and spending law. The Congressional Budget Office is out with its final numbers on the bill as enacted. It’s now estimating that 10 million more people will be uninsured in 2034 as a result of the new law. That’s down from the 11.8 million estimate of the original Senate bill. That’s because the parliamentarian bounced the provisions that would’ve punished states using their own money to cover undocumented people. That was not allowed to be considered under the reconciliation procedure. 

We also have a brand-new poll from my colleagues here at KFF that find that more people know about the law than did before it passed, and it’s still unpopular. We’ll post a link to those numbers so you can see just how unpopular it is. As we’ve discussed, lots of Republican senators and House members expressed concern about the impact the Medicaid cuts could have on rural hospitals in particular. So much so that a $50 billion fund was eventually added to the bill to offset roughly $155 billion in rural Medicaid cuts. Even more confusing, that $50 billion is likely to be distributed before some of the cuts begin — as you were just saying, Alice — and not necessarily to just rural areas. So is this $50 billion fund really just a big lobbying bonanza? 

Ollstein: Well, it’s certainly designed to function as softening the blow. But these are different things. The hospital could be propped up and stay open, but if no one has Medicaid to go there, that’s still a problem. And the money is sort of acknowledging that a bunch of people are going to lose their coverage, because it’s meant to give the hospital something to use for uncompensated care for people who have no coverage and come to the ER. But that still means that people who lost their insurance because of other provisions in the bill, they might not be going to their preventive care appointments that would avoid them having to go to the emergency room in the first place, which costs all of us more in the long run. So there’s a lot of skepticism about the efficacy of this. 

Rovner: Jessie, are you seeing the lobbying already begin for who’s going to get this $50 billion? 

Hellmann: Yeah, because the legislation leaves a lot of how the money will be handed out to the HHS [Department of Health and Human Services] secretary, and so that’s something that they’re going to start thinking about. It reminds me a lot of the provider relief fund that was set up during covid. And that didn’t go very well. There were lots of complaints that providers were getting the funding that didn’t need the funding, and the small safety net hospitals weren’t getting enough of the funding. So I’m wondering if they’re going to revisit how that went and try to learn any lessons from it. And then at the same time, like Alice said, this just isn’t a lot of money. It’s not going to offset some of the pain to rural providers that the bill has caused. 

Rovner: Yeah. Well, another piece that we will be watching. Meanwhile, the cuts to SNAP [Supplemental Nutrition Assistance Program] food benefits conflict with another stated goal of this administration, improving health by getting people to eat healthier food. Except, as we know, healthier food is often more expensive. Other than not letting people buy soda and candy with their SNAP cards, has the administration tried to address this contradiction at all? I’m seeing a lot of blank stares. I’m assuming that the answer to that is no. We’re hearing so much about food and unhealthy food, and we’re getting rid of seed oils and we’re getting rid of dyes, but at the same time, it’s the biggest cut ever to nutrition assistance, and yet nobody’s really talking about it, right? 

Appleby: Sounds like, I think, the states are really worried, obviously, because they’re going to have to make up the difference if they can. And so what other programs are they going to cut? So I’m sure they are talking with folks in Congress, but I don’t know how much leverage they’re going to have. Do you guys have any idea whether the states, is there anything else that they can do to try to get some of this funding? 

Rovner: There’s no — I’ve seen no indication. As we said, there’s already some buyer’s remorse on the health side. Last week we talked about [Sen.] Josh Hawley introducing legislation to restore some of the Medicaid cuts that he just voted for, but I haven’t seen anybody talking about restoring any of these nutrition assistance cuts or any of the other cuts, right? 

Appleby: Right. And from what I’ve read, the SNAP cuts won’t fully take effect until after the midterm elections. So maybe we’re just not hearing about it as much because it hasn’t really hit home yet. People are still trying to figure out: What does all this mean? 

Rovner: Well, one thing that has hit home yet, I’ve wanted for a while to highlight what some of the changes to immigration policy are going to mean for health care. It’s not just ending legal status for people who came and have lived in the U.S. legally for years, or reinterpreting, again, the 1996 welfare law to declare ineligible for Medicaid and other programs many legal immigrants who are not yet permanent residents but who have been getting benefits because they had been made legally eligible for them by Congress and the president. One of the big changes to policy came to light last week when it was revealed that immigration officials are now being given access to Medicaid enrollment information, including people’s physical addresses. Why is this such a big deal? Alice, you’ve been following this whole immigration and health care issue, right? 

Ollstein: Yes. Experts are warning that this is very dangerous from a public health perspective. If you deter people from physically wanting to visit a clinic or a doctor out of fear of ICE [Immigration and Customs Enforcement] enforcement there, which we’ve already seen — we’ve already seen ICE try to barge into hospitals and seize people. And so fear of that is keeping people away from their appointments. That makes it harder to manage chronic illnesses. That makes it harder to manage infectious diseases, which obviously impacts the whole community and the whole society. We all bear those costs. We live in an interconnected world. What impacts part of the population impacts the rest of the population. 

And so what you mentioned about the Medicaid data, as well, deters people who are perfectly eligible, who are not undocumented, who have legal status, who are eligible for Medicaid. It deters them from enrolling, which again deters people from using that health care and keeping their conditions in check. And so there’s a lot of concern about how this could play out and how long the effect could last, because there are studies showing that policies from the first Trump administration were still deterring immigrants from enrolling even after they were lifted by the Biden administration. 

Rovner: And we should point out that this whole address thing is a big issue because, as you say, there, maybe, there are a lot of families where there are people who live there who are perfectly, as you say, perfectly eligible. You’re not eligible for Medicaid if you’re not here legally. But they may live in a family, in a household with people who are not here with documentation, and they’re afraid now that if they have their addresses, that ICE is going to come knocking at their door to get, if not them, then their relatives or people who are staying with them. 

Appleby: Yeah. And I think it’s also affecting employment. So nursing homes are already saying that they’re losing some people who are losing their protected status or this or that. So they’re losing employees. Some of them are reporting, from what I’ve read, that they are getting fewer applicants for jobs. This is going to make it even tougher. Many of them already have staffing issues, and the nursing home industry has said, Hey, how come we’re not getting any special consideration? Like maybe some of the farmers or other places are supposedly getting, but I don’t know if that’s actually happening. But why aren’t they being considered and why are they losing some of their workers who are here under protected status, which they’re going to lose? And some of them may also be undocumented — I don’t know. But that’s just the nursing homes. Think of all the people around the country who need help in their homes, and maybe they’re taking care of elderly parents and they hire people, and some of those people may not be documented. And that’s a vast number of folks that we’re never going to hear about, but if they start losing their caregivers as well, I think that’s going to be a big impact as we go forward. 

Rovner: And it’s also skilled health workers who are here on visas who are immigrants. 

Appleby: Right. 

Rovner: In rural areas in particular, doctors and nurses are usually people who have been recruited from other countries because there are not enough people or not health professionals living in those rural areas. The knock-on effect of this, I think, is bigger than anybody has really sort of looked at yet. 

Ollstein: Absolutely. States have even been debating and in some cases passing legislation to make it easier for foreign medical workers to come practice here, making it so that they don’t have to redo their residency if they already did their residency somewhere abroad, things like that, because there’s such shortages right now, especially in primary care and maternal care and a lot of different areas. 

Rovner: Yeah. This is another area that I think we’re only just beginning to see the impact of. Well, there is also news this week in Trump administration cuts that are not from the budget bill. In a report from the Congressional Budget Office that’s separate from the latest budget reconciliation estimate, analysts said that the Trump administration’s proposed cuts to the budgets of the National Institutes of Health and the Food and Drug Administration could reduce the number of new drugs coming to market. That would not only mean fewer new treatments and cures but also a hit to the economy. And apparently it doesn’t even take into account the uncertainty that’s making many researchers consider offers to decamp to Canada or Europe or other countries. There’s a real multiplier effect here on what’s a big part of U.S. innovation. 

Hellmann: I’ve been talking to people on the Hill about this who traditionally have been big supporters of the NIH and authorizing and appropriating increases for the NIH every year. And they are still kind of playing a little coy. The White House is suggesting a budget cut at the NIH of 40%, which would be massive. It’s so massive that the CBO report was like: We cannot estimate the impact of this. We’re going to estimate a smaller hypothetical. Because they just can’t. 

And so I think it’ll be interesting to see how it plays out in the appropriations process. You do have senators who are more publicly concerned about it, like Sen. Susan Collins of Maine, who obviously is on the Appropriations Committee. So we might see a situation where Congress ignores the budget request. That usually happens, but these are weird times. And so I think there are questions about, even if they do, if Congress does proceed as normal and appropriate the money that they typically do for NIH, what is the administration going to do with it? They’ve already signaled that they’re fine not spending money that has been appropriated by Congress. And so I think that there’s a big question about that. 

Rovner: At some point, this has to come to a head. We’ve been — as I say, I feel like a broken record on this. We talk about it a lot, that this is money that’s been appropriated by Congress and signed by the president and that we keep hearing that people, particularly at NIH, are not being allowed, for one reason or another, to send out. This is technically illegal impoundment. And at some point it comes to a head. We know that Russ Vought, the head of the Office of Management Budget, thinks that the anti-impoundment law is illegal and that he can just ignore it. And that’s a lot of what’s happening right now. I’m still surprised that it’s the end of July and Congress is going out for the August recess — and Jessie, I know you’re talking to people and they’re playing coy — that they haven’t jumped up and down yet. The NIH in particular has been such a bipartisanly supported entity. If you’ve ever been around the campus in Bethesda, all of the buildings are named after various appropriators of both parties. This is something that is really dear to Congress, and yet they are just basically sitting there holding their tongues. At some point, won’t it stop? 

Hellmann: I think maybe they’re hoping to say something through whatever legislation that they come out with, whatever spending legislation. But, yeah, they’re not being very forceful about it. And I think people are obviously just very afraid of making the Trump administration angry. Lisa Murkowski of Alaska has said this, like she kind of fears the repercussions of making the president mad. And he’s on this spending-cut spree. So I definitely expected more anger, especially the bipartisan history of the NIH has lasted so long. It’s kind of a weird thing to see happen. 

Rovner: Yeah. Of all the things that I didn’t expect to see happen this year, that has to be the thing that I most didn’t expect to see happen this year, which was basically an administration just stopping funding research and Congress basically sitting back and letting it happen. It is still sort of boggling to my mind. Well, we also learned this week about hospitals stopping gender-affirming care of all kinds for minors, under increasing pressure from the administration. And we’re not just talking about red states anymore. Children’s hospitals in California and here in Washington, D.C., have now announced they won’t be offering the care anymore. Wasn’t it just a few months ago when people were moving from red states to blue states to get their kids care? Now what are they going to be able to do? 

Ollstein: I think a lot of what we’re seeing play out in the gender-affirming care fight, it reminds me of the abortion rights fight. There are a lot of themes about the formal health care system being very, very risk-averse. And so rather than test the limits of the law, rather than continuing to provide services while things are still pingponging back and forth in courts, which is the case, they’re saying, just out of caution, We’re just going to stop altogether. And that is cutting off a lot of families from care that they were relying on. And there’s a lot of concern about the physical and mental health impacts on — again, this is very small compared to the general population of trans kids — but it’s going to hit a lot of people. And yeah, like you said, this is happening in blue states as well. There’s sort of nowhere for them to go. 

Rovner: Yeah. We’re going to see how this one also plays out. Well, turning to abortion, we talked last week about how a federal appeals court upheld a West Virginia law aimed at banning the abortion pill mifepristone. And I wondered why we weren’t hearing more from the drug industry about the dangers of state-by-state undermining of the FDA. And lo and behold, here come the drugmakers. In comments letters to the FDA, more than 50 biotech leaders and investors are urging the agency to disregard a controversial study from the anti-abortion think tank the Ethics and Public Policy Center that officials are citing as a reason to reopen consideration of the drug’s approval. Alice, remind us what this study is and why people are so upset about it. 

Ollstein: So it’s not a study, first of all. Even its supporters in the anti-abortion movement admitted, in private in a Zoom meeting that I obtained access to, that it is not a study. This is an analysis that they created. They are not disclosing the dataset that it is based on. It did not go through peer review. And so they are citing their own sort of white-paper analysis put out by an explicitly anti-abortion think tank to argue that abortion pills are more dangerous than previously known or that the FDA has previously acknowledged. There’s been a lot of fact checks and debunks of some of their main points that we’ve been through on this podcast also before. The Washington Post did an in-depth fact check if people want to look that up. But suffice it to say that that has not deterred members of Congress from citing this and to pressure the FDA. 

And now you have the FDA sort of promising to do a review. If you look at the exact wording of what [FDA Commissioner Marty] Makary said, I’m not sure. He said something like, Like we monitor the safety of all drugs, we’re going to blah, blah, blah. And so it’s unclear if there’s anything specific going on. But the threat that there could be, like you said, is really shaking up the drugmaking industry. And you’re hearing a lot of the same alarms that we heard from the pharmaceutical industry when this was before the Supreme Court, when they were afraid the Supreme Court would second-guess the FDA’s judgment and reimpose restrictions on mifepristone. And they’re saying, Look, if we can’t count on this being a process that just takes place based on the science and not politics and not courts coming in 25 years later and saying actually no, then why would we invest so much money in developing drugs if we can’t even count on the rules being fair and staying the same? 

Rovner: Yeah. We will see how this goes. I was surprised, though. We know that that Texas case that the Supreme Court managed to not reach the point of, because the plaintiffs didn’t have standing, is still alive elsewhere. But I didn’t realize that this other case was still sort of chugging along. So we’ll see when the Supreme Court gets another bite at it. Meanwhile, the fight over funding for Planned Parenthood — whose Medicaid eligibility, at least for one year, was canceled by the new budget law — continues in court. This week a judge in Massachusetts gave the group a partial win by blocking the defunding for some smaller clinics and those that don’t perform abortions, but that ruling replaced a more blanket delay on the defunding. So many clinics are now having their funding stopped while the court fight continues. Alice, what’s the impact here of these Planned Parenthood clinics closing down? It’s not just abortion that we’re talking about. In fact, it’s not even primarily abortion that we’re talking about. 

Ollstein: Absolutely. So this is one, it’s set to hit a lot of clinics in states where abortion is legal. And so these are the clinics that are serving a lot of people traveling from red states. And so there’s already an issue with wait times, and this is set to make it worse. But that’s just for abortion. Like you said, this is also set to hit a bunch of clinics in states where abortion is illegal and where these clinics are only providing other services, like birth control, like STI [sexually transmitted infection] testing. And at the same time we’re having a lot of other funding frozen, and so this could really be tough for some of these areas where there aren’t a lot of providers, and especially there are not a lot of providers who accept Medicaid. 

Rovner: Meanwhile, a number of states are passing conscience laws that let health professionals opt out of things like doing abortions or providing gender-affirming care if they violate their beliefs. Well, in Tennessee now we have a story of a pregnant woman who says her doctor refused to provide her with prenatal care, because she’s not married to her partner of 15 years. She said at a congressional town hall that her doctor said her marital status violated his Christian beliefs, and he’s apparently protected by the new Tennessee state law called the Medical Ethics Defense Act. I’ve heard of doctors refusing to prescribe birth control for unmarried women, but this is a new one to me, and I’ve been doing this for a very long time. Are these just unintended consequences of these things that maybe state lawmakers didn’t think a lot about? Or are they OK with doctors saying, We’re not going to provide you with prenatal care if you’re pregnant and not married? 

Ollstein: So one, as we just said, we’re in a situation where there is such a shortage of providers and such a shortage of providers who accept certain coverage that being turned away by one place, you might not be able to get an appointment somewhere else, depending where you live. And so this isn’t just an issue of, Oh, well, just don’t go to that doctor who believes that. People have very limited choices in a lot of circumstances. But I— 

Rovner: Apparently this woman in Tennessee said she’s having to go to Virginia to get her prenatal care. 

Ollstein: Well, exactly. Yeah. Exactly. This isn’t like people have tons of options. And also this is an example of a slippery slope, of if you allow people to be able to refuse service for this reason, for that reason, what else could happen? And some states have more legal protections for things like marital status, and some do not. And so it’s worth thinking through what could be sort of the next wave. 

Rovner: Well, we’re certainly going to see what the outcome of this could be. Well, before we end our news segment this week, I want to give a shoutout to tennis legend Venus Williams, who at age 45 won a singles match at a professional tournament here in Washington this week and said in her post-match interview that she came back to playing because she needed the pro tour’s health insurance to take care of several chronic conditions that she has. So see, even rich athletes need their health insurance. All right. That is this week’s news. Now we will play my interview with Medicare historian Jonathan Oberlander, and then we will come back and do our extra credits. 

I am so pleased to welcome Jonathan Oberlander to the podcast. He’s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation’s leading experts on Medicare. Jon, welcome to “What the Health?” 

Jonathan Oberlander: Great to see you, Julie. 

Rovner: So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it’s considered the third rail of politics, yet at its core it’s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here? 

Oberlander: Wow. So let’s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program — and the idea really dates back to the early 1950s — it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete. And the problem is, as you know very well, they haven’t been added to all that much. And here we have a population, and all of us know as we get older, we generally don’t get healthier. I wish it was true, but it’s not. Older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare’s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else. And that may be an individual private plan that they purchase called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare. 

Some low-income Medicare beneficiaries have Medicaid as well as Medicare and they are dual-eligible. Some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I’m sure— 

Rovner: We’ll get to. 

Oberlander: —we’ll have a lot to say. So the bottom line, though, is Medicare has grown. It has, what, about 70 million Americans rely on Medicare. But the benefit package — with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 — really has not kept pace. 

Rovner: So let’s go back to the beginning. What was the problem that Medicare set out to solve? 

Oberlander: Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call a single-payer, federal-government-run program for everybody, they trimmed their ambitions down to, initially, just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition and the American Medical Association and charges of socialized medicine, all things that are really throwing a wrench into plans for national health insurance. It didn’t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enact it. And there was a big, divisive, controversial debate about Medicare’s enactment. But it was fundamentally a solution to that political problem of, how do you enact government health insurance in the United States? You pick a more sympathetic population. 

Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age, and that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn’t want to cover them. And the uninsured rate, if you can believe it, for people over age 65, before Medicare, was around 50%. Not 15 but five zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage. 

Rovner: So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by? 

Oberlander: So in terms of populations in 1972, Medicare added coverage for persons who have end-stage renal disease, so people who need dialysis no matter what the age. It’s a lifesaving technology. They can qualify for Medicare. It didn’t really make sense to add it to Medicare — it’s just it was there. So they added it to Medicare. And also a population we don’t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance. For a couple of years they qualify for Medicare as well and are a very important part in the Medicare population. Beyond that, Medicare’s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody. 

In terms of benefits, the benefit package has been remarkably stable, for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited. 

Rovner: So Medicare is also the biggest payer in the nation’s health care system and for decades set the standard in how private insurance covered and paid for health care. So let’s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion? 

Oberlander: I think it’s the present and probably the future. The future is always so hard to predict, Julie, because it’s unwritten. But this is really a shocking outcome historically, because what Medicare’s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all, through any incremental means. Instead, 60 years later, we don’t have Medicare for all, but Medicare is mostly privatized. It’s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that’s an important new political force in Medicare that you have these large private plans and it’s changed Medicare politics. 

I don’t think Medicare Advantage is going anywhere. I think the question is, how big is it going to get? And I’m not sure any of us know. It’s been on a growth trajectory for a long time. And the question is — given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government, and it’s losing a lot of money on Medicare Advantage, and it’s never saved money — is there going to come a point where they actually clamp down? There’ve been some incremental efforts to try and restrain payments. Really haven’t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you’re getting, no, we can’t do that anymore. So I think it’s an open question about, how big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it’s that small? And that’s one of the great questions about Medicare in the next decade or two. 

Rovner: Thank you so much. 

Oberlander: Oh, thanks for having me. It was great to see you. 

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

Appleby: Yeah. I found this story on NPR quite interesting. It’s maybe something that a lot of us have thought about, but it just added a lot of numbers to the question of how many chemicals are in our beauty products — basically, the makeup we use, the lotions, our hairspray, the stuff that happens at the salon, that kind of thing. And it’s called “Many Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That.” And it was written by Rachel Treisman. Basically it says that the average American adult uses about 12 personal care products a day, resulting in exposure to about 168 chemicals, which can include things like formaldehyde, mercury, asbestos, etc., etc. OK, so that’s interesting. But it also talks about how the European Union has banned more than 2,000 chemicals, basically, but the FDA puts limits on only about a dozen. 

So this has caused four Democratic lawmakers to introduce a package of legislation, actually they’re calling the Safer Beauty Bill Package, and it’s four bills. And basically one of them would ban two entire classes of chemicals, phthalates and formaldehyde-releasing chemicals. And it also calls for some other things as well, which they say hasn’t been done and needs to be looked at. So I just thought it was an interesting thing that pulled together a lot of data from various sources and talked about this package of bills and whether or not it might make a difference in terms of looking at some of these chemicals in the products we use all the time and requiring a little bit more transparency about that. It’s a step. I don’t know if it’s going to resolve everybody’s concerns about this, but I just thought it was an interesting little piece looking at that topic. 

Rovner: It’s worth remembering that the FDA’s governing statute is actually called the Food, Drug, and Cosmetic Act. 

Appleby: That’s right. 

Rovner: The cosmetics often gets very short shrift in that whole thing. Alice, why don’t you go next? 

Ollstein: Yeah. So I have a piece from The Associated Press. It’s called “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals are Ultraprocessed.” And so this really gets at something we’ve been talking about on the podcast, where the administration is really fixated on a few kind of superficial food health things like colored dyes in food and frying something in beef tallow instead of vegetable oil. But something fried in beef tallow is still unhealthy. Froot Loops without the color dye are still unhealthy. And these meals that he is promoting as a service for Medicare and Medicaid enrollees are unhealthy. So this article is about how they do have chemical additives, they are high in sodium and sugar and saturated fats, and so it’s not in sort of keeping with the overall MAHA [Make America Healthy Again] message. But in a way it kind of is. 

Rovner: From the oops file. Jessie. 

Hellmann: My extra credit is from my colleague Ariel Cohen at Roll Call. It’s called “Kennedy’s Mental Health Drug Skepticism Lands at FDA Panel.” She did a story about something that kind of, I think, flew under the radar this week. The Trump administration is starting to make good on its promise to look at SSRIs [selective serotonin reuptake inhibitors], and the panel was very much full of skeptics of SSRIs who sought to undermine the confidence in using them while pregnant. And Marty Makary himself, FDA commissioner, claimed it could cause birth defects and other fetal harm. That was a statement that was echoed by many of the panelists. There was only one panelist who talked about the benefits of SSRIs in pregnant people who need them, the risks of postpartum depression to both the mom and the baby. And so I think this is definitely something to keep an eye on, is it looks like they’re going to keep looking more at this and raising questions about SSRIs without having much of a nuanced conversation about it. 

Rovner: Yeah. I did see something from ACOG, from the American College of Obstetricians and Gynecologists, this week pushing back very hard on the anti-SSRI-during-pregnancy push. So we’ll see how that one goes, too. My extra credit this week is from my KFF Health News colleague Katheryn Houghton, and it’s called “Republicans Call Medicaid Rife With Fraudsters. This Man Sees No Choice but To Break the Rules.” And it’s about something that didn’t really come up during the whole Medicaid debate, the fact that if Republicans really want people to go to work, well, then maybe they shouldn’t take away their health insurance if they get a small raise or a few extra hours. The subject of this story, only identified as James, technically makes about $50 a week too much to stay on Medicaid, but he otherwise can’t afford his six prescription medications and he can’t afford the care that he needs through even a subsidized Affordable Care Act plan, or his employer’s plan, either. 

The point of the ACA was to make coverage seamless so that as you earn more, you can still afford coverage even if you’re not on Medicaid anymore. But obviously that isn’t happening for everyone. Quoting from the story: “‘I don’t want to be a fraud. I don’t want to die,’ James said. ‘Those shouldn’t be the only two options.’” Yet for a lot of people they are. It’s not great, and it’s not something that’s currently being addressed by policymakers. 

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 a review. That helps other people find us, too. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me still on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging on social media these days? Jessie? 

Hellmann: I’m @jessiehellmann on Twitter and Bluesky. 

Rovner: Alice. 

Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky. 

Rovner: Julie. 

Appleby: @julie_appleby on X. 

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

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

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Joanne Kenen
Johns Hopkins University and Politico

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Read Joanne's bio.

Shefali Luthra
The 19th

@shefali.bsky.social

Read Shefali's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

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

Julie Rovner: The New York Times’ “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich.

Joanne Kenen: The New Yorker’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons from Sweden,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

• The Atlantic’s “The Trump Administration Is About To Incinerate 500 Tons of Emergency Food,” by Hana Kiros.
• KFF Health News’ “Vested Interests. Influence Muscle. At RFK Jr.’s HHS, It’s Not Pharma. It’s Wellness,” by Stephanie Armour.
• The Washington Post’s “A Clinic Blames Its Closing on Trump’s Medicaid Cuts. Patients Don’t Buy It,” by Hannah Knowles.

Click to open the transcript

Transcript: The Senate Saves PEPFAR Funding — For Now

[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 KFF Health 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 story, 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 really interesting story 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 KFF Health 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 KFF Health 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 “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True.” 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 “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons From Sweden,” 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 “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” 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 “UnitedHealth’s Campaign to Quiet Critics,” 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, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Shefali? 

Raman: I’m at Bluesky, @shefali. 

Rovner: Sandhya. 

Raman: I’m at X and at Bluesky, @SandhyaWrites. 

Rovner: Joanne? 

Kenen: I’m mostly at Bluesky, @joannekenen.bsky, and I’ve been posting things more on LinkedIn, 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. 

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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Early Thursday afternoon, the House approved a budget reconciliation bill that not only would make permanent many of President Donald Trump’s 2017 tax cuts, but also impose deep cuts to Medicaid, the Affordable Care Act, and, indirectly, Medicare.

Meanwhile, those appointed by Health and Human Services Secretary Robert F. Kennedy Jr. to a key vaccine advisory panel used their first official meeting to cast doubt on a preservative that has been used in flu vaccines for decades — with studies showing no evidence of its harm in low doses.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Maya Goldman of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Maya Goldman
Axios

@mayagoldman_

@maya-goldman.bsky.social

Read Maya's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

@sarahkarlin-smith.bsky.social

Read Sarah's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

@alicemiranda.bsky.social

Read Alice's stories.

Among the takeaways from this week’s episode:

• This week the GOP steamrolled toward a major constriction of the nation’s social safety net, pushing through Trump’s tax and spending bill. The legislation contains significant changes to the way Medicaid is funded and delivered — in particular, through imposing the program’s first federal work requirement on many enrollees. Hospitals say the changes would be devastating, potentially resulting in the loss of services and facilities that could touch all patients, not only those on Medicaid.
• Some proposals in Trump’s bill were dropped during the Senate’s consideration, including a ban on Medicaid coverage for gender-affirming care and federal funding cuts for states that use their own Medicaid funds to cover immigrants without legal status. And for all the talk of not touching Medicare, the legislation’s repercussions for the deficit are expected to trigger spending cuts to the program that covers those over 65 and some with disabilities — potentially as soon as the next fiscal year.
• The newly reconstituted Advisory Committee on Immunization Practices met last week, and it looked pretty different from previous meetings: In addition to new members, there were fewer staffers on hand from the Centers for Disease Control and Prevention — and the notable presence of vaccine critics. The panel’s vote to reverse the recommendation of flu shots containing a mercury-based preservative — plus its plans to review the childhood vaccine schedule — hint at what’s to come.

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

Julie Rovner: The Lancet’s “Evaluating the Impact of Two Decades of USAID Interventions and Projecting the Effects of Defunding on Mortality up to 2030: A Retrospective Impact Evaluation and Forecasting Analysis,” by Daniella Medeiros Cavalcanti, et al.

Alice Miranda Ollstein: The New York Times’ “‘I Feel Like I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow.

Maya Goldman: Axios’ “New Docs Get Schooled in Old Diseases as Vax Rates Fall,” by Tina Reed.

Sarah Karlin-Smith: Wired’s “Snake Venom, Urine, and a Quest to Live Forever: Inside a Biohacking Conference Emboldened by MAHA,” by Will Bahr.

Also mentioned in this week’s episode:

• NBC News’ “Crisis Pregnancy Centers Told To Avoid Ultrasounds for Suspected Ectopic Pregnancies,” by Abigail Brooks.
• ProPublica’s “A ‘Striking’ Trend: After Texas Banned Abortion, More Women Nearly Bled to Death During Miscarriage,” by Kavitha Surana, Lizzie Presser, and Andrea Suozzo.
• The Washington Post’s “DOGE Loses Control Over Government Grants Website, Freeing Up Billions,” by Dan Diamond and Hannah Natanson.

click to open the transcript

Transcript: Trump’s Bill Reaches the Finish Line

[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 KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 3, at 10 a.m. As always, and particularly this week, 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sarah Karlin-Smith at the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: No interview this week, but more than enough news, so we will get right to it. So as we sit down to tape, the House is on the cusp of passing the biggest constriction of the federal social safety net ever, part of President [Donald] Trump’s, quote, “One Big Beautiful Bill,” which is technically no longer called that, because the name was ruled out of order when it went through the Senate. In an effort to get the bill to the president’s desk by the July Fourth holiday, aka tomorrow, the House had to swallow without changes the bill that passed the Senate on Tuesday morning after Vice President JD Vance broke a 50-50 tie. And the House has been in session continuously since Wednesday morning working to do just that, with lots of arm-twisting and threatening and cajoling to walk back the complaints from both conservative Republicans, who are objecting to the trillions of dollars the bill would add to the national debt, as well as moderates objecting to the Medicaid and food stamp cuts. 

There is a whole lot to unpack here, but let’s start with Medicaid, which would take the biggest hit of the health programs in this bill — ironically, just weeks before the program’s 60th anniversary. What does this bill do to Medicaid? 

Goldman: This bill makes some huge changes to the way that Medicaid is funded and delivered in the United States. One of the biggest changes is the first federal work requirement for Medicaid, which we’ve talked about at length. 

Rovner: Pretty much every week. 

Goldman: Pretty much every week. It’s going to be — it’s sort of death by paperwork for many people. They’re not necessarily forced to lose their coverage, but there are so many paperwork hurdles and barriers to making sure that you are reporting things correctly, that CBO [the Congressional Budget Office] expects millions of people are going to lose coverage. And we know from limited experiments with work requirements in Arkansas that it does not increase employment. So, that’s the biggie. 

Rovner: The House froze provider taxes, which is what most — all states but Alaska? — use to help pay their share of Medicaid. The Senate went even further, didn’t they? 

Goldman: Yeah. Hospitals are saying that it’s going to be absolutely devastating to them. When you cut funding, cut reimbursement in that way, cut the amount of money that’s available in that way, it trickles down to the patient, ultimately. 

Karlin-Smith: Especially things like the provider tax, but even just the loss to certain health systems of Medicaid patients end up having a spiral effect where it may impact people who are on other health insurance, because these facilities will no longer have that funding to operate the way they are. Particularly some facilities talked about how the Obamacare Medicaid expansion really allowed them to expand their services and beef up. And now if they lose that population, you actually end up with risks of facilities closing. The Senate tried to provide a little bit of money to alleviate that, but I think that’s generally seen as quite small compared to the long-term effects of this bill. 

Rovner: Yeah, there’s a $50 billion rural hospital slush fund, if you will, but that’s not going to offset $930 billion in cuts to Medicaid. And it’s important — I know we keep saying this, but it’s important to say again: It’s not just the people who will lose Medicaid who will be impacted, because if these facilities close — we’re talking about hospitals and rural clinics and other facilities that depend on Medicaid — people with all kinds of insurance are going to lack access. I see lots of nods going around. 

Goldman: Yeah. One salient example that somebody told me earlier this week was, think about ER wait times. It already takes so long to get seen if you go into the ER. And when people don’t have health insurance, they’re seeking care at the ER because it’s an emergency and they waited until it was an emergency, or that’s just where they feel they can go. But this is going to increase ER wait times for everybody. 

Rovner: And also, if nursing homes or other facilities close, people get backed up in the ER because they can’t move into the hospital when they need hospital care, because the hospital can’t discharge the people who are already there. I had sort of forgotten how that the crowded ERs are often a result of things other than too many people in the ER. 

Goldman: Right. 

Rovner: They’re a result of other strains on sort of the supply chain for care. 

Goldman: There’s so many ripple effects and dominoes that are going to fall, if you will. 

Rovner: So, there were some things that were in the House bill that, as predicted, didn’t make it into the Senate bill, because the parliamentarian said they violated the budget rules for reconciliation. That included the proposed Medicaid ban on all transgender care for minors and adults, and most of the cuts to states that use their own funds to cover undocumented people. But the parliamentarian ended up kind of splitting the difference on cutting funding to Planned Parenthood, which she had ruled in 2017 Congress couldn’t do in reconciliation. Alice, what happened here? 

Ollstein: She decided that one year of cuts was OK, when they had originally sought 10. And the only reason they originally sought 10 is that’s how these bills work. It’s a 10-year budget window. That’s how you calculate things. They sort of meant it to function like a permanent defund. So, the anti-abortion movement was really divided on this outcome, where some were declaring it a big victory and some were saying: Oh, only one year. This is such a disappointment and not what we were promised blah, blah, blah. And it’ll be really interesting to see if even one year does function like a sort of permanent defund. 

On the one hand, the anti-abortion movement is worried that because it’s one year, that means they’ll have to vote on it again next year right before the midterms, when people might get more squirrelly because of the politics of it, which obviously still exist now but would be more potent then. But clinics can’t survive without funding for long. We’re already seeing Planned Parenthoods around the country close because of Title X cuts, because of other budget instability. And so once a clinic closes, even if the funding comes back later, it can’t flip a switch and turn it back on. When things close, they close, the staff moves away, etc. 

Rovner: And we should emphasize Medicaid has not been used to pay for federal abortion funding ever. 

Ollstein: Yes. Yes. 

Rovner: That’s part of the Hyde Amendment. So we’re talking about non-abortion services here. We’re talking about contraception, and STD testing and treatment, and cancer screenings, and other types of primary care that almost every Planned Parenthood provides. They don’t all provide abortion, but they all provide these other ancillary services that lots of Medicaid patients use. 

Ollstein: Right. And so this will shut down clinics in states where abortion is legal, and it’ll shut down clinics in states where abortion is illegal and these clinics only are providing those other reproductive health services, which are already in scant supply and hard to come by. There’s massive maternity care deserts, contraceptive deserts around the country, and this is set to make that worse. 

Rovner: So, while this bill was not painted as a repeal of the Affordable Care Act, unlike the 2017 version, it does do a lot to scale that law back. This has kind of flown under the radar. Maya, you wrote about this. What does this bill do to the ACA? 

Goldman: Yeah. Well, so, there were a lot of changes that Congress was seeking to codify from rule that the Trump administration has finalized that really create a lot of extra barriers to enrolling in the ACA. A lot of those did not make it into the final bill that is being voted on, but there’s still more paperwork — death by paperwork. I think there’s preenrollment verification of eligibility, things like that. And I think just in general, the ACA has created massive gains in the insurer population in the United States over the last decade and a half. And there’s estimates that show that this would wipe out three-fourths of that gain. And so that’s just staggering to see that. 

Rovner: Yeah. I think people have underestimated the impact that this could have on the ACA. Of course, we’ve talked about this also a million times. This bill does not extend the additional subsidies that were created under the Biden administration, which has basically doubled the number of people who’ve been able to afford coverage and bought it on the marketplaces. But I’ve seen estimates that more than half of the people could actually end up dropping out of ACA coverage. 

Goldman: Yeah. And I think it’s important to talk about the timelines here. A lot of the work requirements in Medicaid won’t take effect for a couple of years, but people are going to lose their enhanced subsidies in January. And so we are going to see pretty immediate effects of this. 

Rovner: And they’re shortening the enrollment time. 

Goldman: Yeah. 

Rovner: And people won’t be able to be auto-reenrolled, which is how a lot of people continue on their ACA coverage. There are a lot of little things that I think together add up to a whole lot for the ACA. 

Goldman: Right. And Trump administration ACA enrollment barriers that were finalized might not be codified in this law, but they’re still finalized. 

Rovner: Yeah. 

Goldman: And so they will take effect for 2026 coverage. 

Rovner: And while President Trump has said repeatedly that he didn’t want to touch Medicare, this bill ironically is going to do exactly that, because the amount the tax cuts add to the deficit is likely to trigger a Medicare sequester under budget rules. That means there will be automatic cuts to Medicare, probably as soon as next year. 

All right, well, that is the moving bill, the One Big Beautiful Bill. One thing that has at least stopped moving for now is the Supreme Court, at least for the moment. The justices wrapped up their formal 2024-2025 term with some pretty significant health-related cases that impact two topics we’re talking about elsewhere in this episode, abortion and vaccines. 

First, abortion. The court ruled that Medicaid patients don’t have the right to sue to enforce the section of Medicaid law that ensures free choice of provider. In this case, it frees South Carolina to kick Planned Parenthood out of its Medicaid program. Now, this isn’t about abortion. This is about, as we said, other services that Planned Parenthood provides. But, Alice, what are the ramifications of this ruling? 

Ollstein: They could be very big. A lot of states have already tried and are likely to try to cut Planned Parenthood out of their Medicaid programs. And given this federal defund, this is now going after some of their remaining supports, which is state Medicaid programs, which is a separate revenue stream. And so this will just lead to even more clinic closures. And already, this kind of sexual health care is very hard to come by in a lot of places in the country. And that is set to be even more true in the future. And this is sort of the culmination of something that the right has worked towards for a long time. And so they had just a bunch of different strategies and tactics to go after Planned Parenthood in so many ways in the courts, and there’s still more shoes to drop. There’s still court cases pending. 

There’s one in Texas that’s accusing Planned Parenthood of defrauding the state, and so that judgment could wipe them out even more. This federal legislative effort, there’s the Supreme Court case — and they’ve really been effective at just throwing everything at the wall and seeing what sticks. And enough is sticking now that the organization is really — they were able to beat back a lot of these attempts before. They were able to rally in Congress. They were able to rally at the state level to push back on a lot of this. And that wasn’t true this time. And so I don’t know what conclusion to take from that. There’s, obviously, people are very overwhelmed. There’s a lot going on. There are organizations getting hit left and right, and maybe this just got lost in the noise this time. 

Rovner: Yeah, I think that may be. Well, the other big Supreme Court decision was one we’d talked about quite a bit, the so-called Braidwood case that was challenging the ability of the CDC’s [Center for Disease Control and Prevention’s] Preventive Services Task Force from recommending services that would then be covered by health insurance. This was arguably a win for the Biden administration. The court ruled that the task force members do not need to be confirmed by the Senate. But, Sarah, this also gives Secretary [Robert F.] Kennedy [Jr.] more power to do what he will with other advisory committees, right? 

Karlin-Smith: Right. By affirming the way the U.S. Preventive Services Task Force was set up, in that the HHS [Department of Health and Human Services] secretary is ultimately the authority for appointing the task force, which then makes recommendations around what coverage requirements under the ACA. It also sort of affirms the authority of the HHS secretary here. And I think people think it has implications for other bodies like CDC’s advisory committee on vaccines as well, where the secretary has a lot of authority. 

So, I think people who really support the coverage advantages that have come through the USPSTF and Obamacare have always pushed for this outcome in this case. But given our current HHS secretary, there are some worries that it might lead to rollbacks or changes in areas of the health care paradigm that he does not support. 

Rovner: Well, let us segue to that right now. That is, of course, as you mentioned, the other major CDC advisory committee, the one on immunization practices. When we left off, Secretary Kennedy had broken his promise to Senate health committee chairman Bill Cassidy and fired all 17 members of the committee, replacing them with vaccine skeptics and a couple of outright vaccine deniers. So last week, the newly reconstituted panel held its first meeting. How’d that go? 

Karlin-Smith: It was definitely an interesting meeting, different, I think, for people who have watched ACIP [the Advisory Committee on Immunization Practices] in the past. Besides just getting rid of the members of the advisory panel, Kennedy also removed a lot of the CDC staff who work on that topic as well. So the CDC staffers who were there and doing their typical presentations were much smaller in number. And for the most part, I think they did a really good job of sticking to the tried-and-true science around these products and really having to grapple with extremely, I think, unusual questions from many of the panelists. But the agenda got shrunk quite a bit, and one of the topics was quite controversial. Basically, they decided to review the ingredient thimerosal, which was largely taken out of vaccines in the late ’90s, early 2000s, but remains in certain larger vials of flu vaccines. 

Rovner: It’s a preservative, right? You need something in a multi-dose vaccine vial to keep it from getting contaminated. 

Karlin-Smith: And they had a presentation from Lyn Redwood, who was a former leader of the Children’s Health Defense, which is a very anti-vax organization started by Robert Kennedy. The presentation was generally seen as not based in science and evidence, and there was no other presentations, and the committee voted to not really allow flu vaccines with that ingredient. 

And the impact in the U.S. here is going to be pretty small because, I think, it’s about 4% of people get vaccines through those large-quantity vials, like if you’re in a nursing home or something like that. But what people are saying, and Scott Gottlieb [Food and Drug Administration commissioner in the first Trump administration] was talking a lot about this last week, was that this is really a hint of what is to come and the types of things they are going to take aim at. And he’s particularly concerned about another, what’s called an adjuvant, which is an ingredient added to vaccines to help make them work better, that’s in a lot of childhood vaccines, that Kennedy hinted at he wanted on the agenda for this meeting. It came off the agenda, but he presumes they will circle back to it. And if companies can’t use that ingredient in their vaccines, he’s not really clear they have anything else that is as good and as safe, and could force them out of the market. 

So there were a bunch of hints of things concerning fights to come. The other big one was that they were saying they want to review the totality of the childhood vaccine schedule and the amount of vaccines kids get, which was really a red flag for people who followed the anti-vaccine movement, because anti-vaxxers have a lot of long-debunked claims that kids get too many vaccines, they get them too closer together. And scientists, again, have thoroughly debunked that, but they still push that. 

Rovner: And that was something else that Kennedy promised Cassidy he wouldn’t mess with, if I recall correctly, right? 

Karlin-Smith: You know, the nature of the agreement between Cassidy and Kennedy keeps getting more confusing to me. And I actually talked to both HHS’ secretary’s office and Cassidy’s office last week about that. And they both don’t actually agree on quite exactly what the terms were. But anyway, I looked at it in terms of the terms, like whether it’s to preserve the recommendations ACIP has made over time in the childhood schedule, whether it’s to preserve the committee members. I think it’s pretty clear that Kennedy has violated the sort of heart of the matter, which is he has gone after safe, effective vaccines and people’s access to vaccines in this country in ways that are likely to be problematic. And there are hints of more to come. He’s also cut off funding for vaccines globally. So, I don’t know. I almost just laugh thinking about what they actually agreed to, but there’s really no way Cassidy can say that Kennedy followed through on his promises. 

Rovner: Well, meanwhile, even while ACIP was meeting last week, the HHS secretary was informing the members of Gavi, that’s the Global Alliance for Vaccines and Immunizations, that he was canceling the U.S.’ scheduled billion-dollar contribution because, he said, the public-private partnership that has vaccinated more than a billion children over the past two and a half decades doesn’t take vaccine safety seriously enough. Really? 

Karlin-Smith: Yeah. Kennedy has these claims, again, that I think are, very clearly have been, debunked by experts, that Gavi is not thinking clearly about vaccine safety and offering vaccines they shouldn’t be, and the result is going to be huge gaps in what children can get around the globe to vaccines. And it comes on top of all the other cuts the U.S. has made recently to global health in terms of USAID [the U.S. Agency for International Development]. So I think these are going to be big impacts. And they may eventually trickle down to impact the U.S. in ways people don’t expect. 

If you think about a virus like covid, which continues to evolve, one of the fears that people have always had is we get a variant that is, as it evolves, that is more dangerous to people and we’re less able to protect with the vaccines we have. If you allow the virus to kind of spread through unvaccinated communities because, say you weren’t providing these vaccines abroad, that increases the risk that we get a bad variant going on. So obviously, we should be concerned, I think, just about the millions of deaths people are saying this could cause globally, but there’s also impacts to our country as well and our health. 

Rovner: I know there’s all this talk about soft-power humanitarian assistance and helping other countries, but as long as people can get on airplanes, it’s in our interest that people in other countries don’t get things that can be spread here, too, right? 

Goldman: Yeah. One very small comment that was made during the ACIP meeting this week from CDC staff was an update on the measles outbreak, which I just thought was interesting. They said that the outbreak in the South from earlier this year is mostly under control, but people are still bringing in measles from foreign countries. And so that’s very much a real, real threat. 

Rovner: Yeah. 

Ollstein: It’s the lesson that we just keep not learning again and again, which is if you allow diseases to spread anywhere, it’ll inevitably impact us here. We don’t live on an island. We have a very interconnected world. You can’t have a Well we’re going to only protect our people and nobody else mentality, because that’s just not how it works. And we’re reducing resources to vaccinate people here as well. 

Rovner: That’s right. Turning back to abortion, there was other news on that front this week. In Wisconsin, the state Supreme Court formally overturned that state’s 1849 abortion ban. That was the big issue in the Supreme Court election earlier this year. But a couple of other stories caught my eye. One is from NBC News about how crisis pregnancy centers, those anti-abortion facilities that draw women in by offering free pregnancy tests and ultrasounds, are actually advising clinics against offering ultrasounds in some cases after a clinic settled a lawsuit for misdiagnosing a woman’s ectopic pregnancy, thus endangering her life. Alice, if this is a big part of the centers’ draw with these ultrasounds, what’s going on here? 

Ollstein: I think it’s a good example. I want to stress that there’s a big variety of quality of medical care at these centers. Some have actual doctors and nurses on staff. Some don’t at all. Some offer good evidence-based care. Some do not. And I have heard from a lot of doctors that patients will come to them with ultrasounds that were incorrectly done or interpreted by crisis pregnancy centers. They were given wrong information about the gestation of their pregnancy, about the viability of their pregnancy. And so this doesn’t surprise me at all, based on what I’ve heard anecdotally. 

People should also remember that these centers are not regulated as much as health clinics are. And that goes for things like HIPAA [the Health Insurance Portability and Accountability Act] as well. They don’t have the same privacy protections for the information people share there. And so I think we should also keep in mind that women might be depending more and more on these going forward as Planned Parenthoods close, as other clinics close because of all the cuts we just talked about. These clinics are really proliferating and are trying to fill that vacuum. And so things like this should keep people questioning the quality of care they provide. 

Rovner: Yeah. And of course, layer on top of that the Medicaid cuts. There’s going to be an increased inability to get care, particularly in far-flung areas. You can sort of see how this can sort of all pile onto itself. 

Well, the other story that grabbed me this week comes from the Pulitzer Prize-winning team at ProPublica. It’s an analysis of hospital data from Texas that suggests that the state’s total abortion ban is making it more likely that women experiencing early miscarriages may not be getting timely care, and thus are more likely to need blood transfusions or experience other complications. Anti-abortion groups continue to maintain that these bans don’t impact women with pregnancy complications, which are super common, for those who don’t know, particularly early in pregnancy. But experience continues to suggest that that is not the case. 

Ollstein: Yeah. This is a follow-up to a lot of really good reporting ProPublica has done. They also showed that sepsis rates in Texas have gone way up in the wake of the abortion ban. And so anti-abortion groups like to point to the state’s report showing how many abortions are still happening in the state because of the medical emergency exceptions, and saying: See? It’s working. People are using the exceptions. And it is true that some people are, but I think that this kind of data shows that a lot of people are not. And again, if it’s with what I hear anecdotally, there’s just a lot of variety on the ground from hospital to hospital, even in the same city, interpreting the law differently. Their legal teams interpret what they can and can’t provide. It could depend on what resources they have. It could depend on whether they’re a public or private hospital, and whether they’re afraid of the state coming after them and their funding. 

And so I think this shows that one doctor could say, Yes, I do feel comfortable doing this procedure to save this woman’s life, and another doctor could say, I’m going to wait and see. And then you get the sepsis, the hemorrhage. These are very sensitive situations when even a short delay could really be life-and-death, or be long-term health consequences. People have lost the ability to have more children. We’ve seen stories about that. We’ve seen stories about people having to suffer a lot of health consequences while their doctors figure out what kind of care they can provide. 

Rovner: In the case of early miscarriage, the standard of care is to empty the uterus basically to make sure that the bleeding stops, which is either a D&C [dilation and curettage], which of course can also be an early abortion, or using the abortion pill mifepristone and misoprostol, which now apparently doctors are loath to use even in cases of miscarriage. I think that’s sort of the take-home of this story, which is a little bit scary because early miscarriage is really, really, really common. 

Ollstein: Absolutely. And this is about the hospital context, which is obviously very important, but I’m also hearing that this is an issue even for outpatient care. So if somebody is having a miscarriage, it’s not severe enough that they have to be hospitalized, but they do need this medication to help it along. And when they go to the pharmacy, their prescription says, “missed abortion” or “spontaneous abortion,” which are the technical terms for miscarriage. But a pharmacist who isn’t aware of that, isn’t used to it, it’s not something they see all the time, they see that and they freak out and they say, Oh, I don’t want to get sued, so they don’t dispense the medication. Or there are delays. They need to call and double-check. And that has been causing a lot of turmoil as well. 

Rovner: All right. Well, finally this week, Elon Musk is fighting with President Trump again over the budget reconciliation bill, but the long shadow of DOGE [the Department of Government Efficiency] still lives on in federal agencies. On the one hand, The Washington Post scooped this week that DOGE no longer has control over the Grants.gov website, which controls access to more than half a trillion dollars in federal grant funding. On the other hand, I’m still hearing that money is barely getting out and still has to get multiple approvals from political appointees before it can basically get to where it’s supposed to be going. NPR has a story this week with the ominous headline “‘Where’s Our Money?’ CDC Grant Funding Is Moving So Slowly Layoffs Are Happening.” 

I know there’s so much other news happening right now, it’s easy to overlook, but I feel like the public health and health research infrastructure are getting starved to death while the rest of us are looking at shinier objects. 

Goldman: Yeah. This the whole flood-the-zone strategy, right? There’s so many things going on that we can’t possibly keep up with all of them, but this is extremely important. I think if you talk to any research scientist that gets federal funding, they would tell you that things have not gotten back to normal. And there’s so much litigation moving through the courts that it’s going to take a really long time before this is settled, period. 

Rovner: Yeah. We did see yet another court decision this week warning that the layoffs at HHS were illegal. But a lot of these layoffs happened so long ago that these people have found other jobs or put their houses up for sale. You can’t quite put this toothpaste back in the tube. 

Goldman: Right. And also, with this particular ruling, this came from a Rhode Island federal judge, a Biden appointee, so it wasn’t very surprising. But it said that the reorganization plan of HHS was illegal. Or, not illegal, it was a temporary injunction on the reorganization plan and said HHS cannot place anyone else on administrative leave. But it doesn’t require them to rehire the employees that have been laid off, which is also interesting. 

Rovner: Yeah. Well, we will continue to monitor that. All right, that is as much as this week’s news as we have time for. 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 put the links in our show notes on your phone or other mobile device. Sarah, you were first to choose this week. Why don’t you go first? 

Karlin-Smith: I took a look at a Wired piece from Will Bahr, “Snake Venom, Urine, and a Quest To Live Forever: Inside a Biohacking Conference Emboldened by MAHA.” And it is about a conference in Texas kind of designed to sell you products that they claim might help you live to 180 or more. A lot of what appears to be people essentially preying on people’s fears of mortality, aging, death to sell things that do not appear to be scientifically tested or validated by agencies like FDA. The founder even talks about using his own purified urine to treat his allergies. They’re microdosing snake venom. And it does seem like RFK is sort of emboldening this kind of way of thinking and behavior. 

One of the things I felt was really interesting about the story is the author can’t quite pin down what unites all of these people in their interests in this space. In many cases, they claim there are sort of — there’s not a political element to it. But since I cover the pharma industry very closely, they all seem disappointed with mainstream medical systems and the pharma industry with the U.S., and they are seeking other avenues. But it’s quite an interesting look at the types of things they are willing to try to extend their lives. 

Rovner: Yeah, it is quite the story. Maya, why don’t you go next? 

Goldman: My extra credit this week is from my Axios colleague Tina Reed. It’s called “New Docs Get Schooled in Old Diseases as Vaxx Rates Fall.” And it’s all about how medical schools are adjusting their curriculum to teach students to spend more time on measles and things that we have considered to be wiped out in the United States. And I think it just — it really goes to show that this is something that is real and that’s actually happening. People are coming to emergency rooms and hospitals with these illnesses, and young doctors need to learn about them. We already have so many things to learn in medical school that there’s certainly a trade-off there. 

Rovner: There is, indeed. And Alice, you have a related story. 

Ollstein: Yes, I do. So, this is from The New York Times. It’s called “‘I Feel I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow. And it’s about the measles outbreak that originated in Texas. But what I think it does a really good job at is, we’ve talked a lot about how people have played up the dangers of vaccines and exaggerated them and, in some cases, outright lied about them, and how that’s influencing people, fear of autism, etc., fear of these adverse reactions. But I think this piece really shows that the other side of that coin is how much some of those same voices have downplayed measles and covid. 

And so we have this situation where people are too afraid of the wrong things — vaccines — and not afraid enough of the right things — measles and these diseases. And so in the story people who are just, including people with some medical training, being shocked at how bad it is, at how healthy kids are really suffering and needing hospitalization and needing to be put on oxygen. And that really clashes with the message from this administration, which has really downplayed that and said it’s mainly hitting people who were already unhealthy or already had preexisting conditions, which is not true. It can hit other people. And so, yeah, I think it’s a very nuanced look at that. 

Rovner: Yeah, it’s a really extraordinary story. My extra credit this week is from the medical journal The Lancet. And I won’t read the entire title or its multiple authors, because that would take the rest of the podcast. But I will summarize it by noting that it finds that funding provided by the U.S. Agency for International Development, which officially closed up shop this week after being basically illegally dissolved by the Trump administration, has saved more than 90 million lives over the past two decades. And if the cuts made this year are not restored, an additional 14 million people will die who might not have otherwise. Far from the Trump administration’s claims that USAID has little to show for its work, this study suggests that the agency has had an enormous impact in reducing deaths from HIV and AIDS, from malaria and other tropical diseases, as well as those other diseases afflicting less developed nations. We’ll have to see how much if any of those services will be maintained or restored. 

OK. That’s this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. As always, 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. You can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: I’m a little bit on X, mostly on Bluesky, at @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice? 

Ollstein: Mostly on Bluesky, @alicemiranda. Still a little bit on X, @AliceOllstein. 

Rovner: Maya. 

Goldman: I am on X, @mayagoldman_, and also on LinkedIn. You can just find me under my name. 

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

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As summer ushers in peak mosquito season, health and vector control officials are bracing for the possibility of another year of historic rates of dengue. And with climate change, the lack of an effective vaccine, and federal research cuts, they worry the disease will become endemic to a larger swath of North America.

About 3,700 new dengue infections were reported last year in the contiguous United States, up from about 2,050 in 2023, according to the Centers for Disease Control and Prevention. All of last year’s cases were acquired abroad, except for 105 cases contracted in California, Florida, or Texas. The CDC issued a health alert in March warning of the ongoing risk of dengue infection.

“I think dengue is here with us to stay,” said infectious disease specialist Michael Ben-Aderet, associate medical director of hospital epidemiology at Cedars-Sinai in Los Angeles, about dengue becoming a new normal in the U.S. “These mosquitoes aren't going anywhere.”

Dengue is endemic — a label health officials assign when diseases appear consistently in a region — in many warmer parts of the world, including Latin America, India, and Southeast Asia. Dengue cases increased markedly last year in many of those places, especially in Central and South America.

The disease, which can spread when people are bitten by infected Aedes mosquitoes, was not common in the contiguous United States for much of the last century. Today, most locally acquired (meaning unrelated to travel) dengue cases in the U.S. happen in Puerto Rico, which saw a sharp increase in 2024, triggering a local public health emergency.

Most people who contract dengue don’t get sick. But in some people symptoms are severe: bleeding from the nose or mouth, intense stomach pain, vomiting, and swelling. Occasionally, dengue causes death.

California offers a case study in how dengue is spreading in the U.S. The Aedes aegypti and Aedes albopictus mosquitoes that transmit dengue weren’t known to be in the state 25 years ago. They are now found in 25 counties and more than 400 cities and unincorporated communities, mostly in Southern California and the Central Valley.

The spread of the mosquitoes is concerning because their presence increases the likelihood of disease transmission, said Steve Abshier, president of the Mosquito and Vector Control Association of California.

From 2016 through 2022, there were an average of 136 new dengue cases a year in California, each case most likely brought to the state by someone who had traveled and been infected elsewhere. In 2023, there were about 250 new cases, including two acquired locally.

In 2024, California saw 725 new dengue cases, including 18 acquired locally, state data shows.

Climate change could contribute to growth in the Aedes mosquitoes’ population, Ben-Aderet said. These mosquitoes survive best in warm urban areas, often biting during the daytime. Locally acquired infections often occur when someone catches dengue during travel, then comes home and is bitten by an Aedes mosquito that bites and infects another person.

“They've just been spreading like wildfire throughout California,” Ben-Aderet said.

Dengue presents a challenge to the many primary care doctors who have never seen it. Ben-Aderet said doctors who suspect dengue should obtain a detailed travel history from their patients, but confirming the diagnosis is not always quick.

“There's no easy test for it,” he said. “The only test that we have for dengue is antibody tests.” He added that “most labs probably aren't doing it commercially, so it's usually like a send-out test from most labs. So you really have to suspect someone has dengue.”

Best practices for avoiding dengue include eliminating any standing pools of water on a property — even small pools — and using mosquito repellent, Abshier said. Limiting activity at dusk and dawn, when mosquitoes bite most often, can also help.

Efforts to combat dengue in California became even more complicated this year after wildfires ripped through Los Angeles. The fires occurred in a hot spot for mosquito-borne illnesses. San Gabriel Valley Mosquito and Vector Control District officials have worked for months to treat more than 1,400 unmaintained swimming pools left in the wake of fire, removing potential breeding grounds for mosquitoes.

San Gabriel vector control officials have used local and state resources to treat the pools, said district spokesperson Anais Medina Diaz. They have applied for reimbursement from the Federal Emergency Management Agency, which has not historically paid for vector control efforts following wildfires.

In California, vector control agencies are often primarily funded by local taxes and fees on property owners.

Some officials are pursuing the novel method of releasing sterilized Aedes mosquitoes to reduce the problem. That may prove effective, but deploying the method in a large number of areas would be costly and would require a massive effort at the state level, Abshier said. Meanwhile, the federal government is pulling back on interventions: Several outlets have reported that the National Institutes of Health will stop funding new climate change-related research, which could include work on dengue.

This year, reported rates of dengue in much of the Americas have declined significantly from 2024. But the trend in the United States likely won’t be clear until later in the year, after the summer mosquito season ends.

Health and vector control researchers aren't sure how bad it will get in California. Some say there may be limited outbreaks, while others predict dengue could get much worse. Sujan Shresta, a professor and infectious disease researcher at the La Jolla Institute for Immunology, said other places, like Nepal, experienced relatively few cases of dengue in the recent past but now regularly see large outbreaks.

There is a vaccine for children, but it faces discontinuation from a lack of global demand. Two other dengue vaccines are unavailable in the United States. Shresta’s lab is hard at work on an effective, safe vaccine for dengue. She hopes to release results from animal testing in a year or so; if the results are positive, human trials could be possible in about two years.

“If there's no good vaccine, no good antivirals, this will be a dengue-endemic country,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

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Con el verano marcando el comienzo de la temporada alta de mosquitos, autoridades sanitarias y de control de vectores se preparan para la posibilidad de otro año con tasas históricas de dengue. Y con el cambio climático, la falta de una vacuna eficaz y los recortes federales en la investigación, les preocupa que la enfermedad se vuelva endémica en una franja más amplia de Norteamérica.

El año pasado se reportaron alrededor de 3.700 nuevas infecciones por dengue en Estados Unidos, frente a las 2.050 de 2023, según los Centros para el Control y Prevención de Enfermedades (CDC). Todos los casos de 2024 se adquirieron en el extranjero, excepto 105 contraídos en California, Florida o Texas. Los CDC emitieron una alerta sanitaria en marzo advirtiendo sobre el riesgo continuo de infección por dengue.

"Creo que el dengue ha llegado para quedarse", declaró Michael Ben-Aderet, especialista en enfermedades infecciosas y director médico asociado de epidemiología hospitalaria del Cedars-Sinai de Los Ángeles, sobre la posibilidad de que el dengue se convierta en la nueva normalidad en el país. "Estos mosquitos no se irán a ninguna parte".

El dengue es endémico —una etiqueta que las autoridades de salud pública asignan cuando las enfermedades aparecen de forma constante en una región— en muchas zonas más cálidas del mundo, como Latinoamérica, India y el sudeste asiático. Los casos de dengue aumentaron notablemente el año pasado en muchos de esos lugares, especialmente en Centro y Sur América.

La enfermedad, que puede propagarse por la picadura de mosquitos Aedes que portan el virus, no fue común en Estados Unidos continental durante gran parte del siglo pasado. Actualmente, la mayoría de los casos de dengue adquiridos localmente (es decir, no relacionados con viajes) en el país se registran en Puerto Rico, donde se registró un fuerte aumento en 2024, lo que desencadenó una emergencia de salud pública local.

La mayoría de las personas que desarrollan dengue no se enferman. Sin embargo, en algunas, los síntomas son graves: sangrado por la nariz o la boca, dolor de estómago intenso, vómitos e hinchazón. En ocasiones, el dengue causa la muerte.

California ofrece un caso centinela sobre la propagación del dengue en el país. Hace 25 años, no se conocía la presencia de los mosquitos Aedes aegypti y Aedes albopictus, que transmiten el dengue, en el estado. Actualmente, se encuentran en 25 condados y más de 400 ciudades y comunidades no incorporadas, principalmente en el sur de California y en el Valle Central.

La propagación de los mosquitos es preocupante porque su presencia aumenta la probabilidad de transmisión de enfermedades, afirmó Steve Abshier, presidente de la Mosquito and Vector Control Association of California.

Entre 2016 y 2022, se registró un promedio de 136 nuevos casos de dengue al año en California, cada uno de los cuales probablemente traído al estado por alguien que viajó y se infectó en otro lugar. En 2023, se registraron alrededor de 250 casos nuevos, incluyendo dos adquiridos localmente.

En 2024, California registró 725 nuevos casos de dengue, incluyendo 18 adquiridos localmente, según datos estatales.

El cambio climático podría contribuir al aumento de la población de mosquitos Aedes, afirmó Ben-Aderet. Estos mosquitos sobreviven mejor en zonas urbanas cálidas, y suelen picar durante el día. Las infecciones de transmisión local suelen ocurrir cuando alguien contrae dengue durante un viaje, regresa a casa y lo pica un mosquito Aedes que, a su vez, pica e infecta a otra persona.

"Se han propagado rápidamente por toda California", explicó Ben-Aderet.

El dengue representa un desafío para muchos médicos de atención primaria que nunca lo han visto. Ben-Aderet dijo que los médicos que sospechan dengue deben obtener un historial de viaje detallado de sus pacientes, pero confirmar el diagnóstico no siempre es rápido.

"No existe una prueba sencilla para detectarlo", afirmó. "La única prueba que tenemos para el dengue son las pruebas de anticuerpos". Agregó que "la mayoría de los laboratorios probablemente no lo estén comercializando, por lo que suele ser una prueba que se debe analizar en otra instalación. Por lo tanto, es fundamental sospechar que alguien tiene dengue".

Las mejores prácticas para evitar el dengue incluyen eliminar cualquier agua estancada en una propiedad, aunque sea poca, y usar repelente de mosquitos, dijo Abshier. Limitar la actividad al atardecer y al amanecer, cuando los mosquitos pican con mayor frecuencia, también puede ayudar.

Los esfuerzos para combatir el dengue en California se complicaron aún más este año después de que los incendios forestales arrasaran Los Ángeles.

Los incendios ocurrieron en una zona de alta incidencia de enfermedades transmitidas por mosquitos. Funcionarios del San Gabriel Valley Mosquito and Vector Control District han trabajado durante meses para tratar más de 1.400 piscinas sin mantenimiento que quedaron tras el incendio, eliminando así posibles criaderos de mosquitos.

Estos oficiales han utilizado recursos locales y estatales para tratar las piscinas, dijo Anais Medina Díaz, vocera del distrito. Han solicitado un reembolso a la Agencia Federal para el Manejo de Emergencias (FEMA), que históricamente no ha financiado las iniciativas de control de vectores luego de incendios forestales.

En California, las agencias de control de vectores suelen financiarse principalmente con impuestos y tasas locales que pagan los propietarios.

Algunos funcionarios están implementando el novedoso método de liberar mosquitos Aedes esterilizados para reducir el problema. Eso puede resultar eficaz, pero implementar el método en un gran número de áreas sería costoso y requeriría un esfuerzo masivo a nivel estatal, dijo Abshier.

Mientras tanto, el gobierno federal está reduciendo sus intervenciones: varios medios han informado que los Institutos Nacionales de Salud dejarán de financiar nuevas investigaciones relacionadas con el cambio climático, que podrían incluir trabajos sobre el dengue.

Este año, las tasas de dengue reportadas en gran parte del continente americano han disminuido significativamente desde 2024. Sin embargo, es probable que la tendencia en Estados Unidos no se esclarezca hasta finales de año, después que termine la temporada de mosquitos de verano.

Los investigadores de salud y control de vectores no están seguros de la gravedad de la situación en California.

Algunos afirman que podría haber brotes limitados, mientras que otros predicen que el dengue podría empeorar mucho. Sujan Shresta, profesor e investigador de enfermedades infecciosas en el Instituto de Inmunología de La Jolla, señaló que otros lugares, como Nepal, experimentaron relativamente pocos casos de dengue en el pasado reciente, pero ahora se registran brotes grandes con regularidad.

Existe una vacuna para niños, pero está siendo discontinuada debido a la falta de demanda mundial. Otras dos vacunas no están disponibles en Estados Unidos. El laboratorio de Shresta trabaja arduamente en una vacuna eficaz y segura contra el dengue. Espera publicar los resultados de las pruebas en animales en aproximadamente un año; si son positivos, los ensayos en humanos podrían ser posibles en unos dos años.

"Si no hay una buena vacuna ni buenos antivirales, este será un país endémico para dengue", afirmó.

Phillip Reese es especialista en reportaje de datos y profesor asociado de Periodismo en la Universidad Estatal de California-Sacramento.

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

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CLARKESVILLE, Ga. — Last September, Alton Fry went to the doctor concerned he had high blood pressure. The trip would result in a prostate cancer diagnosis.

So began the stress of trying to pay for tens of thousands of dollars in treatment — without health insurance.

“I’ve never been sick in my life, so I’ve never needed insurance before,” said Fry, a 54-year-old self-employed masonry contractor who restores old buildings in the rural Appalachian community he’s called home nearly all his life.

Making sure he had insurance was the last thing on his mind, until recently, Fry said. He had been rebuilding his life after a prison stay, maintaining his sobriety, restarting his business, and remarrying his wife. “Things got busy,” he said.

Now, with a household income of about $48,000, Fry and his wife earn too much to qualify for Georgia’s limited Medicaid expansion. And he said he found that the health plans sold on the state’s Affordable Care Act exchange were too expensive or the coverage too limited.

In late April, a friend launched a crowdfunding campaign to help Fry cover some of the costs. To save money, Fry said, he’s taking a less aggressive treatment route than his doctor recommended.

“There is no help for middle-class America,” he said.

More than 26 million Americans lacked health insurance in the first six months of 2024, according to the Centers for Disease Control and Prevention.

The uninsured are mostly low-income adults under age 65, and people of color, and most live in the South and West. The uninsured rate in the 10 states that, like Georgia, have not expanded Medicaid to nearly all low-income adults was 14.1% in 2023, compared with 7.6% in expansion states, according to KFF, a health information nonprofit that includes KFF Health News.

Health policy researchers expect the number of uninsured to swell as the second Trump administration and a GOP-controlled Congress try to enact policies that explicitly roll back health coverage for the first time since the advent of the modern U.S. health system in the early 20th century.

Under the “One Big Beautiful Bill Act” — budget legislation that would achieve some of President Donald Trump’s priorities, like extending tax cuts mainly benefiting the wealthy — some 10.9 million Americans would lose health insurance by 2034, according to estimates by the nonpartisan Congressional Budget Office based on a House version of the budget bill.

A Senate version of the bill could result in more people losing Medicaid coverage, with reductions in federal spending and rules that would make it harder for people to qualify. But that bill suffered a major blow June 26 when the Senate parliamentarian, a nonpartisan official who enforces the chamber’s rules, rejected several health provisions — including the proposal to gradually reduce provider taxes, a mechanism that nearly every state uses to increase its federal Medicaid funding.

The number could rise to 16 million if proposed rule changes to the ACA take effect and tax credits that help people pay for ACA plans expire at the end of the year, according to the CBO. In KFF poll results released in June, nearly two-thirds of people surveyed viewed the bill unfavorably and more than half said they were worried federal funding cuts would hurt their family’s ability to obtain and afford health care.

Like Fry, more people would be forced to pay for health expenses out-of-pocket, leading to delays in care, lost access to needed doctors and medications, and poorer physical and financial health.

“The effects could be catastrophic,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

The House-passed bill would represent the largest reduction in federal support for Medicaid and health coverage in history, she said. If the Senate approves it, it would be the first time Congress moved to eliminate coverage for millions of people.

“This would take us back,” Tolbert said.

A Patchwork System

The United States is the only wealthy country where a substantial number of citizens lack health insurance, due to nearly a century of pushback against universal coverage from doctors, insurance companies, and elected officials.

“The complexity is everywhere throughout the system,” said Sherry Glied, dean of New York University’s Wagner School of Public Service, who worked in the George H.W. Bush, Clinton, and Obama administrations. “The big bug is that people fall between the cracks.”

This year, KFF Health News is speaking to Americans about the challenges they face in finding health insurance and the effects on their ability to get care; to providers who serve the uninsured; and to policy experts about why, even when the nation hit its lowest recorded uninsured rate in 2023, nearly a tenth of the U.S. population still lacked health coverage.

So far, the reporting has found that despite decades of policies designed to increase access to care, the very structure of the nation’s health insurance system creates the opposite effect.

Government-backed universal coverage has eluded U.S. policymakers for decades.

After lobbying from physician groups, President Franklin D. Roosevelt abandoned plans to include universal health coverage in the Social Security Act of 1935. Then, because of a wage and salary cap used to control inflation during World War II, more employers offered health insurance to lure workers. In 1954, health coverage was formally exempted from income tax requirements, which led more employers to offer the benefit as part of compensation packages.

Insurance coverage offered by employers came to form the foundation of the U.S. health system. But eventually, problems with linking health insurance to employment emerged.

“We realized, well, wait, not everybody is working,” said Heidi Allen, an associate professor at the Columbia School of Social Work who studies the impact of social policies on access to care. “Children aren’t working. People who are elderly are not working. People with disabilities are not working.”

Yet subsequent efforts to expand coverage to all Americans were met with backlash from unions who wanted health insurance as a bargaining chip, providers who didn’t want government oversight, and those who had coverage through their employers.

That led policymakers to add programs piecemeal to make health insurance accessible to more Americans.

There’s Medicare for older adults and Medicaid for people with low incomes and disabilities, both created in 1965; the Children’s Health Insurance Program, created in 1997; the ACA’s exchange plans and Medicaid expansion for people who can’t access job-based coverage, created in 2010.

As a result, the U.S. has a patchwork of health insurance programs with numerous interest groups vying for dollars, rather than a cohesive system, health policy researchers say.

Falling Through the Cracks

The lack of a cohesive system means that, even though Americans are eligible for health insurance, they struggle to access it, said Mark Shepard, an associate professor of public policy at the Harvard Kennedy School of Government. No central entity exists in the U.S. to ensure that all people have a plan, he said.

Over half of the uninsured might qualify for Medicaid or subsidies that can help cover the costs of an ACA plan, according to KFF. But many people aren’t aware of their options or can’t navigate overlapping programs — and even subsidized coverage can be unaffordable.

Those who have fallen through the cracks said it feels like the system has failed them.

Yorjeny Almonte of Allentown, Pennsylvania, earns about $2,600 a month as an inspector in a cabinet warehouse. When she started her job in December 2023, she didn’t want to spend nearly 10% of her income on health insurance.

But, last year, her uninsured mom chose to fly to the Dominican Republic to get care for a health concern. So Almonte, 23, who also needed to see a doctor, investigated her employer’s health offerings. By then she had missed the deadline to sign up.

“Now I have to wait another year,” she said.

In January, Camden, Alabama, resident Kiana George, who’s uninsured, landed in an intensive care unit months after she stopped seeing a nurse practitioner and taking blood pressure medications — an ordeal that saddled her with nearly $7,000 in medical bills.

George, 30, was kicked off Medicaid in 2023 after she got hired by an after-school program. It pays $800 a month, an income too high to qualify her for Medicaid in Alabama, which hasn’t expanded to cover most low-income adults. She also doesn’t make enough for a free or reduced-cost ACA plan.

George, who has a 9-year-old daughter, said she “has no idea” how she can repay the debt from the emergency room visit. And because she fears more bills, she has given up on treatment for ovarian cysts.

“It hurts, but I’m just gonna take my chances,” she said.

Widening the Gaps

Health insurance is fundamentally a financial product, intended to protect the policyholder’s pocketbook from accidents or illnesses.

Researchers have known for decades that a lack of insurance coverage leads to poor access to health care, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business.

“It’s only more recently we’ve had really good, strong evidence that shows that health insurance really does improve health outcomes,” Buchmueller said.

Research released this spring by the National Bureau of Economic Research found that expanding Medicaid reduced low-income adults’ chances of dying by 2.5%. In 2019, a separate study published by that nonpartisan think tank provided experimental evidence that health insurance coverage reduced mortality among middle-aged adults.

In late May, the House narrowly advanced the budget legislation that independent government analysts said would result in millions of Americans losing health insurance coverage and reduce federal spending on programs like Medicaid by billions of dollars.

A key provision would require some Medicaid enrollees to work, volunteer, or complete other qualifying activities for 80 hours a month, starting at the end of 2026. Most Medicaid enrollees already work or have some reason they can’t, such as a disability, according to KFF.

House Speaker Mike Johnson has defended the requirement as “moral.”

“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system,” he told CBS News in the wake of the bill’s passage.

A Senate version of the bill also includes work requirements and more frequent eligibility checks for Medicaid recipients.

Fiscal conservatives argue a solution is needed to curb health care’s rising costs.

The U.S. spends about twice as much per capita on health care as other wealthy nations, and that spending would grow under the GOP’s budget bill, said Michael Cannon, director of health policy studies at the Cato Institute, a think tank that supports less government spending on health care.

But the bill doesn’t address the root causes of administrative complexity or unaffordable care, Cannon said. To do that would entail, for instance, doing away with the tax break for employer-sponsored care, which he said fuels excessive spending, raises prices, and ties health insurance to employment. He said the bill should cut federal funding for Medicaid, not just limit its growth.

The bill would throw more people into a high-cost health care landscape with little protection, said Aaron Carroll, president and CEO of AcademyHealth, a nonpartisan health policy research nonprofit.

“There’s a ton of evidence that shows that if you make people pay more for health care, they get less health care,” he said. “There’s lots of evidence that shows that disproportionately affects poor, sicker people.”

Labon McKenzie, 45, lives in Georgia, the only state that requires some Medicaid enrollees to work or complete other qualifying activities to obtain coverage.

He hasn’t been able to work since he broke multiple bones after he fell through a skylight while on the job three years ago. He got fired from a county road and bridge crew after the accident and hasn’t been approved for Social Security or disability benefits.

“I can’t stand up too long,” he said. “I can’t sit down too long.”

In February, McKenzie started seeing double, but canceled an appointment with an ophthalmologist because he couldn’t come up with the $300 the doctor wanted in advance. His cousin gave him an eye patch to tide him over, and, in desperation, he took expired eye drops his daughter gave him. “I had to try something,” he said.

McKenzie, who lives in rural Fort Gaines, wants to work again. But without benefits, he can’t get the care he needs to become well enough.

“I just want my body fixed,” he said.

Have you recently lost your health insurance coverage? Have you been uninsured for a while? Click here to contact KFF Health News and share your story.

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

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“A lot of times, health care comes with a job.”

Sen. John Thune (R-S.D.), in an interview with KOTA on May 30, 2025

Millions of people are expected to lose access to Medicaid and Affordable Care Act marketplace health insurance plans if federal lawmakers approve the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package, which is now moving through the Senate.

Senate Majority Leader John Thune discussed health care and the pending legislation in an interview with KOTA, a South Dakota TV station. But he focused on a different kind of health insurance — employer-sponsored insurance.

“A lot of times, health care comes with a job,” Thune said.

Thune’s comments in the interview were made in the context of highlighting part of the GOP’s economic policy objective. “Creating those better-paying jobs that come with benefits is ultimately the goal here,” he said.

KFF Health News reached out to Thune’s office to find out the basis for this comment. His communications director, Ryan Wrasse, responded by reiterating Thune’s message: “Getting a job has the potential to lead a worker to acquiring health care.”

Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute, said Thune’s comment may also be alluding to discussions surrounding Medicaid work requirements. The One Big Beautiful Bill Act would let nondisabled adults enroll in Medicaid only if they prove they’re volunteering, working, or searching or training for work.

Medicaid, funded by the federal government and states, is the country’s main health insurance program for people with low incomes. Some people with disabilities also qualify.

Some Republicans have built on the jobs talking point in defending the Medicaid cuts and work requirements. Sen. James Lankford (R-Okla.), for instance, told CNBC the bill isn’t about “kicking people off Medicaid. It’s transitioning from Medicaid to employer-provided health care.”

But the health policy experts we checked with made clear that getting a job isn’t a guarantee for getting work-sponsored insurance.

Employer-Sponsored Health Insurance: The Basics

These experts said most jobs do offer health insurance. But they also said the link between employment and work-based coverage is not always straightforward.

“When I see this statement, I’m like, ‘I’ve got so much more to say about this.’ But I’m not arguing with the statement,” Fronstin said.

Matthew Rae, an associate director focused on researching private insurance at KFF, a health information nonprofit that includes KFF Health News, also weighed in.

“Employer-sponsored coverage remains the bedrock of how people get health insurance in the United States,” Rae said. “I would say that getting a job is not a guarantee you’re going to have health insurance. It just increases your chances of getting it.”

About 60% of Americans younger than 65 receive health insurance through their job or as the spouse, child, or other dependent of someone insured through their work, according to 2023 KFF data.

Among workers ages 18 to 64 who were eligible but didn’t sign up for their workplace insurance, 28% said the reason they decided not to enroll was that the plans were too expensive, 2023 KFF data showed.

Most of these workers found health insurance elsewhere, such as through a relative’s workplace plan. But a small percentage of eligible employees, 3.7%, were uninsured.

Health insurance has been “the most valued benefit in the workplace” since businesses began offering it to recruit employees in a tight labor market during World War II, Fronstin said.

Federal law also encourages companies to offer plans. Under the Affordable Care Act, employers with 50 or more full-time workers are penalized if they don’t offer most employees insurance that the federal government considers affordable.

As of last year, 54% of companies offered health insurance to at least some employees, according to KFF.

But that’s not the main way the ACA helped lower the rate of people without health insurance, said Melissa Thomasson, a professor at Miami University in Ohio who specializes in the economic history of health insurance. “Nearly all of that” change, she said, came from the ACA creating private marketplace plans and allowing states to expand Medicaid eligibility.

Health policy analysts say the One Big Beautiful Bill would make it more difficult for people to qualify or afford marketplace plans, with proposals that would increase paperwork, shorten enrollment periods, and allow enhanced tax credits to fizzle out. Thomasson also noted that political rhetoric surrounding jobs and health insurance doesn’t always align.

“We often talk about small businesses being the engine of job creation,” but those are the businesses that often can’t afford to offer workplace insurance, she said.

So Who Isn’t Insured Through Workplace Insurance?

The most obvious category of people who don’t have workplace insurance are those who don’t have a job. This group includes children and retirees, people searching for work, people who choose not to work, and those who can’t work, because of a disability or illness.

Another group without employer-provided insurance is the 25% of people ages 18 to 64 who have a job but are unable to obtain such insurance, according to 2023 data from KFF.

Some of these people work for companies that don’t offer health insurance. These employers tend to be small businesses or part of certain industries, such as farming and construction.

Others are part-time, temporary, or seasonal workers at companies that offer health insurance only to full-time employees. Workers with low incomes are significantly less likely than those with higher incomes to be eligible for workplace insurance, according to 2023 KFF data.

People who aren’t employed or don’t get insurance through their job can get coverage in other ways. Some are insured through a relative’s workplace plan, while others purchase plans and may qualify for subsidies on the ACA marketplace.

Others get insurance through Medicaid or Medicare, the federal health insurance program for people 65 or older and some people with disabilities.

Cost and Quality — And Therefore Access to Care — Vary

Just because someone has health insurance doesn’t mean they’ll get the health care they need. People may skip or delay care if their plans are unaffordable or if they limit in-network providers.

“Health benefits come in all shapes and sizes,” Fronstin said. “Some employers offer very generous benefits, and others less so.”

KFF data shows that premiums and enrollees’ cost-sharing expenses grew faster than wages from 2008 to 2018 but have slowed in recent years.

Whether workplace insurance is affordable significantly varies by income. According to 2020 KFF data, lower-income families insured through a full-time worker spent, on average, 10.4% of their income on premiums and out-of-pocket costs. That’s more than twice the rate when looking at families across all incomes.

Our Ruling

Thune said, “A lot of times, health care comes with a job.”

This statement is partially accurate. Most workers in the U.S. get health coverage through work. But it glosses over aspects of our nation’s job-based health insurance system — such as how costs and coverage, especially for those with lower incomes, can make an employer plan out of reach even if it is available.

Bottom line: Not all jobs provide health insurance or offer plans to all their workers. When they do, cost and quality vary widely — making Thune’s statement an oversimplification.

We rate this statement Half True.

Sources

KOTA interview with Sen. John Thune, May 30, 2025.

CNBC interview with Sen. James Lankford, June 5, 2025.

KFF, “2024 Employer Health Benefits Survey,” Oct. 9, 2024.

KFF, “Employer Responsibility Under the Affordable Care Act,” Feb. 29, 2024.

KFF, “Employer-Sponsored Health Insurance 101,” May 28, 2024.

Peterson-KFF Health System Tracker, “What Are the Recent Trends in Employer-Based Health Coverage?” Dec. 22, 2023.

Peterson-KFF Health System Tracker, “How Affordability of Employer Coverage Varies by Family Income,”March 10, 2022.

Peterson-KFF Health System Tracker, “Tracking the Rise in Premium Contributions and Cost-Sharing for Families With Large Employer Coverage,” Aug. 14, 2019.

Manhattan Institute, “Put Employees in Control of Health Insurance with ‘Worker’s Choice ICHRA,’” May 22, 2025.

Brookings, “Uninsurance Rates Have Fallen Significantly Following the Affordable Care Act,” July 22, 2024.

Harvard Business Review, “Why Do Employers Provide Health Care in the First Place?” March 15, 2019.

Congressional Budget Office letter on the One Big Beautiful Bill Act increasing the number of uninsured people, June 4, 2025.

Phone interview with Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute and a member of the Commonwealth Fund’s National Task Force on the Future Role of Employers in the U.S. Health System, June 6, 2025. 

Phone interview with Melissa Thomasson, professor and health economist at Miami University, June 6, 2025.

Phone interview with Maanasa Kona, associate research professor at the Center on Health Insurance Reforms at Georgetown University, June 6, 2025. 

Phone interview with Matthew Rae, associate director for the Health Care Marketplace Program at KFF, June 10, 2025. 

Phone interview with Sally Pipes, president and CEO of the Pacific Research Institute, June 11, 2025.

Email correspondence with Ryan Wrasse, communications director for Sen. John Thune, June 10, 2025.

KFF Health News, “Some Employers Test Arrangement To Give Workers Allowance for Coverage,” Oct. 2, 2024.

KFF Health News, “Trump’s ‘One Big Beautiful Bill’ Continues Assault on Obamacare,” June 3, 2025.

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

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The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

It’s not exactly news that our nation’s health care system is only a “system” in the most generous sense of the word and that no one entity is really in charge of it. Notwithstanding, there are some specific responsibilities that belong to the federal government, others that belong to the states, and still others that are shared between them. And sometimes people and programs fall through the cracks.

Speaking before a live audience on June 23 at Aspen Ideas: Health in Colorado, three former governors — one of whom also served as secretary of the Department of Health and Human Services — discussed what it would take to make the nation’s health care system run more smoothly.

The session, moderated by KFF Health News’ Julie Rovner, featured Democrat Kathleen Sebelius, a former governor of Kansas and HHS secretary under President Barack Obama; Republican Chris Sununu, former governor of New Hampshire; and Democrat Roy Cooper, former governor of North Carolina.

Panelists

Kathleen Sebelius
Former HHS secretary, former Kansas governor (D)

Chris Sununu
Former governor of New Hampshire (R)

Roy Cooper
Former governor of North Carolina (D)

Among the takeaways from the discussion:

• States — and the governors who lead them — are major “customers” of the federal health system. For instance, states run research universities with the aid of federal grants from the National Institutes of Health. States also run Medicaid, the joint state-federal program for those with low incomes and disabilities, through which most of the nation’s care for issues such as mental health and substance use disorders is funded. In fact, most federal money sent to states is for Medicaid.
• Cuts to Medicaid outlined in the House and Senate versions of President Donald Trump’s One Big Beautiful Bill Act would leave a huge hole in state budgets — one that the states, already facing budget constraints, would be unable to fill without making difficult choices. Notably, the bill does not make substantive cuts Medicare, a program that has a significant amount of excess spending and is expected to be insolvent within a decade.
• Controlling health care costs is a major concern for the future of the nation’s fragmented health care system, as is maintaining the health care workforce. More people without insurance coverage means higher overall costs. Pandemic burnout, immigration raids, and even the cost of college are putting pressure on a dwindling workforce. The federal government could do more to encourage medical professionals to go into primary care and rural health care.

Video of this episode is available here on YouTube.

Click to open the transcript

Transcript: Live From Aspen — Governors and an HHS Secretary Sound Off

[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, coming to you this week from the Aspen Ideas: Health conference in Aspen, Colorado. For this week’s podcast, we’re presenting a panel I moderated here with three former governors and one former HHS [Department of Health and Human Services] secretary, on how states and the federal government work together. This was taped on Monday, June 23, before a live audience. So, as we say, here we go. 

Good morning. Thank you all for being here. I’m Julie Rovner. I’m chief Washington correspondent at KFF Health News, and I’m host of our weekly health news podcast — “What the Health?” — which we will do double duty this week for this panel. I am so thrilled to be here, and I welcome you all to Aspen Ideas: Health. As a journalist who’s covered health policy at the federal and state level for, let us just say, many years, I am super excited for this panel, which brings together those with experience in both. 

I will start by introducing our panelists. Here on my left is Kathleen Sebelius. She served as HHS secretary during the Obama administration from 2009 to 2014, presiding over the passage and implementation of the Affordable Care Act. I hope you were all around last night for the wonderful panel where they were reminiscing. Prior to her tenure in Washington, Secretary Sebelius served two terms as Kansas’ elected insurance commissioner and two more as governor. Today she also consults on health policy and serves on several boards, including — full disclosure — that of my organization, KFF. 

Next to her is Chris Sununu. He’s the former Republican governor of New Hampshire. Opposed, he was elected to a record four times before returning to the private sector. He’s also the only trained environmental engineer on this panel. 

Finally, Roy Cooper is the former Democratic governor of North Carolina, where he served alongside Gov. Sununu. I’m sure they have many stories to tell. As a state lawmaker, Mr. Cooper wrote the state’s first children’s health insurance program in the 1980s and as governor championed the state’s somewhat belated Medicaid expansion in 2023, which we’ll also talk about. He’s currently teaching at the Harvard School of Public Health. 

So here’s what we’re going to do. I’m going to chat with these guys for, I don’t know, 30, 40 minutes, and then we will open it to questions from the audience. There will be someone with microphones. I will let you know when it’s time. Just please make sure your question is a question. 

So, I want to set the stage. It’s not exactly news that our nation’s health care system can only be called a system in the very most generous sense of that term. Nobody is really in charge of it. Notwithstanding that, there are some specific responsibilities that belong to the federal government, others that belong to the states and or counties and cities, and still others that are shared between them. Kathleen, you’re the one on this panel who has served as both governor and as HHS secretary, so I was hoping you could give us two or three minutes on what you see as the primary roles for health care at the federal level at HHS, and those for states. And then I’ll let the rest of you weigh in. 

Kathleen Sebelius: Well, good morning, everybody, and thanks, Julie, for moderating. It’s lovely to be with my colleagues. That’s one of my former lives, as governor, so it’s great to be with governor colleagues. And just to make it clear, we’re not trying to gang up on Chris Sununu. Alex Azar, former HHS secretary in the first Trump administration, was supposed to be here today and had a family health issue, so he couldn’t join us. So it was supposed to be a little more balanced just to— 

Chris Sununu: My conservative lifeline has abandoned me, and he’ll buy me dinner in D.C. next time I’m in town. 

Sebelius: So, as Julie said, I think the health system, if you want to call it that, is definitely interrelated. And I think it’s one of the reasons that a lot of HHS secretaries have actually been governors, because we’re customers, if you will, of the federal health system. But just to break down a couple of categories: I was the elected insurance commissioner, which is an unusual spot. Only 11 states elect an insurance commissioner. Most are appointed as part of a governor’s Cabinet, but insurance is an over $3 trillion-a-year industry, still regulated at the state level. It’s the only multitrillion-dollar industry that there is no federal insurance regulator, and it still has a lot of control over health issues at the state level. The insurance commissioners regulate the marketplace plans. They look out for every company selling private insurance. They regulate Medicare supplemental plans. They’re very involved in consumer protection issues for insurance. And that’s all at the state level. 

Then the governor is clearly in charge of health at the state level. Runs the state employee plan in every state, which often is the largest insurance pool. I don’t know about in North Carolina or New Hampshire, but it certainly was in Kansas. Runs Medicaid, a huge health program. Is in charge of mental health, of the whole issues around the opioid crisis and drug issues. So a broad swath. In charge of prison health and corrections. A lot of health issues at the state level. And then you get to HHS, which is an agency that probably interacts more with states than any other Cabinet agency. I wrote down some of these numbers just so I wasn’t making them up off the top of my head, but 69% of all federal grants to states are Medicaid, and HHS transfers more money to state governments than all the other domestic agencies put together. 

So it’s largely Medicaid, but it also is mental health block grants. It’s all the children and families programs. It’s Head Start. It’s agencies on aging. There’s a real interaction. So governors are often good customers, if you will, of HHS. They need to be intertwined. They need to know what’s going on, what grants are on the table. Runs the whole Indian Health Service. A number of us had tribes in our states. So there is a lot of interaction. And even though I wasn’t able to quickly quantify the number, the other thing — and it’s become more apparent with the cuts on the table — is states run universities, which rely on research grants from the federal government. 

So the recently announced NIH [National Institutes of Health] cuts have huge implications in Kansas. We have three major universities, which are losing hundreds of millions of dollars in research projects. But that’s gone on all over the country. So there is a lot of interaction between the state and federal government. And as I say, with the insurance commissioner, we had to build an office at HHS to regulate the marketplace, because there were no federal regulators. So I brought in a lot of my former colleagues who had been in insurance departments around the country, to help set up that regulatory system and that oversight. 

Rovner: So I would like to ask the two former governors who’ve not been HHS secretaries, if you can, to give us an example of cooperation between the federal government and state government on health care that worked really well and an example of one that maybe didn’t work so well. 

Sununu: So I would argue they don’t work well more than they work well, unfortunately. So a big issue I think, across the entire country, is rural access to care, right? So a lot of these grants — and the secretary’s right — a lot of the grants that come in through Medicaid, they’ll go to population centers and population health. That’s really, really important aspects. But rural access to care, where you talk about mental health, the opioid crisis, that’s really where so many folks get left out of the mix. We went down and I inherited — I don’t want to say “inherited” — New Hampshire was at the tip of the spear for the drug crisis, right? The opioid crisis, 2017, we had the second-highest death rate in the country, and we realized the overdose rate, the death rate, was four times higher in rural New Hampshire than our inner cities, right? Four times. Why? It wasn’t that — it’s because nobody was putting services out there. 

Because it’s so much easier to put the services in the city. So a good example is, we went down to D.C. We worked with, at the time, Secretary Azar, the head of CMS —CMS is the center of Medicaid services and Medicare services, that’s really the overseer of these massive, massive programs — to get some flexibility with the grants to be able to do a little more with our dollars and create a hub-and-spoke system for rural access to care. And that worked really, really, really well. And I’m not here to tout [President Donald] Trump or anything, but at the time the Trump administration really got that and it worked well. 

But I would say, more often than not, if you want something done a little different — we call them [Section] 1115 waivers, not to get wonky — you want to try something, the challenge isn’t that D.C. won’t let you do it. The challenge is it can take forever to get it done. It takes six months for my team to put together an 1115 application and then a year and a half sometimes for Washington to decide, after a hundred lawyers look at it, whether they’ll allow you to do it. So I would always argue, at the base of all this, is — Gov. Cooper, at the time, and his team, they know what North Carolina needs in terms of health care, specialized services, better than Washington, right? Or Mississippi. Or New Hampshire. The states know. They’re on the ground. 

And my argument has always been: The best thing Washington can do if you want to save money and get better outcomes in health care, go more to a block-grant-type system. I know people don’t like to hear that, but let the states who are on the ground have more flexibility with those Medicaid dollars, create the efficiency at a localized level, where the patient interactions there with a — because again, I had an opioid crisis. Maybe there’s a huge mental health crisis in North Carolina. Maybe there’s an acute-care crisis in urban populations in California. Let them have flexibility and the ability to make more immediate returns on that. And so that’s why I say more often than not, it doesn’t work, because of the time delay. The bureaucracy, the lawyers. No offense to the — well, I don’t care if you take offense. But the lawyers in the room, the lawyers that get a hold of this thing and then give you a hundred reasons why it can’t happen. 

And then the last thing I’ll throw out there is billing codes. Do you know there’s 10,000 Medicaid billing codes? Trying to ask a small nonprofit who’s providing local health care services and a volunteer to understand 10,000 Medicaid billing codes, and what happens? Often it’s not nefarious, but they get them wrong and then it comes back and it goes back and forth and the cash gets held up because of Washington, as opposed to just having a localized, We have our problem, let’s fix it on the ground, and move forward and get the help they need. So my challenge is always with the bureaucracy and slowing things down more than anything. 

Rovner: Gov. Cooper. 

Roy Cooper: Glad to be with you, Julie, and I worked closely with Gov. Sununu. We served as governors at the same time, and glad to have then-Gov. Sibelius, working with her when I was attorney general of North Carolina. I was an OK governor, but I’ve got the greatest first lady in the history of North Carolina with my wife, Kristin, who’s with us today. And thank you for all the work that you did. Somebody asked me what I miss most about being governor, and I said ingress and egress to sporting events was what I — because I had to learn to drive again. 

So I look at this relationship as the federal government being a major funder to reach goals, but that states have the flexibility within those guidelines to deal with individual challenges that states have. And I don’t disagree completely with Gov. Sununu about how the waiver system is working, but when you get it working, it does some miracles. 

For example, we got the first 1115 waiver in the country, to invest Medicaid dollars in social determinants of health. We called it Healthy Opportunities. And we’ve talked so much again and again about prevention and how investment there can make such a huge difference. We also got another waiver with hospital-directed payments to require all of our 99 hospitals to take part in a medical debt relief plan. When we expanded Medicaid in North Carolina, which we’ll talk a little bit about in a minute, more than 652,000 people were so grateful to have health insurance, but many of them owed so much money in medical debt that it prevented them from buying a house or getting a credit card and was causing all kinds of problems. So we got a waiver to put a requirement in the directed payments that hospitals are getting to make sure that we wipe off the books that $4 billion in medical debt in North Carolina, and that is happening as we speak. 

People are getting the books cleared, all people who were on Medicaid and those making 350% or less of the federal poverty level. And then going forward, in order to continue to get the directed payments, they have to automatically enroll people at that income level into their programs for charity. So the cost of health care is being borne by those who can least afford it. And Medicaid has given us the opportunity and the flexibility with Medicaid has given us an opportunity to make those investments, and that’s why I worry, Governor, about what this bill that’s coming — you talk about red tape now. You look at red tape that’s coming if this legislation passes Congress right now. It’s going to make it 10 times worse. 

So when you think about what Medicaid has done and this system with all of its faults — it has many — we’re at the lowest uninsured rate we’ve been right now. So that thus far has been a success. We’ve got a long way to go, but I think that we need to continue to work to make the investments angle toward prevention and keeping that symbiotic relationship between the federal and the state, make it smoother, eliminate red tape. But I think we’re making some progress. 

Rovner: So let’s talk about Medicaid, which is kind of the elephant in the room right now since the Senate is presumably going to take up a bill that would make some significant cuts to the program, possibly as soon as this week. You’ve all three run Medicaid programs as governors. One of the Republican talking points on this bill is that what’s supposed to be a shared program, states are using loopholes and gimmicks to make the federal government pay more. What would happen if these cuts actually went through? Would states be able to just say: OK, you caught us. Now we’re just going to have to pay up? 

Sebelius: Well, I can talk a little bit about it. So I live in a state, unfortunately, that has not expanded Medicaid. Kansas is one of the 10 states, although 40 states and the District of Columbia have used the Affordable Care Act provision to enroll slightly higher-income working folks in Medicaid. And it’s a huge federal-state partnership, with the federal government paying 90% of the premium cost of that additional population. 

Rovner: And that was because the states didn’t think they had the money to expand otherwise? 

Sebelius: That’s correct. So it was a generous offer, but after the Supreme Court it was a voluntary program. So there are still 10 states in the country, and what you can see easily looking at the map of the country is what the health outcomes are in the states that have not expanded. Expansion was available on Jan. 1, 2014. So we have a 10-year real-time experiment in health outcomes, in budget outcomes, in what has happened to the state economy. And we know a couple of things from a national level. More hospitals have closed, mostly rural hospitals, in states that have not expanded than the states that expanded. There are fairly significant health differences now. There were health differences before, but they have been accelerated. 

There are more maternal-health deaths in states that have not expanded, not because the woman may not be eligible for Medicaid but because the hospital closes and now she’s 50 miles away from her birthing center and transportation issues and don’t have gas in the car and whatever. We are losing women having children, which is really shocking in the United States of America. So I think that not only is Medicaid a huge portion — I had a good friend who some of you may know, Brian Schweitzer, who was the former governor of Montana, and Brian used to say what a governor does is pretty easy. We medicate, we educate, we incarcerate, and the rest is chump change. You can find it in the couch, but it— 

Sununu: Well, I disagree with that. Totally different discussion. 

Sebelius: In terms of where the money is. Those are the big chunks of — and Medicaid in most state budgets, it’s a huge chunk of money. So when you talk about potentially $700 billion in cuts to Medicaid, it will blow up state budgets across the country, and it will leave, to Gov. Sununu and Gov. Cooper’s points, literally millions of people uninsured. The estimates out of the House bill — the Senate bill still hasn’t been scored — out of the House bill is 8- to 9 million people, but I think that’s likely to go up with a Senate bill. 

Sununu: I would add, expanded Medicaid has been — we were an expanded Medicaid state. It’s been wonderful. Health outcomes are definitely a lot better. There’s a lot more access to services, and these are, again, the difference in the population, these are able-bodied working adults as opposed to the traditional Medicaid population that deal with either poverty issues or disability and all this other stuff. So it’s a 50-50 versus split on traditional versus 90-10. I don’t have a problem with changes. The way they’re doing it is awful. So as a state, if you want — they are really adamant about dropping it, and it would lead to bad outcomes, there’s no question — I would say, OK, do it over 10 years. We’re going to drop it 5% a year. Allow states to gradually come in, right? Allow states to alter their budgets. No state can alter their budget and take up — in California it might even be a trillion, hundreds of billions of dollars. 

Sebelius: Yeah. 

Sununu: So it’s so much money. So no state can do that. And so obviously you’d have a collapse of the system. It would be terrible to do that, and they’ve taken that off the table. The meta-scam piece is much more complicated, where states tax hospitals, match it with federal funds and send it back to hospitals in terms of uncompensated care. That’s a bad practice that everybody does, so we should keep it. I don’t know a better way to say it. And I say that because New Hampshire was the first one.  

Sebelius: And it’s legal. It’s legal. 

Sununu: We invented it in ’92. It’s legal. It’s fine. It’s become precedent in practice. It’s OK. And so we should keep doing that. And what they’re going to do is lower the amount that states can tax the hospitals and therefore lower the amount that we would get. And that, really, for us — I don’t know how other states use their dollars — we put a large portion of that back to hospitals for that uncompensated population, the ones that truly are unregistered. I don’t mind going after — we should get the cost at some point, right? You all owe $37 trillion, by the way. I hope you know that. So the savings have to come from somewhere, but Washington has to be smart about how to do it, what the actual outcomes are going to be, and how to ratchet it down so you’re not, again, throwing everybody off the cliff. And that’s what this bill would do. It would throw people right off a cliff. 

Cooper: Yeah, I think the answer is absolutely no states can’t afford it. We governors have to balance budgets. The federal government obviously doesn’t. They just continue to raise the debt ceiling, problems in and of itself, but that’s where the funding should come from. I think there are a few billionaires we could tax a little bit more in order to create more funding to do the work that we need to do, but— 

Sununu: There’s a basket at the door if you all want to drop something in on the way out. 

Sebelius: A big basket. 

Cooper: That, too. But I think that if we’re going to rely on the states — what’s happening now, I think, is a sneaky way to do this. I think they have understood that just openly and notoriously telling the states they have to pay more is not going to work and it’s not politically feasible. But what they have done is gone through the back door and created all of this red tape that’s going to end up with people being pushed off who are otherwise eligible. It’s going to end up with states having to make horrible choices, like with SNAP [Supplemental Nutrition Assistance Program] benefits, for example. 

In North Carolina, we’ll have a shortfall of about $700 million. Now with SNAP benefits, not only do you feed hungry people who need food, but there’s an economic benefit to our state. It’s like a $1.80 economic benefit generated from $1 of SNAP benefit. But I don’t see my Republican legislature putting in an extra $700 million in SNAP benefits in order to be able to feed hungry people. So the choices that states are going to make are going to be bad, because states are limited as to the decisions that they have to make. And this is going to be really tough, particularly if this Senate bill doesn’t change a whole lot. States are going to have a significant problem. 

Sebelius: All I wanted to say is in addition to the Medicaid issue hitting a big portion of the lower-income working population is a corresponding Affordable Care Act hit that isn’t in the bill, because it’s a tax incentive that will expire at the end of this year. So not acting on the additional premium tax credits for the Affordable Care Act hits almost the same — in a state like Kansas, which has not expanded Medicaid, a lot of that population is in the marketplace plans with an enhanced tax credit. That goes away at the end of the year. So we’re looking at potentially 11 million people in states across this country. 

And no governor has the ability to write a check and say: OK, I’m going to just provide, out of 100% state funds, I’ll help you buy your health insurance. But not having health insurance means you don’t get doctors paid, more hospitals go on —it has a ripple. People can’t take their meds. They can’t go to work. They have mental health issues. It is a really spiraling impact. And as Gov. Cooper and Sununu have said, we have the lowest rate of uninsured Americans right now that we’ve ever had in history, and that could change pretty dramatically. 

Sununu: The only other piece I was going to bring up just to highlight the cowardice of Washington, D.C.: Why are they focusing on Medicaid, but no one wants to talk Medicare? Well, it’s easy because states, right? Because they can blame states. Well, we made changes, but it’s up to the states whether they want to keep it or not, right? And they’re going to blame the governors and blame what’s happening at the state level, whether expanded Medicaid survives or not. Meanwhile, it’s the crisis that they’re creating. Then you have Medicare, which, by the way, everyone agrees there’s massive waste and fraud and abuse, and that system needs a massive overhaul because that system, by the way, is going bankrupt, right? It’ll be insolvent in nine or 10 years, something like that, right?. But no one wants to talk about that piece, right?. But that’s an integral piece because both those left and right hands of Medicaid and Medicare drive the non-private sector of health care, right? Which creates not a competitive — we can get into the whole reducing competition in a free market in health care to actually get costs down. 

But it’s really hard as a governor, I think, and I think I speak for all 50, to hear Washington talk about all these massive cuts they want to make to Medicaid, but they’re not going to touch Medicare, because that’s a federal program. And so they have to do both in some way, and they have to do it in a smart way, in an even-keeled way. It has to take place over time. It has to look at population health outcomes. But they don’t think like that. They just don’t. They look at top-line numbers, top-line issues. Maybe they’ll get to the bill in a few weeks. Maybe they won’t. They’ll be on vacation most of the summer. It’ll be very frustrating. Even if it passes in the Senate, it won’t even — what? September, maybe? Maybe they take it up in September? 

Rovner: You don’t think they’re going to make it by July Fourth? 

Sununu: The Senate might, but then they vacation. They’ve got to go on vacation. So isn’t that the frustration we all have? We have a major crisis here. Here’s an idea. Do your jobs. 

Sebelius: Just a small addendum, too. 

Sununu: Sorry. I’m frustrated. 

Sebelius: Gov. Sununu, because he’s the baby of the group, if you can tell, and I’m part of the gray tsunami. Part of the reason Medicare is running out of money is at least when my parents were involved in Medicare, there were six or seven workers for every retiree. We’re now down to two. And I want to know those two workers. I got to tell you, I’m at a point in my life I’d like to bring them home with me, feed them on a regular basis, get them — but we have an aging country. We have many more people enrolled in Medicare right now than we have had in the past and fewer in the workforce. So the math, you’re right, is daunting going forward, but it isn’t, I would suggest, massive waste, fraud, and abuse as much as a changing demographic in our population. 

Sununu: I was quoting [Rep. Nancy] Pelosi on that one. Sorry. 

Rovner: I want to pick up on something. For those who were not there last night for the Affordable Care Act session, one of the things that no one brought up is that in the intervening 15 years since the Affordable Care Act passed, I think, every single one of the funding mechanisms to help offset the cost of the bill has been repealed by Congress. The individual mandate is gone. Most of the industry-specific taxes are gone. The Cadillac tax that was going to try and deter very generous health plans is gone. States don’t have this kind of opportunity to say, We’re going to pass something that pays for itself, and then get rid of the pay force, right? 

Cooper: That’s a really good point. And right now the Affordable Care Act is working to insure a lot of people, but it’s continuing along with all of our system that’s set up to drive up the cost. And I know we’re going to talk a little bit about cost in just a minute, but again, I agree with Gov. Sununu — that’s the coward’s way out. All of the lobbyists come with their special interests who are paying something and should be paying something, but they get it removed piece by piece by piece. And then the only way to get it is from the very people who need it the most. And they’re the ones who end up suffering. And I think it was mentioned last night — $14,600 a person in the United States for investment in health care. That’s wrong on many levels. 

Rovner: So let’s talk about cost. Who is responsible for controlling the cost of health care? Both sides point at each other. And as I mentioned at the opening, we don’t really have a system, but we obviously have the federal government responsible for a lot of health care bills and the state government’s responsible for a lot of health care bills. So at what point does somebody step up and say, We really need to get this under control? 

Sununu: I’ll throw a couple things in there. The average cost to spend overnight, in America, in a hospital: $32,000 — a night. That’s insane, right? That’s insane. And so the argument that I always have is, let’s look at the cost to stay in a hospital. And I know this is going to seem far afield, but it’s all part of health care. What I pay my average social worker — which, by the way, we need a lot more social workers. And if a social worker’s making 50 grand a year, they’re lucky doing it and God bless them. They’re doing incredibly hard work. So why do we have a system that is driving these costs here, that haven’t gotten any of those costs under control, still make it really difficult to pay the workforce? And I think workforce is a huge part of this crisis. 

Rovner: Next question. 

Sununu: Yeah, that’s another the question, especially the social workers and whatnot and generationally and nurses and all that to get them in there. If you don’t have the workforce, it’s not going to work. So the disparity of costs. And then there are certain aspects, let’s talk pharmaceuticals, where you are all, we are all effectively paying massive costs on pharmaceuticals because we’re subsidizing the rest of the world, right? Because they’re developed here. There’s massive cost controls in Europe, so we pay a huge amount of money. And again, I’m going to bring up Trump only because he brought up the “fat shot.” Is that what he called it? The other—? Yeah. The fact that Ozempic here is $1,200 but a hundred bucks in Europe. Why? Because they have cost controls there, and our fairly unregulated system forces those types of costs on the private sector here. 

So I’m a free-market guy. I’m always a believer that the more private sector investment you get and the more, I’ll just call it competition, especially smaller competition, can create better outcomes. But we just don’t have that. There’s no private sector. There’s no competition in health care, because so much of it is driven by Medicaid and Medicare. So I would just argue that you have to look at finding the balance here in the U.S., but don’t forget there’s other issues across the rest of the world that are affecting your costs as well. 

Cooper: And I’ll give you two things. One that you don’t do to affect the cost issue. You may be tempted to reduce your budget to throw people off of coverage, but more people without coverage increases costs significantly, and we all pay for it when you have indigent patients going into those hospitals. They go to the private sector first, which is why a lot of businesses in North Carolina supported our expansion of Medicaid, because 44% of small businesses don’t even provide coverage for their customers. So we should not be kicking people off coverage. In order to reduce costs, we need to cover more people. And the second thing we should do, and this we say a lot here and it was said last night, but collectively, if we can come together and make these short-term investments for long-term gain on primary care and prevention, that is the best way to lower costs to make sure people are healthier. Because our system is geared to spend all the money when it is most expensive and not when it is least expensive and can do the most good to delay that spending at the other end. 

And there are a lot of ways that we can approach this, but what frustrates me about Washington is that you don’t see any real effort there to concentrate on prevention and primary care and making those investments that we know — we know — not only save lives but save money and reduce the cost of health care. And I think that can be a bipartisan way that we can come together to deal with this. Things you mentioned, certainly driving up the cost, but that is a basic thing that we know will make people healthier and will cost the system less. 

Sebelius: I don’t think there’s any disagreement in all of us and probably all of you that we pay way too much for health care per capita. And we have pretty indifferent health results. We have great care for some of the people some of the time. But in terms of universally good care for people across this country, regardless of where you live, it just doesn’t happen. It isn’t delivered, regardless of the fact that we spend much more money. I would say that it’s beginning to have some impact, but a couple things occurred as part of the framework of the Affordable Care Act and other changes at the D.C. level. First, Medicare began to issue value-based payment contracts. They were nonexistent before 2010, and that just means you begin to pay for outcomes. Not just doing more stuff makes more money, but what happens to the patient? Is it a good recovery? Do you come back to the hospital too soon? Is somebody following up? 

So that has shifted now to most Medicare payments are really in a value-based payment outcome. And that has made a difference. I think it makes a difference in patient outcomes. It makes a difference across the board. There has been some change, not nearly enough, in primary care reimbursement. We need a whole lot more of that. Specialty care pays so much more than primary care, and it discourages young docs from going into a primary care field, a gerontology field, a pediatric field. We desperately need folks. I’d say third that a lot of hospitals, and particularly in rural areas, to your point, Gov. Sununu, are beginning to look at a range of services, not just, as we call it, butts in beds, but they’re running long-term care services. They’re running a lot of outpatient. 

And we just had a session on rural health care, and the amount of outpatient care provided by rural hospitals is now up to about 80%. So actually they’re trying to do prevention, trying to meet people where they are. We have to keep some support systems under those hospitals, because if their only payment is how many bed spaces you fill per night, it’s counterintuitive to have hospitals doing prevention and then their bottom line is affected. But I think Gov. Cooper is just absolutely right on target. There was a huge prevention fund for the first time in the Affordable Care Act. It went to states and cities, not to some federal government. It was called, for years, a big slush fund. But it has engaged, I think, a lot of people, a lot of mayors, a lot of governors in everything from bike trails to healthy eating to scratch kitchens in schools, to doing a range of reintroducing physical education back into education classes. But we need to do a lot more of that. 

Sununu: Can I ask a question? Were you guys a managed Medicaid state? 

Cooper: Yeah, we are now. 

Sununu: Were you at the time? So for those who know, maybe 40 states, 41, 42 states? 

Sebelius: I think it’s almost 45. 

Sununu: So the states, I don’t know when this started. It had started right around the time I got in New Hampshire. We hired a couple large companies to basically manage our Medicaid. But to the Gov. Cooper’s point, theoretically you bring those companies in to look at the whole health of the individual and more on the prevention services, more on that side as opposed to just fee-for-service, fee-for-service, right? Where you get inefficiency and waste and all that sort of thing. It’s worked, kind of. I think most of the models still have a lot of fee-for-service built into them. And so it’s not quite there. You have these very large companies, the Centenes and some of these other really, really large companies that are effectively deciding whether — they’re insurance companies that are deciding whether someone should get care or not, or that service is required or not. 

Usually it works, but obviously we have a lot of tragic stories of families getting rejected for service or things like that. So, I think if given more flexibility that it could theoretically work, but I think the managed-care model is mostly working but not great. But it was designed to deal with exactly what Gov. Cooper’s talking about, the whole health of the individual, more preventive care. Don’t wait for the person on Medicaid to lose all their teeth — right? — because they’re a meth addict and they have massive heart and liver issues, right? Get them those prevention services early on because they’re into a recovery program and the whole health of the individual exponentially saves you money and increases their health outcomes and all that. But if you have somebody looking at that from a holistic perspective, theoretically it comes out better. I don’t know. You probably have a better perspective than anyone whether you think it really has worked or not. 

Sebelius: Well, I think it’s beginning to work and it works better in some places than others. But I think that the federal programs, arguably both Medicare and Medicaid, provide, if you will, the most efficient health insurance going. Private plans, in all due deference to your market competition, run anywhere from 15 to 20% overhead. Medicare runs at a 2% overhead. Medicaid is about that same thing. So delivery of health benefits on an efficient basis is really at the public sector, less at the private sector, which is why we were hoping to have a public option in the Affordable Care Act to get that market competition. Medicare Advantage provides market competition now to fee-for-service. And some of the companies do a great job with holistic care. Some of the companies do a really bad job, far more denials, far more issues of people not being able to get the benefits they need. So it is a balanced thing. 

Sununu: And smaller states, we had a trouble because we couldn’t find many companies that wanted to come into a small state like New Hampshire, because the population wasn’t going to be huge. We have the lowest population on Medicaid in the country. So if I got a third company and maybe they get 35-, 40,000 people, what’s the risk pool of those individuals? They might be like, Nah, it’s not going to work for us, right? So the smaller states, because they’re managed at the state level, have challenges. We tried to actually partner with Vermont and Maine. 

Sebelius: Regional. 

Sununu: Right? Regional opportunities. The feds wouldn’t let us do that. Very frustrating. But not you. 

Sebelius: I did a waiver for New Hampshire to have a regional program. 

Sununu: No, I blame Alex for that. That’s another thing — I’ve yelled at Alex for that for years. 

Sebelius: Maybe the next guys took it away. 

Rovner: So we keep talking about people getting care or people not getting care. We haven’t talked a lot about the people who deliver the care. Obviously the health care workforce is a continuing frustration in this country, as we know. We have too many specialists, not enough primary care doctors, not enough primary care available in rural areas. What’s the various responsibility of the federal government and the states to try and ensure that — obviously states need to worry about workforce development. Isn’t that one of the things that states do? 

Sununu: All right, I’ll kick things off because I’ll say something really liberal that you’ll all love. Do you know what the key is? Honestly? It’s an immigration reform bill. 

Sebelius: I was just— 

Sununu: It’s immigration reform. Because this generation is not having kids, right? We’re losing population. So just the math on bodies, if you will, in terms of entering any workforce is going to be challenging as the United States goes forward. More and more if you look at the number of people, social workers, people in recovery, MLADCs [master licensed alcohol and drug counselors] in recovery programs, nurses, whatever it is, those tend to be more people that are born outside of this country, that come to this country. They go to nursing school — whatever it is they become, it’s great. 

But until we get a good immigration reform bill that opens those doors bigger and better and with more regulation on top of them, but open those doors, I think it’s going to be a challenge. It’s not necessarily an issue for the government to — government can’t create people, right? Maybe we can incentivize more schools and that sort of thing. And I think most governors do that. We put in nursing schools in our university system and all that, but you still have to fill the seats and you still have to encourage the young people to want to get into those types of programs. 

Sebelius: I think the government at the state and local level and federal level can do more. More residency programs. The federal government can actually move the needle on some of the payment systems for specialty vs. primary care. And we haven’t moved fast enough on that. I think that’s no doubt. What’s pending right now with ICE [Immigration and Customs Enforcement] raids all over the country and people being terrified to come here or stay here is going to make the workforce issue significantly worse. Home health care workers, folks in nursing homes, people who are LPNs [licensed practical nurses] are now being discouraged from either coming or staying. And I think we’re in for an even bigger shock. 

A lot of folks got burned out in covid. There’s no question that we lost vital health care workers. We need to be on a really massive rebuilding program, and instead we have put up a big red flag. And a lot of people who are here who are providing care, who may have a family member or somebody else who is not at legal status, and they’re gone or they’re not going to go to work or they’re not going to provide those services. And I think we’re about to hit even a bigger wall. 

Cooper: You’ve mentioned compensation. Obviously gearing more toward the preventive side, the primary care side is important. I also think one thing that’s working some, and I think we could do more, obviously requires funding, but providing scholarship money for doctors, nurses, others who agree to give a certain number of years of service in primary care and particularly in rural areas. We’re seeing some of that work. There are a lot of people who feel compelled. You mentioned, when I was up at the Chan School at Harvard and I was teaching a graduate school class, and I love public health people because they care so passionately about others and they want to get in this field. Making it financially viable for them to be able to complete the mission that they feel in their heart, I think, is something that I think is worthy of greater investment. 

Sununu: To that point, I think it’s a great idea and it definitely works. But even before that, just look at what it costs to go to a four-year college now, right? I’m a parent. I have a 20-, 19-, and a 12-year-old. So we’re all absolutely looking at what college costs, and I don’t mind picking on a few of them. Like NYU [New York University], what, a $100,000? So my daughter’s not going to be a nurse, even think about being a nurse, because questioning whether she even goes to college, right? Because she might go to take community college classes instead or do something else. So, or she’s got to find that other pathway. So the initial steps to getting to be a doctor or higher-level primary care physician even, there’s a huge barrier before the barrier. 

And so I think we just need to think holistically about how young people and why they’re making certain choices, and the financial aspects of going to college, I think, over the next 10 years are going to really blow up and create a massive problem. And sometimes it’s very healthy, right?. Sometimes it’s great that young people are thinking differently. It’s not, Go to a four-year college or you don’t have value. No, they think totally different. They know they can have a great life path in other areas, but that postsecondary first-four-year barrier right now is just, we’re just scratching the surface of how big it will be in terms of preventing them from entering the four-year. 

Rovner: We’re running out of time. I do want to let the audience— 

Sebelius: Can I just— 

Rovner: Yes. 

Sebelius: One thing to Gov. Sununu’s point. So there is the national commissioned health corps, which does pay off medical debt for nursing students blah blah blah. What we found, though, is a lot of people couldn’t even get to the medical debt, because they can’t get their college paid off. They can’t get into medical school. So moving that to a much more upstream, into high school, into early college, is the way we get— 

Sununu: Certificate programs in high school, like pre-nursing programs, social-work programs in your vo-tech schools — huge opportunities there. You get like a 14- or 15-year-old excited about helping someone. You’re giving them a certificate. They could enter the workforce at 19 in some ways. And then the workforce is helping them pay off that schooling or expanding those community— 

Sebelius: Or sending them on. 

Sununu: Yeah. There’s all these other ways to do it. So I think that’s the gateway that we have to keep opening. 

Sebelius: It’s got to be earlier though. 

Sununu: Much earlier. 

Rovner: All right, we have time for a couple of questions. I see a lot of hands. Wait until a microphone gets to you. OK. 

Stephanie Diaz: Hi, and thank you for this amazing conversation. My name is Stephanie Diaz. I’m with a corporate venture fund attached to a health system. Really thrilled for this conversation, and where it ended on workforce is really compelling. The Big Beautiful Bill and the Senate version has a cap on financial aid for degrees like medical programs. Considering what you just said, what are the goals of legislation like that and what can— 

Sebelius: No idea. 

Diaz: Why? 

Cooper: Save money. 

Sununu: Yeah, yeah. 

Cooper: Finding a way. 

Rovner: What would the impact be? I think that’s probably a fairer question. 

Sununu: Well, in this field would be devastating, right? I would imagine. I don’t know what the cap is. I don’t know what they’re basing that on. I don’t know if they’re— 

Diaz: $150,000. And we know that a medical degree costs, well, more than $150,000 for a student. 

Rovner: I think they’ve said the goal is that they want to push — they want to force down tuition. 

Sununu: Well, the government forced up tuition. That’s a whole different conversation. 

Cooper: They’re going to force out med students is what they’re going to do. 

Sununu: Look, I’ll be the devil’s advocate$150,000 for primary care, for example. If you’re a primary care — any medical degree, yeah. I don’t know what the thought process is other than they’re probably saying, well, these doctors, once you get your degree, you’re making a heck of a lot of money. These guys can pay stuff off. Let’s move that tuition or scholarship money to the social workers, to the MLADCs, to the community colleges, because that’s where you find more low-income families that can’t pay even $7- or $10,000 at a community college. That’s the real barrier. Low-income families as opposed to, look, giving $150,000, that’s a lot of money. And if these guys — if there’s anyone in America that can actually pay off college debt, it’s a doctor. So I’m being a little bit devil’s advocate because I don’t know the heart of the program, but that’s a heck of a lot of money and that’s a lot more tuition and scholarship funds than any other profession in the country. So I think it’s just about finding a balance. I am being a little devil’s advocate because I don’t know the details. 

Rovner: All right, I think I have time for one more question. 

Speaker: I’m a CFO at an ACO [accountable care organization] in Nebraska, and if I have to brag, our per cost, per beneficiaries, under $10,000 per reported on the latest 2023 numbers. Can you speak to the administration’s thought on value-based care contracting? And I know in Project 2025 it was referenced that — you’re laughing. 

Sununu: No, I hate hearing those words. 

Speaker: I did dig into that. And it is talked about to be attacked, value-based care contracts moving forward. So I was hoping that you could speak to that, maybe the intention of this administration, so thanks. 

Cooper: You want to talk about the intent of this administration? 

Sebelius: I’m not going to speak about this administration. You can speak about that. 

Sununu: No, I have no idea what the intent was. And every time I hear Project 2025 I shudder because it’s like, ah, I hate that thing. But, I don’t know why. 

Speaker: No not why but for behind the scenes do you think there’s still support for— 

Sebelius: I can tell you it’s one of the areas I think there’s huge bipartisan support inside Congress. So folks have come after it often from the health system because they really didn’t — they’d much rather, in some cases, have the fee-for-service payment. If I operate, I want to get my money. If I’m an anesthesiologist, I want to get my money. So value-based care really began to shake up the health system itself, health providers. I don’t know what this administration intends to do, but I know Congress has really wrapped their arms around value-based care and is really pushing the administrative agencies inside D.C. to continue and go faster. Bundled care for an operation where you put all the providers together and look at outcome. A lot of things that the ACOs are doing, congratulations. But that notion didn’t even exist before 2010, and I think it is absolutely on a trajectory now that it’s not going to go back. 

Sununu: And I’ll add this: As kooky as your successor is, the current HHS secretary, because he’s kooky, he’s not on board, either. So I think, again, regardless of what the administration wants, I don’t think that— 

Sebelius: Oh, not on board with getting rid of that. 

Sununu: Yeah, exactly. Not on board with getting— 

Sebelius: I just wanted to clarify. 

Sununu: I don’t think there’s going to be changes. I don’t think Congress is there. I don’t think the current secretary is there. I don’t know where the current secretary is on a lot of different things. He seems to change his mind quite often, but just don’t eat the red dye and you’ll be fine. 

Sebelius: But it’s one of the few places I would say— 

Cooper: Is there anything in the BBB [Big Beautiful Bill] on that? 

Rovner: We are officially out of time before Gov. Sununu gets himself into more trouble. I want to thank the panel so much and thank you to the audience, and enjoy your time at Aspen. 

OK. That’s our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our producer, Francis Ying, holding down the fort in Washington, and our editor, Emmarie Huetteman, here on the ground with me in Aspen. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, all one word. Or you can tweet me. I’m @jrovner. Or on Bluesky, @julierovner. We’ll be back in your feed from Washington next week. Until then, be healthy. 

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“We are full of people who come from other countries,” Goodness, 92, said about Goodwin House Alexandria’s staff. Without them, the retired Episcopal priest said, “I would be, and my building would be, desolate.”

The long-term health care industry is facing a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.

But in January, the Trump administration rescinded former President Joe Biden’s 2021 policy that protected health care facilities from Immigration and Customs Enforcement raids. The administration’s broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. “People may be here on a green card, and they are afraid ICE is going to show up,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.

Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid. Care for 6 in 10 residents is paid for by Medicaid, the state-federal health program for poor or disabled Americans.

“We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges,” said Eric Roberts, an associate professor of internal medicine at the University of Pennsylvania.

The industry hasn’t recovered from covid-19, which killed more than 200,000 long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors’ offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death has risen alarmingly from 17% in 2015 to 28% in 2024.

In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that would require most of the nation’s nearly 15,000 nursing homes to hire more workers.

The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.

In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency “is committed to supporting a strong, stable long-term care workforce” and “continues to work with states and providers to ensure quality care for older adults and individuals with disabilities.” In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers “need to do that by coming here the legal way” but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.

Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the best-staffed nursing homes in the country. Forty percent of the organization’s 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.

“As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization,” said Rob Liebreich, Goodwin’s president and CEO.

Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. “She was sitting outside,” Conteh, 56, recalled in an interview.

Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn’t afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.

Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.

“Nearly every one of us from Africa, we know how to care for older adults,” she said.

Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.

In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents’ skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called “small houses” and a wing for memory care, at least 72 were born abroad, Hutter said.

Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.

“I have a bad leg and I can’t stand on it very much, or I’d fall over,” he said. “She’s in there at 7:30 in the morning, and she helps me bathe.” Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.

Conteh said Goodness was withdrawn when he first arrived. “He don’t want to come out, he want to eat in his room,” she said. “He don’t want to be with the other people in the dining room, so I start making friends with him.”

She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community’s resident council and enjoys distributing the mail to other residents on his floor.

“The people that work in my building become so important to us,” Goodness said.

While Trump’s 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, including refugees who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security revoked the work permits for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.

“I’ve just spent my morning firing good, honest people because the federal government told us that we had to,” Rachel Blumberg, president of the Toby & Leon Cooperman Sinai Residences of Boca Raton, a Florida retirement community, said in a video posted on LinkedIn. “I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals.”

At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. “They’re scared,” she said. “Nobody trusts anybody.” Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.

“If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?” Conteh asked. “What will become of our old people that we’re taking care of?”

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

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