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

Julie Rovner: Hello from 51ÊÓƵ Health News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 51ÊÓƵ Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with 51ÊÓƵ Health News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

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

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

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

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

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

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

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

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

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

Rovner: Yeah, we will, but we’ll believe it when â€¦ we get to the signing ceremony. 

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

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

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at 51ÊÓƵ Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

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

Julie Rovner: Hello from 51ÊÓƵ Health News and WAMU Public Radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 51ÊÓƵ Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 8, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.

We are joined via videoconference by Lauren Weber of The Washington Post.

Lauren Weber: Hello, hello.

Rovner: Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hi.

Rovner: And Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: No interview this week, but tons of news to catch up on, so let us get right to it. So, we start 2026 in health care the same way we ended 2025, with a fight over expiring subsidies for the Affordable Care Act. By the time you hear this, the House will likely have approved a Democratic-sponsored bill to reinstate for three years the expanded ACA subsidies that were in effect from 2021 through the end of 2025.

That vote was made possible by four Republicans crossing party lines in December to sign a discharge petition that forces a floor vote, over the objection to the House leadership. Interestingly, a preliminary vote on the bill on Wednesday drew not just the four moderate Republicans who signed the original discharge petition but five more, for a total of nine. The consensus of political reporters is that the bill is DOA [dead on arrival] in the Senate, which voted an identical proposal down in early December.

But I’m wondering how much heat Republicans were exposed to over the break by constituents whose out-of-pocket costs for insurance were doubling or more, and whether that might change the forecast somewhat. What are you guys hearing?

Weber: So, it seems that there are still some big hurdles to cross. And based on what senators told my colleagues over the past couple days, there’s not even an agreement on what current law is and does, and thus, they can’t agree on how it should change. And so, I’m talking specifically about the still-unresolved abortion issue.

This is the question of whether plans that cover abortion should receive any federal subsidy, even if those subsidies do not directly pay for an abortion. The Republicans are arguing that it’s an indirect subsidy, even though these are going into separate accounts. So, one of the Republican senators who is trying to craft a deal — that’s Bernie Moreno of Ohio — he was saying that they still don’t agree whether, under current law, federal funding is going to abortion.

So, it’s like you don’t even have a shared reality that senators are operating under, and that makes it really hard to come up with a proposal. They say they’re going to have text by Monday, but we’ll see if that actually happens.

Rovner: Yeah. Well, before we get too deeply into the abortion issue, which we will do in a minute, I want to talk a little bit more about that. I won’t even call it an emerging compromise. I’ll call it a potential compromise in the Senate.

Ollstein: Some bullet points were shared.

Rovner: Some bullet points. We know what the bullet points are. They would extend the additional subsidies for two more years, not three, with a couple of changes, including capping income eligibility for those subsidies at 700% of poverty up from 400% that it reverted back to on Jan. 1. It would also replace zero-premium plans with $5-per-month plans. That’s to crack down on brokers who fraudulently sign up people who don’t even know they have insurance so the brokers can collect commissions. And it would allow people to choose whether their enhanced subsidies should go into Republican-favored health savings accounts or directly toward their premiums.

Assuming — and this is obviously a big assumption — they could get past this abortion issue, what are the chances for a compromise that looks something like this? I mean, it sounds like something that could satisfy both Democrats and Republicans, particularly Republicans who are feeling pressured by their own constituents who’ve now seen there — are either dropping their insurance or seeing their out-of-pocket cost just goes wild.

Ollstein: I’ve heard some criticism from the Democratic side about getting rid of zero-premium plans specifically. They’re saying the Republicans want to run on affordability and helping out people who are struggling. How does eliminating the ability to get a zero-premium plan align with that?

And so I expect there will be some clashes over that. But I also think, again, senators aren’t even agreeing on what the current reality is, and that applies there, too. There have been all of these allegations of widespread fraud, and some experts and lawmakers have been pointing out that just because someone who is enrolled doesn’t actually use their benefits, that doesn’t necessarily mean there’s fraud going on.

It does seem like there is some fraud going on. You mentioned the perverse incentives for brokers, but a lot of this is circumstantial evidence rather than direct evidence.

Rovner: Also, one of the ironies here is that if you have somebody who’s healthy, who signs up for health insurance and doesn’t use it, that’s a good thing for the risk pool. You don’t want only sick people.

Ollstein: It helps everyone.

Rovner: There’s a lot of things making my head explode. Well, one of the things that Alice, I know, is making your head explode, too, is this disagreement about reality about abortion. And I would point out that President [Donald] Trump spoke to the retreat of the House Republicans this week and urged some flexibility, put that in air quotes, on this Hyde Amendment issue. Alice, remind us why this is an issue here. Doesn’t the Affordable Care Act already ban federal funding of abortion just like all other federal programs?

Ollstein: Yes. Yes, it does. So basically, this is part of a larger project on the right to expand the definition of Hyde.

Rovner: We should probably go back to the very beginning of what is …

Ollstein: Yes.

Rovner: … the Hyde Amendment because it only applies to annual appropriations, and that’s why it’s been important. I will let you take it from there.

Ollstein: Sure, sure. So, this is a budget rider that dates back to the 1970s that says that there can be no federal funding of abortion, except in a few instances, of there’s a risk to the mother’s life, and rape and incest. And so that has been renewed over and over under administrations of both parties, under Congress majorities of both parties.

And now, what they’re fighting over is, already federal funding that goes to these plans in the form of these subsidies, it does not go to pay for abortion directly. But conservatives are now arguing that if it goes to a plan that covers abortion using other funding, then that functions as an indirect subsidy. This is the same argument they’ve made about Title X, where any federal funding going to a program that uses other funding to pay for abortion, they now consider that sort of an indirect subsidy, even though it’s coming out of different buckets of money.

And so, what they’re pushing for is basically a nationwide restriction on any plan that gets a federal subsidy paying for abortion. So, this would have the most impact in the states where all plans on the ACA market are required to cover abortion, in states like California, New York, and Massachusetts, big states with many, many millions of people. And so that would have a huge impact and force those plans to either drop abortion coverage or forgo the federal subsidy. So, that would have a really big impact.

And Democrats say this is not necessary. There’s already restrictions that prevent federal funding to go to pay for abortion. And that is what the senators and everyone can’t agree on right now.

Rovner: That’s right. And that’s a big fund. Well, we’ll see where that goes. In the meantime, what the president was talking about when he called for flexibility on Hyde was actually health care writ large.

This clearly reflects what we know the president’s pollster has been telling him: that Republicans are currently at a distinct public disadvantage when it comes to health care, and not just the Affordable Care Act. Trump says that Republicans should, again, air quotes, try to “own” the health care issue. And he has spent a good bit of his first year working on health issues. At least he’s been talking about them a lot, but it turns out that his s are not mostly being felt by consumers here in the U.S.

The savings he’s negotiated are mostly going to the state and federal Medicare and Medicaid programs, as well as to people willing and able to pay out-of-pocket for their prescription drugs. And while the administration is making much of its December announcement about the first distribution of rural health funding that was authorized in last summer’s budget bill, that $50 billion in funding won’t make much of a dent compared to the nearly $1 trillion in cuts that were created for Medicaid in that same bill. So, my question from all of this is: Can Republicans use things like this to own the health care issue or at least cut into Democrats’ advantage between now and the midterms?

Weber: Well, I think it depends on what they end up doing with it. He brought up in that same meeting with legislators wanting to own IVF [in vitro fertilization], which is something he floated during his campaign that got a lot of shock from [the] conservative Republican base. So, what does he mean? What is he saying on that? We don’t have particulars.

Bottom line is, voters don’t necessarily know the in-the-weeds policy. So, if he gets out there and says enough things, who knows that they can own the health care issue? But I would say for now that it is solely in the Democrats’ camp and is helping lead them with an advantage for midterms for now.

Rovner: Sarah, he keeps saying on drug prices that he’s done all this stuff, and he has done a lot of stuff, but it hasn’t had a big dent in what people pay for their drugs, right?

Karlin-Smith: Right. And I think the one reason drug pricing has been a popular health policy topic for politicians to focus on is because people really can feel it directly compared to how they feel other health costs. And so, I think that there’s only a certain amount of time where people will just accept Trump saying, Oh, we’re saving you money, without them actually seeing it on the back end. And the problem right now is these most-favored-nation deals where he’s struck privately with a lot of drug companies to get Medicaid, really mostly at this point, in theory lower prices.

It’s not clear how much money it’s actually going to save Medicaid because Medicaid actually gets some of the best deals that the U.S. gets. Most people on Medicaid actually don’t really directly pay copays for most of their products, either. The other problem is they’ve then rolled out a number of other drug-pricing models to try and pair this concept, again, of getting the prices a lot of other countries get for drugs in the U.S., but they then exempted all these companies they’ve struck these private deals with.

So, it’s not really clear who is left in terms of drug companies and drug products. Then you might get cheaper prices under some of these other demonstrations, which by their nature, these are demonstration pilot programs that are not going to reach every Medicare beneficiary they’re pushing for. So, I think it’s going to be a big problem because many people are not actually going to see savings.

For people that have a decent amount of income and can afford some of these direct-to-consumer products where health insurers have often been denying it — like the weight loss, common popular weight loss drugs — some people may feel a little benefit there. But if you’re somebody who’s underinsured or uninsured, even if there’s really good discounts on a direct-to-consumer buying market, you’re probably also still not going to be able to afford these weight loss drugs.

Rovner: Yes, Lauren.

Weber: Just to go back to the rural health fund disbursement, I just have so many thoughts on this, because I mean, at the end of the day, rural hospitals are also the equivalent of rural jobs programs for rural America. And typically, rural hospitals fall in red America. And so, this attempt to prop them up, it sounds flashy, right? I mean, it’s billions of dollars. But when you break it down by the 50 states, it’s hundreds of millions, like tops like $281 million depending on the state.

That’s not going to cover the deficit that the bill has created for those folks. And I understand that it’s meant by the administration to be a flashy way of, Oh, we’re supporting rural health care, but the crushing Medicaid cuts that these rural hospitals are going to face, when they already operate on such thin margins, will be devastating. I mean, it will be devastating for already health care deserts that we already see, and this money is not going to be enough to stop the blood flow there in rural America.

Rovner: And Alice, you guys at Politico pointed out that even this $50 billion was not exactly distributed based on need, right? It was distributed based on deals.

Ollstein: Yes. And to build on Lauren’s point, not only is it not enough to make up for the Medicaid cuts, but there are restrictions. States can only use a little fraction of the money to keep these rural hospitals’ lights on, basically. The money is supposed to be for these transformative projects. It’s very tech focused. It’s very, Let’s try these pilot programs and completely revamp the way rural health care is delivered. Meanwhile, there are all these rural hospitals on the brink of closure, and states aren’t allowed to spend a lot of the money on just paying the salaries of the people who work there, paying for keeping the buildings in good shape. And so, we could see benefit from this money, but we could also, in the meantime, see a bunch more rural hospitals close, as they have been. And once they close, it’s really hard to come back.

And so, to your point, the way the money was distributed is getting a lot of criticism from all around the country because, one, a lot of it was split evenly between states regardless of the size of their population. And so, you saw, for instance, Alaska get more than California despite having a tiny, tiny sliver of its population. And I had people arguing with me online saying, Well, what about the rural population? Yes, California has a huge rural population. It’s not just LA and San Francisco. So, even if you only count the rural population, it’s much, much, much bigger than Alaska.

Also, there were these policy incentives in the program where states that adopted Trump-administration-friendly policies — like restrictions on what people can buy with SNAP [Supplemental Nutrition Assistance Program], on implementing the presidential fitness test, on deregulating short-term insurance plans, which Democrats have criticized and called junk plans — these would get the states more money if they adopted these policies. So, we’ve been digging into that and digging into the struggles on the state level on that front.

Rovner: All right. Well, that’s the rural health news. We’re going to take a quick break. We will be right back.

So, the other big news out of HHS [the Department of Health and Human Services] was on the vaccine front where Secretary Robert F. Kennedy Jr. made unilaterally a major change to the federal government’s childhood vaccine schedule, reducing the number of diseases with explicit vaccine recommendations from 17 to 11. No longer recommended for all children will be vaccines to protect against flu, covid, rotavirus, hepatitis A, and the germs that cause meningitis. Sarah, you’re the mom here on this panel today. How is this schedule change actually going to affect parents and children and doctors?

Karlin-Smith: I think a lot of it is going to depend [on] how the pediatrician health community reacts to this, because there’s been a lot of pushback from the medical public health community that this is not an appropriate or scientifically based change. So, doctors may still guide parents to hopefully making the decision to get these vaccines, but parents who may be a little hesitant, maybe feel more comfortable backing out.

Despite sometimes the rhetoric you hear from this administration, states are really the ones that end up creating policies that end up with actual mandates for people to get vaccinated for school and so forth. So, states may build off this and change their mandates, and that may impact access, but they may also not. So, people may still have to, for school purposes, get some of these shots as well.

Rovner: And I should point out that the American Academy of Pediatrics is fighting this, I would say tooth and nail, but also in court. I mean, they’re actually suing, saying that Kennedy didn’t even have the authority to make this change without going through a much more detailed regulatory process.

So, the administration says that all the vaccines currently on the schedule will remain, quote, “covered by insurance,” but I’m not positive that’s necessarily going to be the case in the long term, right? Isn’t mandatory insurance coverage linked to the recommendations of the CDC [Centers for Disease Control and Prevention]? And if these are no longer actually recommended, are they no longer required to be covered?

I know the insurance industry, we’ve talked about this, has said that they’re going to continue to cover all the vaccines at least through 2026. But I’m wondering about the legality. I tried to track this back, but I couldn’t find it all the way.

Ollstein: We could see a patchwork because a lot of states are moving to change their own laws about insurance coverage and have it be based on something other than these federal recommendations. I think that obviously patchworks are challenging when you’re talking about infectious diseases, which do not respect state or national boundaries, but Sarah can say more.

Rovner: Go ahead, Sarah.

Karlin-Smith: Yeah. To build on Alice’s comment, and the thing that gets really confusing really fast always with U.S. health care is states can regulate certain insurance plans and states cannot regulate certain insurance plans, the ERISA [Employee Retirement Income Security Act] plans. So, you could end up, even if states want to mandate coverage, depending on the type of health care coverage you get in your state, you may live in that state, work in that state, and you’re not going to get covered. So, that adds to the patchwork and always adds to the confusion when trying to explain that issue to people.

But the administration has claimed basically because the vaccines, they’re no longer universally recommended — they’re moving to what’s called the shared decision-making recommendation, where people are supposed to consult with their doctor and figure out whether these vaccines are appropriate for them and their children — that that still, under the way laws and regulations are written, requires the mandatory coverage for health care and no copays and so forth.

And I’ve talked to people who’ve looked at this, and there is precedent for that with other vaccines. I think there’s some concerns, however, that that could be challenged by people in court who don’t want these vaccines to be covered. There’s also concern when it comes to like the HPV [human papillomavirus] vaccine, which they’re now only recommending one shot of instead of two.

In that case, because they’ve really fully eliminated the recommendation for a second shot, if somebody felt like they wanted that two-series shot, I don’t think that would be covered. And the other question is, while they didn’t use the CDC’s Advisory Committee on Immunization Practices to make these changes for the most part. And they are largely advisory, but they do have certain legal authority when it comes to vaccines for children’s program, and their legal authority from Congress very much relates to the coverage and reimbursement. So, it’ll be interesting to see, again, if this all aligns.

Rovner: And we should point out that the Vaccines for Children Program, which many people have never heard of, is actually responsible for vaccinating something like half of all children in the United States. It’s a huge program that’s just basically invisible but really, really important.

Karlin-Smith: Right. And so, I think there’s going to be legal questions that they didn’t vote on those reimbursement questions here.

Rovner: Yeah. There’s a lot that’s going to have to be sorted out here. Well, one of the arguments that HHS officials are making is that they compared the U.S. vaccine schedule to that of, quote, “peer nations” like Denmark, but those peer nations have something the U.S. does not: universal health insurance. That can make a really big difference in vaccine uptake and in just the prevalence of disease, right?

Karlin-Smith: Yeah. And so, one thing that people have tried to look at and explain in recent days is the U.S. isn’t actually that different from most of its peers. Denmark, some have made the case, is actually the outlier. And if you look at Germany, Japan, Canada, Australia, the amount of pathogens, viruses the U.S. is vaccinating against is actually much more in line with most of the peer population. And then when you have a country like Denmark, which has universal health insurance …

Rovner: And a very small population.

Karlin-Smith: Right. I mean, it’s very different, but they’ve made in some cases the calculus that if we don’t vaccinate for rotavirus, and we are able to treat the however many kids each year will need to be hospitalized and treated, and you have a certain comfort — I don’t think that most parents would like the idea of knowing your kid is going to get sick and need to be hospitalized maybe or treated — but there’s a lot more comfort that they would get care, and quick care, and would do better there. But they certainly are not, and there’s data to show, [they] don’t do as well as the U.S. does in terms of the amount of people that get some of these diseases.

The other thing with some of the vaccines I noted that like some of these comparison countries don’t cover is they’re newer and they’re still more expensive. So, sometimes one of the reasons these countries are choosing not to recommend them more broadly is because they’re making decisions based on the fact that they have universal health care — the taxpayers pay for it — and then deciding that at this point, the pricing is not affordable. They’re not making a decision saying if the cost was zero, that the risk-benefit calculus isn’t favorable for people.

Rovner: Right. And it’s all about the risk-benefit calculus. So, one thing we know is that the rise in vaccine hesitancy is leading to outbreaks of previously rare diseases in the U.S., including measles and pertussis, or whooping cough. Lauren, you’ve got a really cool story this week with a tool that can help people figure out if they and their families are at risk. So, tell us about it.

Weber: Yeah. My colleagues at The Washington Post, including Caitlin Gilbert, and I set out last year to tell people across the country what their . And so, we requested records from all 50 states and were able to get school-based records for about, I think, 36 of them and county-based records for vaccination records for 44 states. So, we have a nifty tool where you can look up in your local community what your vaccination rates are.

But taking a step back, what we found in our reporting is that before the pandemic, rates weren’t looking that great. Only half of the country was making 95% vaccination against measles, which is herd immunity. After the pandemic, that dropped to 28%.

And what we found in digging in a lot deeper is that schools, which were once considered kind of this bulwark against infectious disease, because they’re the ones who would enforce whether or not you needed your shots to attend school, are somewhat stepping away from that responsibility in the politically charged environment that is America today. I spoke to a superintendent in Minnesota, which has seen a large drop in vaccination for measles, who said, Look, I’m a record keeper. It’s not my job to promote a medical decision.

And you see that attitude across the country in school nurses and so on where maybe they’re not being empowered by their superintendent or principal to draw the line, or they’re valuing the child going to school over getting vaccinated. And so, there’s a lot of talk about at the state level that we have these mandates for vaccination, but if they’re not enforced and there’s no mechanism to enforce them, our investigation found that you had these slipping rates.

And a lot of folks are really concerned. Because look to South Carolina. You have hundreds of kids quarantined and missing school; you have hundreds of people infected. And, in general, measles cases were at their highest in 33 years last year. So, we have this rise of infectious disease amid an administration headed by a man who has disparaged vaccines for years and is working to roll back policy around them.

Rovner: Is there any talk from Capitol Hill on … we’ve talked so much about Sen. Bill Cassidy [R-La.], who’s a doctor, who was the deciding vote for RFK Jr. and said that he got RFK Jr. to promise not to change the vaccine schedule, which he just did. But it’s not just Cassidy. There’s 534 other members of Congress. Is anybody pushing back on any of this?

Weber: I mean, Cassidy tweeted after the vaccine change that he was appalled. I’m a physician. My job is to protect children. This is a problem. At the end of the day, the person who runs HHS is a man who has repeatedly linked the rising number of vaccines, which are rising because we have more vaccines that can fight more pathogens, to chronic conditions that experts say is not based in evidence.

And so, no, I do not see a massive Capitol Hill pushback. I mean, you have frustration and irritation, but I don’t see Cassidy hauling Kennedy in for a hearing. Hasn’t happened yet, really, besides those couple that were mandated. So, we’ll see how this continues to play out.

But the reality is amid all of this talk of vaccine schedules, the people on the front lines of this are these school nurses or pediatricians who are met with a wave of parents who are so confused. I talked to so many pediatricians who said, Look, we refer to the AAP, the American Academy of Pediatrics, but it’s really hard when the president and the head of the health system is saying something different to convince parents that may be confused. And oftentimes, if you’re confused, it’s easier to not take action, to not get your child vaccinated than to do so. And…

Rovner: And because pediatricians don’t already have enough to do.

Weber: Right. Many are scared that these trends that we identified in our investigation will continue to worsen in the years to come.

Rovner: Well, also this week we got the new food pyramid recommendations from HHS and the Department of Agriculture. Food, obviously another big priority for RFK Jr., who, as we know, is a fan of red meat and whole-fat dairy. Unlike the vaccine schedule, though, the changes to the food pyramid appear, at least at first blush, to hew to fairly consensus opinions in the nutrition world that whole foods are better than processed foods, protein is good, added sugar and refined carbohydrates are bad.

Still, when you get into the details, there are some things that are likely to cause nutrition scientists, some, shall we say, indigestion. What are some of the more controversial recommendations here other than Dr. [Mehmet] Oz saying in Wednesday’s press briefing that you might not want to drink alcohol for breakfast?

Ollstein: So, the alcohol piece has gotten pushback because it’s weakening the previous recommendation that really no amount of alcohol is safe. We talked before about a report about alcohol as a carcinogen that was buried last year, a government report that had been worked on for years that was supposed to come out that got buried by the Trump administration. And so that I think is reflected in these new recommendations. And I saw a lot of conservatives celebrating this and saying, Happy hour’s back, everyone! But look, there’s real science that shows the dangers of even moderate alcohol consumption, and that’s getting sidelined here.

Rovner: The previous recommendations were that, I would say the previous recommendations were like no more than one drink a day for women and two for men, and they took that away? I think that was the actual change here.

Ollstein: There was a push to say that no amount is safe, basically, that even small amounts are potentially harmful to health.

Rovner: And that didn’t happen.

Ollstein: Correct, correct. The other concern I was hearing is about the emphasis on red meat when that is something that Americans eat too much of already.

Rovner: Although I know there’s an irony here that I think the new recommendations state, you still shouldn’t have more than 10% of your calories from saturated fat. But saturated fat isn’t nearly as bad as we used to think it was, Sarah. I see you nodding.

Karlin-Smith: Yeah. I think the saturated fat and the focus on the sources of fat and protein is one of the biggest controversies here because there is lots of research and evidence that saturated fat can lead to heart disease and other medical complications. And people have long been pushed toward plant-based proteins, leaner proteins, and the role of dairy, and whether you should be doing high-fat dairy as well.

And there’s been some good reporting from Stat and others of recent days that there was a lot of who was making these recommendations around their relationships with these various industries. They tried to avoid contradicting the science too much in how they made their push for more red meat and more saturated fat. But it’s probably another area where, if you read it in full, you’re going to get confused and you may not end up making the right decisions because some of the recommendations there are kind of contradictory.

Rovner: Although we’ll point out that the difference between the nutrition guidelines and the vaccine schedule is very large because the new nutrition guidelines are just that. They’re guidelines. They do determine what gets served in school lunches and things like that, but it’s not quite nearly of the level that the vaccine schedule is.

Well, finally this week, turning to reproductive health, the Wyoming Supreme Court struck down two abortion bans, kind of remarkable for one of the reddest states in the nation. Interestingly, one of the reasons the bans were struck down is because the state tried to thwart the Affordable Care Act back in 2012. Alice, explain what these two things have to do with each other.

Ollstein: Yes. So, the state adopted some laws saying that people have the right to make their own health care decisions, and that was squarely aimed at the Affordable Care Act. However, the judges found that it also applied to the right to have an abortion.

Rovner: Oops.

Ollstein: They said, Based on the text of this law, it doesn’t matter what you meant it to say. It matters what it actually says. And we find that it applies here.

That’s actually not the only state where that’s happened over the past few years. There have been other conservative states that have inadvertently protected the right to abortion through these right-to-control-your-own-health care provisions. So, I think we’ve seen over the past few years that state constitutions can be more protective of abortion than the federal Constitution in certain circumstances. But I think it’s also notable that Wyoming had one of the first laws specifically banning abortion pills, and that was also struck down.

So, nothing changes in practice, because these laws were already enjoined and were not being enforced, but it is a big deal. And it could lead to more efforts to hold the ballot referendums that we’ve seen over the past few years. There are set to be a few more this fall, but there could be even more following decisions like this in the courts.

Rovner: Yeah. Along those lines, there’s a really interesting piece in The Guardian that suggests that , but not so much for Republicans, most of whom still consider it a deal breaker for a candidate not to agree with them. What happened to all that enthusiasm for abortion rights that we saw in 2023 and 2024 to some extent?

Ollstein: Look, there’s a lot going on right now. So, it may be that just other issues are overshadowing this. And also, it’s a long way to go before the elections. We do not know what’s going to happen.

If various court cases lead to a big change, another big change in abortion access, this could rear its head once again. As we’ve discussed many times, this is not really ever over or settled.

Rovner: All right. Well, it is January. All right. That is this week’s news, or at least as much as we had time for.

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

Weber: Yeah. I have to shout out another investigation my colleagues and I completed led by Rachel Roubein and Lena Sun and I. [“”] We dug into the first year of Kennedy in office. In interviews with nearly a hundred folks and documents, we uncovered some of his previously undisclosed shaping of vaccine policy. We got ahold of an email in which a top aide asked to replace the membership of ACIP and reconsider the universal hep B vaccine recommendation and revisit the use of multidose flu shot vials. We also analyzed how while Kennedy has talked about food twice as much as vaccines while in office, one of his advisers, Del Bigtree, told us, Look, food is more popular with the American mom. And I think some of these revelations shape and put into context what we’re seeing now, which is this culmination of changing the vaccine schedule and continued policy to upend public health infrastructure in this country.

Rovner: That’s a really good piece. Alice.

Ollstein: So, I have a very depressing piece out of San Francisco called, “” This is yet another death of a young person after heavily using some of these LLMs [large language models] for advice. Some of the chat logs show that he was able to very easily circumvent the protections that were put in place.

ChatGPT is not supposed to give people advice on using drugs recreationally, but that is very easily circumvented by pretending it’s a hypothetical question or various other means. And this article does a good job showing that it’s really a garbage-in-garbage-out scenario. ChatGPT is drawing from the entire internet. And so somebody’s dumb post on Reddit by a person who has a substance abuse issue, for instance, could be informing what advice the bot gives you. And so I think this is especially important to keep in mind as, just this week, ChatGPT is launching, making a big push, launching a whole health-care-focused chatbot and encouraging millions of people to use it.

And so this article … quotes experts who argue that it’s not possible to prevent this bad advice from getting in there, just because these chatbots are trained on huge volumes of text from the entire internet. It’s not possible to weed out things like this. And so I think that’s important to keep in mind.

Rovner: So, what could possibly go wrong? Sarah.

Karlin-Smith: I took a look at some ProPublica pieces on the impact of the U.S.’ USAID cuts [“”]. One of the stories that I looked at was “” It’s just a really deep dive into the decisions that these political leaders made to cut off aid and support for various countries. This one, in particular, was looking at South Sudan, even though they were warned that they would make certain disease outbreaks and other humanitarian situations worse. And it just goes through the hardship of that, as well as the fact that Trump administration officials were making claims throughout this time, once there was pushback, that they were going to not cut off certain life-supporting aid and so forth. And that was not actually the case. They did cut it off, and they did it in ways that were extremely abrupt and fast, that there could not be any safety valve or stopgap to prevent the harm that occurred.

Rovner: Yeah. It’s quite the series and really heavy but really good. My extra credit this week comes from my colleague Fred Schulte, who’s moved on from uncovering malfeasance in Medicare Advantage to uncovering malfeasance in cosmetic surgery. This one is called “Advertisements Promising Patients a ‘Dream Body’ With Minimal Risk Get Little Scrutiny.”

And if you’ve ever been tempted by one of those body-sculpting commercials promising quick results, little pain, and an immediate return to your daily routine, you really need to read this story first. It includes a long list of patients who either died of complications of allegedly minimally invasive techniques or who ended up in the hospital and with scars that have yet to heal. Many of the lawsuits filed in these cases are still in process, but it is definitely “buyer beware.”

OK, that is this week’s show. Hope you feel at least a little bit caught up. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer engineer, Zach Dyer.

A reminder, What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X, , or on Bluesky, . Where are you folks hanging these days? Lauren.

Weber: I am on X, , and same thing on these days.

Rovner: Sarah?

Karlin-Smith: Mostly and at @sarahkarlin-smith.

Rovner: Alice.

Ollstein: Mostly on Bluesky, , and still on X, .

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