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

Julie Rovner: Hello, from 51ÊÓƵ Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 51ÊÓƵ Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, July 23, at 10:30 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go.  

Today we are joined via video conference by Margot Sanger-Katz of The New York Times. 

Margot Sanger-Katz: Hello. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi, Julie. 

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 our “How Would You Fix It?” interview with Louisiana Republican Sen. Bill Cassidy, chairman of the Senate Health, Education, Labor, and Pensions Committee. But first, this week’s news. I want to start this week with what I’m calling the “Shrinking Safety Net.” The Center on Budget and Policy Priorities is reporting that overall participation in SNAP [Supplemental Nutrition Assistance Program], the nation’s food stamp program, is down by more than 4½ million people. That’s about 11% between last year’s enactment of the Republican budget bill and this past April. In Arizona, nearly half the recipients have left the rolls, and in Louisiana, Florida, and Oklahoma, it’s closer to 20%. Nearly half of those losing benefits are children, according to the analysis, and this is before some of the biggest cuts to the program even take effect. What does this mean, and what does it portend for Medicaid cuts that the SNAP declines are so much larger than were anticipated when this bill was passed in 2025? 

Sanger-Katz: The Republican bill put a lot of new burdens on states that to administer SNAP, and it created these penalties that if they had a lot of errors, then they were going to end up having to pay a much larger percentage of that total bill. And I think what’s happened is that that sort of spooked a bunch of states, and I think Arizona in particular, is facing some complicated politics around the program. And so I think in their effort to reduce the error rate, they’ve created a lot more paperwork for beneficiaries to prove that they’re eligible, because the state doesn’t want to take a chance that if they go back and check later, that there will be some mismatch and they will get dinged for making an error. So I think there are real lessons for what’s going to happen in Medicaid. The SNAP changes are happening a little faster than the changes to Medicaid. But I think there are a lot of the same incentives. There also are going to be increased penalties for states that have a high error rate in Medicaid, and there are going to be additional paperwork requirements added to Medicaid for people to prove that they’re complying with the work requirement and certain other things that didn’t exist before. 

Rovner: And as we’ve said a bunch of times before, states who are anticipating these cuts are already making cuts because they have to do budgets before some of these cuts take effect. Joanne, you wanted to say something? 

Kenen: No, I think that Medicaid changed suddenly on June 1, right? I mean, the coverage losses were expected under the legislation. That’s how the money was saved. CBO says people will lose coverage, and that’s where the savings were, by and large. The interim final rule that dropped â€” but we didn’t know how bad it would be. We didn’t know how many people, partly because states had a fair, they had certain things they had to do, but they had a lot of flexibility in how to do them. So that the coverage losses were an unknown, right? They might have been as bad as the liberal critics said, and they might not have been as bad as some of the defenders of the law said. It was a wait-and-see. On June 1, as we’ve talked about before on the podcast, CMS [Centers for Medicare & Medicaid Services] dropped an interim final rule, and it changed things a lot. And it basically took away a lot of the state flexibility. And instead of letting states say, “OK, you have such-and-such a disease. We know you have such a disease. We have your medical records. We have the coding from the bills from Medicaid. This is, clearly, you can’t work.” That’s no longer good enough. You can’t use their medical history. Every single person who’s sick on Medicaid, who can’t work, who contends they can’t work, has to go for a workup by a physician. Right now we’re not sure if it’s other health providers, who really isn’t trained in disability medicine. Manatt just came out with a study just a day or two ago saying that the coverage losses are going to be much higher than anticipated. And there’s a lot of hurdles for individuals, and there’s a lot of costs for the states. So, like, the SNAP is now, like, OK, that was SNAP, and this is Medicaid. Now it’s just much more alarming to watch what happened in SNAP. 

Sanger-Katz: I think another lesson from SNAP is that we’re going to see a lot of state variability in the outcomes. You know, these are both programs, they’re federally funded, but they’re administered by states, and states have different capacities. They have different bureaucracies. They have different tolerances for spending money on these programs. And we’re seeing, even in SNAP, there’s kind of like people are losing coverage everywhere. But like in Arizona, it’s like half of the people. And I think that what we’re likely to see something similar play out in Medicaid, where some states either are just not willing to spend the money, or they’re very scared of penalties, and so they’re like really have very strict criteria. And other ones just, like, won’t be good at it, and they’ll make a lot of mistakes, and that will cause people to lose coverage too. I think every state is different. Every state is building this from the ground up, and there are going to be different levels of policy planning, risk tolerances, and just like general glitchiness as they roll it out. And I think we’re seeing that in SNAP. It’s a lesson of what we’re seeing now that will carry over almost certainly. 

Ollstein: And to that point, I think, in some places, like Joanne said, you are going to have to, you know, basically get a doctor’s note in order to keep your Medicaid coverage. But other states are trying right now to come up with some kind of 51ÊÓƵ to make that not have to happen. So saying, you know, if you have X many inpatient visits per year and Y many outpatient visits per year, or you have this many drugs that you’re on, then that is enough proof that you are too medically frail to work part-time. And so they’re trying to come up with ways to just pull it from data and not have to rely on patients and providers and give them this extra burden. But we’ll see if that’s approved by CMS. We’ll see if that’s successful. I mean, CMS’ guidance left states a little bit in the dark about how to operationalize this. 

Rovner: Well, that is the perfect setup, I would say, for my next question, which is we have a couple of stories from my colleagues here at 51ÊÓƵ Health News about complications to come from the Medicaid cuts, particularly the work requirements that states need to have in place by next Jan. 1. One of the stories, by Sam Whitehead, is about doctors who are worried about being swamped by patients who need medical documentation that they’re too frail to be subject to the work rules. Said one doctor in the story. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We are not trained to make these kinds of work determinations.” The other story, by Rachana Pradhan, Samantha Liss, and Kate Wells, is about how an automated eligibility system from IT giant Deloitte is rejecting eligible people with disabilities in several states, including Michigan, Tennessee, and Texas. Deloitte works on Medicaid eligibility systems in more than half the states. It’s heavily involved in creating these IT systems for their work rules. Fair to say, both of these things, as you guys were all leading up to, do not bode well for what’s about to happen to Medicaid. 

Kenen: No, and an additional factor, it’s not just Deloitte. I mean, states had contracted with the vendors. They didn’t have a lot of time. This bill was signed into law just about a year, almost exactly a year, ago, and they had 18 months to get ready. It’s Jan. 1, 2027. This June change to the rules means they have to really rework a lot of the tech they were doing, and they were given seven months. So is this as big as healthcare.gov? No, but it’s complicated, and the sort of blueprint and tech plans they were doing now have to be modified. And they’re still waiting on more guidance. There are still unknowns. 

Rovner: For those who don’t remember healthcare.gov â€¦  

Kenen: How can anybody not remember healthcare.gov? 

Rovner: There were people who were not around in 2013, Joanne, when healthcare.gov rather dramatically failed to launch. Sorry, Alice, I interrupted you. 

Ollstein: Yeah, no, we did some reporting about this weeks ago, and basically experts told us, Look, it’s problematic if these determinations are left up to individual physicians. There can be biases. Physicians aren’t trained to make these kind of determinations, like you said. People might not even be able to reach a doctor and make an appointment to get that outcome. But they’re saying if it’s not up to physicians, that could be even worse. If it’s up to some sort of algorithm or some sort of state bureaucratic office that never even meets the person and just makes a determination, and they may not know how to appeal it. And so states are worried about it being a lose-lose situation. 

Rovner: Yeah, well, in the Deloitte story, that’s exactly what it was. It was, you know, it was basically an automated system that was bouncing eligible people, either bouncing them out or putting them in inappropriate programs for which they weren’t eligible. They were having trouble finding a real person to fix what was obviously a mistake. 

Sanger-Katz: And I think one thing that both of these stories really emphasized to me is that whatever you think about the merits of this policy change, you know, like I think there are lots of Americans who think that it is reasonable to have a work requirement for Medicaid. And I also think there are lots of people who think that you shouldn’t just get out of that because you have a medical diagnosis. That there should be some reason why you can’t work. If we’re requiring people to work, maybe we want to require people to demonstrate that they can’t work, to get an exception. But whatever you think about the merits of those arguments, this is a monumentally difficult task for states to implement. This is not an easy policy. There is no all-knowing eye that can sort of look over the Medicaid population and decide who is eligible or not eligible according to these criteria. States have to create rules. They have to create what kinds of proof they’ll allow. They have to build computer systems that can sort people and that can make these determinations. And all of that is new and is very difficult. And is very slow. States, in most cases, don’t even build their own computer systems. They work with these contractors that do it for them, and the contractors have a mixed track record in really executing in a really clean way. So, I just think, you know, when you talk to people about this, I feel like we always talk about this in healthcare. There’s like the legislation. There’s like the idea, and Congress is trying to get the idea. These are the people that we want to get Medicaid, and these are the people that we want to encourage to work in order to maintain Medicaid. I think on the theoretical level, there’s that. But then there’s like the nitty-gritty implementation, and that’s like the regulatory process, that’s the state government, that’s the procurement, that’s the contracting. And I just think there’s a lot of sand in the gears of that. This is actually not easy for states to do, and even the states that are devoting a lot of resources to it and want to get it right, and even the states that really believe in the goals of the policy are probably like just bumping into a lot of the difficulties now. 

Kenen: And many of the people affected have chronic diseases; they’re up and down. You can have good periods when you’re working. You can have bad periods when you can’t, and that’s the nature of chronic diseases for many, many, many individuals. It’s inconsistent. So if you go to the doctor on Jan. 1, that doctor really doesn’t know. I mean, this is true of mental health as well. You know, how long can you work? How consistently you work? There’s just going to be all sorts of problems, and I promise to stop there. 

Rovner: OK. Well, also this week there are two immigration-related safety net stories. First, the Trump administration has officially rescinded the Biden administration’s rewrite of the so-called public charge rules, which are designed to ensure that legal immigrants are financially self-sufficient. The new rules, or the lack thereof, give immigration agents far more leeway to decide on their own who might or might not become dependent on government benefits. Alice, you covered this back in Trump I. It ended up with lots of people who were actually eligible for benefits not using them because they feared becoming or being deemed a public charge when applying for a green card or more permanent immigration status. Any reason to think the same thing isn’t about to happen again? 

Ollstein: No, there is no reason to think that history will not repeat itself. Although I will say that the policy now is not exactly the same as it was during the first Trump administration. The new policy just gives a lot of discretion to individual immigration officers to make a determination, looking at, like, the totality of someone’s circumstances. And so, you know, Medicaid and some of these other safety net programs that people are legally eligible for didn’t used to count against someone when they were applying for a green card, and now they could. Again, it’s not mandatory that, Oh, if you’re enrolled in Medicaid, automatically you’re barred. But it is something that an immigration officer would be allowed to consider. And so, yeah, a lot of concern not only from the immigrant ICE [Immigration and Customs Enforcement] community, but from states. I mean, this could affect state budget if people are going to need to turn for uncompensated care to other providers. There’s concern from the public health community about if people don’t have coverage to get vaccinated and to get checkups. It’s not like there are islands of immigrants. This is folks [who] are incorporated into our society. We live in a society, as we discovered during covid, and what impacts some people impacts everybody. 

Rovner: Yeah, and, I think as Margot said, it’s one of these things where the concept sounds great, and the carrying it out is a lot harder. Well, also a couple of weeks ago, we talked about how nursing homes and assisted living facilities are freaking out about the repeal of temporary protected status for immigrants from Haiti and Syria because so many of them work in the long-term care space. This week,  about how this immigration crackdown is reaching even further, to seniors who don’t yet need medical services but still require help with routine activities, who live in these, you know, senior buildings. There’s already a labor shortage for home health aides and others in eldercare, which is generally very hard work for very low pay. This could spiral into a real crisis. We’re going to end up with Gen X and millennials having to take care of their own baby boomer parents. 

Sanger-Katz: There was a really interesting study that was published a few months ago from Jonathan Gruber, the economist at MIT, and some of his colleagues that basically found that increases in the population of immigrants in a given place actually reduced mortality among Medicare beneficiaries. It seems really clear that immigrants are a really important part of the caregiving workforce in America right now. And, as you said, Julie, it’s home health workers, it’s nursing home employees, it’s people who work in hospitals, and it’s also people who are doing some of this kind of, like, informal elder care, helping out in assisted livings, helping people at home. You know, they may not be providing healthcare services, but they are helping elderly people who have healthcare needs. 

Rovner: It’s the people who work in the dining rooms. It’s the custodians in these senior buildings. I mean, it’s the people who, you know, who help people get around and drive them to doctor’s appointments. 

Sanger-Katz: I felt like that study â€” I was really struck by, because you get the sense that it’s not just that we see these people in these jobs, but that having more of them around actually seems to have a health protective effect for the people that live there. Because I think it does make it easier to staff all of these jobs and to staff them with people who are competent and who want to do that kind of work. 

Kenen: And who have language skills. There’s actually been studies showing that it helps to have more Spanish-speaking staff in nursing homes and rehab facilities. 

Rovner: All right. Well, meanwhile, Margot, since you are here, let us talk about surprise medical bills. A few weeks ago, we talked about the blockbuster story you wrote with Sarah Kliff about how some doctors were getting gigantic multiples of what Medicare or private insurance would have paid through the negotiation system that was set up to settle claims between insurers and providers. Now the administration says they may need to fix it? Catch us up. 

Sanger-Katz: Yeah, I mean this was a bit of a surprise to me, I will say.  that sort of gave us a sense of the scope of the system. Wasn’t hugely surprising, but the top-line numbers are. It looks like the amount of money that this system has awarded to doctors and other healthcare providers increased from around $4 billion in 2024 to $14 billion in 2025. So you can just like really see there’s been a huge growth in the number of cases, but it also seems like doctors are winning higher awards per case. And so, what’s happening is that the overall cost of the system has really ballooned. The Trump administration has said very little about this. They did finalize one regulation that had been proposed in the Biden administration that was kind of technical fixes. And yesterday they said that people are gaming the system and that they need to, quote, “clean it up.” So I do think this is the first indication we’ve seen that there is concern by Trump officials that there may be a problem with this arbitration system that doctors are using to resolve these disputes. But they provided no specifics at all about what they will do, what policy avenues they will pursue, and, you know, in a lot of my conversations with the players in this system, people have not identified, like, really obvious, easy places where the regulators can make big changes. I think there are some small changes that the regulators can make, but almost everyone that I talk to about this problem seems to think that Congress probably has to make changes to address some of the excessive spending that we’re seeing. And there seems to be very little appetite for that. So I’m really looking forward to seeing what it is the Trump administration has in mind, what kinds of policies they will pursue here. But, based on what they’ve said so far, I don’t know what they’re going for. And I would say, based on what I know about this topic, it is not obvious to me what the easy levers are for them to pull. 

Rovner: And I will add that I â€¦ in my interview with Sen. Cassidy, I asked him about this, and he kind of demurred, suggesting that, as you will hear, that, Well, if we can fix problems with price transparency in general, that could fix this problem. Because then people won’t end up going to the doctors who are going to go to arbitration and win, you know, multi-$100,000 awards from these arbitrators. But I think you’re right, Margot. I think we’ll see. 

Sanger-Katz: I will just say, to push back on what Sen. Cassidy apparently told you, is one thing that really has worked about this law is patients are completely protected. In these situations where these large arbitration awards are being generated, patients are never asked to pay more than they’re in network cost sharing. And so I don’t know how realistic it is to ask patients to change their shopping behavior in order to resolve these high payouts. I think that the incentives probably really have to be focused much more on the insurance companies and the healthcare providers themselves. 

Rovner: Yeah, well, we will see how that goes. All right, next: testosterone testing at the Department of Defense/War. Really. Secretary Pete Hegseth has ordered that male service members over age 30 will be required to be screened for, quote, “testosterone deficiency” annually, although testosterone replacement therapy, if a deficiency is found, will be voluntary. Hegseth said this is necessary for troops to operate, quote, “at their absolute best.” But doctors warn that rather than maintain military readiness, inappropriate hormone therapy can cause infertility or increase the chance of heart rhythm changes and bone fractures, and that screening at age 30 is inappropriate anyway. And in addition to everything else, isn’t this basically gender-affirming care? I thought this administration was against that. 

Ollstein: So basically, everything that is getting restricted for trans people is much more widely used by cisgendered people. So most young people who are put on puberty blockers are not trans. Most people who get top surgery are not trans. And most people who, you know, use these hormone treatments are not trans. And so, yes, this is an example of that double standard that, you know, is seen in other areas of medicine coming into play for sure. Not to mention the medical risks that you point out. It’s just sort of a cartoonish idea of what masculinity entails and what contributes to it that doesn’t really align with science. 

Rovner: Yeah, I’ve seen just an enormous amount of head-scratching about this whole thing, I mean, I’m just wondering, is he trying to deflect attention from other things going on at his department? 

Kenen: No, there’s a whole subculture that’s all about more testosterone. We should be clear that there’s some people who do, medically, have low testosterone, just like there’s some people who medically have low thyroid or other endocrine problems. I mean, you â€¦ and there’s medication for that, and it’s appropriate if you are clinically, you know, in that category. 

Rovner: Right. And having low testosterone can cause medical problems that can be addressed. 

Kenen: Right. So if you are really low â€” like not, sort of, what the “Bro World” says is low â€” but if you’re what, you know, a medical lab says is low, yes, that’s an appropriate, it’s an appropriate treatment. But there’s this whole sort of cultural thing that more testosterone is better. And it’s just one of these things â€” like with many other supplements, but this is a little bit more complex â€” it has taken off and sort of taken a cultural thing of its own. I mean, I saw a quote and I wrote it down, and I forgot to write down where I saw it, so I apologize for that. It might have been The Times, but I don’t know. And it’s a great quote from a physician who said, “If you just dole out the testosterone, the testes will shrink, and you can’t reliably count on them coming back.” That’s just sort of, like, that’s not penetrating the cultural idea to start T-maxing. 

Rovner: Right, more testosterone is better. 

Sanger-Katz: Although I think our Health and Human Services secretary has also said that he himself takes testosterone, so I think it’s not just the defense secretary. I think there are a number of high-level Trump officials who seem to be enthusiasts for this particular kind of treatment. 

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

So the public health panic of the week concerns cyclospora, a parasite that’s hard to detect, hard to get rid of, and causes a very nasty gastrointestinal illness. Cyclosporiasis, which is the ailment the parasite causes, is more common in the summer because it tends to infect fresh produce, mostly lettuce and herbs, and thin-skinned fruit like berries. But this summer, we’ve seen an explosion of cases (pun intended): more than 11,000 in 41 states. It’s maybe up by the time I’m even saying this. Normally, the FDA and the CDC [Centers for Disease Control and Prevention] would be all over this, trying to trace back where the infected food came from. But we know that both agencies have lost a lot of scientific staff in the past year. Over the weekend, the FDA announced that it had detected the parasite in lettuce from Mexico that wasn’t part of an initial lettuce recall that was linked to Taco Bell and many large grocery chains. Then the FDA backtracked, saying, “Yeah, it was a false positive.” But apparently, that doesn’t mean that the Mexican lettuce from produce giant Taylor Farms is not implicated. Now everybody is confused about what’s safe to eat. Joanne, you wrote an entire book about public health communication. How are we still so bad at communicating this kind of thing?  

Kenen: This is a really difficult thing, right? It’s very hard to track because it takes about two weeks for you to get symptoms. And then now, if people are sick, they’re going to sort of think that might be what they have. But you know, a few weeks ago, before there was publicity, you know, we all get tummy aches, right? And you don’t necessarily seek medical care. In this case â€¦ it can really go on and be very severe and can last, and people will seek medical care. But for some people, it’s not as â€” we don’t really know how many people are affected, and we also don’t know how many people are currently infected and â€¦ not yet showing symptoms. It’s big; it’s thousands. But the confusion here, I mean, first of all, you know, as you noted, CDC and FDA have both had cutbacks. There’s fewer staff. There’s fewer resources. This is really confusing, and it’s been made more confusing by absolutely everybody. There have been people who â€¦ there’s been political contacts. Taylor Farms has contacted the White House. … When the FDA found that false sample, they really did not communicate it that well. They didn’t say, This is one sample that might have led us to find yet another source, but what we’ve told you is already true. And follow our advice. They just â€¦ made it sound like it really wasn’t Taylor Farms. Then there was another thing where Taylor Farms said the FDA apologized. The FDA said they didn’t apologize, and then the Taylor Farms got a lot of attention because it deleted its social media posts. But I went onto their website last night, and it’s still there. They’re still saying that the FDA apologized. It’s confusing, too, because it’s primarily iceberg lettuce, but every summer there’s some of this, and it’s from cilantro, it’s from basil, it’s from raspberries is a biggie. So the CDC isn’t saying, OK, a lot of this is coming from Taylor Farms, but really be careful about these other things because we’re still investigating. I actually saw, I won’t identify the reporter or the publication, but in a major national report, major national paper, once the lettuce was identified at Taco Bell, this person said, “Oh, I’ve had these raspberries in my refrigerator. I’m glad I can eat them now.” Well, we don’t know that they can eat them now, you know. And then there’s the usual rumors that â€¦ everywhere there’s rumors, right? I mean, you can’t stop them. They just proliferate. So I think everybody has made a communication mistake every single step of the way. And then you have you know conspiracy theories about absolutely everything that, you know, it’s not really the lettuce. And then people think â€¦ Oh, we’re hearing it was Taco Bell in five states. Well, if I didn’t eat Taco Bell, I’m OK. No, because you could have bought the lettuce, and not all the lettuce is called Taylor Farms. And then people think, Well, if I go to a fancy organic store, it’s OK. No, you know, just don’t eat raw lettuce. The other thing I learned is it’s, like, the contamination. It’s really, really difficult. â€¦ If farmworkers are not able to, like, wash their hands well, and they were using hand sanitizer. That’s not good enough to get rid of this stuff. Chlorine isn’t good enough to get â€” this is really a hard parasite to deal with. 

Rovner: Yeah, basically, I think I’ve heard them say, If you want to eat lettuce, buy a head of lettuce and throw away the outside three layers, and then eat the rest. 

Kenen: Right, and then wash the rest of it. You’re also seeing all these recipes now online for how to stir-fry your lettuce. 

Rovner: That’s true, yes. Cooking does kill the parasite. 

Kenen: I’m growing my own. That’s my solution. 

Rovner: I’ve been picking my own. 

Kenen: Right, right. But I ran out, so I just had to plant more, but …  

Rovner: All right. Finally, this week at the Department of Health and Human Services, Secretary Robert F. Kennedy announced the latest in the department’s fraud crackdown: the withholding of more than a billion dollars in Medicaid funds from Minnesota and California. HHS is accusing those Democratic-governed states of failing to properly document shared Medicaid spending, mostly for home care services. Minnesota officials told Stateline that the feds have yet to explain exactly what deferrals are for or how they calculated the amount. Similarly, California officials said HHS is targeting the state for political reasons, and that home care actually saves the federal government money by keeping people out of more expensive nursing homes. Now, states and the federal government have been fighting over fraud since the beginning of the Medicaid program, but this is really the first time HHS has withheld this level of funds. I feel like this story is kind of flying under the radar. It’s a big deal. We spent the whole first part of this podcast talking about how states are having to spend time and effort and money to get these work requirements ready. I mean, this could really cripple some states’ Medicaid programs, couldn’t it? 

Sanger-Katz: Yeah, this is real money, and this is a kind of rescinding of money that Centers for Medicare & Medicaid Services really have almost never done before. I think it’s somewhat unpredictable to state. At least with, like, the work requirement, there’s some policy planning. There’s some awareness of what the rules of the road are and things that they can do. I think there’s a couple things going on here at once. One is that there is a lot of fraud in Medicaid. The administration is pointing to a problem that is real. I feel like the comments of the California officials that home-based care for elder people saves money by keeping people out of nursing homes â€” that is true, but only if those services are actually being provided to people. If there are fraudulent services in that sector, which we know that there are, that’s not really benefiting anyone’s health. That’s just wasting money and giving it to criminals. So, I think the administration feels like this fraud message is really powerful for them. There’s obviously a lot of political discussion about healthcare affordability, how healthcare has gotten so expensive, and I think neither party has a really great policy answer for that. I think the Trump administration is focusing on this one. They’re saying, “Well, this is just pure waste. If we can get this pure waste out of the system, that will lower the cost of healthcare.” And so I think they’re kind of banging this drum over and over again. But I don’t know that this particular mechanism is helping states actually reduce fraud. I think it’s more punishing states that are seen as political enemies, and I do think that the loss of those dollars is really going to affect the functioning of those programs. 

Rovner: Well, meanwhile, a new poll from my colleagues here at 51ÊÓƵ suggests that the administration’s focus on health fraud rather than healthcare cost writ large might be politically misplaced. According to the poll, nearly two-thirds of voters think the administration’s anti-fraud efforts towards Medicaid are motivated mostly by politics, and fewer than half think the effort is likely to save taxpayers money. The poll also found that more than two-thirds of respondents, including half of Republicans, say that ensuring Medicaid beneficiaries can get the care they need is a higher priority than preventing fraud. That doesn’t feel like a really winning political issue, does it? 

Kenen: No. And another thing that was interesting in that poll, I mean, the way Dr. [Mehmet] Oz speaks about it is that there’s a lot of people cheating, and it’s sort of the welfare-ization of Medicaid. You know, these are all lazy bums. I mean, it’s not that there’s nobody dishonest on the rolls in any federal program. None of us would say that, but most of the fraud is from providers, and that’s clear. These, you know, huge rings of nursing home fraud in Brooklyn, and â€¦ every few years there’s this enormous one. And I thought it was interesting on the 51ÊÓƵ poll that the majority across both parties actually think it is the providers. It wasn’t a huge majority, I think it was 55%, thought it was the providers, not the individuals. And but also, as you mentioned, Julie, they’re retaliating against blue states. 

Rovner: Yeah, yeah. I mean, this is their, sort of, This is how we’re going to address healthcare affordability, says this administration, and the poll suggests that maybe that’s not a really good way to go about it. All right, that is this week’s news. Now we’ll play my interview with Sen. Bill Cassidy, and then we will come back with our extra credits. 

I am so pleased to welcome Louisiana Republican Sen. Bill Cassidy to “How Would You Fix It?” Sen. Cassidy is a physician and the chairman of the Senate Health, Education, Labor, and Pensions Committee, which has been churning out health legislation of late. Sen. Cassidy, thanks for taking the time to join us. 

Bill Cassidy: Julie, thank you for having me. 

Rovner: I mostly want to talk about your “MVP” health agenda, but first, just a little bit of current events. President Trump has announced a 100% tariff on imported generic drugs starting in two years, and a 200% tariff after that, all in an effort to move that drugmaking back to the U.S. Do you think that’s a good idea, and will it work? 

Cassidy: Is it a good idea? It depends on whether or not it increases our national security and whether or not it actually ultimately ends up giving patients the price of generic drugs at an equal price, and thirdly, whether or not we avoid any contamination or other products like that. The national security might be something worth paying for. We know, God forbid, [if] we ever get in a hot war with China, the question is, can we bring generic drugs, which are principally made across the Pacific, across the Pacific to help us. So there is that national security aspect of it. That’s No. 1. No. 2, though, I’ve gone to a Dr. Reddy’s, which is owned out of India, used to have a generic site in Shreveport, and the cost basis of producing drugs in the United States was just significantly more than in India. And so it may be that consumers pay a little bit more. I’m hoping there’s an economic analysis showing if the cost-benefit ratio is adequate. I will finally say that I do think it’s important that we have some of our drugs produced here. I’m told that drugs like penicillin and cephalosporins are now almost all made in China. Again, going back to: Do we want China to have that sort of leverage for these drugs to be produced principally, maybe 99%, over there, and we don’t have access to them if tension rises between the two countries? I do think that is something worth investing in. 

Rovner: So also this week, U.S. measles cases have now topped last year’s total and are at the highest level in 35 years. You made it clear, even during HHS Secretary RFK Jr.’s confirmation hearing, that you see the risks of weakening federal policy and public confidence in vaccines. Do you think that Kennedy ever intended to keep the promises that he made to you around ACIP [the Advisory Committee on Immunization Practices] and the vaccine schedule? And what would you say to doctors who now place some blame on you for creating an environment where anti-vaccine sentiment is echoed by the nation’s health department? 

Cassidy: Well, first, I can’t get inside somebody’s mind. If they agree to guardrails and disregard those guardrails, you can judge me. But you may decide my judgment wasn’t very good, but I don’t think you can say I acted in bad faith. Why? Because I’m pretty sure that RFK was going to have the president’s ear whether he was in office or not. In office, we had guardrails that I had the expectation would be kept. Out of office, but with influence, there’d be no guardrails. So sometimes in politics and in life, it’s not a black-or-white choice. It’s not like, oh my gosh, this is the pure driven way, and this is, you know, darkness and whatever. No, it is something trying to decide what is the best with countervailing influences. I think doctors particularly know that, because it’s often the cases we care for patients that you have to come to something that you don’t quite yet know what the next step is, and you’re working towards it. Perhaps they’ll have more sympathy if they put it in light of their own medical practice. 

Rovner: So, are you going to try to have him back and keep pushing him to keep the promises that he made? 

Cassidy: I have made a request that he come back before the committee. 

Rovner: But we haven’t heard back yet? 

Cassidy: Not had a confirmation that he will yet. 

Rovner: Well, onto our bigger topic. You’ve proposed something you’re calling the Money and Value for Patients Agenda, or MVP, as a replacement, I guess, for the Affordable Care Act. How would that work? 

Cassidy: It’s not a replacement for the Affordable Care Act. It is only restricted to that which is in the employer-sponsored insurance market. And if we can look at where people are getting subsidies for their health insurance â€” you have a sophisticated audience, so I’ll speak this way— we can see that if you’re on Medicaid, you basically get 100% of your healthcare costs paid for. If you’re on the exchanges and less than 250% of federal poverty, it’s like 85%-plus. And then after that, it’s your marginal tax rate. If you’re at the 15% marginal tax rate, you pay your premium on a pretax basis, which means you get a 15% break. If you’re at the 37% marginal tax rate, much wealthier, you get a 37% pretax break on the money you paid for your premium. So the people who are middle-income on employer-sponsored insurance are the ones who are getting the least assistance from the tax code or the federal government to purchase their health insurance. What?! The people who are trying to do it the best â€” they’re working; they’re not on Medicaid. Some people on Medicaid work, but many don’t. The people who are working are the ones who get the least assistance. So, what can you do about that? What I would do in my MVP plan is give an advanceable tax credit to those on employer-sponsored insurance below a certain marginal tax rate, and if you’re below some percent, you would get it. 

Rovner: So very rich people wouldn’t get this. 

Cassidy: No, it’d be like less than 22% marginal tax rate. And so those are the people who need the help. Let’s focus where people need help. And that’s negotiable, but that’s just an example. Under my calculations, a family of four could get up to $2,000. Now, why is that important? Many families, maybe most, will not have more than $2,000 of out-of-pocket expense in a given year. Now, one year they may â€” the wife’s pregnant, or the son, you know, gets in a car wreck â€” but most years they’ll have less than $2,000. So that would potentially cover all of their out-of-pocket, particularly if you couple it with the price transparency legislation we’ll discuss in a second. And because the family now has $2,000 to cover their out-of-pocket, they can choose a policy with a higher deductible, which means a lower premium. OK, so if currently the average deductible for a small-business plan is about $3,000, you give them $2,000, they’re going to choose a $5,000 deductible, and that will lower their premium substantially. I like to speak, Julie, of the cost of being insured, which is not just your premiums, but your copays and your deductible. We’re given $2,000 for that copay and that deductible, which allows you to take a lower-cost premium, and you put it all together. And my favorite economist, ChatGPT, says that you could potentially save $5,000-$6,000 per year, per family, and that makes a significant, meaningful difference in their ability to afford life. 

Rovner: So, is this in addition to employer coverage, or would this be instead of employer coverage? 

Cassidy: No, this would be in addition to employer coverage. Right now, we see that small businesses are dropping coverage, and so this would, obviously, if the employee is choosing a cheaper plan because the plan they choose is a higher deductible, then it becomes less expensive for the employer. And so they can better afford to continue to offer. So this is a way to help that small business as well. I’ve talked to a small-business owner back home, several small-business owners. It’s becoming very difficult for them to give salary increases and/or hire more people if they continue to provide health insurance. So, if we’re able to take a little bit of that burden off of the employer to give an adequate insurance policy, then hopefully they can increase wages and/or hire more people and expand their business. So it’s a benefit not just for the family, but also for their employer. And frankly, the federal government ends up earning more tax dollars because, not getting too complicated, but the less money you’re spending on a pretax basis, the more money going into your post-tax paycheck, the more taxes you pay for payroll tax, etc. 

Rovner: I’m thinking of private equity and some of the gaming of one of the laws that you were instrumental in getting passed to prevent surprise medical bills. How do you try to protect consumers from people in healthcare who are literally just in it for the profits? 

Cassidy: Why not price transparency? If you don’t know the price of something, you can’t get a better deal. And that’s whether you’re the patient or whether you’re the business. And so the initial step to make sure that people are getting their best deal is price transparency. And, by the way, the wonderful thing in the last year or so, I’ve been exposed to people doing wonderful work, and people are developing apps on the phone, and you could say, “Hey Siri, where’s the urgent care center near me? What is their price schedule for a routine earache?” OK, I’m going to go to this one near me because it’s $50, not $150. So I go there, and then I come out with a prescription. “Hey Siri, where’s the cheapest place to get this prescription for amoxicillin, 500 milligrams BID?” Siri tells you, or the app tells you, not Siri, but the app. And these are, like, being developed now. I mean, this is not â€” no, this is now. And so if you couple money in the pocket with price transparency, giving the individual the ability to determine where to go to get the best price â€” and we have some other provisions in there that protect the patient, a lot of provisions â€” then you are going to bring value to the patient. That’s part of the solution in the employer-sponsored insurance market. 

Rovner: Sen. Bill Cassidy, thank you very much. 

Cassidy: Thank you, Julie. 

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

Ollstein: Yeah, I have a story from our friends over at Roll Call. This is “,” by Ariel Cohen. And this is about a recent decision that, like so many things these days, flies under the radar because there’s so much going on at once. And just in the category of grant cuts, there’s so much going on. So this is about the sudden slashing of a bunch of HIV prevention grants to community organizations. They’re now saying they’re going to redirect the same funding to state and local health departments, and those state and local health departments can, if they want, then pass it on to the community organizations. But 1) that’s, you know, more bureaucracy, more headaches. But also, what this article smartly points out is that that then makes the community organizations no longer eligible for 340B, which was helping them buy all of this medication much more cheaply. And so losing that designation, losing those grants, is a really big deal for these groups that are trying to afford doses of expensive medication like PrEP to distribute to communities. 

Rovner: Yeah, again, some of these things that sort of look small end up with far-reaching consequences. Joanne. 

Kenen: This was the first extra credit that actually made me invent a word, which was “yikes-maxing”! You know, like, it was so wild. It’s from Stat by Adam Feuerstein. I probably have that wrong. 

Rovner: Feuerstein. 

Kenen: OK, and the headline is “.” So, for 20 years, this guy â€” he was a doctor. He was convicted of one assault. He was pending trial on another sexual assault allegation, and he disappeared right before his trial. He left notes that he was going overseas, transferred property to his kids, etc. Well, he did not go overseas to live as a fugitive. He was right here posing as a cancer expert, and he worked for two biotech companies. And he purported to have expertise in all this very advanced, cutting-edge drug development for cancer, which was not his actual background. So, like, how did he get these jobs? Why wasn’t he vetted better? He was finally tracked down on a yacht called the Silver Lining, and, in fact, the alleged assault, because one of them wasn’t ever went to trial, was on yacht. Yachts were his, apparently, his favorite locale for his alleged assaults. So he has been arrested, but it’s not just like this guy needs to go to trial, but, like, how did these companies â€¦ did they even look at his LinkedIn? I mean, he was using a fake name. How did this happen? It’s a huge scandal, and it’s also a great yarn. 

Rovner: I can’t wait to see the movie that somebody’s going to make out of this. Margot. 

Sanger-Katz: I wanted to recommend an article from Andrea Hsu on All Things Considered and NPR. “.” And this is a story about a growing number of men who are entering the nursing profession, and, in particular, a look at the University of Alabama in Birmingham that is really trying to recruit men into the profession. And you know, I feel like caregiving professions have traditionally been kind of a female domain, but I think there’s a new openness by men to enter these careers, which I think can be very fulfilling. They’re very secure. They’re relatively high-paying. My colleague Claire Cain Miller did a story in the Pacific Northwest almost 10 years ago, I think, where she interviewed a number of male nurses about their work and had these beautiful portraits shot of them, and it just is a piece that has stayed with me for a long time. Just thinking about these men in these caregiving roles and why some of our, like, more conventional ideas of masculinity prevent men from entering these professions that I think can be really great careers and really fulfilling for them. So I just thought this new story was really good. I was interested in what this university is doing to recruit men, and I think the idea of male nurses and a nursing profession that is more gender-diverse is really interesting. 

Rovner: And in 2026, unlikely to be taken over by AI. It’s one of those rare career paths. It’s probably still going to be around for a while. All right, my extra credit this week is from The New York Times. It’s called “.” It’s by Arijeta Lajka, Isabelle Niu, Mark Boyer, James Surdam, and Dan T. Peters. It’s a video, and it shows how AI-generated doctors, Eastern medicine health practitioners, and wellness influencers are all over social media, making often dangerous health claims to sell all manner of questionable supplements. The money line from the piece, quote: “Ads like this would be illegal on U.S. television, but on the internet they face little enforcement.” Apparently, some of the big social media companies are trying to find and extinguish ads that make misleading claims or are not noted to be AI. But for now, it is still very much buyer and watcher beware.  

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

Sanger-Katz: I’m on social media , and you can reach me on Signal at sangerkatz.01. 

Rovner: Joanne. 

Kenen: I’m mostly on  and  @JoanneKenen. 

Rovner: Alice. 

Ollstein:  on X, and  on Bluesky. 

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

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

Julie Rovner: Hello, from 51ÊÓƵ Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 51ÊÓƵ Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, July 16, 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: And Sandhya Raman of Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

Rovner: Later in this episode, we’ll have the latest in our “How Would You Fix It?” series, this week with Elizabeth Mitchell of the Purchaser Business Group on Health, which represents employers and institutional buyers of health insurance and health services. But first, this week’s news. 

So, Congress is back from its July Fourth break with lots of changes, but still not a ton of forward progress on its legislative agenda. Sen. Mitch McConnell, who was hospitalized in June for what his office now says was a fall followed by a case of pneumonia, is still out. And close [President Donald] Trump ally South Carolina Republican Sen. Lindsey Graham died suddenly over the weekend. He’s already been replaced temporarily by his sister, Darline Graham Nordone, who presumably will be a reliable vote for Trump priorities, but probably not the dealmaker and mover-and-shaker her brother had been. In the House, members approved a surprisingly divisive bill to make daylight saving time permanent. But there doesn’t look to be a very clear legislative path for things like, oh, the annual spending bills that need to be done by Sept. 30? And yet another party-line Republican budget bill that might or might not be partly paid for by another push on healthcare fraud. What are you folks hearing about the major things that Congress has to do before the end of the fiscal year?  

Ollstein: Well, the thing that amused me the most that I saw was that leadership in the House, who are facing the same struggles over and over, herding the cats and getting enough Republicans to stay in line to pass even these party-line, you know, slim-majority bills, they’re trying the same tactic they tried with the last reconciliation bill, which is Hey, I know you’re disappointed that all of the things you wanted in this bill are not included, but don’t worry; there’ll be another one after it, so just vote for this one. And so they said that when they were working on “Reconciliation 2.0,” they said, Don’t worry; all the things you want, including Planned Parenthood’s Medicaid funding, that’ll be in 3.0. And now that we have 3.0, and it’s not included, and a bunch of other things they want are not included, they’re saying, Don’t worry; we’ll put it in 4.0. Now, there’s a lot of skepticism that even 3.0 can get done, so 4.0 seems like a wild fantasy at this point. 

Rovner: Yeah, I saw the reference to “Reconciliation 4.0,” and it’s important to remember that there’s only a limited number of budget reconciliation bills you can do. Each budget resolution gives you two or three, I guess, if you include â€¦ you can do a separate one to increase the debt ceiling. But generally, each budget resolution gives you a chance to do a tax reconciliation bill and a spending reconciliation bill. And when they neglect to do the budget resolutions, sometimes they can have a year where they’ll do two budget resolutions for two different fiscal years. But really, that just leaves them four. And I think, I’m not sure there’s a budget resolution that can come for a Reconciliation 4.0. But I guess we’re gonna see. I mean, basically, this really is all about: There’s a segment of the Republicans, particularly in the House, but I think also in the Senate, that want to permanently defund Planned Parenthood from Medicaid, which the Senate parliamentarian has said they can’t do on a permanent basis, and that just sort of continues to string this out, right? 

Ollstein: Right, and there are Republicans in the House that don’t want to take a vote on that in an election year. They worry it could hurt them politically, and then you have the more conservative wing of the party that is very upset that Planned Parenthood recently got its Medicaid funding back, because that law from last year was allowed to expire. So you just have a lot of angst and finger-pointing and upset Republican-on-Republican arguments going on this week, you know. Not to mention, there’s only, I think, seven weeks that they’re in session before the midterms. After the midterms, you could start to have attendance problems, and so people are very, very skeptical that 3.0, but especially some sort of 4.0, could happen. 

Rovner: Yeah, well, so the legislative agenda is kind of stalled. But there were confirmation hearings this week for the administration’s nominees for a couple of top Health and Human Services posts: head of the Centers for Disease Control and Prevention and assistant secretary for preparedness and response. Anything newsworthy from the nominees, Erica Schwartz or Sean Kaufman? Sandhya, you were at this hearing, yes? 

Raman: Yeah. I think this was really interesting to me because, up until yesterday, we had a lot of people kind of pleased with the nomination of Erica Schwartz as, you know, a more kind of mainstream, like, career type health official to be the head of the CDC, and you know even Democrats were pretty pleased with this. And, you know, we even had people that were more MAHA [Make America Healthy Again]-aligned, you know, being more skeptical that she would speak to some of their concerns that they’ve had. And what we had at the hearing was her kind of shifting gears, you know, deflecting on a lot of questions, being asked about various things, being asked about cuts to mRNA research, and saying, Oh, you know, I’m not familiar with that. Saying that she wasn’t familiar with some of the changes related to food safety, while we’re in the cyclosporiasis situation that we are right now. And even issues like the CDC Office [on] Smoking and Health, which she said, you know, smoking prevention was like one of her top priorities when she was working pre-government, and, you know, saying she wasn’t familiar with that office being eliminated. So that was interesting. And even you had the [Health, Education, Labor and Pensions Committee] chairman, Sen. Bill Cassidy, saying, you know, it seems like you’re a little overprepared for this and not answering. But I think the main takeaway was just vaccines. We had so many questions about vaccines from Cassidy, but just throughout the members of the [HELP] committee, trying to kind of garner where they were on it. And again, it was kind of, you know, walking that line to kind of appeal to the widest selection of people as possible. And I don’t think that that was what necessarily everyone was expecting there. For the ASPR [assistant secretary for preparedness and response] nominee, Sean Kaufman, there had been reporting earlier in the week about some of his old LinkedIn posts suggesting some of his comments about, you know, pediatric vaccination and things, and him being a little bit more skeptical. But he came out pretty strongly in favor, saying, I think, vaccines are safe and effective. But I think that there’s still some questions there when you talk to both of the nominees about, you know, whether or not they’d be willing to buck the secretary or the president if push comes to shove on some of these issues. And I think that was what really raised some eyebrows by some of the members on the committee. 

Rovner: I would say Cassidy got pretty exercised about some of the vaccine stuff. Do we know whether that’s going to make him not want to vote for some of these nominees? I mean, that’s pretty much up to him whether these things move forward. And you know, he has since said, after voting for Kennedy, that he was he was … I don’t think he said that it was a mistake, but he said that Kennedy has not kept the commitments that he made to Cassidy and the committee. So, you know, Cassidy â€¦ who’s a lame duck, has at least another chance to exercise some power here. Is he gonna? 

Raman: He did do some fiery exchanges with both of them on some of the vaccine-related issues, but at no point, I mean, did he come down as strong as that. I mean, at some point, he was saying to Schwartz, the CDC nominee, that, you know, I came in here ready to support you. Like, I want assurances on some of these things. But he didn’t, you know, indicate that he was gonna draw the line there. I mean, I guess we’ll see. I think one thing that did stand out was that he said that his conversations with her, you know, one-on-one, physician-to-physician, before the hearing were a bit different from what he was hearing in the hearing. So it depends, you know, are there more conversations? Does something sway? But it seems like it’s still, you know, heading towards, you know, getting across the finish line. 

Rovner: And to be clear, Erica Schwartz is, you know, she’s a doctor and an epidemiologist, and, you know, ran healthcare, I think, for the Coast Guard. I mean, she’s got a lot of government experience as well. 

Raman: She’s a former deputy surgeon general. She’s, yes, absolutely. 

Rovner: Yeah. Yeah. I mean, she clearly, clearly, on paper, she is more than qualified for this job. It’s just whether Cassidy is angry enough to actually, you know, put his power where his mouth has been. 

Well, there was some health-related news out of the hearing for Todd Blanche, the acting attorney general nominated to take the job permanently. Under questioning from several anti-abortion Republican senators, Blanche rather specifically promised to examine something called the Comstock Act, an anti-vice law from the late 1800s, to potentially outlaw the mailing of abortion pills, regardless of what the FDA says. Alice, what would that mean? 

Ollstein: So, I think it’s important to emphasize that Blanche only promised to review this. He didn’t promise to make any specific changes. I saw a lot of anti-abortion activists getting, I think, a little overly excited about what he said. You know, they could review it and take no action. I think it’s also important to remember that Trump specifically promised on the campaign trail not to use the Comstock Act to go after abortion pill providers. You already have activists on the other side, pro-abortion rights activists, characterizing that as the kind of national ban, federal ban that Trump also promised not to enact. You know he specifically has this, you know, “leave it to the states” stance, and you could argue he’s already broken that in some ways. But this would be a much bigger way. So, a lot of different ways the government could cut off access to abortion pills by mail came up in the hearing. The Comstock Act is one of them. I think what abortion rights activists find troubling about the Comstock Act, in particular, is that it could be used to cut off access to both mifepristone and misoprostol, whereas the strategies that the anti-abortion movement is using that are focused on the FDA are pretty much only focused on just one of those two drugs that have to be used together for abortions. So, if the FDA were to act to restrict mifepristone, people could still have abortions just using misoprostol. But if they tried to use the Comstock Act, they could cut off access to both, which could also impede people’s access to those drugs for nonabortion purposes, which they are used for. 

Rovner: Misoprostol has a lot of other uses. I mean, mifepristone is primarily an abortion drug that’s also used for miscarriage. But misoprostol is an anti-ulcer drug that’s used for a whole lot of different indications that have nothing to do with reproductive health. 

Ollstein: And that’s a big part of why the Biden administration put out this memo from the DOJ [Department of Justice] saying that they don’t think the Comstock Act should be used to prosecute doctors who prescribe abortion pills and mail them because you can’t know if the person is ordering them for a legal or illegal purpose. And, you know, obviously people quibble with that in various ways, but that is the sort of underlying rationale, and that precedent is still in place, and that’s what these senators were trying to push Blanche to change, if confirmed. 

Rovner: And yeah, I say, and clearly all of this depends on whether or not Blanche gets confirmed as attorney general, which is still up in the air, mostly for other reasons. But â€¦ 

Ollstein: Yeah, absolutely, people are upset with him for the handling of the [Jeffrey] Epstein files and all kinds of stuff. And just one GOP senator on the committee could block him from going forward. So it’s not all about this, but this is definitely in the mix. 

Rovner: Yes, I think so. Well, moving on, as we’ve noted, the big cuts to Medicaid from the 2025 Republican budget bill mostly don’t start until next January. But states whose fiscal years started this July 1 are already making changes in order to be ready. Several states are already trimming back Medicaid benefits that are optional for states, including many community-based long-term care services. This is despite Republican assurances last year that traditional populations of moms and kids, seniors, and those with disabilities wouldn’t be impacted by the cuts. Stat has a  out of Maryland about cuts to a family caregiver program that may leave a family with the choice of either going bankrupt or putting their disabled child into an institution. It’s hard to see how this isn’t going to be a big campaign issue, right? I mean, this, you know, there were all of these claims that, you know, we’re really only going after the able-bodied Medicaid recipients. That’s not what states are doing.  

Raman: I mean, we’ve already seen it becoming a campaign issue. I mean, even before this was passed into law, we saw Democrats really, like, going in on this far before the midterms, you know, emphasizing this over and over and over again. And I see, you know, they’re going to continue doing that, especially when costs are such a big issue for voters this year. And if you lose Medicaid, then that is another added cost for you if you have a health issue of any kind. But I think what’s even more interesting is how this has been really played back on the Republican side. They’re not talking about this as much as they did a few months ago. Even, you know, we passed the anniversary of the law earlier this month, and there wasn’t a big push on this like there has been on other issues. They’ve really shifted into talking more about â€¦ as for in the healthcare bubble, we’re talking about fraud, fraud, fraud, not any of the things that were in the “Big Beautiful Bill.” 

Rovner: Yeah, things that they hoped people would see as an advantage are not so much right now. Well, another tack that states seem to be taking is not to cut Medicaid for recipients, but rather to get someone else to help pay the bill. And they’re targeting large employers of low-wage workers who have Medicaid. New Jersey is planning to charge those larger employers a fee. Other states are looking at ways to do something similar. But there’s not just pushback from business groups, who obviously don’t want to pay a fee for their workers who are eligible for and get Medicaid. Some advocates for low-income people say that it will make it harder for workers who get Medicaid to stay employed if their employers will be penalized. I know this was, you know, this came up many years ago â€” I think just after the beginning of the Affordable Care Act, when there was concern that a lot of big employers were actually going to dump their workers onto Medicaid. Many of them in the end did not. But it’s hard to see how this is really going to catch on. I grant states creativity for, like, OK, we’re not allowed to ask healthcare providers to help pay our Medicaid bills anymore. So now we’re going to ask big employers to help pay our Medicaid bills. 

Edney: Well, I think it’s an interesting â€¦ it’s probably a tough calculation for the people, you know, that are actually making this decision. The person who’s deciding, you know, do I take this employer insurance or Medicaid? And then you do want to push employers to offer plans that are affordable and that are comprehensive. That’s what they’re supposed to do, especially these big employers. But there can be kind of a lot of calculation that goes into this: maybe the size of the household, who else in the household might be working. So you know, I can see why it might feel like it’s not just on the company, but maybe some of the employees who are making these decisions could end up suffering. 

Rovner: Yeah, as I say, kind of points for creativity, but not clear that this is actually going to catch on because there are clearly going to be problems with it. States are going to have to keep looking to figure out how to continue to pay their â€¦ share of the Medicaid bills. As Sandhya already mentioned, some of you may have noticed the U.S. is having an outbreak of something called cyclosporiosis, which is an infection caused by a parasite that causes, let’s just say, major gastrointestinal upset. Screening for the parasite, which, by the way cannot easily be washed off of infected produce or other food products, used to be part of a list of parasites whose reporting was mandatory to the CDC’s Foodborne Diseases Active Surveillance Network, known as FoodNet. But it was made optional last year, and, as of now, we still don’t know what foodstuff is spreading this parasite â€” although suspicion’s being cast on lettuce or some other leafy green vegetable. Is this yet another “I told you so” about cuts to public health? And is anybody really gonna care, other than the thousands of people who are really sick right now? 

Edney: Yeah, I think that, absolutely, this is another “I told you so” in the sense that, like, you can’t just decide what bacteria you’re going to track if, you know, it pops up and you can’t really control that. And I think that a lot of people already care, you know â€” I think you’ve seen a lot of decisions being made, at least that’s what social media has indicated. I have not seen, like, shopping numbers, but people seem to be concerned. â€¦ They don’t want to buy lettuce, raspberries, cilantro, things that have been implicated in these outbreaks before. And so, with states not reporting to FoodNet, it’s harder to track in real time. So it’s taking longer to narrow down what food is responsible for this, what, who the producer is. So people are left wondering and left just cutting, you know, entire fresh fruits and vegetables out of their diet at this point. They’re really worried. 

Rovner: It kind of cuts against the whole “eat healthier.” 

Edney: Exactly. 

Rovner: Like when the healthiest things might cause all kinds of problems. 

Edney: Yeah, I mean, you know, if all you feel comfortable eating is packaged goods and microwaving all your food to make sure it’s safe, I think it is a problem. And there are people I think who do feel that way, especially in states, you know, in the Midwest that have a lot higher numbers of these cases. 

Rovner: I would say the federal government keeps saying, “Oh, we get cyclospora outbreaks every year,” and we do. But this is much, much higher than it has been in many years. Sorry, Alice, you wanted to say something. 

Ollstein: Well, I mean, it’s the classic situation of, you know, when public health is working well, it’s completely invisible, and so it’s easy to take it for granted. And you can say, well, there hasn’t been a serious outbreak in this many years. What’s the point of this expensive monitoring and prevention program? And turns out, this is why. It’s a very thankless sector because when it’s working well, you don’t get any kudos. You don’t get any awards for not having an outbreak of diarrhea parasite. But everybody gets upset when there is an outbreak of diarrhea parasite. 

Rovner: And screwworm, which we also have after we canceled some of the watchouts for it. All right, we’re going to take a quick break. We will be right back.  

OK, we are back. So in news from what I’m calling the “Department of Updates,” a couple of weeks ago we talked about Health and Human Services Secretary Robert F. Kennedy Jr. calling up libertarian candidates in Iowa in an effort to get them to drop out of House races in order to prevent them from siphoning votes from Republicans. Well, now Oregon Democratic Sen. Ron Wyden is officially asking the U.S. Office of Special Counsel for an investigation into whether that violated the Hatch Act, which generally prohibits federal employees from participating in political activities. Of all the, quote, “scandals” attributed to RFK Jr. since he’s been in office, where does this one rank? 

Edney: That’s a really good question. I’m not sure a lot of people might understand the gravity of it, but a person in appointed position is not really supposed to be weighing in and putting their thumb on elections and influencing those outcomes. I mean, that’s the law. And so it is a Democrat asking for this investigation, which the consequences might be less heavy, I guess, you never really know. I mean, I think it does, kind of the whole situation. Secretary Kennedy’s trying to influence these does kind of show you how worried they are, how worried he is, that he might have to go up before Congress should Democrats win the House and answer a lot of questions under subpoena. 

Rovner: Yeah, and of course that’s exactly what he said to the libertarian candidates when he was trying to get them drop out is, like, if the Democrats take over the House, I’m going to spend all of my time, you know, on Capitol Hill rather than working to, you know, make America healthy again. That was his argument.  

All right. Well, another topic we have spoken about before is the proposed rule from the Office of Management and Budget to give political appointees far more power over which scientific and medical grants get funded. The comment period for the rule closed this week with nearly half a million comments filed. That’s a whole lot, by the way. And our friends at Stat, with help from researchers at the University of North Carolina,  that have been posted so far, and found them overwhelmingly in opposition to the rules, with concern about politicization of science dominating the reasons. I still feel like this is an under-covered story. We’re talking about the fate of more than a trillion dollars in federal funding each year, and a huge change in the way this money is allocated and spent. I mean, you know, already we’ve seen the administration trying to hold back some of this money and getting pushback from Congress, but this would basically codify, if you will, the ability of political appointees to say, We’re not going to give you money unless we agree with it. Essentially. 

Raman: I mean, I think even from the get-go of this comment period, there has been that groundswell of people submitting comments. You know, even a few days in, we were hitting numbers that we would usually maybe not see even throughout the whole comment period for other proposed rules. And so much of that in, like you said, the scientific community has been this. But grants extend to so many departments in the federal government and cover so many different things, and I think it’s kind of hard to quantify just how sweeping something like this would be. Even, you know, looking at a few different pieces, just because the types of grants are so different. â€¦ So many grants are multiyear, and might go from one administration to another, and then be implemented. And if politicization of approving or rubber-stamping continuing grants is there, that would create a lot of up and down in terms of Will these things continue? So I will not be surprised if as we get a little further along there is more litigation filed with people trying to stop this. It’s just we’re at this stage now where proposed rule time is not really where you would you would get that. There needs to be a little further in the process. But yeah, I think this is something that a lot of people are really keeping an eye on. But it is something that’s harder, I think, to communicate out to folks that maybe don’t realize that they are using grant money for something that is available in their community.  

Rovner: We need a Schoolhouse Rock! for peer review and grant-making. Maybe I’ll have to do a video with the dog. Yes, my next video with the dog. 

Ollstein: Just quickly, I will say that the abortion rights community is very anxious about this. They worry that it will lead to any sort of research remotely tied to reproductive health will be cut unless it’s, you know, explicitly pro-abstinence, pro-fertility. But again, like we talk about with so many things, when you implement these changes, it cuts both ways, and a Democratic administration in the future could wield this in ways that conservatives don’t like. And so â€¦ 

Rovner: I think what freaks out the science and medical community is just the lack of continuity. It’s that if it’s going to change back and forth, I mean, one of the things that research really depends on is that research takes as long as it takes, and that often stretches way across Democratic and Republican administrations. That’s kind of the idea of not having this be in charge of political appointees. So I think that’s a lot of â€” I mean, I have obviously have not read half a million comments, but many of the comments I’ve seen have suggested that there’s concern about the going back and forth that would be as damaging as anything else. 

All right. Well, speaking of updates,  that the Department of Health and Human Services is backing away from a new regulation proposed with much fanfare last December that threatened to withhold Medicare and Medicaid funding from hospitals that offered transgender care to minors. Some 30,000 comments on that rule were filed, including those from major medical groups urging that the rule be rejected as an unwarranted interference in medical care. The administration actually pushed back against the NPR story, saying the rule hasn’t been officially pulled, which does appear to be the case. But it seems that officials are kind of trying to have it both ways by leaving the possibility that it could be revived hanging over hospitals’ heads. Is this kind of a clever way to put pressure on hospitals to do what the administration wants without actually having it litigated about whether the administration has the legal authority to do this in the first place? 

Edney: Yeah, I think that’s a good point, that are they sort of leaving it in place without ever fully implementing it? Because states are supposed to be able to regulate this, not have the federal government tell them what to do. And certainly, you know, the hospitals could have their say in it. So they could have been facing a lot of litigation, and I think not pulling it doesn’t mean that it’s not gone. It’s just, you know, according to the story, they clearly decided not to go forward with it. But leaving it in place does kind of, for the hospitals that already moved on this, and we did see some that got nervous. Then, you know, they might be the ones who kind of keep everything in place, just because they’re not sure. 

Rovner: Yeah, I mean they’re making the point that they’re not moving forward on it now. But that doesn’t mean that they’re never moving forward on it, which seems to be a theme from this administration on a whole lot of things. It’s like: We’re not going to do this now, but we still could do it later.  

Well, finally this week, there’s always plenty of news on reproductive health. Alice, I feel like I’m being transported back to, like, 2014 or even 2018, but it looks like the Trump administration is going to try again to  as required by the Affordable Care Act. Why are we debating this again now? 

Ollstein: So this is the case that won’t die ever. Apparently. This is about a workaround in the Affordable Care Act that was created so that religious employers who really object to contraception for, you know, deeply held faith reasons, there’s a workaround so they don’t have to pay for the insurance that covers contraception for their employees. But their employees can still access that contraception coverage if they want it. But certain groups have kept suing over this again and again over the years. It went all the way up to the Supreme Court, and then it came back, and now it’s bouncing around in the lower courts because they say that even participating in that workaround is a violation of their beliefs. Now, on a sort of parallel track … 

Rovner: They are facilitating â€¦ right, obviously, they are facilitating. They’re “complicit.” That’s the word they’re using; they are complicit in allowing people to get contraception, which they don’t believe in. 

Ollstein: Correct, and â€¦  

Rovner: “They” not the people who are getting it, “they” the people who are complicit in getting it. 

Ollstein: The bosses, yes. 

Rovner: Right. The bosses. 

Ollstein: So, sort of on a parallel track, the Trump administration tried to vastly expand the number of companies, the kind of companies that could say we don’t want to provide contraception for our employees, so that now it doesn’t have to be because of a religious belief. It could just be because of an ideological belief. And also now this could be, you know, a big for-profit, publicly traded company, not just a small religious group. Folks have been fighting this, and so here we are back in court again. This is, you know, an ongoing struggle. Of course, you know it’s important to remember that the question of whether or not working folks can access contraception has much higher stakes now that abortion is illegal in much of the country. 

Rovner: We will see. Well, and while abortion doesn’t seem to be as big a political issue in 2026 as it was in 2022, we are seeing ballot measures in several key states, as well as abortion being centered in places like the Maine Senate race, where ostensibly pro-choice Republican Sen. Susan Collins’ vote to confirm Supreme Court Justice Brett Kavanaugh is being hung around her neck, even though she doesn’t have an actual Democratic opponent yet, after Graham Platner dropped out. How is abortion shaping up as a political issue this year? Alice, you’re, I assume, following this. Sandhya, so are you, right? 

Ollstein: It’s interesting. I have a story coming on this in the next day or so. The Democrats who are jockeying for the chance to take on Collins and all of the outside groups supporting them and rushing through this process, they’re very anxious about the ability to make the case that Susan Collins has, as they say, betrayed, you know, her promises to protect abortion rights by confirming not only the Supreme Court justices who helped overturn Roe v. Wade, but a lot of lower court judges who have voted for abortion restrictions in a lot of states. And so they want to be able to put that front and center in their campaign against him. And so they’re really anxious about the records of the Democrats running, because they don’t want to muddy that message at all, and to have Susan Collins have the opportunity to say, Actually, these people have a worse record than me on this issue. And so there’s a lot of hand-wringing on that front. And it’s just tough because some of the Democrats running have a mixed record on this. They used to oppose abortion, and then in more recent years have, you know, passed very strong legislation supporting it. And then you have a lot of candidates who have no record at all on this. They have no voting record. Some of them have never held office before, or this issue just has not been something they’ve had a chance to work on. And so, it is tough for voters to compare someone who has a mixed record but made real accomplishments for abortion rights versus people with no record at all. 

Rovner: So, abortion is going to be an issue, but maybe not sort of â€¦ like with the attorney general, “in the mix” — is that a fair way to put it? 

Ollstein: Oh, absolutely! And no matter what, it’s going to be a huge part of the campaign against Susan Collins. You’re already seeing groups start to air ads about it. 

Rovner: All right. Well, that is this week’s news. Now we’ll play excerpts from my “How Would You Fix It?” interview with Elizabeth Mitchell. You can . And then we will come back and do our extra credits. 

I am pleased to welcome Elizabeth Mitchell, President and CEO of the Purchaser Business Group on Health, to “How Would You Fix It?” PBGH represents large employers and other institutional buyers of healthcare from both the public and private sectors. Elizabeth Mitchell, thanks for joining us. 

Elizabeth Mitchell: So glad to be here. A lot to fix. 

Rovner: Yeah, a lot to fix. So I want to start by having you talk a little bit about employers’ role in the U.S. healthcare system â€” how it started, and why it persists. 

Mitchell: Yeah, well, I think we know it was an accident of history, right? They weren’t looking to get into the healthcare business, but when, you know, they were looking for alternatives to wages, when there were limits on what they could offer, and they started with what was a pretty inexpensive offering, helping pay for hospital care. And that has now grown to be the second-largest line item in their budgets after payroll. So it has taken on a life of its own. Employers cover over 160 million Americans, so they are a major player in healthcare in the U.S., for better or worse. But they are committed to achieving just a better system because they’re paying for it and because their employees need it. 

Rovner: What’s unique about large employers, particularly the large employers that you represent â€” the ones that not only pay for their workers’ health benefits but also design and manage them in most cases? 

Mitchell: Yeah, it’s a great question. I work with large and jumbo self-insured employers and public purchasers like CalPERS. 

Rovner: CalPERS, for those who don’t know, is the California pension system. 

Mitchell: Yeah, they are the second-largest purchaser after Medicare, I believe. So not small. And honestly, the major difference for large employers is the leverage, right? They have the ability to negotiate arrangements that small employers just don’t have. You know, there is somewhat of a myth that the health plans are responsive to large employers. That is sadly not often the case. As large employers have sought to exercise that leverage, the system has consolidated in response, so the health insurers have consolidated, the health systems have consolidated. So there’s been this arms race of consolidation, meaning that even the largest employers in the world are smaller and don’t have the leverage many times. So they’re looking at how can they align or aggregate even across large employers to really drive the changes they’re looking for? 

Rovner: Well, the premise of this entire project is that we’re heading towards another major national debate over health because just about every stakeholder is unhappy with the status quo. I assume that’s at least as true for large employers now as it was in the early 2000s, when the ground was being laid for the Affordable Care Act. Do you agree with that? And just how dissatisfied are your members with the current functioning of the healthcare system? 

Mitchell: I do not know any employers that are happy with the current system. I will say that that dissatisfaction is growing exponentially every year of double-digit price increases and lack of access and just administrative complexity. We are seeing readiness for wholesale changes that I’ve never seen before. So there is very high frustration, but I also see that as a big opportunity. 

Rovner: So how would your members fix the system? What are some of those policy changes that they would like to see? 

Mitchell: So there is no simple answer. I know that goes without saying, but there’s a collection of changes that we are prioritizing based on evidence. So one of them is primary care, really robust primary care â€” and not the kind that is just set up as a feeder into the health system â€” is a top priority for our members. Another really is more on the purchasing side, right? There is so much administrative waste in the system. And some of our members now are turning to AI just to look at their contracts and realize that they are paying these absurd fees they never agreed to. And then finally, transparency. It is absolutely essential. There are immediate savings opportunities just by looking at the data and realizing you can get the exact same quality or better-quality service across the street for a fraction of the price. And that has immediate savings for out-of-pocket costs as well. So, using transparent information to find the best partners, banning anticompetitive practices, and investing in primary care and high-quality specialty care. Those are my top few. 

Rovner: There are voices both on the left and now on the right who would like to get rid of the basically employer-based system that we have â€” you know, “Medicare for All” â€” and would anticipate, would take that away, you know, basically would have the government, if not providing them, at least paying for all healthcare services. Now we’re seeing Republicans talking about, you know, big bad insurance companies, and we should just give people money, and they should buy their own care. Where are large employers on that, sort of? I assume they would like to keep some semblance of the system that we have now in a reformed system, or am I wrong? Are they ready to give it up and let everybody fight it out for who provides healthcare? 

Mitchell: Well, I represent a subset of jumbo employers who are very progressive, very innovative, and very invested in fixing the system. That said, I don’t think anybody would say it’s working right now. We have a very real affordability crisis. And I would say jumbo self-insured employers are some of the best-positioned actors to do something about that. They have the opposite incentives. They want lower cost and better quality. So if they are empowered and enabled, in some cases through policy change, to be more effective purchasers, I do think that that is a viable strategy still. Because even if you just gave everyone cash, you still have a price problem. It just becomes the problem of the patient instead of the purchaser, because prices are the issue here, and consolidated, unresponsive providers and plans. There is a tendency, and it’s not totally unjustified, of blaming the customer. But there are some aspects of our system that need to change. Whether the government’s paying for it, individuals are paying for it, or employers are paying for it. So it’s a matter of how do we get at that? If it was Medicare for All, they set prices. Maybe that will work. I think the opponents of that historically have been hospitals and health insurers, not employers. But employers are committed to playing a very active role in achieving affordable, high-value care. 

Rovner: Well, that was sort of my question: Are employers ready to say: We just, we would like to wash our hands of this and let somebody else do it? Or would they prefer to stay involved? Or I guess I’m sure it depends on the details.  

Mitchell: It depends. I mean, again, we don’t work very much with small and midsized employers, but â€¦ 

Rovner: I’ll talk to them separately. 

Mitchell: Yeah, it wouldn’t surprise me if they wanted to wash their hands of it, because they have so little leverage. I think that there are large employers who remain committed to this. But depending on the policy environment that we are in in the next three to five years, who knows? I do think that if employer-sponsored insurance doesn’t demonstrate real affordability in the next few years, you know, I think it’s an open question. 

Rovner: So we seem as a society to be growing further apart rather than closer together on a lot of policy issues â€” not just healthcare, but education, climate, immigration. How do we get back to a place where people who disagree can work together to address something that everybody agrees is a problem, like the state of our healthcare system? I realize that’s sort of beyond your pay grade, but unless people think about it, we’re not going to get there. 

Mitchell: No, I think it’s a really, really important question. I don’t necessarily have the answer. But, I mean, I think it’s also finding where we have agreement, right? Everyone, well, all the people I work with, think we are paying too much for healthcare, so we’ve got to have a clear goal of affordability. And employers alone can’t fix that, right? So how do they partner with clinicians and providers and communities and governments to actually achieve that? I think if you focus on those sort of pragmatic shared goals, I mean, it may lower the temperature a bit. Healthcare is also so complex. Everybody sees different sides of the elephant, and they, so they have very strong views. They’re not wrong. It’s just not the whole system. So really, taking a systems approach, understanding the existing practices and incentives and behaviors. I think level-setting on why we are where we are is also really important. And I do not believe it is well understood. I talk to Congress a lot, and staff, and agencies, and administration, and, you know, there is a pretty deep understanding of Medicaid and Medicare, but not the commercial market. So really understanding the actual barriers, I think, would go a long way to sort of, you know, at least some initial consensus. 

Rovner: So more education, basically. 

Mitchell: Education and alignment on large goals, even if we have some differences on, you know, how we get there, and respecting that there are going to be different strategies, you know. I’m in Maine right now, and rural Maine may need a whole different approach to paying for rural behavioral health than you would have needed in San Francisco. So let’s be open to multiple approaches to the same problems. 

Rovner: Looking forward to the debate. Elizabeth Mitchell, thank you so much. 

Mitchell: Thank you. 

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

Edney: Sure. This is a story that I wrote. It’s “.” During covid, obviously, a lot of personal protective equipment we had issues getting it. There were shortages, and so the government decided to spend almost a billion dollars on these handful of companies that they were going to try to boost medical glove-making here. And those are like the nitrile exam gloves you see in every hospital, every doctor’s office. And we were not fully making them here. The main ingredient, particularly the most important piece, we weren’t making here. Well, fast-forward six years, we are still not making it here. So none of those companies that the government funded are making medical gloves. And so, essentially, we’re at the point where there are full entire factories built with huge reactors and things to try to make this main ingredient because it’s a petroleum product. But they aren’t able to finish the project; they aren’t plugged in and ready to go. And the U.S. government has decided they’re not going to fund that anymore. These went from Trump 1 to Biden to Trump 2, and Trump 2 has said we’re letting this go. We’re not going to do it, and this factory will probably end up being sold for parts. Others have shut down, and we’re getting our medical gloves still mostly from Malaysia. Kind of the reason I wanted to write this now is because it’s just when the government decided to abandon this project, but also because of the war with Iran has raised the cost of petroleum products, which is the main, you know, nitrile butadiene rubber. And so the cost of that has gone way up, and so we’re kind of in this cycle where we still can’t get it, but it’s still being affected by outside forces. 

Rovner: Well, thank you for doing the accountability journalism on this. It was. I really, really liked this story.  

Ollstein: Thank you. 

Rovner: Sandhya. 

Raman: So my extra credit this week is from my colleagues Nyah [Phengsitthy] and Skye [Witley] at Bloomberg Law, and it’s called “.” So they spent a few months looking at the, you know, hundreds of different supplements and different packaged foods that have been, like, trying to gain momentum in this space because of the popularity of GLP-1 medications and just, you know, there has been really limited federal oversight of claims of these, you know, the supplements and the foods. It’s causing â€¦ 

Rovner: I would say, and to be clear, these aren’t people trying to make GLP-1s. These are people making supplements that are to appeal to people who are on GLP-1s, saying, you know, if you want it because you’re not eating as much, here’s a way you could get the nutrition that you need. 

Raman: Yes, absolutely. So you know, it might say like GLP-1-friendly, or, you know, it might be on, you know, a snack food you buy, or, you know, just a supplement that’s unregulated at a drugstore. And just a lot of the confusion there. There’s not a lot of research on some of these things. There’s, you know, a lot of litigation brewing in different places related to this, and there’s not, you know, a standard federal definition of what something like “GLP-1-friendly” even means. So they have a great deep dive into this. So you should take a read.  

Rovner: Yeah, at some point, Congress is going to have to take another look at the whole supplement regulation thing. But I thought this was really fascinating because it’s just a whole new sort of category of supplements that has popped up in the wake of the GLP-1 popularity. Alice. 

Ollstein: I have a story from my co-workers Amanda Chu and Robert King [“”], and it’s about how the federal government’s attempt to crack down on what they claim as widespread Medicaid fraud in Minnesota, in particular, is having all of these damaging spillover effects and has cut off Medicaid payments to a bunch of providers: mental health, eldercare, all kinds of things â€” folks that are not suspected of committing fraud at all. The state is pausing payments to a wide range of providers while they try to implement these new anti-fraud measures, and so it just is a good look at the danger of using kind of a sledgehammer to go after a more narrow problem. 

Rovner: Yep â€¦ I think we’re going to see that more and more as sort of these Medicaid sort of crackdowns and the fraud crackdowns continue. My extra credit this week is from Mississippi Today. It’s called “.” It’s by Sophia Paffenroth and our own podcast pal Joanne Kenen. And it’s about something I’ve been talking about a lot this entire very hot summer, which is the impact that heat and the lack of air conditioning has on health. We know excessive heat takes a special toll on the elderly and those with respiratory issues, but it’s also super dangerous for pregnant people and the very youngest among us. And while Mississippi has been taking some novel steps to address that, a lack of attention by medical professionals and a lack of research, along with budget cuts, have been making that task much harder. It’s a topic I’m sure we will all continue to watch. 

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

Raman: On  and on  @SandhyaWrites. 

Rovner: Anna. 

Edney:  and  @annaedney. 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

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

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

Julie Rovner: Julie, hello from 51ÊÓƵ Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 51ÊÓƵ Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, June 18, 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 Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: Sheryl Gay Stolberg of The New York Times. 

Sheryl Gay Stolberg: Hi, Julie. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hello. 

Rovner: Later in this episode, we’ll have my interview with Michael Cannon of the libertarian Cato Institute and Liz Fowler of the Johns Hopkins Bloomberg School of Public Health. Michael and Liz, who are on opposite sides of most things in the health debate, are jointly promoting the idea of eliminating, or at least scaling back, the employer health insurance tax exclusion that underpins much of the U.S. healthcare system but also drives up health spending. But first, this week’s news. 

Let’s start this week on Capitol Hill, where Democrats in the Senate say they plan to use the Congressional Review Act to force a vote to disapprove the Trump administration’s Affordable Care Act payment rule that was finalized in May. For those who haven’t been paying close attention, this is the rule for next year’s plans. It includes things like allowing non-network plans that could open policyholders to unlimited out-of-pocket spending, or else possibly no available providers of care in their area, as well as new catastrophic policies with lower premiums but deductibles well into the five figures. 

The CRA is a handy tool for Congress. It allows the minority to force a vote on the floor and only requires a simple majority of both houses to pass. Few rules are actually canceled using this procedure, but it does allow members of Congress to highlight an issue, in this case playing into Democrats’ desire to keep one of their best midterm electoral issues, healthcare, front and center. So, will this succeed at getting attention, even if it ultimately doesn’t cancel the rule? Or is there just too much else going on right now? I have to say, I haven’t seen a lot of coverage of this other than from my colleague Julie Appleby. Bless her heart for bringing this story to everybody’s attention. 

Stolberg: I think that by November this will resonate. We’re in a situation now where costs are rising, gas costs are going up, and they may go down if this Iran deal goes through, but healthcare and the cost of care is always an issue for Americans. It’s long been an issue that Democrats have led on. I actually find it interesting. What [President Donald] Trump is trying to do really kind of undercuts the very premise of Obamacare, which was to offer kind of a baseline level of care, to require that plans gave people a baseline level of care. You know, come November, it’s going to be just after the enrollment period of October, and I think Democrats are going to be talking about this. And then, it might not resonate or break through now, but they will point back to this vote in this moment. 

Edney: Yeah. I was going to say that I do think it’s possible by then. I think you were right to say that right now it’s hard for things to break through, but by the midterms we may see, as a direct result of this, people losing coverage. And I think that coverage losses â€” or deciding not to have coverage any longer, because it’s too expensive. So, I do think that coverage losses, whether it’s in the ACA marketplace or Medicaid, are going to be a big campaign issue. And if Democrats can point to this vote as a direct line to We support you having your coverage and Republicans don’t, that could be something that breaks through to those potentially millions of people who no longer have care. 

Rovner: Yeah, last week I described this as the drip, drip, drip of declining coverage, which is that we sort of keep seeing these things bit by bit. Rather than sort of one dramatic, Oh my goodness, I can’t afford my coverage and I’m going to drop it, we’re seeing people scrambling to try and keep coverage, or to buy down to have less expensive plans with bigger deductibles. And then, once they start to seek care, they’ll realize they can’t handle those deductibles. So it’s happening in pieces rather than all at once. 

Well, speaking of that Affordable Care Act rule, props to the eagle-eyed Reed Abelson, your colleague at The New York Times, Sheryl, for spotting a little-noticed piece of the rule that allows insurers to offer loans to patients who can’t immediately come up with those multi-thousand-dollar deductibles should they need medical care. Now, this is not a new idea. Overall, veterinarians have long offered payment plans to pet owners, as have health practitioners, whose services are often not covered by insurance, like cosmetic surgeons. But for necessary medical care, it seems like loading patients with still more medical debt seems like a less-than-popular solution to high healthcare costs. Or is that just me? Lauren. 

Weber: I mean,  was a blockbuster, and also just horrifying. And what kind of dystopian future are we all in? Instead of paying your premiums, you’re also paying your payment plan to the same people. It’s already been said enough that there’s some concern that health insurance plans are gobbling up so many parts of the healthcare market. You wonder what happens when they also become essentially your mortgage broker. And so I think the story deserves a lot more attention, because I think a lot of Americans would be quite terrified if they realized that is potentially the future. 

Edney: And it seems like the point should be to make coverage more affordable, not to find new ways for you to pay the same really high amounts. 

Stolberg: I just was going to say I thought it was interesting that Reed pointed out that roughly a third of Americans have some kind of medical debt, and she linked to an analysis, a  in HealthAffairs, about medical debt and collections being very common and large. 

Rovner: Yeah, I’m just noting the irony of Republicans deciding to come out against Big Insurance, and yet this â€” talk about own goals, going against exactly what you’re saying. Let’s make Big Insurance less popular by having people owe money on a payment plan, have a credit card to pay their insurance company back for things that their insurance company basically isn’t covering anymore. Yes, presumably with interest, so Big Insurance will make even more money. 

Well, moving on, it’s been a busy week on the reproductive health front. In Texas, the state’s Republican platform includes a plank calling for women who have abortions to be held criminally liable for murder after another Texas anti-abortion group fought unsuccessfully to have it removed. , the attorney general’s office is sending cease-and-desist letters to out-of-state organizations that offer abortion pills via telehealth. The letters say the companies, including some well-known ones like Plan C and Cambridge Reproductive Health Consultants, must stop all advertising, sale, and delivery of pills to Alabama residents or face potential legal action, including fines of $2,000 per violation. On the other hand, one former abortion provider in the state pointed out that the letters themselves act as an advertisement for the various services that otherwise people might not know anybody about, or where they are. Is this just performative? Or do we think there are going to be real efforts to reach distributors outside states with abortion bans, despite shield laws in the states where those distributors are actually located. 

Weber: It’s probably a mix of both, right? I think that some of it is for press coverage. I did find the former abortion provider saying this is a giant billboard for all these products to be somewhat quite the comment to be made. But it’s true. If you live in Alabama and you went to this woman who is an abortion advocate, she could not tell you where to look these things up online, and now there’s a plethora of media coverage and attorney general’s letters that lead you right to the source. 

Rovner: With their addresses. 

Weber: With their addresses. With their web addresses. And so— 

Rovner: That’s right. 

Weber: It’s an interesting move on all counts. I think it’s just a one and another. I think I don’t think we’re going to just see this from Alabama. 

Stolberg: Yeah, I was going to say this is part of a broader assault by the anti-abortion movement on abortion medication, and in particular mifepristone. And my colleague Pam Belluck and I  about this lawsuit that was brought by the state of Louisiana, which instead of targeting the manufacturers of the pill, they want courts to bar a policy allowing abortion providers to provide or prescribe mifepristone and send it through the mail. This was the policy of the Biden administration’s FDA [Food and Drug Administration]. The Trump administration has said, We’re studying this issue. That study seems to be going on a very long time. Some people suggest it will go on past the midterms, so— 

Rovner: That seems to be the strategy. 

Stolberg: Right. But nonetheless, now that Roe [v. Wade] is gone and states regulate abortion, we are seeing this kind of clash between states about what can happen from one state to another, and I think this is part of that. 

Rovner: Yeah, and as we’ve pointed out multiple times in multiple ways, anti-abortion groups are furious that the administration has not rolled back this ability to send these pills through the mail, because that is why I think we’re seeing less backlash to some of these bans than we would have otherwise, because a lot of these bans are fairly easily evadable by going, having a telehealth appointment with a doctor in another state and getting the pills in the mail. And there’s very little that the ban states, as we’ve discovered, can do to stop it. So they’re sort of trying everything, including these cease-and-desist letters. But this is clearly a fight that’s going to go on unless and until the administration steps in or the courts step in. And we’re, I guess, at this point waiting on both. 

Meanwhile, the Huffington Post has a truly  about women who get positive home pregnancy tests, arrange to travel or take time off from their jobs to get an abortion, only to discover once they get to the clinic that they weren’t actually pregnant at all. It seems most of the false positives are coming from the same brand, Clearblue. And it’s not that the tests are wrong as much as they appear to be too sensitive, likely picking up pregnancies that either end themselves before they’re fully established or picking up the hormone that the tests detect from sources other than an active pregnancy. The most chilling part of the story is at the very end, with one doctor wondering how many women are doing telehealth abortions with pills who were never actually pregnant to begin with. It seems that do-it-yourself healthcare maybe isn’t as foolproof as we’ve made it out to be? 

Weber: I think the story, just â€” first off, everyone should read it, because it’s an incredible deep dive. She managed to uncover multiple complaints that physicians who provide abortion had made to the FDA, which appear to have been undealt with, and it speaks to the tragedy of some of these people that take time out of their day, raise money, travel across state borders to potentially try to end their pregnancy, and realize they don’t have a pregnancy at all, and the emotional trauma of that. But more than anything it speaks to the fact that as abortion rules have become more restrictive, you need to know if you are pregnant earlier than ever, so that’s why a lot of these people are taking these pregnancy tests. And the fact that this is so sensitive, the article does posit that it could be picking up pregnancies that are called chemical pregnancies, which don’t end up becoming actual pregnancies. But the point is that usually if you wanted to go check that, you would go to a doctor and they would check your blood levels and see if they were rising. But a lot of women are afraid to do that in this current environment. And so I feel like it’s a big story of unintended consequences and horror that has unfolded as some of these pregnancy tests are not accurate. 

Rovner: Yeah, and in some cases there are multiple cases. Go ahead, Sheryl. 

Stolberg: Lauren’s words, “unintended consequences,” were just what I was about to say. This is part of a whole panoply of things that were not foreseen by anyone, really, when Roe was overturned. A couple years ago I went to Idaho  how OB-GYNs, especially those who dealt with complicated pregnancies, were fleeing the state because of the restrictive abortion rules. And that was leading family practice doctors, like one I featured, without help in caring for patients with complicated pregnancies. And that, too, is sort of an unintended consequence. And when we were talking before about the abortion pill being sent across state lines, yes, you can evade the bans that way, but it still leaves women without medical care, without follow-up care should something go awry. So a lot of things happened, have flowed from the Dobbs [v. Jackson Women’s Health Organization] case that we didn’t think about at the beginning. 

Rovner: Yeah, one of the things that I’ve written about is it’s not just OB-GYNs who are leaving states or not going to states in the first place, choosing not to do residencies there. 

Stolberg: Right. 

Rovner: But it’s other doctors who are not going to some of the states with bans, because doctors who finish their medical school and residencies tend to be of reproductive age. And they are women, or if they are men and have spouses and want to start families, they’re worried about being in states that don’t have enough doctors if there’s a difficult pregnancy. We’re talking about people who want to get pregnant being a little bit concerned about going to states with abortion bans, because so many of the doctors who would deal with difficult pregnancies have left. So it’s just, it spins out and out and out and out. 

Well, finally, in something from the Trump administration that will please anti-abortion forces, a new grant announcement for a George W. Bush-era program promoting the adoption of frozen embryos left over from IVF [in vitro fertilization] refers to them as, quote, “children who already exist and are in need of a family.” Is this formal announcement the quiet beginning of this administration’s effort to establish fetal personhood in federal law? Or is it just another way to pacify pro-lifers who are still angry over the other administration policies we were just talking about that they don’t like so much? 

Stolberg: Huh. That’s interesting. 

Rovner: Sheryl, you probably remember the “snowflake babies” from the Bush administration. 

Stolberg: OK, I’m actually the person who  on the front page of The New York Times, and then suddenly snowflake babies and their parents were appearing at the White House and on Capitol Hill, it was a group called— 

Rovner: Remind younger people who these snowflake babies are. 

Stolberg: So, there was a group called â€” this was at a time when we were talking about excess embryos left over from in vitro fertilization and what should happen with them, and— 

Rovner: And whether they should be allowed to be used for stem cell research. 

Stolberg: Right. That’s exactly right. And whether they should be allowed to be used for stem cell research. And there was a group called Nightlight Christian Adoptions. They’re a Christian adoption agency, and they had come up with another way, they said, in which infertile couples were literally adopting embryos that were left over from other people’s pregnancy effort attempts. And this was a solution for deeply religious people who did believe that life begins with the embryo and did not want to destroy their embryos and also did not want to have to pay in perpetuity for them to be housed in a lab somewhere. And they called them snowflake babies. And so this is something that George Bush talked about and became enshrined in, I guess, his administration. And, I don’t know. I guess Trump is looking back 20-some-odd years or so, reviving the past. 

Rovner: Well, there has been, there â€” it’s a program that has continued. 

Stolberg: Right. 

Rovner: And there were some adopted embryos even during the Biden administration. But I guess the question that sort of comes up now is, by describing them as already children— 

Stolberg: Yeah. Are they laying the groundwork for this? 

Rovner: â€”are they setting â€” yes, are they laying the legal groundwork? Lauren, you wanted to add something. 

Stolberg: Maybe. 

Weber: I was just curious. Does this lay the legal groundwork that any leftover embryo would then qualify for this program? What if you didn’t want your leftover embryo to go through this? I’m curious. The regulation seems a little unclear. 

Stolberg: I think parents retain the right. Parents retain the right to, they are in essence the property â€” I don’t like to use that word, but â€” 

Rovner: I think legally, though, that’s what they are. 

Stolberg: And legally, embryos created by an infertile couple belong to that couple. And in fact we’ve seen, and my colleague Caroline Kitchener  a lawsuit between a husband and wife who divorced and the woman wanted to implant the embryo and the man did not. And the question was, who quote-unquote “owned” the embryo. But I think that personhood question is really interesting, Julie, and maybe it does establish, in a way, a government recognition of embryos as people that is unprecedented. 

Rovner: Yeah, that’s certainly the concern, that it’s sort of taking it one step further. All right, we’re going to take a quick break. We will be right back. 

We are back. And speaking of issues the administration is trying to tiptoe around, let’s turn to vaccine policy. Last month, the Journal of Toxicology and Environmental Health announced it was retracting a 2010 study that linked the hepatitis B vaccine to an increased risk of autism, because, and I’m quoting here, “due to fundamental methodological flaws the study’s conclusions are unsound.” That was one of the studies cited by Secretary Robert F. Kennedy Jr.’s handpicked advisory committee to change the recommendations for the birth dose of the hep B vaccine. Separately, the journal Toxicology Reports retracted a 2021 study that claimed a link between vaccines and sudden infant death syndrome, also citing methodological errors â€” which is typical, by the way, for why studies are retracted. Yet that retraction led Secretary Kennedy to write a letter to the journal demanding to know why and giving the journal’s editor a deadline of June 26 to respond. What is Secretary Kennedy trying to accomplish here? And will it work or is it just coming off as bullying? 

Edney: I think certainly it’s coming off a little bit as bullying in the sense that this was a decision that the journal made about something that â€” clearly this happens, because it happened with this other study. I think that in Secretary Kennedy â€” and Sheryl, you’ve written about this, and others â€” he does still have a vaccine agenda, whether he’s allowed, or an anti-vaccine agenda, whether he’s allowed to talk— 

Rovner: We’ll get to that in a moment. 

Edney: â€”or not. So I think when he makes these requests, he’s kind of trying to sow doubt into what these other doubts the journal is bringing out. 

Rovner: Lauren, you want to say something. 

Weber: Yeah, I just, I think in general, this is a pattern of actions by Kennedy that several experts have described to me as somewhat hypocritical. He’s attempting to bully a medical journal. He had a big thing about all information should be free during covid, no one should be silenced. And here he is using his platform to potentially change things on that front. And then he also recently issued a quarantine order for someone with hantavirus to stay in Nebraska, which flies in the face of a lot of his “medical freedom” rhetoric during covid. And so I think some of these moves are really interesting because they seem to strike at a contradiction in a lot of the rhetoric he espoused before coming into office. And even on top of the vaccine of it all, I just, I think that’s important context to consider. 

Rovner: And Sheryl, we spent some time last week talking about  about the secretary. But anything you would like to add, please do. 

Stolberg: Yes. I think this is not at all out of character for the secretary. The secretary has long believed that the established medical journals are censoring what he views as legitimate research, i.e. research into the alleged harms of vaccines. And even before he became secretary, when he was running for president, he laid out a very clear agenda in which he said he was going to use government science to lay the groundwork for research that could be used in court against pharmaceutical makers, vaccine makers, and he was also going to take on the medical journals. And in the aftermath of covid, what we saw was also this sort of alternative ecosystem of medical journals growing up, published by these covid contrarian doctors, the Independent Medical Alliance, and other groups. So it wasn’t surprising to me at all that Kennedy went on the offensive against a journal that retracted a study, because he and his allies have long complained that these journals are censoring them. When journals find fault with research that Kennedy likes or supports his views, he doesn’t want to hear about that. 

Rovner: Well, separately, or perhaps not so separately, the Justice Department, on Kennedy’s behalf, is asking for an expedited appeal of a lower-court ruling that found his changes to the childhood vaccine schedule to be, quote, “arbitrary and capricious” and his handpicked vaccine advisory committee members unqualified for their posts. The administration is arguing that because the ACIP [Advisory Committee on Immunization Practices] is currently frozen, the administration can’t act on new vaccines for this fall, including for things like flu, RSV [respiratory syncytial virus], and covid. The , meanwhile, which brought the lawsuit that got the changes stayed, argues that Kennedy can reconstitute ACIP anytime he wants, as long as he follows the federal advisory committee rules and appoints members with vaccine expertise. How might this standoff get resolved? Or does this standoff need to be resolved? There are arguments the FDA has already approved a vaccine for this fall. Insurers have already said they’re going to cover it. So is this, speaking of things that are performative, also performative? 

Stolberg: That’s â€” I think we’re in uncharted territory, Julie. In the past, the CDC’s [Centers for Disease Control and Prevention’s] vaccine advisory committee has met well in advance of every upcoming fall, the flu season, to discuss vaccines to protect the American public and kind of issue their recommendations, which guide what insurers cover. And as a result of this lawsuit, we’re in a place where kind of everything is going on without that central pillar that backs up these decisions. So insurance companies are saying, Yeah, we’ll cover, and the FDA is saying, Yeah, we’ll approve, but there are no experts, outside experts, really thinking through what the right policy is. So, I suppose— 

Rovner: Technically there’s not even an acting director of the CDC, right? Because it went on too long? 

Stolberg: That’s right. 

Rovner: Or is that — so Jay Bhattacharya— 

Stolberg: Well, Jay Bhattacharya is functioning as the acting director but technically he is not the acting director. He is acting in the capacity of director or something like that? 

Rovner: I believe that is the phrase. 

Weber: Who needs senior leadership? 

Rovner: Yeah. It’s all very weird, so— 

Weber: They’re all gone. 

Stolberg: I think it’s a question of, can the government function without this? Yes. Is the government doing the best work for the American people without this system in place? You know, probably not. 

Rovner: Well, meanwhile, more quietly, since the White House ordered Kennedy to back off his more public anti-vaccine efforts, it appears that things are still happening, just a bit more out of public view. Both  and now  are reporting new efforts to study possible ill effects of vaccines at the CDC, the NIH [National institutes of Health], and elsewhere in the department. Quoting from the Washington Post story, by Lena Sun and our podcast panelist Rachel Roubein: “Kennedy’s allies are embedding his agenda in institutions that decide what gets studied, who does vaccine research and how these findings are translated into policy. This could keep the Trump administration’s questioning of vaccines’ safety alive for years to come,” close quote. Could these changes have an even longer-term impact than some of RFK Jr.’s sort of splashier actions that we were just talking about, that could be more easily overturned by an incoming administration? 

Weber: I think absolutely, Julie. I think at the end of the day, too, some of what my colleagues Rachel and Lena found was that they are exploring adding new members to ACIP, that they’re also exploring adding a new Office of Science in the CDC. What does that mean? If is that an Office of Science that Kennedy agrees with? Or is that an Office of Science? These are the questions one has to ask. And then, what kind of long-term ramifications are there for that? Many public health experts say that this continued back-and-forth on vaccines just leaves a lot of people confused and will likely contribute to lower vaccination rates, which could contribute to the continuous rise of preventable, vaccine-preventable, disease. And so there’s a lot of concern that some of this groundwork that’s being laid to underpin some of Kennedy’s long-held beliefs could have a very, very long tail. 

Rovner: Yeah, and of course we’re already seeing cases, not just measles spreading but whooping cough and the kinds of diseases that are preventable with vaccines that people are now not getting for their kids. 

Well, finally this week, two amazing stories related to HHS but not of HHS. One is from The New York Times’ Christina Jewett and Kenneth Vogel, and it’s a  into how lobbying has helped keep the potentially dangerous supplement kratom, if not on pharmacy shelves everywhere, then at least in gas stations and convenience stores around the country. This story has lots of twists and turns over several presidential administrations, but it does seem that Trump 2.0 has been welcoming, shall we say, to the kratom industry, which has in turn given lots of campaign contributions to the administration and its allies. Anna, I see you nodding. 

Edney: Yeah, I loved the story. I thought it was really well done. And, like you said, lots of twists and turns. And there was a really great quote, and I’m not looking at it, but it was along the lines of this being kind of a coin-operated policymaking administration. So, like, you’re â€” if you give enough money. That’s why we’re seeing it’s not your typical, like, Big Pharma putting a lot of lobbying in, right? It’s kratom, it’s flavored vapes, things that kind of you might have considered on the fringes bubbling up to hit. Even the president’s talking about them, and at press conferences that are completely unrelated. So I think that it was a great look at how this industry really kind of got into the administration, and in their view, in the industry view, it’s like, Listen, we’re just paying to be at the table, and we’ve never really been at the table before. But pretty much anyone who can bend the presidency, or someone in his administration, seems to be able to make these inroads that we haven’t seen before, when the product is not proven safe and has been shown to harm people and cause, lead to death. 

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

Stolberg: Yeah. So I was going to say, I lived through this story by my colleagues Ken Vogel and Christina Jewett, and props to them. We’ve been talking about this for a while. I noticed a while back, when  the MAHA [Make America Health Again] movement and Trump, that this company called Botanic Tonics had kind of donated like a million dollars to the MAHA PAC: And I thought: “What is this? Why are these people donating a million dollars to this PAC? Who are they? What is kratom?” And it turned out that my colleague Ken Vogel and also Christina Jewett were kind of already onto this. And the thing that they found to me that was so amazing is that not only this company and the promoters of kratom, which is kind of like an addictive gas station drug â€” it supposedly boosts energy â€” not only were they cultivating Kennedy, but also Markwayne Mullin, who now leads the Homeland Security Department but formerly was a senator, had an investment worth as much as a million dollars in this company, the company of Botanic Tonics. The company’s founder was an energy executive in Mullin’s home state. He’s this odd guy who I think had some sort of brush with the law and changed his name, and it was just this kind of crazy story of influence, like Anna said, kind of, or maybe you said, Julie, on the fringes but coming to the fore. 

Rovner: Yeah, and the original sin here, I think, and someday we’ll go into a deep dive on this, was the 1994 fight in Congress about dietary supplements and— 

Stolberg: The DSHEA [the Dietary Supplement and Health Education Act]. Yes. 

Rover: Right. 

Stolberg: And I’ve thought a lot about this. That has created kind of the, what critics call, the wellness industrial complex, which allows these companies to sell things that are supplements as food, which means they are not regulated as stringently as drugs, can only be regulated after they come to market. And a lot of shady stuff is sold as a result. 

Rovner: Yeah, as I say, it goes back a lot of administrations. All right. Well, finally this week, my other story, and this is my extra credit this week. It’s the second blockbuster in the last three weeks for my 51ÊÓƵ Health News colleague Darius Tahir about President Trump’s stock trading. The previous one was about the prescription drug industry. This one is about tobacco. It seems that the teetotaling commander in chief is fine with other legal vices, that he holds more than $1.6 million in stock in tobacco giant Philip Morris, as well as positions in Altria and other tobacco companies. The tobacco industry has been good to him, too, giving millions to Trump-affiliated super PACs. And what has the administration given back? Quoting from the story: “It’s FDA piloted a fast-track program to approve nicotine pouches. It unveiled a program to allow vapes on the market more rapidly, despite resistance from career civil servants and leadership, culminating this year in guidance waving through flavored electronic cigarettes. It cut public health employees focusing on anti-tobacco policy. And it broadened enforcement against illicit e-cigarette, competitors to the big industry players with a financial relationship to Trump,” close quote. This is a big difference from the first Trump administration when it comes to tobacco, isn’t it? My recollection is that they were not quite this welcoming to tobacco from 2017 to 2020. Anna, I see you nodding. 

Edney: Yeah. 

Rovner: You did some work on this. 

Edney: Yeah, well, this was when, the first Trump administration was when Scott Gottlieb was the FDA commissioner, and he was quite anti-tobacco. And we went through this whole scare about kids getting some strange lung disease from vaping. And there were a lot more restrictions that â€” and less approvals, or clearances, whatever you want to call the tobacco side of FDA. So, I think it’s been a complete turnaround, where this time around the Trump White House would prefer to run roughshod over the FDA and get what they want for the tobacco industry, because they’re getting a lot of money from them. 

Rovner: Yeah, and props to Darius for connecting all of the dots. Lauren, you want to add something? 

Weber: Yeah. Let’s go back to  about Trump meeting over cheeseburgers with the tobacco guys at the White House. I think Darius’ piece lays out the money that maybe is hanging out there. But props to Darius for having two of these quite good stories looking at these conflicts of interest. 

Stolberg: Yes, during the Trump administration, the first Trump administration, Alex Azar, his health secretary, pressed Trump to take some sort of action restricting vaping, and Trump got really mad at Azar about it, and he complained privately and yelled at Azar, saying to him, You’re costing me votes, because the MAGA crowd likes vaping. This was recounted in a book. I’m pretty sure it was Phil Rucker and Carol Leonnig’s book, the two Washington Post reporters. So, Trump was, maybe he wasn’t this aggressive in supporting the tobacco industry, but then there’s this added component to it, which is that he thinks MAGA [the Make America Great Again movement] likes vaping. And he was yelling at Azar, saying: You’re costing me votes. You’re going to cost me this election. I’m sorry I ever did this. 

Rovner: Oh, we will see how this one plays out. All right, that’s this week’s news. Now, we’ll play my interview with Michael Cannon and Liz Fowler, and then we’ll come back and do our extra credits. 

I am pleased to welcome to the podcast two people who have taught me a lot over my years covering health policy. And full disclosure, I consider both of them friends. Liz Fowler is a distinguished scholar at the Johns Hopkins School of Public Health. During the Biden administration, she ran the Center for Medicare and Medicaid Innovation, an agency created by the Affordable Care Act, which she helped write as the chief health counsel on the Senate Finance Committee and implement as a senior official in the Obama administration. Michael Cannon is the director of health policy studies at the Cato Institute, a libertarian think tank here in Washington, D.C., and has spent most of the past 16 years trying to get the Affordable Care Act repealed after vehemently and almost successfully blocking its passage. Yet this unlikely pair is on a new mission, pointing out why the first step in the next round of health reform should be to get rid of something called the employer health insurance tax exclusion, which we will explain in a minute. Liz and Michael, welcome. Thanks for doing this. 

Liz Fowler: Thanks for having us. 

Michael Cannon: Thanks for having me. 

Rovner: So for most people this would be a hard question, but you guys have been on the circuit, so one of you give me the 30-second explanation of what the employer tax exclusion is and why it exists in the first place. 

Cannon: So when Congress passed the income tax in 1913, there was no such thing as health insurance, really. So they gave no thought to the question of if an employer provides health insurance to its employees, should that be subject to the tax. The Treasury bureaucrats, when someone presented that idea, said: This is really hard. We don’t know. We’ll just say we’ll exclude that from the tax base, so we won’t tax compensation in the form of employee health insurance. That was in the 1920s. In the 1940s â€” so that gave employer health insurance a boost. In the 1940s there were wage and price controls that gave it a further boost, because employer health insurance was exempt from those wage controls, so it gave employers a way to compete. But it’s really that tax exclusion that is responsible for the fact that more than half of U.S. residents have health insurance through an employer, because it works like this: If your employer gives you a dollar of cash, you have to pay federal income and payroll taxes on that, and you’re left with, on average, at the margin, 66 cents. The federal government takes a third of it. But if the employer gives you that same dollar as health insurance, then you get a dollar’s worth of health insurance. So you can see how this sort of distorts the prices, the after-tax prices that people face, when they’re choosing between more cash wages and spending that money on other things versus spending money on health insurance, employer-sponsored health insurance. And so people more often buy employer-sponsored health insurance, they demand more of it than they would otherwise, and this also lets employers end up controlling about, for the average family with employer coverage, $20,000 of the worker’s earnings. And all of these effects end up increasing spending on employer-sponsored insurance and increasing prices for health insurance, and the fact that it’s encouraging a form of insurance that disappears when you change jobs means it’s creating gaps in health insurance coverage. So, for decades, economists have said: Hey, this is a real problem. We need to solve this. And I would argue that it is really the reason that Congress wanted to enact the Affordable Care Act in the first place, to fill some of the gaps that this exclusion created. 

Rovner: So, Liz, originally this was considered a good idea. It’s like, Oh, we’re encouraging the creation of a new fringe benefit for workers: health insurance. When did it outlive its usefulness? 

Fowler: That’s a great question. I think our workforce is very different. Employment is very different than it was back in the 1940s and ’50s, when my parents or grandparents had the same job for decades and they all got health insurance through their workplace. That has eroded over time. I don’t know exactly, Michael probably knows exactly, what the trajectory has been. We’re now down to about 50% of employees receiving healthcare through their workplace. But people are employed in different ways than they used to. I’ve had several jobs throughout the course of my career. People don’t stay in the same job for decades anymore. And people piece together work in ways that they didn’t. Maybe they have more than one job. Maybe they have a part-time job over here and a part-time job over there. This tying health coverage to employment, I think, has become, is starting to become, anachronistic. And I think for me, in particular, watching the debate over HR1 [congressional Republicans’ One Big Beautiful Bill Act] and trying to tie Medicaid coverage to employment or community engagement brought up this whole question of: Why do we tie health benefits to work in 2026? 

And so that’s part of why I wanted to revisit this policy question, which we tried to tackle in the Affordable Care Act and didn’t get very far. And the sort of the distorted version that we included in the law, the “Cadillac tax,” was repealed with a bipartisan â€” what, almost unanimous â€” vote. So I think it’s time to sort of ask these questions again. It’s a very expensive part of the tax code. It’s one of the largest if not the largest tax expenditure in the U.S. tax code, to â€” what â€” close to upwards of $300 billion a year that this benefit provides to a group of workers who are more likely to get health coverage and more likely to get generous health coverage, and at the higher end of the income scale more likely to see a larger benefit. So all of these questions, I think, are ripe for revisiting. 

Rovner: So one of my most vivid memories from covering the Affordable Care Act was a roundtable hearing that the Senate Finance Committee had with all of these economists from across the spectrum talking about how to pay for the Affordable Care Act. And I remember â€” I actually went and looked this back up â€” one of the senators asked what would be the best way to pay for it And one by one by one, these witnesses, eminent health economists from literally every part of the political spectrum, says you need to do something about the employer tax exclusion, literally every one. And obviously, as you said, Liz, they tried. There was sort of the beginnings of this that we called the Cadillac tax, and it was ultimately repealed. Why is this so hard if it, as you guys point out, it doesn’t make very much sense anymore? 

Cannon: Well, it creates a lot of benefits for a lot of very powerful groups. It benefits the health industry because the government is effectively penalizing workers for every dollar of their earnings that they don’t spend on health insurance and medical care. It benefits large employers because they can spread the administrative costs of providing health insurance over a larger number of workers, which means they can take the savings and offer higher salaries than their smaller competitors do, which gives them an advantage in the labor market. So between those two groups right there, you have a very powerful coalition that has blocked, defanged, repealed every effort to try to limit or reform the exclusion, and there have been a lot. Presidents [Ronald] Reagan, [Bill] Clinton, Bush the younger, [Barack] Obama. Presidential candidate John McCain famously tried to reform the tax exclusion, and Barack Obama really, I would say, demagogued that that proposal. I didn’t favor that proposal either, but McCain’s policy director says he still has nightmares about the attack ads that Obama ran. And it’s because of the fear those â€” it’s not just that people have a financial interest in preserving this huge tax break for employer-sponsored insurance. It’s the fear that those special interest groups are able to demagogue, to play upon that people with employer-sponsored health insurance who have expensive medical conditions will lose their coverage and be left with nothing. 

Now I am not a fan of the Affordable Care Act, or what I now call Obamacare. We’ve discussed this. Liz and I do not see eye to eye on that one. I would repeal it tomorrow if I could. But if it is in place, then it actually helps with that problem. It helps with this fear that people would, if we reform the tax exclusion for employer-sponsored health insurance, that people will lose their coverage. There’s a lot of evidence to suggest that employer coverage will stick around for the vast majority of workers, but for those for whom it does not, the Obamacare exchanges are there as a sort of safety net, so that should make the politics a little bit easier. 

Rovner: So, obviously, the Cadillac tax didn’t work. What would be a step that would, that possibly could happen, that we could take to start to move away from this? 

Fowler: Well, one of the things that we initially tried to do in the Senate Finance Committee, in an early version of the Affordable Care Act, was to cap the exclusion. So you can say above the 80th percentile, or the 85th percentile, or something lower â€” below that will still exclude it from income. But if you get very generous coverage, very expensive coverage, we’ll start to— 

Rovner: Like Cadillac-type coverage? 

Fowler: Well, but the difference is we’ll include that as income for the worker. I think that’s where we ran into problems and political challenges. I think there was some reluctance to tax individuals, and Oh, that looks like a new tax increase. So the Cadillac tax was, OK, let’s instead put that tax on employers and insurers instead of the workers, and that became very unpopular with, as you can imagine, the employers and the insurers. So it makes sense why it’s been a tortured history and it’s been hard to get done. I think one of the reasons, and Michael talked about this, why it was a little bit scary to go down this road in the past, because you didn’t know where people would get their health coverage if you tried to change the employer structure we have now. But now there is a place. There are marketplaces. And the bigger that risk pool, and the more people are part of it, I think the more affordable and the more stable it becomes over the long run. 

Additionally, I’m not sure employers want to stay in this business. I think it’s becoming very unsustainable to continue to provide very costly insurance that, where the cost is rising at quite a rapid pace, certainly higher than wages, and is eating more and more of a household’s income over time. And so I think if we really lift up the hood and start looking at the potential impacts, the opportunities, the options, the policy options on the table, and have an honest debate about what this could look like, I think there would be more openness perhaps now than there was back in 2010. 

Rovner: Well, thank you both for kicking this off. Michael Cannon. Liz Fowler. This was great. 

OK, we’re back. It’s time for our extra credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. I’ve already done mine this week. Anna, why don’t you go next? 

Edney: Sure. Mine is in Politico Magazine. One of the co-authors is our podcast colleague Alice Miranda Olstein. It’s “.” And I thought it was a really smart look at something Trump had said, again talking about things he did in his first administration, that we could end the HIV epidemic in the U.S. by 2030 and put policies in place to try to get there. And Alice and her colleague talked to a lot of top former administration people to look at what happened, and it seems to be not one single lightning bolt but sort of that there were all these other policies around Trump 2.0 that â€”DOGE [the Department of Government Efficiency] and other things that cut a lot of this type of funding â€” that created this situation we’re in now, where no one, except maybe Trump himself, thinks we’re going to meet that 2030 goal. 

Rovner: Yeah, a lot of differences between Trump 1.0 and Trump 2.0, as we’ve been discussing. Sheryl. 

Stolberg: So my extra credit is “Tennessee Pharmacies Sell Potent Ivermectin, Led by Anti-Vaccine Doctor Who’s Taken ‘Bucketloads.’” And this appears in 51ÊÓƵ Health News. It’s by Brett Kelman and Rachana Pradhan. And what I love about this story is it talks about how ivermectin, this drug that actually is a Nobel Prize-winning, generally safe drug approved for treating parasitic diseases in humans, has become kind of this ideological touchstone in our society. And it started during the covid pandemic. And now we’re seeing where people on the right and other influencers were pushing it as a treatment for covid without evidence that it worked, and in fact despite FDA warnings that taking too much of it could cause harm. And now it’s sold over the counter in Tennessee, and Marjorie Taylor Greene was promoting it as a treatment for hantavirus, and— 

Rovner: Which it’s not. 

Stolberg: Which it’s not. Exactly. And it’s just sort of taken on this life in our culture, and I guess I just feel like this story sort of reflects something about this cultural moment and how we are addressing medicine and healthcare as a society, 

Rovner: Indeed. Lauren. 

Weber: So I chose a story titled “,” by Benjamin Mazer in The Atlantic. And it posits this basically interesting thesis, which is that a lot of these chatbots that people use, and even doctors use, are not really regulated by the FDA, and so you kind of are interacting with AI in any sort of healthcare setting, whether you know it or like it or not, and whether those tools are up to snuff or not. And the ending of the article is really the most alarming, because it basically is like: Is this like Uber and Lyft, where Uber and Lyft just disrupted the market so much that we all had to get on board without regulating it more, and that that’s what could happen to hospitals? And I think it’s a really interesting and fascinating question of: What is the role of government regulation when it comes to these AI tools being used in a hospital setting? And are they anywhere near equipped to catch up with what’s going on right now? 

Rovner: Yeah, it’s a really thoughtful piece. All right. That is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had production help this week from Taylor Cook. A reminder: What the Health? is 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 questions or comments. We’re at whatthehealth@kff.org, or you can find me still on X, , and on Bluesky, . Sheryl, where are you on social media these days? 

Stolberg: I am @SherylNYT  and . 

Rovner: Anna. 

Edney: @annaedney  and . 

Rovner: Lauren. 

Weber: @LaurenWeberHP â€” the HP is for “health policy” —  and . 

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