But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.

“We really want people to factor that in,” said , managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”

There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.

In addition, as Medicare Advantage plan in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a in February.

“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.

For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.

But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:

• People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
• People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “.”
• If a Medicare Advantage plan leaves Medicare or in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
• If an individual and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said , a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.

There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.

Patient advocates emphasize that it’s often useful to work with a counselor at the , or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.

People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.

Beware: More Underwriting

In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.

The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a of leading insurers’ applications.

When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said , a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.

“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.

Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.

“They have access to a Medigap comparison tool in addition to what is existing on that can give you a very good estimate of what you may pay for those Medigap plans,” said , associate director of health coverage and benefits at the National Council on Aging.

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called , a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found.Ìý

The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”Ìý

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.Ìý

There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.Ìý

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about members, more than half the people eligible for Medicare.Ìý

CMS is set to announce a final rate decision by early next month. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.Ìý

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 published comments as of March 12.Ìý

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.Ìý

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by Ñî¹óåú´«Ã½Ò•îl Health News has found.

The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.

There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.

Medicare Advantage plans differ from traditional Medicare because private insurance companies administer them. The insurance plans enroll about members, more than half the people eligible for Medicare. The plans offer things like vision and drug coverage, but Medicare Advantage insurers restrict the hospitals and doctors that patients can use and require prior approval for various procedures.

CMS is set to announce a final decision by early next month on the rate proposal. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views.

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 comments published as of March 12.

The proposed rate plan “puts my access to care at risk,” the group’s template letter to policymakers reads in part. “If the investment made by Washington in the Medicare Advantage program is nearly flat year-over-year, I could lose benefits I rely on every day, including affordable prescriptions, capped out of pocket costs, and access to trusted doctors and specialists.”

“Medicare Advantage is not optional for me. The cost protections alone have saved me thousands of dollars and made my health care manageable. Without this program, I would face higher costs, fewer providers, and fewer benefits at a time when I can least afford it,” the letter states.

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

“There’s no way for the public to know what wealthy donors or special interests are funding dark money groups like this,” he said. “That means there’s no scrutiny of who’s really calling the shots.”

Some health care policy experts, who have long argued that the government overpays Medicare Advantage plans by tens of billions of dollars every year, believe industry groups or their surrogates routinely overstate possible negative impacts of rate decisions they don’t like.

“The plans always say that the sky is falling,” said Matthew Fiedler, a health care policy expert with the Brookings Institution. “The industry has a lot of money at stake here. They try to exert pressure on policymakers any way they can.”

At the same time, even critics concede that some of the millions of people enrolled in Medicare Advantage plans could face service cuts if insurance companies are not satisfied with government payments.

“It is legitimate for people to be worried,” said Julie Carter, counsel for federal policy at the Medicare Rights Center, a group that advocates for older adults and people with disabilities.

Her group argues that Medicare Advantage plans have never attained expected cost savings and instead have been overpaid for years at least partly due to “actions to maximize profits.” She said the health plans “are supposed to be saving money, not taking extra.”

People struggling to pay health care bills may have little use for the policy debate in Washington.

“If it wasn’t for being able to have this program, I really wouldn’t be able to afford any kind of medical services, to be honest,” said EsterAlicia Rose, 75, who works at the front desk of a hotel in Pagosa Springs, Colorado. She said she signed the Medicare Advantage Majority form letter to reach policymakers.

Kathy Lovely-Marshall, 66, a retired nurse who lives in Brookville, Ohio, did too. She said she receives “a lot of perks” from her plan, such as dental care, eyeglasses, and prescriptions.

“All those things are a big plus as far as I am concerned,” she said. “I’m very happy with the plan I have.”

But Corenia Branham, 90, a widow and cancer survivor who lives in Alum Creek, West Virginia, said she wants nothing to do with Medicare Advantage plans run by private health insurance companies. She said she didn’t turn in any of the four form letters under her name, which were posted online by CMS on Feb. 23 and signed, “Miss Corenia Branham Branham.” It’s not clear why her last name is signed twice.

Branham said she’s not on Medicare Advantage and doubts she could count on it for needed care.

“I wouldn’t recommend it to nobody,” she said. “I sure don’t want anything to do with it.”

Grubb, the Medicare Advantage Majority spokesperson, disputed that account. He said Branham responded to an ad on Facebook. On Feb. 6, she “completed the form with her information and chose to send her comment to CMS as well as to her representatives in Congress and the White House,” he said.

Other Medicare Advantage advocacy groups have stepped up ad campaigns as the rate decision looms.

The Better Medicare Alliance, whose “allies” include a range of health insurers, health care providers, and consumers, is urging seniors to “Tell Washington to Stand Up for Medicare Advantage.”

“We’ve mobilized beneficiaries to write letters and make phone calls, and we’ve run digital ads on streaming platforms,” spokesperson Susan Reilly said.

Reilly said that this year roughly 3 million seniors “were forced to find new coverage” because plans either shuttered operations or left some areas.

She also said Medicare Advantage plans have “scaled back” benefits such as offering transportation to medical appointments, nutrition support, and dental and vision coverage, while over the past two years beneficiaries have faced an average $900 increase in out-of-pocket maximums.

“We do view this as especially serious,” Reilly said. “This isn’t a single bad year; it’s the cumulative effect of years of underfunding and policy disruption from the previous administration that has left the program increasingly vulnerable.”

As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.

CMS spokesperson Catherine Howden said the agency would make more comments public “as soon as practicable.”

“The agency focuses on reviewing the substance of timely submissions and does not speculate on volume, sentiment, or potential impact of comments while the comment period is open/under review,” she said in a statement.

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It’s been a tough week for Health and Human Services Secretary Robert F. Kennedy Jr. In addition to Kennedy having surgery to repair a torn rotator cuff, personnel issues continue to plague the department: The nominee to become surgeon general, an ally of Kennedy’s, may lack the votes for Senate confirmation. The controversial head of the Food and Drug Administration’s vaccine center will be resigning next month. And a new survey finds Americans have less trust in HHS leaders now than they did during the pandemic.

Meanwhile, the Trump administration continues its crackdown over claims of rampant health care fraud. In addition to targeting the Medicaid programs in states led by Democratic governors, the Centers for Medicare & Medicaid Services is also taking aim at previously sacrosanct Medicare Advantage plans.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.

Panelists

Among the takeaways from this week’s episode:

• Americans feel more confident in career scientists at federal health agencies than in the agencies’ leaders, according to a new survey from the Annenberg Public Policy Center at the University of Pennsylvania. Yet the survey also sheds more light on the erosion of trust in public health officials and scientific research.
• The FDA’s vaccine chief, Vinay Prasad, is leaving — again. Prasad was a critic of the agency before he joined it, and his tenure has been shaped by the same attitude, affecting career officials’ morale and the agency’s interactions with outside companies.
• The Trump administration has extended its fraud crackdown campaign into Medicare Advantage plans. The privately run alternative to traditional Medicare coverage has been a GOP darling from the get-go. Yet President Donald Trump is nudging the party away from its pro-business stance on private insurance, arguing the government should give money to patients rather than insurers — a justification for policies undermining the Affordable Care Act.
• And Wyoming became the latest state to enact a six-week abortion ban, a move that’s being challenged in court. The development points to the fact that while federal policymaking on abortion has largely stalled, the issue is still very much in play in the states as abortion opponents keep pushing back on access to the procedure.

Also this week, Rovner interviews Andy Schneider of Georgetown University about the Trump administration’s crackdown on what it alleges is rampant Medicaid fraud in Democratic-led states.

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

Julie Rovner: The Marshall Project’s “,” by Shannon Heffernan, Jesse Bogan, and Anna Flagg.

Anna Edney: The Wall Street Journal’s “,” by Christopher Weaver, Tom McGinty, and Anna Wilde Mathews.

Shefali Luthra: The New York Times’ “,” by Apoorva Mandavilli.

Joanne Kenen: The Idaho Capital Sun’s “,” by Laura Guido.

Also mentioned in this week’s podcast:

• The Annenberg Public Policy Center’s “.”
• Ñî¹óåú´«Ã½Ò•îl Health News’ “Six Federal Scientists Run Out by Trump Talk About the Work Left Undone,” by Rachana Pradhan and Katheryn Houghton.
• Bloomberg Law’s “,” by Sandhya Raman.
• The 19th’s “,” by Shefali Luthra.
• The Georgetown University McCourt School of Public Policy Center for Children and Families’ “,” by Andy Schneider.

Clarification:ÌýThis page was updated at 5:10 p.m. ET on March 12, 2026, to clarify that Vinay Prasad, the FDA’s vaccine chief, will be leaving his job in April. In an email after publication, William Maloney, an HHS spokesperson, said Prasad is “leaving of his own accord.”

[Editor’s note:ÌýThis transcriptÌýwas generatedÌýusing both transcription software and a human’s light touch. It hasÌýbeen editedÌýfor style and clarity.]Ìý

Julie Rovner:ÌýHello fromÌýKFFÌýHealthÌýNews and WAMUÌýpublic radioÌýin Washington, D.C. Welcome toÌýWhat theÌýHealth?ÌýI’mÌýJulie Rovner,Ìýchief Washington correspondent forÌýÑî¹óåú´«Ã½Ò•îl HealthÌýNews, andÌýI’mÌýjoined byÌýsome ofÌýthe best and smartest reporters covering Washington. We are taping this week on Thursday, March 12, at 10Ìýa.m.ÌýAs always, news happens fast and things might have changed by the time you hear this. So,Ìýhere we go.Ìý

TodayÌýweÌýare joinedÌývia videoconference by Shefali LuthraÌýof the 19th.Ìý

Shefali Luthra:ÌýHello.Ìý

Rovner:ÌýAnnaÌýEdney ofÌýBloomberg News.Ìý

Anna Edney:ÌýHi,Ìýeverybody.Ìý

Rovner:ÌýAndÌýJoanneÌýKenenÌýat the Johns Hopkins Bloomberg School of Public Health andÌýPoliticoÌýMagazine.Ìý

Joanne Kenen:ÌýHi,Ìýeverybody.Ìý

Rovner:ÌýLater in this episode,Ìýwe’llÌýhave my interview with Andy Schneider of Georgetown University, who will try to explain how the federal government’s fraud crackdown on blue-state Medicaid programsÌýis somethingÌýcompletely different from any fraud-fighting effortÌýwe’veÌýseen before. But first,Ìýthis week’s newsÌý—ÌýandÌýsome ofÌýlastÌýweek’s.Ìý

Let’sÌýstart at the Department of Health and Human Services, where I thinkÌýit’sÌýsafe to say Secretary Robert F Kennedy Jr.Ìýis not havingÌýa great week. TheÌýsecretaryÌýreportedly hadÌýto have his rotator cuff surgically repaired on Tuesday.ÌýIt’sÌýnot clear if he injured it during one of his famous video workouts. But it is clear, at least according toÌýÌýfrom the University of Pennsylvania’s Annenberg Center, that the American public is not buying whatÌýhe’sÌýselling when it comes to policy. According to the survey, public trust in HHS agencies, which already took a dive during the pandemic, has fallen even more since Kennedy took over the department. Although, interestingly, public trust in career HHS officials is higher than it is for their political leaders. And trust in outside professional health organizations, places like the American Heart Association and the American Academy of Pediatrics, is higher than for any of the government entities.Ìý

Perhaps related to that is another piece of HHSÌýnews fromÌýthis week.ÌýThe FDAÌý[Food and Drug Administration]Ìýapproved a label change for the drug leucovorin, which Secretary Kennedy last fall very aggressively touted as a potential treatment for autism. But the drugÌýwasn’tÌýapprovedÌýto treat autism. Rather, the label changes to treat a rare genetic condition. Kennedy bragged about leucovorin, by the way, atÌýthe same press conference that PresidentÌý[Donald]ÌýTrump urged pregnant women not to take Tylenol, which has notÌýbeen shownÌýto contribute to the rise in autism.ÌýMaybe it’sÌýfair to say the public is paying attention to theÌýnewsÌýand that helps explain the results of this Annenberg Center survey?Ìý

Luthra:ÌýMaybe.ÌýI was just thinking, we do know that Tylenol prescriptions for people who are pregnant did go down,Ìýright? There’s research that shows,Ìýafter that press conference,Ìýbehaviors did change. AndÌýsoÌýto your point,Ìýit’sÌýclear there isÌýa lot ofÌýconfusion, and confusionÌýmaybe breedsÌýmistrust. But IÌýdon’tÌýknow that we can necessarily say that American voters and the public at large are very obviously informed asÌýmuchÌýas they areÌýperhaps disenchantedÌýby things that seem as if theyÌýwere toldÌýwould restore trust and make things clearer and in fact have not done so.Ìý

Rovner:ÌýThat’sÌýaÌýfair assessment.ÌýAnna.Ìý

Edney:ÌýYeah, I thinkÌýthere’s a lot of overpromising and underdelivering, and that can kind of create this issue where this administrationÌý—Ìýand RFK Jr.Ìýhas been doing this as wellÌý—Ìýkind of is making these decisions from the top, rather than having these normal conversations with the career scientists and things like that, where the public can kind of follow along on why the scientific decisions are being made if they so choose to,Ìýor at leastÌýhave an idea that there was a discussion out there. AndÌýthat’sÌýnot happening. SoÌýthat’sÌýnot somethingÌýthat’sÌýcreatingÌýa lot ofÌýtrust.ÌýI think peopleÌýare seeing that as unscientific and chaotic.Ìý

Rovner:ÌýI wasÌýparticularly interested in one of the findings in the survey,Ìýis that Dr.ÌýFauci, Dr.ÌýTony Fauci, who wasÌýsort ofÌýtheÌýbête noireÌýof the pandemic, has a higher approval rating than either RFK Jr.ÌýorÌýsome ofÌýhis top deputies.ÌýJoanne, I see you nodding.Ìý

Kenen:ÌýYeahÌýthat was soÌýstri—ÌýI mean,Ìýit’sÌýstill not high. It was,ÌýI believe itÌýwasÌý—ÌýI’mÌýlooking for my noteÌý—Ìýbut IÌýthinkÌýwas 54%,Ìýwhich is not great. But itÌýwas better thanÌýDr.Ìý[Mehmet]ÌýOzÌý[head of the Centers for Medicare & Medicaid Services]. It was better than Kennedy. ItÌýwas better than a bunch of people.ÌýSo,Ìýbut it also shows thatÌýhalfÌýthe country stillÌýdoesn’tÌýtrust him.ÌýIt wasÌýa really interestingÌýsurvey, but the gaps in trust in credible science are still significant. What was interesting is the declining trust in our government officials in healthÌýcare, butÌýthere’sÌýstill,Ìýnationally, the U.S.Ìýpopulation,Ìýthere’sÌýstillÌýa lot ofÌýskepticism of science and public health. Maybe not as bad as it was, but stillÌýpretty bad.Ìý

Luthra:ÌýAnd Julie, you alluded to these famous push-up and workout videos. And part of whatÌýyou’reÌýgetting atÌý—Ìýright?Ìý—Ìýis that the communications that we seeÌýare targetedÌýtoward a not necessarilyÌývery largeÌýaudience.ÌýIt is these people who are hyper-online,Ìýin particular internetÌýspaces and communities, and that’sÌýsomewhat divorcedÌýfrom most people and how they live their lives.ÌýAnd when you focusÌýyour message and you’re campaigning on this very particular slice, it’s justÌýa lotÌýeasier to lose sight of where people are and what they want from their government and what they willÌýactually appreciate.Ìý

Rovner:ÌýIt’sÌýtrue.ÌýThe onlineÌýAmerica is very separate from the rest of America, which is aÌýwhole lot bigger.ÌýWell—Ìý

Kenen:ÌýAndÌýthere’sÌýalso the young people whoÌýprobablyÌýaren’tÌýin these surveys who,Ìýteenagers,ÌýwhoÌýare gettingÌýa lot ofÌýinformation on TikTok about supplements and raw milk.ÌýAnd the young men and the teenage boys and the supplementsÌýis a big deal, andÌýthat’sÌýonline. AndÌýalsoÌýwe have beenÌýseeingÌýfor a while, but I thinkÌýit’sÌýprobably creepingÌýup,Ìýthe recommendations about psychedelics.ÌýSoÌýthere’sÌýall this stuff out there thatÌýisn’tÌýgoing toÌýbe pickedÌýup by that poll. But yes, it was an interesting poll.Ìý

Rovner:ÌýAll right. Well, meanwhile over at the Food and Drug Administration, in-againÌýout-again in-againÌývaccine chief Vinay Prasad isÌýapparently outÌýagain, orÌýwill be as of later this spring. I feel like Prasad’s very rockyÌýtenure has beenÌýkind of aÌýmicrocosm for the difficulties this administration has had working withÌýcareerÌýscientists at FDA and elsewhere, at HHS.ÌýAnna, what made him so controversial?Ìý

Edney:ÌýWell, I think, Prasad was an FDA critic before he came to the agency. And soÌýessentially,Ìýwhen he was out in public, particularly during covid, but there were even criticisms he had before that.ÌýHe was criticizing these career scientists at the agency. AndÌýsoÌýhe got there, and the way he appeared toÌýoperateÌýwas that he knewÌýbestÌýand heÌýdidn’tÌýneed to talk to any of these people that had been there,ÌýsomeÌýfor decades, and that was getting him inÌýa lot ofÌýtrouble. But he wasÌýbeing defendedÌýand protected by FDAÌýCommissioner Martin Makary, and he really supported Prasad, and he called him a genius and wanted him to stay on.ÌýSoÌýthe first time Prasad left, he convinced him to come back. And now this time, I think, thingsÌýmaybe justÌýwentÌýa bridge too far when there was sort of this behind-the-scenes but very public fight with a company trying to make a rare-disease drug. And this is something that,Ìýparticularly,ÌýseveralÌýsenators really, really hate, is when the FDA is getting in the way of a rare-disease drug getting to market, because they don’t think that that’s something the agency should be trying to do unless the drug isÌýmaybe whollyÌýunsafe. But they thinkÌýanyoneÌýshould be able to try it. AndÌýsoÌýwhen this exploded and FDA officials were and HHS officials were behind the scenes, but very publicly, calling this company a liar, it was just a bridge too far.Ìý

Rovner:ÌýWell, and he,Ìýthis was,Ìýthis incredibly unusualÌýÌýin which he tried to not be quoted by name, but kind of hard when the head of the agency, or the head of theÌýcenter at FDA is basically trashing a company,Ìýtrying to do it on background. Was that kind of the last straw?Ìý

Edney:ÌýYeah, I think so. AndÌýsort of anÌýasideÌýonÌýthat.ÌýI’mÌýcurious how that phone callÌýevenÌýwasÌýallowedÌýto be set up and called.ÌýBecause,Ìýit’sÌýnot like he did it on his own. ThereÌýwere,Ìýthere was an infrastructure around him that helped him set that up.ÌýSoÌýI’mÌýcurious about why that even went down, butÌýI think thatÌýwasÌýdefinitely whatÌýpushed him out the door. You know, this company wanted to get this drug approved. The FDA had said,ÌýNo, not unless you do this extremely difficult trial, which the company said would require drilling holes in people’s heads,Ìýfor what they were trying to get approved, and that it would be a placebo, essentially, for some of those patients, even when you get a hole drilled in your head, and this could be a 10-hour sham surgery, is what the company said. And thenÌýPrasad comesÌýout andÌýsays:ÌýNo,Ìýthey’reÌýlying.ÌýThatÌýdefinitely couldÌýbe a half-hour.ÌýNo big deal.ÌýAndÌýI just think that thereÌýwereÌýsenators frustrated with this, the White HouseÌýnot wanting toÌýsee another thing blowÌýup over rare-disease drugs, because that has, thereÌýhaveÌýbeenÌýa lot ofÌýissues at FDA under his tenure, of just drugs not being able to get to market. OrÌýhaving issues with vaccines that have been years in development not being able toÌýget even reviewed, and then thatÌýbeing reversed.ÌýSoÌýit wasÌýjust,Ìýthat wasÌýkind of theÌýlast straw.Ìý

Rovner:ÌýAndÌýofÌýcourseÌýPresident Trump himself has been a big proponent of this whole Right to Try effort,Ìýthat it should be easier for people with, particularly with terminal diseases to be able to try drugs that may or may not help.ÌýJoanne, you want to add something.Ìý

Kenen:ÌýAlsoÌýwasn’tÌýhe still,ÌýPrasad, still living in California and running upÌýreally hugeÌýtravel bills and—Ìý

Rovner:ÌýYes.Ìý

Kenen:Ìý—not being at the FDA very much, at a time when everybody else hasÌýbeen forcedÌýto come back to work?ÌýSo,Ìýbut I do confess that I keep looking at my phone to check ifÌýhe’sÌýstill out orÌýis heÌýalready back again.Ìý

Rovner:ÌýRight.Ìý

Kenen:ÌýI’mÌýreally notÌýtotally convinced that this is the end of Prasad, butÌýyeah.Ìý

Rovner:ÌýYeah,ÌýI was not kidding when I saidÌýon-againÌýoff-again on-againÌýoff-again. All right. Well, moving over to the National Institutes of Health, which also has a directorÌýthat’sÌýdoing more than one job in more than one place. I know there’s so much news that it’s hard to keep track of it all, but I do think it’s important to continue to follow things that look toÌýbe settled, like funding for the NIH,Ìýwhich CongressÌýactually increasedÌýin the spending bill that passed at the end of January. To that end, a shout-out to our podcast panelistÌýSandhya Raman, formerly of CQ,Ìýnow at Bloomberg, forÌýÌýgrant funding that still pays for most of the nation’s basic biomedical research is still being held up. This is months after itÌýwas orderedÌýresumed by courts and appropriated by Congress.Ìý

Shout-out as well to myÌýÑî¹óåú´«Ã½Ò•îl HealthÌýNews colleaguesÌýRachana PradhanÌýand KatherynÌýHoughton forÌýtheir projectÌýon the people and research projects that have been disrupted by all the cuts at NIH,Ìýas well as new bureaucratic hurdles put in place. I feel like if there weren’t so much else going on, what’s happening atÌýbasically theÌýeconomic and health engine of NIH would be getting much,Ìýmuch,ÌýmuchÌýmore attention, particularly because of the continuing brain drain with researchers moving to other countries and students choosing different careers rather than becoming researchers. I wonder if this sortÌýof drip,Ìýdrip, drip at NIH is going to turn into a very long-term holeÌýthat’sÌýgoing to beÌývery difficultÌýto fill.ÌýAÌýlot ofÌýthese things have years-Ìýif not decades-long runways.ÌýThese great scientific achievements start somewhere, and it looks likeÌýthey’reÌýjustÌýsort of pullingÌýout the whole starting part.Ìý

Kenen:ÌýIt’sÌýalready affecting the pipeline. In graduate schools,ÌýmanyÌýschools fund their PhD candidates, andÌýit’sÌýNIH money, or partly NIH money.ÌýIt’sÌýdifferentÌý—ÌýI’mÌýnot an expert in every single school’sÌýsupportÌýsystemsÌýfor PhD candidates, but I do know that the pipeline hasÌýbeen shrunkenÌýinÌýsomeÌýfields atÌýsomeÌýschools, andÌýthat’sÌýbeenÌýreportedÌýonÌýwidely. AndÌýthere’sÌýbeenÌýa lot ofÌýcoverage about years andÌýyears of research. YouÌýcan’tÌýjust restart a multiyear,Ìýcomplicated clinical trial or research project. Once you stop it,Ìýyou’reÌýlosing everything to date, right? YouÌýcan’tÌýjustÌýsort of say,ÌýOh,ÌýI’llÌýput it on hold for a couple of years and resume it.ÌýYouÌýcan’tÌýdo that.ÌýSoÌýwe’ve already reachedÌýsome kind ofÌýaÌýcriticalÌýpoint.ÌýIt’sÌýjust a matter of how much worse it gets, or whether the ship begins to stabilize in any way going forward. But there’s already damage.Ìý

Rovner:ÌýI say,Ìýare you guys as surprised as I am, though, that this isn’tÌý—Ìýthe NIH has been this sort of bipartisan jewel that everybody has supported over the decades that I’ve been covering it, and now it’sÌýbasically beingÌýdismantled in front of our eyes, and nobody’s saying very much aboutÌýit.Ìý

Kenen:ÌýIt’sÌýalso an engine of economic growth.ÌýYou see different ROIÌý[return on investment]Ìýnumbers when you look at NIH, but I think the lowest number you hear isÌýtwo and a half dollars of benefit for every dollar we invest. AndÌýI’veÌýseenÌýreportsÌýup to $7.ÌýIÌýdon’tÌýknow what the magic number is, but this is an engine of economic growth in the United States. This is basic biomedical research that the private sector or the academic sector cannot do.ÌýItÌýhas toÌýcome from the government.ÌýAnd IÌýdon’tÌýthink any of us have really gotten our heads aroundÌý— why harm the NIHÌýwhen it isÌýbipartisan,Ìýit is economically successful,Ìýand it has humanitarian value.ÌýIt’sÌýthe basis.ÌýThe drug companies develop the drug and bring it to the market. But that basic, basic,ÌýearlierÌýwhat’sÌýcalled bench science,Ìýthat’sÌýfunded by theÌýNIH.Ìý

Rovner:ÌýI know.ÌýIt’sÌýa mystery. Well, adding to RFK Jr.’s bad week are the growing divisions within his base,ÌýtheÌýMake AmericaÌýHealthyÌýAgainÌýmovement. While the White House, seeing that the public doesn’t really supportÌýMAHA’sÌýanti-vaccine positions,Ìýis trying to get HHS to tone it down, there was a major MAHAÌýmeetup just blocks from the White House this week, with sessions urging a complete end to the childhood vaccine schedule and the removal of all vaccines from the market, quote, until they can be provenÌý“safe and effective.”ÌýBy the way,ÌýmostÌýofÌýthem haveÌýbeen already. Meanwhile,Ìýlots ofÌýMAHAÌýfollowers are still angry that the White House is supporting the continuing production of glyphosate, the weed killer sold commercially as Roundup. Democrats,Ìý, are trying to exploit the divisions in the MAHA movement, which leads to the question:ÌýWillÌýMAHAÌýbe a net plus or a net minus for this fall’s midterm elections?ÌýOn the one hand,ÌýI think TrumpÌýappointed Kennedy because he was hoping thatÌýthe MAHA movement would beÌýa boost to turnout.ÌýOn the other hand, MAHAÌýseemsÌýpretty splitÌýright now.Ìý

Edney:ÌýWell, I thinkÌýthat’sÌýthe million-dollar question,ÌýisÌýwhich wayÌýthey’reÌýgoing to swing if they swing at all. And it’s hard to say right now, becauseÌýI think theyÌýare angry at certain aspects of things this administration is doing,Ìýthe two things you mentioned,ÌýonÌýRoundup and on vaccines, kind of telling RFK to kind of talk a little bit less about those. But will they be able to then vote for Democrats instead? IÌýthink,Ìýit’sÌýonly March,ÌýsoÌýit’sÌýso difficult to sayÌýwhat will happen between now and then.ÌýI think there’s still things that the health secretary could do on food thatÌýhe’sÌýtalked about, that could draw attention away from that anger, that might makeÌýmanyÌýof them happy.ÌýI think thereÌýwereÌýsomeÌýthings heÌýkind of startedÌýdoing early in his termÌýthatÌýhasn’tÌýbeen talkedÌýabout as much.ÌýAnd also, I think there’s still the prospect of CaseyÌýMeans becomingÌýsurgeonÌýgeneralÌý—Ìýor notÌý—Ìýout there, and that’sÌýkind of aÌýbig piece of this.ÌýIf she is to get into the administration, and that is sort of up in theÌýairÌýright now, then that couldÌýkind of giveÌýthem something else to focus on, because she is a large part of this playbook of the MAHA movement.Ìý

Rovner:ÌýThat’sÌýright.ÌýAnd we are waiting to see sort of if she can get the votes even to get out of committee, much less get to the floor, seeÌýwhether we’re going to have, asÌýsomeÌýare saying, the firstÌýsurgeonÌýgeneral who does not have an active license to practice medicine. Shefali, you wantedÌýto add something.Ìý

Luthra:ÌýNo, I just thinkÌýwe’veÌýtalked about this before on the podcast, that the food stuff is much more popular than the vaccine stuff. The vaccine components ofÌýMAHAÌýremain very unpopular.ÌýIt’sÌýdifficult to really see or say sort of what the White House can do on food in a sustained, focused way,Ìýwithout goingÌýoff-script, that is also popular. But I think to Anna’s point,Ìýit’sÌýjust so hard to say to what extent thisÌýultimately mattersÌýin November, because there are just so many concerns right now. PeopleÌýcan’tÌýafford their health insurance, and gas prices are going up. AndÌýI just think weÌýhave toÌýwait and see to what extent people are voting based on food policy.Ìý

Rovner:ÌýYeah, well, we will see. AllÌýright,Ìýwe’reÌýgoing to take a quick break. We will be right back.Ìý

OK, turning to another Trump administration priority, fighting fraud. This week, the administration accused anotherÌýDemocratic-led state, New York, of not policing Medicaid fraud forcefully enough. This comes after the Centers for MedicareÌý&ÌýMedicaid Services said it will withhold hundreds of millions of dollars from Minnesota, which our guest,ÌýAndy Schneider,Ìýwill talk about at more length. Minnesota, by the way, lastÌýweek sued the federal government over its Medicaid efforts. So that fight will continue for a while. ButÌýit’sÌýnot just blue states, andÌýit’sÌýnot just Medicaid. In something IÌýdidn’tÌýhave on my bingo card, this administration is also going after fraud in the Medicare AdvantageÌýprogram, which has long been a Republican darling.Ìý

Last week, CMS banned the Medicare Advantage planÌýoperatedÌýbyÌýElevanceÌýHealth, which hasÌýnearly 2Ìýmillion Medicare patients currently enrolled,Ìýfrom adding any new enrollees starting March 31,Ìýfor what the agency described as, quote,Ìý“substantial and persistent noncompliance with Medicare Advantage risk adjustment data.”ÌýAnd on Tuesday, theÌýcongressional Joint Economic Committee reported that overpayments to those Medicare AdvantageÌýplans raised premiums by an estimated $200 per Medicare enrollee annuallyÌý—ÌýandÌýthat’sÌýall Medicare enrollees, not just those in the private Medicare Advantage plans. Is this the end of the honeymoon for Medicare Advantage? Joanne, you were there with me when Republicans were pushing this.Ìý

Kenen:ÌýI’veÌýbeen surprised, as you have,ÌýJulie, becauseÌýbasically MedicareÌýAdvantage has been theÌýdarling, and itÌýis popular with people.ÌýIt’s grown and grown and grown,Ìýnot because the government forced people in. It has good marketing andÌýsomeÌýbenefits for the younger, healthier post-65 population, gyms and things like that.ÌýButÌý—Ìýand vision and dental, whichÌýare a big deal. ButÌýwe’veÌýalso seen a backlash, inÌýsomeÌýways, because there’s the prior authorization issues in Medicare Advantage have gottenÌýa lot ofÌýattentionÌýthe last couple of years. But not just am I surprised byÌýsortÌýofÌýtheÌýswingÌýthatÌýwe’reÌýhearingÌýaboutÌýgenerally.ÌýI’mÌýsurprised by Dr.ÌýOz, because when he ran for Senate a coupleÌýyearsÌýago in Pennsylvania, andÌýmuchÌýof his public persona has been really, really,Ìýreally gung-ho, pro Medicare Advantage.Ìý

And yet,Ìýsome ofÌýyou were at or,Ìýlike me, watched the live stream ofÌý—Ìýhe didÌýa very interesting, thoughtful, and,ÌýI’ve mentioned this at least one time before, hourlong conversation withÌýa lot ofÌýQ&A at the Aspen Institute here in D.C.Ìýa couple of months ago. And one of the questions was someone said:ÌýDr.ÌýOz,Ìýyou’veÌýjust turned 65.ÌýAre you doing Medicare Advantage, orÌýareÌýyou doing traditional Medicare?ÌýAnd the expected answer for me was, well, I knew thatÌýhe’sÌýon government insurance now.ÌýSoÌýhe, youÌýhave to,Ìýat 65 youÌýhave toÌýgo into Medicare Advanta—ÌýMedicare A,ÌýwhetherÌýyouÌý—Ìýthat’s automatic.ÌýThat’sÌýthe hospital part. But you have the choice. But ifÌýyou’reÌýstill working and getting insurance or governmentÌý—Ìýhe’sÌýon a government plan. HeÌýdoesn’tÌýhave to do that. ButÌýhe actually, andÌýhe pointed that out, but the next sentence really surprised me, because he said:ÌýIÌýdon’tÌýknow. My wife and I are still talking about that.ÌýAnd I thought that wasÌýA)ÌýaÌývery honest answer. HeÌýdidn’tÌýhave to evenÌýsay. But it was also,Ìýit just was interesting to me that after all thatÌýRah-rahÌýMedicare AdvantageÌýwe were hearing about, his own personal choiceÌýwas,ÌýNotÌýsure if that one’s right for me.ÌýSoÌý—Ìý

Rovner:ÌýI was going to say,ÌýI feel like the Republicans are sort of twisting right now between Medicare Advantage, which they’ve always pushedÌý—Ìýthey want to privatize Medicare because they don’t like government health insuranceÌý—Ìýand then there’sÌýthe current populistÌýpush against big insurance companies, because, of course, all those Medicare AdvantageÌýplans belong to those big insurance companies that Republicans are suddenly saying are too big and getting too much money.ÌýSoÌýthey’reÌýsort of caughtÌýbetweenÌýtrying to have it both ways.ÌýI’llÌýbe interested to see how they come down. One of the things that did strike me, though, even before Dr.ÌýOzÌýsort of startedÌýhis little crusade against Medicare Advantage, was,ÌýI think itÌýwas at Kennedy’s confirmation hearing that Sen.ÌýBill Cassidy was suddenly questioning Medicare Advantage. That was, I think, the first Republican I saw to like,ÌýOh.ÌýThat made me raise my eyebrows.ÌýAnd I think since then, I’veÌýkind of seenÌýwhy.Ìý

Kenen:ÌýTheÌýpopulist talkÌýagainstÌýinsurance companies,Ìýnot giving money to insurance companies,Ìýis part of the RepublicanÌý—Ìýand,Ìýspecifically, President Trump’sÌý—Ìýdesire to not extend the ACA,Ìýthe Affordable Care Act,Ìýenhanced subsidies. That was the basic:ÌýWell,Ìýwe’reÌýnot going to do this,ÌýbecauseÌýwe’reÌýjust throwing money at these insurance companies. And weÌýdon’tÌýwant to do that. We want to empowerÌýthe patients.ÌýThat wasÌýthe,ÌýI’mÌýnot, and the missing piece of that argument is:ÌýYes, the ACA subsidies go to insurance companies. However, all of us are benefiting inÌýsomeÌýway or other from government policies thatÌýbenefitÌýinsurance companies.ÌýThe tax breaks our employers get. The tax breaks we get for our insurance.ÌýAnd then the biggie, of course, is Medicare Advantage.Ìý

We are paying Medicare Advantage more than we are paying traditional Medicare.ÌýSoÌýMedicare Advantage isÌýprivateÌýinsuranceÌýcompanies, and the government hasÌýbeen justÌýsending themÌýlotsÌýandÌýlots ofÌýmoney for years.ÌýSoÌýI’m not sure it’sÌý—Ìýthis Medicare Advantage thing is just bubbling up, and we’re notÌýreally sureÌýhow this plays out. ButÌýI think thatÌýthe rhetoricÌýagainst insurance companiesÌýisÌýthe rhetoricÌýagainst the ACA.Ìý

Rovner:ÌýOh, it is.Ìý

Kenen:ÌýRather thatÌýhasn’tÌýyetÌýbeen connectedÌýto the Medicare Advantage. I thinkÌýthey’re,Ìýyes, we all knowÌýthey’reÌýconnected. But I think the political debate, it’sÌýnot MedicareÌýAdvantageÌýis bad because insurance companies are bad.ÌýIt’s theÌýACA is bad because it enriches insurance companies.ÌýThere’sÌýa different ideological parade going down the road.Ìý

Rovner:ÌýI was going to say,Ìýit’sÌýimportant to remember at the beginning of Medicare Advantage, which was a Republican proposal back in 2003,Ìýthey purposely overpaid it. They gave it more money because they know that when they give them more money, the insurance companiesÌýare requiredÌýtoÌýreturnÌýsome ofÌýthat money to beneficiaries in the form of these extra benefits.ÌýThat’sÌýwhy there are gym memberships and dental and vision and hearing coverage in these Medicare Advantage plans. It does make them popular, so people sign up. And that wasÌýsort of Republicans’Ìýintent at the beginning. It was toÌýsort of notÌýso much push people into it but entice people into it.Ìý

Kenen:ÌýAndÌýthen—Ìý

Rovner:ÌýAnd then maybe cut it back later.Ìý

Kenen:ÌýNo, butÌýit’s exceededÌýexpectations.Ìý

Rovner:ÌýAbsolutely.Ìý

Kenen:ÌýThe number of people going into Medicare Advantage has beenÌýreally high, higher than people expected.ÌýAndÌýit’sÌýalso hard to get out, depending on what state you live in.ÌýIt’sÌýnot impossible, butÌýit’sÌýcostly and difficult, except forÌýa few,ÌýI thinkÌýit’sÌýseven or eightÌýstatesÌýmake itÌýpretty easy. But also remember that the earlier version of what we now call Medicare Advantage wasÌý—ÌýwhichÌýwas theÌý’90s, right Julie?Ìý—ÌýI think the Medicare Part C,Ìýand that failed.ÌýSoÌý—Ìý

Rovner:ÌýWell after,Ìýthat failed because they cut it when they wereÌý—Ìý

Kenen:ÌýRight.ÌýRight.Ìý

Rovner:ÌýThey cut all the funding when they were balancing the budgetÌý—Ìý

Kenen:ÌýRight.ÌýÌý

Rovner:Ìý—ÌýinÌý1997.Ìý

Kenen:ÌýBut thatÌýgave themÌýtheÌýexcu—Ìýright.Ìý

Rovner:ÌýThey made itÌýfail.Ìý

Kenen:ÌýThatÌýgave them an excuse to give them more money later that, when they revived it, renamed it,Ìýand launched itÌýinÌý2003 legislation,Ìýthat initial push to give them a ton of money, because they could say,ÌýWell, we didn’t give them enough money, and that’s why theyÌýfa—.ÌýThereÌýareÌýall sorts of politicalÌýthings going on thatÌýweren’tÌýstrictly money. ButÌýyeah,Ìýit was part of the narrative ofÌýWhy weÌýhave toÌýgive them more money,ÌýisÌýThey need it.Ìý

Rovner:ÌýYeah.ÌýAnyway,Ìýwe’llÌýalso watch that space. Well, finally, this week, there’s news on the reproductive health front, because there’s always news on the reproductive health front. Shefali,ÌýWyoming has become the latest state to enact a so-called heartbeat ban, barring abortions when cardiac activity canÌýbe detected.ÌýThat’sÌýoften around six weeks, which is beforeÌýmanyÌýpeople are even aware of being pregnant. I thought the Wyoming Supreme Court said just this past January that its constitution prevents abortion bans.ÌýSoÌýwhat’sÌýup here?Ìý

Luthra:ÌýThey did, in fact, say that, and so we are seeing this law taken to court.ÌýIt wasÌýactually addedÌýin a court filing to a preexisting case challenging other abortion restrictions in the state.ÌýI’mÌýsureÌýthat’sÌýgoing to play out for quiteÌýsomeÌýtime. ButÌýwhat’sÌýinteresting about the WyomingÌýConstitutionÌý—Ìýright?Ìý—Ìýis that it protects the right to make health care decisions,Ìýin an effort toÌýsortÌýofÌýfight against the ACA. That was thisÌýconservative approach that now has come to reallyÌýbenefitÌýabortion rights supporters as well. But what I thinkÌýthis underscoresÌýis that even as we are seeingÌýfairly littleÌýabortion policy in Washington, at least in a meaningful way,Ìýa lotÌýis still happening on the state level. That really is where the bulk of action is, whether you see that in Wyoming,Ìýin Missouri, whereÌýthey’reÌýtrying to undo the abortion rights protections there, and just—Ìý

Rovner:ÌýThe ones that passed by voters.Ìý

Luthra:ÌýExactly. AndÌýsoÌýwhat we’re really thinking about is anti-abortion activists are not really that confident in theÌýpresident’s desire, interest, ability, what have you, to get their agenda items done. And for now, they are really focusing on the states, and that is where their interest, I think, will only remain, at least until the primary for the next presidential race begins in earnest.Ìý

Rovner:ÌýWell,ÌýShefali,ÌýI also want to ask you aboutÌýÌýthis week on just how many things ripple out economically from abortion restrictions. NowÌýit’sÌýhaving an impact on rent prices?ÌýPlease explain.Ìý

Luthra:ÌýI thoughtÌýthis was so interesting. It was thisÌýNBERÌý[National Bureau of Economic Research]Ìýpaper that came out this week, and they looked at comparably trending rental markets in states with abortion bans and those without them. And what they saw was that after theÌýDobbsÌýdecision, rental prices declinedÌýrelativeÌýto places without bans, compared to those in those that had them.ÌýAnd this isÌýreally interesting.ÌýIt justÌýsort of continues.ÌýRental prices went down,Ìýand alsoÌývacancies went up.ÌýAnd what the researchers say is this isÌýa very, very dramaticÌýand clear relationship, and it illustrates that people, when they have a choice, are considering abortion rights in terms of where they want to live. And anecdotally, we know that,ÌýbecauseÌýwe’veÌýseen residents make choices about where they will practice.ÌýWe’veÌýseen doctors decide where they will live. We have seen people move. Companies offer relocation benefits if people want them. And this is more data that illustrates thatÌýactually thatÌýaffects the economy of communities, and it really underscores that where we live just simply will look different based on thingsÌýlike abortion rights and abortion policy and other of these things thatÌýare treatedÌýas social but really do affect people’s economic behaviors.Ìý

Rovner:ÌýAnd as we pointed out before,Ìýit’sÌýnot just about quote-unquoteÌý“abortion,”Ìýbecause when doctors choose not to live in a certain place,Ìýit’sÌýother types of healthÌýcare.ÌýIt’sÌýallÌýhealthÌýcare. And we know that doctors tend to marry or partner with other doctors. So sometimes if an OB GYNÌýdoesn’tÌýwant to move to a certain place, then that OB-GYN’sÌýpartner, who may beÌýsomeÌýcompletely other type ofÌýdoctor,Ìýisn’tÌýgoing to move there either.ÌýSoÌýwe are starting to seeÌýsome ofÌýthese geographical shifts going on.Ìý

Luthra:ÌýAnd one pointÌýactually thatÌýthe researcher made that I thought was so interesting was that abortion policy, it can be emblematic, in and of itself, a reason people choose not to live somewhere, but people may also be making these decisions because of what it represents. Do I look at an abortion policy and say,ÌýOh, this reflects social values or gender beliefs?ÌýOr does it also suggestÌýmaybe moreÌýanti-LGBTQ+Ìýlaws?ÌýAnd all of that can create a picture that is broader than simply abortion orÌýnot, andÌýdetermineÌýwhere and how people want to live their lives.Ìý

Rovner:ÌýIt’sÌýa really interestingÌýstory.ÌýWe willÌýlinkÌýto it.ÌýAll right, that is this week’s news. NowÌýI’llÌýplay my interview with Andy Schneider of Georgetown University, and then we will be back to do our extra credits.Ìý

Rovner:ÌýI am pleased to welcome to the podcast Andy Schneider, a research professor of the practice at the Georgetown University McCourt School of Public Policy. And he spentÌýmanyÌýyears on Capitol Hill helping write and shape Medicaid law as a top aide to California DemocraticÌýcongressmanÌýHenry WaxmanÌý—ÌýandÌýmanyÌýhours explaining it to me.ÌýI have asked him here to help untangle the Medicaid fraud fight now taking place between the federal government and,Ìýat least so far, mostlyÌýDemocratic-led states. Andy, thanks for being here.Ìý

Andy Schneider:ÌýThanks for having me,ÌýJulie.Ìý

Rovner:ÌýSo,Ìýit’sÌýnot like fraud in MedicaidÌý—Ìýand other health programs,Ìýfor that matterÌý—Ìýis anything new.ÌýWho are the major perpetrators of health care fraud?ÌýIt’sÌýnot usually theÌýpatients, is it?Ìý

Schneider:ÌýNo,Ìýit’sÌýusuallyÌýsomeÌýbad-actor providers or bad-actor businesspeople.Ìý

Rovner:ÌýSo how are fraud-fighting efforts at both the federal and state level, since Medicaid fundingÌýis shared, supposed to work?ÌýHow does the federal government and the state governmentÌýsort of tryÌýand make fraud as minimal as possible? SinceÌýpresumably they’reÌýnever going to getÌýrid of it.Ìý

Schneider:ÌýUnfortunately, IÌýdon’tÌýthinkÌýyou’reÌýever going to get rid of it in Medicaid or Medicare or private insurance or in otherÌýwalks of life. There are bad actors out there.ÌýThey’reÌýgoing to try to takeÌýadvantage.ÌýSoÌýyou need your defenses up.ÌýSoÌýthe short of this is,ÌýMedicaidÌýis administeredÌýon a day-to-day basis by the states. The federal governmentÌýpays forÌýa majority ofÌýit and oversees how the states run their programs. In that context, the state Medicaid agency and the stateÌýfraudÌýcontrolÌýunit have aÌýprimary role inÌýidentifyingÌýwhere there might be fraud, investigating,Ìýand then,ÌýinÌýappropriate cases,Ìýprosecuting. The federal government also has a role, however. Depending on the scope of the fraud, it could involve the FBI. It could involve the Office of Inspector General at the Department of Health and Human Services.ÌýSoÌýthere’sÌýboth federal and state presence, but the primary responsibilities were theÌýstates’.Ìý

Rovner:ÌýWe know that Minnesota has been experiencing a Medicaid fraud problem,Ìýbecause both the state and the federal government have been working on it for more than a year now. What is the Trump administration doing in Minnesota?ÌýAnd why isÌýthisÌýdifferent from what the federal government has traditionally done whenÌýit’sÌýtrying to ensure that states are appropriately trying to minimize fraud?Ìý

Schneider:ÌýWell, usually theÌýviceÌýpresident of the United States does not get up at a White House press conference and announce he and the Centers for MedicareÌý&ÌýMedicaidÌýServices areÌýwithholding $260 million in federal funds,ÌýcalledÌýaÌýdeferral. That is highly, highly unusual. And normallyÌýtheÌýhead of the CentersÌýfor MedicareÌý&ÌýMedicaid Services does notÌýgo and makeÌývideos in the state before something like thisÌýis announced.ÌýSoÌýI would say that this isÌýway outÌýof the ordinary, andÌýI think itÌýhas to do withÌýsomeÌýanimus in the administration towardsÌýGov.Ìý[Tim]ÌýWalz and his administration.Ìý

Rovner:ÌýRight.ÌýGov.ÌýWalz, for those whoÌýdon’tÌýremember, was theÌývice presidentialÌýcandidate in 2024 running against President Trump, who did win, in fact. But there have been two different efforts to withhold Medicaid money for Minnesota, right?Ìý

Schneider:ÌýYeah. NowÌýyou’reÌýintoÌýthe MedicaidÌýweeds, but since you asked the question,ÌýI’llÌýtake you there. So in January, theÌýadministra—Ìýthe Center for MedicareÌý&ÌýMedicaid ServicesÌý—Ìýwe’ll call them CMS hereÌý—Ìýthey announced they were going to withhold aboutÌý$2 billionÌýa year going forward, not looking backÌýbut going forward,Ìýin matching funds that the federal government would otherwise pay to the state of Minnesota for the services that it was providing to its over 1 million beneficiaries. In February at this White House press conference, what theÌýviceÌýpresident announced was withholding temporarilyÌý—Ìýwe’ll see how temporary it isÌý—Ìýbut withholding temporarilyÌý$260 million in federal Medicaid matching funds that applied to state spending that’s already occurred, happened in the past, happened in the quarter ending Sept.Ìý30, 2025.ÌýSoÌýboth the past expenditures and future expenditures are targets for these CMS actions.Ìý

Rovner:ÌýSoÌýwhat happens if the federal governmentÌýactually doesn’tÌýpay the state this money? I assume more than people who are committing fraud wouldÌýbeÌýimpacted.Ìý

Schneider:ÌýWell,Ìýlet’sÌýbe clear.ÌýTheÌýamounts of money here,Ìýthere’sÌýno relationship between those and howeverÌýmuchÌýfraud is going on in Minnesota. And there has been fraud against Medicaid in Minnesota.ÌýEverybody’sÌýclear about that. The state is clear about it. The feds are clear about it. ButÌý$2 billionÌýgoing forward in a year,Ìý$1 billionÌýgoing,Ìýlooking backwards,Ìý$260 million times fourÌý—Ìýthere’sÌýno relationship between those amounts, right? Should theyÌýcome to passÌý—and all of this is still in processÌý—Ìýshould those amountsÌýcome to pass, you’re looking at, depending on who’s doing the estimates, betweenÌý7Ìýand 18% of the amount of money the federal government pays,Ìýhelps the state with,Ìýeach year in Medicaid.ÌýThat’sÌýjust an enormous hole for a state to fill, and itÌýdoesn’tÌýhaveÌýmanyÌýgood options. It can cut eligibility. It can cut services. It can cut reimbursement rates. Filling in that hole with state revenues,Ìýthat’sÌýgoing to be a real stretch.Ìý

Rovner:ÌýSoÌýit’sÌýnot just Minnesota. Now the administration says it is seeing concerning things going on in New York and has launched a probeÌýthere. Is there anyÌýindicationÌýthat this administration is going after states thatÌýare not runÌýby Democrats?Ìý

Schneider:ÌýSoÌýthe only letters thatÌýwe’veÌýseen from the administration have been to California, New York,Ìýand Maine. There may be other letters out there. We only access the publicÌýrecord.ÌýSoÌýsoÌýfar, based on what we know,Ìýit’sÌýjustÌýbeenÌýDemocraticallyÌýrunÌýstates.Ìý

Rovner:ÌýAs long asÌýI’veÌýbeen covering this, which is now a long time, fraud-fighting has beenÌýpretty bipartisan.ÌýIt’sÌýbeen something that Congress has worked on, Democrats and Republicans in Congress, Democrats and Republicans in theÌýstates.ÌýWhat’sÌýthe danger of politicizing fraud-fighting,Ìýwhich is whatÌýcertainly seems to beÌýgoing on right now?Ìý

Schneider:ÌýYeah,Ìýthat’sÌýa terrific point.ÌýSoÌýitÌýalways hasÌýbeenÌýbipartisan, becauseÌýmoney is green.ÌýIt’sÌýnot red.ÌýIt’sÌýnot blue.ÌýIt’sÌýgreen. And trying to keep bad actors from ripping it off from Medicaid or MedicareÌýhas always been a bipartisan undertaking. The reason that’s important, particularly in a program like Medicaid, where the federal government and the stateÌýhave toÌýtalk to one another when they are flagging potential fraud, when they’re investigating it, when they’re prosecuting it, you don’t want the agencies tripping all over one another. You want themÌýsharingÌýinformationÌýas necessary,Ìýetc.ÌýWhen that gets politicized,Ìýit’sÌývery badÌýfor the results and for the effective operation of the program.Ìý

Rovner:ÌýWellÌýwe will keep watching this space, andÌýwe’llÌýhave you back to explain it more. Andy Schneider, thankÌýyou very much.Ìý

Schneider:ÌýJulieÌýRovner, thank you very much.Ìý

Rovner:ÌýOK,Ìýwe’reÌýback.ÌýNowÌýit’sÌýtime for ourÌýextra-creditÌýsegment.ÌýThat’sÌýwhere we each recognize the story we read thisÌýweekÌýwe think you should read,Ìýtoo.ÌýDon’tÌýworry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us offÌýthis week?Ìý

Edney:ÌýSure.ÌýMine is inÌýThe Wall Street Journal.ÌýIt’sÌý[“”].ÌýThis is a look at the booming business of providing therapy to children with autism. AndÌýthat’sÌýparticularlyÌýbeen big in the MedicaidÌýprogram. And IÌýdon’tÌýwant to give away too much, because thereÌýareÌýjust so many jaw-dropping detailsÌýinÌýthis.ÌýSoÌýI guess the reportersÌýwere able toÌýkind of goÌýthrough the data and billing records in a way that showedÌýsome ofÌýthese companies and what they were doing and how they were becoming millionaires, people who had never done anything in autism before.ÌýSoÌýif you enjoy a sort of jaw-dropping read, I think you shouldÌýtake a lookÌýat it.Ìý

Rovner:ÌýYeah, jaw-dropping isÌýdefinitely theÌýright description.ÌýJoanne.Ìý

Kenen:ÌýSoÌýIÌýsort of rummagedÌýaround the internet to the less widely read sources, and I came across thisÌýgreat storyÌýfrom the IdahoÌýCapitalÌýSun by Laura Guido. It has a long headline.ÌýReminder that 988 is the mental health crisis line and suicide help. The headline is:Ìý“”ÌýThe story is that a 15-year-old boy named JaceÌýWoods calledÌýtwo years agoÌý—Ìýso this stillÌýhasn’tÌýbeen fixedÌýafter two yearsÌý—Ìýand they cutÌýhimÌýoff. TheyÌýsort of gentlyÌýcutÌýhimÌýoff. But theyÌýcan’tÌýtalk to these kids who have,Ìýwho are in crisis,Ìýwithout parental consent. They do a quick assessment. If they think someone’s life isÌýimmediatelyÌýinÌýdangerÌýright then and there, they can stay on. But a kidÌýwho’sÌýwhat they call suicidal ideation, seriously depressed and at risk, and knowsÌýhe’sÌýat risk orÌýshe’sÌýat risk, and made this phoneÌýcall,ÌýtheyÌýdon’tÌýtalk to them unless they thinkÌýit’sÌýimminent.ÌýSoÌýit also affects,Ìýthese parental,Ìýit affects sexual health and STDs and abortion andÌýwholeÌýlot of otherÌýthings.Ìý

Rovner:ÌýThat’sÌýwhat it was for.Ìý

Kenen:ÌýThat was theÌýinitialÌýreason, but it got bigger.ÌýSoÌýa kid who calls in a crisis can get no help at all. And even in those emergency situations where they can stay on the line and try to get emergency help if they doÌýthinkÌýaÌýkid’sÌýin imminent danger,Ìýthey’reÌýnot allowed to make a follow-up call to make sureÌýthey’reÌýOK.ÌýSoÌýthis kid has been trying for two years.ÌýThere’sÌýa state lawmaker.ÌýThey’reÌýrefining a law. They sayÌýit’s,Ìýthey’reÌýrefining a bill.ÌýThey sayÌýit’sÌýgoing to go through. But really this,Ìýtalk about unintended consequences. We have a national mental health crisis, particularly acute for teens. This is not solving any problems.Ìý

Rovner:ÌýIt is not.ÌýShefali.Ìý

Luthra:ÌýMy story is inÌýThe New York Times. It is byÌýApoorvaÌýMandavilli. The headline isÌý“.”ÌýAndÌýit’sÌýjustÌýa good storyÌýabout what is happening with the Ryan White AIDSÌýDrugÌýAssistanceÌýPrograms, which people use to get their HIV medications paid for or for free. They get insurance support. And these areÌýreally important.ÌýFunding has beenÌýpretty flatÌýfor quiteÌýsomeÌýtime because they’re funded by Congress.ÌýAnd what the story gets into is that with growing financial pressure on these programs, there is more-expensive drugs, there are more-expensive insurance premiums, more people might be losing Medicaid. States are having to makeÌývery difficultÌýchoices, and they are cutting benefits. They are changing who is eligible, becauseÌýit’sÌýgetting more expensive and there is more need and there is no support coming. And I wasn’t really on top of this and did not know what was going on, and I just thought it was interesting andÌýa very usefulÌýlook atÌýsome ofÌýthe consequences of the policy choices that are makingÌýall ofÌýthese health programs more expensive and health care,Ìýin general, harder to afford.Ìý

Rovner:ÌýMy extra credit this week is fromÌýThe Marshall Project.ÌýIt’sÌýcalledÌý“.”ÌýIt’sÌýby ShannonÌýHeffernanÌýand JesseÌýBoganÌýand Anna Flagg. It answers the question that I’ve been wondering about since the whole immigration crackdown began, which is:ÌýWhat happens to the people whoÌýare snatchedÌýoff the streets or out of their cars or homes,Ìýflown to a distant state, and then someone says:ÌýOops, sorry. You can go.ÌýHow do you get home from Texas or Louisiana to Minnesota or Massachusetts? AuthoritiesÌýdon’tÌýgive you plane or even bus ticketsÌýto get back to where youÌýwere pickedÌýup, even thoughÌýthat’sÌýwhereÌýmost ofÌýthoseÌýbeing releasedÌýareÌýrequiredÌýto go to report back to immigration authorities. It turns outÌýthere’sÌýa small network of charities that is helping. But as the story detailsÌýpretty vividly, the harm to these familiesÌýdoesn’tÌýend when their detentionÌýdoes./Ìý

OK.ÌýThat’sÌýthis week’s show. As always, thanks to our editor,ÌýEmmarie Huetteman,Ìýand our producer-engineer.ÌýFrancis Ying. AÌýreminder:ÌýWhat theÌýHealth?Ìýis now available on WAMU platforms, the NPR app,Ìýand wherever you get your podcasts, as well as, of course,Ìýkffhealthnews.org.ÌýAlso, as always, you can emailÌýusÌýyour comments or questions.ÌýWe’reÌýat whatthehealth@kff.org.ÌýOr you can still find me onÌýX,Ìý, or onÌýBluesky,Ìý. Where areÌýyou guysÌýhanging these days?ÌýShefali?Ìý

Luthra:ÌýI am at Bluesky,Ìý.Ìý

Rovner:ÌýAnna.Ìý

Edney:ÌýÌýandÌý,Ìý@annaedney.Ìý

Rovner:ÌýJoanne.Ìý

Kenen:ÌýAÌýlittle bit ofÌýÌýand more onÌý,Ìý@joannekenen.Ìý

Rovner:ÌýWeÌýwillÌýbe back in your feed next week. Until then, be healthy.Ìý

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We Have Invested Too Much To Let Research Programs Die Quietly

I have dedicated my life to research, but now that work, along with the trust, data, and progress behind it, is at risk (“NIH Grant Disruptions Slow Down Breast Cancer Research,” Feb. 3).

As a rheumatologist and researcher, I have spent decades studying lupus — a chronic autoimmune disease that can affect nearly every organ system, producing symptoms that are often unpredictable and difficult to manage. Its impact on a patient’s quality of life is profound: Nearly 90% of people with lupus report being unable to maintain full-time work, while many also face interruptions in education or career progression.

But funding uncertainty from the National Institutes of Health, the Centers for Disease Control and Prevention, and other federal programs means that the thousands of patients involved in my research, along with millions of patients nationwide, are at risk. While I appreciate the increase in lupus research funding included in the recently passed congressional funding package, funding disruptions persist nationwide, and recovery takes time.

Increased funding is not like a light switch that we can just turn back on. It will take a lot of time to recruit back those we lost. That doesn’t include the young investigators who would have entered the field and are now lost. It takes time to build back the broken trust and infrastructure needed to keep participants engaged and ensure reliable data.

Medical research connects the bedside to the database to the policymaker’s desk. Without it, we are blind to the very problems we most urgently need to solve. The window to save these programs is closing. We must act now before it’s too late.

— S. Sam Lim, Atlanta

Knocking Down Barriers to Long-Term Hospital Care

For many Americans, being released from their initial hospital stay is just the beginning of their care journey. Depending on the complexity of one’s condition and the clinical need for more specialized post-acute services such as ventilation, long-term care hospitals, or LTCHs, offer highly personalized care to individuals recovering from a catastrophic illness or injury (Broken Rehab: “They Need a Ventilator To Stay Alive. Getting One Can Be a Nightmare,” Dec. 2).

LTCHs play a critical role in the nation’s health care system by providing complex, resource-intensive care to patients leaving acute-care hospitals but who still need sustained support and treatment. Not only do LTCHs help patients who are dependent on ventilation, have complex wounds, or have multiple organ failure, they also serve as a relief valve in our nation’s hospital system by helping free up beds and resources at general hospitals.

However, the ability to access this vital form of care is becoming increasingly difficult — underscoring the need for lawmakers in Washington to act. Since 2016, over 100 LTCHs have closed due to chronic underpayments amid higher costs. This has been exacerbated by Congress’ decision to implement changes to how it reimburses LTCHs for its beneficiaries. As a result, patients have fewer options, and the facilities that remain open are often far away from home for patients and families, particularly in rural areas. Furthermore, insurance company barriers — such as prior authorization requirements put in place by Medicare Advantage plans — are creating harmful delays and denials of necessary and time-sensitive patient care. Consequently, many patients are denied access to an LTCH setting — or transferred to other post-acute care settings like rehabilitation or skilled nursing facilities that aren’t equipped to care for patients with highly complex needs like ventilation.

America’s sickest patients deserve the right level of care at the right time. As this need becomes more urgent by the day, policymakers must work to address these challenges and strengthen access to LTCHs, which help patients get transferred out of the hospital quicker, reduce hospital overcrowding, and ultimately save lives.

— Jim Prister, Chicago; president and CEO of RML Specialty Hospital; chair of the American Hospital Association’s Post-Acute Care Steering Committee

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

Tuszynski was baffled that care for a patient’s eyes would not be covered by vision insurance. She said she didn’t realize that insurers can have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I looked up my eye doctor, and it’s the same thing,” she said in an interview with Ñî¹óåú´«Ã½Ò•îl Health News.

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior counsel for education and federal policy at the nonprofit , said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called to complain to federal officials. She also wrote to Ñî¹óåú´«Ã½Ò•îl Health News, which asked the insurer about the case.

UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. “It doesn’t sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. “They’re tricky,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation byÌýÑî¹óåú´«Ã½Ò•îl Health NewsÌýandÌýÌýthat dissects and explains medical bills.ÌýSince 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share?ÌýTell us about it!

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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The actions of federal Immigration and Customs Enforcement agents are having ramifications far beyond immigration. Medical groups say that ICE agents in health facilities in Minneapolis and other cities are imperiling patient care, while in Washington, the backlash from a second fatal shooting by agents in Minnesota has stalled action on an eleventh-hour suite of spending bills.

Meanwhile, anti-abortion groups remain unhappy with the Trump administration over what they see as its reluctance to scale back the availability of the abortion pill mifepristone.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Maya Goldman of Axios, Alice Miranda Ollstein of Politico, and Rachel Roubein of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• Concerns intensified this week over President Donald Trump’s immigration sweep after federal agents killed a second citizen in the midst of the crackdown in Minneapolis. Democrats in Congress are blocking approval of government spending as they call for renegotiating Department of Homeland Security funding, potentially forcing a partial government shutdown this weekend. In Minnesota and elsewhere, there are reports of patients postponing medical care and doctors pushing back on the presence of federal agents in hospitals.
• After the Department of Health and Human Services cut off some federal funding to Minnesota over allegations of Medicaid fraud, other Democratic-led states in particular are fearing HHS could do the same to them. Typically the federal government conducts investigations and imposes sanctions in response to concerns of fraud; it’s unusual that HHS has opted to halt some funding instead.
• Abortion opponents last week held their annual March for Life in Washington. The Trump administration marked the occasion by reinstating and expanding policies imposed during the president’s first term, including a ban on fetal tissue research and what’s known as the Mexico City Policy. Still, the administration has not made notable progress on a key goal of the anti-abortion movement: barring access to medication abortion.
• Meanwhile, senators are still trying to sort out a bipartisan compromise to restart the enhanced Affordable Care Act premium subsidies that expired last year. And insurance company executives appeared before House lawmakers last week to answer questions about affordability as the Trump administration announced a plan to keep reimbursement rates nearly flat next year for private Medicare Advantage plans.

And Ñî¹óåú´«Ã½Ò•îl Health News’ annual Health Policy Valentine contest is open. You can enter the contest here.

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

Julie Rovner: Science’s “,” by Monica Hersher and Jeffrey Mervis.

Maya Goldman: NBC News’ “,” by Berkeley Lovelace Jr.

Alice Miranda Ollstein: The New York Times’ “,” by Kenneth P. Vogel and Christina Jewett.

Rachel Roubein: Stat’s “,” by O. Rose Broderick.

Also mentioned in this week’s episode:

• Axios’ “,” by Maya Goldman.
• Annals of Internal Medicine’s “,” by Jeremy W. Jacobs, Garrett S. Booth, Noel T. Brewer, and Janet Freilich.
• Politico’s “,” by Alice Miranda Ollstein.
• The Washington Post’s “,” by Lena H. Sun and Rachel Roubein.
• The Georgetown University Center for Children and Families’ “,” by Andy Schneider.
• KFF’s “,” by Shannon Schumacher, Audrey Kearney, Mardet Mulugeta, Isabelle Valdes, Ashley Kirzinger, and Liz Hamel.

[Clarification: This article was revised at 12:30 p.m. ET on Jan. 30, 2026, to clarify that the agents involved in the Trump administration’s immigration crackdown represent not only the U.S. Immigration and Customs Enforcement agency but also the broader Department of Homeland Security.]

[Editor’s note:ÌýThis transcriptÌýwas generatedÌýusing transcription software. It hasÌýbeen editedÌýfor style and clarity.]Ìý

Julie Rovner:ÌýHello fromÌýKFFÌýHealthÌýNews and WAMUÌýpublic radioÌýin Washington, D.C. Welcome toÌýWhat theÌýHealth?ÌýI’mÌýJulie Rovner,Ìýchief Washington correspondent forÌýÑî¹óåú´«Ã½Ò•îl HealthÌýNews, andÌýI’mÌýjoined byÌýsome ofÌýthe best and smartest health reporters in Washington.ÌýWe’reÌýtaping this week on Thursday, Jan.Ìý29,Ìýat 10Ìýa.m.ÌýAs always, news happensÌýfastÌýand things might have changed by the time you hear this. So,Ìýhere we go.Ìý

TodayÌýweÌýare joinedÌýviaÌývideoconference by Alice MirandaÌýOllsteinÌýof Politico.Ìý

Alice MirandaÌýOllstein:ÌýHello.Ìý

Rovner:ÌýMaya Goldman of AxiosÌýNews.Ìý

Maya Goldman:ÌýHi.Ìý

Rovner:ÌýAnd RachelÌýRoubeinÌýofÌýThe Washington Post.Ìý

RachelÌýRoubein:ÌýHi,Ìýeveryone.Ìý

Rovner:ÌýNo interviewÌýthis iced-inÌýweek here in Washington,ÌýbutÌýstillÌýlots ofÌýnews. So last week at this time, Congress was busy patting itself on the back forÌýbeing poisedÌýto pass all 12 annual appropriation bills before their Jan.Ìý30 deadline, including the two biggest ones, those funding the Departments of Defense and Health and Human Services.ÌýStill, asÌýI believe IÌýsaid at the time, it’s not done until it’s done,Ìýand,Ìýwell, it’s not done.ÌýWhat happened, of course, is that after the House passed the remaining six spending bills and left for a week’s recess,Ìýon Saturday,ÌýfederalÌý[Border Patrol]Ìýofficers shot and killed a VAÌý[Department of Veterans Affairs]ÌýICU nurse, Alex Pretti,Ìýon the streets of Minneapolis, where he was participating in anÌýICEÌý[Immigration and Customs Enforcement]Ìýprotest. That second killing of a civilian in three weeksÌýturned Senate Democrats,Ìýwho were supposed to approve the spending package this week,Ìýunanimously against the spending bill for the Department of Homeland Security, which includesÌýICEÌýand whichÌýis includedÌýwithin the appropriations package passed by the House last week. ButÌýit’sÌýnot as easy as splitting off theÌýHomelandÌýSecurity bill and passing the other five. If the Senate changes anything about the package, itÌýhas toÌýgo back to theÌýHouse, which, as I mentioned,Ìýisn’tÌýeven in town this week. So where are we?ÌýAnd how likely is it thatÌýwe’reÌýgoing to look at a partial government shutdownÌýcomeÌýSaturday?Ìý

Ollstein:ÌýSoÌýit’sÌýreally a mess right now. You haveÌýsomeÌýin both parties who are calling for passing the rest of the bills and pulling out theÌýHomelandÌýSecurity funding to keep negotiating.ÌýSomeÌýpeople are saying they should do a very short-term CRÌý[continuing resolution]Ìý—Ìýa week, a coupleÌýweeksÌý—Ìýin order toÌýgive Congress more time to negotiate these reforms and restrictions that Democrats are demanding. But then you have HouseÌýRepublicans who are saying,ÌýOh, ifÌýwe’reÌýopening this all back up again, we haveÌýsomeÌýdemands,Ìýtoo, and we want more of this and more of that and XYZ. AndÌýsoÌýthey’reÌýsaying,ÌýWe’reÌýgonnaÌýdefund all sanctuary cities.ÌýSo, like you said, once you open this back up, itÌýopens upÌýa wholeÌýcan of worms. That said,Ìýthe Democrats’Ìýbase is really sayingÌýdon’tÌýgive one penny more to this agency that they see as completely running amok and violating life and civil liberties. AndÌýsoÌýwe’reÌýreally atÌýkind of anÌýimpasse right now.Ìý

Rovner:ÌýThis is a classicÌýnever-count-your-chickens in Congress. Maya, you want to add something.Ìý

Goldman:ÌýYeah, I was going toÌýsay,Ìýit seems like the healthÌýcare package is collateral damage here, right?ÌýThere’sÌýa lot ofÌýagreement, bipartisan agreement, that these changes thatÌýthey’reÌýtrying to make, PBMÌý[pharmacy benefit manager]Ìýchanges, things like that,ÌýshouldÌýbe passed. But then, like you said, Julie,Ìýit’sÌýnever over tillÌýit’sÌýover, and more time between getting a bill negotiated andÌýactually passingÌýit just gives interest groups more time to get things changed. So that will be interesting to see.Ìý

Rovner:ÌýAnd just a reminder for those who aren’t following this as closely as we are, there is this health package that’s riding along in this spending-bill package that includes the PBM reform and extensions for things like home health care and telehealth and other things that are not technically spending-bill issues but that need to be renewed periodically by Congress. SoÌýthat’sÌýalso sitting out there waiting to see what the Senate decides to do and then what the House decides to do,Ìýdepending on what the Senate decides to do.Ìý

Roubein:ÌýAnd the last government shutdown,Ìýin the fall,ÌýwasÌýbased on health care. But as you mentioned, the fight was over Affordable Care Act subsidies, which is not part of this package that Julie mentioned.Ìý

Rovner:ÌýThat’sÌýright. So that will continue. But I want to talk aboutÌýICE. We have tiptoed into the immigration debate as itÌýimpactsÌýhealthÌýcare in recent months, but nowÌýit’sÌýreally front and center, andÌýI’mÌýtalking about more than just the fight over ICEÌýtactics in Minnesota and blocking the spending bill for the entire Department of Health and Human Services. Maya,ÌýÌýabout howÌýICEÌýpresenceÌýin hospitals and other healthÌýcare facilities is having an impact on patient care. Tell us what you found.Ìý

Goldman:ÌýYeah,Ìýa lot ofÌýphysicians and nurses in Minneapolis, Twin Cities,Ìýand alsoÌýacross the country are saying that this is approaching, or has alreadyÌýbecome,Ìýa public health crisis. And the problem is twofold. It’s,ÌýPartÌý1, patientsÌýaren’tÌýcoming to get the care that they need, becauseÌýthey’reÌýworried about leaving their homes. And one doctor during a press conference said sheÌýeven has patients whoÌýdon’tÌýwant to take telehealth appointments,ÌýbecauseÌýthey’reÌýafraid of getting on the phone or getting on the computer,ÌýbecauseÌýthey’reÌýworriedÌýthey’reÌýbeing surveilled. SoÌýthat’sÌýa huge problem. And thenÌýsomeÌýdoctors are also saying thatÌýICEÌýpresence in and around hospitals is making it harder for them to do their jobs of providing care, because there are reports of agents being aggressive and sort of being in places where they are not supposed to be, or areÌýphysically impeding care.ÌýSoÌýtwo sides of the coin.Ìý

Rovner:ÌýYeah,Ìýa reminder thatÌýICEÌýwasÌýlargely forbiddenÌýfromÌýoperatingÌýin, quote,Ìý“sensitive”Ìýareas like schools and churches and health facilities,Ìýin both Republican and Democratic administrations, untilÌý[President DonaldÌýTrump]Ìýchanged it last January.ÌýWe’veÌýheardÌýa lotÌýsince then aboutÌýICEÌýbeing inÌýall ofÌýthese sensitive locations, right?Ìý

Goldman:ÌýYeah,Ìýyeah. And I thinkÌýit’sÌýimportant toÌýnoteÌýthe Department of Homeland Security, when I reached out to them, said that they are not conducting enforcement operations in hospitals, even though theyÌýare now allowedÌýto. If they take a patientÌýwho’sÌýin custodyÌýtoÌýthe hospital, they are in the hospital. They can get a warrant to come into the hospital. They can be in public spaces like parking lots and waiting rooms, waiting for people.Ìý

Rovner:ÌýAnd asÌýwe’reÌýhearing,Ìýthat’sÌýexactly whatÌýthey’veÌýbeen doing.Ìý

Goldman:ÌýExactly.Ìý

Rovner:ÌýEven thoughÌýthey’reÌýnot, quote-unquote,Ìý“conducting enforcement operations”Ìýthere.ÌýDoesn’tÌýmeanÌýthey’reÌýnot there. So even the American Medical Association, not exactly a left-wing group, issued a statement expressing concern aboutÌýICEÌýactivity in and around hospital emergency rooms, which it called a,Ìýquote,Ìý“tacticÌýfueling fear among patients and hospital staff alike.”ÌýAre we starting to turn a corner here? I feel like this is,Ìýmaybe itÌýwas a combination of what happened last week,Ìýcoincided with the big snowstorm in half the country and people were stuck inside watching TV. I do feel like there’s way more awareness than there was even two or three weeks ago of this stuff.Ìý

Ollstein:ÌýI think itÌýremains toÌýbe seenÌýwhether there isÌýa meaningful policy andÌýpracticeÌýchange or just a sort of symbolic or rhetorical change.ÌýThere’sÌýa different toneÌýbeing struck.ÌýThere’sÌýsort of backpedalingÌýonÌýthe immediate reaction from government officials we heard,Ìýwhich was to blame the people whoÌýwere killedÌýfor their own killings. There are calls for investigations coming from both sides of the aisle. There are calls forÌýsomeÌýtop officials’Ìýresignations. But again,Ìýwe’reÌýhearing from people on the ground that things have not actually shifted in the enforcement behavior of these agents. AndÌýsoÌýI think itÌýreally remains toÌýbe seenÌýwhat happens in Congress in terms of passing policies. There’s discussion of putting limitations in the spending bill on whatÌýICEÌýcan do. But again, there is a lot of concern that I’ve heard from the advocacy community that they’re going to set up some government officialÌý—Ìýwhether it’sÌý[Homeland Security Secretary]ÌýKristi NoemÌýorÌý[Trump deputy chief of staff]ÌýStephen Miller or,Ìýalready we’ve seenÌý[Border Patrol officialÌýGregory]ÌýBovinoÌý—Ìýto be a fall guyÌýand then nothing will actually change substantially beyond that. AndÌýsoÌýthere’s continued anxiety around that.Ìý

Rovner:ÌýYeah, andÌýjust a reminder that even if the spending billÌýdoesn’t,Ìýfor the Department of Homeland Security,Ìýdidn’tÌýpass and theyÌýdidn’tÌýevenÌýdoÌýa continuing resolution,ÌýICEÌýhasÌýI believeÌýit’sÌý$75 billionÌýfrom the budget bill that passed last year.ÌýSoÌýthey haveÌýa big chunkÌýof money to keepÌýoperatingÌýregardless.ÌýTalk about collateral damageÌý—Ìýit would beÌýall ofÌýthese other agencies that would have to sort of stop operating if there isÌýsome kind of aÌýshutdown.Ìý

Well, meanwhile,Ìýit’sÌýnot justÌýICEÌýthat’sÌýgoing after the state of Minnesota. The Centers for MedicareÌý&ÌýMedicaid Services earlier this month cut off a chunk of the state’s Medicaid fundingÌýgoing forward.ÌýThey’reÌýcharging that the state is, quote,Ìý“operating its program in substantial noncompliance”Ìýwith rules to detect waste, fraud,Ìýand abuse. This is not how this is supposed to work. CMS can sanction states for their anti-fraud efforts being lacking, butÌýthere’sÌýsupposed to beÌýa lot ofÌýdue process first, withÌýlots ofÌýhearings andÌýappeals and fact-finding and all kinds ofÌýmumbo jumbo that we do go through before peopleÌýactually getÌýsanctioned.ÌýThat’sÌýapparently notÌýwhat’sÌýhappening here. Although theÌýICEÌýheadlines are overshadowing the other punitive measures theÌýfederal government is taking toward Minnesota,ÌýI’mÌýkind of surprisedÌýthis aspect of the storyÌýisn’tÌýgetting more attention. Might it when other governors realize that this could happen to them,Ìýtoo, even if theyÌýdidn’tÌýhappen to be on the ballot against Trump in the last election, like Minnesota Gov. [Tim]ÌýWalzÌýwas?Ìý

Goldman:ÌýYeah, I was talking to somebody in the Medicaid space from a different blue state who wasÌýsaying this feels like a turning point, something that theyÌýare scaredÌýofÌýhappeningÌýin their state as well.ÌýAnd,Ìýyeah,ÌýI think thereÌýareÌýa lot ofÌýthings that we need to see how they’ll play out, but this isÌýdefinitely raisingÌýeyebrows.Ìý

Rovner:ÌýYeah, and I will post in the show notesÌýÌýby Andy SchneiderÌý—Ìýwho’s at Georgetown University andÌýwhoÌýwrote, when he worked on the Hill, wrote a lot of the Medicaid statuteÌý—Ìýexplaining how this is all supposed to work and quite how different this is. But I would expect to be hearing more about this in the coming days and weeks, particularly if the administrationÌýdoesn’tÌýback off, becauseÌýit’sÌýa lot ofÌýmoney and,Ìýas we know, Medicaid is a huge, huge piece of every singleÌýstate’sÌýbudget.Ìý

Well, meanwhile, on the abortion front, last week was the annual March for Life, marking the anniversary of the now overturned Supreme Court decisionÌýRoe v.ÌýWade, and it’s fair to say that the anti-abortion movement is not happy with the Trump administration’s actions so far on the issue. Let’s start with what the administration did do to prove its devotion to the anti-abortion cause, To mark the movement’s big day in D.C., the Department of Health and Human Services reinstated its first-Trump-term ban on the use of fetal tissue in biomedical research, which PresidentÌý[Joe]ÌýBiden had reversed, and it expanded pretty dramatically the so-called MexicoÌýCityÌýPolicy that bansÌýU.S.Ìýfunding for international groups that, quote,Ìý“perform”ÌýorÌý“promote”Ìýabortion. Now things likeÌýDEI [diversity, equality, and inclusion]Ìýand gender-affirming careÌýare included,Ìýtoo. Alice and Rachel,Ìýyou guysÌýcover this. What should we know about these two new policies? ItÌýdoesn’tÌýseem likeÌýmuch,Ìýbecause they had both been in effect before, butÌýit’sÌýpretty big.Ìý

Ollstein:ÌýSoÌýthe fetal tissue ban is also,Ìýresearch, is also an expansion of the first-term version, just like the Mexico City Policy. It goes further than before. AndÌýsoÌýtheÌýnew versionÌýbans not only in-house government research but also government funding of research at outside institutions that use fetal tissue thatÌýwas donatedÌýfrom abortions,Ìýand that hasÌýbeen usedÌýinÌýall kinds ofÌýreally importantÌýmedical research,ÌýdevelopmentÌýofÌývaccines,Ìýetc.ÌýAndÌýsoÌýthere isÌýa lot ofÌýconcern about that. They also imposed new restrictions on accepting new stem cell lines.ÌýThere areÌýlots ofÌýexisting stem cell lines that they just keep propagatingÌýover and overÌýfrom a long time ago, butÌýthey’reÌýpausingÌýaccepting new ones while,Ìýthey say,Ìýthey’reÌýexploringÌýalternatives that they find more ethical. All of this has really rattled the research community.Ìý

And as for the Mexico City Policy, the expansion there is far beyond the issue of abortion.ÌýIt’sÌýbanning funding going to groups that promote what they considerÌýDEIÌýand what they considerÌýgender ideology. AndÌýsoÌýthis is groups that serveÌýthe trans community in other countries and have programs for specific marginalized groups. So again,Ìýa lot ofÌýconcern inÌýtheÌýpublic health worldÌýbecauseÌýin order toÌýtackle big public health problems, you often need to direct resources to the communities most at risk, and often that is the trans community, that is racial minorities. AndÌýsoÌýthere’sÌýa fear of this really impeding the delivery of services in a way that willÌýimpactÌýthe broader population.Ìý

Rovner:ÌýAll right, so now to what the administrationÌýdidn’tÌýdo that makes the anti-abortion movement so unhappyÌý—Ìýanything further to restrict the abortion pill mifepristone. In fact, as expected, the Justice Department filed its brief in a closely watched lawsuit out of Louisiana this week, urging the court to pause the suit while the FDAÌý[Food and Drug Administration]Ìýfinishes its study of mifepristone, a study that abortion opponents say is the FDA purposely using to drag its feet on any action.ÌýSoÌýwhat the heckÌýis going on here? Rachel, you start.Ìý

Roubein:ÌýYeah,Ìýbasically theÌýDepartment of JusticeÌýÌýin this lawsuit in Louisiana, andÌýbasically theirÌýjustification was that:ÌýThe Food and Drug Administration is reviewing mifepristone. We need time to do that.ÌýSo that wasÌýbasicallyÌýwhatÌýtheirÌýaskÌýwas, was,Ìýlike:ÌýPut this on pause. We will do this reviewÌýthat, as you said, anti-abortion advocates have been upset and said that it has been moving too slowly.Ìý

Ollstein:ÌýSo I really saw theÌýlegalÌýbrief was kind of a Rorschach test that people could see different things and signs in it, because you had the pro-abortion-rights community looking at them saying:ÌýLook, they’re saying that the FDA didn’t properly review this in the past, and that’s why they’re doing this rigorous review now.ÌýThat’sÌýa sign thatÌýthey’reÌýgoing to impose restrictions.ÌýAlso, the anti-abortion side looked atÌýitÌýand they were upset, one,Ìýthat the Justice Department is arguing that the FDA allowing telemedicineÌýdoesn’tÌýharm the states, and theÌýstates believe that it does, and soÌýthey’reÌýsaying:ÌýYouÌýcan’tÌýprove harm. YouÌýdon’tÌýhaveÌýstandingÌýto bring this case.ÌýI think really the common theme in this filing and inÌýsomeÌýotherÌýonesÌýlast yearÌýrelated to these state abortion lawsuits is that the Trump administration is defending federal power and federal decision-making, and that can cut both ways. AndÌýsoÌýthey’reÌýsaying,ÌýLeave it to us. And the anti-abortion groups are saying:ÌýWeÌýdon’tÌýtrust you. WeÌýdon’tÌýwant to leave itÌýtoÌýyou. We want to let these state lawsuits move forward.Ìý

Just to very quickly go back,Ìýthe Trump administration did one other thing around theÌýMarch forÌýLife as a bone to the anti-abortion community,Ìýthrowing them a bone, and that is they are attempting to claw backÌýtensÌýof millions of dollars in covid loans that went to Planned Parenthood affiliates.ÌýA lot ofÌýthese loansÌýwere already forgivenÌýby the Biden administration, but they are trying anyways to claim there was fraud going on and to get their money back. This boils down toÌýsort of wonkyÌýarguments of whether the specific state Planned Parenthood chaptersÌýare consideredÌýenough part ofÌýnational Planned Parenthood that theyÌýcan’tÌýclaim to be a small business. This is going toÌýbe a legal fight. Planned ParenthoodÌýmaintainsÌýthey did absolutely nothing wrong. The state affiliates are separate from the national group, but—Ìý

Rovner:ÌýWhich theyÌýare, by the way.Ìý

Ollstein:ÌýThey are. They are. And courts have found that theyÌýareÌýin the past. However, the anti-abortion movement wasÌýveryÌýexcitedÌýabout this. They see it as the first step towards declaring allÌýPlannedÌýParenthoods ineligible for any government funding,ÌýsomethingÌýthey’reÌýcalling debarment, whichÌýthey’veÌýbeen pushing forÌýforÌýa while. SoÌýthat’sÌýone other thing to keep an eye on.Ìý

Rovner:ÌýAnd a reminder,Ìýmany,ÌýmanyÌýPlannedÌýParenthoodsÌýdon’tÌýand never have offered abortion.ÌýWellÌýweÌýwon’tÌýget as far into the weeds as we could here, but if you press me, I will.ÌýAll right,Ìýwe’reÌýgoing to take a quick break. We will be right back.Ìý

So over at the Department of Health and Human Services, we have yet another mysterious case of stopping funding and then almostÌýimmediatelyÌýrestarting it. Earlier this month, the Substance Abuse and Mental Health Services Administration cut offÌýnearlyÌý$2 billionÌýworth of grants to drug abuse and mental health providers, only to reverse that decision a day later. Now,ÌýnearlyÌýtheÌýsame thing hasÌýbasically happenedÌýwith aboutÌý$5 billionÌýworth of grants from the Centers for Disease Control and Prevention to all 50 state health departments for things like community outreach, emergency preparedness,Ìýand disease outbreaks. According to The Washington Post, which brokeÌý, notices to states were sent out Friday and barely 12 hours later, an HHS official told theÌýPost the funding pause,Ìýquote,Ìý“had been lifted.”ÌýStill, itÌýapparently tookÌýseveralÌýmore days for states to be able to access their funding portals. YouÌýcan’tÌýhelp but think that at leastÌýsome ofÌýthis is an actual effort to destabilize the nation’s public health infrastructure, right?ÌýTheyÌýcan’tÌýbe that sort of disorganized thatÌýthey’reÌýgoing to cut off funding and put it back.ÌýThereÌýhas toÌýbe a reason here.ÌýRachel,Ìýyou’reÌýsmiling.Ìý

Roubein:ÌýMy colleague LenaÌýSunÌýand I were hearing about this on Saturday, ahead of theÌýbig storm. State officials were trying to kind of figure outÌýwhat’sÌýgoing on.ÌýWith the mental health grants, you sawÌýa very kindÌýof concerted push from the advocacy community, from Republicans and Democrats on the Hill,Ìýto push for,Ìýthat was a termination of those grants,ÌýtoÌýbe rescinded, and they were within about a day. This happenedÌýsort of overÌýthe weekend, and it happened very quickly. So, IÌýcan’tÌýsay what the result ofÌýsort of theÌýchange was,Ìýbecause the noticesÌýwere datedÌýFriday, but state officialsÌýdidn’tÌýreally start getting themÌýtillÌýonÌýSaturday. And thenÌýwe’dÌýheard sort of midday Saturday that the temporary pauseÌýwas lifted. ButÌýitÌýdefinitely threw,Ìýsort of,Ìýstate and local health departments that we were talking about into sort of a state of confusion trying to figure out sort of what they needed to doÌýandÌýby when.Ìý

Rovner:ÌýYeah, and we have seen this repeatedly from this administration.ÌýThese are sort of two dramatic cases just this month, but the stopping and starting of grant funding is making it impossible to do any planning and figure out what you can do when.ÌýIt’sÌýjust, it feels like just a matter of,ÌýLet’sÌýmake it as hard as possible for these people to do their jobs.Ìý

Goldman:ÌýYeah, and—Ìý

Rovner:ÌýByÌý“these,”Ìýyeah,ÌýI’dÌýsay byÌý“these people”ÌýI mean the grant recipients, not the people who are overseeing the money.Ìý

Goldman:ÌýIÌýcan’tÌýclaim to know exactlyÌýwhat’sÌýgoing on behind the scenes, but I think,Ìýwhat do you expect to happen when you gutÌýall ofÌýthe administrative functions of these agencies, which is what HHS did earlier this year?ÌýAnd of course,Ìýsome ofÌýthose people have come back, butÌýthere’sÌýa lot ofÌýinstability in HHS’Ìýrank-and-file workforce itself, and so that naturally will trickle down to their grantees.Ìý

Rovner:ÌýRight, and particularly at the CDC. Well, adding to that,Ìýelsewhere at the CDC,ÌýsomeÌýkey databases, mostly concerning vaccines, are notÌýbeing updated.ÌýThat’sÌýaccording toÌýÌýin this week’s Annals of Internal MedicineÌýmedicalÌýjournal. The study found what the authors calledÌý“unexplained pauses”ÌýinÌýnearly halfÌýof the 82 databases they studied thatÌýare normally updatedÌýmonthly.ÌýEighty-seven percentÌýof those databases were on vaccination-related topics. Now,Ìýthis could be political. It could also be due, as Maya was just saying,Ìýto theÌýbudget and personnel cuts at CDC thatÌýwe’veÌýtalked about so much over the past year. But it does seem thatÌýwe’reÌýcontinuing to fly ever more blind on things like disease surveillance, right?Ìý

Goldman:ÌýYeah, and then when you couple that with the state and local public health divisions are the ones who would be the backstop there, but if their funding is in questionÌýnow, that is even more concerning for public health surveillance.Ìý

Rovner:ÌýYeah, and of course, we are in the middle of big measles outbreaks in South Carolina and Texas and trying to watch that closely, butÌýit’sÌýhard to do if you only haveÌýsort of state-by-stateÌýbackups to look at.Ìý

All right.ÌýWell, before we go, we need to talk about the Affordable Care Act. Remember the Affordable Care Act?ÌýBefore itÌýwas subsumedÌýby all the other headlines?ÌýApparently, theÌýSenate is still working on a bipartisan compromise that could restart lapsed subsidies that have spiked health insurance premiums for millions of Americans. AndÌýapparently thingsÌýaren’tÌýgoing all that well. And to add to it,Ìýhere’sÌýthe headline on the press release forÌý,Ìýhot off the presses just this morningÌý—Ìýquote,Ìý“.”ÌýOn the other hand, the poll did find that Republicans still trust Republicans more. And while the ACAÌýremainsÌýpretty popularÌýoverall, it is less popular with Republicans than it was before last fall’s campaign by Republicans to blameÌýall ofÌýthe health care system’s ills on the 2010 health law. So where does that leave us?ÌýWe’reÌýwithÌý—Ìýthis is the end of January. People who have beenÌýsort of reenrolledÌýin the ACA are starting to get these huge premium notices that they may or may not be able to pay. Has Congress justÌýkind of movedÌýonto the next crisis?Ìý

Ollstein:ÌýSoÌýsomeÌýpeople in Congress are still trying to resolve this crisis, even as new crises pile up. The bipartisan talks are still going on, but there is just notÌýa lot ofÌýoptimism here. There is not reallyÌýagreementÌýonÌýlots ofÌýaspects of extending the subsidies, and all of this is really discussing, at most,Ìýsort of aÌýone-year extension. AndÌýsoÌýthey would just have to have this whole fight all over again. But yes, I would say things are lookingÌýmore bleakÌýon that front than evenÌýa fewÌýweeks ago.ÌýIÌýdon’tÌýknow what my fellow panelists think.Ìý

Rovner:ÌýAndÌýany anybodyÌýhaveÌýoptimism for getting these subsidies extended?ÌýI’mÌýnot seeing anybody raising theirÌýhand. Well,Ìýwe will continue, obviously, to watch this space.Ìý

All right. Lastly, health insurers are starting to get the same heartburn as the pharmaceutical industry.ÌýLast week,Ìýin back-to-back hearings at the House Energy and Commerce and Ways and Means committees, the heads of five of the biggest health insurers gotÌýpretty muchÌýfilletedÌýbyÌýmembers of both parties. Then this week, the Trump administrationÌýkind of shockedÌýthe markets by offering a much-smaller-than-expected increase for private Medicare Advantage plans. Those have been the darlings of Republicans for a couple of decadesÌýnow. Maybe Republicans do really mean it when they say they want to stop giving so much taxpayer money to health insurers?Ìý

Goldman:ÌýI was a little bit struck by how surprised everybody was atÌýthis, becauseÌýI thinkÌý[CMS Administrator]ÌýDr.ÌýMehmetÌýOz has been hinting that he’s much more amenable to cracking down on reported improper behavior among Medicare Advantage plans than people anticipated the next Trump administration would be.ÌýAndÌýthere’sÌýreally this groundswell in the House of Representatives as well among Republicans to sort of rein in improper spendingÌýinÌýMedicare Advantage.Ìý

Rovner:ÌýSen.ÌýBill Cassidy has been pretty—Ìý

Goldman:ÌýYes.Ìý

Rovner:Ìý—outspoken on it, which surprisedÌýa lot ofÌýpeople. NowÌýhis,Ìýthe committee thatÌýhe’sÌýtheÌýchairmanÌýofÌýdoesn’tÌýhaveÌýjurisdictionÌýover this, but he is also a member of theÌýFinanceÌýCommittee,Ìýwhich does haveÌýjurisdictionÌýover this.Ìý

Goldman:ÌýExactly. Exactly. AndÌýsoÌýto me itÌýwasn’tÌýthat surprising,ÌýI have to say.ÌýButÌýit sentÌýshockÌýwaves through the markets?ÌýObviously, insurers are saying that if thisÌýisÌýfinalizedÌýas proposed,Ìýthey’reÌýgoing to have to cut benefits for seniors evenÌýmore,Ìýthey’reÌýgoing to have to raise premiums and things like that. And of course this could be a bad political move,Ìýpotentially,Ìýfor Republicans. ButÌýI think—Ìý

Rovner:ÌýBecause there areÌýlots ofÌýRepublican voters who are in Medicare Advantage plans—Ìý

Goldman:ÌýAbsolutely.Ìý

Rovner:Ìý—andÌýdon’tÌýwant toÌýsee their benefits cut.Ìý

Goldman:ÌýAbsolutely,Ìýand Medicare Advantage insurers have been saying thisÌýover and over again.ÌýThe Biden administration was alsoÌýpretty conservativeÌýon Medicare Advantage.ÌýI guess maybeÌý“conservative”Ìýis a funny word choice, but—Ìý

Rovner:ÌýLight-handed.Ìý

Goldman:ÌýYes.Ìý

Rovner:ÌýWere light-handed.Ìý

Goldman:ÌýYes,ÌýI think, andÌýinsurers wereÌýlargely ableÌýto weather that. Of course, there areÌýsomeÌýchanges thatÌýthey’reÌýmaking this year.ÌýWe’reÌýseeingÌýsomeÌýmarket realignment.ÌýSoÌýit, another year of that, who knows what would happen.ÌýButÌýI think itÌýstill remainsÌýtoÌýbe seenÌýhow impactful this willÌýactually beÌýfor beneficiaries.Ìý

Rovner:ÌýYeah, well, another constituency toÌýget riledÌýup in the run-up to the midterms. All right, that is this week’s news. NowÌýit’sÌýtime for ourÌýextra-creditÌýsegment.ÌýThat’sÌýwhere we each recognize the story we read thisÌýweekÌýwe think that you should read,Ìýtoo.ÌýDon’tÌýworry if you miss it.ÌýWe’llÌýpost the links in our show notes on your phone or other mobile device. Alice, why don’t you start us off this week?Ìý

Ollstein:ÌýYeah.ÌýSoÌýI have this fascinating investigation fromÌýThe New York Times. The headline isÌý“.”ÌýSoÌýthis is a story about these nursing home industry groups making massive donations to Trump’s super PAC and,Ìýafter that, gainingÌýa lot ofÌýaccess to him and using that access to lobby for the scrapping of a rule that required minimum staffing inÌýnursing homes. And that rule was already not reallyÌýbeing enforced, but now they are getting rid of it formally. And so I think the story does a good job of saying,ÌýLook, we can’t prove exactly that they got rid of this rule because of the donations, but it is part of a pattern where people who have given a lot of money to theÌýpresident’s various groups have gotten just an incredible amount of access to him and other top officials.ÌýAnd the story also stressesÌýwhy we should care about all of this.ÌýThere’s just been a lot of horrific data coming out of nursing homes of problems caused by understaffing,ÌýpatientsÌýexperiencing preventable injuries, infections and other health problems that go unnoticed until it’s too late or it gets way more serious, and even facilities using, basically drugging patients to keep themÌýeasy to control and complacent,Ìýbecause there just isn’t enough staff to attend to them.ÌýPeople who have dementia and other thingsÌýneedÌýa lot ofÌýcare and can getÌýupset and disoriented.ÌýAnd instead of taking care of them,Ìýthey’reÌýputtingÌýthemÌýon heavyÌýpsychotropic drugs. AndÌýsoÌýit’s aÌýreally sadÌýand serious situation, and this article showsÌýsomeÌýpotential pay to play.Ìý

Rovner:ÌýYeah, I tend to be, in general, skeptical of administrations doing things that we thought they were going to doÌýanywayÌýand someone else happened to give them money.ÌýBut this draws a pretty clear line.ÌýThey did do what they were going to do anyway, which was going toÌýsort of notÌýreally enforce these regulations.ÌýAnywayÌýit’sÌýreallyÌýgood story.ÌýShouldÌýread it. Maya.Ìý

Goldman:ÌýMyÌýextra credit this week isÌý“,”on NBC News by Berkeley Lovelace Jr. AndÌýit’sÌýone of those stories that, wow, I wish I had written this. It’s a really great explanation of one of the sort of lesser-talked-about side effects of losing enhanced ACA subsidies, which is that people are going into plans that areÌý—Ìýthey’re still opting to be in insurance, but they’re taking plans that are lower premiums but much higher deductibles, which means that their coverage is less valuable. And they might still have to payÌýa lot ofÌýmoney out-of-pocket for most services, and then they might not seek those services, whichÌýsort of negatesÌýthe purpose of having health insurance and its effect on public health. And this story shows that Kentucky, Idaho, Massachusetts, New York, Virginia, Rhode Island, California are all seeing decreases inÌý“silver”Ìýplan enrollment, which isÌýsort of thatÌýlower-deductible, higher-premium tier, and increases inÌý“bronze”Ìýenrollment, which is super-high-deductible.ÌýSoÌýhuge thing to watch.Ìý

Rovner:ÌýReally,Ìýreally goodÌýexplanation.ÌýRachel.Ìý

Roubein:ÌýMy extra credit is byÌýStatÌýNews. The headline isÌý“,”Ìýby O.ÌýRose Broderick. And the story lays out how the Department of Health and Human Services yesterday, on Wednesday, announced the appointment of new members to a federal committee that will advise SecretaryÌý[RobertÌýF.]ÌýKennedyÌý[Jr.]Ìýon autism.ÌýBroderickÌýreports thatÌýmanyÌýof the new members of the committee, whichÌýis calledÌýtheÌýInteragency Autism Coordinating Committee, have publicly expressed or belonged to groups that have publicly expressed a belief in the debunked claim that vaccines can cause autism. Stat hadÌýÌýearlier this week that the members of the committee had met in secret and that some members of the kind of broader autism community were worried about the panel.ÌýAnd just kind of for sort of the big-picture point of view, Kennedy, last year, pledged to find the causes of autism. And during his tenure as HHSÌýsecretary,Ìýhe’sÌýchallenged years of public health messaging on vaccines, such as instructing the CDC to contradict the long-settled scientific conclusion that vaccines do not cause autism. Kennedy, in a press releaseÌýyesterday, called the researchersÌý“the most qualified expertsÌý—Ìýleaders with decades of experience studying, researching,Ìýand treating autism.”Ìý

Rovner:ÌýYet another piece of this.ÌýThere’sÌýa lotÌýofÌýadvisory committees at HHS, and there areÌýmanyÌýof them worth keeping a close eye on. All right, my extra credit this week is fromÌýScienceÌýmagazine,Ìýby MonicaÌýHersherÌýand Jeffrey Mervis.ÌýIt’sÌýcalledÌý“,”Ìýand it putsÌýsome actual numbers to the science brain drain thatÌýwe’veÌýbeen talking about. The authors looked at 14 agencies across the federal government, including the NIHÌý[National Institutes of Health],ÌýFDA,Ìýand CDC at HHS. They noted that those 10,000-plus experts represented only 3% of the more than 300,000 federal workersÌýwho’veÌýleft employment since Trump took office, but theyÌýrepresentÌý14% of the total number ofÌýPh.D.sÌýin science, technology, engineering, math,Ìýand health fields. MostÌýquitÌýor retired after taking buyouts rather thanÌýbeing fired, according to the data. But as the authors noted, quote,Ìý“these departingÌýPh.D.sÌýtook with them a wealth of subject matter expertise and knowledge about how these agencies operate.”ÌýCertainlyÌýa win for the Trump administration, which wants to remake the federal government’s approach to science. For the rest of us, we will have to wait and see.Ìý

OK, that’s this week’s show.ÌýBefore we go, a reminder that our annualÌýKFFÌýHealthÌýPolicy Valentine contest is open. We want to see your clever, heartfelt,Ìýor hilarious tributes to the policies that shape health care.ÌýSubmit your poem, whether conventional, free-form, orÌýhaiku, by noon Eastern on Wednesday, Feb.Ìý4. The winning poem will receive a custom comic illustration in theÌýMorningÌýBriefingÌýon Feb.Ìý13.ÌýI will post a link toÌýthe formal announcementÌýin our show notes.Ìý

As always, thanks to our editor,ÌýEmmarie Huetteman,Ìýand our producer-engineer,ÌýFrancis Ying.ÌýAÌýreminder:ÌýWhat theÌýHealth?Ìýis now available on WAMU platforms, the NPR app,Ìýand wherever you get your podcasts, as well as, of course,Ìýkffhealthnews.org.ÌýAlso, as always, you can emailÌýusÌýyour commentsÌýor questions.ÌýWe’reÌýatÌýwhatthehealth@kff.org,Ìýor you can still find me onÌýX,Ìý,Ìýor onÌýBluesky,Ìý. Where are you folks these days?ÌýMaya?Ìý

Goldman:ÌýYou can find me onÌýÌýunder my name or onÌýX,Ìý.Ìý

Rovner:ÌýAlice.Ìý

Ollstein:ÌýStill onÌýX,Ìý,Ìýand onÌýBluesky,Ìý.Ìý

Rovner:ÌýRachel.Ìý

Roubein:ÌýÌýunder my name.ÌýBluesky,Ìý.ÌýX,Ìý.Ìý

Rovner:ÌýWe willÌýbe back in your feed next week. Until then, be healthy.Ìý

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But some health policy experts say the plan could help reduce billions of dollars in overcharges that have been common in the program for more than a decade.

On Jan. 26, Centers for Medicare & Medicaid Services officials announced they planned to raise rates paid to health plans by for 2027, far less than the industry expected. Some of the largest, publicly traded insurers, such as UnitedHealth Group and Humana, saw their as a result, while industry groups threatened that people 65 and older could see service cuts if the government didn’t kick in more money.

The practice has been criticized for more than a decade by government auditors who say it has triggered billions of dollars in overpayments to the health plans. Earlier this month, the Justice Department announced a record $556 million settlement with the nonprofit health system Kaiser Permanente over allegations the company added about half a million diagnoses to its Advantage patients’ charts from 2009 to 2018, generating about $1 billion in improper payments.

KP did not admit any wrongdoing as part of the settlement.

“I do think the administration is serious about cracking down on overpayments,” said Spencer Perlman, a health care policy analyst in Bethesda, Maryland.

Perlman said that while the Trump administration strongly supports Medicare Advantage, officials are “troubled” by plans that rake in undue profits by using chart reviews to bill the government for medical conditions even when no treatment was provided.

In a , CMS Administrator Mehmet Oz said curbing this practice would ensure more accurate payments to the plans while “protecting taxpayers from unnecessary spending that is not oriented towards addressing real health needs.”

“These proposed payment policies are about making sure Medicare Advantage works better for the people it serves,” Oz said.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, called the proposal “at least a mildly encouraging sign,” though he said he suspected health plans might eventually find a way around it.

Kronick has argued that switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in the government-run Medicare program, because of unbridled medical coding excesses. The insurance plans have grown dramatically in recent years and now enroll , or more than half of people eligible for Medicare.

David Meyers, an associate professor at the Brown University School of Public Health, called the proposed restriction on chart reviews “a step in the right direction.”

“I think the administration has been signaling pretty strongly they want to cut back on inefficiencies,” he said.

The outcry from industry, mostly directed at the proposal to essentially hold Medicare Advantage payment rates flat, was quick and sharp.

“If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026,” said Chris Bond, a spokesperson for AHIP, formerly known as America’s Health Insurance Plans.

CMS is accepting public comments on the proposal and says it will issue a final decision on the payment rates and other provisions by early April.

Meyers said health plans often claim they will be forced to slash benefits when they aren’t satisfied with CMS payments. But that rarely happens, he said.

“The plans can still make money,” he said. “They mostly are very profitable, just not as profitable as shareholders expected.”

The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and have alleged that health plans exaggerate how sick their customers are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”

Many Medicare Advantage health plans have hired medical coding and analytics consultants to review patients’ medical charts to find new diagnoses that they then bill to the government. Medicare rules require that health plans document — and treat — all medical conditions they bill.

Yet federal audits have shown for years that many health plans’ billing practices don’t hold up to scrutiny.

A by the Department of Health and Human Services inspector general found that the health plans “almost always” used chart reviews to add, rather than delete, diagnoses. “Over 99 percent of chart reviews in our review added diagnoses,” investigators said.

The report found that diagnoses reported only on chart reviews — and not on any service records — resulted in an estimated $6.7 billion in payments for 2017.

This week’s proposal is not the first time CMS has tried to crack down on chart reviews.

In January 2014, federal officials drafted a plan to restrict the practice, only to abruptly back off a few months later amid what one agency official described as an “uproar” from the industry.

The health insurance industry has for years relied on aggressive lobbying and public relations campaigns to fight efforts to rein in overpayments or otherwise reduce taxpayers’ costs for Medicare Advantage.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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But two years ago, he heard about Peak Health, a new Advantage plan started by the West Virginia University Health System, where his doctors practice. It was cheaper and offered more personal attention, plus extras such as an allowance for over-the-counter pharmacy items. Those benefits are more important than ever, he said, as he’s treated for cancer.

“I decided to give it a shot,” said Wilkewitz, 79. “If I didn’t like it, I could go back to Humana or whatever after a year.”

He’s sticking with Peak Health. Members of Medicare Advantage plans, a privately run alternative to the government’s Medicare program, can change plans through the end of March.

Now entering its third year, Peak Health has tripled its enrollment since last year, to “north of 10,000,” said Amos Ross, its president. It expanded from 20 counties to 49, he said, and moved into parts of western Pennsylvania for the first time.

Although hospital-owned plans are only a sliver of the Medicare Advantage market, their enrollment continues to grow, reflecting the overall increase in Advantage members. Of the 62.8 million Medicare beneficiaries eligible to join Advantage plans, , according to KFF, the health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. While the number of Advantage plans owned by hospital systems is relatively stable, Mass General Brigham in Boston and others are expanding their service areas and types of plan offerings.

Health systems have dabbled in the insurance business for years, but it’s not for everyone. MedStar Health, serving the greater Washington, D.C., area, said it closed its Medicare Advantage plan at the end of 2018, citing financial losses.

“It’s a ton of work,” said Ross, who spent more than a decade in the commercial health insurance industry.

Like any other health insurer, hospitals entering the business need a back-office infrastructure to enroll patients, sign up providers, fill prescriptions, process claims, hire staff, and — most importantly — assure state regulators they have a reserve of money to pay claims. Once they get a state insurance license, they need approval from the federal Centers for Medicare & Medicaid Services to sell Medicare Advantage policies. Some systems affiliate with or create an insurance subsidiary, and others do most of the job themselves.

Kaiser Permanente, the nation’s largest nonprofit health system by revenue, started an experimental Medicare plan in 1981 and now has nearly 2 million people enrolled in dozens of Advantage plans in eight states and the District of Columbia. The Justice Department announced Jan. 14 that KP had agreed to pay $556 million to settle accusations that its Advantage plans fraudulently billed the government for about $1 billion over a nine-year period.

Last year, UCLA Health introduced two Medicare Advantage plans in Los Angeles County, the most populous county in the United States. Other new hospital-owned plans have cropped up in less profitable rural areas.

“These are communities that have been very hard for insurers to move into,” said Molly Smith, group vice president for public policy at the American Hospital Association.

But Advantage plans offered by hospitals have a familiar, trusted name. They don’t have to move into town, because their owners — the hospitals — never left.

Bad Breakups

Medicare Advantage plans usually restrict their members to a network of doctors, hospitals, and other clinicians that have contracts with the plans to serve them. But if hospitals and plans can’t agree to renew those contracts, or when disputes flare up — often spurred by payment delays, denials, or burdensome prior authorization rules — the health care providers can drop out.

These breakups, plus planned terminations and service area cuts, forced more than 3.7 million Medicare Advantage enrollees to make a tough choice last year: find new insurance for 2026 that their doctors accept or, if possible, keep their plan but find new doctors.

About 1 million of these stranded patients had coverage from UnitedHealthcare, the country’s largest health insurer. In a July earnings update for financial analysts, chief financial officer John Rex blamed the company’s retreat on hospitals, where “most encounters are intensifying in services and costing more.”

The turbulence in the commercial insurance market has upset patients as well as their providers. Sometimes contract disputes have been fought out in the open, with anxious patients in the middle receiving warnings from each side blaming the other for the imminent end to coverage.

When Fred Neary, 88, learned his doctors in the Baylor Scott & White Health system in central and northern Texas would be leaving his Medicare Advantage plan, he was afraid the same thing could happen again if he joined a plan from another commercial insurer. Then he discovered that the 53-hospital system had its own Medicare Advantage plan. He enrolled in 2025 and is keeping the plan this year.

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The settlement, , resolves whistleblower lawsuits that accused the giant health insurer of mounting a years-long scheme in which it overstated how sick patients were to illegally boost revenues.

“Medicare Advantage is a vital program that must serve patients’ needs, not corporate profits,” said U.S. Attorney Craig Missakian for the Northern District of California, in announcing the settlement.

“Fraud on Medicare costs the public billions annually, so when a health plan knowingly submits false information to obtain higher payments, everyone — from beneficiaries to taxpayers — loses,” he said.

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans have grown dramatically in recent years and now , more than half of the people eligible for Medicare. About 2 million Medicare members are enrolled in KP plans.

Attorney Max Voldman, who represents whistleblower , said the case shows the need for a “continued effort to fight fraud in health care.”

“It’s important to send a signal to the industry, and this number hopefully does that,” he said.

Taylor, a longtime Kaiser Permanente physician, filed his suit against the company in October 2014.

“It was a long, hard-fought case,” Voldman said.

The Justice Department bundled with others, in July 2021. In court filings, the government in Colorado and California to add diagnoses “regardless of whether these conditions were actually considered or addressed by the physician during the patient visits,” policies that violated Medicare requirements.

From 2009 through 2018, KP added roughly half a million diagnoses that generated about $1 billion in improper payments to the health plan, according to the complaint.

The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and other investigations have alleged that health plans exaggerate how sick patients are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”

The Justice Department alleged that Kaiser Permanente officials knew its practices were “widespread and unlawful” but that the company “ignored numerous red flags and internal warnings that it was violating” Medicare rules. In settling the case, KP did not admit any wrongdoing.

In a on its website, the company said it settled the case “to avoid the delay, uncertainty, and cost of prolonged litigation.”

The company noted that other health plans had “faced similar government scrutiny” over Medicare Advantage billing practices. It said the whistleblower cases “involved a dispute about how to interpret” Medicare’s billing requirements.

The civil suits were filed under the False Claims Act, a federal law that permits private citizens to sue on behalf of the government and share any money collected as a result.

In all, six whistleblowers filed cases against Kaiser Permanente. In June 2021, the District Court for the Northern District of California consolidated the cases into two, one brought by Taylor and the other by Ronda Osinek, also a former KP employee.

Osinek, who trained physicians on medical coding guidelines, filed her case in August 2013. In her suit, she alleged that Kaiser Permanente inflated claims submitted to Medicare by having doctors amend medical files, often months after a patient’s visit, to slap on diagnoses that were not treated at the time or didn’t exist.

Under the settlement, the whistleblowers, known as “relators,” are set to receive a combined $95 million, according to the Justice Department.

The KP settlement comes on the heels of a this month that accused UnitedHealth Group of “gaming” the Medicare Advantage payment system, which is called “risk adjustment.”

“My investigation has shown UnitedHealth Group appears to be gaming the system and abusing the risk adjustment process to turn a steep profit,” Sen. Chuck Grassley (R-Iowa) said in a statement accompanying the report’s release.

Grassley, who chairs the Senate Judiciary Committee, said his findings were based on a review of more than 50,000 pages of internal company documents. UnitedHealth Group disputed the findings and has long denied that its coding practice triggers improper payments.

The report cited several medical conditions that have repeatedly been linked to overbilling by Medicare Advantage plans, such as coding for opioid dependence disorder in patients who are taking their medications as directed for pain.

The Senate report also alleged that Medicare Advantage plans have improperly diagnosed dementia.

The report said that Medicare removed dementia from its list of codes in 2014 partly due to concerns over upcoding. After the Centers for Medicare & Medicaid Services reintroduced the code in 2020, researchers found that “annual incident dementia diagnosis rates in MA increased by 11.5%” relative to traditional Medicare, the report said.

“Medicare Advantage is an important option for America’s seniors, but as the program adds more patients and spends billions in taxpayer dollars, Congress has a responsibility to conduct aggressive oversight,” Grassley said. “Bloated federal spending to UnitedHealth Group is not only hurting the Medicare Advantage program, it’s harming the American taxpayer.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).