�������ýҕ�l

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for �������ýҕ�l Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 20, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

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

Sarah Karlin-Smith: Hello, everybody. 

Rovner: No interview this week but more than enough news to make up for it, so let us jump right in. We’re going to start this week with Medicaid and its possibly murky future. President [Donald] Trump rather famously declined to say he would protect Medicaid while on the campaign trail when he vowed not to touch Social Security and Medicare, but he did add Medicaid to his protection list at an Oval Office event at the end of January. He promised to, quote, “love and cherish” it. And in a joint interview earlier this week with Elon Musk on Fox News, he repeated that, quote, “Medicare, Medicaid, none of that … is going to be touched.” 

Well, you might want to tell lawmakers on Capitol Hill, where the House is trying to find the votes for a budget resolution that calls for the House Energy and Commerce Committee, which oversees Medicaid in that chamber, to reduce the deficit, i.e. cut, $880 billion over the next 10 years. Now, that might not all come from Medicaid, but that’s by far the biggest source of funding that Energy and Commerce has jurisdiction over. And adding to the confusion, the president on Wednesday endorsed the House’s version of the budget resolution, as opposed to the one that the Senate is working on, which is, at least at the moment, much more limited, wouldn’t likely impact health programs in such a big way nor cut taxes. They’re holding that part off for later. So does President Trump want to touch Medicaid or not? 

Kenen: I mean, Julie, every week, you start by saying, We’re recording this on Thursday, and something might’ve changed. And you have to change it to, We’re recording this on Thursday, and by the time we finish, everything will have changed. The Medicaid thing is real. I wrote about the politics of Medicaid and the history of Medicaid for a Politico Magazine— 

Rovner: And we will link to it. 

Kenen: Right. And the mixed signals are unusual, even for pace of this administration. And what I’m about to say does not mean anything changes in Medicaid. There’s lots and lots and lots of small things that cumulatively can add up to affect people’s access and coverage. Just like yesterday, I think it was yesterday, they cut the ACA [Affordable Care Act], the enrollment assistance. There are lots of things that don’t require— 

Rovner: That was last week. 

Kenen: Whatever. There are lots of things they can do around the edges that are actually quite large. 

But this fundamental push to cut almost a trillion dollars out of Medicaid and to fundamentally shape the nature of Medicaid to make it no longer be an entitlement, that’s a big stretch. And the reason it’s been a big stretch is two reasons. They’ve actually been trying things like this since the Reagan years, and it has always been a bridge too far. They cannot get there. 

But what’s really changed about Medicaid is the nature of Medicaid. It used to be a very small program in 1965. I’m very fond of pointing out that it didn’t even get mentioned in the New York Times when Medicaid and Medicare were both enacted. But it keeps changing over the years. They add things. They modify things. It’s mostly adding things. It covers about 80 million-people range now, and people like it. And I said in this story, Medicaid’s secret weapon is it’s popular. So the idea of who is getting Medicaid, well, according to a KFF poll, 2 out of 3 people say either they or a family member or a close friend have been on Medicaid. It covers births. It covers old age — nursing homes, long-term care. It covers treatment for opioid abuse, for disabled kids — just on and on and on. And as it’s added things over the years and it has gotten bigger, its constituency has gotten bigger. And as the Republican Party has realigned, working-class people are relying on Medicaid. You cut Medicaid, you cut your base. 

Rovner: I did notice Sen. Josh Hawley — very, very conservative Republican from Missouri — was suddenly raising questions about big cuts to Medicaid. That was not on my bingo card for this year. 

Kenen: No, because any state that’s had a referendum on Medicaid expansion has passed it big-time. People want health insurance. With all the flaws of the American system, and we all know what they are, people want to be covered. And these are working-class people and poor people, or people with real serious medical problems, such as addiction, and they want to get better, or they want to try. Those in treatment are there because they want to get better or their families want them to get better. So it is a different Medicaid, with a different Medicaid recipient or a broader Medicaid recipient. And it’s hard to do what they’re talking about doing. It is easy to do lots of smaller things that could go sort of semi under the radar. 

Rovner: So one of the sort of in-between things that Republicans do seem to agree on is that there should be work requirements for Medicaid, because it sounds really great to say if you’re going to get government help, you should, you know, have a job. Although, as I have pointed out many, many times, people can’t live on their Medicaid benefits. Health insurance is a good thing to have, but it’s not a cash assistance program — it helps pay for your medical care. Also, they talk about work requirements as if they have not been tried before. 

Alice, for at least the dozenth time, will you tell us what happened when you did such excellent reporting about the Medicaid work requirements in Arkansas? 

Ollstein: So what we learned in Arkansas and what we learned a little bit to a lesser extent in Georgia, which has gone in this direction recently, is that whether or not work requirements, quote-unquote, “work” depends on what you think the goal of them is. If the goal is to save the government money, they work, but they work because a bunch of people lose their health insurance, not because they’re not working, or because they don’t have a legitimate reason not to be working, but because they can’t navigate the bureaucracy and the paperwork and they fall through the cracks and they lose their insurance. And so that does save the government money. It causes a lot more people to be uninsured. 

But if you think the goal is to get people off of Medicaid and onto private insurance through a job, it doesn’t do that. It does not increase employment. We have seen that in Arkansas. We have seen that to a lesser extent, because it’s much more recent in Georgia. That is sort of the lesson that people should be keeping in mind as the federal government is going down this road. 

And I will say, I did some reporting on the savings that House Republicans are claiming they would get from all these Medicaid changes are pretty wildly exaggerated, and it was a conservative source who supports cutting Medicaid who pointed this out to me. They’re basically taking the estimate of how much each policy on its own would save. So work requirements alone would save X amount of money. Per-capita caps would save X amount of money. Doing these other changes would save — and they’re just adding that together without taking into effect that these policies interact with one another and overlap, and so they’re sort of double and triple counting the same savings. These same policies would disenroll the same people. So I think people should be keeping that in mind as well, that they are not likely to get quite as much savings as they are claiming from these policy proposals, which could mean they pursue even deeper cuts, potentially. 

Kenen: The courts have, I mean, when Arkansas and other states tried to do this a few years ago, the courts ruled against it. The Medicaid statute is quite clear that this is about health not work. Now, that was the courts then. The courts are different now. We don’t know how the courts would interpret the Medicaid statute. There’s a pretty good chance that a more conservative court would in fact allow it to go through. Most people, the able-bodied — I’m not talking about the long-term care nursing home kind of population — but most of the working-age population is working. The labor force participation is not that different from non-Medicaid people. A lot of them are working poor. 

Rovner: Most of the working-age population who get Medicaid have jobs that don’t offer health insurance, have jobs that don’t pay very much and don’t offer health insurance. That’s what makes them eligible for Medicaid. 

Kenen: Yeah. And then there are, you know, states do have some exemptions for people who are the sole caregiver for a young child, and things like that, although we don’t know what all the exemptions will look like. So it’s like this ideological thing. Let’s make these poor people work. Well, most of them are already working. Those who aren’t working, doesn’t mean they’re just sitting around. I mean, some of them are probably looking for work. I’m not saying there’s nobodies of the millions of people on Medicaid who are just sitting around, but there are people who don’t work, or stay-at-home parents or something, or they get ACA subsidies, we don’t have to say, You have to get a job to get your ACA subsidy. So it’s going to end up in the courts. It’ll be delayed because it’s in the courts. My hunch is that the courts would uphold it at this point, but we don’t know for sure. 

Ollstein: One final lesson from Arkansas, which really stuck out to me and could fuel conservative opposition to some of these proposals, is that it really doesn’t allow for people who do seasonal work, which is very big in Arkansas in terms of tourism and agriculture. You could work really hard for a few months of the year, and that’s most of your income for the whole year, and the way Medicaid work requirements set the bar does not really account for that, and so you could be kicked off your insurance in that way as well. 

Rovner: Yeah, it’s a lot more complicated than sort of the simplistic way a lot of people are talking about it. Right. Well, I think it’s fair to say that things are not moving very fast on Capitol Hill. The administration, on the other hand, is moving much more quickly to make cuts in the executive branch. Now, it’s not unusual — in fact, it’s fully expected — that political appointees at federal agencies will depart when administrations change, sometimes even when the new administration is of the same party. 

But under the auspices of whatever Elon Musk is, and that seems to change by the day, agencies are reaching deep into the ranks of the civil service, letting go tens of thousands of probationary employees, who are not just people who are newly hired but sometimes longtime employees who’ve been recently promoted, sometimes people who’ve been heavily recruited from the private sector. At the Department of Health and Human Services, pink slips went out mostly by email over the holiday weekend to thousands of workers at the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, and the Centers for Medicare & Medicaid Services, among other agencies. 

Sarah, we heard Trump and his new HHS secretary, Robert F. Kennedy Jr., threaten to clean house at HHS. But what’s actually happening? And what could it mean going forward for the work that they try to do? 

Karlin-Smith: Right. Well, I think a big thing that’s happening now is, they’re very sort of — I don’t know if “arbitrary” is the right word, but they’re not really thinking through sort of the impacts of their cuts, particularly by targeting probationary workers. You’re cutting whole offices that were newly created and are probably seen as important by this administration. Like in FDA, most of their staff working on artificial intelligence and AI were let go, because it’s a new thing, right?. And they’re also losing very senior people, like you said, because people who have recently agreed to take new jobs also end up being pushed back into probationary status, despite maybe having worked for the government for 20 years. 

They’ve also been having some difficulty because they’re realizing on the back end that they may not be able to justify this as even saving money. There were reports of people at the USDA [Agriculture Department] who were laid off who actually aren’t funded by taxpayer dollars. FDA is another good example of that, where industry user fees fund a lot of FDA work. In fact, like the tobacco center is completely funded by user fees, and they were targeted for cuts. So it’s not really clear what benefit taxpayers are getting from these people leaving. 

Rovner: Is that even legal? That was actually a question I had for you. I mean, isn’t the idea, particularly in the FDA, of a lot of these user fees for drug approvals, that this is a quid pro quo? It’s a contract between industry and the government that says, We will pay for these extra examiners, but in exchange, you will finish assessing these drugs in a certain period of time? If they’re letting those people go, are they going to be able to keep up their part of the contract? 

Karlin-Smith: It seems like a very complicated question and one that I think a lot of people hadn’t thought about before. Because last week, I spent a lot of time being sort of pingponged from different experts trying to ask this question of: Will user fees protect certain agency staff? Or will it protect the agency, FDA, in general? And nobody had a good answer, and they kept saying, Oh, but talk to this person. And this person was like, We don’t know. So it’s frustrating, and I feel bad having to say that. 

One thing that gets kind of complicated is how user fees relate to an individual person’s employment is kind of complicated, right? You don’t think of somebody as a user-fee-funded staff member versus a non-user-fee-funded staff member. A lot of people are working on tasks that are both. The other thing, of course, is, just to mention, there’s a lot going on now that is not by the letter of the law, as we’re seeing in the courts. 

First of all, just to kind of backtrack, a lot of these probationary employees are being told their performance is subpar, which is not accurate based on the performance reviews from their direct supervisors. There’s multiple levels of possible legal issues here, but the user fee thing is interesting because you could see the various industries potentially challenging some of this if they feel like, right, their commitments are being violated. There’s also, actually, things set up in Congress, in the law, that FDA has to spend a certain amount of money from taxpayer dollars to actually be able to collect and spend its user fee dollars. So by doing layoffs that are not particularly well thought through at FDA, they could cause other problems for the user fee program. So you can really see sort of the risks here of people that are not really familiar with all the nuances going in and just making quick flicks of the wrist and making changes without really understanding all the consequences. 

Rovner: Yeah. This also feels like a purposely cruel way to fire people. According to , not only were people terminated regardless, as you said, of their performance reviews, but, quote, “the emails came with ‘read receipts’ that automatically froze employees out of their computers some time after they read them.” I’ve lived in the Washington area almost all of my life. I know lots of federal workers who have been downsized occasionally. But this feels very, very different. Almost like they’re — as Russell Vought, the head of the OMB [Office of Management and Budget], said — they want to put the federal workforce in trauma. 

Kenen: Instead of cutting, it’s like a machete. We’re just going to go in and just swing it, and anybody on probation — which is, as people pointed out, doesn’t mean they’re 22 and in their first job; it’s part of the federal bureaucracy — we’re just going to go through and lawn-mower it, or machete it, or whatever you want to call it. It’s just move fast and break things to the degree no one imagined. It’s breaking things. And they’re making so many mistakes. Some people are being told they only worked there for a month when they’ve worked there for a couple years. If you’re only there a month, you don’t get unemployment insurance. So people on contracts, certain contracts aren’t eligible for employment insurance, even if they’ve worked there for a while. It’s just, on an HR level, on a human level, it’s a big mess, and they’re disproportionately in certain cities, including the one we all live in. 

Rovner: Alice, you were going to say something? 

Ollstein: Yeah. In terms of the pain caused by how this was done, I also want to point out that the emails terminating people included language about how they basically were not performing well, but that went out to even people who got stellar performance reviews. And to go back to what Sarah and Joanne said about people not understanding what the term “probationary” means, this includes people who were recently promoted, and so they are cutting people who were deemed the best performers out of everybody. And then in terms of the chaos, you’re seeing, in some offices, a rush to immediately rehire some of the people they just fired, because they realized that really sensitive work will not be able to happen without them. 

Rovner: I’m going to get to that. We’ll come back to it in a second. Sarah, before we leave this, though, one of the things that we’ve also seen is that it’s not just people getting fired. We’re seeing a lot of people quit, too, which I assume is the administration’s goal, but some of these are leaving some big gaps. And the head of the food division at the FDA just stepped down, right? 

Karlin-Smith: Right. And he hasn’t been at FDA for very long, and he was brought in, really, to help transform FDA’s food work after the infant formula crisis and contamination, which killed a lot of people, and the food, and really FDA in general, went under a really big reorganization that was just starting to be implemented to really help protect everybody in the U.S. and make sure food is safe. So losing key leadership like that, particularly at a time when you have Robert F. Kennedy coming in and saying he wants to focus on issues like food safety, is quite interesting and notable. 

Rovner: Yeah, I think also out the door is a scientist who came to work on Alzheimer’s disease, which one would think would be important to Robert F. Kennedy Jr., who is worried about chronic diseases. That’s sort of the most widespread chronic disease that we have right now. So it seems to be sort of throwing everything out and then sort of, We’ll pick it up as we go? 

Karlin-Smith: Well, and I think the long-term issue that a lot of people I’ve spoken to have worried about is that it’s not just these individual people losing their jobs. It’s, how are these people going to recruit new people in the future to work for the federal government, to work for these health agencies, which are really important? Particularly a lot of people who work at NIH, who work at FDA and CDC, these are highly educated people. They have spent a lot of years in school. They can often find very well-paying jobs in the private sector. And to convince them to come to serve in the federal government, you often need to have these benefits of some sort of comfort and stability in your job. 

There are certain things that the government can offer that the private sector can’t, and you start taking that away and some of the things that NIH or CDC does, you just can’t replicate in the private sector. The private sector is not interested in doing some of this basic science. It needs it eventually, but it’s not what makes them money. So just gutting huge parts of these health agencies without thinking through what they do is going to leave us with big gaps in our health research, safety oversight of health products, and all these things in the long run that we may not be able to replicate or get back. 

Rovner: So Alice, as you were saying, it does appear that when some of these things get publicized, they’re being reversed. For example, there was lots of reporting that CDC was going to cut its entire entering class for the Epidemic Intelligence Service. That’s the agency’s famous disease detectives. That didn’t happen. At least it hasn’t happened yet. The staff that manned the VA’s [Department of Veterans Affairs’] mental health hotline, mostly veterans themselves, were fired and then subsequently unfired. And Alice, your extra credit this week is along similar lines. Why don’t you tell us about it now? 

Ollstein: Yeah. I chose a piece in The Washington Post by Lena Sun and Carolyn Johnson. It’s called “.” So they have reporting that all of these covid tests, millions and millions of them, that the government was keeping on hand to do another round of mailing out these free tests to people as they’ve done before, and they were considering instead destroying them, destroying the tests, which would be costly in itself. 

Basically the article lays out this is going to be costly no matter what. It’s costly to mail them out. It’s costly to keep them in storage. It’s costly to destroy them. But these are tests that have really helped people know how to manage their risk and not spread the virus, and they can be quite expensive if people have to buy them out-of-pocket on their own. And so like you said, this is another example of, once this got scrutiny, they backed away from what they were potentially considering in terms of destroying all of these tests and ending the program. So we’ll see what happens in the future, but again, it’s the same sort of haphazard pattern. 

Kenen: These reversals, and there’s only been a few that we’ve heard about, I mean, one was the nuclear safety people, and then they fired them, realized that they were involved with keeping our nuclear weapons in functioning order, and then they’re trying to rehire them, but they can’t find them. But that is a health story, but a different kind of health story. 

Rovner: A mega health story. 

Kenen: In spite of all this immense chaos, most of the reversals have suggested that there’s somebody with some understanding of public health who’s able to get the message through, because the epidemiology service was not cut yet. The USDA cut people involved with monitoring bird flu in cows, and they went back on that. They brought them back. The covid testing — Okay, it’s going to cost money. Let’s do it. They chose the way that’s best for public health. We’re going to not kill this program. And there may be others that haven’t hit the headlines. So somebody is recognizing that certain public health functions have to continue, and somebody is recognizing that bird flu needs to be watched. So whether that’s going to change tomorrow, I found that at least they’re not saying: There’s no such thing as avian flu. We can kill everybody’s job. We haven’t seen that. “Reassurance” is too strong a word, but I’m glad I saw that. 

Rovner: Although meanwhile, I will say that some things that the administration says that they’re not doing, apparently they still are. Remember that funding freeze that the administration tried to implement that was blocked by a federal judge? Well, apparently the NIH is evading that court order by banning notices from being published in the Federal Register, which is required in many cases before grants can be approved or money can be allowed out the door. 

This was first reported by , which is a newsletter for the neuroscience community, but I heard the exact same thing over the weekend from a senior worker elsewhere at NIH. Have you guys heard anything similar? And I’m assuming that when the judge who ordered an end to the freeze finds out about this, he or she, I can’t remember which it was, will not be amused. You have to wonder. It’s like they say, OK, we’re going to obey this court order, but then maybe they’re not? 

Karlin-Smith: It’s very consistent with things we’ve heard from other agencies, like USAID [the U.S. Agency for International Development] having trouble turning back on money, or maybe, are they really turning back on money for key programs that they said they would exempt from cuts, like PEPFAR [President’s Emergency Plan for AIDS Relief] HIV drugs? I’ve reported at FDA that they’re not scheduling new advisory committee meetings because — which are important for the review of drugs and devices and so forth — because, again, their understanding is they can’t publish Federal Register notices announcing the meetings. So it’s a very similar dynamic, where these sort of technicalities that they — you need to announce this meeting, where they can then award or renew grant funding. 

So it seems like, from what The Transmitter is saying, if a grant is in year three of five, they’re still getting the money, but anything that is new or needs to be reupped is on hold. But yeah, I imagine that when this gets to court, it won’t be positive, but in the meantime, you’re seeing reports of universities that rely on this funding maybe not hiring new graduate students, or having to make significant changes. So again, there’s this theme of, even if eventually the courts are able to kind of stop some of this, it’s unclear how that can correct for some of this long-term harm that may result. 

Rovner: I would say, I think it’s fair to remind people that this isn’t just something that’s happening in the Washington, D.C., area and on the campus of the FDA and the campus of the NIH and in Atlanta at the CDC. This is money that goes out to every congressional district. I’m frankly surprised that Congress hasn’t been pushing back more than they have. 

Kenen: The two issues. This big issue of NIH funding in general. And I talked to a friend who’s not in the Washington-Baltimore area, someone in a different institution who’s a scientist, and I sent him the Transmitter article. And, like you said, oh, he’s had both his own grant applications halt in the middle of the street, and he’s also a reviewer for other grants — he’s a high-level scientist, so he’s on these review committees, and he keeps getting cancellation notices, with no explanation, like the night before. So he’s getting it both as a reviewer and as a grantee, and no explanation, just, This is not happening. 

There’s the second issue of when grants do go ahead, and the anticipation is that they’re not shutting down the NIH completely, but they’re going to give less money for what is called overhead, which is very misleading to the general public. The general public thinks overhead is the Christmas party or whatever — it’s stationery, and you don’t need that anymore, you just use your computer or whatever. No, overhead is the rent, paying for the building, paying for computers and the energy used to run the supercomputers for a clinical trial and things like that. 

So the kinds of cuts the academic world is in, slated, are devastating. They won’t exist in the form they exist in. And we don’t know how many — it’s not just the current graduate students. It’s, who do they admit for next year? We’re in that season. Are they going to admit people and not fund them? Are they going to admit people contingent on, See if we get funding? I mean, some universities have bigger reserves than others, and they may decide to spend some money from the endowment for one year while they figure things. I mean, this is all up in the air, but it really is the future of science, because the universities train. Whether you go to private sector or public sector, whatever scientific field, whether it’s health or whether it’s engineering or whatever, that’s how they get trained. The future scientists get trained at universities. It’s not do-it-yourself at home on the back of a cereal box. 

Rovner: And as we mentioned a couple of weeks ago, some of the biggest recipients of NIH funds are not the universities with the biggest endowments. They’re some of these big state research universities, so they’re publicly funded institutions. 

Well, President Trump continues to try to flood the zone, because that clearly is the strategy here. So he’s issuing still more executive orders, some potentially more consequential than others. One of last week’s, for example, purports to cut off federal funding for schools with covid vaccine mandates, except almost no schools, K to 12 or colleges, even have covid vaccine mandates anymore. That is very 2022. Possibly more significant is the creation of a “Make America Healthy Again Commission,” which requires a high-level group of White House and HH [Department of Health and Human Services] officials to come up with a “Make Our Children Healthy Again Assessment” and a strategy to, as the executive order says, quote, “end childhood chronic disease.” What do we make of this one? Are they, I mean, do we really expect something to happen here? This is the kind of executive order where all these high-level people are supposed to go out and make a report and say, This is how we’re going to do this. 

Karlin-Smith: It’s hard to know what’s going to happen with it, but it’s raising a lot of concerns by people who heard Robert F. Kennedy at congressional hearings, as part of his confirmation process, make certain comments that indicated he maybe had changed his views on areas where he had been controversial in the past, including vaccines. And there are sort of hints in this commission, and then in remarks he gave to HHS this week that maybe he isn’t quite as [changed as] some people want to believe. 

Rovner: You mean some people who voted for him on the Senate floor? 

Karlin-Smith: Right. The MAHA Commission EO [executive order] didn’t mention vaccines explicitly, but it kind of tips to it in how it brings up autism. It seems to undercut just a lot of prescription drugs that have been proven valuable for people, whether it’s ADHD medicines, antidepressants, other things. And somebody asked me this morning, kind of just concerned about their personal medication they take, like, what can they really do on this? 

And it’s hard to know when you’re talking about — again, based on the norms and the laws, I think it would be hard for them to pull your antidepressant off the shelf. That said, we’re in a time where norms and laws are not always applying. I think on vaccination, Kennedy again seemed to make explicit promises to kind of uphold the current CDC/ACIP [Advisory Committee on Immunization Practices] recommendations, and then seems to have backtracked on that and suggested they are going to look at that schedule. And that is an area where I think much more easily he could have power to create changes that would impact what vaccines people will get or whether the government is paying for them for low-income children and so forth, which could lead to big problems. 

Rovner: Yeah, this is one of those. We’re going to have to see how this comes out. Now, traditionally, these executive orders are a way that a president says I care about this without actually doing anything about it. That’s not been the case with most of Trump’s executive orders. They’ve had some pretty far-reaching and fairly immediate effects, particularly those on DEI [diversity, equity, and inclusion] and gender-affirming care. But this week he issued an order on making IVF [in vitro fertilization] more available, another campaign promise that he made that doesn’t actually do anything. Does it, Alice? 

Ollstein: That’s right. I was a little frustrated. Some of the coverage I saw, I’m not going to name names, but it seemed like a press release for the administration basically saying, fulfilling their campaign promise to expand access to IVF. And look, to be fair, the Biden administration and every administration has done similar executive orders saying, I direct my officials to look into this issue and issue recommendations and proposals. That’s totally normal, but let’s not overhype it, and let’s not pretend like this is doing what he said he would do, which is to make IVF free for everyone, either by forcing insurance companies to fully cover the cost or by having the government pay for it directly. So we’re supposed to get a report in 90 days about what recommendations they came up with. We will see if that happens at all and whether it says anything that comes close to his campaign trail promises, but no changes for now. 

Rovner: I would say, but people who voted for Trump because he said he was going to make IVF free, that’s not what this does, and that’s not what this even presumably leads to. 

Ollstein: Right. And to Joanne’s point, two totally different parts of the Republican base hate this for different reasons. You have the anti-abortion people who think IVF is akin to abortion, and you have the people who would oppose the massive amount of government spending this would require and oppose a sweeping new government mandate on insurance companies. They opposed that when it was part of the Affordable Care Act, and they would oppose this. 

Rovner: And it’s like GLP-1 drugs. It’s really expensive for the people who need it, and a lot of people need it. While we are on the subject of reproductive health, let’s turn to the continuing faceoff between abortion ban states, Louisiana and Texas, and New York’s abortion provider shield law. Both states are going after the same New York doctor, Maggie Carpenter, who co-founded the group Abortion Coalition for Telemedicine for prescribing abortion pills online. Texas wants to fine her $100,000. In Louisiana, a grand jury has indicted her on a felony, and the governor would like her extradited. Alice, what’s the latest on this case? 

Ollstein: So I think this is an example of something that was inevitable from the moment Roe v. Wade was overturned, which is, you can’t, quote-unquote, “leave abortion to the states,” because the states interact. They interact in several ways. Medications move between states. People move between states. So basically, Texas and Louisiana are saying that New York doctor is meddling in their states and violating their states’ anti-abortion laws with her activities. New York is saying: No, you’re the ones meddling with our laws and our people. The doctor was doing something that was perfectly legal in the place she was doing it by prescribing these drugs, and you have no right to try to reach across state lines and prosecute her. 

And so both states are accusing the other of meddling, and this will have to be something courts work out. But this is playing out, beyond this, this is just playing out in several ways. You have states going back to [U.S. District Judge Matthew] Kacsmaryk’s court in Texas to argue that abortion pill regulations violate their states’ sovereignty. You have different laws being challenged of who can travel across state lines, who can help someone else travel across state lines, who can give referrals across state lines. This isn’t sustainable, this leave-it-to-the-states approach, in so many ways. 

Rovner: For those people who forgot, Matthew Kacsmaryk is the judge who originally had the case that went to the Supreme Court trying to ban the abortion pill. The Supreme Court said that the plaintiffs didn’t have standing, so now the states have stepped in to make that case come back, which they’re working on. So the one thing that could put Dr. Carpenter in more serious legal peril is if the Trump administration decides that the 1873 Comstock Act, which bans the mailing of obscene materials, including anything that could be used for abortion, is still valid, even though it’s been basically dormant since the 1930s. Brand-new attorney general Pam Bondi has already met with Louisiana officials about this case and has said she wants to work with them, although she hasn’t said how. Are we expecting something on this, Alice? 

Ollstein: Again, this is just going to play out for a while in several ways, and I anticipate the Supreme Court will need to weigh in at some point. I think it’s instructive to look back into history about how the Comstock Act was originally enforced back in the day, and basically it’s not possible and would sort of, I’m sure, be viewed as unconstitutional to have the government go through everyone’s mail, everyone’s personal mail. And so the way it was originally enforced back in the 1800s is to pick a high-profile person and make an example out of them and use that to scare other people from the same activities. And so you already see that playing out with this New York doctor. She’s one of many who are doing telemedicine abortions for people in red states, but they have singled her out for prosecution and are trying to make an example out of her, and I am curious to see if even if New York says: Bug off. We are protecting her. We will not extradite her. ����—&�Բ�����;

Rovner: Which is what they’ve said so far, which the governor said. 

Ollstein: Which is what they’ve said so far, but whether even the threat will have a chilling effect and you’ll have other doctors who were prescribing these drugs saying: I don’t know. It’s not worth it. I’m just going to stop doing that. I think that’s sort of a big lesson from the original Comstock era, no matter what happens now. 

Rovner: So and then we have states like Missouri, which continues to be consistently inconsistent on this issue. On the one hand, a judge cleared the way for abortion to resume in the state more than three months after voters approved a ballot measure to add a right to abortion to the state’s constitution. The judge had to strike down the state’s, quote-unquote, “trap law” that made it impossible, basically, for clinics to reopen, because it couldn’t meet the restrictions. But at the same time, a Missouri state lawmaker has introduced legislation to create a registry of all pregnant women in the state, quote, “at risk for seeking an abortion.” Now, that’s obviously not law yet, but I feel like it illustrates the tension that’s still tugging at a lot of states, right? They’re not all either red or blue on this issue. 

Ollstein: Yes. And every state has different rules around how it amends its constitution, in what circumstances does the public get to have a say, what has to happen through the legislature. And so in Missouri, you have the tension of, the public passed this constitutional amendment that was on the ballot protecting abortion access, but the legislature, which the public also elected to legislate, is trying to override that and undo that and walk that back. And so is direct democracy or representative democracy going to win out? And you see this playing out in a bunch of states. 

Rovner: Yeah, this is definitely — as you said at the top of this discussion, you can’t just leave abortion to the states. It’s just really complicated. Well, finally this week, new health and human services secretary Robert F. Kennedy Jr. may be declaring war on chronic diseases. But it’s worth reminding people that chronic disease only becomes a big problem when infectious diseases are no longer killing people, and yet infectious diseases are still with us. And what a coincidence, we have a growing measles outbreak now, not just in Texas but over the border in New Mexico, too. Somebody remind us exactly how this happens with a disease that was officially declared eradicated in this country just a couple of decades ago. 

Kenen: It should have been declared almost eradicated. It’s still present in the world, and it’s extremely, extremely infectious. The Disneyland outbreak a few years ago came, if I’m remembering correctly, when somebody traveled overseas and was exposed there and then brought it back to the States. So it’s spreading fast. It’s now in Texas and New Mexico, although the New Mexico outbreak is still very — I think it’s just one case. Last time I looked, it was only one case. It’s unlikely to remain one case, but they may be able to contain it better there. It’s a couple of counties now in Texas. There are kids who are hospitalized. 

I think that’s one of the problems is that people think, Oh, it’s harmless. And it’s harmless for a lot of kids. They get over it. But it’s not harmless for all kids or all adults. So there’s still people who think getting measles and being hospitalized and possibly having long-term consequences is still safer than a vaccine. But I also think that as word spreads and people see that kids are being hospitalized and it’s not one person — there’s more than a dozen hospitalized, and it’s rising fast. So will this persuade anybody to get their kid vaccinated? We would hope the answer is yes. Is it going to convince everybody? No, because they’re going to say, Well, that’s in Texas, and I’m in Nebraska. Whatever. This disease travels. You couldn’t have arranged the timing to be Kennedy’s first week in office. That didn’t happen. But the timing is— 

Rovner: Coincidental. 

Kenen: —interesting. The fallout will be interesting, because it’s an I told you so moment. And— 

Rovner: Yeah, and also, what I was fishing for is that this happened when herd immunity goes away. I mean, it was declared eradicated because more than 95% of people had been vaccinated, and that was enough to protect the few who couldn’t be vaccinated, or who were otherwise immunocompromised. And we’ve seen vaccine, the prevalence, fall, in just a little bit, but with measles, because it’s so contagious, it only takes a little bit falling to like 92 or 93%, and then you end up with an outbreak. 

Kenen: And there are already a number of counties in America that are below the safe threshold for kindergartners entering school. The vaccination rate is already below. I saw a map of Kentucky a few months ago, and Tennessee, and there are counties in many, many states that are now below the threshold for measles and other childhood diseases. 

Karlin-Smith: And one of the reasons is because exemptions have been extended beyond what Julie described, which is people who legitimately maybe really cannot get the vaccine. They’ve been given sort of religious or other kind of personal belief exemptions that have lowered it. And the other thing, which I kind of completely forgot about — someone sort of scared me a little bit about this earlier this week, another health reporter — but you can’t really be fully protected against measles via vaccination until you’re about 4 in this country, so people who have younger children— 

Rovner: Like you, Sarah. 

Karlin-Smith: Right, I didn’t fully appreciate — they were saying they were scared for their daughter. I thought they were going in one direction given everything going on at the time, and they went in the measles direction. But right. So you have young, vulnerable kids, can’t get the protection and rely on that herd immunity, that are at risk now. 

Rovner: Yeah. Well, we will keep an eye on this. All right, that’s as much news as we have time for. Although, Lord, we could keep going for a while. Now it is time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it, we’ll put the links in our show notes on your phone or other mobile device. Alice, you have done yours already. Joanne, why don’t you go next? 

Kenen: This is in Wired by Elana Klein, and the headline is “.” And it is a wild story about these slumber party retreats, a few days, that very high-profile, kept-anonymous CFOs, CEOs, Silicon Valley mega-leaders come to do — there is a physician, and there is a nurse, and then there’s two facilitators, a psychologist and a spiritual leader, and they have teddy bears. I think there’s a teddy bear that actually holds the ketamine. It’s injected. There is medical supervision, but it’s still a really, really — I mean, the headline tells you how wild this story is. 

Rovner: It explains a lot about Elon Musk and his minions and sort of the ethos from which they are coming. 

Kenen: He has publicly spoken about ketamine use, and he has also said he has a prescription and does it legally. It is a drug with medicinal purposes, both as an anesthetic and it is being used off-label and is being studied as an antidepressant. But it’s a very, very powerful drug, and it needs to be used with appropriate caution. It’s a story worth reading. I can’t even capture it in a few words. 

Rovner: Yeah. Shout-out to Wired here for the amazing work that they’re doing on all things DOGE [the Department of Government Efficiency]. Sarah. 

Karlin-Smith: I looked at about dietary supplements that you think are improving your health and may be damaging your liver, by Lindsey Leake. And again, it’s sort of a timely story because Robert F. Kennedy’s sort of MAHA movement tends to push supplements over other medical interventions that maybe have been better researched or studied. I think a lot of people don’t realize that the FDA has some authority over dietary supplements, but they’re not really reviewing them for safety and efficacy. And it’s a bit of a buyer-beware market. Tests have found that what you think is in them is not always in them. And also just things that people recognize have some health benefit, like turmeric, when you take it in large quantities can actually be quite harmful to your liver, or again, when heavy metals are put into it. So I think it’s just an important story to kind of remember where regulatory gaps are in this country, and also when people are pushing something, because they’re seen as sort of natural or food-based, that there’s often more to it on the medical side that you need to consider. 

Rovner: I like to remind people that you can overdose on water. You can, I mean, you actually, you could kill yourself drinking too much water. So too much of anything can be dangerous. 

All right, my extra credit this week is from my �������ýҕ�l Health News colleague Brett Kelman, and it’s called “Pain Clinics Made Billions From ‘Unnecessary’ Injections Into ‘Human Pin Cushions.’” It’s about a multistate pain management company that operated in Tennessee, Virginia, and North Carolina that was part of a decade-long fraud scheme that gave opioid prescriptions to pain patients, but only if they also agreed to spinal injections that, and I am quoting from the story here, “were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead.” The story is quite the advertisement, as Sarah’s was, for government regulation of the health care industry. 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer and editor, Francis Ying, and this week to our fill-in editor, Stephanie Stapleton. As always, you can email us your comment or questions. We’re at whatthehealth@kff.org, or you can still find me at X, , and increasingly at Bluesky, . Where are you guys these days? Joanne? 

Kenen: I’m mostly Bluesky, at Bluesky. Occasionally on X, . 

Rovner: Sarah. 

Karlin-Smith: I’m trying to move to Bluesky. It’s . Using more as well. 

Rovner: Alice. 

Ollstein: On Bluesky, , and on X, . 

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