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Julie Rovner: Hello, from �������ýҕ�l Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for �������ýҕ�l Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, July 16, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: And Sandhya Raman of Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Edney: Exactly. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Correct, and …  

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

Ollstein: The bosses, yes. 

Rovner: Right. The bosses. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: I’ll talk to them separately. 

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

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

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

Rovner: So more education, basically. 

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

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

Mitchell: Thank you. 

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

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

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

Ollstein: Thank you. 

Rovner: Sandhya. 

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

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

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

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

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

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

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

Raman: On  and on  @SandhyaWrites. 

Rovner: Anna. 

Edney:  and  @annaedney. 

Rovner: Alice. 

Ollstein: On Bluesky  and on X . 

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