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

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, Aug. 20, 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: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have another “How Would You Fix It?” interview, from his car, with businessman and entrepreneur Mark Cuban, who’s now devoting most of his professional attention to the mess that is U.S. healthcare. But first, this week’s news. So, we finally have a nominee to lead the Food and Drug Administration, which has been without a Senate-confirmed commissioner since Marty Makary resigned in May — officially, over a dispute about flavored vapes. The winner of the search is Heidi Overton, a 37-year-old physician and former protégé of Makary’s from Johns Hopkins, who currently oversees the health portfolio at the White House Domestic Policy Council. What do we know about Dr. Overton, and what are her prospects for confirmation? We’ve already seen HELP [Health, Education, Labor, and Pensions] Committee Chairman Bill Cassidy say on social media that he has “concerns” about her, but he’s voted for nominees about whom he’s had concerns as recently as — checks notes — earlier this month. 

Kenen: I mean, Cassidy’s saying he has concerns is not indicative of where this ends up. At the end of the day, President [Donald] Trump has gotten most of his choices through a Senate that often begins hesitant to recalcitrant and usually gives him what he wants. So … sometimes it doesn’t. I mean, it’s not 100%. So, Cassidy is in a different position politically since he’s about to leave the Senate, and partly because President Trump. So we just don’t know where Cassidy is. But it’s not a great start. But it doesn’t mean … it’s the end. 

Rovner: What do we know about Heidi Overton, though? Everything I’ve read about her, she’s either pro-MAHA [Make America Healthy Again] or the MAHA people don’t like her, or she’s, you know, of Marty Makary or not of Marty McCarry. 

Ollstein: Yeah. So my colleagues and I wrote about this yesterday, and a lot of the leading MAHA activists view her as having been a roadblock in the White House to their efforts around pesticides, around vaccines, and other things, and so they are up in arms about the pick. They are, you know, saying she’s … part of the swamp and not part of, you know, the movement that they want to see sweep aside some of these government practices. And I think that her time in the White House and her previous work for the America First Policy Institute could really come back to haunt her. She wrote a lot of papers and op-eds with some controversial takes and policy positions, and I think everybody is sort of scrambling to go over that. People are also talking about her lack of managerial experience. You know, managing a huge agency with a huge staff, and you know, obviously, we have seen recent examples of people who lack that experience being appointed. So that’s also not a deal-breaker necessarily. But all of these things could add up to be problematic for her in the confirmation process. And then what I focused on was her anti-abortion record, which, you know, both could help and hurt her depending on whose votes we’re talking about. 

Rovner: That’s right. I mean, we saw [Sen.] Patty Murray, senior member of the HELP Committee, come out and, you know, and say, Not somebody that I could ever vote for. And also, I mean, she was at the signing of the vaccine executive order that the president had. So that puts her — whether, whatever she says in her confirmation hearings — that sort of puts her with the “Let’s change the vaccine schedule” group. I mean, she seems to fit in nowhere. I guess that’s sort of my question here. 

Luthra: That’s what’s so interesting about her is that there are these sorts of different interests and constituencies that have concerns about her, but sometimes they feel as if they could be contradictory. You obviously have, I mean, Patty Murray — I don’t know if she was ever going to vote for whoever Trump picked — but then you have Susan Collins in a very difficult reelection race, where abortion is a concern. You now have these concerns about vaccines. You have people saying maybe she’s not MAHA enough. And I mean, I think to Joanne’s point, Trump has gotten most people he has wanted. However, this does feel like this could get very complicated, just given how many people may be bringing different criticism from different vantages that could ultimately add up. 

Kenen: I’m not sure we’ve ever seen anything on the Senate floor where she’s going to be called anti-abortion and pro-pesticide. If it gets to the floor, I mean, it’s a weird one. But at the end of the day, you know, does it go through? You know, if you made me bet, my bet would be yes, but I wouldn’t want to bet a whole lot of money. 

Rovner: Well … we’re going to talk about reproductive health later in the podcast, but I do want to talk about abortion right now in the context of this nomination because, Alice, as you point out, Overton is known to be a fairly strident abortion opponent, and if she is confirmed, she’ll take over the study of the safety of the abortion pill mifepristone, which, as we have mentioned many, many, many times, the administration has sort of backbenched, if you will. Given that the new attorney general, Todd Blanche, has raised the specter of invoking the 1873 Comstock Act to bar the mailing of abortion pills, or anything else used for abortions, what is the outlook for medication abortion if Overton actually becomes the FDA commissioner? 

Ollstein: Well, it’s hard to say because we’ve really seen decision-making centralized in the White House, and so often it doesn’t matter what the Cabinet secretaries want to do. It’s about what the White House wants. And the White House, I think, has made it pretty clear that this is not a top, you know, restricting abortion is not a top priority for them. They are certainly sensitive to the politics of it, and so there is speculation that, you know, there’s a delay until after the midterms for anything meaningful on this front, so as not to risk the kind of backlash we saw in 2022 after the fall of Roe v. Wade. But I think it’s also pretty clear that this is just not a top priority for the White House. That doesn’t mean they won’t allow some of these, you know, former activists to do what they want to do — so Blanche, and now Overton potentially. But I think it’s not really a given either way. 

Rovner: Yeah. All right. Well, meanwhile, in administration news that we’ve talked about before but is still relevant, we’re just over a month from the end of the fiscal year, and grant money is still being held up at the National Institutes of Health, according to our podcast pal Paige [Winfield] Cunningham at NOTUS. Despite pressure from Congress, the agency is still delaying funds for already-approved grants while it conducts searches for keywords that could signal that the grant does not adhere to the administration’s political priorities. And it’s not just keywords. Reading from : “In multiple flagged grants, officials expressed concerns that they weren’t worth funding because their only practical use might be to support the writing of new laws.” Now, this is going on against the backdrop of a proposal from the Office of Management and Budget that would officially insert political approval into grant funding. That’s something the Senate has voted to at least temporarily block, but the House hasn’t weighed in on it yet. This could not only have huge implications for federally funded research going forward, but you could argue it’s having implications now. We’re seeing researchers, you know, taking opportunities overseas because they don’t know what their, you know, grant funding continuation is going to look like, and students not going to graduate school or not pursuing research careers. I mean, this is … even some of these sort of small things are having these bigger potential ripples as they go outward, right? 

Kenen: Colleagues who are grant-funded, NIH-funded, or other government-funded. I mean, they try to track the ever-changing rules. First of all, it’s very murky. It is changing. They keep adding things. Basically, they don’t want — not just the banned words — they don’t want research that can be bad, that can be used for policy …  

Rovner: For things they disagree with, for policies they disagree with. 

Kenen: They don’t say it … right. Guidance doesn’t come out and say “policy that you know we don’t like.” It just says “policy.” But it’s really vast and confusing. It’s not new. What Paige wrote about is an update. I mean, this is still happening. It’s been happening since the beginning of the Trump administration. NIH is the biggie. There are some smaller agencies, like Agency for Healthcare Quality and Research [sic], AHRQ, right? 

Rovner: Research and Quality. 

Kenen: Agency for Healthcare Research and Quality. That’s pretty much defunct now. But those grants, the money stopped going out the door many months ago. So …  

Rovner: And the National Science Foundation. I mean, NIH is sort of the biggest of them. Yeah. 

Kenen: It has to have the word “science.” … NIH is the biggie, right? I mean, and it’s also the bench science, the science that the drug industry … people don’t understand, they say, Let the drug industry do it. They can’t do this kind of basic bench research. They take this research and develop drugs, but the fundamental cellular level is NIH, or NIH-funded. And it’s really, I mean, clinical trials have been stopped in the middle — really promising research that is not partisan. … Disease doesn’t care. It’s cliché, and it’s also true. It just stopped, and work has been lost. But people haven’t done things that are several years in. … The deadline, also, for fiscal year spending is, if it’s not out the door, which is Sept 30, anything that’s out that door is, like, that’s done. It’s it. Bye-bye. The money isn’t gonna, unless it would go through a whole new process next year, which is unlikely in these grants, that’s the end of that. 

Rovner: Yeah, and that’s, I mean, my point in wanting to bring this up again — and you’re right, it is sort of an update of what we’ve seen — is that every time one of these top administration officials comes to Congress, they say, You’re supposed to be spending the money that we have appropriated, and they say, Oh yeah, not a problem. We’re going to spend the money that you’ve appropriated. And yet we keep seeing these stories that they are not spending money that Congress has appropriated. 

Kenen: Yeah, and historically NIH has been reasonably bipartisan. There have been years when there have been fights. There’s obviously stem cells and sort of certain issues have been, you know, very hot potato. But the basic enterprise of U.S. science, health science, has been largely bipartisan. Again, not every appropriation season, not every bill. But if you look at the overall arc, it’s bipartisan. 

Rovner: It was Republicans who doubled NIH funding in the 1990s — who led it.  

Kenen: [Arlen] Specter. 

Rovner: It was Newt Gingrich, actually. I mean. 

Kenen: Yeah, Gingrich, too, was very into health tech and things like that before his time. I mean, the War on Cancer was federal, right? That was [President Richard] Nixon. So, but we’re now in a …  

Rovner: Different place. 

Kenen: Yeah, frozen. 

Rovner: Yeah. Meanwhile, Mike Stobbe at the AP is at the Centers for Disease Control and Prevention — again, where money’s been appropriated, but there is literally nobody at home. At the agency’s Office on Smoking and Health, and offices on Alzheimer’s disease, epilepsy, and sickle cell data collection, funds are allocated, but all the staffers have either been laid off or are still on administrative leave. So they’re being paid, but they are banned from working. This is yet another immediate challenge for new CDC Director Erica Schwartz, who had her first meeting with CDC staff yesterday. What do we expect her to take on first? 

Luthra: I don’t envy her. It, frankly, seems very difficult to figure out what your priorities are or should be, if you perhaps don’t have staff. It does seem like, from the reporting, perhaps a priority that she has outlined might be morale. And we know that morale has been very low in a lot of government agencies and the executive — especially places like the CDC, where you have a lot of career people who are mission-oriented, really believe in doing things for public health, and have seen that really attacked. And so I don’t know if that is enough to actually translate into things that are supposed to happen actually happening. But that seems like probably a place where it makes sense to start, right?, is just to help people feel confident that they actually will be able to do the work that they signed up to do. 

Rovner: Yeah, and you know, as you say, CDC is perhaps the most mission-oriented of all the HHS agencies. And because they’re in Atlanta, and you know not in the Washington area the way most of the rest of HHS is, they do often feel cut off. So she does have … she has a lot on her plate. And speaking of the CDC, the agency put out a rather cryptic press release this week on vaccine uptake among kindergartners entering school, noting that “CDC continues to encourage parents to discuss vaccination options with their doctors.” Meanwhile, the data linked to in the press release shows a small increase in parents opting out of having their children vaccinated nationwide. But that masks a much larger increase in some states. In Idaho, for example, just 75% of kindergartners entering school have had the MMR [measles, mumps, and rubella] vaccine. That’s obviously well below the 95% needed to provide herd immunity for measles. As my friend Jonathan Cohn put it in his piece for The Bulwark. “The scientific term for that is yikes.” Yikes indeed. 

Kenen: And it’s even within states … and some rural counties … there’s a lot of variation. The trend … for a number of years now has been dropping vaccine rates. Period. So I mean, whether CDC wants to engage in this as their first issue, they’re going to be asked about it. … They track it … can’t avoid it, because they have to approve and recommend, and, you know, insurance coverage, all sorts of things are imminent. So decisions have to be made. … Back to school’s already started in some parts of the country. 

Rovner: And so … I would say new CDC Director Schwartz was rather pointedly not in the room when the president signed the executive order on vaccines, even though now-FDA nominee Heidi Overton was. 

Kenen: She cannot put her head in the sand on this one. She’s going to have to … 

Rovner: “She” Schwartz?  

Kenen: Yeah. So she’s she says, I mean, what we know so far is she’s been quite, you know, she went to the CDC, and the reports are that she came out and said, you know, I’m going to stick to the science, and the science supports vaccines.  

Ollstein: I thought what was really interesting about the recent reports is that, you know, the executive order the Trump administration signed doesn’t actually change anything legally, but it’s designed to put pressure on states to change their recommendations. And it’s been fascinating to me to see that even the reddest states really aren’t going for it yet. But that doesn’t mean that everything’s fine and everyone’s getting vaccinated. What we are seeing is, you know, individual parents making these moves away from vaccination. And so even without the state officially changing its requirements, the environment is just shifting, and using the bully pulpit in this way is changing people’s behavior — building on trends that were already happening: distrust and misinformation, and all of that. And so … even a small, small decline in the vaccination rate can have huge negative effects. I mean, the difference between having 97% vaccination vs. 91% — it may not seem like a big deal, but that’s the difference between herd immunity and people really being vulnerable. 

Rovner: And lots and lots more cases of measles, as we are seeing already this year. I mean, it’s, you know, talk about things that were completely predictable. Well, meanwhile, as my �������ýҕ�l Health News colleagues Amanda Seitz and Stephanie Armour point out this week, all of this public pronouncing by the president and other health officials about the supposed dangers of vaccines comes as HHS Secretary RFK Jr. blows past deadline after deadline to uncover the promised cause of the rising cases of autism. The story notes that the secretary “has looking for root causes in a research effort that’s offered no public status updates and few details about who, or even which agency, is leading the effort.” We do know that one of the people working on the project is Reyn Archer — he’s a noted vaccine critic, son of a former House Ways and Means Committee chairman, and was head of the Title X Family Planning Program during the George H.W. Bush administration in the early 1990s — even as he was publicly opposing legalized birth control, which of course is what the Title X program does. He later served as Texas’ state health commissioner under then-Gov. George W. Bush, although he was eventually fired for making racist remarks to a subordinate. I had not heard his name since, until now. But he’s going to uncover the root causes of autism, am I right? That’s the plan? 

Kenen: More power to him. I mean, autism. It’s not like there’s no research, and the conclusion is that it’s multi-causal. That there’s not one cause. That’s the current state of the science, which can always evolve. But the current belief is there’s probably a genetic component, but it’s a mix of factors that we don’t fully understand. But vaccines is not one of them. 

Rovner: Or at least so every study, every big study, we have seen continues to say. Well, moving on, lots of news about healthcare prices this week, which remain a pressing issue for both Republican and Democratic voters as the midterms draw near. One interesting story this week noted that prescription drug prices fell year over year by more than 3% — that’s the largest drop since the early 1960s — but it’s not entirely clear why. The Trump administration, of course, says it was their efforts, particularly to bring down the price of those popular but very expensive GLP-1 weight loss drugs. Analysts say it’s more likely the result of the Biden-era Medicare drug price negotiations, which involved more widely used medications. Whichever, I imagine if you’re not seeing your prices drop at the pharmacy, and those drops may well be absorbed by insurers and middlemen and all the people we talk about, will this good news even have much of an impact when people go to the polls? 

Luthra: I can’t imagine it necessarily would be that meaningful because overall the macro trends remain pretty bad. Health insurance is still getting very expensive. Employers are really struggling — those that offer it — they are largely passing more costs to consumers. And so people are getting to have to pay more for healthcare, even if their drug prices may be decreasing in the aggregate. And so it’s just hard to really suggest that this good news could really outweigh those other factors, especially when you think about the broader sort of angst that exists around costs and costs continuing to go up. 

Rovner: Yeah, well, in wonky news that could actually have a larger impact on what people pay for medical care, the Trump administration is actually going after some deep-pocketed healthcare providers. Stat News reports, in separate stories, first that the — that’s the parent of UnitedHealthcare, the insurer, and Optum, the services and tech arm — for allegedly underpaying taxes by funneling money through a foreign subsidiary. And second, the for potential antitrust violations. State attorneys general are also looking at Epic’s alleged anticompetitive practices. Cracking down on some of the monopolistic practices of the largest payers in the healthcare system actually could end up saving the system money, right? I mean, this was … something that we saw a fair bit of during the Biden administration, particularly from the Federal Trade Commission, and not so much of during the Trump administration, which has seemed to have been more favorable, if you will, to big companies. 

Luthra: I guess there’s still that question about providers, and obviously bringing down prices and addressing consolidation in payers, amongst things like electronic health record companies, can be effective, but we probably also would want to see meaningful movement in terms of provider consolidation as well, and that just seems potentially like a bigger hill to climb. 

Rovner: But this is a start. One would say, particularly this administration, going after United, which is sort of the the biggest … United’s power threatens the federal government’s bargaining power at this point. I was interested to see, you know, this story, if nothing else, made public, because obviously somebody leaked it. We will see how these all shake out. Well, finally, Costco, home of the cheap rotisserie chicken and the $1.50 hot dog and soda, is entering the Medicare market, . According to the Journal, Costco will partner with the nonprofit SCAN Group to offer Medicare Advantage plans in two states and a Medicare supplement, Medigap, plan in a third state. Could this eventually make a dent in the private Medicare market? Costco already does big business selling discount prescription drugs, eyeglasses, and hearing aids. I get my dog’s flea and tick medication at Costco. It costs half of what it does at my vet’s office. One presumes this could be, you know, a leader. We’ve not seen this before, right? 

Kenen: The head of SCAN, which is a pretty reputable insurance company … 

Rovner: Nonprofit insurance company. 

Kenen: Nonprofit insurance, and I should say I know … personally the current CEO, president, whatever his post is. I mean, but you know, I’ve written a lot about aging over the years, and it’s basically considered … one of the higher-quality, more reliable elderly-focused health plans. And he has something interesting to write when he announced it or wrote about on LinkedIn about how he personally, like, is a big Costco guy. But he talked about trust, which we’re all talking all the time about how there’s a lack of trust in healthcare. There’s a lot of trust in Costco, and he talked about how branding, SCAN, and Costco, you know … obviously it’s a business decision he made, but he’s also, like, this big Costco guy and who worries — I know him through conferences on trust, actually, that’s where I met him — and he’s thinking, OK, Costco, in addition to, like, giving you way too much of whatever it is you thought you needed, it can also fix the trust crisis in America. Right? 

Rovner: Hey! 

Kenen: And they’re efficient, right? I mean, I don’t know if all four of us are Costco people, but the, you know … 

Rovner: I am. 

Kenen: I saw her. I ran into her buying her veterinarian [unintelligible, through laughter] … I was in the photo section. … It is a trusted brand, and it’s an interesting — and they have national reach in there, you know. 

Rovner: And you will hear in my conversation with Mark Cuban that trust is a really big deal in healthcare right now. I mean, we obviously talk about this every week. I mean, I’m, obviously this is a very small step, but I’m really interested in where it turns out. 

Kenen: It’s a smart business move, and it’s a talker, too. Like, people are gonna see this headline and pay attention to it because it’s, like, just a thing. 

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

So, a good bit of reproductive health news this week. Glad to have both Alice and Shefali here. We will start in Idaho, where a federal district court judge ruled that the state’s abortion ban cannot be used to prosecute doctors who perform abortions to protect the pregnant person’s health, not just her life. Of course, abortion opponents vehemently oppose health exceptions, as they’re called, because they say health includes mental health, and that becomes a loophole so big that it basically eviscerates the ban. The state’s attorney general, former congressman Raúl Labrador, said he would appeal and was confident the decision would be overturned. I would imagine that he’s probably right. Is the Supreme Court eventually going to have to spell this out? I wouldn’t be that surprised if they wanted to. 

Ollstein: I think this gets into some of the same EMTALA [Emergency Medical Treatment and Active Labor Act] territory, where we have seen the Supreme Court sort of back away from in recent years. But again, we just keep circling around and around the same question, which is, when is an abortion OK for a medical emergency purpose? How close to dying does a woman have to get before a doctor can perform an abortion? And we’ve seen again and again in Idaho that doctors are scared and confused, and even when they think that they should have the right to perform the procedure, you know, they’re still putting women on these dangerous life flights to other states in order to get care, leading to hours and hours of delays and potential complications. And so, you know, this court case and this court ruling was sort of aimed at clarifying that and giving doctors the confidence to be able to intervene when they feel it’s medically necessary. But now we’re seeing the state challenge that, and we’re just going around and around. And, you know, there have been similar cases in other states, just a whole mix of rulings, one way or the other, and that just creates more of a patchwork where, you know, some somebody’s ability to get care varies completely between states — and even within states, between hospitals, based on how much you know institutional backing doctors feel like they have. You know, will their hospital’s lawyers go to the mat for them or not? Do they work in a private practice vs. a big hospital system? All of these things come into play, 

Rovner: And, of course, we’ve also seen doctors, particularly in Idaho, leaving the state because they’re afraid that they can’t practice. I mean, they can’t adequately care for their patients. Shefali, I see you nodding. 

Luthra: Yeah, and what’s interesting about this case, other than the fact that Idaho will actually have an abortion ballot measure this November, is that we do have a federal judge here saying, in particular contexts, I see a right to an abortion. And I was talking to some abortion legal scholars about this, and they made the point that, in a way, this runs afoul of the Dobbs decision, because you do have a federal judge saying people are actually entitled to abortions, and that is a right that they have, even if it is much narrower than what Roe v. Wade guaranteed. And obviously, this is going to be appealed. This is going to continue to be litigated. We may not see immediate change for people’s ability to get healthcare in Idaho or other places with very strict bans, but it does underscore how unsettled these legal questions remain — how there remains a lot of debate over whether Dobbs was actually a correct interpretation of constitutional law. And I think it really takes us back to the argument we heard from some of the conservative majority that this would now settle every question about abortion. Obviously, it has not. Obviously, many more questions will continue to be argued and litigated in the courts. 

Rovner: Yeah. Well, meanwhile, in other breaking news, a federal judge here in Washington blocked the Trump administration’s changes to the teen pregnancy prevention program that funds classes on contraception and abstinence, among other things. But they’re still not necessarily getting the money appropriated by Congress, right, Alice? 

Ollstein: So a judge in D.C. is blocking the administration from using its very strict new guidance going forward when it doles out money for the program, but it’s not ordering the administration to give back the money that was already cut earlier this summer from all of these grantees around the country. And, by the way, the money was cut both from grantees like Planned Parenthood, where you would say, “Oh, well, that sort of makes sense that the administration would go after their money.” But they’re also cutting funding from, you know, faith-based programs, abstinence-only programs in very red states, and prompting a fair amount of backlash that I’ve been covering. You know, places like Texas and South Carolina and West Virginia have also lost funding. And, of course, all the programs in those states had to abide by state restrictions around what can be taught. And so they were already following these very conservative guidelines. But that’s not conservative enough for the administration, which put out this guidance saying, you know, while abstinence-only was an option before, now it is basically mandatory. And so that guidance is on hold, but, again, the judge said that he didn’t know if he had the authority to order them to give back the money, or if some other jurisdiction could handle that. And so, this is just a preliminary injunction, which means there’s going to be months and months of litigation going forward. 

Rovner: Finally, this week, a story from the “Who Could Ever Have Imagined This?” files: A California couple hired a surrogate in Alaska to carry their pregnancy. After the fetus was diagnosed with a life-threatening heart condition, the couple exercised their option in the surrogacy contract to terminate the pregnancy. But the surrogate refused to have an abortion, and she traveled to Texas, where abortion is illegal, and gave birth to a baby boy last week. News reports say the baby, who is now in the custody of the couple who are biologically his parents, had the first of several surgeries needed to treat the heart condition. But this is a genuinely wrenching situation. Who gets to decide what here and under which state’s laws? Bioethicist Arthur Caplan told Houston Public Media that there are so many ethical issues here, he could spend an entire semester’s course teaching it. 

Luthra: And I think what is important about this case as well is, I mean, it’s obviously just like so, so, so sad, and this poor family is just having to deal with something really heartbreaking that no one should have to navigate under the national spotlight in Texas. It is really energizing conservatives who want to ban surrogacy, and we have already heard from lawmakers in the state legislature say they will be looking at surrogacy specifically when they convene next year. I have talked to anti-abortion activists in the state who are very hopeful that this case will give them new impetus to ban, at the very least, commercial surrogacy. They would love to ban all forms of surrogacy. And it is seen by a lot of anti-abortion folks who oppose fertility treatment, including IVF [in vitro fertilization], as something maybe easier to target. And I think it’s politically really complicated, because Americans don’t know as many people who get pregnant through surrogacy as they do people who might use IVF. But when I was talking to, again, legal experts about this, one point they made is that if surrogacy restrictions do take off in a meaningful way, often, the intellectual framework and arguments being made are ultimately the ones that would be used for IVF restrictions as well. And so, there is a possibility of a real slippery slope and more of that opening the door to fertility treatment restrictions that could affect a lot of people. 

Kenen: I think there’s a lot of public misunderstanding about what a gestational carrier is. When surrogacy became, not common, but sort of emerged in the public eye, there were a couple of really high-profile court cases. This was in the late ’80s. The “Baby M” was the most famous. And these were situations, at that point, where the woman carrying the child, it was her egg. So in the Baby M case, it was a couple that couldn’t have children. She was-— I don’t even know if that was — that wasn’t probably IVF. That was probably some other kind of artificial insemination. But the woman who decided she didn’t want to give up the baby after carrying it — it was, in fact, her biological child — and the practice became not to let, to separate the surrogate carrier from the egg donor. It’s not 100%. It’s not that it never happens, particularly if there’s family situations where maybe an aunt carries, etc. In this case, we’re really, based on public record, because I did a little reading on it this morning, it’s not clear, of the “biological parents,” it’s his baby. It’s not 100% clear on the public record that it’s actually her egg, the wife’s egg. But it is not the carrier’s egg. The woman suing to keep the child, saying she wants to have the baby, it is not her, it was not her egg. State law varies. Most states say that the surrogate in this kind of situation does not have maternal rights; that it’s the couple that hired her. Texas is, I believe, more blurry. There are a few states that it is more ambiguous, and also remember that this is a really tight, unusually and unexpectedly tight Senate race in Texas, where a very anti-abortion state, obviously, and also in this case the couple says they didn’t even ask for the abortion, but that’s he-said-she-said-they-said, we don’t know. I don’t know, at least, right? But abortion is a huge political driver in Texas; it’s a close race. [Ken] Paxton, who is the state attorney general, who is taking the side of the surrogate mother, is also the Senate candidate. You know, this is, you know, we’re 2½ months out, whatever, from the election. Three, I guess, closer to three still. But it’s very political in a state that probably has more politics around abortion than probably any other state. 

Rovner: Just what we needed: another thorny issue to throw into this mix. All right, that is this week’s news, or at least as much of it as we could get to. Now we will play my in-the-car interview with Mark Cuban, and then we’ll come back and do our extra credits. 

I am so pleased to welcome businessman and entrepreneur Mark Cuban to “How Would You Fix It?” Mark is probably best known to most people as a former shark on the TV show Shark Tank and the former [co-]owner of the Dallas Mavericks NBA team. But he’s also the co-founder of the Mark Cuban Cost Plus Drugs company, which sells generic medications directly to consumers at transparent prices and big discounts. More recently, he’s been talking about even bigger reforms to the healthcare system, which is why I’m so excited to have him here. Mark Cuban, thank you so much for joining us. 

Mark Cuban: Thanks for having me. 

Rovner: I’m curious: Your background’s been mostly in tech and in sports. How did you come to make healthcare such a priority? 

Cuban: I got a cold email from my now co-founder, Dr. Alex Oshmyansky, and he wanted to build a compounding pharmacy that made sterile injectables that are on the FDA short-supply list — which it’s crazy that there is a short-supply list for generic injectables. So that was great, but it wasn’t big enough. And as I looked into it, it was right around the time that “pharma bro” [Martin Shkreli] was going to jail, and I was like, “How can this dude jack up the price of a generic medication to the detriment of so many people?” And then it became obvious that nobody knew what a medication costs, nobody knew why it cost what it costs, and nobody understood why everybody paid a different price for the same medication. That list led to us launching costplusdrugs.com in January of 2022, and it’s just been growing like a weed ever since. 

Rovner: For decades now, the big debate in health policy has been whether the system should be more run by the government or more run by the private sector. Is that even the right way to focus on this anymore? Now everything is sort of hybrid and a mess. 

Cuban: Yeah, no, it’s not, because if the government doesn’t have data, and the government can’t trust the vendors that they’re working with, it doesn’t matter that it’s the government doing all the negotiating. And you see that in other countries. For instance, we get emails from countries around the world — from Canada, England — asking to buy generics from us ’cause our prices for generics, particularly specialty generics, are less expensive than what they sell for in countries that have single-payer or universal care. And so, while I’m not opposed to single-payer or universal healthcare at all, and kind of the analogy I use is: If healthcare costs $1 per person per year — yeah, great, taxpayers would pay that. But it would be a set $1 and it’d be obviously inexpensive. But when you don’t know all the costs, when there’s no transparency, it’s impossible to determine if it’s a better solution or not. 

Rovner: Are there segments of the healthcare industry that would work better if the private sector ran them, and better if the government ran them? I’m thinking, you know, hospitals, doctors, drugs.  

Cuban: I don’t think it’s like that at all. I think it depends on how much transparency there is. The fundamental issue is transparency and trust. If you don’t know … like, there are a lot of hospitals, and you know this better than anybody, that don’t know their costs. And if you just hire the same people and just say, “Look, we’re going to pay Medicare pricing to Mayo Clinic, and Mayo Clinic doesn’t know all their costs,” or “We’re going to take an urban hospital and continue to pay them Medicare and Medicaid because that’s most of their business,” and they don’t know their cost, they just know their cash balance, it doesn’t matter who runs it. 

Rovner: So, what do you fix first? 

Cuban: Transparency. You have to be able to publish contracts so that any contract that’s signed with a federal agency, the federal government, a state agency, a city, not only are the terms of the contract published, but the prices are published, so that Tricare would be required to publish their prices. By seeing the actual contract, you can see where the city-state agency is getting ripped off. Because right now there’s confidentiality requirements, and the companies, like the big insurance conglomerates, they say, you know, we can’t do this. We can’t show this, it’s proprietary information, which is nonsense. You’ve got hundreds of thousands of companies. You’ve got hundreds of agencies and states and cities that negotiate the same contracts. So lots of people know, but they do it to make it more complicated. And so, as a result, nobody knows how the deals are structured. And if you don’t know how the deals are structured, it’s impossible to negotiate better ones. And if they’ll sue you for discussing it with their peers, then nobody … it’s like Fight Club. The No. 1 rule [of] Fight Club is you can’t talk about Fight Club. The No. 1 rule of healthcare contracts is you can’t talk about healthcare contracts. 

Rovner: Yeah, and we’ve, you know, Congress has passed laws. The president has pushed a lot of these transparency rules, and basically, the health industry has said, “Yep, sorry, we can’t do it,” or “We’re going to do it in such a way that you can’t find it out anyway.” 

Cuban: Correct. 

Rovner: “We’re going to send you reams and reams and reams of data, and you can go digging if you would like.” 

Cuban: Correct. And so you take that to the next step. The big healthcare companies — first of all, they’re vertically integrated. They have hundreds, if not thousands, of subsidiaries. People don’t even know what the subsidiaries are when they do business with them, right? And so, when that happens, there’s just no way for any of the states, cities, federal government to enforce the laws. The big healthcare companies have more lawyers, move faster, are better able to find loopholes than the government and the agencies that enforce it are able to enforce it. And so, what ends up happening. You see all these fines. This PBM, this insurance company, whatever got fined for A, B, or C, and then they just go right back to doing business with them. So when I talk to governors, one of the first things I say in terms of reform is A) publish the contracts, and B) if you are doing business with a vertically integrated healthcare company, and they are fined by any federal agency or any state government, they get one mulligan. If they are fined a second time, they can’t do business with you for five years. That will act as the enforcement mechanism to keep them in line. And then the third thing that I always push is that anybody is able to go out and make a cash purchase, whether it’s medical or pharmacy, as long as it’s less expensive than their out-of-pocket, and have it by law count towards their deductible and max out-of-pocket. When you do that, you give them the opportunity to shop. When something is shoppable — not everything is — but you give them the opportunity to shop, and that helps force down prices. 

Rovner: So, I’ve been doing this since the 1980s, and it’s always been the Democrats beating up on the big insurance companies, and the Republicans basically defending them. Now that Republicans are beating up on the big insurance companies, are we kind of inevitably going towards a government-run single-payer? 

Cuban: No. Like, if you look up, if you look at the Break Up Big Medicine bill that was introduced by Josh Hawley, a Republican, and Elizabeth Warren, to me that’s the first step. So the good news: It was introduced on a bipartisan basis. Because if you break up these big, huge conglomerates, everything changes. The price of everything drops like a rock. But the problem is, nobody else, no senators have supported it, and nobody in the House has introduced a comparable bill. Everybody just chickened out. And so that’s the first step. Put aside the economics. Put aside that we don’t know the cost. Put aside that we have no transparency. All those things are important, but making sure we have health care for everybody is more important. That’s the difference. I think that also should be an American dream. As an entrepreneur, I’m a big fan of the American dream. But being able to be healthy and not be afraid that you can’t afford what you need or your family needs, that’s wrong in our American dream. And you know, when we talk about healthcare as a right, doctors freak out because they presume that they’re going to be paid Medicare rates, and they lose control of their life, right? And they talk about opting out and not doing it, you know. And so you need to get all these stakeholders accounted for. And until you start to do that and put together a plan that people will accept, we’re not going to ever be in a position to take care of people like so many of us hope to do. 

Rovner: And yet that would require both parties to basically lay down their arms.  

 

Cuban: Yes, which I think is possible. I think it’s doable because the No. 1 thing that, in every poll, people are concerned about healthcare costs. It’s not the quality of healthcare. Nobody really complains about the quality. Our doctors are great. Our systems are great. It’s the economic side. And who defines the economic side? Those humongous healthcare conglomerates. And what’s the best way to get to a point where we have transparency at the contract level, you know, flexibility and understanding, etc., all the things I mentioned? You break up those huge conglomerates that have thousands of subsidiaries that do $150-plus billion in intercompany transfers, that game the medical loss ratio. I mean, all these things happen because those big companies have more control over the economics of our healthcare system than the government does. 

Rovner: Well, I hope we actually get to that point, and I hope you’re around to help with some of these stakeholder conversations. 

Cuban: Oh, hopefully I’m not going anywhere. 

Rovner: Thank you so much. 

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. Shefali, you picked first. Why don’t you go first this week? 

Luthra: Sure. My story is from The 19th by my colleague Barbara Rodriguez. The headline is “.” And I love this whole genre of story. The GLP-1 market is exploding because these drugs can be so expensive to get from your healthcare provider. You see advertisements everywhere, all over social media, people promising to sell you a GLP-1. And as Barbara’s story gets into, often they are not actually GLP-1s. It is something fake. It is not actually going to help you lose weight, but it is going to take your money. And I just think that this is such an exploding market. So much has changed that we can’t read enough about how the, just the growth of options, or not legitimate options, is affecting people, and I’m really glad she did this story. 

Rovner: Yeah, it was a really good story. Alice. 

Ollstein: I have a story from The Texas Observer by Mary Tuma, and it’s called “.” So this is taking a deep dive on the situation in Texas, but the article does a good job of pointing out that this is a trend across several states that implemented abortion bans, where there was, you know, efforts to pause or revamp, or obscure, or change in some way the groups in every, that exist in every state that study maternal deaths. And there is just a suspicion that this is an attempt to hide from the public the impact of the abortion ban on maternal mortality. You have a lot of experts quoted in this piece. You have the family members who have lost their wives and mothers to pregnancy-related deaths, and so this is just an ongoing fight. And, you know, doctors say we really need this data and this analysis to know how to better provide care in the future. It’s not just a political football; it’s actual medical knowledge that we need to build. 

Rovner: Yeah, I think ProPublica did this for Georgia, I think, last year, so yet another in these series. Joanne. 

Kenen: There’s a story in Politico by Owen Dahlkamp: “.” This is not unique to health law, but given how complicated health law is and how much health law Congress deals with in any given year, it’s quite relevant to health law. So staffers are using AI to actually draft legislation, not just to research something. And I mean, it’s hard to get away from AI now. It’s, like, even pops up on people’s phones, right? But drafting legislation is very precise and complicated, and AI is apparently not very good at it. So the House counsel, which is the Office of Legal Counsel, which actually has to make sure the legislative language is correct and doesn’t accidentally reveal the wrong thing, they’re having a hard time. Although they have now created their own tool to try to correct the AI slop, but they’re getting overwhelmed. There’s, you know, we’ve all seen stories, we’ve all gotten pitches about, you know, so-and-so introduced a law. What the general public doesn’t understand is introducing a law, you know, it’s good for a press release — introducing a bill, excuse me. Introducing a bill does not mean a whole hell of a lot, except that you’re satisfying some constituent or constituent group, right? But congresspeople and senators like to say they introduce this and they introduce that and they introduce the other thing. So the number of bills being introduced was already rising spectacularly, and now with the slop, there’s like the slopth degree of it. So it’s messy. 

Rovner: It is messy, and it does, I mean, it sort of prevents the real work of actually drafting legislation that’s going to become law from getting done. 

Kenen: There’s going to be something, like, really bad that comes out that somebody in the poor OLC office doesn’t catch, and it’s going to repeal, like, you know, the flag. 

Rovner: Yeah. We will see. All right my extra credit this week is from Mother Jones by Sophie Hurwitz. It’s called “.” And you may have heard that ICE [Immigration and Customs Enforcement] is spending $20 million to buy these gloves, which administer an electric shock at the touch of a button on the wrist for their officers. What makes them better than a Taser or other non-[lethal] device? Well, one Missouri police officer whose force uses them said the gloves “allow their wearer to inflict pain without leaving the sort of marks that could look bad to witnesses or leave an officer vulnerable to lawsuits.” In other words, they make it easier for people to inflict pain on others, whether warranted or not, without likely recourse. How very 2026. 

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

Ollstein: on Bluesky and on X. 

Rovner: Shefali. 

Luthra: on Bluesky. 

Rovner: Joanne. 

Kenen: Mostly on and on . 

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