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

Julie Rovner: Hello from Ñî¹óåú´«Ã½Ò•îl Health News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, 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 Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: 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 my interview with Ñî¹óåú´«Ã½Ò•îl Health News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly â€” in the words of longtime Congress watcher  â€” a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year â€” but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when â€¦ we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers â€” which are actually stronger than many predicted, with fewer people actually dropping coverage â€” reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But â€¦ I think what Julie said is it’s â€¦ the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time â€¦ 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more â€” the out-of-pocket cost of insurance for millions of Americans, 20-ish million â€” but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but â€¦ I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high â€” in economically â€” zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not â€¦ it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers â€” and I’ll post a link to them â€” you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside â€” they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why â€” because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right â€” you know, again, including senators like Cassidy, but also these activist groups â€” they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication â€¦ I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

¸é´Ç±¹²Ô±ð°ù:ÌýSo, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

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

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there â€¦ who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs â€¦  

Rovner: Puberty blockers! 

Edney: â€¦ they’re taking â€” exactly â€” and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now â€” most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat â€¦ the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer â€¦ they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion â€” that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over â€” I’m not exactly sure how many years â€” 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes â€” some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health â€” that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just â€¦ like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people â€” and to Alice’s point about how this hasn’t saved money â€” more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just â€¦ a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 â€¦ now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away â€” you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell â€” he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t â€¦ you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer â€” if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

Rovner: OK, we’re back, and now 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 start us off this week? 

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians â€” how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who â€” like, I don’t know how all of you watch it â€” but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS â€” or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer 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, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Sept. 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode, we’ll have my interview with my Ñî¹óåú´«Ã½Ò•îl Health News colleague Tony Leys, who reported and wrote the August “Bill of the Month” about a patient’s unfortunate run-in with a bat and an even more unfortunate run-in with the bill for rabies prophylaxis. But first, this week’s news.  

Well, it is safe to say that there has been quite a bit of health news since we last met in mid-August. Health and Human Services Secretary Robert F. Kennedy Jr. testified before the Senate Finance Committee yesterday, which we will talk about in a moment. But first, I want to catch us up on what you might’ve missed. Our story starts, kind of, with the FDA’s [Food and Drug Administration’s] approval of this year’s covid boosters, which are only being licensed for those over age 65 and those who are younger but have at least one condition that puts them at high risk of serious illness if they contract the virus. That leaves out lots of people that many doctors think ought to be boosted, like pregnant women and children. Sarah, what’s supposed to happen after the FDA acts? The next step happens at CDC [the Centers for Disease Control and Prevention], right? 

Karlin-Smith: Correct. So right now the CDC’s Advisory Committee on Immunization Practices is scheduled to meet Sept. 17 to 18, 18 to 19, but about two weeks from now. And they would typically vote on sort of endorsing use of these vaccines and, again, have like sort of a second chance to weigh in on which populations they would be used for. And that’s often important for triggering insurance coverage without copays. And also many states rely on the CDC recommendations for various state laws that say, again, who can get the vaccine or whether you can get it via a pharmacist or only at a doctor’s office, do you need a prescription, and things like that. So the CDC and FDA, I would say, in general is a little bit behind this year. I could think a lot of people have been trying to go out and get these new shots even though those steps haven’t happened yet. 

Rovner: That’s right. I mean, it is early. Even if there was nothing else going on, there is that little bit of a lag between when FDA acts and when the CDC acts, right? 

Karlin-Smith: Yeah, there usually is. I think in the past they’ve tried to have both FDA approval and the CDC act so that the vaccines could start rolling out more like late summer, early September. So they’re definitely behind, and there’s been a number of reports of covid kind of slowly rising as the summer winds down and school gets back in session. 

Rovner: Yeah, so there’s a lot of other things going on. Well, in the meantime, nothing that was supposed to happen has happened yet, and we still don’t know all the details, but it certainly appears that Susan Monarez, who was just confirmed by the Senate to lead the CDC a month ago, was fired after she refused to override her scientific advisers and approve the new restrictions on covid vaccine availability, even before the ACIP met. In turn, four top CDC leaders resigned as well, going public to warn that the agency is being politicized by the secretary. How much of a mess is the CDC in right now? And how long is it going to take to put the pieces back together? 

Karlin-Smith: I think they’re in a pretty bad place, because not only did they lose their director really quickly, but after she resigned, about I think it was eight or nine senior CDC leaders resigned last week as well. And so, really critical people to various parts of the operation that you don’t just replace very easily. And Kennedy has slotted in Jim O’Neill as the temporary director of the CDC and kind of indicated he wants to remake the agency. And I think there are questions as to how that remaking shapes both its priorities and how it handles public health throughout the U.S. 

Rovner: And of course, morale at CDC is awesome, in part because, as we discussed the last time we met, a gunman came and shot up the place, killing a policeman and leaving the staff pretty upset. And that gunman, who then took his own life, was later found to have had some discontent with vaccines. So things are just really bright and cheery there in Atlanta at the CDC. Alice, I see you nodding. 

Ollstein: These things kind of snowball, you know? I think there are likely to be a lot of staff who were already on the fence about staying and decided to stay because they trusted these pretty senior leaders with a lot of decades of expertise and institutional knowledge. And that was sort of the thread they were hanging on as well, at least: I’m with these people. And now that they’ve left, I think that could trigger a bigger exodus on top of the exodus that was already underway. 

Rovner: And it’s important to say — even though we say it, I think, every time — that these are career scientists who’ve worked for Democrats and Republicans over the years. These are not generally political people. They’re not political appointees. And they basically do their jobs. And until fairly recently, public health wasn’t this partisan, so it wasn’t that hard to be a career public health official just working for public health. That’s just not the case anymore, is it? 

Karlin-Smith: I think there’s been a lot of insult to injury added with what happened with the shooting at the CDC, because there is a sense that the kind of rhetoric that Kennedy in particular has used over the years, even before he came into HHS [the Department of Health and Human Services], on sort of his movement has sort of amplified the criticism of public health workers and put them in this situation where they’re dangerous. And Kennedy, instead of really acknowledging that and maybe apologizing or giving any sense that he was going to shift in a different direction, has actually really kind of doubled down on it. And even in some of the pieces he’s written recently about how he wants to reform the CDC, he kind of keeps criticizing the rank-and-file employees and so forth. So there’s a lot of tension between the political leadership and the career staff, I think, at this moment. 

Ollstein: And in normal times, most of the American public would not even know the names of these people. They’re not public figures. They’re just very behind-the-scenes scientists doing their work. And now their personal photos are being combed through and shared to attack them because they’ve criticized the administration. They’re getting threats. It’s just this whole level, like you said, of politicization that we haven’t seen before. 

Rovner: Well, so, in kind of a coincidence, Kennedy had already agreed to appear on Thursday before the Senate Finance Committee, which by the way doesn’t have jurisdiction over the CDC or the rest of the public health service. But no matter — a Senate hearing is a Senate hearing. And let’s just say it didn’t go that well for the secretary. Democrats were kind of withering in their criticism of Kennedy’s eight-month tenure so far. Here’s Colorado Sen. Michael Bennet. 

Sen. Michael Bennet: This is the last thing, by the way, our parents need when their kids are going back to school, is to have the kind of confusion and expense and scarcity that you’re creating as a result of your ideology. 

Rovner: Republicans weren’t that impressed, either, particularly the Republicans on the committee who are also doctors. [Sen.] Bill Cassidy, a doctor who’s on Finance but is also the chairman of the Health, Education, Labor, and Pensions Committee and is facing a primary challenge in Louisiana, seemed to tread pretty carefully. More surprising, at least to me, was Dr. Sen. John Barrasso of Wyoming, who’s also in the Senate leadership. 

Sen. John Barrasso: So over the last 50 years, vaccines are estimated to have saved 154 million lives worldwide. I support vaccines. I’m a doctor. Vaccines work. 

Rovner: I was super impressed that even the Republicans who criticized RFK were careful not to criticize President [Donald] Trump. In fact, there were several suggestions — this was clearly a talking point — that Trump should be given a Nobel Prize for his work overseeing Operation Warp Speed, just so the senators could kind of bifurcate their complaints. What impact, if any, is this hearing going to have on RFK’s future as secretary? 

Ollstein: Well, I think there was an attempt to, I think, what you just mentioned. That like dual criticism with praise of Trump was meant to drive a wedge and to get Trump to question RFK’s leadership. That does not seem to have worked so far. We don’t know what’s going to happen in the future, but I think it’s an attempt to get the message to Trump that RFK’s reputation and actions could be damaging to the administration overall. And there was some reporting that polling showing that most people do support vaccines was circulated amongst Republican members before the hearing. And so, I think it’s trying to, yeah, get the message that this is both damaging in a public health sense but also potentially damaging in a political sense as well. 

But so far, the reporting is that Trump is standing by RFK, that he liked how combative he was. And so I don’t know where those attempts to drive a wedge will go in the future, but like you said, it was notable that if folks like Barrasso, [Sen. Thom] Tillis, who’s not running for reelection, was also more vocally critical, and a couple others, not a lot. We’re not seeing a great dam breaking yet. But I think there’s more cracks than there used to be on the GOP side. 

Rovner: I did notice that Trump, he had a very strange Truth Social post earlier in the week that basically said that CDC is a mess and it has to be fixed. Kind of just Trump being the omniscient observer. And then, apparently at a dinner with tech titans after the hearing, he said that he had not watched the hearing but that he heard that Kennedy did well, which is not exactly what I would call a ringing endorsement. I feel like Trump is giving himself some runway to go either way depending on sort of how things continue to shake out. I see nodding. 

Karlin-Smith: Yeah. I saw a lot of people reposting that clip on social media last night who are frustrated with Kennedy and using it to try and ramp up their banks and say: Keep calling. Keep pressuring. This shows we have an opening. I think it’s really always hard to read the tea leaves with Trump and his language and words. He’s a harder person to interpret. But I also thought it was really interesting that in some ways Cassidy and some of the other Republicans were throwing RFK a bone and saying: This is your president. This was his greatest achievement. Can you support it? 

And RFK couldn’t even really twist himself into doing that. He sort of tried to, but he could never square it with the bulk of his remarks at the hearing, which were incredibly critical. MRNA vaccines and vaccines in general — he defended the massive cuts in this area for research. He defended people who have really said very untrue things about the harm caused by these vaccines. So in some ways I felt like Cassidy was trying to give him one more chance or something, and RFK couldn’t even take it when it was couched as this Trump achievement. 

Rovner: I can’t help but wonder if this is playing to Trump’s advantage because it’s distracting from Trump’s other problems, that perhaps Trump likes that there’s so much attention on this because it takes attention away from other things. 

Ollstein: Yeah. Although I do find the eagerness of Democratic members of Congress and other folks to wave away certain things as a distraction as a little bit questionable. This is all part of the agenda of the administration, and dismantling government bureaucracy is clearly a core, core part of the administration’s agenda, and so— 

Rovner: And flooding the zone. 

Ollstein: Exactly. Well, it might also serve as a distraction. I think that it should be considered a serious part of what they actually want to do as well. 

Rovner: So there were a couple of things that we learned about RFK Jr. from his confirmation hearings back in the winter. One is that he’s not at all deferential to elected officials, even calling them liars, which is pretty unheard of. And that he doesn’t really know how his department works. And it appears that eight months later, neither of those things have changed. How does he get away with being so rude? I mean, I’ve just never seen a Cabinet official who’s been so undeferential to the people who basically put him in office. Is it just me? 

Karlin-Smith: I think it’s part of the times where politics is really trumping behavior or policy, right? Even though there were a few Republicans that we’ve talked about who have kind of started to get frustrated with RFK and his vaccine policies. You saw at the beginning of the hearing, Chairman [Mike] Crapo was asked by the ranking Democrat, Sen. [Ron] Wyden, to basically swear Kennedy in because Wyden has felt like Kennedy has lied to the committee before. And Crapo just basically brushed that away and dismissed it. And I think, so, in many ways a lot of the Republicans on the committee endorsed Kennedy’s behavior kind of, maybe not overtly but indirectly, and that’s sort of been how they’ve been operating. It’s more of a political theater thing, and they’re OK with sort of this disrespect, of its sort of political fight that somebody on their side is taking up. 

Ollstein: I also think Congress’ unwillingness so far to actually sanction or take action in any way about anything RFK has done seems to have emboldened him. I think the fact that he has broken all these promises he made to Cassidy and other senators and there have been basically no consequences for him so far feeds into that. He kind of has a What are you going to do? attitude that was very evident in the hearing. 

Rovner: Yeah, I think that’s fair. Well, there were, as always, parochial question from senators about home state issues, but one topic I don’t think I expected to see come up as many times as it did was the future of the abortion pill, mifepristone, which is about to celebrate the 25th anniversary of its original approval by the FDA. Alice, what are you hearing about whether FDA is going to rein the drug back in, which is what a lot of these anti-abortion Republicans really want to see happen? 

Ollstein: Yeah, so I think there was nothing new in the hearing this week. What he said was what he’s been saying, that they’re looking into it, that they’re evaluating. He made no specific commitments. He gave no specific timelines. He said basically enough to keep the anti-abortion people thinking that they’re cooking up some restrictions but not explicitly promising that, either. And so I think we’re just where we were before. They continue to reference data put forward by an anti-abortion think tank that was not peer-reviewed and claiming that it is this solid scientific evidence, which it is not, about the risks posed by the pills, which many actual, credible, peer-reviewed studies have found to be very safe. And so we just don’t know what’s going to happen. I think any nationwide restrictions, which is what they’re mulling at the federal level, which would impact states where abortion is legally protected, that would be a potentially politically damaging move. And so it’s understandable why they might not want to pull that trigger right now. So, right. 

Rovner: And Trump has said, I mean, Trump has indicated that he does not really want to wade into this. 

Ollstein: Correct. But again, he’s also very good about not making hard promises in either direction and sort of keeping his options open, which is what they’re doing. The anti-abortion activists, this is not their only iron in the fire. This is just one of many strategies they have going on. They also have multiple pending lawsuits and court cases that are attempting to accomplish the same thing. They’re pursuing new policies at the state level, which we’ll probably talk about, Texas and others. 

Rovner: Next. 

Ollstein: And so yes, this pressure on FDA and HHS to use regulation to restrict the pills is only one of many ongoing efforts. 

Rovner: Well, you have anticipated my next question, which is that while we are on the subject of the abortion pill, Texas, because it is always Texas, has a new bill on its way to the governor for a signature to try to outlaw . What exactly would this Texas law do? And would it work? Because, obviously, this has been the biggest loophole about stopping abortion in these states that have banned abortion, is that people are still able to get these pills from other states via telemedicine. 

Ollstein: Yeah. So in one sense, nothing’s changed. Abortion was already illegal in Texas, whether you use a pill or have a procedure. And so this is just layered on top of that. The groups who backed this explicitly said the attempt is to have a chilling effect. What they’re hoping is that no lawsuits are even needed, because this just scares people away from ordering pills and scares groups in other states away from sending pills. One concern that I saw raised is that the law criminalizes simply the shipping of the pills. Somebody doesn’t even have to take them for a crime to have been committed. 

And so that’s raising concerns that anti-abortion activists will do kind of sting operations, sort of entrapment-y things where they order the pills solely in the interest of bringing a lawsuit. Because there is a cash bounty that you can get for filing a lawsuit — there’s an incentive. So that’s a concern. And then just the general concern of a chilling effect and people who are using less safe means than these pills to terminate their pregnancies out of fear, which studies have shown is already on the rise, people injuring themselves taking herbs and other substances, chemicals. So that’s a concern as well. 

Rovner: We’ll continue to watch this, but back to vaccine policy. With the status of federal vaccine recommendations in limbo, states appear to be going their own way. Blue states California, Washington, and Oregon are banding together in a consortium to make official recommendations in the absence of federal policy, and several blue-state governors are acting unilaterally to make sure covid vaccines, at least, remain available to most people. At the same time, some red states are going the other way, with Florida Surgeon General Joseph Ladapo, who we have talked about before, now vowing to for schoolchildren. Sarah, that would be a really big deal, right? 

Karlin-Smith: Right. I think the big fear then is that the school requirements is kind of what gets us to close to, in many cases, universal vaccine uptake in the country, because everybody needs their kids to be in school. Unless you’re homeschooled, you really must follow these vaccine requirements. And it not only hurts the kids who don’t end up getting vaccinated individually, but it can really hurt the idea of herd immunity and the protection we need for these diseases to disappear in the community. So there’s— 

Rovner: And protection for people who can’t be immunized for some reason. 

Karlin-Smith: Right. Who either can’t be immunized or don’t have an adequate response to the immunization because they’re going through cancer treatment or they have some other medical reason that their body is immunocompromised. 

Rovner: So, I mean, is this going to end up like abortion, where it’s availability absolutely depends on where you live? 

Karlin-Smith: I think that’s hard to say. I think that a policy like what Florida is trying to implement could very quickly and easily go wrong, I think, and be reversed, as we’ve seen, like what’s happening in Texas now, with measles outbreaks. You know you only need just very small fractions of decreases in vaccination to create huge public health crises in places. And so I think it would be more sort of visible, in a way, to some of these states and their populations, the potential harm that could be caused, than maybe it is to them the abortion harm. But we definitely are seeing some sense of, right, the Democratic-controlled states trying to implement policies that help people get better access to vaccines, even when the federal government is trying to maybe harm that, and red states not caring as much. 

So there is going to be some more of a patchwork. And I feel like, in talking to just sort of people outside of the health policy space, there is a lot of confusion about: Where can I get my covid vaccine? Am I going to have to pay? Do I qualify? Especially being in D.C., which has less generous, I guess, pharmacy laws, because of this. So people are confused. If I go to Maryland, which is really close, does that matter even though I live in D.C.? And it’s just all these things we kind of know end up leading to less people getting vaccinated. Because even if they want to do it, the hurdles end up driving people away. 

Rovner: Yeah, I think something you’d said earlier about the fact that we’re seeing kind of a covid spike, so people are anxious to get covid vaccines, I think, a little bit earlier than normal. It’s usually kind of a fall thing and it’s only the beginning of September, but I think there’s just this combination, this confluence of events that has a lot of people very excited about this right now. 

Karlin-Smith: Yeah, I think it does. And covid has been, I think there’s been lots of hope in the public health world that covid would become a little bit like the flu, where we could predict a little bit more when it would really peak and get everybody vaccinated around the same time as they’re getting flu vaccines. Just again, because we know when we make it easier on people to get vaccinated, if you could just one-and-done it, it would be good. Unfortunately, covid has tended to also still have summer peaks, and this year again it’s kind of a late summer peak. And a lot of people, including seniors, are still recommended really actually to get two vaccines a year. So many people are kind of coming due for that second update right now. 

Rovner: Well, we’ll keep watching that space. Moving on, as we kind of pointed out already, Congress is back in town, with just a couple weeks to go before the start of fiscal 2026 on Oct. 1. This was the year Congress was really, truly going to get all of its spending bills passed in time for the start of the new year. How’s that going, Jessie? 

Hellmann: It’s going great. I’m just kidding. There’s a lot of friction on the Hill right now. The White House budget chief is talking about doing more clawbacks of foreign aid, which is frustrating both Democrats and Republicans. It’s about $5 billion, and we’re seeing Democrats kind of start to put their neck out there a little more than they did earlier in the year when they were also kind of making noise about government funding. And they’re now saying that Republicans are going to have to go this alone and they’re not going to support partisan spending bills. So it’s kind of difficult to see where we go from here. And then— 

Rovner: Are we looking at a shutdown on Oct. 1? I mean, that’s what happens if the spending bills aren’t done. 

Hellmann: It’s hard to say. There might be a short-term spending bill, but anything longer-term than that, it seems really difficult at this point. And there are just massive differences between the health bills that the House came out with and the Senate came out with. I mean, there’s differences in all the other appropriations bills, too, but I was just going to focus on health. 

Rovner: Yes, please. 

Hellmann: The Senate bill would allow an increase for HHS, and the House bill would cut it pretty significantly. So it’s kind of hard to see how they could do anything more substantive when there’s so much light between the two. 

Rovner: Yeah. I mean, on the one hand, we have both the Senate and the House subcommittee that’s marked up the Labor HHS [Labor, Health and Human Services, Education, and Related Agencies] appropriation on record as not supporting at least the very deep cuts to the National Institutes of Health that were proposed by President Trump. But on the other hand, as you mentioned, we still have the administration, primarily budget office chief Russell Vought, making the case that the administration doesn’t have to spend money that Congress appropriates. And from all we can tell, at least as of now, there’s a lot of money that won’t be spent as of the end of the fiscal year, despite the fact that that is illegal. It’s known as a pocket rescission, a term I think we’re about to hear a lot more about. Alice, you referred to this earlier: Is Congress just going to quietly ignore the fact that the administration is usurping their power? 

Ollstein: I think that in many areas of politics, there is a faction that wants to play hardball and really use whatever leverage is possible and there’s a faction that wants to play nice and try to get what they can get by negotiation. And I think both parties always fear being blamed for shutdowns, and so that drives a lot of it. But I think there’s mounting frustration with Democratic leadership about not playing hardball enough. I mean, the jokes I hear are Democrats like to bring a spreadsheet to a gunfight, just seen as being unwilling, in the face of what many see as lawlessness, being unwilling to really put a check on that using the levers they have, including this federal spending. But I think we’ve seen that there are risks no matter what they do, and so I think people make reasonable points about the pros and cons of various strategies. 

Rovner: Well, we know that [Sen.] Susan Collins, who’s now the chair of the Senate Appropriations Committee, is very, very concerned — because Susan Collins is always very, very concerned. But she’s the one whose power is basically being thwarted at this point. People have gotten a lot of gray hair waiting for Susan Collins to stand up and be combative, but one would think if there was ever a time for her to do it, this would be it. Jessie, are we seeing, I was going to say, any indication that the appropriators are going to say, Hey, this is our job and our constitutional responsibility, and you’re supposed to do what we say when it comes to money? 

Hellmann: They are saying these things. I feel like we are seeing more Senate Republicans, at least, express discomfort with what the Trump administration is doing, saying things like: This is Congress’ job. We have the power of the purse. And then they are passing some of these spending bills through committee. But what else are they supposed to do? Unless Susan Collins wants to get on Fox News and start screaming about government funding, which I don’t really see happening and I don’t know if it would be effective, you kind of just wonder: What other options do they have at this point? 

Rovner: Yeah. Well, we’ll sort of see how this plays out over the next few weeks. Meanwhile, it’s not just the spending bills that Congress is facing deadlines for. This month is basically the last chance to re-up those, quote, “expanded subsidies” for Affordable Care Act plans before the sticker shock hits 24 million people in the face. Not only are premiums going up by an average of 18% from this year to next — that’s for a lot of reasons: increasing costs of health care, tariffs, drug prices — but eliminating those additional subsidies, or actually letting them expire, will cause some people to have to pay double or triple what they pay now. And it’s going to hit folks in red states like Georgia and Florida and Texas even harder because more folks there are on the Affordable Care Act plans, because those states didn’t expand Medicaid. Do Republicans not understand what’s about to happen to them? 

Hellmann: I think they understand, but they keep acting like there’s no urgency to the situation. They keep saying: We still have time. We have till the end of the year. Which I guess is technically true, but we’re already seeing insurers proposing these giant rate hikes. And it’s not easy to just go back and make changes to some of this. I guess the idea is— 

Rovner: So they really don’t have until the end of the year, though. Because people are going to get, they’re going to see the next year’s premiums that they have to start signing up in November. So, I mean, they basically have this month. 

Ollstein: If there’s uncertainty, they’re going to price very conservatively, aka high. They don’t want to be left holding the bag. And so, yeah, you and Jessie are exactly right that there isn’t time. These decisions are being made now. Even if they pass something to kick the can until after the midterms, I think some damage will already have been done. 

Rovner: Yeah. Jessie, I cut you off, though. I mean, the idea is that sort of their one chance to maybe do this before people actually start to get these bills, or at least see what they’re going to have to pay, would be wrapped into this end-of-fiscal-year continuing resolution. And maybe they can kick the appropriations down the road until November or December, but they can’t really kick the question of the subsidies down the road until November or December. 

Hellmann: Yeah. I think something would have to happen really quickly. We’re seeing some politically vulnerable Republicans, in the House, specifically, say that they want at least a year-long extension. It’s just a really difficult issue. We know, obviously, the Freedom Caucus is already making threats about it. They hate the ACA, maybe more than anything. It’s going to be really interesting how this turns out. I’ve also heard that maybe there might be a paired-back version of an extension that they could do, maybe messing with some of the income parameters. But I don’t know if that kind of compromise would be enough unless Republicans work with Democrats, which as we already said is complicated for other reasons. So it’s just a mess right now. 

Rovner: I love September on Capitol Hill. All right, finally this week it will launch a pilot program next January to test the use of artificial intelligence to perform prior authorization for Medicare fee-for-service patients in six states. The program is aimed at just a handful of services right now that are considered to be often wasteful and of dubious value to patients. So, honestly, what could possibly go wrong here? This is a serious question. I mean, isn’t using AI to do prior authorization what got a lot of these private health plans in trouble over the last year? 

Karlin-Smith: Yeah, they did. UnitedHealthcare I think is sort of infamous for that. There was a lot of irony when they first announced this concept of doing a little more prior auth, essentially, in Medicare. It came right after they made another announcement where they were trying to say, We’re actually going to crack down on prior authorization for a health plan. So there’s a bit of, and I think they were trying to not have the, in this second announcement, not have the words “prior auth,” so that they kind of could get wins on both levels. Because I think they know that prior authorization is generally not popular with health consumers. People see it as kind of a barrier to care that their doctor has said they need and is largely stopped because of cost reasons. And then I think once you add in this idea that artificial intelligence is doing it, not a human being, I think people have less trust that it’s being done in the proper way and really that they’re stopping inappropriate care. 

Rovner: Well, to paraphrase RFK Jr. at the Senate Finance hearing, who said many times, both things can be true, even if they are contradictory. All right, that is this week’s news, or at least as much as we have time for. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our extra credits. 

I am pleased to welcome back to the podcast Ñî¹óåú´«Ã½Ò•îl Health News’ Tony Leys, who reported and wrote the latest Ñî¹óåú´«Ã½Ò•îl Health News “Bill of the Month.” Tony, welcome back. 

Tony Leys: Glad to be here. Thanks, Julie. 

Rovner: So this month’s patient got a literal mouthful when she went to photograph the night sky in Arizona. Who is she and what happened? 

Leys: While Erica Kahn was taking photos at Glen Canyon last summer, a bat flew up, landed on her, and jammed itself between her camera and her face. Kahn screamed, as anyone would, and the bat went into her mouth. It only was in there for a few seconds, and she didn’t feel a bite. But she feared it could have infected her with a rabies virus, which bats frequently carry. 

Rovner: Yeah, not a great thing. So as with any run-in with a bat, Erica wisely reported to the nearest emergency room for preventive rabies treatment, which we know from previous “Bills of the Month” can total many thousands of dollars. How much did her treatment cost? 

Leys: Nearly $21,000, mostly for a series of vaccinations and other treatments, over the course of two weeks, aimed at preventing the deadly virus from gaining a foothold. 

Rovner: Yikes. 

Leys: Yikes, indeed. 

Rovner: Now, the problem here wasn’t so much that she was charged as what her insurance status was. What was her health insurance status? 

Leys: Well, Kahn had been laid off from her job as a biomedical engineer in Massachusetts, and she had turned down the COBRA [Consolidated Omnibus Budget Reconciliation Act] plan, which would’ve allowed her to stay on her employer’s insurance plan. The plan would’ve cost her about $650 a month, which seemed too much for her. And she was a young, healthy adult who was confident that she would quickly find a new job with health insurance. She also thought that if she became ill in the meantime, she could buy a private plan that would cover preexisting health conditions. 

Rovner: Yeah. That was the big problem, right? 

Leys: Right. 

Rovner: So what did she do? And then what happened? 

Leys: So before she went to the hospital for rabies prevention treatment, she signed up for a policy she found online. The policy, which she thought was full-fledged health insurance, apparently wasn’t. But she says the company selling it told her it would cover treatment of a life-threatening emergency, which this sure seemed to be. But the company later declined to cover any of the bills, citing a 30-day waiting period for coverage. 

Rovner: Yeah. Now, I mean, you can’t generally buy any kind of insurance after an insurable event happens. You can’t buy fire insurance the day after a fire or car insurance the day after an accident. Health insurance is no different. Although in her case, she could have actually resumed her previous coverage through COBRA, right? How would that have worked? 

Leys: So after you lose coverage from an employer, you generally have 60 days to decide whether to sign up for COBRA coverage, which would be retroactive to the day your old policy lapsed. Khan was within that period when the bat went in her mouth. So she could have retroactively bought COBRA coverage, but she didn’t know about that option. 

Rovner: Yeah. A lot of people, they initially lose their job or they leave their job and they don’t take COBRA, because it’s really expensive, as a rule — because it’s employer insurance and employer insurance is usually pretty generous — and they think they don’t need it. But this is one of those cases where she actually probably could have gotten it covered, right? 

Leys: Right, right. And in fairness, I’d never heard about that 60-day thing, either, and I’ve covered this, so— 

Rovner: I had, but I was there when COBRA was started. So what’s the takeaway here about people who don’t have insurance or think they can buy it at the last minute? 

Leys: Well, two things. One is you should have health insurance. 

Rovner: Because you never know when a bat’s going to fly in your mouth. 

Leys: And that a bat in the mouth does not count as a preexisting condition. 

Rovner: True. 

Leys: We know that now. 

Rovner: And what happened with this bill? 

Leys: She is still trying to get it worked out. 

Rovner: And presumably she’s going to be paying it off for some time to come. 

Leys: That’s what it sounds like. Yep. 

Rovner: But she won’t get rabies. 

Leys: Nope. 

Rovner: So happy ending of a sort. Tony Leys, thank you so much. 

Leys: Thank you for having me. Appreciate it. 

Rovner: OK, we’re back. And now 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’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it? 

Karlin-Smith: I picked a piece that ran in NPR from KFF’s Blake Farmer, “,” because it’s about the one-year anniversary of my family getting lice from school. And I actually was exposed to this new reality, which is since I was in school, and it’s, I guess, a broader national policy that they no longer kick kids out of school once you see lice and make it kind of difficult before you can go back to school. And I guess the public health rationale is generally that lice is actually, while it’s quite itchy, it’s not really harmful. So trying to think about the best way to cause the least harm, letting kids stay in school while you treat the infection is seen as most appropriate now. 

But there’s been, as a story goes into, some pushback from parents who feel that then it’s just getting them in these cycles where they’re constantly getting lice and having to deal with it. And dealing with getting the shampoos and stuff for lice can be kind of costly. So I thought it was a slightly lighter health care story for people to think about in these times. 

Rovner: Yeah. Risks and benefits. Classic case of risks and benefits. Alice. 

Ollstein: Well, this is definitely more on the risks than the benefits side of things, but I have a very good piece from Vox. It’s an exclusive. It’s called “.” And so they talked to these scientists who were commissioned to compile all of the data about the risk of drinking alcohol to having cancer. And it was compiling high-quality data that was already out there. And it really shows that no amount of drinking is totally safe. Even a very small, moderate amount of drinking includes a cancer risk, and that goes up the more you drink. 

And now, according to this report, the administration is not going to publish this. The authors turned it in in March, and they’ve just been sitting on it and they said they have no plans to publish it. And this is coming as the alcohol industry does a lot of lobbying to try to prevent stuff like this from being put out in the public consciousness. I just found this really fascinating. Already the younger generations are drinking a lot less. And so there does seem to be a growing awareness of the health risks of even moderate drinking. But I think that anything that keeps people from seeing this information is worrying, although this report did say that they are planning on publishing it in a peer-reviewed medical journal, which they were always planning anyways. But not having the federal government’s backing is a big deal. 

Rovner: It’s not exactly “radical transparency” is what they’ve been talking about. Jessie. 

Ollstein: And it’s not exactly “MAHA” [“Make America Healthy Again”]. They’re talking MAHA. They’re talking about lifestyle stuff. They’re talking about what you eat, but apparently not about what you drink. 

Rovner: Jessie. 

Hellmann: My story is from Ñî¹óåú´«Ã½Ò•îl Health News, from Bram Sable-Smith. It’s called “When Hospitals and Insurers Fight, Patients Get Caught in the Middle.” It is about what happens when providers and insurers have contract disputes. The one example in this story is in Missouri, and it kind of focuses on this family that’s caught in the middle of a dispute between the University of Missouri Health Care system and Anthem. And it means patients don’t get care. There’s not a lot of protections for them. There are provisions that were in the No Surprises Act kind of intended to ensure there was some continuity of care in these situations. But at least for this couple, they weren’t really able to access those protections. So unclear if those are working as intended. 

I just thought it was really interesting because it’s not a new problem, but it’s definitely something that we are hearing more and more. It just happened in the D.C .area a few weeks ago. It just happened in New York. And it kind of raises questions about: What are policymakers going to do about this? They complain about rising health care costs, but they don’t often do very much. They complain about competition and consolidation, and this is one of the effects of that. People lose access to care. So I thought this was a really interesting story. 

Rovner: Yeah. These are all the policy issues that policymakers are not working on but could be. My extra credit this week is from ProPublica. It’s called “,” by Brandon Roberts, Annie Waldman, Pratheek Rebala, and Sam Green. And it’s a deep data dive that found that more than 20,500 workers, or about 18% of the Health and Human Services Department workforce, have left or been pushed out in the first month of Trump 2.0. That includes more than a thousand regulators and safety inspectors and 3,000 scientists and public health specialists. The agency, in its official response to the story, said, quote, “Yes, we’ve made cuts — to bloated bureaucracies that were long overdue for accountability.” I guess we will have to see if America gets healthier. In the meantime, it’s good to have some data on where we were and now where we are at HHS. 

OK, that’s this week’s show. Thanks to our fill-in editor this week, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. As always, you can email us your comments or questions at whatthehealth@kff.org, or you can find me on X, , or on Bluesky, . Where are you guys hanging out these days? Sarah. 

Karlin-Smith: Kind of everywhere. At , , — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

Ollstein: Mostly on Bluesky, , and still on X, . 

Rovner: Jessie. 

Hellmann: I am on X, . I’m also on . 

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

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

Julie Rovner: Hello from Ñî¹óåú´«Ã½Ò•îl Health News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, 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 Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: 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 my interview with Ñî¹óåú´«Ã½Ò•îl Health News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly â€” in the words of longtime Congress watcher  â€” a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year â€” but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when â€¦ we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers â€” which are actually stronger than many predicted, with fewer people actually dropping coverage â€” reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But â€¦ I think what Julie said is it’s â€¦ the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time â€¦ 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more â€” the out-of-pocket cost of insurance for millions of Americans, 20-ish million â€” but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but â€¦ I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high â€” in economically â€” zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not â€¦ it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers â€” and I’ll post a link to them â€” you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside â€” they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why â€” because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right â€” you know, again, including senators like Cassidy, but also these activist groups â€” they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication â€¦ I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

¸é´Ç±¹²Ô±ð°ù:ÌýSo, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

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

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there â€¦ who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs â€¦  

Rovner: Puberty blockers! 

Edney: â€¦ they’re taking â€” exactly â€” and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now â€” most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat â€¦ the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer â€¦ they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion â€” that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over â€” I’m not exactly sure how many years â€” 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes â€” some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health â€” that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just â€¦ like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people â€” and to Alice’s point about how this hasn’t saved money â€” more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just â€¦ a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 â€¦ now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away â€” you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell â€” he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t â€¦ you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer â€” if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

Rovner: OK, we’re back, and now 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 start us off this week? 

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians â€” how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who â€” like, I don’t know how all of you watch it â€” but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS â€” or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer 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, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Sept. 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode, we’ll have my interview with my Ñî¹óåú´«Ã½Ò•îl Health News colleague Tony Leys, who reported and wrote the August “Bill of the Month” about a patient’s unfortunate run-in with a bat and an even more unfortunate run-in with the bill for rabies prophylaxis. But first, this week’s news.  

Well, it is safe to say that there has been quite a bit of health news since we last met in mid-August. Health and Human Services Secretary Robert F. Kennedy Jr. testified before the Senate Finance Committee yesterday, which we will talk about in a moment. But first, I want to catch us up on what you might’ve missed. Our story starts, kind of, with the FDA’s [Food and Drug Administration’s] approval of this year’s covid boosters, which are only being licensed for those over age 65 and those who are younger but have at least one condition that puts them at high risk of serious illness if they contract the virus. That leaves out lots of people that many doctors think ought to be boosted, like pregnant women and children. Sarah, what’s supposed to happen after the FDA acts? The next step happens at CDC [the Centers for Disease Control and Prevention], right? 

Karlin-Smith: Correct. So right now the CDC’s Advisory Committee on Immunization Practices is scheduled to meet Sept. 17 to 18, 18 to 19, but about two weeks from now. And they would typically vote on sort of endorsing use of these vaccines and, again, have like sort of a second chance to weigh in on which populations they would be used for. And that’s often important for triggering insurance coverage without copays. And also many states rely on the CDC recommendations for various state laws that say, again, who can get the vaccine or whether you can get it via a pharmacist or only at a doctor’s office, do you need a prescription, and things like that. So the CDC and FDA, I would say, in general is a little bit behind this year. I could think a lot of people have been trying to go out and get these new shots even though those steps haven’t happened yet. 

Rovner: That’s right. I mean, it is early. Even if there was nothing else going on, there is that little bit of a lag between when FDA acts and when the CDC acts, right? 

Karlin-Smith: Yeah, there usually is. I think in the past they’ve tried to have both FDA approval and the CDC act so that the vaccines could start rolling out more like late summer, early September. So they’re definitely behind, and there’s been a number of reports of covid kind of slowly rising as the summer winds down and school gets back in session. 

Rovner: Yeah, so there’s a lot of other things going on. Well, in the meantime, nothing that was supposed to happen has happened yet, and we still don’t know all the details, but it certainly appears that Susan Monarez, who was just confirmed by the Senate to lead the CDC a month ago, was fired after she refused to override her scientific advisers and approve the new restrictions on covid vaccine availability, even before the ACIP met. In turn, four top CDC leaders resigned as well, going public to warn that the agency is being politicized by the secretary. How much of a mess is the CDC in right now? And how long is it going to take to put the pieces back together? 

Karlin-Smith: I think they’re in a pretty bad place, because not only did they lose their director really quickly, but after she resigned, about I think it was eight or nine senior CDC leaders resigned last week as well. And so, really critical people to various parts of the operation that you don’t just replace very easily. And Kennedy has slotted in Jim O’Neill as the temporary director of the CDC and kind of indicated he wants to remake the agency. And I think there are questions as to how that remaking shapes both its priorities and how it handles public health throughout the U.S. 

Rovner: And of course, morale at CDC is awesome, in part because, as we discussed the last time we met, a gunman came and shot up the place, killing a policeman and leaving the staff pretty upset. And that gunman, who then took his own life, was later found to have had some discontent with vaccines. So things are just really bright and cheery there in Atlanta at the CDC. Alice, I see you nodding. 

Ollstein: These things kind of snowball, you know? I think there are likely to be a lot of staff who were already on the fence about staying and decided to stay because they trusted these pretty senior leaders with a lot of decades of expertise and institutional knowledge. And that was sort of the thread they were hanging on as well, at least: I’m with these people. And now that they’ve left, I think that could trigger a bigger exodus on top of the exodus that was already underway. 

Rovner: And it’s important to say — even though we say it, I think, every time — that these are career scientists who’ve worked for Democrats and Republicans over the years. These are not generally political people. They’re not political appointees. And they basically do their jobs. And until fairly recently, public health wasn’t this partisan, so it wasn’t that hard to be a career public health official just working for public health. That’s just not the case anymore, is it? 

Karlin-Smith: I think there’s been a lot of insult to injury added with what happened with the shooting at the CDC, because there is a sense that the kind of rhetoric that Kennedy in particular has used over the years, even before he came into HHS [the Department of Health and Human Services], on sort of his movement has sort of amplified the criticism of public health workers and put them in this situation where they’re dangerous. And Kennedy, instead of really acknowledging that and maybe apologizing or giving any sense that he was going to shift in a different direction, has actually really kind of doubled down on it. And even in some of the pieces he’s written recently about how he wants to reform the CDC, he kind of keeps criticizing the rank-and-file employees and so forth. So there’s a lot of tension between the political leadership and the career staff, I think, at this moment. 

Ollstein: And in normal times, most of the American public would not even know the names of these people. They’re not public figures. They’re just very behind-the-scenes scientists doing their work. And now their personal photos are being combed through and shared to attack them because they’ve criticized the administration. They’re getting threats. It’s just this whole level, like you said, of politicization that we haven’t seen before. 

Rovner: Well, so, in kind of a coincidence, Kennedy had already agreed to appear on Thursday before the Senate Finance Committee, which by the way doesn’t have jurisdiction over the CDC or the rest of the public health service. But no matter — a Senate hearing is a Senate hearing. And let’s just say it didn’t go that well for the secretary. Democrats were kind of withering in their criticism of Kennedy’s eight-month tenure so far. Here’s Colorado Sen. Michael Bennet. 

Sen. Michael Bennet: This is the last thing, by the way, our parents need when their kids are going back to school, is to have the kind of confusion and expense and scarcity that you’re creating as a result of your ideology. 

Rovner: Republicans weren’t that impressed, either, particularly the Republicans on the committee who are also doctors. [Sen.] Bill Cassidy, a doctor who’s on Finance but is also the chairman of the Health, Education, Labor, and Pensions Committee and is facing a primary challenge in Louisiana, seemed to tread pretty carefully. More surprising, at least to me, was Dr. Sen. John Barrasso of Wyoming, who’s also in the Senate leadership. 

Sen. John Barrasso: So over the last 50 years, vaccines are estimated to have saved 154 million lives worldwide. I support vaccines. I’m a doctor. Vaccines work. 

Rovner: I was super impressed that even the Republicans who criticized RFK were careful not to criticize President [Donald] Trump. In fact, there were several suggestions — this was clearly a talking point — that Trump should be given a Nobel Prize for his work overseeing Operation Warp Speed, just so the senators could kind of bifurcate their complaints. What impact, if any, is this hearing going to have on RFK’s future as secretary? 

Ollstein: Well, I think there was an attempt to, I think, what you just mentioned. That like dual criticism with praise of Trump was meant to drive a wedge and to get Trump to question RFK’s leadership. That does not seem to have worked so far. We don’t know what’s going to happen in the future, but I think it’s an attempt to get the message to Trump that RFK’s reputation and actions could be damaging to the administration overall. And there was some reporting that polling showing that most people do support vaccines was circulated amongst Republican members before the hearing. And so, I think it’s trying to, yeah, get the message that this is both damaging in a public health sense but also potentially damaging in a political sense as well. 

But so far, the reporting is that Trump is standing by RFK, that he liked how combative he was. And so I don’t know where those attempts to drive a wedge will go in the future, but like you said, it was notable that if folks like Barrasso, [Sen. Thom] Tillis, who’s not running for reelection, was also more vocally critical, and a couple others, not a lot. We’re not seeing a great dam breaking yet. But I think there’s more cracks than there used to be on the GOP side. 

Rovner: I did notice that Trump, he had a very strange Truth Social post earlier in the week that basically said that CDC is a mess and it has to be fixed. Kind of just Trump being the omniscient observer. And then, apparently at a dinner with tech titans after the hearing, he said that he had not watched the hearing but that he heard that Kennedy did well, which is not exactly what I would call a ringing endorsement. I feel like Trump is giving himself some runway to go either way depending on sort of how things continue to shake out. I see nodding. 

Karlin-Smith: Yeah. I saw a lot of people reposting that clip on social media last night who are frustrated with Kennedy and using it to try and ramp up their banks and say: Keep calling. Keep pressuring. This shows we have an opening. I think it’s really always hard to read the tea leaves with Trump and his language and words. He’s a harder person to interpret. But I also thought it was really interesting that in some ways Cassidy and some of the other Republicans were throwing RFK a bone and saying: This is your president. This was his greatest achievement. Can you support it? 

And RFK couldn’t even really twist himself into doing that. He sort of tried to, but he could never square it with the bulk of his remarks at the hearing, which were incredibly critical. MRNA vaccines and vaccines in general — he defended the massive cuts in this area for research. He defended people who have really said very untrue things about the harm caused by these vaccines. So in some ways I felt like Cassidy was trying to give him one more chance or something, and RFK couldn’t even take it when it was couched as this Trump achievement. 

Rovner: I can’t help but wonder if this is playing to Trump’s advantage because it’s distracting from Trump’s other problems, that perhaps Trump likes that there’s so much attention on this because it takes attention away from other things. 

Ollstein: Yeah. Although I do find the eagerness of Democratic members of Congress and other folks to wave away certain things as a distraction as a little bit questionable. This is all part of the agenda of the administration, and dismantling government bureaucracy is clearly a core, core part of the administration’s agenda, and so— 

Rovner: And flooding the zone. 

Ollstein: Exactly. Well, it might also serve as a distraction. I think that it should be considered a serious part of what they actually want to do as well. 

Rovner: So there were a couple of things that we learned about RFK Jr. from his confirmation hearings back in the winter. One is that he’s not at all deferential to elected officials, even calling them liars, which is pretty unheard of. And that he doesn’t really know how his department works. And it appears that eight months later, neither of those things have changed. How does he get away with being so rude? I mean, I’ve just never seen a Cabinet official who’s been so undeferential to the people who basically put him in office. Is it just me? 

Karlin-Smith: I think it’s part of the times where politics is really trumping behavior or policy, right? Even though there were a few Republicans that we’ve talked about who have kind of started to get frustrated with RFK and his vaccine policies. You saw at the beginning of the hearing, Chairman [Mike] Crapo was asked by the ranking Democrat, Sen. [Ron] Wyden, to basically swear Kennedy in because Wyden has felt like Kennedy has lied to the committee before. And Crapo just basically brushed that away and dismissed it. And I think, so, in many ways a lot of the Republicans on the committee endorsed Kennedy’s behavior kind of, maybe not overtly but indirectly, and that’s sort of been how they’ve been operating. It’s more of a political theater thing, and they’re OK with sort of this disrespect, of its sort of political fight that somebody on their side is taking up. 

Ollstein: I also think Congress’ unwillingness so far to actually sanction or take action in any way about anything RFK has done seems to have emboldened him. I think the fact that he has broken all these promises he made to Cassidy and other senators and there have been basically no consequences for him so far feeds into that. He kind of has a What are you going to do? attitude that was very evident in the hearing. 

Rovner: Yeah, I think that’s fair. Well, there were, as always, parochial question from senators about home state issues, but one topic I don’t think I expected to see come up as many times as it did was the future of the abortion pill, mifepristone, which is about to celebrate the 25th anniversary of its original approval by the FDA. Alice, what are you hearing about whether FDA is going to rein the drug back in, which is what a lot of these anti-abortion Republicans really want to see happen? 

Ollstein: Yeah, so I think there was nothing new in the hearing this week. What he said was what he’s been saying, that they’re looking into it, that they’re evaluating. He made no specific commitments. He gave no specific timelines. He said basically enough to keep the anti-abortion people thinking that they’re cooking up some restrictions but not explicitly promising that, either. And so I think we’re just where we were before. They continue to reference data put forward by an anti-abortion think tank that was not peer-reviewed and claiming that it is this solid scientific evidence, which it is not, about the risks posed by the pills, which many actual, credible, peer-reviewed studies have found to be very safe. And so we just don’t know what’s going to happen. I think any nationwide restrictions, which is what they’re mulling at the federal level, which would impact states where abortion is legally protected, that would be a potentially politically damaging move. And so it’s understandable why they might not want to pull that trigger right now. So, right. 

Rovner: And Trump has said, I mean, Trump has indicated that he does not really want to wade into this. 

Ollstein: Correct. But again, he’s also very good about not making hard promises in either direction and sort of keeping his options open, which is what they’re doing. The anti-abortion activists, this is not their only iron in the fire. This is just one of many strategies they have going on. They also have multiple pending lawsuits and court cases that are attempting to accomplish the same thing. They’re pursuing new policies at the state level, which we’ll probably talk about, Texas and others. 

Rovner: Next. 

Ollstein: And so yes, this pressure on FDA and HHS to use regulation to restrict the pills is only one of many ongoing efforts. 

Rovner: Well, you have anticipated my next question, which is that while we are on the subject of the abortion pill, Texas, because it is always Texas, has a new bill on its way to the governor for a signature to try to outlaw . What exactly would this Texas law do? And would it work? Because, obviously, this has been the biggest loophole about stopping abortion in these states that have banned abortion, is that people are still able to get these pills from other states via telemedicine. 

Ollstein: Yeah. So in one sense, nothing’s changed. Abortion was already illegal in Texas, whether you use a pill or have a procedure. And so this is just layered on top of that. The groups who backed this explicitly said the attempt is to have a chilling effect. What they’re hoping is that no lawsuits are even needed, because this just scares people away from ordering pills and scares groups in other states away from sending pills. One concern that I saw raised is that the law criminalizes simply the shipping of the pills. Somebody doesn’t even have to take them for a crime to have been committed. 

And so that’s raising concerns that anti-abortion activists will do kind of sting operations, sort of entrapment-y things where they order the pills solely in the interest of bringing a lawsuit. Because there is a cash bounty that you can get for filing a lawsuit — there’s an incentive. So that’s a concern. And then just the general concern of a chilling effect and people who are using less safe means than these pills to terminate their pregnancies out of fear, which studies have shown is already on the rise, people injuring themselves taking herbs and other substances, chemicals. So that’s a concern as well. 

Rovner: We’ll continue to watch this, but back to vaccine policy. With the status of federal vaccine recommendations in limbo, states appear to be going their own way. Blue states California, Washington, and Oregon are banding together in a consortium to make official recommendations in the absence of federal policy, and several blue-state governors are acting unilaterally to make sure covid vaccines, at least, remain available to most people. At the same time, some red states are going the other way, with Florida Surgeon General Joseph Ladapo, who we have talked about before, now vowing to for schoolchildren. Sarah, that would be a really big deal, right? 

Karlin-Smith: Right. I think the big fear then is that the school requirements is kind of what gets us to close to, in many cases, universal vaccine uptake in the country, because everybody needs their kids to be in school. Unless you’re homeschooled, you really must follow these vaccine requirements. And it not only hurts the kids who don’t end up getting vaccinated individually, but it can really hurt the idea of herd immunity and the protection we need for these diseases to disappear in the community. So there’s— 

Rovner: And protection for people who can’t be immunized for some reason. 

Karlin-Smith: Right. Who either can’t be immunized or don’t have an adequate response to the immunization because they’re going through cancer treatment or they have some other medical reason that their body is immunocompromised. 

Rovner: So, I mean, is this going to end up like abortion, where it’s availability absolutely depends on where you live? 

Karlin-Smith: I think that’s hard to say. I think that a policy like what Florida is trying to implement could very quickly and easily go wrong, I think, and be reversed, as we’ve seen, like what’s happening in Texas now, with measles outbreaks. You know you only need just very small fractions of decreases in vaccination to create huge public health crises in places. And so I think it would be more sort of visible, in a way, to some of these states and their populations, the potential harm that could be caused, than maybe it is to them the abortion harm. But we definitely are seeing some sense of, right, the Democratic-controlled states trying to implement policies that help people get better access to vaccines, even when the federal government is trying to maybe harm that, and red states not caring as much. 

So there is going to be some more of a patchwork. And I feel like, in talking to just sort of people outside of the health policy space, there is a lot of confusion about: Where can I get my covid vaccine? Am I going to have to pay? Do I qualify? Especially being in D.C., which has less generous, I guess, pharmacy laws, because of this. So people are confused. If I go to Maryland, which is really close, does that matter even though I live in D.C.? And it’s just all these things we kind of know end up leading to less people getting vaccinated. Because even if they want to do it, the hurdles end up driving people away. 

Rovner: Yeah, I think something you’d said earlier about the fact that we’re seeing kind of a covid spike, so people are anxious to get covid vaccines, I think, a little bit earlier than normal. It’s usually kind of a fall thing and it’s only the beginning of September, but I think there’s just this combination, this confluence of events that has a lot of people very excited about this right now. 

Karlin-Smith: Yeah, I think it does. And covid has been, I think there’s been lots of hope in the public health world that covid would become a little bit like the flu, where we could predict a little bit more when it would really peak and get everybody vaccinated around the same time as they’re getting flu vaccines. Just again, because we know when we make it easier on people to get vaccinated, if you could just one-and-done it, it would be good. Unfortunately, covid has tended to also still have summer peaks, and this year again it’s kind of a late summer peak. And a lot of people, including seniors, are still recommended really actually to get two vaccines a year. So many people are kind of coming due for that second update right now. 

Rovner: Well, we’ll keep watching that space. Moving on, as we kind of pointed out already, Congress is back in town, with just a couple weeks to go before the start of fiscal 2026 on Oct. 1. This was the year Congress was really, truly going to get all of its spending bills passed in time for the start of the new year. How’s that going, Jessie? 

Hellmann: It’s going great. I’m just kidding. There’s a lot of friction on the Hill right now. The White House budget chief is talking about doing more clawbacks of foreign aid, which is frustrating both Democrats and Republicans. It’s about $5 billion, and we’re seeing Democrats kind of start to put their neck out there a little more than they did earlier in the year when they were also kind of making noise about government funding. And they’re now saying that Republicans are going to have to go this alone and they’re not going to support partisan spending bills. So it’s kind of difficult to see where we go from here. And then— 

Rovner: Are we looking at a shutdown on Oct. 1? I mean, that’s what happens if the spending bills aren’t done. 

Hellmann: It’s hard to say. There might be a short-term spending bill, but anything longer-term than that, it seems really difficult at this point. And there are just massive differences between the health bills that the House came out with and the Senate came out with. I mean, there’s differences in all the other appropriations bills, too, but I was just going to focus on health. 

Rovner: Yes, please. 

Hellmann: The Senate bill would allow an increase for HHS, and the House bill would cut it pretty significantly. So it’s kind of hard to see how they could do anything more substantive when there’s so much light between the two. 

Rovner: Yeah. I mean, on the one hand, we have both the Senate and the House subcommittee that’s marked up the Labor HHS [Labor, Health and Human Services, Education, and Related Agencies] appropriation on record as not supporting at least the very deep cuts to the National Institutes of Health that were proposed by President Trump. But on the other hand, as you mentioned, we still have the administration, primarily budget office chief Russell Vought, making the case that the administration doesn’t have to spend money that Congress appropriates. And from all we can tell, at least as of now, there’s a lot of money that won’t be spent as of the end of the fiscal year, despite the fact that that is illegal. It’s known as a pocket rescission, a term I think we’re about to hear a lot more about. Alice, you referred to this earlier: Is Congress just going to quietly ignore the fact that the administration is usurping their power? 

Ollstein: I think that in many areas of politics, there is a faction that wants to play hardball and really use whatever leverage is possible and there’s a faction that wants to play nice and try to get what they can get by negotiation. And I think both parties always fear being blamed for shutdowns, and so that drives a lot of it. But I think there’s mounting frustration with Democratic leadership about not playing hardball enough. I mean, the jokes I hear are Democrats like to bring a spreadsheet to a gunfight, just seen as being unwilling, in the face of what many see as lawlessness, being unwilling to really put a check on that using the levers they have, including this federal spending. But I think we’ve seen that there are risks no matter what they do, and so I think people make reasonable points about the pros and cons of various strategies. 

Rovner: Well, we know that [Sen.] Susan Collins, who’s now the chair of the Senate Appropriations Committee, is very, very concerned — because Susan Collins is always very, very concerned. But she’s the one whose power is basically being thwarted at this point. People have gotten a lot of gray hair waiting for Susan Collins to stand up and be combative, but one would think if there was ever a time for her to do it, this would be it. Jessie, are we seeing, I was going to say, any indication that the appropriators are going to say, Hey, this is our job and our constitutional responsibility, and you’re supposed to do what we say when it comes to money? 

Hellmann: They are saying these things. I feel like we are seeing more Senate Republicans, at least, express discomfort with what the Trump administration is doing, saying things like: This is Congress’ job. We have the power of the purse. And then they are passing some of these spending bills through committee. But what else are they supposed to do? Unless Susan Collins wants to get on Fox News and start screaming about government funding, which I don’t really see happening and I don’t know if it would be effective, you kind of just wonder: What other options do they have at this point? 

Rovner: Yeah. Well, we’ll sort of see how this plays out over the next few weeks. Meanwhile, it’s not just the spending bills that Congress is facing deadlines for. This month is basically the last chance to re-up those, quote, “expanded subsidies” for Affordable Care Act plans before the sticker shock hits 24 million people in the face. Not only are premiums going up by an average of 18% from this year to next — that’s for a lot of reasons: increasing costs of health care, tariffs, drug prices — but eliminating those additional subsidies, or actually letting them expire, will cause some people to have to pay double or triple what they pay now. And it’s going to hit folks in red states like Georgia and Florida and Texas even harder because more folks there are on the Affordable Care Act plans, because those states didn’t expand Medicaid. Do Republicans not understand what’s about to happen to them? 

Hellmann: I think they understand, but they keep acting like there’s no urgency to the situation. They keep saying: We still have time. We have till the end of the year. Which I guess is technically true, but we’re already seeing insurers proposing these giant rate hikes. And it’s not easy to just go back and make changes to some of this. I guess the idea is— 

Rovner: So they really don’t have until the end of the year, though. Because people are going to get, they’re going to see the next year’s premiums that they have to start signing up in November. So, I mean, they basically have this month. 

Ollstein: If there’s uncertainty, they’re going to price very conservatively, aka high. They don’t want to be left holding the bag. And so, yeah, you and Jessie are exactly right that there isn’t time. These decisions are being made now. Even if they pass something to kick the can until after the midterms, I think some damage will already have been done. 

Rovner: Yeah. Jessie, I cut you off, though. I mean, the idea is that sort of their one chance to maybe do this before people actually start to get these bills, or at least see what they’re going to have to pay, would be wrapped into this end-of-fiscal-year continuing resolution. And maybe they can kick the appropriations down the road until November or December, but they can’t really kick the question of the subsidies down the road until November or December. 

Hellmann: Yeah. I think something would have to happen really quickly. We’re seeing some politically vulnerable Republicans, in the House, specifically, say that they want at least a year-long extension. It’s just a really difficult issue. We know, obviously, the Freedom Caucus is already making threats about it. They hate the ACA, maybe more than anything. It’s going to be really interesting how this turns out. I’ve also heard that maybe there might be a paired-back version of an extension that they could do, maybe messing with some of the income parameters. But I don’t know if that kind of compromise would be enough unless Republicans work with Democrats, which as we already said is complicated for other reasons. So it’s just a mess right now. 

Rovner: I love September on Capitol Hill. All right, finally this week it will launch a pilot program next January to test the use of artificial intelligence to perform prior authorization for Medicare fee-for-service patients in six states. The program is aimed at just a handful of services right now that are considered to be often wasteful and of dubious value to patients. So, honestly, what could possibly go wrong here? This is a serious question. I mean, isn’t using AI to do prior authorization what got a lot of these private health plans in trouble over the last year? 

Karlin-Smith: Yeah, they did. UnitedHealthcare I think is sort of infamous for that. There was a lot of irony when they first announced this concept of doing a little more prior auth, essentially, in Medicare. It came right after they made another announcement where they were trying to say, We’re actually going to crack down on prior authorization for a health plan. So there’s a bit of, and I think they were trying to not have the, in this second announcement, not have the words “prior auth,” so that they kind of could get wins on both levels. Because I think they know that prior authorization is generally not popular with health consumers. People see it as kind of a barrier to care that their doctor has said they need and is largely stopped because of cost reasons. And then I think once you add in this idea that artificial intelligence is doing it, not a human being, I think people have less trust that it’s being done in the proper way and really that they’re stopping inappropriate care. 

Rovner: Well, to paraphrase RFK Jr. at the Senate Finance hearing, who said many times, both things can be true, even if they are contradictory. All right, that is this week’s news, or at least as much as we have time for. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our extra credits. 

I am pleased to welcome back to the podcast Ñî¹óåú´«Ã½Ò•îl Health News’ Tony Leys, who reported and wrote the latest Ñî¹óåú´«Ã½Ò•îl Health News “Bill of the Month.” Tony, welcome back. 

Tony Leys: Glad to be here. Thanks, Julie. 

Rovner: So this month’s patient got a literal mouthful when she went to photograph the night sky in Arizona. Who is she and what happened? 

Leys: While Erica Kahn was taking photos at Glen Canyon last summer, a bat flew up, landed on her, and jammed itself between her camera and her face. Kahn screamed, as anyone would, and the bat went into her mouth. It only was in there for a few seconds, and she didn’t feel a bite. But she feared it could have infected her with a rabies virus, which bats frequently carry. 

Rovner: Yeah, not a great thing. So as with any run-in with a bat, Erica wisely reported to the nearest emergency room for preventive rabies treatment, which we know from previous “Bills of the Month” can total many thousands of dollars. How much did her treatment cost? 

Leys: Nearly $21,000, mostly for a series of vaccinations and other treatments, over the course of two weeks, aimed at preventing the deadly virus from gaining a foothold. 

Rovner: Yikes. 

Leys: Yikes, indeed. 

Rovner: Now, the problem here wasn’t so much that she was charged as what her insurance status was. What was her health insurance status? 

Leys: Well, Kahn had been laid off from her job as a biomedical engineer in Massachusetts, and she had turned down the COBRA [Consolidated Omnibus Budget Reconciliation Act] plan, which would’ve allowed her to stay on her employer’s insurance plan. The plan would’ve cost her about $650 a month, which seemed too much for her. And she was a young, healthy adult who was confident that she would quickly find a new job with health insurance. She also thought that if she became ill in the meantime, she could buy a private plan that would cover preexisting health conditions. 

Rovner: Yeah. That was the big problem, right? 

Leys: Right. 

Rovner: So what did she do? And then what happened? 

Leys: So before she went to the hospital for rabies prevention treatment, she signed up for a policy she found online. The policy, which she thought was full-fledged health insurance, apparently wasn’t. But she says the company selling it told her it would cover treatment of a life-threatening emergency, which this sure seemed to be. But the company later declined to cover any of the bills, citing a 30-day waiting period for coverage. 

Rovner: Yeah. Now, I mean, you can’t generally buy any kind of insurance after an insurable event happens. You can’t buy fire insurance the day after a fire or car insurance the day after an accident. Health insurance is no different. Although in her case, she could have actually resumed her previous coverage through COBRA, right? How would that have worked? 

Leys: So after you lose coverage from an employer, you generally have 60 days to decide whether to sign up for COBRA coverage, which would be retroactive to the day your old policy lapsed. Khan was within that period when the bat went in her mouth. So she could have retroactively bought COBRA coverage, but she didn’t know about that option. 

Rovner: Yeah. A lot of people, they initially lose their job or they leave their job and they don’t take COBRA, because it’s really expensive, as a rule — because it’s employer insurance and employer insurance is usually pretty generous — and they think they don’t need it. But this is one of those cases where she actually probably could have gotten it covered, right? 

Leys: Right, right. And in fairness, I’d never heard about that 60-day thing, either, and I’ve covered this, so— 

Rovner: I had, but I was there when COBRA was started. So what’s the takeaway here about people who don’t have insurance or think they can buy it at the last minute? 

Leys: Well, two things. One is you should have health insurance. 

Rovner: Because you never know when a bat’s going to fly in your mouth. 

Leys: And that a bat in the mouth does not count as a preexisting condition. 

Rovner: True. 

Leys: We know that now. 

Rovner: And what happened with this bill? 

Leys: She is still trying to get it worked out. 

Rovner: And presumably she’s going to be paying it off for some time to come. 

Leys: That’s what it sounds like. Yep. 

Rovner: But she won’t get rabies. 

Leys: Nope. 

Rovner: So happy ending of a sort. Tony Leys, thank you so much. 

Leys: Thank you for having me. Appreciate it. 

Rovner: OK, we’re back. And now 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’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it? 

Karlin-Smith: I picked a piece that ran in NPR from KFF’s Blake Farmer, “,” because it’s about the one-year anniversary of my family getting lice from school. And I actually was exposed to this new reality, which is since I was in school, and it’s, I guess, a broader national policy that they no longer kick kids out of school once you see lice and make it kind of difficult before you can go back to school. And I guess the public health rationale is generally that lice is actually, while it’s quite itchy, it’s not really harmful. So trying to think about the best way to cause the least harm, letting kids stay in school while you treat the infection is seen as most appropriate now. 

But there’s been, as a story goes into, some pushback from parents who feel that then it’s just getting them in these cycles where they’re constantly getting lice and having to deal with it. And dealing with getting the shampoos and stuff for lice can be kind of costly. So I thought it was a slightly lighter health care story for people to think about in these times. 

Rovner: Yeah. Risks and benefits. Classic case of risks and benefits. Alice. 

Ollstein: Well, this is definitely more on the risks than the benefits side of things, but I have a very good piece from Vox. It’s an exclusive. It’s called “.” And so they talked to these scientists who were commissioned to compile all of the data about the risk of drinking alcohol to having cancer. And it was compiling high-quality data that was already out there. And it really shows that no amount of drinking is totally safe. Even a very small, moderate amount of drinking includes a cancer risk, and that goes up the more you drink. 

And now, according to this report, the administration is not going to publish this. The authors turned it in in March, and they’ve just been sitting on it and they said they have no plans to publish it. And this is coming as the alcohol industry does a lot of lobbying to try to prevent stuff like this from being put out in the public consciousness. I just found this really fascinating. Already the younger generations are drinking a lot less. And so there does seem to be a growing awareness of the health risks of even moderate drinking. But I think that anything that keeps people from seeing this information is worrying, although this report did say that they are planning on publishing it in a peer-reviewed medical journal, which they were always planning anyways. But not having the federal government’s backing is a big deal. 

Rovner: It’s not exactly “radical transparency” is what they’ve been talking about. Jessie. 

Ollstein: And it’s not exactly “MAHA” [“Make America Healthy Again”]. They’re talking MAHA. They’re talking about lifestyle stuff. They’re talking about what you eat, but apparently not about what you drink. 

Rovner: Jessie. 

Hellmann: My story is from Ñî¹óåú´«Ã½Ò•îl Health News, from Bram Sable-Smith. It’s called “When Hospitals and Insurers Fight, Patients Get Caught in the Middle.” It is about what happens when providers and insurers have contract disputes. The one example in this story is in Missouri, and it kind of focuses on this family that’s caught in the middle of a dispute between the University of Missouri Health Care system and Anthem. And it means patients don’t get care. There’s not a lot of protections for them. There are provisions that were in the No Surprises Act kind of intended to ensure there was some continuity of care in these situations. But at least for this couple, they weren’t really able to access those protections. So unclear if those are working as intended. 

I just thought it was really interesting because it’s not a new problem, but it’s definitely something that we are hearing more and more. It just happened in the D.C .area a few weeks ago. It just happened in New York. And it kind of raises questions about: What are policymakers going to do about this? They complain about rising health care costs, but they don’t often do very much. They complain about competition and consolidation, and this is one of the effects of that. People lose access to care. So I thought this was a really interesting story. 

Rovner: Yeah. These are all the policy issues that policymakers are not working on but could be. My extra credit this week is from ProPublica. It’s called “,” by Brandon Roberts, Annie Waldman, Pratheek Rebala, and Sam Green. And it’s a deep data dive that found that more than 20,500 workers, or about 18% of the Health and Human Services Department workforce, have left or been pushed out in the first month of Trump 2.0. That includes more than a thousand regulators and safety inspectors and 3,000 scientists and public health specialists. The agency, in its official response to the story, said, quote, “Yes, we’ve made cuts — to bloated bureaucracies that were long overdue for accountability.” I guess we will have to see if America gets healthier. In the meantime, it’s good to have some data on where we were and now where we are at HHS. 

OK, that’s this week’s show. Thanks to our fill-in editor this week, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. As always, you can email us your comments or questions at whatthehealth@kff.org, or you can find me on X, , or on Bluesky, . Where are you guys hanging out these days? Sarah. 

Karlin-Smith: Kind of everywhere. At , , — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

Ollstein: Mostly on Bluesky, , and still on X, . 

Rovner: Jessie. 

Hellmann: I am on X, . I’m also on . 

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