[Editor’s note: This transcript was generated using transcription software. 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. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Sept. 17, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: And Tami Luhby of CNN. 

Tami Luhby: Howdy. 

Rovner: Later in this episode, we’ll have my interview with Sabrina Corlette, one of the authors of a new paper from the Georgetown University Center on Health Insurance Reforms, about some possible shorter-term fixes for what ails our dysfunctional healthcare system. But first, this week’s news. 

So I try not to talk too much here about artificial intelligence, partly because we at KFF already have a separate podcast devoted to AI and its implications for the business of health, and partly because I am one of the many, many Americans who doesn’t really understand it. But I feel like we really can’t avoid it this week, with AI leaders all but pleading with Congress for regulation, lest they accidentally, or not, create something that could literally kill all us humans. And while I don’t think any of us has the expertise to comment on whether some future AI might actually be justified in trying to rid the planet of humanity, given what we humans have done to the planet, I’m more interested in reports about humans currently using AI to do things like manipulate viruses to create, you know, a pandemic — but maybe even a more deadly one than the one that we just had. Anthropic, which touts itself as the most ethical and responsible of the big AI companies, said it has already . I feel like maybe this is something members of Congress might want to address in the near-term future? 

Edney: Definitely, I think that, like, the timing for this, given what’s going on in the larger AI world with these warnings that we’re seeing, was certainly very ominous for creating that potential worst pandemic that you’re talking about. And it does seem like it could be part of that discussion and what Congress may want to do; it could be sort of its own thing. It’s unclear how that’s going to be handled, especially, I think, we all are aware of the timing as well, with the midterms coming up and Congress not getting a lot done. And this is a really complicated subject, I think — the kind of issues with this report coming out was these could be just regular research queries. You know, it’s really unclear if this was nefarious. If it is, that’s really bad, and if it wasn’t, let’s not get worked up about something that isn’t there yet. But it does show that there’s the potential for that to happen. So …it’s good to think about it early. 

Rovner: And of course, the House, we should mention, has up and left until after the election. So they couldn’t do anything even if they wanted to. Alice, you wanted to add something? 

Ollstein: Yeah. So I was up on Capitol Hill yesterday, and there did not seem to be a groundswell of interest in rapid action and keeping the members in session to deal with this. I mean, when it comes, you know, to technology, especially, often federal policy is decades behind, you know, where the technology is going and moves so much slower. And I don’t know, even if there was the political will to stay in session and do something, if they would even know what to do or be able to come up with something quickly. This is something that could take years. Meanwhile, the technology itself is just leaping ahead in leaps and bounds, and so I am not optimistic about a robust response from Congress, given their record recently, and given what I witnessed on the Hill. Even though there is bipartisan interest in doing something, but what that something is, there is no agreement. 

Luhby: There’s a legitimate concern of how/what China is doing with AI, and even if we control what’s happening within our borders, we can’t control what’s happening with the development in the world. So that is an overarching problem that Congress can’t solve. 

Rovner: Right. 

Ollstein: I also often hear, you know, Oh, we should really pare back AI on everything except healthcare because it has so much promise in the healthcare space. But there’s also a lot of risk in the healthcare space. I mean, you were mentioning the development of potential viruses and bioweapons, but even beyond that, there’s already reports of AI being used to deny people’s claims, to entrench human biases in decision-making. You know, there’s a lot of risk in the healthcare space, too. It’s not all sunshine and rainbows and the risk is only in other areas. 

Rovner: Well, you are actually anticipating my next question, which is: Meanwhile, from the “AI might not actually kill us, but it’s going to make a lot of people rich” file, my former colleague Christina Jewett, now at The New York Times, has a about how medical AI entrepreneurs are exercising perhaps undue influence at the Department of Health and Human Services, and, according to the story, worrying some officials that AI adoption in medicine is coming faster than the evidence that it’s safe and effective — never mind money-saving. Again, as you were saying, Alice, I can’t imagine technology in medicine running ahead of attempts to regulate it. That’s only happened basically every time for the last 50 years. 

Edney: I think the attempts to regulate it are — the issue is who’s going to do the regulating. The FDA seems sort of split right now, where you have the traditional medical devices director, and this is Christina’s reporting, as you mentioned, Julie, someone … more in the commissioner’s office who is a tech-connected person wanting to wrest the AI part of regulation from the medical device center, where it normally sits. So I think that that question, too, is still being figured out. 

Rovner: And there’s even the, you know, what is AI? Is it a medical device? What kind of evidence would one need to approve it? Who would approve it? I mean, there’s definitely a lot more to come here. All right. Well … 

Luhby: Looking at healthcare’s role in the economy, it’s a major source of jobs right now and in the future, but it may not be, depending on what happens with AI. I was just actually at a doctor’s appointment at a major New York City medical center, and the doctor was speaking to, you know, a human assistant in the room, which I was — and I said to her, “Thank you so much for actually, you know, using humans.” And she sort of said, “Well, we’ll see how long that lasts,” indicating that her medical center may be really pushing doctors to use more AI scribes. And I was thinking, Wow, that’s going to cost a lot of people their jobs. 

Rovner: Although I just went to the doctor, and he was starting to use an AI scribe. He said he was just trying it out. So we will see how this all moves on. All right. 

Well, back to the pocketbook issues that seem to be driving voter anger this fall, even more than AI and data centers, President [Donald] Trump, the day after he floated the idea of sending all U.S. adults a $5,000 check if they return Republicans to power after the midterms, separately is proposing to send a $500 check before the elections to about a million unsubsidized enrollees in the Affordable Care Act plans. Unlike the $5,000, which would pretty clearly have to be approved by Congress — spoiler: probably won’t happen; it would be really expensive — the $500 ACA checks at least seem plausible. They represent unspent user fees the federal government has already collected. Two questions about this: One, is it really legal? And, if it is, and the administration does it, will it make up for the huge increases that most unsubsidized ACA enrollees saw in 2026 after the Biden-era extra subsidies expired? A lot of people saw increases that were a lot more than $500 just this year. 

Luhby: I mean, I think it’s questionable as to whether it’s legal and also whether it’s fair, because you’re also talking about giving this money only to be unsubsidized. And you can argue that, yes, the people who got subsidies already got, you know, a federal gift. But there are a lot of questions about these checks. But as far as whether they will make up for the massive increase in premium payments that a lot of folks have paid — especially for the people who didn’t receive subsidies, which, who are generally the people who make more than, you know, 400% of poverty, or … even a higher percentage, because the changes in the subsidy structure — those people are probably among the most … the ones who had the highest increases in premiums between ’25 and ’26. And there’s another round of double-digit premium increases on the way in 2027, or for 2027. So Cynthia Cox, one of our favorite experts at KFF, questioned whether $500 would even cover one month of a premium increase, much less one year. But, you know, as we know, healthcare costs are on the top of voters’ minds, and the Trump administration feels like it has to do something to say that it is helping to lower them ahead of the midterm elections. 

Rovner: Yeah, and this would be, I guess, something that they, in theory, could do. Well, moving on, it may be time to revisit one of the few bipartisan pieces of consumer health legislation of the past decade: the No Surprises Act. That law has successfully spared millions of patients from ending up in the middle of payment disputes between health insurers and medical providers. What it hasn’t done such a good job at, though, is settling those disputes in a cost-effective way. Instead, to quote from the Georgetown study that’s the subject of this week’s podcast interview with Sabrina Corlette, “the dispute resolution process created by the law has cost the health system an estimated $22 billion in just four years.” As a result of that, groups from across the ideological spectrum, from the liberal Families USA to the conservative Paragon Institute, as well as Republicans and Democrats on some key committees in Congress, are that something needs to change. Now this arbitration process that’s gotten so out of whack was the very last thing settled and almost scuttled this law on the launchpad. Is there a suitable alternative available, or will the magnitude of how badly this arbitration process is skewing in favor of providers who are getting enormous payouts going to force some sort of compromise? 

Edney: It seems like there needs to be a compromise. I was a little surprised that that’s being acknowledged. I think when this was first being talked about and coming to light, it seemed like the lawmakers were like, “Well, the law is working for patients,” and, like, “Well, you know, it’ll be OK.” But as you know, those numbers are coming in, that’s … billions of dollars. That’s a huge amount. And, you know, there are options. I think a lot of it was talked about and not agreed upon. But maybe benchmarking these to what Medicare pays or something along those lines when there’s a dispute could be more palatable, given, you know, what’s going on now that they’ve seen the results of what ended up being put into law. 

Rovner: Of course, that was, I mean, that was the hope when they were doing this is that they would set some sort of upward bound of, you know, yes … 

Edney: Right. 

Rovner: And sure, if you’re trying to lowball the provider, we’re going to make sure the provider gets at least something, you know, that’s reasonable if they’re not in-network. Except what’s happening is, with these arbitrations, these providers are getting things that are way more than anticipated, and that’s turning back into these premium increases that we were just talking about. I mean, it’s all sort of one big circle here. 

Luhby: Right, and that’s one thing that, you know, as Politico reported this morning, that’s one thing that employers and insurers want to make sure that people know, and that congresspeople know, is that these increases, these, you know, these payouts that they have to provide for the doctors are going to increase premiums. And you know, as we just discussed, healthcare is on the top of voters’ minds. Already, you know, various consulting groups have said that employer coverage, which is the most prevalent type of coverage, the premiums again are going to increase by a lot for 2027. And, you know, again the employers and insurers are pointing fingers at this arbitration, you know, provision and what doctors are doing and how they’re manipulating it as one of the drivers of these increased healthcare costs and premiums. 

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

Moving to immigration, this week nearly half the states filed suit in federal court to block the Trump administration’s new, quote, “public charge rule.” That’s what gives immigration officials more leeway to block people from entering the country who they think could eventually qualify for government aid. Tami, you wrote about this. What are the states arguing, and what are they asking for? 

Luhby: Well, the main concern here — they want the rule to be blocked, but it looks like it’s supposed to go into effect tomorrow. And at this point, we know that the judge — there are two lawsuits: there’s states and cities — and the judge — it shouldn’t be probably the same judge, but we don’t know for sure yet. And the judge who has been assigned to the state lawsuit is not holding an initial hearing until, I think, it’s Oct. 9, or it’s early October, so it does look like the new rules will go into effect on Friday. But basically, what the concern is is that this is going to end up causing a lot of immigrants, particularly their families, particularly their U.S. citizen children, who may be eligible for benefits like Medicaid, like CHIP [Children’s Health Insurance Program], like housing vouchers, food stamps, school meals, WIC [Special Supplemental Nutrition Program for Women, Infants, and Children]. There’s, you know, a huge number of safety net programs that these immigrants and their families may choose to drop out of or not enroll in, and this is going to cause, obviously, you know, major concerns for hunger, for health, and housing. And the cities and states are arguing that they’re going to be harmed because they’re going to have to pick up the tabs. And, you know, these people will still need to, you know, obviously have healthcare and housing and food when it comes to it, so they’re concerned about their public costs as well as their local economies. 

Rovner: Yeah, and I mean that’s a really important point, which is that this is not just about people coming into the country. This is about people who are already here. Alice, I know you’ve done some reporting on the whole public charge issue, and we’ve got a really good Ñî¹óåú´«Ã½Ò•îl Health News story that I will link to this week that’s called “A Generation of Kids Suffer as Trump Destabilizes Immigrant Families.” This is really reaching much beyond — you know, they originally, he said we’re just going to deport the worst of the worst — but this is reaching much, much further into immigrant communities here legally in the United States, right? 

Ollstein: Yeah, and I think there are just a lot of downstream consequences of this that we saw the first time they did this in the first Trump administration, and that, you know, folks are predicting will happen again that impacts everyone in the community. So for one, immigrants tend to be younger than the general population, and so removing them from these, you know, insurance systems could raise other people’s premiums — you know, the people who remain, because the costs will be higher. It’ll be an older, sicker population sharing those costs. Also, you are seeing that when these rules go into effect, people who remain eligible for the insurance programs, just out of confusion or fear, don’t enroll, and so it impacts even the people it doesn’t officially apply to, through a chilling effect, which, again, you know, leads to those same higher premiums and worse risk pool. But also, you have, you know, you mentioned risks of infectious diseases; if you deter people from getting preventive care, from getting vaccines, from getting checkups, that puts the whole community at risk. 

Rovner: Yeah. 

Luhby: And even DHS [Department of Homeland Security] itself acknowledges that there’s going to be a chilling effect. They estimated that 950,000 people may opt to leave or not enroll in — they examined six public benefit programs: Medicaid, food stamps, CHIP, federal assistance — and I think nearly a million people who, you know, are eligible for these safety net programs who may not participate. 

Rovner: Well, I guess that is one way to cut the budget. 

Turning to reproductive health, Alice, there’s movement on that story you’ve been following about testing wastewater [drinking water] for remnants of abortion pills. Now, what’s the latest? 

Ollstein: Yeah, so this was a story my colleagues and I broke recently that the EPA [Environmental Protection Agency] itself is now going to do some testing on this front. Of course, they’re not testing just for abortion pills; they’re testing for a bunch of different pharmaceutical medications. But putting abortion pills on that bigger list is, you know, something that anti-abortion groups have been clamoring for years and are . Of course, they’re still pushing for a separate process where EPA would require utilities around the country to monitor for certain drugs, including abortion pills. And so they’re still pushing on that front. But they consider this a step towards, you know, potential restrictions. Now, it’s important to know that the test the EPA is using only will show if any amount is detectable in the water; it will not determine the concentration. And so even if they say, “OK, we found traces of this,” it doesn’t mean it has any impact on plants, animals, humans. It does not mean that. So whatever they come up with, it’s important for people to keep that in mind. Environmental experts we talked to stress that this is sort of a bad-faith push. There is no evidence that there’s any actual environmental harm here. Pharmaceutical contamination of water is a real thing, but there are medications that are way more of a threat in their minds than this one. 

Rovner: Yeah, but this is what they’ve been pushing as yet another way to try to go after abortion pills. Well, meanwhile, while the FDA continues to restudy the safety of mifepristone, at the urging of anti-abortion groups, in California, the attorney general is wrapping up a lawsuit against two anti-abortion nonprofits for their proffering of that purport to stop a medical abortion partway through. Unlike mifepristone, which has been studied in many clinical trials in the U.S. and internationally, there is no evidence that giving the hormone progesterone can save a pregnancy partway through a medical abortion. Alice, how big an impact could this case have, and when do we expect to hear from the judge? 

Ollstein: So this could really set a precedent. There are a lot of legal battles around the country. There’s another one the New York attorney general is in the middle of that is similar to this one. But it’s getting into this interesting space between protecting patients versus free speech and what clinics, even, you know, less-regulated crisis pregnancy centers, like the ones that are at issue in this case, what they can tell people and whether states are able to regulate that in the name of protecting patients from potential harm. Like you said, this hormone regimen, where after you take mifepristone, which is an anti-progesterone, you know, they’re saying, Oh, if you change your mind and you don’t want to have an abortion after all, you can take a high dose of progesterone to counteract the effects and save the pregnancy. Again, this has been very little studied, and the studies that have happened are methodologically weak. They don’t have control groups. They don’t have random sampling. They’re very, very small numbers. Whereas, like you said, the medical studies of mifepristone itself have been covered millions over the years, and so there’s just a lot more evidence of the safety record. And so, this could be really interesting coming out of California, in terms of these clinics, which have really become a major front in the anti-abortion movement’s larger battle. These centers are very prevalent around the country and have only grown in number since Roe v. Wade was overturned, and so they’re really seen as sort of the forefront of spreading the anti-abortion movement’s message. 

Rovner: Well, speaking of lawsuits that might set a precedent, the family of Tierra Walker, a 37-year-old pregnant woman who died in Texas of multiple complications after being repeatedly denied an abortion, has filed a malpractice suit against her doctors and is also suing Texas Attorney General and Republican Senate candidate Ken Paxton. Paxton, you may remember, personally threatened individual legal action against doctors who performed abortions, even on women whose medical conditions apparently qualified for exceptions to the state’s ban. What does it mean that they’re actually going after Paxton personally — or, I guess, in his role as attorney general in this case? 

Ollstein: Yeah, they’re going after state officials, and they’re going after the hospital, the doctors. There’s a lot of different charges in this one case. There’s medical malpractice charges. There’s [Americans with Disabilities Act] ADA-like discrimination, refusing-of-care charges. There’s the constitutional charges about the law itself. And so this is really sort of getting into new territory. It’s something I covered in my book, that doctors largely have reported that when they’re operating under abortion bans, they’re more afraid of providing what, even what they consider a medically necessary abortion. They’re more afraid of the legal consequences of providing it than the legal consequences of not providing it. And this is an attempt, and there have been some others to try to change that calculus. So I know there’s an ongoing case in Georgia as well, a medical malpractice case. But it’s sort of attempting to make doctors also afraid of the legal consequences of not providing what could be a lifesaving abortion, and we’ll see what the outcome is in this instance. 

Rovner: And we’ll talk more about this, and we’ll talk more about your book in the coming weeks as we get ready for its launch. Well, finally, this week the House may be gone, but the Senate is still here, and two Senate committees held confirmation hearings this week for Chris Klomp, the Medicare official who’s been nominated to be deputy HHS secretary, as well as a hearing for Nicole Saphier, the radiologist and former Fox News contributor, who is the latest nominee for U.S. surgeon general. At both the Finance Committee, which will vote on Clomp, and the health committee, which will vote on Saphier, there were lots of questions about the administration’s position on vaccines. This comes as Pennsylvania announces its third and fourth measles-related death this summer, and as HHS Secretary RFK Jr. [Robert F. Kennedy Jr.] gives a keynote address here in Washington today at his former nonprofit, the anti-vax group Children’s Health Defense. Interestingly, both Klomp, who is not a doctor, and Saphier, who is a doctor, sort of, kind of endorsed the measles vaccine, but neither appeared enthusiastic enough to satisfy HELP [Health, Education, Labor & Pensions] Committee Chair Bill Cassidy, who’s also on the Finance Committee, of their sincerity. Cassidy delivered some of his strongest critiques yet of the damage the administration is doing by promoting vaccine hesitance. Yet I wonder if Cassidy would plan to vote against either of these nominees, or if any Republicans plan to vote against either of these nominees. 

Edney: I think that’s a great question. And Cassidy clearly has not done that in situations where the stakes — you know, it seemed like, you know, he had more reason almost, I mean, there was more, at least, like, outwardly publicly, you know, conflicting with his stance, and he didn’t do it. So he is leaving Congress, so that could change things for him. But I’m not sure that I would expect some sort of vote that really spoke out against Trump at this point. 

Rovner: He voted to confirm the new CDC [Centers for Disease Control and Prevention] director, about whom he had basically the same questions. 

Edney: Yeah, “Boy Who Cried Wolf,” I think is what that was. 

Rovner: All right. Well, that is this week’s news. Now we’ll play my interview with Sabrina Corlette, and then we’ll come back with our extra credits. 

I am pleased to welcome to the podcast Sabrina Corlette. Sabrina is a research professor, founder, and co-director of Georgetown University’s Center on Health Insurance Reforms. She’s also the co-author of a brand-new paper called “A Three-Part Strategy for Better Health Insurance” that includes a series of policy changes Congress could make in the short term that could help patients better navigate our messed-up healthcare system. Sabrina Corlette, thanks for joining us. 

Sabrina Corlette: Oh, it is such a delight, Julie. Thank you for having me. 

Rovner: So, I think a lot of us have been predicting that rising costs, lowering access, and increasing confusion is frustrating patients to the point that the nation is likely headed for another major healthcare debate, probably after the next presidential election. But this paper focuses on smaller changes that could be made in the nearer future. What made you decide to look at that? 

Corlette: Well, I’ll be honest, Julie, one inspiration was the KFF [Health News] “Bill of the Month” series. You know, I follow that series, and I just saw story after story about patients encountering just the craziest billing situations, coverage challenges, and it just struck me — particularly in this last year, where we had this big debate over Medicaid and the Affordable Care Act marketplaces, and a number of groups and lawmakers were defending a status quo that, quite frankly, nobody was happy with — and so I got together with some of my colleagues, you know, what are some concrete things that would have a tangible impact on people’s experience with their health insurance that can be done quickly, would not require a lot of money — because as you know, Julie, all too well, anytime you want to improve coverage, immediately employers and others say, “Well, this is just going to raise premiums.” So we wanted to come up with something that could immediately improve coverage without raising costs, and learn from some state actions that, you know, are quite frankly happening on a bipartisan basis. So, things that felt achievable. 

Rovner: Right. So, your first part is looking at immediate ways to reduce healthcare costs. What are some of those proposals? 

Corlette: Yeah. Sort of a marquee proposal in here is to bring down deductibles. Deductibles have risen 43% over the last decade or so, and they’re just [an] insurmountable cost barrier for so many American families. So that’s No. 1. But as you know, Julie, if you were to try to lower deductibles across the board, it’s like pushing on a balloon, right? Immediately, premiums are going to go up. So the second part of that proposal is to reduce spending on excessive hospital prices that are, you know, many, many multiples of the Medicare rates. And we’ve seen real progress on that at the state level, with states as diverse as Indiana and Vermont starting to rein in most hospital prices. 

Rovner: And we’ve seen both Democrats and Republicans pointing their fingers at hospitals. We’ve talked about that a lot on the podcast — that hospitals are clearly one of the big drivers right now. That seems to be getting through to policymakers, if not to patients. 

Corlette: That’s right. Yep. 

Rovner: That’s the cost part. Next is reducing unnecessary complexity, which I know is something that everybody would appreciate. What are a couple of the things that we could do there? 

Corlette: Yeah, I mean the main thing that we looked at there was the prolific use of what’s called prior authorization, which is, like, before you can get a healthcare good or service, you have to run it by your health plan and get their advance approval. And that’s just, you know, it used to be that that was really used for certain experimental or very, very high-cost types of services, and now it’s just endemic. And so we propose a number of reforms to — not eliminate that practice because, you know, you do need some checks on the system — but to really try to streamline it and reduce the burden for not only patients but physicians as well. 

Rovner: So last is protecting patients from corporate abuses — again, something that seems to have some bipartisan backing and that people get really furious about? 

Corlette: Yeah, and here the list is pretty long, but I’ll just [home] in on one element, which is reining in some of the more egregious financial practices of private equity, which has really entered the healthcare space in a big way in the last decade or so. And so trying to limit some of the transactions that they engage in that sort of strip assets from a healthcare provider to line the pockets of the investors and really drain away the infrastructure of the, say, the hospital or health system, so that it’s not able to provide as high-quality care. 

Rovner: Things like buying the hospital and then selling the real estate out from underneath, so the hospital now has to pay rent. 

Corlette: Exactly. 

Rovner: And you want to fix the dispute resolution system from something that Congress already tried to fix on a bipartisan basis, which is stopping surprise bills, right? 

Corlette: Oh my gosh, yeah. I mean, you know, that’s one of those issues, again, I think could be very bipartisan. And it’s not every provider in the system, but largely private equity-backed physician group practices really taking advantage of the dispute resolution process under the No Surprises Act to the tune of $22 billion in costs. All that is being passed on in the form of higher premiums for employers and policyholders. So, yeah, we propose some significant reforms to that process. 

Rovner: So, all of these things together are what we health policy types like to refer to as low-hanging fruit, in that it would be less controversial, say, than “Medicare for All.” But we’ve seen that even incremental changes like these that have bipartisan support can be really hard to push through. How optimistic are you that this Congress and this administration, both of which have said they want to do stuff about healthcare and healthcare costs, might be able to actually get any of this stuff done? 

Corlette: Well, I think you and I both, Julie, have been doing this work for long enough. It’s true, nothing is easy. But I will also say that if you look at the polling, Americans now rank healthcare costs higher than groceries and housing as their No. 1 cost concern. I, quite frankly, think that if you’re a politician and you’re not listening to that data and thinking about ways you can reduce costs for people, then you’re committing political malpractice. 

Rovner: We will see if any of this gets picked up. But thank you for doing the paper, Sabrina Corlette, and thank you for joining us. 

Corlette: Thank you for having me. 

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

Edney: Sure. This is a story from a few of my colleagues: “.” And they took a look at some recently released data about prior authorizations and denials, and, essentially, you know, seeing how often people are able to overturn those when they try. Not a lot of people know that they can try to appeal that. And so I really encourage everybody to take a look at it. Check out where your insurer is. I think that that was interesting for me because, you know, they did it by insurer, so you can see what their stance is and how often they’re denying things. 

Rovner: Yeah, and that reminder that we always have with the “Bill of the Month.” It’s, like, don’t pay the first bill, and if you get a bill, don’t be afraid to appeal it. Tami. 

Luhby: My extra credit is a Washington Post story titled “,” by Erica Sloan. The story stood out to me, personally, because I was actually diagnosed with low ferritin 14 years ago, but it took time for the doctor to figure out why I was feeling so tired. So I, actually, I had blood tests, and then I actually went to a sleep doctor because I was figuring, Well, I must not be, you know, sleeping well at night. Maybe I have sleep apnea. But he actually asked to see the blood tests, and he was the one who pointed out my low ferritin levels. So, for those who don’t know, ferritin is a protein that stores iron in the body. And the story cautioned people — the ferritin face, I think, is what got, you know, is trying to get people into the story because apparently this is a thing, although I had not heard of it before this. 

Rovner: A thing on social media. 

Luhby: Yeah, a thing on social media, and I don’t think I actually ever had ferritin face. I asked my husband. But the story cautioned people from trying to diagnose themselves with iron deficiency based on social media and influencers. But the attention, they said, is raising awareness about iron deficiency, which is really important and which is the, you know, the step before anemia. So I thought the story was important because it highlights how common iron deficiency is — nearly one-third of U.S. adults are affected — but how, I was surprised, it’s not part of regular screenings. And the article goes on to explain how to test for iron deficiency, which is to check your ferritin level, and how to treat it, which is to eat more iron-rich food, like spinach, beans, red meat, fortified cereals — or, if your iron levels are very low, to take iron supplements, which I also personally know are not the most fun because they can cause GI [gastrointestinal] issues. So, and if you’re curious about what ferritin face is, which I was, is apparently it falls under the, you know, “looking tired” umbrella: a dull complexion, dry skin, cracked lips, under-eye circles. But, you know, I think those are symptoms of many things other than iron deficiencies. 

Rovner: And yet still news you can use. Alice. 

Luhby: Yes. 

Ollstein: I have a story from KFF [Health News]. It is by Ashley Mizuo, and it’s called “Indigenous Groups Are Exempt From Medicaid Work Rules, but Native Hawaiians Aren’t.” And it examines how, you know, lacking official federal recognition of your tribal status is making Indigenous Hawaiians, who are facing a lot of the same challenges as other Native groups in the mainland U.S., are not exempt from these new Medicaid work requirements that are starting on Jan. 1. And that could be a big barrier to care, and they already have a lot of barriers to care, including sometimes needing to travel from one island to another in order to access services. And so this could really prevent a lot of people who have a lot of health challenges from getting care they need. And so it, you know, looking at a sort of niche overlooked consequence of these new rules. 

Rovner: My extra credit is also about an overlooked consequence. It’s a local story from KJZZ Phoenix public radio called “,” by Camryn Sanchez. And in a situation reminiscent of people in Arkansas losing their Medicaid back in 2018 because the state couldn’t stand up a system allowing them to report their work hours, it seems Arizona can’t figure out how to keep eligible SNAP [Supplemental Nutrition Assistance Program] beneficiaries on that program. Turns out that the state agency that runs the program reported that nearly 9 in 10 interviews with applicants were abandoned, dropped, or otherwise incomplete. The agency itself said it dropped more than 3 million calls due to call-center error or lack of call-center capacity. As a result of that, 53.7% of Arizonans attempting to recertify their food benefits were denied for failing to complete the interview. It is just a really wow story, and, you know, the point that, really, it is incumbent on the states to make these things available. That’s part of why they are supposed to be there. 

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

Edney: on X or . Also on . 

Rovner: Alice? 

Ollstein: on Bluesky and on X. 

Rovner: Tami. 

Luhby: I’m just at these days. 

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

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. Rachel Bernier-Green runs Thrive-O Financial Advisory on Chicago’s South Side. She describes herself as a fractional CFO for small businesses, offering strategic financial advice along with accounting services. And she says employee health insurance was part of her business plan from the beginning.

Before she even had employees, she built extra money into her prices, and at first, she put that extra money into a rainy day fund. But by late 2024, she thought the time had come. 

Rachel Bernier-Green: I’d been in business for a while. I had a few team members, and things were moving along. 

Dan: She wanted to keep those team members around, and she knew health insurance would help do that

Rachel Bernier-Green: And so that’s when I actually started to think, “How do we actually get this in place?”

Dan: She says she moved quickly– and by January 2025, her six-person team had health insurance.  Then things got wobbly.

Early in the year, a major client left. Income took a hit, and by spring she could see big trouble coming toward her. Insurance for 2026 was going to be way more expensive. And she could tell because some of her clients were already seeing rate hikes from their health insurance companies.

They had policies that renewed early in the year, . And these were much steeper increases than they’d been expecting, so they came to Rachel, their fractional CFO, to help them figure out how to adjust, and Rachel knew she would have to do the same.

Rachel Bernier-Green: It was almost like standing on a train tracks and you’re just kind of staring down the impending doom because you know you’re going to be in the exact same situation in a couple of months.

Dan: She says she shared the bad tidings with her team as data came in right from the start, and she said she makes a practice of sharing the company’s finances, details and all, with her colleagues. She calls it open book accounting.

Rachel Bernier-Green: We have regular team meetings where we’re discussing these things and we could all look at the numbers and the writing was on the wall. So when we kind of got to the end of the road, it wasn’t me saying, “Surprise, here’s what’s going on with the health insurance.” It was more, okay, we’ve reached the point where we have to make a decision and call it.

Dan: They made the call at a regular team meeting, which doesn’t mean the meeting was routine.

Rachel Bernier-Green: My heart was just in my stomach. Um, Because like I knew what we needed to do and I just didn’t want to, want to do it. 

Dan: But they’d gotten their renewal notice for 2026. Health insurance was gonna go up by more than 10%. Rachel says everybody agreed the business couldn’t afford it. 

Rachel Bernier-Green: The numbers were pretty clear in black and white. the entire team was on the same page that what was most important was that the business continues to survive so that we could bring back those benefits in the future. 

The thing I remember the most is that another team member who relied on the insurance reassuring me that that was the right thing to do.

Dan: Even with that kind of consensus, and even with a plan in place to bring back those benefits for 2027, Rachel describes the whole episode as devastating. She’s gone on a plan from her husband’s employer. Some other colleagues have done the same, one has left the firm, and two are uninsured. Rachel and her colleagues aren’t alone.

They’re a case study. A reporter named Bob Herman featured them recently in a story for STAT — a news outlet dedicated to health and medicine.  The headline for Bob’s story: America’s Small Businesses are Giving Up on Health Insurance. And the crisis Bob is reporting on goes beyond small employers. That story kicked off an eight-part series called Out of Pocket, Out of Reach, with a subtitle that tells you how big and how deep this crisis goes.

It’s “How America’s Employer-Based Healthcare System Continues to Crumble in Slow Motion,” which sounds scary and absolutely sucks, but it’s the kind of big picture look we really need, and Bob is exactly the person to break it down. He’s the Business of Healthcare Reporter at Stat. He has done the most comprehensive reporting on the giant UnitedHealth Group.

And for years, he’s published a list of the top paid CEOs in healthcare. These compensation packages go to the hundreds of millions of dollars a year in some cases. It’s completely wild. And he knows how to bring a huge story down to earth. He’s coming right up. This is An Arm and a Leg, a show about why healthcare costs so freaking much and what we can maybe do about it.

I’m Dan Weissmann, I’m a reporter. I like a challenge, so the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life and bring you something entertaining, empowering, and useful. Bob Herman joined me from a closet. One of his kids had a friend over, it was the quietest place in his house.

He was sitting on the floor. I should’ve been recording the whole time. But we did have the recorder on when I asked him, “How did you come to the conclusion that employer health insurance doesn’t just suck, it’s crumbling?”

Bob Herman: Well, here, maybe it’ll help if I explain kind of the origins of why we even started it. Um, so I’d gotten back from parental leave last year around November. My wife and I just had our second kid, and literally the first thing I have to do, both of us, we both have to do when we get back, is we have to figure out what health insurance plans we’re gonna enroll for the next year, which, as I’m sure you and every one of your listeners knows, is a miserable experience. Um, and I… And we cover healthcare, and it’s still miserable. It’s tedious but also it’s, it, it is high stakes. And at that time, we had seen all the headlines that employer-sponsored health insurance was experiencing double-digit increases ac- everywhere. It is one of the primary ways that Americans are covered, and we’re all getting slammed in the face with historically high premium increases. It turned into, like, this needs to be a project at Stat. Let’s go after it. Let’s figure out what’s going on. And I think it just became very clear that employer-sponsored health insurance is not, you know, the robust product that I think a lot of people think it is.

Dan: And your conclusion here is, like, there’s a structural problem here, starting with how fast the cost of employer-sponsored insurance is going up. 

There’s a, there’s a really big number in your story where you kind of compare how much more health insurance costs now than it did 40 years ago comparing it to the rate of inflation. And basically, health insurance prices have risen almost four times as much as inflation in general. 

Bob: ?Right. And like, you know, we’re talking over the past several decades, almost 1,000% increase versus wages that were much, much lower than that., 

Dan:  So, one takeaway there is:  This huge increase amounts to something like a hidden pay cut for all of us. 

Bob Herman: Hopefully that’s one thing that this series can accomplish is for all workers out there, when you enroll in your health plan every year, how your employer’s paying for it, how much is getting taken out of your own paycheck. These are things that ultimately affect how someone can pay for their day-to-day things, like groceries feel expensive, rent feels expensive. Why? I think part of it is because your employer health plan, it’s become such a financial burden for everybody

Dan: Yeah. Yeah. That is, I, yes. I mean, you, you’ve said to me, I, I think about all the time, which is like, even if your employer covers your health insurance, , like every dollar that your employer is putting toward health insurance is a dollar they could be paying you. It’s a dollar that’s on the budget line for your position

Bob Herman: It’s exactly right, Dan, and this is like, you know, it’s like an iceberg. I think a lot of people see, like, what’s, what gets taken out of their paycheck every month. Like, okay, I’m paying, you know, a couple hundred dollars toward my health- health insurance premium. That is only, like, 20 to 25% of what your actual premium is.

Your employer’s paying most of it. You just don’t see it. But, like, there is so, like, this big block of compensation that you get, a big and growing chunk of it is for the h- for your health plan, and it’s so hidden, and I think that’s what kind of makes the whole p- the, the whole thing so difficult, uh, for Americans to afford.

Dan: I mean the amounts are really striking. The average employer plan for a family now costs 27 thousand dollars a year. That’s average, not the most expensive. And that’s like? It’s a new car, right? These days it’s y- and not, I mean, not a top-of-the-line car, but a Toyota Corolla is, you know, a car yeah 

Bob Herman: Yeah, it, it’s that new, it’s that new car every year, but the employer’s paying the tens of thousands that makes up most of the car. That’s the part that is hidden and that’s what, you know, I think makes the healthcare system, you know, really take advantage of everything

Dan: And, um, you know I notice you’re saying that the fact that it’s hidden helps the health care SYSTEM take advantage of everything.  Not just the health insurance companies. Because they make profits, band they’re the conduit through which everyone else also gets paid.

Bob: You’re right, like it is the health, the health insurance company often takes some for itself, yes, but majority of that money is, it goes out the door to hospitals, to drug companies, to doctors, to device makers, drug distributors, whoever else. Like, all those different companies know that the employer-sponsored system is like their golden goose. 

Dan: So that wild inflation in health insurance premiums — it’s driven by how much more everything in health care costs. How much prices keep going up.  You’ve said — I mean, everybody knows — we pay more for health care in the US than anywhere in the world. Knee replacement, MRI, any meds you can name, we pay a lot more. And I hear you saying: The fact that some of these costs are hidden — they’re bundled into employer health plans — that actually creates opportunities for price gouging, for all kinds of gaming the system. 

Bob Herman: there’s all this money that employers are dumping into these, you know, health insurance premiums for their workers, and it is, it’s like a feeding frenzy. Uh, you know, years ago I remember going to JP, the JP Morgan conference, uh, out in San Francisco. It’s just like the confab where all the big healthcare industry players, you know, gush about how much money they’re making. And commercial insurance, the employer-based insurance is their golden goose, and they know it. And, I, I went around talking to people, and it’s not like they were dismissing that idea. They know that the commercial insurance market, the, what we get, what we all pay for and through our employers, that’s where they make hay. They could charge whatever they want, they being hospitals, doctors, drugs, doesn’t matter. They know that there’s that massive pool of money there. It is, you know, just imagine, like, Scrooge McDuck, right, where there’s this massive pile of coins, and he’s kinda swimming through it. And

Dan: That image has come up before on this show. 

Bob Herman: Yeah, it, it’s just that is, that is the employer market. And, you know, it’s, it’s a lot easier to make money when, you know, the people who are paying into it don’t understand how much they’re paying into it

Dan: Yeah. So you came into this project ’cause you cover the whole business of healthcare. You were already thinking like, “This is a huge story people need to know about. It’s a hidden pay cut. It keeps making insurance and healthcare more expensive every year. Keeps getting worse.” But it, it sounds like you didn’t realize at first the kind of trouble that small businesses were in

Bob Herman: As I was just doing research and talking with people and reading up, you know, there was a KFF employer health benefits survey, I and just buried deep th- within this, very detailed report, there was this chart showing for companies with 200 or fewer employees, you know, a little bit less than 60% of these small companies were offering health insurance now. Historic low, it’s the lowest it, it had ever been . And I was like, And I was like, oh my God, like, that is a shift. It’s this idea that small companies are giving up on this grand American idea of offering health insurance. It’s actually unraveling right now. 

Dan: and so, you concluded small businesses are giving up on health insurance what does that mean they’re actually doing?

Bob Herman: Yeah. I think when we think about employer-sponsored health insurance, companies do it because it’s a retention tool. And , it could be a deciding factor for an employee to come work for you, right?

Like, “Oh, my gosh,” like, “this health plan looks pretty good. Sign me up.” but if, if it’s actually eating into your bottom line, especially as a small business where you don’t have a whole lot of margin to begin with, like that is, that is huge.

 Small companies, they already kind of live on the bleeding edge, right? They just, you know, if you’re at a Fortune 100 company, you have more money than you know what to do with. If you’re a small company, just by your nature, you don’t, you know, your business is small. And it means that the cost of health insurance eat into your expenses so much more.

 And, you know, if you’re just a company of like, for example, 25 people, and you have one really big medical claim, your insurance company can, could come back to you next year and say, “We gotta raise rates 20% because of that one medical claim.”  and, and you know what the crazy thing is? It’s like a 20% is a, a g- gigantic amount, and it’s not, like, that uncommon for a small business to get slapped with that. Like, I, I spoke with, a business in Pennsylvania, and they were staring down the barrel of, like, a 50% increase.

 It’s not uncommon for premiums to, like, double, which, what are you gonna do then? You have to look for other options.

Dan: A-and what you knew when you started was things are getting bad, like rates have been going up even faster than we’re used to, right?

Bob Herman: And the, the past two years in particular have been really bad because, you know, insurers, like they endured a lot of losses. Not a lot of losses, but like they, this … The, the losses were more than they had expected over the past couple years, and so they’re making up for it now. They made up for it in 2026, and they’re making up for it again in 2027, and that’s exactly what you and others are feeling right now

Dan: C- I mean, they’re the house. It’s a casino and they set the odds, and the house never loses. Like, it’s, it’s made that way. Like, you can’t… Like, the, the bookmaker never loses. Like, , they employ a lot of actuaries, and actuaries are just bookmakers, right?

Bob Herman: Yeah. The actuaries, they are the, the very smart people that analyze, like, how much care everyone’s getting and how much they can predict that that will go up next year. , and they’re pretty good at it. And, you know, obviously the past couple years they were less good at it, but They know if there is a bad year, they can easily adjust the premiums to make up for that bad year. There is no, there’s no multiple years of losing money in health insurance. That, that just doesn’t happen

Dan: Unlike, unlike the rest of us. Yeah. So, if you’re really big, you’re spreading the risk out across a whole bunch of people, and you have reserves, and you have long-term plans.

 And if you’re a tiny little business you don’t have all of the tools to kind of sock money away for something or pull money out of your budget someplace else. Is that, is that basically the, the deal?

Bob Herman: I thi- yeah, I think you have it spot on. If you’re a big company, you can weather these things better.The more people you have, the more money you have to pay out when someone does have to file some kind of claim.

Dan: So but so what did your reporting show you about what small businesses are doing instead and what workers are doing instead?

Bob Herman: Yeah. I mean, none of it is ideal, right? ‘Cause, like, m- a lot of small businesses, they… The ones that I spoke with, and I think this is generally true, like, they wanna offer health insurance. And when they can’t do that, some are just saying, like, “You’re just gonna have to figure it out yourself,” which is, like, it’s a great way to lose an employee, right? Like, “Oh my God, I don’t have the safety net anymore.”

Others are doing, you know, maybe giving their employees extra cash that they can say, “Hey, go buy a health plan on the ACA marketplace.” And you know, it’s not ideal because if you think, you know, when, if you have a employer plan, usually it’s, you know, there’s a, a pretty big network or there’s, like, lower out-of-pocket costs, and when you go to the exchanges, it is a world of difference.

 Like, your doctor may or may not be in-network. Out-of-pocket costs and deductibles are generally much higher, and it’s just, it’s a completely different product. 

Dan: It’s worse. That what you find on the exchanges as an individual is worse than what you’d

Bob Herman: It is. 

Dan: I, I have, I, I, I know this firsthand. Like, the first episode of our podcast, I’m shopping on the exchange. I’m like, “This is bad.”

Bob Herman: Yeah, and like, don’t get me wrong, the ACA provided some kind of baseline level of protection for people who would otherwise be uninsurable. Like b- like, it’s crazy to think about 20 years ago, if you had some kind of preexisting condition, you just couldn’t get insurance. Like, sorry. And, um, but, uh, like the ACA plans are, they’re rough.

Like, it, like it’s, it almost… Like, if you have a $9,000 deductible, is that even insurance at that point? I think that’s a fair question to ask

Dan: And, a- and just to zoom out from there, like that chart you found, the one that showed smaller employers are down to just like 60% offering health insurance, it, it also showed that for larger employers, that number hasn’t changed much, right? It’s like still like 97%.

Bob Herman: Yeah, it’s, um, I think this question’s important because, um, it, it does kind of help explain the economy in terms of haves and have-nots, right? Where the biggest companies are always gonna be able to offer health insurance if they really want to. They just, they have the money to do it. Small businesses, like, we’re living in the shift right now where small businesses are not thriving anymore in terms of offering health insurance, . Well, guess what? Like, I don’t s- foresee this reversing course anytime soon. Ask any small business, and more of them are gonna be like, “You know, my time is, like, up.”

 And, you know, is it, does this, does this spur companies to shut down? I don’t know. Like, it’s totally plausible. Um, it’s not good. It’s not good for the economy, and it, there was even a recent survey that shows that it’s not good for workers either. Like, a lot of people just stick in their jobs, jobs that they hate, because they’re just doing it for the health insurance.

 Like, what kind of economy is that where you’re doing something, you’re collecting a paycheck really to just also get health insurance? It’s not, doesn’t feel particularly productive. So, like, these are all problems that are happening right now

Dan: The, I, I saw that survey and you wrote about it. Like twenty four percent of people in that survey said, “I would leave my job except for the health insurance.” A quarter of people

Bob Herman: Yeah. And what a term, right? Job lock. Like it’s, it’s this well-known economic term, job lock. Like you’re s- you’re locked into your job not because you want to, because, but because you feel like you need to. It’s, 

Dan: And you dug into some of those numbers. You were like, “Yeah, and job lock does not hit all people equally,” right? That people are… Who’s, who’s more vulnerable to job lock?

Bob Herman: It’s, it’s oftentimes it’s people who have more chronic health conditions, right? It’s like, “Oh my God, I know I’m going to be a user of my health insurance.” So like, that makes more s- like especially women because, um, you know, especially if, if you’re planning on having a baby or if you just have any kind of chronic condition, it’s like you are… If you know you’re gonna be using your health plan, you can’t afford to leave your job even if you think it sucks

Dan: , you said at the top of our conversation that, you know, this system is collapsing and that, that health insurance isn’t, employer health insurance is not the kind of robust product we thought it was. And not just for small businesses, even though it’s more obvious for them. But you did report this spring briefly on a survey that said, like, some large number of CFOs were like, “Yeah, we didn’t hire people,” or, “We raised our prices,” uh, because of the cost of health insurance, right?

Bob Herman: Yeah, this is still affecting larger businesses, and it’s happening in all the usual ways that we’ve seen over the past, you know, two decades. It’s making deductibles higher for employees. It’s making them contribute more from their paychecks. It’s changing the health plans. And, you know, I, I just spoke with someone the other day. They said that their out-of-pocket max, it’s the term like after you reach this amount, you don’t have to pay any more for the rest of the year, like it doubled. Like that is a health benefit design change where it actually functions like a wage cut too, right? So th- big companies will always be able to do it, but they have been making changes, and most of the times it just means that the worker and their dependents are taking it on the chin somehow.

Dan: Making health insurance worse. So, I mean, there’s a big story that’s just coming out right now: Did you see the story that Disney is saying, “Actually, your spouse can’t be on your plan anymore if they have an offer from their employer”?

Bob Herman: Yeah, , Disney’s basically saying if your spouse has an offer of insurance through their own employer, they have to take that. They can’t join the Disney plan, which is just, honestly, it’s batshit crazy.

For a company that is, like, supposed to be very family-friendly, this is a very anti-family-friendly thing that they’re doing

Dan: The analysis that I saw was like, look, uh, who chooses our insurance when they have an offer from their insurance? It’s somebody who thinks our insurance is better and is, and thinks they’re likely to use it.

Bob Herman: Right. 

Dan: We think we’re gonna be paying out claims. 

Bob Herman: Right. Yeah, I mean, if you think about it, um, if, if you are sick and you know you’re gonna use insurance, you’re gonna choose the plan that, uh, that offers you more protection. Um, so I mean, like actuarily, like it makes sense. Like they’re, they, they have data showing that like when people join or when dependents join the plan, it is costing them more money, and now they’re going to actively stop it. Like if, if the entire social fabric of employer-based insurance is you, if you have a job, you can get an offer of insurance and your, you and your family can join it, even that is starting to unravel. Like what happens if every other employer did this?

Dan: Yeah, it sounds like the idea you started with — that big employers will keep offering health insurance — they’re not gonna walk away but it sounds like you’re reconsidering this?

Bob Herman: I am kind of reconsidering, and honestly, it’s the GLP-1s that have really started making me reconsider this. Like, Pepsi just this week said, “We’re not offering GLP-1 coverage for weight loss anymore for our employees.” Like, it’s not to say, like, that big… I still think big companies are always gonna offer health insurance, but e- but something like GLP-1 coverage, where it is o- so much money and so many people are using it, 

[00:29:46] Even for that, they’re saying, “No, we can’t do it anymore.” they’re still gonna offer coverage that will, that will try to attract people that they wanna attract. But stuff like this shows that, and, like, it is very clear the employer-sponsored health insurance system is unraveling more than perhaps I’ve ever seen.

Dan:  And yet: The experts Bob talked to all said, they don’t expect this system to change anytime soon.  And Bob ended up with some pretty clear ideas about just why that is. That’s coming right up.

This episode of An Arm and a Leg is a co-production of Public Road Productions and Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom covering health issues in America. It’s a newsroom full of superstar reporters; we are honored to work with them.. 

Dan: The sense I got, you know, from your reporting is it, like, big employers aren’t happy about it. They’re, they’re mad. Um, they’re unhappy, but that this system is not likely to go away, So, if everybody’s like, “This sucks,” why doesn’t somebody do something? And you had, like, you had a kind of analysis of like, who’s getting things out of it. Who’s benefiting from, from the way things are?And who would get hurt if, if things changed?

Bob Herman: Getting rid of the employer sponsored health insurance system is just vehemently opposed by big business. They know, especially the largest businesses, if they offer an attractive health plan, they could get anybody they want.And then going back to the job lock, those people could also stay with them for a long time because they know that they have the health plan. Um, and the, the largest tax break in the entire code is employer sponsored health insurance, so it’s great for, you know, middle and upper class p- you know, people. It’s great for the businesses. They don’t… Like, nobody pays any taxes on it. 

Dan: I was really struck by the note that it’s the biggest, it’s the biggest tax break in the entire tax code, , we’re talking hundreds of billions of dollars that otherwise would go into the federal kitty that don’t. Um, so businesses, they see all of these, things that are beneficial to them, and even though it costs them so much money, it is not worth giving that up. like, “We, we still have way too many advantages from it, even though it costs us an arm and a leg.” You had a specific example, but like the Affordable Care Act was, part of its design was like super suped up, workplace health plans would incur a tax, and that this did 

Bob Herman: Yes. I, I don’t know if you remember that debate, Dan, but it wa- it was called the Cadillac tax, and it was this idea that, you know, if it’s a really, really super generous plan, we’re gonna start to tax a little bit. Everyone lost their minds about it, and it was across the board. It was businesses, it was unions, who obviously fight very hard to, you know, to, to negotiate for their health plans. It was just universally reviled. But the idea was we need to start taxing these. It went terribly. It got killed, and that w- it was honestly, it was a pretty modest change, and look at, look what happened there

Dan: A- and so I think what, what that example shows is there are people with something to lose, and then of course there’s all the people who, uh, you know, make money in healthcare, not just insurance companies, right? 

Bob Herman: Yeah. The healthcare industry is very powerful. If you look at like, like lobbying dollars, like healthcare companies and their trade groups are always at the top. And like, yeah, they want inertia. As they, you know, vacuum up another, you know, $6 trillion this year and exponentially more next yearIt is a feeding frenzy. And again, this was, this is money that otherwise would be in your paycheck.

Dan: Yeah. I mean, it’s just one of the things I think about of like, we become aware of how much things cost, a lot of us, when, like, we get a giant bill, or people we know, and we’re like, “That’s wild.” But as what you’re reporting is showing, like, no, all of this wildness is paid by all of us , a lot of us get insurance from our jobs, that’s money that could be our wages. We’re paying it there. Um, in places where the government pays for healthcare and it, we are paying that through our taxes. Um, and that is a part that I don’t think, I get to enough on this show, is that like, we’re vulnerable individually, but we’re also each of us individually paying a collective price.

Bob Herman: I remember years ago I was interviewing Don Berwick. He used to be the CMS administrator, uh, during President Obama’s term for a short while, and he made the good point that was like, workers pay for every dime of healthcare in this country, either through your wages or through what is owed to you through compensation or through taxes. Um, and I think if you, if your listeners just think of it that way, it’s actually pretty simple. Like, we’re all paying for this. It just doesn’t, it might not seem like it, but that is the reality

Dan: Um, this is a little bit risky, uh, just for our emotional health, but like, as a parent, as you report on these things, do you think about your kids as adults navigating an economy that’s another 20 and change years along this path?

Bob Herman: It’s, oh yeah. I mean, I’ve, uh, I, I don’t know. Maybe a lot of parents are worriers. I’m one of them. , I think about, like, my kids when they eventually have to go off our health insurance, right? When they have to find their own, and, you know, maybe they have their own healthcare needs at that point and they have to find something. Like, is it gonna be affordable for them? Are they gonna be one of those people who gets job locked, where they’re, they find a job but they absolutely hate every minute of it because they’re just doing it for the health insurance? Um, yeah. I, I mean, 20 years from now is a long time. Like, costs aren’t going down, and how will it affect their, you know, basic, uh, standards of living?

I have no idea. I, I mean, it’s hard not to think about it. Um, but it is far in the future, and I think that’s what also prevents people from changing things. Like, we know it’s bad, it’s gonna get worse, but, like, you know, when it’s that far in the future you can’t really address it right now. But I think that’s the perfect time to address, is before it gets so bad that our own kids can’t even, you know, afford their rent or their groceries or whatever else

Dan: I’m, I’m reminded, right, of the saying like, “The best time to plant a tree is 30 years ago, and the second best time to plant a tree is today.”

Bob Herman: Today. Exactly right 

 

Rachel Bernier-Green: I’m a little anxious about what we’ll be paying, but it, you know, it’s not keeping me up at night.

Dan: Back on the South Side of Chicago, Rachel Bernier-Green tells me she’s on track to bring insurance back for her team in 2027. She says changes they made to their business strategy last year have been paying off, so she’s got the money lined up

Rachel Bernier-Green: I mean, we hope that there are not, you know, more sky-high increases because yes, they do drastically, impact, um, our ability to operate the business But, ?I know that we’ll be well positioned to absorb the cost

Dan: as I, I’m preparing for today’s reporting, I’m like, “Oh yeah, this would be a good time for me to email our insurance broker and be like, ‘Hey Kurt, so what are we looking at for next year? Uh, I think it’s gonna be bad.’” And he’s like, “It’s gonna be bad.” He thinks for the plan that we’re on, which because of our needs for networks and stuff, is we don’t have a whole lot of choices. He’s like, “Yeah, you’re looking at like 14 to 18%, I think, for the next year.” 

Rachel Bernier-Green: Yeah. Yep Yeah. And, and the crazy thing is, like, I’m… Which sounds obscene, but I’m thinking is between 20 and 25%, um, that we need to be prepared for jumps of that magnitude. And I hope that that is not the case, but that’s what we are building into our, um, our models moving forward

Dan: And are you advising clients the same way?

Rachel Bernier-Green: Yeah. Yeah

Dan: I’m curious about, um, what it was like reading Bob’s story. What was it like, I mean, whether it was surprising or not, like what was it like seeing all of that kind of put together?

Rachel Bernier-Green: Oh, I was, um, just like silently cheering, um, because those are the, uh, exact conclusions that I, you know, I can’t inform the conclusions that he reaches, but that is exactly where, um, where I am. That the system is fundamentally broken and it is harming people in re- irreparable ways and that we need a significant overhaul,

Dan: Amen to that. Which is the thing about a story like this. On the one hand, it’s full of terrible news. On the other hand: Most of us — maybe all of us — are already experiencing the effects of all this terrible news. And I think it’s helpful, it’s good, to see it all tied together. To know:  We’re not alone. We’re not imagining things.  The whole system truly is completely broken — and as bob says, continuing to actually crumble.  

Even if we don’t have a *solution*, it’s good to know what we’re up against, to peel back the curtain.  

Next time on An Arm and a Leg, we take another look at Medicare Advantage. And, um… it’s more broken than we thought. 

News anchor: Many health insurance providers are dropping their Medicare Advantage plans.

Female voice: I heard that — I was just in tears.

Female voice 2: I don’t know any way to describe it other than total chaos. 

Dan: I’m hoping that you’re right here with me when I say:  It is so much better to know.  We do not want to get taken by surprise.

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Amanda Boyd is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

[Editor’s note: This transcript was generated using transcription software. 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. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Ñî¹óåú´«Ã½Ò•îl Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Aug. 27, at 10:30 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 Margot Sanger-Katz of The New York Times. 

Margot Sanger-Katz: Hello, everybody. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello! 

Rovner: And Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Later in this episode, we’ll have my interview with Dean Rosen about his time working for Kansas Republican Sen. Nancy Landon Kassebaum, who died last week at the age of 94, and how she represented a type of lawmaker we don’t see that much anymore. But first, this week’s news. So we’re taking the next week off for a needed break for our entire team, which makes this the last podcast of the technical summer. And I thought I’d do something just a little bit different. I’m going to break the discussion up into what I’m calling “The Themes of the Summer” — things we’ve talked about nearly every week. I hope it gives some of you the realization that I get from putting this together every week, that we’re looking less at a long list of separate events and items and more at pieces of a much larger picture that we don’t often see. 

So, theme No. 1 this week is declining health coverage. When Republicans passed their big budget bill last summer, they thought they were being clever by backdating most of the Medicaid cuts so they wouldn’t happen before the 2026 midterms. Well, the problem for them is that states and health systems are already making their own cuts in anticipation of those federal cuts to come, and people are already starting to feel them. This week’s evidence is from a Stat News piece called “,” and it includes ways that access is shrinking overall, particularly in heavily rural states like Maine and Louisiana, as the number of people without insurance goes up and the money from the government goes down. Is it really possible that Republicans didn’t see this coming? Or did they really believe they could take a trillion dollars out of the nation’s healthcare system and not have people notice? 

Sanger-Katz: I think that many of them were not paying very close attention. I think it may be accurate to say that they were indifferent to this possibility and are, in fact, surprised now to see the way that it is working out. I just, you know, for context, this bill that made these very large cuts to Medicaid and some smaller cuts to Obamacare funding was part of this huge package that included, you know, major tax cuts and tax reforms that were a big priority for Republicans, changes to energy policy, changes to other social welfare programs, changes to education policy, and, you know, they called it the One Big Beautiful Bill. And I think the bigness of it is easy to forget, in retrospect. But I think for a lot of lawmakers, they were really focused on the parts of the bill that they really cared about. For many of them, it was the tax part of the package. And the president and their leadership repeatedly told them not to worry about the Medicaid changes, characterized them as not being cuts. And I think, you know, a good, responsible lawmaker ought to do some diligence about that. But I think that many of them maybe took their eye off of the healthcare parts of the bill, were focused more on these other parts of the bill, and now are really starting to see what is happening in their home states as these policies are starting to roll out. 

Roubein: And I also think it’s true that, like, some of the full impacts, as I think Daniel Payne pointed out in his Stat piece, won’t be felt for years to come, particularly as the Medicaid work requirements do kick in next year. So once there are more concrete human faces and examples, that tends to come to more the forefront and, like, you know, the political mind. So yes, those changes a lot of them are not fully going into effect till after the midterms. 

Rovner: I do think that one thing that lawmakers really didn’t appreciate was how much this might impact not just people who would be losing coverage, but people who would be losing access. I mean, people who still have coverage, but, you know, if a hospital can’t keep its door open, or a clinic can’t keep its door open, or a doctor can’t, you know, keep the practice going, that’s going to impact people with insurance as well as people who are losing their insurance. I mean, that’s, I think, that’s part of why this piece went to explore some of these more rural places, where people are going to feel this first. Shefali, I see you nodding. 

Luthra: Yeah, one thing I’ve been thinking about a lot is you do hear Republicans, especially someone like [Maine Sen.] Susan Collins, really trying to tout the rural health fund that was part of this, right, and that was meant to, at least rhetorically, offset these massive healthcare cuts. Obviously, you look at math, you look at numbers, and one doesn’t really undo the other. But …  

Rovner: Yeah, the rural health fund is, what, $150 billion of $1 trillion … ? 

Sanger-Katz: $50 billion, I think. 

Rovner: Or, oh, it was even less. 

Luthra: And so, yeah. I mean, I think what maybe people didn’t fully appreciate is that voters are less compelled, perhaps, by [lawmakers] saying I voted for this funding, and more compelled by what they see happening around them, which is these massive cuts resulting in major changes to what is often the biggest employer, what is often the only source of healthcare for miles, something that is very intimate, very much of the community. And that’s why this is just such a potent issue, especially in a lot of these really close Senate races now. 

Roubein: I mean, we’ve seen in the past how rural healthcare can impact politics. With Medicaid expansion, Republicans were really, really, really against it, and then you saw some begin to change their mind — North Carolina being a notable example, and just all of the ballot measures in red states — Oklahoma, for instance. 

Rovner: Idaho. 

Sanger-Katz: I think it’s worth just pointing out how much is still to come. I think a lot of what we’re seeing right now is hospitals and other healthcare organizations that were kind of in a difficult financial situation going into this change in policy. They’re looking around, they’re already in the red, and they see they’re not going to get more money in the future; they’re going to get less money. And so I think a lot of them are accelerating changes that they were hoping to stave off. But the real cuts in almost all cases have not come yet. So, you know, the work requirements, as Rachel noted, are going to reduce the number of people who are covered by Medicaid. So that means that a lot of these healthcare organizations are going to have to absorb uncompensated care that was previously paid for. But then, further down the road, there are actually much larger cuts that are coming to state Medicaid budgets that are done in these kind of complicated, a little bit obscure, formulaic ways. But there are these reductions on how much the state can directly pay hospitals for care. There are reductions in how much states can raise through Medicaid taxes that then get transferred back. And there, I think, have been very valid criticisms of these funding mechanisms for Medicaid. They are this kind of Rube Goldberg complicated ways of financing the program, but they’ve been around for decades, and these healthcare organizations and these state budgets have really been built on the foundation of these funding streams. And so, as that money starts to go away, I think, then we may see even larger impacts because, again, the things that are happening now are healthcare organizations looking down the road and thinking, Ooh, it’s going to get messy. Maybe I should start adjusting now. But down the road, it will start getting messy for them, and I think there are going to be potentially some much harder choices for some of these organizations. 

Rovner: Well, continuing along that theme, , we talked earlier this summer about a new rule from the Centers for Medicare & Medicaid Services to enforce the administration’s ban on the use of the Medicaid or CHIP [Children’s Health Insurance] Program to pay for gender-affirming care for minors. But it seems that the mechanism CMS is using could open the door to denying coverage for other drugs too, or at least some uses of other drugs. Now, this isn’t in the Stat story, but, Shefali, when I read it, I wondered if one goal here is to cut back on the use of drugs like misoprostol, which is used for a lot of things, but also for medication abortion. 

Luthra: That’s a really good question, and I think one that we still don’t really know. And obviously, a lot of states’ Medicaid doesn’t cover abortion to begin with. That really only happens in states that have actively made an effort. But, I mean, misoprostol is not only used for abortion; it is used for miscarriage management. And I think it’s just something really important for us to keep in mind what happens when you see these sorts of approaches to just, like, carving out individual forms of healthcare. And obviously, it’s very interesting as well because drugs used for gender-affirming care are also used for other things. RFK [Robert F. Kennedy] Jr. really loves hormone therapy for many people, just not trans people. And so I think there’s just a lot of questions that we don’t really have answers to about just how sweeping the implications of something like this could be. 

Rovner: Yeah, we will see as it goes. Well, it’s not just Medicaid. that CMS is clawing back billions of dollars in Affordable Care Act premium subsidies from insurers who have allegedly phantom enrollees, people with zero premium plans who don’t file claims. And while that is a known problem, a lot of those people might be actual enrollees who just haven’t needed their insurance yet, as in young, healthy folks who have health insurance just in case, or because their parents told them that they should, and, by the way, they could get a plan with a zero premium. And stripping these people from the rolls is likely to boost premiums overall by making risk pools sicker, in general. I feel like this administration might not be familiar with the bizarre and sometimes illogical way the health insurance market works? 

Sanger-Katz: I think there’s a delicate balance going on here, where if there are people who are enrolled in these plans who are fake, are not real people, do not know that they have insurance, never plan to use their insurance, you know, that is a waste of federal dollars to subsidize those premiums and just give that money to insurance companies. But I don’t think that there’s very strong evidence that there are a lot of these people. And I also think that the mere fact that someone has not used their health insurance yet, in a year, is not by itself evidence that they are a fake person or that their enrollment is fraudulent. As you said, Julie, there are a lot of reasons why people in this market may not have used their insurance. You know, a lot of the people who have become newly enrolled are relatively young and healthy. That is good for the risk pool, but it may mean they don’t have a lot of healthcare needs. There’s also, just because of the nature of the individual market, you know, one expert pointed out to me, there’s just a lot of churn. You know, someone loses their job, they sign up for a plan, then they get a different plan, or, you know, people who are in this market may only be in this market for a short period of time, and that may also explain why there’s a higher share of them who don’t make any claims, because they haven’t sort of gotten through the whole year, they haven’t had a healthcare need yet. So I think deciding to just disenroll people on this basis does risk disenrolling people who are legitimately insured, who are not phantoms, and who are not committing any kind of fraud. To the degree that there is fraudulent enrollment, and I think there’s evidence that there’s some of it, there are, you know, I think that is a valid concern, and I think the federal government is certainly within its rights to try to address that and make sure that these federal tax subsidies are being appropriately spent. 

Rovner: Yeah, I think “delicate balance” is exactly the right word. I mean, that’s, you know, with the work requirements too. I mean, the idea is to make sure that people are doing things. But if you make the administrative requirements so burdensome, then you’re going to throw off people who are legitimately enrolled. 

Moving on to the next theme of the summer: the resurgence of measles, and the continuing fight over vaccine policy. Until this week, the Trump administration had boasted that while measles cases have been rising pretty precipitously — they’re at the highest level in more than three decades — the U.S. was actually doing better than most other countries with outbreaks, and besides, no one had died of measles yet this year. Well, that worked until Tuesday, when the Pennsylvania Department of Health announced two measles-related deaths in Lancaster County — although we have few details other than that both people were unvaccinated and one was an infant. The announcement touched off a rather nasty war of words between Pennsylvania governor (and possible 2028 presidential candidate) Democrat Josh Shapiro and HHS Secretary Robert F. Kennedy Jr., who said that the state was not cooperating with federal health officials, and maybe the people didn’t actually die of measles after all. This isn’t really going to get more people vaccinated, I would suggest — this just sort of fighting back and forth, right? 

Luthra: It’s a good question. It certainly doesn’t help. I think one thing I was thinking about this morning, and this is not measles-specific, but there’s a really great New Yorker piece from this week looking at the actual vaccine data over the past year and a half, and obviously people are affected by public rhetoric, but the declines in vaccination are not as big as one might have feared when RFK Jr. was initially nominated and really made a point of highlighting anti-vaccine beliefs. And so obviously, like, this is, the fact that people are dying is very bad. The fact that they’re sowing confusion … 

Rovner: The fact that people are getting measles is very bad! 

Luthra: Yes, it’s very, very bad. It’s not, none of it is good. But that was actually really striking to me that amidst all of this, like, really terrible news, there is a bright spot, which is that things could be a lot worse. That is something that I hadn’t thought about. 

Roubein: I mean, if, I think … I’ve been thinking about this today, like, if you kind of step back from the really high-level view, I think Americans who are watching this are confused. They are not sure who to trust. There are, you know, Republicans are saying one thing, Kennedy allies are saying one thing, the Department of Health [and Human Services] and Gov. Shapiro, Democrats are saying another thing. You’re seeing a, you know, a war of words between, like, Republican and Democratic county commissioners on this, you know, just from a public health messaging standpoint. 

Rovner: Yeah, it has not been a great job of communication all the way around. I think there, I mean, there are even, you know, public health defenders who are saying, Why don’t we know more about these two deaths yet? There’s been not a lot of information, and that has, of course, as we saw, you know, during covid, the more noninformation you have, the more people try to fill in their own information, whether it’s true or not.  

Well, even before the Pennsylvania news, we had a somewhat excruciating pair of appearances on CBS’ Sunday show Face the Nation this week. First, CMS Administrator Dr. [Mehmet] Oz needed three separate tries to be able to say that, no, President [Donald] Trump was incorrect when he said in his Oval Office vaccine event that the measles, mumps, rubella combination shot was lethal. Spoiler: It is not. Then Florida Republican congressman Byron Donalds, who’s now the Republican candidate for governor, said the measles outbreak there has been caused by illegal immigration rather than residents not getting their children vaccinated. What happened to the idea we heard last winter that being anti-vax wasn’t good politics? I think this speaks to what you were just saying, Shefali. You know, I think in January and February we thought that Republicans were going to sort of leave this alone and focus on other things. 

Sanger-Katz: Well, I think one thing that we’ve learned recently is that while a lot of the president’s advisers and political staff, I think, were concerned that an anti-vaccine message was damaging, what we’ve seen is that the president himself sincerely has anti-vaccine views and has been saying them out in public. And so I think it does put other Republican political figures in a difficult bind, and certainly puts folks like Dr. Oz, who work in the administration, in a difficult place. Whatever his genuine views are, whatever his political advisers and his public health advisers are telling him, he works for President Trump, and President Trump has made it pretty clear what he thinks. And so I think that’s why we are now seeing this kind of new round of muddled messaging around vaccines, when I do think for a little while there was kind of a pullback on the most overt anti-vaccine rhetoric, and, you know, we saw RFK talking less about it, for example, in public. Now, I think we’re in a little bit of a new phase, where the president is leading the way back. 

Roubein: Yeah, I mean, I think that’s exactly right, and I mean, Trump has, you know, privately questioned why his administration had yet to release new vaccine recommendations, , with Lena [H. Sun] and my colleague Dan [Diamond]. And that’s, you know, some of what, a lot of what drove the executive order that we saw from just a few weeks ago to reduce the childhood vaccine schedule. Trump says he wants to break up the MMR shot. That’s not something that is currently available, but, you know, he has driven that by pushing some of his advisers. 

Rovner: Yeah, absolutely. Well, meanwhile, demonstrating just how expensive it is to track, trace, and quarantine people after a confirmed case of measles. One Denver outbreak that ended up being just 10 cases still cost state and local agencies nearly a half a million dollars, almost 7,000 hours of work from 189 staff members, not to mention 91 people being quarantined and 500 days of school being missed. We may call public health invisible when it works, but it is certainly not cheap. 

Roubein: Yeah, I mean we don’t talk about the economics of it very often. I mean, public health officials always say that they are underfunded, but just, in general, the talk of the economics here is generally not a huge part of the conversation. 

Sanger-Katz: And measles is just such a difficult disease to contain because it is so contagious. It is one of the most contagious infectious diseases out there. And so that means that any person who has measles just has the potential to spread it to so many people. And I think that really strains these traditional public health approaches of trying to track, trace, and quarantine because you have to find so many contacts. 

Rovner: Yeah, just a reminder, I mean, measles can linger in the air after the infected person has left for, I think it’s like, two hours. So it’s, you know, anybody who’s been in a place where somebody with measles has been is potentially at risk if they’re not vaccinated. 

Sanger-Katz: I mean, we remember how hard this was with covid. Of course, in the early days, no one was vaccinated, so there were more people who were susceptible to covid. But measles is substantially more contagious even than covid. 

Rovner: Yeah. Well, as yet, as the debate continues to rage over vaccines, the evidence continues to pile up that vaccines are actually, on balance, a very good thing. Just this week, we have two more studies. of 4 million teens and young adults that found that those who received that controversial mRNA-based covid vaccine were less likely than those who just got covid to develop myocarditis or other heart problems. That was something that people were worried about with young people getting this vaccine. appears to confirm that the shingles vaccine, Shingrix, appears to not only have a protective effect against dementia, something we reported earlier this year, but also against cardiovascular disease. How do we get to a place where vaccines have become controversial again? I assume, I mean, I want to go back, Margot, to what you were saying that it does seem that President Trump himself has anti-vax views that I think we didn’t appreciate until this year. I mean, I think most of us thought that this was all being driven by RFK Jr., who’d obviously made a career of being anti-vax. But when he backed off, we saw the president basically fill right in, and that’s kind of where we are? 

Sanger-Katz: And I also think this is a reminder to us, both of these studies and others that have come out recently, that, you know, vaccines have some risks. They do. But infectious disease can be really dangerous for people, and it can have lingering and downstream effects that are not obvious. It’s not just that you get sick in the moment that you get sick, but having that disease affects your body in ways that may show up much later. And I think some of these longer-term studies that are following people — you know, not just in the weeks and months after they get a vaccine, but what happens years later to their heart or to other major organ systems —really shows that preventing people from getting serious illness is good for their long-term health. 

Rovner: Yeah. 

Roubein: And I mean, Secretary Kennedy, just to go back to last year, he did drive changes. He fired CDC’s [the Centers for Disease Control and Prevention’s] vaccine advisers, who had made changes to vaccines. The health department did release a new childhood, slimmed-down childhood immunization schedule earlier this year. A lot of those changes, though, have been on hold from a federal judge. 

Rovner: Yeah, he also fired the head of the CDC, who refused to rubber-stamp his vaccine changes. So, he was busy before he got sort of unbusy with this. All right, we are going to take a quick break. We will be right back. 

OK, our next theme of the summer are the continued cutbacks by the Trump administration to federal health programs, including some of those that have been specifically funded by Congress. First up is a story from Ñî¹óåú´«Ã½Ò•îl Health News this week about how, at the same time President Trump can’t stop talking about the increasing rates of autism and what a problem it is, the administration is scaling back enforcement of civil rights protections for people with autism, research into the education needs of people with all sorts of disabilities, and even data collection efforts. So, on the one hand, the president keeps pressuring RFK Jr. to find a definite cause of autism, but at the same time, this administration is doing less to help those who are already diagnosed? 

Luthra: I think what I find really interesting every time we talk about this is the really, really long tail of funding cuts, because this is something on, like, a broad macro scale that began at the beginning of this administration, right? Just massive funding cuts and freezes across the board and have continued. And because of the way grant-making works, because of the way research works, we keep seeing the consequences. We keep getting more people reporting, “Oh, my funding didn’t come,” or “This was held up,” or “This project I was working on no longer can.” And what I think is also really interesting is we see how slow the ability to respond is because of the long tail of funding cuts. I mean, courts take a long time, finding new funding when you suddenly lose yours actually is very difficult. And this is something that we’re just going to keep coming back to. We are going to be seeing the consequences of these funding cuts for months and years, as we’ve been talking, but also for much longer as the consequences in terms of research, of cures developed or not developed, becomes even more clear. 

Rovner: Yeah, although sometimes I think it’s going to be hard to connect the dots to get from, you know, from you cut this so this didn’t happen. It’s almost going to be like proving a negative at some point. 

Well, another big theme this summer has been drug prices, particularly prices for those expensive GLP-1 weight loss drugs. As part of the administration’s push to make those drugs less expensive for the end users, CMS offered states the option to participate in its direct negotiations with the drug manufacturers if they would offer them through their Medicaid programs. Only, , so far only one state has taken up the offer, and more states are actually cutting back on their GLP-1 coverage through Medicaid that they have been offering because it’s been such a financial strain on their programs. Several state officials told Politico that they worry about the long-term financial sustainability of the program. I know it’s also a worry for the Medicare GLP-1 program, which is basically at this point a year-and-a-half-long pilot for drugs that, as far as we know, need to be taken indefinitely. Is it fair to say that the president has not really been able to keep his promise to make these drugs cheaper and much more widely available, or that if he has, people may end up getting them yanked out from underneath of them? 

Sanger-Katz: I think it’s complicated. I think it’s hard to know how much credit the president should get. But I will say that the prices for these drugs — the kind of cash-pay prices, that he was able to negotiate allegedly, and that he was able to announce certainly a few months ago — were substantially lower than what individuals and insurers, including some public insurers, were paying for those drugs. So we are now seeing a kind of cash price for the main anti-obesity drugs that is much more affordable than it had been in the past. I think some of that was driven by market pressures and would have happened regardless of the president’s intervention. But I think certainly his pushing these companies, his threatening of these companies, his cajoling of these companies probably maybe did induce them to sort of do it at the same time, to do it faster, and to do it more prominently. 

Rovner: Well, some of it already had happened, before he got in. The self-pay cost had already gone down because so many insurers had stopped covering it. 

Sanger-Katz: It had gone down, but it then went down again.  

Rovner: It did. 

Sanger-Katz: The prices that are available now that the president announced are lower than what we had seen in the past, and they are a major discount even compared to the previously lowered prices that had been public. So I think that is a real thing. Whether or not those prices were meaningfully lower than the price that the Medicaid programs in states were already paying is a little bit of an unanswered question. But my understanding from talking to some Medicaid officials is that Medicaid was already getting very similar prices, even before the president announced these discounts. And that’s because Medicaid has, by law, gets the best price for drugs. They get discounts that are not available to other purchasers. And Medicaid budgets are quite tight. You know, as we were just discussing, all of these state Medicaid programs are facing very substantial cuts that are coming down as the rollout of the big tax-and-spending bill is implemented. And the states that went early and did cover GLP-1 drugs for obesity, I think that they saw that interest and uptake really exceeded their expectations. There were a lot of people in the Medicaid population who stood to benefit from these drugs, and that when so many of them enrolled at once and started taking these drugs at once, it did create, I think, an unanticipated budget strain. So I think states are in a difficult position. This pilot is offering them this cash price for their Medicaid programs, and I think a lot of them are looking at that, and they’re saying, “Well, this is, like, a good price. It’s not that much better than what we could have gotten before, and we weren’t doing it before because we didn’t think that we could afford it.” And so I think those circumstances really haven’t changed. It will be interesting to see what happens over time. It does seem like there is huge potential public health benefit for Medicaid populations if these programs can find a way to cover these drugs. You know, the evidence about the health benefits of these drugs for people who have obesity are just really tremendous, and we’re seeing them over numerous, different health conditions and body systems. And, you know, in my own reporting on North Carolina’s Medicaid program, which was one of the early ones to cover these drugs, you know, I just talked to a lot of people who were really excited about having this opportunity to take this drug. People who had really struggled with their weight and related illnesses, and, you know, were glad that the state was offering it to them. And now, you know, North Carolina has had, is one of the states that’s had to roll back. 

Rovner: Yep. All right. Well, finally, this week, a word about Dolly Parton, possibly the only person in America who was pretty literally loved by everyone. The country and pop music superstar and actress who was known for her genuine kindness and generosity was, in fact, also an important healthcare philanthropist. A lot of people probably remember she gave a million dollars to Vanderbilt University in 2020 to help develop the aforementioned mRNA-based covid vaccine. What people might not remember is that she also used her own money to fund pediatric infectious disease research, underwrite a women’s healthcare center in the East Tennessee county where she was raised, and help train pediatric health professionals. There are celebrities who lend their name and their time and sometimes their money to causes to help burnish their personal PR, and then there are those who clearly do it because they want to give back. I think it’s fair to say that Dolly Parton was one of the latter, and I think she’s going to really be remembered for a lot of the work that she did on bringing healthcare to more people, right? 

Luthra: Yeah, yeah. It’s very sad. 

Rovner: It is. And healthcare owes her a debt. All right, that is this week’s news. Now we’ll play my interview with Dean Rosen, and we’ll come back and do our extra credits. 

I am pleased to welcome to the podcast Dean Rosen. Dean is a partner at Mehlman Consulting, where he landed after a long career on both sides of Capitol Hill, during which he helped shape some of the most important health legislation of the 1990s and early 2000s, including President George W. Bush’s HIV/AIDS program, PEPFAR; the Medicare prescription drug law; and the 1997 Balanced Budget Act. But before all those things, Dean was the top health aide to Sen. Nancy Landon Kassebaum, the Kansas Republican who passed away last week at the age of 94. After Republicans took over Congress in the wave election of 1994, Kassebaum chaired the then-Senate Labor and Human Resources Committee, now the HELP [Health, Education, Labor, and Pensions] Committee, and stewarded the surprisingly difficult path to law of what was originally a very bipartisan bill, the Health Insurance Portability and Accountability Act of 1996, or HIPAA. Dean Rosen, welcome. 

Dean Rosen: Thanks, Julie. I’m honored to be here, and I’m a longtime fan of What the Health? — so this is a real great opportunity. Excited to be with you. 

Rovner: Great. So, HIPAA, which was known at the time as Kassebaum-Kennedy for its bipartisan Senate sponsors — your boss and the late Edward M. Kennedy, a Democrat of Massachusetts — is today mostly known for its medical records confidentiality provisions. But that’s not how it started out, right? It was really an effort to do something bipartisan in the wake of the failed Bill Clinton very partisan health plan. Talk about how it kind of came to be. 

Rosen: Yeah, that’s exactly right. It sort of started in the Senate and then moved to the House and then moved to a traditional conference committee, which we don’t seem to do very much of, either, anymore these days. But when it started off, it really did start, as you said, as a health insurance portability bill, and just a really, in some ways, minimalist solutions-oriented legislative proposal that was designed to try to get at what was really, I think, the core concern, or one of the core concerns, at the time, which was people’s ability to get and maintain health insurance if they had preexisting conditions.  

And really what happened was the Clinton plan had kind of imploded spectacularly, as you know, despite the fact that there were huge Democratic majorities in the House and the Senate — not filibuster-proof, but close in the Senate — and the Democrats just couldn’t … get it done. And they couldn’t get any Republican support. They couldn’t get enough Democratic support. And then in the 1994 election, something unexpected happened. I guess polling was a little less sophisticated at the time, but you had the “Republican Revolution” led by [who] was to be Speaker [Newt] Gingrich in the House, and you had the Senate — which had changed hands before, but the House, which had not changed hands and had been in Democratic control for 40 years — switch, and Republicans were ascendant. Bill Clinton was still president. I think probably some of the fact that there was such a gain of seats had something to do with the failure of health reform. And Republicans were getting ready to move a very aggressive deregulatory agenda. And Ted Kennedy, who was a liberal lion of the Senate, who you know was a champion of universal coverage and other liberal causes, moved from the majority side of the dais and having the gavel at the Senate Labor Committee, now the HELP Committee, to the minority side. And Sen. Kassebaum, who had hired me just a few months before that, all of a sudden became the first woman to chair a major committee in the Senate, a standing committee in the Senate. And really, what started it, was that Sen. Kennedy and his team came over and met with us, and somewhat surprisingly, said, “Hey, I know I’m for universal coverage, but I’m willing to do something that’s much more modest,” and shared with Sen. Kassebaum and me and the team a chart that they had put together showing where, not had there been disagreement, but where actually there had been agreement among the major plans, ranging from the most liberal, the Clinton plan, to some of the most conservative plans. And the heart of that, Julie, was health insurance portability, preexisting condition protections at access, and that was the bill that started off in the Senate, and that’s the one that gained traction and passed until we got to the House. 

Rovner: So, Sen. Kassebaum was one of those legislators who actually believed in passing laws, even if it meant compromising — so you only achieved a few of your goals at a time. Why are there so few people like that on either side anymore? 

Rosen: Yeah, well, you know, I think I would say also about HIPAA that it … she was an incrementalist. I think she was one of the reasons … she was considered a moderate Republican in the day, and I think now even more moderate. But she was at her heart a conservative in the sense of she believed that the best legislating was done sort of inch by inch, step by step, as opposed to in one bill. And you sort of saw that proof come to be when the Clinton plan failed, because it tried to really do everything in the healthcare system; it was huge. I think to your question: Today, it’s harder because there’s just less overlap, and the incentives are such that, you know, as one current member of Congress, very senior, told me a couple years ago, if you’re a Republican, you’re looking over your right shoulder. If you’re a Democrat, you’re looking over your left shoulder. And I think that the venerable, you know, Cook Political Report says that in this election, there are only truly 18 toss-up seats in the House out of 435. And so, what it means is that, you know, 5% of the country is going to decide who controls the House ultimately, and the incentives are not to put together bipartisan bills, big or small, healthcare or not healthcare. But the incentive is, frankly, to play to your base, particularly in a midterm election. Now, that’s not always the case. You do have examples of bipartisanship, but I think it’s harder because of those incentives, which we’ve seen become more and more true as politics has changed, and, frankly, as the country’s changed. 

Rovner: You wrote a really lovely tribute to the senator about going to the White House for the signing of HIPAA by Bill Clinton, which I think just showed sort of the generosity of spirit of Sen. Kassebaum. Tell us about it? 

Rosen: Yeah, so, you know, after Nancy passed away, there’s a group of us who’ve been keeping up through chat over the years, and her family, actually granddaughter and stepdaughter, had informed us all before they informed the press over the weekend that she had passed away. And I suddenly was sitting there over the weekend and realizing, Julie, that it had been — she had died 30 years to the day since HIPAA was signed by Bill Clinton. And, you know, to your point of bipartisanship, that bill passed the House with only two dissenting votes and the Senate unanimously. So not only was it bipartisan, but it passed unanimously. 

So we went over to the White House — to kind of tell a little bit of the story — I’d never been to the White House before. This was, like, my first job on Capitol Hill. I was much younger then, and — obviously — and the senator made sure I was on the invitation list. And this was, you know, Sen. Kassebaum was not really known as a legislator who was someone who passed, you know, tons of major bills. This was really, if you read all the obituaries, the health insurance portability law is one of the two bills they mention — the other one being a general aviation bill, and her work internationally, which was significant around apartheid. But they mention this health insurance bill as her signature achievement. So we go to the White House. It’s a hot August day, and as I said, I realized that she died 30 years to the day after this bill was signed. And I was reflecting on the fact of something that I never really shared publicly before, that at the signing ceremony, it’s traditional — as you know, you’ve probably been to many, many, many of these — that the presidents will sign these bills, they’ll use multiple pens, as Bill Clinton did, and he handed one of the pens to Sen. Kennedy, and he handed another one to Sen. Kassebaum — we’re standing over each of his shoulders. And we’re walking out of the Rose Garden, and Sen. Kassebaum came over to me, and it was just the two of us, and she said, “Here, I want you to have the pen. You wrote the bill.” And, you know, I guess as a staff person you do, but I didn’t think of it that way. I thought of the fact that she was giving away to me really one of the most tangible symbols of her signature bill, and I said, “I can’t take this. This is your bill. This is one of your crowning achievements. You worked so hard to get this done.” And she insisted that I keep it.  

And as I said in the piece that I wrote, you know, it struck me that that was just essential Nancy Kassebaum, that not only in the legislation could she find ways to work with Ted Kennedy, who, she said, in subsequent interviews, coming from Kansas — and folks will appreciate this with Wicked being out — that I think a lot of Kansans thought that Ted Kennedy was the Wicked Witch of the East. But working with Ted Kennedy to get something passed into law, and then coming over to me with no ceremony, with no one around, with no political advantage, and just saying, “Here, I’d like to give you credit, as opposed to taking credit for myself,” I think said a lot about her character, and I shared that story with her family, and they gave me permission to share it publicly. I think it just goes to her character and who she was, which, as I said, I think is, much more important than the legislative achievement, was just the kind of person that it takes to get things like that done in Washington today, and, frankly, in Washington then. 

Rovner: Any chance we’re going to get back to seeing those kinds of legislators on Capitol Hill? We’re both in this for the long run. 

Rosen: Yeah, you know, I have to say, you know, I prefer to be somebody, Julie, who looks forward. I mean, you know, you can look back and wring your hands and be pessimistic. But, you know, I came to Washington as a [Ronald] Reagan Republican, and Reagan always said that he felt like American optimism was the heart of the country, and that our best days were ahead. And I really do feel optimistic about the country. We’ve survived a lot over the last 250 years, and you’ve got examples of bipartisan legislation. You’ve got, you know, Dr. [John] Joyce and [Rep. Greg] Murphy, and [Rep. Kim] Schrier, a bipartisan bill in the House that takes on the difficult and expensive issue of Medicare physician reform. You’ve got a bill by Sen. [Chuck] Grassley and [Catherine] Cortez Masto and others in the Senate that got introduced a couple weeks ago on fraud and abuse at a time when that issue could be really political. 

So to me, I do see people of goodwill in both parties who want to get things done. I think we’ve got to recognize, as we talked about a moment ago, that the broader incentives in our country and in our political environment and in our institutions are pulling people apart. And I think it is going to take people of goodwill to find things to do where they can compromise without losing their principles and find ways to make progress. And I do see hopeful signs of that. You know, I’m not sure we’re going to get back to the day where there’s tremendous overlap and a huge number of moderates in either party, but I think it makes it even more important that people of goodwill who come to Washington as citizen legislators and want to solve things find ways to do that. And in this divided government, where we’ve seen 12 change elections of the last 14 and extremely narrow historic margins, it’s going to take both sides to get things done. 

Rovner: We will keep watching, Dean Rosen. Thank you so much. 

Rosen: Thanks, Julie. Thanks for having me. 

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

Roubein: My extra credit is from The New York Times. The headline is “,” by Noah Daly and Andrew Jacobs. And the story is about how Americans are traveling abroad, often to Latin America, for psychedelics, a form of medical tourism, and the authors write that this could carry substantial risks. There’s no official tally of injuries, deaths, or adverse events at the overseas psychedelic clinics. But The New York Times interviewed more than two dozen patients and researchers, who cited just a litany of troubling episodes. Basically, the field of psychedelics is in its infancy, so researchers have found this sort of patchwork of standards and rules. And, just for context, here in the United States, the FDA hasn’t approved a psychedelic as of yet, but the idea has really gained traction in recent years for mental health conditions, but particularly, this spring, when President Trump signed an executive order that was aimed at accelerating research into the drugs and also fast-tracking federal reviews of psychedelic medicines. But advocates for these drugs do have concerns about adverse events at overseas clinics because they don’t want it to, you know, kind of spark a backlash that could hamper this trajectory. The Times did speak to a practitioner who said that his prescribing practices were informed by a patient’s self-reported medical history. But I thought this was a really interesting look at what’s happening overbroad given there’s been so much chatter about psychedelics in the United States. 

Rovner: Something else to worry about. Margot. 

Sanger-Katz: I wanted to recommend an article in Stat from Anil Oza. Headline is “.” And this story outlines that a number of people who had submitted comments on a rule about science funding suddenly found their comments removed from the public record. And it appears that the reason is because they were making reference to Russell Vought, the OMB [Office of Management and Budget] head, who, you know, was behind this rule. He has a child with cystic fibrosis who has benefited from a [National Institutes of Health] NIH-funded drug, and I think a lot of them were making reference to that as part of a personal plea for him not to implement this policy. But it’s a little bit puzzling why OMB removed them, on what basis. They haven’t been transparent about it, and there have been basically no explanations. And I think, you know, Secretary Kennedy, during his confirmation hearings, talked about radical transparency in the HHS process and policymaking. And I think this is one of many examples where that really hasn’t happened. There has been a reluctance, I think, by HHS to go through notice-and-comment rulemaking in situations where it is not necessary. There has been a reluctance sometimes to answer questions from the public, from reporters, and I do think that the kind of deletion without explanation of these comments is part of that broader pattern. There is obviously this personal sensitivity here that is part of it, and there may be some valid reason why this public official’s child should not be in the federal record. But it would be nice if someone would explain. 

Rovner: Yeah, and also props not just to Stat, but to the people who actually have been tracking these comments and noticed that they were taken down. Shefali. 

Luthra: All right. My story is from LJ Dawson. It is a collaboration between Ñî¹óåú´«Ã½Ò•îl Health News and The Washington Post. The headline is “.” This story combines many of my interests, like European vacations, Greece, and fertility treatment. And I think it’s a really, really, like, interesting and useful look into just how expensive this can be for Americans, especially if insurance doesn’t cover it, and the lengths to which people go to become pregnant. And the family that the story follows, they live in Florida. They could only get pregnant through IVF [in vitro fertilization]. They were quoted close to $40,000 for a round, and they were like, This is nowhere near what we can afford. They realized it was much cheaper to travel to Greece, to literally go on vacation in Greece and get IVF done there. And this is a thing that people genuinely do. Like, I know many people who have looked into the costs of IVF in different European countries, including Scandinavian ones. And I think it’s just a really helpful, dramatic look at what happens when people really, really would benefit from a medical treatment for achieving their fertility goals, their reproductive goals, etc., but it is simply not affordable. And I think this is also interesting because there has been so much chatter about making IVF more affordable, but, in fact, it is more expensive than ever and more in demand than ever because people are having children later, more likely to need fertility treatment, and we don’t really have a good solution yet in sight. 

Rovner: No, except that our system is way too expensive. Well, you may have noticed that in my themes of the summer, I left out the unusual spate of foodborne illnesses. Well, fear not. My extra credit this week is also from The Washington Post. It’s by Tamar Haspel. It’s called “.” And it makes a pretty good case that lettuce and its leafy green cousins are not only the foods most likely to result in foodborne illness, but it’s also not got much to offer nutritionally. It doesn’t store very well, and the land that we use to cultivate it could be better used for, well, better food. I have to say, I stopped buying lettuce a long time ago, mostly because it doesn’t keep very well, and I live by myself. And while I do eat plenty of salad, it’s mostly cucumbers, peppers, and tomatoes. Now, you guys all do you, but I can just say that I haven’t contracted cyclospora this summer. 

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

Luthra: I’m on Bluesky . 

Rovner: Margot. 

Sanger-Katz: I am all the places , and on Signal at sangerkatz.01. 

Rovner: Rachel. 

Roubein: Several places: on X, ; Bluesky, ; ; Signal; etc. 

Rovner: As I mentioned at the top, we’re taking next week off. You should too, if you can. It’s going to be a busy fall. We will be back in your feed on Sept. 10. Until then, be healthy.