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

Julie Rovner: Hello, from 吃瓜不打烊 and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 吃瓜不打烊. 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. 13, 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 Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Sandhya Raman of Bloomberg Law. 

Sandhya Raman: Hello, everyone. 

Rovner: Later in this episode, we’ll have my “Bill of the Month” interview with Paula Andalo. But first, this week’s news. We’ll start this week with vaccine policy 鈥� more specifically, vaccine policy being made from the Oval Office. On Monday, President [Donald] Trump, surrounded by HHS [Department of Health and Human Services] Secretary Robert F. Kennedy Jr., and other health officials, signed an executive order calling for “gold-standard” childhood vaccine recommendations. The order calls for the current federal childhood vaccine schedule to be divided into three parts: one with a shorter list of shots recommended for all children, another list for high-risk populations, and a final list of vaccines to be given as a result of “shared decision-making” between doctors and parents. The president also wants to separate the combination measles, mumps, and rubella vaccine into three separate shots, which don’t actually exist in the U.S. at the moment. That would necessitate more visits for parents and more individual sticks for kids. While the order itself has no force of law, it does direct each executive department and agency to “take [any] appropriate steps to advance them, to the fullest extent allowable by law.” So, what’s the immediate impact of this? Besides a whole lot of confusion, because when RFK Jr. tried to do essentially this, back last year, it was blocked by a federal judge. 

Edney: Yeah, I think confusion is the main impact of this right now. You know, this comes in the news every so often because President Trump has not wanted to let this go, even though we kind of thought he was 鈥� or at least RFK Jr. was 鈥� directed to let it go because of the midterms and how that was looking. But this is something that President Trump has really had on his agenda and not let go. And I think that there is not really a possibility for an immediate impact, say, with breaking up the shots. Like it doesn’t, like you said, it doesn’t exist here. Merck, which is a company that makes these MMR shots, said that could take up to 10 years. It’s not just a simple thing for them to do. So, in the meantime, you have some parents who are wondering, Well, is this bad? Like, what should I be doing? How 鈥� you know. So I think confusion is the No. 1 impact here. 

Rovner: Yeah, I want to break this down into sort of what it means for health and what it means for policy and what it means for politics. So, in terms of health, the U.S. is already in the midst of its worst measles outbreak since 1991, and we’re seeing more cases of other vaccine-preventable diseases, including whooping cough and even tetanus. And pediatricians are already slammed. How are they ever going to make room for all these extra appointments and parent discussions of these vaccines that used to be sort of generally recommended and now are going to have to be the subject of individual discussions? Anna, you’re the mom on the panel. 

Edney: Yeah, I was thinking that from the parents’ side, but yes, from the pediatricians’ side as well. I mean, they’re already overwhelmed. They already have a huge list of patients trying to get in for many things. And from the parents’ side and the child’s side, this is, like you had mentioned, more sticks. 鈥� The children will have to be given more shots in this case, and a lot of times that can mean missed shots because going once kind of gets everything done. We all like to have a one-stop shop versus having to go to a bunch of different times. And so, besides the confusion, [it] could decrease vaccine adherence because people just might miss those shots. You know, they’re going into the first year of childhood, so many parents, even in the first couple weeks or months, are back at work and are having to carve out time for this. So it could, you know, it could really overwhelm the physician, the pediatricians’ offices, with these conversations, and you know, kind of just lead to actually less protection for children. 

Rovner: And hence, I’d say, the increase in vaccine-preventable diseases that we’re actually seeing. Go ahead, Maya. 

Goldman: I was just going to say there are also all these other logistical concerns 鈥� like we mentioned, these shots don’t even exist yet in the U.S. So that’s, you know, step one. But then you need more storage at the pediatrician’s office for a shot that’s three separate shots instead of one combination. You need more people working at the office to accommodate all the extra appointments that are already in a shortage of pediatricians in a lot of places in the country, and healthcare support workers. And so it’s just this huge cascade of side effects. 

Edney: Yeah, and I think we should add to that: When President Trump talked about this from the Oval Office, he linked wanting to separate these shots to the rise in autism, and there is evidence that’s showing that that is an issue, and that the shots should be separated for that reason. 

Rovner: And just last week, we had another large-scale study that showed no increase in autism due to childhood vaccines. I want to talk about policy, too. There’s one particularly ominous phrase in the EO [executive order] that says that states, who set the rules on which vaccines are required for school attendance, are “advised to review” the recommendations and “consider updating relevant laws and regulations that define the scope of immunization requirements.” On a brief call with reporters on Monday, one administration official suggested that newly sworn-in Attorney General Todd Blanche could go after states that don’t provide enough exceptions to their immunization policies with violating federal religious freedom laws. Is this really good policy or good politics? I mean, most states 鈥� I did go back and look 鈥� most states have exceptions, have medical exceptions; obviously, if a kid can’t take a shot, a kid can’t take the shot. Most of them also have religious exceptions. But it’s not clear how broad this administration wants those exceptions to be, and what it might do about states that don’t allow exceptions. I would note that one of the few states that has almost no exceptions is West Virginia, which is a very red state. 

Raman: I think this is really the area to watch on this. I mean, a lot of the other pieces of this executive order are broader, and I think a little bit more, you know, messaging to the political base based on some of these logistical issues that we’ve outlined. But this is a direct action to three different agencies, you know, to look at these exemptions. And this is already something that they’ve been investigating 鈥� there are already some lawsuits about some of these exceptions in the five states that don’t have, as you know, the same exemptions as other states. So I think here is really the area to look, especially with Blanche now confirmed, and just keeping an eye on some of the existing cases that are already there challenging some of these exceptions. Because this is really where we could see movement, or, just even on the state level, for them passing additional laws. You know, that was something mentioned in the presser too, that they were going to encourage states to do this. So I think state level is somewhere to really look, especially 鈥� vaccine requirements come down to schools, and those are on a state-by-state level done by [the Department of] Education, not HHS. So that’s where I would be watching. 

Rovner: Yeah, there’s more to come, I suspect, here. Before we leave this, though, I want to talk a little bit about the politics. I mean, Anna, you mentioned this. There were polls that showed that going after vaccines was not very popular with Democrats or Republicans, and that Secretary Kennedy was told earlier this year to focus on other things instead. Why is Trump bringing this up two months before the midterms? I mean, who 鈥� what politics is this aimed at? I guess is my question, because I certainly don’t know. 

Edney: From the reporting that I’ve read, and you know, , and Politico. This is just something that Trump himself believes and does not want to let go. He’s talked to the HHS secretary about it time and time again, saying, you know, basically needling him to get on it, even though others have told him not to do that. And so it seems like something that the president really wanted to happen. And just given this discussion we just had, I think it’s pretty evident that most of it is kind of a “We let him do his thing.” He got to talk about it in the Oval Office, and, like, hopefully he’ll shut up about it now, and nothing will actually happen. I think that that is a possibility. 

Rovner: We’ll see if nothing actually happens. But one more thing before we leave the vaccine wars topic, a story from last week that caught my eye: Texas Attorney General Ken Paxton, who is also Texas Republican Senate candidate Ken Paxton, announced in his AG role that he has opened an investigation into the American Academy of Pediatrics. That’s the group that’s led the charge to preserve the immunization schedule, according to, you know, science. Paxton, in a press release, says his office is looking into “concerns that the organization may be promoting and recommending childhood vaccines for financial gain.” Now, given that most pediatricians lose money on giving vaccines, that feels like a bit of a stretch. Or am I missing something here? 

Goldman: Yeah, I think, what I interpreted from that announcement was, you know, he’s concerned about the organization of AAP, which has some big funders in the pharmaceutical companies. So maybe he’s claiming that the organization is worried they’re going to lose that funding, as opposed to individual pediatricians making money off vaccines. But I think it’s really from AAP’s perspective: damned if you do, damned if you don’t, right? This is something that they have done the science on, looked into, and that’s what their basis is. Be very interesting to see if this actually goes to court and if there’s, you know, a legal argument to be made here. I think this is, like, something that is just starting to unfold. 

Raman: What struck me was it’s similar to what we’ve seen in other areas as well. It’s the same kind of rationale we’ve had going after some of the transgender medical professional groups. You know, saying that they’ve made various recommendations about gender-affirming care for financial gain, and questioning some of those decisions. So in that way it’s not unique, especially since Texas has kind of led the charge on some of those. But I do think it’s interesting that we’re going after some of the same organizations for this again and again. 

Rovner: Yeah, I’m wondering sort of the political benefit for Paxton of going after the American Academy of Pediatrics, but we shall see. All right, speaking of politics, the Centers for Disease Control and Prevention got a new director this week 鈥� at least according to its website; I have not seen that she’s actually been sworn in 鈥� a year after its old director was ousted for refusing to rubber-stamp Secretary Kennedy’s handpicked vaccine advisers’ recommendations. Erica Schwartz, a former deputy surgeon general, told the Senate HELP [Health, Education, Labor, and Pensions] Committee during her confirmation hearings that she supports the vaccine schedule and would “never betray the science.” She’s about to get tested on that, isn’t she? 

Raman: I think it was a really interesting choice they didn’t swear her in before they held that event and bring her out there. You know, we did have [Jay] Bhattacharya as the acting official, but they could have easily brought her in there to speak on that, and they didn’t. I think that was a conscious decision. 

Goldman: I was just going to say they waited until she got confirmed. 

Rovner: I would say she got confirmed last week, and the event was on Monday, so they could have sworn her in in time for the event. 

Goldman: Right, they did the event after they confirmed her, but before they swore her in. 

Rovner: Right. 

Goldman: To shore up support in the Senate. 

Rovner: Fair point. Yes, rather than rub it in [Sen. Bill] Cassidy’s face right before he voted to confirm her; that is an excellent point in terms of the timing. Well, meanwhile, things at the CDC are still apparently not great. It’s been almost exactly a year, not just since the last director was ousted, but since a gunman literally shot up the building, killing a security officer because the gunman’s father said he believed that the covid vaccine had made him suicidal. Secretary Kennedy went to visit the CDC campus in Atlanta for a memorial for the officer last week and held a fireside chat with CDC staff, who were, shall we say, not very impressed with his fireside manner. Among other things, according to a transcript of the meeting, he repeated that scientists are not trustworthy. All this comes at a time when CDC is fighting an Ebola outbreak in Africa, several foodborne outbreaks here in the U.S., and the aforementioned spike in vaccine-preventable diseases. It’s not a great time for the CDC, is it? 

Goldman: It’s really not. And there’s a this week by an anonymous CDC staffer that sort of outlines all of the different things that, you know, I’ve even forgotten the CDC has gone through in the last year 鈥� thinking about Ebola and funding cuts and just, this person said, that they can still see damage from the bullet holes when they’re sitting in their office it hasn’t been fixed. And you really have to feel for these workers that are trying to do their best but not being given the resources or support to do it. 

Rovner: Yeah, and I will say, you know, after decades of covering the CDC, the people who work for CDC are, you know, among the most mission-driven people in healthcare. I mean, they toil in sort of the, you know, most difficult parts of the healthcare system and are, like, constantly fighting uphill battles and not getting a lot of support, I would suggest, from the current administration. Well, meanwhile, the never-ending Medicaid news keeps on coming. This week, the Trump administration issued final rules banning certain gender-affirming care for minors. Now, this is separate from its rules for hospitals, right, Sandhya? You wrote about this, yes? 

Raman: Yeah. So the rule this time is related to Medicaid for under 18, and for states that also fund the CHIP [Children’s Health Insurance Program], under 19 they would also have to comply with this rule. And kind of what struck me was that we, you know, just on this podcast, I think, maybe a month or so ago there was this, you know, is the administration going to pull this back or not? And there had been reporting saying that they were, and then HHS said, Yes, we are still going ahead with this rule. So indeed, they did. I think this is part of the broader framework, like you said, of different things related to them wanting to emphasize biological sex in their various rulemaking. 

Goldman: Yeah, I think an important distinction about this particular policy is that it strips federal funding, federal Medicaid funding, from states to cover gender-affirming care for minors. So states can still use their own state dollars if they choose to. Private insurance can still cover this, no problem. This is not a ban on gender-affirming care, but it will certainly make things more difficult for children on Medicaid who need this care, want this care. And, especially as states are facing so many other cost pressures, it’s going to be hard to come up with money to patch this hole if they want to do that. 

Rovner: And, to be clear, we’re not talking about surgery here. I mean, we’re talking about all kinds of care, including counseling, right? 

Goldman: Counseling actually is not included in this one. 

Rovner: Oh, OK. 

Goldman: They can still use federal Medicaid funding to cover counseling. 

Rovner: But not other forms of nonsurgical gender-affirming care. 

Goldman: Yes, hormone therapy, puberty blockers, exactly, which are recommended for kids with gender dysphoria by most major medical associations. 

Rovner: Including the aforementioned American Academy of Pediatrics. All right, next in the Medicaid realm: those work requirements that begin next January. We’ve talked at some length about how the federal government is going to give people an extra year to self-attest that they are too sick to work before they have to get proof from a medical professional. But points out that some states aren’t taking that option. Eight Republican-dominated states, including Arkansas, Idaho, Ohio, and Indiana, are declining that grace period and making their work rules even stricter than the administration is otherwise requiring. What’s the likely impact of this? That in January they’re going to have to start proving immediately that they’re either too sick to work or they could lose their Medicaid. 

Edney: Well, I think the, usually, at least the point of doing a rollout, I guess, is giving states time to figure it all out and giving people time to understand what they need to do. So those states are choosing not to do that. So it seems like this could create a lot more chaos than even was anticipated in the first place, and maybe potentially a lot more people coming off the rolls than when maybe they shouldn’t have been, just because of paperwork errors or misunderstandings and things like that. 

Rovner: And much like pediatricians who are worried about having to break up vaccine appointments into multiple appointments, doctors are kind of freaked out about having to see all these patients so they can, you know, write them notes to excuse them from the work requirements, which is another burden that I don’t know that Congress really fully accepted when it was deciding, and the administration was deciding, how to implement these work rules. 

Edney: You know, that’s not something they normally do assess, whether someone can go back to work. So I’m sure they would probably prefer not to be doing that, but if they, you know, without the time and the ability to figure this out, it could be even tougher, and people will be trying to rush to get in there to get this done. 

Rovner: Well, I guess we’ll be watching these as “the early states,” when this all begins. All right, we’re going to take a quick break. We’ll be right back. 

So, the vaccine executive order from the president very much overshadowed what I think HHS Secretary Kennedy had hoped would be the big HHS story this week: the unveiling of proposed new standards for food additives that have been deemed “generally recognized as safe,” or GRAS. The rules, which have been a long time coming, as in several administrations long, wouldn’t so much make it harder for companies to use food additives like thickeners and stabilizers that are often seen in highly processed foods, but it would require companies to tell the FDA how it’s using those substances. And it stops well short of what former Republican FDA commissioner David Kessler had been urging in a citizen petition, that he filed more than a year ago, that would have made companies actually prove that those products are safe before they can put them in the food supply. Why are these rules so timid? Isn’t, you know, making the food supply safer Kennedy’s, one of his biggest MAHA [Make America Healthy Again] goals? 

Edney: It seemed to me that the way the FDA put it was that they needed Congress basically to step in to boost their ability maybe to do more. Sometimes that’s an excuse not to do more. Sometimes it really is true that they could really open themselves up to challenges from Big Food and court challenges that they don’t want to fight. And so they do the thing that they think they’re able to, and then tell Congress, you know, we need you to go the rest of the way. 

Rovner: Interesting, because they don’t seem to be afraid of court challenges or, you know, stepping on Congress’ toes on lots of other things. I mean, is this really just emblematic of the power of Big Food? I mean, we’ve already seen, you know, Kennedy be sort of squashed by the power of Big Pesticide. 

Edney: Yeah, I think that that’s absolutely the case 鈥� that Big Food, you know, they put their lobbying to work, and they talked about how this could stop them from being able to innovate and being able to get newer things into our food, and that basically we should trust them 鈥� what they’re putting in there is safe. And so that has had some sway. Particularly, there have been a lot of industries that have been able to go to the White House and make those cases and kind of water down things that RFK or, like you said, former FDA commissioner [Marty] Makary had said they were going to do. 

Goldman: I’ve also seen some statements from, quote-unquote, “Big Food” lobbying groups arguing that this is an affordability issue. You know, if they have to comply with all these extra rules and regulations and pre-market reviews, that could tank the president’s affordability agenda, is something that I saw. 

Rovner: I would say we’re all still waiting for the new definition of highly processed food, so we will see what that ends up. On another subject regulated by HHS, Secretary Kennedy also announced major action to start the process of decertifying the organ procurement organization that coordinates organ transplants for the region that includes Kentucky and parts of Indiana, Ohio, and West Virginia. OPOs are the go-betweens between medical professionals who care for patients who become organ donors and those who care for the transplant recipients. There’s been a lot of attention to some pretty big failings in the organ transplant network over the past couple of years. This case cites instances where potential donors were not yet dead. That’s a big problem. But you have to wonder if the public is going to wonder whether dramatic action like this is warranted because the OPO really is deficient, or whether it’s political, since we’ve seen this administration going after some states and some organizations for what they say is fraud that looks like it might more be about electoral politics. 

Raman: I think this is a little different. With this organization, Network for Hope, we’ve had a lot of action over the past year or so on this organization in general. We had congressional hearings about it. We had letters from lawmakers with concerns about this, and it’s not the first time that they’ve moved to decertify. You know, there was a division of University of Miami Health System that they decertified last year. Again, documented problems about this, and even if you listen to some of the statements from Democratic lawmakers, they are not against this. I think that, you know, it’s a recognized problem across political lines, which is a little different than some of the issues where fraud is being, you know, viewed more through one lens than another. 

Rovner: There is a point at which HHS is supposed to regulate organizations. I mean 鈥� when they find evidence of an organization not doing what it’s supposed to, they’re supposed to take action. That’s kind of how the government works. Sorry. 

Edney: You know, The New York Times has done a lot of great reporting on the organ procurement system and showing many, many flaws. But I think for this one, specifically, when I read about what made HHS look into it, it is shocking and a little scary. So I do understand. You know, what happened was there was a man who overdosed and he wasn’t quite dead, but they were starting the procurement process, and he was waking up. And it just seemed like they kept going on this a little too far. He survived; they didn’t get any organs out of him. But if you sign that form that says you’re an organ donor, it’s not something you want to think about: If something happens to you and you’re not quite dead, that they might decide to go ahead. And then HHS did find that this had happened on many occasions. So I think that it seems like something that the government should have stepped in on. 

Rovner: Yeah, there were some pretty serious deficiencies here. All right, well that is this week’s news, or at least as much as we could get to. Now we’ll play my “Bill of the Month” interview with Paula Andalo, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast my colleague Paula Andalo, who reported and wrote the latest 吃瓜不打烊 “Bill of the Month.” Hi, Paula. 

Paula Andalo: Hi. How are you? 

Rovner: So this month’s patient is kind of a success story, right? Someone with a nonemergency condition and no health insurance who was nonetheless able to shop around for the best price? Tell us who he is, where he lives, and what kind of care he needed. 

Andalo: Yeah, his name is Ronmel Rangel, and he’s from Venezuela. He moved to the U.S. in 2019 to live with one of [his] daughters that live[s] in Portland, Maine, and he has been living there since. 

Rovner: And then he got sick and needed 鈥�  

Andalo: So it was interesting because 25 years ago he had an inguinal hernia and he had surgery in Venezuela. And at the end of last year, he began to feel a pain on the other side of the body. Again, it was a hernia, so he needed surgery. 

Rovner: So he’d been through this before. 

Andalo: Yeah, yeah, in a different health system. So he doesn’t have insurance, although he’s a green-card holder, so he can have insurance. But when he moved here 鈥� now he’s 64, so it was six, seven years ago 鈥� and he was looking around, you know, the Obamacare and all the stuff. But he realized that for his age, the prices were crazy. He’s a pretty healthy person, so he decided to not have insurance. Instead, he began to see a doctor in a concierge medicine. You know these kind of practices that charge as little as $70 per month to unlimited visits and some small procedures like stitches or 鈥�  

Rovner: But not hernia repair. 

Andalo: Not hernia. So at that moment he needed surgery. 

Rovner: Right. So he did the medical tourism thing, looking both here in the U.S. and in some other countries, where he had family that he could stay with. And, a bit surprisingly to me, at least, he found the best price here in the U.S.? 

Andalo: Yeah, it was like a miracle. Yeah, he looked in Oklahoma, but it was far away. Also, he has a daughter living in Santiago, in Chile, and he looked there, and it was very expensive, adding also the cost of traveling to Chile. So, he finally found his place in Maryland. In Rockville, Maryland, in a place called Affordable Surgery Center. He had his procedure in April. 

Rovner: And how much did he end up paying 鈥� I guess both for the travel and for the hernia repair? 

Andalo: Well, the first estimate that he had was in his state in a big health system, and at that moment the estimate was $23,000 for a laparoscopic procedure. In this center in Maryland, the total cost, including anesthesia, was $2,900. 

Rovner: Wow. 

Andalo: So, adding the cost of tickets for him and his wife and one night of hotel, etc., it was less than $5,000. 

Rovner: Wow. So that’s a whole lot less, even than he could have gotten at home in Maine. 

Andalo: Yeah, exactly. 

Rovner: So what’s the takeaway here, other than that medical tourism doesn’t have to mean a trip to another country to find the most cost-effective care? 

Andalo: Well, the takeaway is that you can shop around, especially if you have an elective procedure, so you have time. Because if you have an emergency, you don’t have time. But with these kinds of procedures that are pretty common, and there are different options to do it, you can shop around and look for the best place. He had the help of his family doctor 鈥� that was very helpful, you know, helping him with lists of places. But he has had time to shop around, to look for prices, and to take care of his hernia. 

Rovner: And I guess it’s important to remember that the most expensive isn’t always the best, but the cheapest also isn’t always the best. 

Andalo: Exactly. So one advice is, the expert says, that you need to look at the reviews of the place and do your homework to realize that if it’s a good place. Although the research says that sometimes higher prices doesn’t mean better care, but in these kinds of procedures, you can pay much less if you shop around. 

Rovner: Well, nice to have a happy ending for a change. Paula Andalo, thank you so much. 

Andalo: Thank you. 

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

Goldman: Sure. My extra credit this week is an article titled “.” This one is in The New York Times by Mark Arsenault. I am a University of Michigan alum, just like Julie, and so this one caught my eye. But it’s also very interesting to hear what, you know, universities are taking student mental health seriously to the point where they’re making big policy changes or, at least in this case, piloting policy changes to try to get at the root of the problem. I have my own skepticism that this is, you know, the root of the problem. Academic pressures are certainly a big stressor for students adjusting to college, and so maybe this could help. But I think that this is a multifaceted problem, and I’m interested to see how they’re going to measure the success of this. But this isn’t the first university to have done it. There are a couple others: MIT, Brown. The University of Michigan is a massive school with a lot more students, though, so I think it’ll be interesting to see if other schools of that ilk follow suit. 

Rovner: I would just point out that I went to the University of Michigan in the 1970s, and even then we could take classes pass/fail if we wanted to. It’s not really all that new. But yes, I’ve seen a lot of rolled eyes this week about this story. Anna, why don’t you go next? 

Edney: Mine is from CBS News by Julia Ingram: “.” I thought it was a smart thing to look at, that this farm had not been inspected since 2019. And not just that, but that the FDA has been really lagging on all of their foreign food safety inspections, not even meeting 10% of the goal that Congress had set for them about a decade ago. And I thought that was just a great way to get into this story and talk about inspections and how the FDA is struggling. They’ve struggled for a while to meet these kinds of mandates, but showing how it’s now gotten even worse since there have been lots of cuts within the agency. 

Rovner: Yep, that we’ve been talking about, and these are the result of those cuts. Sandhya. 

Raman: My pick this week comes from NOTUS, and it’s from Margaret Manto, and it’s called “.” I am from West Virginia, so was a reason why I was really intrigued by reading this story. But it’s really good. It looks at the work of a pediatrician in the small town of Summersville, and West Virginia has some of the highest childhood vaccine rates in the U.S. And the county where Summersville is has some really high rates compared to some of the more populous counties that are around it. This is a county that voted three times for President Trump. And just looking a lot at the changing climate regarding, you know, vaccination and attitudes there, and, you know, rural health more broadly. 

Rovner: It’s a really good story. Well, my extra credit this week is from the journal Health Affairs by my soon-to-be boss here at KFF, Mollyann Brodie. It’s a to one of her, and my, health policy heroes, Bob Blendon, the Harvard health policy professor who passed away earlier this summer. Molly was lucky enough to have studied under Bob, which I never got to do. But I still feel like one of his students, as he was always so generous with his time and so very quotable, and contributed so much to my personal understanding of the intersection of health policy and politics, which I try to share with all of you every week. We miss Bob already. May his memory be a blessing, and may he live on in those that he taught. 

All right, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had production help this week from Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts 鈥� 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? Maya? 

Goldman: I’m mostly hanging out on under my name. 

Rovner: Anna? 

Edney: , , @annaedney. 

Rovner: Sandhya. 

Raman: I’m on and on @SandhyaWrites. 

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

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

Julie Rovner: Hello, from 吃瓜不打烊 and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 吃瓜不打烊, and, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, May 7, 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 Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Sandhya Raman of Bloomberg Law. 

Sandhya Raman: Good morning, everyone. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Thanks for having me. 

Rovner: Later in this episode, we’ll have my interview with Andrew Jones, who reported and wrote the latest KFF Health News “Bill of the Month,” about an emergency room bill for what turned out not to be an emergency but could have been. But first, as always, this week’s news. 

Let’s start this week with the continuing fight over the abortion pill mifepristone. Last month, it appeared that the court fight over the pill was put on the back burner. That was after the Trump administration, to the consternation of abortion opponents, asked a federal district court judge to postpone proceedings while it finished a new safety review of the pill by the Food and Drug Administration. Well, the state of Louisiana, which had brought the suit to roll back the pill’s availability, wasn’t satisfied with that, and appealed the delay to the 5th Circuit Court of Appeals. Last Friday, right before dinner, a three-judge appeals court panel ruled in favor of Louisiana and basically ordered a rollback of abortion pill availability to the rules that were in place before 2021. That’s when doctors had to literally hand the pill to patients, meaning no telehealth and no pharmacy distribution. Shefali, you’re one of our abortion experts. Pick up the story from there. What happened over the weekend, and where are we now? 

Luthra: Over the weekend, there was a lot of confusion. I spent a lot of time talking to abortion providers and people who track abortion law quite closely. And providers were prepared to switch regimens, if they had to, to change to what’s misoprostol-only 鈥� using larger doses of the other drug in medication abortions, which is safe, is effective 鈥� is less safe, less effective? 鈥� but still good, though not gold standard. Meanwhile, we saw an appeal from the manufacturers of medication abortion to the Supreme Court. They also saw a stay from the 5th Circuit. While they might get some more time to figure things out, they never heard from the 5th Circuit. But then, on Monday, the Supreme Court weighed in and said, We are blocking this 5th Circuit ruling for a week. You have a few days 鈥� so, until Thursday, today actually 鈥� to submit arguments from both sides. And then, by the end of the day Monday, they are supposed to say whether this stay will be extended, whether they will be ruling, whether they might take up this case. And there’s a lot that could happen, right? They could try and make a ruling now, they could send this back to the lower courts. They could say, We want to hear arguments before this term ends, which would be at the end of June. They could say, We want to hear arguments on this in the fall, right before the midterm elections. But what they do could have real significance for whether mifepristone is available by telehealth, and, as a result, how people in states with abortion bans 鈥� but also where abortion is legal 鈥� get abortions. Because telehealth abortion is increasingly popular. One in 4 abortions are done by telehealth. About half of those are for people in states with bans, but half of them are for people in states where abortion is legal and protected. But going to a clinic and getting a pill handed to you is simply much more inconvenient and often impractical or not really possible, compared to having it mailed to you 鈥� if you have child care, if you can’t get off work, if you live really far from a clinic. And so access to this gold-standard regimen of abortion care is now possibly going to be very much in limbo for all these people across the country. 

I don’t know if we have seen much to indicate that this is going to be a campaign issue. We haven’t really heard as much chatter from Democrats as one might expect. But it is possible that if this becomes more of a live issue, if the Supreme Court makes those restrictions more permanent, or if they, in fact, do take this case up in a manner of timing that would be very influential, that this could, in fact, become a meaningful campaign issue, because most voters don’t like abortion restrictions, especially national ones. 

Rovner: Yeah, among the people who are sort of put in a difficult situation here is the Trump administration. The anti-abortion movement clearly wants more action on this issue. Trump was pretty clear, even on the campaign trail in 2024, that he doesn’t want to further restrict abortion; he’s already getting hammered for not following through on his promise to make in vitro fertilization more available. And now anti-abortion groups are planning to put not just money but their large volunteer power up against those candidates who won’t vow to take more aggressive federal action. How angry are they? And what impact could that have on the midterms, where Republicans are already on defense? 

Luthra: They are furious with the Trump administration. I mean, you have the head of SBA Pro-Life America : Trump is the problem. That’s quite blatant for what is ostensibly a close ally to the White House, an organization that has tried to influence policy, that has hoped for those influences to be translated into actual policy. It’s clear that they’ve given up on that. And many of them were very, very frustrated that the administration took on this purported review of mifepristone and kept saying, We will have more information for you later, probably after the elections. And that they, in fact, argued against Louisiana in the courts, and they defended their policy of having mifepristone available for now. And so I think what you’re seeing politically is this real possibility of schisms in the conservative movement. The people who oppose abortion and, right, are an important part of that base, but also, Trump may be unpopular nationally, but he still carries a lot of influence in a large part of the Republican Party. We just saw that in the primaries in Indiana this week. And so I think we really don’t know who wins. Do anti-abortion voters simply stay home? Do they say, Well, this is still our best option. It’s the Republican Party. And also, in the meantime, how much does the movement start thinking instead about trying to pick a possible successor to Trump? And a lot of them really are focusing now on the midterms, but also on 2028. And so do they just say, Well, we’re done with this. We’re not going to win and move on. Or is there something that they might be able to get if they keep threatening to withhold money and voter influence? Open question. I think we’ll see. 

Rovner: Jessie, Sandhya, you guys are on the Hill. I mean, you know, there’s been a lot written this week: Oh, Democrats haven’t said anything about this. I think this came as a bit of a surprise. I think we, most of us, thought that this was going to be kind of back-burnered until after the election. Do you see Democrats picking this up and running with it at some point? It has, it has been, it’s been an effective political issue, but maybe not so much in terms of votes, right?  

Hellmann: I don’t know if Democrats really saw much gain from focusing on abortion in the last round of elections, which feels like such a weird way to talk about it. But they might think that other campaign issues, like the affordability issue, healthcare costs, more generally, might be more of an issue that they want to hit on 鈥� especially after the ACA tax credits expired. But we might see more from them as this issue continues to play out in the courts. 

Rovner: And I’m just wondering if, you know, if Republicans start 鈥� I mean, we’ve seen people like Bill Cassidy, the chairman of the HELP [Senate Committee on Health, Education, Labor and Pensions] Committee, who’s been very outspoken, you know, and has long anti-abortion bona fides, I mean, going back pretty much his whole career. But it’s interesting that he’s been hammering on this. I’ve seen Republicans on the Hill hammering on this in a way that separates them from the president, which is a little bit surprising. It makes me wonder if Democrats are going to try to exploit that difference or not, or if they can figure out how, or if just, as you say, affordability is so much a bigger issue right now. 

Hellmann: I think the Bill Cassidy race is really interesting. He’s in a heated primary against Julia Letlow, and he seems to think that this mifepristone issue is going to be, like, a wedge issue in that race. He’s the chairman of the HELP Committee, so he spends so much time talking about this. Even when HHS [Department of Health and Human Services] Secretary RFK [Robert F. Kennedy] Jr. was on the Hill a few weeks ago, this is one of the first things that he asked him about, and he didn’t even get to the vaccine issue until later. But I think that maybe in those more conservative primaries, it could be an issue. But then it’ll be interesting to see how he’ll talk about it later on, if he does win that primary. 

Luthra: I think one thing to note about the Cassidy primary that I’m really surprised by 鈥� and I think speaks to the complicated state of things, and maybe the fact that people thought this was a resolved issue 鈥� is he talks about it a lot on the Hill. If you go through his TV ads that he is running in this very close primary, they’re not about abortion. He has not had a single TV ad about abortion, and it is largely instead about trying to assert his bona fides as a true partner to Donald Trump. And I think that’s really interesting because, again, as we’ve discussed, Trump is not really interested in this issue, and Louisiana primary voters certainly are. But there’s a calculation, right? Do you want to situate yourself as the partner to the president, or do you want to talk about abortion? And maybe you can do both, but maybe it’s actually really difficult to do both of those things. 

Rovner: Well, one thing I haven’t seen mentioned in this latest round of debate over abortion is the potential impact on the rest of the drug industry. Once again, justices are being asked to step in and override the presumably evidence-based findings of the Food and Drug Administration. The last time we got this close to a Supreme Court ruling on an FDA approval of mifepristone was in 2024, when the justices were able to punt by pointing out that the doctors group that brought the suit didn’t have standing. But it doesn’t look like that’s as viable an out this time, because it’s the state that’s suing. Why haven’t we heard more from drugmakers, who we know are freaking out about not being able to rely on FDA decisions to make, you know, business plans worth billions of dollars? 

Raman: I think we will. I think it really depends on what we see in the next week, in terms of is this getting escalated, that the Supreme Court would hold arguments, or where we are? If I think back to 2024, I feel like a lot of more of the involvement from the pharmaceutical industry 鈥� when they were speaking out more, holding briefings, maybe submitting those briefs 鈥� was when we got to the Supreme Court stage. So I think it’s a matter of time. And right now it’s, you know, kind of figuring out their options and what they’re going to do. But a ruling could have a huge impact on so many other drugs. So I doubt that they’d be quiet as we get further along. 

Rovner: Yes, I would expect, I mean, we’re going to see a flurry of briefs by the end of the day today, and I would expect that the drug industry would be among those who are going to be filing those briefs. So we will know more. 

Luthra: In fact, we actually already have a brief from PhRMA [. 

Rovner: Oh good. 

Luthra: It came in either last night or this morning, and it says exactly what you’d say, that they are concerned that pharmaceutical development will suffer if Louisiana wins, that this is really problematic for drug research and development. And we are seeing some op-eds from biotech CEOs, etc., in places like Stat just highlighting that they are very concerned about the ramifications for the industry. So I think so I’m just totally right, like, as this case picks up steam, that chorus will get louder and louder, because this is just too consequential for the industry to not talk about. 

Rovner: Right, this is about much, much more than abortion. All right. Well, speaking of the FDA, Commissioner Marty Makary’s job is, quote, “on thin ice” 鈥� that was, were the exact words used in stories from Bloomberg, NOTUS, and The Wall Street Journal, all in the past few days. On the one hand, we’ve heard these rumors before, as things at FDA have been chaotic, to say the least, but this week’s flurry of rumors appears to be over Makary’s overruling of FDA scientists who recommended approval of mango- and blueberry-flavored vapes. Makary was reportedly concerned about attracting children to vaping by approving fruit flavors. This has been a long-standing argument. While the scientists who recommended approval wanted to help adults actually quit smoking, which is demonstrably worse for their health than vaping. As it turns out, the flavored vapes were approved on Tuesday, apparently after President Trump intervened personally by calling Makary. So this raises two questions. First, is this more politicization of FDA policy? It certainly looks like it, even if the ultimate decision here was what the FDA scientists actually wanted. 

Raman: I mean, if you look back to when President Trump was on the campaign trail, he did talk about wanting to save vaping and how that was a big issue for certain voters and stuff. So it has been something that’s been in the back burner. These kind of approvals and authorizations take a very long time. And they’ve, you know, a lot of folks have been complaining for a long time about how long some of these things take. They can be backlogged for years. And we had very different opinions with some of the appointees during the Biden administration about how to handle flavored nicotine and tobacco products. I do think that the short turnaround between some of those conversations over the weekend and then suddenly this getting authorized is a little unusual, but it’s kind of hard to say where they were in the process before that, if they were dotting the i’s, crossing the t’s, or if this shoved things forward a lot more. So it’s hard to tell, but I think it really does build into your earlier point about how folks are just not sure for how long that he remains as FDA commissioner. I mean, there have been things building for months, but it really has heated up in the last couple weeks or so. And I think something that raises for me there is just if he does get out at some point soon, that would make another thing that the Senate has to get through and, you know, find agreement on which could get even more complicated if, depending on what happens with 鈥� 

Rovner: 鈥� with the abortion case. 

Raman: Yeah, and Cassidy’s race! 

Rovner: Oh, Cassidy’s primary! That’s right. Yes. 

Raman: Yeah. So I think there’s a lot of interconnected things that will be really interesting to watch here as this plays out. 

Rovner: Well, there’s also, before we get off of this, there’s a broader question here about harm reduction. Sandhya, we just talked about this a few weeks ago, after the federal government said it would stop paying for test strips to detect fentanyl and other potentially fatal substances added to illicit drugs. So harm reduction is bad when it comes to fentanyl strips, but good for flavored vapes? 

Raman: I think we’ve had a lot of conflicting messaging on this. Flavored vapes, I guess, are a little bit more complicated, because you could be an adult and just go straight into flavored vapes, and it is a little bit more complicated than that. 

Rovner: And it is a legal product. 

Raman: Yes, it is a legal product. You know, it’s regulated very differently. But I think, since you did bring up harm reduction, the interesting thing there that has been happening is just that there’s been so much differences of opinion, despite that guidance. You know, we had the Office of National Drug Control Policy this week put out their drug control strategy plan for the year, and that had language in favor of the testing strip. So we’ve had a lot of conflicting messages between different parts of the administration over the same issue, which is really confusing folks on the ground. 

Rovner: It is. Well, in other news from the FDA this week,  that the agency blocked the publication of several studies that found very few serious side effects from vaccines for covid-19 and shingles. This included top FDA officials ordering the withdrawal of studies that had already been accepted by medical journals. This is far from the first that we’ve heard of this sort of thing from the FDA and from the Centers for Disease Control and Prevention. But it does increase the doubts that this administration is, quote, “following the science,” does it not? 

Raman: I mean, we saw the same kind of reaction in terms of why this happened from HHS, you know, saying that the studies were making really broad claims, and they were not supported by whatever the underlying data that they had was. I think that this and the CDC vaccine study getting pulled are both highly unusual, but the fact that they’re both happening in a short period of time, you know, kind of increases that. I think it’ll be interesting, you know, we saw with the CDC study that it ended up getting leaked, and then people were able to look at it and make their own conclusions. What happens with this? But having these studies about vaccine efficacy being pulled when the administration is trying to pull back on their vaccine messaging is, like, a less salient issue for the midterms is interesting. So I’m curious what happens next there. 

Rovner: Yeah, me too. OK, we’re going to take a quick break. We will be right back. 

OK, we’re back, and of course, we have more personnel news. Last Thursday, just after we taped, thank you very much, President Trump pulled the nomination of Casey Means to become the next surgeon general after it had become clear she did not have the votes to even move out of committee. In her place, the president nominated Dr. Nicole Saphier, a Fox News contributor who did finish her medical residency and is a practicing radiologist specializing in breast imaging, and 鈥� apparently this is now a requirement for a high job at the Department of Health and Human Services 鈥� she’s a podcast host. Just this week, there’s been a  that were critical of some of the health stances taken by President Trump and HHS Secretary RFK Jr. But I imagine that might actually help her nomination, which has generally been pretty well received, by making her look like she’s at least as interested in accurate medical advice as she is in currying favor. Or am I misreading this? 

Raman: I don’t know that the tweets are going to have a huge effect either way, when there’s so many other things going on. And I feel like it’s so interesting that her book from, you know, long before this administration, was called Make America Healthy Again. So it seems like if anyone is committed to this movement, it would be someone with a book titled that six years ago. 

Rovner: Although she’s not really a MAHA person, right? 

Raman: Yeah, yeah. But it just is such a funny coincidence. But I think that right after they pulled the Means nomination, it was interesting 鈥� kind of goes back to what Jessie said was that 鈥� we had the president; we had her brother, Calley Means; and then we had Secretary Kennedy as well digging in on Cassidy and blaming him for that nomination falling through. But they did back the new nominee. So it’s interesting what is going to happen there. But just how political just getting this across is, even though there weren’t other votes in the Senate to get Casey across the finish line. 

Rovner: Yeah. Shefali, you were going to add something? 

Luthra: Oh, I just think that the tweets, I mean, they are really striking, and I think you’ve hit on something that is a fascinating tension. This is someone who has criticized the president’s talking points around Tylenol in pregnancy; who has said that, you know, maybe there is not a link between Tylenol and pregnancy and autism. Maybe I don’t want to be told just tough it out when I am in pain. She also, fascinatingly, is quite anti-abortion, and has talked about that a lot as well. And I think there’s just a lot of really complicated worldviews that she brings. And on the one hand, like, maybe some of that ends up being appealing to lawmakers because, as we’ve discussed many times on this podcast, the stances that are more anti-vax, anti-medicine, anti-science are not necessarily that popular with voters, and lawmakers are reacting to that. That’s why it’s been so difficult to confirm a surgeon general nominee. And maybe this finally changes that. Maybe deleting those tweets does suggest that someone would rather remain in good standing with the president. I don’t think we really know until 鈥� if she gets the job and then see what happens. But it is really fascinating to see the third person picked, where there’s still an unfilled position, possibly being someone a bit more aligned with some things that are, in fact, conventionally accepted medicine. 

Rovner: Well, we will see. And of course, this is 鈥� yet another nomination that has to go through Bill Cassidy’s HELP Committee. And regardless of what happens in his primary, even if he loses his primary, he’s going to be the chairman of that committee until the end of this year. So we will have to see. 

All right. Moving on to the Affordable Care Act, we have more evidence this week about the impact of last year’s big budget bill and the expiration of those covid-era additional premium subsidies that they’re having on enrollment.  that analysts and state officials are expecting a drop of about 20%, dropping from 24 million in 2025 to about 19 million. Insurance company Cigna announced last week that it’s dropping out of the ACA marketplace. It currently sells in 11 states. And hospitals are reporting their first-quarter results that are already experiencing the fallout 鈥� from lower admissions to more uncompensated care. That includes not just people who’ve dropped insurance, but people who had to buy insurance with higher deductibles that they may not be able to pay. Republicans in the Trump administration have tried to downplay the reductions, but as the year wears on and the results get more obvious, aren’t they going to have to have some counterargument to this? 

Hellmann: A 20% decrease in enrollment could be really bad for the marketplaces, especially if the people who are leaving are healthy. It’s going to lead to a sicker risk pool, which is going to possibly lead to higher premiums in the future. So you would think that the administration would have to respond to that. But they have also showed that they’re not really a friend to the ACA, and the first Trump administration also did a lot of things to undermine it. So I’m not sure that they’re going to try to find a way to fix these problems. And they also had a recent marketplace rule that some experts actually think could weaken the health of the marketplaces even more.  

Rovner: Yeah 鈥� I know the Republicans 鈥� one of the big Republican talking points is that a lot of these people were what they call phantom enrollees. They didn’t even know they were enrolled. They didn’t file any claims. But, as you point out, a lot of people have insurance and don’t file any claims because they are healthy. Those are kind of the people that the insurers want. Obviously, not phantom people who don’t know they’re enrolled. That’s fraud. But people who 鈥� have insurance and don’t use it are a good thing for the insurance industry. Shefali, you’re nodding. 

Luthra: No, I was just thinking about all the years I’ve had health insurance and didn’t file a claim. Like, of course you would want that. That’s awesome. It doesn’t mean I wasn’t covered. It meant that I relied on the peace of mind of having health insurance. And I would be very sad if I started filing claims for insurance and suddenly all the healthy people were gone. That would be terrible. 

Rovner: Yeah, we will 鈥� again, I think we’re going to get more evidence as the year wears on, and this is going to become a big, I think, campaign issue, obviously. 

Well, I want to talk about global health, at least briefly. A lot of people are watching that Dutch-flagged cruise ship with passengers sickened and some dying of hantavirus. Now, hantavirus is not normally spread person-to-person, but it is fairly clear that that’s what’s happening in this case, and it appears the outbreak is being fairly effectively handled by the World Health Organization. But of course, the U.S. left the WHO when Trump returned to office, so the U.S. is not only not helping with this, it’s out of the loop, even though there are more than a dozen Americans who’ve been on board, and reportedly seven who could have been exposed to this who have disembarked and already returned to the U.S. This is kind of why the U.S. was part of the WHO, right? When you have an international incident like this? 

Raman: Yeah, and I was just listening in to [an] infectious disease briefing this morning, where they were detailing how this situation is unusual. Usually, at this point in a crisis like this, we would have had more communication from the CDC, from the NIH [National Institutes of Health], just about the state of play, different briefings, or just going and helping with the situation. And we haven’t seen that, and just how striking that is right now. 

Rovner: And of course, I mean, so many people are having PTSD [post-traumatic stress disorder] from covid, and remembering, you know, cruise ships with people with covid. Public health experts say that’s not going to happen here with hantavirus. It’s just this one strain of hantavirus that spreads person to person. It’s hard to spread it. But with so little trust in science and so much misinformation, you got to wonder whether even this incident that shouldn’t cause a panic might anyway. 

Raman: Yeah, I think that has been kind of the concern is that this is something that the experts are worried about, and they’d like to learn more about, because there is a new case that they can learn from, to provide more public health information. But to not panic over this, just because the things that you said: This is not likely to cause another major pandemic in the same way as covid. 

Rovner: Well. Finally, this week, HHS Secretary RFK Jr. has struck out on another cause. Now he wants to get people off of their antidepressants. At a MAHA meeting on Monday, he unveiled a series of steps for doing that, from encouraging non-drug interventions for mental health conditions, to paying doctors to counsel patients for how to taper off the medications. He says he doesn’t want to tell people to stop taking their drugs, which can be lifesaving in many cases, although he’s also said he doesn’t want people not to be allowed to take vaccines, too. So where is this headed? Is this 鈥� this is a big, I guess, some MAHA people think people are overmedicated with antidepressants and ADHD [] drugs. 

Raman: I think it has a lot of the same playbook that we’ve seen with vaccines. He’s talked about over-medicalization as an issue for a while now. It was in the last MAHA report about a year ago, and even before that, he’s brought it up. My sense from attending that event this week was not that they were really looking at changing prescription guidelines, but I guess it’s hard to tell where we’ll see further along down the line. But it was more of just like an exploratory stage, you know, training physicians about different things related to tapering and things like that. But sometimes that’s the start of things changing down the line, and it is interest[ing], that kind of brings back his focus to very much the psychiatric drugs, the ADHD, depression, anxiety, and just wanting to lessen the medications there. So. 

Rovner: I can’t help but wonder if, because he’s been told to back off of the vaccine issue, because it doesn’t play that well with the public, that he’s going to pick this up as his next crusade.  

Raman: There was a huge emphasis on informed consent, which is, I feel, another big talking point with vaccine. So there is a lot of similarities in how it’s approached. So, I would look for more of those kind of clues there. 

Luthra: I think it’s also worth noting, even if this is early rhetoric that we know from research that rhetoric does influence prescribing behavior. We saw that study that showed after the “don’t take Tylenol when you’re pregnant” kerfluffle, prescriptions of Tylenol went down for people who are pregnant. And this is not really the first time RFK has talked about SSRIs, specifically. He’s talked about them with regard to pregnancy, in particular, and that’s already a very stigmatized, very fraught time for people, even though the consensus is, if you are depressed, stay on your medications. And I think this is something absolutely worth keeping an eye on, even if this is largely rhetorical, discouraging use of medications. Does that translate into changes, especially around something that is fraught and is often stigmatized and misunderstood, like antidepressants, which, as you mentioned, Julie, are lifesaving and very important for people with severe depression. 

Rovner: Indeed, and for people with severe anxiety. All right, that’s this week’s news. Now we’ll play my “Bill of the Month” interview with Andrew Jones, and then we’ll come back with our extra credits. 

I am pleased to welcome to the podcast KFF Health News’ Andrew Jones, who reported and wrote the latest “Bill of the Month.” Andrew, welcome. 

Andrew Jones: Thank you so much for having me. 

Rovner: So tell us about this month’s patient 鈥� who she is, where she’s from, and what happened that landed her in the emergency room. 

Jones: Silvana Toska. She’s from Davidson, North Carolina. It’s just north of Charlotte. She’s a professor of political science there, and a mom of two. And while she was outdoor at an event last fall, she got bit by an insect, and she ended up with such a bad systemic allergic reaction that she got anaphylaxis. What anaphylaxis means is that her lungs began to be difficult to breathe. And so she broke out in hives, and she immediately decides, with her husband, to go to an urgent care, where she gets treated with two doses of epinephrine. And then the doctor says you need to be under watch for a couple of hours, so you need to go to the ER, which is kind of where our story starts. 

Rovner: So she doesn’t drive off to the ER, she goes in an ambulance to the ER, right? 

Jones: That’s correct. Yeah. They put her in the back of an ambulance, and they ship her off to the ER. Her husband and her two kids follow. 

Rovner: So by the time she got to the ER, she was already feeling better from the medication that they gave her at the urgent care. That’s what’s in an EpiPen, right? 

Jones: That’s correct, yeah. 

Rovner: The epinephrine. So what happened when she got to the ER? 

Jones: So, not a whole lot, actually. Like you said, she’s feeling fine at that point. A doctor comes in. The doctor sees her for less than five minutes, asks her about her condition, does a quick checkup, doesn’t actually make physical contact with her, which I thought was very interesting. And then the doctor steps out. And she basically spends an hour and a half doing nothing, trying to keep her kids entertained. And she gets a dose of Pepcid to keep the allergic reaction at bay. But after the doctor came in again, just to say that she could leave, she left, and it was an incredibly uneventful ER visit. 

Rovner: And then, as we say, the bill came. So how much is the ER charge for her couple of hours of follow-up 鈥� at which not very much happened? 

Jones: Yeah. So that empty hour and a half, essentially, for that time, she was charged $6,746.50. And at the end of the day, she was responsible for a $150 copay and $3,100.24 鈥� a bill that she got on Christmas Day that year. 

Rovner: Awesome. So what was the justification for such a big bill for such 鈥� I won’t say “little care,” but what seemed to be little care? 

Jones: Yeah, well, she was actually charged for something that wasn’t little. It was called “critical care.” She was coded for critical care, her time there was. And the experts that I spoke to said that while Toska had every right to think that it was an outrageous price to charge, it was probably an appropriate charge for the situation, those codes were. And that’s partly because of a coding system that really isn’t hyper-specific to individual cases. Toska needed to be in the ER setting because of the anaphylaxis. It can return and cause a critical situation. And while she was coded based on what might have happened, rather than what did happen, it ended up not working in her favor as far as the bill went. And so people all over the U.S. experience this. Another expert I spoke to said that people are brought on that train of care when they arrive to the ER. There’s really no way to get off once it starts moving. And you don’t know what it’s going 鈥� what the dreaded bill is going to be once it stops. And there definitely could be reform in the way that U.S. healthcare system does ER coding, although there would have to be some, you know, pretty titanic changes for that to happen. But I’ll say that if listeners ever find themselves concerned about a bill, they should definitely call their insurance company, ask if there was an attempt to negotiate, and they should call the hospital to check the accuracy of the coding. Toska did do both of those things and, unfortunately, nothing changed. But I can say that that was the right thing to do. There was some great back-and-forth. There was a letter that explained why they did that and, ultimately, what happened to her comes down to a coding system that did not work in her favor. And she told me that recently she experienced another allergic reaction, but instead of going to the ER, she just took some Benadryl instead. 

Rovner: And you know, I guess the takeaway here is that when a medical professional tells you to go to the ER, it’s not usually because they’re going to make money from sending you to the ER. It’s because something could happen that you should be in the ER for it. I guess that’s sort of why we have medical insurance, right? 

Jones: Absolutely, absolutely. Yeah. I mean, she really had no other choice. It was the right thing for her to do. But again, because of a coding system that wasn’t specific to her situation, it ended up 鈥� I see, you know, testimonies all the time from people who see this very outrageous bill for a little care. Toska is the first time I’ve seen a bill where there was essentially no care that she could see. And so I think it’s fair for her to have this discussion in her mind and with her family, and here in this article about: Is our coding system fair? But ultimately, when a provider says you need to go to the ER to make sure that you know your situation is taken care of, that’s what you have to do. 

Rovner: Andrew Jones, thank you very much. 

Jones: Julie, thank you. 

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

Hellmann: My extra credit is from Nature. It’s titled “.” They [Max Kozlov, Alexandra Witze, and Dan Garisto] did an analysis showing that more than 100 independent advisory panels have been terminated. These are panels that advise agencies on biomedical environmental policy and other types of health policy. They’re typically staffed by researchers and other experts from outside of the government. And now so many of these groups are being canceled, there’s concern that this could result in less transparency and more of agencies making decisions within their own ranks. And then they also found that groups that are still in existence are meeting less and less. They’re not issuing public reports. An example of this that we all know about is the Advisory Committee on Immunization Practices, which is tied up in a big legal dispute right now. And the White House defended all of this, is saying that these panels are a waste of taxpayer dollars that don’t meaningfully inform policymaking. So I thought that was a good read on something that doesn’t get a ton of attention. 

Rovner: Yeah. Well 鈥� of course, these panels are intended to bring in the public to make public policy. That’s kind of why they’re there. They’ve always been sort of a bipartisan thing. Anyway, really interesting story. Sandhya. 

Raman: So my extra credit is from The Cut, and it’s called “,” and it’s by Juno DeMelo. And this was a story that, you know, they talked to a lot of pediatricians about how their jobs have changed given the increasing vaccine skepticism. And some of these pediatricians are talking about having to really sell to their patients and their families why pediatric vaccines are necessary, or just devoting a lot more time, having a longer appointment just to explain why this is necessary. Sometimes it takes multiple appointments, which is just different with what they’ve had to do from the past. And, you know, the fatigue from having to go into all the science, instead of just presuming the child will get the vaccine and being able to discuss other things 鈥� safety and signs to watch and growth, and all of that. And so I think it was a good look at some of the things that drilled down on that. 

Rovner: Yeah, it was. These policy changes have impacts way down the line. Shefali. 

Luthra: My story is from ProPublica. It is by Duaa Eldeib. The headline is “.” It’s about families opting out of vitamin K shots, which are useful for blood clotting for newborns, and babies dying. And I think the story is remarkable for several reasons. It’s really got remarkable examples, and we see who these children are who are dying. We know how old they are, we know the color of their hair. We know what their symptoms were and what happened to them. There isn’t government data tracking vitamin K shots and whether they are rejected, but the story does a really good job painting a picture anyway. It has interviews with hospitals who have seen more and more parents saying we don’t want this because we are concerned. And it contextualizes this within the rising anti-establishment approach to medicine, more skepticism around well-researched and appropriate interventions. There is data showing how many children die from this spontaneous bleeding that can often happen if you’re deficient in vitamin K. And together, it uses those different points to create a picture of a troubling and avoidable public health trend that’s resulting in kids dying. 

Rovner: Yeah, more fallout from the anti-vax movement. My extra credit this week is from my KFF Health News colleague Stephanie Armour, and it’s called “HHS’ Healthy Food Agenda Puts Hospitals on Notice About Patients’ Meals.” It’s a story about something that we’ve talked about before in the podcast, the new HHS policy that threatens hospitals’ Medicare and Medicaid reimbursement for facilities that don’t conform to last year’s new dietary guidelines. But there’s some pretty vivid detail here about how those guidelines actually fail to address the needs of many hospitalized patients who may be limited in their ability to eat or drink and might actually need Jell-O or ginger ale or Ensure, all of which are now at least theoretically banned. And the administration is also asking patients to report hospitals that are violating the new rules. Again, another thing that was not on my 2026 bingo card. 

All right, that’s this week’s show. As always, 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 鈥� 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 . Sandhya, where are you hanging these days? 

Raman: I’m on  and on  @SandhyaWrites. 

Rovner: Jessie. 

Hellmann:  on  and  and also on . 

Rovner: Shefali. 

Luthra: On Bluesky . 

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

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

Julie Rovner: Hello from 吃瓜不打烊 and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for 吃瓜不打烊, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

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

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with 吃瓜不打烊’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies 鈥� the ones that expired Jan. 1.  

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

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

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

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

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

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

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

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

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

Rovner: Yeah, we will, but we’ll believe it when 鈥� we get to the signing ceremony. 

Ollstein: Exactly. 

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

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

Rovner: Yeah. 

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

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

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

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

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

Rovner: It’s $5.3 trillion. 

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

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

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

Rovner: Right. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner: Puberty blockers! 

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

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

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

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

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

Edney: Yeah. 

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

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

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

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

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

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

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

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

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

Elisabeth Rosenthal: Thanks for having me back. 

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

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

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

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

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

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

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

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

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

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

Rovner: I know the feeling. 

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

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

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

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

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

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

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

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

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

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

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

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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