The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition. Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care. Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next. This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico. Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Among the takeaways from this week’s episode: Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS. ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in. A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill. As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost. Also this week, Rovner interviews KFF Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here. Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: Julie Rovner: The New York Times’ “ E.P.A. to Stop Considering Lives Saved When Setting Rules on Air Pollution,” by Maxine Joselow. Alice Miranda Ollstein: ProPublica’s “ After Sowing Distrust in Fluoridated Water, Kennedy and Skeptics Turn to Obstructing Other Fluoride Sources,” by Anna Clark. Joanne Kenen: The New Yorker’s “ What ‘The Pitt’ Taught Me About Being a Doctor,” by Dhruv Khullar. Anna Edney: MedPage Today’s “ Worried About Liability After CDC Vaccine Changes? You Shouldn’t Be,” by Joedy McCreary. Also mentioned in this week’s podcast: The Washington Post’s “ A Majority in Name Only? House Republicans Are Barely Hanging On,” by Paul Kane. HealthAffairs’ “ National Health Care Spending Increased 7.2 percent in 2024 as Utilization Remained Elevated,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin. Politico’s “ Lawsuit Dismissed After Trump Admin Quietly Restored Tens of Millions to Planned Parenthood,” by Alice Miranda Ollstein. JAMA’s “ The US Food and Drug Administration’s Regulation of Mifepristone,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander. click to open the transcript Transcript: Culture Wars Take Center Stage [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 KFF Health News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today, we are joined via video conference by Anna Edney of Bloomberg News. Anna Edney: Hi, everyone. Rovner: Alice [Miranda] Ollstein of Politico. Alice Miranda Ollstein: Hello. Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. Joanne Kenen: Hi, everybody. Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies — 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 — in the words of longtime Congress watcher Paul Kane of The Washington Post — 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 — 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 … 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 — which are actually stronger than many predicted, with fewer people actually dropping coverage — 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 … I think what Julie said is it’s … 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 2024 national health spending numbers this week, 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 … 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 — the out-of-pocket cost of insurance for millions of Americans, 20-ish million — but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but … 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 — in economically — 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 … it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers — and I’ll post a link to them — 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 — 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 — 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 — you know, again, including senators like Cassidy, but also these activist groups — 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 Journal of the American Medical Association this week, 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 … 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. Rovner: 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 was quietly dropped 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 … 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 … Rovner: Puberty blockers! Edney: … they’re taking — exactly — 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 — 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 … 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 … 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 — 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 — I’m not exactly sure how many years — 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 — 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 — 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 … 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 — and to Alice’s point about how this hasn’t saved money — more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just … 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 … 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 — 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 — 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 … 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 — 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: “ Worried About Liability After CDC Vaccine Changes? You Shouldn’t Be.” 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 — 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 “ After Sowing Distrust in Fluoridated Water, Kennedy and Skeptics Turn to Obstructing Other Fluoride Sources.” 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 “ What ‘The Pitt’ Taught Me About Being a Doctor,” and it was really great, because there’s certain things I think that we who — like, I don’t know how all of you watch it — 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 “ E.P.A. to Stop Considering Lives Saved When Setting Rules on Air Pollution,” 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 — 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 @jrovner, or on Bluesky @julierovner. Where are you folks hanging these days? Alice. Ollstein: Mostly on Bluesky @alicemiranda and still on X @AliceOllstein. Rovner: Joanne. Kenen: I’m mostly on Bluesky or on LinkedIn @JoanneKenen. Rovner: Anna. Edney: Bluesky or X @annaedney. Rovner: We will be back in your feed next week. Until then, be healthy. Credits Francis Ying Audio producer Emmarie Huetteman Editor Click here to find all our podcasts. And subscribe to “What the Health? From KFF Health News” on Apple Podcasts, Spotify, the NPR app, YouTube, Pocket Casts, or wherever you listen to podcasts. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF. USE OUR CONTENT This story can be republished for free ( details ). With lawmakers still mired over renewing enhanced tax credits for Affordable Care Act plans, much of Washington has turned to culture war issues. Meanwhile, “confusion” remains the watchword at HHS as personnel and funding decisions continue to be made and unmade with little notice. Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico join KFF Health News’ Julie Rovner to discuss those stories and more. Also this week, Rovner interviews KFF Health News’ Elisabeth Rosenthal, who wrote the latest “Bill of the Month” report.