[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. Welcome toWhat the Health?I’mJulie Rovner, chief Washington correspondent for KFF Health News.And,as always,I’mjoined by some of the best and smartest health reporters covering Washington.We’retaping this week on Thursday,April 23,at 10a.m.As always, news happens fast, and things might have changed by the time you hear this. So here we go.
Today, we are joinedviavideo conference bySherylGay StolbergofThe New York Times.
Sheryl Gay Stolberg:Hi,Julie.
Rovner:Alice MirandaOllsteinof Politico.
Alice MirandaOllstein:Hello.
Rovner:And we welcome back to thepodcastmy formerKFF Health News colleague Victoria Knight,now at Bloomberg.
Victoria Knight:Hi,everyone.Happyto be back.
Rovner:Later in this episode,we’llhave the latest installment of our“How Would You Fix It?” series.This week with David Blumenthal, aphysician, health policy expert, author,and former Obama administration official.Heliterally wrotethe book on the history of presidents and health reform through George W.Bush, and he has abrand-newbook on the last three presidents and their health care policies. But first, this week’s news.
So,Health and Human Services Secretary Robert F Kennedy Jr.on Wednesday completed his tour of Capitol Hill, having appeared before seven separate House and Senate committees in four days of hearings.Ostensibly, Kennedy’sappearances were to answer questions about President[Donald]Trump’s budget proposal for the Department of Health and Human Services. But,as usual, there were lots of other topics as well,as this was the first time the secretary appeared before some of these panels, and the first time some of these members of Congress got to question him in personever.Victoria, you sat throughall ofthe hearings, right? Or at least all the hearings this week. What was your big takeaway?I guess, not as many fireworks as some of us might have been expecting?
Knight:Yeah,definitely notas many fireworks. I mean, I think thatit’spretty clearKennedy has gotten a mandate in some way from the administration to watch his rhetoric, basically, especiallyhis vaccine rhetoric. And we even,at Bloomberg,we’vehad reporting directly saying thathe’s…there’san internal memo that said, you know,he’dkeep his messaging on chronic diseases and nutrition and health care affordability, you know,more palatable topics.SoI think hedefinitely triedto stick to thatmessaging. But there were points wheretheKennedy that has for years been anti-vaccine came back through.Andsowe saw that in certain lines of questioning.Andalsohe reallywasn’table tojustify the cuts. He was there on the Hill to testify about the HHS budget, which President Trump proposed putting in still significant cuts to HHS. Itwasn’tas deep asproposedlast year.But therewasn’treally any good justification that Kennedy provided, except that the U.S.is in a lot of debt, and they need to, we need to reduce it. But he kept being,like,Theprograms are still good.We need to do these programs.
Rovner:I’mamused, because this, you know, goes back forever of when Cabinetsecretaries come up to justify cuts to their departments that they clearlydon’twant to make, andthey’renot allowed to say,Butitwasn’tmy idea.
Knight:Well,and alsothat they knowCongress will reject it. Andsoit’s,it’skind of allfakeanyways.All these congressional appropriators are like,Yeah, this is not happening.
Rovner:Yeah. Hence thereason whythey get to talk about other things. I will say one thing that I noticedisthat he was less rude to these committees than he had been inpreviousappearances on Capitol Hill.
Stolberg:Really?
Rovner:Yeah.
Stolberg:I sat throughall seven of them.Julie.I thought he waspretty rude.
Rovner:I guessit’sall in how you look at it. I thought hewasn’t. Yes, he was definitely still rude, but I really thought there were times when he had now sort of taken the briefing that you get, which is to try and agree with something that a member of Congress says, and says,I will work with you, which he hasn’t done before.He’djust been combative before.
Stolberg:Thatmaybe istrue, but he has a habit of addressing members of Congress by their first name, which is a serious violation of protocol. And he was rebuked in the House last week for doing that with Frank Pallone, the Democrat of New Jersey.He did apologizefor that, which I thought was interesting.But that did not stop him from also accusing senators of,Democrats,of making stuff up, grandstanding,and, you know, fake indignation.And,you know, he yells at them. And then at one point, DianaHarshbarger, the Republican in the House that was chairingthecommittee, said to him, she just said,I thinkit’dbe best if everybody would just simmer down.
Rovner:Yeah, there were definitely moments.
Stolberg:And I would add to what Alice[Victoria]said, I do think that the big takeaway was that vaccinesreally stilldominate his tenure. That is the defining issue of his tenure.[Sen.Bill]Cassidy yesterday was very pointed in correcting Kennedy when Kennedy cited a study that he said showed that advances in or reductions in deaths fromaninfectiousdisease were largely due to hygiene and sanitation, which is actually true in the first half of the 20th century, before vaccines were introduced. And the second line in that study, whichKennedydid not cite, was that, you know, vaccines had made an incredible difference and were extremely important. AndCassidy had somebody look up that study in the middle of the hearing and came back to Kennedy and said,Thisis what youdidn’tsay.You took it out of context.
Rovner:Yeah, I was actuallyvery impressed, because first Cassidycouldn’tfind the study, and then…
Stolberg:I knew the study because I hadcitedit before.
Rovner:I had a feeling youprobably knewit. I was trying to find it, and Icouldn’tfind it.SoI was glad that theydid.
Stolberg:It’sin theJournalofPediatrics in 2000by an author named Guyer, not DavidGeier, but G-U-Y-E-R.You can look it up.
Rovner:We could. I willput a link to itin the show notes.OK.
Knight:I did want to mention also, I do think Cassidy did press Kennedy on vaccines. Certainly, everyone was watching that very closely because of his hesitation last year to vote for Kennedy, and really talking about struggling with the vote,and extracting all these commitments from Kennedy,ostensibly tovote for him, for HHSsecretary.Cassidy did not mention any of those,like Kennedy violating any of those commitments, which he clearly has. He was supposed to be in frequent contact with theHELP[Health, Education, Labor & Pensions Committee]chair,goup to the Hill quarterly. Hehadn’tbeen to the—Kennedy had not been to the Hill since September. In some of the committees, hehadn’tbeen there since last year, the last budget proposal.SoCassidy also did not mention these childhood vaccine recommendation overhaul that Kennedy did, which is a huge deal. And he did not mention the Advisory Committee on Immunization Practices being completely overhauled as well, and all those members being fired, which are two things Cassidy said he extracted commitments from Kennedy on.SoI just want to make that point.Yes.
Stolberg:One quick on that. After the hearing, I asked Cassidy,“Do you think Kennedy has lived up to his promises to you?”And he looked at me and he said,“We’ll talk later.”
Rovner:I would say, Alice, youwrotea separate story about the fix in whichChairmanCassidy finds himself.He’sbeing challenged in a primary byaRepublicancongresswomanendorsed by the Make AmericaHealthyAgainPAC. I thought Cassidywasactually morerestrained than I expected him to be in yesterday’s hearings.AlthoughI think Iguess it was our colleagues atThe[Washington]Post who thought he waspretty combative. I mean, what did you take away from the Cassidy-Kennedy relationship?
Ollstein:Yeah, definitely. I mean, one thing I noticed with both Cassidy and a few other Republicans is one of the few topics where they feel comfortable really going after Kennedy and the Trump administration more broadly is abortion. They think that the administration has not done enough to restrict access to abortion pills, and so they felt more comfortable hammering Kennedy on that issue. You saw Cassidy do that. You saw[Sen. Steve]Dainesand a couple of other very anti-abortion senators raise that. And I thinkthat’san area where they feel likethey’remore aligned with the sort of activist GOP basethanthe administration is.And so whatever blowback they would get for questioning the administration is outweighed by their anti-abortion bona fides. So…
Rovner:Although I would say, I will interrupt before you finish and sayI thought it was interesting that the members kept doing that because I thought most of it was for show, because we knew early on, because he’s been to all of these committees, that Kennedy was not going to talk about the FDA study on the abortion pill because there’s pending litigation,which is an easy out.But theymade,they all made their little speeches, and they knew exactly what he was going to say.
Ollstein:Oh, absolutely, absolutely. I mean, they want to be seen fighting on the issue, for sure.I’vetalked to a lot of anti-abortion activists who say, you know,Look,the Trump administration keeps saying we got to go through the process with the study.We got to go through the process with the courts. We got to check all the boxes.And the anti-abortion activists point out, you know—correctly, I think—that the administration has been very willing to break with protocol, and even, you know, legal procedure on a bunch of other issues, andthey’resaying…
Rovner:Whichwe’llget toin a moment.
Ollstein:…Why not us? Why are they so careful when it comes to our issue when,clearly, they do whatever they want on other issues?And so, I mean, that is a fair point, and I thinkit’sgoing to be a continuing frustration. Thedynamic we wrote aboutis the influence of the Make AmericaHealthyAgain,MAHA,as a political force.We’regoing to really get a key test of that in Cassidy’s primarythat’scoming up in just a few weeks. MAHA has put a big target on him and wants to knock him out. Andmy colleague and I took areallycriticallook at their influence in the race, andit’ssort of notliving up to the hype,I would say.MAHAis not makinga big impactfinancially in the race, and they are not makinga big impact,really, in messaging. Theyhaven’tsucceeded in puttingMAHAissues—like vaccines, like healthy food, chemicals in the environment—theyhaven’tmade those the top issues in this race.It’ssort of thesame bread-and-butter,cost-of-livingRepublican red meat stuff thatyou’reseeing in other states.And so,I think, you know, we talked to a lot of people, you know, close to the situation, who said, even if Cassidy loses, it’s not going to be because ofMAHA.AndsoIdon’tknow if that makes him more willing to tangle with RFK in these hearings or not.
Rovner:I did think, I thought that it was politics that made him lead with abortion, though, because he…I mean, Louisiana, as we know, is one of the most anti-abortionof all the anti-abortion states.He’sbeen a longtime anti-abortioncrusader. This is not a new position for him, andhe’sgot this primary,so he would like to bring out his supporters. I mean…I saw that.It’slike, oh, aha, politically, that makes sense, even though he knew that Kennedywasn’tgoing to respond to the question.
Aside from thesecretary’s continuing denial of the accusation that he is anti-vax, there was, in fact, considerable anti-vaccine-related news this week.First,overatthe DefenseDepartment, whereSecretary PeteHegseth has decreed that annual flu shots will no longer berequiredfor active-duty and reserve military members. This is, according toHegseth,“because your body, your faith,and your convictions are not negotiable.”Now, flu vaccines have routinely been given to members of the military since just after World WarIIfor thefairly obviousreason that viral infections pass easily among people who are living together in close quarters, like,you know, members of the military. And vaccine requirements in the military,in general,date back to the Revolutionary War,when George Washington ordered troops tosubmitto the thenfairly newsmallpox vaccine.Sheryl,you’reour public health historian at the table. Has there ever been a time when the balance between personal liberty and public health has been tilted so heavily towards personal liberty as it is right now?
Stolberg:Idon’tthink so.We’vehad anti-vaccine activism in the United States for as long aswe’vehad vaccines.And especially at the turn of the 20th century, around the time when smallpox waskind of racingthrough Boston and other cities, there was a big anti-vaccine push. You might remember, in 1905,the Supreme Court ruled that states could mandate vaccination to protect the public health, and that was in a case brought by a pastor in Cambridge, Massachusetts,whodidn’twant to get vaccinated for smallpox. And then we had the’60s, when, you know, vaccines were new, and public health people were touting them, and there was a big embrace of vaccination.Soit’svery interestingto see whatHegseth has done.And what came up yesterday in the HELPCommittee hearing,where[Sen.]Patty Murray reminded Kennedy that during the GreatInfluenzaof 1918,the flu was very indiscriminate, and a lot of soldiers were killed. It did not strike only young people and old people. It struck down people in the prime of their life, many, many in the military. And she said that, you know, this was an issue for readiness.And Kennedy was like,Youthink the flu is going to kill people?Like,the flu is not going to kill people. And it seemed obvious to me that he did not really understand that influenza is not the same all the time, that the virus mutates, and it very well could mutate into a pandemic strain. And he himself is pushing for a universal influenza vaccine, which has beenkind of likethe dream of public health people, so we could guard against, you know, all types of flu strains.
Rovner:And not have to redo the vaccineevery year.
Stolberg:Right. So,inshort answer to your question, I think certainly not in the last 50 or even 100 years have we seen the ascendancy of the medicalfreedommovement and the argument that individual liberty takes precedence over the health of the community.
Rovner:Yeah. Alice,youwantedto add something.
Ollstein:Yeah.I’vealso seen a lot of people pointing out thatit’snot like this is anacross-the-boardembrace of individual liberty. I mean, ifyou’rein the military, you stillcan’tgrow a beardifyou’rea man, even if you have a skin condition where shaving really hurts and is bad for your skin.Youdon’thave the personal medical freedom to transition from male to female, or female to male.Youdon’teven have the personal freedom to wear what you want, to have the hairstyle you want, and so this isreallyjustabout vaccines. And,likeSheryl said, you know, really could threaten military readiness. There have been several wars in the past where more soldiersdied of disease than died of violent combat impacts.Sothis isa very interestingcarve-outthat has a lot of peopleworried.
Rovner:Also on the vaccine front at HHS, NIH[National Institutes of Health]Director Jay Bhattacharya, who was actually acting in his role as acting director of the Centers for Disease Control and Prevention, has reportedly canceled publication of a study that found the covid vaccine dramatically reduced hospitalizations and emergency department visits.Bhattacharya,reportedbothThe Washington Postand The New York Times,complained that the study’smethodologywas flawed. But CDC officials say not only is it the same methodology used in the past, but it’s also basically unheard of for a study approved by CDC’sownscientists not to be published in the agency’s“Morbidity and Mortality Weekly Report”once it reached the stage that this study hadreached. Is there any conclusion to be drawn here? Other thanthatthe study’s results contradict theadministration’s position that the covid vaccine is not helpful.
Stolberg:Raisesaquestion about radical transparency,that’sfor sure. Secretary Kennedy came into office promising radical transparency. Thisdoesn’tseem radically transparent.
Rovner:No. Kennedy keeps saying—and he saidhow many times during these hearings?—thathe’strying to restore trust in the science agencies. And this does not strike a lot of peopleas a way torestore trust when something is canceled because youdon’tlike the results. Victoria, did you want to add something?
Knight:Yeah,I mean, I thinkthat’sa great point. He just said multiple times throughout all these hearings, especially when Democrats were questioning him on vaccines, thatI’m willing to look at studies, I’m willing to look at data, I’m willing to review everything, if you’re bringing up maybe things he allegedly said he had not seen before,data or whatever. Soyeah, exactly thisgoes exactlyagainst that.You would think ifthere’sa study showing something,he’dbe willing to view it. If that was his philosophy.
Rovner:We wouldsee. All right. Well, meanwhile, President Trump continues to make his health policy out of the White House. Last Saturday, he summoned his top health officials, plus popular podcaster Joe Rogan, to the Oval Office to sign an executive order to facilitate research into and to fast-trackFDA review of some previously banned psychedelic substances, includingibogaine and LSD, which are legally considered to have no medicinal uses. This isactually notall that controversial.It’spart of an ongoing push from researchers who say that some of these substances might well be useful for treating things like severe depression, PTSD,and even opioid dependence. But what made this so unusual is that it wasapparently pushedto fruition in just a matter of days by a text from Joe Rogan to President Trump.Sowhat message does this send about the so-calledgold-standard science being the only thing that counts in this administration, when a podcaster with a big following that thepresident wants can spring loose a major policy shift in less than a week?
Stolberg:SoI have a theory aboutthis, actually. Well, first, it is highly unusual that Trump would step in on this,right? Likeit’snot the ordinary course of science that thepresident issues these executive orders.But CaseyMeans,who is President Trump’s nominee forsurgeongeneral,has advocated the use of psilocybin, and sohasSecretary Kennedy, for that matter.But this is one of the things that iskind of stallingher nomination.[Sen.]Susan Collins has raised concerns about this.I guess I just kind of wonder if Trump is trying to put his imprimatur on this research,maybe asa backhanded way to give her a boost? Ormaybe I’mjust too Machiavellian, andmaybeit’sjust that Joe Rogan texted him, and he was like,Yeah,that’sa good idea.
Rovner:And it was, infairness,it was already in the works.
Stolberg:Yeah. And, I mean, thereisa lot of legitimate scientific reasons to do this kind of research.
Rovner:And, I will say, I mean,I’vestudied this, and I believe breaking justtoday,they’re, you know, rescheduling marijuana.Again,all ofthese technical changes are to make it easier to do the research. Part of the problem has been that because these substances were scheduled as having no medicinal uses, youcouldn’tget them to do the research.Soone of the things that this does is make it easier.To have Joe Rogan in the Oval Office on a Saturday morningstruck me as,like,OK, this is a little strange.
Knight:But isn’t that how this administration works?Right? I mean, I think that,just in general,there’sa lot of influencer types that—I would say, Joe Rogan, podcaster, influencer type—that just have influence in this White House because they have forged a connection with Trump.And so,if they say something to him, he will take that into account and change policy sometimes.
Rovner:And he wants the young male demographic, which Joe Rogan very muchrepresents. Allright,we’regoing to take a quick break. We will be right back.
OK, we are back.And turning to the Affordable Care Act,despite reassurances from Trump administration officials that the lapse of the Biden-eraadditionalpremium tax creditsdidn’tresult in a big drop in coverage,we’regettingmore data suggesting that is not the case. A new report this week from the grouprepresentingthe 21 states that run their own marketplaces show[s]about 900,000 enrollees dropped coverage in the first three months of this year.Compared to last year, disenrollments areup24%. Hardesthit, not surprisingly, are older enrollees betweentheage55 and 64.Their premiums are higher to begin with, so the loss ofadditionalsubsidies hits them harder. Meanwhile, even people who have managed to keep coverage are paying more,as many dropped the more generous“gold”and“silver”plans,for those with higher deductibles but lower premiums.And those deductibles are ofteneye-poppingindeed—not just$1,000 or $1,500 a year, but often more than five figures. I know I say thisroughly everyother week, butI’msurprised thisisn’tmaking more of an impact in the national conversation. I mean, you know, I keep seeing people who sayI’mhaving to drop my insuranceor, you know,I have insurance and Ican’tafford to use it because my deductible is $10,000.I know itsort of sweptinto this whole“affordability”thing, but I thought this might have come up more during seven hearings with thesecretary of HHS.
Knight:I mean, I thinkit’spartly because there is just so much happening in the world right now that everything else is getting pushed aside in away,ifit’snot related to the Iran war or gas prices or things like that. But I do think, I mean, we’ll see, but Democrats, once we were starting to get—you know, we just started to get some of this data about ACA enrollment and how it’s changing now that the premium tax credit, enhanced premium tax credits, were not extended by Congress, we’re just now starting to get some of the data. So I think as we see more data,and thenwe’ll see even more of that going into the summer,I think Democrats, at least, will be hitting this really hard on the campaign trail, and maybe that will permeate and become part of more of the national conversation.We’llsee, butthey’reat leastgonnamessage on it,certainly.
Rovner:Yeah, I think, you know, one of the things that’s important to remember is that the administration, it’s telling the truth when it says, you know, most people were still enrolled in January, because a lot of those people got auto-enrolled.Andit takes severalmonths ofnot paying your premiums before you can actually get kicked off your insurance.Soin fact,we’reonly just starting to see how many people.
Ollstein:This is just the beginning. And the fact thatwe’realready seeing such coverage losses means thatthere’sgoing to be more.And I thinkit’sgoing to have a political impact in certain contexts. I mean, there was a reportjustabout thebig drop in enrollment in Georgia, and Georgia is a major swing state with some major races coming up, and so I expect it to havea big impactthere. AndsoI think, rather than being like a dominant national message, I think in certain places whereyou’rereally seeing the strain.I’llalso point out thatit’snot just about people becoming completely uninsured.There’salso a big shift from people being in morecomprehensive health care plans to people moving into skimpy, high-deductible health care plans.Andthat’sgoing to have a lot of ripple effects going forward aswell, andgoing to lead to a lot ofstruggle. AndsoI think itcontributes to the overall sense that people are really in financialdire straitsandcan’taffordbasic daily life.
Stolberg:We’regoing to see that, coupled with a lot of Democrats talking, as they did during the hearings, about cuts to Medicaid. Kennedy insists thatwe’renot cutting Medicaid, but if you talk to any rural hospital executive around the country, they will tell you that they are crumbling under the loss of Medicaid reimbursements.And I think that those,the Medicaidand alsothe ACA enrollments,willemergeas powerful issues for Democrats.
Rovner:Kennedy was repeating the age-old argumentthat’salways made that if the amount of money to Medicaid goes up, itcan’tbe a cut, even though thatdoesn’tkeep up with inflation or enrollment or the number of people. Yeah, so, I mean, it’s like…if you’re paying more, if your mortgage goes up and you’re paying more for it and it goes up more than you’re paying,than you’re able to pay, then that’s really a cut in your income.Soit’sa perennial argument that we do see.
Stolberg:It’sWashington accounting.
Rovner:Yeah. Finally, this week, there is news on the reproductive health front. In Pennsylvania, a state appellate court ruled that a 1982 ban on the use of public funds to pay for abortion violates that state’s Equal Rights Amendment. Now this case could still be appealed to the state Supreme Court, but this is apretty significantruling for a very purple swingstate,right,Alice?And it could lead to state-funded Medicaid coverage forabortion,ifit’supheld.
Ollstein:That’sright. And I will say there was a major state Supreme Court race last year, and it was all about abortion rights—that was, like,the dominating issue in it.And the progressives prevailed on that message. I thinkyou’rereally seeing, like you said, a very mixed state, a very purple state,really being swayed in the direction of supporting abortion rights. Andwe’veseen that in a lot of states, you know, sinceDobbs—statesyou might not expect to go in that direction.And I thinkit’sgoing to continue to dominatestate Supreme Court races as an issue.You’reseeing that right now with Georgia.I wouldadvise folks tokeep an eye on that.There’sa very pro-abortion rights message for those candidates in thatrace.…But this is specifically the issue of Medicaid coverage of abortion, I think,is going to keep coming up over and over as well, becauseit’s really getting at the question of, yes, you can have legal access to abortion on paper, but if you can’t afford it, is it really accessible?Sothis could open up access to a lot of low-income people that would not maybe be able to afford it otherwise.
Rovner:And for the people who are wondering,Waita minute, I thought Medicaid coverage of abortion is banned—it’sfederal Medicaid coverage of abortion is banned. States may use their own money if they wish to pay for abortion, and many bluer states do.That’sthe question at hand here.
Meanwhile, in South Carolina, lawmakers are advancing a ban on abortionthat’sso strict it would subject women who have abortions to punishment, although not as severe as the punishment for those who perform abortions. I thought this was a basic tenet of the anti-abortion movement, that the women who have abortions are also victims andshouldn’tbe punished.Is that changing?
Ollstein:It’sbeen a very loud debaterecently. You have different wings of the anti-abortion movement who are clashing on this, and many are watching the total number of abortions in the U.S.go up sinceDobbs,and say this incremental strategy where we shieldwomen who have abortions from prosecution and only go after the doctors. Some of the hard-linersfeelthatthat’snot working, and so theyhave totry something elsein order toactually havethe chilling effect that they want to have and deter people from evenattemptingto get abortions. And then you have a lot of the more mainstream groups who really are against that strategy, and say that, you know,this will just drive voters into the arms of Democrats if we look like we’re thequote-unquote“war on women”that we’ve been accused of waging all these years. Andsoit’sa very activedebate right now.
Stolberg:I was going to say,do you remember when Trump was running in 2015 and he said that he thought women should be punished for having abortions?And there was a bigfirestorm over it from the anti-abortion movement. And he basicallyshutup on that.
Rovner:Yes, I do remember that.
Stolberg:So…you can see how things have evolved. Of course, that was, youknow, whenRoewas stillintoeffect. Then we gotDobbs, and,as Alice said, things are changing.
Rovner:Yes, things are changing. All right. Well, that is this week’s news, or at least as much as we have time for.Nowwe will play my“HowWouldYouFix It?”interviewwith David Blumenthal, and thenwe’llcome back and do our extra credits.
I am pleased to welcome to“How Would You Fix It?”David Blumenthal, a trueRenaissance manof health policy. When I first met David in the 1980s,he was teaching at Harvard Medical School, doctoring in Boston,and writing about health policy. Since then, he has served as president of thehealthpolicy research organizationThe Commonwealth Fund, and,before that, asnationalcoordinator forhealthinformationtechnology in the Obama administration. In his“spare time,”air quotes, David has written countless journal andother articles andseveral books, most notably,with political scientist James Morone,The Heart of Power:Health and Politics in the Oval Office, which chronicles presidential health policies from Teddy Roosevelt through George W Bush. Now he andMoroneare out with afollow-up book calledWhiplash: From the Battle for Obamacare to the War on Science, which covers therather eventfullast three administrations in healthcare. David Blumenthal, thank you so much for joining us.
David Blumenthal:Oh,it’smy pleasure. What a great introduction. Thank you so much for that.
Rovner:So,ifit’sCongress that makes the laws, why is it that thepresident is so pivotal when it comes to health policy?
Blumenthal:Well, people forget that there is only one official in the United States whoiselected by all the people, and that is thepresident.That gives him—or someday her, we hope—a legitimacy, a symbolic authority,and an ability to rise above the din of Washington conversation to reach the American people and to build support or mobilize opposition to whatever an enterprisingcongressmanor senator has in mind. Those samecongressmenand senators really crave direction, most of them,from thepresident to know what that official’s priorities are, so they can line up behind it. They also want to know what thepresident might vetobefore they put a lot of effort into things.Soall those things are reasons why presidents have a level of authority which is often underappreciated, especially in health care, where theday-to-dayconversation often focuses on what a senator oracongressmanoracommitteechairmanis saying. But in the end, unless thepresident is behind something important,it’snot going to happen in the Congress.
Rovner:Andpretty much everythingmajor in health care has had a president spearheading it,hasn’t it?
Blumenthal:Exactly.Some that have succeeded, like Medicare and Medicaid, Lyndon Johnson’s proposals, and some that have not,like the Clintonhealthplan.And then, of course, the Affordable Care Act, which was uniquely the product of President Barack Obama’s sponsorship, passion, enduring commitment, with a lot ofhelp from Nancy Pelosi.
Rovner:Can you talk a little bit about tinkering versus major reforms, and whatyou’velearned from studying the last dozen or so major health reform debates? I knowjust in the 40 years I’ve been doing this, you know federal government hasgone back and forthbetweenWe should try to do somethingbig;no, we can’t do something big, so we should try to do something small; no, it doesn’t work if we do something small, we should tryto do something big.It’sjust been this constant swaying.
Blumenthal:Well, one of the stories that we tell in both of our books is the story of the dance that has gone on over the ages between proponents of major health care reform and opponents.And this has typically beenDemocratic proponents and Republican opponents. And the story is this:Somebody in the Democratic Party proposes a massive health care reform proposal, and the Republicans scream socialism, government control, death panels, whatever, and propose an alternative that is smaller, more about free markets, more about the private sector, more about competition. The Democratic proposal goes down in flames, and then 20 years later, the Democrats come back and propose what the Republicans proposed the first time. Then the Republicans say socialism, government control,morelimited government, more free market, more private sector.Samething happens. It goes and goes and goes. What we saw with the Affordable Care Act was that the effort to get anything meaningful in the way of coverage,with a less governmentally oriented program,had run out its rope. There was just nowhere else for conservatives to go, which is why we got the Heritage Foundation proposing what Gov.Mitt Romney and Ted Kennedy accepted in Massachusetts as the basis for health care reform. So I think what happened was that—and this, I think, you saw mostly in the repeal-and-replacefailure—the Republicans could not come up with anything that was more incremental, less comprehensive,and still made a difference for people’s insurance, especially on the issue of preexisting conditions.
Rovner:They wereOKwith the repeal, just not with thereplace.
Blumenthal:Exactly, which is a story that we tell,in detail, inWhiplash. So incremental reform is the way Americans do business.We’venow incremented our way to a four-legged stool that can achieve universal coverage. We have employer-sponsored insurance, which, of course, is subsidized by the government. We have Medicare, which is the third rail of healthcare politics. We haveMedicaid, which can be expanded if states and the federal government choose, and we have the Affordable Care Act.And together, those got us,during the last yearsofthe Biden administration, to 93% coverage of Americans. We have the tools to increment our way now to universal coverage, and that just seems… tobe the way Americans want to do business, at least in health care.
Rovner:How does that politicization of not just health insurance coverage but everything that surrounds health and health care becoming red or blue—how’sthat going toimpactthe next big health debate?
Blumenthal:Well,it’sred-blue.It’salso…has racial overtones. It also has xenophobic overtones, with attitudes toward immigration.All these things now run straight through healthcare. I thinkthere’sa difference between the psychology of opposition to vaccination and suspicion of the NIH and the people who come into play when it comes to the cost-control issue. Cost control is abread-and-butterissue. Vaccination is about personal freedom, the sanctity of bodies, the freedom to say no.It has a different overtone and undertone to it. I think that the controversy over cost will be viewed much more as a traditional interest-group struggle, rather than as a red-blue struggle. AndI thinkthere’llbe some people from the Republican Party who will get to the point where their constituents are saying,Wemay have health insurance, butit’snot worth a damn because our deductibles are too high and our copayments are too high. Wegotto do something.And I thinkthere’sa chance for a bipartisan solutiononthat score.
Rovner:Sowe’recalling this series“How Would You Fix It?”How wouldyoufix it if you could wave a wand and put asideall ofthe politics that I know you now know so well.But if you could do one or two things to make our health system function better, what would it be?
Blumenthal:Well, you know, we, inwritingthe book, we spent some time with President Obama, who said, you know,I would have loved to have had“Medicare for All,”but I knew that was impossible.Sowe now have this Rube Goldberg apparatus providing us coverage, and I thinkwe’restuck with that.Sowhat I would do first is make the Affordable Care Act as generous as it should have been and got to be after theInflation Reduction Act. And I think if we did that and worked our way around the Supreme Court’s prohibition about requiring Medicaid expansion, which we almost did in the IRA—it’s little-known, but there was an alternative to expanding Medicaid that would have made it a federal program, added to the state program, and not be… gocrosswise with the Supreme Court.That,plus…so that would be justsort of make doeverything we can to make coverage as universal as it could be.And then add to that a set of incremental changes that would reduce the cost of care.That would involve, I think, more regulation of private insuranceto reduce the complexity of benefits and the complexity of billing. The Netherlands and Germany run their health systems through private insurance. They just standardize whatthe privatecompanies offer. We could do that. In fact, the Affordable Care Actbeginsthat process, especially in marketplaces like California, where private insurers are heavily regulated.
The second is we need to break up the monopolies that have formed at the local level in the healthcare provider system, where you havevirtually nocompetition based on price or anything else. We need to change the way we pay for care much more aggressively. Artificial intelligence has enormous potential to reduce administrative costs, but it also hasan enormouspotential to run them up. If the incentives in the system are not fixed, the incentives in thefee-for-service system will lead tousingAI to maximize billing.
Rovner:Whichwe’vealready seen.
Blumenthal:Right,andnot reduce administrative expenses. Andsowe need to give providers and other powerful interests an incentive to use AI to make the healthcare system work better, rather than to make it generate more revenue.SoI think thoseare some of the things thatwe’llneed to do.So,build on what we have, the four-legged stool, the foundation for universal coverage we already have, and begin to take on the cost ofcare through changes that are,for which there are precedents elsewhere in the world, but which until now, we’ve been unwilling to take on.
Rovner:David Blumenthal,we’llsee how this all plays out.Thank you so much.
Blumenthal:Thank you, Julie.
Rovner:OK,we’reback.Nowit’stime for ourextra-creditsegment.That’swhere we each recognize a story we read thisweekwe think you should read, too.Don’tworry if you miss it. Wewillpostthe links in our show notes on your phone or other mobile device.Victoria, why don’t you start us off this week?
Knight:Sure thing.My story for extra credit is inThe New York Times, and the title is“A $440,000 Breast Reduction: How Doctors Cashed In on a Consumer Protection Law,” by Sarah Kliff and Margot Sanger-Katz, Sheryl’s colleagues.Sothis is a really interesting look at the ramifications of the 2020NoSurprises Act that was passed by Congress. And the whole point of this act was to protect patients from surprise medical bills. Because, you know, it still happens nowadays, but this lawhelpsit. Basically, sometimes patients go to anout-of-networkdoctor,they mightget stuck with a really, really high bill, and it’s really difficult for them to pay.SoCongress wanted to do something about it. They did, and now, basically, insurers and doctorshave togo to an arbitrator if there is a conflict about the price of the bill, ifit’sanout-of-networkbill.This article really had a lot of great data points on how it seems arbitrators are really favoring doctors in these decision-making and awarding doctors with these really high amounts of money for these medical procedures.So basically, thedoctors offer an amount of money that the medical procedure should cost, and the insurers offer one, and the arbitrator just picks one of the two prices. Andsodoctors are really getting awarded waymore.…Some doctors areprofiting off ofthis by certain types of procedures, such as breast reduction that was mentioned in the title. Andsoit was really fascinating. And a few lawmakers were interviewed, and they were like,Well, wedidn’treally think about that happening, but at least patients are protected. Idon’tknowifCongress will do anything about it, butit’sa new twist in our healthcare system.
Rovner:Yeah, I love this story becausethere’sbeen complaints about the arbitration systempretty much sincethe law passed. AndI think ittakes, you know, a story like this for everybodytosay,Oh, my goodness, is thatwhat’shappening?Alice, why don’t you go next?
Ollstein:Yes, I havea[n]analysis fromThe Washington Post. It’s called“Where U.S. Science Has Been Hit Hardest After Trump’s First Year,”and it’s looking at these science and research grants from the National Institutes of Health, and even though Congress has largely protected that funding and approved increases, even where the White House pushed for decreases, that money is not going out, and it’s really not going out to certain researchers researching certain topics, chief among them things that impact women’s health.And this is partially,as the article gets into,aresult of this war onwhat’sviewed asDEI[diversity,equity,andinclusion]. Andsoresearch into conditions that primarily or solelyimpactwomen, like endometriosis,are seen asDEIand are therefore getting cut. Andsoit really gets into the tollthat’staking on these labs around the country that are, you know, potentially discovering breakthroughs, but are now in limbo and having to lay people off and has big consequences.
Rovner:Anotherstory that made me angry.Sheryl, you have one of Alice’s stories as your extra credit.
Stolberg:I do.Sothis is from PoliticobyAlice and her colleague, Amanda Friedman:“Trump’s Surgeon General Pick Faces Mounting GOP Opposition.”And the reason I like this story is because it’s about CaseyMeans, and in how this—there’s a wave of attacks coming against her, kind of under the radar from the right, from abortion opponents, including the policy arm of the Southern Baptist Convention, and also people who, as we mentioned before, are perhaps raised questions about her embrace of psychedelics. AndI think that whathappens with CaseyMeans is reallykind of asymbol, orit’slike a microcosm of what is going to happen with the MAHAmovement. And yesterday, after the hearing, I asked Sen.Cassidy,who iskind of sittingon CaseyMeans’confirmation,“When are we going to see a vote on CaseyMeans?”And he said,“No comment.”SoI just think that thisis something to watch, and IapplaudAlice and her colleague for pointing out this kind ofbelow-the-radarcampaign to hold her up.
Rovner:Yeah, really, really good story.All right. My extra credit,also from one of our podcast panelists, RachelRoubeinatThe Washington Post.It’scalled“KitKat, Gatorade or Granola Bars? What’s Banned Under New SNAP Rules Is Mixed.”And I love this story becauseit’sone of those“what seems simple is anything but”policy stories. What seems simple here is the idea that food stampsshouldn’tbe used to pay for unhealthy food like candy and soda. But whodetermineswhat’shealthy and how is that decided? Thanks to a big pilot program from the Trump administration, two dozen states have received permission to make changes to the food and drinkthat’seligible to be paid for using SNAP[Supplemental Nutrition Assistance Program]benefits, and 10 states have now implemented restrictions.Butit’sa lot harder than just saying youcan’tbuy soda and candy. In some states, Gatorade and even Pedialyte are ineligible, even though those are often given to nursesickkids. In Iowa, KitKat and Twix bars are eligible becausethey’remade with flour and sothey’renot technically candy. SomeSNAPrules are so arbitrary that—and this is not part of Rachel’s story because it just happened—a bipartisan group of U.S.senators on Wednesday introduced the“HotRotisserieChickenAct”to make sure thatCostco’s famous $4.99 roasted bird remains available to those getting federal food assistance. We will watch to see ifthat flies.Sorry.Notreally sorry.
Rovner:OK, that is this week’s show.Thanks to our editorthis week,Stephanie Stapleton, 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 — as well as, of course,kffhealthnews.org. Also,as always, you can emailusyour comments or questions.We’reat whatthehealth@kff.org.Or you canstillfind me onTwitter@jrovner, or onBluesky@julierovner.Where are you folks these days?Sheryl?
Stolberg:I’mat@SherylNYTonX, formerly Twitter, andBluesky.
Rovner:Victoria.
Knight:I’m@victoriaregiskon X.
Rovner:Alice.
Ollstein:@alicemirandaon Blueskyand@AliceOllsteinon Twitter[X].
Rovner:We’llbe back in your feed next week. Until then, be healthy.