\t\t\t<\/p>\n
\tJulie Rovner
\n\tKFF Health News<\/p>\n
\t\t\t \t\t\t \t\t\t \t\t\tJulie Rovner is chief Washington correspondent and host of KFF Health News\u2019 weekly health policy news podcast, \u201cWhat the Health?\u201d A noted expert on health policy issues, Julie is the author of the critically praised reference book \u201cHealth Care Politics and Policy A to Z,\u201d now in its third edition.\t\t<\/p>\n Much of the hubbub in health care this year has been focused on Medicaid, which faces dramatically reduced federal funding as the result of the huge budget bill signed by President Donald Trump earlier this month. But now the attention is turning to the Affordable Care Act, which is facing some big changes that could cost many consumers their health coverage as soon as 2026.<\/p>\n Meanwhile, changes to immigration policy under Trump could have an outsize impact on the nation\u2019s health care system, both by exacerbating shortages of health workers and by eliminating insurance coverage that helps keep some hospitals and clinics afloat.<\/p>\n This week\u2019s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Jessie Hellmann of CQ Roll Call, and Alice Miranda Ollstein of Politico.<\/p>\n \t\t\t \tJulie Appleby \t\t\t \t\t\t \t\t\t \tJessie Hellmann \t\t\t \t\t\t \t\t\t \t\t\t \tAlice Miranda Ollstein \t\t\t \t\t\t \t\t\t Among the takeaways from this week\u2019s episode:<\/p>\n Also this week, Rovner interviews Jonathan Oberlander, a Medicare historian and University of North Carolina health policy professor, to mark Medicare\u2019s 60th anniversary later this month.<\/p>\n Plus, for \u201cextra credit\u201d the panelists suggest health policy stories they read this week that they think you should read, too:\u00a0<\/p>\n Julie Rovner:<\/strong> KFF Health News\u2019 \u201cRepublicans Call Medicaid Rife with Fraudsters. This Man Sees No Choice but To Break the Rules<\/a>,\u201d by Katheryn Houghton.\u00a0\u00a0<\/p>\n Julie Appleby:<\/strong> NPR\u2019s \u201cMany Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That<\/a>,\u201d by Rachel Treisman.\u00a0\u00a0<\/p>\n Jessie Hellmann:<\/strong> Roll Call\u2019s \u201cKennedy\u2019s Mental Health Drug Skepticism Lands at FDA Panel<\/a>,\u201d by Ariel Cohen.\u00a0\u00a0<\/p>\n Alice Miranda Ollstein:<\/strong> The Associated Press\u2019 \u201cRFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed<\/a>,\u201d by Amanda Seitz and Jonel Aleccia.\u00a0\u00a0<\/p>\n Also mentioned in this week\u2019s podcast:<\/p>\n \t\t\t\t\tclick to open the transcript\t\t\t\t<\/p>\n \t\t\t\t\t\tTranscript: Here Come the ACA Premium Hikes\t\t\t\t<\/p>\n [Editor\u2019s note:<\/em><\/strong> This transcript was generated using both transcription software and a human\u2019s light touch. It has been edited for style and clarity.]<\/em>\u00a0<\/p>\n Julie Rovner:<\/strong> Hello, and welcome back to \u201cWhat the Health?\u201d I\u2019m Julie Rovner, chief Washington correspondent for KFF Health News, and I\u2019m joined by some of the best and smartest health reporters in Washington. We\u2019re taping this week on Thursday, July 24, at 10 a.m. As always, news happens fast and things might\u2019ve changed by the time you hear this. So, here we go.\u00a0<\/p>\n Today we are joined via videoconference by Jessie Hellmann of CQ Roll Call.\u00a0<\/p>\n Jessie Hellmann:<\/strong> Hi there.\u00a0<\/p>\n Rovner:<\/strong> Alice Miranda Ollstein of Politico.\u00a0<\/p>\n Alice Miranda Ollstein:<\/strong> Hello.\u00a0<\/p>\n Rovner:<\/strong> And my KFF Health News colleague Julie Appleby.\u00a0<\/p>\n Julie Appleby:<\/strong> Hi.\u00a0<\/p>\n Rovner:<\/strong> Later in this episode we\u2019ll have the first of a two-part series marking the 60th anniversary of Medicare and Medicaid, which is July 30. Medicare historian and University of North Carolina professor Jonathan Oberlander takes us on a brief tour of the history of Medicare. Next week we\u2019ll do the same with Medicaid. But first, this week\u2019s news.\u00a0<\/p>\n So, we have talked a lot about the changes to Medicaid as a result of the Trump tax and spending law, but there are big changes coming to the Affordable Care Act, too, which is why I have asked my colleague Julie Appleby to join us this week. Julie, what can people who buy insurance from the ACA marketplaces expect for 2026?\u00a0<\/p>\n Appleby:<\/strong> Well, there\u2019s a lot of changes. Let\u2019s talk about premiums first, OK? So there\u2019s a couple of things going on with premiums. It\u2019s kind of a double whammy. So, on the one hand, insurers are asking for higher premiums next year to cover different things. So in the summer they put out their rates for the following year. So there\u2019s been a lot of uncertainty this year, so that\u2019s playing into it as well. But what they\u2019re asking for is some money for rising medical and labor costs, the usual culprits, drug costs going up, that kind of thing. But they\u2019re tacking on some extra percentages to deal with some of the policy changes advanced by the Trump administration and the Republican-controlled Congress. And one key factor is the uncertainty over whether Congress is going to extend those more generous covid-era tax subsidies. So we\u2019re looking at premiums going up, and the ask right now, what they\u2019re asking for, the median ask, is 15%, which is a lot higher. Last year when KFF did the same survey, it was 7%. So we\u2019re getting premium increase requests of a fairly substantial amount. In fact, they say it\u2019s about the highest in five years.\u00a0\u00a0<\/p>\n And then on top of that, it\u2019s still not clear what\u2019s going to happen with those more generous subsidies. And if the more generous subsidies go away, if Congress does not reinstate them, there\u2019ll be costs from that, and people could be paying maybe 75% more than they\u2019re paying this year. And we could talk some more about that. But that\u2019s kind of the double whammy we\u2019re looking at, rising premiums and the potential that these more generous subsidies won\u2019t be extended by Congress.\u00a0<\/p>\n Rovner:<\/strong> So there were some things that were specifically in that tax and spending bill that drive up premiums for the ACA, right? Besides not extending the additional subsidies.\u00a0<\/p>\n Appleby:<\/strong> Well, that\u2019s the biggest piece of it, but yes. They\u2019re tacking on about 4% of that 15% medium increase is related to the uncertainty. Well, they\u2019re assuming that the tax credits will expire. It was not in the bill. Congress could still act. They have until the end of the year. They could extend those subsidies. So that\u2019s about 4%. But one of the things that people haven\u2019t really been talking about are tariffs, and some of the insurers are asking for 3% because they expect drug costs to go up. So there\u2019s those things that are going on. And then there\u2019s just sort of the uncertainty going forward for insurers about what\u2019s going to happen with enrollment as a result of both these premium increases, and then looking a little bit further down the line, there are some changes in the tax and spending bill and some rules that are going to substantially reduce enrollment.\u00a0<\/p>\n So insurers are worried that the people who are going to sign up for coverage are the ones who are most motivated, and those are probably going to be the people who have some health problems. And the folks who aren\u2019t as motivated are going to look at the prices and maybe the additional red tape and will drop out and leave them with a sicker and more expensive pool to cover. So all of that is factoring in with these premium rate increases that they\u2019re trying to put together. Now remember, a lot of these insurers put in these premium increase requests before they knew the outcome of the tax and spending legislation. They could still modify them.\u00a0<\/p>\n Rovner:<\/strong> And Jessie, as Julie said, there\u2019s still a chance that Republicans will change their minds on the increased subsidies and tack them onto something. And there\u2019s a big bipartisan health bill on drug prices and other expiring programs that still could get done before the end of the year? Yes?\u00a0<\/p>\n Hellmann:<\/strong> There have been discussions about a bipartisan health bill, though the main author of it, Sen. Bill Cassidy, himself even seems kind of skeptical. I talked to him this week, and he\u2019s like, It might happen, it might not.<\/em> But there are a bunch of other health extenders that Congress will need to get to, like telehealth, some Medicare and Medicaid payment things. So there\u2019s definitely something to attach it to. Republicans are not friendly to the ACA. As you mentioned, they made a bunch of changes to it in this tax and spending bill. So I think the people I talk to think it\u2019s a long shot that they\u2019re going to pass billions of dollars in a subsidy extension in this bill. Though there are Republicans who do care about this issue, like Sen. Lisa Murkowski of Alaska. She\u2019s kind of been sounding the alarm on this. She thinks that Congress needs to do something to mitigate which could be very big premium increases for people. So there is some pressure there, but it doesn\u2019t seem like the people who should be thinking about this right now have started thinking about it much yet.\u00a0<\/p>\n Rovner:<\/strong> One presumes they\u2019ll start thinking about it when they start seeing these actual premium increases. I sound like a broken record, but we keep saying, the people who these premium increases are going to hit the hardest are voters in red states.\u00a0<\/p>\n Appleby:<\/strong> Last year, in 2024, 56% of ACA enrollees lived in Republican congressional districts and 76% were in states won by President [Donald] Trump. So I\u2019ve got to think they\u2019re thinking about it. When I did the reporting on this story<\/a>, I spoke with a couple of folks, and they said that some people in Congress are looking at maybe they can mess around or maybe they can do something with the subsidies that\u2019s not keeping them as they are but might deal with a piece of it. For example, there is something called a subsidy cliff. So if you make more than 400% of the federal poverty level, you used to not get any subsidies. That would come back if they don\u2019t extend this. And so 400% of the federal poverty level, you make a dollar more, you don\u2019t get a subsidy. So this year \u2014 and this year will be the numbers that next year\u2019s rates are based on \u2014 $62,600 for one person is 400% of the federal poverty level and $84,600 for a couple. So people are going to start getting, if they don\u2019t extend the tax credits, they\u2019re going to start getting notification about how much they owe for premiums next year.\u00a0<\/p>\n And this is going to be one of the first effects that people are going to see from all these changes in Washington, the tax and spending bill and the other things, when they get these premiums for January. And if they make even a dollar over that, they\u2019re not going to get any subsidy at all. So what I\u2019m told by some of my sources is that maybe they\u2019re thinking about raising that cliff, maybe keeping the cliff but maybe moving it up a little bit to 500% or 600%. But it\u2019s totally unclear. Like you all are saying, nothing may happen. We may go through Dec. 31 and nothing happens, but I\u2019m hearing that they are maybe talking a little bit about that.\u00a0<\/p>\n Rovner:<\/strong> Alice.\u00a0<\/p>\n Ollstein:<\/strong> Yeah. And there\u2019s a couple interesting dynamics that I think could influence the politics of this and what Congress feels motivated to do or not do. So, like Julie was saying, this would hit in January. And a lot of the stuff in the bill they just passed is designed to not hit until the midterms, but this would hit before the midterms. And so that\u2019s got to be on their minds. And then, like you were saying, not only would this hit Republican voters the hardest, but a reason that\u2019s more true today than it was the last time they took a round at the Affordable Care Act in 2017 is because all of these red states have expanded since then. You have a lot more enrollment, even in states that didn\u2019t expand, and so, like we mentioned, are going to have a lot of Republican voters who get hit and have this sticker shock. And the party in power in Congress and the White House could be to blame.\u00a0<\/p>\n Rovner:<\/strong> Yeah. One of the things in 2017, there were, what, 12 million people who were buying coverage on the marketplaces. And now there\u2019s 24 million people who are buying coverage on the marketplaces. So it\u2019s a lot more people, just plain, in addition to a lot more people who are likely in some of these red states. So we will follow this closely.\u00a0<\/p>\n Meanwhile, the fallout continues as people find out more about the new tax and spending law. The Congressional Budget Office is out with its final numbers<\/a> on the bill as enacted. It\u2019s now estimating that 10 million more people will be uninsured in 2034 as a result of the new law. That\u2019s down from the 11.8 million estimate of the original Senate bill. That\u2019s because the parliamentarian bounced the provisions that would\u2019ve punished states using their own money to cover undocumented people. That was not allowed to be considered under the reconciliation procedure.\u00a0<\/p>\n We also have a brand-new poll from my colleagues here at KFF that find that more people know about the law than did before it passed, and it\u2019s still unpopular. We\u2019ll post a link<\/a> to those numbers so you can see just how unpopular it is. As we\u2019ve discussed, lots of Republican senators and House members expressed concern about the impact the Medicaid cuts could have on rural hospitals in particular. So much so that a $50 billion fund was eventually added to the bill to offset roughly $155 billion in rural Medicaid cuts. Even more confusing, that $50 billion is likely to be distributed before some of the cuts begin \u2014 as you were just saying, Alice \u2014 and not necessarily to just rural areas. So is this $50 billion fund really just a big lobbying bonanza?\u00a0<\/p>\n Ollstein:<\/strong> Well, it\u2019s certainly designed to function as softening the blow. But these are different things. The hospital could be propped up and stay open, but if no one has Medicaid to go there, that\u2019s still a problem. And the money is sort of acknowledging that a bunch of people are going to lose their coverage, because it\u2019s meant to give the hospital something to use for uncompensated care for people who have no coverage and come to the ER. But that still means that people who lost their insurance because of other provisions in the bill, they might not be going to their preventive care appointments that would avoid them having to go to the emergency room in the first place, which costs all of us more in the long run. So there\u2019s a lot of skepticism about the efficacy of this.\u00a0<\/p>\n Rovner:<\/strong> Jessie, are you seeing the lobbying already begin for who\u2019s going to get this $50 billion?\u00a0<\/p>\n Hellmann:<\/strong> Yeah, because the legislation leaves a lot of how the money will be handed out to the HHS [Department of Health and Human Services] secretary, and so that\u2019s something that they\u2019re going to start thinking about. It reminds me a lot of the provider relief fund that was set up during covid. And that didn\u2019t go very well. There were lots of complaints that providers were getting the funding that didn\u2019t need the funding, and the small safety net hospitals weren\u2019t getting enough of the funding. So I\u2019m wondering if they\u2019re going to revisit how that went and try to learn any lessons from it. And then at the same time, like Alice said, this just isn\u2019t a lot of money. It\u2019s not going to offset some of the pain to rural providers that the bill has caused.\u00a0<\/p>\n Rovner:<\/strong> Yeah. Well, another piece that we will be watching. Meanwhile, the cuts to SNAP [Supplemental Nutrition Assistance Program] food benefits conflict with another stated goal of this administration, improving health by getting people to eat healthier food. Except, as we know, healthier food is often more expensive. Other than not letting people buy soda and candy with their SNAP cards, has the administration tried to address this contradiction at all? I\u2019m seeing a lot of blank stares. I\u2019m assuming that the answer to that is no. We\u2019re hearing so much about food and unhealthy food, and we\u2019re getting rid of seed oils and we\u2019re getting rid of dyes, but at the same time, it\u2019s the biggest cut ever to nutrition assistance, and yet nobody\u2019s really talking about it, right?\u00a0<\/p>\n Appleby:<\/strong> Sounds like, I think, the states are really worried, obviously, because they\u2019re going to have to make up the difference if they can. And so what other programs are they going to cut? So I\u2019m sure they are talking with folks in Congress, but I don\u2019t know how much leverage they\u2019re going to have. Do you guys have any idea whether the states, is there anything else that they can do to try to get some of this funding?\u00a0<\/p>\n Rovner:<\/strong> There\u2019s no \u2014 I\u2019ve seen no indication. As we said, there\u2019s already some buyer\u2019s remorse on the health side. Last week we talked about [Sen.] Josh Hawley introducing legislation to restore some of the Medicaid cuts that he just voted for, but I haven\u2019t seen anybody talking about restoring any of these nutrition assistance cuts or any of the other cuts, right?\u00a0<\/p>\n Appleby:<\/strong> Right. And from what I\u2019ve read, the SNAP cuts won\u2019t fully take effect until after the midterm elections. So maybe we\u2019re just not hearing about it as much because it hasn\u2019t really hit home yet. People are still trying to figure out: What does all this mean?\u00a0<\/p>\n Rovner:<\/strong> Well, one thing that has hit home yet, I\u2019ve wanted for a while to highlight what some of the changes to immigration policy are going to mean for health care. It\u2019s not just ending legal status for people who came and have lived in the U.S. legally for years, or reinterpreting, again, the 1996 welfare law to declare ineligible for Medicaid and other programs many legal immigrants who are not yet permanent residents but who have been getting benefits because they had been made legally eligible for them by Congress and the president. One of the big changes to policy came to light last week when it was revealed that immigration officials are now being given access to Medicaid enrollment information, including people\u2019s physical addresses. Why is this such a big deal? Alice, you\u2019ve been following this whole immigration and health care issue, right?\u00a0<\/p>\n Ollstein:<\/strong> Yes. Experts are warning that this is very dangerous from a public health perspective. If you deter people from physically wanting to visit a clinic or a doctor out of fear of ICE [Immigration and Customs Enforcement] enforcement there, which we\u2019ve already seen \u2014 we\u2019ve already seen ICE try to barge into hospitals and seize people. And so fear of that is keeping people away from their appointments. That makes it harder to manage chronic illnesses. That makes it harder to manage infectious diseases, which obviously impacts the whole community and the whole society. We all bear those costs. We live in an interconnected world. What impacts part of the population impacts the rest of the population.\u00a0<\/p>\n And so what you mentioned about the Medicaid data, as well, deters people who are perfectly eligible, who are not undocumented, who have legal status, who are eligible for Medicaid. It deters them from enrolling, which again deters people from using that health care and keeping their conditions in check. And so there\u2019s a lot of concern about how this could play out and how long the effect could last, because there are studies showing that policies from the first Trump administration were still deterring immigrants from enrolling even after they were lifted by the Biden administration.\u00a0<\/p>\n Rovner:<\/strong> And we should point out that this whole address thing is a big issue because, as you say, there, maybe, there are a lot of families where there are people who live there who are perfectly, as you say, perfectly eligible. You\u2019re not eligible for Medicaid if you\u2019re not here legally. But they may live in a family, in a household with people who are not here with documentation, and they\u2019re afraid now that if they have their addresses, that ICE is going to come knocking at their door to get, if not them, then their relatives or people who are staying with them.\u00a0<\/p>\n Appleby:<\/strong> Yeah. And I think it\u2019s also affecting employment. So nursing homes are already saying that they\u2019re losing some people who are losing their protected status or this or that. So they\u2019re losing employees. Some of them are reporting, from what I\u2019ve read, that they are getting fewer applicants for jobs. This is going to make it even tougher. Many of them already have staffing issues, and the nursing home industry has said, Hey, how come we\u2019re not getting any special consideration?<\/em> Like maybe some of the farmers or other places are supposedly getting, but I don\u2019t know if that\u2019s actually happening. But why aren\u2019t they being considered and why are they losing some of their workers who are here under protected status, which they\u2019re going to lose? And some of them may also be undocumented \u2014 I don\u2019t know. But that\u2019s just the nursing homes. Think of all the people around the country who need help in their homes, and maybe they\u2019re taking care of elderly parents and they hire people, and some of those people may not be documented. And that\u2019s a vast number of folks that we\u2019re never going to hear about, but if they start losing their caregivers as well, I think that\u2019s going to be a big impact as we go forward.\u00a0<\/p>\n Rovner:<\/strong> And it\u2019s also skilled health workers who are here on visas who are immigrants.\u00a0<\/p>\n Appleby:<\/strong> Right.\u00a0<\/p>\n Rovner:<\/strong> In rural areas in particular, doctors and nurses are usually people who have been recruited from other countries because there are not enough people or not health professionals living in those rural areas. The knock-on effect of this, I think, is bigger than anybody has really sort of looked at yet.\u00a0<\/p>\n Ollstein:<\/strong> Absolutely. States have even been debating and in some cases passing legislation to make it easier for foreign medical workers to come practice here, making it so that they don\u2019t have to redo their residency if they already did their residency somewhere abroad, things like that, because there\u2019s such shortages right now, especially in primary care and maternal care and a lot of different areas.\u00a0<\/p>\n Rovner:<\/strong> Yeah. This is another area that I think we\u2019re only just beginning to see the impact of. Well, there is also news this week in Trump administration cuts that are not from the budget bill. In a report<\/a> from the Congressional Budget Office that\u2019s separate from the latest budget reconciliation estimate, analysts said that the Trump administration\u2019s proposed cuts to the budgets of the National Institutes of Health and the Food and Drug Administration could reduce the number of new drugs coming to market. That would not only mean fewer new treatments and cures but also a hit to the economy. And apparently it doesn\u2019t even take into account the uncertainty that\u2019s making many researchers consider offers to decamp to Canada or Europe or other countries. There\u2019s a real multiplier effect here on what\u2019s a big part of U.S. innovation.\u00a0<\/p>\n Hellmann:<\/strong> I\u2019ve been talking to people on the Hill about this who traditionally have been big supporters of the NIH and authorizing and appropriating increases for the NIH every year. And they are still kind of playing a little coy. The White House is suggesting a budget cut at the NIH of 40%, which would be massive. It\u2019s so massive that the CBO report was like: We cannot estimate the impact of this. We\u2019re going to estimate a smaller hypothetical.<\/em> Because they just can\u2019t.\u00a0<\/p>\n And so I think it\u2019ll be interesting to see how it plays out in the appropriations process. You do have senators who are more publicly concerned about it, like Sen. Susan Collins of Maine, who obviously is on the Appropriations Committee. So we might see a situation where Congress ignores the budget request. That usually happens, but these are weird times. And so I think there are questions about, even if they do, if Congress does proceed as normal and appropriate the money that they typically do for NIH, what is the administration going to do with it? They\u2019ve already signaled that they\u2019re fine not spending money that has been appropriated by Congress. And so I think that there\u2019s a big question about that.\u00a0<\/p>\n Rovner:<\/strong> At some point, this has to come to a head. We\u2019ve been \u2014 as I say, I feel like a broken record on this. We talk about it a lot, that this is money that\u2019s been appropriated by Congress and signed by the president and that we keep hearing that people, particularly at NIH, are not being allowed, for one reason or another, to send out. This is technically illegal impoundment. And at some point it comes to a head. We know that Russ Vought, the head of the Office of Management Budget, thinks that the anti-impoundment law is illegal and that he can just ignore it. And that\u2019s a lot of what\u2019s happening right now. I\u2019m still surprised that it\u2019s the end of July and Congress is going out for the August recess \u2014 and Jessie, I know you\u2019re talking to people and they\u2019re playing coy \u2014 that they haven\u2019t jumped up and down yet. The NIH in particular has been such a bipartisanly supported entity. If you\u2019ve ever been around the campus in Bethesda, all of the buildings are named after various appropriators of both parties. This is something that is really dear to Congress, and yet they are just basically sitting there holding their tongues. At some point, won\u2019t it stop?\u00a0<\/p>\n Hellmann:<\/strong> I think maybe they\u2019re hoping to say something through whatever legislation that they come out with, whatever spending legislation. But, yeah, they\u2019re not being very forceful about it. And I think people are obviously just very afraid of making the Trump administration angry. Lisa Murkowski of Alaska has said this, like she kind of fears the repercussions of making the president mad. And he\u2019s on this spending-cut spree. So I definitely expected more anger, especially the bipartisan history of the NIH has lasted so long. It\u2019s kind of a weird thing to see happen.\u00a0<\/p>\n Rovner:<\/strong> Yeah. Of all the things that I didn\u2019t expect to see happen this year, that has to be the thing that I most didn\u2019t expect to see happen this year, which was basically an administration just stopping funding research and Congress basically sitting back and letting it happen. It is still sort of boggling to my mind. Well, we also learned this week about hospitals stopping gender-affirming care of all kinds for minors, under increasing pressure from the administration. And we\u2019re not just talking about red states anymore. Children\u2019s hospitals in California and here in Washington, D.C., have now announced they won\u2019t be offering the care anymore. Wasn\u2019t it just a few months ago when people were moving from red states to blue states to get their kids care? Now what are they going to be able to do?\u00a0<\/p>\n Ollstein:<\/strong> I think a lot of what we\u2019re seeing play out in the gender-affirming care fight, it reminds me of the abortion rights fight. There are a lot of themes about the formal health care system being very, very risk-averse. And so rather than test the limits of the law, rather than continuing to provide services while things are still pingponging back and forth in courts, which is the case, they\u2019re saying, just out of caution, We\u2019re just going to stop altogether.<\/em> And that is cutting off a lot of families from care that they were relying on. And there\u2019s a lot of concern about the physical and mental health impacts on \u2014 again, this is very small compared to the general population of trans kids \u2014 but it\u2019s going to hit a lot of people. And yeah, like you said, this is happening in blue states as well. There\u2019s sort of nowhere for them to go.\u00a0<\/p>\n Rovner:<\/strong> Yeah. We\u2019re going to see how this one also plays out. Well, turning to abortion, we talked last week about how a federal appeals court upheld a West Virginia law aimed at banning the abortion pill mifepristone. And I wondered why we weren\u2019t hearing more from the drug industry about the dangers of state-by-state undermining of the FDA. And lo and behold, here come the drugmakers. In comments letters to the FDA, more than 50 biotech leaders and investors are urging the agency to disregard a controversial study from the anti-abortion think tank the Ethics and Public Policy Center that officials are citing as a reason to reopen consideration of the drug\u2019s approval. Alice, remind us what this study is and why people are so upset about it.\u00a0<\/p>\n Ollstein:<\/strong> So it\u2019s not a study, first of all. Even its supporters in the anti-abortion movement admitted, in private in a Zoom meeting that I obtained access to, that it is not a study. This is an analysis that they created. They are not disclosing the dataset that it is based on. It did not go through peer review. And so they are citing their own sort of white-paper analysis put out by an explicitly anti-abortion think tank to argue that abortion pills are more dangerous than previously known or that the FDA has previously acknowledged. There\u2019s been a lot of fact checks and debunks of some of their main points that we\u2019ve been through on this podcast also before. The Washington Post did an in-depth fact check<\/a> if people want to look that up. But suffice it to say that that has not deterred members of Congress from citing this and to pressure the FDA.\u00a0<\/p>\n And now you have the FDA sort of promising to do a review. If you look at the exact wording of what [FDA Commissioner Marty] Makary said, I\u2019m not sure. He said something like, Like we monitor the safety of all drugs, we\u2019re going to blah, blah, blah.<\/em> And so it\u2019s unclear if there\u2019s anything specific going on. But the threat that there could be, like you said, is really shaking up the drugmaking industry. And you\u2019re hearing a lot of the same alarms that we heard from the pharmaceutical industry when this was before the Supreme Court, when they were afraid the Supreme Court would second-guess the FDA\u2019s judgment and reimpose restrictions on mifepristone. And they\u2019re saying, Look, if we can\u2019t count on this being a process that just takes place based on the science and not politics and not courts coming in 25 years later and saying actually no, then why would we invest so much money in developing drugs if we can\u2019t even count on the rules being fair and staying the same?<\/em>\u00a0<\/p>\n Rovner:<\/strong> Yeah. We will see how this goes. I was surprised, though. We know that that Texas case that the Supreme Court managed to not reach the point of, because the plaintiffs didn\u2019t have standing, is still alive elsewhere. But I didn\u2019t realize that this other case was still sort of chugging along. So we\u2019ll see when the Supreme Court gets another bite at it. Meanwhile, the fight over funding for Planned Parenthood \u2014 whose Medicaid eligibility, at least for one year, was canceled by the new budget law \u2014 continues in court. This week a judge in Massachusetts gave the group a partial win by blocking the defunding for some smaller clinics and those that don\u2019t perform abortions, but that ruling replaced a more blanket delay on the defunding. So many clinics are now having their funding stopped while the court fight continues. Alice, what\u2019s the impact here of these Planned Parenthood clinics closing down? It\u2019s not just abortion that we\u2019re talking about. In fact, it\u2019s not even primarily abortion that we\u2019re talking about.\u00a0<\/p>\n Ollstein:<\/strong> Absolutely. So this is one, it\u2019s set to hit a lot of clinics in states where abortion is legal. And so these are the clinics that are serving a lot of people traveling from red states. And so there\u2019s already an issue with wait times, and this is set to make it worse. But that\u2019s just for abortion. Like you said, this is also set to hit a bunch of clinics in states where abortion is illegal and where these clinics are only providing other services, like birth control, like STI [sexually transmitted infection] testing. And at the same time we\u2019re having a lot of other funding frozen, and so this could really be tough for some of these areas where there aren\u2019t a lot of providers, and especially there are not a lot of providers who accept Medicaid.\u00a0<\/p>\n Rovner:<\/strong> Meanwhile, a number of states are passing conscience laws that let health professionals opt out of things like doing abortions or providing gender-affirming care if they violate their beliefs. Well, in Tennessee now we have a story of a pregnant woman who says her doctor refused to provide her with prenatal care, because she\u2019s not married to her partner of 15 years. She said at a congressional town hall that her doctor said her marital status violated his Christian beliefs, and he\u2019s apparently protected by the new Tennessee state law called the Medical Ethics Defense Act. I\u2019ve heard of doctors refusing to prescribe birth control for unmarried women, but this is a new one to me, and I\u2019ve been doing this for a very long time. Are these just unintended consequences of these things that maybe state lawmakers didn\u2019t think a lot about? Or are they OK with doctors saying, We\u2019re not going to provide you with prenatal care if you\u2019re pregnant and not married<\/em>?\u00a0<\/p>\n Ollstein:<\/strong> So one, as we just said, we\u2019re in a situation where there is such a shortage of providers and such a shortage of providers who accept certain coverage that being turned away by one place, you might not be able to get an appointment somewhere else, depending where you live. And so this isn\u2019t just an issue of, Oh, well, just don\u2019t go to that doctor who believes that.<\/em> People have very limited choices in a lot of circumstances. But I\u2014\u00a0<\/p>\n Rovner:<\/strong> Apparently this woman in Tennessee said she\u2019s having to go to Virginia to get her prenatal care.\u00a0<\/p>\n Ollstein:<\/strong> Well, exactly. Yeah. Exactly. This isn\u2019t like people have tons of options. And also this is an example of a slippery slope, of if you allow people to be able to refuse service for this reason, for that reason, what else could happen? And some states have more legal protections for things like marital status, and some do not. And so it\u2019s worth thinking through what could be sort of the next wave.\u00a0<\/p>\n Rovner:<\/strong> Well, we\u2019re certainly going to see what the outcome of this could be. Well, before we end our news segment this week, I want to give a shoutout to tennis legend Venus Williams, who at age 45 won a singles match at a professional tournament here in Washington this week and said in her post-match interview that she came back to playing because she needed the pro tour\u2019s health insurance to take care of several chronic conditions that she has. So see, even rich athletes need their health insurance. All right. That is this week\u2019s news. Now we will play my interview with Medicare historian Jonathan Oberlander, and then we will come back and do our extra credits.\u00a0<\/p>\n I am so pleased to welcome Jonathan Oberlander to the podcast. He\u2019s a professor of social medicine, professor of health policy and management, and adjunct professor of political science at the University of North Carolina School of Medicine in Chapel Hill and one of the nation\u2019s leading experts on Medicare. Jon, welcome to \u201cWhat the Health?\u201d\u00a0<\/p>\n Jonathan Oberlander:<\/strong> Great to see you, Julie.\u00a0<\/p>\n Rovner:<\/strong> So Medicare, to me at least, remains the greatest paradox in the paradox that is the U.S. health care system. It is at once both so popular and so untouchable that it\u2019s considered the third rail of politics, yet at its core it\u2019s a painfully out-of-date and meager benefit that nevertheless threatens to go bankrupt on a regular basis. How did we get here?\u00a0<\/p>\n Oberlander:<\/strong> Wow. So let\u2019s talk about the benefits for a minute. And I think one of the things we can say about Medicare in 2025 as we mark this 60th anniversary is it still bears the imprint of Medicare in 1965. And when Medicare was designed as a program \u2014 and the idea really dates back to the early 1950s \u2014 it was not seen as a comprehensive benefit. It was intended to pay for the most consequential costs of medical care, for acute care costs. And so when it was enacted in 1965, the benefits were incomplete. And the problem is, as you know very well, they haven\u2019t been added to all that much. And here we have a population, and all of us know as we get older, we generally don\u2019t get healthier. I wish it was true, but it\u2019s not. Older persons deal with all kinds of complex medical issues and have a lot of medical needs, and yet Medicare\u2019s benefits are very limited, so limited that actually a very small percentage of Medicare beneficiaries have only Medicare. Most Medicare beneficiaries have Medicare plus something else. And that may be an individual private plan that they purchase called a Medigap plan, or maybe a declining number of people have retiree health insurance that supplements Medicare.\u00a0<\/p>\n Some low-income Medicare beneficiaries have Medicaid as well as Medicare and they are dual-eligible. Some Medicare beneficiaries have extra benefits through the Medicare Advantage program, which I\u2019m sure\u2014\u00a0<\/p>\n Rovner:<\/strong> We\u2019ll get to.\u00a0<\/p>\n Oberlander:<\/strong> \u2014we\u2019ll have a lot to say. So the bottom line, though, is Medicare has grown. It has, what, about 70 million Americans rely on Medicare. But the benefit package \u2014 with some intermittent exceptions that are significant, such as the addition of outpatient prescription drugs in 2006 \u2014 really has not kept pace.\u00a0<\/p>\n Rovner:<\/strong> So let\u2019s go back to the beginning. What was the problem that Medicare set out to solve?\u00a0<\/p>\n Oberlander:<\/strong> Well, it was both a substantive problem and a political problem. The origins of Medicare are in the ashes, the failure, of the Truman administration proposals for national health insurance during the mid- and late 1940s. And after they had lost repeatedly, health reformers decided they needed a new strategy. So instead of national health insurance, what today we would call a single-payer, federal-government-run program for everybody, they trimmed their ambitions down to, initially, just hospital insurance, 60 days of hospital insurance for elderly Social Security beneficiaries. And that was it. And they thought if they just focused on older Americans, maybe they would tamp down the controversy and the opposition and the American Medical Association and charges of socialized medicine, all things that are really throwing a wrench into plans for national health insurance. It didn\u2019t quite work out as they thought. It took about 14 years from the time Medicare was proposed to enact it. And there was a big, divisive, controversial debate about Medicare\u2019s enactment. But it was fundamentally a solution to that political problem of, how do you enact government health insurance in the United States? You pick a more sympathetic population.\u00a0<\/p>\n Now, there was a substantive problem, which was in the 1940s and especially 1950s, private health insurance was growing in the United States for Americans who are working-age, and that growth of employer-sponsored health insurance really left out retirees. They were expensive. Commercial insurers didn\u2019t want to cover them. And the uninsured rate, if you can believe it, for people over age 65, before Medicare, was around 50%. Not 15 but five zero, 50%. And so here you had a population that had more medical needs, was more expensive, and they had less access to health insurance than younger people. And Medicare was created in part to end that disparity and give them access to reliable coverage.\u00a0<\/p>\n Rovner:<\/strong> So as you mentioned, Medicare was initially just aimed at elderly Social Security recipients. What were some of the biggest benefit and population changes as the years went by?\u00a0<\/p>\n Oberlander:<\/strong> So in terms of populations in 1972, Medicare added coverage for persons who have end-stage renal disease, so people who need dialysis no matter what the age. It\u2019s a lifesaving technology. They can qualify for Medicare. It didn\u2019t really make sense to add it to Medicare \u2014 it\u2019s just it was there. So they added it to Medicare. And also a population we don\u2019t talk nearly enough about, younger Americans with permanent disabilities who are recipients of Social Security Disability Insurance. For a couple of years they qualify for Medicare as well and are a very important part in the Medicare population. Beyond that, Medicare\u2019s covered population has not really changed all that much since the beginning, which actually would be a great disappointment to the architects of Medicare, who thought the program would expand to eventually cover everybody.\u00a0<\/p>\n In terms of benefits, the benefit package has been remarkably stable, for better and actually probably for worse, with the exception of, for example, the addition of outpatient prescription drug coverage, which came online in 2006, the addition of coverage for various preventive services such as mammography and cancer screenings. But Medicare still does not cover long-term stays in nursing homes. Many Americans think it does. They will be disappointed to find out it does not. Medicare does not cover, generally, hearing or vision or dental services. Traditional Medicare run by the government does not have a cap on the amount of money that beneficiaries can spend in a year on deductibles and copayments and so forth. So really its benefits remain quite limited.\u00a0<\/p>\n Rovner:<\/strong> So Medicare is also the biggest payer in the nation\u2019s health care system and for decades set the standard in how private insurance covered and paid for health care. So let\u2019s talk about privatization. Medicare Advantage, the private health plan alternative to traditional Medicare, is now more than half the program, both in terms of people and in terms of budget. Is this the future of Medicare? Or will we look back in many years and see it as kind of a temporary diversion?\u00a0<\/p>\n Oberlander:<\/strong> I think it\u2019s the present and probably the future. The future is always so hard to predict, Julie, because it\u2019s unwritten. But this is really a shocking outcome historically, because what Medicare\u2019s architects expected was that the program was going to expand government health insurance to all Americans, first with the older population, then adding children, then adding everybody. Did not turn out that way. The original aspiration was Medicare for all, through any incremental means. Instead, 60 years later, we don\u2019t have Medicare for all, but Medicare is mostly privatized. It\u2019s a hybrid program with a public and private component that increasingly is dominated by private insurance. And the fact that over half of Medicare beneficiaries are enrolled in these private plans is a stunning development historically, by the way with lots of implications politically, because that\u2019s an important new political force in Medicare that you have these large private plans and it\u2019s changed Medicare politics.\u00a0<\/p>\n I don\u2019t think Medicare Advantage is going anywhere. I think the question is, how big is it going to get? And I\u2019m not sure any of us know. It\u2019s been on a growth trajectory for a long time. And the question is \u2014 given that all the studies show that Medicare Advantage plans are overpaid, and overpaid by a lot, by the federal government, and it\u2019s losing a lot of money on Medicare Advantage, and it\u2019s never saved money \u2014 is there going to come a point where they actually clamp down? There\u2019ve been some incremental efforts to try and restrain payments. Really haven\u2019t had much effect. Are we actually going to get to a place where the federal government says: We need savings, yeah. This 22% extra that you\u2019re getting, no, we can\u2019t do that anymore.<\/em> So I think it\u2019s an open question about, how big is it going to get? Is it going to be two-thirds of the Medicare program, three-quarters of the Medicare program? And if so, then what is the future, turning the question on its head, of traditional Medicare if it\u2019s that small? And that\u2019s one of the great questions about Medicare in the next decade or two.\u00a0<\/p>\n Rovner:<\/strong> Thank you so much.\u00a0<\/p>\n Oberlander:<\/strong> Oh, thanks for having me. It was great to see you.\u00a0<\/p>\n Rovner:<\/strong> OK, we\u2019re back. And now it\u2019s time for our extra-credit segment. That\u2019s where we each recognize a story we read this week we think you should read, too. Don\u2019t worry if you miss it. We will put the links in our show notes on your phone or other mobile devices. Julie, why don\u2019t you go first this week?\u00a0<\/p>\n Appleby:<\/strong> Yeah. I found this story on NPR quite interesting. It\u2019s maybe something that a lot of us have thought about, but it just added a lot of numbers to the question of how many chemicals are in our beauty products \u2014 basically, the makeup we use, the lotions, our hairspray, the stuff that happens at the salon, that kind of thing. And it\u2019s called \u201cMany Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That<\/a>.\u201d And it was written by Rachel Treisman. Basically it says that the average American adult uses about 12 personal care products a day, resulting in exposure to about 168 chemicals, which can include things like formaldehyde, mercury, asbestos, etc., etc. OK, so that\u2019s interesting. But it also talks about how the European Union has banned more than 2,000 chemicals, basically, but the FDA puts limits on only about a dozen.\u00a0<\/p>\n So this has caused four Democratic lawmakers to introduce a package of legislation, actually they\u2019re calling the Safer Beauty Bill Package, and it\u2019s four bills. And basically one of them would ban two entire classes of chemicals, phthalates and formaldehyde-releasing chemicals. And it also calls for some other things as well, which they say hasn\u2019t been done and needs to be looked at. So I just thought it was an interesting thing that pulled together a lot of data from various sources and talked about this package of bills and whether or not it might make a difference in terms of looking at some of these chemicals in the products we use all the time and requiring a little bit more transparency about that. It\u2019s a step. I don\u2019t know if it\u2019s going to resolve everybody\u2019s concerns about this, but I just thought it was an interesting little piece looking at that topic.\u00a0<\/p>\n Rovner:<\/strong> It\u2019s worth remembering that the FDA\u2019s governing statute is actually called the Food, Drug, and Cosmetic Act.\u00a0<\/p>\n Appleby:<\/strong> That\u2019s right.\u00a0<\/p>\n Rovner:<\/strong> The cosmetics often gets very short shrift in that whole thing. Alice, why don\u2019t you go next?\u00a0<\/p>\n Ollstein:<\/strong> Yeah. So I have a piece from The Associated Press. It\u2019s called \u201cRFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals are Ultraprocessed<\/a>.\u201d And so this really gets at something we\u2019ve been talking about on the podcast, where the administration is really fixated on a few kind of superficial food health things like colored dyes in food and frying something in beef tallow instead of vegetable oil. But something fried in beef tallow is still unhealthy. Froot Loops without the color dye are still unhealthy. And these meals that he is promoting as a service for Medicare and Medicaid enrollees are unhealthy. So this article is about how they do have chemical additives, they are high in sodium and sugar and saturated fats, and so it\u2019s not in sort of keeping with the overall MAHA [Make America Healthy Again] message. But in a way it kind of is.\u00a0<\/p>\n Rovner:<\/strong> From the oops file. Jessie.\u00a0<\/p>\n Hellmann:<\/strong> My extra credit is from my colleague Ariel Cohen at Roll Call. It\u2019s called \u201cKennedy\u2019s Mental Health Drug Skepticism Lands at FDA Panel<\/a>.\u201d She did a story about something that kind of, I think, flew under the radar this week. The Trump administration is starting to make good on its promise to look at SSRIs [selective serotonin reuptake inhibitors], and the panel was very much full of skeptics of SSRIs who sought to undermine the confidence in using them while pregnant. And Marty Makary himself, FDA commissioner, claimed it could cause birth defects and other fetal harm. That was a statement that was echoed by many of the panelists. There was only one panelist who talked about the benefits of SSRIs in pregnant people who need them, the risks of postpartum depression to both the mom and the baby. And so I think this is definitely something to keep an eye on, is it looks like they\u2019re going to keep looking more at this and raising questions about SSRIs without having much of a nuanced conversation about it.\u00a0<\/p>\n Rovner:<\/strong> Yeah. I did see something from ACOG, from the American College of Obstetricians and Gynecologists, this week pushing back very hard on the anti-SSRI-during-pregnancy push. So we\u2019ll see how that one goes, too. My extra credit this week is from my KFF Health News colleague Katheryn Houghton, and it\u2019s called \u201cRepublicans Call Medicaid Rife With Fraudsters. This Man Sees No Choice but To Break the Rules.<\/a>\u201d And it\u2019s about something that didn\u2019t really come up during the whole Medicaid debate, the fact that if Republicans really want people to go to work, well, then maybe they shouldn\u2019t take away their health insurance if they get a small raise or a few extra hours. The subject of this story, only identified as James, technically makes about $50 a week too much to stay on Medicaid, but he otherwise can\u2019t afford his six prescription medications and he can\u2019t afford the care that he needs through even a subsidized Affordable Care Act plan, or his employer\u2019s plan, either.\u00a0<\/p>\n The point of the ACA was to make coverage seamless so that as you earn more, you can still afford coverage even if you\u2019re not on Medicaid anymore. But obviously that isn\u2019t happening for everyone. Quoting from the story: \u201c\u2018I don\u2019t want to be a fraud. I don\u2019t want to die,\u2019 James said. \u2018Those shouldn\u2019t be the only two options.\u2019\u201d Yet for a lot of people they are. It\u2019s not great, and it\u2019s not something that\u2019s currently being addressed by policymakers.\u00a0<\/p>\n OK. That is this week\u2019s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We\u2019d appreciate it if you left us a review. That helps other people find us, too. As always, you can email us your comments or questions. We\u2019re at whatthehealth@kff.org. Or you can find me still on X, @jrovner<\/a>, or on Bluesky, @julierovner<\/a>. Where are you folks hanging on social media these days? Jessie?\u00a0<\/p>\n Hellmann:<\/strong> I\u2019m @jessiehellmann on Twitter<\/a> and Bluesky<\/a>.\u00a0<\/p>\n Rovner:<\/strong> Alice.\u00a0<\/p>\n Ollstein:<\/strong> @AliceOllstein<\/a> on X and @alicemiranda<\/a> on Bluesky.\u00a0<\/p>\n Rovner:<\/strong> Julie.\u00a0<\/p>\n Appleby:<\/strong> @julie_appleby<\/a> on X.\u00a0<\/p>\n Rovner:<\/strong> We will be back in your feed next week. Until then, be healthy.\u00a0<\/p>\n \tFrancis Ying \tEmmarie Huetteman To hear all our podcasts,\u00a0click here<\/a>.<\/em><\/p>\n And subscribe to KFF Health News\u2019 \u201cWhat the Health?\u201d on\u00a0Spotify<\/a>,\u00a0Apple Podcasts<\/a>,\u00a0Pocket Casts<\/a>, or wherever you listen to podcasts.<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n
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