The guidance, issued in a cable the State Department sent to embassy and consular officials and examined by KFF Health News, directs visa officers to deem applicants ineligible to enter the U.S. for several new reasons, including age or the likelihood they might rely on public benefits. The guidance says that such people could become a “public charge” — a potential drain on U.S. resources — because of their health issues or age.

While assessing the health of potential immigrants has been part of the visa application process for years, including screening for communicable diseases like tuberculosis and obtaining vaccine history, experts said the new guidelines greatly expand the list of medical conditions to be considered and give visa officers more power to make decisions about immigration based on an applicant’s health status.

The directive is part of the Trump administration’s divisive and aggressive campaign to deport immigrants living without authorization in the U.S. and dissuade others from immigrating into the country. The White House’s crusade to push out immigrants has included daily mass arrests, bans on refugees from certain countries, and plans to severely restrict the total number permitted into the U.S.

The new guidelines mandate that immigrants’ health be a focus in the application process. The guidance applies to nearly all visa applicants but is likely to be used only in cases in which people seek to permanently reside in the U.S., said Charles Wheeler, a senior attorney for the Catholic Legal Immigration Network, a nonprofit legal aid group.

“You must consider an applicant’s health,” the cable reads. “Certain medical conditions – including, but not limited to, cardiovascular diseases, respiratory diseases, cancers, diabetes, metabolic diseases, neurological diseases, and mental health conditions – can require hundreds of thousands of dollars’ worth of care.”

About 10% of the world’s population has diabetes. Cardiovascular diseases are also common; they are the globe’s leading killer.

The cable also encourages visa officers to consider other conditions, like obesity, which it notes can cause asthma, sleep apnea, and high blood pressure, in their assessment of whether an immigrant could become a public charge and therefore should be denied entry into the U.S.

“All of these can require expensive, long-term care,” the cable reads. Spokespeople for the State Department did not immediately respond to a request for comment on the cable.

Visa officers were also directed to determine if applicants have the means to pay for medical treatment without help from the U.S. government.

“Does the applicant have adequate financial resources to cover the costs of such care over his entire expected lifespan without seeking public cash assistance or long-term institutionalization at government expense?” the cable reads.

The cable’s language appears at odds with the Foreign Affairs Manual, the State Department’s own handbook, which says that visa officers cannot reject an application based on “what if” scenarios, Wheeler said.

The guidance directs visa officers to develop “their own thoughts about what could lead to some sort of medical emergency or sort of medical costs in the future,” he said. “That’s troubling because they’re not medically trained, they have no experience in this area, and they shouldn’t be making projections based on their own personal knowledge or bias.”

The guidance also directs visa officers to consider the health of family members, including children or older parents.

“Do any of the dependents have disabilities, chronic medical conditions, or other special needs and require care such that the applicant cannot maintain employment?” the cable asks.

Immigrants already undergo a medical exam by a physician who’s been approved by a U.S. embassy.

They are screened for communicable diseases, like tuberculosis, and asked to fill out a form that asks them to disclose any history of drug or alcohol use, mental health conditions, or violence. They’re also required to have a number of vaccinations to guard against infectious diseases like measles, polio, and hepatitis B.

But the new guidance goes further, emphasizing that chronic diseases should be considered, said Sophia Genovese, an immigration lawyer at Georgetown University. She also noted that the language of the directive encourages visa officers and the doctors who examine people seeking to immigrate to speculate on the cost of applicants’ medical care and their ability to get employment in the U.S., considering their medical history.

“Taking into consideration one’s diabetic history or heart health history — that’s quite expansive,” Genovese said. “There is a degree of this assessment already, just not quite expansive as opining over, ‘What if someone goes into diabetic shock?’ If this change is going to happen immediately, that’s obviously going to cause a myriad of issues when people are going into their consular interviews.”

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an associate professor of family medicine at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

Shame is a common and highly uncomfortable human emotion. In the years since that pivotal incident, Bynum has become a leading voice among clinicians and researchers who argue that the intense crucible of medical training can amplify shame in future doctors.

He is now part of an emerging effort to teach what he describes as “shame competence” to medical school students and practicing physicians. While shame can’t be eliminated, Bynum and his research colleagues maintain that related skills and practices can be developed to reduce the culture of shame and foster a healthier way to engage with it.

Without this approach, they argue, tomorrow’s doctors won’t recognize and address the emotion in themselves and others. And thus, they risk transmitting it to their patients, even inadvertently, which may worsen their health. Shaming patients can backfire, Bynum said, making them defensive and leading to isolation and sometimes substance use.

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “just throwing insulin at people.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that one-third of physicians reported feeling repulsed when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said Michael Jaeb, a nurse at the University of Wisconsin-Madison, who has conducted a review of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

Savannah Woodward, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, burnout, sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students reported feeling publicly embarrassed at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said Karly Pippitt, a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with The Shame Lab, a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident Canice Dancel’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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Open enrollment for 2026 Affordable Care Act insurance plans starts in most states Nov. 1, with no resolution in Congress about whether to continue more generous premium tax credits expanded under President Joe Biden or let them expire at the end of this year. It is unclear whether the backlash from millions of enrollees seeing skyrocketing premiums will move Democrats or Republicans to back away from entrenched positions that are keeping most of the federal government shut down.

Meanwhile, the Trump administration — having done away earlier this year with a Biden-era regulation that prevented medical debt from being included on consumers’ credit reports — is now telling states they cannot pass their own laws to bar the practice.

This week’s panelists are Julie Rovner of KFF Health News, Paige Winfield Cunningham of The Washington Post, Maya Goldman of Axios, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Tens of millions of Americans are bracing to lose government food aid on Nov. 1, after the Trump administration opted not to continue funding the Supplemental Nutrition Assistance Program during the shutdown. President Donald Trump and senior officials have made no secret of efforts to penalize government programs they see as Democratic priorities, to exert political pressure as the stalemate continues on Capitol Hill.
• People beginning to shop for next year’s plans on the ACA marketplaces are experiencing sticker shock due to the expiration of more generous premium tax credits that were expanded during the covid pandemic. The federal government will also take a particular hit as it covers growing costs for lower-income customers who will continue to receive assistance regardless of a deal in Congress.
• In state news, after killing a Biden-era rule to block medical debt from credit reports, the Trump administration is working to prevent states from passing their own protections. In Florida, doctors who support vaccine efforts are being muffled, and the state’s surgeon general says he did not model the outcomes of ending childhood vaccination mandates before pursuing the policy — a risky proposition as public health experts caution that recent measles outbreaks are a canary in the coal mine for vaccine-preventable illnesses.
• And in Texas, the state’s attorney general, who is also running for the U.S. Senate as a Republican, is suing the maker of Tylenol, claiming the company tried to dodge liability for the medication’s unproven ties to autism. The lawsuit is the latest problem for Tylenol, with recent allegations undermining confidence in the common painkiller, the only one recommended for pregnant women to reduce potentially dangerous fevers and relieve pain.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage,” by Bernard J. Wolfson.

Alice Miranda Ollstein: ProPublica’s “Citing Trump Order on ‘Biological Truth,’ VA Makes It Harder for Male Veterans With Breast Cancer To Get Coverage,” by Eric Umansky.

Paige Winfield Cunningham: The Washington Post’s “Study Finds mRNA Coronavirus Vaccines Prolonged Life of Cancer Patients,” by Mark Johnson.

Maya Goldman: KFF Health News’ “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown, New England Public Media.

Also mentioned in this week’s podcast:

• The Washington Post’s “Average Obamacare Premiums Are Set To Rise 30 Percent, Documents Show,” by Paige Winfield Cunningham
• KFF Health News’ “Doctors Muffled as Florida Moves To End Decades of Childhood Vaccination Mandates,” by Arthur Allen.
• CBS News’ “The Quiet Collapse of America’s Reproductive Health Safety Net,” by Céline Gounder.

[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, starting this week, from WAMU public radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again. 

Winfield Cunningham: Hi, Julie. It’s great to be back. 

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving. 

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either. 

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America. 

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that. 

Rovner: Well, of course, and SNAP isn’t an HHS program. 

Goldman: Exactly. Exactly. 

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a sneak peek at the premiums for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find? 

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan — which, of course, is what, we know … that’s what the subsidies are pegged to — is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it. 

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand. 

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …  

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks. 

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain. 

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely — because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced … and now they have no cap. 

Rovner: I think 8.5% of their income, actually, under the enhanced premiums. 

Winfield Cunningham: Under the enhanced. OK. 

Rovner: It’s going to go back to 10%. 

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%. 

Rovner: 400%. 

Winfield Cunningham: Right. Yeah. Yeah. 

Rovner: That’s right. 

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it. 

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies. 

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue. 

Winfield Cunningham: This is very true. 

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something. 

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So … 

Rovner: Yeah. Although it is … 

Goldman: Obviously, that’s a lot of what ifs, but … 

Rovner: … only the death spiral that goes back to prior to covid, which — it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA. 

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers — will be subject to the full force of the premium increases because they won’t have any subsidies. 

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.  

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further — this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought — yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget — states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought? 

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that — I don’t know what health systems have said about this particular move, to be honest — but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is. 

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant. 

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC? 

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this. 

Rovner: Yeah. I’ve seen numbers as low as 60,000. 

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels. 

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years. 

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics. 

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades — focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that. 

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic. 

Ollstein: Exactly. 

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My KFF Health News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes? 

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects. 

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head. 

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary. 

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division — that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo — to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way — even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.? 

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data. 

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the … give credence to this idea that — I see you nodding, Maya — that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain. 

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch. 

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So … 

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications. 

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do. 

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line. 

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, according to my colleague Céline Gounder. Is contraception going to become the next health care service that’s only available in blue states, Alice? 

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services. 

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two. 

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something? 

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate. 

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods? 

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want. 

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but … 

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight. 

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week? 

Goldman: Sure. So this story is from KFF Health News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked. 

Rovner: Yeah, it is a public health issue, an interesting one. Alice? 

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “Citing Trump Order on ‘Biological Truth,’ VA Makes It Harder for Male Veterans With Breast Cancer To Get Coverage.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah. 

Rovner: Yeah. A combination of a lot of different factors in that story. 

Ollstein: Definitely. 

Rovner: Paige? 

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “Study Finds mRNA Coronavirus Vaccines Prolonged Life of Cancer Patients.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague. 

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my KFF Health News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.  

OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Maya? 

Goldman: I am on X as @mayagoldman_ and I’m also on LinkedIn, just under my name. 

Rovner: Alice? 

Ollstein: @alicemiranda on Bluesky and @AliceOllstein on X.  

Rovner: Paige? 

Winfield Cunningham: I am still @pw_cunningham on X. 

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

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Robert F. Kennedy Jr. on Sept. 4, 2025, in a Senate hearing

At a September Senate hearing, Health and Human Services Secretary Robert F. Kennedy Jr. boasted about a rural health initiative within  President Donald Trump’s “One Big Beautiful Bill Act.”

“It’s going to be the biggest infusion of federal dollars into rural health care in American history,” Kennedy said, responding to criticism from Sen. Bernie Sanders (I-Vt.). Sanders said the law would harm patients and rural hospitals.

Kennedy was referring to the law’s five-year, $50 billion Rural Health Transformation Program, HHS spokesperson Emily Hilliard said. GOP lawmakers have made similar claims about the program.

The fund was added to the bill at the last minute to secure support from Republican lawmakers who represent rural states. Some were concerned about how the bill’s Medicaid cuts would harm rural America, where more than 150 hospitals have stopped offering inpatient services or been shuttered completely since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

“The transformation fund was really talked about in the context of saving rural hospitals that would be facing these significant Medicaid cuts,” said Carrie Cochran-McClain, chief policy officer at the National Rural Health Association. Medicaid is the joint state-federal health insurance program that primarily covers low-income people and those with disabilities.

So is Kennedy right in his description of the rural health fund as a historic cash infusion, or does it fail to acknowledge critical context?

The Rural Health Transformation Program

Trump’s tax and spending law is expected to reduce federal Medicaid spending in rural areas by at least $137 billion by 2034, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. The Congressional Budget Office predicts the law will increase the overall number of uninsured patients by 10 million by 2034.

Rural health facilities disproportionately rely on Medicaid reimbursement to stay afloat. In 2023, 40.6% of children and 18.3% of adults under age 65 from rural areas and small towns were enrolled in Medicaid, according to the Center for Children and Families at Georgetown University. In metro areas, the rates were 38.2% and 16.3%, respectively.

The Trump administration argues that rural hospitals cannot rely on “legacy” funding sources like Medicaid and Medicare due to the programs’ reimbursement structure, which ties payments to the number of services provided, a model that’s not financially sustainable for rural facilities with typically low patient volumes.

“Distinct from these other programs, the Rural Health Transformation Program is designed to provide a flexible source of investment” to promote innovation, efficiency, and sustainability, the White House wrote in a memo.

Here’s how it works. States can propose projects spearheaded by state agencies, health care providers, consultants, and vendors aimed at various purposes, such as improving technology, access to care, and workforce recruitment.

States can use only 15% of their transformation program funding for provider payments and can direct money to non-rural areas, according to KFF.

Half of the $50 billion will be evenly divided among states whose applications are approved — regardless of their rural and overall populations — according to the “Notice of Funding Opportunity” for the program.

The other half will be awarded based on “the transformative possibilities” of states’ grant proposals; how much they’ve committed to aligning their health policies with the Trump administration’s; and data on their rural population, rural health facilities, uncompensated care, and other measurements.

The application deadline is Nov. 5.

The Big Picture

Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, said the rural health community is excited about the innovations the new program might foster, but he’d “love for it to happen in the absence of these cuts that are going to devastate our rural health system.”

“It’s not going to fill the hole,” Meit said.

KFF estimates that the rural health fund’s five-year, $50 billion investment is a little over a third of the expected loss of federal funding in rural areas that will be spread over 10 years. According to that analysis, Medicaid cuts over that period would tally at least $137 billion in rural areas.

That number doesn’t account for other reductions stemming from the same law, such as cuts to the ACA Marketplaces or the health system revenue loss expected from an increase in the number of people without insurance. 

These factors are important to note because the rural health program is a temporary initiative, while reductions in federal spending are long-term.  

Another issue is the difference in the program’s spirit. The rural health fund is focused on transforming the rural health care system — not providing continued funding to keep facilities open or making up for lost Medicaid funds. Even if the money triggers successful innovations, there are doubts that those will happen in time to prevent rural health facilities from closing.

“There’s a real misperception that somehow these funds are going to be able to save rural America or save rural hospitals,” Cochran-McClain said.

Joseph Antos, a health policy expert and senior fellow emeritus at the conservative-leaning American Enterprise Institute, said Kennedy’s comment is something “politicians say when they want to ignore the rest of the policies.”

“What they wanted was to say that they were creating a new program,” Antos said. “Well, this is a very inefficient way to distribute a relatively very small amount of money to hospitals that will incur much larger bad debt over the coming years, thanks to the cuts in Medicaid.”

One Caveat

Experts said that when viewed outside of mandatory programs like Medicare and Medicaid, the $50 billion rural health fund does appear to be unrivaled, especially for a limited, five-year program.

Several mentioned the Hill-Burton Act as another program that significantly boosted rural health care. The law provided loans and grants that modernized or built 6,800 health facilities, many of which were in rural areas, from 1946 to 1997, according to the Health Resources and Services Administration.

Incomplete funding data makes it difficult to account for inflation, said Kelsey Moran, an assistant professor and health economist at the University of Miami.

But she estimated that, during the life of the program, it spent $47 billion in 2024 dollars when using the Consumer Price Index, or $109 billion when using the CPI’s medical care index. The medical index has a higher inflation rate because health prices have risen more than overall prices.

Our Ruling 

Kennedy said the rural health fund is “going to be the biggest infusion of federal dollars into rural health care in American history.”

The statement contains an element of truth because the new program could be the most significant one-time investment in rural health funding.

But it ignores critical facts and context that create a different impression.

Federal contributions to rural areas from Medicaid and Medicare easily dwarf this program’s $50 billion mark. The new fund offers states flexibility in how they can allocate resources, meaning there’s no guarantee that all the new funding will go to rural Americans’ health care. The program comes at the same time rural areas are expected to lose far more from Medicaid cuts and an increase in uninsured patients than what the rural health fund infusion can backfill.

Experts say the rural health fund’s cash infusion is canceled out by other parts of Trump’s tax and spending law that call for cuts and policy changes.

We rate this statement Mostly False.

Our Sources

“Watch: Sanders, RFK Jr. Get Into Testy Exchange Over COVID Vaccine, CDC Director’s Firing,” CBS News, Sept. 4, 2025.

“$50B Rural Health ‘Slush Fund’ Faces Questions, Skepticism,” KFF Health News, July 21, 2025.

“Rural Hospital Closures,” Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, accessed Sept. 15, 2025.

“Senate GOP Mulls Shielding Rural Hospitals From Medicaid Cuts,” Roll Call, June 20, 2025.

“Key Takeaways From CMS’s Rural Health Funding Announcement,” KFF, Sept. 23, 2025.

“Estimated Budgetary Effects of Public Law 119-21, To Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline,” Congressional Budget Office, July 21, 2025.

“Medicaid’s Role in Small Towns and Rural Areas,” Georgetown University Center for Children and Families, Jan. 15, 2025.

“MEMORANDUM Re: The One Big Beautiful Bill is a Historic Investment in Rural Healthcare,” The White House, undated.

Notice of Funding Opportunity for the Rural Health Transformation Program, government document published on Sept. 15, 2025.

“The Federal Budget in Fiscal Year 2023: An Infographic,” Congressional Budget Office, March 5, 2024.

“The Federal Budget in Fiscal Year 2024: An Infographic,” Congressional Budget Office, March 20, 2025.

“Hill-Burton Facilities Compliance,” HRSA, accessed Sept. 16, 2025.

“Hospital Charity Care & The Hill-Burton Act,” working paper by Kelsey Moran updated on Sept. 15, 2025.

Phone interview with Matthew Fiedler, a senior fellow in economic studies at the Center on Health Policy at The Brookings Institution, Sept. 24, 2025.

Phone interview with Gbenga Ajilore, chief economist, and Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, Sept. 24, 2025.

Phone interview with Larry Levitt, executive vice president for health policy at KFF, Sept. 24, 2025.

Phone interview with Joseph Antos, a health policy expert and senior fellow emeritus at the American Enterprise Institute, Sept. 23, 2025.

Phone interview with Carrie Cochran-McClain, chief policy officer at the National Rural Health Association, Sept. 17, 2025.

Phone interview with Kelsey Moran, assistant professor in the Department of Health Management and Policy at the University of Miami, Sept. 15, 2025.

Phone interview with Alana Knudson, director of the NORC Walsh Center for Rural Health Analysis at the University of Chicago, Sept. 12, 2025.

Phone interview with Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, Sept. 11, 2025.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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President Donald Trump on Sept. 22, 2025, in a press conference

Obstetricians have long advised their pregnant patients that Tylenol is the safest option to reduce fever or pain. President Donald Trump stood before a national audience on Sept. 22 and contradicted that.

“Don’t take Tylenol,” Trump said during an hourlong White House press conference that included his leading health appointees. “There’s no downside. Don’t take it. You’ll be uncomfortable. It won’t be as easy, maybe, but don’t take it. If you’re pregnant, don’t take Tylenol.”

His advice has no clear basis in research and contradicts long-standing science and medical guidance. And there are downsides to avoiding acetaminophen, the active ingredient in Tylenol, when it is needed. Untreated fever during pregnancy can harm a mom and baby, medical experts warn. Untreated pain is a drawback, too.

Trump’s advice is based on the unproven idea that acetaminophen use during pregnancy increases a child’s risk of autism — a stance that he and Robert F. Kennedy Jr., the longtime anti-vaccine activist who is now Trump’s Health and Human Services secretary, touted throughout the announcement.

Although some studies have found that children exposed to acetaminophen during pregnancy were more likely to have autism symptoms or be diagnosed with autism, other studies found no such association. Association is not the same as causation. That means that research showing an association between Tylenol and autism doesn’t mean the medication caused autism.

The Food and Drug Administration’s Sept. 22 press release on the topic said as much.

“It is important to note that while an association between acetaminophen and neurological conditions has been described in many studies, a causal relationship has not been established and there are contrary studies in the scientific literature,” it said. “It is also noted that acetaminophen is the only over-the-counter drug approved for use to treat fevers during pregnancy, and high fevers in pregnant women can pose a risk to their children.”

The White House declined to provide data showing there are no downsides to avoiding Tylenol use. It provided a statement from White House press secretary Karoline Leavitt in which she cited “a connection” between acetaminophen use during pregnancy and autism as the reason for the guidance.

“The Trump Administration does not believe popping more pills is always the answer for better health,” Leavitt said.

Leavitt also shared on the social platform X a statement from Andrea Baccarelli, dean of the Harvard T.H. Chan School of Public Health, who said his research “found evidence of an association” between prenatal acetaminophen exposure and neurodevelopmental disorders in children. Baccarelli warned of the risks of high fever and advocated for cautious acetaminophen use during pregnancy — not blanket avoidance.

The Risks of Untreated Fever During Pregnancy

Maternal and prenatal care groups, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, support the use of acetaminophen during pregnancy.

They reiterated this support in response to Trump’s remarks.

There’s good reason for that: Acetaminophen is one of few safe options pregnant patients have to treat fever and manage pain.

Trump acknowledged this during the press conference.

“Sadly, first question: What can you take instead?” he said. “There’s not an alternative.” He said that other medicines such as aspirin and Advil “are absolutely proven bad.”

In 2020, the FDA advised that nonsteroidal anti-inflammatory drugs, or NSAIDs, which include common pain relievers such as Advil (also known as ibuprofen), Aleve (or naproxen), and aspirin shouldn’t be used during pregnancy after 20 weeks of gestation.

Those medications aren’t recommended during pregnancy because they could harm fetal development, Salena Zanotti, a Cleveland Clinic obstetrician and gynecologist, said this year.

Untreated fevers during pregnancy come with their own risks.

In ACOG’s Sept. 22 statement, Steven Fleischman, the association’s president, said the Trump administration’s anti-Tylenol advice sends a “harmful and confusing message” to pregnant patients.

“Maternal fever, headaches as an early sign of preeclampsia, and pain are all managed with the therapeutic use of acetaminophen, making acetaminophen essential to the people who need it,” Fleischman said.

Christopher Zahn, ACOG’s chief of clinical practice, said pregnant patients should talk with their doctors about the benefits and risks of available treatments. Avoiding treating medical conditions that call for acetaminophen is “far more dangerous than theoretical concerns based on inconclusive reviews of conflicting science,” Zahn said.

Similarly, the Society for Maternal-Fetal Medicine said that untreated fever and pain during pregnancy carry “significant maternal and infant health risks.”

“Untreated fever, particularly in the first trimester, increases the risk of miscarriage, birth defects, and premature birth, and untreated pain can lead to maternal depression, anxiety, and high blood pressure,” it said.

Research on these risks goes back more than a decade: A 2014 Pediatrics review of available evidence on fevers during pregnancy found “substantial evidence” that maternal fever might negatively affect fetal health in the short and long term, including increasing the risks of neural tube defects, congenital heart defects, and oral clefts.

The Centers for Disease Control and Prevention also says that fever during pregnancy has been linked to adverse outcomes including birth defects.

MotherToBaby, a nonprofit that provides information about the benefits and risks of medications and other exposures during pregnancy and while breastfeeding, warns that a fever-caused increase in body temperature during early pregnancy carries risks, including a small chance for birth defects. Some studies also found that fevers are associated with increased chances of a child having attention-deficit/hyperactivity disorder or autism.

Kenvue, Tylenol’s parent company, said acetaminophen is “the safest pain reliever” option available throughout pregnancy.

“Without it, women face dangerous choices: suffer through conditions like fever that are potentially harmful to both mom and baby or use riskier alternatives,” the company’s statement said. “High fevers and pain are widely recognized as potential risks to a pregnancy if left untreated.”

Tylenol, responding to the news attention on Instagram, cited the ACOG position on acetaminophen use during pregnancy and highlighted a section of the Tylenol label that encourages people who are pregnant or breastfeeding to talk to a health professional.

“Your doctor is the best person to advise whether taking medication is right for you based on your specific health needs,” the video said.

Our Ruling

Trump said “there’s no downside” to avoiding Tylenol use during pregnancy.

Researchers have long documented health risks associated with untreated fevers during pregnancy. They can lead to increased risk of birth defects and other pregnancy complications, particularly in the first trimester. Untreated pain can lead to maternal depression and anxiety. These risks outweigh conflicting research into possible links between the drug and autism, according to maternal and fetal health organizations.

Doctors and researchers have found acetaminophen to be a safe pain and fever reducer during pregnancy. By comparison, other over-the-counter pain relievers come with documented risks, making Tylenol one of the only options available to pregnant mothers.

We rate Trump’s statement Pants on Fire!

Sources

Emailed statement from Kenvue, Sept. 22, 2025

Emailed statement from the American College of Obstetricians and Gynecologists, Sept. 22, 2025

Emailed statement from the Society for Maternal-Fetal Medicine, Sept. 22, 2025

Emailed statement from White House press secretary Karoline Leavitt, Sept. 22, 2025

White House press secretary Karoline Leavitt’s X post, Sept. 22, 2025

PolitiFact, “Research Doesn’t Show Using Tylenol During Pregnancy Causes Autism. Here’s What Else You Should Know,” Sept. 15, 2025

Tylenol Instagram post, Sept. 22, 2025

Cleveland Clinic, “Can You Take Acetaminophen While Pregnant?” March 17, 2025

Email interview with Christopher Zahn, American College of Obstetricians and Gynecologists’ chief of clinical practice, Sept. 10, 2025

Centers for Disease Control and Prevention, “Flu & Pregnancy,” Sept. 17, 2024

Centers for Disease Control and Prevention, “Heat and Pregnancy,” June 25, 2024

Centers for Disease Control and Prevention, “About Vaccines and Pregnancy,” June 17, 2024

MotherToBaby, “Fever/Hyperthermia,” Feb. 1, 2025

Food and Drug Administration, “FDA Drug Safety Communication: FDA Has Reviewed Possible Risks of Pain Medicine Use During Pregnancy,” Jan. 19, 2016

Food and Drug Administration, “FDA Responds to Evidence of Possible Association Between Autism and Acetaminophen Use During Pregnancy,” Sept. 22, 2025

American Journal of Obstetrics & Gynecology, “Prenatal Acetaminophen Use and Outcomes in Children,” March 2017

American College of Obstetricians and Gynecologists, “Acetaminophen in Pregnancy,” accessed Sept. 22, 2025

Vogue, “The Latest in Maternal Health Fear Mongering? Tylenol,” Sept. 22, 2025

The HIPAA Journal, “Dr. Dorothy Fink Appointed as Acting HHS Secretary,” Jan. 22, 2025

Pediatrics, “Systematic Review and Meta-Analyses: Fever in Pregnancy and Health Impacts in the Offspring,” March 1, 2014

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Members admitted they didn’t know what they were voting on, first rejecting a combined measles-mumps-rubella-chickenpox vaccine for young toddlers, then voting to keep it funded minutes later. The next day, they reversed themselves on the funding.

Now Jim O’Neill, the deputy health and human services secretary and the Centers for Disease Control and Prevention’s acting director (a lawyer, not a doctor), must sign off. The panel’s recommendations matter, because insurers and federal programs rely on them, but they are not binding. States can follow the recommendations, or not.

In the West, California, Oregon, Washington, and Hawaii have joined forces in the West Coast Health Alliance. Their first move was to issue joint recommendations on covid, flu, and RSV vaccines, going further than ACIP.

“Public health should never be a patchwork of politics,” said Sejal Hathi, Oregon’s state health director.

California’s health director, Erica Pan, described the goal as “demonstrating unity around science and values” while reducing public confusion.

The bloc is also exploring coordinated lab testing, data sharing, and even group purchasing. “Our intent is to restore trust in science and safeguard people’s freedom to protect themselves and their families without endless barriers,” Hathi said.

In the Northeast, New York and its neighbors created the Northeast Public Health Collaborative. Democratic Gov. Kathy Hochul called it a rebuke to Washington, D.C.’s retreat from science.

“Every resident will have access to the COVID vaccine, no exceptions,” she said in a statement.

The group has already gone beyond vaccines. After the CDC disbanded its infection-control advisory body, the Northeast states created their own return-to-work rules. Work groups now span vaccines, labs, emergency preparedness, and surveillance.

“Infectious diseases don’t respect borders,” said Connecticut’s health commissioner, Manisha Juthani. “We had to move in the same direction to protect our residents.”

The two blocs are in regular contact. “We communicate every day,” Hathi said.

“We can’t just sit by while federal agencies are hollowed out,” said acting New York City health commissioner Michelle Morse. “Public health is local, and we have to act like it.”

State leaders describe their coalitions as filling a vacuum left by Washington, D.C.

“You would think emerging from a pandemic, we would be embracing public health, but the federal government was heading in the opposite direction,” said James McDonald, New York state health commissioner.

Massachusetts commissioner Robbie Goldstein added: “The federal government has historically been the entity that held us all together. In January of this year, that tradition seemed to be going away.”

Boston University law professor Matt Motta summarized the dilemma: “States are taking matters into their own hands, sometimes to expand access to vaccines, sometimes to roll it back. That’s technically how the system works, but it risks inefficiency and confusion.”

Public health law has long tilted toward the states.

“If there was a public health issue, we’d say it’s for the states,” said Wendy Parmet of the Northeastern University School of Law.

States have mandated vaccines since the 1800s. Federal agencies can approve vaccines and fund programs, but they cannot force mandates except in very specific circumstances (e.g., federal employees).

UC Law-San Francisco’s Dorit Reiss agreed with Parmet: “Public health authority resides primarily with the states. Recommendations are recommendations.”

ACIP’s votes matter for coverage rules and insurance mandates, but states are free to diverge.

That divergence is already widening. Florida, led by Surgeon General Joseph Ladapo, is moving to eliminate childhood vaccine requirements altogether — a first-in-the-nation step. Georgetown Law’s Larry Gostin warned this could reopen century-old battles dating to Jacobson v. Massachusetts (1905), when the Supreme Court upheld state vaccine mandates for public safety.

Health leaders warn that competing systems risk causing confusion and costing lives. “Federal silence creates a vacuum, and states either step up together or splinter apart,” Hathi said.

Pan added that “without federal credibility, we’re left improvising.”

McDonald cautioned that partisan divides could grow sharper.

And Morse said that “blue and red states could each go their own way, leaving the public even more divided.”

Gostin put it bluntly: “That risks confusion, inefficiency, and ultimately lives.”

This state-by-state tug-of-war is not new. In the 1800s, local boards of health fought cholera with sewers and sanitation when federal authority was absent. In the 1950s, states organized mass polio clinics, with uneven uptake until federal funding smoothed disparities.

During the covid pandemic, Trump White House response coordinator Deborah Birx saw firsthand the limits of federal power. She visited 44 states, urging governors to adopt masks, closures, and vaccines.

“I was trying to get them to tailor responses to their populations, not just follow generic federal guidance,” she later recalled.

Supreme Court Justice Louis Brandeis once said that states are “laboratories of democracy,” where leaders could test out new ideas without putting the whole country at risk. But diseases don’t follow state lines. A virus that starts in Tallahassee could spread to Times Square by the next morning.

Today, states have become laboratories of public health. Each state is experimenting — some expanding protections, others cutting them back. And those choices could, for better or worse, affect us all.

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As in earlier hearings concerning Robert F. Kennedy’s performance as secretary of the Department of Health and Human Services, the focus was on Sen. Bill Cassidy (R-La.), who cast the deciding vote as HELP Committee chair to confirm Kennedy early this year. Since that vote, Cassidy has repeatedly expressed skepticism about Kennedy’s leadership.

Cassidy noted that when Kennedy swore in Monarez on July 31, he extolled her “unimpeachable scientific credentials.” Less than a month later, she was fired. “What happened?” Cassidy said. “Turmoil at the top of the nation’s top public health agency is not good for the health of the American people.”

Monarez said she came into the job aligned with Kennedy’s goals of improving America’s health and was open to changing the policies and structures at the CDC. She wasn’t ready to compromise her scientific judgment, however.

“I could have kept the office, the title, but I would have lost the one thing that cannot be replaced: my integrity,” she said.

Monarez said that at an Aug. 25 meeting, Kennedy demanded she fire senior scientists and agree to approve all changes in vaccine policy put forward by the new members of the Advisory Committee on Immunization Practices. In June, Kennedy fired its members and replaced them with a smaller group that includes leading opponents of the U.S. vaccination program.

When Monarez refused both requests, she said, Kennedy told her to resign. She refused, and the White House fired her, she said.

Kennedy, in testimony this month, denied he’d made the ultimatums and said Monarez had lied. Republican senators repeated that claim at Wednesday’s hearing. Markwayne Mullin of Oklahoma said a recording of the Aug. 25 meeting contradicted Monarez’s account. But later in the hearing, Cassidy said that Mullin had retracted his statement, saying there was no such recording.

The hearing appeared to confirm reports that Kennedy intends to change the childhood vaccine schedule, moving initially against recommending a hepatitis B vaccination shortly after birth, a practice the CDC has supported for more than three decades.

The CDC recommends that children be vaccinated against 16 pathogens with about 25 shots, sprays, or oral vaccinations in their first two years of life. The vaccines protect kids against such diseases as influenza, measles, whooping cough, meningitis, diarrhea, chickenpox, cancer, and pneumonia. It’s up to states to decide which vaccinations are required for schoolchildren.

Sen. Lisa Blunt Rochester (D-Del.) noted that for decades universal vaccination of newborns for hepatitis B has reduced case rates of the disease among young people by 99%, as reported by KFF Health News. Sens. Ashley Moody (R-Fla.), Ed Markey (D-Mass.), and Cassidy (R-La.) asked about plans, first reported by KFF Health News, for ACIP to vote to recommend pushing the first dose of the hepatitis B vaccine from the hours after birth to age 4.

Cassidy, in closing the hearing, spoke gravely of the dangers of ending the hepatitis B dose for newborns. He noted that before 1991 as many as 20,000 babies would become infected with hepatitis B, often leading to liver disease and sometimes death. Today, fewer than 20 babies a year contract the virus from their mothers, he said.

“That is an accomplishment to make America healthy again, and we should stand up and salute the people that made that decision,” he said.

Asked by reporters after the hearing whether the American public should have confidence in the advisory committee if it votes to delay the hepatitis B dose for newborns, he replied, “No.”

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Under federal law, public schools must provide children with disabilities a “free appropriate public education,” to give them the same opportunity to learn as other kids.

The twins’ mother, Emma Miller, and tens of thousands of other parents in the U.S. have elevated complaints to the Education Department alleging that schools and states have ignored mistreatment of their children. Those complaints are in limbo as President Donald Trump’s administration has set about dismantling the federal agency.

Trump once mocked a reporter with a disability. Earlier this year, Health and Human Services Secretary Robert F. Kennedy Jr.’s inaccurate remarks about people with autism were criticized as perpetuating offensive stereotypes.

Now people like Miller are worried their children will be left behind.

“I want justice for my twins, and to sound the alarm so other special needs children are not suffering or being deprived,” said Miller, 53, who lives with her twins in Wake Forest, North Carolina.

The Education Department, which was created in 1979 and helps oversee schools and colleges in the U.S., has the authority to protect students from discrimination based on race, sex, religion, or disability. Its Office for Civil Rights investigates allegations at schools and negotiates corrective actions.

As the school year begins, families throughout the country are unsure what authority will be left to intervene on their behalf if the office is shuttered, said Hannah Russell, an advocate who works with parents in North Carolina trying to obtain educational services for their children with disabilities.

“Without the Department of Education there is no accountability,” said Russell, a former special education teacher. “Everybody is scared.”

Miller described her twins as her “miracle babies” who survived despite each weighing 1 pound at birth. Danielle Price spent the first five months of her life in a neonatal intensive care unit, and her brother, Devon, the first seven months.

She has spent years fighting for them, repeatedly taking on local and state school officials. But even when she notched victories, she said, her children did not get the help they were promised.

Miller said her children are high-functioning and verbal. She said they could have thrived academically if the school system had given them proper services.

“My children have suffered,” Miller wrote in a complaint she filed in September 2024. “The most vulnerable group of children [is] being denied a basic education.”

‘Unusual and Unprecedented’

Miller says her daughter began to self-harm after classmates teased and tormented her and staff secluded her away from her bullies. The Wake County Public School System assigned Devon to a classroom with an instructional assistant who was not a licensed teacher, a violation of policy, according to state documents.

Last year, Miller filed a complaint against Wake County schools with the federal Office for Civil Rights. She alleged the district did not reevaluate her kids to determine their special education needs, did not respond for months to her records requests, and retaliated against her by wrongly withdrawing the twins from the school district.

Wake County schools violated policy when staff did not address the effects of bullying on Danielle, says an April 2024 letter from the North Carolina Department of Public Instruction.

The school system’s education plan for Danielle “was not appropriate considering the student’s unmet social-emotional needs, which resulted in the student’s increased anxiety,” the letter says.

State officials concluded in June 2024 that the school system failed to develop, review, and revise an education plan for Devon, assigned him to a teacher assistant instead of a licensed teacher, and did not provide technology that could help him learn, according to documents.

While the decisions validated Miller’s concerns, she said that the district continues to violate her children’s rights and that the state is now ignoring her pleas for help.

“No one is taking responsibility,” she told KFF Health News. “It has been a nightmare.”

But after she appealed to the federal government last year, the Education Department sent her a letter in March saying it would not look into the complaint.

For decades, parents and advocates for people with disabilities have said the system makes it difficult for them to win against school districts, because the process is often time-consuming, confusing, and, if a family hires a lawyer, expensive. Now they say families could soon face even bigger hurdles.

On March 11, the day the Education Department sent Miller’s denial letter, the agency announced it was firing nearly half its 4,133 employees. Education Secretary Linda McMahon said the move was “a significant step toward restoring the greatness of the United States education system.”

Officials shuttered seven of the 12 regional offices of the agency’s Office for Civil Rights, leaving a skeleton staff to investigate thousands of complaints filed each year, according to attorneys and advocates for the disabled.

Trump, acting on a campaign promise to shrink the federal government, later signed an executive order to eliminate the Education Department, which he said had failed children and built a bloated bureaucracy.

The president instructed officials to “return authority over education to the States and local communities while ensuring the effective and uninterrupted delivery of services, programs, and benefits on which Americans rely.”

Parents and advocacy groups say that would allow local authorities to police themselves at a time when schools remain racially segregated, some selective colleges accept male applicants at higher rates than female applicants, and students with disabilities are struggling to recover academically from the covid pandemic, more so than their peers. Also, they note, the federal laws protecting disabled and disadvantaged children emerged because of state-level failures.

Under North Carolina law, children with disabilities should be reevaluated by schools every three years to help determine their individual needs. But Miller said Wake County officials for nearly a decade refused her requests to have her kids reevaluated. She said it finally happened in late 2024.

“I never expected getting an education for my children would be such a problem,” Miller said.

The Education Law Center, the NAACP, and other advocacy groups have sued to stop Trump’s plans, alleging the changes are illegal and pose a threat to the education of students from vulnerable groups. Some 20 states and the District of Columbia sued to halt the plan, but the Supreme Court ruled in July that the Trump administration could move ahead while the case proceeded through the courts.

Russell said she has heard North Carolina school districts are promising to provide accommodations for students with disabilities, such as extra time on tests.

But families who cannot afford to hire an attorney could find themselves at a disadvantage when disagreements arise over services that cost districts more money, Russell said.

The Trump administration has decimated the Office for Civil Rights’ ability to properly investigate a backlog of thousands of complaints, said Robert Kim, who leads the Education Law Center.

The office reported receiving nearly 23,000 complaints in fiscal 2024, the highest number ever. About 8,400, or 37%, involved allegations of disability discrimination.

Black children and those with disabilities may suffer the worst consequences, since they disproportionately face harsh discipline at school, including physical restraint and isolation in seclusion rooms, Kim said.

The Education Department says children with disabilities make up 14% of students but 75% of those secluded and 81% of those physically restrained.

Black children constitute about 15% of students but 42% of those who are mechanically restrained using a device or equipment.

“Something unusual and unprecedented is happening,” Kim said about what he sees as a shift in the federal government’s responsibility to keep children safe and provide a high-quality education.

The Education Department’s press office declined an interview request for this story in an unsigned email that was copied to agency officials Madison Biedermann, Savannah Newhouse, Julie Hartman, and Ellen Keast.

White House spokesperson Kush Desai did not respond to a request for comment.

In a July statement, McMahon said her agency is performing all of its duties: “We will carry out the reduction in force to promote efficiency and accountability and to ensure resources are directed where they matter most — to students, parents, and teachers.”

‘Nothing but Problems’

Danielle and Devon Price entered 10th grade at Wake Forest High School in August. Their mother said she is uncertain what will happen to them.

Danielle wants to go to college, but her math skills are at a fourth-grade level, school records show.

Like many youths with autism, Danielle struggles with changes in routine, and her mother said she became despondent when school officials repeatedly changed her classes to keep her away from a boy who bullied her. Soon after that, Danielle started to self-harm, Miller said, adding that her daughter receives intensive therapy.

“It has been nothing but problems” with Wake County schools, she said. “It is like no one cares.”

Wake County school officials declined to answer questions about Miller’s complaints, citing privacy laws.

In a written statement, district spokesperson Matthew Dees said that “the school district has worked hard to reach agreement with Ms. Miller on many issues” and remedied complaints that were substantiated.

“The district disputes the remaining allegations in the various complaints she has raised, including the many accusations against various staff,” Dees added.

Under federal law, parents have 180 days from the time of the last alleged violation to file a complaint with the Education Department. Miller submitted her complaint Sept. 12, 2024, exactly 180 days after she says her twins were last denied a “free appropriate public education.”

But the Office for Civil Rights said that was too late. Officials declined to waive the time limit for Miller, who had asked for an exception, according to its March denial letter.

She said she spent months fighting with Wake County school officials and did not turn to federal government sooner because she hoped she could resolve the issues locally.

Miller fears for her children’s future unless something changes at school.

“I’m a single parent, and one day I won’t be here,” she said. “My kids are going to be adults soon, yet my son doesn’t know how to read and write. I’m like, ‘Wow.’ There really is no help here.”

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Just days after his firing of the brand-new director of the Centers for Disease Control and Prevention, a defiant Robert F. Kennedy Jr., the U.S. secretary of health and human services, defended that action and others before a sometimes skeptical Senate Finance Committee. Criticism of Kennedy’s increasingly anti-vaccine actions came not just from Democrats on the panel but from some Republicans who are also medical doctors.

Meanwhile, members of Congress have only a few weeks left to complete work on spending bills or risk a government shutdown, and time is also running out to head off the large increases in premiums for Affordable Care Act health plans likely to occur with additional Biden-era government subsidies set to expire.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of Pink Sheet, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• The FDA approved this year’s covid booster for people older than 65 and for younger people with serious illnesses. Previously, it had been recommended more broadly. All eyes will now turn to the CDC’s Advisory Committee on Immunization Practices, which is scheduled to meet Sept. 18. Usually this panel would endorse these recommendations and perhaps offer more guidance on the booster’s use for specific populations. But it is not clear whether it will do so — or whether it might even impose more limitations.
• Kennedy’s firing of CDC Director Susan Monarez and the subsequent resignation of multiple senior scientists is raising questions about the agency’s future. Many staffers who were already on the fence about staying now are increasingly likely to leave. Many of these career scientists associate Kennedy’s history of harsh criticisms of public health workers with the recent CDC shooting in Atlanta. But since the shooting, Kennedy seems to have doubled down on his position.
• At the hearing before the Senate Finance Committee, even those Republicans who were critical of Kennedy were careful not to criticize President Donald Trump. There’s some speculation that this duality is meant to drive a wedge between Kennedy and the White House, and to communicate that the HHS secretary could be politically damaging.
• With vaccine policy in flux, red and blue states alike seem to be doing their own thing. Some, like California, Oregon, and Washington — which formed what they’re calling the West Coast Health Alliance — appear to be taking steps to protect access to vaccines. Red states could move in the other direction. For instance, this week, Florida Surgeon General Joseph Ladapo announced an effort to undo all statewide vaccine mandates, including those that require certain vaccines for children to attend school. If more states follow suit, it could lead to a geographic patchwork in which vaccine availability and requirements vary widely.
• This month is lawmakers’ last chance to reup the federal ACA tax subsidies. If Congress doesn’t act to extend them, an estimated 24 million people — many of whom live in GOP-controlled states like Georgia and Florida — will see significant increases in their health insurance premium costs. There’s some talk that Congress could opt for a short-term or limited extension that would postpone the pocketbook impact until after the midterm elections. But insurers are already factoring in the uncertainty as they set rates for the upcoming plan year.
• The Centers for Medicare & Medicaid Services announced a Medicare pilot program beginning next year that will use artificial intelligence to grant prior authorization decisions for certain procedures. There is irony here. United Healthcare and other private plans have already gotten into a lot of trouble for doing this, with AI systems often denying needed care.

Also this week, Rovner interviews KFF Health News’s Tony Leys, who discusses his “Bill of the Month” report about a woman’s unfortunate interaction with a bat — and her even more unfortunate interaction with the bill for her rabies prevention treatment.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: ProPublica’s “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, and Pratheek Rebala.

Jessie Hellmann: KFF Health News’ “When Hospitals and Insurers Fight, Patients Get Caught in the Middle,” by Bram Sable-Smith.

Sarah Karlin-Smith: NPR’s “Leniency on Lice in Schools Meets Reality,” by Blake Farmer.

Alice Miranda Ollstein: Vox’s “Exclusive: RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer. Here’s What It Shows,” by Dylan Scott.

Also mentioned in this week’s podcast:

• The Washington Post’s “Florida Moves To End All School Vaccine Mandates, First in Nation To Do So,” by David Ovalle and Lori Rozsa.
• The 19th’s “Texas Passes Bill Banning Abortion Pills From Being Mailed to the State,” by Shefali Luthra.
• The New York Times’ “Medicare Will Require Prior Approval for Certain Procedures,” by Reed Abelson and Teddy Rosenbluth.

[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, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Friday, Sept. 5, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hi there. 

Rovner: Later in this episode, we’ll have my interview with my KFF Health News colleague Tony Leys, who reported and wrote the August “Bill of the Month” about a patient’s unfortunate run-in with a bat and an even more unfortunate run-in with the bill for rabies prophylaxis. But first, this week’s news.  

Well, it is safe to say that there has been quite a bit of health news since we last met in mid-August. Health and Human Services Secretary Robert F. Kennedy Jr. testified before the Senate Finance Committee yesterday, which we will talk about in a moment. But first, I want to catch us up on what you might’ve missed. Our story starts, kind of, with the FDA’s [Food and Drug Administration’s] approval of this year’s covid boosters, which are only being licensed for those over age 65 and those who are younger but have at least one condition that puts them at high risk of serious illness if they contract the virus. That leaves out lots of people that many doctors think ought to be boosted, like pregnant women and children. Sarah, what’s supposed to happen after the FDA acts? The next step happens at CDC [the Centers for Disease Control and Prevention], right? 

Karlin-Smith: Correct. So right now the CDC’s Advisory Committee on Immunization Practices is scheduled to meet Sept. 17 to 18, 18 to 19, but about two weeks from now. And they would typically vote on sort of endorsing use of these vaccines and, again, have like sort of a second chance to weigh in on which populations they would be used for. And that’s often important for triggering insurance coverage without copays. And also many states rely on the CDC recommendations for various state laws that say, again, who can get the vaccine or whether you can get it via a pharmacist or only at a doctor’s office, do you need a prescription, and things like that. So the CDC and FDA, I would say, in general is a little bit behind this year. I could think a lot of people have been trying to go out and get these new shots even though those steps haven’t happened yet. 

Rovner: That’s right. I mean, it is early. Even if there was nothing else going on, there is that little bit of a lag between when FDA acts and when the CDC acts, right? 

Karlin-Smith: Yeah, there usually is. I think in the past they’ve tried to have both FDA approval and the CDC act so that the vaccines could start rolling out more like late summer, early September. So they’re definitely behind, and there’s been a number of reports of covid kind of slowly rising as the summer winds down and school gets back in session. 

Rovner: Yeah, so there’s a lot of other things going on. Well, in the meantime, nothing that was supposed to happen has happened yet, and we still don’t know all the details, but it certainly appears that Susan Monarez, who was just confirmed by the Senate to lead the CDC a month ago, was fired after she refused to override her scientific advisers and approve the new restrictions on covid vaccine availability, even before the ACIP met. In turn, four top CDC leaders resigned as well, going public to warn that the agency is being politicized by the secretary. How much of a mess is the CDC in right now? And how long is it going to take to put the pieces back together? 

Karlin-Smith: I think they’re in a pretty bad place, because not only did they lose their director really quickly, but after she resigned, about I think it was eight or nine senior CDC leaders resigned last week as well. And so, really critical people to various parts of the operation that you don’t just replace very easily. And Kennedy has slotted in Jim O’Neill as the temporary director of the CDC and kind of indicated he wants to remake the agency. And I think there are questions as to how that remaking shapes both its priorities and how it handles public health throughout the U.S. 

Rovner: And of course, morale at CDC is awesome, in part because, as we discussed the last time we met, a gunman came and shot up the place, killing a policeman and leaving the staff pretty upset. And that gunman, who then took his own life, was later found to have had some discontent with vaccines. So things are just really bright and cheery there in Atlanta at the CDC. Alice, I see you nodding. 

Ollstein: These things kind of snowball, you know? I think there are likely to be a lot of staff who were already on the fence about staying and decided to stay because they trusted these pretty senior leaders with a lot of decades of expertise and institutional knowledge. And that was sort of the thread they were hanging on as well, at least: I’m with these people. And now that they’ve left, I think that could trigger a bigger exodus on top of the exodus that was already underway. 

Rovner: And it’s important to say — even though we say it, I think, every time — that these are career scientists who’ve worked for Democrats and Republicans over the years. These are not generally political people. They’re not political appointees. And they basically do their jobs. And until fairly recently, public health wasn’t this partisan, so it wasn’t that hard to be a career public health official just working for public health. That’s just not the case anymore, is it? 

Karlin-Smith: I think there’s been a lot of insult to injury added with what happened with the shooting at the CDC, because there is a sense that the kind of rhetoric that Kennedy in particular has used over the years, even before he came into HHS [the Department of Health and Human Services], on sort of his movement has sort of amplified the criticism of public health workers and put them in this situation where they’re dangerous. And Kennedy, instead of really acknowledging that and maybe apologizing or giving any sense that he was going to shift in a different direction, has actually really kind of doubled down on it. And even in some of the pieces he’s written recently about how he wants to reform the CDC, he kind of keeps criticizing the rank-and-file employees and so forth. So there’s a lot of tension between the political leadership and the career staff, I think, at this moment. 

Ollstein: And in normal times, most of the American public would not even know the names of these people. They’re not public figures. They’re just very behind-the-scenes scientists doing their work. And now their personal photos are being combed through and shared to attack them because they’ve criticized the administration. They’re getting threats. It’s just this whole level, like you said, of politicization that we haven’t seen before. 

Rovner: Well, so, in kind of a coincidence, Kennedy had already agreed to appear on Thursday before the Senate Finance Committee, which by the way doesn’t have jurisdiction over the CDC or the rest of the public health service. But no matter — a Senate hearing is a Senate hearing. And let’s just say it didn’t go that well for the secretary. Democrats were kind of withering in their criticism of Kennedy’s eight-month tenure so far. Here’s Colorado Sen. Michael Bennet. 

Sen. Michael Bennet: This is the last thing, by the way, our parents need when their kids are going back to school, is to have the kind of confusion and expense and scarcity that you’re creating as a result of your ideology. 

Rovner: Republicans weren’t that impressed, either, particularly the Republicans on the committee who are also doctors. [Sen.] Bill Cassidy, a doctor who’s on Finance but is also the chairman of the Health, Education, Labor, and Pensions Committee and is facing a primary challenge in Louisiana, seemed to tread pretty carefully. More surprising, at least to me, was Dr. Sen. John Barrasso of Wyoming, who’s also in the Senate leadership. 

Sen. John Barrasso: So over the last 50 years, vaccines are estimated to have saved 154 million lives worldwide. I support vaccines. I’m a doctor. Vaccines work. 

Rovner: I was super impressed that even the Republicans who criticized RFK were careful not to criticize President [Donald] Trump. In fact, there were several suggestions — this was clearly a talking point — that Trump should be given a Nobel Prize for his work overseeing Operation Warp Speed, just so the senators could kind of bifurcate their complaints. What impact, if any, is this hearing going to have on RFK’s future as secretary? 

Ollstein: Well, I think there was an attempt to, I think, what you just mentioned. That like dual criticism with praise of Trump was meant to drive a wedge and to get Trump to question RFK’s leadership. That does not seem to have worked so far. We don’t know what’s going to happen in the future, but I think it’s an attempt to get the message to Trump that RFK’s reputation and actions could be damaging to the administration overall. And there was some reporting that polling showing that most people do support vaccines was circulated amongst Republican members before the hearing. And so, I think it’s trying to, yeah, get the message that this is both damaging in a public health sense but also potentially damaging in a political sense as well. 

But so far, the reporting is that Trump is standing by RFK, that he liked how combative he was. And so I don’t know where those attempts to drive a wedge will go in the future, but like you said, it was notable that if folks like Barrasso, [Sen. Thom] Tillis, who’s not running for reelection, was also more vocally critical, and a couple others, not a lot. We’re not seeing a great dam breaking yet. But I think there’s more cracks than there used to be on the GOP side. 

Rovner: I did notice that Trump, he had a very strange Truth Social post earlier in the week that basically said that CDC is a mess and it has to be fixed. Kind of just Trump being the omniscient observer. And then, apparently at a dinner with tech titans after the hearing, he said that he had not watched the hearing but that he heard that Kennedy did well, which is not exactly what I would call a ringing endorsement. I feel like Trump is giving himself some runway to go either way depending on sort of how things continue to shake out. I see nodding. 

Karlin-Smith: Yeah. I saw a lot of people reposting that clip on social media last night who are frustrated with Kennedy and using it to try and ramp up their banks and say: Keep calling. Keep pressuring. This shows we have an opening. I think it’s really always hard to read the tea leaves with Trump and his language and words. He’s a harder person to interpret. But I also thought it was really interesting that in some ways Cassidy and some of the other Republicans were throwing RFK a bone and saying: This is your president. This was his greatest achievement. Can you support it? 

And RFK couldn’t even really twist himself into doing that. He sort of tried to, but he could never square it with the bulk of his remarks at the hearing, which were incredibly critical. MRNA vaccines and vaccines in general — he defended the massive cuts in this area for research. He defended people who have really said very untrue things about the harm caused by these vaccines. So in some ways I felt like Cassidy was trying to give him one more chance or something, and RFK couldn’t even take it when it was couched as this Trump achievement. 

Rovner: I can’t help but wonder if this is playing to Trump’s advantage because it’s distracting from Trump’s other problems, that perhaps Trump likes that there’s so much attention on this because it takes attention away from other things. 

Ollstein: Yeah. Although I do find the eagerness of Democratic members of Congress and other folks to wave away certain things as a distraction as a little bit questionable. This is all part of the agenda of the administration, and dismantling government bureaucracy is clearly a core, core part of the administration’s agenda, and so— 

Rovner: And flooding the zone. 

Ollstein: Exactly. Well, it might also serve as a distraction. I think that it should be considered a serious part of what they actually want to do as well. 

Rovner: So there were a couple of things that we learned about RFK Jr. from his confirmation hearings back in the winter. One is that he’s not at all deferential to elected officials, even calling them liars, which is pretty unheard of. And that he doesn’t really know how his department works. And it appears that eight months later, neither of those things have changed. How does he get away with being so rude? I mean, I’ve just never seen a Cabinet official who’s been so undeferential to the people who basically put him in office. Is it just me? 

Karlin-Smith: I think it’s part of the times where politics is really trumping behavior or policy, right? Even though there were a few Republicans that we’ve talked about who have kind of started to get frustrated with RFK and his vaccine policies. You saw at the beginning of the hearing, Chairman [Mike] Crapo was asked by the ranking Democrat, Sen. [Ron] Wyden, to basically swear Kennedy in because Wyden has felt like Kennedy has lied to the committee before. And Crapo just basically brushed that away and dismissed it. And I think, so, in many ways a lot of the Republicans on the committee endorsed Kennedy’s behavior kind of, maybe not overtly but indirectly, and that’s sort of been how they’ve been operating. It’s more of a political theater thing, and they’re OK with sort of this disrespect, of its sort of political fight that somebody on their side is taking up. 

Ollstein: I also think Congress’ unwillingness so far to actually sanction or take action in any way about anything RFK has done seems to have emboldened him. I think the fact that he has broken all these promises he made to Cassidy and other senators and there have been basically no consequences for him so far feeds into that. He kind of has a What are you going to do? attitude that was very evident in the hearing. 

Rovner: Yeah, I think that’s fair. Well, there were, as always, parochial question from senators about home state issues, but one topic I don’t think I expected to see come up as many times as it did was the future of the abortion pill, mifepristone, which is about to celebrate the 25th anniversary of its original approval by the FDA. Alice, what are you hearing about whether FDA is going to rein the drug back in, which is what a lot of these anti-abortion Republicans really want to see happen? 

Ollstein: Yeah, so I think there was nothing new in the hearing this week. What he said was what he’s been saying, that they’re looking into it, that they’re evaluating. He made no specific commitments. He gave no specific timelines. He said basically enough to keep the anti-abortion people thinking that they’re cooking up some restrictions but not explicitly promising that, either. And so I think we’re just where we were before. They continue to reference data put forward by an anti-abortion think tank that was not peer-reviewed and claiming that it is this solid scientific evidence, which it is not, about the risks posed by the pills, which many actual, credible, peer-reviewed studies have found to be very safe. And so we just don’t know what’s going to happen. I think any nationwide restrictions, which is what they’re mulling at the federal level, which would impact states where abortion is legally protected, that would be a potentially politically damaging move. And so it’s understandable why they might not want to pull that trigger right now. So, right. 

Rovner: And Trump has said, I mean, Trump has indicated that he does not really want to wade into this. 

Ollstein: Correct. But again, he’s also very good about not making hard promises in either direction and sort of keeping his options open, which is what they’re doing. The anti-abortion activists, this is not their only iron in the fire. This is just one of many strategies they have going on. They also have multiple pending lawsuits and court cases that are attempting to accomplish the same thing. They’re pursuing new policies at the state level, which we’ll probably talk about, Texas and others. 

Rovner: Next. 

Ollstein: And so yes, this pressure on FDA and HHS to use regulation to restrict the pills is only one of many ongoing efforts. 

Rovner: Well, you have anticipated my next question, which is that while we are on the subject of the abortion pill, Texas, because it is always Texas, has a new bill on its way to the governor for a signature to try to outlaw telemedicine prescribing of the abortion pill. What exactly would this Texas law do? And would it work? Because, obviously, this has been the biggest loophole about stopping abortion in these states that have banned abortion, is that people are still able to get these pills from other states via telemedicine. 

Ollstein: Yeah. So in one sense, nothing’s changed. Abortion was already illegal in Texas, whether you use a pill or have a procedure. And so this is just layered on top of that. The groups who backed this explicitly said the attempt is to have a chilling effect. What they’re hoping is that no lawsuits are even needed, because this just scares people away from ordering pills and scares groups in other states away from sending pills. One concern that I saw raised is that the law criminalizes simply the shipping of the pills. Somebody doesn’t even have to take them for a crime to have been committed. 

And so that’s raising concerns that anti-abortion activists will do kind of sting operations, sort of entrapment-y things where they order the pills solely in the interest of bringing a lawsuit. Because there is a cash bounty that you can get for filing a lawsuit — there’s an incentive. So that’s a concern. And then just the general concern of a chilling effect and people who are using less safe means than these pills to terminate their pregnancies out of fear, which studies have shown is already on the rise, people injuring themselves taking herbs and other substances, chemicals. So that’s a concern as well. 

Rovner: We’ll continue to watch this, but back to vaccine policy. With the status of federal vaccine recommendations in limbo, states appear to be going their own way. Blue states California, Washington, and Oregon are banding together in a consortium to make official recommendations in the absence of federal policy, and several blue-state governors are acting unilaterally to make sure covid vaccines, at least, remain available to most people. At the same time, some red states are going the other way, with Florida Surgeon General Joseph Ladapo, who we have talked about before, now vowing to get rid of all vaccine requirements for schoolchildren. Sarah, that would be a really big deal, right? 

Karlin-Smith: Right. I think the big fear then is that the school requirements is kind of what gets us to close to, in many cases, universal vaccine uptake in the country, because everybody needs their kids to be in school. Unless you’re homeschooled, you really must follow these vaccine requirements. And it not only hurts the kids who don’t end up getting vaccinated individually, but it can really hurt the idea of herd immunity and the protection we need for these diseases to disappear in the community. So there’s— 

Rovner: And protection for people who can’t be immunized for some reason. 

Karlin-Smith: Right. Who either can’t be immunized or don’t have an adequate response to the immunization because they’re going through cancer treatment or they have some other medical reason that their body is immunocompromised. 

Rovner: So, I mean, is this going to end up like abortion, where it’s availability absolutely depends on where you live? 

Karlin-Smith: I think that’s hard to say. I think that a policy like what Florida is trying to implement could very quickly and easily go wrong, I think, and be reversed, as we’ve seen, like what’s happening in Texas now, with measles outbreaks. You know you only need just very small fractions of decreases in vaccination to create huge public health crises in places. And so I think it would be more sort of visible, in a way, to some of these states and their populations, the potential harm that could be caused, than maybe it is to them the abortion harm. But we definitely are seeing some sense of, right, the Democratic-controlled states trying to implement policies that help people get better access to vaccines, even when the federal government is trying to maybe harm that, and red states not caring as much. 

So there is going to be some more of a patchwork. And I feel like, in talking to just sort of people outside of the health policy space, there is a lot of confusion about: Where can I get my covid vaccine? Am I going to have to pay? Do I qualify? Especially being in D.C., which has less generous, I guess, pharmacy laws, because of this. So people are confused. If I go to Maryland, which is really close, does that matter even though I live in D.C.? And it’s just all these things we kind of know end up leading to less people getting vaccinated. Because even if they want to do it, the hurdles end up driving people away. 

Rovner: Yeah, I think something you’d said earlier about the fact that we’re seeing kind of a covid spike, so people are anxious to get covid vaccines, I think, a little bit earlier than normal. It’s usually kind of a fall thing and it’s only the beginning of September, but I think there’s just this combination, this confluence of events that has a lot of people very excited about this right now. 

Karlin-Smith: Yeah, I think it does. And covid has been, I think there’s been lots of hope in the public health world that covid would become a little bit like the flu, where we could predict a little bit more when it would really peak and get everybody vaccinated around the same time as they’re getting flu vaccines. Just again, because we know when we make it easier on people to get vaccinated, if you could just one-and-done it, it would be good. Unfortunately, covid has tended to also still have summer peaks, and this year again it’s kind of a late summer peak. And a lot of people, including seniors, are still recommended really actually to get two vaccines a year. So many people are kind of coming due for that second update right now. 

Rovner: Well, we’ll keep watching that space. Moving on, as we kind of pointed out already, Congress is back in town, with just a couple weeks to go before the start of fiscal 2026 on Oct. 1. This was the year Congress was really, truly going to get all of its spending bills passed in time for the start of the new year. How’s that going, Jessie? 

Hellmann: It’s going great. I’m just kidding. There’s a lot of friction on the Hill right now. The White House budget chief is talking about doing more clawbacks of foreign aid, which is frustrating both Democrats and Republicans. It’s about $5 billion, and we’re seeing Democrats kind of start to put their neck out there a little more than they did earlier in the year when they were also kind of making noise about government funding. And they’re now saying that Republicans are going to have to go this alone and they’re not going to support partisan spending bills. So it’s kind of difficult to see where we go from here. And then— 

Rovner: Are we looking at a shutdown on Oct. 1? I mean, that’s what happens if the spending bills aren’t done. 

Hellmann: It’s hard to say. There might be a short-term spending bill, but anything longer-term than that, it seems really difficult at this point. And there are just massive differences between the health bills that the House came out with and the Senate came out with. I mean, there’s differences in all the other appropriations bills, too, but I was just going to focus on health. 

Rovner: Yes, please. 

Hellmann: The Senate bill would allow an increase for HHS, and the House bill would cut it pretty significantly. So it’s kind of hard to see how they could do anything more substantive when there’s so much light between the two. 

Rovner: Yeah. I mean, on the one hand, we have both the Senate and the House subcommittee that’s marked up the Labor HHS [Labor, Health and Human Services, Education, and Related Agencies] appropriation on record as not supporting at least the very deep cuts to the National Institutes of Health that were proposed by President Trump. But on the other hand, as you mentioned, we still have the administration, primarily budget office chief Russell Vought, making the case that the administration doesn’t have to spend money that Congress appropriates. And from all we can tell, at least as of now, there’s a lot of money that won’t be spent as of the end of the fiscal year, despite the fact that that is illegal. It’s known as a pocket rescission, a term I think we’re about to hear a lot more about. Alice, you referred to this earlier: Is Congress just going to quietly ignore the fact that the administration is usurping their power? 

Ollstein: I think that in many areas of politics, there is a faction that wants to play hardball and really use whatever leverage is possible and there’s a faction that wants to play nice and try to get what they can get by negotiation. And I think both parties always fear being blamed for shutdowns, and so that drives a lot of it. But I think there’s mounting frustration with Democratic leadership about not playing hardball enough. I mean, the jokes I hear are Democrats like to bring a spreadsheet to a gunfight, just seen as being unwilling, in the face of what many see as lawlessness, being unwilling to really put a check on that using the levers they have, including this federal spending. But I think we’ve seen that there are risks no matter what they do, and so I think people make reasonable points about the pros and cons of various strategies. 

Rovner: Well, we know that [Sen.] Susan Collins, who’s now the chair of the Senate Appropriations Committee, is very, very concerned — because Susan Collins is always very, very concerned. But she’s the one whose power is basically being thwarted at this point. People have gotten a lot of gray hair waiting for Susan Collins to stand up and be combative, but one would think if there was ever a time for her to do it, this would be it. Jessie, are we seeing, I was going to say, any indication that the appropriators are going to say, Hey, this is our job and our constitutional responsibility, and you’re supposed to do what we say when it comes to money? 

Hellmann: They are saying these things. I feel like we are seeing more Senate Republicans, at least, express discomfort with what the Trump administration is doing, saying things like: This is Congress’ job. We have the power of the purse. And then they are passing some of these spending bills through committee. But what else are they supposed to do? Unless Susan Collins wants to get on Fox News and start screaming about government funding, which I don’t really see happening and I don’t know if it would be effective, you kind of just wonder: What other options do they have at this point? 

Rovner: Yeah. Well, we’ll sort of see how this plays out over the next few weeks. Meanwhile, it’s not just the spending bills that Congress is facing deadlines for. This month is basically the last chance to re-up those, quote, “expanded subsidies” for Affordable Care Act plans before the sticker shock hits 24 million people in the face. Not only are premiums going up by an average of 18% from this year to next — that’s for a lot of reasons: increasing costs of health care, tariffs, drug prices — but eliminating those additional subsidies, or actually letting them expire, will cause some people to have to pay double or triple what they pay now. And it’s going to hit folks in red states like Georgia and Florida and Texas even harder because more folks there are on the Affordable Care Act plans, because those states didn’t expand Medicaid. Do Republicans not understand what’s about to happen to them? 

Hellmann: I think they understand, but they keep acting like there’s no urgency to the situation. They keep saying: We still have time. We have till the end of the year. Which I guess is technically true, but we’re already seeing insurers proposing these giant rate hikes. And it’s not easy to just go back and make changes to some of this. I guess the idea is— 

Rovner: So they really don’t have until the end of the year, though. Because people are going to get, they’re going to see the next year’s premiums that they have to start signing up in November. So, I mean, they basically have this month. 

Ollstein: If there’s uncertainty, they’re going to price very conservatively, aka high. They don’t want to be left holding the bag. And so, yeah, you and Jessie are exactly right that there isn’t time. These decisions are being made now. Even if they pass something to kick the can until after the midterms, I think some damage will already have been done. 

Rovner: Yeah. Jessie, I cut you off, though. I mean, the idea is that sort of their one chance to maybe do this before people actually start to get these bills, or at least see what they’re going to have to pay, would be wrapped into this end-of-fiscal-year continuing resolution. And maybe they can kick the appropriations down the road until November or December, but they can’t really kick the question of the subsidies down the road until November or December. 

Hellmann: Yeah. I think something would have to happen really quickly. We’re seeing some politically vulnerable Republicans, in the House, specifically, say that they want at least a year-long extension. It’s just a really difficult issue. We know, obviously, the Freedom Caucus is already making threats about it. They hate the ACA, maybe more than anything. It’s going to be really interesting how this turns out. I’ve also heard that maybe there might be a paired-back version of an extension that they could do, maybe messing with some of the income parameters. But I don’t know if that kind of compromise would be enough unless Republicans work with Democrats, which as we already said is complicated for other reasons. So it’s just a mess right now. 

Rovner: I love September on Capitol Hill. All right, finally this week Medicare has announced it will launch a pilot program next January to test the use of artificial intelligence to perform prior authorization for Medicare fee-for-service patients in six states. The program is aimed at just a handful of services right now that are considered to be often wasteful and of dubious value to patients. So, honestly, what could possibly go wrong here? This is a serious question. I mean, isn’t using AI to do prior authorization what got a lot of these private health plans in trouble over the last year? 

Karlin-Smith: Yeah, they did. UnitedHealthcare I think is sort of infamous for that. There was a lot of irony when they first announced this concept of doing a little more prior auth, essentially, in Medicare. It came right after they made another announcement where they were trying to say, We’re actually going to crack down on prior authorization for a health plan. So there’s a bit of, and I think they were trying to not have the, in this second announcement, not have the words “prior auth,” so that they kind of could get wins on both levels. Because I think they know that prior authorization is generally not popular with health consumers. People see it as kind of a barrier to care that their doctor has said they need and is largely stopped because of cost reasons. And then I think once you add in this idea that artificial intelligence is doing it, not a human being, I think people have less trust that it’s being done in the proper way and really that they’re stopping inappropriate care. 

Rovner: Well, to paraphrase RFK Jr. at the Senate Finance hearing, who said many times, both things can be true, even if they are contradictory. All right, that is this week’s news, or at least as much as we have time for. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our extra credits. 

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

Tony Leys: Glad to be here. Thanks, Julie. 

Rovner: So this month’s patient got a literal mouthful when she went to photograph the night sky in Arizona. Who is she and what happened? 

Leys: While Erica Kahn was taking photos at Glen Canyon last summer, a bat flew up, landed on her, and jammed itself between her camera and her face. Kahn screamed, as anyone would, and the bat went into her mouth. It only was in there for a few seconds, and she didn’t feel a bite. But she feared it could have infected her with a rabies virus, which bats frequently carry. 

Rovner: Yeah, not a great thing. So as with any run-in with a bat, Erica wisely reported to the nearest emergency room for preventive rabies treatment, which we know from previous “Bills of the Month” can total many thousands of dollars. How much did her treatment cost? 

Leys: Nearly $21,000, mostly for a series of vaccinations and other treatments, over the course of two weeks, aimed at preventing the deadly virus from gaining a foothold. 

Rovner: Yikes. 

Leys: Yikes, indeed. 

Rovner: Now, the problem here wasn’t so much that she was charged as what her insurance status was. What was her health insurance status? 

Leys: Well, Kahn had been laid off from her job as a biomedical engineer in Massachusetts, and she had turned down the COBRA [Consolidated Omnibus Budget Reconciliation Act] plan, which would’ve allowed her to stay on her employer’s insurance plan. The plan would’ve cost her about $650 a month, which seemed too much for her. And she was a young, healthy adult who was confident that she would quickly find a new job with health insurance. She also thought that if she became ill in the meantime, she could buy a private plan that would cover preexisting health conditions. 

Rovner: Yeah. That was the big problem, right? 

Leys: Right. 

Rovner: So what did she do? And then what happened? 

Leys: So before she went to the hospital for rabies prevention treatment, she signed up for a policy she found online. The policy, which she thought was full-fledged health insurance, apparently wasn’t. But she says the company selling it told her it would cover treatment of a life-threatening emergency, which this sure seemed to be. But the company later declined to cover any of the bills, citing a 30-day waiting period for coverage. 

Rovner: Yeah. Now, I mean, you can’t generally buy any kind of insurance after an insurable event happens. You can’t buy fire insurance the day after a fire or car insurance the day after an accident. Health insurance is no different. Although in her case, she could have actually resumed her previous coverage through COBRA, right? How would that have worked? 

Leys: So after you lose coverage from an employer, you generally have 60 days to decide whether to sign up for COBRA coverage, which would be retroactive to the day your old policy lapsed. Khan was within that period when the bat went in her mouth. So she could have retroactively bought COBRA coverage, but she didn’t know about that option. 

Rovner: Yeah. A lot of people, they initially lose their job or they leave their job and they don’t take COBRA, because it’s really expensive, as a rule — because it’s employer insurance and employer insurance is usually pretty generous — and they think they don’t need it. But this is one of those cases where she actually probably could have gotten it covered, right? 

Leys: Right, right. And in fairness, I’d never heard about that 60-day thing, either, and I’ve covered this, so— 

Rovner: I had, but I was there when COBRA was started. So what’s the takeaway here about people who don’t have insurance or think they can buy it at the last minute? 

Leys: Well, two things. One is you should have health insurance. 

Rovner: Because you never know when a bat’s going to fly in your mouth. 

Leys: And that a bat in the mouth does not count as a preexisting condition. 

Rovner: True. 

Leys: We know that now. 

Rovner: And what happened with this bill? 

Leys: She is still trying to get it worked out. 

Rovner: And presumably she’s going to be paying it off for some time to come. 

Leys: That’s what it sounds like. Yep. 

Rovner: But she won’t get rabies. 

Leys: Nope. 

Rovner: So happy ending of a sort. Tony Leys, thank you so much. 

Leys: Thank you for having me. Appreciate it. 

Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Sarah, you were the first to come up with your extra credit this week. Why don’t you tell us about it? 

Karlin-Smith: I picked a piece that ran in NPR from KFF’s Blake Farmer, “Leniency on Lice in Schools Meets Reality,” because it’s about the one-year anniversary of my family getting lice from school. And I actually was exposed to this new reality, which is since I was in school, and it’s, I guess, a broader national policy that they no longer kick kids out of school once you see lice and make it kind of difficult before you can go back to school. And I guess the public health rationale is generally that lice is actually, while it’s quite itchy, it’s not really harmful. So trying to think about the best way to cause the least harm, letting kids stay in school while you treat the infection is seen as most appropriate now. 

But there’s been, as a story goes into, some pushback from parents who feel that then it’s just getting them in these cycles where they’re constantly getting lice and having to deal with it. And dealing with getting the shampoos and stuff for lice can be kind of costly. So I thought it was a slightly lighter health care story for people to think about in these times. 

Rovner: Yeah. Risks and benefits. Classic case of risks and benefits. Alice. 

Ollstein: Well, this is definitely more on the risks than the benefits side of things, but I have a very good piece from Vox. It’s an exclusive. It’s called “RFK Jr. and the White House Buried a Major Study on Alcohol and Cancer.” And so they talked to these scientists who were commissioned to compile all of the data about the risk of drinking alcohol to having cancer. And it was compiling high-quality data that was already out there. And it really shows that no amount of drinking is totally safe. Even a very small, moderate amount of drinking includes a cancer risk, and that goes up the more you drink. 

And now, according to this report, the administration is not going to publish this. The authors turned it in in March, and they’ve just been sitting on it and they said they have no plans to publish it. And this is coming as the alcohol industry does a lot of lobbying to try to prevent stuff like this from being put out in the public consciousness. I just found this really fascinating. Already the younger generations are drinking a lot less. And so there does seem to be a growing awareness of the health risks of even moderate drinking. But I think that anything that keeps people from seeing this information is worrying, although this report did say that they are planning on publishing it in a peer-reviewed medical journal, which they were always planning anyways. But not having the federal government’s backing is a big deal. 

Rovner: It’s not exactly “radical transparency” is what they’ve been talking about. Jessie. 

Ollstein: And it’s not exactly “MAHA” [“Make America Healthy Again”]. They’re talking MAHA. They’re talking about lifestyle stuff. They’re talking about what you eat, but apparently not about what you drink. 

Rovner: Jessie. 

Hellmann: My story is from KFF Health News, from Bram Sable-Smith. It’s called “When Hospitals and Insurers Fight, Patients Get Caught in the Middle.” It is about what happens when providers and insurers have contract disputes. The one example in this story is in Missouri, and it kind of focuses on this family that’s caught in the middle of a dispute between the University of Missouri Health Care system and Anthem. And it means patients don’t get care. There’s not a lot of protections for them. There are provisions that were in the No Surprises Act kind of intended to ensure there was some continuity of care in these situations. But at least for this couple, they weren’t really able to access those protections. So unclear if those are working as intended. 

I just thought it was really interesting because it’s not a new problem, but it’s definitely something that we are hearing more and more. It just happened in the D.C .area a few weeks ago. It just happened in New York. And it kind of raises questions about: What are policymakers going to do about this? They complain about rising health care costs, but they don’t often do very much. They complain about competition and consolidation, and this is one of the effects of that. People lose access to care. So I thought this was a really interesting story. 

Rovner: Yeah. These are all the policy issues that policymakers are not working on but could be. My extra credit this week is from ProPublica. It’s called “Gutted: How Deeply Trump Has Cut Federal Health Agencies,” by Brandon Roberts, Annie Waldman, Pratheek Rebala, and Sam Green. And it’s a deep data dive that found that more than 20,500 workers, or about 18% of the Health and Human Services Department workforce, have left or been pushed out in the first month of Trump 2.0. That includes more than a thousand regulators and safety inspectors and 3,000 scientists and public health specialists. The agency, in its official response to the story, said, quote, “Yes, we’ve made cuts — to bloated bureaucracies that were long overdue for accountability.” I guess we will have to see if America gets healthier. In the meantime, it’s good to have some data on where we were and now where we are at HHS. 

OK, that’s this week’s show. Thanks to our fill-in editor this week, Stephanie Stapleton, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d 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 at whatthehealth@kff.org, or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you guys hanging out these days? Sarah. 

Karlin-Smith: Kind of everywhere. At Bluesky, X, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Alice. 

Ollstein: Mostly on Bluesky, @alicemiranda, and still on X, @AliceOllstein. 

Rovner: Jessie. 

Hellmann: I am on X, @jessiehellman. I’m also on LinkedIn. 

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

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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What are the biggest takeaways? What comes next? Tune in for a post-hearing discussion with KFF Health News correspondents Stephanie Armour, Julie Rovner, and Arthur Allen, and KFF’s Josh Michaud, associate director for Global Health Policy.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).