A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine whether care is medically necessary — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the No Surprises Act, which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for any care needed in a nursing home if the patient was not first formally admitted to a hospital for at least three days.

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is stable enough to travel to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient to sign a consent form, agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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This story can be republished for free (details).

As long predicted, much of the federal government shut down on Oct. 1, after Congress failed to agree on spending bills that keep most programs running. Republicans need at least a handful of Democratic votes to pass spending bills in the Senate. In exchange, Democrats demanded Republicans renew expanded premium subsidies for Affordable Care Act marketplace plans, which were passed during the pandemic — effectively forcing their own shutdown over ACA policies, as Republicans did in 2013. Republicans so far have refused to continue the subsidies or even discuss them — but now say they won’t negotiate unless Democrats agree to reopen the government.

Meanwhile, President Donald Trump announced a deal with the drugmaker Pfizer to lower some drug prices in the U.S., but it’s unclear how much of a difference it will make for consumers.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Shefali Luthra of The 19th, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• Democrats seized an opportunity to highlight how Republican policies are reshaping the health care system, as health care tends to be a winning campaign issue for Democrats. But as they push to extend enhanced federal subsidies and reverse Medicaid cuts, a big question arises: Will Americans notice?
• Meanwhile, some Republicans suggest they are open to renewing enhanced ACA plan subsidies with certain changes — but do not want to address the issue now, even as open enrollment approaches. And in response to Democrats’ calls to undo Medicaid cuts, the GOP is repeating a misleading talking point about benefits for people living in the U.S. without legal status — when, in fact, the policy change would largely help hospitals.
• And vaccine uncertainty continues, with new recommendations from the remade Advisory Committee on Immunization Practices awaiting sign-off — and holding up some vaccine shipments, particularly for uninsured and underinsured kids. Plus, the Trump administration has struck a deal with Pfizer. Other drug companies are likely to follow with their own deals to spare themselves tariffs. What’s less clear is how patients would benefit from these savings.

Also this week, Rovner interviews KFF Health News’ Cara Anthony, who wrote a recent “Bill of the Month” feature about an out-of-network eye surgery that left one kindergartner’s family with a big bill. If you have an outrageous or inexplicable medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab,” by Michelle Andrews.  

Shefali Luthra: The Washington Post’s “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting,” by Meg Kelly, Joyce Sohyun Lee, Rael Ombuor, Sarah Blaskey, Andrew Ba Tran, Artur Galocha, Eric Lau, and Katharine Houreld.  

Lauren Weber: Time Magazine’s “Trump Is Breaking Americans’ Trust in Doctors,” by Dr. Craig Spencer.  

Rachel Cohrs Zhang: ProPublica’s “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” by Margaret Coker, The Current.  

Also mentioned in this week’s podcast:

• KFF’s “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire,” by Justin Lo, Larry Levitt, Jared Ortaliza, and Cynthia Cox.
• KFF Health News’ “How Federal Shutdown Hits Health Agencies, Explained to Aspen the Corgi,” by Julie Rovner.
• The Washington Post’s “White House Considers Funding Advantage for Colleges That Align With Trump Policies,” by Laura Meckler and Susan Svrluga.
• Politico’s “Top US Researchers Rush To Relocate to Europe,” by Pieter Haeck.
• Bloomberg News’ “RFK Jr. Mulls Adding Autism Symptoms to Vaccine Injury Program,” by Rachel Cohrs Zhang, Madison Muller, and Gerry Smith.
• MSNBC’s “He Helped Build the Anti-Vaccine Movement. RFK Jr. Just Hired Him,” by Brandy Zadrozny.

[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 Thursday, Oct. 2, 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 Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: And Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everyone. 

Rovner: Later in this episode we’ll play my interview with my colleague Cara Anthony, who reported and wrote the latest KFF Health News “Bill of the Month,” about an out-of-network surgery that looked like it had prior approval from the insurer — but maybe not. But first, this week’s news. 

So today is Oct. 2, and to the surprise of just about nobody who’s been paying attention, much of the government is in a shutdown, thanks to Congress’ failure to pass a spending bill or even a temporary patch for the fiscal year that started Wednesday. And just like in 2013, this shutdown is about the Affordable Care Act. Except in 2013 the Republicans shut down the government because they wanted to delay the start of the ACA. This time Democrats are shutting down the government to try to force Republicans to reup the additional ACA subsidies that Democrats passed during the pandemic but which expire at the end of December. That’s just the beginning of the confusion. 

I’m not even going to ask when or how this ends, because truly nobody knows. But there are lots of things that are very different about this shutdown from previous ones, aside from the fact that Democrats, who are usually the ones fighting to keep the government up and running, are the ones who are forcing the shutdown this time. What has changed the most since March, when Democrats went along with a temporary spending measure that they could have blocked at the time? 

Cohrs Zhang: I think obviously we saw a lot of blowback from the Democratic base in response to [Senate Minority Leader] Chuck Schumer’s decision to go along and just continue funding the government. I think the argument has been that it’s not business as usual and that Democratic leaders shouldn’t be treating it that way. And this is one of the few leverage points Democrats have in Washington right now, just because Republicans control the White House and the House and the Senate. So we have seen much more aggressive actions by the White House to exercise control over government spending and testing the waters as to how far they can go to overrule Congress’ directions for how money’s supposed to be spent in the government, which obviously plays into the government spending fight. 

And we’ve also seen the passage of Republicans’ reconciliation bill in the summer, which always poisons the well a little bit when it comes to bipartisan negotiations. Democrats see an opportunity to highlight Republicans’ spending reductions in Medicaid and all these new policies that they’re passing there. And I think Democrats have always viewed health care as a winning issue for them. I think that’s a lesson that they’ve learned over and over again in midterms and elections, that this is just an issue that generally voters think Democrats do a better job on. So I think they’re seeing this as an opportunity to highlight a potential pocketbook issue for health care and setting up for the midterm elections next year. 

Rovner: It’s interesting that back in March, one of the things that Chuck Schumer said is that he didn’t want to close down the government and give [President Donald] Trump basically that much more power. Well, this time they’re giving Trump that much more power and he seems to be running with it. The head of the OMB [Office of Management and Budget], Russ Vought, has already announced on social media that he’s cutting off funding for Democratic priorities, including a tunnel that’s being built between New York and New Jersey and a lot of the green energy projects that were in the Biden administration infrastructure bill, all of which have had money appropriated for them that the administration is supposed to spend. And now just this morning before we started taping, the president himself said he’s going to meet with Russ Vought to see what else they can do to basically throw sand in the gears of Democratic priorities that are supposed to be carried out. I guess this maybe is where Schumer gets to say, See, I told you so back in March. 

Luthra: Potentially. I think it’s worth noting — right? — that a lot of things, which we’ll talk about later, of course, were cut off, in terms of spending that was already allocated, even without the excuse of a shutdown. So it’s not very productive to engage in counterfactuals and hypotheticals, but it’s totally plausible that even without a shutdown a lot of this funding would’ve been cut off anyway. Which — I don’t know. It’s just we are not living under really normal politics anymore, and we can’t really pretend we can know what would’ve happened. 

Rovner: Yes, “unprecedented” is a word I’ve been using a lot lately. Well, we should review what happens to health programs during a shutdown, and I will post a link to the video that I did with my corgi Aspen to help explain it. What’s running and what’s not in terms of health care when the government is, quote-unquote, “shut down”? Because not everything is shut down? 

Cohrs Zhang: I mean, we do have a lot of the core functions continuing in terms of emergency response at the CDC [Centers for Disease Control and Prevention]. They are cutting back on public communications of public health data that are usually pretty routine. The FDA [Food and Drug Administration] has said they’re no longer accepting new drug applications, but obviously the review of applications that they’ve already received will continue because there are a lot of positions at the FDA specifically, but across the government, that are funded through other streams from fees from industry that don’t necessarily go through the routine process. But we certainly will see less information coming out of agencies. Just the general function of them, policy announcements, policy of movement, everything slows down as things that are in motion kind of grind to a halt as everywhere is kind of strained for resources. 

So I think we’ll see. I know at NIH [the National Instituted of Health] they said that they’re not taking in new patients for clinical trials and the grant reviews may be slowed down. So there’s just a lot of things that will slow down. But I think the core functions — of, like, Is this patient care? Is this emergency response? — for the large part are continuing at this time. 

Rovner: And of course mandatory programs, Medicare and Medicaid, continue because they’re not affected by a shutdown, because the shutdown is only for discretionary programs. Lauren, you were going to add something. 

Weber: I was just going to say I was sitting on an unrelated focus group for five hours on Tuesday night, and like 99% of the people when asked Oh, is anything happening in D.C.? had no idea about the shutdown. Like, none. I mean, just absolutely zero idea. So while all of these points are very important to talk through, I also question whether any of the messaging from both sides is getting through to the average person and whether or not the complexities of this are quite clear. 

Rovner: Well, one of the things that the Democrats are shutting the government down over is the failure of Republicans to renew the expanded subsidies for the Affordable Care Act that were passed in 2021 originally and then extended through the end of this year. People are going to find out about those because there’s 24 million people who are getting ACA coverage, and 90% of them are getting subsidies, and they’re all going to find out in the next couple of weeks how much their premiums are going to go up because of the failure to renew these subsidies. How big is this shock going to be? 

Cohrs Zhang: Depends on who it is, right? So, it’s like some people, especially people who are kind of in the higher income range, around 400% of the federal poverty level, if these tax credits expire, they don’t get any subsidies at all anymore. So we could see hundreds of dollars a month for beneficiaries who fall into this category. But for some beneficiaries there’s a smaller dollars-and-cents change that they’re going to see, because they’ll still get some subsidies but not as many. And I think it’s actually unclear who exactly is going to find out about these rate increases. CMS [the Centers for Medicare & Medicaid Services] has given states some flexibility as to whether they put the actual premium increase in these letters that people are going to be getting over the next month. So I think it’s going to be interesting to see how states strategize in terms of communicating with people about the potential for these increases but not scaring them away from the exchange entirely if Washington does manage to figure this out in the next couple weeks. 

Rovner: Yeah, the Republicans keep saying, Oh, this is a December problem. It’s like, no, this is not a December problem. Open enrollment starts Nov. 1, and if people show up and sign up, or if they’re in a plan that suddenly they can’t afford and they might want to move to a cheaper plan if they can find a cheaper plan to move to, I mean, this is definitely not a December problem. 

Luthra: And going back to your question, Julie, I mean, KFF did a very helpful analysis just looking at how much premiums could go up if the tax credits expire. And the last I checked it was they will more than double, which I noticed when my electricity bill went up this year. I think that’s pretty hard for people to not see when suddenly they’re spending potentially twice as much on their health care. 

Rovner: And I will post a link to that analysis which just came out. It’s an updated analysis with new data that shows that premiums are likely to spike even more. Well, one of the big arguments that Republicans are making about this shutdown, because Democrats not only want a renewal of these subsidies, they also want a reversal of a lot of the Medicaid cuts that were in the big budget bill that passed over the summer, and Republicans say Democrats are asking for federal health funding for illegal immigrants, which is not really true. What is it that Democrats are asking for? 

All right. I’m going to have to answer. I will answer this question myself because I went down the rabbit hole on emergency Medicaid. What the bill this summer did is it basically lowered the reimbursement that hospitals get when they provide emergency coverage to people who are not here with documentation. That is a long-standing program. It dates back to 1986, where hospitals can get reimbursed for treating people in medical emergencies who would be eligible for Medicaid other than the fact that they are not documented, meaning undocumented people are not eligible for Medicaid or for Medicare. Shefali, you were saying there’s a lot of this that is used for labor and delivery, right? 

Luthra: Exactly. And I mean if we even think about who benefits from emergency Medicaid, it’s not really undocumented people. It is hospitals, who are required to provide emergency care. But the example where I hear about this a lot is if you are pregnant and you don’t have documentation, you will go to the hospital because you need to give birth, you need to deliver. And emergency Medicaid is what covers the cost of that, which I just found that to be a really interesting point of tension with Republicans given in particular the vice president’s frequent remarks about how much he cares about healthy births and healthy babies. 

Rovner: And there’s a whole brand-new federal program aimed at improving birth outcomes. At the same time, they’re chastising the Democrats for saying, We would like to pay hospitals for delivering healthy babies — who are going to be American citizens, by the way, even if they’re mothers don’t have documentation, unless the Supreme Court changes that. 

Well as if there wasn’t enough to make your head swim here, I think one of the biggest ironies is that if the Democrats get what they want in terms of getting the Republicans to either roll back some of these Medicaid cuts or extend the additional subsidies, isn’t that going to accrue to the benefit of the Republicans? Because if these cuts happen, it’s presumably the Republicans who are going to get blamed come the midterms next year. 

Weber: That’s the irony of all of it, Julie. I mean, that’s the irony of the shutdown. That’s the irony of the messaging. That’s the irony of the whole thing, is that Republicans polls have shown that if these subsidies do increase, if they do double, I mean to Shefali’s point, I think we all notice when — if something costs you a thousand more dollars a year, I think people are going to sit up and pay attention to that. That will cause an issue. So yes, I mean it is somewhat surprising, but at the same day this is a lot of brinksmanship. And again, I question whether the messaging on either side is really cracking through to the American public about why both sides are arguing about the shutdown. 

Rovner: Yeah, they’re not on social media and cable TV in general watching people trade these fact checks back and forth. 

Weber: Yeah. 

Rovner: Well, meanwhile, back at the now partially shut down Department of Health and Human Services, there is still lots of news. We will start with vaccines. Remember that Advisory Committee on Immunization Practices vote a couple of weeks ago that changed recommendations for a whole bunch of vaccines? Well, the committee’s recommendations are not the end of the process. The committee’s work needs to be officially approved by the head of the CDC or the HHS secretary, neither of which has happened yet. Without that approval, shipping can’t begin, for example, for covid vaccines for the federal Vaccines for Children Program, which provides vaccines to about half of all the children in the U.S., by the way. One thing [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has apparently done, according to reporting from MSNBC, is hire as a senior adviser to CDC Mark Blaxill, a high-profile anti-vaccine activist who is neither a physician nor a scientist. Is Kennedy just thumbing his nose now at anyone who believes in vaccines, particularly at Republican senator and doctor Bill Cassidy, without whose vote Kennedy would not now have his job? 

Weber: I think Kennedy has been pretty emboldened by the president even going out further than he has publicly on vaccine issues. And I think we’re seeing his continuing leaning into the vaccine point of it all. Which I mean, this is a man who has been an anti-vaccine activist for many, many years. So it’s not completely surprising that he would hire people in that orbit or institute policies that follow what he’s advocated for for many years. 

Rovner: But I mean, just, I say this every week, he promised at his confirmation hearings that he would not go after the vaccine schedule, and he has definitely not kept that promise. 

Weber: Would you say that most politicians promise things that they do or do not keep, Julia, in your many years of coverage? 

Rovner: I don’t consider Cabinet secretaries who promise things to members of Congress who oversee them to be sort of typical politicians. It’s one thing to run for office and then do something else. It’s quite another thing to say in your confirmation hearing for a job that you won’t do something and then just weeks or months later do it. Shefali wanted to add something. 

Luthra: Oh, I was going to say to that point, Julie, when all of us watched those confirmation hearings, it was really striking to see that what RFK promised was also different from his long record of advocacy. And one watching those could come away deciding to believe what he said in the hearings or decide to believe what he said leading up to those hearings. And if you picked one, you’d be more right than if you picked the other. And I think there’s a real question now, I mean, given the point that you raised, Sen. Cassidy’s role in helping him get confirmed, his public remarks about how much he supports vaccines. There is a role Congress can play here to try and change things. And I don’t think we’ve seen that that will actually happen. 

Weber: So, I’m sorry. I just wanted to throw it back to the confirmation hearing itself. Cassidy asked this question directly. He said something, I’m not quoting it directly, but some version of, You’re a 70-something-year-old man. Does a tiger really change his stripes? — and then voted to confirm him. So as Shefali pointed out, I mean he chose to listen to what he said. But I mean I would say his track record in office has certainly not followed suit on those promises. 

Rovner: Well, while we’re on the subject of vaccines, Rachel, you have a story out this week about Kennedy’s plan to add autism to the list of complications eligible for compensation under the federal Vaccine Injury Compensation Program. What would that mean? 

Cohrs Zhang: We’re unclear exactly what they’re planning to do, but they’re planning to change the list of conditions or symptoms that people can claim are related to vaccines in this kind of arbitration process that the federal government has set up to compensate people who do suffer side effects from vaccines. It does happen, and I think there’s bipartisan agreement that the current system for compensating people, it isn’t really working very well. It’s really backed up, and there’s arguments that it doesn’t pay enough for people who experience these things. However, I think Secretary Kennedy has made clear to his advisers that he wants parents who believe their children have autism because of vaccines to be compensated through this program, which doesn’t currently happen. 

Rovner: No. And would probably bankrupt the program, right? 

Cohrs Zhang: It could. It could. Depending on, there’s just so many children these days that do kind of fall under the definition of autism. They’ve talked about maybe changing a definition of some just general neurological symptoms to maybe allow people with autism to qualify. But I think there’s a clear concern from experts as to how this program works, that it’s already backed up and if it’s flooded with these new claims. There’s actually a statutory limit on how many special masters there are to oversee this process. 

And unless Congress acts, then they can’t increase that number. So there’s a point at which, A, if these claims are getting granted that they just run out of money. They’re funded by a fixed tax on vaccine doses. So, again, unless Congress acts, they have a limited amount of money. And then you’re thinking about just the fixed capacity that they have to process these claims in the first place. And I think there is genuine concern here that without some support from Congress, this could completely overwhelm the program and just kind of be a roundabout way to validate the idea that vaccines cause autism. 

So I think there’s much to watch in terms of what the details are coming out. We’ve just had some high-level comments from an adviser, but stay tuned on that and I think it’ll definitely be something to watch. 

Rovner: Oh, absolutely. In other administration news directly affecting HHS and how it provides research funding to universities, The Washington Post is reporting that the White House is working on a plan that would reward institutions that pledge to, quote, “adhere to the values and policies of the Trump administration.” While others are reporting that Trump is about to close a deal with Harvard that involves the U.S.’ most prestigious university paying $500 million to the federal government and, so we hear, opening up and operating trade schools. And in a related piece of news, Politico EU reports that a program run by the EU’s top research council, essentially the EU’s NIH, has seen a fivefold increase in applications from U.S.-based scientists interested in moving across the pond. I’m not even sure what to make of any of this or what it could mean for the future of biomedical research, but it sounds like potentially big, big changes in how the research operation works here in the U.S.? 

Luthra: It does seem like something that could ripple for years if not generations to come. I mean, research is something that happens in years-long installments. Careers are built over very long periods of time. And, I mean, when I’ve spoken to a lot of young academics, whether that is for work or even in a personal capacity, a lot of them are really navigating so much instability that is just not what they anticipated when they began their years-long Ph.D. programs. And so it’s not at all surprising that we are seeing the EU’s efforts to recruit American scientists really bear fruit. But to your point, it absolutely raises the specter that a lot of cutting-edge research, a lot of really great future biomedical work simply won’t happen here and we won’t reap the immediate benefits in a way that we have historically. I mean, our higher education and research sector has been a real crown jewel, and it’s hard to see if that stays the case. 

Rovner: And it’s been a really important contributor to the economy. I mean, it’s not just the benefits of the research itself. It’s the biomedical research establishment has been something that’s been really important to the United States for a couple of generations now. 

Luthra: When you go to a university town, the university is almost always the largest employer and it plays a really big role in keeping up local economies and state economies. And we don’t have a clear answer for what fills in the gap if the institutions that provide those resources disappear or significantly downsize. 

Rovner: So sort of kind of related to what’s going on in the university community, President Trump is also demanding that U.S. drugmakers lower their prices and move manufacturing back to the USA — which he also demanded in his first term, though he was mostly blocked by the courts in the ways he tried to make that happen. Well, now he’s employing the same strategy that he’s using with other countries with tariffs and with universities, by negotiating individually. He’s now negotiating individually with drug companies and threatening bad things if they don’t do what he wants. And lo and behold, this week he announced a deal with Pfizer. Rachel, what has Pfizer promised to do? And what does it mean for what had been a unified wall of resistance by drug companies to Trump’s demands that they lower prices? 

Cohrs Zhang: Yeah, I agree with your take there that this is a symbolic change for the industry that had warned for so long that if you take, like, put even a toe over the line of imported — tying what Americans pay for medicines to what countries abroad pay, that it was going to be a slippery slope and it was a terrifying concept. So that is a big moment. 

We know at a high level what Pfizer’s committed to, but we don’t have a lot of details yet. There’s little in writing, and the press releases were pretty vague. But at a high level, I think Pfizer has agreed to reduce the prices that they offer state Medicaid programs and make those more in line with what prices abroad are. Again, Medicaid already gets really low prices for drugs, so it really is going to be a drug-by-drug, I think, question of: Is this price even lower? I think in some cases, the experts I’ve spoken with think that it’s possible that Medicaid could save money on some of these drugs, but some of them the price could be higher. And I think there’s a question of exactly what those mean. And drug pricing’s really hard, and they aren’t necessarily public, what each payer is paying for these things. So that’s one big element of this that’s important. 

They’re also agreeing to sell some of their medicines online, straight to consumers, on a website branded TrumpRx. And I think it’s just kind of like a platform, like a shopping platform is how they’ve described it. You can type in the drug name and then the website would direct you to the marketplaces that the drug companies run themselves. 

Rovner: And that just cuts out the middlemen, right? That doesn’t itself save money — I mean, save money for consumers. 

Cohrs Zhang: Right. The price may be discounted, but most people aren’t paying the net price of what their insurer pays for a lot of medicines. They’re paying a copay or a percentage. So again, for some medicines, if you’re uninsured, yeah, it’s a lot better to pay a discounted price. But if you have insurance, it’s unclear how, whether you would save any money by going through this process. And you have to have a prescription anyway for a lot of these medicines. So I think there’s just a lot of unanswered questions about exactly how that would interplay for patients with insurance. And then you also have assurances that Pfizer will launch medicine prices that are kind of aligned with what they charge other countries. Generally companies launch in the U.S. first. So does this create a new floor and leverage for Pfizer? I think that’s going to be a really interesting question. 

And then I think the last commitment that they made was if they raise prices in other countries for medicines that some of this increased revenue that they get from those drug sales abroad would go back to the federal government potentially through the Medicare program. But we don’t have a lot of details. 

Rovner: I saw a story just before we started taping that not only has Pfizer stock gone up since this announcement, but other drug companies’ stocks have gone up since this announcement. Obviously in exchange for this deal, Pfizer has been sort of absolved from having to pay the tariffs that Trump has threatened for three years. And the idea is that other drug companies are likely to make these same deals, which certainly the stock market thinks is not going to cause them to lose money, which suggests that it’s not going to cause big savings for consumers, right? 

Cohrs Zhang: Yes. I think that’s a good question, and it is important that analyst notes have expressed that Pfizer’s U.S. revenue, only like 5% of it is for Medicaid. So it’s a very small amount of what they make on drugs. But I think there is this looming regulatory option where Trump could kind of force drugmakers to comply with price reductions in other programs if they don’t make deals. So I don’t think this story is over. And they’ve foreshadowed that more deals are coming, and they may not have exactly the same terms as Pfizer. So I think we’re very much staying tuned here. 

Rovner: Well, we will cover them as they happen. OK, that is this week’s news. Now we’ll play my “Bill of the Month” interview with Cara Anthony, and then we’ll come back and do our extra credits. 

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

Cara Anthony: Hey, thanks for having me. 

Rovner: So this month’s patient — or her family, more accurately — did everything right before an elective surgery. At least they thought they did. Tell us who the patient was and what kind of care she needed. 

Anthony: Yeah, this month we introduced our readers to a little girl named Chloë Jones. She was in kindergarten at the time. She needed an elective surgery. She had a condition known as ptosis. In layman’s terms, that just means that she had a droopy eyelid. Her parents didn’t want this to interfere with her vision in the future, and so they elected to have this surgery. 

Rovner: And they lived where? 

Anthony: Just outside of St. Louis, pretty close to me, actually. But here’s the thing: They had a hard time finding a provider who was in network, and the story kind of goes on from there. 

Rovner: Yeah. So I guess pediatric ophthalmologists are not a dime a dozen. And they did find somebody. And knowing that it was out of network, they asked their insurer for permission, right? 

Anthony: Yeah. They asked for something called a gap exception and actually worked with their pediatrician, worked with Chloë’s primary care doctor, who wrote a letter on their behalf to say: Hey, she needs to have this surgery. Would you honor it as an in-network treatment? Because the closest person that could do this surgery was in Wisconsin, which wasn’t reasonable for them. This is a family with a lot of little kids. So they did. They dotted all of the i’s, crossed all the t’s — or so they thought, because they ended up with a huge bill. 

Rovner: Yeah. So then she has the surgery, everything is great, and then the bill comes. How big was the bill? 

Anthony: Thirteen thousand dollars, Julie, which was a huge surprise to the family. They didn’t have the means to pay that. So immediately, Chloë’s mom, Keyanna Jones, starts to ask questions, making phone calls, trying to figure out, Hey, what’s going on? They only paid just under $2,000, and there was no way they could pay a $13,000 bill. 

Rovner: So they had this letter from the insurance company that said that they would cover this. What happened? 

Anthony: Yeah, and this is why we had to ask ourselves in this case: What does covered actually mean? And in this case, the insurers said that they would cover it though without offering network discounts, the surgery itself. Now, some of her other exams that she needed, they did honor those as in network and that was fine. But the surgery itself was covered, but they weren’t willing to cover it as in network and offer those discounts, which would’ve made it much more reasonable, which is why we ended up with the $13,000 bill. 

But the tricky part here is that they received letters that looked basically identical. So the letters that said that they would get those in-network discounts were just for the pre-surgery and some post-surgery exams. Those look the same as the letter that said that they were covered for the surgery. But in that letter, the insurer explained that, Hey, we are not going to offer you network discounts. So the family was really confused here, and they had to ask for some serious help. 

Rovner: And what finally happened with the bill? 

Anthony: Well, Keyanna has a brother who was a former state senator. So she got so frustrated with the situation, she reaches out to her brother, who’s former state Sen. Caleb Rowden, here in Missouri, and he says, Hey, reach out to the senator who represents you, Sen. Travis Fitzwater, and they got the ball rolling. She also reached out to the Missouri attorney general, wrote a letter. Representative Fitzwater also contacted the hospital and the insurer, and they worked it out. So it’s really important for people to know that they can contact their local lawmakers, and that’s what they do — they advocate for their constituents. And in this case, the family paid absolutely nothing. 

Rovner: So eventually the bill was basically completely taken care of? 

Anthony: It was taken care of completely. They didn’t even have to pay the copay. That’s how much this was kind of messed up. And UnitedHealthcare and both the hospital here in St. Louis just said: You know what? We’re done. So kind of wild. 

Rovner: So what’s the takeaway here, besides that you can go for help? I mean, that’s obviously a big piece of it. But what’s the takeaway in the asking permission and getting what we think of as these prior authorizations, these preapproval letters for things like elective surgery? 

Anthony: Yeah. I think the main thing is that even if the letters look the same, you have to read every line, make sure that you have clarity there. But it’s also, here’s another reflection of how complicated our health care system is. And in this case, the family had a happy ending. But I don’t know, had she not contacted her brother, who’s a state senator, and not everybody has that kind of advantage. But everyone can contact their local lawmaker for help. But in this case, I would just say read the fine print, and if you think you understand it, read it again because there might be something in there that you’ll catch, and hopefully you can avoid a huge bill. But I’m glad this family was taken care of. 

Rovner: Oh, good advice. Cara Anthony, thank you so much. 

Anthony: Hey, thanks for having me, Julie. 

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

Luthra: Sure. My story is from The Washington Post. I normally try and give every byline, but there are a lot. Many journalists really worked very hard on this piece. The headline is “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting.” And it’s a very impressive, in-depth investigation. It takes us to Congo, where we meet a young girl who has malaria, and she dies because she can’t get the medication she needs even though it is less than 10 miles away. And the medication never comes to her, because of the freeze on USAID [U.S. Agency for International Development] funding, and this is the taking of U.S. aid inside the State Department. 

The story does a remarkable job following the grants and orders that were stopped in the United States when we have the USAID freeze take effect. And then it takes us to the people who suffered and whose lives were lost, including many children, because they couldn’t get medication that was actually not even that far away but simply couldn’t travel the last few miles to get there. It puts all of these against Secretary of State Marco Rubio’s promise that no one has died because of the USAID funding freeze and shows that that probably isn’t true. I mean, not probably, that isn’t true, because these people here in this story did in fact die because they couldn’t get medications that we purchased and sent there and then simply could not get the final step there. I think it’s a really great look at just how devastating this policy choice has been and will continue to be around the world. 

Rovner: Yeah, it was quite an impressive project. Lauren. 

Weber: I picked an op-ed in Time by Dr. Craig Spencer titled “Trump Is Breaking Americans’ Trust in Doctors.” It’s an op-ed after Trump and RFK Jr. talked about Tylenol and Trump went on to talk about vaccines and what that means for the rest of the country. And I will just say personally, I’ve been struck by how many of my friends from the Midwest, mom friends, regular friends, have reached out like: Hey, you are a reporter for The Washington Post that covers health. What is this? And I do think the Tylenol press conference really broke through in a way that a lot of other things have not. 

And Craig makes a bunch of different points about how it essentially pits doctors against the president. And what does that do for decaying trust in medical authorities? What does it do for trust in authorities, period? And I think that’s a question we’re going to continue to see bear out over the next couple of years. 

Rovner: Yeah, I think the byword of 2025 is “losing trust.” Rachel. 

Cohrs Zhang: My extra credit this week is in ProPublica. The headline is “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” and that’s by Margaret Coker with The Current. And I just thought this story did a great job of just kind of being grounded in the local reporting of: What have we seen? I think there’s tremendous interest in how some of these Medicaid policies that Republicans have committed to will play out across the country. We know state Medicaid officials are already scrambling. Insurance companies, hospitals are trying to figure out: How are we going to implement work requirements at the beginning of 2027? And I think this is a really interesting test project of what that could mean. And I think the administrative burden should not be underestimated, and I think this is just a great way to quantify the infrastructure you need to run a program like this. And I think if you’re spending more on the infrastructure to track people than on the actual health care, then I think that just raises questions about the program as a whole and how efficiently it’s running. So. 

Rovner: I would say a lot of eyes on Georgia because they’ve got the only one that’s actually up and running at the moment that people can study. 

My extra credit this week is from KFF Health News by Michelle Andrews, and it’s called “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab.” And it’s about how stupid and bifurcated our health system now is that you can go to a hospital, get approved for charity care, and then still get billed into bankruptcy by doctors who work at the hospital but not for the hospital. It’s kind of a perfect case study into just how dysfunctional things have gotten, and with the impending Medicaid cuts and the ACA premium increases, lots more people are going to become uninsured and likely fall into this same trap. It’s really good story. 

All right, that is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Rachel. 

Cohrs Zhang: I’m still on X, @rachelcohrs. 

Rovner: Shefali? 

Luthra: I’m Bluesky, @shefali. 

Rovner: Lauren. 

Weber: I’m on X and Bluesky, @LaurenWeberHP. 

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

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“I could hear the bones moving around in my elbow,” said Buttgereit, who was 60 when she slipped on a patch of ice in December outside her apartment in Bozeman, Montana.

Emergency room scans showed she had fractured her left arm near the joint. Doctors told her she needed surgery to repair it.

At the time, Buttgereit didn’t have health insurance — she had struggled to afford coverage after her husband’s death. The local health system, Bozeman Health, estimated Buttgereit would have to pay $50,560 out-of-pocket for the outpatient surgery to have her elbow pieced back together.

The estimate noted: “You could be charged more if complications or special circumstances occur.”

Four days after her fall, Buttgereit went in for surgery, which took about three hours. During a follow-up visit, she said, her doctor told her the procedure ended up being more complicated than expected.

Then the bill came.

The Medical Procedure

Buttgereit broke her humerus, the upper-arm bone that meets two other bones and forms the elbow. The way the bone splintered is known as a distal humerus fracture. It’s rare as far as breaks go, accounting for only about 2% of all fractures among adults. But older people, as well as kids in high-contact sports, are more prone to the big falls that lead to such fractures. The injury is painful and can make it impossible to move the elbow.

Some of these types of fractures heal with time in a splint, but most often surgery is the only fix. The patient is put under anesthesia while a surgeon repositions fragmented bones with plates and screws.

The Final Bill

$97,998. That includes at least $44,300 for the operating room and anesthesia administration, plus more than $50,000 for medical supplies and implants, such as screws and plates. After the hospital applied a self-pay discount, Buttgereit was on the hook for $78,398.40.

The Problem: Surprise Complications, Surprising Charges 

The hospital said the price for Buttgereit’s surgery increased because doctors encountered complications midprocedure.

In particular, the fall had shattered Buttgereit’s bone into more pieces than her surgeon anticipated, according to operating notes. That meant it took more time, skill, and supplies to reconstruct her elbow. And, since she was uninsured, Buttgereit alone faced the burden to pay the higher costs.

“I’ll make payments the rest of my life to pay it all off,” she said.

Buttgereit’s husband died suddenly in 2023. About a year later, she left her job with the company that had employed them both. The memories of him in that space were too difficult, she said. That also meant leaving behind her health coverage. She moved to Bozeman to be closer to one of her daughters and found a health plan at healthcare.gov that the federal government subsidized because of her limited income.

But she also faced a higher cost of living in Bozeman than her Social Security benefits could cover, and she needed part-time work. While that new income helped pay her bills, Buttgereit said, she no longer qualified for the same level of subsidized coverage and couldn’t afford her plan. So she dropped her health insurance.

About two months later, she fell.

After getting the surgery bill, Buttgereit began calling and emailing the hospital’s customer service team, asking how the price had risen from the $50,560 estimate to nearly $98,000. The hospital had automatically applied the self-pay discount of $19,600 to Buttgereit’s bill — 20% of the total. But that still left her with a tab of more than $78,000.

After more time to think pain-free, she said, she also wanted to know why the initial estimate was much steeper than those she found online for similar procedures.

Specifically, Buttgereit asked how to dispute her bill. When she felt she wasn’t making progress contesting the charges with the hospital, she asked about her options under the No Surprises Act, a federal consumer protection law.

According to emails reviewed by KFF Health News, a Bozeman Health billing employee incorrectly told Buttgereit the law applies only to ER services. The employee later said Buttgereit had the right to dispute the bill but gave her an incorrect deadline.

Hospital staffers recommended Buttgereit set up a payment plan and apply to the health system’s financial aid program.

Erin Schaible, a spokesperson with Bozeman Health, told KFF Health News that online estimates don’t reflect the specific details of a patient’s care. In addition to the shattered bones noted in Buttgereit’s surgery notes, Schaible said the physician identified nerve damage midsurgery that required additional work to fix.

“This situation highlights the importance of clear and compassionate communication,” Schaible said. “In response, our team leaders are revising internal protocols for escalating patient concerns and are reeducating staff on best practices for communicating cost estimate changes.”

The Resolution

Buttgereit refused to apply for financial aid, opting instead to challenge what she sees as inflated pricing. Using Healthcare Bluebook, an online price comparison tool that draws on insurance claims data, Buttgereit found similar procedures ranged from $8,000 to $40,000.  

She said she believes that there are also errors on her bill and that the complications didn’t justify the price.

“I felt like going through financial assistance means that I’m OK with the price of the bill,” she said. “I want to get the bill reduced on the front end and then, if I need financial assistance, go through it.”

A billing employee emailed Buttgereit in May to offer an additional $7,000 discount if she set up a payment plan. If she later qualified for financial assistance, “we will adjust the amount accordingly,” the email said.

In June, the employee told Buttgereit her account would be put on hold before a collection process was initiated, “so that you have time to decide what to do.”

Buttgereit agreed to a payment plan of $100 a month, though she continued to contest the total charges.

At that rate, it would take about 60 years to pay off the debt — or longer, if the health system were to charge interest.

Buttgereit made one more bid for help: She emailed the White House.

This month, in the same week she got a detailed letter from the hospital standing by its charges, Buttgereit said she received a call from an official with the Centers for Medicare & Medicaid Services, saying she could dispute the bill to federal health officials.

The Takeaway

The best time to push back against a price is before surgery, upon receiving a hospital’s best guess on costs, known as a “good faith estimate.” Otherwise, undergoing surgery is considered tacit acceptance of that price as a baseline.

Patricia Kelmar, director of health care campaigns at the national consumer advocacy group U.S. PIRG, follows ways in which people get tangled financially in the health industry. She said patients should compare cost estimates by searching their hospital’s online pricing tool (as well as those of nearby hospitals) to see whether the estimates align. But not every procedure makes those lists, especially those for uncommon injuries, nor is every hospital’s list easy to access and navigate.

Post-surgery, patients have few resources to fight big bills, but a little-known rule in the No Surprises Act could help, Kelmar said.

The law, which took effect in 2022, is best known for protecting patients from surprise bills for out-of-network, emergency care. But it also created a formal dispute process for uninsured patients, or those paying completely out-of-pocket for nonemergency procedures, if their final tab is $400 or more than the initial estimate.

“This is a valid, important part of making sure that patients who are cash-pay have a watchdog,” Kelmar said.

People can start the patient-provider dispute process online, through the CMS website, by providing medical records and paying a $25 fee. Patients must initiate the process within 120 days of receiving the bill, and the bill may not be sent to a collection agency while under review.

An independent reviewer evaluates whether the final price is drastically different from what a health insurance company would have paid and whether the complication was predictable. If the review finds that the health provider erred on either front, federal health officials could require them to reduce the bill to match the original estimate or the median price insurers pay.

Buttgereit said she initially opted against pursuing that formal dispute process because, after such a review, the floor would be the hospital’s initial estimate, and she still had questions about how it would work. But after hearing from CMS, Buttgereit said it’s the path she plans to take.  

“You’ve got to fight for yourself,” she said. “I don’t know where this is going to end up, but I feel a little bit more hopeful.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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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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Even Chloë, who was in kindergarten, had a good understanding of how things would go that day. Before the procedure, a hospital worker gave her a coloring book that explained the steps of the surgery — a procedure to correct a condition that could have eventually interfered with her vision.

“Chloë is very smart,” Jones said. “She reads at almost a third-grade level now, and she’s only 6.”

Jones did her homework, too. With no pediatric ophthalmologists near their home in Wentzville, Missouri, who would take their insurance, she asked the insurer to cover Chloë’s out-of-network care as if it were in-network. The insurer agreed to let her see an out-of-network specialist.

Chloë made it through surgery without a hitch. Jones said her daughter enjoyed a few popsicles at the hospital before going home.

“ I slept with her every night because she was so worried she would wake up and not be able to see,” she said. “But it healed beautifully, and she was absolutely ready to go back to school.”

Then the bill came. 

The Medical Procedure

Chloë was born with a droopy left eyelid, a condition known as ptosis. To correct the problem, an ophthalmologist surgically lifts the eyelid, preventing it from disrupting the patient’s line of sight.

Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.

The Final Bill

$15,188, including $10,382 for the procedure and $2,730 for anesthesia. Initially, insurance paid just $1,775.79, leaving the Jones family owing $13,412.21 — until Chloë’s uncle, who had recently finished his term as a state senator, asked a colleague to look into it.

The Problem: Phantom Insurance Approval?

Months before Chloë inhaled bubblegum-scented anesthetic at Cardinal Glennon Children’s Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chloë’s pediatrician wasn’t contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.

So Jones requested what’s called a network gap exception, under which the insurer would cover the recommended doctor’s services as in-network.

Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request “because currently there isn’t a doctor, health care professional, or facility in your area to provide these services.” The letter listed several medical billing codes for eye services and said they would be covered “at the network level.”

About a week later, the insurer sent a prior authorization letter approving Chloë’s surgery.

But UnitedHealthcare declined to pay most of the surgery bill, covering it as out-of-network. With approval letters in hand, Jones said, she did not understand why the insurer apparently was not honoring its agreement to cover her daughter’s treatment.

In fact, the similar-looking letters granted different kinds of approval.

UnitedHealthcare’s gap exception approved Chloë’s exams before the surgery as in-network. But in its prior authorization letter for her surgery with the same doctor, the insurer said only that it would cover it — without offering network discounts.

After receiving the bill, Jones contacted the insurer online, but she said a representative told her there was no record of its approval to cover the surgery as in-network.

“At that point, I didn’t even know what to do,” she said. “I’m like, ‘This is crazy.’”

She said she sent over a copy of one of the approval letters, which was on the company’s letterhead, but a representative told her the letter hadn’t come from UnitedHealthcare.

“They said, ‘You saw this surgeon, they’re not covered and you didn’t have permission, so, no, we’re not going to pay,’” Jones said, recounting the phone call.

An insurance representative told Jones she owed more than $13,000 because of “a balance billing issue.” That meant the Jones family would have to pay the $13,000-plus balance.

Spokespeople for UnitedHealthcare confirmed the company provided a gap exception and prior authorization for Chloë’s care. Eric Hausman, a spokesperson for UnitedHealth Group, said in a statement to KFF Health News that “we empathize with anyone who finds themselves in the unfortunate situation of being balance billed by an out-of-network provider for an amount significantly above market rates, and without any advance knowledge.”

Maryanne Wallace, a spokesperson for SSM Health, the health system that includes Cardinal Glennon Children’s Hospital, provided a statement that said SSM followed “standard patient billing procedures.”

“Occasionally, an insurance company may process a claim as an out-of-network service, which can result in a balance being billed to the patient,” the statement said.

The Resolution

Jones said she was blindsided by the big bill. She tried to fix the problem on her own, she said, keeping track of every interaction with the insurer and the hospital. She filed appeals with UnitedHealthcare.

Nothing helped — until she reached out to her brother Caleb Rowden, who had been a Missouri state senator for eight years after serving four years in the state House.

“ I’ve never used my brother’s political clout for anything,” she said. “I actually hate politics.”

Rowden told KFF Health News that he reached out to Travis Fitzwater, the state senator representing his niece’s district. Jones contacted Fitzwater’s office, too, and sent a complaint to Missouri Attorney General Andrew Bailey.

Fitzwater said his office did no more for Chloë than it would for any constituent.

“We’re not going to take a lot of credit for the result of it, because we didn’t ask for anything other than a resolution, so that everybody can be at peace and move on with their lives,” he said in an interview. “We just did what we do every day.”

After Fitzwater’s staff contacted the hospital and the insurer, representatives from both separately called Jones and notified her that UnitedHealthcare had paid the bill in full.

In the end, Chloë’s family paid nothing for her procedure — not even a copay.

The Takeaway

When it comes to insurance approvals, read the fine print carefully; “covered” does not mean an insurer will pay, let alone at in-network rates.

Rowden and Fitzwater said reaching out to your elected representative’s office can help. Advocating for constituents is part of their job.

“They usually have an open line of communication with these insurance companies and hospitals,” Rowden wrote in an email. “They may not always be able to get to a positive outcome since every situation is a little different, but they can usually get you to a next step.”

Jones is grateful that her brother was able to help, though she acknowledged that she probably would not have called him without a nudge from their mother. “I think I would still be fighting,” she said.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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This story can be republished for free (details).

The first was choosing to temporarily forgo health insurance when she was laid off from her job.

The second was screaming when a wild bat later landed on her face.

The bizarre encounter happened last August, while the Massachusetts resident was photographing the night sky during a vacation at the Glen Canyon National Recreation Area in Arizona. Kahn, now 33, noticed a few bats flying around but didn’t worry about them — until one flew up to her and got tangled between her camera and her face.

She screamed, and part of the bat went in her mouth. She doesn’t know which part or for how long, though she estimates it was only a few seconds. “It seemed longer,” she said.

The bat flew away, leaving Kahn shaken.

She didn’t think the animal had bitten her. Regardless, her father, who is a physician and was traveling with her, said she should go to a hospital within a day or so and begin vaccinations against rabies.

Figuring she would be covered as long as she obtained insurance before going to the hospital, Kahn said, she found a policy online the day after the bat incident. She said she called the company before she bought its policy and was told services related to an accident or “life-threatening” emergency would be covered.

Kahn went the next day to a hospital in Flagstaff, Arizona, where she started rabies prevention treatment. Over the next two weeks, she received the rest of the rabies shots at clinics in Arizona and Massachusetts and at a hospital in Colorado.

Then the bills came.

The Medical Procedure

Kahn received a total of four doses of the rabies vaccine. The doses are administered over the course of 14 days. Along with her first vaccination, she received three shots of immunoglobulin, which boosts antibodies against the virus.

Rabies is typically transmitted through bites or scratches from an infected animal. Experts recommend precautionary measures when a person has been potentially exposed to rabies, because once the neurological disease causes symptoms, it is fatal. The Centers for Disease Control and Prevention says postexposure rabies treatment has reduced the number of human fatalities to fewer than 10 a year in the U.S.

The Final Bill

According to explanation-of-benefits statements, Kahn owed a total of $20,749 for her care at the four facilities. Most of the charges were from the hospital where she was first treated, Flagstaff Medical Center: $17,079, including $15,242 for the rabies and immunoglobulin shots.

The Billing Problem: Most Insurance Doesn’t Start Immediately

Kahn’s policy did not pay for any of the services. “The required waiting period for this service has not been met,” said an explanation-of-benefits letter she received in December.

Kahn was stunned. “I thought it must have been a mistake,” she said. “I guess I was naive.”

When Kahn was laid off from her job as a biomedical engineer last summer, she had the option to temporarily stay on her former employer’s insurance under a COBRA plan, at a cost of about $650 a month. But as a young, healthy person, she gambled that she could get by without insurance until she found another job. She figured that if she needed medical care, she could quickly buy a private policy.

According to the Centers for Medicare & Medicaid Services, those who qualify for COBRA must be given at least 60 days to sign up — and if they do, the coverage applies retroactively. Kahn, who was still within that period at the time of the incident, said recently that she did not realize she had that option.

The policy she purchased after the bat episode, which cost about $311 a month, was from a Florida company called Innovative Partners LP. Documents Kahn provided to KFF Health News say the policy has a 30-day waiting period, which “does not apply to benefits regarding an accident or loss of life.”

Kahn said that after receiving notice that her claims were denied, she called the company to ask how she could appeal and was told a doctor would have to file paperwork. She said she wrote a letter that was signed by a doctor at Flagstaff Medical Center and submitted it in March but was unable to reach doctors at the other facilities.

Kahn said she was given conflicting answers about where to send the paperwork. She said a representative with the company recently told her it had not received any appeals from her.

Benefits statements Kahn received in early July show Innovative Partners had not paid the claims. The company did not respond to requests for comment for this article.

Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, said most health coverage plans take effect on the first day of the month after a customer enrolls.

“The insurance companies — for good reason — don’t want people to wait to sign up for coverage until they are sick,” she said, noting the premiums healthy people pay help balance the costs of paying for health care.

The Affordable Care Act requires insurers to cover preexisting conditions, such as diabetes or heart issues. But that doesn’t mean they have to pay for treatment of an injury sustained shortly before a person enrolls in coverage, she said.

Corlette, who reviewed a brief benefits overview provided by Kahn, said the policy appears to have been a limited, “fixed indemnity” plan, which would pay only set amounts toward treatments per day or other period regardless of total expenses incurred. Such plans have been around for decades and aren’t required to meet ACA standards, she said.

But she said even if Kahn had bought comprehensive health insurance, it probably wouldn’t have covered treatment received so soon after she purchased it.

David Shlim, a travel medicine specialist in Wyoming who studies rabies, said Kahn made the right choice by promptly seeking treatment, even though she didn’t feel the bat bite her. The disease is deadly, and the fact that the bat went into her mouth meant she could have been infected from its saliva, he said: “You could hardly have a more direct exposure than that.”

Shlim, who recently co-wrote a federal advisory about rabies prevention, added that  healthy bats don’t normally fly into people, as the one in this case did. The animal’s entanglement with Kahn suggests it could have been sick, possibly with rabies, he said.

Rabies prevention treatment is much more expensive in the United States than in most other countries, Shlim said. The priciest part is immunoglobulin, which is made from the blood plasma of people who have been vaccinated against rabies.

The treatment is often administered in hospital emergency rooms, which add their own steep charges, Shlim noted.

The Resolution

Kahn said she is employed again and has good health insurance but is still facing most of the bills from her misadventure at Glen Canyon. She said she paid a doctor bill from Flagstaff Medical Center after negotiating it down from $706 to $420. She said she’s also arranged a $10-a-month plan to pay off the $530 she owes for one of her rabies shots at another facility.

She said she plans to continue appealing the denials of payment for the rest of the bills, which total more than $19,000.

In a statement on behalf of the Flagstaff hospital — where Kahn incurred the highest charges — Lauren Silverstein, a spokesperson at Northern Arizona Healthcare, said the health system does what it can to limit costs. “We have less ability to control the prices of critical supplies that we use to treat patients, including pharmaceuticals, biologics, diagnostics and medical devices made by other companies,” she said.

Silverstein said the hospital needs to keep immunoglobulin on hand to prevent rabies, even though such cases are relatively rare and the drug is expensive.

The Takeaway

COBRA insurance policies, named for the Consolidated Omnibus Budget Reconciliation Act of 1985, enable many people who lose job-based coverage to pay to stay on those plans temporarily. There is a 60-day window to choose COBRA coverage, and once a beneficiary pays for it, the coverage applies retroactively — meaning that medical care is covered even if it occurred when the person was uninsured.

Corlette said Kahn’s predicament illustrates why people need to make sure they have health insurance.

She said people who lose employer-based coverage should consider enrolling in individual insurance plans sold on federal or state marketplaces. Many people who buy such policies qualify for substantial ACA subsidies to help pay premiums and other costs.

“If you are losing your job, COBRA is not your only option,” Corlette said.

Kahn wishes she had signed up for insurance coverage when she was laid off, even though she felt confident she would find another job within a few months. “That’s a very big lesson I learned the hard way,” she said.

Her wildlife encounter did not destroy her love of the outdoors. She even sees humor in it.

“I know what bats taste like now. It’s an earthy, sweet kind of flavor,” she joked. “It’s actually a pretty funny story — if it weren’t for the horrible medical bill that came with it.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

So, in mid-March, he took his family to a primary care clinic at the University of Texas Medical Branch in Galveston.

By the end of the visit, his son, Anh Hoang, had received one shot protecting against four illnesses — measles, mumps, rubella, and chickenpox. He also received a second shot against tetanus, diphtheria, and whooping cough, as well as a flu shot. His twin daughters, who had already had their measles vaccinations, got other immunizations.

Nguyen, who is a UTMB postdoctoral fellow in public health and infectious disease, said he asked clinic staff whether his family’s insurance would cover the checkups and immunizations. He said he was assured that it would.

Then the bills came.

The Medical Procedure

The first measles vaccine was licensed in 1963 and became part of the combination measles, mumps, and rubella, or MMR, vaccine in 1971. Today the vaccine against chickenpox, or varicella, is sometimes combined into what is known as the MMRV vaccine.

A first dose of the measles vaccine is usually given between 12 and 15 months, with a second between ages 4 and 6. Experts may recommend vaccinating children at younger ages during an outbreak — like the ongoing U.S. measles outbreak, which has led to more than 1,200 cases, 750 of them in Texas. According to the Centers for Disease Control and Prevention, 95% of the cases have occurred in unvaccinated people or those whose vaccine status is unknown.

Recommendations affecting administration and insurance coverage are made by the Advisory Committee on Immunization Practices. In mid-June, Health and Human Services Secretary Robert F. Kennedy Jr. replaced the committee, adding vaccine skeptics. The new panel, which met last week, is expected to scrutinize past recommendations, including for the MMR vaccine.

The Final Bill

UTMB billed $2,532 for the boy’s office visit and three shots. The MMRV shot alone was billed at $1,422, plus $161 for administering it.

The Billing Problem: Coverage Gaps and Provider ‘Errors’

There are guardrails in the U.S. health system intended to prevent recommended vaccines from being prohibitively expensive. They did not help the Nguyen family.

Their health plan, purchased from insurance broker TaiAn for Nguyen’s wife and children and administered by the International Medical Group, does not cover immunizations. And, initially, the family was not offered assistance under the Vaccines for Children Program, a federally funded effort, created after a measles outbreak more than 30 years ago, that provides free immunizations for uninsured and underinsured children.

So the family was exposed to the sticker shock of U.S. medical care without insurance, with providers setting prices. In this case, UTMB’s price for the child’s MMRV shot was about $1,400, more than five times what the CDC says it costs in the private sector.

Nguyen was surprised when their insurer did not pay anything, leaving bills for his three children’s checkups that, combined, were close to $5,000.

He said the family’s income, from his job in UTMB’s labs, is less than $57,000 a year. Nguyen’s job provides him health insurance, but he balked at the $615 a month it would cost to cover his family, too, and instead purchased the one-year policy from TaiAn, which totaled $1,841. The policy covers certain types of office visits, emergency room care, hospitalization, and chemotherapy, but not immunizations or checkups.

Nguyen and his wife, who are from Vietnam, are living in the country on temporary visas while he completes his studies. In Vietnam, Nguyen said, the total cost of the preventive care his family received at the clinic would probably be no more than $300.

He was concerned about the high prices set by the clinic for the vaccines, particularly during a measles outbreak.

“It’s insane,” he said.

Carly Kessler, a spokesperson for International Medical Group, confirmed in an email to KFF Health News that the family’s plan does not cover preventive care, including immunizations.

After UTMB was contacted by KFF Health News, its vice president of clinical contracting strategies, Kent Pickering, looked into the matter. “This situation should not have happened” but did so because of “a series of errors,” he said in an interview.

Most insurance offered in the U.S. must cover, without copays, a variety of preventive care services — including the measles vaccine — under rules in the Affordable Care Act. But some plans are exempt from those rules, including short-term plans or travel insurance. International students on temporary visas do not have to buy an ACA-compliant plan during their first five years in the country.

But what about the cost of the vaccines?

Hospitals and other providers may set their own prices for services, creating price lists called chargemasters. Insurers negotiate discounts for services they agree to cover. People with no insurance coverage are generally on the hook for the full amount.

“One of the most frustrating parts of our health care system is that people who don’t have health insurance coverage have to pay far more than even a health insurance company would pay,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.

While prices can vary, the CDC’s Vaccines for Children Program price list shows the MMRV vaccine — also known by the brand name ProQuad — costs about $278 in the private sector. Consumer prices for ProQuad at Galveston-area pharmacies range from about $285 to $326, according to the prescription cost-tracking website GoodRx.

UTMB’s Pickering told KFF Health News that, initially, the Nguyen family’s insurance was entered incorrectly by the clinic staff, so they did not pick up that his plan didn’t cover vaccines. If they had, UTMB likely would have checked whether the Texas Vaccines for Children Program would cover the cost of the shots, charging only the program’s small administration fee.

A second error was uncovered when Pickering looked into the bill. He said UTMB’s chargemaster had been updated a few months earlier and the vaccine prices for those who do not receive shots through the children’s vaccine program were listed at incorrectly high amounts, resulting in the price Nguyen’s son was charged.

Pickering said the prices had been corrected, though he declined to cite exact figures.

The Resolution

In addition to contacting the insurer, Nguyen reached out to the financial offices at UTMB, asking for a reduction or waiver of the fees.

In mid-May, UTMB sent Nguyen a revised bill for his son’s office visit. It applied a 50% self-pay discount, which its website says is offered to those who are uninsured. His revised total was $1,266, $711 of which was for the MMRV vaccination.

“I expected them to waive the vaccination cost for my children or at least reduce it more, especially for MMRV vaccine,” said Nguyen, noting that his family would still be strapped trying to pay their bills.

After Pickering spoke with KFF Health News, a customer service representative reached out to Nguyen, waiving the cost of the vaccines. His new bill was $202.75 for his son’s office visit, as well as similarly smaller amounts for his daughters’ medical care.

The Takeaway

More Bill of the Month

• A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000. May 29, 2025
• The Patient Expected a Free Checkup. The Bill Was $1,430. Apr 30, 2025
• He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000. Mar 28, 2025

Medical billing experts say it’s always a good idea to check with your insurer before elective treatments like checkups or vaccinations to find out what is covered and how much you might owe.

International students and others who purchase non-ACA-compliant plans, such as short-term coverage, should carefully review their benefits, because there are often limitations.

For some services, including vaccinations, there may be lower-cost options.

Constance Almendarez, the immunization manager for the Galveston County Health District, said in an email that many public health departments, including Galveston’s, offer free vaccinations through the children’s vaccine program to those 18 and under who are eligible, including people without insurance or whose insurance does not cover vaccines.

But those programs are potentially threatened as the Trump administration institutes layoffs of federal workers and moves to cancel grants to health departments.

Finally, you can ask for a discount. Medical providers may offer self-pay discounts for patients who are uninsured or underinsured, or charity care policies to those who meet specified income requirements.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

After narrowly passing in the House in May, President Donald Trump’s “One Big Beautiful Bill” has now arrived in the Senate, where Republicans are struggling to decide whether to pass it, change it, or — as Elon Musk, who recently stepped back from advising Trump, is demanding — kill it. 

Adding fuel to the fire, the Congressional Budget Office estimates the bill as written would increase the number of Americans without health insurance by nearly 11 million over the next decade. That number would grow to approximately 16 million should Republicans also not extend additional subsidies for the Affordable Care Act, which expire at year’s end. 

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• Even before the CBO released estimates of how many Americans stand to lose health coverage under the House-passed budget reconciliation bill, Republicans in Washington were casting doubt on the nonpartisan office’s findings — as they did during their 2017 Affordable Care Act repeal effort.
• Responding to concerns about proposed Medicaid cuts, Iowa Sen. Joni Ernst, a Republican, this week stood behind her controversial rejoinder at a town hall that “we’re all going to die.” The remark and its public response illuminated the problematic politics Republicans face in reducing benefits on which their constituents rely — and may foreshadow campaign fights to come.
• Journalists revealed that Health and Human Services Secretary Robert F. Kennedy Jr.’s report on children’s health may have been generated at least in part by artificial intelligence. The telltale signs in the report of what are called “AI hallucinations” included citations to scientific studies that don’t exist and a garbled interpretation of the findings of other research, raising further questions about the validity of the report’s recommendations.
• And the Trump administration this week revoked Biden-era guidance on the Emergency Medical Treatment and Active Labor Act. Regardless, the underlying law instructing hospitals to care for those experiencing pregnancy emergencies still applies.

Also this week, Rovner interviews KFF Health News’ Arielle Zionts, who reported and wrote the latest “Bill of the Month” feature, about a Medicaid patient who had an emergency in another state and the big bill he got for his troubles. If you have an infuriating, outrageous, or baffling medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: KFF Health News’ “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection,” by Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts.

Alice Miranda Ollstein: Politico’s “‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector,” by Alice Miranda Ollstein.

Lauren Weber: The New York Times’ “Take the Quiz: Could You Manage as a Poor American?” by Emily Badger and Margot Sanger-Katz.

Jessie Hellmann: The New York Times’ “A DNA Technique Is Finding Women Who Left Their Babies for Dead,” by Isabelle Taft.

Also mentioned in this week’s podcast:

• NOTUS.org’s “The MAHA Report Cites Studies That Don’t Exist,” by Emily Kennard and Margaret Manto.
• The Washington Post’s “White House MAHA Report May Have Garbled Science by Using AI, Experts Say,” by Lauren Weber and Caitlin Gilbert.

[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 Thursday, June 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 Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, 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 colleague Arielle Zionts, who reported and wrote the KFF Health News “Bill of the Month,” about a Medicaid patient who had a medical emergency out of state and got a really big bill to boot. But first the news. And buckle up — there is a lot of it. 

We’ll start on Capitol Hill, where the Senate is back this week and turning its attention to that “Big Beautiful” budget reconciliation bill passed by the House last month, and we’ll get to the fights over it in a moment. But first, the Congressional Budget Office on Wednesday finished its analysis of the House-passed bill, and the final verdict is in. It would reduce federal health care spending by more than a trillion dollars, with a T, over the next decade. That’s largely from Medicaid but also significantly from the Affordable Care Act. And in a separate letter from CBO Wednesday afternoon, analysts projected that 10.9 million more people would be uninsured over the next decade as a result of the bill’s provisions. 

Additionally, 5.1 million more people would lose ACA coverage as a result of the bill, in combination with letting the Biden-era enhanced subsidies expire, for a grand total of 16 million more people uninsured as a result of Congress’ action and inaction. I don’t expect that number is going to help this bill get passed in the Senate, will it? 

Ollstein: We’re seeing a lot of what we saw during the Obamacare repeal fight in that, even before this report came out, Republicans were working to discredit the CBO in the eyes of the public and sow the seeds of mistrust ahead of time so that these pretty damaging numbers wouldn’t derail the effort. They did in that case, among other things. And so they could now, despite their protestations. 

But I think they’re saying a combination of true things about the CBO, like it’s based on guesses and estimates and models and you have to predict what human behavior is going to be. Are people going to just drop coverage altogether? Are they going to do this? Are they going to do that? But these are the experts we have. This is the nonpartisan body that Congress has chosen to rely on, so you’re not really seeing them present their own credible sources and data. They’re more just saying, Don’t believe these guys. 

Rovner: Yeah, and some of these things we know. We’ve seen. We’ve talked about the work requirement a million times, that when you have work requirements in Medicaid, the people who lose coverage are not people who refuse to work. It’s people who can’t navigate the bureaucracy. And when premiums go up, which they will for the Affordable Care Act, not just because they’re letting these extra subsidies expire but because they’re going back to the way premiums were calculated before 2017. The more expensive premiums get, the fewer people sign up. So it’s not exactly rocket science figuring out that you’re going to have a lot more people without health insurance as a result of this. 

Ollstein: Honestly, it seems from the reactions so far that Republicans on the Hill are more impacted by the CBO’s deficit increase estimates than they are by the number of uninsured-people increase estimates. 

Rovner: And that frankly feels a little more inexplicable to me that the Republicans are just saying, This won’t add to the deficit. And the CBO — it’s arithmetic. It’s not higher math. It’s like if you cut taxes this much so there’s less money coming in, there’s going to be less money and a bigger deficit. I’m not a math person, but I can do that part, at least in my head. 

Jessie, you’re on the Hill. What are you seeing over in the Senate? We don’t even have really a schedule for how this is going to go yet, right? We don’t know if the committees are going to do work, if they’re just going to plunk the House bill on the floor and amend it. It’s all sort of a big question mark. 

Hellmann: Yeah, we don’t have text yet from any of the committees that have health jurisdiction. There’s been a few bills from other committees, but obviously Senate Finance has a monumental task ahead of them. They are the ones that have jurisdiction over Medicaid. Their members said that they have met dozens of times already to work out the details. The members of the Finance Committee were at the White House yesterday with President [Donald] Trump to talk about the bill. 

It doesn’t seem like they got into the nitty-gritty policy details. And the message from the president seemed to mostly be, like, Just pass this bill and don’t make any major changes to it. Which is a tall order, I think, for some of the members like [Sens.] Lisa Murkowski of Alaska and Susan Collins of Maine, and even a few others that are starting to come out and raise concerns about some of the changes that the House made, like to the way that states finance their share of Medicaid spending through the provider tax. 

Lisa Murkowski has raised concerns about how soon the work requirements would take effect, because, she was saying, Alaska doesn’t have the infrastructure right now and that would take a little bit to work out. So there are clearly still a lot of details that need to be worked out. 

Rovner: Well, I would note that Senate Republicans were already having trouble communicating about this bill even before these latest CBO numbers came out. At a town hall meeting last weekend in Iowa, where nearly 1 in 5 residents are on Medicaid, Republican Sen. Joni Ernst had an unfortunate reaction to a heckler in the audience, and, rather than apologize — well, here’s what she posted on Instagram. 

Sen. Joni Ernst: Hello, everyone. I would like to take this opportunity to sincerely apologize for a statement that I made yesterday at my town hall. See, I was in the process of answering a question that had been asked by an audience member when a woman who was extremely distraught screamed out from the back corner of the auditorium, “People are going to die!” And I made an incorrect assumption that everyone in the auditorium understood that, yes, we are all going to perish from this earth. 

So I apologize. And I’m really, really glad that I did not have to bring up the subject of the tooth fairy as well. But for those that would like to see eternal and everlasting life, I encourage you to embrace my Lord and Savior, Jesus Christ. 

Rovner: And what you can’t see, just to add some emphasis, Ernst recorded this message in a cemetery with tombstones visible behind her. I know it is early in this debate, but I feel like we might look back on this moment later like [Sen. John] McCain’s famous thumbs-down in the 2017 repeal-and-replace debate. Or is it too soon? Lauren. 

Weber: For all the messaging they’ve tried to do around Medicaid cuts, for all the messaging, We’re all going to die I cannot imagine was on the list of approved talking points. And at the end of the day, I think it gets at how uncomfortable it is to face the reality of your constituents saying, I no longer have health care. This has been true since the beginning of time. Once you roll out an entitlement program, it’s very difficult to roll it back. 

So I think that this is just a preview of how poorly this will go for elected officials, because there will be plenty of people thrown off of Medicaid who are also Republicans. That could come back to bite them in the midterms and in general, I think, could lead — combine it with the anti-DOGE [Department of Government Efficiency] fervor— I think you could have a real recipe for quite the feedback. 

Rovner: Yes, and we’re going to talk about DOGE in a second. As we all now know, Elon Musk’s time as a government employee has come to an end, and we’ll talk about his legacy in a minute. But on his way out the door, he let loose a barrage of criticism of the bill, calling it, among other things, a, quote “disgusting abomination” that will saddle Americans with, quote, “crushingly unsustainable debt.” 

So basically we have a handful of Republicans threatening to oppose the bill because it adds to the deficit, another handful of Republicans worried about the health cuts — and then what? Any ideas how this battle plays out. I think in the House they managed to get it through by just saying, Keep the ball rolling and send it to the Senate. Now the Senate, it’s going to be harder, I think, for the Senate to say, Oh, we’ll keep the ball rolling and send it back to the House. 

Ollstein: Well, and to jump off Lauren’s point, I think the political blowback is really going to be because this is insult on top of injury in terms of not only are people going to lose Medicaid, Republicans, if this passes, but they’re being told that the only people who are going to lose Medicaid are undocumented immigrants and the undeserving. So not only do you lose Medicaid because of choices made by the people you elected, but then they turn around and imply or directly say you never deserved it in the first place. That’s pretty tough. 

Rovner: And we’re all going to die. 

Ollstein: And we’re all going to die. 

Weber: Just to add onto this, I do think it’s important to note that work requirements poll very popularly among the American people. A majority of Americans here “work requirements” and say, Gee, that sounds like a commonsense solution. What the reality that we’ve talked about in this podcast many, many times is, that it ends up kicking off people for bureaucratic reasons. It’s a way to reduce the rolls. It doesn’t necessarily encourage work. 

But to the average bear, it sounds great. Yes, absolutely. Why wouldn’t we want more people working? So I do think there is some messaging there, but at the end of the day, like Alice said, like I pointed out, they have not figured out the messaging enough, and it is going to add insult to injury to imply to some of these folks that they did not deserve their health care. 

Ollstein: And what’s really baffling is they are running around saying that Medicaid is going to people who should never have been on the program in the first place, able-bodied people without children who are not too young and not too old, sort of implying that these people are enrolling against the wishes of the program’s creators. 

But Congress explicitly voted for these people to be eligible for the program. And then after the Supreme Court made it optional, all of these states, most states, voted either by a direct popular vote or through the legislature to extend Medicaid to this population. And now they’re turning around and saying they were never supposed to be on it in the first place. We didn’t get here by accident or fraud. 

Rovner: Or by executive order. 

Ollstein: Exactly. 

Rovner: Well, even before the Senate digs in, there’s still a lot of stuff that got packed into that House bill, some of it at the last minute that most people still aren’t aware of. And I’m not talking about [Rep.] Marjorie Taylor Greene and AI, although that, too, among other things. And shout out here to our podcast panelist Maya Goldman over at Axios. The bill would reduce the amount of money medical students could borrow, threatening the ability of people to train to become doctors, even while the nation is already suffering a doctor shortage. 

It would also make it harder for medical residents to pay their loans back and do a variety of other things. The idea behind this is apparently to force medical schools to lower their tuition, which would be nice, but this feels like a very indirect way of doing it. 

Weber: I just don’t think it’s very popular in an era in which we’re constantly talking about physician shortages and encouraging folks that are from minority communities or underserved communities to become primary care physicians or infectious disease physicians, to go to the communities that need them, that reflect them, to then say, Look, we’re going to cut your loans. And what that’s going to do — short of RFK [Robert F. Kennedy Jr.], who has toyed with playing with the code. So who knows? We could see. 

But as the current structure stands, here’s the deal: You have a lot of medical debt. You are incentivized to go into a more lucrative specialty. That means that you’re not going into primary care. You’re not going into infectious disease care. You’re not going to rural America, because they can’t pay you what it costs to repay all of your loans. So, I do think — and, it was interesting. I think the Guardian spoke to some of the folks from the study that said that this could change it. That study was based off of metrics from 2006, and for some reason they were like, The financial private pay loans are not really going to cut it today. 

I find it hard to believe this won’t get fixed, to be quite honest, just because I think hating on medical students is usually a losing battle in the current system. But who knows? 

Rovner: And hospitals have a lot of clout. 

Weber: Yeah. 

Rovner: Although there’s a lot of things in this bill that they would like to fix. And, I don’t know. Maybe— 

Weber: Well, and hospitals have a lot of financial incentive, because essentially they make medical residents indentured servants. So, yeah, they also would like them to have less loans. 

Rovner: As I mentioned earlier, Elon Musk has decamped from DOGE, but in his wake is a lot of disruption at the Department of Health and Human Services and not necessarily a lot of savings. Thousands of federal workers are still in limbo on administrative leave, to possibly be reinstated or possibly not, with no one doing their jobs in the meantime. Those who are still there are finding their hands tied by a raft of new rules, including the need to get a political-appointee sign-off for even the most routine tasks. 

And around the country, thousands of scientific grants and contracts have been summarily frozen or terminated for no stated cause, as the administration seeks to punish universities for a raft of supposed crimes that have nothing to do with what’s being studied. I know that it just happened, but how is DOGE going to be remembered? I imagine not for all of the efficiencies that it has wrung out of the health care system. 

Ollstein: Well, one, I wouldn’t be so sure things are over, either between Elon and the Trump administration or what the amorphous blob that is DOGE. I think that the overall slash-and-burn of government is going to continue in some form. They are trying to formalize it by sending a bill to Congress to make these cuts, that they already made without Congress’ permission, official. We’ll see where that goes, but I think that it’s not an ending. It’s just morphing into whatever its next iteration is. 

Rovner: I would note that the first rescission request that the administration has sent up formally includes getting rid of USAID [the U.S. Agency for International Development] and PEPFAR [the President’s Emergency Plan for AIDS Relief] and public broadcasting, which seems unlikely to garner a majority in both houses. 

Ollstein: Except, like I said, this is asking them to rubber-stamp something they’re already trying to do without them. Congress doesn’t like its power being infringed on, especially appropriators. They guard that power very jealously. Now, we have seen them a little quieter in this administration than maybe you would’ve thought, but I think there are some who, even if they agree on the substance of the cuts, might object to the process and just being asked to rubber-stamp it after the fact. 

Rovner: Well, meanwhile, Health and Human Services Secretary Kennedy continues to try to remake what’s left of HHS, although his big reorganization is currently blocked by a federal judge. And it turns out that his big MAHA, “Make America Healthy Again,” report may have been at least in part written by AI, which apparently became obvious when the folks at the news service NOTUS decided to do something that was never on my reporting bingo card, which is to check the footnotes in the report to see if they were real, which apparently many are not. Then, Lauren, you and your colleagues took that yet another step. So tell us about that. 

Weber: Yeah. NOTUS did a great job. They went through all the footnotes to find out that several of the studies didn’t exist, and my colleagues and I saw that and said, Hm, let’s look a little closer at these footnotes and see. And what we were able to do in speaking with AI experts is find telltale signs of AI. It’s basically a sign of artificial intelligence when things are hallucinated — which is what they call it — which is when it sounds right but isn’t completely factual, which is one of the dangers of using AI. 

And it appears that some of AI was used in the footnotes of this MAHA report, again, to, as NOTUS pointed out, create studies that don’t exist. It also kind of garbled some of the science on the other pieces of this. We found something called “oaicite,” which is a marker of OpenAI system, throughout the report. And at the end of the day, it casts a lot of questions on the report as a whole and: How exactly did it get made? What is the science behind this report? 

And even before anyone found any of these footnotes of any of this, a fair amount of these studies that this report cites to back up its thesis are a stretch. Even putting aside the fake studies and the garbled studies, I think it’s important to also note that a lot of the studies the report cites, a lot of what Kennedy does, take it a lot further than what they actually say. 

Rovner: So, this is all going well. Meanwhile, there is continuing confusion in vaccine land after Secretary Kennedy, flanked by FDA [Food and Drug Administration] Commissioner Marty Makary and NIH [National Institutes of Health] Director Jay Bhattacharya, announced in a video on X that the department would no longer recommend covid vaccines for pregnant women and healthy children, sidestepping the expert advice of the Centers for Disease Control and Prevention and its advisory committee of experts. 

The HHS officials say people who may still be at risk can discuss whether to get the vaccine with their doctors, but if the vaccines are no longer on the recommended list, then insurance is less likely to cover them and medical facilities are less likely to stock them. Paging Sen. [Bill] Cassidy, who still, as far as I can tell, hasn’t said anything about the secretary’s violation of his promise to the senator during his confirmation hearings that he wouldn’t mess with the vaccine schedule. Have we heard a peep from Sen. Cassidy about any of this? 

Ollstein: I have not, but a lot of the medical field has been very vocal and very upset. I was actually at the annual conference of the American College of Obstetricians and Gynecologists when this news broke, and they were just so confused and so upset. They had seen pregnant patients die of covid before the vaccines were available, or because there was so much misinformation and mistrust about the vaccines’ safety for pregnant people that a lot of people avoided it, and really suffered the consequences of avoiding it. 

A lot of the issue was that there were not good studies of the vaccine in pregnant people at the beginning of the rollout. There have since been, and those studies have since shown that it is safe and effective for pregnant people. But it was, in a lot of people’s minds, too late, because they already got it in their head that it was unsafe or untested. So the OB-GYNs at this conference were really, really worried about this. 

Rovner: And, confusingly, the CDC on its website amended its recommendations to leave children recommended but not pregnant women, which is kind of the opposite of, I think, what most of the medical experts were recommending. Jessie, you were about to add something. 

Hellmann: I just feel like the confusion is the point. I think Kennedy has made it a pattern now to get out ahead of an official agency decision and kind of set the narrative, even if it is completely opposite of what his agencies are recommending or are stating. He’s done this with a report that the CDC came out with autism, when he said rising autism cases aren’t because of more recognition and the CDC report said it’s a large part because of more recognition. 

He’s done this with food dyes. He said, We’re banning food dyes. And then it turns out they just asked manufacturers to stop putting food dyes into it. So I think it’s part of, he’s this figurehead of the agency and he likes to get out in front of it and just state something as fact, and that is what people are going to remember, not something on a CDC webpage that most people aren’t going to be able to find. 

Rovner: Yeah, it sounds like President Trump. It’s like, saying it is more important than doing it, in a lot of cases. So of course there’s abortion news this week, too. The Trump administration on Tuesday reversed the Biden administration guidance regarding EMTALA, the Emergency Medical Treatment and Active Labor Act. Biden officials, in the wake of the overturn of Roe v. Wade three years ago, had reminded hospitals that take Medicare and Medicaid, which is all of them, basically, that the requirement to provide emergency care includes abortion when warranted, regardless of state bans. Now, Alice, this wasn’t really unexpected. In fact, it’s happening later than I think a lot of people expected it to happen. How much impact is it going to have, beyond a giant barrage of press releases from both sides in the abortion debate? 

Ollstein: Yeah, so, OK, it’s important for people to remember that what the Biden administration, the guidance they put out was just sort of an interpretation of the underlying law. So the underlying law isn’t changing. The Biden administration was just saying: We are stressing that the underlying law means in the abortion context, in the post-Dobbs context, blah, blah, blah, blah, blah, that hospitals cannot turn away a pregnant woman who’s having a medical crisis. And if the necessary treatment to save her life or stabilize her is an abortion, then that’s what they have to do, regardless of the laws in the state. 

In a sense, nothing’s changed, because EMTALA itself is still in place, but it does send a signal that could make hospitals feel more comfortable turning people away or denying treatment, since the government is signaling that they don’t consider that a violation. Now, I will say, you’re totally right that this was expected. In the big lawsuit over this that is playing out now in Idaho, one of the state’s hospitals intervened as a plaintiff, basically in anticipation of this happening, saying, The Trump administration might not defend EMTALA in the abortion context, so we’re going to do it for them, basically, to keep this case alive. 

Rovner: And I would point out that ProPublica just won a Pulitzer for its series detailing the women who were turned away and then died because they were having pregnancy complications. So we do know that this is happening. Interestingly, the day before the administration’s announcement, the American College of Obstetricians and Gynecologists put out a new, quote, “practice advisory” on the treatment of preterm pre-labor rupture of membranes, which is one of the more common late-pregnancy complications that result in abortion, because of the risk of infection to the pregnant person. 

Reading from that guidance, quote, “the Practice Advisory affirms that ob-gyns and other clinicians must be able to intervene and, in cases of previable and periviable PPROM” — that’s the premature rupture of membranes — “provide abortion care before the patient becomes critically ill.” Meanwhile, this statement came out Wednesday from the American College of Emergency Physicians, quote, ,“Regardless of variances in the regulatory landscape from one administration to another, emergency physicians remain committed not just by law, but by their professional oath, to provide this care.” 

So on the one hand, professional organizations are speaking out more strongly than I think we’ve seen them do it before, but they’re not the ones that are in the emergency room facing potential jail time for, Do I obey the federal law or do I obey the state ban? 

Ollstein: And when I talk to doctors who are grappling with this, they say that even with the Biden administration’s interpretation of EMTALA, that didn’t solve the problem for them. It was some measure of protection and confidence. But still, exactly like you said, they’re still caught in between seemingly conflicting state and federal law. And really a lot of them, based on what they told me, were saying that the threat of the state law is more severe. It’s more immediate. 

It means being charged with a felony, being charged with a crime if they do provide the abortion, versus it’s a federal penalty, it’s not on the doctor itself. It’s on the institution. And it may or may not happen at some point. So when you have criminal charges on one side and maybe some federal regulation or an investigation on the other side, what are you going to choose? 

Rovner: And it’s hard to imagine this administration doing a lot of these investigations. They seem to be turning to other things. Well, we will watch this space, and obviously this is all still playing out in court. All right, that is this week’s news, or at least as much as we could squeeze in. Now we’ll play my “Bill of the Month” interview with Arielle Zionts, and then we’ll come back and do our extra credits. 

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

Arielle Zionts: Hi. Thanks for having me. 

Rovner: So this month’s patient has Medicaid as his health insurance, and he left his home state of Florida to visit family in South Dakota for the holidays, where he had a medical emergency. Tell us who he is and what happened that landed him in the hospital. 

Zionts: Sure. So I spoke with Hans Wirt. He was visiting family in the Black Hills. That’s where Mount Rushmore is and its beautiful outdoors. He was at a water park, following his son up and down the stairs and getting kind of winded. And at first he thought it might just be the elevation difference, because in Florida it’s like 33 feet above sea level. Here it’s above 3,000 in Rapid City. 

But then they got him back to the hotel room and he was getting a lot worse, his breathing, and then he turned pale. And his 12-year-old son is the one who called 911. And medics were like, Yep, you’re having a heart attack. And they took him to the hospital in town, and that is the only place to go. There’s just one hospital with an ER in Rapid City. 

Rovner: So the good news is that he was ultimately OK, but the bad news is that the hospital tried to stick them with the bill. How big was it? 

Zionts: It was nearly $78,000. 

Rovner: Wow. So let’s back up a bit. How did Mr. Wirt come to be on Medicaid? 

Zionts: Yeah. So it is significant that he is from Florida, because that is one of the 10 states that has not opted in to expand Medicaid. So in Florida, if you’re an adult, you can’t just be low-income. You have to also be disabled or caring for a minor child. And Hans says that’s his case. He works part time at a family business, but he also cares for his 12-year-old son, who is also on Medicaid. 

Rovner: So Medicaid patients, as we know, are not supposed to be charged even small copays for care in most cases. Is that still the case when they get care in other states? 

Zionts: So Medicaid will not pay for patient care if they are getting more of an elective or non-medically necessary kind of optional procedure or care in another state. But there are several exceptions, and one of the exceptions is if they have an emergency in another state. So federal law says that state Medicaid programs have to reimburse those hospitals if it was for emergency care. 

Rovner: And presumably a heart attack is an emergency. 

Zionts: Yes. 

Rovner: So why did the hospital try to bill him anyway? They should have billed Florida Medicaid, right? 

Zionts: So what’s interesting is while there’s a law that says the Medicaid program has to reimburse the hospital, there’s no law saying the hospital has to send the bill to Medicaid. And that was really interesting to learn. In this case, the hospital, it’s called Monument Health, and they said they only bill plans in South Dakota and four of our bordering states. So basically they said for them to bill for the Medicaid, they would have to enroll. 

And they say they don’t do that in every state, because there is a separate application process for each state. And their spokesperson described it as a burdensome process. So in this case, they billed Hans instead. 

Rovner: So what eventually happened with this bill? He presumably didn’t have $78,000 to spare. 

Zionts: Correct. Yeah. And he had told them that, and he said they only offered, Hey, you can set up a payment plan. But that would’ve still been really expensive, the monthly payments. So he reached out to KFF Health News, and I had sent my questions to the hospital, and then a few days later I get a text from Hans and he says, Hey, my balance is at zero now. He and I both eventually learned that that’s because the hospital paid for his care through a program called Charity Care. 

All nonprofit hospitals are required to have this program, which provides free or very discounted pricing for patients who are uninsured or very underinsured. And the hospital said that they screen everyone for this program before sending them to collections. But what that meant is that for months, Hans was under the impression that he was getting this bill. And he was, got a notice saying, This is your last warning before we send you to collection. 

Rovner: So, maybe they would’ve done it anyway, or maybe you gave them a nudge. 

Zionts: They say they would’ve done it anyways. 

Rovner: OK. So what’s the takeaway here? It can’t be that if you have Medicaid, you can’t travel to another state to visit family at Christmas. 

Zionts: Right. So Hans made that same joke. He said, quote, “If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state.” Obviously, he’s kidding. You can’t control when you have an emergency. So the takeaway is that you do risk being billed and that if you don’t know how to advocate yourself, you might get sent to collections. But I also learned that there’s things that you can do. 

So you could file a complaint with your state Medicaid program, and also, if you have a managed-care program, and they might have — you should ask for a caseworker, like, Hey, can you communicate with the hospital? Or you can contact an attorney. There’s free legal-aid ones. An attorney I spoke with said that she would’ve immediately sent a letter to the hospital saying, Look, you need to either register with Florida Medicaid and submit it. If not, you need to offer the Charity Care. So that’s the advice. 

Rovner: So, basically, be ready to advocate for yourself. 

Zionts: Yes. 

Rovner: OK. Arielle Zionts, thank you so much. 

Zionts: Thank you. 

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

Hellmann: My story is from The New York Times. It’s called “A [DNA] Technique Is Finding Women Who Left Their Babies for Dead,” which I don’t know how I feel about that headline, but the story was really interesting. It’s about how police departments are using DNA technology to find the mothers of infants that had been found dead years and years ago. And it gets a little bit into just the complicated situation. 

Some of these women have gone on to have families. They have successful careers. And now some of them are being charged with murder, and some who have been approached about this have unfortunately died by suicide. And it just gets into the ethics of the issue and what police and doctors, families, should be considering about the context around some of these situations, about what the circumstances were, in some cases, 40 years ago and what should be done with that. 

Rovner: Really thought-provoking story. Lauren. 

Weber: With credit to Julie, too, because she brought this up again, was brought back to a classic from The New York Times back in 2020, which is called “Take a Quiz: Could You Manage as a Poor American?” And here are the questions: I will read them for the group. 

Rovner: And I will point out that this is once again relevant. That’s why it was brought back. 

Weber: It’s once again relevant, and one of them is, “Do you have paper mail you plan to read that has been unopened for more than a week?” Yes. I’m looking at paper mail on my desk. “Have you forgotten to pay a utility bill on time?” If I didn’t set up auto pay, I probably would forget to pay a utility bill on time. “Have you received a government document in the mail that you did not understand?” Many times. “Have you missed a doctor’s appointment because you forgot you scheduled it or something came up?” 

These are the basic facts that can derail someone from having access to health care or saddle them, because they lose access to health care and don’t realize it, with massive hospital bills. And this is a lot of what we could see in the coming months if some of these Medicaid changes come through. And I just, I think I would challenge a lot of people to think seriously about how much mail they leave unopened and what that could mean for them, especially if you are living in different homes, if you are moving frequently, etc. This paperwork burden is something to definitely be considered. 

Rovner: Yeah, I think we should sort of refloat this every time we have another one of these debates. Alice. 

Ollstein: So I wanted to recommend something I wrote [“‘They’re the Backbone’: Trump’s Targeting of Legal Immigrants Threatens Health Sector”]. It was my last story before taking some time off this summer. It is about the intersection of Trump’s immigration policies and our health care system. And so this is jumping off the Supreme Court allowing the Trump administration to strip legal status from hundreds of thousands of immigrants. Again, these are people who came legally through a designated program, and they are being made undocumented by the Trump administration, with the Supreme Court’s blessing. And tens of thousands of them are health care workers. 

And so I visited an elder care facility in Northern Virginia that was set to lose 65 staff members, and I talked to the residents and the other workers about how this would affect them, and the owner. And it was just a microcosm of the damage this could have on our health sector more broadly. Elder care is especially immigrant-heavy in its workforce, and everyone there was saying there just are not the people to replace these folks. 

And not only is that the case right now, but as the baby boomer generation ages and requires care, the shortages we see now are going to be nothing compared to what we could see down the road. With the lower birth rates here, we’re just not producing enough workers to do these jobs. The piece also looks into how public health and management of infectious diseases is also being worsened by these immigration raids and crackdowns and deportations. So, would love people to take a look. 

Rovner: I’m so glad you did this story, because it’s something that I keep running up and down screaming. And you can tell us why you’re taking some time off this summer, Alice. 

Ollstein: I’m writing a book. Hopefully it will be out next year, and I can’t wait to tell everyone more about it. 

Rovner: Excellent. All right. My extra credit this week is from my KFF Health News colleagues Katheryn Houghton, Jazmin Orozco Rodriguez, and Arielle Zionts, who you just heard talking about her “Bill of the Month,” and it’s called “Native Americans Hurt by Federal Health Cuts, Despite RFK Jr.’s Promises of Protection.” And that sums it up pretty well. The HHS secretary had a splashy photo op earlier this year out west, where he promised to prioritize Native American health. But while he did spare the Indian Health Service from personnel cuts, it turns out that the Native American population is also served by dozens of other HHS programs that were cut, some of them dramatically, everything from home energy assistance to programs that improve access to healthy food, to preventing overdoses. The Native community has been disproportionately hurt by the purging of DEI [diversity, equity, and inclusion] programs, because Native populations have systematically been subjected to unequal treatment over many generations. It’s a really good if somewhat infuriating story. 

OK. That is this week’s show. Before we go, if you will indulge me for a minute, this is our 400th episode of “What the Health?” We launched in 2017 during that year’s repeal-and-replace debate. I want to thank all of my panelists, current and former, for teaching me something new every single week. And everyone here at KFF Health News who makes this podcast possible. That includes not only my chief partners in crime, Francis Ying and Emmarie Huetteman, but also the copy desk and social media and web teams who do all the behind-the-scenes work that brings our podcast to you every week. And of course, big thanks to you, the listeners, who have stuck with us all these years. 

I won’t promise you 400 more episodes, but I will keep doing this as long as you keep wanting it. As always, 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. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks these days? Jessie? 

Hellmann: @jessiehellmann on X and Bluesky, and LinkedIn. 

Rovner: Lauren. 

Weber: I’m @LaurenWeberHP on X and on Bluesky, shockingly, now. 

Rovner: Alice. 

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

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

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Wirt’s breathing became more labored once they returned to the nearby hotel where they and Wirt’s girlfriend were staying while visiting family in Rapid City, South Dakota.

Then he grew nauseated and went pale. Wirt thought the cause might have been the altitude change between his home in Deltona, Florida — 33 feet above sea level — and Rapid City, at the edge of the Black Hills. But his 12-year-old son was worried and called for an ambulance.

“I could tell by the look in his eyes that there was something a little more to this,” Wirt said. “So I can kind of thank my son for saving my life.”

It turned out the 62-year-old was having a heart attack. A “lousy Christmas present,” Wirt said.

Medics stabilized Wirt before taking him to Monument Health — the only hospital in Rapid City with an emergency room — where he was treated over two days.

Then the bill came.

The Medical Procedure

Paramedics used a defibrillator to restore a normal heart rhythm. Doctors at the hospital gave Wirt various medications, used an electrocardiograph and other diagnostic and monitoring devices, and inserted stents into his arteries to improve blood flow to his heart.

The Final Bill

$95,523.73, including $32,998.90 for medical supplies, mostly related to the stents, and $28,879 for treatment in a cardiac catheterization lab. After unspecified hospital adjustments to the bill, Wirt owed $77,574.44.

The Billing Problem: Medicaid Across State Lines

Wirt is covered by Florida’s Medicaid program through Sunshine Health, a managed-care plan. But the South Dakota hospital refused to submit the bill to his out-of-state Medicaid plan, instead sending it to Wirt and eventually threatening to send the debt to a collection agency.

Medicaid, the government health insurance program primarily for low-income people and those with disabilities, is jointly funded by the federal government and states. States are responsible for administering Medicaid, and most contract with private insurance companies like Sunshine Health.

Federal law says state Medicaid programs must reimburse out-of-state hospitals for beneficiaries’ care in an emergency.

Many hospitals bill out-of-state Medicaid plans in such situations. If they don’t, they risk not being reimbursed at all, since Medicaid recipients probably won’t be able to afford large bills, said Katy DeBriere, who was legal director for the Florida Health Justice Project when she spoke with KFF Health News in April.

But there’s no federal law that requires them to do so, she said.

Federal court opinions have noted that hospitals are not required to bill Medicaid for every individual beneficiary they treat, even if they generally accept Medicaid.

Monument Health didn’t bill Wirt’s insurance because the hospital isn’t enrolled as a health care provider with Florida Medicaid, said hospital spokesperson Stephany Chalberg. She told KFF Health News that Monument bills Medicaid plans only in South Dakota and four bordering states: Wyoming, Montana, Nebraska, and Minnesota.

The hospital’s website says Medicaid patients who are not enrolled in one of those states “are responsible for any charges.”

“Due to the significant credentialing requirements of our multiple hospitals and hundreds of physicians we do not participate with all states,” a hospital representative wrote in a message to Wirt.

According to Florida’s Medicaid website, out-of-state providers who have treated one of its enrollees must submit five documents to bill the program, including a six-page application, a copy of the provider’s license, and a claim form.

The process is different in each state, and many Medicaid programs reimburse out-of-state providers at lower rates than those that are in-state, according to the Medicaid and CHIP Payment and Access Commission, a federal agency that advises Congress.

More from this series

• The Patient Expected a Free Checkup. The Bill Was $1,430. Apr 30, 2025
• He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000. Mar 28, 2025
• A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill Feb 28, 2025

Provider enrollment barriers leave “beneficiaries in an untenable situation, preventing them from accessing the coverage to which they are legally entitled,” Chalberg said.

Wirt decided to submit his bill to his Medicaid plan on his own. But he said Sunshine Health told him it can only process bills received directly from providers.

Elizabeth Boyd, a spokesperson for Sunshine Health, told KFF Health News that its staff contacted the hospital on Wirt’s behalf. She did not respond when asked why the plan can’t process bills submitted by patients or what more it could have done to help Wirt.

The Resolution

A few days after KFF Health News emailed officials at Monument Health for this story, Wirt noticed his balance due fell from more than $77,000 to $0.

Chalberg told KFF Health News that Monument Health covered Wirt’s bill through its charity care program. She said that “appropriate patients” are told about the program and that “before any bill is sent to collections, it is evaluated to determine whether the patient may qualify for our financial assistance policy.”

To retain tax-exempt status, nonprofit hospitals must have programs that provide free or discounted care to patients who can’t afford their bills.

But Wirt said that when he first contacted Monument Health after receiving his bill and said he couldn’t afford to pay it, officials didn’t mention the program. He said they didn’t share any resources when he asked whether there were outside groups that could help him pay the bill. Wirt said hospital officials just recommended setting up a payment plan, but the monthly bills were still too high for him to afford. “There’s a reason why I’m on Medicaid,” Wirt said. “It’s just beyond me how they can expect somebody who had Medicaid to come up with that kind of money. It’s unrealistic.”

The Takeaway

Sarah Somers, legal director at the National Health Law Program, said the various “cogs in the Medicaid system” didn’t operate correctly in Wirt’s situation. “Nobody’s exerting themselves enough to just smooth the way for this person.”

States are responsible for managing Medicaid and are therefore the main “cog,” Somers said. She said Medicaid managed-care companies are also supposed to intervene.

Somers and DeBriere said Medicaid recipients who receive bills they don’t think they owe should file a complaint with their state’s Medicaid program and, if they have one, their managed-care plan. They can also ask whether there is a Medicaid or managed-care caseworker who can advocate on their behalf.

The attorneys said patients should also contact a legal aid clinic or a consumer protection firm that specializes in medical debt. DeBriere said those organizations can help file complaints and communicate with the hospital.

DeBriere said that, had she assisted Wirt, she would have immediately sent a letter to Monument Health ordering it to stop billing him and to either register with Florida Medicaid to submit his bill or offer him charity care.

Wirt said the doctors who treated him and the medical care he received at Monument Health were excellent. He said he spoke out about the hospital’s billing practices because he doesn’t want others to endure the same experience.

“If I get sick and have a heart attack, I have to be sure that I do that here in Florida now instead of some other state,” he joked.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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After narrowly passing a budget resolution this spring foreshadowing major Medicaid cuts, Republicans in Congress are having trouble agreeing on specific ways to save billions of dollars from a pool of funding that pays for the program without cutting benefits on which millions of Americans rely. Moderates resist changes they say would harm their constituents, while fiscal conservatives say they won’t vote for smaller cuts than those called for in the budget resolution. The fate of President Donald Trump’s “one big, beautiful bill” containing renewed tax cuts and boosted immigration enforcement could hang on a Medicaid deal.

Meanwhile, the Trump administration surprised those on both sides of the abortion debate by agreeing with the Biden administration that a Texas case challenging the FDA’s approval of the abortion pill mifepristone should be dropped. It’s clear the administration’s request is purely technical, though, and has no bearing on whether officials plan to protect the abortion pill’s availability.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sandhya Raman of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• Congressional Republicans are making halting progress on negotiations over government spending cuts. As hard-line House conservatives push for deeper cuts to the Medicaid program, their GOP colleagues representing districts that heavily depend on Medicaid coverage are pushing back. House Republican leaders are eying a Memorial Day deadline, and key committees are scheduled to review the legislation next week — but first, Republicans need to agree on what that legislation says.
• Trump withdrew his nomination of Janette Nesheiwat for U.S. surgeon general amid accusations she misrepresented her academic credentials and criticism from the far right. In her place, he nominated Casey Means, a physician who is an ally of HHS Secretary Robert F. Kennedy Jr.’s and a prominent advocate of the “Make America Healthy Again” movement.
• The pharmaceutical industry is on alert as Trump prepares to sign an executive order directing agencies to look into “most-favored-nation” pricing, a policy that would set U.S. drug prices to the lowest level paid by similar countries. The president explored that policy during his first administration, and the drug industry sued to stop it. Drugmakers are already on edge over Trump’s plan to impose tariffs on drugs and their ingredients.
• And Kennedy is scheduled to appear before the Senate’s Health, Education, Labor and Pensions Committee next week. The hearing would be the first time the secretary of Health and Human Services has appeared before the HELP Committee since his confirmation hearings — and all eyes are on the committee’s GOP chairman, Sen. Bill Cassidy of Louisiana, a physician who expressed deep concerns at the time, including about Kennedy’s stances on vaccines.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who co-reported and co-wrote the latest KFF Health News’ “Bill of the Month” installment, about an unexpected bill for what seemed like preventive care. If you have an outrageous, baffling, or infuriating medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: NPR’s “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured,” by Andrea Hsu. 

Maya Goldman: Stat’s “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. 

Anna Edney: Bloomberg News’ “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare,” by Zachary R. Mider and Zeke Faux. 

Sandhya Raman: The Louisiana Illuminator’s “In the Deep South, Health Care Fights Echo Civil Rights Battles,” by Anna Claire Vollers. 

Also mentioned in this week’s podcast:

• ProPublica’s series “Life of the Mother: How Abortion Bans Lead to Preventable Deaths,” by Kavitha Surana, Lizzie Presser, Cassandra Jaramillo, and Stacy Kranitz, and the winner of the 2025 Pulitzer Prize for public service journalism.
• The New York Times’ “G.O.P. Targets a Medicaid Loophole Used by 49 States To Grab Federal Money,” by Margot Sanger-Katz and Sarah Kliff.
• KFF Health News’ “Seeking Spending Cuts, GOP Lawmakers Target a Tax Hospitals Love to Pay,” by Phil Galewitz.
• Axios’ “Out-of-Pocket Drug Spending Hit $98B in 2024: Report,” by Maya Goldman.

[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 Thursday, May 8, 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 a videoconference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everybody. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: Later in this episode we’ll have my “Bill of the Month” interview with my KFF Health News colleague Lauren Sausser. This month’s patient got preventive care they assumed would be covered by their Affordable Care Act health plan, except it wasn’t. But first, this week’s news. 

We’re going to start on Capitol Hill, where Sandhya is coming directly from, where regular listeners to this podcast will be not one bit surprised that Republicans working on President [Donald] Trump’s one “big, beautiful” budget reconciliation bill are at an impasse over how and how deeply to cut the Medicaid program. Originally, the House Energy and Commerce Committee was supposed to mark up its portion of the bill this week, but that turned out to be too optimistic. Now they’re shooting for next week, apparently Tuesday or so, they’re saying, and apparently that Memorial Day goal to finish the bill is shifting to maybe the Fourth of July? But given what’s leaking out of the closed Republican meetings on this, even that might be too soon. Where are we with these Medicaid negotiations? 

Raman: I would say a lot has been happening, but also a lot has not been happening. I think that anytime we’ve gotten any little progress on knowing what exactly is at the top of the list, it gets walked back. So earlier this week we had a meeting with a lot of the moderates in Speaker [Mike] Johnson’s office and trying to get them on board with some of the things that they were hesitant about, and following the meeting, Speaker Johnson had said that two of the things that have been a little bit more contentious — changing the federal match for the expansion population and instituting per capita caps for states — were off the table. But the way that he phrased it is kind of interesting in that he said stay tuned and that it possibly could change. 

And so then yesterday when we were hearing from the Energy and Commerce Committee, it seemed like these things are still on the table. And then Speaker Johnson has kind of gone back on that and said, I said it was likely. So every time we kind of have any sort of change, it’s really unclear if these things are in the mix, outside the mix. When we pulled them off the table, we had a lot of the hard-line conservatives get really upset about this because it’s not enough savings. So I think any way that you push it with such narrow margins, it’s been difficult to make any progress, even though they’ve been having a lot of meetings this week. 

Rovner: One of the things that surprised me was apparently the Senate Republicans are weighing in. The Senate Republicans who aren’t even set to make Medicaid cuts under their version of the budget resolution are saying that the House needs to go further. Where did that come from? 

Raman: It’s just been a difficult process to get anything across. I mean, in the House side, a lot of it has been, I think, election-driven. You see the people that are not willing to make as many concessions are in competitive districts. The people that want to go a little bit more extreme on what they’re thinking are in much more safe districts. And then in the Senate, I think there’s a lot more at play just because they have longer terms, they have more to work with. So some of the pushback has been from people that it would directly affect their states or if the governors have weighed in. But I think that there are so many things that they do want to get done, since there is much stronger agreement on some of the immigration stuff and the taxes that they want to find the savings somewhere. If they don’t find it, then the whole thing is moot. 

Rovner: So meanwhile, the Congressional Budget Office at the request of Democrats is out with estimates of what some of these Medicaid options would mean for coverage, and it gives lie to some of these Republican claims that they can cut nearly a trillion dollars from Medicaid without touching benefits, right? I mean all of these — and Maya, your nodding. 

Goldman: Yeah. 

Rovner: All of these things would come with coverage losses. 

Goldman: Yeah, I think it’s important to think about things like work requirements, which has gotten a lot of support from moderate Republicans. The only way that that produces savings is if people come off Medicaid as a result. Work requirements in and of themselves are not saving any money. So I know advocates are very concerned about any level of cuts. I talked to somebody from a nursing home association who said: We can’t pick and choose. We’re not in a position to pick and choose which are better or worse, because at this point, everything on the table is bad for us. So I think people are definitely waiting with bated breath there. 

Rovner: Yeah, I’ve heard a lot of Republicans over the last week or so with the talking points. If we’re just going after fraud and abuse then we’re not going to cut anybody’s benefits. And it’s like — um, good luck with that. 

Goldman: And President Trump has said that as well. 

Rovner: That’s right. Well, one place Congress could recoup a lot of money from Medicaid is by cracking down on provider taxes, which 49 of the 50 states use to plump up their federal Medicaid match, if you will. Basically the state levies a tax on hospitals or nursing homes or some other group of providers, claims that money as their state share to draw down additional federal matching Medicaid funds, then returns it to the providers in the form of increased reimbursement while pocketing the difference. You can call it money laundering as some do, or creative financing as others do, or just another way to provide health care to low-income people. 

But one thing it definitely is, at least right now, is legal. Congress has occasionally tried to crack down on it since the late 1980s. I have spent way more time covering this fight than I wish I had, but the combination of state and health provider pushback has always prevented it from being eliminated entirely. If you want a really good backgrounder, I point you to the excellent piece in The New York Times this week by our podcast pals Margot Sanger-Katz and Sarah Kliff. What are you guys hearing about provider taxes and other forms of state contributions and their future in all of this? Is this where they’re finally going to look to get a pot of money? 

Raman: It’s still in the mix. The tricky thing is how narrow the margins are, and when you have certain moderates having a hard line saying, I don’t want to cut more than $500 billion or $600 billion, or something like that. And then you have others that don’t want to dip below the $880 billion set for the Energy and Commerce Committee. And then there are others that have said it’s not about a specific number, it’s what is being cut. So I think once we have some more numbers for some of the other things, it’ll provide a better idea of what else can fit in. Because right now for work requirements, we’re going based on some older CBO [Congressional Budget Office] numbers. We have the CBO numbers that the Democrats asked for, but it doesn’t include everything. And piecing that together is the puzzle, will illuminate some of that, if there are things that people are a little bit more on board with. But it’s still kind of soon to figure out if we’re not going to see draft text until early next week. 

Goldman: I think the tricky thing with provider taxes is that it’s so baked into the way that Medicaid functions in each state. And I think I totally co-sign on the New York Times article. It was a really helpful explanation of all of this, and I would bet that you’ll see a lot of pushback from state governments, including Republicans, on a proposal that makes severe changes to that. 

Rovner: Someday, but not today, I will tell the story of the 1991 fight over this in which there was basically a bizarre dealmaking with individual senators to keep this legal. That was a year when the Democrats were trying to get rid of it. So it’s a bipartisan thing. All right, well, moving on. 

It wouldn’t be a Thursday morning if we didn’t have breaking federal health personnel news. Today was supposed to be the confirmation hearing for surgeon general nominee and Fox News contributor Janette Nesheiwat. But now her nomination has been pulled over some questions about whether she was misrepresenting her medical education credentials, and she’s already been replaced with the nomination of Casey Means, the sister of top [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] aide Calley Means, who are both leaders in the MAHA [“Make America Healthy Again”] movement. This feels like a lot of science deniers moving in at one time. Or is it just me? 

Edney: Yeah, I think that the Meanses have been in this circle, names floated for various things at various times, and this was a place where Casey Means fit in. And certainly she espouses a lot of the views on, like, functional medicine and things that this administration, at least RFK Jr., seems to also subscribe to. But the one thing I’m not as clear on her is where she stands with vaccines, because obviously Nesheiwat had fudged on her school a little bit, and— 

Rovner: Yeah, I think she did her residency at the University of Arkansas— 

Edney: That’s where. 

Rovner: —and she implied that she’d graduated from the University of Arkansas medical school when in fact she graduated from an accredited Caribbean medical school, which lots of doctors go to. It’s not a sin— 

Edney: Right. 

Rovner: —and it’s a perfectly, as I say, accredited medical school. That was basically — but she did fudge it on her resume. 

Edney: Yeah. 

Rovner: So apparently that was one of the things that got her pulled. 

Edney: Right. And the other, kind of, that we’ve seen in recent days, again, is Laura Loomer coming out against her because she thinks she’s not anti-vaccine enough. So what the question I think to maybe be looking into today and after is: Is Casey Means anti-vaccine enough for them? I don’t know exactly the answer to that and whether she’ll make it through as well. 

Rovner: Well, we also learned this week that Vinay Prasad, a controversial figure in the covid movement and even before that, has been named to head the FDA [Food and Drug Administration] Center for Biologics and Evaluation Research, making him the nation’s lead vaccine regulator, among other things. Now he does have research bona fides but is a known skeptic of things like accelerated approval of new drugs, and apparently the biotech industry, less than thrilled with this pick, Anna? 

Edney: Yeah, they are quite afraid of this pick. You could see it in the stocks for a lot of vaccine companies, for some other companies particularly. He was quite vocal and quite against the covid vaccines during covid and even compared them to the Nazi regime. So we know that there could be a lot of trouble where, already, you know, FDA has said that they’re going to require placebo-controlled trials for new vaccines and imply that any update to a covid vaccine makes it a new vaccine. So this just spells more trouble for getting vaccines to market and quickly to people. He also—you mentioned accelerated approval. This is a way that the FDA uses to try to get promising medicines to people faster. There are issues with it, and people have written about the fact that they rely on what are called surrogate endpoints. So not Did you live longer? but Did your tumor shrink? 

And you would think that that would make you live longer, but it actually turns out a lot of times it doesn’t. So you maybe went through a very strong medication and felt more terrible than you might have and didn’t extend your life. So there’s a lot of that discussion, and so that. There are other drugs. Like this Sarepta drug for Duchenne muscular dystrophy is a big one that Vinay Prasad has come out against, saying that should have never been approved, because it was using these kind of surrogate endpoints. So I think biotech’s pretty — thinking they’re going to have a lot tougher road ahead to bring stuff to market. 

Rovner: And I should point out that over the very long term, this has been the continuing struggle at FDA. It’s like, do you protect the public but make people wait longer for drugs or do you get the drugs out and make sure that people who have no other treatments available have something available? And it’s been a constant push and pull. It’s not really been partisan. Sometimes you get one side pushing and the other side pushing back. It’s really nothing new. It’s just the sort of latest iteration of this. 

Edney: Right. Yeah. This is the pendulum swing, back to the Maybe we need to be slowing it down side. It’s also interesting because there are other discussions from RFK Jr. that, like, We need to be speeding up approvals and Trump wants to speed up approvals. So I don’t know where any of this will actually come down when the rubber meets the road, I guess. 

Rovner: Sandhya and Maya, I see you both nodding. Do you want to add something? 

Raman: I think this was kind of a theme that I also heard this week in the — we had the Senate Finance hearing for some of the HHS [Department of Health and Human Services] nominees, and Jim O’Neill, who’s one of the nominees, that was something that was brought up by Finance ranking member Ron Wyden, that some of his past remarks when he was originally considered to be on the short list for FDA commissioner last Trump administration is that he basically said as long as it’s safe, it should go ahead regardless of efficacy. So those comments were kind of brought back again, and he’s in another hearing now, so that might come up as an issue in HELP [the Senate Committee on Health, Education, Labor and Pensions] today. 

Rovner: And he’s the nominee for deputy secretary, right? Have to make sure I keep all these things straight. Maya, you wanting to add something? 

Goldman: Yeah, I was just going to say, I think there is a divide between these two philosophies on pharmaceuticals, and my sense is that the selection of Prasad is kind of showing that the anti-accelerated-approval side is winning out. But I think Anna is correct that we still don’t know where it’s going to land. 

Rovner: Yes, and I will point out that accelerated approval first started during AIDS when there was no treatments and basically people were storming the — literally physically storming — the FDA, demanding access to AIDS drugs, which they did finally get. But that’s where accelerated approval came from. This is not a new fight, and it will continue. 

Turning to abortion, the Trump administration surprised a lot of people this week when it continued the Biden administration’s position asking for that case in Texas challenging the abortion pill to be dropped. For those who’ve forgotten, this was a case originally filed by a bunch of Texas medical providers demanding the judge overrule the FDA’s approval of the abortion pill mifepristone in the year 2000. The Supreme Court ruled the original plaintiff lacked standing to sue, but in the meantime, three states —Missouri, Idaho, and Kansas — have taken their place as plaintiffs. But now the Trump administration points out that those states have no business suing in the Northern District of Texas, which kind of seems true on its face. But we should not mistake this to think that the Trump administration now supports the current approval status of the abortion bill. Right, Sandhya? 

Raman: Yeah, I think you’re exactly right. It doesn’t surprise me. If they had allowed these three states, none of which are Texas — they shouldn’t have standing. And if they did allow them to, that would open a whole new can of worms for so many other cases where the other side on so many issues could cherry-pick in the same way. And so I think, I assume, that this will come up in future cases for them and they will continue with the positions they’ve had before. But this was probably in their best interest not to in this specific one. 

Rovner: Yeah. There are also those who point out that this could be a way of the administration protecting itself. If it wants to roll back or reimpose restrictions on the abortion pill, it would help prevent blue states from suing to stop that. So it serves a double purpose here, right? 

Raman: Yeah. I couldn’t see them doing it another way. And even if you go through the ruling, the language they use, it’s very careful. It’s not dipping into talking fully about abortion. It’s going purely on standing. Yeah. 

Rovner: There’s nothing that says, We think the abortion pill is fine the way it is. It clearly does not say that, although they did get the headlines — and I’m sure the president wanted — that makes it look like they’re towing this middle ground on abortion, which they may be but not necessarily in this case. 

Well, before we move off of reproductive health, a shoutout here to the incredible work of ProPublica, which was awarded the Pulitzer Prize for public service this week for its stories on women who died due to abortion bans that prevented them from getting care for their pregnancy complications. Regular listeners of the podcast will remember that we talked about these stories as they came out last year, but I will post another link to them in the show notes today. 

OK, moving on. There’s even more drug price news this week, starting with the return of, quote, “most favored nation” drug pricing. Anna, remind us what this is and why it’s controversial. 

Edney: Yeah. So the idea of most favored nation, this is something President Trump has brought up before in his first administration, but it creates a basket, essentially, of different prices that nations pay. And we’re going to base ours on the lowest price that is paid for— 

Rovner: We’re importing other countries’— 

Edney: —prices. 

Rovner: —price limits. 

Edney: Yeah. Essentially, yes. We can’t import their drugs, but we can import their prices. And so the goal is to just basically piggyback off of whoever is paying the lowest price and to base ours off of that. And clearly the drug industry does not like this and, I think, has faced a number of kind of hits this week where things are looming that could really come after them. So Politico broke that news that Trump is going to sign or expected to sign an executive order that will direct his agencies to look into this most-favored-nation effort. And it feels very much like 2.0, like we were here before. And it didn’t exactly work out, obviously. 

Rovner: They sued, didn’t they? The drug industry sued, as I recall. 

Edney: Yeah, I think you’re right. Yes. 

Goldman: If I’m remembering— 

Rovner: But I think they won. 

Goldman: If I’m remembering correctly, it was an Administrative Procedure Act lawsuit though, right? So— 

Rovner: It was. Yes. It was about a regulation. Yes. 

Goldman: —who knows what would happen if they go through a different procedure this time. 

Rovner: So the other thing, obviously, that the drug industry is freaked out about right now are tariffs, which have been on again, off again, on again, off again. Where are we with tariffs on — and it’s not just tariffs on drugs being imported. It’s tariffs on drug ingredients being imported, right? 

Edney: Yeah. And that’s a particularly rough one because many ingredients are imported, and then some of the drugs are then finished here, just like a car. All the pieces are brought in and then put together in one place. And so this is something the Trump administration has began the process of investigating. And PhRMA [Pharmaceutical Research and Manufacturers of America], the trade group for the drug industry, has come out officially, as you would expect, against the tariffs, saying that: This will reduce our ability to do R&D. It will raise the price of drugs that Americans pay, because we’re just going to pass this on to everyone. And so we’re still in this waiting zone of seeing when or exactly how much and all of that for the tariffs for pharma. 

Rovner: And yet Americans are paying — already paying — more than they ever have. Maya, you have a story just about that. Tell us. 

Goldman: Yeah, there was a really interesting report from an analytics data firm that showed the price that Americans are paying for prescriptions is continuing to climb. Also, the number of prescriptions that Americans are taking is continuing to climb. It certainly will be interesting to see if this administration can be any more successful. That report, I don’t think this made it into the article that I ended up writing, but it did show that the cost of insulin is down. And that’s something that has been a federal policy intervention. We haven’t seen a lot of the effects yet of the Medicare drug price negotiations, but I think there are signs that that could lower the prices that people are paying. So I think it’s interesting to just see the evolution of all of this. It’s very much in flux. 

Rovner: A continuing effort. Well, we are now well into the second hundred days of Trump 2.0, and we’re still learning about the cuts to health and health-related programs the administration is making. Just in this week’s rundown are stories about hundreds more people being laid off at the National Cancer Institute, a stop-work order at the National Institute of Allergy and Infectious Diseases research lab at Fort Detrick, Maryland, that studies Ebola and other deadly infectious diseases, and the layoff of most of the remaining staff at the National Institute for Occupational Safety and Health. 

A reminder that this is all separate from the discretionary-spending budget request that the administration sent up to lawmakers last week. That document calls for a 26% cut in non-mandatory funding at HHS, meaning just about everything other than Medicare and Medicaid. And it includes a proposed $18 billion cut to the NIH [National Institutes of Health] and elimination of the $4 billion Low Income Home Energy Assistance Program, which helps millions of low-income Americans pay their heating and air conditioning bills. Now, this is normally the part of the federal budget that’s deemed dead on arrival. The president sends up his budget request, and Congress says, Yeah, we’re not doing that. But this at least does give us an idea of what direction the administration wants to take at HHS, right? What’s the likelihood of Congress endorsing any of these really huge, deep cuts? 

Raman: From both sides— 

Rovner: Go ahead, Sandhya. 

Raman: It’s not going to happen, and they need 60 votes in the Senate to pass the appropriations bills. I think that when we’re looking in the House in particular, there are a lot of things in what we know from this so-called skinny budget document that they could take up and put in their bill for Labor, HHS, and Education. But I think the Senate’s going to be a different story, just because the Senate Appropriations chair is Susan Collins and she, as soon as this came out, had some pretty sharp words about the big cuts to NIH. They’ve had one in a series of two hearings on biomedical research. Concerned about some of these kinds of things. So I cannot necessarily see that sharp of a cut coming to fruition for NIH, but they might need to make some concessions on some other things. 

This is also just a not full document. It has some things and others. I didn’t see any to FDA in there at all. So that was a question mark, even though they had some more information in some of the documents that had leaked kind of earlier on a larger version of this budget request. So I think we’ll see more about how people are feeling next week when we start having Secretary Kennedy testify on some of these. But I would not expect most of this to make it into whatever appropriations law we get. 

Goldman: I was just going to say that. You take it seriously but not literally, is what I’ve been hearing from people. 

Edney: We don’t have a full picture of what has already been cut. So to go in and then endorse cutting some more, maybe a little bit too early for that, because even at this point they’re still bringing people back that they cut. They’re finding out, Oh, this is actually something that is really important and that we need, so to do even more doesn’t seem to make a lot of sense right now. 

Rovner: Yeah, that state of disarray is purposeful, I would guess, and doing a really good job at sort of clouding things up. 

Goldman: One note on the cuts. I talked to someone at HHS this week who said as they’re bringing back some of these specialized people, in order to maintain the legality of, what they see as the legality of, the RIF [reduction in force], they need to lay off additional people to keep that number consistent. So I think that is very much in flux still and interesting to watch. 

Rovner: Yeah, and I think that’s part of what we were seeing this week is that the groups that got spared are now getting cut because they’ve had to bring back other people. And as I point out, I guess, every week, pretty much all of this is illegal. And as it goes to courts, judges say, You can’t do this. So everything is in flux and will continue. 

All right, finally this week, Health and Human Services Secretary Robert F. Kennedy Jr., who as of now is scheduled to appear before the Senate Health, Education, Labor, and Pensions Committee next week to talk about the department’s proposed budget, is asking CDC [the Centers for Disease Control and Prevention] to develop new guidance for treating measles with drugs and vitamins. This comes a week after he ordered a change in vaccine policy you already mentioned, Anna, so that new vaccines would have to be tested against placebos rather than older versions of the vaccine. These are all exactly the kinds of things that Kennedy promised health committee chairman Bill Cassidy he wouldn’t do. And yet we’ve heard almost nothing from Cassidy about anything the secretary has said or done since he’s been in office. So what do we expect to happen when they come face-to-face with each other in front of the cameras next week, assuming that it happens? 

Edney: I’m very curious. I don’t know. Do I expect a senator to take a stand? I don’t necessarily, but this— 

Rovner: He hasn’t yet. 

Edney: Yeah, he hasn’t yet. But this is maybe about face-saving too for him. So I don’t know. 

Rovner: Face-saving for Kennedy or for Cassidy? 

Edney: For Cassidy, given he said: I’m going to keep an eye on him. We’re going to talk all the time, and he is not going to do this thing without my input. I’m not sure how Cassidy will approach that. I think it’ll be a really interesting hearing that we’ll all be watching. 

Rovner: Yes. And just little announcement, if it does happen, that we are going to do sort of a special Wednesday afternoon after the hearing with some of our KFF Health News colleagues. So we are looking forward to that hearing. All right, that is this week’s news. Now we will play my “Bill of the Month” interview with Lauren Sausser, and then we will come back and do our extra credits. 

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

Lauren Sausser: Thank you. Thanks for having me. 

Rovner: So this month’s patient got preventive care, which the Affordable Care Act was supposed to incentivize by making it cost-free at the point of service — except it wasn’t. Tell us who the patient is and what kind of care they got. 

Sausser: Carmen Aiken is from Chicago. Carmen uses they/them pronouns. And Carmen made an appointment in the summer of 2023 for an annual checkup. This is just like a wellness check that you are very familiar with. You get your vaccines updated. You get your weight checked. You talk to your doctor about your physical activity and your family history. You might get some blood work done. Standard stuff. 

Rovner: And how big was the bill? 

Sausser: The bill ended up being more than $1,400 when it should, in Carmen’s mind, have been free. 

Rovner: Which is a lot. 

Sausser: A lot. 

Rovner: I assume that there was a complaint to the health plan and the health plan said, Nope, not covered. Why did they say that? 

Sausser: It turns out that alongside with some blood work that was preventive, Carmen also had some blood work done to monitor an ongoing prescription. Because that blood test is not considered a standard preventive service, the entire appointment was categorized as diagnostic and not preventive. So all of these services that would’ve been free to them, available at no cost, all of a sudden Carmen became responsible for. 

Rovner: So even if the care was diagnostic rather than strictly preventive — obviously debatable — that sounds like a lot of money for a vaccine and some blood test. Why was the bill so high? 

Sausser: Part of the reason the bill was so high was because Carmen’s blood work was sent to a hospital for processing, and hospitals, as you know, can charge a lot more for the same services. So under Carmen’s health plan, they were responsible for, I believe it was, 50% of the cost of services performed in an outpatient hospital setting. And that’s what that blood work fell under. So the charges were high. 

Rovner: So we’ve talked a lot on the podcast about this fight in Congress to create site-neutral payments. This is a case where that probably would’ve made a big difference. 

Sausser: Yeah, it would. And there’s discussion, there’s bipartisan support for it. The idea is that you should not have to pay more for the same services that are delivered at different places. But right now there’s no legislation to protect patients like Carmen from incurring higher charges. 

Rovner: So what eventually happened with this bill? 

Sausser: Carmen ended up paying it. They put it on a credit card. This was of course after they tried appealing it to their insurance company. Their insurance company decided that they agreed with the provider that these services were diagnostic, not preventive. And so, yeah, Carmen was losing sleep over this and decided ultimately that they were just going to pay it. 

Rovner: And at least it was a four-figure bill and not a five-figure bill. 

Sausser: Right. 

Rovner: What’s the takeaway here? I imagine it is not that you should skip needed preventive/diagnostic care. Some drugs, when you’re on them, they say that you should have blood work done periodically to make sure you’re not having side effects. 

Sausser: Right. You should not skip preventive services. And that’s the whole intent behind this in the ACA. It catches stuff early so that it becomes more treatable. I think you have to be really, really careful and specific when you’re making appointments, and about your intention for the appointment, so that you don’t incur charges like this. I think that you can also be really careful about where you get your blood work conducted. A lot of times you’ll see these signs in the doctor’s office like: We use this lab. If this isn’t in-network with you, you need to let us know. Because the charges that you can face really vary depending on where those labs are processed. So you can be really careful about that, too. 

Rovner: And adding to all of this, there’s the pending Supreme Court case that could change it, right? 

Sausser: Right. The Supreme Court heard oral arguments. It was in April. I think it was on the 21st. And it is a case that originated out in Texas. There is a group of Christian businesses that are challenging the mandate in the ACA that requires health insurers to cover a lot of these preventive services. So obviously we don’t have a decision in the case yet, but we’ll see. 

Rovner: We will, and we will cover it on the podcast. Lauren Sausser, thank you so much. 

Sausser: Thank you. 

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

Goldman: My extra credit is from Stat. It’s called “Europe Unveils $565 Million Package To Retain Scientists, and Attract New Ones,” by Andrew Joseph. And I just think it’s a really interesting evidence point to the United States’ losses, other countries’ gain. The U.S. has long been the pinnacle of research science, and people flock to this country to do research. And I think we’re already seeing a reversal of that as cuts to NIH funding and other scientific enterprises is reduced. 

Rovner: Yep. A lot of stories about this, too. Anna. 

Edney: So mine is from a couple of my colleagues that they did earlier this week. “A Former TV Writer Found a Health-Care Loophole That Threatens To Blow Up Obamacare.” And I thought it was really interesting because it had brought me back to these cheap, bare-bones plans that people were allowed to start selling that don’t meet any of the Obamacare requirements. And so this guy who used to, in the ’80s and ’90s, wrote for sitcoms — “Coach” or “Night Court,” if anyone goes to watch those on reruns. But he did a series of random things after that and has sort of now landed on selling these junk plans, but doing it in a really weird way that signs people up for a job that they don’t know they’re being signed up for. And I think it’s just, it’s an interesting read because we knew when these things were coming online that this was shady and people weren’t going to get the coverage they needed. And this takes it to an extra level. They’re still around, and they’re still ripping people off. 

Rovner: Or as I’d like to subhead this story: Creative people think of creative things. 

Edney: “Creative” is a nice word. 

Rovner: Sandhya. 

Raman: So my pick is “In the Deep South, Health Care Fights Echo Civil Rights Battles,” and it’s from Anna Claire Vollers at the Louisiana Illuminator. And her story looks at some of the ties between civil rights and health. So 2025 is the 70th anniversary of the bus boycott, the 60th anniversary of Selma-to-Montgomery marches, the Voting Rights Act. And it’s also the 60th anniversary of Medicaid. And she goes into, Medicaid isn’t something you usually consider a civil rights win, but health as a human right was part of the civil rights movement. And I think it’s an interesting piece. 

Rovner: It is an interesting piece, and we should point out Medicare was also a huge civil rights, important piece of law because it desegregated all the hospitals in the South. All right, my extra credit this week is a truly infuriating story from NPR by Andrea Hsu. It’s called “Fired, Rehired, and Fired Again: Some Federal Workers Find They’re Suddenly Uninsured.” And it’s a situation that if a private employer did it, Congress would be all over them and it would be making huge headlines. These are federal workers who are trying to do the right thing for themselves and their families but who are being jerked around in impossible ways and have no idea not just whether they have jobs but whether they have health insurance, and whether the medical care that they’re getting while this all gets sorted out will be covered. It’s one thing to shrink the federal workforce, but there is some basic human decency for people who haven’t done anything wrong, and a lot of now-former federal workers are not getting it at the moment. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate if you left us a review. That helps other people find us, too. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Ying. Also, as always, you can email us your comments or questions, We’re at whatthehealth@kff.org, or you can still find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Sandhya? 

Raman: I’m on X, @SandhyaWrites, and also on Bluesky, @SandhyaWrites at Bluesky. 

Rovner: Anna. 

Edney: X and Bluesky, @annaedney. 

Rovner: Maya. 

Goldman: I am on X, @mayagoldman_. Same on Bluesky and also increasingly on LinkedIn. 

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

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