\t\t\t<\/p>\n
\tJulie Rovner
\n\tKFF Health News<\/p>\n
\t\t\t \t\t\t \t\t\tJulie Rovner is chief Washington correspondent and host of KFF Health News\u2019 weekly health policy news podcast, \u201cWhat the Health?\u201d A noted expert on health policy issues, Julie is the author of the critically praised reference book \u201cHealth Care Politics and Policy A to Z,\u201d now in its third edition.\t\t<\/p>\n A week into the reorganization of the Department of Health and Human Services announced by Secretary Robert F. Kennedy Jr., the scope of the staff cuts and program cutbacks is starting to become clear. Among the biggest targets for reductions were the nation\u2019s premier public health agencies: the Centers for Disease Control and Prevention, the National Institutes of Health, and the FDA.<\/p>\n Meanwhile, Kennedy did not show up as invited to testify before the Senate Health, Education, Labor and Pensions Committee, known as HELP, but he did visit families in Texas whose unvaccinated children died of measles in the current outbreak and called for an end to water fluoridation during a stop in Utah.<\/p>\n This week\u2019s panelists are Julie Rovner of KFF Health News, Victoria Knight of Axios, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.<\/p>\n \t\t\t \tVictoria Knight \t\t\t \t\t\t \t\t\t \tAlice Miranda Ollstein \t\t\t \t\t\t \t\t\t \tSandhya Raman \t\t\t \t\t\t Among the takeaways from this week\u2019s episode:<\/p>\n Also this week, Rovner interviews Georgetown Law School professor Stephen Vladeck about the limits of presidential power.<\/p>\n Plus, for \u201cextra credit\u201d the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:\u00a0<\/p>\n Julie Rovner:<\/strong> The New York Times\u2019 \u201cWhy the Right Still Embraces Ivermectin<\/a>,\u201d by Richard Fausset.\u00a0\u00a0<\/p>\n Victoria Knight:<\/strong> Wired\u2019s \u201cDr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall<\/a>,\u201d by Leah Feiger and Steven Levy.\u00a0\u00a0<\/p>\n Alice Miranda Ollstein:<\/strong> The Guardian\u2019s \u201c\u2018We Are Failing\u2019: Doctors and Students in the US Look to Mexico for Basic Abortion Training<\/a>,\u201d by Carter Sherman.\u00a0\u00a0<\/p>\n Sandhya Raman:<\/strong> CQ Roll Call\u2019s \u201cIn Sweden, a Focus on Smokeless Tobacco<\/a>,\u201d by Sandhya Raman.\u00a0<\/p>\n Also mentioned in this week\u2019s podcast:<\/p>\n \t\t\t\t\tClick to open the transcript\t\t\t\t<\/p>\n \t\t\t\t\t\tTranscript: The Dismantling of HHS\t\t\t\t<\/p>\n [Editor\u2019s note:<\/em><\/strong> This transcript was generated using both transcription software and a human\u2019s light touch. It has been edited for style and clarity.]<\/em>\u00a0<\/p>\n Julie Rovner:<\/strong> Hello, and welcome back to \u201cWhat the Health?\u201d I\u2019m Julie Rovner, chief Washington correspondent for KFF Health News, and I\u2019m joined by some of the best and smartest health reporters in Washington. We\u2019re taping this week on Thursday, April 10, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.\u00a0<\/p>\n Today we are joined via videoconference by Alice Miranda Ollstein of Politico.\u00a0<\/p>\n Alice Miranda Ollstein:<\/strong> Hello.\u00a0<\/p>\n Rovner:<\/strong> Sandhya Raman of CQ Roll Call.\u00a0<\/p>\n Sandhya Raman:<\/strong> Good morning, everyone.\u00a0<\/p>\n Rovner:<\/strong> And Victoria Knight of Axios news.\u00a0<\/p>\n Victoria Knight:<\/strong> Hello, everyone.\u00a0<\/p>\n Rovner:<\/strong> Later in this episode we\u2019ll have my interview with Georgetown University law professor Stephen Vladeck, who will talk about the limits of presidential power \u2014 if there are any left. But first, this week\u2019s news.\u00a0<\/p>\n So the dust is starting to settle, sort of, in that ginormous reorganization of the Department of Health and Human Services launched by Secretary Robert F. Kennedy Jr. last week, which I am now calling \u201cThe Great Dismantling.\u201d Here\u2019s some of what we know about the casualties at the CDC [Centers for Disease Control and Prevention]. Offices that worked on sexually transmitted disease prevention, injury prevention, lead poisoning surveillance, and tobacco were basically gutted. At NIH [the National Institutes of Health], the chronic pain division was eliminated, as was the Office of Long Covid. And at the FDA [Food and Drug Administration], offices handling veterinary medicine, generic drugs, and food safety were dramatically reduced. Now that we\u2019ve had a week to absorb what\u2019s been done and, despite claims of the contrary from Secretary Kennedy, we are told there is no plan to hire back some of those workers who were apparently let go in error, what are you guys hearing about where we are?\u00a0<\/p>\n Ollstein:<\/strong> Yeah, there\u2019s a lot of people who were put on administrative leave, which is going to run out in a few weeks. By and large, they are not expecting to be called back. They are holding out hope. They would love to be called back. They keep telling me that they would love to get back to the work they were doing. They\u2019re really worried about it not continuing without them, but they\u2019re mostly assuming that these cuts are permanent for now. And contrary to claims from HHS that work isn\u2019t being eliminated, it\u2019s just being consolidated or folded in or there\u2019s different words they\u2019re using, all of these different laid-off workers told me from different divisions that they were basically given no opportunity to hand over their ongoing projects to anyone else, to train anyone else, to make sure it keeps going. So as far as they know, a lot of this surveillance work, research work, coordination work is just not going to be happening going forward.\u00a0<\/p>\n Rovner:<\/strong> As far as I can tell, money that\u2019s supposed to be going out the door from places like the NIH isn\u2019t.\u00a0<\/p>\n Knight:<\/strong> Yeah, you hit some of the offices, programs that have been cut, but also I think at FDA, we did some reporting this week on the user drug fee program and how staff that do the evaluating drugs and things like that have been cut. And it\u2019s interesting because pharmaceutical companies pay these fees hoping that they\u2019ll get timely evaluations of their drugs, and also\u2014\u00a0<\/p>\n Rovner:<\/strong> They pay these fees and are told<\/em> they will get timely evaluation of these drugs in exchange. That\u2019s the deal.\u00a0<\/p>\n Knight:<\/strong> Exactly. And I know pharmaceutical companies are definitely concerned about this, and it\u2019s also concerning for patients who may be waiting for certain drugs to be approved and things like that. And I think it\u2019s interesting, also, Republicans like to talk a lot about innovation and getting new drugs approved and things like that, and this would harm that process if the staff are not rehired. I haven\u2019t really heard an update on that, so\u2014\u00a0<\/p>\n Raman:<\/strong> I would also add that part of it is that we just don\u2019t have a lot of information, right? We had Secretary Kennedy invited to come testify before the Senate HELP Committee this week and go through some of these things and explain the rationale and get into that, and that did not happen.\u00a0<\/p>\n Rovner:<\/strong> Yeah, we\u2019ll get to that.\u00a0<\/p>\n Raman:<\/strong> Yes, and I think, at the same time, a lot of those cuts were also to the communications folks within those agencies that could be disseminating this information to external folks, to internal folks to provide more clarity about where things would be going. And we don\u2019t have those there now, so it will take some time to kind of see where things are going, and even when there\u2019s going to be a delay in some of that stuff, getting that information out is going to be difficult.\u00a0<\/p>\n Ollstein:<\/strong> Sandhya is absolutely right about the communications issue here, and I\u2019m just hearing that on so many fronts. States are desperate to get in contact with someone in the federal government to understand what\u2019s going on. Do they have to keep collecting data and sending it to the federal government even though there\u2019s no one left to compile and process it? They\u2019re reaching out asking: Are certain grants going to continue or not? What should we do? Are we going to be in legal trouble if we continue some of this work?<\/em> And there\u2019s just no one answering, sometimes because all the people that would\u2019ve answered have been let go. But also the communications freeze that was supposed to be temporary at the very beginning of the administration, a lot of federal workers told me that never really ended.\u00a0<\/p>\n So there are these email accounts that they were ordered to stop checking and responding to. So one example is the entire team that worked on IVF [in vitro fertilization], evaluating which IVF clinics had the best pregnancy success rates, monitoring safety, all of that \u2014 they were all eliminated. And one consequence of that is that there was this email account that doctors, patients, anybody could reach out to for information and to ask questions, and no one\u2019s checking it, no one\u2019s responding.\u00a0<\/p>\n Rovner:<\/strong> I don\u2019t know about you guys. I am starting to hear from health care stakeholders. The federal government is so intertwined in, basically it\u2019s a fifth of the economy, what we spend on health care, and it\u2019s creating so much uncertainty. As you were saying, people don\u2019t know if they\u2019re going to get in trouble for not<\/em> doing things or for doing<\/em> things. But we do know, as we said, we talked about last week, FDA missed a deadline to rule on a Novavax vaccine. This is going to have ramifications way beyond just the people who are losing their jobs in the federal government, right?\u00a0<\/p>\n Raman:<\/strong> There\u2019s so many people that receive the services that we contract out, that we put grants through across the country. And I think that even in speaking to some of these employees that have lost their jobs, one of the top concerns is not even for their own job but that no one else can do the work that they did. Or in some cases, the only person that could have done that work has also already been let go. And just that those things are going to fall through the cracks for a lot of vulnerable communities.\u00a0<\/p>\n Ollstein:<\/strong> Some of the folks also told me that even if this is reversed in the future, the damage will just be there for a very long time, especially on things like surveillance and data collection. If you have a gap in there, that skews things. That messes things up for the future. It makes it harder to make comparisons. It makes it harder to know if things are getting better or worse on, like, asthma rates and levels of lead in people\u2019s blood, all kinds of things, things that are not politically controversial or partisan. And so it\u2019ll just be really difficult going forward to know which programs are working, which interventions are working or not working.\u00a0<\/p>\n Rovner:<\/strong> So things are happening almost too fast to keep track of. But in his latest round of executive orders on Wednesday, President [Donald] Trump signed one called Directing the Repeal of Unlawful Regulations, in which he basically instructs the heads of all departments to repeal rules they consider unlawful, without notice or comment, which is not how this is supposed to work. I\u2019m not sure even, though, quite what to make of all this. And it seems to be going mostly unnoticed in all of the attention, deservedly, to the other news that\u2019s happening, some of which we\u2019ll get to. But repealing rules basically on a whim could be as important to how the federal government functions as firing all these people, right?\u00a0<\/p>\n Raman:<\/strong> Yeah, there\u2019s a reason that the rulemaking process is the way it is, that it takes a certain amount of time. You allow stakeholders to weigh in, to meet, to revise, and that the things aren\u2019t changing too drastically. And there are some rules that go back and forth between the administrations, but a lot of things last over time, and the process is the way it is to make sure that you get the best possible result for whatever you\u2019re changing and\u2014\u00a0<\/p>\n Rovner:<\/strong> That you get stability.\u00a0<\/p>\n Raman:<\/strong> Yes.\u00a0<\/p>\n Rovner:<\/strong> I think that\u2019s the theme here, is that that\u2019s what we\u2019re lacking right now. Nobody can count on what the rules are.\u00a0<\/p>\n Knight:<\/strong> And I was going to say, from an industry perspective, industries make decisions based on these rules and knowing when they\u2019re going to come out and when they might change. Think about the insurance industry, physicians, people within the health care industry. And so that could really impact those groups as well a lot. So, and exactly, going back to what you said about stability, so it\u2019ll make it really hard to make business decisions.\u00a0<\/p>\n Rovner:<\/strong> Right. So this goes along with the stuff with the tariffs, is that we have no idea what the rules of the road are going to be going forward if rules can be sort of disappeared in a matter of days the way staff is being. Well, let\u2019s move to Congress. Remember Congress? Late last Friday, or I guess it was technically early Saturday, the Senate passed what was supposed to be a compromise Republican budget resolution between the House and the Senate. For those who have forgotten, while the House passed a resolution that would lead to a single gigantic budget reconciliation bill, including tax cuts and likely big cuts to Medicaid, the Senate\u2019s original budget resolution would only have led to a bill on immigration and energy, saving the tax and health fights for later in the year.\u00a0<\/p>\n Well, it seems like the compromise, which is kind of a vaguer version of the House blueprint, didn\u2019t go over so well in the House, where Speaker Mike Johnson had hoped to push it through this week. A vote was scheduled for Wednesday, then it got delayed, then it got shelved, at least for the night. They\u2019re apparently trying to regroup and do this this morning. Where are we in this?\u00a0<\/p>\n Knight:<\/strong> Yeah, so you gave a pretty good rundown. I was here late last night talking to Freedom Caucus members, the House Freedom Caucus, the hard-liners. Their concerns with, this is basically a Senate amendment to the House\u2019s resolution. And so what the Senate passed was an amendment, and it technically really just gives instructions for the Senate. It didn\u2019t touch the House\u2019s resolution. So the House\u2019s budget resolution they passed is the same thing, but House Freedom Caucus members had issue that the Senate ceilings for cuts is much lower than the House\u2019s. And so they\u2019re saying\u2014\u00a0<\/p>\n Rovner:<\/strong> It\u2019s in the billions instead of trillions.\u00a0<\/p>\n Knight:<\/strong> Exactly. Exactly. So coming out, they holed up with Speaker Johnson last night and House GOP leadership and were saying, We need more binding cuts on the Senate side<\/em>, and were like: We need you guys to commit to this, otherwise we\u2019re unhappy with this amount of cuts. This is going to increase spending. <\/em>There\u2019s been a lot of discussion on how to do the budget math for these things, but it\u2019s pretty clear the Senate\u2019s resolution would not cut spending as much as the House\u2019s. So that was what they came out demanding last night. This morning, Speaker Johnson and Senate Majority Leader John Thune came out, did a press conference, and said: We\u2019re going to proceed with this. We\u2019ll see if that changes.<\/em> But it was interesting to note that Thune said, he noted that there are Senate Republicans that do want cuts that may be up to the $1.5 trillion, but he did not commit to making cuts on his side. So we\u2019ll see how this goes. That seems to be the state of play. It\u2019s very in flux. That could change over time. So if anyone has anything to add, I think that\u2019s a rundown.\u00a0<\/p>\n Rovner:<\/strong> Yeah, it feels like they\u2019re kind of buying time to see if they can keep together what\u2019s clearly a very fractious group here.\u00a0<\/p>\n Knight:<\/strong> Yeah, and jet fumes are always a good motivator, and also holidays. So there\u2019s supposed to be a two-week recess right after this, and Passover starts this weekend and Easter next weekend, so we\u2019ll see if that motivates people to vote for it. I will say, an argument that we\u2019ve heard from a lot of the moderates that are concerned about the Medicaid cuts, when they voted for these, they\u2019ve said: This is just an outline. It\u2019s just a blueprint. It\u2019s not committing us to anything.<\/em> But hard-liners don\u2019t seem to like that argument as much. So can they convince them that way? I don\u2019t know.\u00a0<\/p>\n Rovner:<\/strong> Well, let\u2019s talk about those Medicaid cuts for a minute, which, by the way, as you pointed out, Victoria, is not really what\u2019s holding up the vote in the House. Our New York Times podcast pals Sarah Kliff and Margot Sanger-Katz had a really interesting story<\/a> over the weekend about three red states that would really be stuck if Medicaid gets cut. Oklahoma, Missouri, and South Dakota all passed their Medicaid expansions by ballot measure, including it as part of their state constitutions. Now this is exactly the opposite of those states that would immediately cancel their expansions if Congress cuts the Medicaid match. These three states would be totally stuck, unless they could have another ballot measure that would then eliminate what they added. I guess that helps explain why very conservative Missouri Republican Sen. Josh Hawley says he is so opposed to reducing the Medicaid match. But he seems OK with Medicaid work requirements that would also cut people off the rolls, just not necessarily in a way that would cost the state so much money, right?\u00a0<\/p>\n Ollstein:<\/strong> Yeah, I think we\u2019re going to see a lot of interesting semantic games going forward. I think we\u2019re going to see a lot of different interpretations of what a cut is. We\u2019re going to see a lot of claims made about who does and doesn\u2019t deserve Medicaid coverage. We\u2019ve been seeing this for a long time, but as these tough decisions have to be made on the Hill, I think a lot of that is going to come to a head. And so I think you see a lot of conservatives wrestling with believing very strongly in cutting government spending but also recognizing that a lot of their constituents could be harmed by these policies and they would be very angry with their members if that happened.\u00a0<\/p>\n And so trying to thread that needle, we\u2019ll see how they do it, whether they can do it successfully without getting a lot of political blowback. Even though there has been a lot of turnover in Congress, you have a decent number of folks who were there last time Congress tried to take a big whack at Medicaid in the Affordable Care Act repeal fight.\u00a0<\/p>\n Rovner:<\/strong> In 2017.\u00a0<\/p>\n Ollstein:<\/strong> Exactly. Exactly. And the impact on Medicaid is one of the biggest things that garnered a backlash. And Capitol Hill was covered in folks with disabilities protesting, and it was a really bad look, and it contributed to that effort failing.\u00a0<\/p>\n Knight:<\/strong> And I think interesting talking about Hawley, but also the Republican Governors Association joined up with some other conservative groups this week to start an ad saying, Don\u2019t cut Medicaid<\/em>, basically. And so we\u2019re starting to hear that from the states. States are really concerned how this could affect their budgets. They\u2019ve already expanded the program. It would be really hard for them to have to make up in the state that amount of money if the federal government takes away money from the Medicaid program for them or caps it or whatever. It\u2019s interesting to see people walk that line. And House GOP moderates, they are more likely to fold, I think, than hard-liners, but they keep telling me when I talk to them, We\u2019re OK with work requirements, but anything past that might be really hard for us to vote for<\/em>. But who knows? They could fold if they have enough pressure, but they\u2019re trying to walk the line at this moment.\u00a0<\/p>\n Rovner:<\/strong> This is going to be a very different Medicaid fight than it was in 2017. Well, turning to this week in \u201cMake America Healthy Again,\u201d I think we mentioned last week that HHS Secretary RFK Jr. had been invited to testify before the Senate Health, Education, Labor, and Pensions Committee today. Well, as Sandhya pointed out, that did not happen. We\u2019re not entirely sure why, but the secretary continues to do things, well, things he kind of promised senators that he wouldn\u2019t, like saying that he\u2019s going to order the CDC to stop recommending adding fluoride to public water supplies, which he did on a trip to Utah this week. Once more for those in the back, why do most public health professionals support water fluoridation?\u00a0<\/p>\n Raman:<\/strong> It really reduces dental decay, by like 25%. ADA [the American Dental Association] has been recommending fluoride for years. So it\u2019s a big proponent of that.\u00a0<\/p>\n Rovner:<\/strong> And as someone pointed out, it\u2019s against dentists\u2019 interests to be recommending something that gives them less work and yet they\u2019re still recommending it.\u00a0<\/p>\n Ollstein:<\/strong> And even though we have a very silly system in the U.S. where dental care is siloed off from the rest of health care, it does impact your overall health a lot. So it could lead to lung issues, heart issues, all kinds of things if you have dental issues. So it\u2019s not just a cosmetic problem, it can be a very serious health problem. And I will say, too, people should keep in mind that there\u2019s a lot of pointing at studies about negative health impacts from excessive consumption of fluoride, but those studies have a level that is much, much higher than what\u2019s in the U.S. tap water right now. So anything in excess can be bad for you \u2014 even just plain water can kill you if you have too much of it. And so I think that people should keep that in mind and remain skeptical about claims being made.\u00a0<\/p>\n Rovner:<\/strong> Well, RFK Jr. also continues to make news in his handling of the measles outbreak in Texas, which is now the largest in the nation in the past 30 years, having sickened nearly 600 people, mostly unvaccinated children. Kennedy traveled to the heart of the outbreak last week and visited with the families of the two children that we know have died so far of the virus. He also praised the measles vaccine, but then just hours later posed with and praised two doctors who are using unapproved treatments for measles, including one who was disciplined by Texas medical regulators. Meanwhile, Peter Marks, the FDA vaccine official forced to resign last month, is speaking out, calling Kennedy\u2019s actions thus far, quote, \u201cvery scary\u201d in an interview with The Wall Street Journal<\/a> and telling the AP<\/a> [Associated Press] that he got fired for trying to keep Kennedy\u2019s team from editing or possibly erasing the very sensitive Vaccine Adverse Event Reporting System kept by the FDA. Is there any way we didn\u2019t see all of this coming?\u00a0<\/p>\n Knight:<\/strong> Well, going back to the congressional aspect. The HELP chair, [Sen.] Bill Cassidy, he had both the HELP hearing and the Senate Finance hearing where he questioned Kennedy repeatedly about his views on vaccines, his views on the link between vaccines and autism, I think also measles and autism. And he didn\u2019t really ever get a super substantial answer from Kennedy. And yet the compromise was somewhat that Cassidy said, You\u2019ll have to come quarterly before the HELP Committee and testify about what\u2019s going on, what your views are.<\/em> And we saw Cassidy try to do that last week. And Kennedy has, as far as I know, the latest is that he received the request but he hasn\u2019t accepted it yet, and unclear if he will.\u00a0<\/p>\n So that congressional oversight was supposed to be the way to keep him in check, somewhat. And that\u2019s not happening. It\u2019s not really that enforceable. So I think it\u2019s pretty predictable what\u2019s happening. I think what will be interesting is if the White House gets unhappy with some of Kennedy\u2019s things that he\u2019s doing. There\u2019s been some stories of how they\u2019re having to take over his communications because there\u2019s been no communications from HHS on it, and so they\u2019re kind of unhappy with that. We\u2019ll see if that reaches to a level where they could change leadership or something. But, not there yet, certainly, but something to watch.\u00a0<\/p>\n Rovner:<\/strong> Again, so much going on. I think this would normally rise to a higher level than it has given all of the other news that\u2019s happening. Moving on to abortion. We talked last week, or maybe it was the week before, about the Overton window moving towards criminalizing women who have or even seek abortions. That\u2019s apparently the point of a bill introduced in the Alabama Legislature. In North Carolina, a new bill could subject anyone convicted of performing or receiving an abortion to life in prison. We talked a few weeks ago about a similar bill in Georgia that got a legislative hearing. Even if none of these bills pass \u2014 and it seems that none of them will pass, at least this year \u2014 it certainly seems that claims by the anti-abortion movement that they don\u2019t want to punish women are either not true or falling on deaf ears.\u00a0<\/p>\n Ollstein:<\/strong> So the anti-abortion movement, just like the pro-abortion-rights movement, is not a monolith. And just like the political parties, there are moderates and hard-liners. There are people who disagree on tactics. And so I think for so long the movement appeared united because their main goal was just overturning Roe v. Wade<\/em>. And they were able to paper over other divisions by focusing pretty exclusively on that, or not exclusively but that being the overriding goal. And now that they\u2019ve accomplished that and now that there are a lot more opportunities for them, you\u2019re seeing these divisions. And we\u2019ve seen that over the past few years. There were people who said, OK, a 15-week ban is better than nothing, and we can build on it.<\/em> And there are people who say: No, that\u2019s an unacceptable compromise, and it has to be a total ban or nothing. And if you do a 15-week ban, you\u2019re endorsing the murder of most babies, because most abortions happen before 15 weeks of pregnancy.<\/em>\u00a0<\/p>\n So I think this is a continuation of that. And it\u2019s also a reflection that there is a lot of frustration in the anti-abortion movement that not only have abortions not ceased when states enact bans, in some cases they\u2019ve gone up, nationally. And that\u2019s a combination of people traveling, that\u2019s a combination of people using telehealth and getting pills mailed to them. That\u2019s become a huge thing that people rely on. And so looking at ways to crack down on those things, including this kind of criminalization of the pregnant patient that\u2019s been sort of a third rail that is now more in the conversation. Of course, people have been proposing such things for a while now, but it\u2019s getting more prominent attention than before.\u00a0<\/p>\n Rovner:<\/strong> Yeah. And that was my question, is it used to be a real outlier, and now we\u2019ve seen legislation introduced in 10 states that would criminalize the woman in some way, shape, or form. Sandhya, you wanted to add something.\u00a0<\/p>\n Raman:<\/strong> I was going to say it\u2019s also a long game. There are things that we\u2019ve had proposed years ago that I think garnered attention then as being very outside the realm of something that people would consider. And then a few years later, when we first saw some of these personhood bills years ago, I think those got attention as being a little different than some of the other things that were being considered. And now that has become more mainstream. We see that in a lot of states now. And I think that something like this, even though it is very different than the messaging we\u2019ve seen in the past, it doesn\u2019t mean that, down the line, a greater portion of the movement pivots toward this. Because we\u2019ve seen so much of this throw the spaghetti at the wall with seeing different things that they can see, what can pass, what doesn\u2019t get litigated, that kind of thing. So a lot of this is kind of a long game.\u00a0<\/p>\n Ollstein:<\/strong> Yeah. And there is an imbalance between the two sides where the right is much more willing to throw spaghetti at the wall and see what sticks, much more willing to throw out things that could anger people, could generate controversy, could generate backlash, but they do believe will advance the goal. And you\u2019re not really seeing the same willingness on the left. You\u2019re not really seeing states propose, Let\u2019s get rid of all abortion restrictions in total<\/em>. And so you have this imbalance of what each side is willing to even consider, where the left has been, overall, not exclusively, but overall much more cautious and much more consensus-seeking.\u00a0<\/p>\n Rovner:<\/strong> Well, meanwhile, in Texas, where over the past few years we\u2019ve had story after story about women with wanted pregnancies nearly dying from complications, the legislature finally has before it a compromise bill that would better define when doctors can end a doomed pregnancy without risking going to prison, except it\u2019s turning out to be not as much of a compromise as its backers had hoped. Is there any way to actually find a compromise on what is a necessary abortion and what is saving the woman\u2019s life? They write these things and they say: Well, look. Here are the exceptions, and they should work.<\/em> But now they\u2019re trying to spell out the exceptions and they can\u2019t seem to agree on those, either.\u00a0<\/p>\n Ollstein:<\/strong> So it\u2019s really a catch-22. And I was just in Texas. I was interviewing OB-GYNs, and they were explaining \u2014 and those in other states with bans have said the same thing \u2014 that, look, it\u2019s really tough, because if a law is too broad and too vague, then doctors don\u2019t feel comfortable doing even things they feel are absolutely medically necessary. But if a law is too prescriptive \u2014 if, for example, it tries to list every single possible condition that would necessitate an emergency abortion or an abortion to save someone\u2019s life for health \u2014 you\u2019re never going to be able to list everything. So many things can go wrong during a pregnancy, and so any attempt to be comprehensive will inevitably leave something out. And so if you go the route of listing specific conditions and someone comes in with a condition that\u2019s not on the list, doctors won\u2019t feel comfortable, because they\u2019ll feel that, Oh, well, because the law lists these other conditions, that must mean that anything else is not allowed.<\/em>\u00a0<\/p>\n But on the other hand, if it\u2019s too vague, you have the opposite problem. And so really a lot of mainstream medical groups like ACOG, the American College of Obstetricians and Gynecologists, have really come down on, like: Just don\u2019t legislate this at all. Just let us do our jobs.<\/em> Because they are in this conundrum. I will say, there are divides within the medical community despite that, where some feel like, OK, well, if we can add a few more exceptions and that can even help a few more people, that\u2019s at least something to consider<\/em>, where others think, OK, no, if we endorse these quote-unquote \u201cfixes,\u201d that kind of in a way is endorsing the underlying ban, and we don\u2019t want to do that.<\/em> And so there\u2019s some tension there as well.\u00a0<\/p>\n Rovner:<\/strong> Yeah, this is going to continue to be an issue going forward. All right, well, finally this week there is some other policy news. The Trump administration last week reversed a Biden administration decision to start covering those GLP-1 [glucagon-like peptide 1] drugs for people with obesity as well as those with diabetes. According to The New York Times<\/a>, the administration didn\u2019t attribute the decision to Secretary Kennedy\u2019s known dislike of the drugs, which he has said are inferior to people just, you know, eating better, and that it may reconsider the decision in the future. But obviously cost is a huge issue here. These drugs are less expensive than they were, but they are still super expensive if they\u2019re going to be taken by the millions of people who would qualify for an indefinite period of time. Is there any talk of finding a way to bring that cost down? That would obviously be popular and something that President Trump has said he wants to do in terms of drug prices overall.\u00a0<\/p>\n Raman:<\/strong> I have not heard of anything on bringing the cost down. I think that the only discussions that really come about are really tailoring who would qualify within that bucket, and to narrow that as a piece to bring the cost down rather than the cost of the specific drugs. And we\u2019ve been \u2014 yeah.\u00a0<\/p>\n Rovner:<\/strong> I would say, I know that Ozempic is on the list of Medicare drugs to be negotiated this year, but I think that\u2019s only for the diabetic indication. So on the one hand, that could bring down the cost for\u2014\u00a0<\/p>\n Ollstein:<\/strong> And that wouldn\u2019t help people for years and years. Yeah.\u00a0<\/p>\n Rovner:<\/strong> Exactly. So I mean we might \u2014 if you have diabetes, Medicare could start saving money on one of the GLP drugs, but I guess it\u2019s going to be a while before we see the cost fall. And of course, we didn\u2019t even talk about the potential tariffs on prescription drugs, because we\u2019re not going to talk about that this week.\u00a0<\/p>\n That is this week\u2019s news. Now we will play my interview with law professor Stephen Vladeck, then we will come back and do our extra credits.\u00a0<\/p>\n I am so pleased to welcome to the podcast Stephen Vladeck, professor at Georgetown University Law School and author of the invaluable Substack \u201cOne First,\u201d which helps explain the workings of the Supreme Court to us lay folks. Steve Vladeck, welcome to \u201cWhat the Health?\u201d\u00a0<\/p>\n Stephen Vladeck:<\/strong> Thanks, Julie. Great to be with you.\u00a0<\/p>\n Rovner:<\/strong> So I\u2019ve asked you to help us with the next in a series I\u2019m calling \u201cHow Things Are Supposed to Work in Health Policy.\u201d And I\u2019m particularly interested in how much power the president has vis-\u00e0-vis Congress and the courts. Is there kind of a 30-second law school description of who has the power to do what?\u00a0<\/p>\n Vladeck:<\/strong> It\u2019s a little longer than 30 seconds, but to make the long version shorter: Congress makes laws, the president carries those laws into effect, and the courts decide whether everyone\u2019s playing by the rules and abiding by those laws. That\u2019s how it\u2019s supposed to go \u2014 and if only that were how it actually was.\u00a0<\/p>\n Rovner:<\/strong> Now, I\u2019m not a lawyer, but I have been at this for a long time, and I always understood that executive orders from presidents were mostly for show. They were expressions of intent that needed to be carried out by someone else in the executive branch most of the time, usually using the formal regulatory process. But that is not at all what this administration is doing with its executive orders, right?\u00a0<\/p>\n Vladeck:<\/strong> So, Julie, I think part of the problem is that we really are at the apex of something that\u2019s been building for a while, which is that as Congress has stopped doing its job, as Congress has stopped passing statutes to respond to our pressing issues of the day, presidents of both parties have been left to govern more and more aggressively based on increasingly, for lack of a better word, creative interpretations of old statutes and constitutional authorities. And so, yes, I think we\u2019re seeing differences in both degree and kind from President Trump, but some of this has been building for a while where, we haven\u2019t had meaningful immigration reform since 1986. We haven\u2019t had meaningful financial systems reform in 25 years. And so in those spaces, presidents are going to do what they can to try to accomplish their policy goals, which means more and more executive orders where the presidents are at least purporting to interpret authorities that they\u2019ve been given, either by statute or the Constitution, as we get further and further away from those authorities themselves.\u00a0<\/p>\n Rovner:<\/strong> So this is the unitary executive theory that we\u2019ve, those of us who play to be lawyers sometimes, have heard about. But how abnormal is what Trump is doing now? Is this even legal, a lot of what he\u2019s doing?\u00a0<\/p>\n Vladeck:<\/strong> So a lot of what he\u2019s doing is not legal, but some of it is legal. And one of the complications is that the illegalities are at scales and in ways that we haven\u2019t really seen before and that therefore our existing legal processes aren\u2019t necessarily well set up to respond to. I would break Trump\u2019s behavior into a couple of categories. So I think there\u2019s the internal stuff, which is firing tons of people, hollowing out the bureaucracy, demanding political fealty from even those who are civil servants. And we\u2019ve seen, Julie, I think, flash points of those before. What\u2019s novel about what\u2019s happening now is just the sheer scale on which it\u2019s happening. I think the biggest area of real novel action is the effort by Trump really to sort of change how all federal money is spent, right? Money is supposed to be Congress\u2019s, like, superpower. Not only is appropriations Congress\u2019 most important function, but it\u2019s actually the only thing that the Constitution specifically says only Congress can do.\u00a0<\/p>\n And yet we\u2019re seeing really novel assertions by the president of the power to not spend money Congress has appropriated, of the power to stop paying for contracts where the work has already been performed, of the power to threaten Maine and other jurisdictions with the withholding of federal funds if they don\u2019t just bend the knee to Trump. And that is really, I think, both shocking and dangerous because it basically means that the president\u2019s trying to seize unilateral control over what has historically been Congress\u2019 principal vehicle for doing policy. And at that point, you don\u2019t really have much of a separation of powers anymore. You\u2019ve just got a president.\u00a0<\/p>\n Rovner:<\/strong> Could Congress take back this authority if it wanted to?\u00a0<\/p>\n Vladeck:<\/strong> Sure. But just before letting folks get too optimistic, one of the problems is that taking back this authority probably means, at the very least, passing new statutes, and Trump\u2019s not going to sign those statutes. So one of the things that has been a fear of separation-of-power scholars for a long time is that when Congress delegates authority to the president, or when Congress acquiesces in the drift of power to the president, it\u2019s actually really hard for Congress to get that power back, because it\u2019s usually going to require veto-proof supermajorities, and really hard to see in our current political climate a veto-proof supermajority agreeing even to the fact that today is Tuesday, let alone that we should take back power from the president. So Congress could do tons of things. The problem is that assuming Congress won\u2019t, we really are left to these series of confrontations between the president and the courts, because the courts are all that\u2019s left.\u00a0<\/p>\n Rovner:<\/strong> Which brings me to something that I think most people would think would be not really health-policy-related but really is, which are all these threats against these big law firms. How does that play into this whole thing?\u00a0<\/p>\n Vladeck:<\/strong> So I think it\u2019s a big piece of the puzzle because what the threats, I think, are really intended to do is to cow law firms into submission, to try to increase the cost both economically and politically of bringing lawsuits challenging what the federal government\u2019s doing. And Julie, I think that the long-term idea is to chill people from suing the federal government, to chill people from hiring folks who worked in administrations from the wrong party in ways that I think are really disruptive not just to the economics of law firms but to the courts. The courts depend upon a strong, robust, and independent bar that is able to actually move freely when it comes to challenging the government. Courts can\u2019t go out and find cases. Lawyers bring the cases to them. And if the lawyers are for some reason disincentivized from bringing those cases, part of the separation of powers breaks down even further.\u00a0<\/p>\n Rovner:<\/strong> Or basically, in this case, I guess they\u2019re promising not to bring cases that the administration doesn\u2019t like.\u00a0<\/p>\n Vladeck:<\/strong> Exactly. We should be terrified. No matter what you think of lawyers, no matter what you think of the administration, we should want a world in which there\u2019s no disincentive to challenge what the government\u2019s doing in court. We should want a world, as James Madison put it, where ambition is counteracting ambition, where the branches are pushing up against each other, not where they are stunned into submission.\u00a0<\/p>\n Rovner:<\/strong> And finally, you\u2019re an expert in the Supreme Court. Is there any chance that the Supreme Court\u2019s going to rescue us here?\u00a0<\/p>\n Vladeck:<\/strong> No, but I think what I would say \u2014 to try to both be a little more optimistic and to try to put a little more depth into my one-word answer \u2014 it\u2019s not the Supreme Court\u2019s job to rescue us. It\u2019s the Supreme Court\u2019s job to protect the separation of powers. And as you and I are sitting here, we\u2019ve seen a couple of early rulings from the court that have kind of sided with Trump in these sort of very, very fleeting technical emergency postures without actually saying anything about what he\u2019s doing is legal. I have at least a modicum of faith, Julie, that when the courts get to the legality questions, they\u2019re going to find that most of this stuff actually is illegal.\u00a0<\/p>\n I think the question is, what happens then? And this is why, although I\u2019m as big a believer in a powerful and independent judiciary as anyone, the courts alone can\u2019t save us, right? What we need is we need the courts backed by Congress, by the people, by our other institutions, universities, law firms. I mean it should be all of the institutions of our civil society, not opposing Trump to oppose Trump but standing up for the notion that our institutions matter and that the way that we can be confident that the government is working the way it\u2019s supposed to is when the institutions are pushing up against each other with all their might and without the fear of what\u2019s going to happen to them if they lose.\u00a0<\/p>\n Rovner:<\/strong> I feel like one of the bright spots out of this is that finally the nation is getting the lesson in civics that it\u2019s needed for a while.\u00a0<\/p>\n Vladeck:<\/strong> I couldn\u2019t agree more. I think we are seeing the very, very real costs of generations of insufficient civics education, but I also think this opens the door to real conversation about how to fix this. And in the short term, some of it is about stopping a lot of what Trump is doing, and that\u2019s what a lot of these lawsuits are about. When we talk about, Julie, building back institutions, whether it\u2019s in the public health space or more broadly, I hope that we keep having the civics lesson, and I hope that we don\u2019t forget that it\u2019s actually really important to have independent agencies, and it\u2019s important to have a civil service, and it\u2019s important to have institutions that are actually not just subject to the whims of whoever happens to be the current president. And the more that we can build off of that going forward, maybe the more that we can prevent what has happened already over the first 11 weeks of the second Trump administration from becoming a permanent feature of our constitutional system.\u00a0<\/p>\n Rovner:<\/strong> Well, we will keep at it. I hope you\u2019ll come back and join us again.\u00a0<\/p>\n Vladeck:<\/strong> I\u2019d love to. Thanks for having me.\u00a0<\/p>\n Rovner:<\/strong> OK, we\u2019re back. Now it\u2019s time for our extra-credit segment. That\u2019s where we each recognize the story we read this week we think you should read, too. Don\u2019t worry if you miss it. We\u2019ll put the links in our show notes on your phone or other mobile device. Sandhya, why don\u2019t you go first this week?\u00a0<\/p>\n Raman:<\/strong> So my piece for extra credit is from me, on Roll Call. It\u2019s called \u201cIn Sweden, a Focus on Smokeless Tobacco<\/a>,\u201d and it\u2019s the first in my series I\u2019m doing through the Association of Health Care Journalists, where I went to Sweden to learn about smoking cessation and public health between Sweden and what we can learn in the U.S. And the story looks at the different political factions of the Parliament over there and how they found some common ground in areas to become hopefully the first country in Europe below 5% daily smokers, and just what lessons the U.S. can learn as they\u2019re trying to reduce smoking here as well.\u00a0<\/p>\n Rovner:<\/strong> So jealous that you got to do this. Alice, why don\u2019t you go next?\u00a0<\/p>\n Ollstein:<\/strong> I chose a piece from The Guardian by Carter Sherman [\u201c\u2018We Are Failing\u2019: Doctors and Students in the US Look to Mexico for Basic Abortion Training<\/a>\u201d] on an issue that has interested me for a long time, which is how U.S. residents are learning how to provide abortions when their training opportunities have been eliminated in so many states. I\u2019ve been covering those who have been traveling to different U.S. states, but this piece is about a small but growing number who are traveling to Mexico for this training. Mexico, like many countries in Latin America and really around the world over the last few years, has moved in the direction of decriminalizing abortion as the U.S. has moved in the opposite direction and is very eager to help train more people.\u00a0<\/p>\n But the article stresses that this is not a solution for everyone in the U.S. who needs this training, because you have to be able to speak fluent Spanish in order to do it. You have to already have some abortion experience, which not every medical resident has. And it\u2019s also expensive. There are fellowships, but the trip and the training and everything costs thousands of dollars. And so I think it\u2019s a very interesting opportunity for some people. And the article also talks about folks who are doing some training in the U.K., as well. And so I wonder if these international opportunities will become more of a piece of the puzzle in the future.\u00a0<\/p>\n Rovner:<\/strong> Victoria.\u00a0<\/p>\n Knight:<\/strong> OK, my extra credit for this week is an article in Wired called \u201cDr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall<\/a>.\u201d So basically this was Dr. [Mehmet] Oz\u2019s first town hall talking to CMS [Centers for Medicare & Medicaid Services] staff, and he talked about a lot of his personal story and not as much of the goals of the agency, seemed to be the vibe of the meeting. But also, interestingly, he talked about using AI avatars instead of actual people. So that\u2019s like people that do simple health diagnoses using AI instead to diagnose people, is kind of what it sounded like. And that\u2019s in part because\u2014\u00a0<\/p>\n Rovner:<\/strong> My comment to this story was: Not at all creepy. Sorry.\u00a0<\/p>\n Knight:<\/strong> Right. And\u2014\u00a0<\/p>\n Rovner:<\/strong> I interrupted you, Victoria.\u00a0<\/p>\n Knight:<\/strong> No, no, that\u2019s OK. But he was saying the benefit of this is that it could cost less because it could only cost maybe like $2 an hour versus a doctor could be a hundred dollars for a consult. And so people interviewed in the story were CMS employees that felt very concerned about that and also felt like it could come off a bit tone-deaf when there have been a bunch of CMS staff also just recently let go. And CMS was actually on the agencies that was hit with less workforce cuts. But even so, people are still upset about it. And so, it was like, Why are you replacing great people that worked here with AI?<\/em> It was just an interesting look at his first week at the agency\u00a0<\/p>\n Rovner:<\/strong> Yeah. And it\u2019s a big agency with a lot of money. All right, my extra credit this week is from The New York Times. It\u2019s called \u201cWhy the Right Still Embraces Ivermectin<\/a>,\u201d by Richard Fausset. And it\u2019s a pretty hair-raising story of medical malfeasance, foisted on people by those seeking political or financial gain or both. Quoting from the story: \u201cIvermectin has become a sort of enduring pharmacological MAGA hat: a symbol of resistance to what some of the movement described as an elitist and corrupt cabal of politicians, scientists and medical experts.\u201d This is another in a long list of unproven remedies people take just to thumb their noses at treatments that have, you know, actual scientific evidence behind them. It\u2019s a really interesting read.\u00a0<\/p>\n OK, that is this week\u2019s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We\u2019d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We\u2019re at whatthehealth@kff.org. Or you can still find me at X, @jrovner<\/a>, and at Bluesky, @julierovner<\/a>. Where are you folks these days? Alice, you\u2019re the birthday girl. Where can we all wish you a happy birthday?\u00a0<\/p>\n Ollstein:<\/strong> Mainly on Bluesky, @alicemiranda<\/a>, but still hanging on X, @AliceOllstein<\/a>.\u00a0<\/p>\n Rovner:<\/strong> Sandhya.\u00a0<\/p>\n Raman:<\/strong> On X<\/a> and Bluesky<\/a>, @sandhyawrites.\u00a0<\/p>\n Rovner:<\/strong> Victoria.\u00a0<\/p>\n Knight:<\/strong> I\u2019m just on X, @victoriaregisk<\/a>.\u00a0<\/p>\n Rovner:<\/strong> We will be back in your feed next week. Until then, be healthy.\u00a0<\/p>\n \tFrancis Ying
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