The Host
Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.Millions of people in Republican-dominated states are among those seeing their Affordable Care Act plan premiums spike for 2026 as enhanced, pandemic-era subsidies expire. Yet Republicans in the White House and on Capitol Hill are firming up their opposition to extending those additional payments — at least for now.
Meanwhile, Democrats may not have achieved their shutdown goal of renewing the subsidies, but they have returned health care — one of their top issues with voters — to the national agenda.
This week’s panelists are Julie Rovner of KFF Health News, Paige Winfield Cunningham of The Washington Post, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.
Panelists
Paige Winfield Cunningham The Washington Post @pw_cunningham Read Paige's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories.Among the takeaways from this week’s episode:
- Democrats’ focus on insurance costs has pushed health care back into the national spotlight. But far from a bipartisan compromise, lawmakers remain split over how to address the issue, with the enhanced premium ACA subsidies still set to expire and top Republicans musing about instead putting that money into health savings accounts.
- A new change to the Centers for Disease Control and Prevention website suggests a link between vaccines and autism, amplifying the unsubstantiated claim championed by Health and Human Services Secretary Robert F. Kennedy Jr. Meanwhile, the Trump administration is facing blowback over a major report on transgender health that was written by critics of such care — and without peer review.
- And some Republicans are seeking to tie ACA subsidies to abortion restrictions, providing only the latest example of how the issue regularly becomes tangled in government spending battles. Democrats are unlikely to agree to such changes, especially if Republicans push to direct subsidies into health savings accounts — meaning, theoretically, that any abortion limitations there would be targeting citizens’ private funds.
Also this week, Rovner interviews Avik Roy, a GOP health policy adviser and co-founder and chair of the Foundation for Research on Equal Opportunity.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: CNBC’s “Cheaper Medicines, Free Beach Trips: U.S. Health Plans Tap Prescriptions That Feds Say Are Illegal,” by Scott Zamost, Paige Tortorelli, and Melissa Lee.
Paige Winfield Cunningham: The Wall Street Journal’s “Medicaid Insurers Promise Lots of Doctors. Good Luck Seeing One,” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty.
Joanne Kenen: ProPublica’s “What the U.S. Government Is Dismissing That Could Seed a Bird Flu Pandemic,” by Nat Lash.
Shefali Luthra: ProPublica’s “‘Ticking Time Bomb’: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas,” by Kavitha Surana and Lizzie Presser.
Also mentioned in this week’s podcast:
Click to open the transcript Transcript: The GOP Circles the Wagons on ACA[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello from KFF Health News and WAMU Public Radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 20, 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 video conference by Paige Winfield Cunningham of The Washington Post.
Paige Winfield Cunningham: Hi, Julie.
Rovner: Shefali Luthra of The 19th.
Shefali Luthra: Hello.
Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with Avik Roy, longtime Republican health care adviser and chair of the Foundation for Research on Equal Opportunity. But first, this week’s news.
So, Democrats may not have “won the shutdown,” but they definitely got health reform back on the national agenda. The last time we had such a full-scale health debate was in 2017, which didn’t end particularly well for Republicans. For a while, it looked like there might be enough Republicans who were worried about — oh, I don’t know — their voters seeing their ACA [Affordable Care Act] insurance made effectively unaffordable that there might be a compromise in the offing. But now it seems that ship has sailed, and the two sides have retreated to their respective corners. That certainly seemed to be the case at the Senate Finance Committee hearing on Wednesday, where Republicans and Democrats basically talked past each other for three hours. Am I missing something? Is there some glimmer of hope here that I’m not seeing that when they have this vote in a couple of weeks, the Republicans are all going to say, Yeah, let’s extend those subsidies?
Winfield Cunningham: It’s funny, Julie, I was thinking, was it last weekend, I think, that Trump tweeted about we need to bypass the insurers and send the money directly to consumers? And for a couple of days, there was all this buzz around Is this going to be yet another chance for Republicans to do something big on health care? And the whole time I was thinking: Was anybody around in 2017? This isn’t going to go anywhere. And especially, you could sort of predict this just because calls to redirect the subsidies — which are a core part of the ACA — away from the marketplaces, also a core part of the ACA — directly into tax-free savings accounts obviously [were] always going to be a no-go with Democrats. So the idea that this was kind of what Republicans were talking about, this isn’t even in the realm of possibilities that could be a bipartisan agreement on health care.
There seems for a little while to be a semi-earnest effort in the Senate to come up with some kind of bipartisan plan. I know I spoke with folks for Sen. [Jeanne] Shaheen [D-N.H.] earlier this week who say they’ve been talking to 10 to 12 Republican offices who say they’re interested in some kind of deal and extending the subsidies. But honestly, when you start stacking up all of the barriers that would be in the way of getting a deal, one of them is abortion funding. I mean, this seems —
Rovner: We’ll get to that later. Don’t jump the gun on that.
Winfield Cunningham: But that’s a huge one. And then also, just the inability, and just how far apart the parties are on talking about health care affordability and how you manage to bring down costs for people. It’s just really hard to see this going anywhere. So, my prediction is that we see Republicans kind of coalesce around their own thing. Democrats coalesce around their own thing. And ultimately, we don’t see an extension of the subsidies.
Rovner: What happens in January, though, when people actually start coming to town hall meetings and saying: Hey, we had to give up our health insurance because it was going up $4,000 a month? Might this build when these cuts actually occur in January?
Kenen: The Republicans have floated health savings accounts for actually a couple of decades now.
Rovner: Since the 1990s.
Kenen: Right, that’s decades.
Rovner: The first pilot project was in HIPAA [Health Insurance Portability and Accountability Act] in 1996.
Kenen: And it is not what people want. I mean, it is what some people want in conjunction with an HSA alone. There are plans that are a combination of — in the exchange it would be a “bronze” — but this is not what the American people have. … They have not been saying: Please, take away my health care, and give me a couple of thousand bucks instead. That’s not what we’re hearing, or my health insurance, I should say, and take away.
Rovner: That’s the point. Also, I’m seeing all these Republicans now saying we should not be giving money to the big, rich, bloated insurance companies, who we do know are unpopular instead —
Kenen: Except for Medicare Advantage.
Rovner: Thank you for finishing my sentence. So, finish my sentence for me, Joanne.
Kenen: Medicare Advantage, which has bipartisan support now — not without some qualifications and criticism — Medicare Advantage is here. Many Democrats use it, and many Democratic lawmakers support it. But Medicare Advantage is private insurers who are being paid more than government-traditional Medicare to pay for people’s health care. So it is not a coherent, well-thought-out ideologically, or technically, or politically savvy plan that is going to solve the Republicans’ problems on Jan. 1, Jan. 2, Jan. 3, and you name the date after that. People who got subsidies for health care insurance are going to lose them, and many of them are [President Donald] Trump voters. And that’s a reality, period.
Rovner: Paige, I know you’ve been looking into this pretty closely. Is there anything new here? I mean, it does seem that giving people money to go out and bargain on their own has been the Republican mantra, I know, since the 1990s. They’ve had all this time. Where is the plan?
Winfield Cunningham: Let’s just think about the numbers here on HSA. So, I think the average subsidy [that] the average marketplace consumer gets is around $6,500. OK, that’s fine — great — if you’re healthy. If you’re sick — if you have diabetes, or you have cancer — say you have $6,500 in your account, [and] you don’t have health insurance, that’s not going to come anywhere close to the cost that you need to cover your cost of care. So this whole conversation isn’t about the healthy people, right? The conversation is about the sick people who bring up the costs, who need the insurance, who can’t afford the care. And HSAs and FSAs [flexible spending accounts] — especially HSAs, though — I think are largely used by wealthier people, healthier people, and it is a way to maybe put a couple extra hundred bucks in your pocket to pay for health care. It is not a sweeping long-term solution to making sure that people can afford the cost of care.
Rovner: Right. It’s a great way to pay for your eyeglasses and your dental care, maybe, if you don’t need a lot of dental care.
Kenen: It’s not just sick people. It’s also pregnancy. It’s also people who are healthy until they get sick. You can —
Rovner: I keep saying this: I fell and broke my wrist, and it cost $30,000. $6,500 would not have begun to put a dent in it. Sorry, Shefali. You wanted to say something?
Luthra: No, I was just going to say to Joanne’s point about pregnancy and your point about breaking bones: Some of the people who are most vulnerable in this kind of situation [are] families. Maybe you give birth, something the administration really talks about supporting. Maybe, I don’t know, you use fertility treatment. Maybe you have two kids. One gets the flu; one breaks a bone. These are not expenses you anticipated. And the very core of this pronatalist, conservative ideology of supporting families, helping it become easier to raise children, becomes a lot harder when you don’t have affordable health insurance.
Kenen: I mean, there are some. [Louisiana Republican Sen. Bill] Cassidy’s plan is a little different. Democrats are still not going to love it. It is money in your pocket of a health savings account or a flexible spending account — I keep reading different details of what it is — combined with some kind of health insurance so that the exposure is not infinite, but it’s also not nothing. It’s not the same as Trump’s plan. There’s more protection for people in his version. But we haven’t really seen what his version looks like in detail. I keep reading about all these proposals, and I can’t figure out exactly what they look like because I don’t think they know yet.
Rovner: Right, I don’t think they’ve been put on paper yet.
Winfield Cunningham: Well, yeah, I asked Cassidy’s office for details earlier this week, and they didn’t respond. I don’t know if they’re waiting to see what polls well among colleagues. But I was going to say: On the politics, I’m never great on political analysis because I feel like I’m always wrong. But I would say [the] last time Republicans tried to go after ACA in 2017, Democrats really successfully leveraged that in the following year. They talked about trying to go after protections for preexisting conditions. And you’ve already seen, I think, [that] the DCCC [Democratic Congressional Campaign Committee] already put out some ads on the subsidies. So, this is going to be a huge, huge point for Democrats. They’re going to be talking about this nonstop next year. So, I imagine it would hurt Republicans.
I’d also add, I think that Democrats sometimes have more to lose on health care than Republicans only because health care is not a top issue for Republican voters in the way that it is for Democratic voters. So, sometimes, Republicans can make missteps, and then their voters are more forgiving of it than maybe they would be of Democrats.
Rovner: Although we’ll see, because as we keep saying, there’s a lot of Republicans in a lot of these states that have been using these extra subsidies. When they go away, they’re going to be really ticked off.
Kenen: Could I just say one last thing? And we’ve said this again, we’ve said this repeatedly, but it is worth bearing, repeating is: Congress usually gives people benefits. Taking away benefits is not really a politically savvy approach. And then, yes, Medicaid isn’t until after the election, after the 2026 elections. But there’s going to be repercussions from the Medicaid law that [are] also going to be felt in the near term in terms of how are hospitals preparing, and responding, and cutting back, and what’s available in communities, and debates in their state legislatures about how they fill budget holes, and what services will be cut. This is turning into a health care year on both the ACA health costs and affordability and the impact of Medicaid that usually helps Democrats. But we are living in a time of intense short attention spans. We’re not living in … the parallels don’t always apply to the current situation, but it’s a Democratic issue.
Rovner: Yeah. Well, continuing on my theme of maybe Democrats didn’t really lose the shutdown despite what many of them said, I’m kind of surprised at all the things that did get into the continuing resolution that passed last week and reopened the government. Democrats got all the federal workers back pay, which, despite being the law, was not a given. They got the federal worker firings during the shutdown reversed with a promise of no more RIFs [reductions in force] until at least the end of the next CR at the end of January. Because the CR also included full-year funding for the Department of Agriculture, they also got SNAP [Supplemental Nutrition Assistance Program] fully funded through next September.
But two other really nerdy things were tucked into the bill that could turn into a big deal. One is the explicit rejection of a proposal to cut in half the budget of the Government Accountability Office, GAO, and preserving the right of the GAO’s head, the comptroller general, to sue the administration for violating the Impoundment Act, which is what protects Congress’ power of the purse. This is really the fight over the funding bills, right? We’ve got the Trump administration saying, Congress, we don’t actually care what you do in these spending bills. We’re going to decide how to spend this money. — which is not what the Constitution says.
Kenen: But the Congress has its objective. I mean as the administration —
Rovner: The GAO has, and they’re suing.
Kenen: Right. But at the end of the day, what’s happening in the courts is not really changing behavior all that much, so it’s still —
Rovner: Because it hasn’t all been resolved yet.
Kenen: It’s a TBD [to be determined]. I think we’ll know more after the tariffs ruling. But when they do suffer a defeat in court, they just sort of find another way around. Even if they do something, the court says they just find another way of doing what they wanted to accomplish.
Rovner: Yes, which we have seen. And apparently they did. I saw a story this week that they were trying to put in a provision that would stop what we call the pocket rescissions. Right now, the administration can say, We don’t want to spend this money, and then Congress votes on whether or not to agree with the administration. But if they do it at the end of the fiscal year, it’s too late. And that’s called a pocket rescission. There was some language to stop that, which also appears on its face to be illegal. And apparently Russell Vought of OMB [Office of Management and Budget] complained, and it was taken out of the bill before it was passed. So that fight [is] going to still continue.
Well, there’s another even more nerdy provision that resets something called the PAYGO [pay-as-you-go] scorecard to zero. Among other things, this cancels the required cuts to Medicare that would’ve been the result of the Republicans failing to offset the cost of the tax cuts in last summer’s big budget bill. You may have heard Democrats referring to these cuts and thought they meant Medicaid, thought they were misspeaking. They were not. There actually was a half-a-billion-dollar cut to Medicare that was in the offing. But canceling this kind of cuts both ways because it takes away a talking point for Democrats, right?
Kenen: Yes, but I don’t know that that one’s going to matter so much in six, 10, 12 months. Because also, we’re used to them not doing the cuts to Medicare that they’ve said. I mean, they walk to the very edge of the plank and jump back into the boat over and over again since 2012 at least, probably before that. So I don’t know that that has the staying power. It’s hard. Like the word sequester, unfortunately we understand it, but a lot of people think it’s a jury. I mean cuts that didn’t happen —
Rovner: Right, and cuts that are not going to happen. We’ll see how long it takes the Democrats to wipe the Medicare cuts out of their talking points, which they now have to do because that was in the bill. Well, meanwhile, even with the government back open, the chaos continues at Robert F. Kennedy Jr.’s Department of Health and Human Services, where just this morning we’ve seen a change to the CDC [Centers for Disease Control and Prevention] website suggesting that vaccines might cause autism. They do not. And a new large-scale study showing that fluoride in typical doses doesn’t lower kids’ IQs, which is the exact opposite of what RFK Jr. has been saying. Paige and Shefali, you’re following this report on transgender care, which is another sort of big controversial issue over at HHS.
Winfield Cunningham: Yeah. So what we saw yesterday was basically the final release of this report, which was ordered up by Trump via executive order earlier this year. And they had released an initial draft last spring, but at that time, they didn’t release the names of the authors on the report, nor did it have any peer reviewers. And that was the focus of a lot of the criticism of the report — that there wasn’t transparency there to see who was actually reviewing all of this evidence around gender-transition care for kids. So, we saw the names of the nine authors were released yesterday, as well as about eight peer reviewers. This also, not shockingly, did not engender a lot of wide confidence in the medical community about this report. And the authors of the report all have prior histories of criticizing how gender-transition care is delivered in the U.S. And critics have pointed to that saying: Well, the report’s not legitimate because basically the people were handpicked by the administration to deliver a particular conclusion.
And so I’ve been talking to some of the authors. They are of course defensive. They say, Look at the research. Look at the report. The report does skew very critical of transition care and recommends counseling first, which is something that some of the leading medical organizations are pushing back against. So, I don’t know where all this is going to go. I think the debate [is] going to continue, but certainly we’re going to see the administration use this report to try to undergird its arguments for a dramatic crackdown on transition care. They’re actually working on two rules at CMS [Centers for Medicare & Medicaid Services] right now which would penalize hospitals for providing transition care for kids. Those rules are being reviewed I think by the White House right now, but we’re probably going to see those finalized sometime next year.
Luthra: I think some really important context for us to consider here — in this conversation as well as what the actual reality of health care looks like for trans youth — and in particular, the thing that really stands out to me as we look at this report and look at these criticisms that these authors are levying, is that already, for young people who are getting gender-affirming care, it’s a very involved process. There aren’t a lot of providers who offer this to begin with. There is a lot of counseling. The idea that young people are getting these gender-affirming surgeries at a young age without any sort of long-thought, long conversation just isn’t really borne out by evidence. There is a lot of conversation, a lot of counseling. A lot of youth start with things that are reversible. You start with maybe something that doesn’t have that same level of permanence before ensuring that this is something that people truly do want. And I think that’s really important.
The other thing that really sits with me in this conversation — which I think this is a conversation that has been really built up by a lot of social conservatives who are looking for a new target after they sort of lost the war on gay marriage — is that young people are sort of a starting point. And we’ve already seen a lot of efforts in some states to expand restrictions on gender-affirming care — not only for young people, but for people of all ages who are trans. It reminds me a lot, actually, of the conversation around abortion, where you began with restrictions for young people as a pathway to restricting it writ large. And I think we have to be really aware of that context when we look at how this political and policy fight unfolds.
Rovner: Yeah, there’s also a lot less of this care you’re saying. It is hard to get. There’s less available than there was at the start of the year. We’ve seen so many of these universities and hospitals knuckle under and say, We just don’t want to be part of this because they’re threatening to take away all of our funding. There’s a new study in JAMA Internal Medicine this week that found that HHS cuts from earlier this year disrupted more than 400 clinical trials, and treatment for more than 74,000 patients who were participating in those trials. Most impacted, according to the report, were trials on infectious diseases and prevention. But a second study chronicled the deep cuts to gender-affirming care. So, it’s not even how it’s being delivered, it’s if it’s being delivered at this point, right?
Luthra: The people who are getting this health care have gone through a lot of hoops to get this care already. They have shown a real … desire is the wrong word. They have worked very, very hard to get here in a way that you don’t do if this isn’t something you have thought about a lot.
Rovner: It’s not like quitting smoking.
Winfield Cunningham: But I also add, this isn’t a conversation that’s only happening in the U.S. This is happening around the world. You have seen a huge surge of young people seeking this care. So it’s kind of a relatively new thing. And in a way, just in terms of the number of people, and you’ve seen. … I think New Zealand actually this week announced that they’re putting new restrictions on puberty blockers for young people. You’ve also seen similar things in the U.K. [United Kingdom] and the Netherlands. And they’ve also conducted reviews, just raising questions around how much evidence we have around the long-term benefits or harms of giving these treatments to kids. So I think it’s an important conversation for researchers to be having. And I think it’s unfortunate it’s gotten so politicized, because this is, to Shefali’s point, really important for a lot of children in the U.S. and around the world. And yeah, it’s really important for researchers to have a really clear picture of the best way to help them.
Rovner: Yeah, I was going to say this is one of those things that’s both a culture war issue, and a legitimate medical scientific issue that we’re looking at.
Well, meanwhile, it’s not just policy that’s a little chaotic at HHS. According to The Wall Street Journal, the secretary reportedly considered sidelining FDA [Food and Drug Administration] Commissioner Marty Makary because of his inability to control infighting between some of his division directors. Yet it feels like FDA is kind of the least of Kennedy’s worries right now. Also ongoing are fights between supporters of MAGA, the Make America Great Again movement, and MAHA, the Make America Healthy Again movement, over who should be in charge of health policy. Is this just usual infighting, or is this sort of new and different and [at] a more significant level than we often see?
Kenen: I’m not sure we know yet, because some of this stuff is boiling up pretty quickly. But we’re seeing all sorts of splits and fractures on the Republican side that we have not been accustomed to seeing. Trump is very good at unifying his party, and papering over things, and changing the subject. He’s a very, very gifted controller of narrative. And the fact that we’re seeing policy splits as well as the [Jeffrey] Epstein scandal, and all sorts of other things, it’s not one crack. There’s a bunch. And crack might be too strong a word — we don’t know yet — but we’re seeing more dissent, and more disagreement bubbling over in public than we had before.
Rovner: Yes, and that’s what’s so unusual to me. Have these people had long knives out for each other? Absolutely. Have we seen big front-page stories about it? Not so much.
Kenen: And it’s heightened since the New Jersey and Virginia races. It’s more blame-gaming going around. So I think we’re seeing a slightly different internal landscape among Republicans, as we just said, it’s apparent how much these health care versus public health versus vaccine versus MAHA versus MAGA, these … how much they splinter and stay splintered. It’s interesting to watch right now. I mean, Kennedy hasn’t been that engaged on the health policy side, the insurance fight, the HSAs, FSAs, subsidies. That’s not where his public energy is.
Rovner: He’s left that to Dr. [Mehmet] Oz mostly.
Kenen: Right. And we know what’s important to him. There’s a long list of changes he wants to make on that side. So, I think it’s interesting. I think it’s significant. I don’t know what it’s going to look like in a month.
Rovner: OK. We’re going to take a quick break, and we will be right back.
OK. We’re back. Well, there is also news, finally, this week on the reproductive health front, as you tried to jump the gun, Paige. Circling back for a minute to the impending vote on extending the enhanced ACA subsidies, abortion turns out to be a big obstacle to any potential compromise, even if there was one to be had. This shouldn’t really be surprising. Abortion very nearly scuttled the passage of the ACA itself in 2010 —
Luthra: At the very last minute.
Rovner: At the very last minute. And anti-abortion forces still think the law is too lenient, even though it’s a lot more restrictive than abortion-rights backers had wanted and fought for. Shefali, are Republicans really going to refuse to stop premium increases for voters just to please the anti-abortion movement?
Luthra: I don’t see why not. It seems like this is … I mean, really, though, the anti-abortion movement in some ways took a pretty big loss getting Trump as the Republican president. This is someone who does not really want to capitalize on the post-ops momentum with a national ban. And so they’re looking where they can to try and restrict abortion through other means — whether that meant the Planned Parenthood defunding, whether that means trying to get this mifepristone reviewed, or if it means trying to enact more restrictions through ACA subsidies. It really seems like kind of a no-brainer. If you can’t get this win for a very important constituency from the president, you do what you can everywhere else to try and get it, or get at least what you can.
Rovner: OK. Paige, now you get to say what you wanted to say before.
Winfield Cunningham: Well, no, I guess I was just going to say again, I’ve just been thinking a lot about 2017 and how health reform never seems to go forward. But yeah, this is a perennial issue. It’s all about the Hyde [Amendment] language and anti-abortion folks, and Republicans have always been very resentful of how the debate about the ACA went about. And they are upset because they think these plans are that taxpayer dollars are still going to abortions, et cetera, et cetera. And actually, I was thinking with this HSA idea of rerouting the subsidies to the HSAs, the problem would actually be even more pronounced, because they’re going to demand that you attach then abortion restrictions to money that people have in their own accounts that they’re supposed to be using for health care. And that just seems like even more of a no-go with Democrats. I think all of us knew this was a big obstacle, but it takes a little bit of time for people on [Capitol] Hill to figure this out, but I think it’s becoming more and more clear that this is just a really massive barrier.
Rovner: Yeah, it is. All right, well the abortion fight also continues in the states. South Carolina lawmakers this week held a hearing on what would’ve been the strictest abortion ban in the country, allowing judges to send women who have abortions to prison, and potentially restricting IVF [in vitro fertilization] and some forms of birth control. Apparently, that bill went a little too far, even for some Republicans on the subcommittee. The bill failed to advance, at least for now. Are we likely to see more laws like this, though, as states try to top one another in pleasing what the anti-abortion forces want?
Luthra: I think we will. This is a really long-standing and deep debate in the state-based anti-abortion movement, and in particular the debates over contraception, the debates over IVF, and especially around whether you send someone who gets an abortion to prison, whether they’re held criminally liable. And there is a very extreme movement; they call themselves abortion abolitionists. They are introducing bills and growing numbers every year, trying to build up support. Even some of the pretty conservative abortion opponents say, Oh, those people are too extreme for me. But they’re gaining influence. And I see this as a conversation and a debate that the anti-abortion movement only continues to have, especially as this is something that progresses on the state level and not necessarily the federal one.
Winfield Cunningham: I do wonder, though, how much more room there is for state bans, because you saw this huge surge in red states placing bans after Dobbs [Dobbs v. Jackson Women’s Health Organization]. At this point, I think around 17 or so states have almost-complete bans on abortion. So in a way, I think there’s been a lot of work done there. And I think the opportunity that the anti-abortion folks see is at the federal level, but of course they’re running into top appointees — Kennedy, some of the others at HHS, who, for them, this is really not a priority — and it doesn’t sound like anti-abortion folks would love to see them roll back access to mifepristone, for example. I’m not convinced that’s going to happen anytime soon because the folks pulling the levers there aren’t necessarily in the camp.
Rovner: Yeah, apparently one of the reasons that people aren’t angry with Marty Makary at FDA is because he appears to be slow-walking this mifepristone study, and he approved, even though he had to, another generic of the medication. So, I know that that’s also part of this.
Luthra: If I can add one more thing, Julie?
Rovner: Yes, please.
Luthra: Frankly, a really good litmus test for where states are heading is coming in only a few weeks when Texas’ new abortion law takes effect. And this is one of the most ambitious efforts to stop telehealth and shield law provision of abortion. And this is an area where state-based abortion opponents are very frustrated, because they see it as breaking or fundamentally incapacitating their abortion bans when people can still get medication through the mail from doctors who have not been successfully prosecuted for doing so. And so, when this law takes effect, it enables civil lawsuits against people who make medication abortion available in Texas. I think we will see: Are there civil suits filed by abortion opponents, for instance. Is there any really concerted effort to use this new tool to stop telehealth? And if so, does that spread to other states? Especially since Texas has for so long been a real pioneer in abortion restrictions and making it even harder to get.
Rovner: Yeah, where Texas goes, so go the rest of the red states.
All right, that is all the time we have for the news this week. Now we will play my interview with Republican health expert Avik Roy, and then we will come back and do our extra credits.
I am so pleased to welcome to the podcast Avik Roy here in person in our studio at KFF. Avik is co-founder and chairman of the Foundation for Research on Equal Opportunity, which studies and recommends social policies for the half of the population that earns less than the U.S. median. But he’s also a longtime health policy wonk and health adviser to Republicans, including several Republican presidential candidates over the years. And full disclosure, he is, like me, a fellow Michigan Wolverines fan.
Avik Roy: Go, Blue.
Rovner: Avik, welcome to “What the Health?”
Roy: Great to see you, Julie.
Rovner: So, how did you come to health policy? It was a bit of a winding road, wasn’t it?
Roy: Yeah, I kind of fell into it. I was working as a health care investor, actually, at Bain Capital and a couple of other places like that, as a health care investor. In 2008, [Barack] Obama gets elected and starts to talk about what we now call the Affordable Care Act, or Obamacare. And I wasn’t reading anything I agreed with. At that time, you had Ezra Klein, then at The Washington Post, and you had Jonathan Cohn at The New Republic. You had that group of young bloggers who are writing, Hey, there’s this brilliant MIT economist named Jonathan Gruber, and he’s got it all figured out, and everything’s going to work great, and premiums are going to go down. And Obama himself promised that premiums for the average family of four would decline by $2,500 per year. That’s what he campaigned on in 2008. Then on the conservative side, you had a lot of people writing things like, It’s big government. It’s unconstitutional. It’s welfare.
And I found these arguments kind of like empty calories, because for the average American who’s struggling to afford health insurance and health care, I just don’t see how that person is going to respond to that kind of argument. They’re going to be like, Look, if one side is telling me they’re going to reduce my premiums by $2,500 per family per year, and the other side is just saying, ignore this all because it’s big government, which side is the average person going to choose? They’re going to choose a side that’s going to try to reduce their health care bills. And my point of view was not aligned with either of those positions. My point of view was actually: Health care bills are going to continue to increase, and the design of the ACA has a number of flaws that are not being called out because the conservative critics just weren’t digging into the technical design — the architecture of the bill. And even though I’m not as eminent as Jonathan Gruber, I did go to MIT. And so I maybe felt a little more willing to engage in that debate.
Rovner: And you’re a doctor.
Roy: Well, I went to med school. I never practiced, don’t have a license.
Rovner: But you have, at least, the medical education. So you have a good bit of background in this. I want to think broadly. Every other developed country has some sort of national health insurance scheme. Most of them are hybrids of public and private. Some of them more public; some of them more private. Why hasn’t the U.S. been able to solve this problem that every other developed country has?
Roy: We actually do a lot of work on this at the Foundation for Research on Equal Opportunity. We have a whole annual research product we put out called the World Index of Healthcare Innovation, where we compare 32 countries around the world with the highest GDP [gross domestic product] per capita that have a population over 5 million on quality, choice, science and technology, and fiscal sustainability. So, a number of other people do these kinds of comparisons, but our study is different for two reasons. One, we don’t just look at OECD [Organization for Economic Co-operation and Development] countries, which is typically where most academics get their data. We look at countries that are outside the OECD, particularly in Asia. And we also again score countries not merely on health outcomes and equity-type measures, but we also look at things like fiscal sustainability, which we think matters for long-term equity, and science and technology. One of the defenses of the American system that you always hear is, Well, yes, our system is so expensive, but we’re also the innovation center of the world, and you can’t have one without the other.
So, one thing that we wanted to study was: Is that really true? Can you have innovation at a U.S.-like level but with a universal system that covers everybody and has good quality? And the system that has ranked No. 1 in our study every year is Switzerland. The reason that’s really interesting is because there’s a misconception, both on the left and the right, that to achieve universal health insurance you have to have a single-payer system. And that’s not actually true. There are plenty of countries — they are a minority of the industrialized countries, but it’s a robust and significant minority — that have achieved universal coverage using private insurance, not necessarily a single-payer, government-run insurer. And Switzerland is, in our view, the best example of that because Switzerland is a place where there’s an innovative pharmaceutical and biotech, and med devices ecosystem. They have universal coverage. It’s basically like Medicare Advantage for all, or Obamacare for all. It’s a universal individual market where the market is regulated and subsidized, but it works.
Rovner: I would say big subsidies. I’ve been to Switzerland. I’ve studied the Swiss health care system.
Roy: Big subsidies. It depends on your vantage point. Relative to the American system, the subsidies are actually quite low. So what Switzerland spends subsidizing health care is about 45% of what the U.S. spends per capita subsidizing health care. We actually subsidize health care per capita more than any other country in the world, because the cost of health care is so high in America that the cost of subsidizing health care is so high.
Rovner: Which was going to be my second point about Switzerland is that it’s way more regulated than a lot of Republicans think.
Roy: Well, it’s about as regulated as Medicare Advantage, or the ACA plans in terms of the insurance plan to sign. There are other things — and we don’t have to spend all of our time on Switzerland here — but you ask the question, it’s like, Why can’t we do this in America? That was your original question, and there’s a number of reasons for that. One is path dependence. With any health care system, once you’ve established it, it’s hard to change. The one thing I’ll say that we did in the mid-20th century that really put us on this path was when we excluded from taxation employer-sponsored insurance, because in World War II there were wage and price controls. Employers figured out how to get around that by offering employer-sponsored insurance that wasn’t regulated by wage and price controls. And then after the war, [Dwight D.] Eisenhower said, Yeah, let’s not tax those insurance policies because they seem to be important for people.
And it was kind of an offhanded decision. No one really knew that that was going to be this big thing. But sure enough — 80 years later, or 70 years later — here we are. And I would argue that’s the biggest driver of health care inflation, because we don’t merely have third-party payment for health care. Every country has third-party payment for health care. But we have third-party payment of third-party payment of health care. We have ninth-party payment of health care basically. And no wonder that no one has any sense of why everything is so expensive. But that’s the core driver. And unfortunately, Medicare, in particular, built on that system. When the Medicare law was passed in 1965, a key element of Medicare was to build upon and drive the benefits based on the traditional Blue Cross employer-based plan, which had by that point already ballooned into something resembling what we have now.
Rovner: So why has health care been such a low priority for Republicans? I always hear, Well, Republicans don’t really work on this because it’s not important to their voters. That can’t possibly be true anymore.
Roy: I think everything you said is just right. I think that historically, Republicans didn’t feel that it was relevant to their voters. And their voters weren’t really pushing for it because their voters were — relative to the median constituent — perhaps more likely to be employed, or more likely to be on Medicare — and therefore didn’t feel like they had to worry about affordability. But affordability, as everybody at KFF knows, and the audience that listens to your program knows, affordability is a big deal for everyone. Premiums in the employer-sponsored market have gone up, and people don’t necessarily notice that. But they notice that their paychecks have been flat. They notice their deductibles going up, and their copays going up, and that’s been a big problem both in the ACA markets, and the employer market.
But affordability is a big deal. And now that the Trump GOP has become more of a working man and woman’s party — and you see it in all the exit polls that if you actually look at who’s voting for Democrats and who’s voting for Republicans in presidential election years — the Republican electorate is now a bit more lower-income than the Democratic constituency, which has a lot more of those college grads, and grad school grads. I think you’re starting to see more of that populist concern about the affordability of health care, but there’s still an enormous amount of intellectual catch-up to get there. And I think because of this experience of studying the international health care world, I’ve been much more optimistic about the ability to achieve universal coverage in a way that’s friendly to free marketeers, people who believe in private-sector competition.
Whereas I think the traditional Republican view, which you kind of alluded to earlier — and I ran into this a lot in the 2017 repeal-and-replace debate — was it’s not the federal government’s job to ensure that everybody has affordable health insurance. That’s what I heard from a lot of the kind of old-line Republicans and Republican staffers in the 2010s. It’s not the federal government’s job to guarantee affordable health insurance for people. That should be up to ordinary people to make enough money to afford health insurance. And I disagree with that very strongly. And the reason I disagree with that very strongly is because it was the federal government that screwed it up in the first place. It was the tax exclusion for employer-sponsored insurance, and then some of the things around the design of Medicare that drive all the health care inflation that we’ve seen over the last 80 years.
So the federal government created the mess, and it is the federal government’s job to clean up the mess. And I guess you could say a big purpose of my work is to try to convince more Republicans to agree with me on that.
Rovner: So why has it been so hard for Republicans to come together on anything? The Democrats have big divisions, too, on health care. They have a big chunk of Democrats who would like “Medicare for All,” and another chunk of Democrats who would like to build on the existing system. Republicans presumably have the same kinds of divisions, just in the other direction, and yet we almost never see Republican proposals, and we do see Democratic proposals.
Roy: Well, I will quibble with you a little bit, Julie, in that there are Republican proposals. They don’t always get the same amount of media coverage that the Democratic proposals get. There is a bill that’s been introduced in both the House and the Senate, based on our work at FREOPP, called the Fair Care Act, which would achieve voluntary universal coverage. It wouldn’t force anyone to buy coverage, but everyone who wants to buy health insurance would be guaranteed to have an affordable option. It would reduce the deficit, increase coverage by about 9 to 10 million, and also reduce federal spending. It would reduce taxes, and reduce federal spending, because it would reduce the underlying cost of health care.
Rovner: How?
Roy: By, in particular, tackling the power of hospital monopolies, and being more aggressive about high drug prices. And it would also means-test the subsidies. And by means-testing, I don’t just mean means-testing Medicare, which is often what people talk about, but also means-testing the employer tax break for health insurance, for example, and really having —
Rovner: So more like Switzerland.
Roy: Exactly. So all these random digressions that I’ve been coming … there is actually a coherent idea here that I’m trying to get to, and I thank you for reminding me on that.
Rovner: Well, we’re back in the thick of it. Avik Roy, hope we can have you back again.
Roy: Thanks, Julie. I’d love it.
Rovner: OK. We’re back. 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 will put the links in our show notes on your phone or other mobile device. Paige, why don’t you go first this week?
Winfield Cunningham: Sure. Yeah. Well, I was really struck by this story in The Wall Street Journal called “Medicaid Insurers Promise Lots of Doctors. Good Luck Seeing One.” And this was just a really, really intensive look at some of the struggles faced by Medicaid patients when they go to their plan, they look up doctors, they try to get appointments, but it turns out that a lot of the doctors listed in the directories for these Medicaid plans don’t see patients anymore, or they’re far away. And there’s a real mismatch here between the providers’ insurer networks’ claim to offer and what is actually available to people. And of course, a lot of Medicaid patients live in medically underserved areas. So I just thought this article, they had actually looked at some patients that live near St. Louis, my hometown, and how difficult it was for them to find a timely appointment with a specialist. I just thought it was a really good, intensive look at some of the real challenges here in the Medicaid program.
Rovner: Yeah, provider directories are sort of an underappreciated huge problem in the entire health care system. Joanne?
Kenen: This is a piece from ProPublica, “What the US Government Is Dismissing That Could Seed a Bird Flu Pandemic,” by Nat Lash, with pretty cool graphics by Chris Alcantara. And basically, they’re arguing that the USDA [United States Department of Agriculture] for three and others prior to Trump — it’s not just a Trump administration policy — has been emphasizing sanitation, and what they call biosecurity practices to stop bird flu entering. They blame it on sort of bad control, like the farms let bad stuff in. And in fact, there’s increasing evidence — and ProPublica worked with researchers and experts on climate and wind patterns and everything — that it’s airborne. That it’s coming in on wind and dust. That it’s not just what’s tracked on the floor. It’s on the feathers. And that the whole approach is therefore inadequate. And also the USDA has refused to do vaccination, which many European countries are doing. So the combination of underemphasizing the role of wind and air current, and the reluctance has to do with import policies and the economy of poultry and eggs, is really putting us at greater risk.
Rovner: Yeah, very scary story. Shefali?
Luthra: My piece is from ProPublica. It is by Kavitha Surana and Lizzie Presser. It is called “Ticking Time Bomb: A Pregnant Mother Kept Getting Sicker. She Died After She Couldn’t Get an Abortion in Texas.” The story really wrecked me. It’s really important journalism. It is a story about one woman, in particular, but then gets into the fact that there are many cases like this of people who are pregnant, have medical conditions that make their pregnancy very high risk. So their health is threatened but not their lives. And as such, they don’t qualify for an exception under an abortion ban like Texas’. And the woman in this story, Tierra Walker, died. She already had a kid who now does not have his mom because she couldn’t get an abortion.
And I think what this story really gets at is a few important things. One is that the exceptions that states have passed don’t account for the fact that pregnancy can make your health really at risk, even if there’s not something really dramatic like sepsis. It is just simply all the other things that make you at greater risk of dying. The other thing that’s really important is that all these doctors who treated her never suggested an abortion. That’s important because it underscores that years later, there is still a lot of fear for health care providers operating in these states that is very obvious that being pregnant was a risk for this patient. And there was a conversation that she could have had with her medical provider, a choice that she and her family could have made about her circumstances and what was best for her. Doctors didn’t feel safe having that conversation because of state laws. And now she’s dead.
Rovner: And yeah, this is a continuation of a ProPublica series that won a Pulitzer this year. So they’ve been tracking this through several states and lots of patients, unfortunately.
All right, my extra credit this week is from CNBC. It’s by Scott Zamost, Paige Tortorelli, and Melissa Lee. It’s called “Cheaper Medicines, Free Beach Trips: U.S. Health Plans Tap Prescriptions That Feds Say Are Illegal,” and it’s a lovely take on how the U.S. health system has become such a mess that employers can now hire third-party companies who pay for patients to take all-expense paid trips to the Bahamas or the Cayman Islands to buy expensive prescription drugs at a price that still saves enough money from what’s charged in the U.S. to pay for the trip. There’s just one catch, though. While it’s not illegal to go to another country to get your own medication, some of these third parties also import drugs themselves, and that is illegal. For the umpteenth time, if the U.S regulated drug prices the way all these other countries do, drugs here would be a lot less expensive. Although I will say, I have been to both the Bahamas and to the Caymans, and they are both lovely.
OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at [email protected]. Or you can find me on X @jrovner, or on Bluesky @julierovner. Where are you guys hanging around these days? Shefali?
Luthra: I’m on Bluesky @Shefali.
Rovner: Paige?
Winfield Cunningham: I am on X @PW_Cunningham.
Rovner: Joanne?
Kenen: I’m either at LinkedIn or Bluesky @JoanneKenen.
Rovner: We’ll be back in your feed early next week for the Thanksgiving holiday. Until then, be healthy.
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