[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. We have a special episode today, direct from the annual meeting of the Association of Health Care Journalists in Los Angeles, where I moderated a panel called “Shock and Awe in Federal Health Policy,” featuring some pretty impressive guests. This was taped on Friday, May 30, at 1 p.m. Pacific time. As always, things might have happened by the time you hear this. So, here we go. 

Thank you all for joining us. We have a lot to cover, so I want to dive right in. I’m going to exercise a point of personal privilege for a moment, just to set the stage. In March, I started my 40th year of covering health policy in Washington, D.C. That was not supposed to be an applause line. I can safely say that what we’ve witnessed in terms of sweeping policy change these last four months is like nothing that I have ever seen or experienced before. I spend so much of my time telling editors and other reporters, “Yeah, that’s like what happened in 1993,” or, “Yeah, that’s like what happened in 2005.” But 2025 in terms of health policy is literally witnessing the dismantling of programs that I’ve spent my entire career chronicling the building of. It’s more than a little bit disorienting, to say the least. 

So that is my perspective, but you’re not here to see me. You’re here to see these very smart people around me. We are lucky to have a national expert and two local experts from Southern California. You have their full bios in the conference program, so I’ll just do the short versions. Our D.C. expert next to me here is Rachel Nuzum, senior vice president for policy at the Commonwealth Fund. And to help us get an idea of how this is all playing out on the ground here in Southern California, we’re also joined by Berenice Núñez Constant, senior vice president of government relations and external affairs at AltaMed Health Services, and Anish Mahajan, who’s the chief deputy director of the L.A. County Public Health Department. 

I thought we’d actually divide up this conversation into two parts — what’s happened so far and what the fallout has been from that, and what might happen in the coming weeks or months with the budget reconciliation bill and the rest of the federal budget. I know it’s really confusing with all the headlines about what’s been done and what’s being proposed, so let’s start with what has actually occurred. Rachel, give us the very short version. 

Rachel Nuzum: Sure. Thanks, Julie. Hi, everybody. Thanks so much for having us. Before we get started, I just want to say a little bit about the Commonwealth Fund. So we are a private foundation. We’re based in New York, and we also have an office in D.C. Our focus is making grants and doing our own research to really understand what the implications of some potential policy changes would be. So when we speak on behalf of the Commonwealth Fund, we’re talking about what we know from the evidence. Maybe that’s a state that’s tried a policy before, maybe it’s researchers that have modeled potential implications, but that we’re coming at it from an evidence-based perspective. It’s not an ideological kind of debate. So I just wanted to say that about the fund. A lot of the things that I’ll talk about today we have on our website, including state-by-state data, so that might be helpful for you all as you think about your pieces. 

But to get back to your question, Julie, I would just agree. I’ve also been in D.C. a long time, not quite 40 years, but I was on the Hill in several places. I’ve worked at the state level as well. And I think I would agree. I don’t think we were fully anticipating the sheer amount of the volume, right? We saw executive orders kind of at an unprecedented level. Those were then followed by litigation. So we’ve got, I think, an unprecedented number of cases that are happening right now, which just kind of puts a lot of uncertainty around some of the policies that have been proposed. We’ve seen pretty big HHS [Department of Health and Human Services] reorganizations. We talked a little bit about, in the last panel, a reduction of 20% of federal staff that run really important, critical programs. I think the effects are still being felt and sorted out, how that’s going to play out. 

Obviously, we knew that one of the top priorities would be the tax bill that is pending in Congress right now, and that’s really where a lot of the current policy conversations are happening in Congress. So that has been underway for the past three months, and it’s still going and gearing up for the summer. And a lot of uncertainty about funding and funding freezes. I think we’ve seen some stops and starts in terms of federal funding. So it hasn’t been that long. It’s been a lot of activity, a lot of people trying to get the lay of the land, letting new folks get settled in their positions, and really understanding: What can we take away from the executive orders in terms of policy direction? We’ve seen things like an outline for the skinny budget that also gives us a sense of administration priority, but we’re just over the first-hundred-days mark, and we’ve seen quite a lot of activity so far. 

Rovner: Berenice, how has what’s happened so far impacted your ability to provide the services that you provide? And why don’t you tell everybody what is it you do? 

Berenice Núñez Constant: Absolutely. Good afternoon, and great job on my name. We practiced. You did a great job. So AltaMed Health Services is the largest federally qualified health center in the nation. We serve about 700,000 patients in L.A. and Orange County, employ approaching 5,700-plus employees, providers, nurses, nurse practitioners, and predominantly serve a majority of Latino patients in Southern California on the primary care front, and bringing in a lot of the innovative models and really setting the best practice in a lot of spaces that we are in. 

We come at the work and have always come at the work from a social justice perspective and making sure that the most vulnerable have what they need in order to be successful and healthy. So for us, it has really been a moment of taking a look at how we speak about the programs that we administer and provide every single day. How do we make sure that patients continue to come into the clinic while there is activity happening in the communities and in the local surrounding areas that may be targeting them, their family, their community in a way that we haven’t seen in a while? 

And so what we actually do is really leverage our position as a trusted messenger. We are brick and mortar in these communities. I often say, regardless of what the issue is, whether it’s access to medical care, whether it’s an upcoming election, whether it’s a covid pandemic or a fire, as we had recently, we are that trusted voice and that trusted messenger. And I’m really proud that because of that, we’ve done so much work in this space, for some community health centers, more than 60 years — we’ve been around more than 57. So we thankfully are still not seeing a drastic decline for our appointments coming in, because we’ve done a lot of work to make sure that folks feel that they can come in and access their programs. 

But of course, for us, there are just so many questions. I know for you, there are also a lot of questions, but the questions that we’re hearing every single day from our patients, our communities, are: Am I going to lose my Medi-Cal? I don’t have Medi-Cal. I have Covered California. There’s a lack of understanding in terms of the programs that they qualify for. And then, of course, because we have made such progress here in California with innovative models using promotoras, or community health workers, for example, that started in the community health center as a position, we are also watching things like food benefits and social services and housing supports and all of that, all the way to the local level, while we are also facing a state deficit here in the state of California. And so together, that leaves me with sleepless nights and a lot of questions every single day. But thankfully, because of our role in the community, so far, so good. But we are obviously worried with what’s to come. 

Rovner: We heard early on about FQHCs [federally qualified health centers] not being able to draw down federal payments. Has that been an issue? And has it been resolved? 

Núñez Constant: Initially, right? Initially, I think, we were all in the same boat. We actually received notices that we were not going to be able to do that, so we initiated an immediate kind of emergency proactive drawdown. We were successful in doing that. We all had the same great idea — right? — to advance that request, and so we were able to do that, and we were really thankful for that. Then there have been a lot of questions around grants that we have, given the executive orders. Are they going to be canceled? So far, we really have only had one of our grants impacted out of the CDC [Centers for Disease Control and Prevention], but everything else, thankfully, is still in place, and so we are hopeful that those will stay in place. 

Rovner: Dr. Mahajan, public health has not been so lucky in this, have they? 

Anish Mahajan: Yeah, that’s right, Julie. Thanks so much. It’s a pleasure and honor to represent public health here and the L.A .County Department of Public Health, which works to ensure the health of 10 million Angelenos every day. I’m going to start by saying public health work is nonpartisan, but it’s also not well understood by the public, and I’m so delighted to have a room full of journalists to try to help tell the story. I want to just say a couple words about what public health is. Public health works to keep entire populations healthy. It focuses on things that you think of, like acute infectious diseases, but it also focuses on chronic diseases. It works on preventing heart disease and diabetes and cancer. It looks at environmental toxins, ocean water safety. If you’re going to go for a swim today out in the ocean, you’re glad that we’re testing the ocean water right now to make sure it doesn’t have bacterial overgrowth or other problems. Lots of surfers in L.A. are looking at our reports every single day. 

Public health has a gamut of programs, which is why it’s a hard story to tell. But we have not been fortunate so far, and Julie started with saying: What have the impacts been so far? In public health, unfortunately, we’ve already had some impacts. And I’m going to also say that public health is an essential upstream component of what we spend a lot of our time focusing on, which is health care delivery. All of us go to the doctor, but our goal is to try to stay out of the doctor’s office and work on prevention. And so it’s easier to cut prevention than it is to cut care, and so we’re facing that. 

And so what have we faced so far? We have faced a sort of chaotic immediate rescission of key public health grants nationwide. Example: HIV prevention and STD prevention. The CDC center, division for HIV prevention is proposed to be eliminated. Many of the people who work there no longer, they may be still on the books, but they don’t work anymore. For example, we have a five-year cooperative grant agreement with the CDC for HIV prevention going back decades, and our most recent five-year grant, we’re about to enter our second year starting — day after tomorrow is the start of the second year of this grant. It’s $19 million that comes to us, the local health department, each year, and we use that money to give to our community partners, as we heard from Berenice and many of them out there, who mount HIV testing, education, biomedical kinds of HIV prevention like pre-exposure prophylaxis. I’m sure you’ve heard of this. This is where antiretroviral drugs help prevent the acquisition of HIV among high-risk groups. This funding is critical to do all of this work. 

We simply never received the notice of award for June 1. We still haven’t. We can still hope that over the next 24 to 48 hours we will, but we know we won’t. There was never a notification from the government as to whether we would in fact receive anything or if the program is over. It’s left the entire infrastructure for HIV prevention, not just here in L.A. but across the nation, with a giant question mark of: What are we supposed to do beginning June 1? This is a massive dismantling. Another thing that’s occurred, back in late March, jurisdictions around the country received notices that their CDC grants for Epidemiological and Laboratory Capacity grants, these are called ELC grants, are immediately terminated midstream during their grant period. This meant about $45 million of potential loss to us at L.A. County Department of Public Health. 

We used this money from these grants to pay for outbreak response for infectious diseases in places like jails and schools and other congregate care settings. This money was being used to improve the laboratory capacity of public health so that we could do genomic sequencing better and faster. It was also being used to modernize our data systems so that data could transfer more quickly from the field to the hospital and to other entities that need it so that we can respond timely. The immediate rescission fortunately was taken to court, and there’s currently a preliminary injunction, so the money is still flowing. But it’s sort of senseless to have these kind of immediate rescissions, because so much money has gone into creating these projects of infrastructure, laboratory modernization, computer system modernization, that if you pull the rug out from underneath, you end up having a lot of sunk costs, let alone the lack of those services. And so this has been very difficult and challenging for us. 

Rovner: I want you to talk about — obviously administrations change, administration priorities change, but we’ve never seen this kind of, sort of wholesale, We don’t agree with this so we’re going to stop spending the money, right? 

Núñez Constant: No. Oh my gosh. I’ve realized that, probably, laughing and smiling has become a little bit of a coping mechanism. But, no, we have not. In fact, for the last few decades we’ve really, in this space, have enjoyed really a growth trajectory, right? We’ve been able to expand the benefit model, making it a lot more comprehensive. We’ve been able to put forth innovation, right? When the community health center was once small — the free clinic is what everybody remembers it as a local community free clinic — now there are a lot of us that are really sophisticated, Medi-Cal health care delivery systems. We have become that at AltaMed — right? — because the system has sustained that level of innovation and growth, and so, though, I think it was really kind of more rose-colored glasses at the beginning. 

We got one of our grants canceled immediately out of the CDC. We are expecting that, as of now — right? — no HIV funding coming, and hopefully the state will do something about it in the May revise. I know we will get there, but it is really alarming. We have built this very sophisticated system that is actually producing the outcomes that we have all been working so hard to produce. Our folks are getting healthier. Our folks who didn’t have access to care in a sustainable, consistent way, now they do, all the way from birth to earth as they say, right? And so it has been really amazing, and that is slipping through our fingers as we speak. 

Rovner: So that’s a wonderful segue to actually what I wanted to talk about next, which is what’s potentially coming down the pike. We have this skinny budget for HHS that we’ve seen that proposes pretty dramatic cuts. We keep being told of a possibility of a rescissions package to officially take back some of the money that’s been appropriated. And then of course we have the tax bill. So Rachel, why don’t you sort of give us an idea of what’s on the horizon? 

Nuzum: The tax bill is real. The tax bill is happening, and the tax bill’s concrete. So where we are in the process right now is the House last week passed a piece of legislation that has about a $880 billion cut to Medicaid. I will say that again. It’s an $880 billion cut to Medicaid. Because we just saw some recent polling that showed that 40% of voters, if they know about the bill, they don’t know that there’s Medicaid cuts in there, and there are. It would be the largest reduction of resources, federal resources, for the Medicaid program since its inception. So that’s kind of one key thing to know. 

I think the other thing is there’s a lot of implications for Medicaid, for the beneficiaries, for the families, but a tremendous amount of implications for state and local economies. There’s job loss associated with cuts of this magnitude, and it just kind of goes on and on. We’re talking about community health centers. Forty-five percent of community health centers’ revenue, on average — in some places it’s higher, some places it’s lower — comes from Medicaid, right? So you can’t really talk about these issues in isolation. We’re dealing with rescissions. We’re dealing with changes to the way the Health Resources and Services Administration office that oversees community health centers, how they’re staffed, and we’re also potentially talking about a pretty major cut to the Medicaid program. 

So at the fund, we focus a lot on people’s ability to access care and to afford care. So one of the first things we look at when we’re looking at potential policy implications is: Will this expand or contract access to health care? And with the policies in this bill, we could see as many as 13.7 million people losing coverage. That could take us back to kind of pre-ACA-level cuts. So what I would say is that there is still time. This is going to the Senate next week. The Senate will go through their exercise. They will think about what they need to do to kind of get a bill across the finish line, and then if there are major differences with the House bill, the House will have to vote on it again. So we are maybe in the fifth inning, maybe rounding home and getting ready to start the sixth inning, but there are a lot of implications in this bill. It’s a thousand pages. It came together pretty quickly. So there’s just a lot to kind of … 

Rovner: Those who listened to last week’s “What the Health?” will know that at the last minute there were a lot of changes inserted for the Affordable Care Act [ACA], too. At first it was just this matter of, well, they’re not going to extend these additional subsidies and that will cause a lot of people to be priced out of their coverage. But it’s more than that, right? 

Nuzum: I think we just saw an estimate — we put out a piece last week — 24 million people that have marketplace coverage could see major changes to their plans. That’s above and beyond the people that may lose coverage under the bill. So in general, there is nothing in the reconciliation bill or the budget bill that changes how we’re delivering care, or it doesn’t make health care more affordable. What it does is it shifts costs to the states or to beneficiaries or their families. It is primarily an exercise to reduce the federal resources we’re spending on these programs. The need doesn’t go away. These programs are designed to grow when the economy has a downturn. That’s why they’re called entitlement programs. They grow as they’re needed. And so this is really about reducing the federal share. So again, a much bigger proportion going to states and states feeling that hit as well. 

Rovner: So I want to hear from both of you about what this level of reduction could mean to your ability to continue to do what you do. 

Núñez Constant: So stating the obvious, right? We don’t pay it up front. We will pay it times 10 on the back end. We all understand that, and it really frustrates me when I hear the conversation about savings up front, because it’s not going to be that, and we’ve seen that and we’ve been there before, for community health centers that serve 32 million patients nationally, about 8 million patients here in California. And even though, for example, children — right? — are thankfully not included, we understand that families enroll together, right? We know that there are mixed-status families. We know that if someone is fearful, they’re not going to go, and go access the care regularly as we need them to, as we think about population health and public health and the strides that we need to make. 

But in a very real way, clinics will close. Hospitals, emergency rooms will fill up. Folks will go to the ER for a flu instead of accessing it at a provider, because they no longer have care. Things like a dental benefit here in California that’s being eliminated for the folks with unsatisfactory immigration status, is the new term that we are using, that can lead to what it leads to. We’ve done so much work to make sure that dental care is included as a person’s overall health. And so clinic doors will close. It will shutter the health care delivery system across the country, and we will see folks showing up in the ER for services that they do not need to show up for. And more generally, and I will hand it over to my colleague, there will be implications to public health, and the public health of the most vulnerable communities more disproportionately. 

Mahajan: Yeah, thanks so much. I’ll just mention that Medicaid changes certainly could impact our ability to effectively treat those who are suffering from substance use disorders as well. But in public health, apart from Medicaid we’re looking at the skinny budget and the budget proposal from Congress and the reorganization that was noted at HHS, and the tea leaves are very concerning, extremely concerning. I’m going to give a few examples. Something that’s not in the proposed budget from Congress is the Public Health Emergency Preparedness grant. This is a national grant that supports the emergency preparedness of communities around the country to be ready for things like emerging infectious diseases, things like mpox, Ebola, covid. They also help jurisdictions deal with weather-related events, wildfire like we had here in L.A., earthquakes, floods, and also acts of terrorism, bioterrorism specifically, in medical countermeasures or having the coordinated response you would need in the event of a biological attack to access the stockpiles of medications to help prevent the fallout from the deployment of such things. 

And so, for example, here, these are over $20-, $25 million worth of grants to this jurisdiction here in L.A. County annually. It’s eliminated. It’s not in the budget proposal. There has been rhetoric about it being something called a state’s responsibility. If this were to be eliminated, our ability to coordinate on things like the BioWatch system, which is a system set up by the Department of Homeland Security that monitors the air at major events like the Olympics or the Super Bowl, which we in public health deploy as well as in certain jurisdictions including this one. There are 30 around the nation, but one here in L.A., where there are 30 locations around the city where BioWatch is deployed. And it looks for these things like anthrax, tularemia, and other dangerous biological weapons, and it’s constantly monitored in our public health lab daily. We test for it. This is what the Public Health Emergency Preparedness grant funds, and so it’s an immediate risk to public safety with what we’re seeing in the budget. 

I also want to mention there’s a lot of discussion about cutting the Vaccines for Children’s program and generally support for vaccination in the president’s proposed skinny budget and in Congress’ budget. I just want to remind folks that back in the late ’80s we had a large measles outbreak in the United States. We had 55,000 people infected, some 11,000 hospitalizations, 123 children lost their lives. And what we’ve learned from that in history is that there were mainly Black and brown populations that were having trouble accessing care. The cost of vaccines were too high. Even individuals who were going see the doctor couldn’t get the vaccine. There was vaccine hesitancy. And it led to the Vaccines for Children’s program. And here we are now, and we’re looking at the situation and the sort of undermining of potential funding streams to continue to support the deployment of vaccination, and we are going to see more and more outbreaks. 

At the end of the day, what we see in the proposed budget is a complete decrease in our ability to fund outbreak response. A single person who flies into LAX here, just a few yards from here, who’s discovered to have measles results in hundreds of contact tracing that’s needed. We have specialized experts who go out into the community and figure out who might’ve come into contact with that individual who’s now tested positive for something like measles, and we deploy the testing and the medications and the connection to care. All of this is at risk in what’s being proposed. 

Rovner: So a lot of people think, Well, I’m not on Medicaid, or, I’m not on a marketplace plan, so this isn’t really relevant to me. But what happens to those programs impacts the rest of the health care delivery system. You’ve just given such a wonderful example of how it impacts a public health system. What would it mean to the rest of the health care delivery system if we see cuts of this magnitude? 

Nuzum: I think this is where it just illustrates what a web this all is. If you have safety net hospitals or hospitals in rural areas that are disproportionately dependent on Medicaid and we blow a hole through those budgets, they are more likely to close. We see hospital closures, and I know a lot of you are writing about these issues all across the country, especially in rural areas. Or maybe the hospital’s not closing but the OB wards are closing and you can’t find a place to have a baby in states like Kansas that have lost 17 rural hospitals in the last decade. Those changes will be felt by everyone living in that area kind of regardless of your ability to pay or who your coverage source is. So if a hospital closes, the hospital closes. If providers say, I can’t make it work here, I can’t pay my bills and raise my family, that’s a loss for the entire community. And so I think keeping in mind how connected these pieces are is really critical. 

We also know that programs like Medicaid, direct cuts to those don’t just impact Medicaid families. Thirty percent of Medicaid resources are directed towards Medicare beneficiaries because there are cost-sharing expectations that happen in the Medicare program and Medicaid steps in to be able to help low-income seniors pay for out-of-pocket costs, pay for long-term care. Most of us know it is the default long-term care program in our country, Medicaid, and it’s our default behavioral health, mental health, addiction program in our country. It’s the number one payer for inpatient mental health stays. Everybody knows, I think, how much of a shortage and how difficult it is to find an inpatient bed for mental health services, so just imagine if the largest payer is no longer able to kind of step up. So those are things that are going to be felt by every single person here. We already talked about how these changes in the marketplace and uncertainty around those policies would impact commercial pricing and plans. So it’s just a kind of a domino effect. 

Mahajan: Yeah, I just want to quickly add to that. I think there’s things that Congress has the power to do, and there are things that we just heard from the previous acting CMS [Centers for Medicare & Medicaid Services] administrator on Medicaid waivers. Just to pick up on a point Rachel’s making, we in California rely on a Medicaid waiver for substance use residential treatment that allows us to be paid by Medicaid for institutions that have more than 16 beds, and we’re able to get paid by Medicaid to put a substance use sufferer into those beds, because of a Medicaid waiver. If CMS decides not to continue that waiver when it’s due in 2026 or decides to rescind it, we will suddenly have a sudden drop in the ability to actually house people that are needing housing while they’re receiving substance use care. 

Nuzum: Can I just say one other thing on the waiver point? Even if the waivers are allowed to continue, we have to ask ourselves what will happen and what will states be able to continue to do, again, if we have cuts of this magnitude. So even without kind of ending waivers that have been approved, I’m very worried about some of those voluntary, optional activities that states have taken on through the waiver process. 

Núñez Constant: So my add would be that folks say, I don’t, I’m not impacted. You don’t need Medicaid, but you don’t need Medicaid now. I think it’s important because it’s a safety net program for a reason. And so any changes in any formulas for federal funding or federal matches that states receive, obviously, if there’s a big cut it’s going to cause a budget hole. That will have economic implications to jobs. Those folks that are, and we are already seeing major deficits — city of Los Angeles, monumental deficit. We’re seeing layoffs in different industries already happening, starting with the federal level. So these folks will eventually qualify for Medicaid and really need this program. 

The other thing that I will say is, health care, we produce jobs in communities, very well-paying jobs — nurses, doctors, behavioral health specialists, but even folks like me on the administrative side as well. And we have also done so much work to train the next generation of doctors and nurses and done so much work to get them to come to the community health center, because that’s a whole other conversation. And so we’re going to lose that. All of that infrastructure that is now in place, we’re going to lose. And so when something changes in the future, we’re going to have to rebuild all of that. But also all the investments that we made to date are just going to go away, and that’s really a frustrating part. 

Rovner: It’s obviously not just health care that’s getting shaken up right now in terms of policy. Immigration is a gigantic priority for this administration, both in terms of stopping the inflow and ejecting immigrants already here, including those here legally. That really impacts both health care delivery and public health, right? 

Mahajan: Yeah. No, I think when we think about sort of the approaches that are being taken at the moment, it started with executive orders and it sort of has flown down into policy perspectives about ensuring that federal dollars are not utilized on folks who are — what’s the new— 

Núñez Constant: Unsatisfactory immigration status. 

Mahajan: Thank you. Unsatisfactory immigration status. And I think this is going to be a huge challenge nationwide for us to understand how we maintain continuity of services for people in need to prevent the fallout on individual health, and then certainly the implications on population and public health. 

Núñez Constant: For us, we are in the business of taking care of anyone and everyone who needs care. That is why federally qualified health centers started, received the designation, receive the funding that they do, because we are located in all of the high-need communities across the country to care for some of the most complex patients. And so for us, a health care provider, that is not our business to really get into the status of someone. Where I really worry is where there are proposals now being proposed in this last bill that penalize states who have expanded programs to cover the UIS [unsatisfactory immigration status] population and penalizing and bringing down that federal match. That’s going to be from 90% to 80%, and obviously that’s going to cause another budget hole that we’re going to have to solve for. 

Rovner: All right. Well, I’m sitting here in a room full of health reporters, so I know you guys have questions. If you want to start lining up, there’s a microphone right here. I will ask you to please tell us who you are and where you’re from, and while you’re sort of getting yourselves together, I’m going to ask one more question. Reproductive health hasn’t gotten the headlines that it did before [President Donald] Trump came back to office, but that doesn’t mean it’s not still being affected in a big way. What have we maybe missed looking at all of these other things on the reproductive health front? 

Nuzum: I’m going to sound like a broken record, but Medicaid is a major payer of women’s health services. It’s the number one payer for live births, for births, in this country, and it’s a major cover source for newborns. So again, any changes to Medicaid is going to really impact that. We’ve seen, I think we’re up to 40 states that have decided to move forward and extend Medicaid coverage for women after birth, so the postpartum extension up to 12 months. Again, that’s all through a waiver, which is great. It’s really exciting to see kind of the evidence be reflected in the fact that blue states, red states, purple states, everyone is kind of recognizing that the time for complications or for death, it doesn’t just happen in those first few weeks but it can really extend into that first year. That’s one of those other programs that I am worried about as an optional program for states to take on and do through waivers, again, that if they don’t have the ability and the resources to do that. 

Rovner: In other words, so if the federal government makes them pay a larger share of other Medicaid costs, they’re going to have to cut back on the option. 

Nuzum: Right, and I think there’s a lot of uncertainty around: Where does this leave Title X safety net family planning clinics and services? Again, we still haven’t seen the full skinny budget. So we’ve seen outlines, but what we’ve seen so far is not really encouraging in terms of what would be available for contraceptive coverage or cervical cancer screenings across the country. 

Núñez Constant: I would just add, just one of the callouts were on essential health benefits. We got that out of the Affordable Care Act. Women’s reproductive health became something that we didn’t have to pay copays for, really kind of provided some equity and access there for many women, and so that’s concerning that the “essential health benefit” term is starting to come back up. And then just here in California, we constitutionalized a women’s reproductive right to choose, and some of the proposals that we’re now starting to see here in California are defunding that. We do not provide abortion services. We provide women’s services, reproductive health support, at federally qualified health centers at AltaMed. However, there obviously will be implications just more generally. 

Mahajan: Well, the first thing that came to mind, Julie, with your question was the Women’s Health Initiative and the cancellation for one day by NIH [the National Institutes of Health]. And I’m glad it was only one day. And I think that it raises for us the question of the focus on DEI [diversity, equity, and inclusion], as it were, and the executive orders around it and sort of the policy approaches that are being sort of embedded in the budget proposals around DEI. DEI doesn’t feel really well explained. And when we think about health inequities, my argument would be DEI doesn’t have anything to say about health inequities. Health inequities are a fact, and we see health inequities in Black and brown perinatal morbidity and mortality, and that needs to remain a focus even if federal dollars are utilized for it, and I hope that we can continue to do that. 

Rovner: We have a long line, so please tell us who you are, and please make your question a question. 

Christine Herman: I’m Christine Herman with Illinois Public Media, and I’m on the board of AHCJ. Thank you for being here. We got a little pushback on a question that we had to our former speaker, CMS Deputy Administrator Stephanie Carlton, about Medicaid cuts. And she said it’s not cuts — it’s a reduction in the rate of growth of Medicaid expenses. Is it wrong for us to talk about this in terms of Medicaid cuts? Is that the accurate phrasing? And is there any conceivable way that you see the proposed changes to Medicaid leading to improvements to Medicaid in part or in whole? I’d love to hear your thoughts. Thank you. 

Nuzum: I would say that I think it’s hard to argue with the Congressional Budget Office that shows the reduction in federal spending. We have direct savings mapped to the changes in Medicaid, and it’s about $880 billion in savings over 10 years, and we see the coverage loss associated with that. So I think it’s fair to say that on the federal side we are talking about a pretty massive reduction in resources towards the program. They have to make assumptions about what states do in response, right? And we could have a long conversation about, well, a state could fill the hole or a state could do this or that. It’s hard to see any state being in the position to kind of fully fill that hole, which is why I think it’s more realistic to talk about it as a reduction of federal resources and a shift to the states to really make that determination. 

Núñez Constant: I would add also just the fact that it puts more rigid requirements on things like provider taxes, for example, and how a state utilizes those dollars is also going to be limiting. We use a lot. We receive some, what we call wraparound payments, or some additional payments for quality programs. And so there will be implications if there are reductions to funds, if there are reductions to provider taxes and how we can — or limitations on how we can use them, restrictions. And then penalizing states for certain expansions that they have put in place and literally bringing a match rate from 90 to 80%, for example. And then ultimately whatever happens on women’s health and reproductive health and changes to maybe essential health benefits, programs like HIV services and funding for that. For me, I also agree it’s hard to argue that that’s not a cut when we will see it as less funding ultimately at the state level and local level. 

Mahajan: Yeah, I’ll just quickly add that clearly coverage reductions means a reduction in spending, which is — you can call it a cut, but it’s a reduction in spending. I do want to say, or at least the rhetoric is that it’s about reducing waste, fraud, and abuse at Medicaid. I’m also a primary care doctor, and I took care of patients for 10 years in primary care, many in, basically, in the safety net, in Medicaid and uninsured people. These are working people. Many of them are working people, and those who weren’t working, I can tell you, at least in my experience, were unable to work, for good reasons. I think about the administrative cost of trying to ascertain and document everybody’s work requirements is a cost and just adds to the administrative burden of our insurance programs rather than actually doing what it needs to do, which is expand access to care. 

Nuzum: Can I add one more thing on work requirements? So this is an example of where we have seen states give this a try, so we have real experience and ability to kind of look and see what happened. So Georgia’s a great example. Georgia’s the most recent state to roll out the Georgia Pathways program, which was unique because it both expanded Medicaid and brought the work requirement with it at the same time, right? And so the projections for the Georgia Pathways program was that they were going to enroll a hundred thousand people in the first year and 250,000 total. They spent $26 million to implement the program and to staff up, to put the processes in place. They enrolled 4,500 people in Georgia in the first year. We see in Michigan — they invested $30 million — that they only had the program around for two years before it was struck down. 

But we have real data from states and from folks who have been trying to follow the law and implement some of these programs, and so hopefully as we kind of see some of these policies come back, taking those earlier experiences into consideration, thinking about: If a policy is to move forward, what resources do states and local economies and providers need to actually make this work? States have to balance their budget every year. The federal government does not. So it is not an option for them to take action in these spaces. 

Rovner: So I stayed up all night last week watching the House Rules Committee and then the House itself work through this bill, and I heard from any number of Republicans: But we’re not cutting Medicaid for kids or for pregnant women or for elderly people. It’s just the people who should be working and aren’t. But as you were saying with the maternal health part, that’s not how the Medicaid budget works, right? 

Nuzum: It’s just more interrelated than that. What we know from decades of research, of studying what happens when you give a child continuous Medicaid coverage, is that not only are their childhood health outcomes improved, their educational attainments improved, but their health status in their adult years is better and their earning potential is better, right? So this is the upstream points you were making before that investing in kids — you asked what was different. Medicaid coverage for kids never used to be political, right? We all remember the stories, the Democratic and Republican senators hanging out together talking about the CHIP program [the Children’s Health Insurance Program]. Community health center funding never used to be political. That could be something that you could join hands on, and no one wanted to see this— 

Rovner: NIH funding never used to be political. 

Nuzum: Right? We could go on and on. And so, but the reality is when you start pulling dollars out of the system, you start seeing how fragile these connections are and how connected. 

Mahajan: I just want to add one quick point to the sort of hard-to-reach folks, folks who are homebound and groups that have trouble accessing care in a traditional way. We have funding from the CDC that we hope persists that we’re very worried about, which we’ve dedicated to an experiment here in L.A. called Community Public Health Teams. We’ve taken eight census or eight locations where we see the worst inequities in health outcomes and where people have the hardest access, for a variety of reasons, hardest ability to access health care, even if they’re insured, and we’ve created teams of a federally qualified health center, a community-based organization, and public health professionals, along with community health workers, to really use a Costa Rica public health model to go out there and know the community, engage them, connect them to the services. These other upstream strategies, these strategies to try to get at folks who are really being left behind, the funding for that is even, is clearly, at risk when we’re talking about Medicaid being at risk. 

Maia Anderson: Hi, my name is Maia Anderson. I’m a reporter at Morning Brew. My question is for Dr. Mahajan specifically. With so many of your grants being canceled, I’m curious: What is your department doing to combat that? Are you looking for other sources of funding? Or what kind of work are you doing to combat that? 

Mahajan: Thanks so much for the question. I really appreciate it. I do want to say, the CDC’s budget prior to its proposed cuts, nearly 80% of it goes to state and local health jurisdictions like us. Public health is local, and local health jurisdictions and states have the authority and statute to do public health. At L.A. County Department of Public Health, 50% of our budget is federal dollars. Some jurisdictions it’s as high as 70, 80%. Other jurisdictions may be less, a little less than that. But as we see a closure of funding or reductions, major reductions of funding for public health, there doesn’t appear to be any other places to look to fill the gap. There is a budget crisis here in L.A. city and county. There’s a budget crisis at the state-of-California level, and we are now looking at strategically downsizing our services. It will likely mean workforce reductions and certainly program closures and slower responses to an outbreak of measles coming through LAX, as an example. We may not be able to test the ocean water if these cuts come to pass. 

And so these are very real things that we want our community to know. How are we doing it? We are engaging our community and our stakeholders and explaining to them what we are facing and asking them for their input about what’s most important to do with the limited dollars that we’ll have left. We’re looking at what are the criteria with which we can downsize and reserve whatever money that is in federal to continue it. These are extremely hard choices, and I fear for the public health outcomes that we’re going to see as a result. 

Cassie McGrath: Hi. Good afternoon. My name’s Cassie McGrath. I also work with the Morning Brew. We’re a curious bunch. My question is asking a response to the CMS chief of staff’s proposal that some of the programs that Medicaid currently covers could go to other departments, like the Department of Education funding student loan repayment, things like that. So I’m wondering what your response is to that. How possible is it to reallocate those Medicaid dollars in your eyes and that sort of restructuring? 

Nuzum: There’s a number of places where agencies have been proposed to be cut. The Administration for Children and Families said, We can deliver these services in other areas. I don’t think anyone is arguing that there aren’t any efficiencies in the way the federal government is organized. I do think the Medicaid program is uniquely complicated, with all of the populations that we’ve talked about — from there’s Medicaid in schools, there’s Medicaid for moms and babies, there’s Medicaid for the dual-eligibles. It’s just a very complicated program. And in general, pulling pieces of programs apart and spreading them out doesn’t usually provide a more coordinated, kind of thoughtful response. So that said, I’m sure there are efficiencies within HHS and the rest of the federal government, but thinking about the complexity of the Medicaid program and the populations that all have very different needs, that seems concerning to start pulling it apart. 

Nathan O’Hara: Hi. I’m Nathan O’Hara. I’m a researcher at the University of Maryland. Thank you very much for a very insightful discussion. As a researcher, I’m very concerned about reductions in federal research funding, and you’ve highlighted a number of major health shocks that have started or are potentially coming. I’m curious on your comments on how these reductions in health care research funding are going to influence our ability to understand the magnitude of these changes. 

Nuzum: I think that’s a really great question. My colleague Dave Radley did a workshop this morning, too, on data availability and how important that is. We do a number of our own kind of intramural research pieces at the Commonwealth Fund, too, and we’re very reliant on publicly reported, regularly updated, trustworthy data at the federal level. So first off, I would just say that could and should be a bipartisan place for us all to agree on how important it is to have that data, to know: Are we moving in the right direction on things like maternal mortality? Are we getting in on top of emerging infections before it kind of gets out of hand? So just a major plug for kind of the need for data and really maintaining that, and I know there’s a lot of efforts underway to kind of push on that. 

I think the other signals that are going to universities in terms of research, we also see that as a foundation. A lot of these universities are our research partners. Several of them have research areas that are on pause, or they’re having to kind of halt the work. And so I think it’s going to take some time for us to kind of fully grasp and see the results of some of these reductions. And they’re not all concrete endings of research priorities. There’s a lot of kind of fear about getting it wrong, kind of given some of the executive orders are kind of overstepping. And so it’s a hard time to be doing research, whether you’re at NIH, whether you’re at a university. So I sympathize. I think it’s going to take some time for us to figure out kind where everything lands. 

Rovner: I want to piggyback on that question because it was a question I wanted to ask, which is there seems to be sort of a war on expertise, if you will, both in terms of medical research, in terms of public health, in terms of just health care in general. How much of that is going to influence sort of what happens going forward, just a rejection of evidence? 

Mahajan: Well, I was surprised and shocked at the secretary’s notion that the major medical journals that we look to for the top-line, highest-quality research may not be something he would want to see federal-dollar research being published in, and it was very surprising to me. I look at the MAHA [Make America Healthy Again] report on children’s health that just came out, and there’s a lot in there that’s good that we want to have related to children’s nutrition. Yet we’re looking at SNAP [the Supplemental Nutrition Assistance Program] being ended, and we’re looking at SNAP-Ed, which is a small component of SNAP which is around how we do the education component to vulnerable groups who are behind on nutrition, especially children, on how to eat healthy. And so there is sort of these mixed signals coming, and there’s great research just to know SNAP-Ed works, peer-reviewed research, but I’m not sure that that’s going to win the day anymore, because there doesn’t seem to be an appreciation, widely, about the importance of that expertise. 

Núñez Constant: I would add that on the federally qualified health center front, we really rely on data that designates certain areas as medically underserved or health professional shortage areas, and so that’s where we’re located. And so we are also in the business of the social determinants of health, and we really leverage a lot of the public health data that’s available. And as we look at innovations and opportunities to build out new programs, we really are relying on a lot of these reports that are coming from the federal level. And obviously we’re administered by these federal departments, HRSA being our administrator. And so we need correct data, but also we need to make sure that that data is also reflecting the actual communities and the actual local picture in a very accurate way. 

Lisa Aliferis: Hi. I’m Lisa Aliferis. I’m a longtime former health journalist and now at the California Health Care Foundation. So you talked about the lessons we have from states that instituted work requirements, yet we also heard Stephanie Carlton say that we’ve learned from the experience from those states and the feds will help the states put together better systems so that will be, I guess, easier for people to demonstrate that they’re working. Can you talk about how realistic it is that these better systems can come to pass in the next two to three years that the feds are talking about instituting work requirements? 

Nuzum: What I will say is that if anyone has worked at the state level, you know the state of their IT systems. 

Unidentified speaker: That’s very kind. 

Nuzum: Right? And so they’ve been working with these systems for decades, and regardless of if the resources do materialize, it will take time, to your point. And it’s not just: Do we have an infrastructure for getting the word out? Someone made the analogy a couple days ago — I forget now who, I’ve talked to so many people. What we’re potentially asking Medicaid beneficiaries to do is the equivalent of doing your taxes twice a month. Who of us have access to those documents or the time or the kind of wherewithal? And then, so there’s a really great piece on a man in Georgia who was really excited to get on. He lost his coverage three times in nine months, just from administrative hurdles. They had a system, but he kept getting kicked off the system. So it’s not just having a system in place. That’s a big part of it. But also, how do the beneficiaries interact with that system? Because we know that a lot of the people that are losing coverage or are projected to lose coverage under the work requirements, they’re still eligible, but they’re losing coverage because of the administrative burden. 

Mahajan: Yeah, I’ll just quickly add, leaving even the institution of work requirements out of it, just annually the redetermination, or when somebody’s on Medicaid, or Medi-Cal in California, and they come up on their year and they have to renew, we see such a churn and a loss of people falling off. And then suddenly they can’t get their meds and then they realize. It’s administratively extremely challenging with our systems in place currently, and for a variety of reasons, to maintain these kinds of things for the people who need it most. 

Drew Hawkins: Hello. My name is Drew Hawkins. I cover public health in the Gulf States Newsroom, so I cover Louisiana, Mississippi, and Alabama. Mississippi, Alabama — two non-expansion. Louisiana, an expansion state. I was in [Louisiana’s] District 4 last weekend, Speaker Mike Johnson’s district, and I was talking to a lot of people who are on Medicaid, many of them who didn’t work or worked part time —hairdressers, did some mechanic work — a lot of people I think that could lose coverage. I heard several times Medicaid is really important to them. It’s all they have, some people said. But not this connection that these cuts are happening or could impact them. I’m curious to get y’all’s perspective on what or why that disconnect might exist between a lot of people who have Medicaid coverage but maybe aren’t realizing that this is coming down the line for them. 

Nuzum: Well, that’s why we’re here talking to all of you. We want your help telling the stories. But one of the things we were talking about in the hall, Medicaid can be called something different in every state depending on where you are. So it’s BadgerCare in Wisconsin. It’s Medi-Cal here in California. So one of the easiest things to do, or kind of the low-hanging fruit, is just make sure people know. You can still have Medicaid and have a card that says Aetna, right? So a lot of people don’t potentially know. And then I think just being able to put those real stories in front of them and talk about: What is it that you need? How do you use your benefits? Oh, actually, those are safe because you’re disabled. Or, Those are safe because you are a mom and baby. Or, Those are potentially at risk. So again, just the nature of the complexity of the program, there’s so many different coverage eligibility categories depending on the population. I think just getting really specific and having those conversations like you were doing, just keeping it up. 

Núñez Constant: I would add that there’s a lot of — y’all are doing a really great job at talking about the cuts that are to come. How that’s being translated and, I think, absorbed at a patient level is: Oh no, I’m going to lose my Medicaid. And it’s happened already, right? And so just reminding folks as well that these are proposals, that this is coming maybe, right? It’s being worked out. But also we keep reminding our patients — and our workforce, by the way, because they ask us also: Am I going to lose my job? Is there going to be a reduction in workforce? And we just keep reminding them when something happens that it is a proposal and ultimately that we will let them know. 

But also, I do a lot of work in these communities. Obviously you’ve heard that. Sometimes — right? —these folks need one, two, three, four, five times hearing the same message for them to begin to understand. We all know that these folks are vulnerable. They’re left out of the systems, right? And so these systems are built essentially to lock out sometimes. It’s so complex. There’s language issues. There are cultural issues. And so we continue to do the work, and we understand that when we are serving our patients that it is a much heavier lift and we are going to have to invest resources to get the — make sure it’s in language, make sure they’re getting it one, two, three, four, five times, and make sure that they’re hearing from a trusted messenger. 

So figuring out how you bring the community health center voice forward, the promotoras, the community health workers, the folks who are in the community, in addition to the patients themselves, to share their story. That goes really far for engaging and really educating the communities that we are in. But they won’t open the door, they won’t come and show up, if they really don’t have that trust. So the trusted messengers are really key to any messaging. 

Rovner: All right, well, we are out of time. I want to ask you one very quick question before we go, because this has been so heavy. Is there something, briefly, that keeps you optimistic? OK. 

Nuzum: Man. So what I will say that keeps me optimistic about just kind of what’s happening in Congress is that it feels like every day there’s more understanding and appreciation of kind of what’s in the bill, what’s at stake. We’re finding different ways to talk to different communities about it. And again, this isn’t to kind of raise up one provision over the other, but at the end of the day we want people to understand what’s in the bill, what the potential implications are, and then make informed choices. And I do think there’s an effort going on, in large part thanks to the stories that you all are writing and the data that has been collected, to help shift that narrative. 

Núñez Constant: People are talking about Medicaid, right? When this all started, we were like: Oh no, we are going to be left behind. This is going to be — that voice is not going to emerge in the conversation. And it has become front and center. So the advocacy work that we are doing together is working. Folks are asking the questions, and so I’m really excited about that. And it is actually getting to community, because we receive the questions all the time. And oftentimes, even in our own workforces, folks don’t really understand policy and the implications. And so as these things have rolled out, doctors are engaged. They want to know more. Our nurses want to advocate. Folks want to get involved. 

And to me — right? — I am in the business. In order to do my job every single day, I have to remain hopeful. And it really does give me a lot of hope that we’ve done the work to engage folks that are typically left out, and that folks are seeing this work as meaningful, and that Medicaid has really emerged as a priority program and a safety net program and something that we are all trying to protect and preserve. 

Mahajan: Yeah, I’ll say I am encouraged, maybe not optimistic, but I’m encouraged by advocacy for sure, and I’m also encouraged by the actions that are being taken in court to ensure that we follow a process in how we make decisions about budget in the United States of America. 

Rovner: Well, I want to thank the panel, and I want to thank the audience for your great questions, and thank you, AHCJ. 

OK, that’s our special show for this week. As always, if you have comments or questions, you can write us at whatthehealth@kff.org. Or hit me up on social media, @jrovner on X or @julierovner on Bluesky. We’ll be back in your feed later this week with all the regular news. Until then, be healthy.