Episode Title: RFK Jr.’s Vaccine Schedule Changes Blocked — For Now 
Episode Number: 438 
Published: March 19, 2026 

[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. 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, March 19, at 10:30 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 Margot Sanger-Katz of The New York Times. Welcome back, Margot. 

Margot Sanger-Katz: Thanks. It’s good to see you guys. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: And Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi, there. 

Rovner: Later in this episode, we’ll kick off our new series, “How Would You Fix It?” The idea is to let experts from across the ideological spectrum offer their ideas for how to make the U.S. health care system function at least better than it does right now. We’ll post the entire discussions on our website and social channels, and we’ll include a shortened version here on What the Health? And to help me set the stage for the series, we’ll have one of the smartest people I know in health care policy — also my boss — KFF President and CEO Drew Altman. But first, this week’s news. 

We’re going to start this week with vaccine policy. On Monday, a federal judge in Massachusetts sided with a coalition of public health groups and blocked the new childhood vaccine schedule recommendations from the Department of Health and Human Services, at least for now. The judge ruled that HHS violated the law governing federal advisory committees when HHS Secretary Robert F Kennedy Jr. summarily fired all 17 members of the Advisory Committee on Immunization Practices and replaced them, largely with people who share his anti-vaccine views. The judge also blocked the January directive from then-acting Centers for Disease Control and Prevention Director Jim O’Neill, formally changing the vaccine recommendations. The administration is appealing the decision, so it could change back any minute now — you should check. What’s the public health impact of this ruling, though? 

Ollstein: I mean, I think we’ve seen that the more back-and-forth we have and the more clashing voices and shifting guidance, you know, trust just continues to drop and drop and drop amongst the public. The average person, I’m sure, doesn’t know what ACIP is, or how it functions, or how these decisions usually get made versus how they’re getting made under this administration. And so all of that just makes people throw up their hands and not know who to trust. 

Rovner: Lauren. 

Weber: I think, to add to what Alice said, I think when you inject so much confusion, it’s easier to choose not to get vaccinated. Several pediatricians have told me it’s, you know, when they’re like, Oh, I don’t know, the president’s saying one thing, and the pediatrician’s saying something else. And I’m just, I’m just going to walk away from this. Because that’s almost easier than to make an active choice. And so there’s a lot of concern among health professionals that even with all this, who knows what people will decide. And I do think what’s very interesting about this is, obviously, you know, it’s getting appealed and so on. This is just a slew of vaccine headlines that the administration does not want right now. And I am very curious to see how that continues to play out, as there’s been this concentrated effort to not talk about vaccines, after doing a lot on vaccines. And this is going to put vaccines firmly in the headlines for quite a period of time. 

Rovner: Yeah, actually, you’ve anticipated my next question, which is one of the immediate things the ruling did is postpone the ACIP meeting that was scheduled for this week and, with it, consideration of whether to recommend further changes to the covid vaccine policy. Margot, your colleagues got ahold of a pretty provocative working paper that suggested the creation of a whole new category of reported covid vaccine injuries, basically putting more focus on a subject the Trump administration is trying to get HHS to downplay. Yes?  

Sanger-Katz: Yeah. I mean, I just think that this issue is becoming increasingly politicized. As Lauren and Alice said, I think that does affect the confusion around it, does affect people’s willingness to take up vaccine. But I do wonder also if we’re just going to see over time that there is not a kind of scientific expertise-based way that we make these decisions as a country. But instead … it’s going to become much more polarized along the lines that many other health policy areas are. I think this has historically been a rare area of relatively broad consensus across the parties. Not that there haven’t been disagreements among scientists or among different groups of Americans. There’s always been resistance to vaccines or concerns about vaccine safety in this country. But I think there was a sense that it’s not — that one party is for and one party is against, and I think all of this debate and the ping-ponging and the desire to highlight vaccine injury in ways that haven’t been done before, I think, risks this becoming a much bigger kind of partisan political issue going into the next election. 

Rovner: And yet, the backdrop of this is this continuing seemingly spread of outbreaks of measles. I mean, we’ve seen big outbreaks in Texas and, particularly, South Carolina. But now we’re seeing … smaller outbreaks in lots and lots of places. I’m wondering if there’s going to come a point where complications from vaccine-preventable diseases are going to maybe push people back into the oh, maybe we actually should get our kids vaccinated camp. 

Ollstein: I think we’ve seen that start to bubble up. I think there’s been reporting about a surge in parents wanting to get their kids vaccinated, like in Texas, for instance, in places where outbreaks have gotten really big already. And I think news coverage of those outbreaks, you know, helps raise that awareness. It’s not just word of mouth. So I don’t know whether that will vary from place to place that trend, but it’s definitely something you see.  

Rovner: Apparently, public health requires us to relearn things. Before we leave this … yes, Lauren, you want to add something?  

Weber: My colleagues and I had an investigation at the end of last year that found that, you know, in order to be protected against measles, your county or area or school needs to be above 95% vaccinated. And we found in December that the numbers on that are pretty bad around the country. According to our analysis of state school-level and county-level records, we found that before the pandemic only about 50% of counties in the U.S. could meet that herd immunity status from among kindergartners. After the pandemic, that number dropped to about a quarter, to 28%. That’s not great. That does mean, obviously, there are still places that could be vaccinated at 94% or so on. But there’s a lot more that are also vaccinated at 70% and really risk high outbreak spread. And so I think amid this confusion, and it’s important to note that vaccine rates have been dropping for some time as the anti-vaccine movement has gained power. And it remains to be seen how much this confusion continues to contribute to that. 

Rovner: Speaking of long-running stories, let’s revisit the grant funding slowdown at the National Institutes of Health. Again this year, grants, particularly grants for early career scientists, are slow leaving the agency, which is one of the few HHS subsidiaries that actually got a boost in appropriations from Congress for this fiscal year. According to researchers at Johns Hopkins, the NIH has awarded 74% fewer new awards than the average for the same time period, from 2021 to 2024. Last year, only a gigantic speed-up at the very end of the fiscal year prevented the NIH from not disbursing all the funding ordered by Congress. Coincidentally, or maybe not so coincidentally, the Office of Management and Budget removed one hurdle just this week, approving NIH’s funding apportionment the night before NIH Director Jay Bhattacharya appeared before a House Appropriations Subcommittee. But, much as with vaccines, public health groups are worried about the impact of this sort of closing funding funnel on biomedical research, which, as we have pointed out, is not just important to medical advancement, but to a large chunk of the entire U.S. economy. Biomedical research is a very, very large export of the United States. 

Sanger-Katz: Yeah, the NIH has just been giving out this money in a very weird way. It’s not just that they gave it all out at the end of the fiscal year before it was too late, but they didn’t distribute it in the way that they normally distribute the funding. So, normally, the way that these things work is people submit applications for multiyear grants, or for these shorter grants for early researchers, they get a multiyear grant, and they get one year of money at a time. And so over the course of, say, the four or five years of their grant, they get money out of the NIH’s appropriation in each of those years. And then … it’s kind of rolling so new grants come in. What the Trump administration did last year is they got all the money out the door, but they actually funded much fewer research projects than in a typical year, because instead of funding the first year of lots of new grants, what they did is they paid for all the years of a much smaller number of grants. They sort of prepaid for the whole thing. And so my colleague Aatish Bhatia did a wonderful story on this around the end of the fiscal year, sort of pointing this out. And I think this is the kind of pattern that will result in NIH actually funding a lot less research. I mean, over time, presumably, they’re going to, I guess they could, catch up. But I think in the short term, what it’s allowing them to do is to fund many fewer scientists and many, many fewer research projects. And I think that that does have an effect on the kind of reach and diversity of the projects that are getting funded by NIH and that are the kind of scientific research that’s being conducted. And it’s also, of course, extremely destabilizing to universities and other institutions that depend on this money to pay for the bills of not just the salaries of their researchers, but also for their facilities and their students. And there’s just much less money going to much fewer people, because even those prepaid grants, they can’t all be spent in the first year. So it’s kind of like, almost like, the money is no longer with the NIH, but it’s kind of like sitting in a bank account somewhere. It’s not actually out there in the economy, in the university, in the researcher’s pocket funding research in each of those years. 

Rovner: And as we pointed out, it’s also sort of impacting the pipeline of future researchers, because why do you want to go into a line of work where there might not be jobs?  

Sanger-Katz: And not just that. A lot of these universities are really tightening their belts, and they’re bringing in fewer PhD students because they’re concerned that they won’t be able to support them. So there’s less potentially interest in pursuing science, because it doesn’t seem like as valuable career. But there’s also just fewer slots for even those scientists who want to move forward in their careers. They can’t get jobs, they can’t get spots as PhD students, they can’t get slots as post-docs because all these universities are really tightening their belts. 

Rovner: Yeah, this is one of those stories that I feel like would be a much bigger story if there weren’t so many other big stories going on at the same time. Congress is kind of busy these days not figuring out how to end the funding freeze for the Department of Homeland Security and not having much say over the ongoing war with Iran. Something else that Congress is not doing right now is continuing the debate over the Affordable Care Act. At least right not at the moment. But that doesn’t mean it’s not still a big political issue looming for the midterms. Just today, my colleagues in our KFF polling unit are out with a new survey of marketplace enrollees that finds 80% say their health care costs are up this year, and 51% say their costs are, quote, “a lot higher.” More than half report they have or plan to cut spending on food or other basic expenses to pay for their health care, including more than 60% of those with chronic health conditions. I saw a random tweet this week that kind of summed it up perfectly. Quote, “Health insurance is cool because you get to pay a bunch of money each month for nothing, and then if something happens to you, you pay a bunch more.” So where are we in the ACA debate cycle right now?  

Sanger-Katz: I think as far as the ACA debate, as like a policy matter, we’re a little bit nowhere. I think there is no one in Congress currently who is actively discussing some kind of bipartisan compromise that might make major reforms to the law or might bring more of this funding back that expired at the end of the year. But there is some regulatory action by the Trump administration, who, I think, officials there are sensitive to the idea that insurance is so expensive, and they want to think about how to address that. And then we’re starting to see, just today, some green shoots from the Democrats in the Senate that they’re looking to explore kind of big ideas in this space. So I think we shouldn’t think of this as some kind of legislation or policy debate that’s going to happen right now. But I think they’re thinking about what would happen in a future where Democrats controlled the government again, what would they want to do about these issues? And they feel like they want to start getting ready, having these internal debates and having some hearings, maybe, and talking to experts and doing some of the kind of work I was thinking that they did before they debated and passed the ACA, right? They did a process like this. So we don’t know what that’s going to be.  

Rovner: Exactly. That’s sort of the origin of our series of “How Would You Fix It?” — that we’re in that stage where people are starting to think about the big picture. And in order to think about the big picture, you have to do an enormous amount of planning and stakeholder discussions and all kinds of stuff before you even get to a point where you can have legislative proposals. 

Sanger-Katz: Which is … all of which is fine, except, I think it is important to say, like, this is not close to a concrete policy proposal, that even if the Democrats had the votes that they could, you know, there’s not like they’re gonna come forward with, OK, here’s what we’re gonna do about this. I think this is: Let’s do some studies, let’s talk, let’s debate, let’s think. Let’s get ready for the future.  

Rovner: Let’s be ready in case we get the White House back in 2028 is basically where we are right now.  

Sanger-Katz: What the Trump administration has proposed for ACA is some pretty radical changes to the kind of nature and structure of health insurance for people who are buying in this market. And I think it’s tied to their concern that premiums are really high and people can’t afford coverage. So they’re trying to think about, like, OK, what are some things that we could do that would make insurance more affordable for people? And one of the things that they propose is making the availability of what are called catastrophic plans. This is something that was created by the ACA — plans that have really high deductibles, but, you know, still have comprehensive coverage after the deductible. Could they make those available to more people, and could they kind of jack up the deductible even more? So those would be plans, still pretty expensive, and you would end up with, you know, having to pay tens of thousands of dollars before your insurance kicked in, but you would have insurance if something really bad happened to you. That’s one of their ideas. They also have some other ideas that are actually, like, really new, including having a kind of insurance where you don’t actually have a guaranteed network of doctors and hospitals, but there is a sort of a payment rate that your insurance will pay for certain services. And then you, as the patient, have to go around and say, Will you take this amount for my knee replacement or for my pneumonia hospitalization? or whatever. And then you might be on the hook for the difference if no one wants to accept that price. So it —  

Rovner: I call this “the really fancy discount card.” 

Sanger-Katz: The really fancy discount card. That’s good. And, you know, the idea is not that different than what some employer plans do, but generally, these kinds of bundled, capped payments are in relatively discreet services, and they’re being overseen by HR professionals. And I do think the idea that individual people are going to be able to navigate a system like this is it seems a little extreme. So I think that’s sort of where we are on ACA, is that enrollment is down. People are really struggling with the affordability of it, and it just doesn’t look like anyone is going to come forward, at least in this year, and do anything that’s going to substantially change that. Even these Trump proposals, whether you think they’re a good idea or a bad idea, are proposals for next year. 

Rovner: The general consensus is, by next month, we’re going to have a better handle on how many people dropped coverage because their costs went up too much, and I’m wondering if that may restart some of the debate. 

Weber: Again, to talk about midterms conversations, I mean the folks that are often hit hardest by this, as I understand, are middle-income earners, early retirees, or folks that live in expensive states. And that’s a voting bloc. I mean, early retirees … who else is voting? I mean that’s who’s voting. So I’m very curious how this will continue to animate a conversation around the election, as there’s so much conversation around how folks are forgoing medical care or forgoing other expenses in order to make up the difference of what we’re seeing.  

Rovner: Well, meanwhile, in news that I think counts as both bad and good: Health care jobs took a dip in February, according to the Labor Department, the first such decline in four years. On the one hand, every new health care job means more health care spending, which contributes to health care unaffordability, at least in the aggregate. But I wonder if this dip is an anomaly or it represents the health care sector bracing both for people dropping their insurance that they can no longer afford or bracing for the Medicaid cuts that we know are coming. Alice, you wanted to add something?  

Ollstein: Yeah. I mean, I think that these things have a cascading effect, and it can take years to really see, like, the full damage of something. And so we’re just starting to see the very beginning of a trend of people dropping their insurance because they can’t afford it. But then it’ll take a while to see when people have emergencies or get sick and need care. And then is that uncompensated care? And are hospitals that are already on the brink of closure having to cover that uncompensated care? And does that lead to more closures, and that leads to health deserts? And so, you know, there could be this domino effect, and we’re just at the very beginning of it, and we can sort of infer what could happen based on what’s happened in the past. But that’s a challenge for the political cycle, because it’s hard to talk about things that haven’t happened yet, both good and bad. I mean, you see that also with promising to lower drug prices; if voters don’t actually see lower prices by the time they go to cast their votes, it feels like an empty promise, even if you know it pays off down the line. 

Rovner: Well, speaking of things that weren’t supposed to happen yet, a shoutout to my KFF Health News colleague Tony Leys for a wrenching story he did last week about a family in Iowa facing a cut in home care through Medicaid for their adult son with severe autism and deafness. It appears that Iowa is not the only state cutting back on expensive but optional Medicaid services like home and community-based care in anticipation of the Medicaid cuts to come. But this was not what Republicans were hoping were going to happen before the midterms, right?  

Sanger-Katz: Yeah, I think there was this idea that a lot of Republicans were saying that, because most of the Medicaid cuts are not scheduled to take place until after the midterms, I think there was an expectation that there would be no reason for states to start making changes to their program in the short term. And that just really hasn’t happened. States kind of went into this budget cycle already a little bit in the hole, and then they looked ahead and saw that, you know, their finances and their Medicaid program are not going to get any better next year. And so we’re seeing, like, a pretty large number of states that have been making substantial cutbacks, either to, as you say, some of these benefits that are optional to the payments that they make to doctors, hospitals, and other kinds of health care providers. It’s pretty ugly out there.  

Rovner: It is. All right. Well, finally, this week, still more news on the reproductive health front. Alice, you’ve been following some last-minute scrambling on yet another federal program that’s technically funded but the federal government’s not actually passing the money to those who are supposed to receive it. That’s the nation’s Title X family planning program. What is happening there?  

Ollstein: Well, nothing happened for a while. The things that were supposed to happen didn’t happen, and now they may be happening, but it may be too late to avoid some problems happening. So to break that all down: The way it normally works is that all of these clinics around the country that provide subsidized or entirely free birth control and other reproductive health services, you know, things like STI [sexually transmitted infections] testing and treatment, cancer screenings, etc., to millions of low-income people, men and women, they were supposed to get guidance last fall or winter in order to know how to apply for the next year of funding. So that funding runs out at the end of this month, March, and they only just got the guidance a few days ago. And I will say there was no guidance for months and months and months. I wrote a story about it; a couple days later, the guidance came out. Not saying that was the reason, but that was the timing.  

Rovner: But a lot of people are thanking you. 

Ollstein: The issue is, all of the clinics now have only one week to apply for the next round of funding. Normally, they have months. And then HHS only has like a week or so to process all of those applications and get the money out the door. And they usually take months to do that. And so people are anticipating a gap between when the money runs out and when the new money comes in, unless there’s some sort of last-minute emergency extension, which there’s been no mention of that yet. And so they’re bracing for this funding shortfall, and, you know, are worried that they won’t be able to offer a sliding scale, or they’ll have to curtail certain services they offer, or have fewer hours that the clinics are open. And we’ve already seen, based on what happened last year where some Title X clinics had their funding formally withheld for months and months and months, and even though they got it back later, that came too late for a lot of places; they closed. You know, these clinics are sometimes hanging on by a thread, and even a short funding gap can really do them in. And so at a time when demand for birth control is up and the stakes are high, this is really worrying a lot of people. 

Rovner: Well, speaking of federal funding on reproductive-related health care, a story from States Newsroom found that most of the money that Missouri is giving to crisis pregnancy centers — those are the anti-abortion alternatives to Planned Parenthoods and other clinic … that the crisis pregnancy centers provide neither abortions nor, in most cases, contraceptives — has been coming from TANF [Temporary Assistance for Needy Families] — that’s the federal welfare program that’s supposed to pay for things like housing and job training. It turns out that at least eight states are using TANF money for these crisis pregnancy centers, and this is just the tip of the iceberg in public money going to these often overtly religious organizations, right?  

Ollstein: Yeah, I think we’ve seen that more and more over the last few years. These centers were, by conservative activists and politicians, have held them up as an alternative to reproductive health clinics that are closing around the country, and these centers can really vary. Some of them employ trained health care providers. Some of them don’t. Some of them offer real health services. Some of them don’t. And there’s very little oversight and regulation. There’s been some really strong reporting by ProPublica about this money going to them in Texas and other states with very little accountability and being spent on, you know, things that arguably don’t help the people that they should be helping. And so I think that we haven’t yet seen that on the federal level, but we’re absolutely seeing it on the state level. And I think this is just contributing to the national patchwork of, you know, where you live determines what kind of services you can access, because we do not see blue states funneling money to these centers. And so you’re going to see a real split there. 

Rovner: And I will point out, before people complain, that some of these centers do provide social services, and, you know, even things like diapers and car seats, but many of them don’t. So it’s a very mixed bag, from what we’ve been able to see.  

Well, lastly, ProPublica, speaking of ProPublica, has another jaw-dropping story this week about women in labor in Florida who are required to undergo court-ordered C-sections, even if they don’t want them, in order to protect the fetus. It turns out a lot of states have these laws that let the state intervene to protect fetal life, even if it means further threatening the life of the pregnant patient. Is this “fetal personhood” quietly taking hold without our even really noticing it? It seems these laws, some of them, have been challenged, and the courts have sort of gone different ways on it, but mostly just left it to the states.  

Ollstein: So I thought the article did a good job of pointing out that this isn’t a phenomenon caused by the overturning of Roe v. Wade. This was an issue before that. So I think that’s really important for people to remember. Obviously, these personhood laws that have been on the books or are newly on the books have taken on a heightened significance after Dobbs. But this is not a brand-new phenomenon, and this tension between whose life and health should be prioritized in these situations is not new. But it’s important that it’s getting this new scrutiny, and the details in the article were just horrifying. I mean, having to participate in a court hearing when you’re in active labor on your back in the bed is just a nightmare.  

Rovner: And without legal representation. I mean, there’s a court hearing with the judge, and, you know, a woman who’s 12 hours into her labor, so it would, yeah, it is quite a story. I will definitely post the link to it. Anybody else? Lauren, you looked like you wanted to say something.  

Weber: Yeah. I mean, I just wanted to add — I think you all covered it. But, I mean, the story is absolutely worth reading for its dystopian details. I just don’t think anyone realizes that in America, you could be in your hospital bed — in active labor with all that entails — and then a Zoom screen with a judge and a bunch of other people appears. I mean, I had no idea that could even happen. So kudos to ProPublica for continuing to really charge forward on this coverage. 

Rovner: Yeah, all right. That is this week’s news. Now we’ll play my interview with KFF President and CEO Drew Altman, and then we’ll come back with our extra credits. 

I am so pleased to welcome back to the podcast Drew Altman, president and CEO of KFF. And yes, Drew is my boss, but since long before I worked here, Drew has been one of the people I turn to regularly to help explain the U.S. health system and its politics. So I can’t think of anyone better to help launch our new interview series called “How Would You Fix It?” 

Here is the premise. I think it’s pretty clear that the U.S. is heading for another major debate about health care. It’s been 16 years since the Affordable Care Act passed and, once again, we’re looking at increasing numbers of Americans without health insurance, increasing numbers of Americans with insurance who are still having trouble paying their bills and just navigating the system, and just about everyone, from patients to doctors to hospitals to employers, pretty frustrated with the status quo. The idea behind the series is to start to air — or, in some cases, re-air — both old and new ideas about how to reshape the health care “system” — I put that in air quotes — that we have now into something that works, or at least works better than what we currently have. In the months to come, we plan to interview experts and decision-makers from a variety of backgrounds and perspectives and ask each of them: How would you fix it? You’ll hear a condensed version of each interview here on the podcast, and you can find the full versions on the KFF Health News website and our YouTube page. 

So Drew, thank you for helping us kick off the series. What do you see as the big signs that it’s time for another major debate about health care? 

Drew Altman: Well, first of all, Julie, I’m thrilled to be here, and we’re very proud of What the Health? And I’m always happy to join you on this program. There’s no question that health care is going to be a big issue in the midterms. We’re seeing something now that we haven’t seen maybe ever before, but we’ve, certainly, seldom seen it before. And that is when we ask people what their top economic concerns are, their health care costs are actually at the very top of the list. It’s a real problem for people, and so it will be front and center in the midterms. 

Rovner: And this is bigger even than it was, as I recall, before the Affordable Care Act debate, before the Clinton debate even? 

Altman: No, health care has always been a hot issue. Sometimes it’s been a voting issue. So now it’s a hot issue and a voting issue. And we just don’t see that a lot. 

Rovner: I feel like every time the U.S. goes through one of these major political throwdowns over health care, it’s because the major stakeholders are so frustrated they’re ready to sue for peace — the hospitals, the insurance companies, the doctors. In other words, as painful as change is, it’s better than the current pain that everyone is experiencing. Are we there yet, in this current cycle? 

Altman: No, I don’t think so. I mean, I’ve seen this many times before. The country has never had either the courage or the political system capable of mounting a significant effort on health care costs. We neither have a competitive health care system — the industry is too consolidated — or the political chemistry to regulate health care costs or health care prices— the two big answers. So we fumble around the edges. We are about to enter a stage of more significant fumbling around the edges, what we political scientists would call incremental reforms. But it’s unlikely to be more than that. We have made, as a country, very significant progress on coverage. Now 92% of the American people [are] covered; that [is] now endangered by big cutbacks, unprecedented cutbacks. But we made very little progress on health care costs. And there are two big problems. The big one that is really driving the debate are the concerns that the American people have about their own health care costs, which impinges on their family budgets and their ability to pay for everything they need to pay for their lives. And that is what has made this a voting issue, and that’s what’s really driving this debate. And the other one is the one that we experts talk about, and that’s just overall national health care spending as a share of gross national product, and how that affects everything else we can do in the country, almost one-fifth of the economy. But we’re pretty much nowhere on that one and going backwards on the other one. So, without being the captain of doom and gloom here, I think what we’re looking at is an interest in incremental changes at the margin that will be blown all out of proportion as bigger changes than they really are. 

Rovner: You had a column earlier this year about how the fight to reduce health care spending is more about everyone trying to pass costs to someone else than about lowering costs in general. In other words, I spend less, so you spend more. Can you explain that a little bit? 

Altman: Well, I think in the absence of some kind of a global solution, every other nation, wealthy nation, has a way to control overall health care spending. How they do it differs from country to country. But they have a way to control the spigot. We don’t. And so instead, we micromanage everything to death, and make ourselves pretty miserable in the health care system in the process. Nobody likes the prior authorization review or narrow networks or all the other things that we do. But what it has resulted in is what I called, in that column, a “Darwinian approach” to health care costs. Kind of every payer on their own. And so the federal government tries to reduce their own health care costs, as they just did galactically, in the so-called Big Beautiful Bill, reducing federal health spending by about a trillion dollars. What happens? That burden then falls to the states, which have to try and deal with that. Or employers have only so much they can do to try and control their own health care costs, so a lot of that burden gets shifted onto working people. And on and on and on. That’s not a strategy on health care costs. And if you think about it, we don’t actually have a national strategy on health care costs. The Congress has never mandated that someone come up with a strategy on that. There are parts of agencies that have pieces of it. There are places in the government that track spending, but we don’t actually have anyone responsible for an overall strategy on health care costs. And it shows. 

Rovner: So, if anything, the politics of health care have become more partisan over the years. We are both old enough to remember when Democrats and Republicans actually agreed on more things than they disagreed on when it came to health care. Is there any hope of coming together, or is this going to be one more red-versus-blue debate? 

Altman: It’s red versus blue right now. There is hope for coming together. What is important, and what the media struggles with a lot, is what I call proportionality, or recognizing proportionality. They can come together on small things. They might come together on site-neutral payment, not paying more for the same thing, you know, in a hospital-affiliated place than a free-standing place. They might come together on juicing up transparency. These are not solutions to the health cost problem, but they’re helpful. And, you know, so there are a broad range of areas. AI [artificial intelligence] is another area which, of course, is going to demand tremendous attention, where there’s potential for tremendous good and also tremendous harm. And that discussion is important, and that’s a part of it that KFF will focus on. 

Rovner: Are there some lessons from past major health debates that — some of which have been successful, some of which haven’t — that policymakers would be smart to heed from this go-round? 

Altman: Well, you know, the biggest lesson, maybe in the history of all these debates, is people don’t like to change what they have very much. And it’s hard to sell them on that. A second lesson is: Ideas seem very popular. And you’ll see a lot of polls: Would you like this? And 90% of people like everything. That doesn’t mean that they will still like it when you get to an all-out debate about legislation, with ads and arguments about the pros and cons, because the other horrible lesson of health policy is absolutely everything has trade-offs. And so when you get to actually discussing the trade-offs, support falls. It becomes a much, much tougher debate. And the fate of legislation turns on a set of other issues, like, who wins, who loses? How much does it cost? Which states are affected? Not just on public opinion. So those are a couple of lessons. There is also a silent crisis, I think, in health care costs that doesn’t get enough recognition. And that is the crisis facing people with chronic illness and serious medical problems. They are the people who use the health care system the most, who face the biggest problems with health care costs. So we may see that 25%, sometimes it gets up to 30%, of the American people tell us they’re really struggling with their health care costs. They have to put off care. They may be splitting pills, whatever it may be. But those numbers for people who have cancer, diabetes, heart disease, a long-term chronic illness can go up to 40% or 50%, and it truly affects their lives. I don’t think that problem gets enough attention. So you could say, OK, Drew, well, that’s just obvious. They use the most health care. You could also say, yes, but that’s the reverse of how any functioning health care system should work; it should first of all take care of people who are sick, and we are not doing that in our health insurance system. 

Rovner: Well, that seems like as good a place to leave our starting point as anything. Drew Altman, thank you so much. 

Altman: Great, Julie. Thank you, appreciate 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 post the links in our show notes on your phone or other mobile device. Margot, why don’t you go first this week?  

Sanger-Katz: Sure. So I’m so excited to encourage everyone to read this wonderful story from Tara Bannow at Stat called “How a Texas Couple Is Getting Rich Off Out-of-Network Medical Bills.” And I say that it’s a wonderful story, but it’s not necessarily good news. This is a story about a Texas couple of entrepreneurs who have figured out how to exploit the system that was set up by the No Surprises Act in order to get extremely rich. As you guys may remember, this was the bill that ended most surprise medical billing, so you would never go to an emergency room and suddenly end up with a doctor that was out-of-network that was sending you an extra bill. And the law, since it was passed a few years ago, has been extremely effective in preventing those bills from getting sent to individuals. But it created this very complicated and Byzantine arbitration system on the back end so that the insurers and the health care providers could figure out what everyone should get paid. And this company has very effectively exploited that system. And the story just does a really interesting job of laying out what their strategies have been, of just kind of flooding the system with tons and tons of claims, some of which are bogus, recognizing that the system didn’t have a good mechanism for differentiating between valid and invalid claims, and recognizing that some of them would just be paid even though they were invalid, recognizing that the insurance companies might not be fast enough to reply if they came in these huge batches. So they were sending hundreds of thousands at the same time, so that someone would have to respond to all of them by a deadline or lose by default. And this couple that they wrote about, Alla and Scott LaRoque, were personally very colorful. She was a former contestant on The Apprentice, and they had a sort of crazy wedding where they gave everyone luxury gifts. And, anyway, I thought that the story was extremely good, both because the details about these people were very interesting, but also because I think it shows how the No Surprises Act, which I covered at the time of its passage, you know — 

Rovner: We talked about it at great length on the podcast.  

Sanger-Katz: I think in a lot of ways, it was like a, it was a kind of health policy triumph. It was a bipartisan bill. There was a lot of cooperation. There was a lot of this kind of discussion and planning we were talking about earlier in the podcast, about how to do this right. It was a real problem in the health care system that Congress came together to try to solve, and yet, and yet, the work is never done. And there are always unanticipated problems.  

Rovner: It also illustrates the continuing point of because there’s so much money in health care, grifters are going to find it, even if it seems unlikely. Lauren. 

Weber: I had a little bit of a different plot twist this time. It’s called “Sucker: My Year as a Degenerate Gambler,” by McKay Coppins at The Atlantic. And it is just a gut-wrenching tale of how Coppins, who it talks about how he’s Mormon, and so gambling isn’t really a part of his religion. That special dispensation from religious authorities to gamble. For The Atlantic to learn, you know, how one can kind of fall into a gambling rabbit hole or not. And despite thinking that maybe he would be above the fray, that this wasn’t something that would really catch him. He finds himself utterly sucked in and exhibiting incredibly addictive tendencies, and basically talking about how — essentially, the moral of the story is, I cannot believe the guardrails are off of American gambling, and a lot of people will suffer. If he’s not able to really survive being given $10,000 by The Atlantic to gamble away. It’s a great piece. I highly recommend it. And I also recommend as a follow-up, one of my friends from college just wrote a book called Everybody Loses: The Tumultuous Rise of American Sports Gambling. That kind of gets into the history of why this has happened and why it matters now. And I think this is going to end up being a health policy issue that we end up talking about a lot, because this is an addiction problem that now is accessible from your pocket, and that you can constantly be on. And you know, we’re all women on this podcast right now. And the article actually gets into how gambling is not as, psychologically, as enticing to women, at least for sports gambling. But it’s very enticing to men, it appears, from the science that he points out. And so I think there’s a lot that’s going to come out on this in the next couple of years. And it’s a great piece to read.  

Rovner: Oh, this is a huge public health problem, particularly for young men. I mean … it’s the vaping of this decade, I call it. Alice. 

Ollstein: So I have a piece by The New York Times by Stephanie Nolen, and it is about how the Trump administration is trying to use HIV funding for Zambia as a lever to coerce them to grant minerals access. So a completely unrelated economic and infrastructure priority, and they’re using this health funding as a bargaining chip. And so this caught my attention. It came up in a recent hearing with the head of the NIH on Capitol Hill, and lawmakers were pressing him, saying, you know, if the United States is doing things like this and threatening to cut HIV funding abroad, how are we supposed to meet our goal of eliminating HIV in the U.S. by 2030? Because, as we learned during covid, we live in a global society, and things that impact other countries impact us as well. And [Jay] Bhattacharya answered, you know, oh, I think we can still eliminate HIV in the U.S., not necessarily in the whole world. So really, really urge people to check out this piece. 

Rovner: Yeah, it was a really good story. My extra credit is also from The New York Times. It’s by Rebecca Robbins, and it’s called “Trump Promised the ‘World’s Lowest’ Drug Prices. We Checked the Numbers.” And, spoiler, the TrumpRx website does not offer the best prices for medications in the world. The Times, along with three German news organizations, sent secret shoppers to pharmacies in eight cities around the world, and also compared TrumpRx’s prices to Germany’s publicly published prices. It seems that while TrumpRx, at least for the few dozen drugs that it sells right now, has narrowed the gap between what the U.S. and European patients pay. “But,” quote from the story, “the gap persists.” I will note that the administration disputes the Times’ reporting and says that when you factor in economic conditions in every country that TrumpRx prices can count as cheaper. You can read the story and judge for yourself. 

OK, that is this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying, and this week for special help to Taylor Cook. 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 whatthehealth@kff.org. Or you can find me on X @jrovner, or on Bluesky @julierovner. Where are you guys hanging these days? Alice. 

Ollstein: I am mostly on Bluesky @alicemiranda and still on X @AliceOllstein. 

Rovner: Lauren? 

Weber: On X and Bluesky as LaurenWeberHP; the HP is for health policy. 

Rovner: Margot. 

Sanger-Katz: At all the places @sangerkatz and at Signal @sangerkatz.01. 

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