The Host
Julie Rovner
KFF Health News
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Congress is running out of time to avert a huge increase in health care premium payments for millions of Americans who buy insurance through the Affordable Care Act marketplaces. Dec. 15 is the deadline to sign up for coverage that begins Jan. 1, and some consumers are waiting to see whether the credits will be extended, enabling them to afford coverage next year.
Meanwhile, a federal vaccine advisory panel handpicked by Health and Human Services Secretary Robert F. Kennedy Jr. voted last week to end the universal recommendation for a hepatitis B vaccine dose at birth. It’s just the start of what are expected to be major changes in childhood vaccine recommendations overall.
This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Maya Goldman of Axios, and Sheryl Gay Stolberg of The New York Times.
Panelists
Anna Edney
Bloomberg News
Maya Goldman
Axios
Sheryl Gay Stolberg
The New York Times
Among the takeaways from this week’s episode:
- As of Thursday morning, the Senate was preparing to vote on competing health proposals, neither of which was expected to pass: one, from Democrats, that would extend the enhanced ACA premium tax credits and a second, from Republicans, that would instead add money to health savings accounts for some ACA enrollees. With the credits set to expire and time running out to sign up for plans, it is likely that coverage will be unaffordable for some Americans, leaving them uninsured.
- The Advisory Committee on Immunization Practices’ decision to end its recommendation that newborns be immunized against hepatitis B is a major development in the federal government’s shift away from promoting vaccines. While the panel coalesced around the claim that babies are most likely to contract hepatitis B from their mothers, the reality is that the virus can live on household items, posing a threat of chronic disease and death to unvaccinated children.
- In reproductive health news, House Speaker Mike Johnson removed insurance coverage of fertility treatment for service members from the National Defense Authorization Act before the legislation’s passage, and anti-abortion groups are calling for the firing of Food and Drug Administration head Marty Makary over reports he is slow-walking policy changes on medication abortion.
Also this week, Rovner interviews Georgetown University professor Linda Blumberg about what the GOP’s health plans have in common.
Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too:
Julie Rovner: The Washington Post’s “Rural America Relies on Foreign Doctors. Trump’s Visa Fee Shuts Them Out,” by David Ovalle.
Anna Edney: Bloomberg News’ “Abbott Fired a Warning Shot on Baby Formula — Then Launched a Lobbying Blitz,” by Anna Edney.
Sheryl Gay Stolberg: The New York Times’ “The Married Scientists Torn Apart by a Covid Bioweapon Theory,” by Katie J.M. Baker.
Maya Goldman: ProPublica’s “These Health Centers Are Supposed to Make Care Affordable. One Has Sued Patients for as Little as $59 in Unpaid Bills,” by Aliyya Swaby.
Also mentioned in this week’s podcast:
- Politico’s “’Sort of Blackmail’: Billions in Rural Health Funding Hinge on States Passing Trump-Backed Policies,” by Alice Miranda Ollstein, Ruth Reader, and Liz Crampton.
- The New York Times’ “Kennedy’s Methodical 2-Decade Quest To Dismantle Vaccine Policy,” by Sheryl Gay Stolberg and Christina Jewett.
- Bloomberg News’ “FDA Slow Walking a Long-Awaited Abortion Pill Safety Study,” by Charles Gorrivan, Riley Griffin, and Rachel Cohrs Zhang.
- The Associated Press’ “Affordable Care Act Enrollment Is Slightly Ahead of Last Year So Far, Despite Expiring Subsidies,” by Ali Swenson and Nicky Forster.
Click to open the transcript
Transcript: Crunch Time for ACA Tax Credits
[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, Dec. 11, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today, we are joined via video conference by Anna Edney of Bloomberg News.
Anna Edney: Hi, Julie.
Rovner: Maya Goldman of Axios News.
Goldman: Great to be here.
Rovner: And I’m pleased to welcome to the podcast panel my friend and longtime health reporting colleague, Sheryl Gay Stolberg of The New York Times. Sheryl, so glad to have you join us.
Stolberg: I’m so glad to be here, Julie.
Rovner: So, later in this episode, we’ll have my interview with Linda Blumberg of Georgetown University. Linda has spent years analyzing Republican proposals to fix health care and has some interesting observations to share. But first, this week’s news.
We will start again with the continuing saga of the expiring enhanced tax credits for the Affordable Care Act. Starting Jan. 1, millions of people who get their insurance from the Obamacare marketplaces will face huge increases in what they have to pay in premiums. Some will find those increases so big they’ll have no choice but to drop their insurance altogether. And next Monday, Dec. 15, is the deadline for people to sign up for coverage that starts in January. So, the Senate is set to vote today on two different options. The first, backed by all the chamber’s Democrats, calls for a straight, three-year extension of the enhanced payments that were first implemented in 2021. Those extra payments made insurance so much more affordable that enrollment basically doubled from about 12 million people in the marketplaces to about 24 million. That bill, though, is unlikely to achieve the 60-vote majority it would need to advance. The Senate is also scheduled to consider a Republican alternative, sponsored by Finance Committee Chairman Mike Crapo of Idaho and Health Committee Chair Bill Cassidy of Louisiana. It wouldn’t extend the enhanced tax credits at all. Instead, it would provide either $1,000 or $1,500 for a tax-preferred health savings account that individuals could use for routine health expenses to be coupled with a high-deductible insurance policy. “High-deductible” meaning many thousands of dollars. It’s not expected to achieve 60 votes either. So, assuming both of these plans fail to muster the needed 60 votes, where does that leave us?
Edney: I think that leaves us looking for what the next turn of the key will be. I mean, will they be able to come to some agreement on extending the tax credits — likely — or the subsidies — likely after. Like you said, enrollment has been underway, and people are enrolling even though they don’t really know what the fate of these will be. So, it’ll be interesting to see how the marketplace reacts given what happens. But I don’t think there’s a really clear idea yet, except that everyone thinks that something might start moving once these votes are dispensed with.
Stolberg: I think what happens is that a lot of Americans are going to lose their health insurance. We know that the number of Americans insured on the Obamacare exchange is more than double after the enactment of these extended tax credits in 2021. I think there were 11 million; now there are 24 million. And people, as you said in the outset, have to decide now. And maybe they’ll sign up now. But if they lose these credits, I think that a lot of folks are going to suddenly find themselves without insurance coverage. And I think politically for Republicans, that is going to be a big problem going into next year’s midterms. They know this, and that’s why they’re scrambling to come up with some kind of alternative that does not have Obamacare in its name. But we also know that the alternatives that they’re proposing won’t go very far in terms of offsetting out-of-pocket costs for people who are struggling to pay for health care.
Rovner: Things are starting to bubble up in the House, too. I mean, we’ve seen this. … We knew we were going to have this Senate vote, which is everybody protected by everyone to be a show vote, but now Republicans in the House are getting skittish as well.
Goldman: Yeah, absolutely. And we’ve seen a couple different proposals in the House. So, there are some moderates that are Republican moderates that are proposing a straight, two-year extension. I think, like Anna said, we’ll see what happens after the Senate votes today, if that brings people to the table or not. I think one thing that struck me this week is The Associated Press reported that ACA sign-ups are actually slightly ahead of where they were at this time last year. But of course, that doesn’t mean that that’s going to result in more overall enrollment. There is still a lot that needs to be ironed out there. One thing that I’m wondering is: Is health coverage just something that people are biting the bullet on at this point? And they’re like, Well, I know it’s really expensive, but I still need to have health insurance. And is that going to … even if people do drop off, we’re so far away, politically speaking, from the November elections, that, is that actually going to resonate still? I don’t know.
Rovner: Yeah. I mean, one of the things that … I saw that AP story, too, that enrollment is actually higher than it was last year at this time. But you have to worry if there’s going to be what they call the death spiral, where only the people who need insurance the most sign up. You have to wonder whether these are the people who would sign up no matter what. And it’s the healthier people for whom it’s a bigger question mark — whether they actually need the health insurance at this much higher price — who are probably waiting right now. If you’re sick, you’re probably going to sign up no matter what. So, in some ways, I wondered if that was more of a warning signal than anything else.
Goldman: That’s a great point.
Stolberg: I think the death spiral is a real concern, especially with the plan that Cassidy and Crapo are putting forward. It would drive people into either catastrophic plans or “bronze” plans, which are lower costs, but high-deductible. And the people who are going to get into those plans are healthy people. That is going to deprive the risk pools for sick people of the healthy. And we know what happens when the risk pools become imbalanced like that. Then insurance costs really skyrocket for the people who need it most.
Rovner: Yeah. Now, even if Republicans do decide they want to sue for peace, if you will, there are a lot of other obstacles to a bipartisan deal. We’ve talked about abortion. But it looks like there are other things that Republicans want to do that Democrats are not going to want to accept.
Stolberg: Such as ending support for IVF [in vitro fertilization] coverage like they did in the defense bill this week?
Rovner: Yeah, which we’ll get to in a little while.
Stolberg: OK.
Rovner: Yeah. I mean, I could see a bipartisan deal. I’m just dubious partly — and we’ve said this, I think, every week for the last five or six weeks — that Republicans won’t vote for an extension without permanent abortion restrictions, and Democrats won’t vote for an extension with permanent abortion restrictions. But I know that some of these Republican bills also would deprive legal immigrants. There are anti-fraud provisions, some of which might be supported by Democrats, some of which might be seen as so onerous that they would prevent legitimate people from legitimately signing up. Does anybody actually see a bipartisan deal happening? I guess how scared do Republicans have to get before they’re willing to do something that the Democrats would agree to?
Stolberg: I don’t see a bipartisan bill happening in time. I mean, Cassidy said at this hearing last week, literally pleading with his colleagues saying, We can talk about grand plans, Bernie [Sanders, I-Vermont] can talk about “Medicare for All,” and we can talk about this, but we got to do something in three weeks. Well, now it’s two weeks, and they’re not going to come to some compromise, especially not one involving abortion or undocumented immigrants by Christmas. It’s not going to happen.
Rovner: Yeah. Congress loves to give itself deadlines and then not meet them.
Goldman: Absolutely. And I think we have Republicans with their grand plans, and you can’t implement a full HSA [health savings account] expansion in the time that they’ve allotted. That’s just not practicable.
Rovner: Yeah. I think this is a war of talking points at this point. All right. Well, the ACA may be this week’s news, but I don’t want to miss out on the vaccine news from late last week after we taped. As predicted, HHS Secretary RFK Jr.’s [Health and Human Services Secretary Robert F. Kennedy Jr.] handpicked CDC [Centers for Disease Control and Prevention] advisory committee on vaccine practices voted to roll back the universal recommendation for a first dose of the hepatitis B vaccine for infants, right after birth. Instead, the panel recommended making the vaccine the subject of “individual-based decision-making.” What’s the difference between that and actually recommending the vaccine? Is this a really big change? Anna, Sheryl, you guys have been watching this closely.
Edney: Yeah, I think that it’s a big change in the sense that it can be pretty confusing for parents. And it injects this idea of the vaccine possibly being harmful — although that’s not something that’s seen in the data — and also that maybe it’s just not that big of a deal, which is the problem of the success of the vaccine is the vaccine works. Hepatitis B cases in newborns go down, and people think, Oh, well, we don’t really have to worry about this anymore. But that’s just not the case. Obviously, as we’ve seen with other diseases of late, these things can come back.
And so I think it’s not going to change at the moment, at least, necessarily insurance coverage for having the vaccine, but it does leave open this door that, Well, maybe you should talk to your doctor, see if it’s really the best thing. And there’s just a lot coming at you as a new parent or a parent with a new child on the way, and a lot of medical advice to wade through, and things like that. So, this adds an extra piece to that for which a lot of the medical societies and doctors, Sen. Cassidy included, have said, This isn’t something that we’ve had a big question mark on. It’s been actually really, really helpful in the health of children.
Rovner: Yeah. Hepatitis B cases in children and teens have gone down 99%.
Stolberg: That’s right, since 1991. I was going to say, I think this is a really big deal. And it’s a really big deal for a couple of reasons. One, it’s not science-based. There’s no evidence that delaying the vaccine makes it any safer for children. Two, it’s a really big deal because of the debate that Kennedy and his allies have created around what was once not given any thought. And it’s also a big deal because, as doctors will tell you, in theory, one could argue, as Kennedy and his group do, that this is a disease that’s transmitted sexually, or it’s transmitted through intravenous drug use. And for infants, the real risk is mother-to-child transmission. Well, first of all, that’s not entirely true. The virus can last and live on household items like scissors, or tables, or whatever. We know that newborns are the ones that are most at risk.
And we also know that the best time to capture or vaccinate a newborn is when they’re there in the hospital, and they have access to medical professionals who can administer the vaccine. And unlike countries like Denmark, which follow up their babies, our babies don’t get that kind of follow-up. And so the likelihood is that kids will not get vaccinated when they’re older. Parents will forget about it, and they will have missed that critical opportunity to be protected against an infection that can cause chronic liver disease and death.
Goldman: Yeah. And there was a lot of discussion during the meeting on, Oh, well, we need to do a better job of screening the mothers for hepatitis B, and you should still get the newborn vaccine if you test positive, et cetera, et cetera. But that’s not ACIP’s [Advisory Committee on Immunization Practices] job to say that we should be screening mothers, so they don’t have any authority there to enforce that. And a CDC staff member said, We’re working on that. But, like Sheryl said, we don’t have the same kind of system that they have in other countries, where you can get those follow-up appointments, and get women in for prenatal care that they need. And so I agree, it’s going to be a huge, huge issue.
Rovner: Yeah. Well, speaking of those other countries, later on Friday after the meeting, in news that some might have missed, President [Donald] Trump issued an executive order basically telling RFK Jr. that he can do anything he wants with the childhood vaccine schedule because he should compare it to our “peer nations.” Sheryl, you had a big story last week about RFK’s plans for vaccine policy. What are they?
Stolberg: Well, what I reported with my colleague Christina Jewett is that Kennedy has been on this two-decade crusade to really upend American vaccine policy. Ultimately, he would like to end all mandates for childhood vaccination. That’s not within his purview. That’s in the purview of the states. But he wants to revisit the entire childhood vaccine schedule. And you can see in what he has done by installing his allies, some of whom presented at this ACIP meeting last week, he’s put them in key places. People like Mark Blaxill, who is a parent of a child with autism, who was a founder of a group called Safe Minds, which was an advocacy group. Mark Blaxill now works for the CDC. He’s a smart, Harvard-educated businessman, not a doctor, but he presented on hepatitis B. We saw Aaron Siri, Kennedy’s lawyer, presenting on the childhood vaccine schedule.
This is a committee that is supposed to be comprised of medical experts — people who are physicians who’ve administered care. And what we are seeing is Kennedy installing these people and others, sprinkling them throughout the department, or bringing them in, to carry out his vision. And he was very clear about that vision in an interview with me. I mean, he firmly believes, as he said — he was careful — he said that autism has gone up over these past decades, and it’s the same time as the childhood vaccines have become … we’ve had more widespread use of vaccines. We’ve also had more widespread drinking of pumpkin spice lattes, as Kennedy’s critics note, but Kennedy has said vaccines must be a potential culprit. I thought that was very interesting that he put that word in — potential. It was a wiggle word. But frankly, what he thinks is that vaccines are responsible, and he has said as much in other interviews.
Rovner: And yet, while this is going on at this very high level, we’re now having a huge and growing measles outbreak in South Carolina, in addition to the one that we’ve already had in Texas. This is really having an impact on parents’ willingness to have their children vaccinated. I mean, that, I think at this point, cannot be denied just by the evidence.
Edney: Yeah. Fewer parents are getting their kids vaccinated for school. They’re getting more waivers and things like that, too. So, we do see that this is definitely giving parents who maybe had concerns, or have felt some kinship with the MAHA [Make America Healthy Again] movement as it’s grown, the ability to do what they feel is right, less so following the science.
Stolberg: Peter Hotez, who is at Baylor University, told me that he was not surprised when there was a measles outbreak in Texas, and in particular in that part of West Texas, because vaccination rates in that corner of the state had been dropping precipitously in the years prior to the outbreak. And he said he could see it coming.
Goldman: I think it’s also, it’s not just people that are very in line with the MAHA movement at this point. I think if you’re not paying as close of attention as we are, the messages that you’re seeing are, Vaccines are bad. We need to look into vaccines. I don’t know, should I get a vaccine? Should I give my children vaccines? And I think that’s really taking hold.
Rovner: Another story that we’re going to follow into 2026. All right, we’re going to take a quick break. We will be right back.
Turning to reproductive health, the last big bill Congress is trying to finish before leaving for the year is the National Defense Authorization [Act]. And for the second year in a row, House Speaker Mike Johnson has ordered the removal of a provision passed by both the House and the Senate that would provide military personnel the same fertility coverage that other federal employees and members of Congress get. Right now, fertility treatments like IVF are only covered for those in the military who have service-related injuries or illnesses. I thought this was a priority for President Trump. At least he keeps saying that it is.
Stolberg: I think this is daylight between Trump and Mike Johnson, clearly.
Rovner: I have to say, I was surprised. Since when can the speaker just take something out of a bill that was passed by both the House and the Senate?
Stolberg: Also, not to mention that members of Congress have this coverage.
Rovner: That’s right, which they only got fairly recently. I’m surprised that there’s, I would say, less pushback. There obviously is pushback. There are people who are really furious about this, but in the manner of how things work in Congress, this is literally the second time he’s done it. And his spokespeople admit that he did it. And he says, Well, I only want this if it’s done ethically. And a reminder, he’s from Louisiana, which is the state that has current restrictions on the destruction of excess embryos from IVF that’s made IVF difficult to obtain in that state. It’s one person exerting his will over the rest of the Congress.
Stolberg: Yeah. I think that’s the most interesting thing about it is the daylight between Johnson and Trump and also Kennedy on this issue. Because while Trump and Kennedy profess to be anti-abortion, it’s not really a top-of-mind issue for either one of them. But it is for Johnson. And I guess I can’t imagine Trump vetoing the defense bill, so I guess this is going to go through.
Rovner: Yeah, without it. Again. Well, speaking of who it’s a priority for, much [to] the frustration and anger of the anti-abortion movement, a new report finds that the percentage of medication abortions using telehealth continues to grow, including those from states with shield laws that protect prescribers to states that have abortion bans, to patients in those states that have abortion bans, which underlines a story from your colleagues at Bloomberg, Anna, suggesting that FDA commissioner Marty Makary is “slow-walking” the safety study of the abortion pill that was promised to anti-abortion lawmakers, that he’s apparently slow walking that until perhaps after the midterms.
I hasten to add that HHS spokesman Andrew Nixon denies the studies being deliberately delayed. But just the story has angered anti-abortion forces so much [that] they’re now calling for Makary’s firing. And Missouri Republican Sen. Josh Hawley, who’s been at the forefront of the fight against the abortion pill, and I believe the person who got the promise for this study, has called the allegations unacceptable and is demanding answers by this Monday. Combined with what’s going on with the carousel of center directors at the FDA, how much longer can Makary last under this continuing onslaught?
Edney: Yeah, what I was thinking of when you were talking about this story is this is just one in a tiny slice of all the things that seem to be coming at Makary and going wrong, and calling into question his ability to manage the FDA. I think specifically — you were just mentioning this with abortion, Sheryl — that it’s not top of mind for Trump or RFK. So, I’m not sure that this is the thing that does him in unless Sen. Hawley or something breaks on that end. Maybe there are some senators who will be upset enough as more, or if, more details come out.
I think that definitely Makary appears to be fighting for his job. I think there have been some great stories in The Washington Post and The Wall Street Journal talking about these discussions at the White House every few weeks, where should we keep doing this? Do we need to think of maybe putting someone different in leadership? He’s still there. And so, it seems that RFK is backing him pretty publicly. Obviously, that can change at a moment’s notice. So, something to keep a really close eye on.
Goldman: Something that we’ve been talking about on my team related to that is that it’s going to be really hard to get anyone else approved through the Senate for any of these positions. And they can install an acting director, but there are limits to how long that can last. And so I think that that is maybe partially helping with some job security for a lot of these people at these high levels.
Stolberg: I think it would be very hard to get someone else installed given the broken promises that Kennedy has made to Cassidy. They’re going to be very wary. And also, Makary is in the arc, or the spectrum, of people who could fill that job. He’s actually kind of moderate, if you will. And I talked to someone close to Kennedy who said that Kennedy still has confidence in him. So, his ouster, I think, would require the White House bigfooting Kennedy. And I’m not sure that that would happen.
Rovner: And they have, as we’ve noticed, other things to deal with right now. Finally this week, remember that $50 billion Congress included for rural health in last summer’s big budget bill to offset the nearly $1 trillion in cuts to Medicaid? Well, now the Trump administration is effectively telling states that if they want to claim a share of that money, they need to make changes that align with other Trump administration policies — things like barring people from using food stamps for junk food, or legalizing short-term insurance plans that many states worry could destabilize the individual insurance market. Now, I wouldn’t call this outright coercion, but I remember that the Supreme Court basically did just that when they ruled that the ACA’s Medicaid expansion had to be voluntary. Is this really going to fly, that the Trump administration could say, You can’t have this money unless you do other things that we want you to do?
Goldman: If I’m remembering correctly, all states that have all right to applications will get a baseline of money, and states can get more money for certain things that they apply for. And so I think that maybe that makes this a little different. But I think states will be very upset if they don’t get the money that they want, that they are asking for. And it’ll be interesting to see if there is legal action on the back end, too.
Rovner: Yeah. I mean, clearly this $50 billion for rural health is not enough to even begin to make up for the cuts that are coming to Medicaid. So, we’re talking about small amounts of money. It’s just, I don’t remember seeing conditions that were quite this blatant. And you’re right, Maya, it’s not all of the money, but it is some segment of the money. But for them to just literally come out and say, We’re going to give you money if you do what we want. I would think at some point Congress gets to say, Hey, not what we had in mind.
Stolberg: But Congress won’t say it. Not this Congress.
Rovner: Yeah, not this Congress. So maybe a future Congress. All right. Well, that is this week’s news. Now, we will play my interview with Linda Blumberg of Georgetown University, and then we will come back and do our extra credits.
I am pleased to welcome to the podcast Linda Blumberg. Linda is a research professor at Georgetown University and an institute fellow in the Health Policy Division of the Urban Institute, and one of my go-to people whenever I have a really complicated question about health policy. Linda, welcome to What the Health?
Linda Blumberg: Thanks so much for having me here.
Rovner: So, to the unpracticed eye, it looks like Republicans in the House and Senate are just now coming up with all these new and different health plans. But, in fact, most of them are variations on what Republicans have been pushing, not just for years, but for decades in some cases. Is there anything really new, or is this just a long list of golden oldies?
Blumberg: I think this is basically a list of things that have been brought out before. Now, they have to present them and talk about them in the context of the Affordable Care Act, which they didn’t have to do many years ago. They’re working around in terms of what they’re impacting on the Affordable Care Act, and how these other pieces would fit in with what they want to do there. But they’re essentially the same things they’ve been talking about for a long time.
Rovner: So, you’ve been analyzing these plans for years now. And while they may look different on the surface, you say they all have one thing in common: that they work to segment rather than pool risk. Can you explain that in layman’s terms?
Blumberg: Sure. When I talk about segmenting health care risk, what I’m talking about is policies, or strategies that place more of the financial responsibility of paying for medical care on the people who need that care when they need it, or on those who are most likely to need medical care. That is the opposite of pooling risk more broadly, which actually takes health care costs and spreads them to a greater extent across people, both healthy and sick.
Rovner: So basically, protecting sick people, which is the idea of health insurance in general, right?
Blumberg: Well, from my perspective, yes. The situation is because there is — what we in economics call — a very skewed distribution of health care spending, that means that in any particular year, at any particular moment in time, most people are pretty healthy and don’t use much medical care, and the great bulk of health care spending falls on a small percentage of the population. And so, when you’re only looking in the short term, when you’re not looking broadly across time, or across somebody’s life, then people who, when you segment health care risk, you can create savings for people when they’re super healthy. The problem is that it increases the cost even more when they are not healthy, and none of us are healthy forever.
Rovner: And just to be clear, the percentage of people who use the majority of health care is really, really tiny, isn’t it?
Blumberg: Yeah. So, for example, there is a rule of thumb that around the top 5% of health care spenders account for basically half of all health care spending, and the bottom half of spenders account for less than 3% of health care spending. But that is at a particular moment in time, again. And I think the problem is when we think about health care spending as Who’s going to win? Who’s going to lose? in terms of money, right now, at a particular moment in time. Instead of thinking about what happens to us over the course of our lifetime, which is, then, when we spread the costs much more broadly, we’re more protected. We have access to adequate affordable health care under broad-based pooling of health care risk. When we segment it, we’re really making people much more vulnerable to not being able to get the care they need when they need it.
Rovner: And how do things like health savings accounts, and giving consumers more power to go out and negotiate on their own, how do those actually segment risk?
Blumberg: So, the more you take the dollars that are being spent on health care and remove it from the health insurance pool — the amount of money that is going to pay for claims through health insurance, whether it’s public or private insurance — the more you take it out of the insurance pool and you put it on the individuals, the more we’re separating the risks and putting heavier costs on people when they need care. So, a health savings account gives us some cash, or allows us to put some cash into an account to use when we’re needing care. But it also comes with health insurance plans that are much higher deductibles and much larger out-of-pocket costs.
And so what we see in practice is that the people who have these accounts, they tend to not … First of all, they tend to be much wealthier people because they’re tax advantages for wealthy people, not for people who are [of] much more modest means. And when they go to get care, there’s usually not that much money in the account to help them pay for these much larger deductibles and out-of-pocket costs. And so they’re paying for a lot more when they need the care. The insurance kicks in at a much higher level of spend. And so the financial burden, even though they’ve paid lower premiums when they need the care, the financial hit is on the individual.
Rovner: So why shouldn’t we put higher-risk people in a different pool? Since, as you point out, most people are healthy most of the time. That would reduce costs for more people than it would raise costs for. Right?
Blumberg: Well, it would, at a particular moment in time, but the problem is we don’t stay healthy all of the time. And so, I’m not born with a stamp on my head that says, You’re going to be a low spender, and so you’re going to be better off over here. All I need is a broken leg. All I need is somebody in my family to develop diabetes. God forbid, a kid gets hit by a car, or develops a brain tumor. Stuff happens from out of the blue. And then, if that’s the case, if I’m in a situation that could really make it so that I can’t access, or my loved ones can’t access, the care that they need when they need it. And by the way, as we age, everybody tends to use more and more care.
So, you can save money at a moment of time by segmenting risk in these ways, but if you do it, you’re putting so many people at risk for not being able to get adequate care when they need it. And because of that skewed distribution of health care spending, it’s a situation where what you save when you’re healthy from segmenting risk is really pretty small compared to the extra amount you have to spend for pooling risk. Because if you take these dollars, and you spread them over everybody, then the increment that you have to spend in order to make sure you’re protected, and everybody else is protected when they need medical care, is not that big.
Rovner: Is there some ideological reason why Republicans seem to be coalescing around these risk-segmentation ideas?
Blumberg: I’m not a psychologist, so the motivation escapes me. Because I do think people are better off over the course of their lifetimes when we spread risk broadly. I think part of the issue is the other philosophical difference between conservatives and more progressive policymakers is the idea of income distribution. And the truth of the matter is that really wealthy people, if they get sick and have a high-deductible plan, or they have a much more narrow set of benefits that are being offered to them, they have wealth that can take them a long way to get to buy medical care. They can pay for the broken limb. They can pay for various different medications.
If they have a very serious illness, or injury that’s longer lasting, they may not — even wealthy people — may not be able to cover the costs, or it may really have a big impact on them. But by and large, wealthy people are able to insulate themselves to some degree, even with very pared-down coverage. Whereas somebody who’s middle-income, who’s lower-income, who’s not super wealthy, is not going to be able to access that care. So, if your focus is on protecting the assets of those with a lot of wealth, this is a positive in that regard.
Rovner: So how does this ongoing debate about these enhanced premium subsidies play into this whole thing?
Blumberg: When we’re talking about the enhanced premium tax credits, which seem to be, by the end of this week, will be going by the wayside, those are actually pooling mechanisms, too. And I think it’s important for people to understand that financial assistance for lower- and middle-income people, one of the great things that it does — as a secondary effect of just giving those people insurance coverage — is it brings a lot more healthier people into the pool. People who are healthy, young, who wouldn’t have been able to afford health insurance coverage before, and so would have remained uninsured and did before these credits were in place. It brings them into the pool. It lowers the average medical expenses of people insured. And by pooling risk in that way, it actually lowers the premium. Because as the average cost of the individuals enrolled goes down, the premiums go down, too.
And so one of the things besides these other strategies, which would tend to segment risk further, as we talked about, the strategy that they are denying — which is continuing these enhanced subsidies — is also going to further segment risk because it’s going to push healthier people out of the pool that can’t afford it anymore. Same with, by the way, the people who are immigrants but are residing here legally, who are no longer going to be able to access assistance to buy coverage in the marketplaces as they have been for the last number of years, they also tend to be people who use less medical care on average. And so those immigrants being in our insurance pools are actually helping to subsidize American citizens who are less healthy. And so by saying, Listen, we’re not going to let you in. We’re not going to give you subsidies to make it affordable for you to come in. We’re actually pushing the average cost of the health insurance coverage upward for no good reason, honestly.
Rovner: Linda Blumberg, thanks very much.
Blumberg: My pleasure. Good to see you.
Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it; we will put the links in our show notes on your phone or other mobile device. Anna, you have a story written by you this week. Why don’t you go first?
Edney: Yeah, thank you. I had a story just published today. It’s in Bloomberg: “Abbott Fired a Warning Shot on Baby Formula — Then Launched a Lobbying Blitz.” And I took a deep look at this issue of preterm infant formula. So, for preemies that are born really early, there’s this big debate right now on whether formula is harming them, or whether it’s something else that’s causing one a day, essentially, to die from this awful disease, necrotizing enterocolitis. And so Abbott is struggling because they don’t make a lot of money off of this formula, but they’re being sued for billions and billions of dollars. So they really want Congress, any agency, the White House, whoever, to intervene in some way.
They’re throwing everything at the wall to see what can stick. And I’ll just say one tidbit that I found that was really interesting. There’s a lot of debate. There was an NIH [National Institutes of Health] report on this disease recently that moved in Abbott’s favor a little bit. I did learn through my reporting that the report was ghostwritten by a company that does a lot of work with Abbott, and lists them as a client. So that’s an interesting conflict of interest there, maybe a hook to get you guys to go read it. Thanks.
Rovner: Oops. I’m definitely going to go read it. Maya, why don’t you go next?
Goldman: Yeah, I’m excited to read that, Anna.
Edney: Thank you.
Goldman: My extra credit this week is from ProPublica. It’s by Aliyya Swaby and it’s called “These Health Centers Are Supposed To Make Care Affordable. One Has Sued Patients for as Little as $59 in Unpaid Bills.” There are a lot of details in the story, but I think the headline tells you the gist of it. But what stuck out to me about this is I think in health journalism and health policy, we often talk about the safety net as if it’s magic and going to catch everyone, or at least I find myself slipping into that mindset sometimes. And I think it’s really important to look into how people on the ground are actually experiencing these services. And it’s also a reminder, unfortunately, that there are bad actors everywhere.
Rovner: Alas. Sheryl.
Stolberg: So, my extra credit this week is actually more of a science policy story than a health policy story, but it is a fascinating yarn. It’s titled “The Married Scientists Torn Apart by a COVID Bioweapon Theory.” It’s in The New York Times by my colleague Katie J.M. Baker. And this is the story of two Chinese virologists who were married, and the woman came to believe that covid was a bioweapon created in a lab, and that the Chinese government had purposefully grown this virus and released it to set off the pandemic. And this doctor fell under the sway of people like Steve Bannon, Trump’s ally, and an exiled Chinese billionaire who had reason to want to blame the Chinese government, and who brought her to the United States, placed her in a series of safe houses once she arrived, and arranged for her to meet some of Trump’s top advisers.
And she has now gone underground, and her husband actually moved to the United States to try to find her. And she’s basically in hiding. She’s cut off contact with her family. And it’s heartbreaking, and poignant, and also, from my perspective, revelatory about just the politics that have come to define our debates around science and health in the wake of the pandemic.
Rovner: Yeah, it is quite the story. All right. My extra credit this week is from The Washington Post. It’s called “Rural America Relies on Foreign Doctors. Trump’s Visa Fee Shuts Them Out,” by David Ovalle. And we’ve talked about this issue before. These fees were mainly aimed at tech companies, who are the biggest users of the H1B visa program, but this new $100,000 fee is already preventing particularly rural practitioners from bringing medical professionals to places in the United States that Americans just don’t want to practice. This story centers on an overworked kidney disease practice in North Carolina that’s still waiting on a U.S.-trained doctor that it hired months ago, who is stuck in India. We’ve already talked about how the Medicaid cuts are going to hit rural areas particularly hard. This fee to bring in international medical professionals sounds like it’s making that even worse.
OK, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our producer-engineer, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcast, 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 still on X @jrovner or on Bluesky @julierovner. Where are you folks hanging these days, Maya
Goldman: I am on X @mayagoldman_ and on LinkedIn under my name.
Rovner: Anna
Edney: X or Bluesky @AnnaEdney,and LinkedIn as well.
Rovner: Sheryl.
Stolberg: And I’m on X and Bluesky @sherylnyt, and LinkedIn under my own name.
Rovner: We will be back in your feed next week. Until then, be healthy.
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