Trump Says He’ll Stop Health Care Fraudsters. Last Time, He Let Them Walk.

Five years ago, the CEO of one of the largest pain clinic companies in the Southeast was sentenced to more than three years in prison after being convicted in a $4 million illegal kickback scheme.

But after just four months behind bars, John Estin Davis walked free. President Donald Trump commuted Davis’ sentence in the last days of his first term. In a statement explaining the decision, the White House said that “no one suffered financially” from Davis’ crime.

In court, however, the Trump administration was saying something very different. As the president let him go, the Department of Justice alleged in a civil lawsuit that Davis and his company defrauded taxpayers out of tens of millions of dollars with excessive urine drug testing. The DOJ alleged that Comprehensive Pain Specialists made such a “staggering” sum from cups of pee that employees had given the testing a profit-minded nickname: “liquid gold.”

Davis and the company denied all allegations in court filings and settled the DOJ’s fraud lawsuit without any determination of liability. Davis declined to comment for this article.

Since returning to the White House, Trump has said he will target fraud in Medicare, Medicaid, and Social Security, and his Republican allies in Congress have made combating fraud a key argument in their plans to slash spending on Medicaid, which provides health care for millions of low-income and disabled Americans. During an address to Congress last month, Trump said his administration had found “hundreds of billions of dollars of fraud” without citing any specific examples of fraud.

“Taken back a lot of that money,” Trump said. “We got it just in time.”

But Trump’s history of showing leniency to convicted fraudsters contrasts with his present-day crackdown. In his first and second terms, Trump has granted pardons or commutations to at least 68 people convicted of fraud crimes or of interfering with fraud investigations, according to a KFF Health News review of court and clemency records, DOJ press releases, and news reports. At least 13 of those fraudsters were convicted in cases involving more than $1.6 billion of fraudulent claims filed with Medicare and Medicaid, according to the Department of Justice.

And as one of the first actions of his second term, Trump fired 17 independent inspectors general responsible for rooting out fraud and waste in government.

“It sends a really bad message and really hurts DOJ efforts at creating deterrence,” said Jacob Elberg, a former assistant U.S. attorney and law professor at Seton Hall University in New Jersey. “In order to reduce health care fraud, you need people both to be afraid of getting in trouble, but also for people to believe in the legitimacy of the system.”

Elberg said considerable fraud in Medicare and Medicaid exists largely because the programs’ “pay-and-chase models” prioritize paying for patient care first and tracking down stolen dollars second. To prevent more fraud, the programs would likely need to be redesigned in ways that would be slower and more cumbersome for all patients, Elberg said.

Regardless, Elberg said the president’s claimed focus on fraud appears to be a pretext for slashing spending that has been legally appropriated by Congress. Trump has empowered the Elon Musk-led Department of Government Efficiency, which he established and named by executive order, to make deep cuts in federal budgets, halting some medical research and aid programs in addition to cutting spending on climate change, transgender health, and diversity, equity, and inclusion programs.

“What’s been the focal point to date of the administration is not what anybody has ever referred to as health care fraud,” Elberg said. “There is a real blurring — a seemingly intentional blurring — between what is actually fraud and what is just spending that they are not in favor of.”

Jerry Martin, who served as a U.S. attorney for the Middle District of Tennessee under President Barack Obama and now represents health care fraud whistleblowers, also said Trump’s focus on fraud appeared to be “just a platform to attack things that they don’t agree with” rather than “a genuine desire to root out and combat fraud.”

Even so, Martin said some of his whistleblower clients have been emboldened.

“I’ve had clients repeat back to me ‘President Trump says fraud is a priority,’” Martin said. “People are listening to it. But I don’t know that what he’s saying translates into what they believe.”

The White House did not respond to requests for comment for this article.

A Billion-Dollar Fraud Case and Needless Eye Injections

Presidents enjoy the unique authority to erase federal convictions and prison sentences with pardons and commutations. In theory, the power is intended to be a final bulwark against injustice or overly harsh punishment. But many presidents have been accused of using the pardon power to reward powerful allies and close associates as they leave the White House.

Trump issued about 190 pardons and commutations in the final two months of his first term, including for some health care fraudsters convicted of schemes with astonishing costs.

For example, Trump granted a commutation to Philip Esformes, a Florida health care executive convicted in 2019 of a $1.3 billion Medicare and Medicaid fraud scheme. After he was sentenced, DOJ announced in a press release that “the man behind one of the biggest health care frauds in history will be spending 20 years in prison.” Trump freed him 14 months later.

Trump also granted a commutation to Salomon Melgen, a Florida eye doctor who was serving a 17-year prison sentence for defrauding Medicare of $42 million. Melgen falsely diagnosed patients with eye diseases, then gave them unnecessary care, including laser treatments and painful eye injections, according to DOJ and court documents.

“Salomon Melgen callously took advantage of patients who came to him fearing blindness,” said a DOJ news release after Melgen was sentenced in 2018. “They received medically unreasonable and unnecessary tests and procedures that victimized his patients and the American taxpayer.”

DOJ: $70 Million Spent on ‘Excessive’ Urine Testing

Despite the flurry of pardons and commutations at the end of Trump’s first term, the leniency he showed Davis was unique. Davis was the only convicted health care fraudster to receive clemency while the Trump administration was simultaneously accusing him of more fraud.

As CEO of Comprehensive Pain Specialists from 2011 to 2017, Davis oversaw a rapid expansion to more than 60 locations across 12 states, according to federal court documents.

He was indicted in 2018 for using his CEO position to refer Medicare patients in need of medical equipment to a conspirator in return for kickbacks paid through a shell company, according to court documents. He was convicted at trial in April 2019 of defrauding Medicare.

Three months later, the DOJ filed a fraud lawsuit against Davis and CPS that piggybacked on the claims of seven whistleblowers. The lawsuit alleged that CPS collected more than $70 million from federal insurance programs for urine drug testing, most of which was “excessive,” and that an audit of a sampling of the tests had found at least 93% “lacked medical necessity.”

Typically, government insurance programs pay for urine testing so pain clinics can verify that patients are taking their prescriptions properly and not abusing any other drugs, which could contribute to an overdose. Patients could be tested as little as once a year or as often as monthly depending on their level of risk, according to the DOJ lawsuit.

But Comprehensive Pain Specialists performed “myriad urine drug testing on virtually every CPS patient on virtually every visit” then conducted “at least 16 different types of tests” on each sample, and sometimes as many as 51, according to the lawsuit.

Trump commuted Davis’ sentence for his criminal conviction in January 2021 as the DOJ was finalizing a settlement in the civil lawsuit. The commutation was supported by country music star Luke Bryan, according to a White House statement.

Months later, with President Joe Biden in office, CPS and its owners agreed to repay $4.1 million — less than 10% of the damages sought in the suit — and the case was closed.

In the settlement, Davis agreed not to take any job where he would ever again bill Medicare or other federal health care programs. He was not required to personally repay anything.

Martin, who represented one of the whistleblowers who first raised allegations against Davis and CPS, said the leniency that Trump showed to him and other health care fraudsters may discourage DOJ employees from pursuing similar investigations during his second term.

“There are a lot of rank-and-file people who are operating at the lowest point in their professional careers, where they’ve seen a lot of their work essentially be water under the bridge,” Martin said. “That’s got to be really demoralizing.”

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Their Physical Therapy Coverage Ran Out Before They Could Walk Again

Mari Villar was slammed by a car that jumped the curb, breaking her legs and collapsing a lung. Amy Paulo was in pain from a femur surgery that wasn’t healing properly. Katie Kriegshauser suffered organ failure during pregnancy, weakening her so much that she couldn’t lift her baby daughter.

All went to physical therapy, but their health insurers stopped paying before any could walk without assistance. Paulo spent nearly $1,500 out of her own pocket for more sessions.

Millions of Americans rely on physical and occupational therapists to regain strength and motor skills after operations, diseases, and injuries. But recoveries are routinely stymied by a widespread constraint in health insurance policies: rigid caps on therapy sessions.

Insurers frequently limit such sessions to as few as 20 a year, a KFF Health News examination finds, even for people with severe damage such as spinal cord injuries and strokes, who may need months of treatment, multiple times a week. Patients can face a bind: Without therapy, they can’t return to work, but without working, they can’t afford the therapy.

Paulo said she pressed her insurer for more sessions, to no avail. “I said, ‘I’m in pain. I need the services. Is there anything I can do?’” she recalled. “They said, no, they can’t override the hard limit for the plan.”

A typical physical therapy session for a privately insured patient to improve daily functioning costs $192 on average, according to the Health Care Cost Institute. Most run from a half hour to an hour.

Insurers say annual visit limits help keep down costs, and therefore premiums, and are intended to prevent therapists from continuing treatment when patients are no longer improving. They say most injuries can be addressed in a dozen or fewer sessions and that people and employers who bought insurance could have purchased policies with better therapy benefits if it was a priority.

Atul Patel, a physiatrist in Overland Park, Kansas, and the treasurer of the American Academy of Physical Medicine and Rehabilitation, said insurers’ desire to prevent gratuitous therapy is understandable but has “gone too far.”

“Most patients get way less therapy than they would actually benefit from,” he said.

Hard caps on rehab endure in part because of an omission in the Affordable Care Act. While that law required insurers to cover rehab and barred them from setting spending restrictions on a patient’s medical care, it did not prohibit establishing a maximum number of therapy sessions a year.

More than 29,000 ACA health plans — nearly 4 in 5 — limit the annual number of physical therapy sessions, according to a KFF Health News analysis of plans sold last year to individuals and small businesses. Caps generally ranged from 20 to 60 visits; the most common was 20 a year.

Health plans provided by employers often have limits of 20 or 30 sessions as well, said Cori Uccello, senior health fellow at the American Academy of Actuaries.

“It’s the gross reality in America right now,” said Sam Porritt, chairman of the Falling Forward Foundation, a Kansas-based philanthropy that has paid for therapy for about 200 patients who exhausted their insurance over the past decade. “No one knows about this except people in the industry. You find out about it when tragedy hits.”

Even in plans with no caps, patients are not guaranteed unlimited treatment. Therapists say insurers repeatedly require prior authorization, demanding a new request every two or three visits. Insurers frequently deny additional sessions if they believe there hasn’t been improvement.

“We’re seeing a lot of arbitrary denials just to see if you’ll appeal,” said Gwen Simons, a lawyer in Scarborough, Maine, who represents therapy practices. “That’s the point where the therapist throws up their hands.”

‘Couldn’t Pick Her Up’

Katie Kriegshauser, a 37-year-old psychologist from Kansas City, Missouri, developed pregnancy complications that shut down her liver, pancreas, and kidneys in November 2023. After giving birth to her daughter, she spent more than three months in a hospital, undergoing multiple surgeries and losing more than 40 pounds so quickly that doctors suspected her nerves became damaged from compression. Her neurologist told her he doubted she would ever walk again.

Kriegshauser’s UnitedHealthcare insurance plan allowed 30 visits at Ability KC, a rehabilitation clinic in Kansas City. She burned through them in six weeks in 2024 because she needed both physical therapy, to regain her mobility, and occupational therapy, for daily tasks such as getting dressed.

“At that point I was starting to use the walker from being completely in the wheelchair,” Kriegshauser recalled. She said she wasn’t strong enough to change her daughter’s diaper. “I couldn’t pick her up out of her crib or put her down to sleep,” she said.

The Falling Forward Foundation paid for additional sessions that enabled her to walk independently and hold her daughter in her arms. “A huge amount of progress happened in that period after my insurance ran out,” she said.

In an unsigned statement, UnitedHealthcare said it covered the services that were included in Kriegshauser’s health plan. The company declined to permit an official to discuss its policies on the record because of security concerns.

A Shattered Teenager

Patients who need therapy near the start of a health plan’s year are more likely to run out of visits. Mari Villar was 15 and had been walking with high school friends to get a bite to eat in May 2023 when a car leaped over a curb and smashed into her before the driver sped away.

The accident broke both her legs, lacerated her liver, damaged her colon, severed an artery in her right leg, and collapsed her lung. She has undergone 11 operations, including emergency exploratory surgery to stop internal bleeding, four angioplasties, and the installation of screws and plates to hold her leg bones together.

Villar spent nearly a month in Shirley Ryan AbilityLab’s hospital in Chicago. She was discharged after her mother’s insurer, Blue Cross and Blue Shield of Illinois, denied her physician’s request for five more days, making her more reliant on outpatient therapy, according to records shared by her mother, Megan Bracamontes.

Villar began going to one of Shirley Ryan’s outpatient clinics, but by the end of 2023, she had used up the 30 physical therapy and 30 occupational therapy visits the Blue Cross plan allowed. Because the plan ran from July to June, she had no sessions left for the first half of 2024.

“I couldn’t do much,” Villar said. “I made lots of progress there, but I was still on crutches.”

Dave Van de Walle, a Blue Cross spokesperson, said in an email that the insurer does not comment on individual cases. Razia Hashmi, vice president for clinical affairs at the Blue Cross Blue Shield Association, said in a written statement that patients who have run out of sessions should “explore alternative treatment plans” including home exercises.

Villar received some extra sessions from the Falling Forward Foundation. While her plan year has reset, Villar is postponing most therapy sessions until after her next surgery so she will be less likely to run out again. Bracamontes said her daughter still can’t feel or move her right foot and needs three more operations: one to relieve nerve pain, and two to try to restore mobility in her foot by lengthening her Achilles tendon and transferring a tendon in her left leg into her right.

“Therapy caps are very unfair because everyone’s situation is different,” Villar said. “I really depend on my sessions to get me to a new normalcy. And not having that and going through all these procedures is scary to think about.”

Rationing Therapy

Most people who use all their sessions either stop going or pay out-of-pocket for extra therapy.

Amy Paulo, a 34-year-old Massachusetts woman recovering from two operations on her left leg, maxed out the 40 visits covered by Blue Cross Blue Shield of Massachusetts in 2024, so she spent $1,445 out-of-pocket for 17 therapy sessions.

Paulo needed physical therapy to recover from several surgeries to shorten her left leg to the length of her right leg — the difference a consequence of juvenile arthritis. Her recovery was prolonged, she said, because her femur didn’t heal properly after one of the operations, in which surgeons cut out the middle of her femur and put a rod in its place.

“I went ballistic on Blue Cross many, many times,” said Paulo, who works with developmentally delayed children.”

Amy McHugh, a Blue Cross spokesperson, declined to discuss Paulo’s case. In an email, she said most employers who hire Blue Cross to administer their health benefits choose plans with “our standard” 60-visit limit, which she said is more generous than most insurers offer, but some employers “choose to allow for more or fewer visits per year.”

Paulo said she expects to restrict her therapy sessions to once a week instead of the recommended twice a week because she’ll need more help after an upcoming operation on her leg.

“We had to plan to save my visits for this surgery, as ridiculous as it sounds,” she said.

Medicare Is More Generous

People with commercial insurance plans face more hurdles than those on Medicare, which sets dollar thresholds on therapy each year but allows therapists to continue providing services if they document medical necessity. This year the limits are $2,410 for physical and speech therapy and $2,410 for occupational therapy.

Private Medicare Advantage plans don’t have visit or dollar caps, but they often require prior authorization every few visits. The U.S. Senate Permanent Subcommittee on Investigations found last year that MA plans deny requests for physical and occupational therapy at hospitals and nursing homes at higher rates than they reject other medical services.

Therapists say many commercial plans require prior authorization and mete out approvals parsimoniously. Insurers often make therapists submit detailed notes, sometimes for each session, documenting patients’ treatment plans, goals, and test results showing how well they perform each exercise.

“It’s a battle of getting visits,” said Jackee Ndwaru, an occupational therapist in Jacksonville, Florida. “If you can’t show progress they’re not going to approve.”

An Insurer Overruled

Marjorie Haney’s insurance plan covered 20 therapy sessions a year, but Anthem Blue Cross Blue Shield approved only a few visits at a time for the rotator cuff she tore in a bike accident in Maine. After 13 visits in 2021, Anthem refused to approve more, writing that her medical records “do not show you made progress with specific daily tasks,” according to the denial letter.

Haney, a physical therapist herself, said the decision made no sense because at that stage of her recovery, the therapy was focused on preventing her shoulder from freezing up and gradually expanding its range of motion.

“I went through those visits like they were water,” Haney, now 57, said. “My range was getting better, but functionally I couldn’t use my arm to lift things.”

Haney appealed to Maine’s insurance bureau for an independent review. In its report overturning Anthem’s decision, the bureau’s physician consultant, William Barreto, concluded that Haney had made “substantial improvement” — she no longer needed a shoulder sling and was able to return to work with restrictions. Barreto also noted that nothing in Anthem’s policy required progress with specific daily tasks, which was the basis for Anthem’s refusal.

“Given the member’s substantial restriction in active range of motion and inability to begin strengthening exercises, there is remaining deficit that requires the skills and training of a qualified physical therapist,” the report said.

Anthem said it requires repeated assessments before authorizing additional visits “to ensure the member is receiving the right care for the right period of time based on his or her care needs.” In the statement provided by Stephanie DuBois, an Anthem spokesperson, the insurer said this process “also helps prevent members from using up all their covered treatment benefits too quickly, especially if they don’t end up needing the maximum number of therapy visits.”

In 2023, Maine passed a law banning prior authorization for the first 12 rehab visits, making it one of the few states to curb insurer limitations on physical therapy. The law doesn’t protect residents with plans based in other states or plans from a Maine employer who self-insures.

Haney said after she won her appeal, she spaced out the sessions her plan permitted by going once weekly. “I got another month,” she said, “and I stretched it out to six weeks.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Montana Examines Ways To Ease Health Care Workforce Shortages

HELENA, Mont. — Mark Nay’s first client had lost the van she was living in and was struggling with substance use and medical conditions that had led to multiple emergency room visits.

Nay helped her apply for Medicaid and food assistance and obtain copies of her birth certificate and other identification documents needed to apply for housing assistance. He also advocated for her in the housing process and in the health care system, helping her find a provider and get to appointments.

After a year of “steady engagement,” Nay said, the client has a place to live, is insured, is connected to the health care system, and has the resources needed to “really start to be successful and stable” in her life.

Nay is one of two community health workers in a program that St. Peter’s Health of Helena started in 2022, focusing on people experiencing or at risk of homelessness who had five or more ER visits in a year. Nay and his colleague, Colette Murley, link their clients to services to meet basic needs, whether it’s health care, food, housing, or insurance. The goal is to provide stability and, ultimately, to improve health outcomes.

Similar work is done in hospitals, community health centers, and other settings across Montana by people with titles such as case manager, outreach worker, navigator, and care manager. State Rep. Ed Buttrey, a Great Falls Republican, is sponsoring a bill in Montana’s legislative session to put a common title — community health worker — to the type of work they do and define in law what the role entails. The bill also would provide for licensure and allow, but not require, Medicaid to cover the service.

“Health care is just a very difficult system to navigate, especially when you’re trying to sign up for service and you’re trying to get access to coverage for service,” Buttrey said. “So that’s where I see the biggest benefit.”

Buttrey’s HB 850 is one of several bills still alive this session that are related to Montana’s health care workforce, which is stretched thin throughout the state, the fourth-largest by land area. According to the U.S. Health Resources and Services Administration, more than one-fourth of the state’s residents live in an area with a shortage of primary care health professionals.

Other pending workforce bills include three interstate compact bills, to recognize licenses issued in other states for physician assistants, psychologists, and respiratory therapists. Then there are bills to prohibit noncompete clauses for physicians and some categories of mid-level practitioners. Other measures would allow more unsupervised activities by certain aides and assistants, let nurses provide low-cost home visits to low-income patients, allow licensure of doulas, and let physician assistants and physical therapists be considered “treating physicians” for workers’ compensation purposes.

State Rep. Jodee Etchart, a Billings Republican and a physician assistant, is sponsoring two of the interstate compact licensure bills and one of the bills to limit noncompete clauses.

Etchart termed the compact bills “a no-brainer” because they allow people to get licensed, get a job, and start working in Montana right away.

In 2023, Etchart sponsored successful bills to allow physician assistants to practice without physician supervision and to expand the scope of practice for direct-entry midwives. Those bills, she said, helped pave the way for the progress this year’s workforce bills have made this session.

“It opened a lot of people’s eyes about how we can increase access to health care all over Montana,” she said.

The 2023 bill allowing independent practice by physician assistants drew opposition from physicians, with the Montana Medical Association saying it extended their scope of practice without requiring additional training. This session, the MMA has supported the bills to remove noncompete provisions but opposed bills on expanding the scope of practice for chiropractors and optometrists. MMA CEO Jean Branscum said the group generally believes scope-of-practice changes don’t fix workforce problems if the expanded practice isn’t supported by evidence or training.

Buttrey said this session’s bills to extend unsupervised practice and enact licensure compacts are an acknowledgment of the difficulty that small, rural communities have in attracting doctors. Physician assistants and nurse practitioners have been filling those gaps, he said.

Community health workers fill a different type of gap. They don’t provide direct medical care, instead helping people find the health care and support services they need to become and remain healthy.

Many states have already adopted definitions for community health workers and started providing Medicaid reimbursement for their services.

The requests to add to the list of Medicaid-covered services come at a time when Congress is considering significant budget cuts that could affect the amount of funding the federal government contributes to the Medicaid program. Although the legislature this session continued Montana’s Medicaid expansion program for low-income adults without disabilities, some legislators expressed concern about potential federal changes that could lower the amount of federal funds available for the program.

State Sen. Carl Glimm, a Kila Republican, was one of those legislators. He said he has similar concerns about increasing the types of services covered by Medicaid.

“The more stuff we add,” he said, “the more responsibility the state has” if the federal government shifts more of the program’s costs to the states.

Buttrey’s bill would define a community health worker as a “frontline public health worker” who helps people obtain medical and social services, advocates for their health, and educates individuals, providers, and the community about health care needs. Workers could be licensed after completing training and supervision requirements.

Most medical providers don’t have time to delve into all the outside factors influencing a patient’s health, said Cindy Stergar, CEO of the Montana Primary Care Association, which is supporting Buttrey’s bill. Community health workers can assist with that, she said, adding that research shows people with complex needs become healthier faster when their basic nonmedical needs, such as food and housing, are met.

“At the end of the day, the patient is better,” Stergar said. “That’s first and foremost.”

The Area Health Education Center at Montana State University has been offering community health worker training since 2018, and the University of Montana’s Center for Children, Families and Workforce Development began a training program in 2023. Together, the programs have trained nearly 500 people in how to identify the medical and social factors influencing a person’s health and in strategies for connecting the person with the right community resources.

“Ideally, what community health workers are doing is getting out of the clinic walls, meeting people where they are, and addressing the priorities of the client to get to the root cause of their health conditions and health needs,” said Mackenzie Petersen, project director for the training program at the University of Montana.

Supporters of the community health worker role say the workers are uniquely positioned to observe, understand, and address the barriers preventing a person from getting and staying healthy.

The barriers might be a lack of transportation or insurance or, for a homeless person, the inability to refrigerate a prescribed medication. A community health worker can arrange rides to appointments, help with insurance applications, or make sure a health care provider prescribes a medication that doesn’t need refrigeration.

Murley, with the St. Peter’s Health program, recalled that one of her clients was making frequent trips to the ER with suicidal ideation. Murley learned that he faced bullying in his apartment building and helped him relocate. The ER visits dropped off.

As Nay put it: “It’s really about helping the people that we work with create a path to their health.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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‘I Am Going Through Hell’: Job Loss, Mental Health, and the Fate of Federal Workers

The National Institutes of Health employee said she knew things would be difficult for federal workers after Donald Trump was elected. But she never imagined it would be like this.

Focused on Alzheimer’s and other dementia research, the worker is among thousands who abruptly lost their jobs in the Trump administration’s federal workforce purge. The way she was terminated — in February through a boilerplate notice alleging poor performance, something she pointedly said was “not true” — made her feel she was “losing hope in humans.”

She said she can’t focus or meditate, and can barely go to the gym. At the urging of her therapist, she made an appointment with a psychiatrist in March after she felt she’d “hit the bottom,” she said.

“I am going through hell,” said the employee, who worked at the National Institute on Aging, one of 27 centers that make up the NIH. The worker, like others interviewed for this story, was granted anonymity because of the fear of professional retaliation.

“I know I am a mother. I am a wife. But I am also a person who was very happy with her career,” she said. “They took my job and my life from my hands without any reason.”

President Trump and his allies have increasingly denigrated the roughly 2 million people who make up the federal workforce, 80% of whom work outside the Washington, D.C., area. Trump has said federal workers are “destroying this country,” called them “crooked” and “dishonest,” and insinuated that they’re lazy. “Many of them don’t work at all,” he said earlier this month.

Elon Musk — who is the world’s richest person and whose Department of Government Efficiency, created by a Trump executive order, is infiltrating federal agencies and spearheading mass firings — has claimed without evidence that “there are a number of people on the government payroll who are dead” and others “who are not real people.” At a conference for conservatives in February, Musk brandished what he called “the chain saw for bureaucracy” and said that “waste is pretty much everywhere.”

The firings that began in February are taking a significant toll on federal employees’ mental health. Workers said they feel overwhelmed and demoralized, have obtained or considered seeking psychiatric care and medication, and feel anxious about being able to pay bills or afford college for their children.

Federal employees are bracing for more layoffs after agencies were required to deliver plans by this month for large-scale staff reductions. Compounding the uncertainty: After judges ruled that some initial firings were illegal, agencies have rehired some workers and placed others on paid administrative leave. Then, Trump on March 20 issued a memo giving the Office of Personnel Management more power to fire people across agencies.

Researchers who study job loss say these mass layoffs not only are disrupting the lives of tens of thousands of federal workers but also will reverberate out to their spouses, children, and communities.

“I’d expect this will have long-lasting impacts on these people’s lives and those around them,” said Jennie Brand, a professor of sociology at UCLA who wrote a paper about the implications of job loss. “We can see this impact years down the road.”

Studies have shown that people who are unemployed experience greater anxiety, depression, and suicide risk. The longer the period of unemployment, the worse the effects.

Couples fight more when one person loses a job, and if it’s a man, divorce rates increase.

Children with an unemployed parent are more likely to do poorly in school, repeat a grade, or drop out. It can even affect whether they go to college, Brand said. There’s an “intergenerational impact of instability,” she said.

And it doesn’t stop there. When people lose their jobs, especially when it’s many people at once, the wealth and resources available in their community are reduced. Kids see fewer employed role models. As families are forced to move, neighborhood stability gets upended. Unemployed people often withdraw from social and civic life, avoiding community gatherings, church, or other places where they might have to discuss or explain their job loss.

Although getting a new job can alleviate some of these problems, it doesn’t eliminate them, Brand said.

“It’s not as if people just get new jobs and then pick up the activities they used to be involved with,” she said. “There’s not a quick recovery.”

Slashing Cultural Norms

The firings are upending a long-standing norm of the public sector — in exchange for earning less money compared with private-sector work, people had greater job security and more generous benefits. Now that’s no longer the case, fired workers said in interviews.

With the American economy moving toward temporary and gig jobs, landing a traditional government job was supposed to be “like you’ve got the golden goose,” said Blake Allan, a professor of counseling psychology at the University of Houston who researches how the quality of work affects people’s lives.

Even federal workers who are still employed face the daily question of whether they’ll be fired next. That constant state of insecurity, Allan said, can create chronic stress, which is linked to anxiety, depression, digestive problems, heart disease, and a host of other health issues.

One employee at the Centers for Medicare & Medicaid Services, who was granted anonymity to avoid professional retaliation, said the administration’s actions seem designed to cause enough emotional distress that workers voluntarily leave. “I feel like this ax will always be over my head for as long as I’m here and this administration is here,” the employee said.

Federal workers who passed on higher-paying private sector jobs because they wanted to serve their country may feel especially gutted to hear Trump and Musk denigrate their work as wasteful.

“Work is such a fundamental part of our identity,” Allan said. When it’s suddenly lost, “it can be really devastating to your sense of purpose and identity, your sense of social mattering, especially when it’s in a climate of devaluing what you do.”

Andrew Hazelton, a scientist in Florida, was working on improving hurricane forecasts when he was fired in February from the National Oceanic and Atmospheric Administration. The mass firings were carried out “with no humanity,” he said. “And that’s really tough.”

Hazelton became a federal employee in October but had worked alongside NOAA scientists for over eight years, including as an employee at the University of Miami. He lost his job as part of a purge targeting probationary workers, who lack civil service protections against firings.

His friends set up a GoFundMe crowdfunding page to provide a financial cushion for him, his wife, and their four children. Then in March, after a federal judge’s order requiring federal agencies to rescind those terminations, he was notified that he had been reinstated on paid administrative leave.

“It’s created a lot of instability,” said Hazelton, who still isn’t being allowed to do his work. “We just want to serve the public and get our forecasts and our data out there to help people make decisions, regardless of politics.”

Health Coverage Collateral

Along with their jobs, many federal workers are losing their health insurance, leaving them ill equipped to seek care just as they and their families are facing a tidal wave of potential mental and physical health consequences. And the nation’s mental health system is already underfunded, understaffed, and overstretched. Even with insurance, many people wait weeks or months to receive care.

“Most people don’t have a bunch of money sitting around to spend on therapy when you need to cover your mortgage for a couple months and try to find a different job,” Allan said.

A second NIH worker considered talking to a psychiatrist and potentially going on an antidepressant because of anxiety after being fired in February.

“And then the first thought after that was: ‘Oh, I’m about to not have insurance. I can’t do that,’” said the worker, who was granted anonymity to avoid professional retaliation. The worker’s health benefits were set to end in April — leaving too little time to get an appointment with a psychiatrist, let alone start a prescription.

“I don’t want to go on something and then have to stop it immediately,” the worker said.

The employee, one of several NIH workers reinstated this month, still fears getting fired again. The worker focuses on Alzheimer’s and related dementias and was inspired to join the agency because a grandmother has the disease.

The worker worries that “decades of research are going to be gone and people are going to be left with nothing.”

“I go from anxiety to deep sadness when I think about my own family,” the employee said.

The NIH, with its $47 billion annual budget, is the largest public funder of biomedical research in the world. The agency awarded nearly 59,000 grants in fiscal 2023, but the Trump administration has begun canceling hundreds of grants on research topics that new political appointees oppose, including vaccine hesitancy and the health of LGBTQ+ populations.

The NIH worker who worked at the National Institute on Aging was informed in mid-March that she would be on paid administrative leave “until further notice.” She said she is not sure whether she would find a similar job, adding that she “cannot be at home doing nothing.”

Apart from loving her job, she said, she has one child in college and another in high school and needs stable income. “I don’t know what I’m going to do next.”

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand the impact of what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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KFF Health News' 'What the Health?': Federal Health Work in Flux

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie’s stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie’s stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah’s stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel’s stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

[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, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.

Today we are joined via videoconference by Rachel Roubein of The Washington Post.

Rachel Roubein: Hi.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, everybody.

Rovner: And Jessie Hellmann of CQ Roll Call.

Jessie Hellmann: Hello.

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one.

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea?

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu.

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu.

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs.

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting.

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in.

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this.

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker?

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point.

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week.

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them.

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would.

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit?

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy.

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce.

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government.

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency.

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out.

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?.

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward.

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it.

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities.

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda?

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people—

Rovner: And of course the inspector general has also been laid off in all of this.

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go.

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it.

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time.

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have.

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7.

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration?

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration.

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that.

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people?

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so—

Rovner: I think most states have waiting lists.

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so—

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention.

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone.

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left?

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and—

Rovner: Before the Marty Makary hearing.

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House.

Rovner: And of course, Hawley’s not a disinterested bystander here, right?

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants.

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle.

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward.

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing.

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right?

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals.

Rovner: Eating better and exercising.

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly.

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is 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. Jessie, you’ve done yours already this week. Rachel, why don’t you go next?

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines.

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants.

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah.

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer.

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job.

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place.

OK, that’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Sarah?

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith.

Rovner: Jessie.

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days.

Rovner: Great. Rachel.

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn.

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

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

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And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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Congressman Blames Trump Team for Ending Telehealth Medicare Benefit. Not Quite Right.

“Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1. … We need to stand up to these Medicare cuts.”

Rep. Ro. Khanna (D-Calif.), in a TikTok video posted Feb. 20, 2025

Rep. Ro Khanna (D-Calif.) posted a Tiktok video on Feb. 20 saying he had “breaking news” about the fate of Medicare coverage for telehealth visits, which allow patients to see health care providers remotely from their homes.

“Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1,” Khanna said. “We need to stand up to these Medicare cuts.”

The same day, the Centers for Medicare & Medicaid Services posted a document online titled “Telehealth” that said, “Through March 31, 2025, you can get telehealth services at any location in the U.S., including your home. Starting April 1, 2025, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services.”

CMS did not respond to requests for comment about the post. The White House also did not respond to requests for comment.

The telehealth benefit was first put in place as a temporary Trump-era addition to Medicare coverage during the covid-19 public health emergency.

Khanna’s statement took on more significance leading up to the threat of a government shutdown, but late last week Congress averted one by approving a stopgap spending bill.

The expiration date for the benefit has been known since December, when Congress extended coverage around telehealth through March 31. The roughly 90-day reprieve was part of a compromise after then-President-elect Donald Trump and his ally Elon Musk criticized a sweeping, end-of-year legislative package that would have, among other things, continued those benefits for two years.

Their opposition forced Congress to pass a stripped-down version of the end-of-year bill. Telehealth’s two-year extension, included in the initial bill, became collateral damage.

Last week, just as the clock was ticking down, House Republicans passed a spending bill for the rest of the fiscal year that includes another extension of telehealth flexibilities — this one lasting through September. The Senate then cleared the bill for Trump’s signature, with the support of 10 Democrats, including Senate Minority Leader Chuck Schumer.

Regardless, the two-year extension proposed in December — or a permanent extension, as Khanna has urged — looks unlikely.

“President Trump and Elon Musk blew up the continuing resolution last December that would have extended these telehealth authorities by two years,” Khanna told us via email. “Trump should work with Congress to extend telehealth coverage for Medicare beneficiaries.”

It wouldn’t come free. Permanently extending telehealth for medical care under Medicare could cost taxpayers about $25 billion over 10 years, the Congressional Budget Office has estimated. The CBO calculated five months of expanded telehealth coverage as costing $663 million, and calculated that that would total almost $25 billion through fiscal year 2031 if spending remained level, which it may not do.

Also, the agency and the Government Accountability Office have raised concerns about fraud and overuse of the benefit, among other potential issues.

Congress made Medicare coverage of behavioral health services delivered remotely permanent in December 2020, but left other telehealth benefits hanging on by a string. Instead, lawmakers extended them for short periods during the nearly two years since the public health emergency officially ended in May 2023.

“Now, once again, we’ve got another deadline where, if Congress doesn’t act, our flexibilities go away,” said Kyle Zebley, senior vice president of public policy for the American Telemedicine Association.

And if, at some point, the telehealth benefits aren’t extended, is it fair to describe the policy change as a cut? Khanna, for instance, plans to introduce the Telehealth Coverage Act, which would require Medicare to cover seniors’ telehealth services.

Politically speaking, it’s a powerful question when trying to leverage public support — and politicians in both parties often accuse their opponents of “cutting” federal benefits when they make changes to programs.

“Khanna is overly dramatic,” said Joseph Antos, a senior fellow emeritus at the American Enterprise Institute, a conservative think tank.

If the provision expires, Antos said, “this is not a Trump cut.”

But beneficiaries might have a different experience. Since the early days of the pandemic — five years now — millions of patients have come to rely on telehealth for their medical services. That benefit, even with another temporary reprieve, would still be at risk.

According to CMS, more than 1 in 10 Medicare beneficiaries used virtual care services as of 2023. And, after the Trump administration green-lighted telehealth for Medicare recipients in 2020, many private insurers did the same.

Overall telehealth claims rose from fewer than 1% of all commercial claims before the covid pandemic to a peak of 13% in April 2020. Now they stand at close to 5%, according to Fair Health, a nonprofit that tracks health care costs.

Those in the telehealth industry are optimistic about the current extension. The Trump administration, they say, has been sending encouraging signals — even highlighting its previous support of telemedicine in its fact sheet on the launch of the President’s Make America Healthy Again Commission.

“We’ve been sweating bullets,” Zebley said. “But it’s been nerve-wracking before. I think we’re going to get it done.”

Antos said, however, that after the extension in the House-passed spending bill, Medicare’s telemedicine benefits could be dead.

Our Ruling

Khanna said, “Breaking news: The Trump administration just announced that Medicare will stop covering telehealth starting April 1. … We need to stand up to these Medicare cuts.”

The statement is partially accurate, because the Trump administration announced the March 31 sunset of Medicare telehealth visits, and some beneficiaries who were using that benefit could see it as a “cut.” But the claim lacks key context that the expiration date was set by Congress, not the Trump administration.

After Khanna’s claim, Congress extended access to telehealth coverage through September.

Based on information that was available at the time, we rate Khanna’s statement Half True.

Our Sources:

Rep. Ro Khanna’s Feb. 20, 2025 TikTok video.

The American Relief Act, 2025.

Vice President J.D. Vance’s X post on behalf of himself and President Donald Trump on the year-end legislative package, Dec. 18, 2024.

One of a flurry of Elon Musk’s X posts deriding the government’s year-end legislative package, Dec. 20, 2024.

Email interview with Rep. Ro Khanna’s office, March 3, 2025.

H.R.1968 — Full-Year Continuing Appropriations and Extensions Act, 2025.

H.R.133 — Consolidated Appropriations Act, 2021

Phone interview and follow-up texts with Kyle Zebley, senior vice president of public policy for the American Telemedicine Association and executive director of ATA Action, March 3, 2025.

Email interview with Joseph Antos, senior fellow emeritus for public policy research at the think tank the American Enterprise Institute, March 8, 2025.

A Centers for Medicare & Medicaid Services post CMS post titled “Telehealth” that includes information to recipients about Medicare telehealth benefits ending April 1, 2025.

The journal Primary Care, “The State of Telehealth Before and After the COVID-19 Pandemic,” April 25, 2022.

CMS, “Medicare Telehealth Trends,” Jan. 1, 2020 and June 30, 2024.

“Fiscal Considerations for the Future of Telehealth,” Committee for a Responsible Federal Budget, April 21, 2022.

H.R. 2471, the Consolidated Appropriations Act, 2022, Congressional Budget Office, March 14, 2022.

“Medicare and Medicaid: COVID-19 Program Flexibilities and Considerations for Their Continuation,” U.S. Government Accountability Office, May 19, 2021.

Preprint: “Telehealth and Outpatient Utilization: Trends in Evaluation and Management Visits Among Medicare Fee-For-Service Beneficiaries, 2019-2024,” March 6, 2025.

Preprint: “Association Between Telehealth Use and Downstream 30-Day Medicare Spending,” Feb. 11, 2025.

Ro Khanna’s press release on the telehealth bill he’s introducing.

“Annual Number of Users of Online Doctor Consultations Worldwide From 2017 to 2028,” Statista Market Insights, March 15, 2024.

ATA Action letter to Congress, Jan. 13, 2025.

Make America Healthy Again fact sheet, Feb. 13, 2025.

CMS, “Medicare Telehealth Trends Report,” October 2024.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Watch: The Dr. Oz Show Comes to Congress

The Senate Finance Committee got its chance March 14 to question Mehmet Oz, President Donald Trump’s nominee to lead the vast Centers for Medicare & Medicaid Services, the largest agency within the Department of Health and Human Services. Oz, with his long history in television, was as polished as one would expect, brushing off even some more controversial parts of his past with apparent ease. In this special bonus episode of “What the Health?,” KFF Health News’ Rachana Pradhan and Stephanie Armour join host Julie Rovner to recap the Oz hearing. They also provide an update on the progress of nominees to lead the National Institutes of Health, the Food and Drug Administration, and the Centers for Disease Control and Prevention.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

KFF Health News' 'What the Health?': The Cutting Continues

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie’s stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Health and Human Services Secretary Robert F. Kennedy Jr. is already acting on his anti-vaccine views, ordering an end of research into why people become vaccine-hesitant and requesting new research on the long-debunked theory that vaccines can cause autism in children. Coincidentally, the Trump administration at the last minute pulled the nomination of former GOP congressman and vaccine skeptic Dave Weldon to head the Centers for Disease Control and Prevention, perhaps signaling that Republicans in the Senate are growing uncomfortable with the issue.

Meanwhile, Congress continues to contemplate how to cut as much as $880 billion in spending — possibly from Medicaid — at a time when more beneficiaries of the government health program for those with low incomes and disabilities have become Republican voters.

 This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna’s stories.

Shefali Luthra
The 19th

@shefalil

Read Shefali’s stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice’s stories.

Among the takeaways from this week’s episode:

• The Trump administration’s last-minute decision to pull the nomination of Dave Weldon to head the CDC — shortly before his confirmation hearing before the Senate Health, Education, Labor and Pensions Committee was set to begin Thursday morning — has fueled speculation that Weldon’s anti-vaccine views meant he didn’t have enough Senate support to win confirmation. Weldon, a physician and former Florida congressman, has advanced debunked theories about vaccines and autism.
• Senate Democrats threatened to vote against a continuing resolution, or CR, to fund the government through Sept. 30. The measure passed narrowly in the House, with just one Democrat, Jared Golden of Maine, voting for it. Senate Democrats oppose the stopgap spending bill on many fronts, including its proposed cuts to medical research and its lack of a “fix” to prevent payment cuts to doctors who accept Medicare patients. The Democrats propose a 30-day government funding bill to allow negotiations on a bipartisan measure. The House adjourned after passing the CR on Tuesday and is not scheduled to return to Washington until March 24.
• The Medicaid program may be garnering more support as Republicans continue to debate how to cut federal spending to finance a major tax cut package. The impact of Medicaid funding cuts on rural hospitals and on the Medicaid expansion population that gained coverage as part of the Affordable Care Act are two areas of discussion as House Republicans deliberate.
• Continued staffing reductions at federal agencies are stoking concerns about lower levels of service to constituents and worsening mental health in the federal workforce. If federal workers are dismissed for poor performance — a charge many federal employees have called false because they received positive job performance reviews — then they don’t receive severance and cannot collect unemployment. With 8 in 10 federal workers employed outside the Washington, D.C., area, the sweeping impacts of reductions in the federal workforce are being felt far beyond the Beltway.
• The Trump administration’s decision to cancel $250 million in National Institutes of Health grants to Columbia University is the latest in an ongoing campaign to cut federal research funding. The uncertainty in federal funding has caused several schools to freeze hiring and rescind some graduate student admissions, raising concerns that the Trump administration’s policies are disrupting scientific research. Recent moves from HHS to allow new rules and regulations without public comment and new restrictions from the National Cancer Institute on what topics require review before publication (vaccines, fluoride, and autism are now on the list) are raising concerns that politics is playing a larger role in federal health policy.

Also this week, Rovner interviews Jeff Grant, who recently retired from CMS after 41 years in government service.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: NBC News’ “‘You Lose All Hope’: Federal Workers Gripped by Mental Health Distress Amid Trump Cuts,” by Natasha Korecki.

Shefali Luthra: The New York Times’ “15 Lessons Scientists Learned About Us When the World Stood Still,” by Claire Cain Miller and Irineo Cabreros.

Alice Miranda Ollstein: The Atlantic’s “His Daughter Was America’s First Measles Death in a Decade,” by Tom Bartlett.

Anna Edney: Bloomberg News’ “India Trade Group Blasts Study Linking Drugs to Safety Risks,” by Satviki Sanjay.

Also mentioned in this week’s podcast:

• ProPublica’s “National Cancer Institute Employees Can’t Publish Information on These Topics Without Special Approval,” by Annie Waldman and Lisa Song.
• WIRED’s “Social Security Workers Aren’t Allowed To Read This Story,” by David Gilbert.
• Stat’s “Former NIH Director Francis Collins, Once Beloved in Washington, Now Worries for His Safety There,” by Anil Oza and Katherine MacPhail.

click to open the transcript

Transcript: The Cutting Continues

[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, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 13, at 10 a.m. As always, news happens fast — really fast, as you’ll hear in a moment — and things might’ve changed by the time you hear this. So, here we go.

Today we are joined via videoconference by Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Hi.

Rovner: And Anna Edney of Bloomberg News.

Anna Edney: Hi, everyone.

Rovner: Later in this episode we’ll have my interview with Jeff Grant, formerly of the Centers for Medicare & Medicaid Services. Recently retired after 41 years in the government, he has thoughts about the way the Trump administration is handling the downsizing of that agency. But first, this week’s news.

As we sit down to tape, we have some breaking news. The White House has reportedly pulled the nomination of former Republican Congressman Dave Weldon of Florida to lead the Centers for Disease Control and Prevention.

Weldon was scheduled for his confirmation hearing this very morning at 10 a.m. before the Senate Health, Education, Labor and Pensions Committee. The hearing cancellation notice came out at 9:24 a.m. We obviously don’t know any real details yet about why this nomination was pulled, but somebody remind us why Dave Weldon was a controversial pick to head this agency.

Edney: He was holding on to some anti-vax theories that do align with some who have already been approved by these senators, but he—

Rovner: Notably the secretary of health and human services.

Edney: Exactly. But he was still claiming that there’s mercury in vaccines and that’s the reason for autism. I don’t know if that made him a bit of a step too far for some of these people, particularly Sen. [Bill] Cassidy, who chairs the HELP Committee and is probably already frustrated by what’s going on when he thought that he had some promises from RFK [Robert F. Kennedy] Jr., the HHS [Department of Health and Human Services] secretary, to not be going after vaccines in different ways.

Rovner: And we will get to that later in the podcast. Also, I should note that Weldon was also a big anti-abortion voice when he was in Congress. Although, again, I doubt that that’s what got his nomination pulled. I mean, obviously what got his nomination pulled was that he didn’t have enough votes to be confirmed.

Ollstein: Sure. But like Anna said and like you said, Julie, there seems to be some inconsistency of criteria across the Cabinet nominations. Saying that this is about his anti-vax views, well, that didn’t stop RFK Jr. from getting confirmed, and if this is related to his anti-abortion views, that hasn’t stopped many of the nominees from getting confirmed. And so that leads me to believe that it’s about something else. I think we’ve seen this before. Matt Gaetz’s nomination was pulled. He had this history of sexual misconduct allegations, but other nominees who also had a history of sexual misconduct allegations sailed through their confirmations. And so that leaves me to believe there’s something else going on, some other shoe that was going to drop or some other issue at play.

Rovner: We will definitely see. And just a note here, tomorrow, Friday, after the confirmation hearing at the Finance Committee for Mehmet Oz to head the Centers for Medicare & Medicaid Services, I’m going to sit down with a couple of my KFF Health News colleagues to wrap up that hearing as well as the other HHS nominations, and that will appear in your podcast feeds as well, as a bonus podcast episode.

All right, moving on to the next-biggest news. As we tape, the government is less than 48 hours away from a potential shutdown. Friday after midnight is when the three-month funding patch Congress passed just before Christmas expires. The House on Tuesday barely passed a bill that was advertised as a clean CR [continuing resolution], meaning it just continues current funding for the rest of the fiscal year, but it would actually cut billions of dollars from domestic programs and add billions of dollars for defense and immigration enforcement.

Among the little surprises in that bill are a more than 50% cut in medical research funded by the Defense Department. And while the bill does include a bunch of so-called health extenders, like continuing authority for Medicare telehealth, funding for community health centers, and delaying a cut to hospitals that serve large populations of people with low incomes, it rather pointedly does not include relief for doctors from a Medicare pay cut, much to the dismay of the American Medical Association. What are the prospects for this to become law? Or is the government going to shut down in addition to all the people who’ve been fired?

Ollstein: The situation is very fluid. It barely passed the House, and Democratic senators are making noises about blocking it and putting forward a very short-term, actually clean CR because, as you noted, what they’re claiming is a clean CR is sort of more like an omnibus that makes a bunch of changes that only Republicans want to see. And not even all Republicans — just some Republicans want to see. And so I think because of the math here, the very narrow majority Republicans have in the House, they can really only lose a tiny handful of votes on this.

I think you get into both policy and political dangerous territory when you make decisions that piss off some Republicans as well as Democrats, such as not including the so-called doc fix that would prevent doctors who serve people on Medicare from getting hit. That is a priority for some Republican members of Congress, and they can’t afford to lose their votes. And so there’s a lot of back-and-forth. There’s talk about a stand-alone health bill that scoops up some of the things that were abandoned at the end of last year. Who knows? Congress is very good at not getting things done. So I’m always skeptical.

Rovner: We should point out that the House did kind of leave it all on the Senate’s doorstep by leaving and won’t be back until March 24. So even if the Senate were able to pass this 30-day clean CR, there’s no House to pass it, so the government would shut down anyway, which is what the House likes to do. It’s like: We’re going to do this. We’re not going to negotiate with you. We’re going to do this and leave, and you take it or you shut the government down. And that’s basically where we are at the moment.

So, well, moving on to Medicaid and a reminder that the possibly impending Medicaid cuts are not part of this fight to keep the government open. I know reporters tend to refer to both the spending bill and the not-yet-written reconciliation bill as, quote, “the budget.” But the spending bill is something that’s left over from last year, while the budget resolution is something intended to lead to a bill that will be written this year. Anyway, regular listeners will know that the budget resolution approved by the House in February calls for $880 billion in mandatory spending reduction from the House Energy and Commerce Committee, which cannot be done without cutting from Medicare or Medicaid or both.

But Medicaid is in a much different place politically now than it was even in 2017, when it was surprisingly popular and it helped defeat the Republican efforts to repeal the Affordable Care Act. How much more politically volatile are Medicaid cuts for Republicans now than they were? Alice, you’ve been following this, right?

Ollstein: Yeah. So we did a story about all of the states that have expanded Medicaid by popular vote, and I think that’s a very different political dynamic than the states that did it through the legislature. This is something that a majority of folks in these states overwhelmingly voted for very recently. They said, Yes, we do want this. They said it directly. And I think that makes it more politically precarious for lawmakers to then come and basically override the will of the people and say, We’re going to make cuts. Especially because a lot of the cuts that are being discussed would hit the expansion population pretty squarely.

There’s a lot of rhetoric recently sort of setting up different constituencies of Medicaid beneficiaries and sort of ranking them and implying that some are deserving and some are undeserving. And the expansion population in the eyes of many conservatives are undeserving, people who are low-income but not so low-income that they qualify for traditional Medicaid. They’re not parents, they don’t have disabilities, but they have not been able to afford insurance if not for this program. And so I think that as lawmakers in Washington discuss policies that would in many states automatically get rid of the expansion, a lot of these states have these trigger policies where if the federal level of support and funding goes down, then the expansion, poof, goes away.

And I think that would upset a lot of people. And so this is a new dynamic. And these states only went the popular-vote ballot measure route because it was impossible to get it passed through the legislature and signed by their governors, who in many circumstances opposed it. And so it’s a very expensive, time-consuming route, but it’s something that a bunch of states pursued, and these are overwhelmingly states that voted for [Donald] Trump that are represented by Republicans in Congress.

Edney: I also think that since 2017 we’ve seen more and more news articles, discussion, we’ve been paying attention more to rural hospitals and how they are impacted by Medicaid. This stat that really stuck out to me is that half of them are operating in a deficit, and so they need that Medicaid money, and threatening it threatens closing them down in places that wouldn’t have any other options.

Luthra: The other component that I think is worth adding is I think what Alice pointed out about these hierarchies of deserving recipients is really astute and really important. And it also is a point that critics of Medicaid like to lean on without considering necessarily how interconnected these groups are. And an example of that I think about a lot is pregnant Americans. People love to provide insurance for people when they’re pregnant. It is very popular. You are seen as much more deserving when it is insurance not just for you but for your pregnancy.

But one thing that we know is that your health in pregnancy is better if you have access to health care before you get pregnant as well and after you get pregnant. And there is a large body of research that shows that expanding eligibility for Medicaid actually does improve one’s health during pregnancy and improves long-term outcomes. And so I think it’s really important for us to underscore that if the kinds of cuts that we’re talking about do in fact take effect, there will be very meaningful implications, including for the people who Republicans claim would be protected.

Rovner: So why aren’t we hearing more from lobbyists on this? You’d think the hospitals and the drug companies and other big for-profit parts of the health system would be shouting from the rafters by now. It seems that most of the emails and claims and things, ads, that I’m seeing are coming from consumer protection groups, not so much from the sort of big stakeholders in the health industry.

Edney: I think there is a lot going on. So I think that this can be said in so many situations right now, but there’s only an ability to focus on so much. And you mentioned the doctors cut earlier. There are things that these groups have right in front of them. Medicaid, we all know that cuts are, in some way, are coming but maybe don’t have the picture yet exactly of how that will happen. So it might be tougher to fight quite yet. And they’re focusing on the things that are happening immediately in front of their face, which seems to be all anyone’s able to do with the onslaught of changes and cuts and things going on.

Rovner: I feel like, move fast and break things, that’s why it works is that it doesn’t let people, there’s just not enough time to react before they’re on to the next thing.

Well, we will move on to the next thing, which is Trump administration news, which is, obviously, there’s more than we can possibly get to. As you’ll hear more in our interview with Jeff Grant, key people are losing their jobs at CMS. Everyone left at HHS was offered a $25,000 cash buyout to quit, and there’s likely more to come with reorganization proposals due to DOGE [the Department of Government Efficiency] today.

Social Security and the Department of Veterans Affairs are cutting thousands of workers as well and clearly jeopardizing services, even though the administration insists that’s not its goal. Many of these workers are being fired for poor performance, even the ones who have stellar performance records. That’s important because not only are they not getting any severance, people fired for cause aren’t generally eligible for unemployment insurance, either. It does seem like one campaign promise being met is the one by OMB [Office of Management and Budget] Director Russell Vought to put federal workers, quote, “in trauma.” Right?

Luthra: I was going to say there is really compelling reporting that has shown exactly that. There are very severe mental health consequences we are seeing for these federal workers who are losing their jobs in a situation that will obviously lead to reduced services and where they may not be eligible for things like severance, like unemployment. It’s really pretty alarming to see the mental health degradation that’s been reported on.

You hear about former federal employees contemplating self-harm as a result. And I think we are going to be continuing to see the impact for a very long time — and not just in the Washington, D.C., area, because federal employees work and live all around the country.

Rovner: Eighty percent of federal employees are outside the Washington, D.C., metro area, which they seem to keep forgetting. I kept wondering why there hasn’t been more pushback on this, and now I’m starting to hear that the lack of pushback isn’t just people worried about future jobs or their careers. Some of it is about actual personal safety. Francis Collins, the former NIH [National Institutes of Health] director and White House science adviser who retired from his own NIH lab last month, told Stat News that he’s worried for his and his family’s safety and that he’s had to hire personal security.

Are you all hearing that kind of story, too? I mean, is there literal concern for physical safety as much as for, Oh my goodness, if I speak out I’ll be blacklisted?

Ollstein: Well, for some high-level people, also high-level former administration officials, the Trump administration has been stripping them of publicly funded security, and so they feel they’ve had to hire their own. And so those folks who are more recognizable feel even more at risk. But I think what Shefali was saying, too, it’s just hard to, even as we say that most federal workers are outside of D.C., it has been hard for me to convey to people outside of D.C. just how grim the mood has been. And just so many people we know are suffering, out of work, don’t know how they’re going to support their families.

This is going to have repercussions for D.C.’s tax revenue, the ability to keep running our local schools and public transit and public safety and libraries. So it’s just going to continue to have these ripple effects.

Rovner: And I should point out, I mean, I was born in Washington, D.C. I grew up here. I’ve lived here all of my adult life. Administrations change, and people come and go. That’s not unusual. This is unusual. Trying to sort of shut down entire agencies is definitely much more unusual than anything I have seen before.

Well, meanwhile, at the helm of the Department of Health and Human Services, Secretary Robert F. Kennedy Jr. is behaving pretty much like you’d expect. He says the measles outbreak in Texas, which has now spread to New Mexico and to Oklahoma, is due at least in part to poor nutrition and exercise habits, which is a link not established by science.

NIH is shutting down research into why people become vaccine-hesitant and how to increase vaccine uptake. And the CDC has announced a large-scale study to once again examine whether there’s a connection between vaccines and autism, even though there are reams of studies saying that there is not. Is anybody actually surprised by all of this? Maybe Sen. Cassidy, who I think was promised that this wouldn’t happen?

Edney: No, not surprised. I can’t imagine he’s surprised, either. I think it was maybe just sort of a dance for them, where Cassidy knew he needed to make that vote and said the things he said. But, no, not surprised that it’s going this way. I think that there are a lot of people out there, a lot of groups who do want to know the cause of autism, and that is something that could be looked at more. Focusing it on vaccines, doing more damage than actually being helpful, doesn’t seem to be the way to do it, but it’s certainly the hypothesis this administration is going with, and they seem to refuse to look at any other direction.

Rovner: Do you think sort of the growing measles outbreak in Texas—? I mean we’re obviously speculating here, though. You were saying earlier with the pulling of the Weldon nomination, might’ve had something to do with that. I mean, this is the biggest measles outbreak that we’ve had I think I saw in 10 years. It is unusual. I mean despite what RFK said, which we have measles every year, we don’t have outbreaks like this every year. And I’m wondering if that’s sort of making some of the Republicans who were sort of swallowing the fact that there is going to be a real anti-vaxxer at the helm of HHS giving them a little bit more pause.

Edney: Yeah, I mean, the timing is, there’s no good word for it. I mean the fact that this measles outbreak happened when a vaccine skeptic, an anti-vaxxer basically, has gotten into the HHS secretary position. I’m sure they thought that, and I feel like I had a lot of conversations with people like this, not necessarily lawmakers but who said, Well, I really like a lot of things RFK Jr.’s doing, and I don’t think the vaccine thing’s really going to come up or matter that much. Guess what. It did. And they have to deal with that now. And I think particularly people who have been out very prominently in the news, like Sen. Cassidy, is going to have to try to reconcile that somehow, and maybe not having Weldon come before his committee and draw more attention to this was one way of digging in.

Rovner: Yes, I think that’s definitely one of the possibilities. Well, the dismantling of science and medicine continues outside the federal government’s buildings as well. This week NIH canceled $250 million in grants to Columbia University, citing the university’s, quote, “continued inaction in the face of persistent harassment of Jewish students.” Meanwhile, in December, The Wall Street Journal reported that incoming NIH director Jay Bhattacharya wants to base funding at least in part on campus academic freedom-of-speech rankings, except the group that does those rankings said this week that they are, quote, “not the right tool for this particular job.” Is NIH just going to become another way for this administration to reward its friends and punish its enemies?

Luthra: That’s what it seems like so far. We’ve seen hiring freezes take effect at a lot of universities, even as recently as this week. We are seeing a lot of universities that are politically more liberal in their members, in their general inclination, also reporting that they are under investigation for purported antisemitism. And I think we should know that often this framing is simply that protests existed on campus some, and there’s some debate over whether the term is being used a little liberally, but this is having real consequences for people’s ability to do research, to build a research pipeline, and as a result to improve our health.

And I think it’s really striking that, yet again, this effort to use a federal funding institution as part of a political agenda is having real implications for how we live and our ability to become a healthier society.

Rovner: And I would point out that Columbia University’s biomedical research establishment is nowhere near Columbia University’s main campus. It’s a totally different part of Manhattan. So it’s not about things that happen, quote-unquote, “on campus,” even though it is obviously all part of the same university. But we have seen a lot of universities getting grants pulled in the middle of them. It’s not like, We’re not going to renew your grant. It’s like, We’re just going to stop giving you money now, and you’re going to have to either fire all of your lab workers or see if you can figure out where else you can get money. I mean, it does seem to be really disrupting the practice of science right now.

Luthra: And one other thing I think is worth noting is, I mean, this is very similar to what we saw with the USAID [U.S. Agency for International Development] grants that were suddenly canceled, and sometimes often it is more expensive to cancel things midway as opposed to not renewing them, because you’re paying for broken leases, you have already invested in things that will not yield results. Maybe there is severance that you have to pay. And all of these sort of sunk costs and new costs incurred by abrupt termination come without the benefits of the gains that one hopes to reap.

Ollstein: Yeah, I mean, to Shefali’s point, so not only is it more costly in the short term, but it’s absolutely more costly in the long term. These research grants generate way more economic revenue than they cost, and they support tons of jobs all around the country. And so this will absolutely have detrimental economic effects in the long term as well.

Rovner: Well, finally this week I have a heading I’m calling “Your Government Is No Longer Any of Your Business.” This is pretty much the opposite of the radical transparency this administration was promising. First, the good news: The administration apparently will still issue rules and regulations under the legal process known as the Administrative Procedure Act, which I talked about with law professor Nick Bagley earlier this year. How do we know this? Because HHS has put out a policy statement that it will no longer take public comment on a broad array of rules for which public comment had been required since 1971.

Is this legal under the APA? Yes, the law allows for exceptions. But not only is this not exactly radically transparent, it could make it a lot easier to do some pretty unpopular things, like, I don’t know, cutting NIH overhead funding to 15%. Anna, you’re nodding.

Edney: Well, yeah, I think that is the point, is that they want to move quickly and public comment slows that down. But it does it for a reason, because there are consequences, which Shefali and Alice just laid out, for things like cutting grants and things like that that maybe a health care expert in the administration isn’t thinking about when they first post something and groups come in and they say, Hey, this is actually how we’re affected. And so public comment maybe sounds like your aunt and grandma winding up to talk about it, which can also happen, but it’s really educated experts in these areas that are saying, Here’s this one thing you didn’t think about, or there’s a lot of reasons to get public comment.

I can understand it. It’s something that when I cover the FDA [Food and Drug Administration] that sometimes they’ll complain, not complain but they’ll say, Things go slow because we have to do an advanced notice of proposed rulemaking and then we do a notice of proposed rulemaking. And these are all times when the public can come in and comment, but to not do that, it seems like they want to be able to do unpopular things quickly.

Ollstein: It’s just struck me how crazy a contrast it is between the two parties on this front. The Democratic Party was criticized for being so cautious and moving so slowly on some pressing priorities when [President Joe] Biden was in office and checking all the boxes and doing the long version of the process to make sure everything was legally on the up-and-up when they could have expedited some things and done interim final rules and taken comment after. So there was a lot of frustration from some groups on that front. Meanwhile, the Republican administration is doing just the opposite, moving as fast as possible with as little public input as possible.

Rovner: Which leads into my next topic, over at the National Cancer Institute. According to ProPublica, staff have been notified that manuscripts, presentations, or basically any sort of public communications that touch on any of nearly two dozen sensitive, controversial, or high-profile issues must be cleared first by a special NCI clearance team. Now it’s obviously not unusual for political appointees to want to see potentially newsworthy things before they go public, but this list of what has to be specially cleared is pretty comprehensive.

And it includes not just obvious hot-button things like abortion and stem cell or fetal tissue research but also things like obesity, vaccines, quote “discussion of federal policies” quote, and even peanut allergies. This feels quite a bit more sweeping than your usual Don’t put out stuff that will surprise us in a bad way. Right?

Luthra: Yeah, it’s very striking. It’s hard for me not to say that this is very strange. I have a peanut allergy, and I would personally like information about peanut allergies to be put out in the world, and I guess that may not always happen anymore. But it is part of this, as we have discussed, ability and interest in amplifying, often, conspiracy theories and taking us away from medically established science. We just saw efforts to restrict fluoride in the water in Utah this week. This is something that is happening at high levels of government and more local levels of government, and it’s something that is going to continue, is trying to leverage our health institutions to promote things that will make us less healthy.

Rovner: Yeah, well, and finally this week, Wired magazine informs us that a new policy at the Social Security Administration bars workers from looking at news websites on work devices. Now this is obviously aimed at things like making sure employees aren’t watching the NCAA basketball tournament or checking their 401(k)s during work hours or reading Wired, for that matter, except Social Security workers also use news sites for, you know, work, like checking obituaries to make sure the agency isn’t sending checks to people who have died. That seems to be a big issue these days. Is this just another way DOGE is trying to make federal workers feel like grade school children so they’ll quit?

Ollstein: Well, this is a twofer, because it punishes federal workers and it punishes news outlets who, including myself and my colleagues at Politico. They forced many federal workers to cancel their subscriptions to our Pro news. And so all that does is make sure the lobbyists are better informed than the federal agencies, which is troubling, for sure.

Rovner: And probably not what the administration wanted. All right, well that is as much news as we have time for this week. Now we will play my interview with Jeff Grant, formerly of CMS, and then we will come back and do our extra credits.

I am pleased to welcome to the podcast Jeff Grant, most recently the deputy director for operations at CCIIO, the Center for Consumer Information and Insurance Oversight, at the Centers for Medicare & Medicaid Services. Jeff retired last month after 41 years in government, following the firing of 15% of his staff. Now he’s starting a consulting firm that will try to help those being let go from the government find new jobs. Jeff Grant, thank you so much for joining us.

Jeff Grant: Oh thanks for having me.

Rovner: So you were a career employee at CMS. Tell us what you did and how that would normally change between administrations. Obviously, you were there 40 years. You’ve seen a lot of administrations come and go.

Grant: So I was actually at CMS for just under 30 years, and then I had Navy and Navy Reserve experience prior to that and a little bit at Commerce and GAO [the Government Accountability Office], but was all over CMS. My last job was running operations for the Center for Consumer Information and Insurance Oversight. So I was a deputy center director. I reported to the political appointee that ran the center, and I was in charge of our major operations, like HealthCare.gov, getting payments out to health plans that provided care for folks that registered in the private insurance marketplace, running things like the risk adjustment program.

And then the independent dispute resolution program was also huge out of the No Surprises Act. And we ran that for three Cabinet departments — ourselves, Labor, and Treasury. So we handled all the disputes that came in over surprise bills.

Rovner: So obviously in your 30 years you’ve had Republican and Democratic administrations come and go. How did things normally change for the career workforce when the administration changes?

Grant: What we really do, especially at a senior level like I was at at the tail end of my career, is we meet with the new officials coming in. And frankly, we read things about them before they come in, study up on who we’re going to be working with, what their policy priorities are, and then we prepare to move forward on a new policy agenda. And what I found over 30 years of working for Republicans and Democrats, Democrats will move it one direction, Republicans will move it another direction.

There’s a big wide middle there where policies that tend to make sense to both parties over time, when they see them working, remain. And then you have some shifts around the edges on the rest of the policies. And it’s actually, I think the changes in administrations are usually quite beneficial for the stability of health programs, not taking them too far in one direction or another.

Rovner: So how important is the career workforce to the operations of this agency? I think people, they just see Medicare and Medicaid, CHIP [the Children’s Health Insurance Program], ACA, and assume that it all runs on its own.

Grant: It absolutely does not, and the career workforce is absolutely essential to the operations of these programs. I think what people should understand is this is 6,700 people, or it was before they started removing folks, but 6,700 people to handle $1.5 trillion in health insurance. So we’re the largest health insurance agency in the world, and we’re running it with 6,700 people, which is smaller than most federal agencies and probably smaller than most Americans would think.

Rovner: So who were the people who were let go? We’ve been led to believe they were people who didn’t or couldn’t do their jobs or didn’t bother to come to work or were working on the side elsewhere.

Grant: That’s absolutely, 100% false in terms of what I think people believe about these workers, if they believe the letters. So the letters informed them that their knowledge, skills, and abilities were insufficient to meet the needs of the agency and that their performance was not adequate to justify retention. Both of those were just blatant falsehoods. The people that had been there long enough to get performance appraisals, many of them had the highest appraisals you could get, and that’s not an automatic. There’s a distribution of performance appraisal numbers. These were really exceptional individuals.

We had a very rigorous hiring process that’s gotten better over the years, and we’ve really identified top talent to come in and work for us. Some of these folks had been there five weeks, six weeks, three weeks. I don’t know what the shortest amount of time was. I think the shortest amount of time was three weeks. You have to have 90 days on board to make a performance-based judgment. You could make a conduct-based judgment. So if they were not showing up for work, we fire them for that. I’ve actually personally fired an employee for not showing up for work. That was a probationary employee. It’s very easy to do. We did not have that problem.

They did work a mix of in the office and at home, but all of our recent employees were local to one of our offices. So they all came in the office at times. At times they work remotely. That has always been true of our workforce, that we have employees that work both in office and at home, and it’s actually a very efficient way to do things, because they don’t waste time commuting. And sometimes being quiet at home for activities that require uninterrupted work, you can actually be much more efficient working at home than you are in the office.

But then you come in the office for activities that it’s beneficial to be around people and work things out. So you organize your days in such a way that makes sense, but you can have some interruption-free workdays where you can be super productive.

Rovner: Yes. And that’s how, I confess, that’s how I work. Partly I’m home, partly in the office.

Grant: That is how I work. Now that I’m on my own, I’m 100% remote. And I can assure you, running my own business, I’m not just sitting around doing nothing.

Rovner: So what do you think people most misunderstand about the way the Trump administration is trying to make the government run more “efficiently”? And I’m putting efficiently in air quotes.

Grant: Well then, I think, the first thing I would say, especially for an agency like CMS — I can’t speak for all of government, but for an agency like CMS, we’ve got 6,700 workers. They’re managing contractors that in turn manage this ginormous benefit that we are paying out. The money’s in the benefit. Let’s just start there. So if there are inefficiencies that are leading to overspending, it’s not the 6,700 people that are too small a workforce already to effectively run these programs. The smartest thing you could do is probably hire more people into CMS to give you more degrees of freedom to make more changes that actually might transform these programs and make them more efficient.

I can tell you, personal experience in the Trump administration, I cut costs for the marketplace operations by $100 million per year for three consecutive years. But it took people and contractors to make those cuts. But over time that resulted by the third year we were saving $300 million a year. Those savings carry forward. So every year after that you’re saving that $300 million a year. That’s real money. Tinkering around with 82 probationary employees, that’s about $15 million a year by comparison.

It is ludicrous to say that you’re taking your cheapest employees, cutting them, and eliminating your degrees of freedom to make transformative change and that’s going to make you more efficient. That’s the least efficient thing you can do.

Rovner: So what’s your biggest fear about long-term damage to the programs if these kinds of cuts continue? I mean they say they’re not finished yet. The probationary employees were the easy ones to let go. Now they’re going to move into the buyouts and RIFs [reductions in force] and other ways, I guess, of trying to downsize the workforce.

Grant: Yeah, well, first I think the probationary were easy, but I’m hoping that one of those lawsuits on the way they did it, that points out how wrong their method for doing it was, might still restore those jobs, because I don’t think those were as easy as they thought they were. They should have run a reduction in force. But they’re now talking about a reduction in force. They’re talking about reducing contracts, and I think reduction in force is going to be more randomly distributed. Just the probationary people are random, who happen to be where and be probationary at that time. So it’s not a thoughtful way of saying: We don’t need this function anymore. Let’s get rid of it and save money.

A RIF would be less thoughtful. And I think the one that’s also really dangerous is the return to workplace with a mandatory five days a week. And at the end of this month, all workers within 50 miles of an HHS office have to be in the workplace. If they cannot be in five days a week without some kind of exceptions process, they’re going to be gone. And that will be really randomly distributed again among who is actually able to do that at the end of April. People that are not within 50 miles of a CMS office are still required to find an office and then go to work. And my component had 75 of those people.

So I think it would be very hard for those folks to come in. And again, a lot of these are senior people, really talented, and you’re just losing a skill set randomly because they can’t get to the office, yet they’ve been performing superbly without going to an office.

Rovner: So what happens to these programs?

Grant: So, I can’t tell you exactly. I know there was one person that we have in during government shutdowns for running the payment process, one of two people that really knows the payment process backwards and forwards. That person cannot get to an office. And without an exceptions process, that person is gone. And that hampers our ability to pay health plans the money they need for covering our insured individuals. And it’d just be these little pockets of people here and there that have advanced expertise. We’re not that big an agency. We don’t have a lot of people that back people up.

That’s one of the problems with being an underfunded agency, is you do not have more than one or two people that work on any given subject. The redundancy they think is there does not exist. And so you will start losing key capacity to actually operate programs. Did you see that they were also proposing to sell the Woodlawn building [in Maryland]?

Rovner: I did.

Grant: It’s the only place that can house 4,000 people. Evidently there may be an administration connection and, who might buy it and then lease it back to the government. You may know that there are some people—

Rovner: It’s going to be like the private equity thing with the hospitals. We’re going to—

Grant: This is exactly what I said, that everything that’s being done right now is being done like private equity firms do it. It doesn’t make you run better. It just kind of lightens the cost, and you have a better-looking statement just for a short time. So your financials look good for a very short period of time, then everything starts spiraling downhill, customer service goes down the tubes, and you’re all of a sudden paying twice as much.

Rovner: And I guess I should have asked you this at the beginning. Is that why you left? I mean, you worked for [President] Trump last time.

Grant: I did. And I actually liked the person that came in. I left because it was becoming clearer and clearer that the people that they brought in that are very good to run CMS aren’t in charge of these key policies about how many people we will have, how big our contracting budget will be. And I could see us having large-scale loss. I mean, we lost 82 in one day. I’ve mentioned 75. I could get to a number that was easily 200 of 600 employees I had, and I felt I could do more on the outside than I could on the inside.

And that’s what I’m doing now. And hopefully we can get these people either restored to their jobs, which is one angle I am fighting hard on. And if they can’t get restored to their rightful positions, try to find them a position outside of government.

Rovner: Great. Jeff Grant, thank you so much.

Grant: Thank you.

Rovner: OK, we are back, and 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’ll put the links in our show notes on your phone or other mobile device. Shefali, this week is the fifth anniversary of the covid shutdown, which we didn’t even get a chance to talk about, but that’s what your extra credit is. So tell us now.

Luthra: There were a lot of really great pieces this week about the five-year anniversary of the covid shutdown, but I feel like I learned the most and had the most fun with this piece from TheUpshot. It is by Claire Cain Miller and Irineo Cabreros. It is “15 Lessons Scientists Learned About Us When the World Stood Still.” It’s got some great charts. It talks about things we learned that were kind of neat, like we don’t have to have really bad flu seasons, and actually there are ways to improve pregnancy-related health outcomes by letting people rest when they’re pregnant.

And there are also things we learned that are really bad, like it is actually harder to learn virtually as opposed to in person and that there is no substitute for in-person socialization. And that even during lockdowns, men are less likely to do housework than women in heterosexual couples. But I really loved how this took us back to a time that upended everything we knew and it pulled out some of the most salient facts that we’ve learned for better and for worse. It’s really fun, and I recommend it.

Rovner: It is really fun. Anna.

Edney: I did one by my colleague in India called “India Trade Group Blasts Study Linking Drugs to Safety Risks.” And I was glad that she was able to write this, because I thought this was a really interesting study that came out. And it was published in an operations journal, so it was kind of not prominently displayed. But it showed that drugs that are made in India — so these are mostly generics — were 54% more likely to result in a serious adverse event.

So that includes hospitalization, disability, and death compared to drugs made anywhere else. And the study’s authors think this may be due to a lot of the manufacturing issues that probably listeners of this podcast have heard me talk about before so I don’t have to get into. But I think it’s an interesting story to give a read.

Rovner: Yes. Anna with the scary drug stories. Alice.

Ollstein: So I have a very heartbreaking story from The Atlantic called “His Daughter Was America’s First Measles Death in a Decade.” And a Texas-based reporter went to the small rural community where a Mennonite community was really at the epicenter of the recent measles outbreak. And he sort of stumbled upon the father of the child who died. And the piece really illuminates just how challenging a public health crisis this is. A lot of people in that community don’t speak English. They speak Low German. So it’s very hard to communicate. It’s very hard to even know the scope of the problem, because people aren’t testing.

A lot of folks in that community are not enrolled in public schools or even accredited private schools where vaccination rates are tracked. And so it’s just very, very challenging to communicate and build trust and even have a sense of how bad the situation is. And at the same time, the piece walks through all of the things going on that are not helping, like RFK Jr. not only downplaying the outbreak but also sort of doing some light victim-blaming, implying that if you have good health habits and nutrition, you won’t die of measles. And this was a little child.

And so not only is that not scientifically proven, but it’s sort of painful to hear when you’re talking about a little child. So I highly recommend this story.

Rovner: Yeah, I have a different blaming-the-victim story. My extra credit is from NBC News. It’s called “‘You lose all hope’: Federal workers gripped by mental health distress amid Trump cuts,” by Natasha Korecki. And it’s the best roundup I’ve seen of the mental distress on federal workers across agencies being caused by the way the administration is going about this downsizing. Some of these workers voted for Trump. They support cutting waste and fraud in the federal government. But said one former CDC worker, quote: “Taking a sledgehammer approach and having an unelected billionaire in my email is just insane. What are his qualifications for doing this? The government is not a startup; we’ve been in business since 1776.” A really good if depressing read.

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer and editor, Francis Ying, and our fill-in editor this week, Mary Agnes Carey. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys mostly these days? Shefali?

Luthra: I am on Bluesky, @shefali.

Rovner: Anna.

Edney: X and Bluesky, @annaedney.

Rovner: Alice.

Ollstein: @AliceOllstein on X and @alicemiranda on Bluesky.

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

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In Trump’s Team, Supplement Fans Find Kindred Spirits in Search of Better Health

President Donald Trump’s health officials want you to take your vitamins.

Mehmet Oz, the nominee to lead the Centers for Medicare & Medicaid Services, has fed calves on camera to tout the health wonders of bovine colostrum on behalf of one purveyor in which he has a financial stake. Janette Nesheiwat, the potential surgeon general, sells her own line of supplements.

Robert F. Kennedy Jr., the secretary of Health and Human Services, said he takes more vitamins than he can count — and has suggested he’ll ease restrictions on vitamins, muscle-building peptides, and more.

Their affection for supplements might lead to tangible consequences for Americans’ health regimens. Late in the 2024 campaign, Kennedy claimed the federal government was waging a “war on public health” by suppressing a vast array of alternative therapies — many of them supplements, like nutraceuticals and peptides.

In February, Trump announced the “President’s Make America Healthy Again Commission” with Kennedy at the helm, calling for “fresh thinking” on nutrition, “healthy lifestyles,” and other pathways toward combating chronic disease. Spokespeople for Kennedy did not reply to multiple requests for comment.

Supplements can be beneficial, particularly in aiding fetal development or warding off anemia, said Pieter Cohen, a general internist at the Cambridge Health Alliance, who researches supplements. “I recommend supplements routinely,” he said.

Still, “the majority of use is not necessary to improve or maintain health,” and due to only light regulations, supplement makers may make claims about their benefits without sufficient evidence, Cohen said. “No supplement needs to get tested or vetted by the FDA before it’s sold.”

Consumer watchdogs, regulators, and researchers have reported cases of finding traces of lead and other toxins in supplements. And a 2015 analysis from a team of federal health researchers attributed about 23,000 emergency department visits annually to supplement use. (The Council for Responsible Nutrition, the industry’s lobbying group, challenged the findings, arguing some visits were due to over-the-counter and homeopathic medicines that should not have been included.)

Nevertheless, many Americans are ready to buy in. Internet forums populated by biohackers, weight lifters, and enthusiasts of alternative medicine, along with supplement producers, applauded Kennedy’s elevation to health secretary. Many express hopes that he’ll loosen what they perceive as unwarranted restrictions on these products.

The Natural Products Association saluted Trump’s health nominees as a victory for “health freedom.”

“For the first time in our industry’s history, the top healthcare political appointees think it is important that Americans have the right to use nutritional supplements,” wrote Kyle Turk, the association’s vice president for government affairs.

The worlds of supplement users and the Trump team overlap substantially when it comes to being skeptical of the traditional health system.

Supplement use is part of “a broadening sort of health populist movement,” said Callum Hood, the head of research at the Center for Countering Digital Hate, a nonprofit that researches online disinformation, pointing to influencers who criticize conventional public health measures and offer alternatives like supplements, powders, or peptides.

To many supplement enthusiasts, Kennedy’s views align with theirs — particularly his dislike for Big Pharma and Big Food, which he characterizes as corrupt, profiting from Americans’ ill health.

Kennedy promotes supplements as a key part of good health. In a prerecorded interview aired this month, amid a growing measles outbreak that started in West Texas, he said doctors had had “very, very good results” by treating those patients with cod liver oil, which can be delivered in pill form, along with a steroid and an antibiotic. (Separately, he wrote in a Fox News op-ed that parents should discuss the vaccine with their doctors, adding, “The decision to vaccinate is a personal one.”)

“What we’re trying to do is really to restore faith in government and to make sure that we are there to help them with their needs and not particularly to dictate what they ought to be doing,” Kennedy said in a Fox News interview.

Kennedy spoke of federal officials delivering vitamin A to affected communities — a treatment he pushed in past remarks as chairman of the anti-vaccine group Children’s Health Defense.

“What is the cure for measles?” he told an audience in 2021 at an Amish country fair in Pennsylvania. “Chicken soup and vitamin A. And neither of those things can be patented.”

The World Health Organization advises people who contract measles to take vitamin A, which can prevent blindness and death — but it also strongly urges all children be vaccinated against the disease.

While the image of natural wellness has long evoked organic supermarket-patronizing, liberal types, supplement use is bipartisan — and now slightly more popular with Republicans. A December poll from Ipsos and Axios found that 63% of Republicans take supplements daily or most days, versus 58% of independents and 52% of Democrats.

Supplement companies sometimes explicitly court right-wing customers. In the days before Trump’s inauguration, the brand Nugenix posted an ad on the social platform X for its testosterone supplement with the president’s trademark red hat perched on the bottle, bearing the slogan “Make Your T-Levels Great Again.” (Adaptive Health, Nugenix’s parent company, did not respond to requests for comment.)

Some industry observers think the shift rightward happened during the pandemic. “During the covid era, Democrats became the party of science and establishment,” said John Roulac, a California-based supplements entrepreneur. In his telling, the party and especially its elected officials were more likely to trust the FDA and other big institutions — and to discount any potential contribution to health from supplements.

“Under RFK, you have people associated less with pharmaceutical drugs and more with healthier lifestyle choices, whether that’s eating organic food or using herbs or taking vitamins,” Roulac said.

Kennedy and others in Trump’s orbit have found a particularly warm reception among some of the biggest supplement evangelists: influencers, who often promote personal responsibility, in the form of vitamins and other products, as the key to health — and have provided plenty of airtime in recent years for Trump’s newly minted health officials.

On popular podcast host Lex Fridman’s show in 2023, Kennedy accepted praise for being in “great shape” and attributed it, in part, to his vitamin regimen. “I take a lot of vitamins,” he said. “I can’t even list them to you here because I couldn’t even remember them at all.”

In November, Oz endorsed Kennedy’s nomination on his TikTok channel — and then, in his next post, told viewers they need “an alphabet soup” of vitamins to protect their brains and power their organs.

Oz, who at the time had not yet been named to lead CMS, pointed viewers to a “trusted source” of vitamins: iHerb.

Federal ethics rules generally bar public officials from using their office for financial gain. Last month, in a letter to the health agency’s ethics official, Oz disclosed that he is an adviser to iHerb and holds a financial stake in the company. He wrote that, if he is confirmed, he plans to resign and divest from iHerb, as well as recuse himself from policy matters directly involving the company “until I have divested.”

Oz’s Senate confirmation hearing is scheduled for March 14. A spokesperson for Oz did not reply to multiple requests for comment.

Nesheiwat, Trump’s pick for surgeon general, has touted BC Boost, a combination of vitamins promising to toughen one’s immune system and rev energy. The supplement — which advertising claims was formulated by Nesheiwat herself — bears her name and portrait on the package.

“After years of educating my patients, now I made it a little easier to get all the nutrition you need to live strong and stay healthy,” reads a marketing quote attributed to Nesheiwat.

The surgeon general, considered “the nation’s doctor,” does not set policy but rather acts as a spokesperson for public health. During the Biden administration, Surgeon General Vivek Murthy outlined the ills from alcohol, loneliness, and social media.

Nesheiwat, whose financial disclosures are not yet public, did not reply to an inquiry to her website, nor did an HHS spokesperson reply to a request for comment.

It’s unclear what moves the administration might take to boost supplements. Industry officials say they hope the government will make it easier for everyday consumers to use health savings accounts to buy vitamins and other products. The FDA could also decide to allow manufacturers to make more aggressive claims about their wares’ health benefits.

Contrary to Kennedy’s claim of a “war on public health,” in recent years the supplements industry has seen its fortunes grow, and attempts to increase regulations have fallen short amid pressure from supplement makers.

According to the Nutrition Business Journal, revenues for the supplement industry surged during the pandemic, as customers became “more invested in their health,” said Journal analyst Erika Craft. Revenues have continued to increase since then, outpacing earlier industry expectations and boosting product sales to some $70 billion per year, she told KFF Health News.

One FDA attempt to put more stringent regulations — like registration — on businesses, during the 1990s, was defeated soundly after the industry and its clients lobbied Congress.

“It was one of the largest campaigns to Congress imaginable,” David Kessler, the FDA commissioner at the time, said in an oral history.

Grace Sparks, a survey analyst at KFF, the health policy research, polling, and news organization that includes KFF Health News, provided research assistance for the Ipsos-Axios poll.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Sent Home To Heal, Patients Avoid Wait for Rehab Home Beds

After a patch of ice sent Marc Durocher hurtling to the ground, and doctors at UMass Memorial Medical Center repaired the broken hip that resulted, the 75-year-old electrician found himself at a crossroads.

He didn’t need to be in the hospital any longer. But he was still in pain, unsteady on his feet, unready for independence.

Patients nationwide often stall at this intersection, stuck in the hospital for days or weeks because nursing homes and physical rehabilitation facilities are full. Yet when Durocher was ready for discharge in late January, a clinician came by with a surprising path forward: Want to go home?

Specifically, he was invited to join a research study at UMass Chan Medical School in Worcester, Massachusetts, testing the concept of “SNF at home” or “subacute at home,” in which services typically provided at a skilled nursing facility are instead offered in the home, with visits from caregivers and remote monitoring technology.

Durocher hesitated, worried he might not get the care he needed, but he and his wife, Jeanne, ultimately decided to try it. What could be better than recovering at his home in Auburn with his dog, Buddy?

Such rehab at home is underway in various parts of the country — including New York, Pennsylvania, and Wisconsin — as a solution to a shortage of nursing home and rehab beds for patients too sick to go home but not sick enough to need hospitalization.

Staffing shortages at post-acute facilities around the country led to a 24% increase over three years in hospital length of stay among patients who need skilled nursing care, according to a 2022 analysis. With no place to go, these patients occupy expensive hospital beds they don’t need, while others wait in emergency rooms for those spots. In Massachusetts, for example, at least 1,995 patients were awaiting hospital discharge in December, according to a survey of hospitals by the Massachusetts Health & Hospital Association.

Offering intensive services and remote monitoring technology in the home can work as an alternative — especially in rural areas, where nursing homes are closing at a faster rate than in cities and patients’ relatives often must travel far to visit. For patients of the Marshfield Clinic Health System who live in rural parts of Wisconsin, the clinic’s six-year-old SNF-at-home program is often the only option, said Swetha Gudibanda, medical director of the hospital-at-home program.

“This is going to be the future of medicine,” Gudibanda said.

But the concept is new, an outgrowth of hospital-at-home services expanded by a covid-19 pandemic-inspired Medicare waiver. SNF-at-home care remains uncommon, lost in a fiscal and regulatory netherworld. No federal standards spell out how to run these programs, which patients should qualify, or what services to offer. No reimbursement mechanism exists, so fee-for-service Medicare and most insurance companies don’t cover such care at home.

The programs have emerged only at a few hospital systems with their own insurance companies (like the Marshfield Clinic) or those that arrange for “bundled payments,” in which providers receive a set fee to manage an episode of care, as can occur with Medicare Advantage plans.

In Durocher’s case, the care was available — at no cost to him or other patients — only through the clinical trial, funded by a grant from the state Medicaid program. State health officials supported two simultaneous studies at UMass and Mass General Brigham hoping to reduce costs, improve quality of care, and, crucially, make it easier to transition patients out of the hospital.

The American Health Care Association, the trade group of for-profit nursing homes, calls “SNF at home” a misnomer because, by law, such services must be provided in an institution and meet detailed requirements. And the association points out that skilled nursing facilities provide services and socialization that can never be replicated at home, such as daily activity programs, religious services, and access to social workers.

But patients at home tend to get up and move around more than those in a facility, speeding their recovery, said Wendy Mitchell, medical director of the UMass Chan clinical trial. Also, therapy is tailored to their home environment, teaching patients to navigate the exact stairs and bathrooms they’ll eventually use on their own.

A quarter of people who go into nursing homes suffer an “adverse event,” such as infection or bed sore, said David Levine, clinical director for research for Mass General Brigham’s Healthcare at Home program and leader of its study. “We cause a lot of harm in facility-based care,” he said.

By contrast, in 2024, not one patient in the Rehabilitation Care at Home program of Nashville-based Contessa Health developed a bed sore and only 0.3% came down with an infection while at home, according to internal company data. Contessa delivers care in the home through partnerships with five health systems, including Mount Sinai Health System in New York City, the Allegheny Health Network in Pennsylvania, and Wisconsin’s Marshfield Clinic.

Contessa’s program, which has been providing in-home post-hospital rehabilitation since 2019, depends on help from unpaid family caregivers. “Almost universally, our patients have somebody living with them,” said Robert Moskowitz, Contessa’s acting president and chief medical officer.

The two Massachusetts-based studies, however, do enroll patients who live alone. In the UMass trial, an overnight home health aide can stay for a day or two if needed. And while alone, patients “have a single-button access to a live person from our command center,” said Apurv Soni, an assistant professor of medicine at UMass Chan and the leader of its study.

But SNF at home is not without hazards, and choosing the right patients to enroll is critical. The UMass research team learned an important lesson when a patient with mild dementia became alarmed by unfamiliar caregivers coming to her home. She was readmitted to the hospital, according to Mitchell.

The Mass General Brigham study relies heavily on technology intended to reduce the need for highly skilled staff. A nurse and physician each conducts an in-home visit, but the patient is otherwise monitored remotely. Medical assistants visit the home to gather data with a portable ultrasound, portable X-ray, and a device that can analyze blood tests on-site. A machine the size of a toaster oven dispenses medication, with a robotic arm that drops the pills into a dispensing unit.

The UMass trial, the one Durocher enrolled in, instead chose a “light touch” with technology, using only a few devices, Soni said.

The day Durocher went home, he said, a nurse met him there and showed him how to use a wireless blood pressure cuff, wireless pulse oximeter, and digital tablet that would transmit his vital signs twice a day. Over the next few days, he said, nurses came by to take blood samples and check on him. Physical and occupational therapists provided several hours of treatment every day, and a home health aide came a few hours a day. To his delight, the program even sent three meals a day.

Durocher learned to use the walker and how to get up the stairs to his bedroom with one crutch and support from his wife. After just one week, he transitioned to less-frequent, in-home physical therapy, covered by his insurance.

“The recovery is amazing because you’re in your own setting,” Durocher said. “To be relegated to a chair and a walker, and at first somebody helping you get up, or into bed, showering you — it’s very humbling. But it’s comfortable. It’s home, right?”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).