WAIANAE, Hawai‘i — Native Hawaiians will need to comply with new work requirements to qualify for Medicaid after being excluded from exemptions carved out for other Indigenous groups, an omission that clinicians fear will exacerbate the challenges the marginalized population already faces in getting healthcare.

In 43 states and the District of Columbia, President Donald Trump’s signature One Big Beautiful Bill Act will require most adults to work, go to school or enter a training program, or volunteer for at least 80 hours a month. Native Americans and Alaska Natives are exempt from the mandates, which take effect in January.

Of the nearly 700,000 Native Hawaiians in the U.S., around 47% live in Hawai‘i. Within the contiguous United States, California, Washington, Nevada, Texas, and Oregon have the largest populations of Native Hawaiians.

Hawaiʻi’s Medicaid administrator, Meredith Nichols, said the Centers for Medicare & Medicaid Services didn’t respond to the state’s request to include an exemption for Native Hawaiians but said she believes the decision came down to the population’s lack of recognition as a tribal nation. Hawai‘i has about 390,000 Medicaid enrollees, 15% of whom identify as Native Hawaiian, Nichols said.

“We know that when we’ve asked similar questions in the past, it all comes down to federal recognition,” she said.

Hawaiʻi health administrators met with Trump administration officials in June. Some unsuccessfully pushed to add an exemption to the new law, which would need congressional approval.

White House spokesperson Kush Desai did not respond to requests for comment. In a statement, CMS spokesperson Timothy Foster confirmed that the agency met with 16 health centers in Hawai‘i about Medicaid changes but didn’t respond to other questions.

Barriers to Care

Native Hawaiians face many of the same health disparities as Native Americans and Alaska Natives, including higher risks during pregnancy, higher infant mortality rates, and higher rates of being uninsured than the white population. And in Hawaiʻi, Native Hawaiians have the second-lowest life expectancy among ethnic groups after other Pacific Islanders.

Kapono Chong-Hanssen is the medical director of Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i that also serves the privately owned island of Ni‘ihau, whose 170 full-time residents are predominantly Native Hawaiian. Chong-Hanssen said he anticipates many of his patients will no longer receive the care they need once the new work requirements take effect.

Chong-Hanssen says new Medicaid work requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients. (Ashley Mizuo/KFF Health News) Ho‘ōla Lāhui, the Native Hawaiian healthcare system on Kaua‘i, operates out of multiple locations, including its clinic in Waimea on the west side of the island. Kaua‘i and Ni‘ihau were impacted by Hurricane Lowell this week, forcing Ho‘ōla Lāhui to temporarily close facilities. (Ashley Mizuo/KFF Health News)

The new requirements will erode the trust healthcare providers worked hard to build among Native Hawaiian patients, who, in response to historical disenfranchisement, are more likely to disengage and “throw the whole system out” when they run into barriers, Chong-Hanssen said. “It just flies in the face of everything that we’re trying to do.”

Beyond medical services, Medicaid covers transportation expenses when patients travel between islands for care. A round-trip ticket between Kaua‘i and O‘ahu, for example, can cost hundreds of dollars.

Congress placed over 200,000 acres of land in a trust for Hawaiian homesteads in 1921 to bring Hawaiians back to their native lands after the U.S. backed the 1893 illegal overthrow of the Hawaiian kingdom. Nearly 30,000 Native Hawaiians are still waiting for land, while, as of the 2020 census, more than 34,000 people lived on Hawaiian homelands. The homesteads are often far from Honolulu, where most health services are located.

Waianae Coast Comprehensive Health Center primarily serves the west side of O‘ahu, which is home to the island’s largest Native Hawaiian population, near four Hawaiian homesteads.

Waianae Coast Comprehensive Health Center CEO Rich Bettini (right) and Vice President Leinaala Kanana demonstrate how to use pods throughout the campus that connect patients via phone to an employee who will help them submit needed information and applications to the state’s Medicaid program. (Ashley Mizuo/KFF Health News)

The center’s vice president, Leinaala Kanana, said that many of its patients are geographically isolated and that few jobs are available in the area. Patients also have trouble securing transportation to get to work or finding affordable childcare.

The center’s CEO, Rich Bettini, said Hawai‘i’s high living costs and depressed wages have pushed many people into homelessness, creating another barrier to complying with the new Medicaid requirements. Native Hawaiian and Pacific Islanders make up about 60% of O‘ahu’s homeless population. The center estimated about 2,800 of its patients may be affected by the requirements, half of whom are Native Hawaiian.

The annual “cost of living for a family of four in Hawaiʻi on O‘ahu is $100,000-plus. The average income of our patients is under $30,000 a year,” he said. “That is an enormous gap.”

‘Bigger Fish To Fry’

Native Hawaiians face obstacles to being granted the same exemptions as other Indigenous groups. While several federal laws refer to Native Hawaiians as an Indigenous group, they are not among the 575 tribes recognized by the federal government. Federal recognition can be granted either by Congress or administratively through a process established by the Department of the Interior. Native Hawaiians remain divided about whether they would even want federal recognition, with some fearing it would jeopardize their ability to restore Hawaiian independence.

Laws governing Medicaid also don’t acknowledge Native Hawaiians, aside from the 2021 American Rescue Plan Act, signed by former President Joe Biden. In the covid-era law, the federal government fully reimbursed Native Hawaiian health centers for Medicaid services for two years. However, all the qualifying Native Hawaiian health centers were in Hawai‘i, where fewer than half of Native Hawaiians in the country now live.

The federal government fully reimburses Indian Health Service and tribal facilities for healthcare services provided to Native Americans and Alaska Natives. Native Hawaiian healthcare systems instead receive the same reimbursement rate as in the rest of Hawaiʻi.

Waianae Coast Comprehensive Health Center CEO Rich Bettini said Hawai‘i’s high cost of living and depressed wages have pushed many people into homelessness, creating another barrier for Native Hawaiians to comply with new Medicaid requirements. (Ashley Mizuo/KFF Health News)

Keolamaikalani Dean, the CEO of the King Lunalilo Trust, which provides services for Native Hawaiian elders, pointed to the new Medicaid requirements as just one of many federal policies limiting Native Hawaiians’ healthcare.

“It’s horrible as a policy, but there are bigger fish to fry,” he said.

Dean said he’d rather advocate for giving Native Hawaiian healthcare systems the same full Medicaid reimbursement that the Indian Health Service receives. The change would have greater impact on patients seeking care, he said.

Native Hawaiian advocates said they have been overextended as they work to guard against an onslaught of threats to revoke other federal funding by the Trump administration.

In Trump’s proposed 2027 budget, cuts to Native Hawaiian programs cited the group’s lack of federal recognition as a “tribal nation.” The proposed cuts coincide with lawsuits from conservative groups challenging Native Hawaiian education programs and long-standing legislation that provides homestead land to some Native Hawaiians at almost no cost, alleging the programs racially discriminate against other groups.

Papa Ola Lōkahi, a nonprofit that oversees the Native Hawaiian healthcare systems in the state, declined to comment for this article. The group is involved in a lawsuit filed by a conservative group aiming to stop a university scholarship for Native Hawaiians pursuing healthcare careers.

U.S. Rep. Jill Tokuda (D-Hawaiʻi) viewed the exclusion of Native Hawaiians from the exemptions to Medicaid work requirements as an attempt to further erode Native Hawaiians’ Indigenous status, pointing to recent challenges by the Trump administration and lawsuits.

“These are not one-offs,” Tokuda said. “This is a targeted, coordinated attack to undercut the Indigenous status of Native Hawaiians.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

TROY, N.Y. — Like many residents of this aging industrial city on the Hudson River, Starletta Washington was stunned when she heard Troy’s last remaining hospital planned to close its birthing center.

“It was devastating,” said Washington, who heads the local YWCA. Washington was born at the hospital and had her children there. She couldn’t believe families would now have to get to a hospital half an hour away or face the prospect of an emergency delivery.

“Nobody else was going to be born in the city of Troy unless they were born on a city bus, in the back of a cab, or, disgustingly, on the side of the street?” Washington said. “Blew my mind.”

Troy wasn’t the first community to face this prospect. Since 2010, hospitals have closed hundreds of maternity units as cities and towns shrink and hospitals consolidate into larger systems.

Troy found a more hopeful ending.

State Assembly member John T. McDonald III (center), a Democrat, worked to secure $5 million in state funding to help keep the Burdett Birth Center open in Troy, New York. (Katherine Bruno/Upper Hudson Planned Parenthood) Carmella Mantello, the Republican mayor of Troy, New York, says even nonprofit hospitals seem to have become more corporate. “The whole hospital scene has changed,” she says. (Hannah Norman/KFF Health News) Starletta Washington, who heads the YWCA in Troy, was born at the hospital where Burdett Birth Center is located. Like many in the community, she says she was blindsided by Trinity Health’s plan to close the center. (Hannah Norman/KFF Health News)

Elected officials from both major parties joined patient advocates, mothers, midwives, doulas, and community leaders like Washington to challenge Trinity Health, the large Catholic health system that owns Troy’s hospital and birthing center. The campaign even united Planned Parenthood and the Catholic diocese.

“Whether you were Republican or Democrat, or if you didn’t vote, it literally brought everyone together,” said Carmella Mantello, the city’s Republican mayor. “Everyone just said, ‘We can’t let this happen.’”

Throughout the country, healthcare remains a flash point as politicians square off ahead of November’s elections. But in many places, Americans are also quietly finding common ground.

In this small city, residents were brought together by frustration over large, corporate health systems that can seem to put profits over patients. And they resolved to work together to keep critical medical services in their community.

A Community Institution

Babies have been delivered at Samaritan Hospital on a hill above Troy since this city’s once bustling factories produced most of America’s shirt collars a century ago.

More recently, Samaritan’s Burdett Birth Center had become a model for patient-focused care. Midwives and doulas work alongside OB-GYNs and support mothers who want to avoid a delivery by cesarean section unless necessary.

Patient safety advocates have pushed for years to reduce surgical deliveries, which can lead to complications. At Burdett, only about a quarter of newborns are delivered by C-section, compared with about a third statewide, according to 2025 hospital data. Burdett also had fewer preterm births and fewer babies with low birth weights.

“I wouldn’t go anywhere else,” said Lidia Zambrano-Madera, who gave birth to both her children at Burdett with the help of a midwife.

Lidia Zambrano-Madera, a Troy resident, gave birth to both her children at the Burdett Birth Center with the help of a midwife. “I wouldn’t go anywhere else,” she says. (Jayana Espinoza)

For Zambrano-Madera, who recently opened a children’s play center in Troy, Burdett offered another advantage: It was just five minutes from home.

But three years ago, Trinity Health, a multibillion-dollar Michigan-based hospital system, said the birth center was losing money and would close. Families from Troy and surrounding Rensselaer County would have to deliver at another Trinity hospital in Albany, up to a half-hour’s drive away. The hospitals are branded under St. Peter’s Health Partners in the Albany region.

“We’ve been frantic about trying not to cut the care at the bedside,” said Steven Hanks, a physician who oversees Trinity hospitals in New York and New England. “But, you know, you get to a point where you can only consolidate so much. You can only spread people so thin, and then you have to start taking harder looks at your actual services.”

Corporate Backlash

Trinity’s plans — news of which broke in a local newspaper — came without warning, surprising the obstetrical staff and community leaders. They set off a firestorm.

Within days, midwives, mothers, community leaders, and politicians held a rally at the YWCA in downtown Troy. Others would follow. Volunteers led by doulas and midwives made T-shirts and handed out pink “Save Burdett” signs at the local farmers market.

Activists were outraged that the hospital hadn’t adequately assessed the impact of the closure, particularly on low-income families. They conducted a community survey that found 1 in 4 Troy residents didn’t have access to a car and would have trouble getting to Albany.

The campaign drew on deep connections that many residents had to Burdett. “They realized what a gem Burdett is, and what a great community service they provide,” said Jessica Hayek, a doula and birth educator who helped lead the campaign.

Jessica Hayek, a doula and birth educator, helped lead the campaign to stop Trinity Health from closing the Burdett Birth Center. She says Michigan-based Trinity didn’t appreciate how important the center was to the Troy community. (Hannah Norman/KFF Health News)

Hayek and others also tapped into deep-seated frustration with Trinity, a healthcare behemoth that operates 91 hospitals and last year recorded more than $25 billion in revenue and a healthy operating margin that topped 5%.

“Trinity Health is in the Midwest, and they are not in the community,” Hayek said. “So when you’re looking at just the numbers from an office in the Midwest somewhere, they’re not looking at the benefit that this place has on the community.”

Hayek describes herself as a liberal Democrat. But Trinity’s focus on its bottom line also irked many Republicans, including Mantello, who was the City Council president at the time.

“The whole hospital scene has changed,” Mantello said. “It was very personable. You had nurses and doctors who were able to give more care and spend more time with patients.” Now, by contrast, many hospitals have what she described as a “more corporate type of atmosphere.”

Even the Catholic bishop decried the planned closure of the birthing center as out of step with the values of his faith and the hospital system’s.

“Nothing is more central to the Catholic healthcare mission than supporting life and all those who bring it into the world,” Bishop Edward Scharfenberger said after Trinity announced the closure plan. Scharfenberger has since retired.

A Bipartisan Solution

Despite the backlash, Trinity Health executives for months insisted they had no choice. The system even sued the state to push through the closure.

Ultimately, though, powerful state officials, including New York Attorney General Letitia James, a Democrat, joined the fight to save the birthing center, launching an investigation into the proposed closure and hosting a daylong hearing in Troy.

State Assembly member John T. McDonald III, a Democrat who represents Troy, worked with Republican elected officials, including the county executive and the state senator representing Troy, to secure $5 million in state funding to help keep Burdett open.

 “You had a Democrat and a bunch of Republicans all working together on the same issue,” McDonald said, “because, at the end of the day, our job is to listen to what the public has to say.”

Community leaders, politicians, midwives, doulas, and families from Troy rallied for months to stop the Burdett Birth Center from closing, including at the state Capitol in Albany. (Katherine Bruno/Upper Hudson Planned Parenthood) Community volunteers in Troy celebrated the success of their campaign to save the Burdett Birth Center by adding a yellow tag to the pink protest signs. (Hannah Norman/KFF Health News)

Nearly a year after announcing the closure, Trinity reversed itself and said Burdett would remain open.

Lois Uttley, a New York City-based researcher and activist who has worked with communities facing hospital consolidation, said Troy’s success reflects a growing bipartisan suspicion of corporate healthcare organizations.

“The executives of these health systems will tell the community that joining a big health system will be good, that the quality of care will improve, that efficiencies will mean they can keep the costs low,” Uttley said. “But what I have seen over the last 30 years of work is that those promises often are broken.”

As hospitals close or downsize, she said, communities are catching on. “They’re becoming more skeptical.”

There’s another, more hopeful lesson in Troy’s success, said McDonald, the state lawmaker.

“If we take down our swords,” he said, “and put out our arms, maybe we can get something done.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

AUSTIN, Texas — Musician Zack Morgan jokes that when he lost his corporate job in 2015, it was like being pushed off a cliff. For years, he said, he’d been playing both sides of the Austin coin: tech worker by day, funk keyboardist by night.

“Maybe this is my sign to try the full-time music thing,” Morgan recalled thinking. “Step one in that was: Get health insurance again.”

Austin bills itself as “the Live Music Capital of the World,” but it can be unaffordable for the artists who provide the city with its cultural cachet — and help drive its tourism revenue.

Morgan has supported himself by patching together gigs with a number of bands. To help pay for health insurance, he turned to a local nonprofit, the Health Alliance for Austin Musicians, or HAAM.

“That’s part of being able to make this whole thing work,” Morgan said.

HAAM subsidizes the monthly insurance premiums of local musicians who purchase plans through the Affordable Care Act marketplace. To fund the roughly $4 million program, it works with Central Health, a public agency that provides healthcare resources for low-income residents of Austin and surrounding Travis County. Many of the performing artists pay $0 toward monthly premiums.

After more than a decade, including through the coronavirus pandemic, the assistance program has become an established and reliable financial support for Austin’s musician community.

This year, after Congress failed to extend pandemic-era subsidies, premiums skyrocketed for many ACA plans. A recent report found that 5 million people nationwide had dropped the coverage. HAAM helped blunt the impact for its members. It has emerged as a potential model for other cities hoping to make healthcare more affordable for key populations and industries.

Morgan plays keyboard with pop singer Ruthie Craft at the Saxon Pub in Austin on July 27. (Ysa Mendoza/KUT News)

A Growing Idea

Texas had the highest uninsured rate among states, with 19% of people age 64 and under uninsured, as of 2024.

Even before the launch of the ACA marketplace in 2014, HAAM had spent a decade connecting musicians with free and low-cost care at clinics and hospitals in and around Austin. But roughly 85% of HAAM members remained uninsured, leaving them exposed when traveling to gigs in other cities and states.

“When the Affordable Care Act came out, and we knew it was here to stay, it really made sense for us to start getting our musicians fully insured,” said Rachel Blair, HAAM’s chief strategy officer.

Similar nonprofits in other U.S. cities with strong live music cultures, such as Seattle, New Orleans, and Nashville, Tennessee, help musicians get medical care. With the advent of the ACA, some of these organizations began helping musicians navigate the sometimes complex enrollment process for the online marketplaces, though they stopped short of pitching in on premiums.

But the team at HAAM recognized that without direct support to help pay premiums, many of their members would still struggle to retain coverage.

“When you think about the average HAAM member making about $30,000 a year, there’s no way that they would be able to spend a third of their income on healthcare,” Blair said.

The organization’s membership has grown by 77% to more than 3,300 people since HAAM began offering premium assistance, and more than 90% of members are now insured.

To help subsidize costs for members, HAAM partnered with Central Health, which is Travis County’s public hospital district — a type of health agency in Texas charged with using tax dollars to fund safety net healthcare for low-income residents. Central Health also operates the nonprofit Sendero Health Plans, which offers marketplace insurance to Travis County residents.

To qualify, HAAM members must enroll in one of Sendero’s silver-level, or benchmark, plans. If their income is between one and two times the federal poverty level, Central Health pays the balance of their monthly premium after federal tax credits are applied. For members who fall above that income range, HAAM offers a more limited subsidy, covering 50% of their premium balances.

Each year, the Health Alliance for Austin Musicians hosts the HAAM Day Music Festival, its annual event to raise money to help local musicians afford insurance premiums and other healthcare services. Bands play in common spaces across the city, from grocery stores to the Texas Capitol steps. (Shunya Carroll/KUT News)

In 2017, HAAM helped set up a similar program in Denton, a college town north of Dallas that has served as a testing ground for successful musicians, from Meat Loaf to Norah Jones.

The Denton Music and Arts Collaborative works differently: It connects members with an independent insurance agent who helps them find the best health plan for their needs. The nonprofit then offers members a monthly subsidy of $100.

The subsidies are a way of keeping Denton’s culture of jazz and “weird art rock” alive, said the collaborative’s president, Jennifer Kapinos.

“More and more people were maybe graduating college and leaving and going to find better opportunities in other places,” Kapinos said. “People who had lived here a long time suddenly were finding it harder and harder to afford to be here.”

In Austin, other sectors have been watching HAAM’s work. In 2025, Good Work Austin, a nonprofit that advocates for restaurant workers, launched a small pilot program with Central Health to help local food workers enroll in Sendero plans and cover their premiums.

Kit Abney Spelce, vice president of operations for Central Health, said partnering with an advocacy group focused on a particular workforce is key because simply announcing “free insurance for you” doesn’t mean people will sign up.

“We are very much dependent on our partner entity to go out and connect with the community, to have that relationship and that trust,” she said.

Navigating Federal Headwinds

Though premium payments often increase year over year, the 2026 plan year was particularly expensive, increasing by 58% on average.

Citing medical and pharmacy costs, Sendero raised rates by an average of 16% for its enrollees. At the same time, Congress allowed the pandemic-era enhanced premium tax credits to expire, reducing the federal subsidies that many marketplace customers relied on.

“Our premiums for our members went up 60% from one year to the next,” Blair said.

HAAM stepped up its fundraising into 2026, but it wasn’t enough to cover everyone who requested assistance. They had to turn away hundreds of qualified people. Still, they were able to buffer existing members, said Spelce with Central Health.

“We’re going to make sure their monthly premium is paid every month,” she said.

Austin-based Latin-folk singer Gina Chavez plays on the steps of the Texas Capitol in 2025 for the HAAM Day Music Festival, an annual fundraiser for the Health Alliance for Austin Musicians. (Shunya Carroll/KUT News)

A Viable, if Limited, Model

Beyond the eligible musicians they turned away in 2026, another population remains out of HAAM’s coverage reach for premium assistance: Austin’s poorest residents.

Under the ACA, the marketplace plans that HAAM helps subsidize are for low- and middle-income earners, but the people with the very lowest incomes — below 100% of the federal poverty level, set at about $15,000 — are supposed to be covered by expanded Medicaid.

But Texas is one of 10 states that chose not to expand Medicaid after the ACA became law, so many of the poorest Texans remain uncovered.

With no federal subsidies available for that group, HAAM and Central Health have tried to develop separate solutions for this subpopulation. Central Health has its Medical Access Program, an alternative to health insurance that gives low-income, uninsured people access to a network of local care providers. HAAM has also established relationships with primary care providers to serve its uninsured members — but Blair acknowledges it’s not an equivalent benefit to what Medicaid expansion would offer.

“It’s not a very sustainable solution, especially when there’s a really good alternative,” Blair said.

This article is from a partnership that includes KUT, NPR, and KFF Health News.

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

A group of Democratic lawmakers is calling for the Trump administration to suspend a new surveillance program it quietly launched to collect the personal and identifiable health data of Americans who visit emergency rooms.

KFF Health News first reported that the Consumer Product Safety Commission — a federal agency tasked with monitoring injuries from household items — was pressuring hospitals to provide a private company with personally identifiable health information for analysis. The rollout of the program has inspired broad pushback from hospitals and privacy advocates.

The CPSC’s goal is to obtain millions of Americans’ medical records from emergency rooms for most injuries, even when a consumer product is not involved, internal emails and documents reviewed by KFF Health News revealed. The agency instructed hospitals to share detailed patient information for more than 10,000 types of injuries or conditions, such as vaccine reactions, suicide attempts, or stingray stabs.

The scope of data CPSC is collecting far exceeds the agency’s mission and should be immediately suspended, Massachusetts Sen. Ed Markey, who sits on the Senate Health, Education, Labor, and Pensions Committee, and other House and Senate Democrats wrote in a letter to CPSC acting Chairman Peter Feldman.

“This unprecedented and sweeping effort to collect identifiable patient data is untethered from the Commission’s statutory mission and authority, and is ripe for misuse by an administration that has repeatedly sought access to Americans’ most personal information,” the letter stated. “Americans should be able to seek medical care without fear that their personal health information will be swept into a federal database and repurposed for political ends.”

Among other Democrats signing the letter were Sen. Richard Blumenthal of Connecticut, Rep. Jan Schakowsky of Illinois, and Sen. Ron Wyden of Oregon, the ranking member of the Senate Finance Committee.

CPSC spokesperson Steve Roney did not answer several questions about the program and the call for it to be suspended.

“We received the letter, and will respond directly, through the appropriate channels,” he said in a statement.

The CPSC is one of several agencies that have launched broad acquisitions of Americans’ sensitive medical records during Trump’s second term. The Office of Personnel Management has requested federal workers’ sensitive health information. Health and Human Services Secretary Robert F. Kennedy Jr. deputized at least one private organization to collect more medical records for his studies on vaccines and autism.

The CPSC has operated a voluntary program for decades that enables trained hospital workers based in about 70 hospitals nationwide to report injuries involving consumer products, called the National Electronic Injury Surveillance System, or NEISS. Compared with the current initiative, the agency’s data collection has historically been far narrower, and previously requested patients’ identifiable information, generally for follow-up, in fewer than 1% of cases.

Without public notice, CPSC staffers overhauled the program early this year — rebranding it as NEISS-R — and told hospital executives that participation is mandatory, requiring they report far more identifiable patient details from more injuries to a private company called Konza Health. The Kansas-based company won a five-year contract last year worth up to $15.9 million with the CPSC.

In emails and contract language reviewed by KFF Health News, Konza representatives described hospital participation as “mandatory” or “required.” Emails sent this year by CPSC chief data officer Elizabeth Puchek said hospitals would need to apply for an exemption from participation or face penalties. Those penalties, for what’s called unlawful “information blocking,” were established in a federal data-sharing regulation designed to make sure patients could access their medical records. The agency’s website reiterated that threat, claiming information-blocking regulations require hospitals “to make electronic health information (EHI) available to public health authorities, such as CPSC, upon request, unless a specific exception applies.”

The power play inspired widespread resistance. The American Hospital Association sent a letter in August asking for modifications to the program, citing “confusion and concern about the scope of patient information” demanded by the agency.

Now the agency is backtracking, removing in recent weeks mentions of “information blocking” penalties from its public page.

The CPSC’s Feldman, a Trump appointee, said in an interview last month with Nextgov/FCW that the new program would “remain a voluntary” one.

The Democrats highlighted these discrepancies and changes, also noting that the agency has bypassed regulations and failed to publicly lay out any detailed plan for its data collection, as required by law.

“The Commission has since quietly removed the information blocking rationale from its public NEISS webpage, without any public correction or acknowledgment that the claim it spent months promoting was without basis,” the letter said. “This reversal does not undo the coercion hospitals experienced, but rather raises the question of whether the Commission’s purported legal justifications were ever more than post-hoc cover for an agenda that had little to do with its statutory authority.” The Democrats’ letter asks CPSC to respond by Sept. 18.

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

In the thick of his competitive reelection race in Michigan, Republican Rep. Tom Barrett joined Health and Human Services Secretary Robert F. Kennedy Jr. at a sprawling 400-acre apple orchard, farm, and winery. They touted Trump administration efforts to improve the American diet, including the removal of some artificial dyes from processed foods.

“We had a great discussion about healthy options for all Americans and taking back control of our healthcare,” Barrett said in a June Instagram post, after sampling the farm’s apple cider.

Like the focus on artificial dyes, however, many of the administration’s highest-profile health initiatives rely on voluntary agreements. The goals, such as lower drug prices and nutrition classes for doctors, have widespread appeal, cutting across party lines and economic divisions.

But the administration-industry deals lack the enforcement teeth of more traditional federal regulation. Their details are vague, and minimal oversight makes it hard to monitor progress. In some cases, the administration has claimed victories that have yet to materialize.

Republicans consider the dealmaking a winning strategy. It fits with the party’s anti-regulatory stance, they say, and enables the administration to quickly forge agreements President Donald Trump and his allies can tout as accomplishments. In the run-up to the midterm elections, some, like Barrett, hope to woo voters by trumpeting the Trump administration’s efforts to shape health policy.

The practice also raises questions. Though the deals are announced with great fanfare — often during televised events on stages, with live audiences — there’s little documentation or follow-through, creating doubts about whether the administration’s health agenda will lead to lasting change or unravel once the political attention fades.

The distinction could prove important to voters as Republicans defend their health records in November’s midterm elections.

“These deals are often not transparent, so there’s no way for the public to judge how meaningful they are,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Dealing With Dyes

The push to remove certain artificial dyes from food and drugs, for example, was a headline grabber. In April 2025, Kennedy strode onto an HHS stage to announce deals with food makers. He was flanked by young children and mothers holding placards reading “Make America Healthy Again.”

He and former FDA commissioner Marty Makary drew a standing ovation from an audience selected by Kennedy’s staff as they said companies had pledged to phase out all petroleum-based synthetic dyes from the nation’s food supply and medicines. They targeted nine synthetic dyes for removal.

Voters love the idea of stopping the use of such dyes. In a nationally representative March survey by Consumer Reports, 72% of adults said they were at least somewhat concerned about synthetic dyes, and two-thirds said companies should be required to phase them out.

A year after making the first announcement at HHS, Kennedy declared victory during a discussion at the Conservative Political Action Conference, an annual political event.

“We’ve gotten rid of the nine synthetic-based food dyes,” he said.

Not quite. At the initial HHS event, federal officials said companies would voluntarily stop using six specific synthetic dyes by the end of this year. (The administration has also revoked or proposed revoking authorization for two other synthetic food dyes.)

Later, the FDA on its website quietly changed the deadline to the end of 2027. So, most are still in use.

In fact, the FDA posted a list of 27 companies it said had made voluntary pledges as of December 2025 to remove six synthetic dyes from products such as Doritos and Kellogg’s Froot Loops. More than a year and a half later, seven food makers — fewer than 30% of those who bought in — had met their promised goals.

Many major food makers, such as the Coca-Cola Co. and Unilever, have made “no concrete commitments” to remove the synthetic dyes, according to Consumer Reports. In addition, no pharmaceutical companies have publicly said they have plans to remove dyes from drugs.

“It’s just all talk,” said Leslie Dach, who chairs Protect Our Care, a healthcare advocacy group that supports the Affordable Care Act. “They just govern for a day of publicity, and then it’s over. None of it happens. Yet the people don’t know because they have busy lives, so they think, ‘Just look at all these initiatives.’”

In fact, the administration loosened labeling requirements, allowing companies to say their products contain no artificial colors — as long as they don’t use petroleum-based dyes. Previously, food makers could not make that claim unless their products contained no added colors. Some food dyes made from natural ingredients can contain contaminants and may pose their own health risks, such as diabetes.

“The federal government hasn’t taken any regulatory action on food dyes, for the most part, since the beginning of this administration,” said Melanie Benesh, vice president for government affairs at the Environmental Working Group, an advocacy group.

HHS said the voluntary approach has yielded significant action, including commitments to remove synthetic dyes from products sold in schools for the 2026–27 school year.

“HHS and the FDA are moving forward with clear timelines and concrete industry commitments, with major changes expected in foods served in schools during the coming school year and across full product portfolios by the end of 2027,” HHS spokesperson Emily Hilliard said in an email.

At the same CPAC convention event, Kennedy said “the MCAT testing companies are going to put nutrition on the MCAT for the first time, so the students will actually want to do it.” MCAT refers to the Medical College Admission Test, an exam required for admission to medical schools.

Again, not quite.

The Association of American Medical Colleges administers the MCAT. Spokesperson Stuart Heiser said Kennedy misspoke and may have meant to refer to a test taken by students to be licensed as doctors.

An Insurance Deal Falls Short of Promises

Kennedy again took to the HHS stage in June 2025, this time with Centers for Medicare & Medicaid Services Administrator Mehmet Oz, to make what was billed as a game-changing announcement. Major insurers, they said, had agreed to reduce the volume of healthcare services subject to prior authorization, a practice widely used by the insurance industry that often requires patients or their medical teams to seek preapproval before undergoing treatment.

The administration said 80% of insurers pledged changes to preauthorization requirements for 80% of diseases and injuries by January 2026. The administration also promised “public dashboards” to track progress.

“It will happen very quickly,” Oz said at the event. “Necessary care will be delivered when it’s needed, in the right way.”

As of July, months past that January target date, health plans had reduced prior authorization for medical services by about 11%, according to AHIP, the insurer trade group. But no public dashboards have debuted to track the deal, and some insurers that signed the pledge last summer told KFF Health News this year that they will not implement all the promised reforms as outlined by AHIP.

Hilliard did not respond to questions about the pace of progress.

The American Medical Association, in a 2025 web-based survey, asked 1,000 practicing doctors whether they believed the voluntary pledges would make a meaningful difference. Only 1 in 3 said they believed they would.

Insurers made a similar promise in 2018, during the previous Trump administration. The next year, more than 80% of doctors said the number of prior authorization requests for drugs and medical services had been increasing, based on another AMA survey.

Meanwhile, the administration is testing an artificial intelligence-powered prior authorization system for Medicare, the federal health program for people 65 and older or with disabilities. In six states, Medicare beneficiaries must get preapproval for a few treatments that CMS considers to have little clinical benefit and to be susceptible to fraud or waste, including skin substitutes and knee arthroscopy for arthritis. The program began in January, the same deadline insurers had set for curtailing preauthorization delays.

Deals and Deregulation

The healthcare industry’s voluntary agreements appeal to voters who feel government regulation drives up costs and places unnecessary burdens on businesses, some supporters say.

“Secretary Kennedy is the antithesis of a public health industry that uses coercion over communication — and has demonstrated this by taking the time and effort to push voluntary initiatives over the typical approach of governmental mandates,” said David Mansdoerfer, a political consultant who was a political appointee at HHS in Trump’s first term.

But voluntary agreements with the health industry can prove ineffective. Former President Jimmy Carter in 1977 proposed a legislative plan to curb rising hospital costs. Hospitals fought back, and Congress rejected the proposal, instead favoring a voluntary approach desired by the industry. It ultimately failed once public attention faded.

One upside: Deals are fast. Enacting a federal regulation can take two to three years. And some health analysts say the tempo of the agreements advanced by Kennedy and Trump may help take voters’ attention off the Trump administration’s inability so far to produce a long-promised health plan.

Instead, Republicans can point to the array of accords reached with industry, including the administration’s voluntary arrangement with drugmakers to cut prices so they’re in line with lower amounts charged in peer countries. The White House calls it the “most-favored-nation” prescription drug pricing policy.

Seventeen companies, including Pfizer and AstraZeneca, announced agreements with the administration to lower prices for Medicaid enrollees and cash-paying consumers using TrumpRx, a narrow, government-run consumer platform.

Many details remain unknown, but the lower prices apply only to new drugs and existing drugs available through Medicaid. And prices at TrumpRx aren’t as low as out-of-pocket prices for most consumers with insurance. But the voluntary deals appeal to an industry that has railed against mandatory approaches drugmakers deride as harmful price controls.

“Each company makes its own decisions about how it prices medicines, and our industry is committed to working with the Trump administration to ensure Americans have access to affordable medicines,” said Chanse Jones, a spokesperson for PhRMA, a pharmaceutical industry trade group.

Policies that lead to reductions in drug prices typically worry investors because profits also can drop. But rather than seeing their stock prices fall after the agreements were announced, the drugmakers saw largely positive market reactions.

Analysts say that’s partly because the deals are narrow in scope, largely exist only in principle, and don’t apply to existing drugs used by the more than 200 million Americans with commercial or private health insurance.

The Trump administration, however, is claiming success.

“The most-favored-nation agreements on drug prices that we just did are delivering the largest drug price cuts in history,” Trump said in June at a Mack Trucks plant in Pennsylvania. “That alone should win us the midterms.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

One year into its creation, a $50 billion federal program aimed at improving rural healthcare lacks transparency, which could make it difficult to protect against fraud, identify successful projects, and ensure the program delivers on its promise to transform the system.

Transparency “is really important to help protect the integrity of the program, ensure funds are reaching the communities they’re meant to serve,” said Maya Sandalow, director of health policy for the Bipartisan Policy Center, a nonprofit think tank.

The federal government and states are compelled by public records laws to share documents when requested. But those requests can take months to fulfill, making their release too late for meaningful oversight as states rush to spend their allotments under tight federal deadlines.

In the meantime, the Centers for Medicare & Medicaid Services — which oversees the Rural Health Transformation Program — and some states aren’t proactively sharing information about where the funding is going and how it will be used.

CMS spokesperson Timothy Foster said the agency “will publish an annual report on state progress.”

States’ individual reports to CMS are “intended to be” shared upon request, but the agency won’t be proactively publishing the individual state reports, according to a CMS document.

Foster didn’t respond to questions about whether the agency will share examples of projects that are and aren’t working or create a tracker of funding recipients, award amounts, and what organizations plan to do with their funding — ideas that health and government transparency advocates have requested.

Instead, much of the program’s transparency thus far has been up to state governments, and “the level of details that states have publicized really varies,” said Sandalow, who co-wrote a recent paper on how the federal government can strengthen the rural health program, including through transparency.

Some states are sharing information with lawmakers, holding public meetings, and explaining where organizations plan to invest their money.

Others are more secretive, with multiple states declining to release public records in response to KFF Health News’ requests. Mississippi’s governor vetoed a transparency-related bill, West Virginia holds closed-door advisory meetings, and a South Dakota official wrote that he hoped CMS would keep its application from public view.

“I just don’t believe in all this secrecy,” said Mississippi state Sen. Hob Bryan, who chairs his chamber’s public health committee. “If they’re not up to something nefarious, why do they have to do it all in secret?”

Bryan, a Democrat, said there’s bipartisan concern about the lack of transparency in his state.

Reaching Rural Patients

Congressional Republicans created the five-year Rural Health Transformation Program last summer as an eleventh-hour sweetener to President Donald Trump’s signature One Big Beautiful Bill Act. The money was intended to offset concerns about the outsize fallout anticipated in rural communities from the law, which is expected to reduce overall Medicaid spending by more than $900 billion over a decade.

Sandalow said some states may be struggling to share information since they’re busy rushing to hire staff and meet the program’s tight deadlines, including an annual report due Aug. 31.

In the meantime, a slew of media outlets, nonprofits, and businesses are stepping in to make it easier for the public to track the rural health program.

KFF Health News is collecting states’ applications and approved plans and budgets, not all of which have been posted on state websites.

Rural Health Payout Tracking Applications for Rural Health Transformation Funds

KFF Health News is working to collect and post complete application materials, by state, here and will update this repository as new materials, released in response to public records requests, arrive.

Dec. 4, 2025 Rural Health Payout Tracking State Rural Health Transformation Plans

KFF Health News is working to collect and post approved plans as more states respond to emails and public records requests for their documents.

July 27, 2026

And several health nonprofits and companies have created trackers that describe states’ rural health initiatives, post funding opportunities, or list award recipients. But some resources are available only through paid services, aimed at helping businesses interested in applying for money.

Sandalow said previous federal programs “tend to draw attention for gaps in transparency and oversight rather than for doing it well.”

As an example, she pointed to the lack of oversight and transparency with the CARES Act and other covid relief programs, which saw fraud and improper payments.

In March, CMS published proposed quarterly and annual state reporting requirements for the rural health program, and a notice seeking comments. At least three groups replied with letters expressing concerns about transparency.

CMS should share states’ progress reports, funding recipients, and what organizations plan to do with their awards, wrote Zachary Gaumer, the Bipartisan Policy Center’s vice president for health policy.

Sharing this information would make it easier to track progress, identify successful programs that other states may want to replicate, and “ensure funds reach the rural communities they are intended to serve,” he wrote.

Molly Smith, group vice president for public policy at the American Hospital Association, asked CMS “to be as detailed as possible” about the “final destinations of these funds, given the complexity of the grant funding process.”

In her letter, Charlene MacDonald, who leads the Federation of American Hospitals, noted that some funding recipients, such as large health systems and academic medical centers, will be distributing their awards to other entities.

CMS should collect those “downstream subrecipients,” wrote MacDonald, whose group represents for-profit hospitals and healthcare systems.

Without this information, she said, it will be difficult to know if “funding is reaching the rural hospitals, providers, and communities primarily intended to benefit from the program.”

It can also be difficult to know which for-profit companies are being paid with rural health money.

For example, Nevada and Kansas have listed hospitals and other health facilities that received funding to purchase telehealth, scanning devices, and other health technology. But the states list only some of the companies from which recipients will buy those products.

States won’t have to report “downstream” funding in their August reports to CMS but will have to do so for all future reports, according to the agency’s recently finalized reporting requirements.

The CMS documents say states must list subrecipients that receive subawards as well as vendors or contractors paid by an organization using rural health funding. Although states must report how much money these downstream recipients receive, they don’t have to describe which specific services or products the recipient is providing.

DIY Dashboards

As groups ask CMS to share more information, some states have created their own rural health spending dashboards or recipient lists, with varying levels of detail.

Alaska, Kansas, Oklahoma, and other states list which organizations receive funding, their award amounts, and detailed descriptions of how recipients will spend the money.

Florida and Nebraska, however, are among the states that don’t share what awardees plan to do with their funding.

New Hampshire is posting recipient contracts that detail projects and their budgets on its Rural Health Transformation Program website. Some other states have uploaded contracts and grants on general procurement or award databases, which can be difficult to navigate.

Ohio, Virginia, and New Jersey have used press releases to announce awards. But the announcements aren’t posted on their Rural Health Transformation Program websites, which could make it difficult to find this information.

Many states created advisory groups to provide transparency and accountability for their programs. Most committees host public meetings and upload minutes, recordings, or other materials from the discussions.

But the West Virginia Department of Health won’t share what’s discussed in its rural health advisory panel’s closed-door meetings, according to spokesperson Gailyn Markham.

“The panel is intended to serve as an informal forum for discussion and feedback among invited participants and program staff,” Markham said.

South Dakota, North Dakota, and Mississippi are among the states without advisory committees.

In response to public records requests, South Dakota released a nearly completely redacted version of its budget for the rural health program while Mississippi declined to release its budget.

Mississippi’s governor said he vetoed a transparency-related bill because it would “create an unnecessary layer of bureaucracy” that would have slowed the award process, which could cause the state to lose out on future funds. Mississippi is “an incredible outlier in all this secrecy,” Bryan, the state lawmaker, told KFF Health News.

Sandalow said it’s important for states to publish the impact of their rural health projects, adding that CMS should share which rural health projects are and aren’t working.

She said national and state health organizations are creating networks and holding conferences to help spread this information. States should “be able to learn from each other, get a sense of lessons learned and best practices, and then be able to pivot their initiatives accordingly,” Sandalow said.

Michael Cannon, who oversees health policy studies at the libertarian Cato Institute, said people should know how their $50 billion in taxes is being spent on the rural health program, and whether state projects are making rural patients healthier.

If investors put that much money into a project, there is “no way” they “would let the recipients of those funds get away with the shoddy approach to transparency and accountability that the states are taking,” he said.

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

California is weighing stiff penalties for hospitals and other healthcare entities that don’t stay under state spending limits, potentially levying hundreds of millions of dollars in fines if these providers don’t take steps to rein in rising healthcare costs.

If the state Office of Health Care Affordability adopts the fines next week, hospitals, medical groups, insurers, and others could face penalties that amount to as much as 125% of the total they spend above the state’s annual growth targets.

The penalty proposal comes after healthcare entities in California were asked to limit growth by 3.5% last year and ramp down to 3% by 2029. Seven hospitals that state officials consider particularly expensive face even smaller growth targets: 1.8% in 2026, dropping to 1.6% by 2029.

Consumer advocates argue that state financial deterrents are critical to bring relief to millions of Californians struggling with high insurance premiums and out-of-pocket expenses. Hospitals accounted for 40% of the increase in U.S. health spending from 2022 to 2024, compared with 11% from retail prescription drugs. But adding teeth to those targets sets up a fight with the powerful hospital industry, which has a pending lawsuit challenging the spending limits as unreasonable. Hospitals warned that they will cut back on vital services, including in emergency rooms, obstetrics, and behavioral health.

Healthcare industry representatives said the state affordability office hasn’t accounted for year-to-year volatility or other factors beyond the industry’s control, such as rising minimum wages, state earthquake retrofit requirements, and expensive new drugs.

“They’re building the plane while flying it,” said Ben Johnson, group vice president for financial policy at the California Hospital Association. “We know improvements in affordability are needed, but we have serious questions about how and about what the unintended consequences could be under OHCA’s rather stringent approaches.”

When calculating penalties, California regulators would consider various factors, including a healthcare entity’s financial situation, its market impact, and the gravity and number of offenses, according to a board presentation in June. And entities would first be given opportunities to implement performance improvement plans to bring their spending into line before penalties are imposed. For those that don’t comply, the board is considering penalties of $10,000 a day or a flat $500,000.

The penalties, which the affordability office’s eight-member board is required by state law to adopt, are slated for discussion, and a potential vote, at the board’s Aug. 26 meeting. The soonest healthcare providers would be subject to penalties is 2028, because it’s expected it will take two years to collect and publicly report spending data to measure against the 2026 targets. The state is still collecting data on how entities performed against the 2025 targets, which aren’t enforceable, according to Andrew DiLuccia, a spokesperson for the California Department of Health Care Access and Information.

States Set Targets

California is one of at least eight states that have set spending targets as part of an expanding effort to curb soaring healthcare spending across the nation. Connecticut, Massachusetts, Oregon, and Rhode Island have also authorized the use of some type of financial penalty. The specifics of each vary widely, although so far no state has applied them.

A survey last year by the California Health Care Foundation found that 4 out of 10 state residents said they had medical debt, and 6 in 10 reported that they or a family member had skipped or delayed medical care in the previous 12 months because of cost. Nationwide, about half of adults say it is difficult to afford healthcare costs.

After Rosalyn Book got stiches on her chin, the elementary school teacher received a $15,000 ER bill from a local hospital, despite having insurance. Many teachers in her district leave because they can’t afford the cost of healthcare and insurance premiums, she said.

“The healthcare charges are just insanity, and what we get as patients for the care, it’s not the best either,” said Book, president of the Monterey Bay Teachers Association. “If you’re a working, regular individual in terms of how much you make, the cost of living and especially the healthcare is just not doable.”

Meanwhile, hospitals are warning there’s a risk of more closures. According to Yale University’s Health Care Affordability Lab, 17 hospitals have closed in the state since 2016, compared with only six openings.

Hospitals and other healthcare providers have said the proposed multimillion-dollar penalties are too steep and could destabilize their operations at a time when they’re facing funding challenges, including massive federal cuts to Medicaid, the end of enhanced federal subsidies for Affordable Care Act plans, and a sharp rise in uninsured patients. The One Big Beautiful Bill Act, passed by congressional Republicans and signed by President Donald Trump last summer, is expected to reduce federal Medicaid spending by more than $900 billion — including by $30 billion in California — and increase the rolls of the uninsured in the U.S. by 10 million people over a decade.

Johnson said hospitals raise prices on commercial payers to offset the expense of treating uninsured patients, as well as patients on Medicaid and Medicare, which can reimburse care providers at rates that fall short of treatment costs.

In addition, said Anete Millers, vice president of legal and regulatory affairs at the California Association of Health Plans, tax increases on managed-care plans recently approved by state legislators to offset federal Medicaid cuts will force plans to increase their prices for consumers.

“Some spending pressures originate outside of the control of health plans and are the result of public policy decisions rather than underlying changes in healthcare utilization or efficiency,” she told the affordability office’s board at the June meeting.

Kristof Stremikis, the director of market analysis and insight at the nonprofit California Health Care Foundation, acknowledged that external forces can drive costs but said that plenty of unnecessary spending is within the healthcare system’s control, such as administrative waste and duplicative tests and procedures. Almost 25% of U.S. healthcare spending is considered wasteful, according to research published in JAMA.

Elizabeth Mitchell, a former Office of Health Care Affordability board member whose term ended in May, agreed.

“Every business has external challenges,” said Mitchell, who is now president and CEO of Purchaser Business Group on Health, a nonprofit coalition representing large employers. “The hospital industry has not taken accountability to actually manage costs. I have heard those excuses for decades, and at some point, they have to make changes.”

First Step To Bring Down Costs

An analysis of five states with cost growth benchmarks, published in June, found that some have succeeded in modestly slowing healthcare spending, particularly those with enforcement mechanisms. However, spending growth in most states has still exceeded the targets set. 

Jeremy Vandehey, a consultant with the Peterson-Milbank Program for Sustainable Health Care Costs, said setting benchmarks and collecting data to analyze which entities meet them is only a first step. Armed with information about what and who is driving up costs, states are more empowered to take additional action, such as imposing penalties or regulating prices, to bring down costs, he said.

“I don’t think anybody in any state is declaring victory on healthcare costs, but I wouldn’t say that that means the programs are a failure,” Vandehey said. “In all of these states, there’s much more robust conversations happening about, OK, we haven’t solved our cost crisis, so we need additional action.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

The ongoing debate over the U.S. health system shouldn’t be based on whether the government or the private sector is the dominant player, billionaire entrepreneur Mark Cuban said this week. The bigger issue, he said, is whether the system’s participants are transparent about what they charge and what they pay.

“I’m not opposed to single-payer or universal healthcare at all,” Cuban said Aug. 18 in an interview with KFF Health News. But “when you don’t know all the costs, when there’s no transparency, it’s impossible to determine if it’s a better solution or not,” he said.

Cuban’s remarks came on the heels of primary election victories by progressive supporters of “Medicare for All” — most notably Abdul El-Sayed, who recently clinched the Democratic Senate nomination in Michigan.

The former majority owner of the Dallas Mavericks and a former investor on the hit TV show Shark Tank, Cuban changed the way generic prescription drugs are sold in 2022 by co-founding Mark Cuban Cost Plus Drugs. The website, which posts all its costs and takes a blanket 15% markup, sells thousands of medications, often at deep discounts compared with buying through private insurance plans or self-pay pharmacies.

“We took the transparent path for an industry where there was zero transparency,” Cuban said. “Everybody else prices to the market; we price to what we thought was fair.”

Cuban said that, in thinking about the broader problems facing the U.S. healthcare system, the key is to rebuild trust. “Trust really is a formula,” he said. “Trust equals transparency divided by self-interest.”

One way to build trust, he said, is to give consumers incentives to find the best price for nonemergency health services. Cuban said that means every medical purchase should count toward health insurance deductibles and out-of-pocket maximums, which is not currently the case.

He also advocates breaking up some of the vertically integrated health companies that have grown so large — owning insurers, care providers, and the companies that serve them — that they can dictate their prices. “If you break up these big, huge conglomerates, everything changes. The price of everything drops like a rock,” he said.

But so far, only a few lawmakers have been brave enough to push that goal, Cuban said, citing the Break Up Big Medicine Act co-sponsored by senators Josh Hawley of Missouri, a Republican, and Elizabeth Warren of Massachusetts, a Democrat.

In the end, Cuban said, what matters is not who is running the system but whether all the cards are on the table — in particular, whether the terms of healthcare contracts are public. Whether it’s the government or private businesses doing the negotiating, “if you don’t know how the deals are structured, it’s impossible to negotiate better ones.”

The interview was part of the “How Would You Fix It?” series featuring Julie Rovner, KFF Health News’ chief Washington correspondent and host of the What the Health? podcast.

An abbreviated version of this interview aired Aug. 20 in Episode 460 of What the Health? From KFF Health News: “Headless FDA Gets a New Nominee.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Evelyn Griffin had led a life out of the spotlight until she testified at the Louisiana Statehouse five years ago and experienced what she called her “great awakening.”

The state health department wanted to add covid vaccines to the school immunization schedule, a move no state has ever implemented. Robert F. Kennedy Jr., then known as a leading vaccine skeptic, had already claimed the covid shot was “the deadliest vaccine ever made” during a poster board presentation at the legislative hearing.

Griffin, a longtime OB-GYN, relied on nearly identical images during her own blistering testimony against the proposal. After the hearing, she expected splashy headlines about Kennedy’s assertions, shifting the public debate over covid policies and vaccines. But that did not happen; one news outlet dismissed him as a promulgator of propaganda. Griffin was shocked.

That is “when I saw how the world worked,” she recalled in a podcast interview. Griffin said she and her husband, a vascular surgeon, decided to take action and “shine light on things.”

Now, Kennedy is the nation’s health secretary, and Griffin holds prominent roles that position her to help carry out his vision.

Last September, Kennedy appointed her to ACIP, the advisory panel for federal immunization policy, where she voted to recommend limiting access to covid vaccines and ending universal newborn immunizations for hepatitis B, steps that a federal judge has blocked. In December, Gov. Jeff Landry of Louisiana, a conservative Republican and an ally of President Donald Trump’s, named Griffin as the state’s surgeon general.

That makes her the top public health physician in Louisiana, which has the worst health outcomes among states.

She is an unconventional choice. Griffin has no background or specialty training in infectious diseases or public health. She is aligned with alternative health movements — including Make America Healthy Again, or MAHA — and has hosted some speakers promoting fringe medical views.

Griffin declined interview requests for this article. “My vision as Louisiana’s surgeon general is to help shift our healthcare system toward preventing disease, not just managing or treating it,” she said in a statement.

Eight months into her tenure, she has yet to make major changes at the health department. She has faced hurdles in her efforts to tighten access to vaccines and limit public health powers, testifying on several bills that legislators rejected.

Still, Griffin’s political rise reflects the gains of Kennedy’s vaccine agenda at the state level, a vital testing ground for laws aimed at eroding government mandates. State officials have enormous power to set health policy and beat back infectious disease outbreaks. While Griffin’s post is largely a bully pulpit, she could spur real change by advising the governor, state health secretary, and lawmakers.

Some public health and infectious disease experts warned that if Griffin eventually succeeded in curtailing the state’s authority, illnesses and deaths could escalate and Louisiana could be hamstrung in a future pandemic. At one vaccine panel meeting last year, she said it was “unclear” whether vaccines were linked to autism, as Kennedy has suggested. When asked by The New York Times, she declined to say whether she believed any vaccines should be mandated for schoolchildren.

“Someone who has expressed the views she has, who’s now in a public policy position, is very dangerous,” said Georges Benjamin, the chief executive of the American Public Health Association.

But Kirk Milhoan, a pastor and pediatric cardiologist who serves as chair of the federal vaccine panel, defended Griffin as an “excellent choice” for surgeon general. “No one should be afraid of Dr. Evelyn Griffin having the heart’s desire to take care of the population of Louisiana,” he said in an interview.

While Griffin is on a learning curve as a political novice, she has signaled big ambitions.

She called for “dramatic transformational change” during a public meeting in January, promising to focus on women’s health, rural health, and the root causes of disease. An accompanying slide presentation said Louisiana would lead through “family, faith, and fearlessness.”

Griffin, 49, often cites her family background in explaining her trajectory.

She was born Ewelina Bulczynski under Communist rule in Poland in 1976. When she was 5, her family defected to a refugee camp in Austria before immigrating to Canada. She and her two brothers later came to the United States to practice as physicians. She has credited this history with giving her a “different perspective” as a doctor and influencing her skepticism of government mandates.

“My parents escaped Communist Poland so that we could come here for the freedoms, such as medical freedom, that this country has,” she told Louisiana lawmakers in 2022.

Evelyn Griffin, Louisiana’s surgeon general, and her husband, Joseph Griffin, attend a wellness event sponsored by the Northshore Alternative Health Alliance in Mandeville, Louisiana, in June. (Christiana Botic for The New York Times)

She met her husband, Joseph Griffin, while they attended Ross University School of Medicine, then located in Dominica. After residency programs in New Orleans, they settled in Baton Rouge and raised two children.

People who have known Griffin during her 20-year career delivering babies and treating women described her as a kind, caring, and smart physician. “Patients loved her,” said Francis Dauterive, who worked with her.

In the years before the pandemic, Griffin had noticed a rise in chronic health problems among her patients. She began studying how nutrition and lifestyle choices could treat and prevent illness, and pursued online training in functional medicine. She started an Instagram account filled with images of jackfruit sloppy Joes and vegan jambalaya, her dog lounging on a yoga mat, and her backyard strawberry plants.

She also learned of Barbara O’Neill, a Christian wellness figure popular on social media. O’Neill was barred in 2019 from giving medical advice in Australia after claiming that cancer was caused by a fungus and could be treated with baking soda, and that vaccines caused “an epidemic of ADHD, autism, epilepsy and cot death.” In a 2025 podcast, Griffin called O’Neill a “sage” teacher who was ostracized for focusing on lifestyle solutions to medical issues. She said she kept O’Neill’s advice for a healthy life — including exercise, sunshine, and trust in God — posted on her fridge.

But it was the pandemic that transformed her career. In speeches and interviews, she said she began to question public health guidance and that of her former employer, Ochsner Health, Louisiana’s largest health system, on masking, vaccines, and mandates.

Griffin wanted to share research with colleagues that wasn’t “mainstream” science, as she put it, studies she said were from contacts in Europe on early covid treatments. Griffin was repeatedly rebuffed, she said.

Eventually, she resigned. “I’m going to stick to my principles,” she later recalled thinking. She now works at the Baton Rouge General health system. Ochsner officials declined to comment.

Louisiana had been hit hard by the pandemic. By December 2021, more than 14,000 people had died from covid. That summer, the Delta surge had killed six pregnant women there over two months, and maternal health organizations were urging vaccination.

But in her testimony to lawmakers that December, Griffin had questioned the vaccine’s safety after health officials had reported rare adverse reactions. She invoked a public health catastrophe: The drug thalidomide, prescribed during pregnancy in Europe (and tested in the United States) in the 1950s, had left thousands of babies with missing or malformed limbs. She also reminded lawmakers of the Nuremberg trials, where Nazi collaborators had been sentenced to death for medical experimentation.

“So everyone has to be on notice when making these types of decisions,” Griffin said, looking at the politicians. The state later dropped plans to require covid vaccines for students.

Griffin and her husband have since embedded themselves in Louisiana’s right-leaning alternative health communities. They have espoused views that, amid the swirl of social-media-fueled wellness trends, pandemic backlash, and widespread dismay over Americans’ poor health, have become ascendant in the second Trump presidency.

Jay Luneau (top center), a Democrat in Louisiana’s Senate, questions Griffin in May about a bill to prohibit businesses and schools from mandating new vaccines or other medical interventions. (Christiana Botic for The New York Times)

Griffin returned to the state Capitol over the next three years to testify for favored causes, including bills supported by Health Freedom Louisiana, a group aligned with Kennedy. One would have expanded access to ivermectin, an antiparasitic drug popular among vaccine skeptics, though numerous studies have shown it is ineffective in treating covid, and another would have banned future government health mandates, which Griffin has called “a slippery slope.” Neither got out of committee. She also testified in support of a ban on gender-transition treatments for minors, which became law.

After the U.S. Supreme Court overturned Roe v. Wade in 2022 and Louisiana’s near-total abortion ban took effect, Griffin became an ally of Louisiana Right to Life, the state’s leading anti-abortion group. She recorded videos arguing that the law did not impede pregnancy care. The ban was later found to delay miscarriage treatment and lead to unnecessary cesarean sections, according to doctors and reproductive rights groups.

Griffin and her husband struck up a friendship with Tony Spell, the pastor of Life Tabernacle Church in Baton Rouge, sometimes joining him for Bible study. Pastor Spell refused to shut his evangelical church during the pandemic, leading to criminal charges that were overturned by the Louisiana Supreme Court. Griffin called him “an absolute hero.”

Benjamin Clapper, executive director of Louisiana Right to Life (center left), speaks to Griffin at the Louisiana Capitol in May. (Christiana Botic for The New York Times) Tony Spell, the pastor at Life Tabernacle Church in Baton Rouge, is friends with Griffin and her husband. (Christiana Botic for The New York Times)

She has spoken at annual health freedom gatherings on the church’s sprawling grounds and launched her own wellness events there two years ago. Guests have talked about backyard gardening, naturopathic medicine, the benefits of doulas and raw milk — a passion of Kennedy’s — which recently sickened nearly a dozen Louisiana residents.

One speaker, an OB-GYN, said contraception encouraged abortion. Another, an ophthalmologist, questioned the safety of wireless technology, as has Griffin. Quoting O’Neill, the Australian wellness figure, Griffin warned the crowd to “stay away from sunscreen,” adding there were “lots and lots of chemicals” in it.

Spirituality is “the foundation for health,” she said during the event in 2025, and some of her speakers have presented faith in Jesus as essential to being healthy. At the 2024 gathering, Sean Troxclair, an internist who is now her deputy, said that when he was “injured” by a vaccine, “I got with Jesus.” He added, “If you’re not with him, no matter what you do, you’re not going to get better.”

In written comments to the Times, Griffin said that faith was not a prerequisite for good health, and that she “may not share every perspective presented” by her speakers.

Griffin’s appointment is among Gov. Landry’s wider efforts to move Louisiana, already a deeply red state, further to the right. He has supported a crackdown on doctors who mail abortion pills to Louisiana patients and a lawsuit against the Food and Drug Administration to stop the practice nationwide. The U.S. Supreme Court said the pills could still be sent by mail while the FDA case continues in the lower courts.

The governor’s first appointee as surgeon general, Ralph Abraham, another supporter of Kennedy’s, blocked his staff from promoting any vaccines amid an outbreak of whooping cough that killed two babies.

Griffin has begun her tenure more quietly, seeking ties with the state’s medical community while trying to find her place in a health department hierarchy where the secretary still wields much of the power.

Griffin and her deputy, Sean Troxclair (right), attend a women’s wellness event at the Louisiana Capitol in May. (Christiana Botic for The New York Times)

For her staff, she’s recruited figures from wellness and vaccine-skeptical circles, including Troxclair and Kathleen Willis, an internist who has questioned the safety of the childhood vaccine schedule, as has Trump.

A surprising presence in the department is Griffin’s husband, whom she’s called “like-minded.” Though he is not employed by the agency, he has joined her appointments with state and federal officials and participated in department meetings, sometimes providing feedback or asking questions, according to two people present at the sessions. Griffin has also placed him on a Medicaid advisory subcommittee. Griffin said in a statement that he was “not involved in formal decision-making.”

Bruce Greenstein, the state health secretary, introduced the couple during a public meeting in January, saying, “We basically get two doctors for the price of one.” In May, Griffin’s husband joined the governor on a contentious trip to Greenland, which Trump has periodically threatened to control.

Griffin’s beliefs represent a shift away from public health policies that prioritize the protection of the wider community in favor of ones that prioritize individual choice. Like Kennedy, she has said this is necessary to restore faith in public health systems battered by the anger over pandemic restrictions.

Such a reframing of the government’s role would upend long-standing public health principles and risk harming society’s most vulnerable, said Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

“Are we in no way responsible for people who we are going to sit next to on a bus or get into a crowded elevator?” he asked. “Do we have no sense of responsibility to other members of society?”

Florida’s former health secretary and surgeon general, Scott Rivkees, whose successor tried to roll back vaccine mandates, said rising vaccine skepticism was already contributing to outbreaks of measles and whooping cough. “This is something that our country will regret as we start seeing our sons, daughters, neighbors, friends, cousins, pay the price,” he said in an interview.

Even though Griffin has allied herself with some lawmakers in the Republican-controlled legislature, she testified on three bills this year that failed to proceed. One would have created new informed-consent requirements for vaccines — including banning mothers from agreeing to vaccines for 12 hours after giving birth, when Griffin said hormones and other factors could impede their thinking.

Another would have significantly limited the government’s ability to require vaccines, testing, or masks in a future outbreak, mandates that Griffin testified infringed on individual rights and were discriminatory. A third bill, her own proposal, would have given her office sweeping access to all medical records in the state, which are now protected by medical privacy laws.

Gov. Landry did not publicly push for the measures, a sign that they may not be priorities for his administration. A majority of Louisiana voters support school vaccine mandates, according to polls by Louisiana Families for Vaccines and the Center for Individual Freedom. Most proposals to weaken vaccine laws also failed in other states this year.

Since her appointment, Griffin has traveled the state to meet with residents. In June, she and her husband wandered through a wellness event, sponsored by the Northshore Alternative Health Alliance, in Mandeville. She had been invited to give the keynote address by Abigail Licatino, a member of Health Freedom Louisiana who has said that vaccines cause “most” autism.

Booths featured local farmers, reiki practitioners, functional medicine doctors, chiropractors, spiritual healers, and purveyors of peptides, supplements, and IV treatments. The event represented some of the “holistic approaches” Griffin said she planned to highlight as surgeon general.

In speeches before her appointment, Griffin had offered a far-reaching vision. While conventional medicine would still play an indispensable role, she said, the current health system was failing Americans and would “collapse.” The health freedom and wellness movements would help show “the path forward.”

The New York Times’ Kitty Bennett, Sheelagh McNeill, and Kirsten Noyes contributed research for this article.

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Heidi Overton, a physician and White House domestic policy adviser, is President Donald Trump’s choice to be the next head of the Food and Drug Administration. Overton, an abortion opponent and supporter of Trump’s proposed changes to the childhood vaccine schedule, has made enemies while working on health policy from the White House and could face some tough questioning from senators.

Meanwhile, prescription drug prices are dropping for some people, and the wholesale retailer Costco is entering the Medicare market. Still, overall, the problem of healthcare being too expensive remains stubbornly hard to solve.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• Trump’s selection of Overton to lead the FDA is prompting concerns from a diverse crowd of skeptics that includes Sen. Bill Cassidy (R-La.) and adherents to the Make America Healthy Again movement. Her lack of managerial experience and history of controversial writings could be liabilities during the confirmation process, though Trump has a decent track record of clearing nominees through a hesitant Senate.
• Grant money continues to be held up at the National Institutes of Health pending political reviews, and new reporting sheds light on “zombie programs” at the Centers for Disease Control and Prevention, where money has been appropriated but there’s no staff to use it. Plus, the trend of declining childhood immunizations continues, with vaccine exemptions for kindergartners jumping to another high.
• New data shows the largest drop in prescription drug prices since the 1960s, and while the Trump administration is taking credit, it’s unclear what exactly caused it. Meanwhile, the federal government is investigating major health companies for allegedly dodging taxes or engaging in anticompetitive practices. And the wholesaler Costco is getting into the health insurance game, partnering with a nonprofit insurer to provide Medicare Advantage or Medigap plans in a few states.

Also this week, as part of the “How Would You Fix It?” series, Rovner interviews billionaire businessman Mark Cuban, who has already reshaped the generic drug market and now has his eye on the rest of the healthcare system.

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

Julie Rovner: Mother Jones’ “The Orwellian Company Behind ICE’s New Electric Shock Gloves,” by Sophie Hurwitz.

Shefali Luthra: The 19th’s “TikTok’s Fake GLP-1 Market Preys on Women Trying To Lose Weight,” by Barbara Rodriguez.

Alice Miranda Ollstein: The Texas Observer’s “Texas Maternal Mortality Committee’s Next Report Will Skip Post-‘Roe’ Deaths. Lawmakers Suspect Political Influence,” by Mary Tuma.

Joanne Kenen: Politico’s “AI Slop Is Swamping a House Office That Drafts US Laws,” by Owen Dahlkamp.

Also mentioned in this week’s podcast:

• NOTUS’ “‘Graveyard for Grants’: NIH Is Holding Up Medical Research Funding,” by Paige Winfield Cunningham.
• The Associated Press’ “The CDC Has Zombie Programs. Congress Funds Them, but Few People Are Left To Do the Work,” by Mike Stobbe.
• KFF Health News’ “Kennedy’s Quiet Hunt for Autism Culprits Stalls as Trump Orders Baseless Changes to Childhood Shots,” by Amanda Seitz and Stephanie Armour.
• The Wall Street Journal’s “Costco Sells Vacations, Gas and, Soon, Medicare Plans,” by Anna Wilde Mathews.
• Stat’s “Epic’s Alleged Anticompetitive Practices Under Scrutiny From Federal, State Investigators,” by Casey Ross and Brittany Trang.
• Stat’s “UnitedHealth Faces IRS Probe Over Potential Tax Avoidance,” by Bob Herman.

Click to open the transcript Transcript: Headless FDA Gets a New Nominee

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

Julie Rovner: Hello, from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Aug. 20, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have another “How Would You Fix It?” interview, from his car, with businessman and entrepreneur Mark Cuban, who’s now devoting most of his professional attention to the mess that is U.S. healthcare. But first, this week’s news. So, we finally have a nominee to lead the Food and Drug Administration, which has been without a Senate-confirmed commissioner since Marty Makary resigned in May — officially, over a dispute about flavored vapes. The winner of the search is Heidi Overton, a 37-year-old physician and former protégé of Makary’s from Johns Hopkins, who currently oversees the health portfolio at the White House Domestic Policy Council. What do we know about Dr. Overton, and what are her prospects for confirmation? We’ve already seen HELP [Health, Education, Labor, and Pensions] Committee Chairman Bill Cassidy say on social media that he has “concerns” about her, but he’s voted for nominees about whom he’s had concerns as recently as — checks notes — earlier this month. 

Kenen: I mean, Cassidy’s saying he has concerns is not indicative of where this ends up. At the end of the day, President [Donald] Trump has gotten most of his choices through a Senate that often begins hesitant to recalcitrant and usually gives him what he wants. So … sometimes it doesn’t. I mean, it’s not 100%. So, Cassidy is in a different position politically since he’s about to leave the Senate, and partly because President Trump. So we just don’t know where Cassidy is. But it’s not a great start. But it doesn’t mean … it’s the end. 

Rovner: What do we know about Heidi Overton, though? Everything I’ve read about her, she’s either pro-MAHA [Make America Healthy Again] or the MAHA people don’t like her, or she’s, you know, of Marty Makary or not of Marty McCarry. 

Ollstein: Yeah. So my colleagues and I wrote about this yesterday, and a lot of the leading MAHA activists view her as having been a roadblock in the White House to their efforts around pesticides, around vaccines, and other things, and so they are up in arms about the pick. They are, you know, saying she’s … part of the swamp and not part of, you know, the movement that they want to see sweep aside some of these government practices. And I think that her time in the White House and her previous work for the America First Policy Institute could really come back to haunt her. She wrote a lot of papers and op-eds with some controversial takes and policy positions, and I think everybody is sort of scrambling to go over that. People are also talking about her lack of managerial experience. You know, managing a huge agency with a huge staff, and you know, obviously, we have seen recent examples of people who lack that experience being appointed. So that’s also not a deal-breaker necessarily. But all of these things could add up to be problematic for her in the confirmation process. And then what I focused on was her anti-abortion record, which, you know, both could help and hurt her depending on whose votes we’re talking about. 

Rovner: That’s right. I mean, we saw [Sen.] Patty Murray, senior member of the HELP Committee, come out and, you know, and say, Not somebody that I could ever vote for. And also, I mean, she was at the signing of the vaccine executive order that the president had. So that puts her — whether, whatever she says in her confirmation hearings — that sort of puts her with the “Let’s change the vaccine schedule” group. I mean, she seems to fit in nowhere. I guess that’s sort of my question here. 

Luthra: That’s what’s so interesting about her is that there are these sorts of different interests and constituencies that have concerns about her, but sometimes they feel as if they could be contradictory. You obviously have, I mean, Patty Murray — I don’t know if she was ever going to vote for whoever Trump picked — but then you have Susan Collins in a very difficult reelection race, where abortion is a concern. You now have these concerns about vaccines. You have people saying maybe she’s not MAHA enough. And I mean, I think to Joanne’s point, Trump has gotten most people he has wanted. However, this does feel like this could get very complicated, just given how many people may be bringing different criticism from different vantages that could ultimately add up. 

Kenen: I’m not sure we’ve ever seen anything on the Senate floor where she’s going to be called anti-abortion and pro-pesticide. If it gets to the floor, I mean, it’s a weird one. But at the end of the day, you know, does it go through? You know, if you made me bet, my bet would be yes, but I wouldn’t want to bet a whole lot of money. 

Rovner: Well … we’re going to talk about reproductive health later in the podcast, but I do want to talk about abortion right now in the context of this nomination because, Alice, as you point out, Overton is known to be a fairly strident abortion opponent, and if she is confirmed, she’ll take over the study of the safety of the abortion pill mifepristone, which, as we have mentioned many, many, many times, the administration has sort of backbenched, if you will. Given that the new attorney general, Todd Blanche, has raised the specter of invoking the 1873 Comstock Act to bar the mailing of abortion pills, or anything else used for abortions, what is the outlook for medication abortion if Overton actually becomes the FDA commissioner? 

Ollstein: Well, it’s hard to say because we’ve really seen decision-making centralized in the White House, and so often it doesn’t matter what the Cabinet secretaries want to do. It’s about what the White House wants. And the White House, I think, has made it pretty clear that this is not a top, you know, restricting abortion is not a top priority for them. They are certainly sensitive to the politics of it, and so there is speculation that, you know, there’s a delay until after the midterms for anything meaningful on this front, so as not to risk the kind of backlash we saw in 2022 after the fall of Roe v. Wade. But I think it’s also pretty clear that this is just not a top priority for the White House. That doesn’t mean they won’t allow some of these, you know, former activists to do what they want to do — so Blanche, and now Overton potentially. But I think it’s not really a given either way. 

Rovner: Yeah. All right. Well, meanwhile, in administration news that we’ve talked about before but is still relevant, we’re just over a month from the end of the fiscal year, and grant money is still being held up at the National Institutes of Health, according to our podcast pal Paige [Winfield] Cunningham at NOTUS. Despite pressure from Congress, the agency is still delaying funds for already-approved grants while it conducts searches for keywords that could signal that the grant does not adhere to the administration’s political priorities. And it’s not just keywords. Reading from Paige’s story: “In multiple flagged grants, officials expressed concerns that they weren’t worth funding because their only practical use might be to support the writing of new laws.” Now, this is going on against the backdrop of a proposal from the Office of Management and Budget that would officially insert political approval into grant funding. That’s something the Senate has voted to at least temporarily block, but the House hasn’t weighed in on it yet. This could not only have huge implications for federally funded research going forward, but you could argue it’s having implications now. We’re seeing researchers, you know, taking opportunities overseas because they don’t know what their, you know, grant funding continuation is going to look like, and students not going to graduate school or not pursuing research careers. I mean, this is … even some of these sort of small things are having these bigger potential ripples as they go outward, right? 

Kenen: Colleagues who are grant-funded, NIH-funded, or other government-funded. I mean, they try to track the ever-changing rules. First of all, it’s very murky. It is changing. They keep adding things. Basically, they don’t want — not just the banned words — they don’t want research that can be bad, that can be used for policy …  

Rovner: For things they disagree with, for policies they disagree with. 

Kenen: They don’t say it … right. Guidance doesn’t come out and say “policy that you know we don’t like.” It just says “policy.” But it’s really vast and confusing. It’s not new. What Paige wrote about is an update. I mean, this is still happening. It’s been happening since the beginning of the Trump administration. NIH is the biggie. There are some smaller agencies, like Agency for Healthcare Quality and Research [sic], AHRQ, right? 

Rovner: Research and Quality. 

Kenen: Agency for Healthcare Research and Quality. That’s pretty much defunct now. But those grants, the money stopped going out the door many months ago. So …  

Rovner: And the National Science Foundation. I mean, NIH is sort of the biggest of them. Yeah. 

Kenen: It has to have the word “science.” … NIH is the biggie, right? I mean, and it’s also the bench science, the science that the drug industry … people don’t understand, they say, Let the drug industry do it. They can’t do this kind of basic bench research. They take this research and develop drugs, but the fundamental cellular level is NIH, or NIH-funded. And it’s really, I mean, clinical trials have been stopped in the middle — really promising research that is not partisan. … Disease doesn’t care. It’s cliché, and it’s also true. It just stopped, and work has been lost. But people haven’t done things that are several years in. … The deadline, also, for fiscal year spending is, if it’s not out the door, which is Sept 30, anything that’s out that door is, like, that’s done. It’s it. Bye-bye. The money isn’t gonna, unless it would go through a whole new process next year, which is unlikely in these grants, that’s the end of that. 

Rovner: Yeah, and that’s, I mean, my point in wanting to bring this up again — and you’re right, it is sort of an update of what we’ve seen — is that every time one of these top administration officials comes to Congress, they say, You’re supposed to be spending the money that we have appropriated, and they say, Oh yeah, not a problem. We’re going to spend the money that you’ve appropriated. And yet we keep seeing these stories that they are not spending money that Congress has appropriated. 

Kenen: Yeah, and historically NIH has been reasonably bipartisan. There have been years when there have been fights. There’s obviously stem cells and sort of certain issues have been, you know, very hot potato. But the basic enterprise of U.S. science, health science, has been largely bipartisan. Again, not every appropriation season, not every bill. But if you look at the overall arc, it’s bipartisan. 

Rovner: It was Republicans who doubled NIH funding in the 1990s — who led it.  

Kenen: [Arlen] Specter. 

Rovner: It was Newt Gingrich, actually. I mean. 

Kenen: Yeah, Gingrich, too, was very into health tech and things like that before his time. I mean, the War on Cancer was federal, right? That was [President Richard] Nixon. So, but we’re now in a …  

Rovner: Different place. 

Kenen: Yeah, frozen. 

Rovner: Yeah. Meanwhile, Mike Stobbe at the AP is reporting on so-called zombie programs at the Centers for Disease Control and Prevention — again, where money’s been appropriated, but there is literally nobody at home. At the agency’s Office on Smoking and Health, and offices on Alzheimer’s disease, epilepsy, and sickle cell data collection, funds are allocated, but all the staffers have either been laid off or are still on administrative leave. So they’re being paid, but they are banned from working. This is yet another immediate challenge for new CDC Director Erica Schwartz, who had her first meeting with CDC staff yesterday. What do we expect her to take on first? 

Luthra: I don’t envy her. It, frankly, seems very difficult to figure out what your priorities are or should be, if you perhaps don’t have staff. It does seem like, from the reporting, perhaps a priority that she has outlined might be morale. And we know that morale has been very low in a lot of government agencies and the executive — especially places like the CDC, where you have a lot of career people who are mission-oriented, really believe in doing things for public health, and have seen that really attacked. And so I don’t know if that is enough to actually translate into things that are supposed to happen actually happening. But that seems like probably a place where it makes sense to start, right?, is just to help people feel confident that they actually will be able to do the work that they signed up to do. 

Rovner: Yeah, and you know, as you say, CDC is perhaps the most mission-oriented of all the HHS agencies. And because they’re in Atlanta, and you know not in the Washington area the way most of the rest of HHS is, they do often feel cut off. So she does have … she has a lot on her plate. And speaking of the CDC, the agency put out a rather cryptic press release this week on vaccine uptake among kindergartners entering school, noting that “CDC continues to encourage parents to discuss vaccination options with their doctors.” Meanwhile, the data linked to in the press release shows a small increase in parents opting out of having their children vaccinated nationwide. But that masks a much larger increase in some states. In Idaho, for example, just 75% of kindergartners entering school have had the MMR [measles, mumps, and rubella] vaccine. That’s obviously well below the 95% needed to provide herd immunity for measles. As my friend Jonathan Cohn put it in his piece for The Bulwark. “The scientific term for that is yikes.” Yikes indeed. 

Kenen: And it’s even within states … and some rural counties … there’s a lot of variation. The trend … for a number of years now has been dropping vaccine rates. Period. So I mean, whether CDC wants to engage in this as their first issue, they’re going to be asked about it. … They track it … can’t avoid it, because they have to approve and recommend, and, you know, insurance coverage, all sorts of things are imminent. So decisions have to be made. … Back to school’s already started in some parts of the country. 

Rovner: And so … I would say new CDC Director Schwartz was rather pointedly not in the room when the president signed the executive order on vaccines, even though now-FDA nominee Heidi Overton was. 

Kenen: She cannot put her head in the sand on this one. She’s going to have to … 

Rovner: “She” Schwartz?  

Kenen: Yeah. So she’s she says, I mean, what we know so far is she’s been quite, you know, she went to the CDC, and the reports are that she came out and said, you know, I’m going to stick to the science, and the science supports vaccines.  

Ollstein: I thought what was really interesting about the recent reports is that, you know, the executive order the Trump administration signed doesn’t actually change anything legally, but it’s designed to put pressure on states to change their recommendations. And it’s been fascinating to me to see that even the reddest states really aren’t going for it yet. But that doesn’t mean that everything’s fine and everyone’s getting vaccinated. What we are seeing is, you know, individual parents making these moves away from vaccination. And so even without the state officially changing its requirements, the environment is just shifting, and using the bully pulpit in this way is changing people’s behavior — building on trends that were already happening: distrust and misinformation, and all of that. And so … even a small, small decline in the vaccination rate can have huge negative effects. I mean, the difference between having 97% vaccination vs. 91% — it may not seem like a big deal, but that’s the difference between herd immunity and people really being vulnerable. 

Rovner: And lots and lots more cases of measles, as we are seeing already this year. I mean, it’s, you know, talk about things that were completely predictable. Well, meanwhile, as my KFF Health News colleagues Amanda Seitz and Stephanie Armour point out this week, all of this public pronouncing by the president and other health officials about the supposed dangers of vaccines comes as HHS Secretary RFK Jr. blows past deadline after deadline to uncover the promised cause of the rising cases of autism. The story notes that the secretary “has spent millions of taxpayer dollars looking for root causes in a research effort that’s offered no public status updates and few details about who, or even which agency, is leading the effort.” We do know that one of the people working on the project is Reyn Archer — he’s a noted vaccine critic, son of a former House Ways and Means Committee chairman, and was head of the Title X Family Planning Program during the George H.W. Bush administration in the early 1990s — even as he was publicly opposing legalized birth control, which of course is what the Title X program does. He later served as Texas’ state health commissioner under then-Gov. George W. Bush, although he was eventually fired for making racist remarks to a subordinate. I had not heard his name since, until now. But he’s going to uncover the root causes of autism, am I right? That’s the plan? 

Kenen: More power to him. I mean, autism. It’s not like there’s no research, and the conclusion is that it’s multi-causal. That there’s not one cause. That’s the current state of the science, which can always evolve. But the current belief is there’s probably a genetic component, but it’s a mix of factors that we don’t fully understand. But vaccines is not one of them. 

Rovner: Or at least so every study, every big study, we have seen continues to say. Well, moving on, lots of news about healthcare prices this week, which remain a pressing issue for both Republican and Democratic voters as the midterms draw near. One interesting story this week noted that prescription drug prices fell year over year by more than 3% — that’s the largest drop since the early 1960s — but it’s not entirely clear why. The Trump administration, of course, says it was their efforts, particularly to bring down the price of those popular but very expensive GLP-1 weight loss drugs. Analysts say it’s more likely the result of the Biden-era Medicare drug price negotiations, which involved more widely used medications. Whichever, I imagine if you’re not seeing your prices drop at the pharmacy, and those drops may well be absorbed by insurers and middlemen and all the people we talk about, will this good news even have much of an impact when people go to the polls? 

Luthra: I can’t imagine it necessarily would be that meaningful because overall the macro trends remain pretty bad. Health insurance is still getting very expensive. Employers are really struggling — those that offer it — they are largely passing more costs to consumers. And so people are getting to have to pay more for healthcare, even if their drug prices may be decreasing in the aggregate. And so it’s just hard to really suggest that this good news could really outweigh those other factors, especially when you think about the broader sort of angst that exists around costs and costs continuing to go up. 

Rovner: Yeah, well, in wonky news that could actually have a larger impact on what people pay for medical care, the Trump administration is actually going after some deep-pocketed healthcare providers. Stat News reports, in separate stories, first that the Internal Revenue Service is investigating UnitedHealth Group — that’s the parent of UnitedHealthcare, the insurer, and Optum, the services and tech arm — for allegedly underpaying taxes by funneling money through a foreign subsidiary. And second, the Federal Trade Commission is investigating medical records behemoth Epic Systems for potential antitrust violations. State attorneys general are also looking at Epic’s alleged anticompetitive practices. Cracking down on some of the monopolistic practices of the largest payers in the healthcare system actually could end up saving the system money, right? I mean, this was … something that we saw a fair bit of during the Biden administration, particularly from the Federal Trade Commission, and not so much of during the Trump administration, which has seemed to have been more favorable, if you will, to big companies. 

Luthra: I guess there’s still that question about providers, and obviously bringing down prices and addressing consolidation in payers, amongst things like electronic health record companies, can be effective, but we probably also would want to see meaningful movement in terms of provider consolidation as well, and that just seems potentially like a bigger hill to climb. 

Rovner: But this is a start. One would say, particularly this administration, going after United, which is sort of the the biggest … United’s power threatens the federal government’s bargaining power at this point. I was interested to see, you know, this story, if nothing else, made public, because obviously somebody leaked it. We will see how these all shake out. Well, finally, Costco, home of the cheap rotisserie chicken and the $1.50 hot dog and soda, is entering the Medicare market, reports The Wall Street Journal. According to the Journal, Costco will partner with the nonprofit SCAN Group to offer Medicare Advantage plans in two states and a Medicare supplement, Medigap, plan in a third state. Could this eventually make a dent in the private Medicare market? Costco already does big business selling discount prescription drugs, eyeglasses, and hearing aids. I get my dog’s flea and tick medication at Costco. It costs half of what it does at my vet’s office. One presumes this could be, you know, a leader. We’ve not seen this before, right? 

Kenen: The head of SCAN, which is a pretty reputable insurance company … 

Rovner: Nonprofit insurance company. 

Kenen: Nonprofit insurance, and I should say I know … personally the current CEO, president, whatever his post is. I mean, but you know, I’ve written a lot about aging over the years, and it’s basically considered … one of the higher-quality, more reliable elderly-focused health plans. And he has something interesting to write when he announced it or wrote about on LinkedIn about how he personally, like, is a big Costco guy. But he talked about trust, which we’re all talking all the time about how there’s a lack of trust in healthcare. There’s a lot of trust in Costco, and he talked about how branding, SCAN, and Costco, you know … obviously it’s a business decision he made, but he’s also, like, this big Costco guy and who worries — I know him through conferences on trust, actually, that’s where I met him — and he’s thinking, OK, Costco, in addition to, like, giving you way too much of whatever it is you thought you needed, it can also fix the trust crisis in America. Right? 

Rovner: Hey! 

Kenen: And they’re efficient, right? I mean, I don’t know if all four of us are Costco people, but the, you know … 

Rovner: I am. 

Kenen: I saw her. I ran into her buying her veterinarian [unintelligible, through laughter] … I was in the photo section. … It is a trusted brand, and it’s an interesting — and they have national reach in there, you know. 

Rovner: And you will hear in my conversation with Mark Cuban that trust is a really big deal in healthcare right now. I mean, we obviously talk about this every week. I mean, I’m, obviously this is a very small step, but I’m really interested in where it turns out. 

Kenen: It’s a smart business move, and it’s a talker, too. Like, people are gonna see this headline and pay attention to it because it’s, like, just a thing. 

Rovner: Yeah, it is. All right, we’re going to take a quick break. We will be right back. 

So, a good bit of reproductive health news this week. Glad to have both Alice and Shefali here. We will start in Idaho, where a federal district court judge ruled that the state’s abortion ban cannot be used to prosecute doctors who perform abortions to protect the pregnant person’s health, not just her life. Of course, abortion opponents vehemently oppose health exceptions, as they’re called, because they say health includes mental health, and that becomes a loophole so big that it basically eviscerates the ban. The state’s attorney general, former congressman Raúl Labrador, said he would appeal and was confident the decision would be overturned. I would imagine that he’s probably right. Is the Supreme Court eventually going to have to spell this out? I wouldn’t be that surprised if they wanted to. 

Ollstein: I think this gets into some of the same EMTALA [Emergency Medical Treatment and Active Labor Act] territory, where we have seen the Supreme Court sort of back away from in recent years. But again, we just keep circling around and around the same question, which is, when is an abortion OK for a medical emergency purpose? How close to dying does a woman have to get before a doctor can perform an abortion? And we’ve seen again and again in Idaho that doctors are scared and confused, and even when they think that they should have the right to perform the procedure, you know, they’re still putting women on these dangerous life flights to other states in order to get care, leading to hours and hours of delays and potential complications. And so, you know, this court case and this court ruling was sort of aimed at clarifying that and giving doctors the confidence to be able to intervene when they feel it’s medically necessary. But now we’re seeing the state challenge that, and we’re just going around and around. And, you know, there have been similar cases in other states, just a whole mix of rulings, one way or the other, and that just creates more of a patchwork where, you know, some somebody’s ability to get care varies completely between states — and even within states, between hospitals, based on how much you know institutional backing doctors feel like they have. You know, will their hospital’s lawyers go to the mat for them or not? Do they work in a private practice vs. a big hospital system? All of these things come into play, 

Rovner: And, of course, we’ve also seen doctors, particularly in Idaho, leaving the state because they’re afraid that they can’t practice. I mean, they can’t adequately care for their patients. Shefali, I see you nodding. 

Luthra: Yeah, and what’s interesting about this case, other than the fact that Idaho will actually have an abortion ballot measure this November, is that we do have a federal judge here saying, in particular contexts, I see a right to an abortion. And I was talking to some abortion legal scholars about this, and they made the point that, in a way, this runs afoul of the Dobbs decision, because you do have a federal judge saying people are actually entitled to abortions, and that is a right that they have, even if it is much narrower than what Roe v. Wade guaranteed. And obviously, this is going to be appealed. This is going to continue to be litigated. We may not see immediate change for people’s ability to get healthcare in Idaho or other places with very strict bans, but it does underscore how unsettled these legal questions remain — how there remains a lot of debate over whether Dobbs was actually a correct interpretation of constitutional law. And I think it really takes us back to the argument we heard from some of the conservative majority that this would now settle every question about abortion. Obviously, it has not. Obviously, many more questions will continue to be argued and litigated in the courts. 

Rovner: Yeah. Well, meanwhile, in other breaking news, a federal judge here in Washington blocked the Trump administration’s changes to the teen pregnancy prevention program that funds classes on contraception and abstinence, among other things. But they’re still not necessarily getting the money appropriated by Congress, right, Alice? 

Ollstein: So a judge in D.C. is blocking the administration from using its very strict new guidance going forward when it doles out money for the program, but it’s not ordering the administration to give back the money that was already cut earlier this summer from all of these grantees around the country. And, by the way, the money was cut both from grantees like Planned Parenthood, where you would say, “Oh, well, that sort of makes sense that the administration would go after their money.” But they’re also cutting funding from, you know, faith-based programs, abstinence-only programs in very red states, and prompting a fair amount of backlash that I’ve been covering. You know, places like Texas and South Carolina and West Virginia have also lost funding. And, of course, all the programs in those states had to abide by state restrictions around what can be taught. And so they were already following these very conservative guidelines. But that’s not conservative enough for the administration, which put out this guidance saying, you know, while abstinence-only was an option before, now it is basically mandatory. And so that guidance is on hold, but, again, the judge said that he didn’t know if he had the authority to order them to give back the money, or if some other jurisdiction could handle that. And so, this is just a preliminary injunction, which means there’s going to be months and months of litigation going forward. 

Rovner: Finally, this week, a story from the “Who Could Ever Have Imagined This?” files: A California couple hired a surrogate in Alaska to carry their pregnancy. After the fetus was diagnosed with a life-threatening heart condition, the couple exercised their option in the surrogacy contract to terminate the pregnancy. But the surrogate refused to have an abortion, and she traveled to Texas, where abortion is illegal, and gave birth to a baby boy last week. News reports say the baby, who is now in the custody of the couple who are biologically his parents, had the first of several surgeries needed to treat the heart condition. But this is a genuinely wrenching situation. Who gets to decide what here and under which state’s laws? Bioethicist Arthur Caplan told Houston Public Media that there are so many ethical issues here, he could spend an entire semester’s course teaching it. 

Luthra: And I think what is important about this case as well is, I mean, it’s obviously just like so, so, so sad, and this poor family is just having to deal with something really heartbreaking that no one should have to navigate under the national spotlight in Texas. It is really energizing conservatives who want to ban surrogacy, and we have already heard from lawmakers in the state legislature say they will be looking at surrogacy specifically when they convene next year. I have talked to anti-abortion activists in the state who are very hopeful that this case will give them new impetus to ban, at the very least, commercial surrogacy. They would love to ban all forms of surrogacy. And it is seen by a lot of anti-abortion folks who oppose fertility treatment, including IVF [in vitro fertilization], as something maybe easier to target. And I think it’s politically really complicated, because Americans don’t know as many people who get pregnant through surrogacy as they do people who might use IVF. But when I was talking to, again, legal experts about this, one point they made is that if surrogacy restrictions do take off in a meaningful way, often, the intellectual framework and arguments being made are ultimately the ones that would be used for IVF restrictions as well. And so, there is a possibility of a real slippery slope and more of that opening the door to fertility treatment restrictions that could affect a lot of people. 

Kenen: I think there’s a lot of public misunderstanding about what a gestational carrier is. When surrogacy became, not common, but sort of emerged in the public eye, there were a couple of really high-profile court cases. This was in the late ’80s. The “Baby M” was the most famous. And these were situations, at that point, where the woman carrying the child, it was her egg. So in the Baby M case, it was a couple that couldn’t have children. She was-— I don’t even know if that was — that wasn’t probably IVF. That was probably some other kind of artificial insemination. But the woman who decided she didn’t want to give up the baby after carrying it — it was, in fact, her biological child — and the practice became not to let, to separate the surrogate carrier from the egg donor. It’s not 100%. It’s not that it never happens, particularly if there’s family situations where maybe an aunt carries, etc. In this case, we’re really, based on public record, because I did a little reading on it this morning, it’s not clear, of the “biological parents,” it’s his baby. It’s not 100% clear on the public record that it’s actually her egg, the wife’s egg. But it is not the carrier’s egg. The woman suing to keep the child, saying she wants to have the baby, it is not her, it was not her egg. State law varies. Most states say that the surrogate in this kind of situation does not have maternal rights; that it’s the couple that hired her. Texas is, I believe, more blurry. There are a few states that it is more ambiguous, and also remember that this is a really tight, unusually and unexpectedly tight Senate race in Texas, where a very anti-abortion state, obviously, and also in this case the couple says they didn’t even ask for the abortion, but that’s he-said-she-said-they-said, we don’t know. I don’t know, at least, right? But abortion is a huge political driver in Texas; it’s a close race. [Ken] Paxton, who is the state attorney general, who is taking the side of the surrogate mother, is also the Senate candidate. You know, this is, you know, we’re 2½ months out, whatever, from the election. Three, I guess, closer to three still. But it’s very political in a state that probably has more politics around abortion than probably any other state. 

Rovner: Just what we needed: another thorny issue to throw into this mix. All right, that is this week’s news, or at least as much of it as we could get to. Now we will play my in-the-car interview with Mark Cuban, and then we’ll come back and do our extra credits. 

I am so pleased to welcome businessman and entrepreneur Mark Cuban to “How Would You Fix It?” Mark is probably best known to most people as a former shark on the TV show Shark Tank and the former [co-]owner of the Dallas Mavericks NBA team. But he’s also the co-founder of the Mark Cuban Cost Plus Drugs company, which sells generic medications directly to consumers at transparent prices and big discounts. More recently, he’s been talking about even bigger reforms to the healthcare system, which is why I’m so excited to have him here. Mark Cuban, thank you so much for joining us. 

Mark Cuban: Thanks for having me. 

Rovner: I’m curious: Your background’s been mostly in tech and in sports. How did you come to make healthcare such a priority? 

Cuban: I got a cold email from my now co-founder, Dr. Alex Oshmyansky, and he wanted to build a compounding pharmacy that made sterile injectables that are on the FDA short-supply list — which it’s crazy that there is a short-supply list for generic injectables. So that was great, but it wasn’t big enough. And as I looked into it, it was right around the time that “pharma bro” [Martin Shkreli] was going to jail, and I was like, “How can this dude jack up the price of a generic medication to the detriment of so many people?” And then it became obvious that nobody knew what a medication costs, nobody knew why it cost what it costs, and nobody understood why everybody paid a different price for the same medication. That list led to us launching costplusdrugs.com in January of 2022, and it’s just been growing like a weed ever since. 

Rovner: For decades now, the big debate in health policy has been whether the system should be more run by the government or more run by the private sector. Is that even the right way to focus on this anymore? Now everything is sort of hybrid and a mess. 

Cuban: Yeah, no, it’s not, because if the government doesn’t have data, and the government can’t trust the vendors that they’re working with, it doesn’t matter that it’s the government doing all the negotiating. And you see that in other countries. For instance, we get emails from countries around the world — from Canada, England — asking to buy generics from us ’cause our prices for generics, particularly specialty generics, are less expensive than what they sell for in countries that have single-payer or universal care. And so, while I’m not opposed to single-payer or universal healthcare at all, and kind of the analogy I use is: If healthcare costs $1 per person per year — yeah, great, taxpayers would pay that. But it would be a set $1 and it’d be obviously inexpensive. But when you don’t know all the costs, when there’s no transparency, it’s impossible to determine if it’s a better solution or not. 

Rovner: Are there segments of the healthcare industry that would work better if the private sector ran them, and better if the government ran them? I’m thinking, you know, hospitals, doctors, drugs.  

Cuban: I don’t think it’s like that at all. I think it depends on how much transparency there is. The fundamental issue is transparency and trust. If you don’t know … like, there are a lot of hospitals, and you know this better than anybody, that don’t know their costs. And if you just hire the same people and just say, “Look, we’re going to pay Medicare pricing to Mayo Clinic, and Mayo Clinic doesn’t know all their costs,” or “We’re going to take an urban hospital and continue to pay them Medicare and Medicaid because that’s most of their business,” and they don’t know their cost, they just know their cash balance, it doesn’t matter who runs it. 

Rovner: So, what do you fix first? 

Cuban: Transparency. You have to be able to publish contracts so that any contract that’s signed with a federal agency, the federal government, a state agency, a city, not only are the terms of the contract published, but the prices are published, so that Tricare would be required to publish their prices. By seeing the actual contract, you can see where the city-state agency is getting ripped off. Because right now there’s confidentiality requirements, and the companies, like the big insurance conglomerates, they say, you know, we can’t do this. We can’t show this, it’s proprietary information, which is nonsense. You’ve got hundreds of thousands of companies. You’ve got hundreds of agencies and states and cities that negotiate the same contracts. So lots of people know, but they do it to make it more complicated. And so, as a result, nobody knows how the deals are structured. And if you don’t know how the deals are structured, it’s impossible to negotiate better ones. And if they’ll sue you for discussing it with their peers, then nobody … it’s like Fight Club. The No. 1 rule [of] Fight Club is you can’t talk about Fight Club. The No. 1 rule of healthcare contracts is you can’t talk about healthcare contracts. 

Rovner: Yeah, and we’ve, you know, Congress has passed laws. The president has pushed a lot of these transparency rules, and basically, the health industry has said, “Yep, sorry, we can’t do it,” or “We’re going to do it in such a way that you can’t find it out anyway.” 

Cuban: Correct. 

Rovner: “We’re going to send you reams and reams and reams of data, and you can go digging if you would like.” 

Cuban: Correct. And so you take that to the next step. The big healthcare companies — first of all, they’re vertically integrated. They have hundreds, if not thousands, of subsidiaries. People don’t even know what the subsidiaries are when they do business with them, right? And so, when that happens, there’s just no way for any of the states, cities, federal government to enforce the laws. The big healthcare companies have more lawyers, move faster, are better able to find loopholes than the government and the agencies that enforce it are able to enforce it. And so, what ends up happening. You see all these fines. This PBM, this insurance company, whatever got fined for A, B, or C, and then they just go right back to doing business with them. So when I talk to governors, one of the first things I say in terms of reform is A) publish the contracts, and B) if you are doing business with a vertically integrated healthcare company, and they are fined by any federal agency or any state government, they get one mulligan. If they are fined a second time, they can’t do business with you for five years. That will act as the enforcement mechanism to keep them in line. And then the third thing that I always push is that anybody is able to go out and make a cash purchase, whether it’s medical or pharmacy, as long as it’s less expensive than their out-of-pocket, and have it by law count towards their deductible and max out-of-pocket. When you do that, you give them the opportunity to shop. When something is shoppable — not everything is — but you give them the opportunity to shop, and that helps force down prices. 

Rovner: So, I’ve been doing this since the 1980s, and it’s always been the Democrats beating up on the big insurance companies, and the Republicans basically defending them. Now that Republicans are beating up on the big insurance companies, are we kind of inevitably going towards a government-run single-payer? 

Cuban: No. Like, if you look up, if you look at the Break Up Big Medicine bill that was introduced by Josh Hawley, a Republican, and Elizabeth Warren, to me that’s the first step. So the good news: It was introduced on a bipartisan basis. Because if you break up these big, huge conglomerates, everything changes. The price of everything drops like a rock. But the problem is, nobody else, no senators have supported it, and nobody in the House has introduced a comparable bill. Everybody just chickened out. And so that’s the first step. Put aside the economics. Put aside that we don’t know the cost. Put aside that we have no transparency. All those things are important, but making sure we have health care for everybody is more important. That’s the difference. I think that also should be an American dream. As an entrepreneur, I’m a big fan of the American dream. But being able to be healthy and not be afraid that you can’t afford what you need or your family needs, that’s wrong in our American dream. And you know, when we talk about healthcare as a right, doctors freak out because they presume that they’re going to be paid Medicare rates, and they lose control of their life, right? And they talk about opting out and not doing it, you know. And so you need to get all these stakeholders accounted for. And until you start to do that and put together a plan that people will accept, we’re not going to ever be in a position to take care of people like so many of us hope to do. 

Rovner: And yet that would require both parties to basically lay down their arms.  

 

Cuban: Yes, which I think is possible. I think it’s doable because the No. 1 thing that, in every poll, people are concerned about healthcare costs. It’s not the quality of healthcare. Nobody really complains about the quality. Our doctors are great. Our systems are great. It’s the economic side. And who defines the economic side? Those humongous healthcare conglomerates. And what’s the best way to get to a point where we have transparency at the contract level, you know, flexibility and understanding, etc., all the things I mentioned? You break up those huge conglomerates that have thousands of subsidiaries that do $150-plus billion in intercompany transfers, that game the medical loss ratio. I mean, all these things happen because those big companies have more control over the economics of our healthcare system than the government does. 

Rovner: Well, I hope we actually get to that point, and I hope you’re around to help with some of these stakeholder conversations. 

Cuban: Oh, hopefully I’m not going anywhere. 

Rovner: Thank you so much. 

OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Shefali, you picked first. Why don’t you go first this week? 

Luthra: Sure. My story is from The 19th by my colleague Barbara Rodriguez. The headline is “TikTok’s Fake GLP-1 Market Preys on Women Trying To Lose Weight.” And I love this whole genre of story. The GLP-1 market is exploding because these drugs can be so expensive to get from your healthcare provider. You see advertisements everywhere, all over social media, people promising to sell you a GLP-1. And as Barbara’s story gets into, often they are not actually GLP-1s. It is something fake. It is not actually going to help you lose weight, but it is going to take your money. And I just think that this is such an exploding market. So much has changed that we can’t read enough about how the, just the growth of options, or not legitimate options, is affecting people, and I’m really glad she did this story. 

Rovner: Yeah, it was a really good story. Alice. 

Ollstein: I have a story from The Texas Observer by Mary Tuma, and it’s called “Texas Maternal Mortality Committee’s Next Report Will Skip Post-‘Roe’ Deaths. Lawmakers Suspect Political Influence.” So this is taking a deep dive on the situation in Texas, but the article does a good job of pointing out that this is a trend across several states that implemented abortion bans, where there was, you know, efforts to pause or revamp, or obscure, or change in some way the groups in every, that exist in every state that study maternal deaths. And there is just a suspicion that this is an attempt to hide from the public the impact of the abortion ban on maternal mortality. You have a lot of experts quoted in this piece. You have the family members who have lost their wives and mothers to pregnancy-related deaths, and so this is just an ongoing fight. And, you know, doctors say we really need this data and this analysis to know how to better provide care in the future. It’s not just a political football; it’s actual medical knowledge that we need to build. 

Rovner: Yeah, I think ProPublica did this for Georgia, I think, last year, so yet another in these series. Joanne. 

Kenen: There’s a story in Politico by Owen Dahlkamp: “AI Slop Is Swamping a House Office That Drafts US Laws.” This is not unique to health law, but given how complicated health law is and how much health law Congress deals with in any given year, it’s quite relevant to health law. So staffers are using AI to actually draft legislation, not just to research something. And I mean, it’s hard to get away from AI now. It’s, like, even pops up on people’s phones, right? But drafting legislation is very precise and complicated, and AI is apparently not very good at it. So the House counsel, which is the Office of Legal Counsel, which actually has to make sure the legislative language is correct and doesn’t accidentally reveal the wrong thing, they’re having a hard time. Although they have now created their own tool to try to correct the AI slop, but they’re getting overwhelmed. There’s, you know, we’ve all seen stories, we’ve all gotten pitches about, you know, so-and-so introduced a law. What the general public doesn’t understand is introducing a law, you know, it’s good for a press release — introducing a bill, excuse me. Introducing a bill does not mean a whole hell of a lot, except that you’re satisfying some constituent or constituent group, right? But congresspeople and senators like to say they introduce this and they introduce that and they introduce the other thing. So the number of bills being introduced was already rising spectacularly, and now with the slop, there’s like the slopth degree of it. So it’s messy. 

Rovner: It is messy, and it does, I mean, it sort of prevents the real work of actually drafting legislation that’s going to become law from getting done. 

Kenen: There’s going to be something, like, really bad that comes out that somebody in the poor OLC office doesn’t catch, and it’s going to repeal, like, you know, the flag. 

Rovner: Yeah. We will see. All right my extra credit this week is from Mother Jones by Sophie Hurwitz. It’s called “The Orwellian Company Behind ICE’s New Electric Shock Gloves.” And you may have heard that ICE [Immigration and Customs Enforcement] is spending $20 million to buy these gloves, which administer an electric shock at the touch of a button on the wrist for their officers. What makes them better than a Taser or other non-[lethal] device? Well, one Missouri police officer whose force uses them said the gloves “allow their wearer to inflict pain without leaving the sort of marks that could look bad to witnesses or leave an officer vulnerable to lawsuits.” In other words, they make it easier for people to inflict pain on others, whether warranted or not, without likely recourse. How very 2026. 

OK, that is this week’s show. Thanks to our editor, Emmarie Huetteman, and our fill-in producer-engineer this week, Zach Dyer. We also had production help from Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts — as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X @jrovner, and on Bluesky @julierovner. Where are you guys hanging these days? Alice? 

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

Rovner: Shefali. 

Luthra: @shefali on Bluesky. 

Rovner: Joanne. 

Kenen: Mostly on Bluesky @JoanneKenen and on LinkedIn. 

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

Credits Zach Dyer Audio producer Taylor Cook Audio producer Emmarie Huetteman Editor

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