Health Care & President Trump: What’s Happened So Far

Mark Masselli (00:04)
We're in the beginning of President Donald Trump's first a hundred days of his second term. What decisions and
actions he's he taken so far on healthcare and what effect are they having?

Michael McAuliff (00:14)
Yeah, it's a new world. Trump wants to have, you know, a former Democrat who doesn't like vaccines or run
HHS.

Margaret Flinter (00:22)
We're talking to the reporters in the nation's capital who are covering the Trump administration, as it says it
wants to quote, make America healthy again. Our guests are Shannon Firth with MedPage today, Michael
McCullough with Modern Healthcare and Sarah Owermohle with stat.

Sarah Owermohle (00:38)
Some of these are gonna be easier to get than others, but it really shows the mindset that they're going in on a,
we need to look at aggressive cuts, cost cuts, and we're putting every option on the table to start.

Margaret (00:48)
This is Conversations on Healthcare.

Mark (01:01)
Well, let me welcome all of you to conversations on Healthcare, and let's start with asking Sarah about the
actions. President Trump took upon resuming offices. He's withdrawn the United States from the World Health
Organization. He's also signed other executive orders affecting healthcare. I'm wondering if you could give us
an overview, Sarah.

Sarah (01:20)
Right. So the, definitely the big news was his intent to withdraw from the World Health Organization. The
WHO has said that they hope he'll reconsider that. There's questions about how quickly that could happen. It's
never happened before. There's in fact, not even a process within the WHO to withdraw your membership. So
we're gonna see this happen in real time, what that looks like. Then, of course, he rescinded more than 70 other
executive orders from President Biden across a range of things. Some of them include, you know, requiring
people to go back to the office to work, which of course will affect healthcare agencies and plenty of others.
Then there were several that had to do with the Affordable Care Act, with expanding the enrollment period, with
certain provisions that Biden had ordered to experiment on lowering the cost of drugs in Medicare and
Medicaid, and then several things, having to do with gender affirming care or really discriminations against
people on the basis of sex and gender. I'll say that while there was a litany of these orders, much like when
Biden issued those orders, that's just the start of the process. So we'll still have to see what that looks like and
how agencies are going to carry out those missions that he's given them. We could see legal challenges also.
Some of these things are tied to laws, so it's not so easy as saying, okay, now pull back this program, reverse
this, process.

Margaret (02:38)
Well, Shannon, maybe somewhat of a general question then onto a specific, when we talk about public health,
what are the hopes and fears that you might be hearing from some parts of Congress about the new
administration? I think the hopes and fears are probably both important to think about, and maybe on a specific
level, you know, a program like Vaccines for Children, not known by that name, probably by lots of people in
the United States, but massively important if you're talking about pediatric health and primary care. What does
the future hold for a program like that?

Shannon Firth (03:10)
Thank you, Margaret. So thank you, first of all for having me on the show. When we talk about public health,
there's a lot of concerns right now among physicians, public health experts, researchers about the future of, of
public health Under this new administration. There's a lot of concern about, Robert F. Kennedy Jr. He's been
nominated as Trump's Health Secretary. There's petitions. There's one petition with over 20,000 signatures of
physicians. My colleague Joyce Fried, wrote a story about that. There's also, a competing petition from the
Make American Healthy Again cam, group, and that has about 800 physicians who are, in support of, Robert F.
Kennedy Junior, becoming HHS secretary. So one of the big concerns, obviously, around Kennedy as, as most
people know in the health space, is that he, he was the founder of the Children's Health Defense, which is an
anti-vaccine group. He said that there is no safe and effective vaccine. And what where that becomes very

concerning is as H-H-S-H-H-S secretary, sorry, he would have oversight of the CDC, the F-D-A-H-H-S-C-M-S,
and CDC and FDA in particular. CDC has an advisory body that, sets, recommends a schedule for vaccines,
who should take which vaccine at what age, and what populations should, should be, I guess, prioritized for that.
And then in terms of approvals, the FDA has its own advisory committee, so there's concerns that there could be
changes to those committees. There's also, as you mentioned, the Vaccines for Children's program, that provides
free, access to VA free vaccines for underinsured and uninsured children through across the country. So more
than 50% of the children in the US are eligible for vaccines through the program. That includes children on
Medicaid, that includes children in the Indian Health Services. There's, you know, 19 disease specific vaccines
that they can get. And it's really, I think, important public health, health public health experts say it's really
important that that program continues. So, in each of these cases, there's concern that there could be changes to
either these independent committees who are advising and approving vaccines, or there could be potentially
changes in funding. I spoke with, sorry, potentially changes in funding for the vaccines program. I spoke with,
Larry Bean last week, who's a former congressman. He's a cardiothoracic surgeon, and he, he is a Republican,
and he said that he was reassured, he felt that Congress would, defend the program, against any sort of, attack
like this that could happen in terms of funding. So he's not concerned. Republic, sorry. Representative Schreyer,
Kim Schreyer, who's a pediatrician from Washington, she's been, really intent on expanding the Vaccines for
Children program. And she is concerned, she said that between, stated intents to cut both Medicaid and cut
funding for CDC, she worries that this program could be caught in, you know, caught in the crossfire. She did
say however that she, she did say however, that she believes that her Republican colleagues, she hopes that her
Republican colleagues will follow the science and look at the track record of this excellent program, and we're
in a bipartisan fashion to ensure that it, continues. So I, I think…

Mark (07:12)
That's great. Let me, let me pick up on the theme of potential changes. And maybe a question to all of you. The
ways and means, committee has a proposed list of changes, in the tax bill, front and center, was health. I note a
couple of things that might pose a little controversy that, elimination of the nonprofit status for hospitals and,
and of course certainly the FMAP program. Any thoughts as you sort of looked at that document and, it covers
sort of a wide range of, potential, dramatic cuts, in the healthcare arena?

Michael (07:48)
Well, I mean, when I looked at that, I mean, first I think it actually comes from the budget committee. It just
happens to be that Ways and Means was the, the first committee mentioned, right? That's right. Everybody's in
there. And, Jody Arrington, the chair of the budget committee is sort of in charge of quarterbacking that. But,
my initial read of that, and from some conversation with some of the lawmakers who are, you know, gonna be
considering these things, is that it really is a menu. It is, it is not even a wish list. For some people, it's a wish
list, but for most of Congress, it's like, here are all the things where we have some kind of score where we can
say, okay, if we go Ho Hog on this, it's gonna save $146 billion by, by doing a really robust site neutral plan for
hospitals. Right? That's, you know, 900 billion if we wanna really block grant in the most aggressive way, the
Medicaid program. Right? So that's really what I think that is. And, as they start to talk amongst themselves and
in, in among the committees, then they're gonna have to start winnowing down what they actually want. And if
you really read that document and it's, it's, it is hard going when you get to the Energy and Commerce
Committee, which is, you know, one of the most important committees for all of this, you see a lot of things in
there, like, well, the Energy and Commerce Committee did not provide details on this proposal. So just, just,
you don't usually dime out your colleagues in, in the, in the document that you're circulating amongst all the
other lawmakers to try and come to some sort of consensus. So it, it suggests just even in the form of the thing
that there is a long way to go before lawmakers settle in on what they actually want to do.

Mark (09:23)
Michael, I thought it was an advertisement for lobbying firms to make sure you had enough.

Michael (09:27)
Oh, yeah. Well, you know what? Everybody's got something in there, so, so everybody's gonna be diving in to
say, Hey, hey, wait a second. Not us.

Sarah (09:35)
I just, I, I completely agree with the way that Michael characterized it as, as looking at it like, like a menu as sort
of a starting block to, the levers that they could potentially pull. And, and like you both said, you know, then the
lobbying really starts. And so I don't think that we'll see necessarily hospitals take the hits that they are
projecting here. And like Michael said, there's certain, there, there was a funny lack of ownership when we all
saw that document of like, who, who wrote this? Who's backing this? So you need that first. You need the

champions for those things. Some of these are gonna be easier to get than others, but it really shows the mindset
that they're going in on, we need to look at aggressive cots, cost cuts, and we're putting every option on the table
to start.

Margaret (10:11)
Well, we heard a good bit, during the campaign about the future of subsidies for the Affordable Care Act, still
known to most people I think in America, is Obamacare. And I think it was assumed that Republicans would not
want to extend them. But Michael, you've reported that maybe there is support and those subsidies are not
doomed, after all in the new administration. Why is that, and why might they be perceived as something that
really has to be kept?

Michael (10:37)
Well, it's sort of, you see it in that big document we were just talking about. There's a lot of conflicting sort of
imperatives and needs that the folks in Congress are wrestling with. And while you may have a historic
ideological opposition to Obamacare, especially if you call it Obamacare, rather than the ACA, that has
benefited, red states in particular, especially rural people and poor populations disproportionately so, those states
would really suffer. And you do have a fair number of medical practitioners in Congress, guys like Greg
Murphy or, or the pharmacist, buddy Carter, who's now chairing the Health Subcommittee of ENC. And those
folks actually know what it means when you take away that amount of money from their system. Doesn't mean
they don't want to do it, but they want to figure out, okay, how can I, you know, save maybe some of this so that
we're not completely creamed. And that whole, you know, barometer of, you know, where do you cut, where do
you save is really gonna be very hard for, for the Republican party. And that's gonna be true for subsidies, for
Medicaid reforms, for site neutral laws, you know, just about anything has a plus and a minus. And if you are in
power, it means you have constituents, businesses and, and regular people who will suffer one way or the other,
if you actually go through with a cut. So, you know, I think that's one of the reasons they wanna do these things
quickly, because it takes, it takes a little bit of time for understanding and pushback to come that, that doom
these things. And then you have a Congress that's, you know, they have, 218 Republicans right now, 215
Democrats, you need a majority to pass something. So if you lose one, you're doomed.

Mark (12:30)
You know, Sarah, let me pull the thread…

Michael (12:31)
So it's gonna be very, very interesting. Yeah. And some of those things that you might think would be doomed if
they actually help their districts might not be.

Mark (12:39)
Sarah, Obamacare, or as Michael said, a CA faces some other threats. And you've written about the Supreme
Court's upcoming decisions regarding access to preventative health services with no out-of-pocket cost. Tell us
what's at stake here.

Sarah (12:54)
Right. So the Braidwood case, the Supreme Court has agreed to hear arguments on that. So that could come up
in the next few months with a decision expected by July. And what's significant about that case, it's the first one
you've seen for a little bit to come before the court, that is essentially an attack on a form of protection or
expansion that a CA gave to covering certain preventive care at no cost. So in this case, really what the Supreme
Court's going to be hearing about is this one panel of advisors, in particular, the US Preventive Services Task
Force, and what they recommend or require insurers to cover for people at no cost. The main target from the
plaintiffs is PREP, the medicine that prevents HIV transmission. But PREP is not one of the only, by far, one of
the only things that the Preventive Services Task Force requires, coverage of its cancer screenings,
mammograms, certain other, you know, preventive, services. What is going to be significant about this is if the
court does decide that we could see insurers decide that they may not cover these medicines and services, or
more likely will cover them at a certain cost to that patient. So that could have, particularly for prep, significant
impact for certain patients. Another aspect of Braidwood that, the Supreme Court won't be hearing this time
around, but that is still floating around, is that the plaintiffs originally also wanted to question the authority of
two other expert panels at HHS. One of them, ASIP, which covers, vaccines and it requires coverage on, of,
immunizations. And one of them is essentially women's health, birth control, family planning, which is covered
under a part of HHS called hrsa. For now, ASIP and HRSA are not part of this particular argument, but we
could see the question of their authority. And if they're allowed to do that, which again, is also protected by a
CA, it's going to matter, I think what trump's future health officials, including Robert F. Kennedy Jr, would

decide to do when staffing these panels or what kind of authority they would allow them to have in the future as
well.

Margaret (14:51)
Well, it's gonna be particularly interesting 'cause if I'm correct, I think the Congressional Budget Office had to
score all those things, and the, the sciences or the economic data is pretty overwhelming that they save money in
the long run. So it'll be interesting to see what the, the people in charge of, cost cutting, are going to do, about
that. And I, I guess along those lines, Michael, you wrote an interesting piece about the Republican leaders in
Congress, and their role relating to health issues. And, you all called out a couple of names, but who are the
Republican leaders, that are really front and center on the health issues, and are they all in lockstep with the
president on his goals?

Michael (15:33)
No, I don't think they are in lockstep with the president on his goals. I, I think they are just sort of, sentimentally
and psychologically. But as I was saying before, like when you start getting down to brass tax and it start starts
affecting your district or the, or your campaign donors, you know, then all of a sudden you start having a, a
slightly different take on things. And we're in a really interesting time, you know, after the past the, the ACA,
right? There was, it was really partisan in healthcare, and it's become less so. So, now you've got, now it's not
Greg Murphy. Brett Guthrie from, Kentucky taking the chair of the Energy and Commerce Committee. He had
been the Health Subcommittee chair, and the ACA is very popular in Kentucky. Right. You know, when they
tried to repeal it in 2017, that was when Mitch McConnell was in real trouble, and in some ways, he got saved
by John McCain, you know, killing the repeal. So, so he's, he's aware of that. He knows that, and he's been, he
ran a business before, he was part of family business before he came to Congress, so he's, he has a pretty wonky
almost understanding of how the healthcare system works. So he's not gonna go charging right ahead. And, and
in that document we were talking about before, they have things that will cost money that are on the list for, you
know, potentially getting selected for reconciliation. So there is definitely a more nuance understanding of how
the healthcare system works on the Energy and Commerce Committee. But if you go over to Ed and Workforce,
which has, you know, association plans and, and all the other sorts of things that go with the employer world,
there, they seem a little bit more ideological. And the new chairman, Tim Walls is a, he's, he's, he wants to
charge ahead and go with anything that reduces these costs. So I think they're more ideological there, and I think
they will try and push, more cuts to the ACA and things like that just because of, they don't have the sort of, you
know, the hospitals and the doctors lobbying them quite the way, energy and commerce does. And then over in
the Senate, you've got, bill Cassidy, who is a doctor Right. And has quite a deep understanding of how all these
things work, right. He's, he's a true wonk. He likes to do requests for information on, on, you name it, and he's
probably done it. He already started doing it before, he got the chairmanship this year. And then over on Senate
Finance, which has all of those big health programs that the federal government runs, you have Mike Rabo,
who's sort of a traditional, very staid, Republican, very in the old sort of pro business, you know, be be slow
and, and, and calm kind of rule of, doing things. So I, I don't think you're gonna see either of those guys rushing
to do some of these huge cuts that we're talking about. I think it's gonna be much more like the sort of
traditional, we want to pair back and have, you know, eligibility standards, and we want to root out fraud and
abuse and, and we wanna let the private sector do its thing. And it'll be more like that from those guys. But, you
know, again, it's a new world. Trump wants to have, you know, a former Democrat who doesn't like vaccines
run HHS, right. So, and, and it'll be, it'll, you know, I, I'm really interested to see how much those guys in
particular sort of go along with the more sort of MAGA Trumpian sort of line. I don't know that they will, but I
also don't know that they won't. Right. They haven't really tipped their hand too hard, one way or the other.
Although Cassidy doesn't sound like he's too happy about the vaccine sentiments of Mr. Kennedy. Beyond that,
I, you know, we'll have to see.

Mark (19:16)
Sarah, thinking about where the money is in healthcare, certainly in Medicare and Medicaid are the two big
ones. We noticed that President Trump promised not to cut Medicare during the campaign, but didn't say a lot
about Medicaid, which has many more, enrollees than Medicare does. STAT has been researching what
Medicaid looks like in that second Trump presidency. Maybe talk a little bit about what your findings have
been.

Sarah (19:42)
Right. So well as both, Shannon and Michael have alluded to, there've already been these discussions on the
Hill, certainly about what it looks like to reform Medicaid and potentially get savings from it. Well, not a lot of
what we know about what Trump would do comes from his first administration. What efforts were made during,

by officials at Medicare and Medicaid during that time. So we know, for instance, that block grants are
something that has been floated and, and, you know, that would essentially be flat spending, spending from the
federal level, more responsibility onto the state programs for their funding. And potentially cost caps spending
caps, I'm sorry. And then another thing that was popular in the first Trump administration that we are already
seeing returning on the state level to a certain degree, is the idea of work requirements. So people who are able
to work, having some sort of, requirement to hit a certain number of hours a week in order to have Medicaid
coverage. We've seen, even in this past election, at least one state passed a referendum that could implement
that. We saw during the first Trump administration that Medicare issued waivers to several states to allow those
programs. The Biden administration revoked that, but we could really, I would expect to see a version of that
back again. We also know that, you know, there's discussions of, changing the benefits, and what that could
mean for, you know, the CHIP program as well, the, the, the program for children's health insurance. So I think
there's a lot that's going to be on the table. And the fact that President Trump has been so explicit that Medicare
will not be touched, but not said the word Medicaid necessarily, is leaving that door open.

Mark (21:14)
What about the governors in those red states? The impact that Medicaid might, reductions or pairing back on
Medicaid might have?

Sarah (21:22)
Well, I mean, like the other panelists were discussing, this is going to be really, really politically tricky. Because
if you're going to be pairing back Medicaid at the same time that the federal government is discussing changing
or eliminating the subsidies for the A CA, then you're going to have a lot of people starting to fall through the
cracks. And in these particular states, in these red states where there hasn't been great coverage, or there has
been a heavy reliance on subsidies and on Medicaid expansion. So I think what we're going to see when it
comes down to it, is that some of these governors in these states will see that this is not a very good bargain for
them. And some of the Congress people who represent those states will see that if they have to go home and sell
that they voted on things like this, what is that going to look like? And, you know, if their voters see their
coverage change or that they lose it, that's gonna be something that will hit them in the next election.

Margaret (22:08)
Michael, President Trump has nominated former TV host Dr. Oz, to lead the Centers for Medicare and Medicaid
Services. How do you think his nomination looks and what kind of vision he'll bring to the position if, if he has
it?

Michael (22:22)
Well, I've actually been trying to hunt around on that, and I, I honestly haven't found all that much. So I'm sort
of reading a little bit between the tea leaves. I think they're looking at Kennedy first and, and seeing if they can
get him through. And he's running into some problems. Certainly all the Democrats aren't too crazy about him.
Lisa Murkowski and Susan Collins on the Republican side aren't that crazy about him. Cassidy doesn't seem to
be committed to him. And then there are some folks who are worried about his purity on the sort of, pro-life
issue. So that seems to be taking up a lot of their attention. And then on Oz himself, he seemed, I think it was
stat who had some good reporting on who is would be coming in as his team over there. So they seem to be
bringing in some sort of older hands who have a good handle on ho on, on how CMS works. And the big
questions that have been erased about him so far have been about conflicts of interest and a little bit about some
of the, cures and, tv, you know, endeavors he's done to, to sell sort of shady products and things like that. But I
have not heard, Republicans getting too worried by that. They seem more interested in supporting, Donald
Trump in, in his nominees than, than raising sort of those conflict of interests and, and product question. So I
think he's on relatively firm ground. But again, that'll become clear probably after we see if, if, if Kennedy's
gonna go anywhere.

Mark (23:55)
Yeah. Shannon, Congress passed what's called a skinny budget of the end of the year, and many have missed,
the part of it, that congress, did not include a fix, to the Medicare doctor pay. What's the problem here and what,
what happens next?

Shannon (24:11)
Thank you. So there was a bill, there was an initial agreement, as we all know, that had a lot more, a lot of more
healthcare provisions in it. And one of those provisions would have not eliminated the cuts for physicians, but
basically made it a lot easier. The Medicare has been cut. Medicare physician reimbursement has been cut the
last two years, 1.7% last year, and 2.83% this year was what ended up happening in the, the bill that passed

after, some interference from people like Elon Musk and President Trump coming in and saying the original bill
was not, up to par with what they wanted to see. The challenge is, physicians, particularly the AMA, the
American Medical Association has spoken, very strongly about the fact that physician pay has not kept pace
with PR practice cut practice costs. So reimbursement, they'd like to see reimbursement tied to inflation. And a
lot of physicians are saying that if pay doesn't catch up, they are gonna be forced to either not take Medicare
patients or even some may close their practices. The Medicare Payment Advisory Commission, MedPAC has
waited on this, and they also feel that physician pay this is a problem. I mean, this could be a problem for access
for patients in the future if physicians start either not taking Medicare patients or closing down their practice
'cause they just can't afford, to keep up with the rising costs of, of care.

Margaret (26:01)
Well, a question, to Michael and Shannon, in our, last couple of minutes with you. We heard a lot about the end
of Roe versus Wade, of course, during the past two years. Is abortion a settled issue now at the federal level, or
is there more that you think will or could happen, on the subject in this administration?

Michael (26:21)
Well, I think the Trump administration will go back to all the positions that it had the first time around, and I
think we saw these, some of the executive orders already coming out to that effect. But, you know, it's, it's, it's
gonna be a lot, I think, in the legal space, and I'm not really an expert in it, but, you know, that those lawsuits
will continue. The states doing their thing will continue. And then you had this sort of weird, almost wild card
come in there at the end of Biden's, presidency where he published the Equal Rights Amendment. Which, you
know, there's some legal disagreement about, about how binding it is, but I think technically it should be
considered part of the Constitution. And I think there will be people who want to test whether it is, and they will
probably do it with sort of some of the reproductive rights questions and other questions about equity for
women, that, that in theory could be considered guaranteed in the Constitution now. And I, I really don't know
how that will play out, but I, I saw that happen and I thought, huh, that could be very interesting. I wish I were
more of a legal scholar.

Shannon (27:31)
I'm also not a legal scholar, but I've been trying to gauge from the experts what they think will happen. And of
course, as Michael said, this is definitely not a settled issue at the federal level. We saw two cases last year, on
abortion. We saw the Supreme Court, kind of punted in both cases.

Mark (27:50)
Let me ask one, final question to all three of you. What's the biggest healthcare policy issue? And you're gonna
have so much to write about this year that's, on your radar that hasn't bubbled up yet, but you think will, be, one
that arises up in 2025, Michael?

Michael (28:06)
Well, you know, it's funny, it was starting to bubble up last year, but I think the whole question about three 40 B
Is going to become a hotter issue just because, well, and PBMs, again, they're, they're related, and the pharmacy
industry seems to be lobbying quite hard on those issues. And I'm sure they would dearly love to get, some
restrictions and greater clarity on, on Hall, on how all that is supposed to work. So I think that might be one
place to look.

Mark (28:35)
Sarah?

Sarah (28:36)
There's two, if I can quickly do it. I think, things that, well, they haven't maybe bubbled up as much, they are on
people's radars a bit. One would be the extent to which Trump wants to take down Biden's Healthcare legacy,
even on things that are fairly popular, like the Advanced Research Projects Agency for Health. That
preparedness that doesn't have to do with COVID-19 and all the mental health care resources and legislation and
funding that went out. So that's, that would be one thing is just kind of the extent of Biden's legacy. The other
thing also started to come up towards the end of last year and towards the end of the election, but we didn't
really see it get fleshed out there. We just saw the recognition that this was a problem, and that would be long-
term care and caregiver support. We do know that we have a rapidly aging population and that there's many
voters who are already caregivers or expecting to be caregivers. Trump did suggest that he would subsidize or
fund some sort of caregiver support, but has not talked about that since then. And so I think that's going to be a
really big issue, especially for senior voters.

Mark (29:31)
And Shannon?

Shannon (29:32)
I would say, Medicare Advantage, basically there was a lot of interest in, prior authorization, denials there.
Under the Biden administration, it's kind of remains to be seen whether that interest will continue, whether
there'll be more scrutiny, more, oversight in terms of reigning in some of the, the complaints that we've seen
around Medicare Advantage. And, right. I think, I think that will, I think that will be a, a big issue. I also agree
that PBMs, what happens to pharmacy benefit managers, whether, whether Congress tries, tries to reign them in,
in terms of their activity, which has been seen unfairly as unfairly raising drug prices. We'll, we'll see, see what
happens there as well.

Margaret (30:27)
Well, it is guaranteed to be an interesting year. Thank you for joining us. Shannon Firth with MedPage today,
Michael McCall with Modern Healthcare and Sarah Owermohle with stat. And thank you to our audience for
being here. Just a reminder, subscribe to our videos on YouTube. Find us on Facebook and X with our account
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