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

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 9, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Tami Luhby of CNN. 

Tami Luhby: Hello. 

Rovner: Later in this episode we’ll play my interview with Sarah Grusin of the National Health Law Center. She’ll help untangle the claims that Republicans are making that Democrats want to give free health care to undocumented immigrants. Spoiler, they don’t. But first, this week’s news. 

So, today is Day 9 of the government shutdown, and so far there’s still no discernible end in sight. While last week it seemed like some Democrats might be getting cold feet, at least in the Senate, about keeping government workers either at home or at work and not getting paid, this week it’s looking like some Republicans are getting cold feet about the coming lapse in additional Obamacare subsidies that will subject lots of Republican voters to huge premium increases come January. Any evidence either side is actually giving in? Or are we still in a state of pretty complete standoff here? 

Ollstein: I was up on the Hill this week, and it seemed like pretty complete standoff. There were some testy in-person exchanges, which is not as usual, just outright raised voices, arguments between lawmakers just in the hallways in full view of the press, about this ongoing shutdown and about the stakes for health care. And Republicans are saying, Oh, we want to address the health care issue and prevent the subsidy hikes, but you have to open the government first and then we’ll do it. Democrats are basically saying: We’re not idiots. We need to use the leverage we have, and the leverage we have is the shutdown. I mean, there were some notable moments here. I mean, one, there’s just been polling coming out showing that the public is blaming Republicans more than Democrats, and so I think that’s strengthening Democrats’ spine a little to hang on a little longer. I mean, people are not only blaming Republicans because Republicans are in control of the House, Senate, and White House but also because Democrats are staking their claim on these, wanting to prevent people’s plans from becoming much more expensive, which is a popular stance. 

Rovner: And plus people are used to blaming Republicans for shutdowns. I really think a big —I do — I seriously think a big part of it is, If the government is shut down, it must be the Republicans who shut it down— 

Ollstein: Right. 

Rovner: —because they’re the ones that don’t like government. 

Ollstein: Right, right. And this comes amid a bigger public souring on our political leaders. But one thing that really caught people’s attention this week was Marjorie Taylor Greene, the very conservative congresswoman from Georgia, coming out and saying, Look, I’m no fan of Obamacare, but my kids’ plans are about to get way more expensive, and Republicans have no, no idea what to do. 

Rovner: Yeah. I would say, I think it’s safe to say I did not have Marjorie Taylor Greene— 

Ollstein: Nope. 

Rovner: —on my bingo card as the Republican who was going to come out in favor of saving the extra subsidies. 

Luhby: Right, although the interesting thing is she noted that her kids, their premiums would double, so it’s really hitting home for her, and she’s bringing that to the attention of the Congress. 

Rovner: Yeah, and we should note that, I mean, she is emblematic. She’s got kids who are in their late 20s, who have just aged out of her congressional health insurance, so they’re buying their own coverage. She lives in Georgia, which is one of the states where Obamacare enrollment went up dramatically after the enhanced subsidies. She is like the poster child for what the lapse of these increased subsidies will do, which I find kind of amusing. And she’s been doubling down, saying: I don’t like Obamacare. I wasn’t here when it passed. I think it’s dumb. I think all these other things. But I also don’t think it’s fair to take it out on my kids and my constituents. Which is kind of what I’m wondering: Is this the beginning of the cave for the Republicans? Or is she just going to go her own way, as she sometimes does? 

Ollstein: Exactly. I mean, she often goes her own way. She is more willing than most on the GOP side to buck the party line. And so, I mean, she is influential. She has a huge platform. And so you could see strange bedfellows where some of the more moderate Republicans sort of join with her on this. It’s hard to see where it’s going right now, but it was a very interesting development this week. 

Rovner: Yeah, for a week in which nothing much happened, there’s sure been a lot to follow. Well, the shutdown is actually starting to pinch, which you would know if you were trying to fly in or out of an airport that’s missing some of its air traffic controllers. On the health side, not much is happening yet, except there’s a curious new twist with the Women, Infants, and Children feeding program, known as WIC, which was about to run out of money. Tami, what is happening there? 

Luhby: Right. So, it’s a program that serves almost 7 million people, mainly pregnant women, new mothers, infants, toddlers, young children. And it’s long had bipartisan support. It’s a 50-year-old program. And just to explain what it does, it provides funding for families to get vouchers to get basics like milk, eggs, bread, fresh fruit and vegetables, peanut butter, cereal. And it was — the National WIC Association had said that it only had enough funding maybe for a week or two, so the clock was ticking down. I spoke to a couple of moms last week, who were very concerned about what they were going to do. One mom told me she’s already conserving the milk her kids drink to try to stretch it out more. And this week, the Trump administration said that it was going to use tariff money to keep the program operating. 

So, people have been very happy about that, but at least one budget expert I spoke to questioned whether the administration actually has the authority to do that. He said it’s not that the administration doesn’t have the money to pay for it. It’s that Congress hasn’t told them what they can do with the money. So, it’s a little unclear how the administration will be able to take these tariff funds and use it to fund the WIC benefits, but that’s what they said they’re going to do. 

Rovner: Yeah, that was creative. It’s not unusual. I think you can reprogram money during a shutdown. But again, there’s a question about whether these tariffs are even legal. That’s something the Supreme Court’s going to decide later this year. So, it is interesting to say the least. Well, meanwhile, some of the other places that health cuts are showing up actually have nothing to do with the lapse in appropriations. Most Medicare telehealth authority ended with the end of the fiscal year, leaving rural and homebound patients hanging in many cases. And even though Republicans set up their budget bill this summer to delay most of the Medicaid cuts until after the midterms, a lot of states who were trying to close budget holes are cutting Medicaid now. This is likely to put even more pressure on Republicans, right? 

Luhby: They knew it was going to happen. I mean, I’m not sure how much more pressure or how much new information they’ve received. I mean, for the first six months of the year, states, advocates, hospitals, everyone was saying that if the One Big Beautiful Bill goes into effect it’s going to be a big problem. So, we’re starting to see the early effects. 

Rovner: Yeah, I would say that the Democrats aren’t really shutting down the government over health care, although they do care a lot about these subsidies. The Democrats are really shutting down the government over wanting promises that the Trump administration will stop basically second-guessing and violating what Congress is passing in terms of funding bills. But this is turning into a pretty big health debate, which kind of surprises me. I think it may surprise some of the Democrats. I mean, the Democrats wanted to use health care because it’s one of the few issues where they have an advantage over the Republicans politically, but this seems to be kind of building on itself to a level of health system debate that I haven’t seen I don’t think since 2017. 

Luhby: And I know you’re going to get into this later in the podcast, but I mean the Republicans are trying to take back some ownership over this by saying, Well, what the Democrats really want to do is provide free health care to, as they term it, illegal aliens. So, they are trying to use one of their few leverage points in the health care debate to take back the conversation. But there’s been a lot of blowback on that, as you will discuss. 

Rovner: We will see how this all goes. Well, moving on. This is the week with the first Monday of October in it, which means the Supreme Court is back in session, and they’re diving right back into the culture wars. On Tuesday, the justices took up a case challenging Colorado’s law outlawing so-called conversion therapy intended to help LGBTQ+ people turn straight. The plaintiff in the case is a Christian counselor who says the law violates her free speech rights. If the court strikes down the Colorado law, which those who watch the argument suggest seems likely, it could lead to the striking down of similar laws in about half of the states. Now, these laws are based on decades of research showing that attempts to change people’s sexual orientation are often more harmful than beneficial. Is this yet another example of the justices playing doctor? It would hardly be the first time. 

Ollstein: It was interesting. In the oral arguments, there was a lot of justices questioning the medical consensus. And I think we see this in several areas now, where they’re sort of like, Well, the eggheads got it wrong on X other thing, so we should be skeptical on Y thing, sort of an attitude which is extremely common in laypeople circles on the right. But it’s very interesting to see the Supreme Court, who is this elite specialized authority, questioning other elite specialized authorities, basically. 

Rovner: Yeah, going back to, I think Hobby Lobby [Burwell v. Hobby Lobby Stores] was the first time where I think that the justices said: We don’t believe you medical experts who have all filed in this case. We’re going to make our own decision. And it looks kind of like they’re planning on going the same way this time. 

Well, while we are on the subject of culture wars, last week, the Food and Drug Administration tried unsuccessfully to avoid one. It quietly — so quietly I don’t think there was even a press release —approved a generic copy of the abortion pill mifepristone. Now, this isn’t the first generic. There’s another one already on the market, and it’s actually part of the overall series of lawsuits over states trying to ban medication abortion. But I found out about this new pill, as I imagine you probably did, Alice, from a press release from outraged anti-abortion groups, followed by outraged press releases from outraged anti-abortion members of Congress. What happened here? And actually, Sarah, you can probably explain this better. How did this pill get approved at the same time when the FDA says it’s reexamining the approval of the original abortion pill? 

Karlin-Smith: Right. And the way that the FDA and some of the HHS [Department of Health and Human Services] leadership that says they are committed to reexamining the abortion pill and the way it is prescribed and used have sort of justified it, they’re saying that under current law, when you approve a generic, basically generics just need to essentially show they’re what’s known as bioequivalent to the brand version, and that’s really the only parameters the FDA has in terms of whether they can approve or deny the drug. If it’s essentially the same product, they have to approve it. But they’re sort of saying at the same time to people who are concerned about the use of abortion medicine and abortions in this country: But wait, wait. Hold up. We have to do this, but we’re still committed to and looking at the science around the drug, how the drug is — the safety programs around how the drug is prescribed. So, I think that while obviously people in the anti-abortion community are upset about this, the message that the political leadership at HHS is trying to send is, We are still looking at potentially making changes that could decrease access to this drug. 

Rovner: Alice, one of my colleagues said, after this, Well, why did they decide that they had to follow the law this time? There have been plenty of cases where they have decided they don’t have to follow the law. Does this signal something about the — I know that [Health and Human Services Secretary Robert F.] Kennedy [Jr.] is not an anti-abortion advocate through most of his life. I don’t think Marty Makary, the head of FDA, has either. Are they trying to have it both ways here? 

Ollstein: So, on the one hand, I wouldn’t read too much into it. Like Sarah said, there’s a very standard process for this. As long as the new generic can prove it’s the same as the old generic, it’s sort of a rubber-stamp, normal thing. And I think it’s notable that they tried to keep it so quiet, whereas maybe another administration would’ve said, Hey, look, new generic for you. But yeah, I would not take it as a sign either way. But I think it’s interesting that the anti-abortion movement is so frustrated. And they really feel sort of sidelined right now, not just with this decision. They’re very skeptical of the review that HHS announced about the abortion pills. They’re worried it’s going to come to nothing, or they’re already sort of trying to prebut what they anticipate it’s going to be, saying: Oh, just slapping a new warning label on the pills is not enough. We need to restrict them. 

And so they’re already signaling that they’re not going to be satisfied with anything less than new restrictions and bans on the drugs. So, I mean I think it’s interesting in that sense. I also think social conservatives have been disappointed. The administration talked a big game about IVF [in vitro fertilization] on the campaign trail, and now we’re not really seeing anything on that front. And of course there are divisions within the right about that. But I think there is some skepticism and disillusionment from the anti-abortion movement about what this administration has done so far. 

Rovner: We’ll get to more “MAHA” [“Make America Healthy Again”] news in a minute, but first I want to talk about the little bit of vaccine news that we have. Last week I said that neither the acting head of the CDC [Centers for Disease Control and Prevention] nor HHS Secretary Robert F. Kennedy Jr. had yet approved the changes to the vaccine schedule recommended by the advisory committee on vaccine practices last month. Well, it turns out that acting CDC Director Jim O’Neill had in fact approved the changes, but the CDC didn’t bother to tell us that until Monday. Sarah, remind us what these changes are that the ACIP [Advisory Committee on Immunization Practices] made and how this is going to impact the availability of the vaccines that the schedule’s being changed for. 

Karlin-Smith: So, the CDC and ACIP have basically changed from a universal covid vaccine recommendation, saying everybody 6 months and older should be getting at least one covid shot a year, to now they’re saying you should basically consult with your doctor and do what’s known as shared decision-making. So, have a conversation with, well, a doctor or some other provider and make a decision as to whether the shot at this time is appropriate for you. And when the ACIP voted on it, they sort of emphasized that their recommendation was people 65 and older or with certain health conditions are where they believe the shot is most appropriate, which kind of aligns with how FDA has adjusted their approval for it. The impact of CDC fully signing off on this is now that there were a number of states that it made it very hard for you to get a shot at the pharmacist, or without getting a prescription, without CDC and ACIP acting. 

Also, there’s the Vaccines for Children Program, which provides free vaccines to about half the children in this country, children on Medicaid who are under- and uninsured, and without the CDC signoff, the ACIP recommendations for covid vaccines, that program wasn’t activated. So, a number of children will now have access to shots that couldn’t have. 

Luhby: I was just going to say, one other issue is that insurers have said, because it’s — one thing is getting the vaccine. There’s also a question of whether insurance will pay for it. When I went to get my vaccine last month, initially CVS said, Oh, sure, no problem. And then when I got there, they said, I’m sorry, your insurance won’t pay for it, and they took it off. And then I protested a bit and they said, Oh, well, actually your insurance will pay for it, and it’ll be covered. So I got it. I specifically did this, of course, before the ACIP meeting, but— 

Rovner: Yes, I did that too. 

Luhby: Yes. But insurers have come out and said that they will cover it at least through the end of next year, so people should be able to get insurance coverage for it for now. There’s a question of what will happen going forward, and there also is a bit of a concern that there is a little uncertainty whether some insurers will interpret the shared medical decision-making as not a requirement for a vaccine at no charge under the ACA [Affordable Care Act] regulations. But so far it does seem that people will be able to get it at no cost for now. 

Rovner: I was saying does that shared medical decision-making apply to pharmacists? It’s only in some states, right? 

Karlin-Smith: No, you can do — shared decision-making can occur at a pharmacy and with a pharmacist. You don’t need to go to your medical doctor. And I honestly think, in practice, most providers are not going to make a big deal about it. If you make an appointment, they’re not going to force you into a long conversation. But I think what Tami flagged is important because technically the ACA coverage requirements for zero-cost coverage does apply, but I think with other vaccines in the past there has been confusion or just more people needing to actually fight to ensure they actually get the coverage that is technically in law. 

Rovner: More to come. Well, there’s other news out of HHS. Alice, you were part of an interesting story this week about how RFK Jr.’s following through on his vow to send more people to staff the Indian Health Service is having an impact elsewhere in the department. What has he done, and what impact is it having? 

Ollstein: Yes, Kennedy has touted his commitment to Native American populations and their health and has had a lot of meetings with tribal leaders and really raised hopes. And these Indian Health Service centers have been just really underfunded and understaffed for so long. They desperately need help. But based on our reporting, the help they’re getting is causing harm elsewhere. They’re not hiring more people. They’re just shuffling people around. And they’re shuffling pretty important people out of state and federal agencies and local health departments, where people are depending on them to run very key programs. HHS did not disclose who all these people are or where they’re being sent, but based on our reporting, we uncovered a few examples, including a pretty senior person at SAMHSA [the Substance Abuse and Mental Health Services Administration] and a very important person at the New York City health department. And so, we just kept hearing that what is really needed here is a permanent staffing-up, not a shuffling around. 

There were also some folks we talked to who were wondering if this was yet another tactic to try to get people to quit, to say, Oh, we’re sending you to Arizona or Montana or these sort of remote rural areas for four months, over the holidays, with just a couple weeks’ notice. But according to our reporting, no one has resigned so far. They’re all carrying out this assignment. But yeah, it could really feel the pinch, and they’re really feeling the pinch more than ever because during a government shutdown, these Commissioned Corps officers are some of the only people protected from being furloughed or laid off. And so, while tens of thousands of their colleagues are on furlough, they’re really running the show. So, they really can’t afford to lose a bunch of them at this time. 

Rovner: Yeah, it was a really interesting story. Meanwhile, there’s more reporting about the MAHA movement. The Washington Post has an excellent story about the seemingly successful lobbying effort by the pesticide industry to keep their products out of the line of fire in the recent MAHA report. And I’ve seen a bunch of stories in the past few weeks on the efforts to improve the lot of lab animals or get rid of animal testing in general, replacing it with cell cultures or other modalities. When did lab animal welfare become part of the MAHA movement? I did see that Laura Loomer is part of this, the oft-mentioned right-wing person who whispers in the ear of the president. It seems striking to me that a president who clearly is not an animal lover in the way previous presidents have been — I believe the Trumps have no pets — is suddenly, I am seeing stories out of HHS where they really are doing things to try to minimize the use of lab animals or get rid of them altogether. 

It struck me. Obviously it has its following. It is significant, and it is bipartisan. It’s often been Republicans who’ve led it. I’ve just — this is the first time I’ve seen sort of this much activity actually at HHS in all the years I’ve been covering HHS. I’m wondering, is this sort of another way that [President Donald] Trump is gathering together small groups of people who feel very strongly about something to sort of draw into his base, like he did with MAHA in general? 

Ollstein: Well, I think, like you know, Trump is no animal lover himself, and famously he uses like a dog as one of his favorite insults. So, I don’t think this is necessarily coming from the top, but it’s certainly part of this MAHA coalition he put together. And it predated this administration, because I kept seeing conservative groups in part of their crusade against [Anthony] Fauci bringing up animal testing issues. And so, this isn’t brand-new. It’s sort of been bubbling up. But yeah, I think Sarah knows more than I do about this. 

Karlin-Smith: I was going to say, I think they’ve also been able to tap into scientific literacy — or illiteracy — issues or lack thereof here, because, again, there is this bipartisan element of it. Because who isn’t going to think, like, Aw, who wants to be experimenting — right? — and giving animals terrible diseases or experimental drugs and all this stuff? And FDA and NIH [the National Institutes of Health] and so forth are now under a lot of pressure to switch away from requirements related to animal research and do things in cell-based and model-based. I think the technicalities around that in terms of where the technology actually is, in terms of people talk about organ-on-the chip technology and really being able to test it, is maybe not quite where it needs to be to move away from using some of these animals. 

I don’t think anybody in an ideal world wants to have to use animals for so many experiments. Unfortunately, I think it’s been the best tool, sometimes, we have, that ethicists have had. But I think, again, like I said, it’s hard to kind of explain all that science and technology. And what are the other options if you don’t use animals? And it’s very easy to just get the reaction of, You’re treating animals terribly and cruelly. 

Rovner: Hey, I used to write fundraising appeals over lab animals, so I know how to do this. But yes, it’s kind of sad that I did this in the early 1980s and it’s now 40 years later and we’re still working on developing alternatives to animal models. But I could go on, but I will not. 

But before we leave HHS, I want to call attention to a pretty remarkable op-ed co-authored by six former U.S. surgeons general — three Republicans and three Democrats — who together are saying, quote, “The actions of Health and Human Services Secretary Robert F. Kennedy Jr. are endangering the health of the nation,” actions that they say pose a, quote, “profound, immediate and unprecedented threat.” Over on Earth 2, this would’ve been enormous news, but in the world of Trump 2.0, where just about everything is unprecedented, it hasn’t gotten much more than a nod. Does all this criticism just kind of make Kennedy stronger among the people who support him? 

Ollstein: I think that there is a hardcore group of people who are going to support Kennedy no matter what. They’re the die-hards. But I think just like with Trump, where that’s also the case, there’s a bunch of people who supported them recently who were not hardcore, long-term devotees, and they are more flexible. And so as new information comes in and as they see what they’re doing in power, what they’re not doing, that support can erode. And so you have seen polling showing Kennedy’s popularity slipping, as well as just the Trump administration overall, people having a more negative view. And so it’s interesting to see which issues break through and which don’t. So, whether it’s animal welfare or vaccines or Native American health or, I mean, just pick your issue. 

Abortion — obviously there’s anger coming at Kennedy from both sides of that. It’ll be really fascinating to see which issue, if anything, is the downfall. I mean it’s kind of fascinating because there was a lot of Cabinet turnover in Trump’s first administration, famously with HHS, too, but other agencies as well. And so I know we’re just coming up on three-quarters through Year 1, but it’ll be interesting to see who stays and who gets booted. 

Rovner: Yeah. And whether. I mean I do — it does seem in some cases that the more criticism somebody gets, the more supporters, and also the more President Trump, kind of dig in, so — until they don’t. So, I guess we will — go ahead. 

Karlin-Smith: I was going to say, Kennedy’s core supporters seem like they are not pushing him to moderate at all. They are not. They’re pushing him the other way. They’ve been more frustrated not just in the abortion debate but with vaccines, with food— 

Rovner: Yeah 

Karlin-Smith: —with other things that he’s made some progress, but it’s been a lot smaller than I think they want. He’s still allowing mRNA vaccines on the market. Yes, some people are frustrated that he’s restricting covid vaccines, but for them he’s basically practically left the status quo when he’s promised to get rid of it. So, the momentum from his supporters is actually pushing him farther towards his MAHA agenda than towards what these surgeon generals were arguing for. 

Rovner: Yeah. That’s true. All right, well that is this week’s news, now we’ll play my interview with Sarah Grusin of the National Health Law Program, and then we will come back and do our extra credits. 

I am pleased to welcome to the podcast Sarah Grusin, a senior attorney with the National Health Law Program. Sarah is a civil rights lawyer and an expert in the exact fight that’s going on now in Congress, so I have asked here to help us break it all down. Sarah, welcome. 

Sarah Grusin: Hello. Thanks for having me. 

Rovner: So, we’ve now been subjected to more than a week of finger-pointing, with Republicans insisting that Democrats, in the words of House Speaker Mike Johnson, quote, want to “reinstate free health care for illegal aliens paid by American taxpayers.” Democrats, meanwhile, say that is flatly not true. So let’s start at the beginning. What kind of government-funded health care has been available to legal immigrants and to those who are undocumented, at least until this summer? 

Grusin: Well, for undocumented immigrants, the answer is easy. They are not eligible for any sort of comprehensive federally funded coverage. The answer for lawfully present immigrants is more complicated. So I’ll take that one program by program. So, start first with the Affordable Care Act premium subsidies. Those are only available to lawfully present individuals. They’re not available to undocumented immigrants. And that’s been true since the ACA was first passed, and it hasn’t changed. In fact, undocumented individuals are not even eligible to enroll in marketplace plans, even if they pay full cost. So this whole fight over extending the enhanced ACA subsidies has nothing to do with coverage for undocumented immigrants. But like I said, the Affordable Care Act subsidies are generally available to lawfully present immigrants, with a big asterisk for DACA recipients, or Deferred Action for Childhood Arrivals. They are not in fact eligible for those subsidies. 

Rovner: But they were for a while, right? 

Grusin: They were for a few months this year. So they weren’t for a long time, the Biden administration tried to fix it, then the Trump administration undid that, and so they are now, again, without access to the marketplace subsidies. Medicaid and CHIP [Children’s Health Insurance Program] eligibility is more complicated. The main thing to understand though is that Medicaid and CHIP is available to a smaller group of lawfully present immigrants than the ACA subsidies. So, Medicaid has only been available to a narrow group of what the statute calls qualified immigrants. So these are LPRs [lawfully permanent residents] or people colloquially known as green card holders — Cuban-Haitian entrants, refugees, asylees, and certain other humanitarian statuses, like people with protection under the Convention Against Torture, victims of trafficking, survivors of domestic violence and battery. But just having a qualified immigration status is not enough to necessarily guarantee Medicaid eligibility. Many qualified immigrants, most notably LPRs, are subject to a five-year waiting period, meaning that they have to have that status for five years before they can be eligible. 

So a lot a lot of people who live here lawfully, who live here permanently, who have robust, complete lives here, people on student visas, people here with work visas, asylum applicants, and even LPRs who are being sponsored by a family member, aren’t eligible for Medicaid in a lot of situations. I will say there are some options that states have to expand Medicaid with federal funding for other immigrants beyond these sort of narrow set of qualified statuses, but that’s limited to children and coverage for pregnancy. There are no equivalent options for non-pregnant adults. And then, each state has to elect whether to take up those options. And so there are dozens of states that have taken it up for either children or pregnancy or both, but that leads to a lot of variation across the country in terms of who’s available for those services. But bottom line, lawfully present immigrants are generally eligible for the ACA subsidies, and some but not all lawfully present immigrants are eligible for Medicaid and CHIP. Undocumented individuals are not eligible for either. 

Rovner: But there is this emergency Medicaid, right? 

Grusin: There is this thing called emergency Medicaid. And so, emergency Medicaid, I want to explain what it is. It covers people who would otherwise be eligible for Medicaid if it weren’t for their immigration status. So, they still have to meet the income requirements. They still have to fall, in a non-expansion state, into one of the covered population groups, so child, parent, person with a disability. And then in addition, the coverage is extremely limited, so it is only coverage necessary to treat an emergency medical condition. But if somebody gets into a car accident and goes to the emergency room, emergency Medicaid could cover their hospital bill if they can otherwise establish their Medicaid eligibility. It also does cover labor and delivery services, but just labor and delivery, not prenatal care. So, and that reimbursement that the hospital gets is a combination of state and federal funds. 

Rovner: How did the “big, beautiful” Republican budget Bill change that? It sort of contracted some of it, right? 

Grusin: Well, so it didn’t change the eligibility, who’s eligible for emergency Medicaid, and it didn’t change what services are covered under emergency Medicaid. All it did was reduce — like I said, the reimbursement was federal and state money — all it did was reduce the federal amount of money that’s going to pay for these services. So that means that the states are just going to have to pick up the bill. Really all it’s doing is shifting the cost to the states. And I had one other point about emergency Medicaid, which is, to be clear, it does cover individuals who don’t have status, but it also is the only source of coverage available for all of those lawfully present folks who aren’t eligible for full-scope Medicaid. So I often hear people talking about emergency Medicaid as though it only covers undocumented individuals, and I just want to be clear that that’s not true. 

There are a lot of people who are lawfully present, including LPRs, who haven’t met that five-year waiting period, for whom emergency Medicaid is in fact their only option. So, we talk about emergency Medicaid when we’re talking about people who don’t have status because that’s the only thing available to them, but it’s also the only thing available to a whole group of lawfully present folks, too. 

Rovner: And the budget bill also contracted who’s eligible, of the lawfully present people, who can get some of these programs, right? 

Grusin: Dramatically. It dramatically reduced it. So, following the implementation of those changes in both Medicaid and the Affordable Care Act subsidies, the only groups that will be eligible for coverage are LPRs, still with the same five-year waiting period, migrants under the Compact of Free Association, or COFA migrants, and Cuban and Haitian entrants. So this means that one of the primary effects that this bill has is ending eligibility for people with humanitarian statuses. So refugees, people granted asylum for fear of persecution in their home country, people with protection under the Convention Against Torture, survivors of trafficking, survivors of domestic violence, these are the people who the Republican bills stripped of their health coverage. And really, there are not going to be any other options left for most of those lawfully present immigrants to get meaningful coverage once those changes go into effect, unless they happen to live in a state that is providing exclusively state-funded services, but there’s not that many of those. 

Rovner: What’s the practical impact of this going to be? 

Grusin: I mean we all know what the consequence of taking away people’s health care coverage is. It’s more suffering. It means people will have no viable option to receive necessary care. It means more deaths. It means more disease. It means more enduring pain due to chronic conditions. There are refugees, other folks who are currently living in nursing homes, they’re going to be evicted. There are people who won’t be able to afford their insulin. There are people who are going to have to skip prenatal appointments. The other thing is we know that the effects and the loss of coverage will extend well beyond the people who are explicitly losing coverage. After PRWORA [the Personal Responsibility and Work Opportunity Reconciliation Act] was passed, there were a lot of families, whether due to confusion or fear or both, chose not to enroll household members who were still eligible, including citizen children in mixed-status households. 

And we live in a country where 1 in 4 kids lives with an immigrant parent, and so we know that this effect is going to be enormous. And then, of course, there’s also the economic effects as well, right? Increased costs for states. Increased costs for hospitals due to uncompensated care. More people having to leave the workforce due to untreated medical conditions. I mean, the tolls are going to be enormous. 

Rovner: And just to back up a little bit, PRWORA being the 1996 welfare bill, where they last had a huge fight about coverage for immigrants in general. And I covered that one, too, because I’m old. 

Grusin: That’s great. Yeah. PRWORA, the worst acronym that anyone’s ever come up with. 

Rovner: Bottom line, it’s not really fair to say that if the Republicans were to reverse the Medicaid cuts, which of course is what the Democrats are asking for, it would not, quote-unquote, “reinstate” coverage for illegal immigrants. You’re shaking your head. 

Grusin: No. No. They didn’t have it before. They don’t. They wouldn’t have it after. What it would do is reinstate coverage for humanitarian lawfully present immigrants. 

Rovner: Excellent. I hope that as this goes on, we can come back and ask you to revisit it. Sarah Grusin, thank you very much. 

Grusin: Thank you. 

Rovner: OK, we are back, and 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’ll put the links in our show notes on your phone or other mobile device. Alice, why don’t you go first this week? 

Ollstein: Yeah, I have a piece by friend of the pod Shefali Luthra of The 19th. [“Ice Fears Put Pregnant Immigrants and Their Babies at Risk,” by Mel Leonor Barclay and Luthra.] It is a fascinating and sad story about how the current ramped-up immigration enforcement is making a lot of immigrant women who are pregnant afraid of going to seek prenatal care, and that’s already having repercussions. It’s so important to have prenatal visits. That’s where you diagnose things early, whether it’s a syphilis infection that you can catch in time, or it could be hypertension or high blood pressure or low blood pressure or something. And when you don’t catch those things early, they can become really dangerous later on, both for mothers and babies. And so she talked to people around the country who are already seeing the repercussions of this, and people are just afraid to drive to these appointments. And so it’s a downstream effect that’s important to keep in mind. 

Rovner: And of course, that was why in previous administrations immigration officers were not allowed at health care facilities, so as to not deter people from getting health care. Sarah, why don’t you go next? 

Karlin-Smith: I took a look at a New York Times piece: “It’s Just a Virus, the E.R. Told Him. Days Later, He Was Dead” [by Lisa Miller]. And it’s a really tragic story about a young college student who went to the ER twice with an illness and was both times sent home sort of just to recover at home, and he did die. And what I find really interesting is the piece highlights the broader public health policy questions about how our overstrapped emergency rooms are equipped to handle the wide range of patients that come into them, given how much the system is put on them, and how do we set up a system, given the complexity of the people they see and the amount of space and time they have to see them, that can really dig into these unique situations. 

Because it seems like there were some maybe unique flags about this particular person’s blood work and so forth that were missed potentially, but it’s not like a clear-cut case, it seems like from reading it, these doctors really missed something clear and obvious and did harm, but points out a bunch of broader systematic things that set everybody up to potentially fail here. 

Rovner: Yeah, I was interested in the interactions with the electronic medical record that’s supposed to help them catch these things. But because it ends up giving doctors so many alarms that aren’t really accurate, that when it does give one that’s accurate, that gets ignored, which seems to be one of the many things that happened kind of tragically in this case. Tami. 

Luhby: Well, my story is by Meryl Kornfield and Lisa Rein of The Washington Post, titled “Trump Plan Would Limit Disability Benefits for Older Americans.” It’s a scoop for The Post, which has done fantastic reporting over the years on Social Security disability, and they found out that the Trump administration is preparing a plan that would make it harder for older Americans to qualify for Social Security disability payments and could result in hundreds of thousands of people losing their benefits. The story explains that the Social Security Administration considers age, work experience, and education when evaluating disability claims. Older applicants, those typically over 50, have a better chance of qualifying, because aid is treated as a limitation in being able to adapt to a new job that one with disabilities might be able to do. 

But the administration is considering eliminating age as a factor or raising the threshold to 60. So it’s already pretty well known that disability benefits are very tough to qualify for. The process can take years. And this change would make it even harder for folks to get the disability benefits. So it’s something I’m sure The Washington Post will continue following closely, and as will I and many others who are interested in this issue. 

Rovner: So, my extra credit this week is kind of the flip side of Tami’s. It’s also from The Washington Post, and it’s called “How Some Veterans Exploit $193 Billion VA Program, Due to Lax Controls,” by Craig Whitlock, Lisa Rein, and Caitlin Gilbert. It’s a reminder that every government program, no matter how well meaning, is subject to fraud, and it’s kind of our job as journalists to point that out when we find it, so it can be fixed. You really should read the whole thing, but here’s the nut graph: “About 556,000 veterans receive disability benefits for eczema, 332,000 for hemorrhoids, 110,000 for benign skin growths, 81,000 for acne and 74,000 for varicose veins, the most recently available figures from VA [Department of Veterans Affairs] show. Individual payouts for such mundane conditions vary, but collectively they cost billions of dollars a year.” The VA has already called this an attack on veterans programs, but it’s really an effort to point out how these programs could be saved for the people for whom they’re actually intended. So, good journalism from The Washington Post on sort of both sides of this issue. 

OK, that is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you could subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. 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, or on Bluesky, @julierovner. Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky, @alicemiranda. Still on X, @AliceOllstein. 

Rovner: Sarah? 

Karlin-Smith: Also mostly on Bluesky and LinkedIn, @sarahkarlin-smith. 

Rovner: Tami. 

Luhby: I’m at cnn.com. 

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