“We’re going to fight for much better health care than Obamacare. Obamacare is a catastrophe,” Trump said at a campaign stop in Iowa on Jan. 6.

The perplexing revival of one of Trump’s most politically damaging crusades comes at a time when the Obama-era health law is even more popular and widely used than it was in 2017, when Trump and congressional Republicans proved unable to pass their own plan to replace it. That failed effort was a big part of why Republicans lost control of the House of Representatives in the 2018 midterms.

Despite repeated promises, Trump never presented his own Obamacare replacement. And much of what Trump’s administration actually accomplished in health care has been reversed by the Biden administration.

Still, Trump secured some significant policy changes that remain in place today, including efforts to bring more transparency to prices charged by hospitals and paid by health insurers.

Trying to predict Trump’s priorities in a second term is even more difficult given that he frequently changes his positions on issues, sometimes multiple times.

The Trump campaign did not respond to a request for comment.

Perhaps Trump’s biggest achievement is something he rarely talks about on the campaign trail. His administration’s “Operation Warp Speed” managed to create, test, and bring to market a covid-19 vaccine in less than a year, far faster than even the most optimistic predictions.

Many of Trump’s supporters, though, don’t support — and some even vehemently oppose — covid vaccines.

Here is a recap of Trump’s health care record:

Public Health

Trump’s pandemic response dominates his overall record on health care.

More than 400,000 Americans died from covid over Trump’s last year in office. His travel bans and other efforts to prevent the global spread of the virus were ineffective, his administration was slower than other countries’ governments to develop a diagnostic test, and he publicly clashed with his own government’s health officials over the response.

Ahead of the 2020 election, Trump resumed large rallies and other public campaign events that many public health experts regarded as reckless in the face of a highly contagious, deadly virus. He personally flouted public health guidance after contracting covid himself and ending up hospitalized.

At the same time, despite what many saw as a politicization of public health by the White House, Trump signed a massive covid relief bill (after first threatening to veto it). He also presided over some of the largest boosts for the National Institutes of Health’s budget since the turn of the century. And the mRNA-based vaccines Operation Warp Speed helped develop were an astounding scientific breakthrough credited with helping save millions of lives while laying the groundwork for future shots to fight other diseases including cancer.

Abortion

Trump’s biggest contribution to abortion policy was indirect: He appointed three Supreme Court justices, who were instrumental in overturning the constitutional right to an abortion.

During his 2024 campaign, Trump has been all over the place on the red-hot issue. Since the Supreme Court overturned Roe v. Wade in 2022, Trump has bemoaned the issue as politically bad for Republicans; criticized one of his rivals, Florida Gov. Ron DeSantis, for signing a six-week abortion ban; and vowed to broker a compromise with “both sides” on abortion, promising that “for the first time in 52 years, you’ll have an issue that we can put behind us.”

He has so far avoided spelling out how he’d do that, or whether he’d support a national abortion ban after any number of weeks.

More recently, however, Trump appears to have mended fences over his criticism of Florida’s six-week ban and more with key abortion opponents, whose support helped him get elected in 2016 — and whom he repaid with a long list of policy changes during his presidency.

Among the anti-abortion actions taken by the Trump administration were a reinstatement of the “Mexico City Policy” that bars giving federal funds to international organizations that support abortion rights; a regulation to bar Planned Parenthood and other organizations that provide abortions from the federal family planning program, Title X; regulatory changes designed to make it easier for health care providers and employers to decline to participate in activities that violate their religious and moral beliefs; and other changes that made it harder for NIH scientists to conduct research using fetal tissue from elective abortions.

All of those policies have since been overturned by the Biden administration.

Health Insurance

Unlike Trump’s policies on reproductive health, many of his administration’s moves related to health insurance still stand.

For example, in 2020, Trump signed into law the No Surprises Act, a bipartisan measure aimed at protecting patients from unexpected medical bills stemming from payment disputes between health care providers and insurers. The bill was included in the $900 billion covid relief package he opposed before signing, though Trump had expressed support for ending surprise medical bills.

His administration also pushed — over the vehement objections of health industry officials — price transparency regulations that require hospitals to post prices and insurers to provide estimated costs for procedures. Those requirements also remain in place, although hospitals in particular have been slow to comply.

Medicaid

While first-time candidate Trump vowed not to cut popular entitlement programs like Medicare, Medicaid, and Social Security, his administration did not stick to that promise. The Affordable Care Act repeal legislation Trump supported in 2017 would have imposed major cuts to Medicaid, and his Department of Health and Human Services later encouraged states to require Medicaid recipients to prove they work in order to receive health insurance.

Drug Prices

One of the issues the Trump administration was most active on was reducing the price of prescription drugs for consumers — a top priority for both Democratic and Republican voters. But many of those proposals were blocked by the courts.

One Trump-era plan that never took effect would have pegged the price of some expensive drugs covered by Medicare to prices in other countries. Another would have required drug companies to include prices in their television advertisements.

A regulation allowing states to import cheaper drugs from Canada did take effect, in November 2020. However, it took until January 2024 for the FDA, under Trump’s successor, to approve the first importation plan, from Florida. Canada has said it won’t allow exports that risk causing drug shortages in that country, leaving unclear whether the policy is workable.

Trump also signed into law measures allowing pharmacists to disclose to patients when the cash price of a drug is lower than the cost using their insurance. Previously pharmacists could be barred from doing so under their contracts with insurers and pharmacy benefit managers.

Veterans’ Health

Trump is credited by some advocates for overhauling Department of Veterans Affairs health care. However, while he did sign a major bill allowing veterans to obtain care outside VA facilities, White House officials also tried to scuttle passage of the spending needed to pay for the initiative.

Medical Freedom

Trump scored a big win for the libertarian wing of the Republican Party when he signed into law the “Right to Try Act,” intended to make it easier for patients with terminal diseases to access drugs or treatments not yet approved by the FDA.

But it is not clear how many patients have managed to obtain treatment using the law because it is aimed at the FDA, which has traditionally granted requests for “compassionate use” of not-yet-approved drugs anyway. The stumbling block, which the law does not address, is getting drug companies to release doses of medicines that are still being tested and may be in short supply.

Trump said in a Jan. 10 Fox News town hall that the law had “saved thousands and thousands” of lives. There’s no evidence for the claim.

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Some background: Ehrenfeld is a Wisconsin anesthesiologist, researcher and medical school professor who also directs a health-care philanthropy in his state. He’s an Afghanistan combat veteran, the first openly gay president of the AMA and a national advocate for LGBTQ+ rights.

This transcript has been edited for clarity and brevity. You can hear the whole interview later today on “What the Health?”

Rovner: Congress is coming back and working on a budget, or so we hear. I know physicians are facing, again, a cut in Medicare pay, but that’s not the only AMA priority here in Washington at the moment, right? [Note: A 3.37 percent cut to Medicare physician payments took effect Jan. 1.]

Ehrenfeld: It’s unconscionable. And so we’re optimistic that we can get a fix, hopefully retroactive, as the omnibus consolidation work goes forward.

Physicians continue to struggle. My parents lost their own primary care physician because of a challenge with their primary care doctor not being able to take Medicare anymore. And what we’re seeing is more and more doctors just stopping seeing new Medicare patients, or opting out of the program entirely.

Rovner: Now we have the Supreme Court — none of whom have an M.D., as far as I know — about to decide whether doctors [treating] women with pregnancy emergencies should obey state abortion bans, the federal Emergency Medical Treatment and Active Labor Act, or their medical ethics, all of which may conflict. What’s the AMA doing to help doctors navigate these very choppy and changing legal waters?  

Ehrenfeld: Choppy is a good word for it. It’s confusing. And since the Dobbs decision, we have been working with all of our state and federation partners to try to help physicians navigate this. It’s unbelievable that now physicians are having to call their attorneys, the hospital legal counsel, to figure out what they can and can’t do. And, obviously, this is not a picture that supports women’s health. So we are optimistic that we might get a positive ruling with this EMTALA decision on the Supreme Court. But, obviously, there’s a long way that we need to go to make sure that we can maintain access for reproductive care.

Rovner: Do you think that’s something that has dawned on the rest of the members of the AMA that this is not necessarily about abortion, this is about the ability to practice medicine?  

Ehrenfeld: If you look at some of these socially charged restrictive laws, whether it’s in transgender health or abortion access, or other items, we take the same foundational approach, which is that physicians and patients ought to be making their health-care decisions without legislative interference. 

Rovner: It’s not just abortion and reproductive health where lawmakers are trying to dictate medical practice, but also care for transgender kids and adults and even treatment for covid and other infectious diseases. What are you doing to fight the sort of “pushing against” scientific discourse?  

Ehrenfeld: Our foundation in 1847 was to get rid of quackery and snake-oil salesmen in medicine. And yet here we are trying to do some of those same things with misinformation, disinformation. And obviously, even if you look at the attack on PrEP, preexposure prophylaxis for HIV prevention — making it basically zero out-of-pocket cost for many Americans — [not providing PrEP is] just unconscionable. We have treatments. We know that they work. We ought to make sure that patients and their physicians can have access to them.

Rovner: Artificial intelligence can portend huge advances and also other issues, not all of which are good. How is the AMA trying to push [medicine] more toward the former, the good things, and less toward the latter, the unintended consequences?  

Ehrenfeld: We need to make sure that we have appropriate regulation. The [Food and Drug Administration] doesn’t have the framework that they need.  We just need to make sure that those changes only let safe and effective algorithms, AI tools, AI-powered products come to the marketplace.

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“The highest investment priority in Washington should be to double the federal budget for scientific research,” former House Speaker Newt Gingrich (R-Ga.) wrote in a 1999 op-ed in The Washington Post. Big spending increases for the National Institutes of Health soon followed. 

Just four years later, when Republicans controlled both Congress and the presidency, they created the President’s Emergency Plan for AIDS Relief, a $15 billion program to fight AIDS and HIV overseas that’s credited with saving millions of lives. “In the face of preventable death and suffering, we have a moral duty to act, and we are acting,” President George W. Bush said at the bill’s signing.

What a difference 20 years makes.

The GOP-led House this year wants to cut funding for the Department of Health and Human Services by more than 12 percent — including nearly $4 billion from the once-revered NIH. “We cannot continue to make our constituents pay for our reckless DC beltway spending,” Rep. Robert B. Aderholt (R-Ala.), chair of the House Appropriations subcommittee that oversees HHS, said when the bill came to the floor last month. 

And for the first time, bipartisan support for PEPFAR has eroded, with antiabortion Republicans blocking the latest renewal of the program. “Regrettably, PEPFAR has been reimagined — hijacked — by the Biden administration to empower pro-abortion international nongovernmental organizations, deviating from its life-affirming work,” said Rep. Christopher H. Smith (R-N.J.) on the House floor in September.

Washington’s a more polarized place than it was in the early 2000s (take it from me, a reporter who covered the Bush administration and PEPFAR’s creation). And some of the health issues Republicans confronted back then were thrust upon them by 9/11 and the anthrax attacks on Congress, all but forcing boosts to programs and funding to fight bioterrorism.

But then came Donald Trump, the embodiment of the party’s turn toward populism and skepticism of institutions and authority figures. 

“He made fun of people who wore masks,” said Jim Greenwood, a former Republican House member from Pennsylvania who made a lot of health policy in the 1990s and 2000s and later headed what is now the Biotechnology Innovation Organization. “He turned scientists and ‘elitists’ into the bad guys and made it seem as if good old common sense is what we need, not science.” 

The pandemic, and the government’s response to it, hasn’t helped.

“Covid was public health’s moment on the public stage,” said Dean Rosen, a GOP lobbyist who worked in both the House and Senate in the 1990s and 2000s, including as the top health adviser to Senate Majority Leader Bill Frist (R-Tenn.). 

Public health officials “overreached and under-delivered,” he said, while much of the public perceived ill-explained mandates and restrictions as “overreach and intrusion into our lives.”

Anti-vaccine sentiment has surged among Republicans since the pandemic, according to KFF, even as support for vaccination has remained steady among Democrats.

Science historians Naomi Oreskes and Erik Conway say it’s not populism or perceived government incompetence driving Republican distrust of science. Rather, it’s the continuation of a century-old trend of “conservative hostility toward ‘big government,’” they wrote in a 2022 research paper. 

“In short, contemporary conservative distrust of science is not really about science,” they wrote. “It is collateral damage, a spillover effect of distrust in government.”

Any change in GOP sentiment toward public health looks to be a long way off. You don’t hear much support for government public health officials or for vaccination from the Republicans challenging Trump for the 2024 presidential nomination. They “don’t want to get any light between them and his attitudes and approaches to these kinds of things,” Greenwood lamented.

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“Frankly I think it’s unethical and immoral to allow for abortions up until the day of birth,” Sen. Tim Scott (R-S.C.) said at last week’s GOP presidential primary debate.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

At that same debate, entrepreneur-turned-presidential candidate Vivek Ramaswamy noted that voters in his home state of Ohio had just passed a constitutional amendment that, he said inaccurately, “now effectively codifies a right to abortion all the way up to the time of birth without parental consent.”

The Ohio election, in which 57 percent of voters in what’s lately been a red state chose to enshrine abortion rights in the state constitution, has abortion opponents reeling. In addition, Virginia voters gave Democrats control of the state legislature, effectively rejecting Republican Gov. Glenn Youngkin’s plans to ban abortion after 15 weeks, while Kentucky voters reelected Democratic Gov. Andy Beshear after he highlighted his Republican opponent’s support for the state’s abortion ban.

Combined, the election results put in question whether voters will accept even post-15-week abortion bans outside the most conservative parts of the country. Scott, the most vocal proponent of a federal 15-week ban in the GOP primary, suspended his campaign on Sunday.

But do some expectant mothers really opt for abortions as late as the day they’re due? Hardly, says Katrina Kimport. Many women who undergo later abortions wanted their pregnancies to continue, she said, “and it’s very upsetting to be mischaracterized in these public settings and maligned.”

Kimport should know. A medical sociologist and professor at the University of California at San Francisco, she’s one of the nation’s top experts on abortions later in pregnancy, having carried out in-depth formal interviews with more than 50 women who terminated pregnancies after 24 weeks (roughly the time a fetus is viable outside the womb). She said she’s spoken with at least 20 more informally.

(Take note: There’s no such thing as a “late-term” abortion. According to the American College of Obstetricians and Gynecologists, late-term refers to the period after 40 weeks, when the pregnancy has exceeded full-term. The Associated Press in 2022 changed its stylebook to read: “Do not use the term ‘late-term abortion.’”)

The number of abortions performed after viability are vanishingly small. Only about 1 percent occur after 21 weeks, according to the Centers for Disease Control and Prevention — and most of those, Kimport said, are before 24 weeks. More than 93 percent are performed at or before 13 weeks. So what about those abortions at “the time of birth?”  

For one thing, there’s almost no one in the U.S. who performs abortions so late in pregnancy. “There are only three providers publicly known to offer abortion after 28 weeks,” Kimport said.

Women who seek abortions later in pregnancy generally do so for two reasons, she said. One is new information: They find out something they didn’t know earlier about their own health or the fetus’s, or they don’t realize they are pregnant.

In the latter case, it’s not just teenagers. One woman Kimport interviewed was in her 40s, and had a series of health issues that involved taking medications “with side effects that included weight fluctuations, irregular periods and nausea.” She didn’t take a pregnancy test until 25 weeks. 

The other main reason some women seek abortions later in pregnancy is that they tried to access it earlier, but faced barriers. Those include having to travel to another state, getting an appointment, raising money for the procedure, and navigating things like two-visit clinic requirements or parental-involvement laws.

A later abortion is a big deal, both medically and financially. The later in pregnancy an abortion is performed, the more complex — and expensive — it becomes. It often takes multiple days, and many women end up going through a full labor and delivery anyway. The procedure can cost as much as $30,000 late in a pregnancy, according to the group Who Not When, which tracks later abortions. That may or may not be covered by health insurance.  

For women who have had such procedures, it was “emotionally complicated,” Kimport says. And they don’t appreciate how politicians “insult their decision-making.”

But given that public support for abortion declines the later in pregnancy it happens, don’t expect antiabortion forces to give up this particular talking point anytime soon.

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For more than a century, the most influential U.S. physician group has stridently opposed what could generally be described as “national health insurance.” It famously helped defeat health reform efforts in the 1930s and 1940s, delayed the establishment of Medicare for years, and helped sink President Bill Clinton’s health overhaul in the 1990s.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

So it was a big deal when the AMA endorsed the Affordable Care Act in 2009. 

(An aside: A main reason the organization offered its support was the promise, in its early forms, that Obamacare would end a pernicious Medicare payment cut. That didn’t happen until 2015. But that’s a whole ‘nother story.)

The last time the AMA’s House of Delegates, its policymaking body, debated single-payer health care was in 2019. That effort was spearheaded by the more left-leaning medical student section. The students’ resolution would not have specifically endorsed a single-payer program, such as Medicare-for-all. Instead, they just aimed for the AMA to be neutral on single-payer, dropping its longtime official opposition.

The students’ resolution failed, but much more narrowly than anticipated: 53 percent to 47 percent.

This time, it’s not the student section of the organization pushing for a single-payer resolution to be offered at the House of Delegates meeting later this month, at National Harbor outside Washington. It’s the delegation of practicing doctors from New England.

That alone should help the resolution get taken more seriously than in 2019, said Rohan Khazanchi, who was involved in the student effort in 2019 and is now a second-year resident in internal medicine and pediatrics at Harvard.

• “For better or worse, the student section is the conscience of the organization,” Khazanchi said. “They’re always bringing issues of health and social justice to the floor. But sometimes it’s a little harder for other stakeholders in the House to get behind that.”

He’s also more optimistic because the makeup and leadership of the AMA has shifted in recent years, embracing challenges like health inequities and racism in medicine. “Really big, meaty health justice issues are now being taken on as an express priority of the organization,” he said.

That leftward shift in political outlook is showing up not just in the AMA, but in medicine as a whole. As the physician population has become younger, more female and less White, doctors (and other college graduates in medicine) have moved from being a reliable Republican constituency to a more reliable Democratic one.

But even if the AMA votes to stop fighting single-payer, as a practical matter, the resolution won’t have much impact. The organization maintains other policies that would still preclude support for any proposal that would increase the power of payers — including the government — over patients and physicians, an AMA spokesperson said in an email. 

Another stab at a broad overhaul of the U.S. health-care system is pretty unlikely in the near future anyway, said Zeke Emanuel, a physician who helped former president Barack Obama win passage of the Affordable Care Act and is now vice-provost for global issues and co-director of the Healthcare Transformation Institute at the University of Pennsylvania.

• “The system sucks worse than ever. I do think there’s more dissatisfaction” among patients and care providers, he said, despite the ACA extending insurance coverage to millions of Americans.
• “I don’t think it’s at a critical level, and more importantly, we don’t know how to do the strategic reform,” he added.

So the AMA adopting a single-payer resolution won’t “fundamentally change the equation,” Emanuel said. But he feels it would send an important signal. “Docs feel pulled in a million different ways,” he said, “undermining their ability to do the job and their satisfaction. They’re not doing what they came into medicine for, to care for patients.”

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If it happens, some government functions would stop completely and some in part, while others wouldn’t be immediately affected — including Medicare, Medicaid, and health plans sold under the Affordable Care Act. But a shutdown could complicate the lives of everyone who interacts with any federal health program, as well as the people who work at the agencies administering them.

Here are five things to know about the potential impact to health programs:

1. Not all federal health spending is the same.

“Mandatory” spending programs, like Medicare, have permanent funding and don’t need Congress to act periodically to keep them running. But the Department of Health and Human Services is full of “discretionary” programs — including at the National Institutes of Health, Centers for Disease Control and Prevention, community health centers, and HIV/AIDS initiatives — that must be specifically funded by Congress through annual appropriations bills.

The appropriations bills (there are 12 of them, each covering various departments and agencies) are supposed to be passed by both chambers of Congress and signed by the president before the start of the federal fiscal year, Oct. 1. This almost never happens. In fact, according to the Pew Research Center, Congress has passed all the appropriations bills in time for the start of the fiscal year only four times since the modern budget process was adopted in the 1970s; the last time was in 1997.

Congress usually keeps the lights on for the government by passing short-term funding bills, known as “continuing resolutions,” or CRs, until lawmakers can resolve their differences on longer-term spending.

This year, however, a handful of conservative Republicans in the House have said they won’t vote for any CR, in an attempt to force deeper spending cuts than those agreed to this spring in a bipartisan bill to raise the nation’s borrowing authority. House Speaker Kevin McCarthy and his allies could join with Democrats to keep the government running, but that would almost certainly cost McCarthy his speakership. Several of the rebellious conservatives are already threatening to force a vote to oust him.

2. The Biden administration decides what stays open.

The White House Office of Management and Budget is responsible for drawing up contingency plans in case of a government shutdown and publishes one for each federal department. The plan for Health and Human Services estimates that 42% of its staff would be furloughed in a shutdown and 58% retained.

The general rule is that two types of activities may continue absent annual spending authority from Congress. One is activities needed “for safety of human life or the protection of property.” At HHS, that would include caring for patients at the hospital on the campus of the National Institutes of Health — though new patients generally would not be admitted — as well as the agency’s laboratory animals, and CDC investigations of disease outbreaks.

Other activities that may continue are those with funding sources that aren’t dependent on annual appropriations. Medicare and Social Security, for example, are entitlements funded by taxes and premiums. Drug approvals at the FDA are largely funded by user fees paid by drugmakers, so approvals in process could continue, but questions remain about whether new approval processes could start.

Also unaffected are programs that have been funded in advance by Congress. For example, the Indian Health Service is already funded through the 2024 fiscal year.

3. What happens to enrollment in Medicare and Affordable Care Act plans?

It depends on how long the shutdown lasts. In the short term, mandatory spending programs would be mostly, but not completely, unaffected by a government shutdown. Benefits would continue under programs like Medicare, Medicaid, and the Affordable Care Act, and doctors and hospitals could continue to submit bills and get paid. But federal staffers not considered “essential” would be furloughed.

That means initial Medicare enrollment could be temporarily stopped. According to the Committee for a Responsible Federal Budget, an independent group that tracks federal spending, during the 1995-96 federal shutdown, “more than 10,000 Medicare applicants were temporarily turned away every day of the shutdown.”

A shutdown shouldn’t much affect Medicare’s annual open enrollment period, which starts Oct. 15 and allows current beneficiaries to join or change private Medicare Advantage or prescription drug plans. That’s because much of the funding to help seniors and other beneficiaries choose or change Medicare health plans has already been allocated.

Rebecca Kinney, who runs the HHS office that oversees the federal program that counsels Medicare beneficiaries about their myriad choices, said Sept. 22 that funding for both the 1-800-MEDICARE hotline and federally funded state counseling agencies has already been distributed for this year, so neither would be affected, at least in the short run.

The same is true for Affordable Care Act plans, which open for enrollment Nov. 1. The HHS contingency documents say the Centers for Medicare & Medicaid Services, which oversees the federal health exchange, healthcare.gov, “will continue Federal Exchange activities, such as eligibility verification,” using fees paid by insurers left over from the previous year.

Still, about half of CMS staffers would be furloughed in a shutdown. That could complicate a lot of other activities there, starting with drug price negotiations set to begin Oct. 1. HHS Secretary Xavier Becerra told reporters at the White House last week that a shutdown would likely push back the timeline for negotiations.

A shutdown would also threaten HHS oversight of the Medicaid “unwinding” process, as states reevaluate the eligibility of those enrolled in the program for low-income people. State workers would be unaffected, according to the Georgetown University Center for Children and Families, so eligibility reviews would continue regardless. But because of federal furloughs, “technical assistance to help states address unwinding problems and adopt mitigation strategies could cease,” wrote the center’s Kelly Whitener and Edwin Park. “Efforts to determine if there are further renewal processes that are out of compliance with federal requirements could be limited or ended.”

4. What if the shutdown is prolonged?

More programs could be affected. For example, the HHS shutdown contingency document says that “CMS will have sufficient funding for Medicaid to fund the first quarter” of fiscal year 2024. The government has never been shut down long enough to know what would happen after that. The 2013 shutdown, which included HHS, lasted just over two weeks. Most of the agency wasn’t affected by the 2018-19 shutdown because its annual appropriations bill had already been signed into law. (The FDA is funded under the appropriations bill that covers the Agriculture Department rather than the one that funds HHS.)

5. Do federal employees get paid during a shutdown?

It depends. Employees whose programs are funded continue to work and be paid. Those considered “essential” but whose programs are not funded would continue to work, but they wouldn’t get paid until after the shutdown ends. A 2019 law now requires federal workers to get back pay when funding resumes, which was not always the case. However, federal contractors, including those who work in food service or maintenance jobs, have no such guarantee.

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But not all important work is serious.

One former HHS secretary, Kathleen Sebelius, recalled a highlight of her tenure: recording a public service message with “Sesame Street.” “The Elmo commercial was to teach kids how to sneeze,” she said. “We were trying to spread good health habits.”

The script called for Sebelius to ask her co-star to “bend your elbow and sneeze into your arm.”

“Elmo has no elbow,” the beloved red Muppet replied, veering off script. So, Sebelius said, they swapped roles: “Elmo taught me how to sneeze.”

Her story punctuated a rare, intimate conversation Wednesday with three HHS secretaries, past and present — and across party lines. Secretary Xavier Becerra, the agency’s current leader, joined Sebelius, who worked under then-President Barack Obama from 2009 to 2014, and Alex Azar, who worked under then-President Donald Trump from 2018 to 2021. Their candid discussion took place at Aspen Ideas: Health, part of the Aspen Ideas Festival, about the job each of them held.

The panel discussion, taped in Aspen, Colorado, before a standing room-only crowd, was hosted as a live episode of KFF Health News’ weekly policy news podcast, “What the Health?,” and is now available to stream.

Becerra, Azar, and Sebelius spoke not only about the common bullet point on their resumes, but also about their shared understanding of what it means to lead the agency at a time when health is at the front of American minds — and in the crosshairs of American politics. Becerra and Azar have led HHS during the covid-19 pandemic, and Sebelius was in charge during the implementation of the Affordable Care Act.

They offered frank and at times strikingly similar perspectives on leading a department with more than 80,000 employees; a budget of more than $1.5 trillion; and an agenda most often set by outside events or their boss at 1600 Pennsylvania Ave.

Azar, who described fielding “two to five” daily phone calls from Trump, which could come at nearly any hour, said he started his days huddling with senior staff “to discuss what could hit us in the face today.”

“The White House is not a patient place,” said Becerra, who described losing 11 twin towers’ worth of Americans to covid-19 every day when he took the reins. “They want answers quickly.”

“It truly is life and death at HHS,” Becerra added. “The gravity, it hits you. And it’s nonstop.”

The panel offered some behind-closed-doors takes on today’s top issues, including the bruising fights over skyrocketing drug prices under Trump and ACA contraceptive coverage under Obama.

Deciding which “hills do you die on” was Azar’s top challenge as HHS secretary, he said. “When do you fight and when do you not fight with, say, the White House?” He pointed to his push to eliminate drugmaker rebates paid to health plans and pharmacy benefit managers, which drugmakers and others have criticized for driving up drug costs.

“I left a lot of blood on the field of battle just to try to outlaw pharmaceutical rebates,” he said.

All three secretaries agreed that one of the least understood but most important aspects of the department’s work happens outside the United States, performing what Sebelius called “soft diplomacy.” While many countries are loath to welcome officials from the State Department or the military, “they welcome health professionals,” she said. “They welcome the opportunity to learn.”

Asked what they felt unprepared for when they got the job, Azar — who had worked at HHS previously as general counsel then deputy secretary — replied: “The Trump administration.”

Coming from the administration of former President George W. Bush and later a stint as president of the U.S. division of the drugmaker Eli Lilly, Azar said he was “used to certain processes and ways people interact.” Working in the Trump administration, “it was different.”

The atypical assembly of current and former political appointees also offered a chance for some unusually friendly banter.

Becerra noted that one reason he was familiar with HHS programs was because he had filed numerous lawsuits challenging the agency’s actions when he was attorney general of California.

“Oh, he sued me a lot,” Azar quipped, as the group laughed. “Becerra v. Azar, all over the place.”

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Policy analysts, Democrats, and Republicans dissatisfied with the deal agree: Federal health programs have dodged a budgetary bullet in the Washington showdown over raising the nation’s debt ceiling.

A compromise bill, approved late Thursday by the Senate, includes some trims and caps on health spending for the next two years.

But the deal spares health programs like Medicaid from the deep cuts approved in April by the Republican-led House. The bill suspends the debt ceiling — the federal government’s borrowing limit — until January 1, 2025, after the next presidential election.

The need for Congress to act to avoid an unprecedented debt default and its rippling economic consequences gave House Republicans leverage to extract spending concessions from Democrats. But in the end the compromise bill, negotiated primarily by House Speaker Kevin McCarthy and Biden administration officials, limits health spending only slightly.

The most conservative Republicans said they are outraged at what they see as a giveaway to Democrats. “It is a bad deal,” said Rep. Chip Roy (R-Texas), one of the bill’s most outspoken opponents, during a news conference at the Capitol. “No one sent us here to borrow an additional $4 trillion to get absolutely nothing in return.”

Besides the spending limits, the main health-related concession made by Democrats is the clawback of about $27 billion in money appropriated for covid-related programs but not yet spent.

Only a portion of the money being reclaimed from covid programs is specifically health-related; money is also being returned to the federal government from programs centered on housing and transportation, for example.

Of the unspent covid funds, according to the Congressional Budget Office, the biggest single rescission is nearly $10 billion from the Public Health and Social Services Emergency Fund. The CDC would have to give back $1.5 billion. But exempted from those health-related givebacks are “priority” efforts such as funding for research into next-generation covid vaccines; long covid research; and efforts to improve the pharmaceutical supply chain.

“The deal appears to have minimal effect on the health sector,” concluded Capital Alpha Partners, a Washington-based policy strategy firm.

That would not have been the case with the House Republicans’ “Limit, Save, Grow Act,” their first offer to raise the debt ceiling and slow — in some areas dramatically — the growth of federal spending. That bill would have reduced the federal deficit by nearly $5 trillion over the next decade, including through more than $3 trillion in cuts to domestic discretionary programs, which account for roughly 15 percent of federal spending. A part of that 15 percent goes to health programs, including the National Institutes of Health, the Centers for Disease Control and Prevention, and the FDA.

The Republican bill would also have imposed nationwide work requirements on the Medicaid health program, a proposal that was vehemently opposed by Democrats in Congress and the Biden administration.

Democrats argued that such requirements would not increase work but rather would separate eligible people from their health insurance for failing to complete required paperwork. That is already happening, according to a KFF Health News analysis, as states begin to trim rolls following the end of the covid public health emergency.

The compromise bill, however, leaves untouched the major federal health programs, Medicare and Medicaid — amounting to a political victory for Democrats, who prioritized protecting entitlement programs. The deal includes no new work requirements for Medicaid.

The bill also freezes other health spending at its current level for the coming fiscal year and allows for a 1% increase the following year. It will be up to the House and Senate Appropriations Committees to determine later exactly how to distribute the funds among the discretionary programs whose spending levels they oversee.

Advocacy groups have argued that even a funding freeze hurts programs that provide needed services to millions of Americans. The result, said Sharon Parrott, president of the liberal Center on Budget and Policy Priorities, “will still be cuts overall in key national priorities when the very real impact of inflation is taken into account.”

Even less happy, however, are conservatives who had hoped the debt ceiling fight would give them a chance to take a much bigger bite out of federal spending.

“Overall, this agreement would continue America’s trajectory towards economic destruction and expanded federal control,” Kevin Roberts, president of the conservative Heritage Foundation, said in a statement.

[Update: This article was updated at 8:10 p.m. ET on June 1, 2023, to reflect news developments.]

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Doctors are showing — through their words and actions — that they are reluctant to practice in places where making the best decision for a patient could result in huge fines or even a prison sentence. And when clinics that provide abortions close their doors, all the other services offered there also shut down, including regular exams, breast cancer screenings, and contraception.

The concern about repercussions for women’s health is being raised not just by abortion rights advocates. One recent warning comes from Jerome Adams, who served as surgeon general in the Trump administration.

In a tweet thread in April, Adams wrote that “the tradeoff of a restricted access (and criminalizing doctors) only approach to decreasing abortions could end up being that you actually make pregnancy less safe for everyone, and increase infant and maternal mortality.”

An early indication of that impending medical “brain drain” came in February, when 76% of respondents in a survey of more than 2,000 current and future physicians said they would not even apply to work or train in states with abortion restrictions. “In other words,” wrote the study’s authors in an accompanying article, “many qualified candidates would no longer even consider working or training in more than half of U.S. states.”

Indeed, states with abortion bans saw a larger decline in medical school seniors applying for residency in 2023 compared with states without bans, according to a study from the Association of American Medical Colleges. While applications for OB-GYN residencies were down nationwide, the decrease in states with complete abortion bans was more than twice as large as those with no restrictions (10.5% vs. 5.2%).

That means fewer doctors to perform critical preventive care like Pap smears and screenings for sexually transmitted infections, which can lead to infertility.

Care for pregnant women specifically is at risk, as hospitals in rural areas close maternity wards because they can’t find enough professionals to staff them — a problem that predated the abortion ruling but has only gotten worse since.

In March, Bonner General Health, the only hospital in Sandpoint, Idaho, announced it would discontinue its labor and delivery services, in part because of “Idaho’s legal and political climate” that includes state legislators continuing to “introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

Heart-wrenching reporting from around the country shows that abortion bans are also imperiling the health of some patients who experience miscarriage and other nonviable pregnancies. Earlier this year, a pregnant woman with a nonviable fetus in Oklahoma was told to wait in the parking lot until she got sicker after being informed that doctors “can’t touch you unless you are crashing in front of us.”

A study by researchers from the State University of New York-Buffalo published in the Women’s Health Issues journal found that doctors practicing in states with restrictive abortion policies are less likely than those in states with supportive abortion policies to have been trained to perform the same early abortion procedures that are used for women experiencing miscarriages early in pregnancy.

But it’s more than a lack of doctors that could complicate pregnancies and births. States with the toughest abortion restrictions are also the least likely to offer support services for low-income mothers and babies. Even before the overturn of Roe, a report from the Commonwealth Fund, a nonpartisan research group, found that maternal death rates in states with abortion restrictions or bans were 62% higher than in states where abortion was more readily available.

Women who know their pregnancies could become high-risk are thinking twice about getting or being pregnant in states with abortion restrictions. Carmen Broesder, an Idaho woman who chronicled her difficulties getting care for a miscarriage in a series of viral videos on TikTok, told ABC News she does not plan to try to get pregnant again.

“Why would I want to go through my daughter almost losing her mom again to have another child?” she said. “That seems selfish and wrong.”

The anti-abortion movement once appeared more sensitive to arguments that its policies neglect the needs of women and children, a charge made most famously by former Rep. Barney Frank (D-Mass.), who once said: “Conservatives believe that from the standpoint of the federal government, life begins at conception and ends at birth.”

In fact, an icon of the anti-abortion movement — Rep. Henry Hyde (R-Ill.), who died in 2007 — made a point of partnering with liberal Rep. Henry Waxman (D-Calif.) on legislation to expand Medicaid coverage and provide more benefits to address infant mortality in the late 1980s.

Few anti-abortion groups are following that example by pushing policies to make it easier for people to get pregnant, give birth, and raise children. Most of those efforts are flying under the radar.

This year, Americans United for Life and Democrats for Life of America put out a joint position paper urging policymakers to “make birth free.” Among their suggestions are automatic insurance coverage, without deductibles or copays, for pregnancy and childbirth; eliminating payment incentives for cesarean sections and in-hospital deliveries; and a “monthly maternal stipend” for the first two years of a child’s life.

“Making birth free to American mothers can and should be a national unifier in a particularly divided time,” says the paper. Such a policy could not only make it easier for women to start families, but it could address the nation’s dismal record on maternal mortality.

In a year when the same Republican lawmakers who are supporting a national abortion ban are even more vehemently pushing for large federal budget cuts, however, a make-birth-free policy seems unlikely to advance very far or very quickly.

That leaves abortion opponents at something of a crossroads: Will they follow Hyde’s example and champion policies that expand and protect access to care? Or will women’s health suffer under the anti-abortion movement’s victory?

HealthBent, a regular feature of KFF Health News, offers insight and analysis of policies and politics from KFF Health News chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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“I took on this role, at your request, with the goal of leaving behind the dark days of the pandemic and moving CDC — and public health — forward into a much better and more trusted place,” she wrote in her resignation letter to President Joe Biden, which was released Friday.

In a statement from the White House, Biden said Walensky “led a complex organization on the frontlines of a once-in-a-generation pandemic with honesty and integrity.”

Her departure is another mark of the federal government’s official winding down of the covid pandemic response. The nation’s declared public health emergency expires May 11, and on Friday the World Health Organization downgraded the virus from a “global emergency” to a “global health threat.”

White House officials widely expect covid czar Ashish Jha to leave Washington and return to his job in Rhode Island as dean of the Brown University School of Public Health.

Walensky was seen from the start of her tenure as a curious choice to lead the influential agency. An infectious disease specialist who practiced in Boston and taught at Harvard Medical School, she came with little direct experience in public health and none leading a large and labyrinthine organization.

She took over the CDC, which is headquartered in Atlanta, at one of the most difficult times in the agency’s history. Once among the most trusted agencies in the federal government, the CDC fell on particularly hard times during the Trump administration, when officials intervened in the agency’s pandemic response and prompted accusations that the CDC was putting politics ahead of public health.

The perception inside the agency that its science-based recommendations were being ignored or altered contributed to a staff exodus, particularly from the agency’s senior tier. The departures further undercut Walensky’s ability to turn around the agency’s reputation, as well as to reassure a skeptical public that its recommendations were based on what was best for public health, not politics.

Biden has not yet announced a replacement for Walensky. The head of the CDC is one of the few top jobs in the Department of Health and Human Services that does not require Senate confirmation. That is scheduled to change, but not until 2025. So, Biden’s next choice could take the helm immediately.

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