An Arm and a Leg: A Health Policy Veteran Puts 2025 in Perspective

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Dan: Hey there–

2025 has been a LOT so far, especially since the second Trump Administration got started. We hear about a lot of sudden moves, a lot of cuts, maybe some reversals — in health care (and everywhere else). With bigger moves maybe still to come.

What’s ACTUALLY happened so far? I can’t keep up.

But I know some people who might. Our pals at KFF Health News have a whole NEWSROOM — dozens and dozens of people — publishing stories every day.

And one person in particular there is as plugged-in as can be.

Julie Rovner has been covering health care in Washington, DC for longer than anybody. Close to four decades.

When we first start talking, Julie gestures behind her. On a bookshelf in her office are copies of Congressional Quarterly, where she started reporting in the 1980s.

Julie Rovner: I mean. Literally every time somebody in Congress sneezed on healthcare, I wrote a story. That was my job. For eight years. It was sort of the beginning of my career, but I’ve sort of thought about it ever since.

Dan: Over the decades, she’s watched big changes happen incrementally, one sneeze at a time.

Julie covered health care for NPR for more than 15 years, and since 2017, she’s hosted KFF’s podcast What the Health.

Every week, she convenes a roundtable of top health-care reporters for a total inside-the-beltway nerd-fest.

And it turns out: Even Julie Rovner has a hard time maintaining an up-to-date scorecard.

Julie Rovner: I’m trying to keep a running list of what’s been cut and what’s been restored, and it’s virtually impossible ’cause there’s 20 things every day. I mean, basically the way I do my news podcast now is I spend four days a week making a list, and then on the fifth day, I cut it in half about the things we can talk about.

Dan: Oh my gosh.

Julie Rovner: And on the day of the podcast, I usually cut it in half again. Dan: So, the scorecard keeps changing too fast. But Julie does see a big picture.

And because she knows all the details– four decades of them– she can help us see it by telling us two stories:

One about a teeny part of the health care system that most of us have never heard about. Which is now one of the too-many-to-keep-track-of offices that the Trump Administration has taken a chainsaw to.

Then we’ll look at something everybody’s heard about — and lots of people are worried about: Medicaid. And Julie’s gonna show us why it may not be so easy to take apart.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann– I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

Our first story — this little agency — teeny, by government standards — Julie actually watched it get built, early in her career. And it turns out to be a great example for this show to look at.

I mean, here’s how Julie starts telling its origin story:

Julie Rovner: In the late 1980s, there was kind of an agreement between Republicans and Democrats that healthcare costs were going up really fast and we didn’t know why. And one of the reasons is that we didn’t actually know what worked.

Dan: That is, everybody wanted to know: Why does health care cost so freaking much, and what can we maybe do about it?

And they thought: Maybe somebody should do some research about what’s actually worth paying for. Between Medicare, Medicaid, and health benefits for government workers and veterans, the federal government does a lot of the paying.

Julie Rovner: There was consensus that the federal government is spending all of this money on healthcare, they should spend at least a little bit of it, trying to figure out what works. And there should be some kind of, you know, referee, like a government agency.

Dan: And of course that agency would need a name..

Julie Rovner: It was originally gonna be the Agency for Healthcare Research and Policy, but somebody figured out at the last minute that that would make its acronym AH-CRAP and they decided that was a bad idea.

Dan: So they reversed the last two bits and called it the Agency for Healthcare Policy and Research.

Julie Rovner: My favorite piece of health policy trivia.

Dan: What can you tell me about the various sneezes and hiccups and coughs along the way?

Julie Rovner: Oh, well there was quite a fight in creating “ah-crap.”

Dan: Even though the idea had backers among both Democrats and Republicans, they had to deal with constituencies — interest groups — with turf to protect.

Julie Rovner: There were medical organizations and insurance companies and they did not want the government dictating how medicine would be practiced. So it was not, you know, it was not a done deal. It took a lot of negotiating.

Dan: And in 1989, the first year of George H.W. Bush’s presidency, neither political party could muscle anything through.

Julie Rovner: Democrats are in charge of Congress. Republicans are in charge of the White House. Hence, anything that’s gonna happen is gonna be bipartisan. Unless they’re gonna try to override a veto. And hint hint, there were a couple of attempts to override George HW Bush vetoes, and

they all failed by a couple of votes, mostly on abortion stuff. And there was an NIH bill because I remember obscure things like this.

Dan: I mean, you see why Julie is THE person to give us this story, right?

So the agency gets created in 1989. and one of its jobs is creating practice guidelines. Official federal recommendations about treatments: Which ones worked, which ones don’t.

Julie Rovner: It puts out an awful lot of guidelines and surprise, some of them were really controversial.

Dan: Some eye doctors didn’t like a guideline on cataracts. The Pharma industry hated A guideline that recommended reducing the use of brand-new drugs.

Julie Rovner: Then mid nineties they come out with one on back pain, on acute back pain. And one of the things this guideline found at looking at. All of the evidence is that. Back surgery doesn’t actually work very well for acute back pain. Um, needless to say, the nation’s spine surgeons were not thrilled.

Dan: That guideline came out in 1994. That November, Republicans scored big majorities in both houses of Congress.

NEWS ANCHOR 1: We begin tonight with the most straightforward reaction we’ve heard all day to the results of yesterday’s election. The Democratic chairman David Wilhelm said simply,“We got our butts kicked.”

NEWS ANCHOR 2: Republicans called their promises a contract.

GOP MEMBER: Today, we Republicans are signing a contract with America.

Dan: A contract that required, among other things, big budget cuts. And this little agency ended up on their hit list.

Julie Rovner: they were representing their spine surgeon constituents, and they were ready to just get rid of the whole thing. they tried to just wipe it out in the appropriation bill and they came very close, but didn’t quite

Dan: They did cut funding — including the money for creating guidelines. And they didn’t forget. In 1999, Congress passed legislation that formally kicked the agency out of the guidelines business altogether

And gave it a new name: The Agency for Healthcare Research and Quality. AHRQ (arc), for short.

Julie Rovner: Congress loves to give health agencies new names – even when they’re the same agency– because they want to sort of rid it of its baggage from the past. So we’ve renamed it, gotten it out of the guidelines business, but it is still the main Federal agency that looks at the quality of healthcare and how healthcare works.

Dan: For example, Julie says AHRQ runs the Healthcare Cost and Utilization Project. HUP for short, of course.Which keeps track of some important numbers:

Julie Rovner: How many people were in the hospital for how long? How many of them were kids? How many people got ambulatory surgery? How many hospital readmissions were there? This is that database

Dan: And maintaining that database is part of AHRQs job.

Julie Rovner: So it’s very small. But it’s the only agency that basically does what it does, which is to say we spend a fifth of our economy on healthcare. We should try to figure out how well it works. [

Dan: Or rather it was, until now. In March, officials from the Trump Administration’s Department of Government Efficiency — DOGE for short — held their first meeting with AHRQ’s leaders.

Arthur Allen: it was a meeting in person at, at their office where this was done

Dan: Julie’s KFF Health News colleague Arthur Allen talked with one of those ARQ staffers.

Arthur Allen: It was just told, we don’t know what you do. We’re gonna cut you 80, 90%.

Dan: Arthur says he found out about the whole thing by following up on a tip in a LinkedIn post. He says pitching the story wasn’t the easiest sell, even at KFF.

Arthur: Everybody was making jokes about it, They were like, yeah, good luck making an interesting story out of this. You know, good luck explaining what AHRQ does or making it into something anybody would want to read.

Dan: He did, and they published it. And it led to a new tip: As Arthur reported, ARQ was getting merged with another office in the department of Health and Human Services– the Assistant Secretary for Planning and Evaluation.

Sources from that office saw his ARQ story and told him: Their office was getting cut dramatically too.

According to his sources, between the two agencies, almost three quarters of the people are gone.

Including: everybody who was involved in calculating the federal poverty line.

As the headline for Arthur’s story says: eighty million people qualify for benefits based on that number.

Arthur Allen: It’s used by, you know, literally thousands of agencies, private, public, state, local, federal, to decide whether people qualify for benefits: food stamps, Medicaid, subsidies for childcare– you know, pretty much anything you can think of where there’s assistance to lower income people.

Dan: One of the fired workers told Arthur, quote: “There’s literally no one in the government who knows how to calculate the guidelines. And because we’re all locked out of our computers, we can’t teach anyone how to calculate them.”

Arthur Allen: The guy had been doing it for like 20 years. He was just thrown out the door and email removed. No way to reach him.

Dan: He told Arthur that using a different methodology would produce different results. If the new calculation didn’t fully account for inflation, for one example, some people could end up losing benefits. And there are a lot of other examples.

Arthur Allen: Over years, you know, you’re trying to develop the best way to do this. Any kind of number like this, which you’re trying to hone down and make it as accurate as possible, you develop this sort of fingerspitzengefühl…

Dan: What’s fingerspitzengefühl?

Arthur Allen: Well, it’s a German word that means like, feeling at the end of your fingers, where it’s like, it, it’s an undefinable ability to do something like

Dan: Like pick a lock?

Arthur Allen: Yeah. Yeah. Like Right. Exactly.

Dan: An HHS spokesperson told Arthur the department would continue to comply with statutory requirements and maintain critical programs. After the article was published, another spokesperson called KFF to say “the idea that this will come to a halt is totally incorrect. Eighty million people will not be affected.”

Arthur Allen: They were like, there are other people at HHS who can do that and, you know, it’s, it’s true. It’s just, you could have made it so much easier. And also they haven’t been the most reliable always in terms of, you know, saying something and then following through on it. So, you know, there’s reason to be skeptical.

Dan: Well, it’s, it’s a reporter’s credo, right? If your mom says she loves you, get another source.

Arthur Allen: Yeah.

Dan: So now we’ve actually looked at a COUPLE of small examples. And there are so many more. Julie Rovner sees them as part of the bigger picture..

Julie Rovner: How I’ve been thinking about this is that our healthcare system is a giant Jenga tower and it’s a little wobbly and what holds it up is everything that happens from the Department of Health and Human Services, it’s all the rules of the road. It’s all the enforcement, it’s all the protections. In many cases, it’s actually the funding. It’s what funds a lot of programs for people with low incomes, the training of, not just doctors, but future researchers. And they’re yanking out sticks from this Jenga tower as fast as they possibly can, and when the whole thing comes down, it’s gonna be very, not pretty.

Dan: She sees all those blocks getting pulled from the Jenga tower. She knows why they’re there. And what could happen as they get yanked away.

Julie Rovner: I feel a lot like I did during the early parts of the pandemic. It’s just that feeling of, oh my God, what fresh hell is next? And will we ever be able to fix it? I’m, and I’m really worried about that. And you know, at least during the pandemic, I felt like everybody felt that way.

Dan: With cuts and changes we’ve seen so far, the administration has acted on its own– and courts may or may not stop or reverse some of them.

But then there’s one of the big things lots of people worry about: huge cuts to Medicaid, which insures something like 79 million people.Cuts on the scale we’re hearing about would requires Congress to act. To pass legislation.

Which Julie Rovner thinksCongress will find very hard to do.

Julie Rovner: Not so much because it’s hard to cut Medicaid, which it is, but because it’s gonna be really hard for this Congress with these little tiny Republican majorities to agree on anything.

Dan: Julie, of course, has some very specific reasons these particular cuts will be so difficult for these particular Republican majorities. That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists — like Julie Rovner and Arthur Allen — do amazing work. We’re honored to be colleagues.

So just to recap, here’s why cuts to Medicaid loom so large.

NEWS ANCHOR 3: Republicans are looking to slash $2 trillion with a T in long-term spending. And Medicaid could be a target

Dan: Congressional Republicans have passed a budget framework— basically, an outline — with big cuts spread across ten years.

They’ve assigned committees to find specific cuts, and they’ve given more than 800 billion dollars in cuts to a committee that doesn’t have a lot of other options

NEWS ANCHOR 4: A new analysis from the Congressional budget office shows the proposed budget would require MASSIVE cuts to Medicaid spending.

NEWS ANCHOR 5: It’s mathematically impossible for Republicans to meet their own target without cutting Medicaid.

Dan: And Julie says, cuts on this scale could hurt a lot of people.

Julie: I’ve seen estimates that 20 million people could lose their Medicaid coverage,…it’s maybe a quarter of the people on Medicaid.

Dan: Julie says Republicans want to avoid saying they’ll make these kinds of cuts. So…

Julie Rovner: You know, now Republicans are saying we’re not gonna cut Medicaid, puts the air quotes.

Dan: What they’re saying they WILL do, that’s gonna require some unpacking. Here’s the official line, as Julie puts it

Julie Rovner: We’re just gonna reduce the extra money that Medicaid pays states for the Medicaid expansion, under the Affordable Care Act.

Dan: OK. Extra money for states. Medicaid Expansion. Affordable Care Act.

Let’s break that down. The Affordable Care Act is best known for “Obamacare” marketplaces, where people can buy health insurance even if they have pre-existing conditions.

But another big thing it did was to expand Medicaid: It raised income cut-off so more people could qualify.

Now, the way Medicaid is designed, states share the cost with the federal government. But under the ACA, the feds send extra money to states, to pay for most of that expansion. Like 90 percent of it.

That’s the context for this line that Congress wouldn’t cut Medicaid, just the “extra” money to states for the expansion.

Julie Rovner: And we see a lot of Republicans saying, oh, if states wanna continue it. They can just pay their regular share. Well, that regular share is $626 billion over the next 10 years that states would cumulatively have to come up with. Um, states, unlike the federal government, pretty much have to balance their budgets every year. They don’t have 626 billion extra dollars hanging around to do that.

Dan: Julie thinks a lot of states would end up cutting Medicaid. Some would do it automatically, with laws that are already on the books.

Julie Rovner: We have 12 states that say if Congress reduces that threshold from 90%, we immediately cancel our Medicaid expansion. They’re called trigger laws and there’s 12 states with trigger laws.

Dan: But some states — not only do they not have trigger laws. They have a big problem.

Julie Rovner: Three states, three very red states, Missouri, Oklahoma, and South Dakota. Expanded Medicaid, not just by ballot measure, but by amending their state constitutions.

Dan: Yeah, this was kind of interesting: All the states that initially rejected the Medicaid expansion were led by Republican politicians.

It seems like a big reason they opposed it was because, well, it was part of the ACA– ya know, “OBAMA-care”? Their legislators would never vote for it.

But expanding Medicaid is popular with a lot of people. The legislatures in these states didn’t vote for the expansion, the people did — they voted for ballot initiatives that actually added Medicaid expansion into their state constitutions..

Julie Rovner: These three states, that change their constitutions, don’t have trigger laws because they have changed their constitution. That maybe helps explain why Senator Hawley from Missouri, who is not known as a big defender of Medicaid, uh, has said he’s not gonna vote for Medicaid cuts because his is one of the states that could be left holding a very large and expensive bag if they’ve rolled back this additional federal match. So that’s just one example. You know, when he first said it, it’s like, why is Josh Hawley suddenly so gung-ho for Medicaid? Um, that helps explain why.

Dan: That is very interesting. So this is an example of why it’s hard to cut Medicaid. Um,

Julie Rovner: Very, yes.

Dan: And Julie says, there are other reasons too.

Julie Rovner: I mean, if you go back to 2017, when the Republicans try to repeal and replace the Affordable Care Act for the first time, Medicaid turned out to be a main reason why they couldn’t, because suddenly people discovered that Medicaid is not just for, you know, moms and kids on welfare, medicaid pays. The vast majority of the nation’s nursing home bills, so everybody’s grandparents who were in nursing homes were probably getting Medicaid. Suddenly we discovered how many people were getting Medicaid and people discovered how many people were getting Medicaid, and they came to Congress.

NEWS ANCHOR 6: On Capitol Hill where there were protests and many arrests today

Crowd: Kill the bill.

News reporter: Senate Republicans today received a bruising. Welcome back to Capitol Hill…

Crowd: Kill the bill. Health care is a human right.

Julie Rovner:I was there and they said, we don’t want you to do this, you know, it, it was very close, but in the end, I think Medicaid was really a major reason why Congress proved unable to repeal the ACA, if anything, Medicaid is now more entrenched and there are more people on it than there were in 2017. Um, and Congress has even smaller majorities. You judge how hard it’s gonna be.

Dan: And as you’ve said, three states with two Republican senators each. Julie Rovner: Each. That’s correct. So there’s six.

Dan: Republicans hold 53 Senate seats. They could lose three votes and call in Vice President JD Vance to break a tie. They need 50 votes.

Julie Rovner: So they have 53 votes and six of those votes come from states. That would be left holding a very expensive bag. And another three or four senators who voted against it in 2017 are still there. So even counting to 50 is hard.

Dan: First, that’s one of Julie’s beloved Corgis in the background, amped up because he hears a neighbor dog outside.

Wally: Woof!

Julie Rovner: Wally, are you barking at Churchy? I’ll let you go play with him later.

Second, of course we don’t know what Congress will actually do in this very-unusual year.

But no matter what, it is fun talking about politics with Julie Rovner.

And even if it does not seem like a fun time to be Julie Rovner, to be doing the job she does — drinking from the firehose, as she says — I don’t think she’s going anywhere.

Julie Rovner: Yeah, I mean, you know, my mom was a journalist. My dad was a, a political staffer, basically. He worked at the state, federal, and local level in his career and basically, you know, made policy happen. And, , that is my legacy and I really care about it.

Dan: And, she is not taking in absolutely EVERYTHING. For instance, she has not been watching “The Pitt.” The super-exciting– and super-stressful–new medical drama we talked about last time–the one that chronicles an especially-intense day in a busy urban emergency room.

Julie Rovner: I started to watch it –and I watched every episode of ER. I mean, I’m one of those people. I’ve also seen every episode of Grey’s Anatomy which is insane. Um, but I started to watch the Pitt and I got about three quarters of the way into the first episode, and I thought, I cannot deal with this right now. And I turned it off.

Dan: Yeah.

Julie Rovner: I just– and I watched severance! I’m like,‘Why am I watching severance? I do not need anything creepy in my life right now.’ But it was very good. It’s funny, I could get through severance, but I could not get through The Pitt.

Dan: So, even Julie Rovner has her limits. Which I think is great.

She is doing the thing I remind everyone to do at the end of every episode of this show: Taking care of herself.

If you have not subscribed to our First Aid Kit newsletter yet, I think this is a great time to check it out.

It’s where we boil down some of the practical things we’ve learned about taking care of ourselves and each other:

My colleague Claire Davenport has been helping her roommate fight back against more than 14 thousand dollars in medical bills. They wiped out ten thousand with some due diligence.

And I’m collecting advice for what could be a one-page resource: Some quick advice and links that everybody should get before the first hospital bill arrives.

You can sign up– and read everything we’ve done so far — at arm and a leg show dot com, slash first aid kit.

We’ll be back with a new episode in a few weeks.

Until then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann–, with help from Emily Pisacreta, Claire Davenport, and Zach Dyer of KFF Health News –And edited by Ellen Weiss.

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.

Bea Bosco is our consulting director of operations.

Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America —

and a core program at KFF: an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is Distributed by KUOW– Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at arm and a leg show, dot com, slash: support. Thanks! And thanks for listening.