Health Affairs' Jeff Byers welcomes Katie Keith of Georgetown Law back to the pod to discuss President Trump's potential changes to the rulemaking process, how that may impact rulemaking at HHS, and break down the house Republican budget reconciliation bill and the impacts it could have on Medicaid and more.
Become an Insider today to get access to our May 29 event on the FDA under the second Trump Administration as well as our upcoming premiere trend report on AI in health care.
Also, join us on May 27 for a free virtual event featuring a conversation between Clifford Ko and Katherine Ornstein on how the new Age-Friendly Hospital Measure aims to improve the quality and experience of inpatient care for older Americans.
Related Articles:
- The House Republican Budget Reconciliation Legislation: Unpacking The Coverage Provisions (Health Affairs Forefront)
- New Trump Directive To Further Erode Notice And Comment Rulemaking (Health Affairs Forefront)
- Tracking The Trump Administration’s Early Deregulation Agenda (Health Affairs Forefront)
- The House Republican Budget Reconciliation Legislation
- RFK Jr. kills policy on public comment for health regulations (Axios)
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jeff Byers (00:08):
Hello, and welcome to Health Affairs This Week. I'm
your host, Jeff Beyers. We'rerecording on Tuesday,
05/13/2025. I know I've talkedabout the May 29 event for
insiders on the changes at theFDA coming up quite a bit. Sign
up for that.
But today, I wanted to highlightthat next week, we are releasing
as part of our insider program,our first trend report for
(00:31):
insiders. It's on the use of AIin healthcare, and you don't
wanna miss that. In addition tothe report, you get access to
all the exclusive events that wehost, as well as different
newsletters we publish on drugpricing, the economy, and more.
Sign up. If you are more intofree stuff, you know, what's
your deal?
But also we have a free event onMay 27 with Clifford Co. And
(00:54):
Catherine Orenstein titled HowCan the New Age Friendly
Hospital Measure Transform theInpatient Experience? Sign up
for that if that's also ofinterest. Today on the pod, we
have Katie Keith to discuss allthe different goings ons in the
administration this week. It'sbeen a big week as well as some
recent happenings.
From the Big Apple, Katie Keith,welcome back to the program.
Katie Keith (01:16):
Thank you as always for having me.
Jeff Byers (01:18):
Yeah. So you're in New York currently. What are
what are the streets saying inNew York? Are they talking about
health policy?
Katie Keith (01:26):
They might be, but certainly not as much as DC.
Jeff Byers (01:30):
Yeah. So speaking of, you know, great transition
to, you know, what's happeningin DC. So we are gonna talk
about it is Tuesday. There'sbeen a lot happening on the
regulation front for proposedrules and markups and texts
being released, and I'm notreally familiar with it all, so
(01:52):
that's why you're here. Butbefore we get into that, wanted
to talk about the current stateof rulemaking.
So earlier this year, HHSannounced it would reverse
soliciting public commentsbefore it issues regulations
affecting government benefits orgrants. What can you tell us
about this?
Katie Keith (02:08):
First, would say well done. That was a good
summary. What you're referringto is called the Richardson
waiver. It's called that becauseit was put in place by then
Department of Health and HumanServices Secretary Richardson
under the Nixon administration.So we are talking about a policy
that has been in place for aboutfifty years, that secretary
Robert F.
Kennedy Jr. Rolled back inFebruary of this year. And what
(02:32):
that policy had done, and again,had been maintained by every
administration since Nixon, wasreally say HHS prioritizes
public comment. We want inputfrom the public. We wanna give
notice before we make changes tothings like public benefits and
contracts and grants.
Even if we don't have to, underthis law called the
Administrative Procedure Act, weshould. And it was sort of
(02:54):
internal HHS policy that said,we need to give notice and allow
an opportunity for the public togive us feedback before we make
changes that can affect thosesort of categories. And I wrote
about this. You can see more ofthe details there. The other
thing that the prior Richardsonwaiver policy had said is it's
sort of disfavored to invokewhat we call the good cause
(03:15):
exception under theAdministrative Procedure Act.
So and maybe the step back isthe APA, the Administrative
Procedure Act, is a law thatgives you the rules about the
rules. It lays out all therequirements that agencies are
supposed to follow, when theyare changing federal
regulations. It's you know, anagency will typically publish to
(03:37):
give notice to the public, andthen take comment for you know,
there's no set period of time,but generally, let's say thirty
or sixty days. Then when theyfinalize that rule, they have
to, you know, review thosecomments, generally respond to
them, and finalize the rule.It's you know, the idea is that
transparency improves therulemaking process.
It gives the agency feedback,especially from those who are
(03:58):
gonna be most impacted, whetherit's patients or health care
providers or insurance companiesor states, for example. So
health care is extremely complexas all of your regular listeners
know, and the idea that youcould make these changes without
letting someone know in advanceor giving the opportunity to
sort of be heard or get moredata or get more feedback is
really, really challenging. Andyet that is exactly what sort of
(04:19):
pulling back on this Richardsonwaiver is doing at HHS. We
haven't yet seen or, well,speaking for myself, I haven't
yet seen HHS leverage this yet.They have not sort of pulled
back on a ton of things yet.
I have a couple examples that Ican give, but I think more is
coming. And so we could talkabout that as well. And then
maybe we're going to get tothis, but this is not only just
(04:40):
happening at HHS. It's reallyhappening kind of across the
agencies, due to some prettyhigh level directives from
president Trump.
Jeff Byers (04:46):
Yeah. I do wanna ask about, some of those public
comments and about the state ofthose. But before that, you
wrote in Health AffairsForefront about, from a broader
perspective about a president'srole memorandum that encourages
federal agencies to be lesstransparent and sidestep public
input on major regulatorychanges. Is that any different
(05:08):
than what you're talking aboutfrom HHS? Or walk me through
that.
Katie Keith (05:11):
No. It's quite similar. So, really, I think
this is a Trump administrationwide project. And I think the
president, and I would say thedirector of the office of
management and budget, I think,clearly have a a vision for a
deregulatory agenda that theywanna see across the board. And
so far, they've been extremelyaggressive at, say, the
department of energy.
(05:32):
Even the department of justicehas already rolled a lot of
things back. The consumerfinancial protection bureau, the
CFPB, has rolled a bunch ofthings back. I'm still waiting
and watching for a moresignificant impact in health
care, but I think it is coming,which is why I was so excited
that you wanted to talk aboutthis because I think there is a
cloud of this deregulatoryagenda really hanging over the
(05:52):
policy that the Trumpadministration is going to do.
And what it means is they'removing extremely quickly. I
think that is the part forlisteners to really pay
attention to.
If you don't have to do this,you know, or even try or attempt
to do notice and public comment,you can just be putting out what
we call interim final rules. Youcan just be revoking policies.
And so what we're seeingexamples is just short notices
being published in the federalregister that say, here's the 20
(06:15):
things that the consumerfinancial protection bureau is
pulling back today, and no onegets to say anything about it.
You shouldn't rely on it. And inthe meantime, the agencies
aren't gonna enforce it either.
So it it could it could beextremely disruptive without any
opportunity to weigh in.
Jeff Byers (06:29):
Yeah. So going back on that, like, what you
mentioned a vision. What is thisvision? Or, like, what's the
purpose of this vision?
Katie Keith (06:37):
I I mean, I think it's a deregulation writ large,
and it's probably an ideologicalvision. And I'll give one
example. A different executiveorder that the president signed,
is a requirement that agenciesthat want to do new regulations
have to pull back or identify 10regulations that they don't want
anymore, that we call it sort ofthe 10 for one executive order.
So that is not the mostrationalized thing in the world.
(06:59):
It is purely a numbers game ofwe just want fewer regulations.
So I think that is part of thethe approach and the vision.
During the first Trumpadministration, they had a five
for one regulation EO, and herethey really upped the stakes by
taking it to 10 to one. And sowe're still kind of watching to,
again, see how that will playout, but you're really seeing it
across the board for differentindustries. President Trump
(07:19):
signed, an executive orderrecently specifically to say, I
want you to repeal thisDepartment of Energy rule that
defines showerhead in a certainway. And you should have no
notice and comment, and thatchange is going into effect in
thirty days.
So those are the types ofexamples that we're seeing,
very, very specific, and I'mwaiting for that to come to the
(07:39):
health care world.
Jeff Byers (07:40):
Yeah. So on the public comment thing, question,
how it's gonna be a roundaboutway. And just to get to, like,
how helpful are public comments?So, you know, we all know about
the if you're a listener of acertain age, the Boaty McBow
face scandal. I don't know ifit's scandal, but event where
the public named a boat.
(08:01):
You know, there was a publiccontest, naming contest. Here in
Richmond, Virginia, they had anaming contest for the baseball
team Richmond Flying Squirrels.I'll let you decide if you like
that name. But there's beentalks, so there's that of just,
like, people kinda messingaround with comments. Generally,
I would imagine, like, some ofthese people are informed, more
informed than the general publicif they're commenting on
(08:23):
regulations.
But people that are definitelymore informed are potential
lobbyists. So there always hasbeen some talks about a bunch of
comments from lobbyists in thesepublic rulemaking. So, like, how
helpful is this process fromwhat you can tell?
Katie Keith (08:37):
Yeah. Helpful seems like a value word. I will say, I
do think the comments make adifference. And I've I found
that being in government myself.I don't know if they will make a
difference to thisadministration that seems very,
you know, intent on doing whatit wants to do.
And I could give some exampleswhere the first Trump
administration received, Ithink, probably hundreds of
(08:57):
thousands of comments and didn'tchange a word in the final rule,
that kind of thing. But I dothink it is. The comments are
valuable if only because theyput people on notice of the
changes. And then it's anopportunity, I think, especially
for you know, you sort ofmentioned lobbyists, but I think
industry comments are oftenhelpful to talk about the burden
to you know, government agenciesonly know what they know. And so
(09:18):
giving more of that sort ofoperational feedback, sometimes
it's used to push compliancestates out to give more industry
and states and others more timeto to adjust to the rules.
Sometimes it results in truetweaks. So I I think comments
are extremely valuable inaddition to sort of the the
value of, in and of itself,being able to comment and give
(09:38):
your feedback on somethingthat's happening. So there
there's that sort of intrinsicvalue to it as well. But I do
think that comments can make adifference if they are being
considered in an open mindedway. I think what I I think what
we're seeing the trend acrossthis deregulatory agenda is
there's not a lot of interest intaking that, you know, taking
that feedback or even seeingwhat it is.
(09:59):
And so we'll sort of see wherethey go from here. But I I'm
expecting them to get I thinkparticularly after we, the
collective we, gets through,this budget reconciliation
process, which I know we'regonna talk about, I am
expecting, I think, the Trumpadministration to turn even more
full heartedly, if you will, torulemaking and rolling back some
of this stuff, and I'm expectingthem to do a fair amount of it,
(10:21):
without notice and comment.
Jeff Byers (10:22):
Okay. So before we move on to budget
reconciliation, is thereanything else that you wanna
talk about from deregulation?
Katie Keith (10:29):
I think one one of the reasons I'm anticipating
more action from the Departmentof Health and Human Services on
health care policies, is in partbecause I know agencies have,
were directed to go through anew process to identify all the
regulations that should bepulled back both because they
don't match thisadministration's policy
priorities, but also becauseagencies have been asked to
(10:51):
identify rules that aren'tconsistent with supreme court
laws. And so agencies are doingthey've been doing that work
quietly by themselves. They hadto submit a big package and send
over their list to the office ofmanagement budget in mid April.
And I think we're beginning tosee some of that come to
fruition as I'm you know, havebeen giving examples of other
agencies posting guidance,rescinding a whole bunch of
(11:12):
stuff there. So just wantlisteners to know that there was
a whole process that is going onbehind this, and I think that is
going to be ongoing work thatthe agencies are doing quietly
to identify the things they wantto roll back without notice and
comment.
Jeff Byers (11:24):
Looking to the budget reconciliation, new text
was released this week. A lot ofthings were released this week.
There's the drug pricingexecutive order, which we are
not gonna get into. A lot ofstuff we're watching. What are
the top line findings for healthcare policies that's that's come
out, full stop, this week.
Katie Keith (11:43):
What an easy question. So it's only we are
recording on Tuesday. That'sright. That's a caveat. It has
already been a very busy healthpolicy week.
You mentioned the executiveorder on prescription drugs that
the president signed on Monday.The Centers for Medicare and
Medicaid Services also issuednew guidance on the Medicare
drug negotiation program, whichI know some of, my favorite
(12:05):
prescription drug experts willbe writing about for forefront.
There was a new proposed rule onMedicaid provider taxes also
coming out of CMS. So there's aton of activity, and it's only,
you know, day day two of a verylong week. I know I and many
other people all around DC haveour eyes glued to the markups
for the house energy andcommerce committee and ways and
means committee that areoccurring later day on Tuesday.
(12:27):
But for this, you know, megabudget reconciliation package
that is currently moving throughthe house, happy to talk about
some of what's in there. It is ahuge health care bill that, you
know, if enacted, wouldrepresent the largest cuts to
Medicaid in the history of theprogram. You know, more than not
even more than at least thirteenpoint seven million people will
(12:48):
be newly uninsured in 02/1934.As a result, lots of disruption
coming for health care if thisbill makes it across the finish
line.
Jeff Byers (12:56):
Yeah. So let's dive in. You mentioned Medicaid work
requirements and you mentionedthe CBO estimates for how many
people might lose healthinsurance based on this. But,
yeah, what what are the details?So I I noticed some Medicaid
work requirements stuff.
I have in my notes capping SDPs,which is a great acronym that I
don't know what it is.
Katie Keith (13:17):
State directed payments.
Jeff Byers (13:18):
Thank you. So yeah. So what's in there?
Katie Keith (13:21):
Another, soft ball Yeah. On health care.
Jeff Byers (13:25):
Let's start with Medicaid work requirements.
Katie Keith (13:28):
What can
Jeff Byers (13:28):
you tell us about what's in there for that?
Katie Keith (13:30):
Yeah. So, I mean, a few top lines, and, you know, I
and others will be publishing onthis and on forefront so folks
can dig in on all the nittygritty details. But mandatory
Medicaid work requirements wouldso every state would have to do
this. I think it would result inhuge administrative burdens for
enrollees and states to actuallyadminister this program. We know
(13:52):
it results in coverage losses, Ithink it will be exacerbated by
some of the other red new redtape that would be being imposed
through the bill.
So it would essentially requireenrollees to show that they are
doing work requirements orschool or other sort of
community engagement rights forup to at least eighty hours a
month. States would be requiredto confirm that on at least a
(14:15):
monthly basis, but they could doit more often if they wanted.
They could do weekly checks.And, you know, all of the
experience, and Sarah Rosenbaumhas a great past piece on this,
laying out the evidence and dataand what we know about Medicaid
work requirements shows that,you know, it results in coverage
losses because these arecomplicated requirements to have
to follow-up on. And we knowfrom data from folks like KFF
(14:37):
that the vast majority ofMedicaid employees are working.
This to me seems like a hugesolution in search of a problem
in many ways, and I think it isdesigned to reduce the Medicaid
roles in this instance. And I Isort of mentioned this. It's not
just the Medicaid workrequirements. There's a whole
bunch of other, you know, again,new red tape that's being
imposed. Eligibilityredeterminations would be
(15:00):
happening more frequently forthe expansion population.
There'd be a lot more, you know,address verifications and all
kinds of things there. So justlots and lots of burdens. For
beneficiaries themselves,there'd be new cost sharing
requirements, so folks would payhigher. So so for those who are
able to jump through all thosehoops already and keep their
coverage, you would face highercosts. And, you know, there's a
(15:20):
whole bunch of stuff in thereon, I think, limiting state
flexibility for how they fundand finance, their state
Medicaid program.
So there seems to be, this ideathat you can lock in what's
currently happening, but stopstates from raising provider
taxes or doing other changeslike that. And I think it's
gonna really tie states' handsgoing forward even as this bill
(15:41):
loads up on all the new stuffthat states are gonna have to do
to manage their programs there.Two, maybe other things on the
Medicaid side to flag, the billwould defund Planned Parenthood.
It doesn't say the words PlannedParenthood, but it seems very
targeted at, that organizationand prohibit states from using
federal funds for the treatmentof gender dysphoria, for kids.
(16:01):
So that would be a significantnew policy.
And that's everything I'm sayingis, like, scratching the surface
on the Medicaid front. And thenthere's a whole bunch of
Affordable Care Act changes too.
Jeff Byers (16:10):
On the Medicaid front, so, again, I don't know.
I don't think I'm a policy wonkper se, but, like, my cursory
reading, so correct me if I'mwrong, that they're are they
putting more burdens on statesto enact the Medicaid program in
general? And to what end ifthat's correct in your reading,
just why?
Katie Keith (16:30):
I think it's definitely correct that there
will be many more burdens onstates. I think those paper it's
it's a lot of paperwork burden.It's a lot of, you know,
checking eligibility. It'shaving beneficiaries come in and
report that they'll I think theburdens that are going to be
placed on states are going to bepushed down to enrollees who are
inevitably not going to be ableto keep up with this complicated
(16:51):
system of what they and we haveevidence from this. You don't
have to take my word for it.
It's when this was rolled out inArkansas. People lost coverage
not because they weren't workingor doing the community service
that they were supposed to bedoing, but because they couldn't
they didn't know or weren't ableto submit the paperwork to prove
that they were doing all thosethings. And in fact, in
Arkansas, you saw people losetheir jobs because they lost
(17:13):
their Medicaid coverage, and soit's this perverse thing. So I
think the requirements on stateswho are designed to get pushed
down to enrollees and, again,inevitably result in in coverage
losses that you you sort ofmentioned the the CBO is already
suggesting. And so the top linesjust from the energy and
commerce draft, again, we've gotmultiple committees doing
multiple things.
(17:33):
All of this will get wrapped up,but they're moving really
quickly, so we don't have a fullpicture yet. As of Tuesday, the
overall energy and commerce billwould cut at least
715,000,000,000 from healthcare. That's both Medicaid and
Affordable Care Act, and theyestimate that at least
13,700,000 people would beuninsured. More people would be
(17:53):
uninsured in 2034 based on this.I'm saying at least very
pointedly because I thinkeveryone expects those numbers
to go up as CBO is able tocontinue to do its analysis.
There's been certain thingswhere they haven't been able
they haven't had time yet tolook at, you know, what's the
interaction of this Medicaidchange with this marketplace
change? Because, of course, allof this is additive, and so they
have said as much that theythink the coverage losses are
(18:14):
gonna go up. You know, the waysand means bill has some things
that are gonna result in, Ithink, people losing coverage as
well. So double digit coveragelosses and, you know, hundreds
of billions of dollars beingtaken out of health care if this
becomes law.
Jeff Byers (18:27):
So you mentioned we're only really scratched the
surface on Medicaid. So lookingout from Medicaid, just like
we're not gonna be able to covereverything in this time. So was
anything surprising to you inthe text of the reconciliation
bill?
Katie Keith (18:42):
I don't think anything is surprising in that
the top lines of this budgetreconciliation reconciliation
resolution suggested thesechanges had to be sweeping, and
I think that's what folks havebeen sounding the alarm about
for a very long time. And Ithink the scope and degree of
the changes is still sooverwhelming and significant
even as I read it. I think maybeI had an understanding of what
(19:04):
the top line policies would be,but getting the drafts, reading
through it, seeing all of ittogether, and trying to
understand the impact that wouldhave on patients and states and,
frankly, state economies andhealth care providers and
uncompensated care. And it itwill I I don't think you can
overstate the impact that thiswould have on the health care
system. So I is that surprising?
I don't know, but it is it itdef I definitely felt the impact
(19:27):
of, what would happen if if thisbecomes law.
Jeff Byers (19:30):
So every episode could be someone's first, and
maybe this is everyone this issomeone's kinda introduction
into health policy world or ordeeper into the health policy
world than before. With that,like, what are the next steps
for this package?
Katie Keith (19:45):
Yeah. Well, a, don't let this be your last.
You're listening to this andwant to run
Jeff Byers (19:50):
That's right.
Katie Keith (19:51):
In the opposite direction because I not blame
you. Yeah. That was my pitch.There you go. No.
In terms of next steps, so,again, recording on Tuesday.
This afternoon, two of thesecommittees, House Energy and
Commerce, House Ways and MeansCommittee, are doing a, quote,
markup of the bill, so there'llbe amendments. Some people are
suggesting, you know, thesecould run all night. So we'll
(20:14):
see sort of what state thosebills are at the end of that
process, and then it willcontinue to move through the
house. So there'll be otherhouse hearings.
All of that will get packagedtogether. It will go to the
house floor at some point. Andthen once that's done, it will
go over to the senate. So thisis a long slog. I don't think
we've seen the end of even thepolicy changes, and so I think
folks should absolutely staytuned both to the podcast and
(20:36):
health affairs forefront wherethere will be a ton of analysis
as this continues to movethrough.
But much more to come and sortof a what could be a devastating
starting point. Let's put itthat way.
Jeff Byers (20:49):
Yeah. You mentioned Health Affairs Forefront, our
digital publication outside ofthe journal. This will publish
on Friday. On this particularaspect of it, what what's in the
hopper for you to discuss?
Katie Keith (21:00):
I am certainly I could speak for myself, which is
I am working on a very long,wonky, detailed, as is my style,
summary of what is in thesepackages as of their sort of
introduction or considerationfor these markups. And then I
think we'll use that as thebaseline to kind of update over
time as it moves through theprocess. Anything can happen.
(21:23):
You know, there's already beensome outcry from governors about
some of the cuts. I think a lotof the hospitals and provider
associations are maybemobilizing against some of the
pieces of this given that so Iam expecting sort of changes
over time.
Certainly, maybe changes by thetime this gets through the
senate, which has its own rulesthat we haven't talked about.
But president Trump andRepublicans in congress seem
(21:44):
quite motivated to get this donequickly. So, you know, I think
count on us here to be doing thequick turn analysis that folks
need, recognizing that, thingswill certainly change over time.
Jeff Byers (21:55):
Yeah. And what's that word count currently?
Katie Keith (21:58):
Don't ask me. You don't wanna know.
Jeff Byers (22:02):
Well But
Katie Keith (22:03):
it'll be linked below everyone. Yeah.
Jeff Byers (22:04):
That's right. That's right. Well, Katie Key, thanks
again for joining us today onhealth affairs this week. To you
the listener, if you enjoyedthis episode please send it to
The Budget Hawk in your life andwe will see you next week.
Thanks all.
Hello, and welcome to Health Affairs This Week. I'm
your host, Jeff Beyers. We'rerecording on Tuesday,
05/13/2025. I know I've talkedabout the May 29 event for
insiders on the changes at theFDA coming up quite a bit. Sign
up for that.
But today, I wanted to highlightthat next week, we are releasing
as part of our insider program,our first trend report for
(00:31):
insiders. It's on the use of AIin healthcare, and you don't
wanna miss that. In addition tothe report, you get access to
all the exclusive events that wehost, as well as different
newsletters we publish on drugpricing, the economy, and more.
Sign up. If you are more intofree stuff, you know, what's
your deal?
But also we have a free event onMay 27 with Clifford Co. And
(00:54):
Catherine Orenstein titled HowCan the New Age Friendly
Hospital Measure Transform theInpatient Experience? Sign up
for that if that's also ofinterest. Today on the pod, we
have Katie Keith to discuss allthe different goings ons in the
administration this week. It'sbeen a big week as well as some
recent happenings.
From the Big Apple, Katie Keith,welcome back to the program.
Katie Keith (01:16):
Thank you as always for having me.
Jeff Byers (01:18):
Yeah. So you're in New York currently. What are
what are the streets saying inNew York? Are they talking about
health policy?
Katie Keith (01:26):
They might be, but certainly not as much as DC.
Jeff Byers (01:30):
Yeah. So speaking of, you know, great transition
to, you know, what's happeningin DC. So we are gonna talk
about it is Tuesday. There'sbeen a lot happening on the
regulation front for proposedrules and markups and texts
being released, and I'm notreally familiar with it all, so
(01:52):
that's why you're here. Butbefore we get into that, wanted
to talk about the current stateof rulemaking.
So earlier this year, HHSannounced it would reverse
soliciting public commentsbefore it issues regulations
affecting government benefits orgrants. What can you tell us
about this?
Katie Keith (02:08):
First, would say well done. That was a good
summary. What you're referringto is called the Richardson
waiver. It's called that becauseit was put in place by then
Department of Health and HumanServices Secretary Richardson
under the Nixon administration.So we are talking about a policy
that has been in place for aboutfifty years, that secretary
Robert F.
Kennedy Jr. Rolled back inFebruary of this year. And what
(02:32):
that policy had done, and again,had been maintained by every
administration since Nixon, wasreally say HHS prioritizes
public comment. We want inputfrom the public. We wanna give
notice before we make changes tothings like public benefits and
contracts and grants.
Even if we don't have to, underthis law called the
Administrative Procedure Act, weshould. And it was sort of
(02:54):
internal HHS policy that said,we need to give notice and allow
an opportunity for the public togive us feedback before we make
changes that can affect thosesort of categories. And I wrote
about this. You can see more ofthe details there. The other
thing that the prior Richardsonwaiver policy had said is it's
sort of disfavored to invokewhat we call the good cause
(03:15):
exception under theAdministrative Procedure Act.
So and maybe the step back isthe APA, the Administrative
Procedure Act, is a law thatgives you the rules about the
rules. It lays out all therequirements that agencies are
supposed to follow, when theyare changing federal
regulations. It's you know, anagency will typically publish to
(03:37):
give notice to the public, andthen take comment for you know,
there's no set period of time,but generally, let's say thirty
or sixty days. Then when theyfinalize that rule, they have
to, you know, review thosecomments, generally respond to
them, and finalize the rule.It's you know, the idea is that
transparency improves therulemaking process.
It gives the agency feedback,especially from those who are
(03:58):
gonna be most impacted, whetherit's patients or health care
providers or insurance companiesor states, for example. So
health care is extremely complexas all of your regular listeners
know, and the idea that youcould make these changes without
letting someone know in advanceor giving the opportunity to
sort of be heard or get moredata or get more feedback is
really, really challenging. Andyet that is exactly what sort of
(04:19):
pulling back on this Richardsonwaiver is doing at HHS. We
haven't yet seen or, well,speaking for myself, I haven't
yet seen HHS leverage this yet.They have not sort of pulled
back on a ton of things yet.
I have a couple examples that Ican give, but I think more is
coming. And so we could talkabout that as well. And then
maybe we're going to get tothis, but this is not only just
(04:40):
happening at HHS. It's reallyhappening kind of across the
agencies, due to some prettyhigh level directives from
president Trump.
Jeff Byers (04:46):
Yeah. I do wanna ask about, some of those public
comments and about the state ofthose. But before that, you
wrote in Health AffairsForefront about, from a broader
perspective about a president'srole memorandum that encourages
federal agencies to be lesstransparent and sidestep public
input on major regulatorychanges. Is that any different
(05:08):
than what you're talking aboutfrom HHS? Or walk me through
that.
Katie Keith (05:11):
No. It's quite similar. So, really, I think
this is a Trump administrationwide project. And I think the
president, and I would say thedirector of the office of
management and budget, I think,clearly have a a vision for a
deregulatory agenda that theywanna see across the board. And
so far, they've been extremelyaggressive at, say, the
department of energy.
(05:32):
Even the department of justicehas already rolled a lot of
things back. The consumerfinancial protection bureau, the
CFPB, has rolled a bunch ofthings back. I'm still waiting
and watching for a moresignificant impact in health
care, but I think it is coming,which is why I was so excited
that you wanted to talk aboutthis because I think there is a
cloud of this deregulatoryagenda really hanging over the
(05:52):
policy that the Trumpadministration is going to do.
And what it means is they'removing extremely quickly. I
think that is the part forlisteners to really pay
attention to.
If you don't have to do this,you know, or even try or attempt
to do notice and public comment,you can just be putting out what
we call interim final rules. Youcan just be revoking policies.
And so what we're seeingexamples is just short notices
being published in the federalregister that say, here's the 20
(06:15):
things that the consumerfinancial protection bureau is
pulling back today, and no onegets to say anything about it.
You shouldn't rely on it. And inthe meantime, the agencies
aren't gonna enforce it either.
So it it could it could beextremely disruptive without any
opportunity to weigh in.
Jeff Byers (06:29):
Yeah. So going back on that, like, what you
mentioned a vision. What is thisvision? Or, like, what's the
purpose of this vision?
Katie Keith (06:37):
I I mean, I think it's a deregulation writ large,
and it's probably an ideologicalvision. And I'll give one
example. A different executiveorder that the president signed,
is a requirement that agenciesthat want to do new regulations
have to pull back or identify 10regulations that they don't want
anymore, that we call it sort ofthe 10 for one executive order.
So that is not the mostrationalized thing in the world.
(06:59):
It is purely a numbers game ofwe just want fewer regulations.
So I think that is part of thethe approach and the vision.
During the first Trumpadministration, they had a five
for one regulation EO, and herethey really upped the stakes by
taking it to 10 to one. And sowe're still kind of watching to,
again, see how that will playout, but you're really seeing it
across the board for differentindustries. President Trump
(07:19):
signed, an executive orderrecently specifically to say, I
want you to repeal thisDepartment of Energy rule that
defines showerhead in a certainway. And you should have no
notice and comment, and thatchange is going into effect in
thirty days.
So those are the types ofexamples that we're seeing,
very, very specific, and I'mwaiting for that to come to the
(07:39):
health care world.
Jeff Byers (07:40):
Yeah. So on the public comment thing, question,
how it's gonna be a roundaboutway. And just to get to, like,
how helpful are public comments?So, you know, we all know about
the if you're a listener of acertain age, the Boaty McBow
face scandal. I don't know ifit's scandal, but event where
the public named a boat.
(08:01):
You know, there was a publiccontest, naming contest. Here in
Richmond, Virginia, they had anaming contest for the baseball
team Richmond Flying Squirrels.I'll let you decide if you like
that name. But there's beentalks, so there's that of just,
like, people kinda messingaround with comments. Generally,
I would imagine, like, some ofthese people are informed, more
informed than the general publicif they're commenting on
(08:23):
regulations.
But people that are definitelymore informed are potential
lobbyists. So there always hasbeen some talks about a bunch of
comments from lobbyists in thesepublic rulemaking. So, like, how
helpful is this process fromwhat you can tell?
Katie Keith (08:37):
Yeah. Helpful seems like a value word. I will say, I
do think the comments make adifference. And I've I found
that being in government myself.I don't know if they will make a
difference to thisadministration that seems very,
you know, intent on doing whatit wants to do.
And I could give some exampleswhere the first Trump
administration received, Ithink, probably hundreds of
(08:57):
thousands of comments and didn'tchange a word in the final rule,
that kind of thing. But I dothink it is. The comments are
valuable if only because theyput people on notice of the
changes. And then it's anopportunity, I think, especially
for you know, you sort ofmentioned lobbyists, but I think
industry comments are oftenhelpful to talk about the burden
to you know, government agenciesonly know what they know. And so
(09:18):
giving more of that sort ofoperational feedback, sometimes
it's used to push compliancestates out to give more industry
and states and others more timeto to adjust to the rules.
Sometimes it results in truetweaks. So I I think comments
are extremely valuable inaddition to sort of the the
value of, in and of itself,being able to comment and give
(09:38):
your feedback on somethingthat's happening. So there
there's that sort of intrinsicvalue to it as well. But I do
think that comments can make adifference if they are being
considered in an open mindedway. I think what I I think what
we're seeing the trend acrossthis deregulatory agenda is
there's not a lot of interest intaking that, you know, taking
that feedback or even seeingwhat it is.
(09:59):
And so we'll sort of see wherethey go from here. But I I'm
expecting them to get I thinkparticularly after we, the
collective we, gets through,this budget reconciliation
process, which I know we'regonna talk about, I am
expecting, I think, the Trumpadministration to turn even more
full heartedly, if you will, torulemaking and rolling back some
of this stuff, and I'm expectingthem to do a fair amount of it,
(10:21):
without notice and comment.
Jeff Byers (10:22):
Okay. So before we move on to budget
reconciliation, is thereanything else that you wanna
talk about from deregulation?
Katie Keith (10:29):
I think one one of the reasons I'm anticipating
more action from the Departmentof Health and Human Services on
health care policies, is in partbecause I know agencies have,
were directed to go through anew process to identify all the
regulations that should bepulled back both because they
don't match thisadministration's policy
priorities, but also becauseagencies have been asked to
(10:51):
identify rules that aren'tconsistent with supreme court
laws. And so agencies are doingthey've been doing that work
quietly by themselves. They hadto submit a big package and send
over their list to the office ofmanagement budget in mid April.
And I think we're beginning tosee some of that come to
fruition as I'm you know, havebeen giving examples of other
agencies posting guidance,rescinding a whole bunch of
(11:12):
stuff there. So just wantlisteners to know that there was
a whole process that is going onbehind this, and I think that is
going to be ongoing work thatthe agencies are doing quietly
to identify the things they wantto roll back without notice and
comment.
Jeff Byers (11:24):
Looking to the budget reconciliation, new text
was released this week. A lot ofthings were released this week.
There's the drug pricingexecutive order, which we are
not gonna get into. A lot ofstuff we're watching. What are
the top line findings for healthcare policies that's that's come
out, full stop, this week.
Katie Keith (11:43):
What an easy question. So it's only we are
recording on Tuesday. That'sright. That's a caveat. It has
already been a very busy healthpolicy week.
You mentioned the executiveorder on prescription drugs that
the president signed on Monday.The Centers for Medicare and
Medicaid Services also issuednew guidance on the Medicare
drug negotiation program, whichI know some of, my favorite
(12:05):
prescription drug experts willbe writing about for forefront.
There was a new proposed rule onMedicaid provider taxes also
coming out of CMS. So there's aton of activity, and it's only,
you know, day day two of a verylong week. I know I and many
other people all around DC haveour eyes glued to the markups
for the house energy andcommerce committee and ways and
means committee that areoccurring later day on Tuesday.
(12:27):
But for this, you know, megabudget reconciliation package
that is currently moving throughthe house, happy to talk about
some of what's in there. It is ahuge health care bill that, you
know, if enacted, wouldrepresent the largest cuts to
Medicaid in the history of theprogram. You know, more than not
even more than at least thirteenpoint seven million people will
(12:48):
be newly uninsured in 02/1934.As a result, lots of disruption
coming for health care if thisbill makes it across the finish
line.
Jeff Byers (12:56):
Yeah. So let's dive in. You mentioned Medicaid work
requirements and you mentionedthe CBO estimates for how many
people might lose healthinsurance based on this. But,
yeah, what what are the details?So I I noticed some Medicaid
work requirements stuff.
I have in my notes capping SDPs,which is a great acronym that I
don't know what it is.
Katie Keith (13:17):
State directed payments.
Jeff Byers (13:18):
Thank you. So yeah. So what's in there?
Katie Keith (13:21):
Another, soft ball Yeah. On health care.
Jeff Byers (13:25):
Let's start with Medicaid work requirements.
Katie Keith (13:28):
What can
Jeff Byers (13:28):
you tell us about what's in there for that?
Katie Keith (13:30):
Yeah. So, I mean, a few top lines, and, you know, I
and others will be publishing onthis and on forefront so folks
can dig in on all the nittygritty details. But mandatory
Medicaid work requirements wouldso every state would have to do
this. I think it would result inhuge administrative burdens for
enrollees and states to actuallyadminister this program. We know
(13:52):
it results in coverage losses, Ithink it will be exacerbated by
some of the other red new redtape that would be being imposed
through the bill.
So it would essentially requireenrollees to show that they are
doing work requirements orschool or other sort of
community engagement rights forup to at least eighty hours a
month. States would be requiredto confirm that on at least a
(14:15):
monthly basis, but they could doit more often if they wanted.
They could do weekly checks.And, you know, all of the
experience, and Sarah Rosenbaumhas a great past piece on this,
laying out the evidence and dataand what we know about Medicaid
work requirements shows that,you know, it results in coverage
losses because these arecomplicated requirements to have
to follow-up on. And we knowfrom data from folks like KFF
(14:37):
that the vast majority ofMedicaid employees are working.
This to me seems like a hugesolution in search of a problem
in many ways, and I think it isdesigned to reduce the Medicaid
roles in this instance. And I Isort of mentioned this. It's not
just the Medicaid workrequirements. There's a whole
bunch of other, you know, again,new red tape that's being
imposed. Eligibilityredeterminations would be
(15:00):
happening more frequently forthe expansion population.
There'd be a lot more, you know,address verifications and all
kinds of things there. So justlots and lots of burdens. For
beneficiaries themselves,there'd be new cost sharing
requirements, so folks would payhigher. So so for those who are
able to jump through all thosehoops already and keep their
coverage, you would face highercosts. And, you know, there's a
(15:20):
whole bunch of stuff in thereon, I think, limiting state
flexibility for how they fundand finance, their state
Medicaid program.
So there seems to be, this ideathat you can lock in what's
currently happening, but stopstates from raising provider
taxes or doing other changeslike that. And I think it's
gonna really tie states' handsgoing forward even as this bill
(15:41):
loads up on all the new stuffthat states are gonna have to do
to manage their programs there.Two, maybe other things on the
Medicaid side to flag, the billwould defund Planned Parenthood.
It doesn't say the words PlannedParenthood, but it seems very
targeted at, that organizationand prohibit states from using
federal funds for the treatmentof gender dysphoria, for kids.
(16:01):
So that would be a significantnew policy.
And that's everything I'm sayingis, like, scratching the surface
on the Medicaid front. And thenthere's a whole bunch of
Affordable Care Act changes too.
Jeff Byers (16:10):
On the Medicaid front, so, again, I don't know.
I don't think I'm a policy wonkper se, but, like, my cursory
reading, so correct me if I'mwrong, that they're are they
putting more burdens on statesto enact the Medicaid program in
general? And to what end ifthat's correct in your reading,
just why?
Katie Keith (16:30):
I think it's definitely correct that there
will be many more burdens onstates. I think those paper it's
it's a lot of paperwork burden.It's a lot of, you know,
checking eligibility. It'shaving beneficiaries come in and
report that they'll I think theburdens that are going to be
placed on states are going to bepushed down to enrollees who are
inevitably not going to be ableto keep up with this complicated
(16:51):
system of what they and we haveevidence from this. You don't
have to take my word for it.
It's when this was rolled out inArkansas. People lost coverage
not because they weren't workingor doing the community service
that they were supposed to bedoing, but because they couldn't
they didn't know or weren't ableto submit the paperwork to prove
that they were doing all thosethings. And in fact, in
Arkansas, you saw people losetheir jobs because they lost
(17:13):
their Medicaid coverage, and soit's this perverse thing. So I
think the requirements on stateswho are designed to get pushed
down to enrollees and, again,inevitably result in in coverage
losses that you you sort ofmentioned the the CBO is already
suggesting. And so the top linesjust from the energy and
commerce draft, again, we've gotmultiple committees doing
multiple things.
(17:33):
All of this will get wrapped up,but they're moving really
quickly, so we don't have a fullpicture yet. As of Tuesday, the
overall energy and commerce billwould cut at least
715,000,000,000 from healthcare. That's both Medicaid and
Affordable Care Act, and theyestimate that at least
13,700,000 people would beuninsured. More people would be
(17:53):
uninsured in 2034 based on this.I'm saying at least very
pointedly because I thinkeveryone expects those numbers
to go up as CBO is able tocontinue to do its analysis.
There's been certain thingswhere they haven't been able
they haven't had time yet tolook at, you know, what's the
interaction of this Medicaidchange with this marketplace
change? Because, of course, allof this is additive, and so they
have said as much that theythink the coverage losses are
(18:14):
gonna go up. You know, the waysand means bill has some things
that are gonna result in, Ithink, people losing coverage as
well. So double digit coveragelosses and, you know, hundreds
of billions of dollars beingtaken out of health care if this
becomes law.
Jeff Byers (18:27):
So you mentioned we're only really scratched the
surface on Medicaid. So lookingout from Medicaid, just like
we're not gonna be able to covereverything in this time. So was
anything surprising to you inthe text of the reconciliation
bill?
Katie Keith (18:42):
I don't think anything is surprising in that
the top lines of this budgetreconciliation reconciliation
resolution suggested thesechanges had to be sweeping, and
I think that's what folks havebeen sounding the alarm about
for a very long time. And Ithink the scope and degree of
the changes is still sooverwhelming and significant
even as I read it. I think maybeI had an understanding of what
(19:04):
the top line policies would be,but getting the drafts, reading
through it, seeing all of ittogether, and trying to
understand the impact that wouldhave on patients and states and,
frankly, state economies andhealth care providers and
uncompensated care. And it itwill I I don't think you can
overstate the impact that thiswould have on the health care
system. So I is that surprising?
I don't know, but it is it itdef I definitely felt the impact
(19:27):
of, what would happen if if thisbecomes law.
Jeff Byers (19:30):
So every episode could be someone's first, and
maybe this is everyone this issomeone's kinda introduction
into health policy world or ordeeper into the health policy
world than before. With that,like, what are the next steps
for this package?
Katie Keith (19:45):
Yeah. Well, a, don't let this be your last.
You're listening to this andwant to run
Jeff Byers (19:50):
That's right.
Katie Keith (19:51):
In the opposite direction because I not blame
you. Yeah. That was my pitch.There you go. No.
In terms of next steps, so,again, recording on Tuesday.
This afternoon, two of thesecommittees, House Energy and
Commerce, House Ways and MeansCommittee, are doing a, quote,
markup of the bill, so there'llbe amendments. Some people are
suggesting, you know, thesecould run all night. So we'll
(20:14):
see sort of what state thosebills are at the end of that
process, and then it willcontinue to move through the
house. So there'll be otherhouse hearings.
All of that will get packagedtogether. It will go to the
house floor at some point. Andthen once that's done, it will
go over to the senate. So thisis a long slog. I don't think
we've seen the end of even thepolicy changes, and so I think
folks should absolutely staytuned both to the podcast and
(20:36):
health affairs forefront wherethere will be a ton of analysis
as this continues to movethrough.
But much more to come and sortof a what could be a devastating
starting point. Let's put itthat way.
Jeff Byers (20:49):
Yeah. You mentioned Health Affairs Forefront, our
digital publication outside ofthe journal. This will publish
on Friday. On this particularaspect of it, what what's in the
hopper for you to discuss?
Katie Keith (21:00):
I am certainly I could speak for myself, which is
I am working on a very long,wonky, detailed, as is my style,
summary of what is in thesepackages as of their sort of
introduction or considerationfor these markups. And then I
think we'll use that as thebaseline to kind of update over
time as it moves through theprocess. Anything can happen.
(21:23):
You know, there's already beensome outcry from governors about
some of the cuts. I think a lotof the hospitals and provider
associations are maybemobilizing against some of the
pieces of this given that so Iam expecting sort of changes
over time.
Certainly, maybe changes by thetime this gets through the
senate, which has its own rulesthat we haven't talked about.
But president Trump andRepublicans in congress seem
(21:44):
quite motivated to get this donequickly. So, you know, I think
count on us here to be doing thequick turn analysis that folks
need, recognizing that, thingswill certainly change over time.
Jeff Byers (21:55):
Yeah. And what's that word count currently?
Katie Keith (21:58):
Don't ask me. You don't wanna know.
Jeff Byers (22:02):
Well But
Katie Keith (22:03):
it'll be linked below everyone. Yeah.
Jeff Byers (22:04):
That's right. That's right. Well, Katie Key, thanks
again for joining us today onhealth affairs this week. To you
the listener, if you enjoyedthis episode please send it to
The Budget Hawk in your life andwe will see you next week.
Thanks all.
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