Bill Kristol (4:21)

So that's the reconciliation fight, I guess. Yeah. Which, and they've already passed a budget which implies, I guess or to pay for the tax cuts, pretty massive cuts in Medicaid. And just say a word about what people know Medicaid. Some people maybe, I don't know. Yeah, various reasons. But say a word about, you know, What? This isn't money sloshing around for some extra nice things at some community health centers mostly. Right. This is pretty fundamental health care for lots of people.

Jonathan Cohn (4:46)

Yeah. I mean, look, Medicaid is a huge program nowadays. You know, more than 70 million Americans get coverage through Medicaid. It actually pays for more than 40% of live births in America. Huge reach. It is the. You know, it also underwrites a huge part of our healthcare system, especially in rural areas. Hospital. Rural hospitals, which typically struggle financially. It's become a real lifeline for them. The money they get from Medicaid. It has gotten very expensive. It's grown. It started in 1965. It was part of the Great Society. LBJ was the same legislation that created Medicare, created Medicaid. It was a much narrower program than. It's a much bigger program now. And that's part of what the debate is at a sort of abstract level. It has grown so much because its champions have turned it into sort of a pillar of what they hope will someday be a universal coverage system. And that was the big change that happened with the Affordable Care Act. The critics, Republicans, they didn't like it then, they don't like it now. It is expensive. It is an intrusion. It's a government program. Right. It's a big government program interfering in health care. So they want to, you know, downsize it, get it closer to where it was. And that's really the debate we're having right now. And this bill going through would, in effect, you know, depending on the details, and they're negotiating over them, and it could go in about 10 different ways, but, you know, one way or another, they are looking to take hundreds of billions of dollars out of the program and, you know, downsize it, in effect, so it would look more like it used to look. The flip side is that because several million people will lose insurance, and these are people who were added to the program very deliberately because the thought was, okay, we want to get to universal coverage. Let's build on Medicaid as one of the ways to do that. So that's in an abstract. That's the debates. The debate left and right have been having for decades, the debate over universal coverage that goes back to 100 years ago. So, I mean, it's just the latest iteration of this debate, and, you know, we'll see how it turns out.

Bill Kristol (6:56)

But it's a more radical, isn't it, proposal by Trump, that is to say, in the first term, after McCain gave the famous thumbs down on the big health care reform they were pushing then. My impression is they kind of receded for three years and didn't make. Maybe they nominally were in favor of cutting it, but they didn't do much about it, certainly. And then they lost Congress anyway. Obviously, Biden did nothing in that direction. Bush expanded actually elements of Medicare with prescription drugs and so forth. So I do feel like with a Republican president, Republican Congress, and the incredible pressure on them to pay for the tax cuts, this is more of a real debate in a way, on the actual, on a pretty important part of Obamacare, which was the expansion of Medicaid and the federal government picking up, what is it, 90% of it. And a lot of conservative states, I'm not mistaken, went along with this. And so they have this embedded in their budgets. And if the federal share gets cut back, more goes to the states, do or don't pick it up. So it's a pretty real, it's abstract, as you were saying, in the sense it's a familiar debate, but it's pretty real right now. Right. I guess of all the things they're going to change in the federal government strikes me as one of the biggest ticket items that could actually get changed.

Jonathan Cohn (8:06)

Oh, yeah, super real. This would be if, again, depending on the details of what they decide to do, but very conceivably, this could be the single biggest retrenchment of a government health care program we've seen in American history and would affect millions of people, it would affect hospitals, it would affect the whole healthcare system. And you alluded to the politics. What makes this politically interesting, tricky for the Republicans is that they have very thin margins. A lot of their states have expanded Medicaid now. And they've done it because, in some cases they've done it because Republican governors or lawmakers and the legislature said, hey, you know, we're not the biggest fans of Medicaid. But on the other hand, we do, you know, these people are here in our state, they're showing up at our hospitals. This is a way to get federal money into the hospitals to pay for it, especially again, in rural areas. That's true in rural states. It's true in rural districts of blue states who account for the House majority.

Bill Kristol (9:09)

Right.

Jonathan Cohn (9:09)

You know, you know, we're talking rural parts of New York, Pennsylvania, Michigan, where I live. So, you know, that is tricky. And, you know, different states are in different positions. So some states actually, again, this was, you know, part of what we, you know, the Medicaid expansion, which you alluded to the way it works. Medicaid is a joint federal state program. So as you said, the federal government puts up most of the money. If that money goes away. Some states, the law they passed to expand Medicaid, there's a trigger in it. So if the federal money gets reduced right off the bat, automatically the expansion goes away unless they act to replace it. And the assumption is in most of those states, it's a huge budget item for a state to pick up. So they probably won't. And then what's really interesting is you have three states, one of which is Missouri, where the Medicaid was expanded because the voters approved it and put it in their Constitution, and there's no provision for taking it back out. So if the federal money goes out in Missouri and two other states, the state's gonna have to find that money and they won't have a choice unless they can somehow repeal a constitutional amendment, which, as you know, is hard. So that's why, interestingly, surprisingly, among, you know, you look at, you know, Capitol Hill, what Republicans are really vocal against this, it's Josh Hawley has been, you know, early, loud, very clear, like he does not want that money to go away. So that's the, that's where we are on that.

Bill Kristol (10:39)

No, that's so interesting. And I do think, I mean, I myself have focused much more on the rule of law issues and some of the foreign policy issues. But I think we're about to move to just on the calendar to a couple of months where the reconciliation bill will be a very, very big story, don't you think? I mean, up till, I guess, they want to get it through the house by July 4th. And so that gives us what's two months, basically, and, and, and maybe go into the summer, obviously further. And then, and the reconciliation bill, when you really get down to it in the big items, is the tax cuts on the one hand and the Medicaid cuts on the other. Is that, is that basically right?

Jonathan Cohn (11:15)

That is all correct. You know, two other things to keep in mind. At least, you know, the assumption is the hard deadline here is the debt ceiling because they're going to have to vote to raise the debt ceiling. And that's as, you know, as our listeners, many of them know, that's a really tough vote for a lot of Republicans. And the thought is rap, they get into this bill that also has the tax cuts, other Republican priorities is the way to kind of get that through. The other thing is what is an interesting, slightly unexpected and I think something to watch. I mentioned that Josh Hawley was skeptical. Trump has Been. And the Trump White House, or at least part of the Trump White House. I mean, again, you know better than I do. There's camps there and, you know, different camps. But, you know, early on, Steve Bannon, a couple months ago was on his show. He's like, don't cut Medicaid, you know, or be real careful. And then we've had this, like, three separate leaks of internal polls saying that, you know, Republican voters don't want to cut Medicaid. And the reporting and the bits I've heard suggest that the Trump, or people around Trump are very aware this is politically dangerous for them. They are not excited about it, which is different from 2017, when it was all about, we want to repeal Obamacare, whatever you want to do. And Paul Ryan always wanted to sort of transform Medicaid, so he went on. Trump does not seem that enthusiastic about this, which I do think is important, because at the end of the day, if he really, really pushes for it, just given recent history, right. We have to assume House Republicans probably go along, or there's a good chance they do. But it's not clear to me he's gonna push the Medicaid cuts per se. At the very least, I think he's watching to see how. How unpopular this would be, which is, you know, if you're somebody who wants, you know, to keep the Medicaid expansion in place, a reason to make some noise, because I do think that's going to register.

Bill Kristol (13:11)

And the response when I've said that I don't think he's going to go through with it actually is, well, you don't understand, Bill, the way reconciliation works, they have to. They have to pay for it, but they don't have to do anything. I mean, the parliamentarian will say that because of the reconciliation rules, you have to balance spending and, and taxes and, you know, they have to pay. But the parliamentarian can be overruled with 51 votes. So I'm actually more inclined, given that they don't have a huge respect for procedures and norms and the rule of law, previous law. I don't know. I wonder. That'll be a very interesting thing to watch. But there will be revolt if he does that. Also from the right, because this is a key part of, as you said, of a more traditional but conservative Republican critique of sort of the expansion of big government under. Oh, sure, the Affordable Care Act. A very interesting thing to watch going forward. Something, as I say, that some of us have not been as focused on, but will come front and center here and Be a congressional story as well. Be an intra administration story, as you said. I think that's a very good point to make at a congressional story. I guess it's not been a Kennedy thing particularly. It's an OMB thing really. Not a Kennedy HHS thing. Right. In terms of this is a budget thing, not a health care debate in this funny way.

Jonathan Cohn (14:17)

Yes.

Bill Kristol (14:18)

Healthcare to me, but I mean the driving of it. I'm just thinking of Kennedy now as secretary of hhs. He's not. It would be the same if Kennedy, if someone we'd never heard of was secretary of hhs.

Jonathan Cohn (14:28)

Yeah, yeah. I mean, I know we'll talk about Kennedy in a bit. I just don't think this is on his radar screen at all. This is not of interest to him, which, you know, is an interesting thing to say about someone who's, you know, you know, you look at the money that goes through hhs, the vast majority of it is going through Medicare and Medicaid. And, and I don't think he's particularly interested in either, you know, but that does, I think also speak to the extent to which the White House and OMB will be driving the administration views on this.

Bill Kristol (14:57)

Yeah, that'll be interesting. Well, let's get to the second. What has been a bigger story in the healthcare, HHS side of things, which is the cuts quite dramatic in nih, N cdc, the center for Disease Controls, Diseases Control. I was getting a speak anymore, center for Disease Control, whatever it's called and well known parts of the research establishment that exist and the cuts there have been more immediate or attempted to be immediate. The courts have held up a fair amount of them. What's, I mean, why. That's not something Trump in my, to my knowledge focused on in the first term he got. There was fights in the pandemic, obviously with Fauci and stuff. So maybe it's now a different story. But Trump seemed perfectly happy to preside over NIH and cdc. And you know, I assume Trump's buddies from New York and big donors are okay with funds flowing to Sloan Kettering and MD Anderson and so forth. They seem to give a lot. Right. Some of them. Right. Trump doesn't because he's a cheapskate. But some of them write big checks to those organizations to pay for the new buildings and so forth. And suddenly he's cutting that. He's cutting $7 billion, he thinks from Harvard, which goes to 7 of the $9 billion from Harvard is medical, I believe. How real is that? How big is that? What do you make of that?

Jonathan Cohn (16:15)

Yeah, yeah. Well, let me say in terms of how big it is, it's a little hard to be certain. And just sort of a side comment, I mean, this is. I've been writing about government for a long time. You've been in and writing about government for a long time. Government, typically when they make changes, right, they sort of announce that here's what we're going to do and then they do it and you know, it gets studied in Congress and whatever. I've never seen anything like this. I mean, there have been waves of firing, waves of cancellations of grants, waves of programs suspended, but frequently with no announcement, no public announcement. You find out about it because news organizations suss it out. And then even then it's hard to get details. I mean, a couple weeks ago I was trying to find out what had happened to a particular office at HHS which runs the early childhood programs like Head Start, and I asked, what do you do when you're a reporter? I went to omb, I went to hhs. Can you tell me how many, what divisions were cut? How many people? No answer. No answer. Eventually, the only information, it turns out that a bunch of former employees together kind of group sourced with their contacts a spreadsheet that they were sending around that had what they thought was a pretty accurate read. And it does look like it was an accurate read, but I mean, so that's the kind of information we're operating here. It's really quite difficult to be certain about any of this, just to be clear before we describe it, but they are very significant. We have seen, Kennedy has said, and it does seem like they're on their way to reducing the staff at the staff at the Department of Health and Human services overall by 25% with heavy, heavy cuts to the staff of the National Institutes of Health, Centers for Disease Control and again many smaller offices as well, like the child care office I was just describing. In addition, there's been a dramatic reduction in the grants going out the door. NIH considered I think around the world as the crown jewel of America's biomedical research establishment, responsible for literally endless, countless lists, numbers of medical breakthroughs, life saving breakthroughs. They've dramatically cut down the money going out, both through direct cancellations of grants, but also layoffs of people who manage the grants, restrictions on the activities of people who manage the grants, just kind of really throwing sand in the gears.

Bill Kristol (18:50)

Cutting back the overhead for that was a very early, remember, announcement, kind of across the board, huge restriction and cutback which would require people to really cut back their own efforts, obviously, if they're using it to pay for the building and keep the electricity on and pay for the staff and so forth.

Jonathan Cohn (19:06)

Right, yeah, yeah. And you know, look, I always say this. I mean, nobody who has seen nih, nobody who has seen government up close would deny that you can't make it more efficient. And there's been a lot of efforts over the years that have been frustratingly slow. And there was, you can imagine a version where an administration, Democratic or Republican, comes in and says, we really want to reorganize NIH and consolidate it. They have all these different centers and institutes, and I know Democrats and liberals who have called for that in the last five to 10 years. I know Republicans who have called for that. So there was a version of that that you could see playing out and leading to a more efficient operation and better funding choices, et cetera. You can see a version of that where you would expect they won the election. When you win the election, you get to change the direction and priorities to some extent of the way government works. I can imagine whether or not I like it, other people like it, them coming and saying, look, we don't want to be. We think we're now doing too much on disparities or diversity or whatever it is that they want to reduce the studies for. I mean, that you do have, you know, that's. When you win the election, that's part of what you get to do within, you know, certain parameters. What they've done though, is just, you know, it, you know, there were several ways. So there was the kind of Doge wave, which just, you know, it's, it's still impossible to know exactly what on, but I mean, I think it's entirely possible. We, you know, we were in a situation where you had 20 something former Tesla employees or tech gurus coming in and saying, why do we have three different procurement office? Let's just close two of them, which might make sense, but it may be because one of them actually specializes in actual lab equipment and one does contracting with research scientists and actually they don't do the same thing. And now you can't get supplies, which is a real thing that's happened, by the way. NIH does some of his own research and there are stories about internal emails like, hey, do you have a couple of these reagents? Can we swap some test tubes? I mean, it sounded like something. If you remember that, you probably remember the show Mashup. They were always bargaining for supplies. Do you have bandages? I mean, it Felt like that the National Institutes of Health. It's crazy. So you had that, then you had overlapping that, you know, a wave of cuts that were about, you know, getting rid of dei. And if you look, I just saw it was either nature or science, I forget who. And boy, by the way, science, Nature, Statin News, kff, Health News have been doing just heroic work trying to keep track of all of this. You know, the single biggest category of grants that got cut out were related to hiv. The second biggest were related to transcare, the third was related to Covid and the fourth was related to climate. So, you know, there was that wave and, and you know, and again, whatever you think of the merits of more or less, number one, it was, it was a complete, it wasn't like we should do less of this. It's like we're getting rid of anything, you know, that's got the word HIV in it. I mean that's a whole other, there's a whole mini story about the end. Like the, the amount of HIV related programs and projects that the federal government has run for years are just getting wiped out across the federal government. But there was also, again, this speaks to the sort of clumsiness of it. There were grants that got cut of biodiversity, not because you were dei, but because someone did a word search and picked up the word diversity and you ended up cutting biodiversity. So you had that range of, you had that level of cuts. Then you had the cuts that were targeting particularly universities and the war on universities, so like Columbia, Harvard, et cetera. And yeah, so it's just, you know, it's just this sort of wide swath of destruction. Again, you know, whatever you think of the agenda, whether you think, yeah, we should be doing more to maybe you think it's, you know, it's too big, it should be directed differently. There's places to make it more efficient. You know, whatever you think, it was clearly done in the clumsiest haste, you know, most hasty, you know, way possible by people, I don't think. I think it's pretty clear. Didn't know what they're doing. The reporting backs that up. And I think the attitude was this is our chance, we can just, you know, do all of this and you know, we need to build things back up. Well, okay, fine. And they sort of said that, but you know, I know, you know, when you have medical studies that have been going on for 20 years, you interrupt them, you can't just start them up again. Institutional knowledge, you fire people, they're going to get other jobs. They're not going to come back to the government. You lose that. And there was a sensible way to do all of that. And I don't feel like there's zero reason to feel like that's what they're actually doing right now.

Bill Kristol (24:03)

I've been talking to people who are very experienced in scientific biomedical research, not hysterical, have their own criticisms of NIH over the years or CDC for all kinds of bureaucratic and other reasons who really think, I mean, just the most basic stuff. Nothing, nothing. Biodiversity, I mean, cancer research, you know, Alzheimer's research. I mean, things that presumably are very important for biomedical research are going to be set back considerably. I mean, I'm sort of struck at how alarmed they are. You talk to more people in this area than I. You agree with that? Or is this kind of a blip? But it goes down 5%, we get back on trend, so to speak. I mean, I don't know. What do you think?

Jonathan Cohn (24:41)

I mean, I'm hearing is apocalyptic too big a word? I'm not sure. I mean, when you add up the sort of senior, senior people who are titans in their field who are being pushed out of government and some who are very public figures like Peter Marks, who was the head of top vaccine state, but a lot of people less well known, but do things like monitoring of lab protocols and things like that, that you really need to have that expertise around so people can. So you add up the sort of loss of expertise, the loss of funding for studies that either won't get done or will get interrupted and stopped. All the money that's not going to bring in the next generation of scientists, which is so important. And that's not just at hhs, but National Science foundation, which is something else I wrote about, has this very famous early graduate student fellowship program, like something I don't remember the exact number of. I want to say it was, oh, since, you know, after World War II was established and I think 40 Nobel laureates have gone through that program. I mean, it's, you know, founder of Google, you know, mother of artificial intelligence. I mean, just incredible alumni network. We're cutting that. And you know, that is when you think about innovation, future developments. I mean, that's 10 years from now, that's 20 years from now. Those are the discoveries we won't have the innovations. The scientists that won't be there won't. Or to some extent, which is so ironic, it will be the innovations that were discovered and developed in China or Canada or France because those countries are. Now they're trying to Bring those scientists over there and I don't think they'll do as good a job because we actually had a pretty good system here, all warts and all but for a agenda and a program that supposedly is about making America great and the leader of the world. We are, I mean I feel like we are giving away one of our greatest strengths as a country. And it's just. It's mind boggling.

Bill Kristol (26:40)

Yeah it is. And it very much dovetails with the hostility to immigrants and making it not a welcoming place not just for people trying to come across the border or undocumented people from Central America, but also for people who postdocs who are coming from as we've seen, you know. And I'm struck how many I've heard personally you know, sort of friends of friends kind of thing. I'm not sure I want to be there and who knows what it'll be like the next three or four years. I'll just take a job as you say in FR Or I'm from France or I'm from Estonia. I heard one story very promising the great dream if you're in a very good undergraduate in Estonia and in some medical, you know, pre med medical or medical student there, many of them the dream is to come here and maybe stay here but certainly contribute here for a while, maybe go back. And that is just a pure loss it seems to be of. I mean yeah, all these breakthroughs we've had, I don't know what percentage of them. I'm not sure anybody could do this math too accurately because it's kind of complicated but come from people who were not born in the United States, who immigrated to the United States partly because they were attracted by the idea of doing medical and scientific research, practicing medicine here. But it's not a. That's not a small percentage I'm going to just, you know that I'm pretty confident of. Right. So they to the degree they don't come here as you say hopefully the breakthroughs happen elsewhere because just for the sake of humanity, you know. But it's kind of mind boggling actually. I do think the make America great again people think all great breakthroughs in America have come from people who were born here and maybe have been here for a couple of generations which is not true. If you go back to the Manhattan who exactly developed a nuclear bomb here. I mean kind of important World War, you know to end World War II and for the Cold War it wasn't anyway not worth that's so there's that part of it. And now we've left a little less time than I hope, but it's enough time to really capture, I think the, we can go a little long. The Bobby Kennedy, Robert Kennedy, Jr. Secretary of HHS, a vaccine skeptic to say the least. I mean, when it was confirmed, I think people thought, I even thought a little, he'll pull back. He's not going to go ahead on these various wacky mini crusades and anti science and kind of crackpot theories that he's indulged in for 20, 30, 40 years. Well, has he? I mean, what's the story of Kennedy as secretary of hhs?

Jonathan Cohn (28:51)

Yeah, I think for people who were worried that he would use the position as secretary to undermine America's, you know, this sort of, you know, to undermine vaccines in the broad sense, by which I mean, you know, undermine public faith in them, you know, slow down or, you know, stop the process of sort of approving and distributing them, discouraging their development. I don't want to say it's the worst case scenario. I don't think it's that far from the worst case scenario. To me, the easiest way to point it out is how he has been his public actions in the face of this measles outbreak, which is well on its way to becoming the worst measles outbreak in decades. You've already had two children die and you know, let's. I always say this, but children should not die of measles. We have a vaccine that will prevent people from getting the measles. It will save lives. Measles used to kill a lot of people. It does not anymore. Certainly doesn't kill a lot of children because they get the vaccine. There is vaccine skepticism out there. Rfk, before he got into government, played no small part, I think, in spreading that skepticism. Then he gets to Congress. You know, Trump appoints him, he has those confirmation hearings. He makes his statements. I won't, I won't undermine vaccines. I'll go with the science. There was that very famous set of hearings with Senator Cassidy from Louisiana, who's a physician who very much believes in vaccines. And he famously voted for Kennedy, saying, well, I've gotten assurances and Kennedy won't undermine vaccines. And here we are in this measles outbreak. He's really never kind of, you would expect this is the biggest measles outbreak in decades. Again, the first children's death in quite some time. You would expect an HHS secretary to aggressively be out there saying, this is what we want to do. We want people to get Vaccinated. He's done nothing of the sort. On a handful of occasions, he's made statements that say vaccination is good and it's the best way to prevent measles. But if you look closely, most of them were written, so who knows if he wrote it or somebody wrote it for him and said, you have to put this out.

Bill Kristol (31:24)

He's made a handful of statements and more than a handful the other way. Right. We don't know what's in these vaccines. We're not sure what their effects are and so forth.

Jonathan Cohn (31:32)

Yeah. I mean, the ratio, I think I haven't done the math, but I feel like it's a two or a three to one ratio of state public statements that are skeptical of vaccines one way or another outweighing the ones that are pro vaccine. And of course, he's also. What is he actually doing? Well, he's commissioned this study to get to the roots of what is causing autism, which. And he has said, we're going to get to the roots of vaccine safety. As if there were questions about whether vaccines cause autism, as if there were questions about whether vaccines are safe, and there aren't. I mean, this has been studied extensively. The latest thing, just this past week. I think it was this week.

Bill Kristol (32:15)

I don't know.

Jonathan Cohn (32:15)

Do you find it hard to keep track of what happens when I just.

Bill Kristol (32:18)

Totally. Yeah. You know, dog ears. Kind of under Trump, right?

Jonathan Cohn (32:21)

Yeah. So I think it was this week. I apologize if I'm getting this wrong. I think it was this week he announced that all, you know, all new vaccines would have to be placebo tested, which implied that vaccines, New vaccines were not placebo. Actually, new vaccines are placebo tested. What is true is that when you sometimes are, you know, when you're developing a kind of, you know, modification of an existing vaccine for, say, the measles, it will be tested against, you know, you know, once, you know, once the safety is sort of, you know, assured, you know, they will test it against the existing vaccine, for example, or the flu vaccine doesn't get placebo tested.

Bill Kristol (33:02)

But, you know, it's updated every year, right? Yeah.

Jonathan Cohn (33:05)

I mean, there just isn't time. By the time you were done placebo testing, we'd have a new flu, you know, new flu strain. So. But, you know, that is just an example. And I want to be careful. I'm trying to be careful not saying too much on the science side, because I'm not a scientist and, you know, I don't want to get over my skis, but, you know, I feel very comfortable saying vaccines are safe. And every time he gets up there and he says, you know, introduces questions, you know, he's validating a skepticism that exists for a whole bunch of reasons. Although, again, I think he did more than a little to spread that, you know, in past years. And it's just, it's just, it's grossly irresponsible for the nation's top healthcare leader to do that, especially at a time when we have people getting in the worst cases, dying from the measles, Covid.

Bill Kristol (33:50)

And the flu and all these other things haven't gone away. And to say nothing of the fact that my impression is, and again, you would know the science better than either. Neither of us is a scientist. So I'll hasten to say that, as you just did, that the progress on MRNA and so forth on vaccines was really promising in other areas. People I know in that world thought this could be a huge thing over the next few years, that just as we made much more progress against Covid than people expected, much faster with a safe, actually and effective vaccine, after that nightmarish first year of not having a vaccine again, pickup hasn't been what it could have been. Fewer people would have died if it had been. But I don't know how much progress we're now going to make in the future. And people are going to think there's a hostile federal government spy, are going to spend quite the money they were going to spend, their doctors going to do the work they were planning on doing. So I think, as in these other areas, the unseen costs, opportunity costs, I guess maybe what economists will call it, are going to be pretty great as well.

Jonathan Cohn (34:54)

Yeah, yeah, I know. I mean, MRNA research suddenly, you know, into question when, as you said, there are lots of prom. You know, it was, there were lots of promising uses coming forward. And I, you know, I continue. I don't know. I mean, we've all talked about this, but I just continue to be amazed. I mean, if I, you know, when I look back at the first Trump administration, things they got right, or they could legitimately claim credit for warp speed, I mean, that was amazing, you know, I mean, what an accomplishment, you know, and the fact that they basically now disown it, it just, again, mind boggling. I don't really know what other word to come up with it.

Bill Kristol (35:31)

But yeah, yeah, I mean, the lesson of 2020 could have been. There are two possible lessons. One was the vaccine skepticism to, not to say denial and, you know, bad science and all that. The attack on science and the other was the actual progress on war speed, on the vaccine. Trump could have taken one or both or he could have tried to straddle as he did and sort of be for both. I see none of the warp speed side of them. I mean, is there anyone in the US Government who's sort of like invested in that side of it? That could be in theory, but, you know, but it doesn't sound like there is. The OMB wants to cut everything and Kennedy wants to discredit the science, I guess.

Jonathan Cohn (36:08)

Yeah. And look, and that's I think another case where you can imagine, I think, you know, the public health establishment got a lot of things wrong, it turns out, you know, policy wise, rhetoric wise and you know, you'll hear that from people in public health, you know, and you can imagine a version of okay, we're going to work to, you know, we're really going to look at what we got right and wrong, try to get it, you know, someday this hope, you know, hopefully we don't get another Covid like. But you know, it's nature, the world, you know, these things happen. You know, you can imagine a version of going through and trying carefully to understand the errors, to correct the errors while still, you know, keeping the good. But that's just, I mean this is not what we're doing.

Bill Kristol (36:51)

Yeah, I do feel if I close with this, but I'm curious on your thoughts. I sort of feel like this set of issues, both on the kind of macro, if you want side of, you know, the kind of just cuts and in health care for government provided health care at least combined with the cuts in research people, you know, I kind of feel that will be visible to people. Different people will see different things. I mean Medicaid will affect though it's not only for poor people, will affect more, as you say, rural areas and people who will lose health insurance. Presumably the people who know about the failure to make progress in scientific research is a little more of a well educated strata of people who are physicians or relatives of physicians or move in that world, the university world and so forth, the research institute world. But I feel like in both cases actually there'll be real world. I mean, I feel this, Maybe I'm wrong 6 months, 12 months from now, I feel like this issue is going to be. The set of issues will be as big or bigger than they are now, not, not the opposite. Do you agree or do you think they sort of. It's too complicated and we sort of, we adjust to a new normal.

Jonathan Cohn (37:55)

No, I agree with you you know, two things that come to mind. Number one, you were mentioning Medicaid. How many people there's a statistic, I think it's from kff. They want their polling or their studies which is a research group based in California. The national everybody trusts them. Something like I want to say about two thirds of Americans personally know someone who has benefited from Medicaid. You know, a big part of that is that is the single biggest financier of nursing home care in America.

Bill Kristol (38:23)

Yeah. Say a word about that. Which is people do not appreciate that. And yeah, yeah.

Jonathan Cohn (38:27)

So you know, nursing homes are. If any of you have certainly in my life, you know, you have elderly relatives or people with disabilities who need long term full time care. It's extremely expensive. It's expensive. If you're going to go into an institution, it's going to expensive. You're going to have someone come to your house. Medicaid is the single biggest source of that spending for people. You have to qualify for income. So typically what often happens and this is all other people will spend down their assets or whatever, but at some point you qualify. And that's how most people nursing home, the entire nursing home industry of America, you know, both the industry itself and the people who go there depend on Medicaid. And you take Medic, you know, Medicaid cuts, you know, even if they're not directly, you know, even if the cuts only affect the able body, which is one of the, you know, they don't affect the, you know, you'll hear, you know, Speaker Johnson say, well we're going to protect the vulnerable. The problem is that's not how Medicaid works. You know, once, you know, once the states have less money to work with, they're going to find ways to cut. They could, you know, nursing home care can get cut. A real another, you know, area can get cut. Medicaid pays has programs that pay for home care, which is what most people would prefer. Most people, if they can age in place, if they could stay at home, that's what they would want. Medicaid pays for that. Not as well as, not as much widely as a lot of us would like, but it does pay a lot of that. The thing is that's what's called in the parlance is an optional benefit for states, meaning they don't have to cover it. They don't want to. And states have that kind of leeway. So if states start losing the federal match, you could see that being a place where they cut. So people who need help at home with the daily living at home, living in a nursing institution, they will feel that, they'll feel that rural hospitals will feel the cuts to Medicaid. I do think all that will get cut. I think the research will be seen, too. I think that's an easy thing to visualize in the context of a campaign. You can imagine the ads, people waiting for a breakthrough, what's happening to it. And I do think politically, because I do think, you know, you know better than I do. But I tend to think that when, you know, issues become salient when they work to a party's clear advantage and, you know, there are all kinds of issues where Republicans have a natural advantage. Right. I think crime is probably one of them. Immigration, doesn't matter. You really, the people's default position is I want to, you know, I want to control crime. I'm going to trust the Republicans more than the Democrats. Right. The default position on health is to trust the Democrats for better or worse, right or wrong. That's, I think the voter perceptions are. So if you get into this fight, the more salient that issue becomes, the more it helps Democrats, Democrats know that. So they are then going to elevate that, I do think. And so I do think that will become a cycle. I do think we're going to hear a lot more about that.

Bill Kristol (41:19)

So interesting that 2026 is an election year and so we heard a lot about it in 2018, the last midterm election during a Trump presidency, obviously after the attempt to cut Obamacare and McCain's scotching it. But I don't know if they're better off failing to cut or they get accused of having tried something or succeeding in cutting and then people are looking at the consequences. But we will have to follow this. So, no, this has been very interesting and actually, as I say, I sort of intended to talk a little more about Kennedy personally, but I think the actual substance of the issues is so important and, and of course, it overlaps a lot too that, I mean, we have again, an HHS secretary who seems uninterested in the actual trillions, I don't know of dollars that are flowing through HHS and, and very interested in his also, I think somewhat irresponsible views about vaccines and, and, you know, just health itself as opposed to healthcare financing. But to have that one, two punch could be that's something we haven't really seen before, I guess. Right.

Jonathan Cohn (42:21)

Yeah. Yeah. Well, I imagine we'll have more. More.

Bill Kristol (42:24)

We will have more to talk about. People should need to read your newsletter and and watch other discussions with you and others of our correspondents who cover aspects of this, too at the Bulwark. So thank you, Jonathan, for taking the time on Sunday to join me, and thank you all for joining us on the Bulwark on Sunday.