← Bulwark Takes
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- [00:00]
Bill Kristol
At Energy Trust of Oregon, we understand that energy isn't just what happens when you flip a switch, it's what happens afterwards. It's a home that can provide both shelter and peace of mind. It's a business that can run more efficiently and keep their dream alive. And it's communities that can thrive today and flourish tomorrow. That's energy. And that's why we partner with local utility companies to help you save energy and lower costs. For cash incentives and resources that can help power your life, visit energytrust.org hi. Welcome to Bulwark Sunday. I'm Bill Kristol and I'm joined by my colleague Jonathan Cohn, expert on all things health care and a few other things as well, that genuinely has followed this, not just this healthcare debate, but years, decades, I guess, of healthcare debates very closely and written very interestingly.
- [00:50]
Jonathan Cohn
Let's not talk about how many decades.
- [00:52]
Bill Kristol
Yeah. Let's not informatively about them. So thank you for joining us today. And I mean, there's been a lot going on. Right. The last couple of weeks with RFK Jr. And you should describe it, I guess for me, the sort of striking, just super top line, but tell me if I'm wrong, is that he got confirmed and friends of mine or qu ex friends of mine who I still chat with occasionally were saying, well, don't worry. I mean, I hadn't focused as much on Kennedy. It's on Tulsi Gabbard and Cash Patel and Pete Hexeth and sort of national security area. And so worry. I mean, Congress has a huge amount to say about health policy and the experts there, he's not going to just override them. He'll just give some silly speeches and so forth. But how's that working out?
- [01:34]
Jonathan Cohn
Yeah, that's not quite how it's worked out. And you may remember in the confirmation hearings, Senator Cassidy from Louisiana, who's a doctor, who takes this stuff very seriously, he was skeptical of Kennedy and Kennedy assured him. I'm not going to assured Kennedy. He assured Cassidy and all the senators, by extension the American people. I'm not going to just impose my own agenda. I'm just here to improve transparency and preside over good science. And yeah, that's not at all what he's doing.
- [02:08]
Bill Kristol
Broaden the kind of thinking that was going on. Right?
- [02:10]
Jonathan Cohn
Yeah, right. And that would have been great, actually, because some of what he says about healthy eating, getting rid of environmental toxins, I think there's a lot to that. And if, you know, there was, I will say when he was getting Confirmed that was my best case scenario was, well, you know, maybe that's where he'll put his energies and, you know, that would be a genuinely positive thing. But as it turns out, he is, in fact, I think a very fair reading as he is absolutely imposing his views on a whole variety of issues, but especially on vaccines. And he is making the kinds of changes to vaccines and undermining vaccine programs, taking them away in ways that he said he wasn't going to do.
- [02:56]
Bill Kristol
So there was news this past week, which you've written about on our website excellently, but we're really going over both on the. On a promising Moderna vaccine project, if I'm not mistaken, that they were funding, and then also on guidance on the COVID vaccine. So say a word about both of those.
- [03:13]
Jonathan Cohn
Yeah. So Moderna, for people who don't recognize the name by now, is one of the companies that built the original Covid vaccines. And it was in particular used a technology called MRNA technology. People can Google, read my article, follow the links. There's lots of great illustrated videos out there on how they work. It's a breakthrough technology that, among other things, allows you to make a vaccine much more quickly than you could previously. And that's why we were able to get a COVID vaccine so quickly. And it was a real breakthrough. I feel like it's been a little memory hold, what a huge development that was. I mean, the two scientists who were responsible for that breakthrough won the Nobel Prize in medicine for good reason, and not just because we were able to get a COVID vaccine quickly, but because that technology could be used for other pathogens. And so when, during the Biden administration, they have a program, among the programs they had, which was to prepare for future pandemics, future bio threats. And if you know anything about this area, you know, one of the really big fears is bird flu. Birds, you know, the bird flu spreads and there's always been this fear that it'll jump species, jump to humans, become transmissible from human to human. And you could get, you know, easily. I mean, who knows? You know, it could be mild, it could be a small outbreak, but you could very easily get a big, another Covid style or even worse, if you can imagine, pandemic. So having a vaccine that you could develop quickly for that, it would be a really useful thing to have in the arsenal. So Moderna got a contract basically to develop a kind of platform where they'd sort of do a lot of the initial work so that if a blue bird flu strain appeared, they would Be ready to jump, get that vaccine going. It would have already been sort of through some of the early testing and you could get a vaccine very quickly. Well, Kennedy pulled the plug on it. He canceled the contract. And they did so saying, well, this MRNA technology is under tested and it's risky and we're just being careful and being mindful about safety and the credibility of the federal government.
- [05:22]
Bill Kristol
That's kind of amazing, right, because it was a contract not to produce something that was going to go into the arms of 80 million Americans or something. It was a contract to do scientific work on something that I don't think there's much controversy. Well, there's some controversy, I suppose, some fever swamps, but not much real controversy that this is a very promising technology. And as you say, for me, I really focus on this that goes beyond Covid to a host of other diseases. Is that right?
- [05:48]
Jonathan Cohn
It really does. It really does. You know, and I would say in terms of, you know, controversy among mainstream scientists, there's not a lot of controversy about it. I interviewed a few from my article and you know, if you get, if you read the article, you'll hear from them and from a variety of different specialties. Some people who you've seen on TV a bazillion times, and one of them, Ashish Jha, who was in the Biden White House, you may remember, he sort of made the point, I sort of said, do you think this is under tested? Which was the line from Kennedy's office. And he didn't understand that at all. He pointed out that first of all, the COVID vaccines, when they were rolled out, were tested extensively with placebo trials. I mean, it was a very thoroughly tested vaccine. And then we've watched it very closely. You know, hundreds of millions of people around the world have gotten these vaccines and we have monitored them very closely. Very low incident. I mean, there's always, you know, any, anything you put in your body is going to have some occasional side effects. You always watch. There's always a risk versus reward. These particular vaccines have a very low incident incidence of serious side effects. And we, that we've observed they seem to be very safe to call this under tested. It just, it's, it's, it's completely, it' ignorant of the context of looking at other vaccines. So it's a very safe technology. And actually the same technology, not only could you deploy it against a bird flu, but now they're studying ways because of the way the technology allows you basically to in effect kind of commandeer the cells in Your body to produce something that's useful to fight a disease. Well, they're looking at treatments for cancer. In fact, there's a trial that was just the early results were announced from Memorial Slo Kettering in New York, which a lot of people know is very famous cancer hospital, which showed real progress against pancreatic cancer, which if you know anything about cancer, I mean that's got one of, you know that the survival rate is very low, it's very aggressive. We don't have good tools for dealing with that. So this same technology could help there. And you know, here we're pulling the funding for development of this technology for an imaginary threat that doesn't exist.
- [08:03]
Bill Kristol
And I mean Kennedy could have said, again, I speak here as a total layman, quite ignorant about it, but I mean he could have said we're continuing the funding but I want to assure everyone in my vaccine skeptical community of friends and in the country that we're going. Nothing gets, you know, approved right, by the fda, you know, without full testing, full assurance that it's not going to harm anyone. This isn't. We're not. I'm not approving sticking stuff in your arms, as I said before. I'm just approving further development of what could well be or might be at least a very promising technology. And it is very revealing, right, that he doesn't say that. I mean that shows that it's all about being anti vaccine, not about being more cautious about vaccines.
- [08:43]
Jonathan Cohn
Yeah, that's a really good point. I mean this was to develop, you know, to develop so you could test this vaccine, you know, and the fact that, you know, he's playing it now, I mean just. It shows that that's not really what he's interested in.
- [08:59]
Bill Kristol
Meanwhile, the COVID vaccines which have been thoroughly administered to zillions of Americans and where we probably know if there were serious effects. But anyway, as you say, except a very tiny small number of cases. But that was confusing this week the guidance we were getting about who should get those. Who should or could even be eligible to get those booster shots.
- [09:23]
Jonathan Cohn
Yeah, confusing is it might be understating the case a little bit. So Kennedy pops up on Tuesday morning with this video on social media, says we are going to pull the recommendation. Vaccines are recommended by the Centers for Disease Control, cdc, Centers for Disease Control and Prevention has a recommended vaccine schedule which serves both as guidance for physicians. Also legally is binding for insurers because the Affordable Care act and its mandate on preventative services it affects program called the. Oh gosh, I may get the acronym wrong, but it's a program that provides free vaccines to low income children. And he said they were pulling the recommendation for booster shots for healthy children and for pregnant women. And it was strange in a couple of ways. So first of all, he was there with the head of the FDA and he was here there with the head of the National Institutes of Health. He was not there with the head of the Centers for Disease Control because there is no head of the Centers for Disease Control. And there's a whole side thing we can talk about in a minute that I'm not actually sure who's running CDC right now. No one's really sure. And I know it sounds like, how can you not be sure who's running the cdc? Believe me, there's some mystery. So there was that going on. But then it was strange too, because, okay, he makes this announcement and you would expect again as someone, Bill, you've been around government for a long time. I've covered government for a long time. You would have expected to see an official release from the department. You would have said, guidelines, nothing for two days. Except this directive that was running around on email. Someone sent it to me, which it's a one page letter signed by Kennedy, but not on like HHS secretary, HHS letterhead had a typo in it, I think, in which it sort of continued as, you know, it sort of said, this is what we're going to do. And then we heard nothing. We heard nothing. And then on Thursday night, CDC finally online, its main page updates the vaccine recommendations. Except it's not the same thing that he said. So for healthy children now, they didn't pull entirely the recommendation. Instead they kind of dialed it back and said, well, you should discuss with your doctor. If you're a parent, you should discuss with your doctor whether to give it to your children. So it's kind of like a middle ground. And then for pregnant women, there's a color chart where they show, like, what's recommended. It was just sort of grayed out, no guidance. And, you know, I called people afterwards, I said, what does that mean? And people who follow this were like, I'm not sure what that means. And there was a lot of confusion. The news stories came out and said, okay, he's actually not pulling these recommendations after all. HHS got very upset, tweeted out, yes, we are. Yes, we are. We're pulling the recommendations. And they made it sound like there was the same guidance for both. You know, it is still not 100% clear what exactly was recommended. And not, I mean, it seems pretty clear now that children have been moved to this sort of what they call shared decision making status where you're supposed to consult on pregnant women. It's a lot fuzzier in part because there's again, on the sort of main chart and with the guidelines that go with it, it says there's no guidance, but if you click over to other pages at cdc, it still recommends it for pregnant women. The fda, the leaders of the FDA previously, a week before, in a separate, whole other separate article, they wrote about what they were planning to do when FDA does. It's a little complicated. FDA authorizes drugs, CDC recommends drugs. They said that pregnant women should still get the vaccine. And there's a reason for that, by the way, which is that pregnant women are very vulnerable to serious complications of COVID In addition, for newborns, where they can't get the shot right away, their immune systems are based on antibodies they get in utero. So giving pregnant women the shot while they're pregnant helps build the immunity of a newborn. So they're very good recommendations. I mean, I spend a lot of time talking to physicians. I'm not a scientist, I'm not a physician, but I spend a lot of time talking to them. And most of them said, look, on the issue of kids, it's a bit. They're the risk for. It's always risk versus benefit. And reasonable people can kind of disagree on healthy kids. Actually, a lot of the European countries do not recommend boosters for healthy kids. But on pregnant women, there was a lot of head scratching and frankly, more than head scratching for people who thought this is really dangerous. The American College of Obstetricians and Gynecologists. Or is it obstetrics and gynecology? I forget, but it's ACOG is the acronym. Put out a blistering statement. They were just, they could not understand this. And if you talk to most of the obstetricians I've talked to felt similar. They thought like this really, you know, not recommending this for pregnant women they think is really dangerous.
- [14:20]
Bill Kristol
It has real world effects in the sense that I suppose they're not banning it exactly for pregnant women, but there are questions of whether insurers would cover it and whether physicians would even feel they were at some risk of recommending or prescribing it.
- [14:36]
Jonathan Cohn
I suppose, yeah, there is. And again, it's a little murky because the guidance is murky. So it's not entirely clear, but it does affect insurance, it could affect the vaccine for children. Program. Apparently, CDC has put out the word that, no, the vaccine will continue to be on the Vaccine for Children's program. I mean, in general, as long as the shot is authorized by the fda, like any drug. And if you know this, a lot of people know this from other conditions. If a drug is out there, a physician can always prescribe it, what's called off label, meaning they can give it to you for a condition where it's not specifically recommended. And then that could happen. But the catch is you have to go through a consultation. You know, a lot of people get their shots through a pharmacy as you can. That's always an easy place to do. And there's sometimes there's, you know, there's. There's rules about who you can and can't talk to, but there's like a. There's a whole other layer to this and you know, which is that physician, you're a family physician, you know, and wherever. Someplace in the country, you know, I live in Michigan. So you're a physician working in suburban Detroit. You're busy. You've got patients, you've got paperwork you don't have time to sit with. Hours and days reading the studies on who should get the COVID shot and who doesn't. That's why you look at things like CDC guidance. You depend on that in part because you trust it. You think, all right, well, this is what the CDC recommends. That's what I'm going to recommend to my patients. Well, now you're in a situation where either the CDC is maybe giving bad advice or maybe people just come not to trust the cdc. And you think about that. I mean, why do we have a cdc? Why do we have a federal government? One of its most important functions, right, is to supply that kind of expertise, that authority that people can trust. And that's not to say they haven't made mistakes in the past. I mean, you could do a whole show, right, kind of re litigating some of the decisions in Covid. I think we all agree that there were some mistakes made, some pretty big ones. They also got a lot right, and it was a tough situation. But again, this isn't about. We're trying to figure out a process and trying to make the CDC work better. Again, if that was what was going on, we would see some sort of procedural changes at CDC that made it more scientific and more transparent. And instead, what we have here is Kennedy saying there's no CDC director. They didn't have the normal meetings and advisory committee sessions to hash this out. In public. Instead, he just said, this is what I'm going to do.
- [17:13]
Bill Kristol
It is kind of amazing. And this is what, three months after, four months into the administration, is that right? I guess that's right. And three months after he's been confirmed, I think. And so it's not as if, okay, in the first week you get a few things. They got out of the way to do the video. I mean, that's what I guess strikes me is three months in and we're running this important part of a major cabinet department in this way. I mean, one could dislike the substantive conclusions they're coming to, but still say, okay, they're, you know, if it's within the bounds of the law and Congress doesn't override them, they have the ability to do this. But there are well established procedures, as you say, for this, and they're. They seem to be just contemptuous in them, I guess. Or.
- [17:54]
Jonathan Cohn
They are. And I thought one interesting angle on this, I spoke to Sam Bagenstos, who's a law professor now here at the University of Michigan, but he served as general counsel at HHS during the Biden administration. Knows this stuff inside and out. And he made the point to me that there are laws on the administrative laws. We have laws in this country that say federal agencies cannot make decisions capriciously or arbitrarily. Right. I mean, there's standards is reading. The government has to have a reasoning. It's not supposed to be just someone, some political appointee doesn't like a regulation and they get rid of it or changes a rule. Well, one of the ways that sort of agencies will satisfy that requirement is by going through the sort of traditional process, Right. You have hearings, you do it, you know, for. So for something like, you know, the WHO to recommend vaccines for, you would go through a normal process where you have the scientific evidence. You would air it out in a public hearing. There would be reports and documents. The secretary, you know, the CDC director, would issue a recommendation which the HHS secretary would then approve of or not. And there would be a paper trail for every step. There'd be evidence every step of the way to document why they were making the decisions. And if there was some reason to deviate from the usual process, they would document that. They say, yeah, we did this a little differently, but here's why. It was an emergency situation. Whatever they did none of that. So, you know, legally, actually, that does, I think, make, you know, according to Sam, that makes these decisions legally questionable. You could challenge them in court. And we've seen courts rule that way for much smaller deviations from the process. But again, it gets back to this broader point, which is there's a legal reason for that process, but there's also, there's an institutional reason for that process which is that's, that's how we come to trust that this sort of government information is reliable. We see the way they make the decision and it might be the wrong decision, we might criticize the decision decision, but we can see how they made it. We can say, and you know, if you want to criticize it, fine, if you want to say, come up with a different process, fine. But it's all documented, it's all out there foresee, and we've had none of that in this case.
- [19:56]
Bill Kristol
And you make the point in the article, in this morning's article also, which is very interesting. I think this is an under appreciated point that of course, companies come to once you've gone through this whole process and satisfied the procedures, the Administrative Procedure act, which governs kind of all the government, but also the particular procedures the HHS has in its rule books of this book and it's so to speak, and it's the regulations there. Presumably Moderna or Pfizer, whoever can sort of rely on until, unless there's new science and new hearings and stuff, that this will be approved or won't be approved. You know, they'll make investment decisions and scientists will make decisions on what to research and so forth accordingly. And that seems to me, I mean, you make the point that serious people now are worried about the whole US Enterprise in vaccines and I suppose maybe in other areas of pharmaceutical, you know, of pharmaceutical and other kinds of research too, being sort of slowed down or going offshore or whatever is that I was struck by that in your piece.
- [20:54]
Jonathan Cohn
Yeah, I mean, there's sort of a one, two punch happening right now. So you have on vaccines specifically and maybe some other medications. We'll see. As we go into this administration, you know, the signal is being sent that this government under, you know, this HHS under Kennedy, the US Government under Donald Trump is not going to be a partner in producing and distributing vaccines and developing them as it has been, you know, for decades. So, you know, you, you know, if you're, you know, you're a company like Moderna, you know, you can't count on the U.S. government, you know, helping you in the research, helping you through the approval process and then sort of getting the vaccines out. So that's the first punch. And then on the other hand, right, as we've Been to. We've talked about here. We've all at the bulwark talked about. Everyone has talked a lot. Everyone in our, I think in the. In the. In biomedical community is talking about there's this massive cut to scientific research funding in general and medical funding in general. Cuts to the National Institutes of Health, cuts to the National Science foundation, and unprecedented massive amounts of money. We're seeing the defunding of studies all over the country. And that's, by the way, on top of potential cuts to Medicaid, which also feeds money into the biomedical system because it supports a lot of the big teaching hospitals. So the entire biomedical research and development enterprise of the United States is taking this huge hit, or really these two huge hits at the same time, which has always been thought of, at least in my lifetime, as a great strength of the United States. I mean, you want make America great again. I mean, that's what we're great at, right? Developing new treatment, whatever else is wrong with our health care system. We're good at innovation. But, you know, so, so what happens as a result? Well, maybe there's less innovation. Maybe we don't get the future vaccine when we need it for bird flu, or maybe we don't get some other treatment. But, you know, there are other countries just would quite happy to have that happen there. And actually, as it turns out, one of the countries that's really been for the last 10, 15 years really stepping on the gas, putting money into biomedical research is China. And China is a very attractive place to do a lot of this research. You have a large pool of very qualified scientists. They make it very easy to do clinical trials, which is a super important part of medical research. Obviously, despite those factors and despite the money being put there, until relatively recently, companies were reluctant to go over there because it is not a country that operates by rule of law. It is not a country, frankly, that respects human rights. And you worry, you know, when you talk about clinical trials, start to worry about that too. And, you know, even if, you know, that all made us work. And of course, it was also a country that didn't have the kind of universities that we have here, you know, the Johns Hopkins, the Harvard, the University of California, San Francisco, Vanderbilt, University of Michigan, where I am, you know, these are the centers that have been pumping out these innovations. Well, if you lose the support for universities because they're in the crosshairs and you lose the medical research funding and the government, at least on vaccines, is signaling we're not interested anymore, that money is going to Go abroad. It's already going abroad. Companies are going to go where they can do the business. Maybe, best case scenario, this innovation continues to take place, but not here. Of course. We lose the jobs, we lose the economic activity, we, we lose the innovation. But again, if you want to go back to the moderna example, you think ahead to the next pandemic. We hope we don't have one, obviously, but it's five, ten years from now. There's another bird flu epidemic and the only shot available is in China. Do you think we're going to get it as quickly? Do you think we're going to have to. Will we be in some situation where there's a hostile relationship and they'll have leverage over us? You play out the scenarios and one way or another, you're looking at a situation where Americans are, are like everyone else around the world, you know, facing this lethal threat. And unlike in Covid, when we were at the front of the line, we were the first to get the vaccine and now we're in the back of the line.
- [25:12]
Bill Kristol
Yeah, the side of COVID was underreported. I remember at the time talking to Ashish, who you mentioned earlier about this. He was then, I think, Dean at Brown and before he went in to serve in the Biden administration. And a lot of these, a lot of the vaccines that we use that we got for Covid, that first wave especially, were not manufactured in the U.S. i'm not mistaken. A lot were actually in Europe. I think they had very modern. I mean, some of these companies actually were partly European or certainly they are, they're all global, so they have some European base. And some of the work was done in Europe and we, because we were, you know, the US a big market, but also because we had, frankly, you know, these were our allies and we had quite a lot of clout. I think we were able to get the stuff as early or earlier in some cases as some of the places that might have wished to get ahead of us in line, so to speak. That's the case where just the kind of globalized, the much derided globalized international trade structure helped us say nothing. The fact that we actually had these companies that the ability to draw the best scientists around the world, not just in the US and also while we're just listing things their administration is doing to not make America first, the immigration stuff fits into this a lot. Right? I mean, if, you know, we, we are benefiting a lot here in the US we have from having an awful lot of young scientists and by Researchers to either do work here or stay, do some work here, postdocs and so forth, or student work, stay here for a while, stay here for a long time, become citizens, you know. And I mean if you start thinking that's a bad. We don't want any of those foreigners here which they're kind of signaling in both in the attack on universities and more broadly of course, in terms of immigration policy. I mean, I don't know, I really, it does seem, it seems like such a totally self inflicted wound too. Like what exactly? Like what? Sometimes there are cost benefits, right? What exactly are the costs? The costs of having a lot of people wanting to work on biomedical research here. You know, I mean.
- [27:13]
Jonathan Cohn
It'S mind boggling. I don't know the cost. I mean we gain from the innovation. So many of these scientists end up staying here. Like you said, they found companies, someone's got a list somewhere. It was running around a couple of weeks ago. I'm on the number at my end, number of sort of Nobel Prizes or major developments that were by here in the US by scientists or engineers or who have you who had come from other countries and stayed here. And sure, some of them go back to their countries, but that is not a bad thing. I mean, this is a case where international cooperation really helps. You think of two ways. One way is to think of American education. American research is an export, right? People come here, we are exporting knowledge and we get paid for it. When foreign students come to the United States, they pay full freight, a lot of the money. If you look at the way the money works, a lot of those foreign students are in effect subsidizing American students that, you know, for the privilege of studying at our universities with our professors. I mean, what that, that, that, that's good for us, right? We get the benefit of this sort of collaborative knowledge. Many of these people end up staying here, starting companies, contributing to communities in other ways and we get the dollars. So, you know, you can think of it that way. And then you were mentioning earlier just you know, this sort of this cooperative relationship we have with these other countries when it comes to healthcare, the, you know, fighting bio threats. Cooperation really matters being a part of the world. You know, I remember with the very, one of the, it seems like, you know, one of the very first things Trump did when he got to office and it seems like it was 10 years ago now, was pull us out of the, you know, World Health Organization, right? That kind of collaboration is so important for early detection of threats. And also if it helps on the research side as well, having these collaborative relationships, I mean, all of humanity benefits and we benefit as Americans from these. I mean, this is a win win and this is just, you know, we're just undercutting all of this for, you know, because I guess we don't like people from other countries, you know.
- [29:21]
Bill Kristol
Yeah, I mean, this was fake arguments honestly, that, you know, we're subsidizing these people from other countries to come study at universities. But some of those universities, those universities get money from the ih, which is US Taxpayer money. And this, you know, it's not totally false to put it that way, but I've looked at some very quick, the top line of some studies. You've probably looked at the net net effect of the US Subsidy on the one hand and the return to the US on the other. It's like one of those positive investments we can make. That's not the only grounds on which we should judge obviously our expenditures in terms of the kind of pure economic trade offs as it were. But this is a good investment, not a costly one or a negative one for us.
- [30:01]
Jonathan Cohn
But yeah, I mean, you know, the one argument I have seen that, you know, occasionally comes up in the context of China mostly, although some other countries, well, there's an intelligence issue. Right. So if you're working on, and this is less on the bio side, probably more on the engineering physics side, you know, there's chin, you know, there's, there's, there's worries about espionage. What I have read about this, what I've heard from people is that this is wildly overblown. And of course if that's the case, then, you know, you know, we have an intelligence apparatus and, and there are ways to, you know, go after that. Right. I mean if you're worried about restricted.
- [30:32]
Bill Kristol
I mean as right now from certain jobs in certain companies and in certain research institutes for, you know, national security reasons. It's not like we've never done this before. We did it for decades and maybe we're too lax, maybe more people should have space restrictions. But that's not the heart of what they're doing. Let's take the final five minutes on. You discussed the Sam sign on a short, shorter bulbour take. But it's, I mean the reconciliation bill, such the biggest piece of legislation for Congress, Medicaid, one of the biggest, maybe the biggest issue in it on certainly on the expenditure side, the cutting the cuts for Medicaid, Trump administration denies that there that anyone's going to lose health care availability or, or access I guess even I'm not sure what. So what's happening there? The House passed the bill. It's now before now up in the Senate.
- [31:22]
Jonathan Cohn
Yeah. So the House passed a bill, now it goes to the Senate. The House bill takes more than $600 billion out of Medicaid projections suggest, you know, more than 7 million people will end up uninsured because of that. There is on top of that a set of cuts to the Affordable Care act that the CBO projects will mean another 2 to 4 million people losing insurance. You're looking north of 10 million people becoming uninsured as a result of this. This morning, Speaker Johnson Asvad from OMB were on TV Sunday morning shows doing the rounds. Vought said nobody will lose coverage because of this. I found that mind blowing. I mean, look, we've had arguments in this country for decades about, you know, what is the proper role for government and health insurance. Should we spend more, should we spend less, Is it government's job or not? And that's a, that is a legitimate debate we should have in politics. And you know, we've gone back and forth and you know, and if, you know, they want to make the argument that we are better off cutting that spending, even if people lose health insurance because we can use the money in some other place, then fine, argue that, make that case. To get up there and say that no one is going to lose health, I mean, that is, that is as bold and blatant a lie as you will see in American politics. It's just not so. And Russ Vaught knows that's not so because if we didn't have millions of people losing Medicaid coverage, you wouldn't be getting the budget savings that they're saying, you know, will help offset the cost of the tax cuts that they want to pass. So, you know, they also said incidentally.
- [33:02]
Bill Kristol
That they defend the proposition and maybe it's not totally crazy. I think there are reasons for being dubious about it. But that able bodied young man, I guess, or just people without kids, I don't know how they put it sometimes or maybe or just anyway, able bodied people could work, should work and they should get their health insurance that way or pay for it, I guess, through the exchanges. Therefore they shouldn't be on Medicaid and some of them are covered now. So they're explicitly saying people will lose coverage, but it's better pop public policy and for reasons of, I suppose, incentives and, you know, it's just saving money and so forth for those people not to be covered. By this government program. It's not a crazy position in the sense that every government program has some limits on coverage unless they're literally universal. So you know, that's got to be limited somewhere. They want to move the limit from here to here. That's an argument, as you said earlier, more traditional.
- [33:49]
Jonathan Cohn
Yeah. And that's what.
- [33:51]
Bill Kristol
No one's going to lose coverage. I mean, that's sort of the, the point. Right.
- [33:56]
Jonathan Cohn
That is the whole point. And Speaker Johnson kind of makes that argument more that, you know, it's just able bodied. You know, the things I would say there are, number one, most people on Medicaid turns out do work. The reason Medicaid was expanded to cover people who were able bodied is that, you know, if you work in a low income workforce, chances are really good you have part time jobs or you're in a retail job, you don't get health insurance. And a lot of these people don't have any other way to get health insurance if it's not subsidized or provided by the government. So that was the argument for doing that in why Medicaid was expanded over the years. You know, they can argue the opposite.
- [34:29]
Bill Kristol
Argument in a sense that you don't want to create an incentive not to work so that you can get, you don't want to make it. So you can only get Medicaid if you can't work, if you don't work. Because that's an incentive not to work. Right? It's the opposite. Right.
- [34:41]
Jonathan Cohn
Yeah. And in fact, there's actually evidence that sort of giving people Medicaid helps them stay on the job and keep the job. Because of course, if you think about it, when you lose your healthcare, if you have some kind of, you know, disability, some kind of chronic conditions, more likely you won't be able to keep working. So there is actually some evidence of that. And then the other issue of course is, I mean there's a practical question. This comes up every time we debate work requirements. I mean, people can argue about the merits of work requirements as a kind of moral issue. And that's again one of these debates we should have. Should you be entitled to health insurance if you're not working? We can go back and forth on that. But as a practical matter, what has happened every single time we tried to do that is that it turns out to be quite hard to document. Especially again, these are a lot of seasonal workers, part time workers. If you dial up the knobs enough to really kind of catch people, you're going to dial up the knobs. And they'll have to catch a lot of people who are following the rules and doing the work and they just can't get the paperwork done. They can't make it through the bureaucracy. These are typically underfunded state data systems that are glitchy. Arkansas tried this and in a few months 18,000 people lost insurance. They looked back at who these people were. They were mostly people who were working. They just, they couldn't, you know, the system wasn't working well, they filed the wrong form, whatever. And so that's, you know, as a practical matter that's what tends to happen. You know, you can already that's worthwhile. It's more important to not to get the people who could work. Fine, make that argument but then recognize you're good. The trade off for that is you're going to be a lot of people out there who need the insurance who have no way to get in on their own and are going to get caught up in this system.
- [36:15]
Bill Kristol
I also feel like this is sort of a zombie version of what was once a more credible argument which was if you have generous welfare systems, people might choose, but you only get it if you're unemployed. People might choose unemployed plus generous welfare and sit around and you know, have fun for a few months rather than getting a job. And maybe you wanted to turn out. I do. And so let's be restrict welfare availability. Welfare being cash payments or food stamps for conceivable or something. I don't think a lot of it's just hard to believe a lot of 25 year old able bodied young men are not taking a job because they want to be on Medicaid. You know, the problem with 25 year old young men is they don't think of themselves as getting sick much and they don't get sick much, honestly. And so they're probably not, you know, so the whole thing is a little bizarre, honestly. And the people who care a lot about their Medicaid availability are probably people who have reason to care because they're not entirely, you know, able bodied, if you want to put it that way, or they have illnesses and, and so you seem like you want to cover those people so they can work and get the health care. I don't know, it just seems like the argument is much phonier in a way, if I could put it that way, than the kind of more traditional argument that goes way, way back to the late 60s and 70s and 80s about welfare. Really?
- [37:28]
Jonathan Cohn
Yeah, well, and there's a lot of. There's Some smart conservative analysts out there, I know have made that argument explicitly and said look, we think there's a really strong case for a work requirement in a cash benefit like what we used to the old afdc, which is now TANF or even food stamps maybe. But it really doesn't make sense for health insurance because you can't spend it, you can't do it, do anything with it, you know, you know, you know I was saying to Sam like, you know what, you're gonna get an extra colonoscopy. Woohoo. You know, except for people who know, like you said, I mean most 25 year old men, they think they're invincible. Right. They don't. The problem is getting them to go to the doctor in the first place. Except for people who are chronically ill who know they're gonna have medicine and of course for them what you want them, you know, they're the ones we want getting the healthcare because we, we want them to get the preventative care. We want them getting their diabetes medication, we want them getting their heart medication and things like that. So really you can make. I think there is. And again I've seen many conservatives make this case that work requirements for cash benefits. Sure. For health insurance doesn't really make sense.
- [38:33]
Bill Kristol
Yeah, that's interesting. Well we'll see if that has any. How much resonance that has in Congress over the next two, three weeks. Final question. So that'll be the big debate on reconciliation which will be, you'll be covering, we'll all be covering, but on the sort of Kennedy side of things, the vaccine side, let's call it. Is there much, do you sense much this clearly people in the public health community are pretty concerned and kind of appalled. But what about the Republicans who voted to confirm him on the Hill? What about sort of conservative media outlets? I mean do you see much pushback there?
- [39:05]
Jonathan Cohn
I have not yet. I mean there are some, they tend to be the conservative outlets that were angry about Kennedy in the first place. But I don't detect a lot of political pushback. I think just in this particular, you know, we're in this moment where that is sort of scanning politically to a lot of people as oh, it's you know, Kennedy is part of this, you know, shaking up the system. He's up against the bureaucracy, you know, he's fighting the woke people at HHS and all those, you know, pointy headed academics out in, you know, the teaching institutions. And so I think that just is getting dumped in that bucket that might change. I do think I mean politically vaccines actually are still pretty popular it turns out. You know, if you look at the polling on this and I think at some point, I mean everyone, you know, people will start to think through some of these changes in their own lives. You know, they're vaccinating their kids, you know, you're a member of Congress or whatever and they're going to start to worry about things. They say like wait a minute, why are we, you know, why are we not developing this potentially powerful weapon against bird flu when we have bird flu circulating? And you know, I would think at some point that starts to, I mean we saw Elon Musk kind of get pushed out. I guess I don't seems to be what happened and you know, don't have to. You know, I can imagine something like that happening with Kennedy, but I don't see it yet.
- [40:31]
Bill Kristol
I mean it is unless a friend of mine who's on that's working in the business side of healthcare, keeps his hand in on that. Does point out though that tariffs you have kind of an immediate effect. So it's pretty large parts of the business community react very, very quickly and the Hill hears from that. But you know, if tariffs are affecting US Business, who's using steel and your products, whatever, a lot of the effects of this are a little bit down the road. Not all of them, but some of them would have to do with the actual vaccines available this year or next year. But the moderna type stuff, you're, you're, it's for it and the immigration and the universities and the NIH cuts, it's a lot of that is very damaging in the future. Not even the far off future, but maybe medium term future but not like unless you literally are in that field or you have, you know, you know, someone who's a researcher, which isn't nobody incidentally but isn't, you know, hundreds of tens of millions of people probably. Yeah, it has less direct effects. So I mean unfortunately one could do a lot of damage in the way Kennedy seems to be without quite the immediate maybe reaction that you get for something like terrorists.
- [41:39]
Jonathan Cohn
Yeah, you know, that's, that's the problem. Right. You know, for.
- [41:41]
Bill Kristol
That's why you need to keep writing about it. No, seriously, one, one job of journalism is to kind of bring the stuff that's otherwise isn't totally obvious and immediate to people's attention. Right. At every, I mean it's doing all over the place foreign policy, you know, things that decisions that have medium and longer term effects that are bad important to get voters to be a little more aware of them than they would be just, you know, living their day to day lives, you know, where they might not see some of that stuff.
- [42:08]
Jonathan Cohn
Yeah. Well, hopefully, hopefully we're doing that. Hopefully we'll keep doing that.
- [42:11]
Bill Kristol
You're doing that. You're doing a good job with it. So thank you for doing this on a Sunday and thank you for what you've been writing and. And we'll keep on top of this topic.
- [42:21]
Jonathan Cohn
All right.
- [42:22]
Bill Kristol
And thank you for joining us on the Bulwark on Sunday.