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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello, and welcome to Health Affairs This Week. I'm your host, Jeff Beyers. We are recording this on 10/16/2025. Some quick up fronts. Do you like these episodes coming on on Friday?
Jeff Byers:Would you prefer them on Thursday? If you have a strong opinion about this, put some comments into the episode on Spotify or send a note to communications@healthspares.org. We've been thinking about moving the show to Thursdays, but I also know people love routines. So sound off in the comments. Just wanna hear what you think.
Jeff Byers:And a quick plug on November 5, there's an insider event with KFF's Matthew Ray on health benefits in 2025. Insights from the KFF employer health benefit survey. Join us. And also next week, we should be releasing our third trend report for the Insider Program. It's on private equity and health care.
Jeff Byers:Join Insider to get this report and attend this event. So by now, we're about two, two and a half weeks into a government shutdown. You as a listener probably are already aware of this. The focus of contention has largely been on the premium tax credits related to the ACA. We'll get into that today as on the pod, we have Kathleen Haddad to talk about the government shutdown and its impact on health policy.
Jeff Byers:Kathleen, welcome back to the program.
Kathleen Haddad:Hey, Jeff. How are you?
Jeff Byers:Doing well. Doing well. So before we get into the discussion, I should note, as I said, we're recording midday, October sixteenth. Things tend to change in the space pretty quickly. Right?
Jeff Byers:Yeah. They do. Yeah. I opened an email at 06:32 yesterday from stat news, a breaking news alert, title of it said Medicare payments to doctors paused as government shutdown drags on. And I thought that'll be an interesting talking point today, Kathleen.
Jeff Byers:We're gonna have a good time talking about that, breaking it all down. And then I woke up, I checked it out this morning, and the headline changed to Medicare backs off plan to pause doctor payments amid shutdown. So not even, you know, twelve hours later did it change. So please keep that in mind, listener, if you're listening to this on Friday or after that. We there may be outdated information.
Kathleen Haddad:Yeah. Jeff, I'm glad that you got the second email because I hadn't seen the first, and you just scared me. Like, oh, I know nothing about that.
Jeff Byers:Yeah. So where are we currently with the shutdown? There have been some layoffs, some furloughs, but it's also kinda hard to tell since people are being asked back. And I guess now there's some new updates from last night as well on this front.
Kathleen Haddad:Yeah. Jeff, the, US district judge Susan Ilston in the Northern District Of California issued a ruling just last night halting layoffs, but already 4,100 RIF notices have been issued. Our listeners may have been aware there was a great impact in HHS. That agency had the second highest number of layoffs during, the shutdown. I'm hearing numbers from 1,200 to 1,400 and most of those from CDC.
Kathleen Haddad:However, about half of the notices issued to CDC employees were rescinded. Morbidity and Mortality Weekly Report and CDC's Epidemic Intelligence Service Officers, the disease detectives, those a rift to those employees were rescinded. And the MMWR is what everyone in health policy and clinicians relies on to do their work and be aware of what's happening in terms of disease surveillance. And the the disease detectives, I find it interesting that they realize, yeah, that's an important activity. Anyone who has a degree in public health probably remembers their first exercise epidemiology where you had to use a set of facts to uncover the origins of a salmonella epidemic so that the people who attended could be alerted and they wouldn't infect anyone else.
Kathleen Haddad:That's how this works. It was traced to the eggs used in a ladies' luncheon sometime, I think, in the 1960s. I think the Ladies at lunch? Yes. Ladies at lunch.
Kathleen Haddad:Wow. I think it really illustrates how the disease detection works, and it was kind of a fun activity when you first start that course. But, anyway, there is an important problem here in that the NHANES survey, the National Health and Nutrition Examination Survey, the work on that and the data collection has been stopped. And that survey is very important because it does in-depth, work to find out what people eat, what medicines they take, how they exercise. And, you know, it includes visits to mobile exam centers for dental exams and body measurements and actual lab tests.
Kathleen Haddad:So that was rift, and that's probably going to mess up future research where there'll be an inability to compare results over time because there's a glitch. One other agency that has been rift is the Center for Mental Health Services in SAMHSA. They issue millions of dollars in grants for new health clinics that focus on mental health, and they were a cornerstone of the 2022 bipartisan Safer Communities Act, which followed the Uvalde mass school shooting, a a significant effort to both deal with some gun control issues as well as mental health issues. And, so that's affected. So there we are.
Kathleen Haddad:I don't know if there's anything else going on. That's that's what I know.
Jeff Byers:You know, thanks for sending these notes over before we began recording. And I say that to say when I was looking through your notes and you were like, this was RIFT. This was RIFT. I thought I was, like, reading some slang I wasn't aware of yet. This isn't a funny issue, but I found that funny of, like, rift.
Kathleen Haddad:Reduction reduction and force. And, you know, there is supposed to be a sixty day waiting period or severance, and the issue in this subdistrict court case of yesterday focused on the via a violation in the Anti Deficiency Act, which requires this kind of notice. So that's the legal basis as far as I I can discern.
Jeff Byers:Yeah. And that came out late yesterday. Is that right?
Kathleen Haddad:That's correct.
Jeff Byers:Yeah. Just for some context setting, I was looking Politico reported earlier in the day yesterday that the White House said that the shutdown layoffs will be north of 10,000 individuals. Again, that was before, I think, this judge ruling came down. Also, for context setting, in November 2024, there were about 3,000,000 federal employees. I just find that scene setting a little interesting.
Jeff Byers:There's a really good article from NPR that will, post a note in the show notes titled judge pauses shut down layoffs at more than 30 federal agencies, which kinda goes into the to the court case a little bit more in-depth.
Kathleen Haddad:Yeah. You know, it's unclear to me how this will affect the existing RIFs, notices that already went out. And also, like you say, the intention to lay off as many as, or cut as many as 10,000 more employees, I'm not sure what will happen with that, that commitment.
Jeff Byers:Yeah. I know I've seen some reports saying that some were some of the RIFs were premature, I think, a is one way to put it. In that same NPR article, they noted that RIF notices were erroneously sent to about 800 HHS employees.
Kathleen Haddad:Right. Right. The the CD's mostly CDC. Half of those, you know, were rescinded.
Jeff Byers:Yeah. We'll put a link into the show notes on that. People can get caught up with that, especially as there's probably gonna be new information in between our recording today and by the time you hear this. So back to the subsidies. So as I said, health policy folks likely know that the shutdown kinda came to, in essence, these premium tax benefits related to the ACA.
Jeff Byers:Can you describe these benefits and generally how we got here?
Kathleen Haddad:Yeah, Jeff. In 2020, the American Rescue Plan temporarily expanded tax credit eligibility for people with incomes between 406100% of the federal poverty level, and that occurred during COVID to help people who were suffering, financially, people on the, who had ACA plans. Earlier, information showed that the plan premiums were were too high for many of the people who are at these low income levels. So that was intended to help expand coverage and enable people to sign up. So then the Inflation Reduction Affordability Act, the IRA, extended the subsidies to the end of this year.
Kathleen Haddad:That happened in 2022. So now people are getting notices of their new premiums, and the KFF says that many of them are just doubling for policies that will start January 1.
Jeff Byers:Yeah. Again, anecdotal evidence here, but my wife was looking at, either TikTok or Instagram, and there's already parody videos of people opening
Kathleen Haddad:up. I can't about them. I can only imagine what I would do if I were in those shoes.
Jeff Byers:Yeah. So, again, social media is trash, but check it out if you're inclined. So to have these premium tax benefits affected the ACA marketplace so far? As I am to understand it, they greatly extended coverage and kinda boosted that.
Kathleen Haddad:Well, right. I think that it's around 20,000,000, people who got new coverage, under the ACA. Back in the day, the numbers of uninsured were at about 30,000,000 people before the ACA, and many of these, were full time low wage workers who had no health insurance coverage, and they did not qualify for Medicaid. So now after the ACA, with the marketplaces and Medicaid expansion, the number of uninsured is down to about 8,000,000 Americans. That's that's a huge, huge improvement.
Kathleen Haddad:If these subsidies are canceled, the numbers of uninsured will go back up, and that's after decades of effort to do the opposite. I think you had pointed out to me a CBO analysis Mhmm. From September. Part of that said, permanently expanding the subsidies to 2,035 would provide health insurance to an additional 3,800,000 people, and that would cost 350,000,000,000. I wanted to say that that's about I did a little math.
Kathleen Haddad:My funny story. My calculator on my phone would not do this for me. And, of course, in my head, I couldn't do it, so I AI ed it. Okay. For people who like English better than math, I'll just put the words in what is $350,000,000,000 of $3,500,000,000,000 I got 10% and then I did it on paper and got the same, so 10% of the 3,500,000,000,000.0 deficit, that's why I use that denominator, that is created by the reconciliation bill, the big beautiful bill.
Kathleen Haddad:That amount is that's what 3,500,000,000.0 will cost, 10% of the deficit created by the big beautiful bill over ten years. This is largely due to the tax cuts. The the 3,500,000,000,000.0 deficit is largely due to tax cuts that benefit everyone, but more so, higher income people. So the cost of insuring these, additional people is a reflection like in any budget of what our country values.
Jeff Byers:Yeah. So I didn't know I was gonna go to math class when we signed on today. But I'm happy we're here. Yeah. I pointed out that CBO analysis.
Jeff Byers:We were doing some work for Health Affairs Insiders for potential new products. And in that work, I came across a paper from John Zhu. My apologies if I if I mispronounced that. And coauthors wrote that the ARPA increased premium subsidies for marketplace enrollees and provided cautionary protection for people seeking testing prevention or treatment for COVID nineteen. And they wrote that the changes could dramatically increase people's health insurance coverage and affordability.
Jeff Byers:They will also increase the size of the federal debt. And I just thought that was interesting. You know, we write a lot about health spending and healthcare costs in the pages of health affairs. And, you know, whether you think that's a good or bad thing, I'm not gonna make that judgment call for you, but I do think that's a very real trade off that we talk about when we talk about these things. And I think that's been underreported in the media about about this thing.
Jeff Byers:So thought it was good to point it out that these things do have a price tag.
Kathleen Haddad:Fair enough. So, Jeff, I have a question for you. How long do you think the shutdown will last?
Jeff Byers:Oh, okay. Let me pull out my crystal ball here and saying the magic words. Tell me something good. No. Sorry.
Jeff Byers:It says, please ask again later. I think I pulled my my magic eight ball out instead of my
Kathleen Haddad:Oh, oh, oh, oh, oh.
Jeff Byers:So I have no idea.
Kathleen Haddad:You're really opting out here.
Jeff Byers:Yeah.
Kathleen Haddad:I'm what? You're opting out.
Jeff Byers:I'm opting out. Yeah. That's right. I I can't call a friend
Kathleen Haddad:or report. Alright. But I do have some thoughts nonetheless.
Jeff Byers:Okay.
Kathleen Haddad:So, anyway, what I'm observing from a political point of view, my my undergrad degree was political science. The health care issues do seem to have some traction for the Democrats, and, you can see that from, for instance, a KFF survey showing that 75% of Americans, seem to support this issue of wanting these subsidies to continue. So I'm also noticing that Republicans seem to be changing their arguments. It started with focusing on that that we provide subsidies for immigrants, and we pay for immigrant health care, and that that's untrue. It's not possible, by law to pay for nondocumented immigrants' health care except under an act, from the nineteen eighties I believe it was 1986, EMTALA, that required hospitals to care for anyone who had an emergency who was came in, and that resulted because there were hospitals who were taking people out the door who didn't have insurance.
Kathleen Haddad:It was quite amazing. So my guess is that, right now, I believe the Republicans are backing off from that message and focusing on not having anything to negotiate with the Democrats because they haven't signed onto a clean CR to continue while negotiations go on, continue government.
Jeff Byers:Yeah. I have seen, that there is a little bit of a inherent contradiction of, like, a lot of potential red states didn't expand Medicaid. A lot of these subsidies, as we've talked about, did impact Medicaid beneficiaries for being able to use these premium tax credits to be able to afford coverage through the ACA marketplace. So there's this inherent, I would say, maybe odd tension of the GOP party trying to not use these credits even though they're positively impacting their own constituents when the Democrats are the ones pushing for it. So it's, like, kinda almost a mismatch of priorities and or, like, not priorities, but it's almost a mismatch of, like, what they're going for.
Kathleen Haddad:I like your phrase odd tension. That's a good one. And I think politically that the, that Republicans may members of congress, as they see the midterms coming up, may pressure for some negotiations over time. So that's my my prediction is that, eventually, that this will go before and just before Christmas or in January after these premiums, increases create such a public clamor, and it will lead to, the president signals, signaling some willingness to compromise, and the congressional Republicans will come up with a message that allows them to get to the negotiating table but still appear to have won. That's all just a guess, though.
Jeff Byers:Yeah. That's, we need more predictions on this show. Something to keep, you know, people tuned in to see if we are right or wrong. Right.
Kathleen Haddad:I think it's an informed guess.
Jeff Byers:Informed guess. That's right. So you're you're you think, as a guess, not until January or right before Christmas?
Kathleen Haddad:I I do think it's going to take more pressure from Republican constituents about this before they develop a message that allows them to say, we didn't lose. We we won. Now we're getting to the negotiating table, something something like that. I'm not the the best constructor of messages, but it's I think that's something that will happen.
Jeff Byers:Well, we'll we'll have to have you back on in January so we can we can keep ourselves honest.
Kathleen Haddad:Yeah. Right. Right. Okay. I'm not putting money on any of this.
Jeff Byers:Same. Same. Well, Kathleen, thanks, again for joining us today on Health Affairs This Week. If you, the listener, enjoyed this episode, send it to the Taylor Swift fan in your life, in hopes for this reach, more people. And with that, we'll we'll see you next week.
Jeff Byers:Thanks all.
Kathleen Haddad:Thanks, Jeff.