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[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for �����鶹��ƷHealth News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 13, at 10 a.m. As always, news happens fast — really fast, as you’ll hear in a moment — and things might’ve changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hi. 

Rovner: And Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Later in this episode we’ll have my interview with Jeff Grant, formerly of the Centers for Medicare & Medicaid Services. Recently retired after 41 years in the government, he has thoughts about the way the Trump administration is handling the downsizing of that agency. But first, this week’s news. 

As we sit down to tape, we have some breaking news. The White House has reportedly pulled the nomination of former Republican Congressman Dave Weldon of Florida to lead the Centers for Disease Control and Prevention. 

Weldon was scheduled for his confirmation hearing this very morning at 10 a.m. before the Senate Health, Education, Labor and Pensions Committee. The hearing cancellation notice came out at 9:24 a.m. We obviously don’t know any real details yet about why this nomination was pulled, but somebody remind us why Dave Weldon was a controversial pick to head this agency. 

Edney: He was holding on to some anti-vax theories that do align with some who have already been approved by these senators, but he— 

Rovner: Notably the secretary of health and human services. 

Edney: Exactly. But he was still claiming that there’s mercury in vaccines and that’s the reason for autism. I don’t know if that made him a bit of a step too far for some of these people, particularly Sen. [Bill] Cassidy, who chairs the HELP Committee and is probably already frustrated by what’s going on when he thought that he had some promises from RFK [Robert F. Kennedy] Jr., the HHS [Department of Health and Human Services] secretary, to not be going after vaccines in different ways. 

Rovner: And we will get to that later in the podcast. Also, I should note that Weldon was also a big anti-abortion voice when he was in Congress. Although, again, I doubt that that’s what got his nomination pulled. I mean, obviously what got his nomination pulled was that he didn’t have enough votes to be confirmed. 

Ollstein: Sure. But like Anna said and like you said, Julie, there seems to be some inconsistency of criteria across the Cabinet nominations. Saying that this is about his anti-vax views, well, that didn’t stop RFK Jr. from getting confirmed, and if this is related to his anti-abortion views, that hasn’t stopped many of the nominees from getting confirmed. And so that leads me to believe that it’s about something else. I think we’ve seen this before. Matt Gaetz’s nomination was pulled. He had this history of sexual misconduct allegations, but other nominees who also had a history of sexual misconduct allegations sailed through their confirmations. And so that leaves me to believe there’s something else going on, some other shoe that was going to drop or some other issue at play. 

Rovner: We will definitely see. And just a note here, tomorrow, Friday, after the confirmation hearing at the Finance Committee for Mehmet Oz to head the Centers for Medicare & Medicaid Services, I’m going to sit down with a couple of my �����鶹��ƷHealth News colleagues to wrap up that hearing as well as the other HHS nominations, and that will appear in your podcast feeds as well, as a bonus podcast episode. 

All right, moving on to the next-biggest news. As we tape, the government is less than 48 hours away from a potential shutdown. Friday after midnight is when the three-month funding patch Congress passed just before Christmas expires. The House on Tuesday barely passed a bill that was advertised as a clean CR [continuing resolution], meaning it just continues current funding for the rest of the fiscal year, but it would actually cut billions of dollars from domestic programs and add billions of dollars for defense and immigration enforcement. 

Among the little surprises in that bill are a more than 50% cut in medical research funded by the Defense Department. And while the bill does include a bunch of so-called health extenders, like continuing authority for Medicare telehealth, funding for community health centers, and delaying a cut to hospitals that serve large populations of people with low incomes, it rather pointedly does not include relief for doctors from a Medicare pay cut, much to the dismay of the American Medical Association. What are the prospects for this to become law? Or is the government going to shut down in addition to all the people who’ve been fired? 

Ollstein: The situation is very fluid. It barely passed the House, and Democratic senators are making noises about blocking it and putting forward a very short-term, actually clean CR because, as you noted, what they’re claiming is a clean CR is sort of more like an omnibus that makes a bunch of changes that only Republicans want to see. And not even all Republicans — just some Republicans want to see. And so I think because of the math here, the very narrow majority Republicans have in the House, they can really only lose a tiny handful of votes on this. 

I think you get into both policy and political dangerous territory when you make decisions that piss off some Republicans as well as Democrats, such as not including the so-called doc fix that would prevent doctors who serve people on Medicare from getting hit. That is a priority for some Republican members of Congress, and they can’t afford to lose their votes. And so there’s a lot of back-and-forth. There’s talk about a stand-alone health bill that scoops up some of the things that were abandoned at the end of last year. Who knows? Congress is very good at not getting things done. So I’m always skeptical. 

Rovner: We should point out that the House did kind of leave it all on the Senate’s doorstep by leaving and won’t be back until March 24. So even if the Senate were able to pass this 30-day clean CR, there’s no House to pass it, so the government would shut down anyway, which is what the House likes to do. It’s like: We’re going to do this. We’re not going to negotiate with you. We’re going to do this and leave, and you take it or you shut the government down. And that’s basically where we are at the moment. 

So, well, moving on to Medicaid and a reminder that the possibly impending Medicaid cuts are not part of this fight to keep the government open. I know reporters tend to refer to both the spending bill and the not-yet-written reconciliation bill as, quote, “the budget.” But the spending bill is something that’s left over from last year, while the budget resolution is something intended to lead to a bill that will be written this year. Anyway, regular listeners will know that the budget resolution approved by the House in February calls for $880 billion in mandatory spending reduction from the House Energy and Commerce Committee, which cannot be done without cutting from Medicare or Medicaid or both. 

But Medicaid is in a much different place politically now than it was even in 2017, when it was surprisingly popular and it helped defeat the Republican efforts to repeal the Affordable Care Act. How much more politically volatile are Medicaid cuts for Republicans now than they were? Alice, you’ve been following this, right? 

Ollstein: Yeah. So about all of the states that have expanded Medicaid by popular vote, and I think that’s a very different political dynamic than the states that did it through the legislature. This is something that a majority of folks in these states overwhelmingly voted for very recently. They said, Yes, we do want this. They said it directly. And I think that makes it more politically precarious for lawmakers to then come and basically override the will of the people and say, We’re going to make cuts. Especially because a lot of the cuts that are being discussed would hit the expansion population pretty squarely. 

There’s a lot of rhetoric recently sort of setting up different constituencies of Medicaid beneficiaries and sort of ranking them and implying that some are deserving and some are undeserving. And the expansion population in the eyes of many conservatives are undeserving, people who are low-income but not so low-income that they qualify for traditional Medicaid. They’re not parents, they don’t have disabilities, but they have not been able to afford insurance if not for this program. And so I think that as lawmakers in Washington discuss policies that would in many states automatically get rid of the expansion, a lot of these states have these trigger policies where if the federal level of support and funding goes down, then the expansion, poof, goes away. 

And I think that would upset a lot of people. And so this is a new dynamic. And these states only went the popular-vote ballot measure route because it was impossible to get it passed through the legislature and signed by their governors, who in many circumstances opposed it. And so it’s a very expensive, time-consuming route, but it’s something that a bunch of states pursued, and these are overwhelmingly states that voted for [Donald] Trump that are represented by Republicans in Congress. 

Edney: I also think that since 2017 we’ve seen more and more news articles, discussion, we’ve been paying attention more to rural hospitals and how they are impacted by Medicaid. This stat that really stuck out to me is that half of them are operating in a deficit, and so they need that Medicaid money, and threatening it threatens closing them down in places that wouldn’t have any other options. 

Luthra: The other component that I think is worth adding is I think what Alice pointed out about these hierarchies of deserving recipients is really astute and really important. And it also is a point that critics of Medicaid like to lean on without considering necessarily how interconnected these groups are. And an example of that I think about a lot is pregnant Americans. People love to provide insurance for people when they’re pregnant. It is very popular. You are seen as much more deserving when it is insurance not just for you but for your pregnancy. 

But one thing that we know is that your health in pregnancy is better if you have access to health care before you get pregnant as well and after you get pregnant. And there is a large body of research that shows that expanding eligibility for Medicaid actually does improve one’s health during pregnancy and improves long-term outcomes. And so I think it’s really important for us to underscore that if the kinds of cuts that we’re talking about do in fact take effect, there will be very meaningful implications, including for the people who Republicans claim would be protected. 

Rovner: So why aren’t we hearing more from lobbyists on this? You’d think the hospitals and the drug companies and other big for-profit parts of the health system would be shouting from the rafters by now. It seems that most of the emails and claims and things, ads, that I’m seeing are coming from consumer protection groups, not so much from the sort of big stakeholders in the health industry. 

Edney: I think there is a lot going on. So I think that this can be said in so many situations right now, but there’s only an ability to focus on so much. And you mentioned the doctors cut earlier. There are things that these groups have right in front of them. Medicaid, we all know that cuts are, in some way, are coming but maybe don’t have the picture yet exactly of how that will happen. So it might be tougher to fight quite yet. And they’re focusing on the things that are happening immediately in front of their face, which seems to be all anyone’s able to do with the onslaught of changes and cuts and things going on. 

Rovner: I feel like, move fast and break things, that’s why it works is that it doesn’t let people, there’s just not enough time to react before they’re on to the next thing. 

Well, we will move on to the next thing, which is Trump administration news, which is, obviously, there’s more than we can possibly get to. As you’ll hear more in our interview with Jeff Grant, key people are losing their jobs at CMS. Everyone left at HHS was offered a $25,000 cash buyout to quit, and there’s likely more to come with reorganization proposals due to DOGE [the Department of Government Efficiency] today. 

Social Security and the Department of Veterans Affairs are cutting thousands of workers as well and clearly jeopardizing services, even though the administration insists that’s not its goal. Many of these workers are being fired for poor performance, even the ones who have stellar performance records. That’s important because not only are they not getting any severance, people fired for cause aren’t generally eligible for unemployment insurance, either. It does seem like one campaign promise being met is the one by OMB [Office of Management and Budget] Director Russell Vought to put federal workers, quote, “in trauma.” Right? 

Luthra: I was going to say there is really compelling reporting that has shown exactly that. There are very severe mental health consequences we are seeing for these federal workers who are losing their jobs in a situation that will obviously lead to reduced services and where they may not be eligible for things like severance, like unemployment. It’s really pretty alarming to see the mental health degradation that’s been reported on. 

You hear about former federal employees contemplating self-harm as a result. And I think we are going to be continuing to see the impact for a very long time — and not just in the Washington, D.C., area, because federal employees work and live all around the country. 

Rovner: Eighty percent of federal employees are outside the Washington, D.C., metro area, which they seem to keep forgetting. I kept wondering why there hasn’t been more pushback on this, and now I’m starting to hear that the lack of pushback isn’t just people worried about future jobs or their careers. Some of it is about actual personal safety. Francis Collins, the former NIH [National Institutes of Health] director and White House science adviser who retired from his own NIH lab last month, that he’s worried for his and his family’s safety and that he’s had to hire personal security. 

Are you all hearing that kind of story, too? I mean, is there literal concern for physical safety as much as for, Oh my goodness, if I speak out I’ll be blacklisted? 

Ollstein: Well, for some high-level people, also high-level former administration officials, the Trump administration has been stripping them of publicly funded security, and so they feel they’ve had to hire their own. And so those folks who are more recognizable feel even more at risk. But I think what Shefali was saying, too, it’s just hard to, even as we say that most federal workers are outside of D.C., it has been hard for me to convey to people outside of D.C. just how grim the mood has been. And just so many people we know are suffering, out of work, don’t know how they’re going to support their families. 

This is going to have repercussions for D.C.’s tax revenue, the ability to keep running our local schools and public transit and public safety and libraries. So it’s just going to continue to have these ripple effects. 

Rovner: And I should point out, I mean, I was born in Washington, D.C. I grew up here. I’ve lived here all of my adult life. Administrations change, and people come and go. That’s not unusual. This is unusual. Trying to sort of shut down entire agencies is definitely much more unusual than anything I have seen before. 

Well, meanwhile, at the helm of the Department of Health and Human Services, Secretary Robert F. Kennedy Jr. is behaving pretty much like you’d expect. He says the measles outbreak in Texas, which has now spread to New Mexico and to Oklahoma, is due at least in part to poor nutrition and exercise habits, which is a link not established by science. 

NIH is shutting down research into why people become vaccine-hesitant and how to increase vaccine uptake. And the CDC has announced a large-scale study to once again examine whether there’s a connection between vaccines and autism, even though there are reams of studies saying that there is not. Is anybody actually surprised by all of this? Maybe Sen. Cassidy, who I think was promised that this wouldn’t happen? 

Edney: No, not surprised. I can’t imagine he’s surprised, either. I think it was maybe just sort of a dance for them, where Cassidy knew he needed to make that vote and said the things he said. But, no, not surprised that it’s going this way. I think that there are a lot of people out there, a lot of groups who do want to know the cause of autism, and that is something that could be looked at more. Focusing it on vaccines, doing more damage than actually being helpful, doesn’t seem to be the way to do it, but it’s certainly the hypothesis this administration is going with, and they seem to refuse to look at any other direction. 

Rovner: Do you think sort of the growing measles outbreak in Texas—? I mean we’re obviously speculating here, though. You were saying earlier with the pulling of the Weldon nomination, might’ve had something to do with that. I mean, this is the biggest measles outbreak that we’ve had I think I saw in 10 years. It is unusual. I mean despite what RFK said, which we have measles every year, we don’t have outbreaks like this every year. And I’m wondering if that’s sort of making some of the Republicans who were sort of swallowing the fact that there is going to be a real anti-vaxxer at the helm of HHS giving them a little bit more pause. 

Edney: Yeah, I mean, the timing is, there’s no good word for it. I mean the fact that this measles outbreak happened when a vaccine skeptic, an anti-vaxxer basically, has gotten into the HHS secretary position. I’m sure they thought that, and I feel like I had a lot of conversations with people like this, not necessarily lawmakers but who said, Well, I really like a lot of things RFK Jr.’s doing, and I don’t think the vaccine thing’s really going to come up or matter that much. Guess what. It did. And they have to deal with that now. And I think particularly people who have been out very prominently in the news, like Sen. Cassidy, is going to have to try to reconcile that somehow, and maybe not having Weldon come before his committee and draw more attention to this was one way of digging in. 

Rovner: Yes, I think that’s definitely one of the possibilities. Well, the dismantling of science and medicine continues outside the federal government’s buildings as well. This week NIH canceled $250 million in grants to Columbia University, citing the university’s, quote, “continued inaction in the face of persistent harassment of Jewish students.” Meanwhile, in December, that incoming NIH director Jay Bhattacharya wants to base funding at least in part on campus academic freedom-of-speech rankings, except the group that does those rankings that they are, quote, “not the right tool for this particular job.” Is NIH just going to become another way for this administration to reward its friends and punish its enemies? 

Luthra: That’s what it seems like so far. We’ve seen hiring freezes take effect at a lot of universities, even as recently as this week. We are seeing a lot of universities that are politically more liberal in their members, in their general inclination, also reporting that they are under investigation for purported antisemitism. And I think we should know that often this framing is simply that protests existed on campus some, and there’s some debate over whether the term is being used a little liberally, but this is having real consequences for people’s ability to do research, to build a research pipeline, and as a result to improve our health. 

And I think it’s really striking that, yet again, this effort to use a federal funding institution as part of a political agenda is having real implications for how we live and our ability to become a healthier society. 

Rovner: And I would point out that Columbia University’s biomedical research establishment is nowhere near Columbia University’s main campus. It’s a totally different part of Manhattan. So it’s not about things that happen, quote-unquote, “on campus,” even though it is obviously all part of the same university. But we have seen a lot of universities getting grants pulled in the middle of them. It’s not like, We’re not going to renew your grant. It’s like, We’re just going to stop giving you money now, and you’re going to have to either fire all of your lab workers or see if you can figure out where else you can get money. I mean, it does seem to be really disrupting the practice of science right now. 

Luthra: And one other thing I think is worth noting is, I mean, this is very similar to what we saw with the USAID [U.S. Agency for International Development] grants that were suddenly canceled, and sometimes often it is more expensive to cancel things midway as opposed to not renewing them, because you’re paying for broken leases, you have already invested in things that will not yield results. Maybe there is severance that you have to pay. And all of these sort of sunk costs and new costs incurred by abrupt termination come without the benefits of the gains that one hopes to reap. 

Ollstein: Yeah, I mean, to Shefali’s point, so not only is it more costly in the short term, but it’s absolutely more costly in the long term. These research grants generate way more economic revenue than they cost, and they support tons of jobs all around the country. And so this will absolutely have detrimental economic effects in the long term as well. 

Rovner: Well, finally this week I have a heading I’m calling “Your Government Is No Longer Any of Your Business.” This is pretty much the opposite of the radical transparency this administration was promising. First, the good news: The administration apparently will still issue rules and regulations under the legal process known as the Administrative Procedure Act, which I talked about with law professor Nick Bagley earlier this year. How do we know this? Because HHS has put out a policy statement that it will no longer take public comment on a broad array of rules for which public comment had been required since 1971. 

Is this legal under the APA? Yes, the law allows for exceptions. But not only is this not exactly radically transparent, it could make it a lot easier to do some pretty unpopular things, like, I don’t know, cutting NIH overhead funding to 15%. Anna, you’re nodding. 

Edney: Well, yeah, I think that is the point, is that they want to move quickly and public comment slows that down. But it does it for a reason, because there are consequences, which Shefali and Alice just laid out, for things like cutting grants and things like that that maybe a health care expert in the administration isn’t thinking about when they first post something and groups come in and they say, Hey, this is actually how we’re affected. And so public comment maybe sounds like your aunt and grandma winding up to talk about it, which can also happen, but it’s really educated experts in these areas that are saying, Here’s this one thing you didn’t think about, or there’s a lot of reasons to get public comment. 

I can understand it. It’s something that when I cover the FDA [Food and Drug Administration] that sometimes they’ll complain, not complain but they’ll say, Things go slow because we have to do an advanced notice of proposed rulemaking and then we do a notice of proposed rulemaking. And these are all times when the public can come in and comment, but to not do that, it seems like they want to be able to do unpopular things quickly. 

Ollstein: It’s just struck me how crazy a contrast it is between the two parties on this front. The Democratic Party was criticized for being so cautious and moving so slowly on some pressing priorities when [President Joe] Biden was in office and checking all the boxes and doing the long version of the process to make sure everything was legally on the up-and-up when they could have expedited some things and done interim final rules and taken comment after. So there was a lot of frustration from some groups on that front. Meanwhile, the Republican administration is doing just the opposite, moving as fast as possible with as little public input as possible. 

Rovner: Which leads into my next topic, over at the National Cancer Institute. , staff have been notified that manuscripts, presentations, or basically any sort of public communications that touch on any of nearly two dozen sensitive, controversial, or high-profile issues must be cleared first by a special NCI clearance team. Now it’s obviously not unusual for political appointees to want to see potentially newsworthy things before they go public, but this list of what has to be specially cleared is pretty comprehensive. 

And it includes not just obvious hot-button things like abortion and stem cell or fetal tissue research but also things like obesity, vaccines, quote “discussion of federal policies” quote, and even peanut allergies. This feels quite a bit more sweeping than your usual Don’t put out stuff that will surprise us in a bad way. Right? 

Luthra: Yeah, it’s very striking. It’s hard for me not to say that this is very strange. I have a peanut allergy, and I would personally like information about peanut allergies to be put out in the world, and I guess that may not always happen anymore. But it is part of this, as we have discussed, ability and interest in amplifying, often, conspiracy theories and taking us away from medically established science. We just saw efforts to restrict fluoride in the water in Utah this week. This is something that is happening at high levels of government and more local levels of government, and it’s something that is going to continue, is trying to leverage our health institutions to promote things that will make us less healthy. 

Rovner: Yeah, well, and finally this week, that a new policy at the Social Security Administration bars workers from looking at news websites on work devices. Now this is obviously aimed at things like making sure employees aren’t watching the NCAA basketball tournament or checking their 401(k)s during work hours or reading Wired, for that matter, except Social Security workers also use news sites for, you know, work, like checking obituaries to make sure the agency isn’t sending checks to people who have died. That seems to be a big issue these days. Is this just another way DOGE is trying to make federal workers feel like grade school children so they’ll quit? 

Ollstein: Well, this is a twofer, because it punishes federal workers and it punishes news outlets who, including myself and my colleagues at Politico. They forced many federal workers to cancel their subscriptions to our Pro news. And so all that does is make sure the lobbyists are better informed than the federal agencies, which is troubling, for sure. 

Rovner: And probably not what the administration wanted. All right, well that is as much news as we have time for this week. Now we will play my interview with Jeff Grant, formerly of CMS, and then we will come back and do our extra credits. 

I am pleased to welcome to the podcast Jeff Grant, most recently the deputy director for operations at CCIIO, the Center for Consumer Information and Insurance Oversight, at the Centers for Medicare & Medicaid Services. Jeff retired last month after 41 years in government, following the firing of 15% of his staff. Now he’s starting a consulting firm that will try to help those being let go from the government find new jobs. Jeff Grant, thank you so much for joining us. 

Jeff Grant: Oh thanks for having me. 

Rovner: So you were a career employee at CMS. Tell us what you did and how that would normally change between administrations. Obviously, you were there 40 years. You’ve seen a lot of administrations come and go. 

Grant: So I was actually at CMS for just under 30 years, and then I had Navy and Navy Reserve experience prior to that and a little bit at Commerce and GAO [the Government Accountability Office], but was all over CMS. My last job was running operations for the Center for Consumer Information and Insurance Oversight. So I was a deputy center director. I reported to the political appointee that ran the center, and I was in charge of our major operations, like HealthCare.gov, getting payments out to health plans that provided care for folks that registered in the private insurance marketplace, running things like the risk adjustment program. 

And then the independent dispute resolution program was also huge out of the No Surprises Act. And we ran that for three Cabinet departments — ourselves, Labor, and Treasury. So we handled all the disputes that came in over surprise bills. 

Rovner: So obviously in your 30 years you’ve had Republican and Democratic administrations come and go. How did things normally change for the career workforce when the administration changes? 

Grant: What we really do, especially at a senior level like I was at at the tail end of my career, is we meet with the new officials coming in. And frankly, we read things about them before they come in, study up on who we’re going to be working with, what their policy priorities are, and then we prepare to move forward on a new policy agenda. And what I found over 30 years of working for Republicans and Democrats, Democrats will move it one direction, Republicans will move it another direction. 

There’s a big wide middle there where policies that tend to make sense to both parties over time, when they see them working, remain. And then you have some shifts around the edges on the rest of the policies. And it’s actually, I think the changes in administrations are usually quite beneficial for the stability of health programs, not taking them too far in one direction or another. 

Rovner: So how important is the career workforce to the operations of this agency? I think people, they just see Medicare and Medicaid, CHIP [the Children’s Health Insurance Program], ACA, and assume that it all runs on its own. 

Grant: It absolutely does not, and the career workforce is absolutely essential to the operations of these programs. I think what people should understand is this is 6,700 people, or it was before they started removing folks, but 6,700 people to handle $1.5 trillion in health insurance. So we’re the largest health insurance agency in the world, and we’re running it with 6,700 people, which is smaller than most federal agencies and probably smaller than most Americans would think. 

Rovner: So who were the people who were let go? We’ve been led to believe they were people who didn’t or couldn’t do their jobs or didn’t bother to come to work or were working on the side elsewhere. 

Grant: That’s absolutely, 100% false in terms of what I think people believe about these workers, if they believe the letters. So the letters informed them that their knowledge, skills, and abilities were insufficient to meet the needs of the agency and that their performance was not adequate to justify retention. Both of those were just blatant falsehoods. The people that had been there long enough to get performance appraisals, many of them had the highest appraisals you could get, and that’s not an automatic. There’s a distribution of performance appraisal numbers. These were really exceptional individuals. 

We had a very rigorous hiring process that’s gotten better over the years, and we’ve really identified top talent to come in and work for us. Some of these folks had been there five weeks, six weeks, three weeks. I don’t know what the shortest amount of time was. I think the shortest amount of time was three weeks. You have to have 90 days on board to make a performance-based judgment. You could make a conduct-based judgment. So if they were not showing up for work, we fire them for that. I’ve actually personally fired an employee for not showing up for work. That was a probationary employee. It’s very easy to do. We did not have that problem. 

They did work a mix of in the office and at home, but all of our recent employees were local to one of our offices. So they all came in the office at times. At times they work remotely. That has always been true of our workforce, that we have employees that work both in office and at home, and it’s actually a very efficient way to do things, because they don’t waste time commuting. And sometimes being quiet at home for activities that require uninterrupted work, you can actually be much more efficient working at home than you are in the office. 

But then you come in the office for activities that it’s beneficial to be around people and work things out. So you organize your days in such a way that makes sense, but you can have some interruption-free workdays where you can be super productive. 

Rovner: Yes. And that’s how, I confess, that’s how I work. Partly I’m home, partly in the office. 

Grant: That is how I work. Now that I’m on my own, I’m 100% remote. And I can assure you, running my own business, I’m not just sitting around doing nothing. 

Rovner: So what do you think people most misunderstand about the way the Trump administration is trying to make the government run more “efficiently”? And I’m putting efficiently in air quotes. 

Grant: Well then, I think, the first thing I would say, especially for an agency like CMS — I can’t speak for all of government, but for an agency like CMS, we’ve got 6,700 workers. They’re managing contractors that in turn manage this ginormous benefit that we are paying out. The money’s in the benefit. Let’s just start there. So if there are inefficiencies that are leading to overspending, it’s not the 6,700 people that are too small a workforce already to effectively run these programs. The smartest thing you could do is probably hire more people into CMS to give you more degrees of freedom to make more changes that actually might transform these programs and make them more efficient. 

I can tell you, personal experience in the Trump administration, I cut costs for the marketplace operations by $100 million per year for three consecutive years. But it took people and contractors to make those cuts. But over time that resulted by the third year we were saving $300 million a year. Those savings carry forward. So every year after that you’re saving that $300 million a year. That’s real money. Tinkering around with 82 probationary employees, that’s about $15 million a year by comparison. 

It is ludicrous to say that you’re taking your cheapest employees, cutting them, and eliminating your degrees of freedom to make transformative change and that’s going to make you more efficient. That’s the least efficient thing you can do. 

Rovner: So what’s your biggest fear about long-term damage to the programs if these kinds of cuts continue? I mean they say they’re not finished yet. The probationary employees were the easy ones to let go. Now they’re going to move into the buyouts and RIFs [reductions in force] and other ways, I guess, of trying to downsize the workforce. 

Grant: Yeah, well, first I think the probationary were easy, but I’m hoping that one of those lawsuits on the way they did it, that points out how wrong their method for doing it was, might still restore those jobs, because I don’t think those were as easy as they thought they were. They should have run a reduction in force. But they’re now talking about a reduction in force. They’re talking about reducing contracts, and I think reduction in force is going to be more randomly distributed. Just the probationary people are random, who happen to be where and be probationary at that time. So it’s not a thoughtful way of saying: We don’t need this function anymore. Let’s get rid of it and save money. 

A RIF would be less thoughtful. And I think the one that’s also really dangerous is the return to workplace with a mandatory five days a week. And at the end of this month, all workers within 50 miles of an HHS office have to be in the workplace. If they cannot be in five days a week without some kind of exceptions process, they’re going to be gone. And that will be really randomly distributed again among who is actually able to do that at the end of April. People that are not within 50 miles of a CMS office are still required to find an office and then go to work. And my component had 75 of those people. 

So I think it would be very hard for those folks to come in. And again, a lot of these are senior people, really talented, and you’re just losing a skill set randomly because they can’t get to the office, yet they’ve been performing superbly without going to an office. 

Rovner: So what happens to these programs? 

Grant: So, I can’t tell you exactly. I know there was one person that we have in during government shutdowns for running the payment process, one of two people that really knows the payment process backwards and forwards. That person cannot get to an office. And without an exceptions process, that person is gone. And that hampers our ability to pay health plans the money they need for covering our insured individuals. And it’d just be these little pockets of people here and there that have advanced expertise. We’re not that big an agency. We don’t have a lot of people that back people up. 

That’s one of the problems with being an underfunded agency, is you do not have more than one or two people that work on any given subject. The redundancy they think is there does not exist. And so you will start losing key capacity to actually operate programs. Did you see that they were also proposing to sell the Woodlawn building [in Maryland]? 

Rovner: I did. 

Grant: It’s the only place that can house 4,000 people. Evidently there may be an administration connection and, who might buy it and then lease it back to the government. You may know that there are some people— 

Rovner: It’s going to be like the private equity thing with the hospitals. We’re going to— 

Grant: This is exactly what I said, that everything that’s being done right now is being done like private equity firms do it. It doesn’t make you run better. It just kind of lightens the cost, and you have a better-looking statement just for a short time. So your financials look good for a very short period of time, then everything starts spiraling downhill, customer service goes down the tubes, and you’re all of a sudden paying twice as much. 

Rovner: And I guess I should have asked you this at the beginning. Is that why you left? I mean, you worked for [President] Trump last time. 

Grant: I did. And I actually liked the person that came in. I left because it was becoming clearer and clearer that the people that they brought in that are very good to run CMS aren’t in charge of these key policies about how many people we will have, how big our contracting budget will be. And I could see us having large-scale loss. I mean, we lost 82 in one day. I’ve mentioned 75. I could get to a number that was easily 200 of 600 employees I had, and I felt I could do more on the outside than I could on the inside. 

And that’s what I’m doing now. And hopefully we can get these people either restored to their jobs, which is one angle I am fighting hard on. And if they can’t get restored to their rightful positions, try to find them a position outside of government. 

Rovner: Great. Jeff Grant, thank you so much. 

Grant: Thank you. 

Rovner: OK, we are back, and it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Shefali, this week is the fifth anniversary of the covid shutdown, which we didn’t even get a chance to talk about, but that’s what your extra credit is. So tell us now. 

Luthra: There were a lot of really great pieces this week about the five-year anniversary of the covid shutdown, but I feel like I learned the most and had the most fun with this piece from TheUpshot. It is by Claire Cain Miller and Irineo Cabreros. It is “.” It’s got some great charts. It talks about things we learned that were kind of neat, like we don’t have to have really bad flu seasons, and actually there are ways to improve pregnancy-related health outcomes by letting people rest when they’re pregnant. 

And there are also things we learned that are really bad, like it is actually harder to learn virtually as opposed to in person and that there is no substitute for in-person socialization. And that even during lockdowns, men are less likely to do housework than women in heterosexual couples. But I really loved how this took us back to a time that upended everything we knew and it pulled out some of the most salient facts that we’ve learned for better and for worse. It’s really fun, and I recommend it. 

Rovner: It is really fun. Anna. 

Edney: I did one by my colleague in India called “.” And I was glad that she was able to write this, because I thought this was a really interesting study that came out. And it was published in an operations journal, so it was kind of not prominently displayed. But it showed that drugs that are made in India — so these are mostly generics — were 54% more likely to result in a serious adverse event. 

So that includes hospitalization, disability, and death compared to drugs made anywhere else. And the study’s authors think this may be due to a lot of the manufacturing issues that probably listeners of this podcast have heard me talk about before so I don’t have to get into. But I think it’s an interesting story to give a read. 

Rovner: Yes. Anna with the scary drug stories. Alice. 

Ollstein: So I have a very heartbreaking story from The Atlantic called “.” And a Texas-based reporter went to the small rural community where a Mennonite community was really at the epicenter of the recent measles outbreak. And he sort of stumbled upon the father of the child who died. And the piece really illuminates just how challenging a public health crisis this is. A lot of people in that community don’t speak English. They speak Low German. So it’s very hard to communicate. It’s very hard to even know the scope of the problem, because people aren’t testing. 

A lot of folks in that community are not enrolled in public schools or even accredited private schools where vaccination rates are tracked. And so it’s just very, very challenging to communicate and build trust and even have a sense of how bad the situation is. And at the same time, the piece walks through all of the things going on that are not helping, like RFK Jr. not only downplaying the outbreak but also sort of doing some light victim-blaming, implying that if you have good health habits and nutrition, you won’t die of measles. And this was a little child. 

And so not only is that not scientifically proven, but it’s sort of painful to hear when you’re talking about a little child. So I highly recommend this story. 

Rovner: Yeah, I have a different blaming-the-victim story. My extra credit is from NBC News. It’s called “,” by Natasha Korecki. And it’s the best roundup I’ve seen of the mental distress on federal workers across agencies being caused by the way the administration is going about this downsizing. Some of these workers voted for Trump. They support cutting waste and fraud in the federal government. But said one former CDC worker, quote: “Taking a sledgehammer approach and having an unelected billionaire in my email is just insane. What are his qualifications for doing this? The government is not a startup; we’ve been in business since 1776.” A really good if depressing read. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer and editor, Francis Ying, and our fill-in editor this week, Mary Agnes Carey. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, , and at Bluesky, . Where are you guys mostly these days? Shefali? 

Luthra: I am on Bluesky, . 

Rovner: Anna. 

Edney: and , @annaedney. 

Rovner: Alice. 

Ollstein: on X and on Bluesky. 

Rovner: We will be back in your feed next week. Until then, be healthy.