CMS says its efforts are working, pointing to the 30% drop in complaint casework.

This article was published on Monday, November 25, 2024 in KFF Health News.

By Julie Appleby

Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.

Now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?

"They really have this tightrope to walk," said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. "The more you tighten it up to prevent fraud, the more barriers there are that could inhibit enrollment among those who need the coverage."

CMS said in July that some types of policy changes — those in which the agent is not "affiliated" with the existing plan — will face more requirements, such as a three-way call with the consumer, broker, and a healthcare.gov call center representative.

In August, the agency barred two of about a dozen private sector online-enrollment platforms from connecting with healthcare.gov over concerns related to improper switching.

And CMS has suspended 850 agents suspected of being involved in unauthorized plan-switching from accessing the ACA marketplace.

Still, the clampdown could add complexity to enrollment and slow the process. For example, a consumer might have to wait in a queue for a three-way call, or scramble to find a new agent because the one they previously worked with had been suspended.

Given that phone lines with healthcare.gov staff already get busy — especially during mid-December — agents and policy analysts advise consumers not to dally this year.

"Hit the ground running," said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, reports are emerging that some rogue entities are already figuring out workarounds that could undermine some of the anti-fraud protections CMS put in place, Nolan said.

"Bottom line is: Fraud and abuse is still happening," Nolan said.

Brokers assist the majority of people actively enrolling in ACA plans and are paid a monthly commission by insurers for their efforts. Consumers can compare plans or enroll themselves online through federal or state marketplace websites. They can also seek help from people called assisters or navigators — certified helpers who are not paid commissions. Under a "find local help" button on the federal and state ACA websites, consumers can search for nearby brokers or navigators.

CMS says it has "ramped up support operations" at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, and it expects "minimal wait times," said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight.

Wu said those three-way calls are necessary only when an agent or a broker not already associated with a consumer's enrollment wants to change that consumer's enrollment or end that consumer's coverage. It does not apply to people seeking coverage for the first time.

Organizations paid by the government to offer navigator services have a dedicated phone line to the federal marketplace, and callers are not currently experiencing long waits, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through its Covering Florida navigator program.

Navigators can assist with the three-way calls if a consumer's situation requires it.

"Because we have our quick line in, there's no increased wait time," Jacobs said.

The problem of unauthorized switches has been around for a while but took off during last year's open enrollment season.

Brokers generally blamed much of the problem on the ease with which rogue agents can access ACA information in the federal marketplace, needing only a person's name, date of birth, and state of residence. Though federal regulators have worked to tighten that access with the three-way call requirement, they stopped short of instituting what some agent groups say is needed: two-factor authentication, which could involve a code accessed by a consumer through a smartphone.

Unauthorized switches can lead to a host of problems for consumers, from higher deductibles to landing in new networks that do not include their preferred physicians or hospitals. Some people have received tax bills when unauthorized policies came with premium credits for which they did not qualify.

Unauthorized switches posed a political liability for the Biden administration, a blemish on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more oversight and punishment of rogue agents, while Republicans said fraud attempts were fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes power. But the premiums and subsidies that come with 2025 plans that people are enrolling in now will remain in effect for the entire year.

The actions taken this year to thwart the unauthorized enrollments apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having in place additional layers of security.

For its part, CMS says its efforts are working, pointing to the 30% drop in complaint casework. The agency also noted a 90% drop in the number of times an agent's name was replaced by another's, which it says indicates that it is tougher for rival agents to steal clients to gain the monthly commissions that insurers pay.

Still, the move to suspend 850 agents has drawn pushback from agent groups that initially brought the problem to federal regulators' attention. They say some of those accused were suspended before getting a chance to respond to the allegations.

"There will be a certain number of agents and brokers who are going to be suspended without due process," said Nolan, with the health agents' group. She said that it has called for increased protections against unauthorized switching and that two-factor authentication, like that used in some state marketplaces or in the financial sector, would be more effective than what's been done.

"We now have to jump through so many hoops that I'm not sure we're going to survive," she said of agents in general. "They are just throwing things against the wall to see what sticks when they could just do two-factor."

The agency did not respond to questions asking for details about how the 850 agents suspended since July were selected, the states where they were located, or how many had their suspensions reversed after supplying additional information.

Julie Appleby: jappleby@kff.org, @Julie_appleby

Congress could theoretically change the ACA without a single Democratic vote.

This article was published on Thursday, November 21, 2024 in KFF Health News.

By Stephanie Armour and Sam Whitehead and Julie Rovner

President-elect Donald Trump's return to the White House could embolden Republicans who want to weaken or repeal the Affordable Care Act, but implementing such sweeping changes would still require overcoming procedural and political hurdles.

Trump, long an ACA opponent, expressed interest during the campaign in retooling the health law. In addition, some high-ranking Republican lawmakers — who will now have control over both the House and the Senate — have said revamping the landmark 2010 legislation known as Obamacare would be a priority. They say the law is too expensive and represents government overreach.

The governing trifecta sets the stage for potentially seismic changes that could curtail the law's Medicaid expansion, raise the uninsured rate, weaken patient protections, and increase premium costs for millions of people.

"The Republican plans — they don't say they are going to repeal the ACA, but their collection of policies could amount to the same thing or worse," said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities, a research and policy institute. "It could happen through legislation and regulation. We're on alert for anything and everything. It could take many forms."

Congressional Republicans have held dozens of votes over the years to try to repeal the law. They were unable to get it done in 2017 after Trump became president, even though they held both chambers and the White House, in large part because some GOP lawmakers wouldn't support legislation they said would cause such a marked increase in the uninsured rate.

Similar opposition to revamping the law could emerge again, especially because polls show the ACA's protections are popular.

While neither Trump nor his GOP allies have elaborated on what they would change, House Speaker Mike Johnson said last month that the ACA needs "massive reform" and would be on the party's agenda should Trump win.

Congress could theoretically change the ACA without a single Democratic vote, using a process known as "reconciliation." The narrow margins by which Republicans control the House and Senate mean just a handful of "no" votes could sink that effort, though.

Many of the more ambitious goals would require Congress. Some conservatives have called for changing the funding formula for Medicaid, a federal-state government health insurance program for low-income and disabled people. The idea would be to use budget reconciliation to gain lawmakers' approval to reduce the share paid by the federal government for the expansion population. The group that would be most affected is made up largely of higher-income adults and adults who don't have children rather than "traditional" Medicaid beneficiaries such as pregnant women, children, and people with disabilities.

A conservative idea that would let individuals use ACA subsidies for plans on the exchange that don't comply with the health law would likely require Congress. That could cause healthier people to use the subsidies to buy cheaper and skimpier plans, raising premiums for older and sicker consumers who need more comprehensive coverage.

"It's similar to an ACA repeal plan," said Cynthia Cox, a vice president and the director of the Affordable Care Act program at KFF, a health information nonprofit that includes KFF Health News. "It's repeal with a different name."

Congress would likely be needed to enact a proposal to shift a portion of consumers' ACA subsidies to health savings accounts to pay for eligible medical expenses.

Trump could also opt to bypass Congress. He did so during his previous tenure, when the Department of Health and Human Services invited states to apply for waivers to change the way their Medicaid programs were paid for — capping federal funds in exchange for more state flexibility in running the program. Waivers have been popular among both blue and red states for making other changes to Medicaid.

"Trump will do whatever he thinks he can get away with," said Chris Edelson, an assistant professor of government at American University. "If he wants to do something, he'll just do it."

Republicans have another option to weaken the ACA: They can simply do nothing. Temporary, enhanced subsidies that reduce premium costs — and contributed to the nation's lowest uninsured rate on record — are set to expire at the end of next year without congressional action. Premiums would then double or more, on average, for subsidized consumers in 12 states who enrolled using the federal ACA exchange, according to data from KFF.

That would mean fewer people could afford coverage on the ACA exchanges. And while the number of people covered by employer plans would likely increase, an additional 1.7 million uninsured individuals are projected each year from 2024 to 2033, according to federal estimates.

Many of the states that would be most affected, including Texas and Florida, are represented by Republicans in Congress, which could give some lawmakers pause about letting the subsidies lapse.

The Trump administration could opt to stop defending the law against suits seeking to topple parts of it. One of the most notable cases challenges the ACA requirement that insurers cover some preventive services, such as cancer screenings and alcohol use counseling, at no cost. About 150 million people now benefit from the coverage requirement.

If the Department of Justice were to withdraw its petition after Trump takes office, the plaintiffs would not have to observe the coverage requirement — which could inspire similar challenges, with broader implications. A recent Supreme Court ruling left the door open to legal challenges by other employers and insurers seeking the same relief, said Zachary Baron, a director of Georgetown University's Center for Health Policy and the Law.

In the meantime, Trump could initiate changes from his first day in the Oval Office through executive orders, which are directives that have the force of law.

"The early executive orders will give us a sense of policies that the administration plans to pursue," said Allison Orris, a senior fellow at the Center on Budget and Policy Priorities. "Early signaling through executive orders will send a message about what guidance, regulations, and policy could follow."

In fact, Trump relied heavily on these orders during his previous term: An October 2017 order directed federal agencies to begin modifying the ACA and ultimately increased consumer access to health plans that didn't comply with the law. He could issue similar orders early on in his new term, using them to start the process of compelling changes to the law, such as stepped-up oversight of potential fraud.

The administration could early on take other steps that work against the ACA, such as curtailing federal funding for outreach and help signing up for ACA plans. Both actions depressed enrollment during the previous Trump administration.

Trump could also use regulations to implement other conservative proposals, such as increasing access to health insurance plans that don't comply with ACA consumer protections.

The Biden administration walked back Trump's efforts to expand what are often known as short-term health plans, disparaging the plans as "junk" insurance because they may not cover certain benefits and can deny coverage to those with a preexisting health condition.

The Trump administration is expected to use regulation to reverse Biden's reversal, allowing consumers to keep and renew the plans for much longer.

But drafting regulations has become far more complicated following a Supreme Court ruling saying federal courts no longer have to defer to federal agencies facing a legal challenge to their authority. In its wake, any rules from a Trump-era HHS could draw more efforts to block them in the courts.

Some people with ACA plans say they're concerned. Dylan Reed, a 43-year-old small-business owner from Loveland, Colorado, remembers the days before the ACA — and doesn't want to go back to a time when insurance was hard to get and afford.

In addition to attention-deficit/hyperactivity disorder and anxiety, he has scleroderma, an autoimmune disease associated with joint pain and numbness in the extremities. Even with his ACA plan, he estimates, he pays about $1,000 a month for medications alone.

He worries that without the protections of the ACA it will be hard to find coverage with his preexisting conditions.

"It's definitely a terrifying thought," Reed said. "I would probably survive. I would just be in a lot of pain."

Stephanie Armour: sarmour@kff.org, @StephArmour1

Sam Whitehead: swhitehead@kff.org

Julie Rovner: jrovner@kff.org, @jrovner

Research shows hospital consolidation fuels price hikes and healthcare spending, driving up costs for families, employers, Medicare and Medicaid.

This article was published on Wednesday, November 20, 2024 in KFF Health News.

By Samantha Liss

Indiana residents and federal officials are urging state health regulators to stop two rival hospitals in Terre Haute from merging. The deal, if approved, would leave residents with a hospital monopoly.

The Indiana Department of Health received hundreds of comments on the proposed merger, according to documents KFF Health News obtained through a state public records request. Most people expressed opposition to the deal, citing concerns about longer travel times to get emergency care, higher prices, and fewer choices for Terre Haute's 58,000 residents and those in Vigo County's nearby rural communities.

"Monopoly should be just a board game. Not a healthcare system," a commenter listed as H. Osborne wrote to the state health agency.

Doctors, health economists, and the Federal Trade Commission called on the Indiana Department of Health to deny Union Hospital's merger application. Such mergers became possible after Indiana enacted a Certificate of Public Advantage law, or COPA, in 2021, shielding the deals from federal anti-monopoly laws.

Two dozen states have had COPA laws on their books at some point, despite FTC warnings that such mergers can become difficult to control and may decrease the overall quality of care. The trend has come amid a broader wave of hospital consolidation, which research shows fuels price hikes and healthcare spending, driving up costs for families, employers, and taxpayers who foot the bill for Medicare and Medicaid.

Union Health said its proposed deal would improve care and increase access to services while "maintaining cost efficiency" for patients.

"This is not merely a business transaction; it is a strategic effort to improve healthcare delivery in our community," Union said in a statement.

John Collett, an executive with Garmong Construction who also serves on the board of the Terre Haute Chamber of Commerce, wrote that the deal would help the region achieve its goal of boosting population and income levels. (Garmong Construction served as construction manager for Union on multiple projects, including one worth hundreds of millions of dollars, according to an online brochure of its past projects.)

"I firmly believe this to be a step in the right direction," Collett wrote.

But the FTC — using italics for emphasis — said the deal is "unlikely to result in improved quality and access" and "would not lead to a healthier workforce or a stronger local economy," according to comments the agency submitted to Indiana regulators.

Zack Cooper, a health economist and associate professor at Yale University, said the merger would probably damage the local economy and squeeze residents' wallets. Cooper's analysis estimates the price of care would rise by at least 10% for area residents and lead to 500 lost jobs, while nurses' pay would drop by at least 7%. His research predicts the deal also would lead to unnecessary deaths from suicide or overdose, stemming from those job losses.

"I firmly believe this merger would harm members of the public in Terre Haute and Vigo County," Cooper wrote.

As a condition of these types of mergers, state agencies typically agree to monitor hospital quality and prices to make up for the loss of competition. Union said monitoring would hold it accountable, according to its response to the FTC's public comments opposing the deal.

The FTC pushed back, saying the oversight mechanism "would be insufficient to contain costs" and is a "poor substitute" for competition. Even though Union would face limits on raising prices in Vigo County, the FTC said, the system might be able to hike them elsewhere, including at its hospital in neighboring Vermillion County to the north.

Indiana has some of the highest hospital prices in the nation, according to studies by Rand Corp., a research organization.

In Terre Haute, some doctors worry the deal would exacerbate existing problems. Kathleen Stienstra, a physician in private practice, voiced her concerns about Union's management style, saying it has led to an exodus of doctors.

"A monopoly will lead to further deterioration in services," she wrote.

Separately, the FTC referenced KFF Health News' reporting on Tennessee's Ballad Health, a 20-hospital monopoly in Appalachia, as a cautionary tale against such mergers.

COPAs, such as the one that Ballad operates under, "have proven unwieldy," are "difficult to manage," and "have failed to protect local communities from the harmful effects of anticompetitive hospital mergers," the FTC said in its comments on the Union-Regional merger.

Since Ballad launched in 2018 and became the nation's largest state-approved hospital monopoly, it has not lived up to some of its promises, KFF Health News reported. It has fallen short on meeting quality and charity care goals, according to annual reports from Ballad and the Tennessee Department of Health. After years of problems and complaints from patients, the state is now trying to hold Ballad more accountable for its quality of care.

Ballad declined to respond to KFF Health News inquiries regarding the FTC's comments.

Now the Indiana Department of Health must consider the comments and decide by early December whether the proposed merger would improve health outcomes, access to services, and quality of care. Under the department's standards, those benefits must "outweigh any potential disadvantages."

KFF Health News correspondent Brett Kelman contributed to this report.

Samantha Liss: sliss@kff.org, @samanthann

Should Kennedy win Senate confirmation, critics say a radical antiestablishment medical movement would take power.

This article was published on Friday, November 15, 2024 in KFF Health News.

By Arthur Allen

Many scientists at the federal health agencies await the second Donald Trump administration with dread as well as uncertainty over how the president-elect will reconcile starkly different philosophies among the leaders of his team.

Trump announced Thursday he'll nominate Robert F. Kennedy Jr. to be secretary of the Health and Human Services Department, after saying during his campaign he'd let the anti-vaccine activist "go wild" on medicines, food, and health.

Should Kennedy win Senate confirmation, his critics say a radical antiestablishment medical movement with roots in past centuries would take power, threatening the achievements of a science-based public health order painstakingly built since World War II.

Trump said in a post on the social platform X that "Americans have been crushed by the industrial food complex and drug companies who have engaged in deception, misinformation, and disinformation when it comes to Public Health," echoing Kennedy's complaints about the medical establishment. The former Democratic presidential candidate will "end the Chronic Disease epidemic" and "Make American Great and Healthy Again!" Trump wrote.

Vaccine makers' stocks dipped Thursday afternoon amid news reports ahead of Trump's RFK announcement.

If Kennedy makes good on his vision for transforming public health, childhood vaccine mandates could wither. New vaccines might never win approval, even as the FDA allows dangerous or inefficient therapies onto the market. Agency websites could trumpet unproven or debunked health ideas. And if Trump's plan to weaken civil service rights goes through, anyone who questions these decisions could be summarily fired.

"Never has anybody like RFK Jr. gotten anywhere close to the position he may be in to actually shape policy," said Lewis Grossman, a law professor at American University and the author of "Choose Your Medicine," a history of U.S. public health.

Kennedy and an adviser Calley Means, a health care entrepreneur, say dramatic changes are needed because of the high levels of chronic disease in the United States. Government agencies have corruptly tolerated or promoted unhealthy diets and dangerous drugs and vaccines, they say.

Means and Kennedy did not respond to requests for comment. Four conservative members of the first Trump health bureaucracy spoke on condition of anonymity. They eagerly welcomed the former president's return but voiced few opinions about specific policies. Days after last week's election, RFK Jr. announced that the Trump administration would immediately fire and replace 600 National Institutes of Health officials. He set up a website seeking crowdsourced nominees for federal appointments, with a host of vaccination foes and chiropractors among the early favorites.

At meetings last week at Mar-a-Lago involving Elon Musk, Tucker Carlson, Donald Trump Jr., Kennedy, and Means, according to Politico, some candidates for leading health posts included Jay Bhattacharya, a Stanford University scientist who opposed covid lockdowns; Florida Surgeon General Joseph Ladapo, who opposes mRNA covid vaccines and rejected well-established disease control practices during a measles outbreak; Johns Hopkins University surgeon Marty Makary; and Means' sister, Stanford-trained surgeon and health guru Casey Means.

All are mavericks of a sort, though their ideas are not uniform. Yet the notion that they could elbow aside a century of science-based health policy is profoundly troubling to many health professionals. They see Kennedy's presence at the heart of the Trump transition as a triumph of the "medical freedom" movement, which arose in opposition to the Progressive Era idea that experts should guide health care policy and practices.

It could represent a turning away from the expectation that mainstream doctors be respected for their specialized knowledge, said Howard Markel, an emeritus professor of pediatrics and history at the University of Michigan, who began his clinical career treating AIDS patients and ended it after suffering a yearlong bout of long covid.

"We've gone back to the idea of 'every man his own doctor,'" he said, referring to a phrase that gained currency in the 19th century. It was a bad idea then and it's even worse now, he said.

"What does that do to the morale of scientists?" Markel asked. The public health agencies, largely a post-WWII legacy, are "remarkable institutions, but you can screw up these systems, not just by defunding them but by deflating the true patriots who work in them."

FDA Commissioner Robert Califf told a conference on Nov. 12 that he worried about mass firings at the FDA. "I'm biased, but I feel like the FDA is sort of at peak performance right now," he said. At a conference the next day, CDC Director Mandy Cohen reminded listeners of the horrors of vaccine-preventable diseases like measles and polio. "I don't want to have to see us go backward in order to remind ourselves that vaccines work," she said.

Stocks of some the biggest vaccine developers fell after news outlets led by Politico reported that the RFK pick was expected. Moderna, the developer of one of the most popular covid-19 vaccines, closed down 5.6%. Pfizer, another covid vaccine manufacturer, fell 2.6%. GSK, the producer of vaccines protecting against respiratory syncytial virus, hepatitis A and B, rotavirus, and influenza, fell just over 2%. French drug company Sanofi, whose website boasts its products vaccinate over 500 million annually, tumbled nearly 3.5%.

Exodus From the Agencies?

With uncertainty over the direction of their agencies, many older scientists at the NIH, FDA, and Centers for Disease Control and Prevention are considering retirement, said a senior NIH scientist who spoke on the condition of anonymity for fear of losing his job.

"Everybody I talk to sort of takes a deep breath and says, 'It doesn't look good,'" the official said.

"I hear of many people getting CVs ready," said Arthur Caplan, a professor of bioethics at New York University. They include two of his former students who now work at the FDA, Caplan said.

Others, such as Georges Benjamin, executive director of the American Public Health Association, have voiced wait-and-see attitudes. "We worked with the Trump administration last time. There were times things worked reasonably well," he said, "and times when things were chaotic, particularly during covid." Any wholesale deregulation efforts in public health would be politically risky for Trump, he said, because when administrations "screw things up, people get sick and die."

At the FDA, at least, "it's very hard to make seismic changes," former FDA chief counsel Dan Troy said.

But the administration could score easy libertarian-tinged wins by, for example, telling its new FDA chief to reverse the agency's refusal to approve the psychedelic drug MDMA from the company Lykos. Access to psychedelics to treat post-traumatic stress disorder has grabbed the interest of many veterans. Vitamins and supplements, already only lightly regulated, will probably get even more of a free pass from the next Trump FDA.

'Medical Freedom' or 'Nanny State'

Trump's health influencers are not monolithic. Analysts see potential clashes among Kennedy, Musk, and more traditional GOP voices. Casey Means, a "holistic" MD at the center of Kennedy's "Make America Healthy Again" team, calls for the government to cut ties with industry and remove sugar, processed food, and toxic substances from American diets. Republicans lampooned such policies as exemplifying a "nanny state" when Mike Bloomberg promoted them as mayor of New York City.

Both the libertarian and "medical freedom" wings oppose aspects of regulation, but Silicon Valley biotech supporters of Trump, like Samuel Hammond of the Foundation for American Innovation, have pressed the agency to speed drug and device approvals, while Kennedy's team says the FDA and other agencies have been "captured" by industry, resulting in dangerous and unnecessary drugs, vaccines, and devices on the market.

Kennedy and Casey Means want to end industry user fees that pay for drug and device rules and support nearly half the FDA's $7.2 billion budget. It's unclear whether Congress would make up the shortfall at a time when Trump and Musk have vowed to slash government programs. User fees are set by laws Congress passes every five years, most recently in 2022.

The industry supports the user-fee system, which bolsters FDA staffing and speeds product approvals. Writing new rules "requires an enormous amount of time, effort, energy, and collaboration" by FDA staff, Troy said. Policy changes made through informal "guidance" alone are not binding, he added.

Kennedy and the Means siblings have suggested overhauling agricultural policies so that they incentivize the cultivation of organic vegetables instead of industrial corn and soy, but "I don't think they'll be very influential in that area," Caplan said. "Big Ag is a powerful entrenched industry, and they aren't interested in changing."

"There's a fine line between the libertarian impulse of the 'medical freedom' types and advocating a reformation of American bodies, which is definitely 'nanny state' territory," said historian Robert Johnston of the University of Illinois-Chicago.

Specific federal agencies are likely to face major changes. Republicans want to trim the NIH's 27 research institutes and centers to 15, slashing Anthony Fauci's legacy by splitting the National Institute of Allergy and Infectious Diseases, which he led for 38 years, into two or three pieces.

Numerous past attempts to slim down the NIH have failed in the face of campaigns by patients, researchers, and doctors. GOP lawmakers have advocated substantial cuts to the CDC budget in recent years, including an end to funding gun violence, climate change, and health equity research. If carried out, Project 2025, a policy blueprint from the conservative Heritage Foundation, would divide the agency into data-collecting and health-promoting arms. The CDC has limited clout in Washington, although former CDC directors and public health officials are defending its value.

"It would be surprising if CDC wasn't on the radar" for potential change, said Anne Schuchat, a former principal deputy director of the agency, who retired in 2021.

The CDC's workforce is "very employable" and might start to look for other work if "their area of focus is going to be either cut or changed," she said.

Kennedy's attacks on HHS and its agencies as corrupted tools of the drug industry, and his demands that the FDA allow access to scientifically controversial drugs, are closely reminiscent of the 1970s campaign by conservative champions of Laetrile, a dangerous and ineffective apricot-pit derivative touted as a cancer treatment. Just as Kennedy championed off-patent drugs like ivermectin and hydroxychloroquine to treat covid, Laetrile's defenders claimed that the FDA and a profit-seeking industry were conspiring to suppress a cheaper alternative.

The public and industry have often been skeptical of health regulatory agencies over the decades, Grossman said. The agencies succeed best when they are called in to fix things — particularly after bad medicine kills or damages children, he said.

The 1902 Biologics Control Act, which created the NIH's forerunner, was enacted in response to smallpox vaccine contamination that killed at least nine children in Camden, New Jersey. Child poisonings linked to the antifreeze solvent for a sulfa drug prompted the modern FDA's creation in 1938. The agency, in 1962, acquired the power to demand evidence of safety and efficacy before the marketing of drugs after the thalidomide disaster, in which children of pregnant women taking the anti-nausea drug were born with terribly malformed limbs.

If vaccination rates plummet and measles and whooping cough outbreaks proliferate, babies could die or suffer brain damage. "It won't be harmless for the administration to broadly attack public health," said Alfredo Morabia, a professor of epidemiology at Columbia University and the editor-in-chief of the American Journal of Public Health. "It would be like taking away your house insurance."

Sam Whitehead, Stephanie Armour, David Hilzenrath, and Darius Tahir contributed to this report.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

Arthur Allen: aallen@kff.org, @ArthurAllen202