Veep Was a Documentary

Veep was a documentary (except for the part where a woman could be president), and it’s Jonah Ryans all the way down. Needless to say, the later Jonah Ryan, when he goes anti-vax, spreads chickenpox, and attacks immigrants.

While this despair applies broadly to the Trump Cabinet picks in public health and beyond, right now I’m talking specifically about the selection of Mehmet Oz to lead the Centers for Medicare and Medicaid Services, which provides health coverage to over 160 million Americans.

Yes, that Oz. The noted disseminator of pseudoscience including alternative therapies (buy this unregulated over-the-counter supplement with coffee bean extract if you want to magically lose weight!) and miracles in healing. Who needs modern medicine? The Oz who led then-Senator Claire McCaskill to say in a 2014 committee hearing, “I don’t know why you need to say this stuff, because you know it’s not true. Why—when you have this amazing megaphone and this amazing ability to communicate—would you cheapen your show by saying things like that?”

The Oz who has platformed people who believe they talk with spirits.

The Oz who claimed that he “misspoke” when advocating for schools’ reopening in 2020 amid the COVID-19 pandemic.

The Oz who claimed that abortion is murder at any stage because life begins at conception.

The Oz who claimed that having 200 orgasms a year makes you live six years longer. Sounds fun, but I’m skeptical about its validity. Might want to do more investigation into the mechanism. For science.

The Oz who in 2015 incited from ten prominent physicians at Columbia University a letter characterizing his continued employment there as unacceptable, citing his “egregious lack of integrity.”

The Oz who in 2014 said that uninsured Americans “have no right to health.”

The Oz who ran unsuccessfully for the United States Senate in 2022 when living not in Pennsylvania, but rather New Jersey, and who in doing so mocked now Sen. John Fetterman’s disability. (Now, do we know of a president who would relate to the mocking of a disability?)

The natural fit for running the Centers for Medicare and Medicaid Services, right?

I’ll be honest with you, dear readers, this one wasn’t on my radar. RFK Jr. and Joe Ladapo have been on my radar, but outside of the parallels in carpetbagging Republican Senate candidates in 2022 and 2024 in Pennsylvania, I’d forgotten about (or perhaps blocked) Oz.

In a way, it makes perfect sense that the person who tries to sell Trump Bibles and Trump coins would gravitate toward the person who sells fake supplements. That someone who prioritizes image over governance would gravitate toward someone who prioritizes entertainment over sound science and medical ethics. And remember: For all of Republicans’ denigration of the liberal elite, Donald Trump loves people who have the flashy pedigrees of the Ivy League (even those who have been ostracized from their Ivy League colleagues).

Now, what does this mean for Medicare, Medicaid, and the Affordable Care Act?

Let’s start with Medicare. Not too surprisingly, Oz is a fan of and thus would accelerate the already growing reliance on Medicare Advantage (that is, the privatized Medicare Part C, which was created through the Balanced Budget Act of 1997). This functions as supplemental insurance for the Medicare population, which can have more expansive benefits. You’ve probably seen ads for such plans: An older couple is sitting at the table and looking at various medical bills, and one of them expresses surprise that Medicare didn’t cover anything, and the other suggests that they get Medicare Advantage through Humana or UnitedHealthcare, what have you. Sounds great, right?

On the one hand, having the more expansive benefits is a good thing. But as with most of American health insurance, there’s a catch (well, actually, a few catches). Let’s start with administrative burden. Unlike Medicare, which has extremely limited reliance on prior authorization (that is, pre-approval for more expensive medical care), 99% of Medicare Advantage enrollees are in a plan that uses prior authorization. This is because by definition, Medicare Advantage is operated through private insurance companies which are conscious of needs for profitable growth and thus exercise utilization management tools toward cost containment. Prior authorization serves a couple of core, related functions: guard against runaway health care costs, and protect patients from overtesting and overtreatment (that is, prescribed care that is not viewed as medically necessary). Imposing guardrails may have utility, but challenges arise when prior authorization becomes a vehicle for coverage denials, since what next unfolds is a morass of administrative burden imposed on an older population, which tends to have lower health literacy on which to draw in navigating the complexities of the American health insurance system.

There has also been research on the quality of care in Medicare Advantage, and the results are mixed. On the one hand, we see that Medicare Advantage enrollees use more preventive services and experience fewer hospital admissions. Good news! However, there are equity considerations: the Kaiser Family Foundation finds that Black and Hispanic patients are more likely to be in lower-quality plans, and there are pronounced racial disparities in health outcomes (whether preventive services, hospitalizations, mental health, etc.) among Medicare Advantage enrollees.

So, the acceleration of reliance on Medicare Advantage comes with a price: it exacerbates administrative burden, which is distributed unevenly across the population, on top of deepening existing inequities in health care access.

Now, let’s talk Medicaid. Oz hasn’t spoken much directly on this subject, but one thing that we know – a tale as old as time – is that Republicans will be eying Medicaid cuts to offset the cost of tax breaks for the wealthy. Starving the beast. And alongside this, we are likely to see the reintroduction of Medicaid work requirements – that is, the requirement that in order to stay on Medicaid insurance, one must work a certain number of hours per month (e.g., 80 hours) or else have an approved exception (e.g., being a student or very sick). The problem here comes back to administrative burden (a theme!): it isn’t enough for people to simply work those hours. Rather, they must report those hours, which in the case of the implemented work requirements in Arkansas proved difficult for many people (many were not even made aware of the policy change), such that many people who were technically compliant with the policy nevertheless were dropped from their insurance. This is all to say that Medicaid work requirements don’t have the effect of increasing employment (ostensibly its goal), but they do have the effect of imposing cumbersome administrative burdens that many people (especially from marginalized groups such as the Medicaid population) struggle to overcome.

Surely Oz will be responsive to this empirical evidence, right? Right??? (We laugh to keep from crying.)

As for the Affordable Care Act… Well, he’s flip-flopped, and not in the correct direction. (Remember when “I was for it before I was against it” could kill a political career? Such quaint times.) Oz initially said that he supported the Affordable Care Act, which brought the uninsured rate to a historic low and has helped millions of people have access to preventive and life-saving medical treatments. When he ran for Senate in 2022, his tone changed, and he said he opposed the ACA, through which 871,000 Pennsylvanians received Medicaid thanks to expansion. And joining the Trump Administration, it’s safe to say that this opposition will stick.

Now, what does that mean practically speaking? In 2017, despite unified control of government, Republicans broadcast their failure (after 8 years) to cobble together a viable replacement plan, and the American Health Care Act (which had Quinnipiac poll favorables that, if Rotten Tomatoes scores, would have been toward the bottom among Rob Schneider movies) failed narrowly thanks to a late-night thumbs-down vote by the late Sen. John McCain.

Will that be the end of the repeal effort? It’s hard to say. On the one hand, the AHCA was foiled by a single senator who is no longer alive, who belonged to a coalition of Republicans that no longer exists in Congress. There are no more McCains, or Flakes, or Hellers. On the other hand, the ACA is substantially more popular now than it was in 2017 (when people still raised hell in its defense). In March 2017, 49% of Americans viewed the ACA favorably. In April 2024, that number was 62%. So, that creates different challenges for Republicans in office. Not only is it more difficult to take away a benefit to which people have become accustomed (and people definitely like having their preexisting medical conditions covered), but majorities across parties believe in the importance of the guaranteed issue provision. Indeed, the Kaiser Family Foundation found in February 2024 that 79% of Democrats, 66% of Independents, and 54% of Republicans want to keep this core part of the ACA in place. The numbers are slightly lower when it comes to prohibiting insurers from charging sick people more (“high risk pools”) but it’s still the case that over half of Republicans want to preserve the status quo. While it wouldn’t be the first time that politicians would pursue an unpopular policy (consider, for example that 6 in 10 Americans would like stricter gun laws), pursuing ACA repeal (as Trump has suggested he would like to do) is both bad policy and bad politics. It’s bad policy because it keeps people from getting needed health coverage and, in turn, care, resulting in a sicker population and more uncompensated care that some health care providers can’t afford to take on. It’s bad politics because, to draw on the work of David Mayhew, members of Congress are single-minded seekers of re-election. And while voters do have a habit of misinterpreting economic indicators and misattributing blame for them, they’ll know who is responsible for rescission of health coverage, especially when it’s unified government and there’s no one else to point fingers at.

This is all to say, I’m not placing any monetary bets on the future of the ACA, but I won’t be surprised if, like in 2017, incompetence outshines the malevolence of whatever they pursue. To be clear, this is not the only way that the Trump Administration can address the ACA. They can also undercut it, such as by reducing outreach and opportunities for enrollment through ACA exchanges, discouraging legal immigrants from enrolling in Medicaid, and facilitating cheaper, lower-quality plan options. This sabotage (or efforts toward it) will be harmful for people who rely on this vital health insurance program, and there’s little way around that.

Lastly, a reminder that the Centers for Medicare and Medicaid Services is responsible for the implementation of EMTALA, or the Emergency Medical Treatment & Labor Act. This is a key piece of legislation initially aimed at addressing patient dumping by ensuring that regardless of income or insurance status, those going into an emergency department are entitled to stabilizing treatment before discharge. It has also become newly salient in the context of post-Dobbs v. Jackson abortion strictions in which there are state exceptions to preserve the health or life of the woman. Such provisions are written rather vaguely and raise concerns among medical professionals as to the legal liability that they take on when, for example, treating a person with an ectopic pregnancy. This has led to lawsuits by a group of women in Texas whose lives were in grave danger due to the highly restrictive nature of the law, and resulted in the death of Amber Thurman in Georgia, who developed septic shock amid the delay in being able to obtain a D&C procedure.

Oz has said that he is pro-life, that abortion is murder at any stage, and that life begins at conception. So, how would an Oz-administered CMS implementation of EMTALA in states with restrictive abortion laws? Will physicians be able to treat their patients using their best medical judgment, or will they have to be on the brink of death before medical intervention will be permissible, as was the case for Amanda Zurawski in Texas? These are questions to which we don’t yet have answers, though we can certainly speculate.

And on a non-policy note, there is the further question: What, if any, are Mehmet Oz’s credentials to run a massive technocratic bureaucracy such as CMS, which is comprised of approximately 6,400 employees? As someone whose career has been in medicine and television and emphatically not in administration or policy implementation, running a government agency is, shall we say, not likely to be in his wheelhouse. Cynically, that may be a good thing if his worst impulses are tempered by his incompetence.

While the embrace of pseudoscience in the highest levels of our public health bureaucracy is not surprising coming from Donald Trump, it is certainly galling. Trump and Oz both enjoy the entertainment world, but unlike television, health care is serious business that has life-or-death consequences. And it is frustrating to see this likely incompetence given that CMS Administrators can do such good. Just last week, the Biden Administration’s CMS announced the approval of five new section 1115 demonstration amendments that will promote continuous eligibility for children and for those leaving incarceration. People should join the public health bureaucracy because they want to expand health care access, but that’s unlikely to be the goal over the next few years. Oz himself wrote that “we should be on the cusp of a golden age in health care delivery,” but pseudoscientific grifting isn’t the path to better pastures.

I have no illusions that Oz will be confirmed by this Senate. There are only so many nominees over whom Republicans will be willing to break from party ranks, and Matt Gaetz is a pretty natural target for opposition (I’ll leave you to Google why). But Senate Democrats should use their time in the confirmation proceedings to push back on the patterns of anti-scientific rhetoric and policy that we’re seeing Trump embrace with open arms, and to impress upon him the damage that is done when administrative burdens are placed in the way of accessing health care.