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Hello and welcome to Healthbeat’s weekly report on stories shaping public health in the United States.
I am Dr. Jay K. Varma, a physician, epidemiologist, and public health expert currently serving as chief medical officer at Fedcap, a national nonprofit focused on economic mobility and well-being for vulnerable communities. Views expressed here are my own.
In this week’s issue, the federal government is finding new ways to cut the programs that keep the sickest and poorest Americans alive, while a celebrated cancer screening test marketed to healthiest and wealthiest just failed its first big trial.
Medicaid under attack
As part of the most recent budget bill passed by Congress (“The One Big Beautiful Bill”), Congress made large cuts to Medicaid, the federal government’s health insurance program for low-income people. Public health experts decried these cuts, because people on Medicaid are also the most likely to have health conditions that require intensive medical care and cause the most overall illness and death without treatment, such as diabetes, coronary artery disease, and HIV.
Unfortunately, the latest news is that federal officials are targeting another way to cut Medicaid: suspending payments to some states over allegations of fraud.
In Minnesota, the Trump administration froze $259 million in Medicaid payments, citing previous instances of fraud in social services programs. To be clear, hundreds of millions of dollars were stolen through state social service programs, and dozens have been convicted. But the recent Medicaid suspension appears intended not to punish those who committed fraud, but to withhold essential medical services to “turn the screws on [Minnesota] a little bit,” according to Vice President JD Vance. The state’s attorney general, Keith Ellison, has sued to restore the funds, calling the freeze “weaponized Medicaid against Minnesota as political punishment,” and Gov. Tim Walz has called it “targeted retribution.”
New York is next up. Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz sent New York Gov. Kathy Hochul a letter demanding information within 30 days or risk deferred payments, citing what he called a “high proportion” of beneficiaries receiving personal care services like bathing, grooming, and meal preparation. New York’s Medicaid program is the most expensive per-enrollee in the country, at $115.6 billion in fiscal year 2025, covering roughly 1 in 3 New Yorkers.
What Oz’s letter omits is that the underlying Medicaid data can be challenging to analyze accurately: It excludes hospital spending, lacks procedure and diagnosis codes, and a single personal care billing code can represent anywhere from 15 minutes to a full day of care.
Government officials must be rigorous stewards of the public’s money. That was one of the first lessons my supervisors taught me when I began working for the Centers for Disease Control and Prevention in 2001. At the same time, I worry that the suspension of Medicaid payments are guided by political animus, rather than fiscal responsibility, and do not consider the immense potential consequences to Americans that depend on Medicaid.
Fraud exists in all sectors, public and private, and public programs must always balance their legitimate interest in minimizing fraud against the real and immediate harms of suspending funding. When it comes to programs that people’s lives literally depend on, such as Medicaid, I believe that the bar for a complete suspension should be extremely high — the evidence incontrovertible, the scope vast — and funding should continue until an investigation clears that bar.
Cutting HIV and other safety net clinical services
The cuts to publicly funded health services, unfortunately, are not just to the larger Medicaid program. A separate federal government program provides HIV care and treatment funding for people who are not covered by other public or private insurance programs. The Ryan White HIV/AIDS Program is the payer of last resort for about 25% of the 1.2 million Americans living with HIV. The Ryan White program covers medications, laboratory monitoring, and related services for people who fall through the gaps of Medicaid and private insurance.
About 18 states have tightened eligibility or cut covered HIV medications under the Ryan White-funded AIDS Drug Assistance Program, with five more considering changes. The starkest example is Florida, home to the largest ADAP in the country. On March 1, Florida cut off more than 16,000 clients, roughly half its caseload, by dropping the income eligibility threshold from 400% of the federal poverty level ($63,840) to 130% ($20,748), and removing Biktarvy, the most prescribed HIV medication in the country, from its formulary.
With HIV, the harms are particularly worrisome. Effective antiretroviral therapy suppresses the virus to undetectable levels, keeping patients healthy and, crucially, making them unable to transmit the virus to others. Interrupting treatment also risks drug resistance that can itself be transmitted. If HIV treatment disruptions push the United States back toward 2018 infection rates, this will mean an estimated 4,500 additional HIV infections and $3.8 billion in lifetime costs.
We are also seeing cuts in other public safety net health care services. Counties and municipalities across the country, such as Los Angeles, are cutting clinical programs from immunizations to sexual health to behavioral health, as federal funding reductions ripple down to local budgets.
When I began leading infectious disease programs for New York City in 2011, we had to drastically cut back our clinic hours and services because of the Great Recession. We hoped that patients would continue to be able to receive some of these services at other facilities — such as federally qualified health centers and the public hospital system — but we also understood there’s a reason it is called a safety net and not a safety blanket: The net has holes that people fall through.
The other long-term consequence of public health agencies cutting their clinics is that they lose a direct connection to the community. It is difficult for people to advocate for public health when most of the work of public health is not visible to them. Clinics are a tangible way for them to see what public health agencies do for them, ensuring that they are more likely to trust public health officials during emergencies, and providing a constituency that will oppose budget cuts in the future.
Update on blood tests for cancer detection
In a previous newsletter, I discussed how companies were marketing blood-based multi-cancer detection tests to consumers who are eager for any way to find cancer early. The results are now in from a large, rigorous clinical trial of the best-known of these tests, called Galleri, developed by a company called Grail. The Galleri test looks for tiny fragments of tumor-associated DNA in the blood and screens for more than 50 types of cancer. The test has been sold in the United States since 2021 for $949, without Food and Drug Administration approval, under a regulatory framework that permits certain laboratory-developed tests to be marketed without prior review.
The company ran a trial in partnership with the UK’s National Health Service on 142,000 healthy adults aged 50 to 77. It was exactly the kind of rigorous, large-scale prospective study that the field needs. The hope was to show a 20% reduction in advanced cancer diagnoses among people who received the test. The study failed to meet that primary endpoint. There was no statistically significant reduction in Stage 3 or Stage 4 cancers in the group that received Galleri testing compared to the control group.
Most experts interpreted this study to mean that the Grail test should not be funded as part of routine cancer screening for adults in either the UK or the United States. That said, I believe there may be benefit to this and similar tests in selected populations, such as those already at higher risk of cancer due to family history or known genetic abnormalities.
The broader lesson here is how we, as a society, decide what to invest in. The evidence is clear that screening for cancer in adults using a blood-based test does not work. The evidence is also clear that cutting Medicaid and HIV services will lead to more sickness and death. How we get policy and practice to align with evidence is the most difficult challenge in public health.
Until next week,
Jay
Dr. Jay K. Varma, who is recognized globally for his leadership in the prevention and control of infectious disease, writes about public health for Healthbeat. He has guided epidemic responses, developed policies, and implemented programs that have saved lives across Asia, Africa, and the United States. He is based in New York. Contact Jay at jvarma@healthbeat.org.
