Bulwark Takes - Will RFK Jr's Make America Healthy Again Get People Killed?

Episode Date: March 31, 2025

Explore the Trump administration's controversial changes at Health and Human Services (HHS), including major job cuts, the reorganization under Robert F. Kennedy Jr., and their impacts on public health, opioid crisis response, and vaccine policy. When ‘Make America Healthy Again’ Actually Means the Opposite https://www.thebulwark.com/p/when-make-america-healthy-again-actually-means-opposite-rfk-trump-opioid-overdose-hhs-samhsa-painful

Hey guys, it's me, Sam Stein, Managing Editor at The Bulwark, and I'm joined by Jonathan Cohn, who is now a member of the fam, officially, since he put out his first newsletter, The Breakdown, came out on Sunday. If you haven't seen it, you should subscribe. The piece is great. I encourage people to read it. It's titled When Make America Healthy Again Actually Means the Opposite. And you and I were talking about through the course of the week about why we wanted to do this piece, but I thought you captured the essence of it, which is the opioid epidemic, which fueled so much of Trump's rise. It was such a huge focus for him and to a degree, a success of his first administration. What we've seen so far in the first two months is scaling back of our investments in fighting it. Can you talk a little bit about

both the micro elements here, what we're doing that's scaling back, and sort of the macro elements, what this symbolizes more broadly about the Trump agenda? So, I mean, the micro elements are, you know, are part of the larger sort of project that the Trump administration is undertaking at HHS, specifically Department of Health and Human Services, but which is, and we'll get to the Secretary Robert Kennedy in a second, but, you know, at the Department of Health and Human Services and throughout the federal government, which is, you know, these broad sweeping job cuts, which started in February, you may remember, where they just got all the

probationary employees. And now they're kind of going through a second round of sort of more serious cuts. The rifts, the reduction in forces cuts. Reduction in forces. And then at HHS specifically last week, Secretary Robert F. Kennedy Jr. announced a major overhaul of the entire department, which will include not just significant job cuts. I mean, the idea is to basically reduce the agency, HHS as a whole, from 80,000 employees to 60,000 employees. That's a 25% cut. But in addition to that, they're reorganizing things, and they're taking a bunch of the smaller agencies inside it and sort of consolidating them and putting them into one agency. Let's pause for a second on that. Why do that? I mean, 20,000 cuts is a lot. Now, I know, obviously, prior administrations have looked for efficiencies.

They've tried to do consolidation. Certainly, in a sprawling bureaucracy like HHS, there's overlap, there's ways to do this, but that seems like cutting off a lot in hopes of gaining efficiency. Yeah. I mean, look, nobody would, you know, if, if, if the idea was to come in here and say, look where, you know, you look at the org chart for HHS. It's insane. There's a million sub-agencies. And actually, Kennedy, he gave a video speech where he was explaining what they were doing. And he made that point that the sort of attitude is whenever we want to solve a new problem, we add a new agency.

And then you blink, and now you've got all these bazillion agencies. I mean, there's absolutely a rationale for trying to, like, rationalize it. It might very well involve reducing staff. It might not, you know, and we can talk about that in a minute. Like, you know, sometimes if you want to be more efficient, you actually need more people, not fewer people. But, you know, they're not, this is not what is happening here. This is not some thoughtful exercise in, well, how do we sort of, you know, cleanly sort of combine like purposes? I mean, sometimes, you know, just to take one example, um, you know, you, you hear sort of consolidation, you think, well, maybe they can combine human resources, for example, right? Does everybody, you know, and, and, and maybe you can, and, you know, to some extent that's already true at HHS. But sure. On the other hand, if you think about it, the person you're hiring to, say, work at the CDC, that's a pretty different skill set than someone who's going to oversee Head Start, which is also very… Yes, they're totally different skills, and you wouldn't want someone to handle that.

You have economists, you have a whole NIH. I look at it the other way though. It's like how much is healthcare in terms of our GDP? What is it? Like one-sixth? It's getting close to 20%. I forget where it landed last time. Almost a fifth of ours.

Between a sixth and a fifth of our economy. Okay. So the amount of government resources you want should be corresponding to the size of the economy that it touches. And that's almost 20, you know, if you're talking about 20%, it doesn't strike me as crazy to put that many bureaucrats in charge of administering health care. Now, obviously, you want efficiency and so on and so forth. But let's talk about the opioid epidemic as a microcosm of what's happening here, because among the consolidations is SAMHSA, which is the Substance Abuse and Mental Health Services Agency. It's basically,

you know, tasked with trying to help manage that epidemic. Tell us a little bit about the history of the agency, what it does, and I guess more to the point, what its recent successes have been. Yeah, yeah. So, I mean, it's not that old. It came into existence in the early 1990s. And it's got both mental health and substance abuse in the name. And it has a fairly broad portfolio that deals with both of those. It really kind of about 10 years ago, as the opioid epidemic really started to get worse in this country, they got a lot of attention in Washington. This is sort of the late Obama era. There was a real sense that the federal government

needs to sort of step in and do more here. And there's a whole variety of things. We need to, first of all, we need to figure out what do we do to help people who are dealing with opioid addiction? What kind of programs? Do we need prevention? Do we need treatment?

Do we need recovery? Do we need harm reduction? And, you know, and the answer, you know, from most of the people who study this is all. You need all of it. Yeah, all of it. And so SAMHSA is now, you know, they, you know, through a series of laws, starting with something that was signed at the end of the Obama presidency in 2016, put a lot of federal money behind these efforts and then, you know, gave SAMHSA most of the responsibility for administering them. So SAMHSA is there, right? I mean, it's in charge of giving grants out to the states. States come, you know, and they say, we're going to spend this money, you know, on these

programs. SAMHSA administers it, but also watches to make sure there's sort of these programs are sort of working and doing best practices. There's no waste and fraud. Another really important function of SAMHSA is it conducts the national, I'm going to get the name wrong, but there's a national survey. We'll edit it out. Don't worry. There's another really important function for SAMHSA is it is in charge of the gold standard national survey of drug abuse in this country. And that is incredibly important for crafting policy, right? Because, you know,

you want to know what kinds of drugs are people using, where, who's using them. Right. If you're fighting an epidemic, you need to know the stats behind the epidemic you're fighting, right? Basic one-on-one, right? The basic, you know, information is the basic foundation of your strategy. So they do that. They do a lot more also, you know, they, they, they do things like they provide training for, for, for workers. They maintain these regional offices to really. So what are the, what are the consolidations that are happening now? So it's, you know, it's hard to know, and this is, you know, Sam, you know, this from trying to report this, one of the crazy things about what's going on in the Trump administration,

it's not like they really tell you what they're doing. You have to piece it together. And in fact, they don't tell the people they are employing what they're doing. I talked to a number of HHS folks who were like, first I heard about this was through press reports. They just did not communicate to the staff. Anyways, yeah. So we don't really know is the end of it. We don't know. And I'll mention we're recording this at 1030 to the staff. Anyways, yeah, so we don't really know is the end of it. We don't know.

And I'll mention, we're recording this at 10.30 in the morning. I will say that the last I heard, you know, Kennedy announced this reorganization, including, you know, 10,000 new job cuts on, what was it, Thursday or Wednesday. As of this morning, the HHS people I knew had not yet heard who was getting fired. They were still waiting.

Like there was no notice, not even like. The first press story was Thursday morning. Yeah. People were waiting for guidance. And I guess they've had to wait through the weekend to know if they're going to be fired or not. Yeah. They're going to have their jobs. They're going to have a job.

So, I mean, there's the job cuts in general. But in addition, they are, again, you know, sort of slimming down some of the agencies and consolidating some of them. They're also closing about half of these regional offices. And, you know, the argument, you know, they haven't said much, right? I mean, there was this video from Kennedy, there was like a statement put out at one point, like a one page fact sheet. And, you know, it just said, look, this will make operations more efficient. Kennedy had this line, we're going to do more with less, you know, which, again, you know, sure. Okay, how, you know, are you know, and they haven't specified exactly what's going to get cut, but you can kind of get a sense that, like, you know, again again there's a version of reorganizing hhs and reorganizing

samsa that probably makes sense but number one it's certainly not this dramatic and number two you'd want to know that was being done carefully and the best proof that it's not being done carefully is to look what they already did in that sort of first round of firings when they did the probationary uh right um they basically de facto like just shut down two of the regional offices because there was no one left in them at that point. What happens when a regional office is shut down? So the regional offices, they're not that big. So these are part of the HHS has regional divisions. So this is sort of the SAMHSA division within the regional office. And it's a handful of employees. It's not a lot of people, but over the course of the year, they visit communities constantly to sort of, you know,

in a kind of sort of circular conversation that is going on between SAMHSA, the agency that's providing this money and the people on the ground, the people who are using it to provide services. And there's this, you know, back and forth, you know, what are you seeing on the ground? Tell us so we know how to sort of better allocate money going forward. And the people on the ground are like, you tell us, what do you want to see? What are you, you're, you know, we're, I'm a, I'm, I'm, I'm the state, you know, I'm, I live in Michigan, right? So I have the state mental health department here. I don't have probably the resources at the time to be keeping up with the latest research, the latest scientific research. So I need that from the national office. So, but, you know, I can read that on a website if they summarize it, but it's a big difference if the

regional guy comes to me and we can talk about it and they say, see, you're doing it this way. You're really want to do it this way. Or Jonathan, just, just replace it with some AI bot. Yeah, that's fine. That's what happens. It's bad. I understand why. But it fits with the pattern of you don't fund these surveys. You don't get information. You don't have regional offices. You don't get information. It's sort of depriving them of on-the-ground information as they go about trying to do this. Let's put it in the macro, which is that we've made some progress on the opioid fight.

And it's kind of been remarkable because it was this really glaring, horrible issue that was hitting the country. We know this because it was really a lot of what politics was focused on, frankly, during the early Trump years. I remember being in Manchester, New Hampshire, just decimated by the opioid epidemic. And this was what Trump was focusing on when he was running the primaries there. Are we risking that progress now? And if so, why? The background here, right, is that about two years ago, things started to turn around. And in the last year, things seem to be really like the number of overdose deaths are plummeting. What do people attribute to, why do we have a turnaround? What is the common theory here? So, I mean, we can't be sure yet. And, you know, that's the nature of public

health. This is happening now in real time. And if you talk to the sort of people studying this, the first thing they'll tell you is we're not sure. And it's probably a bunch of different things. And you can tick off the factors, you know, and it's everything from the fact that, the purity of the fentanyl available on the street has changed. There's been, you know, there's the morbid explanation. There's a really morbid explanation, which is that if you think about deaths of despair, that basically this is sort of burning itself out as the people most susceptible to the level of, you know, overdosing and dying, die off. And that's, you know, that's a real possibility. So, I mean, you have that kind of

group of factors there. And, you know, they'll be studying this in 10 years from now, you know, that's a real possibility. So, I mean, you have that kind of group of factors there. And, you know, they'll be studying this in 10 years from now. You know, we'll have a more definitive look at that, hopefully. But everybody who looks at this, I think most everybody, I don't want to say everybody, but certainly everyone I talk to says, look, you can't, you know, the fact that the federal government has really ramped up all this support and really kind of provided all this extra money. A lot of, you know, even just making sure that, you know, Narcan gets to everybody. The medicine given to people who've OD'd. Yeah. If you get an OD, it keeps you alive, you know, and you can get, you know, the emergency care you need then, which is a game changer, right, for this. And getting that out to everybody, and not just getting it out there, but, you know, getting the awareness out there so people know it's out there, you know, the first responders and all of that. And that has probably made a

big difference. And, you know, a lot of that is SAMHSA and a lot of that is their guiding this and they're, you know, sort of driving this process. And again, let's be clear, are they perfect? You know, could they do a better job at some things? I'm sure they could. You know, if someone wants to sort of do a sort of careful study of that and then come out with some changes, great. That's clearly not what's going on here. And that's the danger. You cut all these people.

You cut the regional offices. You cut the data. It's just going to be harder to do that. You were joking before, like, well, an AI bot could do that. I actually think that's what they think. I mean, I'm not kidding. I was not joking. I actually think that's what they think. I think they'll get enough. They probably believe they can get enough data inputs and put into some AI bot and it will tell them with some precision

these therapeutic methods work better than others. These interventions work better than others. We can cut some SAMHSA offices because if we're just getting data inputs anyway, why do you need people to actually go out into the field? It's all data driven. And look, there might be, I'm not going to, there might be something to that. I don't want to discount that. Like it's possible we live in a reality where that is, you know, an achievable way to run this. But it's a, it's a gamble. It's a real gamble and you're risking real progress. Uh, and I'm surprised, I suppose, because, um, as a strictly

political matter, this has been something that Trump has been so passionate about and so focused on hyper-focused on and Kennedy too, uh, who has been open about his own struggles with addiction, um, for him to do this, it seems, I don't know. I have trouble figuring out what the explanation is for this. Yeah. You know, one interesting thing I do think is worth noting. I went back and read some of Trump's rhetoric from his first term when he was talking about this. He gave this speech, and I talked about this in the article, 2017 at the White House.

And it was a very moving speech, you know, certainly by his standards. And it really, if you read the speech and you watch it, it's what you would expect a president to say. I had a lot of empathy for it, which, you know, let's face it, with Trump is not a thing you get with him from, you know. It's very rare. So, yeah. Very rare. But there was, you know, and, you know, he talked about his, you know, his brother had alcohol problems and he talked about being connected to that. And, you know, who knows how, you know, I'm not going to speculate on how much this was heartfelt and how much was this, you know, political or whatever.

But it sent the message that, you know, we realize that this is a human tragedy and that people need help. Whatever else we're doing to the supply of drugs and law enforcement, we need to be focusing on helping these people. And if you listen to the rhetoric now, he still talks about fentanyl all the time, but now it's always a hundred percent. It's like foreign menace. We need to close the border. We need to get tough with our allies about cutting down on the fentanyl trade. You can make the same point about criminal justice reform, right? Like the first administration was first step back. That was like,

they're big. We've done the first step back. We're going to have people reintegrate into society. We're going to get people second chances. Now it's all just throw them out, throw them out of the country. It's a totally different approach. It's kind of interesting to see how they've just gone completely away from

that. I don't know if I want to call it moderate, but it was definitely a more empathetic approach. It was like his version of compassionate conservative. Yeah, it was in a way. All right, last thoughts on RFK specifically. He's been at the helm for a couple of weeks now. I saw the journal, you know, wrote an op-ed,

or I should say an editorial, saying our worst fears have been realized. I know that's mostly on the vaccine stuff and measles, which remains a big problem in West Texas. What's your impression about what he's been up to and sort of why he's doing this reorganization and how he's conducted himself in this post? Yeah, Yeah. So, I mean, it's a little hard to know with the reorganization part, what's him and what's Doge and what's coming from the White House. I mean, there's, you know, I think we, I try to always keep in mind with this administration in particular, there's usually layered agendas, right? You know, things going

on at the same time. I think his agenda very clearly is what we thought it was going to be. I mean, there's no surprise here. I mean, he's an anti-vax guy. And you look, I mean, this is not a secret. I mean, the only person who seems to have sort of, you know, believed he changed his stripes was Senator John, Bill Cassidy, you know, who, you know, made that big speech. Well, you know, because you remember in the confirmation hearings, he was all about, oh, you know, he really gave Kennedy a hard time about the vaccine stuff. For, you know, listeners, if you don't know, Cassidy is a physician and a serious guy on these issues, by the way, on health issues. He really does take them seriously. And then he voted for Kennedy. And he said, well, we had these long talks and he assured me and I'm going to be, you know, I'm going to be in on all these major decisions on vaccines. And instead, you know, there's just this long list of actions he's taken, the most recent of which was the one over the weekend, where it came out that he pushed out from HHS, from FDA,

a guy named Peter Marks, really kind of senior, internationally known figure on vaccine safety and drug safety. Played a very big role in Operation Warp Speed, which may have contributed to his downfall with Kennedy. Right? Yeah. And, you know, we can talk about that more some other time. But, I mean, you just sort of look at these and you add them up. And, you know, in 10 different ways, he is just reorienting our public health infrastructure away from vaccines.

I mean, it's clear as day. There's no mystery here. There's no hidden agenda. There's no dog whistling even. I mean, it's right out there. It's actually pretty much Occam's razor, honestly. It's like this is who he is and he's doing what he wants to do. And anyone who

thought it would be otherwise kind of deluded themselves yeah yeah i do think i do think going for that one interesting question is going to be this is freaking this is when you mentioned the wall street journal uh editorial yeah okay let's let's let's noodle on this because i've had conversations where people have been like why isn't like big pharma, the biggest, uh, baddest, uh, influence group in Washington, DC. Like, why are they not making more of a stink? Where is their influence? I mean, I, the Wall Street Journal editorial board is influential, but it's different. And my question has been, yeah, where are these interest groups who would in theory, you know, want to push back strongly against some of this stuff

yeah well that's a really good question um made for another newsletter another newsletter they have mostly uh been sort of you know playing you know been quiet um i i did see some comments there were some comments just since Marx got pushed out. There was a great article on Stat News, which is one of my favorite publications, which covers the healthcare sector, quoting a bunch of biotech executives who were very upset. And I think you combine that with the cuts to medical research through NIH, which is potentially going to have a devastating effect on the future of scientific research in this country, which is, you know, potentially can have a devastating effect on the future of scientific research in this country, which is a whole other conversation. Right.

And I think it's finally dawning on people in this sector that, holy cow, like, this could really wreck the American ecosystem for developing new medical treatments. I got to say, just like as someone who has followed debates in this sector for a long time, Sam, you know this, you know, whenever, you know, the topic of, you know, of having, you know, drug, you know, having the government do something about prescription drug prices came up, right? You know, having the government negotiate drugs. Yeah.

Whenever we, any small steps towards towards that the pharmaceutical industry would like freak out freak and like if you even touch you know you can give the government a little bit of influence over drug prices it's going to kill innovation which was you know wildly overstated yes but it but definitely was the case yeah right right so here we have like a true existential threat and they're nowhere i can, it's unbelievable to me. I don't, I honestly don't understand it. Like, and it's the academia. I mean, they're going to drive scientists out of this country.

They are already. It's the biomedical research, which Big Pharma actually benefits from in very tangible ways. It's all these weird regulatory moves. It's the revamping of HHS in mysterious ways. And I mean, that industry could very well be in for a huge, huge disruption if not, if they're not already. And yet we sit here and they're barely making a noise as far as I can tell. Yeah. Yeah. We'll have to see if that changes. And just a side note here, I would just remind people, or maybe people are listeners being sophisticated bulwark followers that they are.

This probably occurred to them already. But it's kind of a weird thing when you're sort of whole, you know, your whole shtick is make America great again. And you're basically undermining the one place in terms, you know, the one thing at which the United States is clearly, unquestionably a world leader, which is, you know, medical innovation. This, I mean, the amount of damage being done. The Washington Post had a story a couple of days ago. They looked at how much money, like it's already down 60%, like already sort of the money going out. That's crazy. I remember, I remember, and we'll end here.

I remember the sequestration days with Obama where it was a 5% cut and people were freaked. I mean, totally freaked and rightfully so. All right, Jonathan, we got on it there. Great first piece, really fantastic. We'll be obviously talking throughout the next couple weeks about all this stuff, but thank you for doing this. I encourage everyone to read it,

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