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To President Trump, bigger is better.

He has inflated the size of his buildings (counting stories that aren’t there). He exaggerated the size of the crowd at his inauguration (a million and a half — it wasn’t). And he, of course, famously lashed out when he was accused of having small hands. (If that implied something else must be small, he said during a nationally televised debate, “There’s no problem. I guarantee you.”)

But when it comes to the health care bill, the Trump administration believes smaller is better.

When House Republicans released their plan to repeal and replace Obamacare, press secretary Sean Spicer brought props to his daily briefing — a table next to his lectern with the 123-page GOP bill, sitting next to a 974-page Affordable Care Act.

“As you’ll see, this bill right here was the bill that was introduced in 2009 and 10 by the previous administration,” Spicer said Wednesday. “Notice how thick that is.”

He later went on to elaborate that the GOP replacement plan is even smaller than it looks.

“So far, we’re at 57 for the repeal plan and 66 pages for the replacement portion,” Spicer said. “We’ll undo this. And remember, half of it, 57 of those pages, are the repeal part. So when you really get down to it, our plan is 66 pages long, half of what we actually even have there.”

This tactic isn’t new to the Trump administration; making page counts into a talking point has been a fixture of policy debates since at least the Reagan administration, particularly among conservatives. But a bill’s length has very, very little to do with its quality. And experts say that keeping major legislation short is getting tougher.

Why all the hate for long bills?

Politicians have criticized long bills for decades, and that history shows a few reasons why people feel (or say they feel) that those bills are a problem.

For one, critics believe these lengthy bills are signs of legislative inefficiency. President Reagan in his 1988 State of the Union address gave a particularly memorable example of it.

“The budget process has broken down; it needs a drastic overhaul,” he declared, shaming Congress for late and “monstrous” budget resolutions. And like Spicer this week, Reagan made his point with his own table piled high with paper (the relevant portion begins around 15:50 in the below video):

“Along came these behemoths. This is the conference report — 1,053 pages, report weighing 14 pounds. Then this — a reconciliation bill six months late that was 1,186 pages long, weighing 15 pounds. And the long-term continuing resolution — this one was two months late, and it’s 1,057 pages long, weighing 14 pounds. Now, that was a total of 43 pounds of paper and ink. You had three hours — yes, three hours — to consider each, and it took 300 people at my Office of Management and Budget just to read the bill so the government wouldn’t shut down. Congress shouldn’t send another one of these. No, and if you do, I will not sign it.”

Reagan held up each of three different, massive budget bills, to laughter and applause from congressional members. He underlined his point by dropping each stack of papers with a theatrical thump. (He added a final flourish of shaking out his hand, as if he had injured it.)

A bill’s length has also been taken as a sign that bills were simply unworkably byzantine. The Atlantic’s James Fallows in 1995 cited the 1,342 pages of Hillary Clinton’s health care overhaul as evidence that the bill was “fatally overcomplicated” and “impossible for anyone except the plan’s creators … to understand.”

Yet another dimension to the fear of long legislation is the fear that it will contain buried, objectionable provisions that lawmakers won’t find until it’s too late.

After the George W. Bush White House passed its prescription-drug plan, for example, one Republican lawmaker told 60 Minutes that members of Congress weren’t given enough time to understand the legislation.

“The bill was over 1,000 pages,” North Carolina Rep. Walter Jones said. “And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning.”

This is a regular concern, said one former Hill staffer.

“What got snuck into there? What got airdropped into there in conference or whatever?” said Billy Pitts, a longtime GOP congressional aide, explaining a common reaction to long bills. “That’s always the threat of a big, fat bill — there’s always something hidden inside of it.”

That notion was hammered home for conservatives with Nancy Pelosi’s infamous 2010 remark to the Legislative Conference for the National Association of Counties, that “we have to pass the bill, so that you can find out what’s in it.”

She has since said that that quote was taken out of context, but Republicans seized upon it as evidence of shady lawmaking. Right-leaning website the Daily Signal characterized its view of Pelosi’s message as follows:

“What lurks within the House and Senate health care bills will be revealed in the fullness of time, and it’s really good for us if we only knew better.”

And finally, there is the symbolic argument — perhaps the most common type of argument against long bills. It makes an intuitive sense that Republicans often lambast legislation for being lengthy.

“For conservatives, [long legislation] becomes a metaphor for complicated government,” said Norm Ornstein, a resident scholar at the American Enterprise Institute, a right-leaning think tank. “You throw down 1,000 pages or 1,500 pages, and it looks like they’re doing stuff that gets into every detail of everybody’s lives.”

Here’s how bills get so long (and are getting longer all the time)

A thousand pages might sound insane to people who don’t read legislation on a daily basis. But there are substantive reasons why bills can become so large.

The following three reasons explain why worries about lengthy bills are often overblown:

1. Making laws is harder than it looks

Interestingly, Spicer hinted at one of these reasons in his comments this week, when he said that repealing Obamacare itself took 57 pages. That’s a lot of pages for doing something that can be explained in two words: “repeal Obamacare.”

So while it might seem repealing a law would be simple — say, writing a bill that says something along the lines of, “This bill will fully repeal the Affordable Care Act” — it often instead requires making many, many changes to many, many different parts of different, specific and carefully crafted laws.

“The fact is even most aficionados could not read most bills and get anything out of them,” Ornstein said of the desire to cut length, “which is why we have this army of people in the legislative branch, the Legislative Counsel’s Office, to take policies and translate it into the gibberish.”

2. Polarization means bills crammed full of things

Another reason why laws can get so long is that polarization has created gridlock that makes passing laws remarkably hard, said Sarah Binder, professor of political science at Georgetown University.

“Laws are long — and probably longer today than in the past,” she said in an email to NPR, “because the difficulty of legislating pushes lawmakers to craft new laws with big, multidimensional deals: Your team gets X; my team gets Y; we sew them up into one huge bill.”

She added, “When you come up against a deadline, everything is multiple trains are leaving the station, and you put them all on the same track. And that’s how you make deals.”

To illustrate, she points to the fact that the number of bills passed keeps dropping — but the length of those bills keeps rising.

In other words, less legislation (by number of bills) is getting passed, but each bill that’s passed has way more legislation in it (by number of pages).

This means that the fear of surprise policies being shoehorned into a large bill makes some sense. But as Binder points out, cramming things into bills is also often the only option for passing legislation these days.

3. Some policy areas are just super complicated

Pitts emphasized to NPR the benefits of simple legislation: It’s easier to understand, and it’s easier to foresee its effects and how it will interact with existing laws.

However, it’s also true that some legislation simply deals in complicated policy areas that can’t be boiled down to a few dozen pages.

“What you have to keep in mind here in something like this area is you’re talking about policy that affects close to one-fifth of the economy,” Ornstein said. “And it gets into tax law; it gets into Medicare and Medicaid, which have grown greatly in complexity; it gets into divisions between the states and the federal government.”

A similar principle applies to the tax code — another area where the more-pages-is-bad argument is often made, as Ed Kleinbard, professor of law and business at the University of Southern California, told NPR last year.

“The tax code is thousands of pages long for a very simple reason: It is a model, in the economic sense, of all of economic activity,” he said. “Most Americans don’t spend a lot of time worrying about the taxation of cutting timber or of being crew on a tuna boat. But there are rules for that, and you may find the rules irrelevant to you, but the rules are complex for a reason.”

So putting too much stock in the length of the bill often makes little sense. This may be something repeal proponents will want to keep in mind in the coming weeks, because this bill is just the first part of a three-part plan.

“One of the reasons that this bill is shorter at this point,” Ornstein points out, “is they’re taking on only parts of the Affordable Care Act and making changes.

“If they manage to do all these things, and you look at the nature of the regulations and then you do a third bill, it’s probably going to be about as long as the Affordable Care Act.”

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On Christmas Day, I found out that I was pregnant. It was the best present I could have hoped for. My husband and I have wanted to start a family for years, and we could not wait to share the news with our loved ones.

But my initial exhilaration quickly turned to anxiety. As a physician, I knew many of the things that could go wrong. I wanted to do everything I could do to have a healthy baby.

I found an obstetrician and made an appointment for my first prenatal visit. I was so relieved when I saw the baby’s heartbeat on the ultrasound. My blood was drawn to check for anemia and thyroid problems. I had the rest of my recommended first trimester tests, including a Pap smear and testing for HIV and sexually-transmitted infections.

The appointment also provided other valuable information. I talked to my doctor and his nurse practitioner about combating morning sickness and eating nutritious meals. I don’t smoke, but if I did (as 1 in 10 pregnant women do), they would have counseled on why and how to quit. My providers asked additional questions to assess for domestic violence, a concern for up to 1 in 6 pregnant women.

Even though I’m a relatively healthy 34-year-old, I have several medical conditions that call for more frequent monitoring. My doctor recommended that I return every two weeks for a physical exam and ultrasound. Closer to delivery, I should plan to see him every week.

I didn’t hesitate to follow my doctor’s recommendations. I have excellent health insurance with no copay for doctor’s visits and a minimal cost for tests.

But what would I have done if I didn’t have insurance?

One obstetrician visit would cost $150. With an ultrasound each time, it would be $400. A Pap smear would cost $53. One set of blood tests would add another $300. All told, my prenatal care with all visits and tests included would be over $10,000. This is not counting labor and delivery, which in my area is estimated to be up to $30,000 for a vaginal birth and $50,000 for a cesarean section.

Facing these astronomical costs, would I be forced to pick and choose care based on my ability to pay, rather than the best available medical evidence? What services would I forgo, and with what consequences?

These are not hypothetical questions.

The Republican proposal to replace the Affordable Care Act would drastically cut Medicaid, which provides health coverage for women, children, seniors, and individuals with disabilities. In Baltimore, where I serve as the health commissioner, the majority of pregnant women are insured through Medicaid. Thousands of low-income women could lose coverage and have to pay out-of-pocket for services; others who have insurance may only be able to afford bare-minimum plans that don’t cover needed services.

As a physician who worked in the ER before the Affordable Care Act went into effect, I have seen what happens when patients forgo needed interventions because of cost. I have treated patients who end up in irreversible comas because they couldn’t afford seizure medications. I have treated people who died from drug overdoses because their insurance didn’t cover addiction treatment. And I have treated women who were priced out of prenatal care, whose babies suffered the consequences in the form of preventable diseases, prematurity, birth defects, and even death.

Prenatal and maternity care are considered an essential benefit under the Affordable Care Act; the American Health Care Act introduced in Congress last week doesn’t address that because it can only cover fiscal topics. However, the bill does propose cutting essential benefits for Medicaid recipients. And it aims to defund services to Planned Parenthood clinics that provide birth control and reproductive services. That will only result in more unintended pregnancies.

There are those who attribute these consequences to choice: Isn’t it a woman’s choice to become pregnant? But nearly 1 in 2 pregnancies in the United States are unintended. For women whose insurance stops offering maternity coverage, and for the others who do not have at all, what kind of “choice” do they actually have, and at what cost?

Women without prenatal care are seven times more likely give birth to premature babies, and five times more likely to have infants who die. The consequences are not only poor health, but also higher cost passed down to taxpayers. The average medical cost for a baby with problems of prematurity is $79,000, compared to $1,000 for a healthy newborn. Hospitalizations for a preemie in the first year can be upwards of $500,000; intensive care can cost in the millions.

Conversely, studies have shown that for every dollar spent on prenatal care, there are expected savings of nearly $5. Early intervention saves lives and cuts cost. Our health care system should incentivize prevention and discourage rationing of needed services.

Like other expecting moms, I hope more than anything to have a healthy child. I am fortunate to have access to high-quality, affordable health care. Unfortunately, that’s not the case for all mothers of the nearly 4 million babies born in the U.S. each year. Our nation needs to safeguard the well-being of our families. The next generation, and the generations to come, depend on it.

Dr. Leana Wenis an emergency physician and the health commissioner of Baltimore City. She is the author of When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care. And she’s on Twitter: @DrLeanaWen

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Dr. Scott Gottlieb is expected to become President Trump’s choice to lead the Food and Drug Administration.

Gottlieb is a political conservative and fellow at the American Enterprise Institute, where he has focused his research on the FDA and the Centers for Medicare & Medicaid Services.

An internist and hospitalist, Gottlieb has played leading roles in various government health agencies, including as deputy commissioner for medical and scientific affairs at the FDA during the George W. Bush administration. Before that, he was a senior policy advisor at CMS working on the implementation of Medicare’s then-new drug coverage for seniors.

Gottlieb is a prolific writer on health care issues, particularly the pharmaceutical industry. He is seen as a strong supporter of that industry and has championed deregulation.

“I think Scott is absolutely qualified,” lawyer John Taylor of Greenleaf Health tells STAT. “He has good professional credentials and personal integrity, and a track record that shows the ability to make difficult decisions.”

While Trump has promised at various times to make fairly radical changes at the FDA, Gottlieb is a seen as a conventional choice for commissioner by a Republican president.

Earlier in the year, odds were favoring the nomination of Jim O’Neill, an associate of Silicon Valley entrepreneur and billionaire Peter Thiel, a close Trump adviser. O’Neill created waves when he called for drugs to be approved as soon as they had been judged to be safe, but before they’re proved to be effective, as required under current law.

Should Gottlieb be approved by the Senate, one early target he may aim for is so-called off-label promotion of prescription drugs. The Obama administration issued tighter restrictions on how companies could market drugs for conditions not mentioned on drug labels — signifying the lack of FDA approval for that cause. Gottlieb has been highly critical of the Obama rules.

Gottlieb has many possible financial conflicts that could feature prominently in his confirmation hearings. He serves on advisory boards for several major pharmaceutical companies.

“Gottlieb is entangled in an unprecedented web of Big Pharma ties,” says Dr. Michael Carome, the director of Public Citizen’s Health Research Group, a pro-consumer advocacy group. “He has spent most of his career dedicated to promoting the financial interests of the pharmaceutical industry and the U.S. Senate must reject him.”

According to the ProPublica website Dollars for Docs, Gottlieb received more than $400,000 between August 2013 and December 2015 in promotional talks, research, consulting and travel while practicing at Stamford Hospital in Connecticut.

As FDA commissioner, Gottlieb would oversee an agency that has regulatory power over a quarter of the US economy, including not just pharmaceuticals, but medical devices, food safety, cosmetics and other areas of human and animal health.

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The maximum workday for first-year medical residents just got substantially longer. The group that sets rules for training doctors announced Friday it will be scrapping the 16-hour cap on shifts worked by doctors who have just graduated from medical school.

As of July 1, the Accreditation Council for Graduate Medical Education will allow these first-year residents, also known as interns, to work 24 hours without a break — and sometimes as long as 28, if a particular transition between doctors demands it.

The ACGME is discarding a requirement that was implemented in 2011, arguing that the 16-hour cap simply did not deliver on its promises — and caused some new problems to boot.

“The Task Force [review panel] has determined that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized,” the ACGME notes in its announcement of the rule changes, “and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and effectiveness of care delivery of the team as a whole.”

For instance, task force member Dr. Anai Kothari tells Forbes the cap would occasionally prevent doctors from seeing a treatment or surgery through from beginning to end. Patients want to know “you are the doctor taking care of them,” Kothari says.

“The long shifts are infrequent, but they are important when needed.”

The group says its conclusion is based on “over 4,200 hours formulating the new requirements, including systematically reviewing over 1,000 published articles and extensive input from all stakeholders.”

As NPR’s Rob Stein reported when the rule change was proposed in November 2016, the move has its fair share of critics.

“Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public,” Dr. Michael Carome, director of Public Citizen’s Health Research Group, told Rob. “It’s disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health.”

The Associated Press notes the American Medical Student Association and the Committee of Interns and Residents also oppose the change.

The long shifts are “based on a patriarchal hazing system,” first-year resident Samantha Harrington tells the wire service. She says the underlying message from longtime physicians is: “I went through it, so therefore you have to go through it too.”

“The question of work hour standards appropriately provokes great emotion in both the graduate medical education community and among segments of the general public,” the ACGME acknowledges in its Friday announcement.

But “it is important to note that 24 hours is a ceiling, not a floor,” the group adds. “Residents in many specialties may never experience a 24-hour clinical work period.”

While the ACGME is relaxing its restrictions on interns’ shifts, it is maintaining previous regulations in other areas. Residents and fellows still cannot work more than 80 hours in a single week, and they must have at least one day off from clinical experience or education in any seven-day span.

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A bill to replace the Affordable Care Act is making its way through Congress. Steve Inskeep talks to Dr. J. Mario Molina, CEO of Molina Healthcare, for his reaction to the House measure.

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Conservatives are revolting against the GOP health care measure. David Greene talks to David Urban, president of American Continental Group, and a former adviser to the Trump presidential campaign.

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The battle over womb rights is brewing in Minnesota.

Last month, state legislators proposed a bill that would regulate gestational surrogacy — potentially adding legal oversight to fertility clinics that facilitate these pregnancies, when one woman carries a pregnancy for another.

Minnesota’s surrogacy legislation and the debates that surround it echo the larger national debate on reproductive rights.

From state to state, these battles include advocates who oppose the idea of surrogacy altogether, along with those who think it should be a legal and viable option for building families. But even among supporters, a major sticking point remains about whether carriers should be allowed to accept payment. And if so, how much?

The Minnesota bill doesn’t address compensation, even though a state commission recommended that carriers be able to accept up to $15,000 for time, pain and health risks on top of reimbursed expenses.

About 12 percent of reproductive-age women in the U.S. have trouble getting pregnant or carrying a pregnancy to term, according to the Centers for Disease Control and Prevention.

A small percentage of those women end up pursuing surrogacy arrangements, as do some men. In the early days, that meant that a woman would carry a baby conceived with donated sperm and her own egg. The practice led to plenty of controversy, including the 1988 case of “Baby M,” in which a surrogate in New Jersey changed her mind and decided she wanted to keep the baby.

A flurry of legislative activity followed that high-profile custody battle, according to Kathleen Pontius, lead counsel of the Minnesota Senate Judiciary Committee, but not on a national level. Instead, each state has been left to decide how to regulate the practice, resulting in a patchwork of laws.

States vary widely in regulating surrogacy. While many states impose no restrictions, others, including Michigan, compensated surrogacy is against the law and contracts are unenforceable. Washington, D.C. goes a step further, imposing fines of up to $10,000 or as much as a year in prison for violating the law. Those punishments have also come under fire recently, with a bill proposed to eliminate them.

Even states that allow the practice offer a hodgepodge of rules on what is and isn’t allowed. In Washington State, surrogacy is legal but carriers can’t be compensated. In New Hampshire, intended parents must be married and at least one needs to provide sperm or eggs. In Louisiana, only heterosexual married couples can pursue surrogacy, only with an uncompensated surrogate, and they can’t use donor eggs, sperm or embryos.

It can cost prospective parents $100,000 or more to fund the IVF and other procedures required for a gestational surrogacy. In Minnesota, carriers can expect to receive $20,000 to $30,000, according to Steven Snyder, an assisted reproduction law attorney in Maple Grove, Minn., who is immediate past president of the American Bar Association’s Assisted Reproductive Technology Committee. Those payments can rise to $35,000 on the East Coast and $45,000 in the west, Snyder says..

Parental rights aren’t always assumed. In some places, intended parents must adopt the child as parents or stepparents. And in 31 states, including Minnesota, there are no laws regulating the relationship, according to a report published last year by the Columbia Law School.

Since the heated days of the Baby M case, surrogacy practices have changed, says Julie Berman, director of the Minnesota chapter of RESOLVE: The National Infertility Association, a nonprofit education and advocacy organization. Today, the majority of surrogates are not traditional surrogates (like the woman who had Baby M) but gestational carriers, meaning they are not genetically related to the babies they carry.

Gestational surrogacy is recommended by the American Society of Reproductive Medicine. The society’s guidelines also recommend extensive physical and psychological screening tests for both the carrier and intended parents, as well as independent legal representation for all parties involved.

Doctors, lawyers and parents typically create a contract that considers all sorts of potential scenarios and expectations about things like how often the carrier will get check-ups or take vitamins. Only a handful of Minnesota IVF clinics work with gestational carriers, Berman says, and all of them follow ASRM guidelines.

“This is not something taken lightly, casually or quickly,” Berman says. “It’s an intensive process.”

And it still doesn’t happen often. In Minnesota, 30 babies were born via gestational surrogacy in 2014, according to the ASRM. Around the country, the number is about 2,000 annually, according to data collected by the Society for Assisted Reproductive Technology.

In Minnesota, which must decide whether to go ahead with the legislation this week or let the bill die without a hearing, opposition has come from a California-based organization called the Center for Bioethics and Culture network, which has been a vocal opponent to the practice of surrogacy nationwide.

The Minnesota Catholic Conference takes an ethical stance against the procedure and the potential for disadvantaged women to be exploited, says Jason Adkins, executive director of the organization.

“Surrogacy separates pregnancy from parenthood,” Adkins says. “It undermines the right of every child to be conceived, carried in the womb, brought into the world and brought up within the context of a loving marriage between his or her parents.”

“Women are not for rent,” he adds. “And children are not for sale.”

On the flip side, dozens of people spoke and wrote about the benefits of surrogacy to the Minnesota commission that reviewed the issue, citing their own happy endings. Support also came from Bruce Campbell, president of the Center for Reproductive Medicine, an infertility clinic in Minneapolis and St. Paul that performs the most IVF cycles in the state.

“I see little chance for abuse of this therapy as long as the procedures currently in place to screen for abuse are followed by physicians in this field,” he wrote. “In the 23 years we have been performing these cycles, I cannot recall a situation which has caused me to question whether this therapy should be available.”

The Minnesota bill garnered support from RESOLVE and ASRM, among others, which agreed on the need for regulation over a complicated process.

“We think women are perfectly capable of making informed decisions about how they make money or practice their reproductive lives,” says Sean Tipton, a spokesperson for ASRM, whose headquarters are in Washington, D.C. “It’s incredibly insulting to women to say, ‘You can’t make informed decisions about whether or not to take this on.'”

Minnesota’s bill would not allow surrogates to be paid. Opponents of payment say it makes women vulnerable to exploitation.

Berman argues that many carriers simply loved being pregnant and altruistically want to help others become parents. If their lawyers and doctors get paid to do their work, she adds, why shouldn’t the carriers get compensated, too?

“At the end of the day, these are people who desperately, desperately want to be parents,” she says. “These children are so wanted. This is about making babies. That gets lost in these discussions.”

Emily Sohn is a freelance journalist in Minneapolis who writes regularly about health and science for Nature, the Washington Post, Discovery News and others. More at www.tidepoolsinc.com.

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NPR takes a look at who stands to benefit and who could be hurt if the House GOP plan to repeal and replace Obamacare becomes law.

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