Updated at 4:30 p.m. ET

President Trump gave a speech and signed an executive order on health care Thursday, casting the “Medicare for All” proposals from his Democratic rivals as harmful to seniors.

His speech, which had been billed as a policy discussion, had the tone of a campaign rally. Trump spoke from The Villages, a huge retirement community in Florida outside Orlando, a deep-red part of a key swing state.

His speech was marked by cheers, standing ovations and intermittent chants of “four more years” by an audience of mostly seniors.

Trump spoke extensively about his administration’s health care achievements and goals, as well as the health policy proposals of Democratic presidential candidates, which he characterized as socialism.

The executive order he signed had previously been titled “Protecting Medicare From Socialist Destruction” on the White House schedule but has since been renamed “Protecting and Improving Medicare for Our Nation’s Seniors.”

“In my campaign for president, I made you a sacred pledge that I would strengthen, protect and defend Medicare for all of our senior citizens,” Trump told the audience. “Today I’ll sign a very historic executive order that does exactly that — we are making your Medicare even better, and … it will never be taken away from you. We’re not letting anyone get close.”

The order is intended, in part, to shore up Medicare Advantage, an alternative to traditional Medicare that’s administered by private insurers. That program has been growing in popularity, and this year, premiums are down and plan choices are up.

The executive order directs the Department of Health and Human Services to develop proposals to improve several aspects of Medicare, including expanding plan options for seniors, encouraging innovative plan designs and payment models and improving the enrollment process to make it easier for seniors to choose plans.

The order includes a grab bag of proposals, including removing regulations “that create inefficiencies or otherwise undermine patient outcomes”; combating waste, fraud and abuse in the program; and streamlining access to “innovative products” such as new treatments and medical devices.

The president outlined very little specific policy in his speech in Florida. Instead, he attacked Democratic rivals and portrayed their proposals as threatening to seniors.

“Leading Democrats have pledged to give free health care to illegal immigrants,” Trump said, referring to a moment from the first Democratic presidential debate in which all the candidates onstage raised their hands in support of health care for undocumented migrants. “I will never allow these politicians to steal your health care and give it away to illegal aliens.”

Health care is a major issue for voters and is one that has dominated the presidential campaign on the Democratic side. In the most recent debate, candidates spent the first hour hashing out and defending various health care proposals and visions. The major divide is between a Medicare for All system — supported by only two candidates, Sen. Bernie Sanders and Sen. Elizabeth Warren — and a public option supported by the rest of the field.

Trump brushed those distinctions aside. “Every major Democrat in Washington has backed a massive government health care takeover that would totally obliterate Medicare,” he said. “These Democratic policy proposals … may go by different names, whether it’s single payer or the so-called public option, but they’re all based on the totally same terrible idea: They want to raid Medicare to fund a thing called socialism.”

Toward the end of the speech, he highlighted efforts that his administration has made to lower drug prices and then suggested that drugmakers were helping with the impeachment inquiry in the House of Representatives. “They’re very powerful,” Trump said. “I wouldn’t be surprised if … it was from some of these industries, like pharmaceuticals, that we take on.”

Drawing battle lines through Medicare may be a savvy campaign move on Trump’s part.

Medicare is extremely popular. People who have it like it, and people who don’t have it think it’s a good thing too. A recent poll by the Kaiser Family Foundation found that more than 8 in 10 Democrats, independents and Republicans think of Medicare favorably.

Trump came into office promising to dismantle the Affordable Care Act and replace it with something better. Those efforts failed, and the administration has struggled to get substantive policy changes on health care.

On Thursday, administration officials emphasized a number of its recent health care policy moves.

“[Trump’s] vision for a healthier America is much wider than a narrow focus on the Affordable Care Act,” said Joe Grogan, director of the White House’s Domestic Policy Council, at a press briefing earlier.

The secretary of health and human services, Alex Azar, said at that briefing that this was “the most comprehensive vision for health care that I can recall any president putting forth.”

He highlighted a range of actions that the administration has taken, from a push on price transparency in health care, to a plan to end the HIV epidemic, to more generic-drug approvals. Azar described these things as part of a framework to make health care more affordable, deliver better value and tackle “impassable health challenges.”

Without a big health care reform bill, the administration is positioning itself as a protector of what exists now — particularly Medicare.

“Today’s executive order particularly reflects the importance the president places on protecting what worked in our system and fixing what’s broken,” Azar said. “Sixty million Americans are on traditional Medicare or Medicare Advantage. They like what they have, so the president is going to protect it.”

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Updated at 3:30 p.m. ET

A judge has ruled that a Philadelphia nonprofit group’s plan to open the first site in the U.S. where people can use illegal opioids under medical supervision does not violate federal drug laws, delivering a major blow to Justice Department lawyers who have been working to block the facility.

U.S. District Judge Gerald McHugh ruled Wednesday that Safehouse’s plan to allow people to bring in their own drugs and use them in a medical facility to help combat fatal overdoses does not violate the Controlled Substances Act.

“The ultimate goal of Safehouse’s proposed operation is to reduce drug use, not facilitate it,” McHugh wrote in his opinion.

The decision means that America’s first supervised injection site, or what advocates call an “overdose prevention site,” can go forward. Justice Department prosecutors had sued to block the site, calling the proposal “in-your-face illegal activity.”

Ronda Goldfein, who is Safehouse’s vice president and secretary, said winning judicial approval is a major feat for advocates of the proposed site, which also has the backing of top city officials.

“Philadelphia is being devastated. We’ve lost about three people a day” to opioid overdoses, Goldfein said. “And we say we had to do something better and we couldn’t sit back and let that death toll rise. And the court agreed with us.”

Similar facilities exist in Canada and Europe, but no such site has gotten legal permission to open in the U.S. Cities like New York, Denver and Seattle have been publicly debating similar proposals, but many were waiting for the outcome of the court battle in Philadelphia.

Prosecutors had contended that the plan violated a provision of the Controlled Substances Act that makes it illegal to own a property where drugs are being used — known as “the crack house statute.” But backers of Safehouse argued the law was outdated and not written to prevent the opening of a medical facility aimed at saving lives in the midst of the opioid crisis.

“We have consistently said we did not have an illegal purpose. We have a lawful purpose. Our purpose is to save lives,” Goldfein said.

On Wednesday, in a move that surprised observers, McHugh agreed.

“The statutory language that matters most is ‘purpose,’ and no credible argument can be made that a constructive lawful purpose is rendered predatory and unlawful simply because it moves indoors. Viewed objectively, what Safehouse proposes is far closer to the harm reduction strategies expressly endorsed by Congress,” McHugh wrote.

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A sheriff’s deputy in Perry, Ga., filed a lawsuit in federal court Wednesday against the county where she works for refusing to allow her health insurance plan to cover her gender-affirmation surgery.

Sgt. Anna Lange came out as transgender in 2017, after working in the Houston County Sheriff’s Office since 2006. She has taken hormone therapy and outwardly changed her appearance over the past three years to treat gender dysphoria, the distress resulting from the mismatch between her sex assigned at birth and her gender identity.

Her next step was going to be gender-affirmation surgery, but that plan came to a halt when, as NPR previously reported, her insurance provider denied coverage for the procedure, based on an exclusion specified by her employer.

Now, Lange is suing the Houston County Board of Commissioners to remove that exclusion. Early on Wednesday, she and her lawyer, Noah Lewis of the Transgender Legal Defense and Education Fund, filed suit in U.S. District Court in Macon, Ga., alleging unlawful discrimination under federal and state equal protection clauses, Title VII of the Civil Rights Act and the Americans with Disabilities Act.

County officials did not return calls for comment.

Lange’s case is the latest in the U.S. to challenge the exclusion of transgender care from state and municipal employee insurance plans — and could create legal precedents for cases across the South.

Other transgender people have won similar fights elsewhere. The managers of Wisconsin’s state employee insurance program excluded transgender employees from coverage but later reversed that decision. Separately, two University of Wisconsin employees sued the state and won. Another lawsuit successfully challenged transgender exclusions in Wisconsin’s Medicaid plan.

Earlier this year, Jesse Vroegh, a transgender employee of the Iowa Department of Corrections, won a lawsuit he’d filed after being denied coverage by his employer’s health insurance plan.

And in Georgia, the state’s university system recently settled an insurance exclusion claim for gender-affirmation surgery filed by Skyler Jay, known for his appearance on the Netflix series Queer Eye. In addition to changing its employee health plan to be inclusive of transgender care, the university system paid Jay $100,000 in damages.

“The university clearly agreed that it was discrimination,” says Lange’s attorney, Lewis, who also represented Jay. “That’s why they wanted to do the right thing and remove the exclusion.”

In 2011, another Georgia case, Glenn v. Brumby, set the legal precedent protecting transgender people from employment discrimination. However, that case did not address discrimination in employee benefits and, like Jay’s case, many that deal with benefits have been settled out of court, according to Lewis.

The Affordable Care Act, which took effect in 2014, specifically prohibits discrimination by health insurance issuers on the basis of gender identity, and Title VII of the Civil Rights Act also has been interpreted to prohibit such discrimination.

Despite broad legal consensus that transgender insurance exclusions are unlawful, state and local governments continue to pursue expensive legal fights to preserve them. The issue remains contentious for many social conservatives.

“Ultimately, what’s happening is that, politically, I presume they think it’s unpopular or they think they have to defend” the law or regulation, says John Knight, an attorney with the American Civil Liberties Union.

Resisting paying for such care can be more expensive than providing it. Not including the costs of state attorneys’ salaries or appeals, Wisconsin’s litigation against the employees of its university system cost the state more than $845,000, while Iowa’s cost about $125,000.

Furthermore, the cost of managing untreated gender dysphoria can outweigh the costs of providing transgender-inclusive health care, according to a 2015 study.

“Given the small number of people who actually need this kind of care and the large pool of people, it will have absolutely no impact on the total cost of insurance for any state,” Knight says.

While settlements such as Jay’s may be good for individuals, they do not require institutions to admit wrongdoing and do not result in a legal precedent that other, lower courts must follow.

“The court doesn’t have to look at that settlement and say, ‘Oh, this was discrimination,’ ” Lewis says. “Transgender workers in the South are being left behind, which is why we’re seeking a court ruling to clearly establish that this conduct is unlawful throughout the South.”

Lange’s suit argues that the county’s exclusion of transgender health care from coverage was deliberate: In documents Lewis obtained under the Freedom of Information Act, Kenneth Carter, the county’s personnel director, opted out of compliance with Section 1557 of the Affordable Care Act, which prohibits discrimination by health programs on the basis of gender identity.

“Houston County will be responsible for any penalties that result if the plan is determined to be noncompliant,” he wrote in a letter to a representative of Anthem Blue Cross and Blue Shield, which administers the plan.

Carter did not return calls for comment.

Lange’s case could end up before the 11th U.S. Circuit Court of Appeals, yielding a decision that could influence other courts in Alabama, Florida and Georgia. And, if the ruling is in Lange’s favor, Lewis says, that would signal that transgender exclusions should be removed nationwide.

In its next term, the U.S. Supreme Court will hear three cases that will determine workplace protections of LGBTQ individuals, including one case involving a transgender woman.

Lange says she merely wants the same protections everyone else has. The co-workers with whom she shares a health plan might have used “something on the policy that I may never use or need, but it’s covered,” she says. “When it’s finally something that I need that one of my co-workers will probably never use or need, mine’s excluded. And that’s just not fair.”

Keren Landman, a practicing physician and writer based in Atlanta, covers topics in medicine and public health. Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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Artificial stone used to make kitchen and bathroom countertops has been linked to cases of death and irreversible lung injury in workers who cut, grind, and polish this increasingly popular material.

The fear is that thousands of workers in the United States who create countertops out of what’s known as “engineered stone” may be inhaling dangerous amounts of lung-damaging silica dust, because engineered stone is mostly made of the mineral silica.

Jose Martinez, 37, worked for years as a polisher and cutter for a countertop company that sold engineered stone, as well as natural stone like marble. He says dust from cutting the slabs to order was everywhere.

“If you go to the bathroom, it’s dust. When we go to take lunch, on the tables, it’s dust,” he says. “Your nose, your ears, your hair, all your body, your clothes — everything. When you walk out of the shop, you can see your steps on the floor, because of the dust.”

Now, he’s often weak and dizzy, and has pain in his chest — he can no longer play soccer or run around with his kids. Doctors have diagnosed silicosis, a lung disease that can be progressive and has no treatment except for lung transplant. Martinez is scared, after hearing that two other workers from the same company, who were also in their 30s, died of silicosis last year.

“When I go to sleep, I think about it every night — that if I’m going to die in three or four, five years?” he says, his voice breaking. “I have four kids, my wife. To be honest with you, every day I feel worse. Nothing is getting better.”

His experience is just one of those described in a new report on 18 cases of illness, including two deaths, among people who worked principally with engineered stone in California, Colorado, Texas and Washington.

The workers were nearly all Hispanic, almost all were men, and most had “severe, progressive disease.”

“I am concerned that what we may be seeing here may just be the tip of the iceberg,” says Dr. Amy Heinzerling, an epidemic intelligence service officer with the Centers for Disease Control and Prevention, who is assigned to the California Department of Public Health.

Engineered stone took off as a popular option for countertops about a decade ago, and is now one of the most common choices for kitchens and bathrooms. From 2010 to 2018, imports of the material rose around 800 percent.

Manufacturers say the material is preferable to natural stone because it’s less likely to crack or stain. Companies make their engineered stone by embedding bits of quartz in a resin binder, and that means it’s almost entirely composed of crystalline silica.

“Engineered stone typically contains over 90% silica,” says Heinzerling. “Granite, for instance, usually contains less than 45% silica. Marble usually contains less than 10%.”

While all this silica isn’t a concern once the countertop is installed in a kitchen or bathroom, it is a potential problem for the businesses that cut slabs of this artificial stone to the right shape for customers.

“Workers who cut with the stone can be exposed to much higher levels of silica,” says Heinzerling, “and I think we’re seeing more and more workers who are working with this material who are being put at risk.”

A spokesperson for a trade organization that represents major manufacturers of engineered stone, A.St.A. World-wide, sent NPR a written statement, noting that dust-related diseases can come from unsafe handling of many different materials and that “these risks are not specific to engineered stone.”

What’s more, the statement goes on, engineered stone surfaces “are totally safe in their fabrication and installation if it is performed according to the recommended practices.” Manufacturers, according to the trade group, have been working to educate fabricators about these practices.

Still, Heinzerling believes that “the fact that all of our affected workers worked with engineered stone, as did many of the workers reported internationally, is really important.”

One recent study in Australia found that at least 12% of workers who cut stone countertops had silicosis. Those cases, and the new cases in the United States, have public health experts now wondering about the nearly 100,000 U. S. workers in this industry.

Officials estimate that there are more than 8,000 stone fabrication businesses in the United States. Many are small-scale operations that might not understand the dangers of silica or how to control it.

Clusters of silicosis cases, some requiring lung transplants, had already occurred among workers who cut engineered stone in Israel, Italy, and Spain when doctors saw the first North American case in 2014.

That was a 37-year-old Hispanic man who had worked at a countertop company and had been exposed to dust, including dust from engineered stone, for around a decade.

More cases were then discovered in California when public health workers did a routine search of hospital discharge records for a diagnosis of silicosis. They identified a 38-year-old man who had died of silicosis in 2018 after working for a countertop manufacturer.

When they investigated his former workplace, they learned of another worker who had died of silicosis in 2018 at the age of 36. Four other workers from that same company, including Martinez, have been diagnosed with silicosis.

Meanwhile, in Colorado, an unusually high number of people with silicosis were showing up at the occupational health practice of Dr. Cecile Rose, professor of medicine at National Jewish Health and the University of Colorado.

“Over a period of less than 18 months, I had seen seven cases of silicosis in younger workers,” says Rose.

In the past, her patients with silicosis tended to be miners, who had dug for metals like gold and silver many years before. Her new patients were younger, and were working with companies that processed slabs of engineered and natural stone.

“We actually not only saw people who were directly cutting and grinding the stone, but we saw people who were just sweeping up the work site after the stone had been cut,” says Rose. “They were exposed to the silica particles that were suspended in the air just with housekeeping duties.”

More cases have been found in Texas. And in 2018, public health workers identified a 38-year old Hispanic man with silicosis in Washington who fabricated countertops. “He is facing serious health issues and is being considered for a lung transplant,” according to Washington State Department of Labor & Industries.

None of this surprises David Michaels, an epidemiologist at George Washington University who used to run OSHA, a safety agency within the Department of Labor. In 2015, he says, OSHA issued a “Hazard Alert” warning of a significant exposure risk for workers who manufacture natural and artificial stone countertops.

“We knew we’d see more cases,” says Michaels. “It’s disappointing that OSHA hasn’t done anything to stop these cases from occurring. These cases were predictable, and they were preventable.”

Prevention basically comes down to controlling the dust. Stone cutting businesses can choose from a variety of proven methods, ranging from working with stone while it’s wet to using vacuum or filtration systems that remove dust from the air.

In 2016, OSHA issued new workplace limits on how much silica could be in the air. This controversial new rule reduced the permissible exposure level to half of what it had been. Safety experts hailed the new, tighter limit as an important step forward; the previous regulations had been based on decades-old science, they said. But many industry groups opposed it.

A year later, the incoming Trump administration ended the safety agency’s national emphasis program for silica. That program would have allowed OSHA to target the countertop fabrication industry for special inspections, says Michaels.

“That way OSHA can have an impact on the entire industry,” says Michaels. “But OSHA is not doing that.”

Without that program, says Michaels, OSHA is limited in what it can legally do. OSHA can investigate a workplace injury or a complaint. But these workers, some of whom are undocumented immigrants with few employment options, are unlikely to complain.

A spokesperson for OSHA tells NPR that the agency will determine “at a later date” if a revised silica special emphasis program is needed; in the meantime the agency “continues to enforce the 2016 silica standard.”

“Employers are responsible for providing a safe and healthy workplace free from recognized hazards,” the spokesperson says.

Some countertop manufacturers are well aware of the dangers of silica. David Scott, the owner and operator of Slabworks of Montana, in Bozeman, estimates that about 40 to 50% of what he sells and cuts is the engineered stone.

He’s been able to dramatically reduce the amount of silica dust in his countertop fabrication shop over the last five years, he says.

One of his insurers provided testing for airborne silica, and Scott says levels were initially only marginally acceptable, even though his facility doesn’t do any dry processing of stone, which creates more dust. “We were a wet shop at that time, and we were still marginal,” he says.

Part of the problem was that water with silica dust would end up on the floor, he explains, and some of the water would evaporate before going down the drain.

“If you came in in the morning, you would see a white residue on our floor, and that was the dust,” says Scott. “So the first thing we did was bring in a floor scrubber. We call it our Zamboni.”

The machine scrubs and vacuums up the water, and Scott says that reduced the silica load in the air substantially. He then added new air handling systems to further remove dust. “We brought our silica levels, at times, down to undetectable,” says Scott.

He says consumers who want to make sure they’re buying a countertop from a responsible vendor can vet fabricators by looking to see if they are accredited by the Natural Stone Institute, which trains companies on how to safely cut and polish stone. Accreditation requires that companies to basically invite OSHA in to do an inspection.

But many operators, especially smaller ones, won’t have gone through this process. If a showroom is attached to a manufacturing stop, Scott says, a countertop buyer could simply look around.

“How much dust do you see? Because it gets everywhere,” says Scott. “General cleanliness is going to tell you a lot.”

In Australia, where government officials are grappling with a spike in aggressive cases of silicosis among workers who cut engineered stone, medical organizations are urging doctors to screen young workers to identify those who have lung disease.

Dr. Graeme Edwards, an occupational health physician in Brisbane, Queensland, says that currently there are more than 250 known cases of silicosis among people who manufacture countertops — or “benchtops,” as they are called in Australia.

Anyone who has worked with engineered stone for more than three years should have a high-resolution CT scan to check for lung injury, says Edwards, even if they don’t have any symptoms. He says this is especially true if they engaged in any dry-cutting of this material for more than a year, regardless of whether they used respiratory protection.

In an email, he says that American researchers’ assertion in their new report that, based on Australia’s experience, “there might be many more U. S. cases that have yet to be identified” is “a GROSS understatement.”

Jose Martinez, who is worried about his future, says he wants workers to know that the danger is real and that they have to protect themselves, because some companies may not care.

“At the end, it’s your family, it’s your health. It’s not about other people. It’s not about if your boss likes it or not,” says Martinez. “If you die, who is going to feed your kids? Who is going to take care of your family?”

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