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Month: October 2025

Trade Ya Subsidies For a Government

By KIM BELLARD

As you may have heard, the federal government is currently shut down, although for many federal workers – those deemed “essential” – that just means they keep on working but don’t get paid (and, in fact, some might never get paid). The cause is the now-standard failure of Congress to pass a budget. As it often does in these instances, the House did pass a continuing resolution (CR) to keep the government open (for seven weeks), and Senate Republicans are willing to go along, but Senate Democrats are balking. Even though they’re usually the ones who advocate “clean’ CRs, this time they’re holding out to include some other legislative fixes. Their key demand: continuing the expanded ACA premium tax credits.  

I am a little puzzled why this is the hill upon which they’re willing to keep the government shut down.

Let’s back up. When ACA was passed in 2010, a crucial component was subsidies to help low- income people afford ACA coverage (along with subsidies for cost-sharing features like deductibles). Subsidies were, and are, crucial for the ACA marketplace to survive. These subsidies came in the form of premium tax credits. 

If you recall the dismal individual health insurance marketplace pre-ACA, individuals couldn’t get coverage unless they passed medical underwriting, and, even then, preexisting conditions exclusions applied.  As a result, few qualified and everyone complained. ACA did away with medical underwriting and pre-existing conditions exclusions, but the only way to ensure that enough healthy people would join the risk pool was to generously subsidize their coverage, much as employers do with employment-based health insurance. Thus the premium tax credits.

The trade-off worked for almost ten years. About ten million people got coverage through the exchanges. Then the pandemic hit. People needed coverage more than ever, yet many people’s incomes crashed. So in 2021 Congress passed “enhanced” premium tax credits as part of the American Rescue plan Act. They increased the amounts of the credits and made them available to some higher income families. Those expanded credits were extended to the end of 2025 as part of the Inflation Reduction Act. 

It is those expanded premium tax credits that are expiring. The original credits would remain. Things would go back to the way they were pre-pandemic (although, of course, premiums are now higher due to inflation). It’d be more of a setback than a catastrophe. 

The expanded tax credits did have a dramatic impact. Enrollment went from about ten million to over 24 million – 22 million of whom had the expanded credits. So it certainly is a non-trivial matter if they expire. KFF estimates that average premiums would double in 2026. 

Still, though, CBO estimates loss of the expanded credits would result in about 3.8 million people losing coverage, which is a far cry from the 14 million whom gained coverage since they were implemented. 

I’m not sure if the CBO is being overly optimistic, or if ACA has taught people to appreciate their coverage. 

Everyone in Congress knew, or should have known, that these tax credits were expiring this year.

Continue reading…

Lynn Rapsilber on Nurse Practitioners

There are a lot of nurse practitioners in the US–over 400,000 (compared to around 900,000 MDs & DOs), and we are training 40,000 a year. But how they are going to be used is not entirely clear. Lynn Rapsilber is an NP whose organization, the National Nurse Practitioner Entrepreneur Network, is working to help her fellow NPs with their professional and business development. She came on THCB to discuss how NPs are developing and how she thinks NPs will contribute in the future as we deal with the current crisis in primary care–Matthew Holt

TytoCare–The Last Few Inches of Telehealth?

Tamir Gottfried, the Chief Commercial and Strategy Officer at TytoCare came on THCB to show us how their remote device works to deliver the last few inches of telehealth. Most telehealth is just a video call but with Tyto’s device, the patient can asynchronously (and/or synchronously) take their vital signs including videos and pictures of the skin, ears, mouth, heartbeat et al, and share it with their doctor. It actually amazes me that they haven’t been more popular but in the last few years Tyto has made significant inroads with health plans and providers delivering their devices, as well as adding chronic care management module, with a forthcoming smart clinic (AI) companion. Tamir explained who, how what and why to me, and gave a not too gruesome demo–Matthew Holt

Penguin–The Flightless Bird of Health AI

Fawad Butt and Missy Krasner started a new AI company which is building a big platform for both plans and providers in health care. Penguin Ai has a cute name, but is serious about trying to provide an underlying platform that is going enable agents across the enterprise. They are health care only, as opposed to the big LLMs. But does health care need a separate AI company? Are the big LLMs going to give up health? And what about that Epic company? Join us as we discuss how this AI thing is going to be deployed across health care, and how Penguin is going to play. Oh and they raised $30m series A to start getting it done–Matthew Holt

Teledoc Medication Abortions Under Attack

By MIKE MAGEE

For those prepared to take a deep breath and relax in the aftermath of the MAGA induced assault on the First Amendment that whipsawed Disney leadership last week as they abandoned and then rescued Jimmy Kimmel, be advised reproductive health access is at the top of the list when it comes to MAGA campaigns to “restrict liberties.”

Consider the ongoing campaign to federally restrict telemedicine enabled medication abortion.

A few facts:

  1. Medication abortion is a process that involves taking two medications (mifepristone and misoprostol) at specific intervals over one to three days. It is approved for use up to the first 70 days of a pregnancy and costs on average about $500.
  2. As defined by Yale Medicine, “Mifepristone is a medication that blocks progesterone activity in a female’s body. Progesterone is a critical hormone for supporting an early pregnancy. The second medication, misoprostol, causes contractions and expels the pregnancy tissue. It typically takes 12 to 24 hours to pass the tissue.”
  3. The overall number of abortions have risen since the Dobbs decision overturned Roe v. Wade. There were 1.1 million US abortions in 2023, that is 88,000 per month compared to 80,000 the year before.
  4. Medication abortions account for 2/3 of all abortions in the US. At least 1 in 4 of these last year involved telemedicine provision by mail order including to citizens from states with highly restrictive abortion laws.
  5. Success rate in terminating pregnancy is 99.6%. Major complications occur in .4% of cases and mortality is nearly non-existent.
  6. Anti-abortion advocates are currently focused on obstructing legal access to abortion pills.

Immediately following the Dobbs decision, 12 states banned abortion and 4 states imposed a 6-week gestational limit on access to abortion. Nine of these states now explicitly ban telehealth enabled medication abortion. Countering these measures, eight states where abortion remains legal have passed “shield laws” that protect health professionals from prosecution by other states for engaging in telehealth support of patients seeking self-care within states where abortion is illegal. By latest count, 1 in 7 telehealth assisted medication abortions involved practitioners from shield states.

President Trump’s campaign pledge to reinstate the dormant 1873 Comstock Act to cripple telehealth efforts in support of medication abortion has gone nowhere. In a similar vein, flawed science studies engineered by anti-abortion advocates attempting to challenge FDA clearances for safety and self management of the drugs involved have been exposed as unscientific, deceptive and biased. Multiple state suits, for and against imposing additional FDA hurdles to access in the absence of demonstrable medical benefit or risk mitigation are piling up in the courts. And Louisiana recently took a different tact, reclassifying misoprostol a “controlled substance” and inviting provider countersuits.

As Cornell legal experts remind us, the freedom of expression and the right to freedom of speech may be exercised “in direct (words) or a symbolic (actions) way.” When first written, and adopted as the first of the original 10 entries in the Bill of Rights in 1791, the First Amendment said: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

Nowadays, the provision applies to the entire federal government and is reinforced by the Due Process Claus of the 14th Amendment which protects citizens from state government interference as well.

For better or worse, the actions leading up to the Dobbs decision were led, funded, organized and executed primarily by religious groups, primarily Roman Catholics and Evangelical Christians, joining ranks on the issue five decades ago. Those very religions legitimacy and independence has long been protected by the First Amendment.

A simple listing of the opening salvo of our Bill of Rights reveals a complex tangle of protections that define not only our primary rights as citizens, but also our power and legitimacy as a healthy representative democracy.

What’s included? According to legal experts, our 1st Amendment “protects the right to freedom of religion and freedom of expression from government interference. It prohibits any laws that establish a national religion, impede the free exercise of religion, abridge the freedom of speech, infringe upon the freedom of the press, interfere with the right to peaceably assemble, or prohibit people from petitioning for a governmental redress of grievances.”

Religious leaders remain deeply divided. Opposing reproductive choice while protecting the religious freedom assured by the very same 1st Amendment is a difficult needle to thread. Consider the comment of Baltimore Archbishop William Lori, Chairman of the U.S. Conference of Catholic Bishops’ Committee on Pro-Life Activities, on June 24, 2022, the day of the Dobbs decision: “I recognize there are people on both sides of the question in the Catholic Church. What we are finding though is that when people become more aware of what the church is doing to assist women in difficult pregnancies … hearts and minds begin to change.”

Well, not exactly. A March, 2025 Pew Survey of Catholics nationwide revealed that 6 in 10 Catholics believe that abortion should be legal in all or most cases.

It is ironic that, in attempting to usurp women’s rights to their own reproductive freedoms, that some religious leaders continue to attack the country’s foundational 1st Amendment that has assured the continued existence of their sponsoring organizations.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

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