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A Comprehensive Examination of Primary Care Disparities in California: Navigating the Abyss

By SUHANA MISHRA

Residing in the often overlooked San Joaquin Valley, I’ve personally felt the impact of the shortage of primary care physicians. My family struggled to access basic medical attention for common illnesses like the flu. Getting local doctor appointments wasn’t just difficult—it often meant resorting to urgent care or driving long distances for simple treatments. Non-emergency issues that could have been resolved with accessible primary care instead overwhelmed urgent care centers, which often had long wait times and suboptimal conditions. These firsthand experiences revealed just how critical primary care access is for our community. They also sparked my passion for change. Leading a HOSA community service campaign on California’s physician shortage gave me a clearer view of the systemic nature of the issue—and fueled my determination to seek long-term solutions.

California, despite being a hub of innovation, faces a severe and growing deficit in primary care access. Nowhere is this more apparent than in regions like the San Joaquin Valley. Long travel distances, physician burnout, and systemic neglect manifest in community-wide health decline. A UCSF study reported that only two regions in California meet the federally recommended threshold of 60–80 primary care physicians per 100,000 residents. The San Joaquin Valley, predictably, falls far below this benchmark.

While programs like the Steven M. Thompson Physician Corps Loan Repayment Program attempt to incentivize doctors to practice in underserved areas, the impact is limited. According to CapRadio, a third of California’s doctors are over 55 and nearing retirement. CalMatters estimates that by 2030, the state will be short more than 10,000 primary care physicians. The implications are dire—not only for logistics and care delivery, but also for the long-term health outcomes of Californians.

When patients face barriers to consistent care, chronic conditions go unmanaged.

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Concierge Care for all: What would it look like?

By MATTHEW HOLT

A few weeks back I wrote an article on what’s wrong with primary care and how we should fix it. The tl:dr version was to give every American a concierge primary care physician paid for by the government. We would give everyone a $2k voucher (on average, dependent on age, medical status, location, etc) and have an average panel of 600 people per PCP.

My argument was that a) this would be cheaper than health care now – due to cutting back on Emergency Department visits and inpatient admissions and that b) it would enable us to pay PCPs the same as specialists (roughly $500K a year). This would mean that many current ED docs, internists, hospitalists etc would convert to being PCPs. I also think that we could and would make better use of the now 400,000 nurse practitioners in the US. We would only need about 600,000 PCPs to make this work. Although it would double spending on primary care, it would reduce health care costs overall. (OK there’s some debate about this but the Milliman study linked above and common sense suggests it would save money).

There are obviously two huge issues with my proposal. First we would have to go through the conversion process. Second, we would have to do something big with the three major players who are sucking at the teat of health care $$ right now—those being big hospital systems and their associated specialists, health insurers, and pharma and device companies.

I don’t think that there will be any problem selling this to most doctors or to the American people.

The doctors know that they are trapped in the current system. This would free them to practice as they want to practice, and to remember why they got into medicine in the first place—to care for their patients holistically.

People know all too well that accessing primary care is both good for them and also very difficult. Wait lists are way too long. In this system primary care would be abundant. And I and many others have only horror stories of how big hospital systems, insurers and big pharma treat them badly. They would much rather have an empowered PCP on their side.

The only concern about primary care for patients is if the PCP is incented to not refer them to needed specialty care. In my system there would be no global capitation or risk to the PCP, and thus no incentive not to refer out. But no reason to refer out unnecessarily. They would do the right thing because it is the right thing. (It has taken Jeff Goldsmith 30 years to convince me of this). So there would be no need for insurance companies to manage primary care at all. No claims, no bills, no utilization management. Instead we should have 600,000 primary care docs paid well and able to manage their practices to do the right thing.

And this would probably involve a ton of variation. There would be PCPs who work in groups. There would be solo. There would be those specializing in specific types of patients (think kids or people with serious diseases or geriatricians). They would all make the same amount of salary but their practice’s revenue and number of patients would be adjusted in a similar way to how we do risk adjustment for Medicare Advantage now, but without the games, and with no profit motive.

This system would create a lot of innovation. PCPs would be responsible for those with chronic conditions. They would have budget from the $2,000 per head (of which they would get roughly $800 as income) to build remote monitoring programs, to use AI, to build teams of assistants and nurses et al.

So can it be done in the US? Yes it already has. I urge you to take the time to read this ingenious ChatGPT summary of the Nuka system in Alaska. (I believe created by Steve Schutzer MD). Nuka went from being a hidebound bureaucratic expensive system–that its patients hated–to being a system with culturally appropriate care that its “consumer-owners” love today. And its costs are lower and outcomes better. There are lots of other examples of similar approaches across the US.  Just ask Dave Chase. They just haven’t scaled because the current incumbents have killed them.  (One great example is this case in Texas where a hospital chain bought and killed a big primary care group led by Scott Conard because it was costing them $100m a year in reduced hospital FFS admissions).

What we need is to set up the incentives, prod doctors and patients hard to get into these arrangements and let American ingenuity and medical professionalism go at it.

The other side of the equation is the need to reign in the costs of specialty and hospital care. How this would happen is up for debate.

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What A Digital Health Doc Learned Recertifying His Boards

By JEAN LUC NEPTUNE

I recently got the good news that I passed the board recertification exam for the American Board of Internal Medicine (ABIM). As a bit of background, ABIM is a national physician evaluation organization that certifies physicians practicing internal medicine and its subspecialties (every other specialty has its own board certification body like ABOG for OB/GYNs and ABS for surgeons). Doctors practicing in most clinical environments need to be board-certified to be credentialed and eligible to work. Board certification can be accomplished by taking a test every 10 years or by participating in a continuing education process known as LKA (Longitudinal Knowledge Assessment). I decided to take the big 10-year test rather than pursue the LKA approach. For my fellow ABIM-certified docs out there who are wondering why I did the 10-year vs. the LKA, I’m happy to have a side discussion, but it was largely a career timing issue.

Of note, board certification is different from the USMLE (United States Medical Licensing Examination) which is the first in a series of licensing hurdles that doctors face in medical school and residency, involving 3 separate tests (USMLE Step 1, 2 and 3). After completing the USMLE steps, acquiring a medical license is a separate state-mediated process (I’m active in NY and inactive in PA) and has its own set of requirements that one needs to meet in order to practice in any one state. If you want to be able to prescribe controlled substances (opioids, benzos, stimulants, etc.), you will need a separate license from the DEA (the Drug Enforcement Administration, which is a federal entity). Simply put, you need to complete a lot of training, score highly on many standardized tests, and acquire a bunch of certifications (that cost a lot of money, BTW) to be able to practice medicine in the USofA.

What I learned in preparing for the ABIM recertification exam:

1.) There’s SO MUCH TO KNOW to be a doctor!

To prepare for the exam I used the New England Journal of Medicine (NEJM) review course which included roughly 2,000 detailed case studies that covered all the subspecialty areas of internal medicine. If you figure that each case involves mastery of dozens of pieces of medical knowledge, the exam requires a physician to remember tens of thousands of distinct pieces of information just for one specialty (remember that the medical vocabulary alone consists of tens of thousands of words). In addition, the individual facts mean nothing without a mastery of the basic underlying concepts, models, and frameworks of biology, biochemistry, human anatomy, physiology, pathophysiology, public health, etc. etc. Then there’s all the stuff you need to know for your specific speciality: medications, diagnostic frameworks, treatment guidelines, etc. It’s a lot. There’s a reason it takes the better part of a decade to gain any competency as a physician. So whenever I hear a non-doc saying that they’ve been reading up on XYZ and “I think I know almost as much as my doctor!”, my answer is always “No you don’t. Not at all. Not even a little bit. Stop it.”

2.) There is so much that we DON’T KNOW as doctors!

What was particularly striking to me as I did my review was how often I encountered a case or a presentation where:

  • It’s unclear what causes a disease,
  • The natural history of the disease is unclear,
  • We don’t know how to treat the disease,
  • We know how to treat the disease but we don’t how the treatment works,
  • We don’t know what treatment is most effective, or
  • We don’t know what diagnostic test is best.
  • And on, and on, and on…

It’s estimated that there are more than 50,000 (!!) active journals in the field of biomedical sciences publishing more than 3 million (!!!!) articles per year. Despite all this knowledge generation there’s still so much we don’t know about the human body and how it works. I think some people find doctors arrogant, but anyone who really knows doctors and physician culture can tell you that doctors possess a deep sense of humility that comes out of knowing that you actually know very little.

3.) Someday soon the computer doctor will FOR SURE be smarter than the human doctor.

The whole time I was preparing for the test, I kept telling myself that there was nothing I was doing that a sufficiently advanced computer couldn’t accomplish.

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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.

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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

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.

HHS’s Independence: If Not Now, When?

By DAVID INTROCASO

After having worked in DC for sixteen years, in 2013 I created The Healthcare Policy Podcast.  The title was in part intended to be sarcastic because healthcare policymaking in DC is very narrowly drawn.  Consequently, healthcare delivery is excessively commodified, reductionistic and financialized or in sum anachronistic and ironically lacking purchase.  If the policy objective was health, we’d be healthier.  We’re not.  For example, though anthropogenic warming poses the greatest threat to human health, we’ve no related healthcare policy. 

Among more conventional issues, there is no serious policy discussion regarding HHS’s mission “to enhance . . . the well-being of all Americans.  That we treat the disease not the person means we define health as simply the absence thereof.  The same for excess deaths, comparatively declining life expectancy and compressing morbidity among Medicare beneficiaries who will soon exceed 20% of the population.  As for children, HHS’s recent “Make Our Children Healthy Again” report expressed concern about children’s aerobic fitness but was silent about the prevalence of childhood sexual abuse despite Jeffrey Epstein and the Congress’s own serial child molester former House Speaker Dennis Hastert.  Bizarrely, the AMA has yet to rescind Speaker Hastert’s 2006 Nathan Davis award for “outstanding contributions to the betterment of public health.”  The HHS report was also silent about Medicaid reform even though the program provides healthcare for roughly half of US children.  It is similarly remarkable how seldom if ever names like Arrow, Canguilhem, Farmer, Foucault, Illich, Marmot, Starfield and Virchow are discussed in healthcare policy circles.  

Now after OBBBA cuts to the Medicaid and Medicare programs, 500 rounds fired into six CDC buildings, one killing a police officer, and seven months of HHS moral obliquity we are confronted with the reality that healthcare policymaking is now unambiguously on the road to nowhere.  This may be because, having failed to appreciate Richard Hofstadter, Humphrey Building leadership is busy fomenting a new chapter in anti-intellectualism.  We’re left to ask if healthcare enshittification has now been achieved possibly because healthcare policymakers have adopted Mark Manson’s “The Subtle Art of Not Giving a F*ck.”

The good news is the storm and stress about HHS no longer being fit for purpose could be effectively cured if the Congress, along with support from MedPAC, MACPAC and others, would work to free the department from politicization or partisan influence by redefining it as an independent agency.  If policymakers exercised more imagination such a simple and obvious reform would have already received serious attention.          

The idea of an independent HHS has at least been recognized.  Roughly twenty years ago Dr. Arnold Relman, the esteemed former editor of The New England Journal of Medicine, argued healthcare be managed by a “National Health Care Agency” defined as a hybrid public-private entity like, he said, the Federal Reserve.  Similarly, HHS would be governed by an independent board whose members would be nominated by the president and confirmed by the Senate for 14-year terms. 

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Lessons From The Medical Error That Orphaned A Cabinet Secretary

By MICHAEL MILLENSON

It was a small anecdote, buried in a lengthy profile in The New Yorker of Commerce Secretary Howard Lutnick, “Donald Trump’s Tariff Dealmaker-in-Chief.” But as a patient safety activist, the stark depiction of the effect of medical error felt like a sudden shock.

Lutnick, the article related, knew tragedy early in life: “his mother died of lymphoma while he was in high school; in his first week of [Haverford] college, his father was accidentally administered a fatal dose of chemotherapy. Other relatives receded into the background, leaving Lutnick and his two siblings on their own.”

A medical error and, suddenly, three kids are abruptly orphaned and effectively abandoned. With World Patient Safety Day just past us on Sept. 17, I wanted to put that devastating event into the broader patient safety context.

As is frequently the case, The New York Times obituary of Sept. 15, 1979, for Solomon Lutnick gave no cause of death. There were a handful of personal and professional details (he was a history professor at Queens College) and that he died at age 51 at Syosset (Long Island) Hospital.

Invisible Harm

Unfortunately, treatment-caused harm has often been invisible, even where it occurred. The year before Solomon Lutnick died, the first study to examine adverse events at multiple hospitals concluded that given the benefits of modern medicine, the incidence was “remarkably low.” The 1978 study, commissioned by California hospital and medical associations worried about rising malpractice premiums, was overseen by physician-attorney Don Harper Mills, who assured the worried sponsors there were few “potentially compensable events.”

There’s no indication Solomon Lutnick’s death prompted a lawsuit; he was being treated for metastatic colon cancer when a nurse accidentally administered 100 times the recommended chemotherapy dose, according to accounts Howard Lutnick has shared elsewhere. It’s unclear how Syosset Hospital reacted, but the Mills study, reflecting the attitude of many at the time, didn’t count deaths of individuals who the research team assessed would have died anyway within a year.

Even with that methodology, when in my 1997 book I extrapolated Mills’ results nationally, his “remarkably low” incidence of harm amounted to 120,000 people killed each year by medical care. I wonder whether anyone told the three Lutnick children, “Your dad was going to die soon, anyway,” and whether they found that any sort of comfort.

In 2025, addressing patient harm was long ago supposed to have become part of hospital culture, but invisibility nonetheless continues. The Office of the Inspector General of the Department of Health and Human Services Hospitals has repeatedly found that millions of Medicare patients every year are harmed by their medical care. Yet hospitals still fail to capture even half of harm events, while also failing to report two-thirds of events for which reporting is required, according to the most recent OIG report. Worse, few incidents of harm are even investigated “and even fewer led to hospitals making improvements for patient safety,” the OIG concluded.

Echoing Another Error

But it wasn’t only the way Solomon Lutnick’s avoidable death would have been minimized during that era that struck me. It also stood out for its eerie echo of a later death that became a patient safety milestone. On Dec. 3, 1994, an obituary in the Boston Globe for its personal health columnist, Betsy Lehman, related that the 39-year-old married mother of two young daughters had died at Dana-Farber Cancer Institute due to complications of breast cancer. However, it wasn’t until after a routine record review by Dana-Farber clerks found the error, which was relayed to her family and then to her Globe colleagues, that a page one story appeared on March 23, 1995, detailing how an accidental overdose of a powerful chemotherapy drug had actually caused Lehman’s death.

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New Bereavement Cost Calculator shows that grief is expensive

by EMMA PAYNE

Grief is expensive. In addition to the significant human impacts, research shows that bereavement leads to a 20%-30% increase in health care utilization.

Grief is also common. While we may not like to talk about it, 37% of Americans are grieving a recent death. The U.S. averaged 3.26 million deaths per year over the last five years and data suggests that an average of nine people grieve a single death. The CDC started measuring bereavement for the first time in 2021, but most health plans aren’t yet measuring the incidence or cost of grief.

So we decided to take a look. Here’s just some of what we found.

When a member is bereaved, health plans — especially those serving older adults — see significant jumps in utilization and costs across multiple claims categories. Examples include:

● 51% increase in Emergency Department visits and 43% increase in hospitalizations for bereaved spouses whose partners died in hospital
● 67% higher risk level for psychiatric hospitalization in the first year of bereavement for parents who have lost a child
● 74% of husbands and 67% of wives are hospitalized at least once in the nine years following the death of their spouse
● 463% higher odds of antidepressant use for people who have a prolonged grief disorder diagnosis

These increases lead to escalating claims costs that add up quickly, especially in populations 65+. But what are these costs? And what can insurers do to mitigate them?

To make these hidden costs visible, my team at Help Texts created a tool that health plans can use to model bereavement’s financial impacts. With just member numbers, the Bereavement Cost Calculator from Help Texts will estimate a health plan’s:

● Projected Per Member Per Month (PMPM) cost increase after bereavement
● Total cost impact of grief when no intervention is provided
● Estimated savings when plans provide Help Texts’ clinically sound, scalable, grief support for bereaved members

Consider a Medicare Advantage Plan with 250K members ages 65+. It should expect:
● Potential year one cost reduction (with intervention): $22.8M
● 11,500 members to be grieving the death of a partner or child
● 81,500 members to be grieving other losses (eg. parent, sibling, friend)
● Average PMPM increase (without intervention): $120
● Total estimated year one cost impact (without intervention): $134M *

What can a health plan do to save money and improve care and outcomes for its members? The numbers are powerful, showing that grief is expensive, but also that bereavement presents a clear opportunity to provide an impactful upstream intervention that can save millions, while also caring for people during what is often the loneliest time in their lives.

Help Texts is a clinically sound, scalable, bereavement intervention. With subscribers in 59 countries and all 50 states, Help Texts delivers affordable, multilingual grief support via text message. With extraordinary acceptability (95%) and 6-month retention (90%) rates, Help Texts’ light-weight solution makes it easy for health plans and others to improve health and community outcomes, while also realizing significant cost savings for those in their care.

Health Plans, particularly Medicare Advantage plans, can use the new bereavement cost calculator from Help Texts to estimate the true cost of bereavement and their cost savings when grief support is provided. The Bereavement Cost Calculator from Help Texts uncovers the savings potential when caring for grieving members. In less than a minute, you can start to see how much bereavement is costing, and how much could be saved by supporting members grieving the loss of a loved one.

Because the true cost of bereavement isn’t only emotional, it’s also financial. And for health plans, addressing both is the smartest investment you can make.

Emma Payne is the CEO of Help Texts


Does American Health Care Violate the ICJ’s Recent Climate Advisory Opinion?

By DAVID INTROCASO

In late July the UN International Court of Justice (ICJ) announced its long-awaited and highly-anticipated climate advisory opinion.  The ICJ ruling represents an historic moment in climate accountability.

“Obligations of States in Respect of Climate Change”

In a rare unanimous decision, the ICJ opinion concluded “a clean, healthy and sustainable environment” is in part a precondition for the enjoyment of human rights including the right to life and the right to health.  Consequently, the ICJ ruled states including their private actors are obligated to ensure the climate is protected from anthropogenic greenhouse gas emissions (GHGs) and can be held legally culpable by other harmed or unharmed states, groups and individuals for failing to protect the climate.

The 140-page opinion is the result of a 2023 UN resolution that requested the ICJ produce an advisory opinion answering two questions: what are states’ obligations under international law to ensure protecting the climate and what are the legal consequences for causing significant climate harm?  In a failed attempt the US State Department opposed the resolution arguing the ICJ can only consider applicable climate treaties such as the 2015 Paris Agreement and to the exclusion of other rules of international law.

In sum, the ICJ found states have substantive, urgent and enforceable obligations under UN climate treaties and international laws to prevent significant harm to the environment from GHG emissions that includes those resulting from fossil fuel use.  The court broadly defined fossil fuel use as the adoption of laws, regulatory policies and programs that promote fossil fuel production and consumption via leases, licenses and subsidies. 

States must act using “all means at their disposal” that includes adopting appropriate legal and regulatory measures, acquiring and analyzing scientific and technological information and risk and impact assessments, meeting a duty of cessation and acting in good faith that includes a duty to cooperate and collaborate internationally.  The ruling also allows for legal action to protect future generations.  The court rejected the argument attributing harm on a case-by-case basis is unachievable stating it is “scientifically possible” to determine each state’s current and historical emissions.  Without naming the US, the ICJ affirmed states not party to UN treaties must still meet their equivalent responsibilities under international law.  (Columbia’s Sabin Center Climate Change Law Blog has examined at length the ICJ opinion.)

US Healthcare’s Contribution to Anthropogenic Warming

Because the ICJ recognizes an inherent link between anthropogenic warming and human rights, the opinion implies the right to health cannot be secured without addressing US health care’s own climate obligations.  Meeting these pose a substantial challenge for the industry for several reasons.

US health care significantly contributes to anthropogenic warming.  Per Northeastern Professor Matthew Eckelman, the industry accounts for a growing amount GHG emissions currently at over 600 million metric tons of carbon dioxide equivalents (CO2e), or 9-10% of total US emissions and 25% of global healthcare emissions.  If US healthcare was its own country it would likely rank 9th, less than Saudi Arabia but more than Germany.      

Two reasons largely explain US healthcare’s carbon footprint.  The industry is immense.  Despite providing care for 4% of the world’s population, last year it constituted a $5.3 trillion market or roughly half of total global healthcare spending.  The industry wastes an enormous amount of energy.  Despite spending over $5 billion annually on energy, equivalent to at least 15% of profits, hospitals are significantly energy inefficient because they continue to consume fossil fuels to first generate heat to produce electricity that is dramatically less efficient than using renewable resources that directly generate electricity or work demand.  End-use energy inefficiency compounds the problem.  For example, only a trivial number of hospitals are EPA Energy Star certified for energy efficiency.  For the ten-year period ending in 2024, 85 or 1.4% of over 6,000 hospitals were on average certified. 

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