Category: Health Policy

Residency and Parenting Are Incompatible

Apr 22, 2025

By EMILY JOHNSON

Being a parent during residency requires one or more of the following:

● Family and/or friends nearby who are willing and able to provide free childcare

● A stay-at-home spouse/co-parent

● A spouse/co-parent who is willing to let their own career to be a distant second priority beneath family responsibilities and the resident’s career

● Significant amounts of generational wealth that allow you to outsource household and childcare obligations with money you didn’t personally earn

● High levels of financial risk tolerance and willingness to incur extraordinary levels of debt above and beyond average medical school debt ($234k!).

Because medical residency in the United States is incompatible with being a parent.

It is a Sunday evening, and I am writing this as I wait for my husband to get back from the hospital. He was “on call” today, which, in lay terms means his work hours were “all day.” He was out the door before I woke up, and it is now 9:30pm and Find My shows that he is still at the hospital. So that means he’s on hour 15 or 16 of his workday, and he could be leaving in a few minutes, or he could be there for another few hours (and I have no idea which).

I do know he got at least a 15-minute break today, because our toddler and I went to the hospital today to have lunch with him. Why interrupt his workday, drag a toddler across town right before nap time (thereby risking the loss of my cherished mid-day downtime because of the dreaded car nap), and pay for parking and mediocre cafeteria food on a Sunday? Because if I hadn’t, I truly don’t know when my son would have seen his dad next.

This pattern – out before the family wakes up, back after bedtime- is the rule, not the exception. An “early” day might mean he gets out before 7pm – but that doesn’t guarantee that he’ll see our toddler, who goes to bed between 7 and 7:30pm.

As a medical spouse with a young child, of the most infuriating comments I ever hear is among the lines of “but don’t they cap work hours now?” Or even worse – the occasional insinuation that perhaps today’s residents have it “too easy” because of work hour restrictions. Because the answer is yes – work hours are technically capped at 80 hours/week – but let’s talk about that:

First, here’s what an 80 hour/week schedule looks like, in case you haven’t worked one lately:

	Mon	Tues	Weds	Thurs	Friday	Sat	Sun
Start	6:45am	6:45am	6:45am	6:45am	OFF(but studying for upcoming board exam)	6:45am	6:45am
End	8pm	6pm	5:30pm	8pm		8pm	10pm
Total Hours	13+	11	11	13+		13+	16 (and counting)

Total: 77 + study time (Bingo! No problems here! Under 80 hours/week)

Second, from a caregiving perspective, an 80/hour week cap is laughable, because you can still miss 100% of a toddler’s waking hours most days of the week on an 80 hour/week schedule.

How Using Opioids for Acute Pain is Like Burning Coal for Energy

Apr 21, 2025

By MATT McCORD

Using opioids to treat acute pain is a lot like burning coal to power our homes. Both are legacy solutions from an earlier era. Both were once celebrated as breakthroughs. And both have since proven to be dirty, dangerous, and incredibly costly to clean up. Despite this, we continue to rely on them, even as safer, smarter alternatives sit right in front of us.

Coal fueled the Industrial Revolution—but it did so at a steep price: polluted air, poisoned water, caused respiratory illness, and climate instability. It was never a clean solution, just a convenient one. Similarly, opioids became the go-to solution for pain not because they were ideal, but because they were easy. They blunt pain quickly, require no special skill to administer, and were aggressively marketed to physicians as safe and effective. We now know the truth: opioids for acute pain can ignite a chain reaction that leads to dependence, chronic pain, disability, and even death.

Short-Term Relief, Long-Term Consequences

The similarities run deep. Coal gives you power today but saddles society with pollution and disease tomorrow. Opioids offer pain relief in the moment but often leave patients worse off in the long run. In both cases, what’s convenient in the short term creates massive long-term externalities—not for the industries that profit, but for the workers, families, and communities left to clean up the mess.

Systemic Pollution

Coal pollution clogs lungs and chokes rivers. Opioids pollute something more intimate—the brain’s natural ability to regulate pain.

Acute use of opioids disrupts normal pain modulation, leading to a phenomenon called opioid-induced hyperalgesia—a worsening sensitivity to pain. It’s like installing a furnace that makes your house colder over time, requiring more fuel just to maintain baseline comfort. That’s the trap many patients fall into after routine surgery or injury.

Hidden Costs and Broken Systems

Coal seems cheap—until you calculate the health consequences, environmental damage, and regulatory burden. The same is true for opioids. The prescription may be covered by insurance, but the downstream effects—addiction treatment, emergency room visits, lost productivity, broken families, foster care placements, criminal justice costs, and overdose deaths—are paid for by the rest of us. And the price is staggering. Like coal, opioids externalize their costs, masking the true price we all pay.

Entrenched Interests and Resistance to Change

Just as coal was propped up by powerful lobbies and outdated infrastructure, opioids have persisted because of habit, inertia, and industry influence. For decades, pharmaceutical companies promoted opioids with junk science and aggressive marketing. Today, the pharmaceutical industry continues to shape public perception—not just through lobbying, but through the media itself. Pharmaceutical companies are among the largest advertisers on television, particularly during news programming. This significant advertising presence may influence media narratives, potentially downplaying the role of prescription opioids in the opioid crisis.

As a result, the public is often fed a new narrative: that fentanyl is the problem, not prescription opioids.

How Health Systems are Losing Contact with their Clinicians

Apr 18, 2025

By JEFF GOLDSMITH

Jeff wrote this article for Hospitals & Health Networks in the July 5, 1998 edition. He republished it this week on his substack calling it a “27th anniversary edition”. It’s an enlightening piece, but as you read it please ask yourself. What, if anything, has changed, and did anything get better?–Matthew Holt

It is hard not to be impressed by the sweep of change, both in the capabilities of the American health system and in health care organizations, over the last 20 years. In the space of a single generation, health services have evolved from a cottage industry into a substantial corporate enterprise. A breathtaking array of new technologies has been added to the hospital’s diagnostic and therapeutic capability. Hospitals have also managed-though not always gracefully-the transition to a more ambulatory and community-based model of care.

Through all these changes, the hospital has remained a central actor in the health system — and despite periodic political challenges, its economic position has significantly strengthened. But this success has come at a terrible price: the increasing alienation of professionals who are the lifeblood of health care and who bear most of the moral risk of the health care transaction.

As organizations have integrated structurally, they have disintegrated culturally. Not merely physicians, but also nurses, technicians, and social workers have seen themselves transformed into commodities and marginalized by the corporate ethos of health services. Professional discontent has intensified as physician practice has become increasingly incorporated into the hospital and as health systems have begun rationing care through captive health plans.

The gulf between managers and professionals — and even between senior and middle management — has widened into a chasm. At its peak financial strength and amid a record economic expansion, the health field has grown ripe for unionization. In fact, the labor climate among health professionals has become so hostile toward management that organizing health services could single-handedly revive the dying union movement in the United States.

Some of this tension is a by-product of the pressure to reduce the excess hospital capacity that health systems have inherited. To move from the present concentration of ownership to consolidation of excess capacity will inevitably mean workforce reductions or redeployment. The fact that little actual reduction in hospital workforce capacity has taken place so far doesn’t mean that the pressure to cut jobs and improve productivity isn’t real and tangible — or that it won’t increase in the future.

But the origin of workforce problems in hospitals and health systems runs deeper than the pressure to consolidate. In little more than a generation, management of hospitals has moved from a passive, custodial, and largely benign “administrative” tradition to an aggressive, growth-oriented entrepreneurial management framework.

Saving U.S. Manufacturing: Think Biotech, Not Cars

Apr 16, 2025

By KIM BELLARD

Amidst all the drama last week with tariffs, trade wars, and market upheavals, you may have missed that the National Security Commission on Emerging Biotechnology (NSCEB) issued its report: Charting the Future of Biotechnology. Indeed, you may have missed when the Commission was created by Congress in 2022; I know I did.

Biotechnology is a big deal and it is going to get much bigger. John Cumbers, founder and CEO of SynBiobeta, writes that the U.S. bioeconomy is now already worth $950Bn, and quotes McKinsey Global Institute as predicting that by 2040, biology could generate up to 60% of the world’s physical inputs, representing a $30 trillion global opportunity. Not an opportunity the U.S. can afford to miss out on – yet that is exactly what may be happening.

The NSCEB report sets the stakes:

We stand at the edge of a new industrial revolution, one that depends on our ability to engineer biology. Emerging biotechnology, coupled with artificial intelligence, will transform everything from the way we defend and build our nation to how we nourish and provide care for Americans.

Unfortunately, the report continues: “We now believe the United States is falling behind in key areas of emerging biotechnology as China surges ahead.”

Their core conclusion: “China is quickly ascending to biotechnology dominance, having made biotechnology a strategic priority for 20 years.¹ To remain competitive, the United States must take swift action in the next three years. Otherwise, we risk falling behind, a setback from which we may never recover.”

NSCEB Chair Senator Todd Young elaborated:

The United States is locked in a competition with China that will define the coming century. Biotechnology is the next phase in that competition. It is no longer constrained to the realm of scientific achievement. It is now an imperative for national security, economic power, and global influence. Biotechnology can ensure our warfighters continue to be the strongest fighting force on tomorrow’s battlefields, and reshore supply chains while revitalizing our manufacturing sector, creating jobs here at home.

“We are about to see decades of breakthrough happen, seemingly, overnight…touching nearly every aspect of our lives—agriculture, industry, energy, defense, and national security,” Michelle Rozo, PhD, molecular biologist and vice chair of NSCEB, said while testifying before the April 8 House Armed Services Committee Subcommittee on Cyber, Information Technologies, and Innovation. Yet, she continued, “America’s biotechnology strengths are atrophying—dangerously.”

We Need to Nationalize to Prevent Fraud

Apr 15, 2025

By MATTHEW HOLT

Two weeks ago I wrote an April Fool’s piece that claimed that Elon Musk and DOGE were going to nationalize American health care to save some money. That piece was half-joking but full-serious.

If you look at what Musk is complaining about there are two major areas of “waste, fraud and abuse” in government spending.

One is people directly employed by government agencies. Most of the people I’ve ever met in government work damn hard and for much less money than they’d get in the private sector. But you can of course find stories about useless government bureaucrats, who don’t do any work and pad their expense accounts. Those stories are probably about as true as Reagan’s pink Cadillac driving welfare queen in that there is some basis in reality for there being a tiny minority of bad actors, but the politics has far outrun the truth. (BTW that Welfare Queen article by Josh Levin in Slate is remarkable and very long!)

The other major area where Musk claims to be finding fraud is in work contracted out. There are of course lots of types of government work contracted out. If, like me, you’re old enough to remember the Iraq war, you probably are thinking of beltway bandits like Halliburton supplying any number of services to the military. (Remember when the Cheneys were baddies?). Another is the Blue Cross & Blue Shield plans who were the original contractors processing Medicare & Medicaid claims. Funnily enough they couldn’t actually deliver on that so in turn they outsourced it to Ross Perot at EDS and others like ACS, later Conduent. But there’s a ton more across every agency.

Musk & DOGE have been running around in the most ham-fisted way imaginable, axing both actual employees–including 20,000 of the 80,000 working at HHS– and allegedly slashing $150 billion in contracts. Of course on closer examination, many of the “contracts” were already over, or were made up. DOGE has been a pathetic piece of performance art that would be funny if it hadn’t ruined so many careers of people doing great work, or killed so many desperately poor children in poor countries.

The clever people at Brookings, (Elaine Kamarck and Paul Light) in a detailed piece on the topic, came up with an estimate of the ratio between direct employees and contractors.

“Health Care” vs. “Healthcare” Signals Change Greater Than Grammar

Apr 14, 2025

By MICHAEL MILLENSON

“The New Yorker House Style Joins The Internet Age” announced the magazine’s daily newsletter under the byline of Andrew Boynton, whose appropriately old-fashioned title was “Head of Copy.” Among the alterations Boynton acknowledged readers might feel “long overdue,” were “Internet” becoming “internet,” “Web site” consolidating to “website” and “cell phone” becoming “cellphone.” Other quirky spellings (teen-ager, per cent, etc.) were deliberately retained.

But what about “health care” vs. “healthcare”?

A New York Times interview described Boynton as “tight-lipped” about the style changes, which came as the publication celebrated its 100^th anniversary year. When I nonetheless sought to discover whether a descriptor central to a massive chunk of the U.S. economy was more like a cellphone or a “teen-ager,” the magazine graciously responded.

“’Health care’ is our style,” a spokesperson wrote me in an email. “There has not been any discussion of diverging from this.”

Not even a discussion? This was shocking news! But as I dug deeper, it seemed to me that the choice of the one-word versus two-word term often sent an underlying signal about the evolution of not just language, but of health care as both a profession and an industry.

Debating Evolution

Back in 2012, after I dived into the “health care vs. healthcare” debate for The Health Care Blog, my friend and colleague, the determinedly data-driven David Muhlestein, PhD, JD, accused me of ignoring language evolution by insisting on the “two words” usage. He eventually presented me with Google searches showing that the ratio of uses of the one-word to the two-word term ineluctably indicated “health care” was going the way of “Web site.”

When I solicited a 2025 update, Muhlestein obliged with a Google trends graph tracing relative usage since 2004.

Apart from a brief time that “health care” was more prevalent as discussion of the Affordable Care Act dominated the news, the preference for “healthcare” has steadily strengthened. “As of now, people use the one-word version more than twice as often as two words,” Muhlestein wrote in an email.

He added, “You can’t predict how language will evolve, you just have to go with what it is, and for the U.S., healthcare is definitely going to one word.”

Perhaps. But even a cursory qualitative analysis suggests a more nuanced picture than volume alone provides. After poking into the preferences of publications, corporations, the U.S. government and others, I decided that a 2022 April Fool’s column in Health Affairs actually provided a rough guide to understanding many usage decisions.

Elevare Law launches!

Apr 11, 2025

There’s a new health innovation law firm in town! Rebecca Gwilt & Kaitlyn O’Connor have started Elevare Law to help health tech companies. We spent a little time talking about the new firm and who it’s going to work with, and a lot about the different legal and regulatory challenges facing digital health companies. Deep dives into the regs around RPM, RTM & more, and also a lot about what we might expect from the FDA and the rest of the chaos in the new Administration. Plus a little about how AI helps lawyers be more efficient and a lot about how AI may or may not be influenced by health care regulation (TL:DL, it’s going to be slow & state by state) –-Matthew Holt

The World’s Psychoactive Drug of Choice

Apr 4, 2025

By MIKE MAGEE

Question: What is the world’s most widely used psychoactive drug?

Answer: Caffeine

In the U.S., caffeine is consumed mainly in the form of coffee, tea, and cola. But coffee dominates. Worldwide, humans consume over 10 million tons of coffee beans a year. Roughly 16% (1.62 million tons) is devoured by Americans. The daily intake of caffeine varies depending on type of beverage and brand as the chart below indicates.

On average, each American consumes approximately 164 mg of caffeine each day. That’s roughly 1 small cup of Dunkin or (3.5) 12-ounce Diet Cokes (Trump consumes at least 12 cans of Diet Coke a day).

Across the globe, daily consumption of caffeine is close to universal. Eight in 10 humans consume a caffeinated beverage daily. That makes this chemical substance the “most commonly consumed psychoactive substance globally.” Its popularity is related to its ability to deliver three useful physiological enhancements – wakefulness, motor performance, and cognition.

Chemically, caffeine is a close cousin of adenosine which is present in brain neurons. Adenosine builds up in synaptic connections between brain neurons. When it binds to special receptors, it activates neurons that promote sleepfulness. Ingested caffeine is water and lipid soluble, and therefore is able to traverse the blood-brain barrier. Once inside, its chemical structure mimics that of adenosine, and it occupies adenosine receptors because it shares the same approximate shape and size. When these receptors are occupied by caffeine, adenosine molecules are unable to activate the receptors. The net effect is wakefulness.

Musk Moves US to Socialized Medicine

Apr 1, 2025

By THCB STAFF

After a few weeks analyzing government spending and putting all of his calculations into Grok, the head of DOGE, Elon Musk, has made another decisive move in the attempt to save the government money. Speaking on the Joe Rogan show, Musk declared that his team had given Big Balls and Little Balls instructions to stop screwing around with the minor stuff like cutting off foreign aid saving the lives of children or getting all worked up about storing paper records in a mine, and to “go after the real money”. It turns out that means putting all US health care into a national health service and eliminating all private, non state-run health care.

He told Rogan, in between injections of what he claimed were vitamin supplements, that “the DOGE team realized that the British government spends about $7,500 per capita on health care, and the US government spends about $8,000”. After observers noticed a few puffs of smoke coming from Musk’s side of the room he went on to say, “that means our government can use the example of the Brits and cut spending by $500 a head and as an added bonus, private employers can stop wasting money on health care premiums”. When asked by Rogan if this new move was influenced by his desire to cut costs at his companies, Musk appeared to be unaware that he ran any companies.

Musk went on to say, “it’s incredible that we’ve been giving all these hospitals and health insurers government money and they’ve been sticking it in their hedge funds. Little Balls told me that he read a post from some blogger claiming that there’s over $500 billion sitting on the balance sheets of big hospitals and non-profit health plans. Now we have nationalized them all, that money can be put to better use.”

Rogan asked him how this would work and Musk said that all doctors, nurses and hospitals now worked for the Federal government and could just deliver care for free. “They’ll be paid British wages, and they’ll be happy–British people are still rich enough to be buying Teslas, no one else is! And if the line is too long, then people can fly to Scotland where they’ve got this socialized health care thing down pat. I understand President Trump has a special going at his hotel on that golf course, if you don’t mind looking at the windmills.”

When asked whether he supported Musk’s move, President Trump told the White House press corps that he wasn’t on the group call but that Don Jr had mentioned that Adderall was free in the UK, so it seemed like a good idea to both of them.

In unrelated news, Tesla also announced a stock buy-back in the amount of $500 billion.

Emory, Balloon Angioplasty, and the Musk Attack on Medical Diplomacy

Mar 28, 2025

By MIKE MAGEE

“The recently announced limitation from the NIH on grants is an example that will significantly reduce essential funding for research at Emory.”

Gregory L. Fenes, President, Emory University

In 1900, the U.S. life expectancy was 47 years. Between maternal deaths in child birth and infectious disease, it is no wonder that cardiovascular disease (barely understood at the time) was an afterthought. But by 1930, as life expectancy approached 60 years, Americans stood up and took notice. They were dropping dead on softball fields of heart attacks.

Remarkably, despite scientific advances, nearly 1 million Americans ( 931,578) died of heart disease in 2024. That is 28% of the 3,279,857 deaths last year.

The main cause of a heart attack, as every high school student knows today, is blockage of one or more of the three main coronary arteries – each 5 to 10 centimeters long and four millimeters wide. But at the turn of the century, experts didn’t have a clue. When James Herrick first suggested blockage of the coronaries as a cause of heart seizures in 1912, the suggestion was met with disbelief. Seven years later, in 1919, the clinical findings for “myocardial infarction” were associated with ECG abnormalities for the first time.

Scientists for some time had been aware of the anatomy of the human heart, but it wasn’t until 1929 that they actually were able to see it in action. That was when a 24-year old German medical intern in training named Werner Forssmann came up with the idea of threading a ureteral catheter through a vein in the arm into his heart.

His superiors refused permission for the experiment. But with junior accomplices, including an enamored nurse, and a radiologist in training, he secretly catheterized his own heart and injected dye revealing for the first time a live 4-chamber heart. Two decades would pass before Werner Forssmann’s “reckless action” was rewarded with the 1956 Nobel Prize in Medicine. But another two years would pass before the dynamic Mason Sones, Cleveland Clinic’s director of cardiovascular disease, successfully (if inadvertently) imaged the coronary arteries themselves without inducing a heart attack in his 26-year old patient with rheumatic heart disease.

But it was the American head of all Allied Forces in World War II, turned President of the United States, Dwight D.Eisenhower, who arguably had the greatest impact on the world focus on this “public enemy #1.” His seven heart attacks, in full public view, have been credited with increasing public awareness of the condition which finally claimed his life in1969.

Cardiac catheterization soon became a relatively standard affair. Not surprisingly, less than a decade later, on September 16, 1977, an East German physician, Andreas Gruntzig performed the first ballon angioplasty, but not without a bit of drama.

Dr. Gruntzig had moved to Zurich, Switzerland in pursuit of this new, non-invasive technique for opening blocked arteries. But first, he had to manufacture his own catheters. He tested them out on dogs in 1976, and excitedly shared his positive results in November that year at the 49th Scientific Session of the American Heart Association in Miami Beach.

He returned to Zurich that year expecting swift approval to perform the procedure on a human candidate. But a year later, the Switzerland Board had still not given him a green light to use his newly improved double lumen catheter. Instead he had been invited by Dr. Richard Myler at the San Francisco Heart Institute to perform the first ever balloon coronary artery angioplasty on an awake patient.

Gruntzig arrived in May, 1977, with equipment in hand. He was able to successfully dilate the arteries of several anesthetized patients who were undergoing open heart coronary bypass surgery. But sadly, after two weeks on hold there, no appropriate candidates had emerged for a minimally invasive balloon angioplasty in a non-anesthetized heart attack patient.

In the meantime, a 38-year-old insurance salesman, Adolf Bachmann, with severe coronary artery stenosis, angina, and ECG changes had surfaced in Zurich. With verbal assurances that he might proceed, Gruntzig returned again to Zurich. The landmark procedure at Zurich University Hospital went off without a hitch, and the rest is history.