Dr. Sophia Yen is the Chief Medical Officer (and Founder) of Pandia Health. She is about as expert as it comes on the topics contraception, emergency contraception, medication abortion, menopause and lots more. Her PR peeps asked if I’d interview her about Pandia Health, which is a fantastic online clinic & pharmacy for women at basically all ages. But I couldn’t have her on THCB without having her tell all about the world of contraception, menopause and of course reproductive health. I promise you that if you are a woman or somone who knows a woman, this is a fascinating interview. You will learn a lot, and there are lots of suggestions for how to manage many aspects of your health–Matthew Holt
Convention Invisibility Teaches A Crucial Health Policy Lesson
By MICHAEL MILLENSON
It’s close to an iron rule: Politics drives policy. In that context, the health policy issues that were largely invisible at the Republican and Democratic conventions taught a crucial political lesson.
Start with access. According to KFF (formerly the Kaiser Family Foundation), more than 25 million Americans have been disenrolled from Medicaid as of Aug. 23. Ten states, all dominated by Republican legislatures and/or governors, have declined to expand the program, leaving 2.8 million Americans unnecessarily uninsured.
Yet if you were looking to either convention to find protestors telling heart-rending personal stories to humanize those statistics, you’d search in vain. There were none.
The Poor People’s Army, a group advocating for economic justice, did invite reporters covering both conventions to focus on one of the most urgent issues facing the poor and near-poor – not medical care access, but the lack of basic housing.
Homelessness set a record in 2023, according to the National Alliance to End Homelessness, affecting one in 500 Americans, while the number of renters forced to pay more than 50 percent of their income has surged since 2015. The former is apparent on the streets of every big city, while the latter is felt by millions in every paycheck.
The political lesson is clear. While support for Medicaid expansion was buried deep in the Democratic platform, at the grassroots level there’s no sign of the kind of passionate involvement that could drive votes in a close election. Medicare, of course, is a separate issue, with both parties promising to protect the program dear to the hearts of the nation’s elderly, who have the highest percentage voting turnout of any age group.
Of course, even those with good health insurance often have to worry about medical costs, with KFF polling finding that a shocking 41% of U.S. adults have medical debt. However, although the phrase, “It’s the prices, stupid!” has become a bipartisan policy refrain, there are no swing state votes to be swung by harping on the alleged cupidity of the local hospital. So while denouncing “medical debt,” no one did.
On the other hand, Democrats spoke repeatedly about the depredations of “Big Pharma.” The GOP platform satisfied itself with a vague promise to “expand access to new…prescription drug options” to address prescription drug costs that “are out of control.” The responsibility for those prices was unspecified.
As for health insurers, articles about questionable denials of medical claims by giant insurers like United Healthcare and Humana have garnered headlines and expressions of outrage. Once again, however, the grassroots reaction is the key. There has been no outpouring of public indignation remotely comparable to the HMO backlash of the 1990s. As a result, health insurers have largely vacated the role of politically visible corporate villain.
Continue reading…How’s Human Evolution Going? The Harris-Walz Health Policy team wants to know.
By MIKE MAGEE
Clearly the Harris-Walz ticket has been doing their homework. Last week, the book above was spotted on one prominent thought-leader’s pile: “Human Evolutionary Demography.” It’s a 780 page academic Tour de force read by veteran scientist Oskar Burger, leader of the Max Planck Institute for Demographic Research and the Laboratory of Evolutionary Biodemography.
That’s the Institute founded in 1917 in Berlin whose first director was Albert Einstein. These days, its researchers work (in an age of “alternate facts”) to separate justified belief from opinion. Their major focus is on “categories of thought, proof, and experience” at the crossroads of “science and ambient cultures.”
This is the field of Human Evolutionary Demography, a blending of natural science with social science. Demographers study populations and explore how humans behave, organize and thrive focusing heavily on birth, migration, and aging.
This has been a year of just that in American politics. First, the fallout of the Dobbs decision caught Republicans with their electoral pants down in reproductive freedom referendums in Kansas, Michigan, Kentucky and Vermont. Southern migration of Democrats to former red states like Michigan, Arizona, Georgia, and North Carolina have turned them various shades of purple. And this summer, octogenarian candidates from both parties have been all the rage, literally.
Up until July 21, 2024, the race for the Presidency was between two aging candidates with visible mental and physical disabilities. The victor was destined to a term of office that would extend into his 80’s.
The emergence of Kamala Harris as the Democratic nominee was a reflection of the electorates growing discomfort with turning a blind eye to the realities of aging. It also suggested that Americans, especially Gen X’ers, have grown tired of Boomer dominance in the lives of an increasingly multi-cultural America – tired as well of growing income disparity, attacks on reproductive freedom, and declining life expectancy in America.
But why the sudden interest in “Human Evolutionary Demography?” The answer lies in the numbers. Back in 2012 Oskar Burger studied Swedes and noted that in 1800 their life expectancy was 32 years. They gained an additional 20 years in the century that followed, and 30 more years by 2000.
What stumped Burger was not the gains over these two hundred years. Instead he focused on the question, “Why did it take the human race so long to progress?” The bottom line is this, we left chimpanzees behind in the evolutionary dust some 6.6 million years ago. We limped along, not faring very well, for all but the last 200 years. In the past century, a moment in time spanning just 4 of our historic 8000 plus human generations, we took off.
This period coincided with rapid scientific and technologic advances, cleaner air and water, greater nutritional support, improved education and housing, expanded public health related governmental policy, and establishment of a safety net for our most vulnerable citizens.
But in the past decade, growth in U.S. life expectancy has all but stalled. For the first time, we actually saw declines each year from 2014 to 2019. For the decade just past, the numbers improved overall by less than 1/2 of 1 %. When first studied, declines were blamed on losses in working age adults due to trauma, addiction, suicide or “deaths of despair.”
But recent studies reveal losses due to poor maternal/fetal care, especially in red states, and made worse by fallout of the Dobbs decision. A second complicator has been losses starting at age 65 from complications of cardiovascular disease and diabetes, made worse by obesity and poor health care follow-up.
This has led the Max Planck Institute to issue an alert to U.S. health experts: “Our findings suggest that the U.S. faces a ‘double jeopardy’ from both midlife and old-age mortality trends, with the latter being more severe.”
Women’s reproductive advocates say it’s really a “triple jeopardy” demanding grass roots advocacy focused on access today, and political victory up and down the ballot in November. In their words, “Today, and every day, we work to ensure that every patient who seeks sexual and reproductive health care can access it, and to build a just world that includes nationwide access to abortion for all — no matter what.”
If this is true, a careful read of “Human Evolutionary Demography” could direct a 3-prong approach for the health policy leaders in the Harris-Walz campaign:
- Expanded safety net to address “deaths of despair.”
- Expansion of the ACA toward Universal Health Insurance to address the chronic disease burden of older Americans.
- Federal guarantees of reproductive freedom and open access to reproductive care.
Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)
“Moral Distress” Has Arrived On Health Care’s Stoop
By MIKE MAGEE
When Andrew Jameton, a Nursing Professor at the Department of Mental Health and Community Nursing at UCSF in 1984 published “Nursing Practice: The Ethical Issues”, the term “Moral Distress” was a novel term in clinical health care. It focused primarily on “care that they were expected to provide but ethically opposed.”
Over the past four decades, the definition has expanded and now encompasses the “inability to provide the care that one feels morally compelled to provide.” Beyond its’ impact on individual health professionals, it has growing health policy implications, explosively reverberating in the wake of the recent Dobbs decision.
There are approximately 1600 health care facilities nationwide that provide abortion care in the U.S. In the wake of the Dobbs decision overturning Roe v. Wade, 14 states have near complete bans on all abortions and this reproductive care is severely restricted in an additional 11 states “with few or no exceptions for maternal health or life endangerment.”
The impact of these rulings has created not only a moral dilemma for health professionals, but also intense legal jeopardy. As one Tennessee Obstetrician recently put it, “There are weeks when I commit multiple felonies.”
There now exists a validated psychometric tool to measure the mental health impact of the Supreme Court’s actions called the Moral Distress Thermometer(MDT). Experts recently surveyed 310 practicing clinicians involved in women’s reproductive health care, with a focus on comparing moral distress in those from restricted versus unrestricted states. What they reported in JAMA was that those in restricted vs. protected states had scores on the MDT that were more than double their comparators.
As one might expect, high scores on the MDT also correlate with higher rates of job burnout and attrition. This means lower rates of abortion care, but also a smaller maternal health workforce overall. This is in states that had already been lagging behind in access to obstetrical and reproductive health care in general. Clinical shortages are expected to rise in the months approaching an historic Presidential election.
Project 2025’s agenda for future women in America is much more expansive and aggressive than restriction of abortion alone. Trump’s denials aside, his selection of JD Vance as a running mate signals an intent to thoroughly engage in restriction of women’s reproductive rights in allegiance with a Supreme Court that appears equally committed.
With that in mind, the massive response to the Harris-Walz ticket appears to be offering a response that appears to be go well beyond simple “weird” labeling. Those words are a promise to each other, “We’re not going back.”
Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)
Fake News from MedPac on Medicare Advantage Needs to Be Corrected, Part 2
By GEORGE HALVORSON
Special Needs Plans Change Lives for The Lowest Income and Highest Need Patients
The people who benefit the most from Medicare Advantage are clearly the very low-income and high health-need people who are eligible for both Medicare and Medicaid as programs and who enroll as members in the Medicare Advantage Special Needs Plan programs.
There clearly aren’t any other programs existing in our country that do more good for large numbers of needing people than the Medicare Advantage Special Needs Plans do for those members.
Those people with that dual eligibility are in major need for care.
We have millions of retirees who are eligible for both programs who have gone through years of inequities, inadequacies, and deficiencies relative to our care systems for a number of reasons, and who are now in need of care and support at multiple levels in their lives.
The plans do extremely good things for those high-need patients.
Medicare Advantage Special Needs Plan programs now help and provide services to millions of people who’ve actually never had good or adequate care in their entire lives.
The Special Needs Plan programs for Medicare Advantage reach into people’s homes and provide layers of service and support that are life changing, badly needed, and the Special Needs Plans are much appreciated, with very high satisfaction levels from the patients they serve for that better care and far better life support levels.
We tend, as a country, to abandon and under serve people in too many settings and communities who are old and who have no money and who are in significant need of care. The Medicare Advantage programs do wonderful and badly needed things for many of those patients that we need to understand, appreciate, and then protect as we look at Medicare Advantage plans and the overall Medicare Advantage programs and approaches.
The people at MedPac who are trying so hard to reduce the benefit levels for Medicare Advantage members and who do shamelessly inaccurate, distorted, and clearly intentionally fake news pieces on the cost of Medicare Advantage plans are trying to undermine and weaken the Special Needs Plan program in order to somehow create a level playing field with higher income patients for Medicare for the patients who get the most benefits from those programs.
That’s a very bad practice, and protecting those high-income people is a very wrong functional priority for MedPac to have. But they have it year after year in uncaring, insensitive, and cold ways relative to those patients and they seem impervious to data and information from all of the plans about those patients and that care, and their need for those benefits and services in their lives.
We need MedPac to clean up their act relative to their lowest income people, and we need them to start telling the truth about the actual relative cost of Medicare Advantage.
And we very much need them to understand how much the lowest income members need those benefits.
We need them to stop saying that the plans are overpaid when they know better from having more than 6 million people enrolled as Special Needs Plan members and benefit levels, and when they know that two out of three of the lowest income Members are in plans, and it should be painfully obvious to even the most cold-hearted observer, that those people clearly need the care and benefits that they get there from the plans.
The Medicare Advantage attacks from MedPac in their current report now say that the total cost of Medicare Advantage is 22% higher than those members would have cost as normal Medicare members.
They actually say in their most recent report that if all of the Medicare Advantage enrollees were now actually enrolled in fee-for-service Medicare, those enrollees who are currently in the plans would cost 22% less money for the overall Medicare program.
That’s obviously impossible and it’s a complete fabrication that they do not support in their document with even a wisp of data.
They use that false information, and they use a very skillful and intentional fake news context to attack the plans with that information.
Continue reading…Fake News from MedPac on Medicare Advantage Needs to Be Corrected, Pt 1
By GEORGE HALVORSON
MedPac has just released a report on Medicare Advantage that’s incorrect on multiple key points that need to be corrected.
Medicare Advantage currently enrolls the majority of Medicare members in the country, and it’s now the new basic plan for the Medicare program because of that majority enrollment level.
That’s very good news for Medicare because the average cost for those members is significantly less than those members would’ve cost under fee-for-service Medicare — and we can be comfortable and know that the lower cost is permanent because of the way we pay for the program.
The plans are paid a capitation for each member, and they’re not paid a fee for each piece of care that’s delivered to Medicare patients.
The capitation is an excellent purchasing approach for the program because it limits the amount paid for the enrollees, and when that amount, paid in capitation, is lower than the average cost of care for the traditional Medicare members, it guarantees that those lower costs will be paid for those members for the Medicare program, and that those costs will continue to be lower for Medicare.
The program that’s used to set the bids for the plans annually calculates the average cost of the traditional Medicare program in every county, and then lets the plans bid for the amount they will be paid for their members for the next year.
Those average costs for Medicare members are accurately calculated, and they’re based on consistent information that Medicare records, computes, and then reports on actual spending in every county by fee-for-service Medicare for the members every year.
The plans look at the information from the fee-for-service Medicare program in every county each year and then they each bid a capitation that’s always lower than that average cost, because those average Medicare costs are actually higher than the Plans need to provide the full set of required care for their members.
That bidding process guarantees that the plans will cost less than fee-for-service Medicare because it’s legitimately, appropriately and accurately based on the actual costs of that program in every county as the starting points for the bids each year.
We know that’s how much Medicare costs in every county using those numbers — and when the plans submit bids that are lower than that average cost, we know that the lower amount in those bids represents actual savings to the Medicare program.
In the world of insurance, having a bid that sets and determines the payment level for the coverage from every plan is a competent, appropriate, intellectually sound, financially legitimate, accurate, and fully functional payment approach and price for Medicare to spend on that coverage as a buyer.
Medicare is a buyer for Medicare Advantage and not just a payer as it is for the rest of the fee-for-service Medicare program.
Once the bid is set, all of the concerns, worries, risks, and uncertainties of the payment process that people used to have about the payments disappear, because that bid amount is exactly how much the plans will be paid for their members and it can’t be modified or changed in any way by the plans.
There are no possible upcoding approaches or risk pool manipulation processes or any possible subsequent plan fudging on the right cost for payments based on the risk levels of the patients that can happen for those payments because the capitation payment is the only one that Medicare will give to the plans, and that locks the cost in place.
That protection against future up coding problems is clear and true because the bids are the final payment to the plans, and there’s no way of doing any kind of risk-pool manipulation after the fact to create any level of overpayment after that capitation payment is made to each plan.
CMS Uses Good Encounter Data to Get that Risk-Level Information
CMS now has very good information about the actual risk levels of the members because they competently, appropriately, effectively and completely eliminated all of the old coding systems that were using estimates from the plans that they previously used to get the patient risk-level information to create the payments.
They replaced that old data flow from the plans with actual encounter data from the care delivered to each patient with information about each actual encounter, and that encounter data at the point of care ties back to the actual medical records that exist and that are used in the care settings for each patient.
The risk levels of the members in the plans are now determined and set by an extremely accurate process that uses the actual care encounter reports for each patient that are filed with the Medicare program to get each diagnosis for each piece of care.
There were some earlier systems for paying the plans that were built on plans filing data about the risk levels of the members, and there were some instances where some plans did filings in ways that upcoded and increased their payment levels, but CMS has actually completely eliminated and cancelled those old processes and reports, and now gets the needed diagnosis data for the payment system from the actual encounters that are filed by the providers for each piece of care.
We now have very current data about the patients, and the reporting process is extremely accurate in its information flow.
Continue reading…What will Harris mean for Health Care? – Not much
By MATTHEW HOLT
The Democratic convention wrapped with a fine speech from Kamala Harris, star power from the Obamas and Clintons, and a bunch of Republicans telling their ideological brethren that it was better to be a Democrat than a Trumper. More importantly no Beyonce/Taylor Swift duet–as we were promised by Mitt Romney.
There was a lot of talk about some aspects of health care. But overall if Harris wins, don’t expect much change to the current health care system.
Why not?
First there’s the pure politics. The Dems need to win back the House (probable but not certain) and hold the Senate to pass legislation. Right now they have a 51-49 edge in the Senate. Most likely that goes to 50-50 as the Republicans will definitely pick up Joe Manchin’s seat in West Virginia. There’s a series of seats the Dems currently hold in close races (Montana, Ohio, MIchigan, Nevada, Arizona) that they’ll need to keep to maintain it at 50-50, and it’s hard to see any pickups from Republicans (perhaps Florida or Texas if you squint really hard). The good news is that Manchin (WV) and Sinema (AZ) will soon both be gone, so the Dems that will be there won’t be as difficult to persuade to follow a Presidential agenda. But that will still leave Walz as VP to do what Harris did and pass a bunch of deciding votes under reconciliation, which massively limits what the legislation can do–it has to be “budget related.”
Which leads us to what we have been hearing from Harris and her campaign about health care? We’ve heard a lot about issues that have impacts on health, specifically creating affordable housing and fighting child poverty, but little that is directly related to health care itself. Really only two issues stand out. Abortion and reproductive rights, and drug prices.
Clearly Harris will take a swing at reversing Dobbs and passing a national right to abortion. This will need either a packing of the Supreme Court (my favorite) or ending the filibuster or both. Either of these will be incredibly tough to pull off constitutionally and politically and will take huge amounts of political oxygen. Of course the cynics would say, the Democrats are better off leaving this as an issue to use to beat up the Republicans on. But if it gets done, womens’ and reproductive rights will only be back where they were in 2022.
Regarding the cost of drugs, there will continue to be much justified bashing of big pharma, but the extension of insulin price controls is something that (eventually) the market via CivicaRX and others is getting to anyway. Meanwhile the IRA gave Medicare the right to negotiate drug prices and the results are not exactly earth shattering. For example, CMS says it’s negotiated the cost of blood thinner Eliquis from about $6,000 a year to under $3,000 This sounds good until you realize that the price is only that high because of patent games the manufacturer BMS plays in the US, and the price in the rest of the world is under $1,000. We’ll hear more about this as the price cuts come into effect, (although not till 2026!) and more drugs get negotiated, but overall this isn’t exactly an earth-shattering change.
Finally there’s already a guaranteed fight about extending the premium subsidies for ACA plans. These were first in the pandemic American Rescue Act, then extended in the IRA, but they currently are scheduled to end in 2025. It’s hard to imagine them not being extended further whatever the makeup of the Senate, assuming a Democratic House of Representatives. (A Marjorie Taylor Greene speakership does give me pause!). But again there’s nothing new here and the overall flavor of expensive premiums and high deductibles in the current ACA marketplace won’t change.
So what’s not going to happen? Virtually all the interesting stuff we were promised by Harris and for that matter Biden in 2020. You may have missed the one actual “policy-first” speech at the convention which came from Bernie Sanders. To be fair a lot of his agenda was already in the Biden legislation. That was no accident as Biden deliberately reached out to him in 2020 and 2021 and enacted a pretty radical agenda on infrastructure, climate, industrial policy and more. And when I say radical I mean milquetoast social democrat by European standards! But what wasn’t in that agenda? No Medicare for all, which Bernie ran on in 2019/20 and brought up again at the convention. Who else proposed that in 2019? Why, a certain Kamala Harris. That never made it into the Biden agenda. We didn’t even get legislation introduced about lowering the Medicare age to 60, which was a campaign promise. There’s been no conversation about any of this from Harris or from Biden before he withdrew. It’s just a bridge too far.
Which leads to the stuff that gets debated about in THCB and elsewhere as to how the system actually works. There’s been nothing about Medicaid expansion (or its continued contraction). No talk about reining in hospital consolidation. No mention even of insurers gaming Medicare Advantage or private equity buying up physician practices. Nothing about the expansion of value-based care.
What we can expect in a Harris administration is more of the same from CMS and potentially a slightly more aggressive FTC. That will mean continued efforts to veer slightly away from fee-for-service in Medicare, a few more constraints on the worst behavior in Medicare Advantage, and possibly some warning shots from the FTC about hospital monopolies. But the trends we’ve seen in recent years will largely continue. We’re not getting a primary-care based capitated system emerging from the wreckage of what we have now, and unlike the Clinton and even Obama administrations, there’s not even any rhetoric from Harris or Biden about how that would be a good idea.
So politically I don’t think the Harris administration will be very exciting for health care. And if the other guy wins, as Jeff Goldsmith wrote on THCB last month, expect even less.
Take My Gun, I Mean, Phone, Please
By KIM BELLARD
I understand that states are “racing” to pass laws designed to help protect school-aged kids against something that has been a danger to their mental and physical health for a generation now, as well as adversely impacting their education. Certainly I’m talking about reasonable gun control laws, right?
Just kidding. This is America. We don’t do gun control laws, no matter how many innocent school children, or other bystanders, are massacred. No, what states are taking action on are cellphones in schools.
Florida seems to have kicked it off, with a new last year banning cell phones and other wireless devices “during instructional times.” It also prohibits using TikTok on school grounds. Indiana, Louisiana, Ohio, and South Carolina followed suit this year, although the new laws vary in specifics. Connecticut, Kansas, Oklahoma, Washington, and Vermont have introduced their own versions. Delaware and Pennsylvania are giving money to schools to try lockable phone pouches.
It’s worth pointing out that school districts were not waiting around for states to act. According to a Pew Research survey earlier this year, 82% of teachers reported their district had policies regarding cellphones in classrooms. Those policies might not have been bans, but at least the districts were making efforts to control the use.
Surprisingly, high school teachers – whose students were most likely to have cellphones — were least likely to report such policies, but, not surprisingly, the most likely to report that such policies were difficult to enforce. Also not surprising, 72% of high school teachers say students being distracted by cellphones in the classroom is a major problem.
Russell Shaw, the head of school at Georgetown Day School in Washington, D.C., writes in The Atlantic that his parents were given free sample packs of cigarettes in school, and warns:
I believe that future generations will look back with the same incredulity at our acceptance of phones in schools. The research is clear: The dramatic rise in adolescent anxiety, depression, and suicide correlates closely with the widespread adoption of smartphones over the past 15 years. Although causation is debated, as a school head for 14 years, I know what I have seen: Unfettered phone usage at school hurts our kids.
Similarly, last year Jonathan Haidt, a social psychologist at NYU, urged emphatically: Get Phones Out of School Now. At the least, he writes, they’re a distraction, harming their learning and their ability to focus; at worst, they weaken social connections, are used for bullying, and can lead to mental health issues. “All children deserve schools that will help them learn, cultivate deep friendships, and develop into mentally healthy young adults,” Professor Haidt believes. “All children deserve phone-free schools.”
Mr. Shaw agrees. “For too long, children all over the world have been guinea pigs in a dangerous experiment. The results are in. We need to take phones out of schools.”
Believe it or not, not everyone agrees. Some argue that, like it or not, our world is filled with cellphones, and to try to pretend that is not true will just make it harder for kids once they become adults. Along those lines, skeptics note that classrooms are filled with other devices; if kids aren’t distracted by their cellphones, there’s usually a tablet, laptop, or other device handy. And the kids can argue, hey, the adults – the teachers, the administrators, the volunteers – all have cellphones; why shouldn’t we?
Some parents are opposed to the bans. They want to know where their kids are at all times, and to be able to track them in case of an emergency. Even more chilling, some parents argue that if there is a school shooting, they want their kids to be able to call for help, and to let them know their status. None of us can forget the heartbreaking calls that some of the Uvalde children made.
Of course, even if cellphones are banned during class time or even on school grounds entirely, those phones are going to be there once they leave the school grounds, so their potential for adverse mental impacts will still be there. If distraction is the problem – and I can see where it would be – isn’t it a similar problem for adults? How many meetings, conferences, or social situations have you been in where many of the adults are paying more attention to their phone than to whatever is being discussed?
I wonder if the Supreme Court has a policy about cellphones during its deliberations.
All this brings me back to guns. According to the K-12 Shooting Database, there have already been 193 school shooting incidents already this year, with 152 victims (fatal and wounded). That compares to 349 and 249 respectively in 2023, and 308/273 in 2022. I needn’t point out – but I will – that no other nation has numbers anywhere close to those.
I recently read John Woodrow Cox’s searing Children Under Fire. He points out that, even beyond the fatalities, wounded kids need not just medical care but ongoing mental health treatment. Their families usually need it too. The trauma goes well beyond the direct victims. The victim’s classmates and families often need it as well, as do schoolchildren in other districts, even in other states. Even practicing lockdowns have an impact on mental health.
He estimates that there are millions, perhaps tens of millions, of impacted schoolchildren and their families. Yet states aren’t racing to ensure support for all those victims.
Mr. Cox suggests that the least we could do, the very least, are to ensure more background checks, to hold adults more responsible for the guns in their homes, and to conduct more research on gun violence. Instead, states are rushing to “harden” schools and to get more people with guns guarding (and teaching in) those schools.
Oh, and to ban cellphones. We must have priorities, after all.
Look, if I was a teacher, I’d hate seeing kids on their phones during class. If I was administrator, I’d be worried about kids hanging out on their phones instead of talking with each other. If I was a parent I’d be nagging my kids to study or read a book instead of being on a screen. I get all that; I understand the drive to better manage cellphone use.
But if people think cell phones are more of a danger to their kids than gun violence, I’m going to have to disagree.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor
What the Health System Can Expect from a Second Trump Term
By JEFF GOLDSMITH
Though the results of the November election are by no means a foregone conclusion, it is worth thinking about how a second Trump administration might affect the nation’s $4.7 trillion health system. People were not the problem with the first Trump term; his healthcare team was strong and capable: Alex Azar, Scott Gottlieb, Seema Verma,. Bret Giroir, Brad Smith etc.
After the embarrassing political failure of Repealing and Replacing ObamaCare in 2017 (for which blame look to his White House staff), his healthcare team settled in to a quiet and unremarkable term until the COVID wave broke over them and helped drive them out of office. It was not merely ironic but deeply disturbing that MAGA politics prevented Trump from claiming credit for the Operation Warp Speed vaccine miracle his team produced.
A second Trump term would likely be very different- both more ideologically driven but also fiscally constrained. The people part is completely unreadable at this early hour. But health policy will almost certainly be a second tier priority because trade and tariffs, conflicts with our traditional allies and trading partners, and inflamed social issues like illegal immigration, wokeness, and abortion will crowd out changes in health coverage, costs and payment policy.
Show Me the Money!
However, fiscal pressures will force a second Trump administration to confront federal health spending and set him on a collision course with the hospital and pharmaceutical industries, two of the three largest organized actors in healthcare. Trump inherits a 2024 $5 trillion federal budget with a $1.7 trillion deficit, an anomalous degree of fiscal stimulus at the height of an economic boom. That deficit is also a major driver of the inflation Trump has promised to conquer.
Trump is committed to reauthorizing the individual tax cuts from his 2017 Tax Cuts and Jobs Act which are scheduled to expire in 2025, which would add $3.3 trillion to the deficit over the next ten years. He also wants to reduce the corporate tax rate from 21% to 15%. If Trump does nothing meaningful about federal spending, his FY 26 budget, due shortly after he arrives in the White House, would harbor immense out year deficits and completely gross out both the bond and currency markets–a “Liz Truss” moment for the new regime. The promise of immediately reducing inflation which Trump made in his RNC acceptance speech goes sailing out the window.
Savaging Medicaid Spending (or Trying to)
Trump has tied his budgetary hands by committing to not cutting a single penny from Medicare and Social Security, which are forty percent (!) of the federal budget. This commitment appears both in the Republican platform and in Agenda47, which is the Trump campaign’s compilation of commitments made in his speeches. Trump has also committed to not reducing the $850 billion spent on Defense.
Ringfencing Social Security, Medicare and Defense leaves the more than trillion dollar Medicaid program (state and federal combined) as the largest single potential source of potential budgetary savings to avoid inflationary blow-out growth in the federal deficit. At its peak in March of 2023, Medicaid/CHIP enrolled 94 million people, or 28% of the US population. Expect an incoming Trump administration to attack Medicaid spending, both by accelerating the decline in enrollment that began in 2023 with the expiration of the COVID Public Health Emergency and by cutting rates and payments to Medicaid Managed Care providers. Some 24 million Medicaid beneficiaries have been “redetermined” and over 15 million have lost coverage. KFF says present Medicaid enrollment is about 80 million in mid-2024 but that number is certainly moving down
While Trump has distanced himself from the Heritage Foundation’s Project 2025, that policy blueprint characterized the ObamaCare Medicaid expansion as “inappropriate” and the program itself as a “cumbersome, complicated and unaffordable burden on nearly every state”. It advocated ending what it called “financing loopholes” (e.g. provider taxes that have trued up Medicaid rates to hospitals and physicians vs. Medicare), tightening Medicaid eligibility, and imposing both work requirements and cost sharing, “reforming” disproportionate share payments, time limits and lifetime caps on Medicaid benefits and ending coverage for “middle and upper income beneficiaries”! We can certainly expect inflammatory publicity from a Trump White House on states that have expanded Medicaid eligibility to “undocumented aliens”, followed by pressure on Congress to prohibit this coverage by statute.
When former Trump press secretary and present Arkansas Governor Sarah Huckabee Sanders, announced her removal of 400 thousand Arkansans from Medicaid enrollment, she said she was “liberating them from dependency”. It is likely that that millions more Americans will be “liberated from dependency” on Medicaid during the first two years of a second Trump Administration. There will be work requirements (with politically damaging pressure on the 11 million very poor or disabled “dual eligibles” eg. Medicare plus Medicaid) population), as well as cost sharing and an voucher option to purchase private insurance (!?) for Medicaid beneficiaries. An aggressive effort to “re-welfare-ize” the Medicaid program will raise numerous bureaucratic barriers to Medicaid enrollment, scaring off a lot of otherwise eligible beneficiaries.
Continue reading…My Trip To Paris This Week
By MIKE MAGEE
While others regale in the accomplishments of quirky pommel horse specialist, Stephen Nedoroscik, from Worcester, MA, or Celine Dion’s remarkable performance at the closing of the Olympics Opening Ceremonies in Paris this week, I time-traveled to Paris this week on a different mission.
I was there to visit Germaine de Staël. The French writer, who in 1803 tangled with Napoleon at the height of his power and asked him, “Who is the greatest woman in the world?” His reply was immediate, “She who has borne the greatest number of children.” The question alone earned her an exile from Paris to Switzerland.
It called to mind the JD Vance 2021 interview on FOX, where he tied women’s worth to birthing, stating that “We should give miserable, childless lefties less control over our country and its kids…” and claimed that their choice of cats over babies had created a collection of disgruntled women politicians who “are miserable.”
In 1803, Germaine de Stael had the last laugh, decamping to the bucolic Le château de Coppet on Lake Geneva in Switzerland. She spent the next 10 years organizing his opposition, until fleeing to Austria, then St. Petersburg, while carefully avoiding Napoleon’s northward advancing troops. On Napoleon’s defeat, she returned to Paris in 1814.
Napoleon’s campaign of terror, and ultimate defeat were also the subject of Leo Tolstoy’s legendary 1869 literary feat, War and Peace. But he could have as easily been reflecting on our two MAGA leaders and their Project 2025 sycophants a century and half later. And yet, as with Germaine de Staël, they appear to have missed that Vice President Harris was born to lead, something Tolstoy would surely have highlighted.
In his brilliant Epilogue (p.1131), Tolstoy undresses Napoleon while pointing a contributory finger at an endless array of knowing followers. Written 155 years ago, his expose’ is poignant and devastating, and worth careful consideration from all those concerned with ethical leadership, governance, and compliance.
On The Rise To Power
“(The launch requires that) …old customs and traditions are obliterated; step by step a group of a new size is produced, along with new customs and traditions, and that man is prepared who is to stand at the head…A man (like Trump) without conviction, without customs, without traditions, without a name (like Vance)…moves among all the parties stirring up hatreds, and, without attaching himself to any of them, is borne up to a conspicuous place.”
Early Success
“The ignorance of his associates, the weakness and insignificance of his opponents, the sincerity of his lies, and the brilliant and self-confident limitedness of this man moved him to the head…the reluctance of his adversaries to fight his childish boldness and self-confidence win him…glory…The disgrace he falls into…turns to his advantage…the very ones who can destroy his glory, do not, for various diplomatic considerations…”
Fawning and Bowing to Power
“All people despite their former horror and loathing for his crimes, now recognize his power, the title he has given himself, and the ideal of greatness and glory, which to all of them seems beautiful and reasonable….One after another, they rush to demonstrate their non-entity to him….Not only is he great, but his ancestors, his brothers, his stepsons, his brothers-in-law are great.”
Turning a Blind Eye
“The ideal of glory and greatness which consists not only in considering that nothing that one does is bad, but in being proud of one’s every crime, ascribing some incomprehensible supernatural meaning to it – that ideal which is to guide this man and the people connected with him, is freely developed…His childishly imprudent, groundless and ignoble (actions)…leave his comrades in trouble…completely intoxicated by the successful crimes he has committed…”
Self-Adoration, Mobs, and Conspiracy
“He has no plan at all; he is afraid of everything…He alone, with his ideal of glory and greatness…with his insane self-adoration, with his boldness in crime, with his sincerity in lying – he alone can justify what is to be performed…He is drawn into a conspiracy, the purpose of which is the seizure of power, and the conspiracy is crowned with success….”
The Spell is Broken by a Reversal of Chance
“But suddenly, instead of the chances and genius that up to now have led him so consistently through an unbroken series of successes to the appointed role, there appear a countless number of reverse chances….and instead of genius there appears an unexampled stupidity and baseness…”
The Final Act – Biden Anoints Kamala
“A countermovement is performed…And several years go by during which this man, in solitude on his island, plays a pathetic comedy before himself, pettily intriguing and lying to justify his actions, when that justification is no longer needed, and showing to the whole world what it was that people took for strength while an unseen hand was guiding him…having finished the drama and undressed the actor.”
As both Trump and Vance are learning the hard way, celebrity in America is a double-edged sword. In an inaugural speech, prosecutor met defendant head on.
“I took on perpetrators of all kinds. Predators who abused women, fraudsters who ripped off consumers, cheaters who broke the rules for their own gain. So hear me when I say, I know Donald Trump’s (and JD Vance’s) type.”
Kamala Harris #understands the assignment.
Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)
