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Personal and Professional Choices in PSA Testing: A Teaching Moment

By KELLI DEETER  

I was intrigued by Daniel Stone’s piece on THCB in May titled “Biden’s cancer diagnosis as a teaching moment”. In my practice as a board-certified nurse practitioner, I am frequently asked about prostate specific antigen (PSA) testing by my male patients.  

Nursing practice and medical practice often get blurred or lumped together. In the state of Colorado, nurse practitioners practice under their own license, and can independently diagnose and treat patients. In some settings where I have worked, I found myself frequently correcting patients who refer to me as ‘doctor’. “I am not a medical  doctor, I am a nurse practitioner,” is repeated by me multiples of times per day. In this discussion of PSA testing, I want to share my decisions to order or not to order PSA testing for individuals, based on my nursing training.  

It is important to refer to the guidelines for PSA testing recommended by the US Preventive Services Task Force (USPSTF), and published by the Journal of the American Medical Association (JAMA). The last updates made to the guidelines were in 2018. It is key to remember that these are guidelines, and that medical doctors, physician assistants, and  nurse practitioners use these guidelines in their consideration of the patient. In nursing, a holistic and team approach with the patient’s preferences, history, cultural considerations, and desired outcome are all weighted in decision making for assessment, testing, referral, and treatment. Guidelines are just that, a GUIDE, not an absolute.  

Guidelines state that for patients aged 55-69: Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction… Clinicians should not screen men who do not express a preference for screening. And for patients  aged 70 and older: The USPSTF recommends against PSA-based screening for prostate cancer. This does not mean that we as providers should not test men younger than 55 or older than 70. We need to look at each patient case independently of one another and not  lump everyone together. 

Additionally, patients may not know how to “express a preference for  screening”. It is imperative that providers have the allotted time to explore their family history of prostate and other cancers, explain to them the benefits and risks of testing, listen to and discuss their signs and symptoms, perform a digital rectal exam (DRE) if appropriate and agreed on by the patient, take into consideration their medication regimen and their age, as well as if they would want treatment or not. Certainly, if they are symptomatic, and a new medication for their symptoms is being prescribed, or if they are symptomatic and a DRE is obtained that is abnormal, a PSA should be obtained with the  patient’s approval to establish a baseline, and a follow-up appointment made with repeat  labs or referral, if desired by the patient. If there is a family history of prostate cancer, an  early PSA screening test to establish a baseline might be preferable. Again, patient  preferences must be taken into account.  

People have very different feelings about western medicine and about what they want for  themselves and their bodies. We must realize that just because someone has an ever increasing PSA with or without symptoms, they may not agree to a DRE or to referral to  urology, surgery, or oncology. As a provider, we should obtain a refusal of recommended care. It is ok to not want testing, follow-up, or treatment, no matter one’s age. In Biden’s  case, there had been no PSA testing since 2014, during his vice presidency. The fact that no reason was given is irrelevant, in 2014 he was 72 years old. Guidelines are not to test  starting at age 70. The PSA level if drawn may not have aƯected his health outcome or  treatment, but it may have affected the outcome of his nomination for the presidency, thus politicizing nursing and medical practice. Pointing fingers now at the past changes nothing. I agree with Stone, that this is a teaching moment: advocate for yourself as a patient, advocate for your patient as a provider, and consider that so much of one’s health is a personal choice and that it should be honored and protected.  

I agree with Peter Attia’s contention in his May 24, 2024, A timely though tragic lesson on  prostate cancer screening, that the PSA screening guidelines are out of date; the last revision was in 2018. Attia indicates many men remain healthy and live well past the age of  80, and aggressive cancers if caught early and treated, will better benefit the patient’s quality of life and length of life. I would also argue this is true of screening earlier in life, at age 50. Access to health care is an issue for many in our society. Marginalized populations such as  the indigent, homeless, geriatric, mentally ill, and incarcerated experience greater  disparities, and have a higher risk of missing any PSA testing at all. In my work as a nurse  practitioner in the correctional system, for individuals entering jails and prisons this is  often the first time they have ever seen a healthcare provider. These individuals often have  a history of indigence, homelessness, and/or mental illness. Additionally, new cancer diagnoses are increasing and for men; 29% of new cancer types are prostate. 

Age 50 is a  milestone for most individuals, and they know they are supposed to get screening for colorectal cancer at this age as well as other screening tests. Consolidating care by capturing a PSA at this same time would establish an early baseline; there is never a guarantee that a patient with healthcare access issues will ever return for another appointment, due to finances, transportation, fear, or other factors. Another consideration for revising the PSA screening guidelines is lowering the threshold for PSA levels based on patient age that drive referral to urology for imaging, and putting simple language into the guidelines to look at a two-fold increase in PSA over 6-12 weeks as likely urgent referral to  urology. Initiating early watchful waiting with PSA screening has the potential for saving  more lives and maintaining desired qualities of life.

Kelli Deeter is a board-certified family nurse practitioner with 12 years of experience in geriatrics, rehabilitation, correction, women’s health, mental health, and complex chronic care.

Biden’s cancer diagnosis should be a teaching moment

By DANIEL STONE

Joe Biden’s metastatic cancer diagnosis brings together two controversial issues: PSA testing for prostate cancer and presidential politics. To understand what is at stake Americans need basic information about PSA testing, and a frank discussion of the reasoning behind the prostate cancer screening decisions in the former president’s case. The dribble of information we’ve gotten only creates more uncomfortable questions for Biden and his family. The absence of adequate explanation also fails to contribute to public appreciation of these important medical issues.

The prostate, a walnut-shaped gland at the base of the bladder, produces “prostate specific antigen,” or PSA. Chemically classed as a glycoprotein, a sugar/protein aggregate, it leaks from the prostate into the blood, where its level can be measured with routine blood testing.

As men age, the prostate enlarges, increasing PSA levels. Screening tests take advantage of the fact that prostate cancer usually leaks more PSA than normal prostate tissue. And in the case of prostate cancer, the PSA typically rises relatively fast.

Beyond these basic facts, the PSA story becomes hazy. Although an elevated PSA may signal cancer, most men with an elevated PSA have benign prostate enlargement, not prostate cancer. Worse yet for screening, many men with prostate cancer have a mild and slow-moving disease that requires no treatment. They coexist with their disease rather than dying of it. This fact leads to the old adage that prostate cancer is the disease of long-lived popes and Supreme Court justices.

Medical advisory panels view PSA screening with skepticism partly due to the challenges of distinguishing benign PSA elevations from those related to cancer. Confirming a suspected cancer diagnosis requires prostate biopsies that can be painful and can produce side effects. Additionally, once a diagnosis is made, patients who might have coexisted with their disease may needlessly be subject to the harms of treatment, such as radiation and surgery. Finally, the benefits of early treatment of prostate cancer have been difficult to prove in clinical studies.

For all these reasons medical advisory panels have discouraged widespread testing or recommend a nuanced approach with careful discussion of risk and benefits between patients and their

Despite these concerns, the pendulum has swung toward more PSA testing in recent years. One reason is that improvements in radiographic imaging, such as MRI, allow for “active surveillance” that can track early lesions for signs of spread, allowing doctors to distinguish between relatively benign cases of prostate cancer and those likely to progress. Interventions can then be directed more specifically to those at high risk.

In my medical practice, I have generally been an advocate for prostate cancer screening despite the controversy surrounding the clinical benefits. My experience leads me to believe that early diagnosis improves prognosis. But even without improved medical outcomes, patients and their families still benefit from early diagnosis for the purposes of planning. No one wants to be sideswiped by a late-stage symptomatic disease that limits both clinical and life choices.

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The Real Red Wave: Why the Biden Presidency is in Peril

By JEFF GOLDSMITH

Democrats’ despair after Joe Biden’s pallid and halting debate performance stems from the realization  that the uphill climb needed to prevent the return of Donald Trump might be too steep. What is less obvious is the awareness of the urban intelligentsia of the root causes of the adverse political climate, which can be seen in this map, taken from the Economist’s April 20 feature on declining US population.

A map of the united states Description automatically generated

America’s economy is booming, and the gap between its economic performance and that of the rest of the world is widening. The on-the-ground political reality is very different depending crucially on where you live. People who live in the red parts of this map do not need convincing that all that wealth, and the power that goes with it, has eluded them. Many of them believe that it has been stolen from them by corrupt leaders and the oligarchs and corporate interests that finance their campaigns.

That is the underlying reality of MAGA.  Ninety percent of those red counties voted for Donald Trump in 2020. People in metro Austin, Manhattan or the suburbs of Houston do not resonate with the need to make America great again. It’s already great for many of them.

For folks living in the abandoned parts of the US, the on-the-ground reality is absurd gas prices, unaffordable mortgages, a mountain of forever debt, deteriorating public services, dreams cruelly out of reach and the despair that goes with all of it-alcohol and drug dependency, depression and anxiety, obesity, domestic violence. There is an almost perfect correspondence between the above map and that of the epidemic of “deaths of despair” suicide, drug overdoses and alcohol poisoning. This phenomenon is rooted in middle-aged whites, the overwhelming demographic of the red parts of this map, but affects all demographic segments including black and Hispanic folks who traditionally supported Democrats.     

After 2016, political analysts believed that the prevalence of non-college educated whites in a local electorate was the single best predictor of Donald Trump’s shocking victory. That was not the case. A post-election analysis by the Economist revealed that a better predictor of Trump’s victory was a composite measure of health/life expectancy, specifically “county-level data on life expectancy and the prevalence of obesity, diabetes, heavy drinking and regular physical activity (or lack thereof)”, the mapping of which again correlates remarkably with the map of population decline above.

The very same forces of outmigration and economic stagnation are destroying these communities’ local health systems, as well as their schools, commercial businesses and churches. The same red areas are also areas where local physicians have retired and were not replaced, and whose hospitals closed or merged with larger regional conglomerates. A recent scurrilous analysis by Yale and University of Chicago economists blamed the rising deaths of despair and  local business’s economic struggles on hospital mergers, an absolutely “from central casting” example of blaming the victim. 

The bitter irony of this political season is that the Biden Administration’s remarkable roster of Congressional achievements in 2021 and 2022- the American Rescue Plan, the American Infrastructure and Jobs Act, the Chips and Science Act and the Inflation Reduction Act showered many tens of billions in temporary relief spending and capital investment for manufacturing and infrastructure on these red areas. Because many of these investments take years to execute, credit for them will be claimed by future administrations.

Yet due to the arrogance and isolation of the progressive policy advocates that shaped this legislation, it was simply self-evidently obvious that the most ambitious domestic reconstruction program in the ninety years since Roosevelt will help many of the most economically challenged areas in the country. Proud and sparsely attended ribbon cutting ceremonies made the local newspaper, if there still is one. News of these investments never arrived via the partisan news channels and hyper-targeted social media venues on which most ordinary Americans rely these days. That attitude of “self-evident good works”  is of a piece with the “Why Bother Visiting Wisconsin” arrogance that let Trump into the White House in the first place. 

If post-debate polling is any guide, all these trillions of dollars of good works, funded with money borrowed from our grandchildren, will not be enough to turn the red tide, which could well leave the Republicans firmly in control of all three branches of the federal government. As they go to their cushy post-administration redoubts at the Brookings Institution, Yale, Hopkins and Harvard’s Kennedy School of Government, and hobnob at Aspen Institute and Martha’s Vineyard cocktail parties, the executors of all these good works, for the unforgiveable political sin of failing to communicate effectively with the struggling working class they used to champion, will have fully earned their retirement. 

Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This comes from his personal substack

Jake and Dana: Please Ask This Question.

By MIKE MAGEE

In case you were trying to forget, the first Presidential Debate is this week.

Question: Would Healthy Women Create a Healthy Democracy?

When he assumed the role as the AMA’s 178th president on June 13, 2023, Jesse M. Ehrenfeld, MD, MPH focused on inequities in health care as a top priority for his year in office. In a memorable opening that day in Chicago, the Wisconsin anesthesiologist shared a personal mission with 700 AMA delegates centered on his then 4 year old son. Ethan was born 10 weeks premature at 2 lbs 7 oz.

“Watching my son cling to life, I was struck by the painful reality that, even though I was a physician and now, a father, neither I, nor my husband, could donate blood simply because we are gay. Discriminatory policies—policies rooted in stigma, not science—barred us from doing the most humane of acts, donating our blood.”

Dr. Ehrenfeld used that story as a jumping off point to share his priorities as their new President. He pledged that day to seek justice and equity, highlighting:

“Black women are at least three times as likely as white women to die as a result of their pregnancy.

“Black men are 50% more likely to die following elective surgery.

“LGBTQ+ teens and young adults suffer higher rates of mental health challenges that often go undiagnosed.”

He also warned, in the shadow of the Dobbs decision on June 24, 2022, of  “… discouraging trends related to health outcomes—maternal mortality rates in the U.S. are more than double those of other well-resourced nations, for instance—and are becoming more prevalent.”

But when it came to the politics of reproductive health access, he chose his words carefully and took a quieter tone with the audience of politically savvy doctors from red and blue states.

“Certain aspects of the country’s political climate have become dangerously polarized. Politicians and judges are making decisions about health care formerly reserved for patients and physicians and patients…” he said.

This statement, coming one year after Dobbs, clearly did not mirror, in intensity, the words of his predecessor, Jack Resneck Jr.,MD, who wrote on the day of the decision, “The American Medical Association is deeply disturbed by the U.S. Supreme Court’s decision to overturn nearly a half century of precedent protecting patients’ right to critical reproductive health care…In alignment with our long-held position that the early termination of a pregnancy is a medical matter between the patient and physician, subject only to the physician’s clinical judgment and the patient’s informed consent, the AMA condemns the high court’s interpretation in this case.”

That sentiment was reinforced by the nation’s 25,000 OBGYNs, 60% of whom are women. Their association (ACOG) wrote, “Today’s decision is a direct blow to bodily autonomy, reproductive health, patient safety, and health equity in the United States. Reversing the constitutional protection for safe, legal abortion established by the Supreme Court nearly 50 years ago exposes pregnant people to arbitrary state-based restrictions, regulations, and bans that will leave many people unable to access needed medical care.”

Statements on behalf of the American Nurses Association, and the organizational arms for both physicians associates (PAs) and nurse practitioners (NPs) were equally forthright.

There are 4.2 million nurses, over 1 million doctors, and over 1/2 million PAs and NPs in the US. And as the latest US Census Report headlined, “Your health care is in women’s hands. Women hold 76% of all health care jobs.” This includes 90% of all nursing positions, 66% of PAs, and 55% of all current Medical School slots.

Not surprisingly, as women numbers have risen, traditional oaths for the caring professions have reflected changing priorities. For example, the women majority 2022 entering class of Penn State’s College of Medicine for the first time gave top billing in their professional oath to patients, not to the gods: “By all that I hold highest, I promise my patients competence, integrity, candor, personal commitment to their best interest, compassion, and absolute discretion, and confidentiality within the law.”

Seven years earlier, the American Nurses Association (ANA), created a formal Code of Ethics, which largely supplanted the 1893 Nightingale Pledge, with a four pillared Code which celebrated Autonomy (patient self-determination), Beneficence (kindness and charity), Justice,(fairness) and Nonmaleficence (do no harm), as anchors to Nursing’s 9 Provisions (or Pledges) that commit to: compassion and respect, patient-focus, advocacy, active decision making, self-health, ethical environment, scholarly pursuit, collaborative teamwork, professional integrity and social justice.

During Dr. Ehrenfeld’s one-year tenure following the Dobbs decision women’s access to health care deteriorated in red state after red state, a point reflected in clear losses for Republicans on statewide initiatives supporting abortion access from Kansas to Kentucky, and Vermont to Michigan. But as the Kaiser Family Foundation reported this year, “As of April 2024, 14 states have implemented abortion bans, 11 states have placed gestational limits on abortion between 6 and 22 weeks…” Add to this that 1 in 5 current OB residents say they have decided to steer away from restrictive red states when they pursue practice opportunities on graduation.

And still, red states embracing MAGA’s marriage to White Nationalists seem to have doubled down on everything from restricting access to medication abortion and contraception, to book banning, to limiting  LBGTQ+ rights and promoting prayer in public schools in the hopes of achieving a Christian Nationalist society.

Which brings us to the fast approaching 2024 Presidential debate. Women’s reproductive autonomy will be well represented. It is arguably the premier equity and justice issue before us, central to both America’s patients and their caring health professionals. But let’s not forget it is also central to the health of our democracy.

John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.”

What other form of government is there that so closely aligns with the aspirational pledges and oaths of our doctors, nurses, and body politic?

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.

What Scares Healthcare Like EVs Scare Detroit

By KMI BELLARD

I’m thinking about electric vehicles (EVs)…and healthcare.

Now, mind you, I don’t own an EV. I’m not seriously thinking about getting one (although if I’m still driving in the 2030’s I expect it will be in one). To be honest, I’m not really all that interested in EVs. But I am interested in disruption, so when Robinson Meyer warned in The New York Times “China’s Electric Vehicles Are Going to Hit Detroit Like a Wrecking Ball,” he had my attention. And when on the same day I also read that Apple was cancelling its decade-long effort to build an EV, I was definitely paying attention.

Remember when 3 years ago GM’s CEO Mary Barra announced GM was planning for an “all electric future” by 2035, completely phasing out internal combustion engines? Remember how excited we were when the Inflation Reduction Act passed in August 2022 with lots of credits and incentives for EVs? EVs sure seemed like our future.

Well, as Sam Becker wrote for the BBC: “Depending on how you look at it, the state of the US EV market is flourishing – or it’s stuck in neutral.” Ford, for example, had a great February, with huge increases in its EV and hybrid sales, but 90% of its sales remain conventional vehicles. Worse, it recently had to stop shipments of its F-150 Lightning electric pickup truck due to quality concerns. Frankly, EV is a money pit for Ford, costing it $4.7b last year – over $64,000 for every EV it sells.

GM also loses money on every EV it makes, although it hopes to make modest profits on them by 2025.  Ms. Barra is still hoping GM will be all electric by 2035, but now hedges: “We will adjust based on where customer demand is. We will be led by the customer.”

In more bad news for EVs, Rivian has had more layoffs due to slow sales, and Fisker announced it is stopping work on EVs for now. Tesla, on the other hand, claims a 38% increase in deliveries for 2023, but more recently its stock has been hit by a decline in sales in China. It shouldn’t be surprising.

As Mr. Meyer points out:

The biggest threat to the Big Three comes from a new crop of Chinese automakers, especially BYD, which specialize in producing plug-in hybrid and fully electric vehicles. BYD’s growth is astounding: It sold three million electrified vehicles last year, more than any other company, and it now has enough production capacity in China to manufacture four million cars a year…A deluge of electric vehicles is coming.

He’s blunt about the threat BYD poses: “BYD’s cars deliver great value at prices that beat anything coming out of the West.”

The Biden Administration is not just sitting idly.

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Let’s Finish The Job

BY MIKE MAGEE

In President Biden’s State of the Union Address, the most oft repeated phrase was “Let’s Finish The Job!” This came as part of an appeal for partnership as well as an assertion that in his first two years as President much had been accomplished.

Several days later, as if on cue, U.S. Senator Amy Klobuchar (D-MN) and Senator Chuck Grassley (R-IA), joint chairs of the Senate Subcommittee on Competition Policy, Antitrust, and Consumer Rights, announced that two bipartisan pieces of legislation focused on reducing the price of drugs to consumers had passed the Senate Judiciary Committee.

Both bills focus on the range of shenanigans Pharma firms have engaged in to extend their 20 year patents on blockbuster brands and delay generic versions from coming on the market.

The first bill – the Preserving Access to Affordable Generics and Biosimilars Act – is designed to prevent Big Pharma firms from flooding the FDA with sham requests for patent extensions. In the process, opponents have popularized a new term – “patent thicket” to describe the barrage of skimpy patent extension tricks companies use to extend their original 20 years of exclusivity. 

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Promises Made – Promises Kept:  President Biden’s Support for “Obamacare.”

BY MIKE MAGEE

As the saying goes, “History repeats!” This is especially true where politics are involved. 

Consider for example the past three decades in health care. It is striking how many of the players in our nation’s health policy drama remain front and center. And that includes President Biden who recently commented on the 12th anniversary of the passage of the Affordable Care Act (Obamacare): 

“The ACA delivered quality, affordable health coverage to more than 30 million Americans — giving families the freedom and confidence to pursue their dreams without the fear that one accident or illness would bankrupt them. This law is the reason we have protections for pre-existing conditions in America. It is why women can no longer be charged more simply because they are women. It reduced prescription drug costs for nearly 12 million seniors. It allows millions of Americans to get free preventive screenings, so they can catch cancer or heart disease early — saving countless lives. And it is the reason why parents can keep children on their insurance plans until they turn 26.”

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State-Based Marketplaces 2.0 Part 2: Engines of Innovation, Competition, and Consumerism

By ROSEMARIE DAY and DAVID W. JOHNSON

Within the current political reality, how can America implement policies that increase access to health insurance while also reducing premium costs and enhancing responsiveness to consumer priorities and needs? 

Large-scale healthcare reform appears off-the-table for the Biden Administration. Yet, given the impact of the COVID pandemic on people who have lost (or have worried about losing) their employer-based insurance coverage and the intensifying pressure to reduce overall healthcare costs, solutions that increase health insurance access and affordability have become more important than ever. A significant answer to this complex puzzle can be found at the state level. 

Enabled by the Affordable Care Act (ACA) in 2010, state-based marketplaces (SBMs) currently operate in 14 states and the District of Columbia. Another six states operate as SBMs using the federal government’s HealthCare.gov technology platform. Three states, Kentucky, Maine, and New Mexico, will become full SBMs by 2022.

While federal measures to improve insurance access have stalled or been reversed over the past eight years, SBMs have quietly implemented programming modifications for stabilizing local markets that improve the quality and marketability of health insurance offerings to the benefit of consumers.

In Part 2 of our series on marketplace health plan innovations, we examine how SBMs have operated as experimental policy laboratories. They’ve taken their own paths to expand consumer choice, increase access to vital healthcare services, and lower premiums.

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The Vaccine Brawl – A Legal Battle in Process

By MIKE MAGEE

The power to mandate vaccines was litigated and resolved over a century ago. Justice John Marshall Harlin, a favorite of current Chief Justice Roberts, penned the 7 to 2 majority opinion in 1905’s Jacobson v. Massachusetts. Its impact was epic.

In 1905, Massachusetts was one of 11 states that required compulsory vaccinations. The Rev. Henning Jacobson, a Lutheran minister, challenged the city of Cambridge, MA, which had passed a local law requiring citizens to undergo smallpox vaccination or pay a $5 fine. Jacobson and his son claimed they had previously had bad reactions to the vaccine and refused to pay the fine believing the government was denying them their due process XIV Amendment rights.

In deciding against them, Harlan wrote, “liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own [liberty]…” 

Of course, a state’s right to legislate compulsory public health measures does not require them to do so. In fact, as we have seen in Texas and Florida among others, they may decide to do just the opposite – declare life-saving mandates (for masks or vaccines) to be unlawful. At least 14 states have passed laws barring employer and school vaccine mandates and imposing penalties in Republican-controlled states already.  

So state powers are clearly a double-edged sword when it comes to health care. 

Questions anyone?

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Biden Should Extend a “Public Option” as a Message to “Health Care Royalists”

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By MIKE MAGEE

In this world of political theatrics, with Democratic legislators from Texas forced into exodus to preserve voters’ rights, and Tucker Carlson rantings about Rep. Eric Swalwell riding shirtless on a camel in Qatar streaming relentlessly, Americans can be excused if they missed a substantive and historic news event last week.

On Friday, July 9th, President Biden signed a far-reaching executive order intended to fuel social and economic reform, and in the process created a potential super-highway sized corridor for programs like universal healthcare. In the President’s view, the enemy of the common man in pursuit of a “fair deal” is not lack of competition but “favoritism.”

To understand the far-reaching implications of this subtle shift in emphasis, let’s review a bit of history. It is easy to forget that this nation was the byproduct of British induced tyranny and economic favoritism. In 1773, citizens of Boston decided they had had enough, and dumped a shipment of tea, owned by the British East India Company, into the Boston Harbor. This action was more an act of practical necessity than politics. The company was simply one of many “favorites” (organizations and individuals) that “got along by going along” with their British controllers.  In lacking a free hand to compete in a free market, the horizons for our budding patriots and their families were indefinitely curtailed.

Large power differentials not only threatened them as individuals but also the proper functioning of the new representative government that would emerge after the American Revolution. Let’s recall that only white male property owners over 21(excluding Catholics and Jews) had the right to vote at our nation’s inception.

Over the following two centuries, power imbalances have taken on a number of forms. For example, during the industrial revolution, corporate mega-powers earned the designation “trusts”, and the enmity of legislators like Senator John Sherman of Ohio, who as Chairman of the Senate Republican Conference, led the enactment of the Sherman Antitrust Act of 1890.

He defined a “trust” as a group of businesses that collude or merge to form a monopoly. To Sen. Sherman, J.D. Rockefeller, the head of Standard Oil, was no better than a monarch. “If we will not endure a king as political power, we should not endure a king over the production, transportation and sale of any of the necessities of life”, he said.   The law itself stated “[e]very contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal.”

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