It happened so quickly you might have missed it. In early September, media outlets across the country reported alarming news for everyone on employer-based health insurance plans.

A national survey of 1,700 businesses that offer health insurance to their workers found that 2026 will bring the steepest increases in their medical costs in 15 years—6.7 percent, on top of a 6 percent rise in 2025. They blame higher hospital and drug prices, greater demand for care, and other factors. According to the consulting firm Mercer, which conducted the survey, much of that burden will be foisted onto employees in the form of higher premiums taken out of their paychecks and higher co-pays and deductibles when hospitalized, seeing a doctor, or filling a prescription.

This pain is hitting at a time when most Americans are struggling financially, and “affordability” is dominating political debate. President Donald Trump’s poll numbers are sinking because voters feel he has betrayed his campaign promise to bring down living costs. Democrats, meanwhile, swept off-year elections by laser-focusing on that vulnerability. 

Yet neither party has managed to come up with a plan to address exploding health care costs for the 165 million Americans with employer-provided insurance. During their failed six-week government shutdown, Democrats in Congress put their political chips on a different health care cost crisis: the expiration of the Obamacare tax credits that Republicans refused to extend in their One Big [Ugly] Bill last summer.

Restoring those tax credits is certainly a worthy fight. More than 7 million Americans face an average 26 percent increase in their premiums in 2026, according to KFF (formerly Kaiser Family Foundation). Some 5 million will likely drop coverage altogether, unraveling much of the gain made since passage of the Affordable Care Act in 2010. Another 8 million will lose Medicaid coverage over the next decade because of cuts to that program in the OBBBA, according to the Congressional Budget Office. As I recently explained in the Washington Monthly, universal coverage is a necessary, though not sufficient, condition for addressing the long-term affordability crisis in health care. 

But in terms of basic political arithmetic, the failure of both parties to offer voters a specific plan for dealing with rising employer-provided health care costs is hard to fathom. After all, 70 percent of working-age Americans get their health insurance from their employers, compared to 10 percent from Medicaid and under 5 percent from Obamacare. (The rest are either uninsured or have military or Medicare disability coverage.)

Employer-provided plans not only cover most working-age Americans and their families, but are also where the health care system’s inflation is worst. Thanks to cost control requirements in the Obama administration’s Affordable Care Act and other government measures, spending per enrollee in Medicare and Medicaid has risen far more slowly over the last 15 years than in employer-sponsored plans. The latter aren’t subject to such controls and are increasingly vulnerable to price gouging by provider and insurer conglomerates that enjoy geographic monopolies. 

The rapid inflation in the prices paid to hospitals, doctors, labs, and other health care providers by employer-sponsored plans also contributes to the slow or stagnant real wage growth that most Americans have experienced for many years. Corporate revenues that might otherwise have gone to raises have instead been spent on the ever-rising costs that employer plans are compelled to absorb. 

For a long time, most workers covered by these plans were only dimly aware of how these rising prices affected their standard of living because they rarely had to reach directly into their own pockets to pay them. But that is becoming less true as employers try to offset the ballooning costs by exposing their employees to ever-higher premiums, deductions, co-pays, and co-insurance. In recent years these out-of-pocket costs have on average been speeding ahead at a rate faster than inflation and workers’ wage gains. 

Just as rising electric bills turned out to be the sleeper concern of voters in the 2025 off-year elections, so might higher employer-provided health care costs in the 2026 midterms. It would be political malpractice if Democrats did not offer the 165 million Americans with employer-provided coverage real relief from costs that are eating away at their paychecks and standard of living.

In what follows, I sketch out the basics of a three-part plan that offers a practical and enduring solution to the health care affordability crisis. 

First, the plan would place a reasonable cap on the percentage of income any individual or family must pay for health care annually, regardless of whether or how they are insured. This will radically reduce the financial toxicity visited on many insured persons when they get sick, and the scourge of new medical debt heaped on the un- and underinsured. 

Second, the plan would require health care providers to charge the same price for the same service, regardless of a patient’s insurance status. This will save the system hundreds of billions of dollars annually by reducing administrative expenses and by bringing down the grossly inflated prices providers charge patients with employer-provided coverage—currently two and a half times what they charge Medicare. 

Finally, the plan would put all hospitals on a budget—a move that would end insurers’ prior authorization schemes and incentivize providers to keep people well and deliver the most effective and efficient care when they get sick.

This three-part reform plan will put the American health care system on a long-term path to controlling overall costs. It will also help employers’ bottom lines and increase the likelihood that more small businesses will be able to offer health insurance to their employees. Best of all, if accompanied by a mandate that employers share a portion of the savings with their employees, it will deliver immediate relief of between $1,500 and $4,000 to the typical working American family—a rebate, if you will, on the excessive health care expenses they have been unwittingly paying. That’s a benefit any self-respecting political candidate ought to be happy to run on.

One bold solution that many left-of-center Democratic candidates competing in next spring’s primaries will likely run on is Medicare for All. But in general elections, that program will run into the same political buzz saw that doomed the effort in Senator Bernie Sanders’s Vermont, the only state that has tried to create a M4A model. Its Democratic governor concluded that the level of taxation necessary to entirely replace employer contributions and reduce individual out-of-pocket expenses was prohibitive. Moreover, a single-payer health care system remains vulnerable to politically charged slogans like “You’ll lose what you have.” Despite the staggering growth in costs, most businesses, unions, and employees want to keep employer-based coverage.

Other Democrats, meanwhile, are already fashioning long lists of health care system changes they hope to enact should they regain Congress and the White House in 2029. Those include curbing provider and insurer consolidation through rigorous application of antitrust law; lowering the Medicare eligibility age to 60; extending the government’s price negotiations to more drugs; prohibiting drug advertising on television; cracking down on pharmacy benefit managers; allowing greater use of physician and nurse assistants; allotting more funding for fighting substance abuse and treating mental health; and more. Few will read this small-bore, incrementalist agenda, and even fewer will understand how it saves them money.

What the Democratic Party and health care reformers need to address directly is affordability, the main issue bedeviling the American people. The reforms needed to achieve affordability must be few in number, easy to understand, and provide real relief. As former Labor Secretary Robert Reich recently noted, people are not persuaded by a “‘10-point plan’ with refundable tax credits that no one understands.”

To that end, I propose that every Democratic candidate looking for a popular, easy-to-sell health care agenda unite around these three simple reforms.

A firm cap on all out-of-pocket expenses

All payers, whether private or public, must restructure their health plans so that no individual or family spends more than 8 percent of their annual income on health care. This cap covers all premiums, co-premiums, deductibles, co-pays, and Medicare payroll taxes and Part B premiums. A hard cap will sharply reduce the number of people accruing new medical debt. The medical debt crisis has left at least 20 million adults with either unpaid bills or long-term debts (some estimates are as high as 36 percent of all U.S. households). This forces millions of people into credit card debt, the arms of predatory lenders, or bankruptcy. It forces them to cut back spending, eliminate “frills” like home repairs and family vacations, and skip payments on other bills. 

A firm cap on out-of-pocket spending will substantially reduce the unseemly sight of Americans, alone in the developed world, launching GoFundMe pages to pay their medical bills. It will also finally make the U.S. health insurance system fair because it spreads the financing of high-cost patients across all plan members without unduly burdening the sick. This is, after all, what insurance is supposed to be about.

All government programs and the individual market under Obamacare will also be governed by this cap. In the latter case, it will replace its current complicated subsidy formula. There is a precedent for this principle: The Biden administration’s enhanced subsidies for exchange-purchased plans included an 8.5 percent cap on individual premiums. 

One price for all

America must adopt a single-pricing system under which each provider charges all payers the same amount for the same service or product. This will sharply lower prices for private plans, which paid on average two and a half times more than Medicare and Medicaid in 2022, according to a Rand survey. This in turn will provide substantial premium relief for both employers and workers.

The U.S. is the only country in the world that has an optional private insurance market for the working-age population with no government-mandated mechanism for controlling prices or premiums. (As noted above, those are slated to rise by nearly 7 percent in 2026.) Multiple payers in that private insurance market create multiple prices that are largely determined by the relative market power of providers and insurers, which have been combining into geographic monopolies that extract ever-higher payments from employers. 

As a result of multiple players each paying different prices, U.S. hospitals and physicians’ offices administer the most confusing and expensive billing systems in the world. Some providers have as many as a dozen different prices for the same service: one for traditional Medicare, one for Medicaid, and one for each insurer in their service territory—each of which negotiates different rates for its different plans, including privately managed Medicare Advantage and Medicaid. Then there’s the rack rate for anyone who walks in off the street.

The cost estimates for administering this complex system range into the hundreds of billions of dollars a year. I estimate that the administrative savings alone from simplified single pricing could save employers and employees at least $100 billion a year in reduced premiums. 

Prices would instead be determined by a process like the one Medicare has used for decades to set the amount doctors and hospitals receive for treating patients with specific conditions (with individual hospitals having some pricing flexibility as long as they charge all patients the same—see next section). In practice, that would mean raising Medicare and Medicaid rates while dropping commercial rates, thereby creating a single-price schedule sufficient to meet the overall financial needs of the system. The exact amount of savings would depend on how much government program prices would have to rise to accommodate the economic needs and political power of providers. But the savings to employers and covered employees would be enormous, likely reducing premiums by hundreds of billions of dollars annually in addition to the $100 billion in administrative savings. 

Another benefit of single pricing is transparency for consumers. Not many medical services are shoppable. No one experiencing what they think is a heart attack rushes to their computer before the ambulance arrives to find out who has the cheapest ER prices. Indeed, a recent study by the Health Care Cost Institute estimated that only 12 percent of 2017 medical expenditures, excluding prescription drugs, were either delayable or discretionary, and thus shoppable.

But greater competition in this limited set of services can help keep prices down. Unfortunately, current transparency laws have proven largely unworkable for consumers hoping to shop around for the cheapest alternative for, say, an MRI scan on that troublesome knee, or a routine colonoscopy. Most providers, given the multiple prices they must post, have created disclosure websites that are about as easy to navigate as a health insurance policy. Requiring every provider to list a single price, especially if linked to the federal government’s existing quality ratings, will foster competition previously unknown in the health care sector.

Put providers on a budget

Serious problems can arise after moving to a single-price system, as Maryland, the only state that has one, discovered over a decade ago. Hospitals there began to game the system by increasing unnecessary surgeries, tests, and procedures.

Maryland’s solution was to require that hospitals and hospital systems, which collect a third of all health care spending, adhere to an annual budget no matter what price they set on individual services. The state’s regulator, the Health Services Cost Review Commission, also sets limits on how much those budgets can grow each year after accounting for changes in demographics, best practices, and technology. Providers are guaranteed their annual budgets. If an individual service is used more or less than anticipated, the price for that service can be adjusted up or down for all patients, but hospitals may not exceed their budgets. 

Requiring providers to adopt these so-called global budgets that grow more slowly than the rest of the economy creates a financial incentive for eliminating wasteful care, and frees up resources to boost primary and preventative care. Hospitals on a budget earn more money if they don’t have to provide as much care for the sick, meaning that they’re incentivized to keep people healthy while generating the best health outcomes at the lowest possible price for their patients when they do get sick. 

These three reforms work best if adopted in tandem. Each cannot succeed on its own. But if adopted together as part of new federal legislation, these reforms could put the U.S. health care system on a glide path to financial sustainability. 

Making them work will require significant federal expenditures. How much, and how to pay for it, is a difficult but solvable question. 

Phillip Longman, senior editor at the Washington Monthly, has long argued for a single-price system that would reduce what self-insured businesses and private insurers pay by 60 percent, matching the prices that Medicare currently pays. If this were possible, no federal funds would be needed to finance a single-price system. Alas, I don’t believe it is possible. 

Though it’s true that many hospitals and physicians serving mostly working-age and Medicare-covered patients are financially stable and offer excellent care, those serving less healthy patients in low-income areas—so-called safety-net hospitals—are frequently on the brink of bankruptcy. Survival for many depends on the additional monies brought in by their relatively few well-insured patients and federal subsidies. It would be a disaster for these providers if rates paid by privately insured patients dropped to current Medicare rates.

Hospitals in well-off areas, meanwhile, feast off the higher payments extracted from their well-insured clientele. That’s where the fat in the system is. But lowering their prices to existing Medicare rates would deliver an immediate financial shock to existing operations, generating tremendous pushback from local hospital leaders, physicians, and their elected representatives, regardless of party. 

To make a single-price system work economically and politically, then, Medicare payment rates to providers will also need to rise. How much? By 60 percent, I would estimate, based on a real-world test case. When Democratic leaders in Washington offered a publicly funded option on that state’s Obamacare exchange, provider organizations successfully lobbied for payment rates that were 160 percent of Medicare rates—still lower than existing commercial rates, but well above the government program’s rates. They convincingly argued that many hospitals and doctors’ offices could not survive without the cross-subsidization provided by the sky-high prices paid by employer-provided plans.

A single-pricing system that made a similar average rate cut for private payers would save employers and their employees, according to my own rough estimate, more than $400 billion a year. That works out to a reduction of $1,200 in annual premiums for the average working family, or a total of $1,500 a year when administrative savings are added in (presuming employers are mandated to share the savings with their employees). 

The problem, of course, is how to finance that extra $400 billion, which will now be coming from the federal government. The obvious fix would be to recapture the $400 billion in employer savings by raising their Medicare taxes by an equal amount (while not raising such taxes on employees). 

Financing single pricing in this way will have the additional benefit of boosting manufacturing in the U.S. by making the health care cost burden between firms more progressive. Old-line firms like General Motors, Caterpillar, and John Deere pay the highest premiums because their workforces are older, sicker, and middle income. Meanwhile, the highly profitable tech titans that now dominate the U.S. economy, like Apple, Meta, and Google, have workers who are younger, healthier, and better paid. They spend far less per worker for health insurance. Tripling the employer Medicare payroll tax will have the beneficial effect of lowering total health care costs for those firms with older, sicker workforces while raising costs for those businesses with younger, healthier ones. 

For this reason, old-line firms with older workers would have good reason to provide crucial political support for the plan. We can also expect, however, well-funded and intense pushback from other corporate sectors that would face sharp payroll tax increases. Their opposition, plus resistance from providers, will make reform a tough road.

But there’s no law saying that the only way to fill the $400 billion gap is by raising Medicare taxes. Other forms of federal revenue would work. Lawmakers could, for instance, tax things that make people less healthy: air pollutants, sugar-laden foods, or other detrimental products. Alternatively, they could pay for the plan by raising tax rates on corporate and top earners—moves that voters overwhelmingly favor. Indeed, much of the plan could be financed merely by closing the insane new loopholes (such as gutting the alternative minimum tax) that the Trump administration is creating for major corporations and wealthy individuals above and beyond the OBBBA. 

This would be a huge net advantage to the vast majority of employers, who would be relieved of a significant share of their health care liabilities with no requirement that they pay higher Medicare payroll taxes. And Democrats could mandate that an appropriate portion of that money be rebated to employees in the form of higher pay. In 2024, the total estimated cost to a typical family of four in an employer-provided health plan was around $27,000, according to KFF. If such a family received a 25 percent share of the savings from these reforms, its pretax income would increase by around $4,000.

To win back working- and middle-class voters who already trust them more than Republicans to do the right thing on health care, Democrats need to offer a plan that immediately limits workers’ out-of-pocket costs. For employers, unions, and others who want to “keep what they have,” single pricing tied to annual budgets preserves the employer-based system while providing them with the long-term benefit of slower-growing costs. For the millions of small businesses that don’t currently provide coverage, the plan will make it much cheaper to do so. Such a plan might even win support from the few GOP officials willing to free themselves from the fear-driven grip of Trump’s faux populism.

The post For Democrats, a New Way to Make Health Care Affordable appeared first on Washington Monthly.

The Trump administration’s wrecking ball has succeeded in shattering one of the core beliefs of centrist health care reformers, which states: Incremental reforms will eventually lead the U.S. to the promised land of health insurance for all—something most advanced industrial nations achieved more than 75 years ago. 

Even many Republicans once signed onto the gradualist approach to achieving the goal of universal coverage. In the early 1970s, President Richard Nixon proposed covering everyone through insurance industry-managed plans. In the 1990s, a Republican-controlled Congress authorized universal coverage for children. Even President Trump in 2017 vowed to replace Obama’s Affordable Care Act with a new plan that would provide “insurance for everyone.” Ultimately, he failed to either release a plan or repeal Obamacare.  

But now, for the first time, the U.S. is making a U-turn on the long road to health care for all, with the GOP not even pretending that universal coverage is a desirable national goal. 

The One Big Ugly (not Beautiful) Bill signed by the president last July will drive an estimated 17 million people from the insurance rolls by 2034, according to KFF. More than two-thirds of those losses will come from cuts to Medicaid. Half those cuts, which establish bureaucratic roadblocks for obtaining coverage, won’t be reversed even if the Democrats succeed in forcing concessions from the majority party during the shutdown negotiations, which are still underway as of this writing.  

Thanks to legislation Democrats passed during Joe Biden’s administration, the national uninsured rate fell last year to 8 percent, which is within hailing distance of universal coverage (generally considered to be 5 percent or less). Some states are already below that threshold, which might have occurred nationally had not 10 Republican-run states, including populous Texas (still 16.4 percent uninsured) and Florida (10.9 percent), refused to expand Medicaid to cover the working poor. That overall rate is certain to rise next year and for the rest of this decade. If no changes are made, it will soar into the mid-teens, nearly to the levels seen before the Affordable Care Act passed in 2010. 

Universal coverage doesn’t guarantee Americans will enjoy better health. Nor does it ensure health care will be affordable. However, it is inconceivable that either of those goals can be achieved without universal coverage, which is a necessary, though not sufficient, condition for addressing the long-term health care cost crisis affecting most American households. 

The incrementalist strategy emerged in the wake of President Harry Truman’s failed attempt after World War II to implement a government-run, universal health insurance plan, similar to those adopted by many European countries. Opposition from the American Medical Association, labor unions with their newly negotiated employer-based plans, and a burgeoning health insurance industry doomed the bill.  

But calls for universal coverage never ceased. A decade-and-a-half later, with the White House and Congress in Democratic hands after Lyndon B. Johnson’s 1964 landslide, the government created Medicare and Medicaid for the old, disabled, and poor. In 1997, after the Bill Clinton administration’s significant push for universal coverage failed, a Republican-led Congress included a separate plan for uninsured children in the Balanced Budget Act. 

Then, in 2010, with Barack Obama in the White House and the country reeling from the Great Recession, a Democratic Congress passed the Affordable Care Act. It created a subsidized individual market for those without employer coverage; expanded Medicaid to include individuals and families earning up to 137 percent of the poverty level; and began experimenting with a host of delivery system reforms to hold down costs. 

However, cost-saving measures cannot be effective unless everyone is in the insurance pool. Uninsured individuals often postpone necessary but non-emergency care. When they become so sick that they must seek care, they show up in emergency rooms, where care is the most expensive, and where their outcomes are usually worse because they waited too long. For their troubles, they are often saddled with unpaid debts. 

The dysfunction wrought by a growing pool of uninsured people affects everyone’s pocketbook. Providers and insurers use the uninsured’s unpaid bills as an excuse to pass along those expenses in the form of higher prices to the privately insured, who already pay 2 ½ times what Medicare recipients pay on average. This results in not just more expensive plans for employers (the median family plan cost a staggering $27,000 in 2025), but higher co-premiums, co-pays, and deductibles for their employees, whose share of the total cost of “employer-financed” care has hovered between 25 and 30 percent for decades. (I put scare quotes around “employer-financed” because employer contributions are a tax-deductible business expense that otherwise would go to workers as wages if it weren’t spent on benefits.) 

Universal coverage doesn’t guarantee that health care will become more affordable for everyone. But it reduces the level of more expensive, uncompensated care in the system, which is necessary to lower prices for everyone, including private insurers and their employer customers. Universal coverage is a crucial prerequisite for achieving more affordable health care.  

Yet now, under Trump and a supine Republican Congress, America is deliberately reducing the ranks of the insured. The process has already begun. Premiums for individual plans being sold on the exchanges for next year are soaring due to the expiration of enhanced subsidies, which will discourage many people from buying plans. 

Though the bill’s new Medicaid work requirements were postponed until after the 2026 mid-term elections to hide their full effects from voters, states were given the green light to begin enforcing twice-annual recertification requirements. Many red states are already moving to do that, as well as cut their Medicaid spending in response to the cutbacks in federal support for the joint federal-state program. Millions of low-wage workers will start losing their Medicaid coverage next year, not because they aren’t working, but because they become frustrated by the paperwork requirements set up by hostile bureaucrats beholden to their Republican overlords. 

Democrats on Capitol Hill are singularly focused on maintaining the enhanced subsidies and restoring the cuts in Medicaid financing. That means the work requirements and other bureaucratic roadblocks will remain because they can’t be addressed in a reconciliation bill. No matter how the shutdown is resolved, a sharp decline in both coverage and access is inevitable. 

That will financially harm almost everyone covered by employer-sponsored plans. This year, those rates soared at twice the inflation rate on average, according to the annual KFF employer survey of just under 1,300 firms. Mercer, a leading benefits consulting firm, says rates will rise by a similar level next year. Plan structures will undoubtedly include higher co-payments, higher deductibles, and higher co-premiums for workers and their families. 

No matter how the government shutdown is resolved, the health care affordability crisis, exacerbated by the historic GOP U-turn on universal coverage, will remain a salient issue during next year’s House and Senate campaigns. The only question is whether Democrats will be able to take advantage by offering a program that addresses voters’ number one concern when it comes to health care. 

The post Republicans Have Stopped Pretending to Care About Health Care appeared first on Washington Monthly.

Robert F. Kennedy Jr.’s Make America Healthy Again (MAHA) commission on children’s health reached its ignominious conclusion Tuesday by issuing a final report that failed to mention the biggest threats to childhood ill-health in the U.S.

The final 73-page report, which was accompanied by a 20-page strategy memo, made no mention of:

• Gun violence, the number one killer of American children under 18;
• Smoking, a lifelong habit most take up when teenagers; or
• Global warming, the greatest long-term threat facing the youngest generation.

Mentioning these issues would have required the report call attention to the biggest roadblocks standing in the way of addressing each of these issues. They are, respectively, the Gun Lobby, Big Tobacco and Big Oil & Gas.

Those industries are fervent supporters of the U.S.’s authoritarian headman, Donald Trump. His only consistent political position—one that he requires all his lackeys adhere to—is steadfast support for the nation’s richest and most powerful corporations and individuals, especially those that have given him huge campaign contributions.

Even when it came to addressing the issues that Kennedy claims to care most about, his need to please Trump by giving special interests a pass denuded the final report of any meaningful measures. Those issues include the prevalence of ultra-processed food; chemical food additives; environmental toxins; and excessive use of psychotropic drugs and vaccines. Other than vaccines (last week, his denigration of vaccines led even a few Republican physician-Senators to question his honesty), those are issues that most Americans and unbiased researchers would also like to see addressed.

Yet the final report failed to outline any concrete steps that the Health and Human Services Department, the Agriculture Department or the Environmental Protection Agency plan to take. “A lot of this is nice (but) it’s a report about intentions, not about actions,” New York University professor of nutrition emeritus Marion Nestle told the PBS NewsHour. “How on earth are they going to do these things (when) the word regulation is only mentioned once?”

Regime actions contradict recommendations

Many of the deregulatory and budget cutting actions taken by the Trump regime since taking office work directly against the goals outlined in the report. For instance, the Environmental Protection Agency’s research department has been gutted, all but eliminating the agency’s ability to scientifically determine which environmental toxins are causing significant harm to children’s health.

The budget for the Supplemental Nutrition Assistance Program (colloquially food stamps) has been cut sharply, which will reduce food assistance to almost three million children. Rather than taking steps at the federal level to limit the ability of low-income beneficiaries to purchase sugar-laden beverages or salt-heavy snack foods (instead, they plan to offer technical assistance to states that want to do that), the Trump regime is making more children go hungry. Common sense suggests allowing three million kids to go hungry will destroy the health of far more children than allowing parents of kids on food stamps to continue buying soda pop.

The strategy report called on the Department of Education to “help states” reinstitute the presidential fitness test. The DoE is currently being dismantled by the Trump regime.

Also, it claimed HHS’ Administration for Children and Families will “promote greater physical activity” in after-school and summer programs. Meanwhile, Trump’s budget cutters slashed $7 billion to support those programs in June, only to restore a mere $1 billion a month later after widespread protests from educators in both Red and Blue states.

Perhaps the most curious oversight in yesterday’s strategy report was its turnaround on the chemicals, dyes and other additives in ultra-processed foods (UPFs), a major bête noire for Kennedy and a long-time concern of mainstream nutritionists. The main report’s 7-page section on UPFs contained 75 footnotes. Yet the strategy memo contained just a single action item of little significance: “USDA, HHS, and FDA will continue efforts to develop a U.S. government-wide definition for ‘Ultra-processed Food’ to support potential future research and policy activity.”

“What this says to me is that the first report was written by MAHA,” Jerold Mande, an adjunct professor of nutrition at the Harvard T.H. Chan School of Public Health and a former senior policy official for nutrition in the Bush, Clinton, and Obama administrations, told Time Magazine. “The second one, the White House let industry lobbyists write it.”

The post RFK Jr.’s MAHA Movement: Industry Takes Control appeared first on Washington Monthly.

You would think protecting veterans’ access to health care would be sacrosanct in the current political environment.

So how can we explain the Trump regime wielding a budget axe at the Veterans Health Administration? The agency—the largest health care system in America—is in the process of eliminating 30,000 jobs for physicians, nurses and other personnel. That’s nearly one of every 12 employees at the VHA, which is responsible for delivering health care to over nine million veterans.

In recent weeks, Veterans Affairs Secretary Doug Collins, a former Georgia Congressman and military chaplain, cancelled every union contract with the VHA’s physicians, nurses and other employees. This came after the Baptist minister-turned-politician sent letters to VHA workers encouraging them to either retire or look elsewhere for work. Morale at the agency is plummeting.

These were only the first steps in the Trump regime’s plan to dramatically downsize the VHA during his second term in office. The 2026 budget he sent to Capitol Hill called for spending more than a third of the VHA’s $115 billion budget on outside physicians and other private providers. That’s a nearly 50% increase over previous outsourcing, a move that some progressive Democrats in Congress are calling the stealth privatization of the VHA.

“They want every employee to be pushed out so they can decimate the VA’s workforce,” Rep. Delia Ramirez (D-IL) said during a July House Veterans Affairs committee meeting. It “wants them to leave” as part of its plan to privatize services.

The Trump regime’s escalation of VHA privatization extends a decade-long trend. It began in 2014 after a Phoenix VHA administrator was accused of under-reporting appointment wait-times in the reports sent to Washington. (No other health care system reports wait-times. If they did, the VHA would probably look good by comparison.)

Ensuing demands that veterans be allowed to access private-sector providers led to passage of the 2014 Choice Act, signed into law by President Barack Obama. The law launched pilot projects in rural and under-served areas that, while allowing for outsourcing, limited it to situations where the local VHA facility was more than a 30-minute drive from the veteran’s home, or, the facility could not schedule an appointment within 20 days for primary or mental health care or within 28 days for specialty care.

The program became system-wide with passage of the 2018 Mission Act, which also had bipartisan support. Though touted as a major benefit for the 25% of veterans who live in rural areas, the bill broadened the criteria to include instances where veterans and their VHA physicians thought it was in “their best medical interest.” But they needed a second opinion to that effect. Earlier this year, VA Secretary Collins removed the second opinion requirement.

No choices

But is “choice” helping rural veterans? Earlier this month, The American Prospect reported on a comprehensive survey by the Veterans Healthcare Policy Institute that questioned private providers’ ability to serve the needs of the 2.8 million rural veterans enrolled in the VHA. The “analysis reveals a system that cannot provide even basic medical and mental health services to non-veteran patients,” Suzanne Gordon, co-founder of VHPI wrote. “Hundreds of hospitals in America’s rural counties and under-served areas have curtailed critical services or closed entirely. And thousands of counties across America are experiencing significant health provider shortages.”

Things are likely to get a lot worse over the next several years as millions of rural residents on Medicaid or Affordable Care Act insurance plans lose coverage due to the cutbacks recently signed into law. “President Trump, VA Secretary Collins, and Republicans in Congress want to send more veteran patients into an already troubled private-sector system, while depleting that system of the resources necessary to absorb this extra load,” Gordon wrote. “The idea that this will work well is shaped more by ideology than reality.”

If helping rural veterans is the goal, a far more fruitful approach would be shifting VHA resources into the areas where most veterans now live. The system rapidly expanded during the quarter century after World War II to serve the needs of veterans who, for the most part, hailed from urban areas. The system’s 170 hospitals are located mostly in large and medium-sized metropolitan areas.

The VHA also staffs almost 1,200 outpatient facilities. Unfortunately, most rural areas remain poorly served by these clinics. Many rural counties have none. This should come as no surprise. Residents of these areas often have to drive an hour or more to access pharmacies, grocery stores and other retail outlets. Accessing medical services, whether public or private, often involves even longer drives.

Moreover, rural hospitals, which would be a logical place for providing additional services for veterans, are also dying. There simply aren’t enough patients in sparsely populated areas to support comprehensive medical services. The idea that the private sector can meet the special needs of veterans, who suffer disproportionately from chronic diseases, whether related to their service (Agent Orange and burn pit exposure; PTSD and other mental conditions) or not, is absurd.

Here’s an idea. Why not use the VHA budget to establish clinical capacity in these regions? Indeed, they could open their doors to the entire local population, turning the VHA in rural America into the equivalent of a federally qualified health center. This could provide the agency with an additional source of revenue to the extent other payers (Medicare, Medicaid, private insurance) offered coverage to people living in these sparsely populated areas.

Best care

But, you’re probably asking, wouldn’t this take money away from the urban medical centers that are the backbone of the VHA system? These large complexes are currently underutilized, spatially mismatched to where current and future generations of veterans live, and often in need of renovation—a set of circumstances documented by numerous commissions and reports. (See here and here, for instance.)

To help solve these problems, one idea I found intriguing while doing research for this article (it comes from the right-leaning Manhattan Institute) would be to allow the VHA’s urban hospital systems to provide services to people covered by public programs like Medicare and Medicaid and the privately insured.

The VHA model for delivering care is everything a wannabe reformer like myself dreams about (as Phil Longman documented in his 2012 book, “Best Care Anywhere: Why VA Healthcare Would Work Better for Everyone.”). Its physicians are salaried; they are mission-driven (they work for less than their private sector counterparts); they are trained to follow clinical practice guidelines; and, as a general rule, they deliver high quality care (studies have repeatedly documented how VHA outcomes equal or surpass those of comparable facilities). The VHA also provides comprehensive coordinated care for people who require it (including addressing housing and food insecurity and other social issues) and pays the lowest price for drugs.

Unfortunately, its facilities are disproportionately located in regions that no longer house many veterans. Manhattan Institute senior fellow Chris Pope summed up the problem in his recent proposal, “Making Use of VA Hospital Overcapacity: Expand Access to Reduce Costs”:

“The VA operates essentially the same hospitals in the same locations as it did in the 1970s, despite a great shift of the veteran population to the Sunbelt. In 1970, far fewer civilian veterans lived in Arizona (0.2 million) than in New York (2.4 million). By 2020, the number in Arizona had surged (to 0.5 million), while that in New York had plummeted (to 0.6 million). While the VA still operates twice as many hospitals in New York as in Arizona, facilities in the Grand Canyon State have been strained. The VA has substantial excess capacity across the country as a whole; but in a few areas, clinicians have been overworked while patients face long waiting times.

His proposal?

“VA hospitals should be permitted to treat and bill Americans covered by other insurance plans (privately financed, Medicare Advantage, or Medicaid managed care), regardless of their eligibility for VA-financed care. Congress has repeatedly demonstrated that it is unwilling to cut funding for existing VA hospitals, as this may threaten their continued operations. Policymakers should therefore attempt to make better use of these facilities, so that their fixed costs can be spread over more patients.”

Since many veterans who receive free care at VHA facilities are also enrolled in taxpayer-financed private plans like Medicare Advantage and Medicaid managed care, it would also save the government money. “This proposal would provide increased revenues to allow the continued maintenance of VA institutions, without increasing federal expenditures per patient as the veteran population continues to decline,” he wrote. “It would also end the double payment for veterans receiving care through the VA who are also enrolled in Medicare Advantage or Medicaid managed care.”

This seems like an idea well worth exploring—one that has the potential to generate bipartisan support on Capitol Hill.

The post Why Stealth Privatization of Veterans’ Care Is Doomed to Fail appeared first on Washington Monthly.

They go by different names in different states. In Tennessee, it is TennCare. In Ohio it is the Buckeye Health Plan. In California, it is Medi-Cal.

In Florida, it “sounds like an orange juice brand: Simply Healthcare,” wrote N. Adam Brown, an emergency room physician and professor at the University of North Carolina business school, in a commentary posted earlier this week on the MedPage Today website.

What they have in common is that they are Medicaid plans run by private insurance companies. Over the past several decades, 41 states and the District of Columbia have turned over their low-income health insurance programs to what industry jargon refers to as Medicaid managed care organizations or MCOs.

The nation’s 280-plus MCO plans cover an estimated 75% of the 85 million people (as of March 2024) on Medicaid, the joint federal-state program targeted for massive cuts by the GOP-run Congress. While many are run by non-profits or government agencies (like CountyCare in Chicago where I live), five for-profit private insurers (Centene, UnitedHealth Group, Elevance, Molina and Aetna/CVS) account for more than half of all Medicaid MCO enrollment, according to the Kaiser Family Foundation.

While the websites of most of these firms indicate their plans are connected to Medicaid, a significant share of their clientele have no idea they are covered by a government-financed program. A recent study published in JAMA found that between 2019 and 2022 when enrollment increased by 5.2 percentage points, surveys that asked where people obtained their health insurance showed only a 1.3 percentage point growth in Medicaid.

“Because Medicaid is not branded as Medicaid, if you tell a patient in South Carolina they might lose Medicaid, their eyes may glaze over,” Brown wrote. “Tell them Healthy Connections is at risk? You have their attention.”

His solution? “In every state, we need to call Medicaid by its real name,” he wrote. Instead of saying “‘Republicans want to reduce Medicaid by $880 billion,’ try ‘If Republicans’ Medicaid plans come to fruition, you could lose your Buckeye Health Plan health insurance.’”

Where are the lobbyists?

No one is in better position to call Medicaid by its real name than the private insurers in charge of the program. Yet with the sole exception of Centene, the largest MCO operator, most companies have remained silent in the face of the GOP’s assault on the program.

For instance, I can’t find a single press release or public statement by a private insurer that counters claims contained in a specious hit piece released earlier this month by conservative think tanks that estimated Medicaid made $1.1 trillion in improper payments over the past decade. Since they’re managing at least half the money that flows through Medicaid, they ought to be offended.

The Paragon Health Institute and Economic Policy Innovation Center paper based its claims on eligibility reviews conducted during the last two years of the first Trump administration. It then applied that percentage to all Medicaid spending. However, the government estimated just a 5% improper payment rate or about $31 billion in 2024, which, if eliminated in every year over the next decade, would only save half of what conservatives claim.

Nor have those insurers risen to defend the the 92% of adults under 65 who are on Medicaid despite working full or part-time. More than a quarter of all workers in the private sector are not offered health insurance as a benefit, most whom are earning poverty- or near-poverty wages and are eligible for Medicaid, especially in the 41 states that have expanded the program (with 90% federal funding) to cover people earning up to 138% of poverty wages.

Even among those offered health insurance on the job, only three-quarters purchase plans. Why? Most can’t afford the premiums being taken out of their paltry paychecks.

So let’s begin describing Medicaid for what it is: A massive subsidy for employers who rely on low-wage labor. This subsidization is necessary because we have what, theoretically at least, is an employment-based health insurance system. Yet the government doesn’t require all employers provide and pay for health insurance.

Of course that’s not what you hearing from Republicans like Rep. Eric Burlison (R-Mo). During hearing held earlier this month, he, like the president he slavishly follows, said there would be no cuts to Medicaid. “My definition of cutting does not include getting people who are fraudsters and getting people who are not supposed to be on the list as recipients.”

Democrats should answer with the following: “When we make Florida’s orange growers pay for their orange pickers’ health insurance, we’ll be able to shrink ‘Simply Health’ as much as they shrank the amount of juice put in each bottle.”

The post Medicaid Needs Rebranding appeared first on Washington Monthly.

Robert F. Kennedy Jr. is brimming with wacky and potentially dangerous ideas, but some are not. For instance, the 70-year-old’s focus on the health harms caused by processed foods and environmental toxins draws praise from across the political spectrum, including Senator Bernie Sanders of Vermont.

Here’s another one that stands out as eminently sensible and long overdue. Donald Trump’s nominee to head the Department of Health and Human Services says he wants to change how Medicare compensates physicians, overcompensating specialists and underpaying primary care physicians.

The government program and private payers overpay those who replace knees and hips, clean out clogged arteries, and administer complex cancer chemotherapy regimens. At the same time, the healthcare system shortchanges the primary care docs who promote prevention and wellness, manage patients with multiple chronic conditions, and daily see people with symptoms of unknown origin.

Those compensation priorities are set by a little-known committee of the physicians’ lobby, the American Medical Association, which, despite its outsized clout, represents just one in five physicians today. Each year, its Relative Value Scale Update Committee (RUC), whose membership is dominated by highly paid specialists, recommends what the Centers for Medicare and Medicaid Services (CMS) should pay for the nearly 10,000 procedural codes physicians use to charge for services. The RUC routinely overvalues specialist codes and undervalues primary care codes. Each year, CMS adopts the vast majority of those recommendations without changes. (Editor’s note: See Special Deal: The Shadowy Cartel of Doctors that Control Medicare by Haley Sweetland Edwards in the Washington Monthly, July 5, 2013.)

The result is a healthcare system focusing most resources on treating the very sick. Just 5 percent of its resources are spent on preventing sickness, diagnosing diseases early, and helping the chronically ill, who consume an estimated 80 percent of all healthcare services, avoid more serious illness. These misplaced priorities are also responsible for America’s shortage of primary care physicians. Few medical students choose to jump on a primary care treadmill marked by 10-minute office visits when they can earn two to three times more by becoming a high-paid specialist, allowing most of them to pay off exorbitant loans.

Stat, the online publication that covers the healthcare industry, reported last month that advisers close to Kennedy put changing physician compensation on the former presidential candidate’s radar screen. They included Calley and Casey Means, wellness entrepreneurs and bestselling authors whose company, Levels, sells continuous glucose monitoring to the worried well. Casey Means is a surgeon who left her practice to become chief medical officer of the brother-and-sister’s start-up in 2019.

The two initially backed RFK’s short-circuited presidential campaign. After the election, Calley Means posted on X, “Our CMS codes embed a system that waits for Americans to get sick and profits. This is ground zero for driving better health outcomes and government efficiency.”

The Means siblings won right-wing adulation after appearing on Tucker Carlson’s show when Kennedy was still running as a third-party candidate. Just before the election, Joe Rogan interviewed them on his top-rated podcast. “After joining the Trump transition team, Kennedy shouted the Meanses out by name,” Stat reported, “saying in a public appearance that he would put people like them atop the nation’s health agencies if given his choice.” Casey has worked for Republicans, including the late Senator John McCain, and Calley told Bill Mahar on his HBO show that she’s not a Trumper.

If either takes a top post at CMS, they will face a formidable enemy in the AMA and the physicians whose specialties benefit from current pay scales. (Trump’s nominee to head CMS is Mehmet Oz, the author, celebrity, and physician who lost his U.S. Senate bid in Pennsylvania in 2022.) The AMA owns a copyright on physician payment codes. It receives royalties estimated at over $200 million annually—nearly half of the organization’s yearly income—from its use in billing software.

The medical profession justifies higher pay for specialists by claiming it takes more time, practice, and know-how to perform or manage complex procedures and cases. They also undergo training programs that last anywhere from one to three years longer than primary care physicians.

But critics point out that it’s a circular argument that fuels the self-interest of specialists. The AMA estimates time through surveys of physicians in each specialty conducted by the medical societies that sit on the AMA’s RUC. While the AMA insists it has taken steps to reduce the disparity in recent years, the spread between top specialist pay and primary care physician pay has grown wider (see chart).

Should the Trump administration, with or without a Secretary Kennedy, take on the RUC-AMA phalanx, they will face opposition from the GOP Doctor’s Caucus on Capitol Hill. Twenty of 26 medical professionals in Congress are physicians, and 19 belong to the GOP Doctor’s Caucus.

On the other hand, if a CMS under Dr. Oz takes on the current pricing scheme, he should find considerable support from groups on the left, who have pushed for physician pay reform for over a decade. As the Washington Monthly reported in mid-2022, the National Academies of Science issued a report the previous year that called for raising investment in primary care to 10 percent of all health care expenditures, a doubling from current levels.

Trump’s first administration did launch a few pilot projects to expand primary care pay. But Joe Biden’s administration was the first to attempt something systemwide. CMS’s latest update of the physician pay scale, which agency officials estimated will lead to a 2.8 percent cut in overall physician pay, included new payment codes for primary care physicians. They can collect a flat monthly payment from CMS if they engage in activities coordinating care for their chronically ill patients.

“These efforts move us in the right direction, but we have a long way to go,” said Ann Greiner, president of the Primary Care Collaborative, a coalition of groups fighting for more significant funding for primary care. “We can’t just change how we pay. We have to change how much we pay. Pricing is an issue that must be addressed.”

The Trump administration could exploit modest cracks in the GOP Doctor’s Caucus. Senator Bill Cassidy, the Louisiana Republican and a physician, introduced the Pay PCPs Act along with his colleague, Sheldon Whitehouse, the Rhode Island Democrat. In addition to adding new hybrid payments for primary care that were included in the latest CMS rule, the bill would create “a new technical advisory committee to help CMS more accurately determine fee schedule rates.” However, Louisiana State Treasurer John Fleming has announced he will challenge Cassidy in the 2026 Republican primary because Cassidy voted to impeach Trump for his role in the January 6, 2021 insurrection.

The Urban Institute’s Robert Berenson, a physician and among the original architects of the fee-for-service physician fee schedule at CMS, called adjusting pay scales the key to deriving higher value and better outcomes from the current system. “If you pay a lot for certain procedures, you’re going to get a lot of those procedures. Other countries have improved value through adjusting the fee schedule,” he said.

Berenson has an idea that goes further than the Cassidy-Whitehouse effort. He wants legislation to establish an independent technical advisory panel that isn’t dependent on professional societies to determine how much their time and expertise are worth—a blatant conflict of interest in the AMA’s current setup. “If it’s done by CMS, it will be captured by the AMA,” he said. He’s right, and this is one place where Kennedy/Oz could do some good if confirmed.

The post A Hidden Gem in RFK Jr.’s Agenda appeared first on Washington Monthly.

Dr. Marty Makary, Donald Trump’s nominee to head the Food and Drug Administration, is a contrarian.

Near the end of the Johns Hopkins professor of medicine’s latest book, Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health, he asks, “Can diabetes be more effectively treated with a cooking class instead of prescribing insulin? Can we lower high blood pressure by improving sleep quality and reducing stress instead of throwing antihypertensive medications at people? Can we discuss school lunch programs, not just bariatric surgery and Ozempic?”

Alone among Trump’s health care appointees, Makary has escaped criticism on Capitol Hill and in the mainstream media. If the Senate confirms him, his penchant for questioning conventional wisdom could unleash the FDA to pursue the positive public health aspects of Robert F. Kennedy Jr.’s agenda, requiring greater regulation of the nation’s food supply.

But while the FDA’s role in food oversight is essential, it is less than half the agency’s mandate. Its main job is ensuring the safety and efficacy of drugs, biologicals, medical devices, and vaccines. Based on his book’s questionable use of medical evidence, Makary could push to change evidentiary standards at the divisions of the FDA that grant approval for those crucial aspects of health care. That would mean undermining public trust in an agency once considered the gold standard for regulators worldwide.

Makary has often criticized the medical and regulatory establishment throughout his career, accusing them of “groupthink” and being prone to drawing conclusions not justified by evidence. Yet, he can be just as guilty of cherry-picking evidence to justify preconceived conclusions as those he accuses. Like the vaccine-skeptic slated to become his boss, he could do far more harm than good.

While the CDC and Surgeon General have nominal responsibility for public health, Congress gave neither the power to make changes in policy. The CDC only issues recommendations. Implementation is voluntary and left to the states. The Surgeon General occupies the medical bully pulpit but otherwise lacks authority.

The FDA, on the other hand, has the power to prevent market access for unsafe or ineffective drugs, vaccines, and medical devices. It ensures safe manufacturing processes for the products it regulates. It protects the public from food-borne illnesses. It issues nutritional advice and drug labeling guidelines. It polices false medical claims on packaging and in advertisements. It safeguards about one in every four products that eventually reach the market.

To carry out that broad mandate, the agency leans heavily on the scientific judgments of its in-house employees, most of whom are well-trained physicians, scientists, and statisticians. Their jobs entail evaluating the scientific studies behind manufacturers’ claims that their new drugs and devices are safe and effective, almost all provided by industry-funded clinicians. They also must monitor and respond to post-marketing surveillance studies that identify harms not seen in the short-term clinical trials used for regulatory approval. Agency scientists frequently rely on the advice of independent outside experts, who are supposed to be free from financial relationships with companies whose products they are reviewing.

Having served on several FDA advisory committees as a consumer representative, I know from personal experience that the agency’s regulators offer a far more objective review of the scientific evidence than the drug, medical device, and food industry-funded clinicians and scientists hired by companies seeking product approvals. When the science is unclear, they are slow to act. But when outside pressure is intense (especially from companies or patient advocacy groups), they sometimes approve products that lack sufficient evidence. One need look no further than recent drug approvals for Alzheimer’s disease or Duchenne’s muscular dystrophy, both approved on questionable evidence, to see how far the FDA has slipped from its once-vaunted reputation.

The need to carefully evaluate the science before leaping to conclusions makes Makary’s book a thought-provoking yet disturbing read. He lays the blame for several public health fiascos on advice offered in the 1990s by medical professional societies. He documents how the advice to families not to expose toddlers to peanuts until age three (from the American Academy of Pediatrics) and that addiction is not a threat from short-term use of opioids (from the American Pain Society) were based on expert opinion, not rigorous studies. Both have since been withdrawn.

With contempt, he dismisses the weakness of the evidence behind long-standing recommendations to avoid cholesterol-laden and high-fat foods, much of which has been either walked back (dietary cholesterol) or become highly nuanced (avoiding saturated fats, not all fats). Makary takes sides in the media-fueled debates over hormone replacement therapy for menopause and the use of silicone-filled breast implants, coming down in favor of their widespread use despite controversies about their safety.

In short, he routinely sides with contrarians in scientific debate, including the use of school lockdowns early in the pandemic. He frequently deploys the epithet “groupthink” at those with whom he disagrees, including the research choices of the National Institutes of Health, the guidelines offered by many medical professional societies, the advice provided by the CDC, and the choices made by many practicing physicians who blindly follow their advice.

Yet he does not apply his contrarian mindset to two groups that are usually the target of journalistic accounts of medical mistakes: the pharmaceutical and medical device industries, which are the main targets of contrarians on the left. These two industries depend on favorable judgments from the FDA he hopes to lead. They also provide nearly half its budget through user fees, which is a blatant conflict of interest.

A book about medical blind spots contains just two paragraphs questioning pharmaceutical industry actions. Makary criticizes Purdue Pharma for promoting the use of Oxycontin without mentioning that the company funded the clinicians who formed the American Pain Society, which wrote guidelines touting opioids for minor pain. The British-born surgeon also criticizes the massive price increases on EpiPens (its maker, Mylan, goes unnamed) in response to the peanut allergy epidemic.

It is a curious oversight. While Makary digs deep in the medical literature to find studies that justify his opinions, he avoids mention of the hundreds of medical journal studies published throughout his quarter-century career that document the pernicious effects of industry’s role in financing medical research, clinical practice guidelines, patient advocacy groups, continuing medical education, and physician marketing. He ignores how industry-funded research supported the extensive use of drugs and devices beyond the indications included on the FDA-approved label, often causing great harm in the process.

Had the FDA nominee looked past that blind spot, he would have found many stories that would have fit nicely with the central theme of his book. Off-label drug promotion by industry has been responsible for some of the worst medical disasters of the past three decades.

For instance, throughout the 1990s and into this century, Amgen, the nation’s largest and most profitable biotech firm, promoted the overuse of its Epogen in dialysis patients. The company gave financial support to researchers whose studies proved that greater use of Epogen elevated their red blood cell counts and gave patients more energy. The company also funded the creation of guidelines by the National Kidney Foundation that promoted the off-label use of the drug for that purpose. The side effects were overlooked. The result? An excess of heart attacks and strokes among an already vulnerable population led to a black box warning from the FDA. The NKF eventually withdrew the guidelines.

Nor does Makary mention the better-known Vioxx case, where Merck heavily promoted the use of its high-priced, anti-inflammatory alternative to generic ibuprofen for minor aches and pains despite clear signals in the drug’s clinical trials that it raised the risk of heart attacks and strokes. Tens of thousands of people died from Vioxx before it was finally pulled from the market by Merck, which paid close to $5 billion to settle claims made by aggrieved families.

One of the most disturbing aspects of Makary’s book is his inconsistent use of medical evidence, a habit that seators should scrutinize at his confirmation hearing. He is quick to critique the quality of studies used to justify the expert opinions he questions but enthusiastically embraces studies that use even lower levels of evidence when they suggest potential upsides from the therapies he supports.

This double standard is on full display when he derides research indicating health risks associated with taking hormone replacement therapy (HRT) to relieve symptoms of menopause. There is no question HRT benefits women experiencing hot flashes and vaginal dryness. But for over two decades, HRT has carried a label based on the Women’s Health Initiative (WHI). This NIH-funded clinical trial compared more than 20,000 post-menopausal women taking hormones to two similarly sized groups taking other non-hormonal therapies. The trial also compared the hormone-taking group to a much larger “matched cohort” that was not in the trial.

The FDA warning states women taking an estrogen/progestin combination drug experience “increased risks of stroke, deep vein thrombosis, pulmonary embolism, and myocardial infarction.” The trial “also demonstrated an increased risk of invasive breast cancer.” It is that latter finding that draws fire from Makary.

Makary correctly points out that the trial’s finding that HRT increased the risk of breast cancer was problematic. The range of data points in the original study, known as the confidence interval, straddled the line between statistical significance and insignificance. (In statistics, “significance” refers to the likelihood that the results are correct, not that there is a major effect.) The data showed a trend indicating increased cancer risk, but no conclusive proof.

Since breast cancer is always a hot-button issue, the interim results led the organizers, over the protests of some of its participating clinicians, to stop the trial and hold a press conference. The widespread publicity triggered an immediate drop in HRT use and an ongoing reluctance to begin estrogen supplementation to relieve symptoms of menopause.

More than two decades later, Makary interviewed the primary organizers and authors of the study, who reluctantly confirmed his critique of the original study. “The finding (on breast cancer) is very borderline,” Dr. JoAnn Manson, a professor of medicine at Harvard Medical School and the study’s leader, told him. Yet earlier this year, Manson and 18 co-investigators published an updated review of the clinical implications of the WHI in JAMA based on a 2020 study that included longer follow-up. It found elevated cancer risk, and this time, it was statistically significant.

After critiquing the original breast cancer finding, Makary makes broad claims for the health benefits of HRT, including delaying the onset of Alzheimer’s disease; preventing cardiovascular disease and heart attacks; and reducing colon cancer risk. “Women taking estrogen have a 35% lower incidence of Alzheimer’s,” he declares. What evidence does he cite? A 1996 study of 8,877 women in a southern California retirement community mailed a general health survey in 1981, less than half of whom had died by 1995. The researchers then examined death records and found 248 mentioning Alzheimer’s or other forms of dementia, with about 35% more mentions in women who had not taken HRT than in the group that had.

This type of research is known as an observational study of matched cohorts, which is a much less trustworthy source of medical evidence than randomized clinical trials like the WHI. The possibility that unmeasured or unidentified variables such as underlying health conditions or family history will confound the results is enormous. The best one can say about conclusions drawn from observational studies is that they offer clues for further research but are inadequate for making definitive claims about efficacy.

Makary’s claim that HRT reduces the risk of heart disease is based on another observational study called the Nurses Health Study, published in 1991 and updated in 2000. This frequently criticized study recorded the self-reported health habits, treatments, and outcomes of over 70,000 nurses over two decades. “Heart disease is the leading cause of death in American women. HRT reduces that risk by about 50%,” he declares.

Yet in 2015, the Cochrane collaboration (“a highly respected group of experts who conduct extensive scientific reviews,” to use Makary’s description from another section of his book) found “no evidence that hormone therapy provides any protective effects against death from any cause, and specifically death from cardiovascular disease, non-fatal heart attacks or angina, either in healthy women or women with pre-existing heart disease.”

The Cochrane group further concluded HRT increased risk of stroke for post-menopausal women.”

The recent update of the WHI, a randomized controlled clinical trial, again found no cardiovascular benefits. The study, which appeared this past May in JAMA, showed HRT significantly increased the risk of stroke and blood clots. The overall incidence of heart disease among women also increased, although that finding was not statistically significant.

And, as for Makary’s major claim that HRT presented no risk of cancer, this latest WHI study confirmed the trial’s original suspicion about just that. Except this time, the findings were statistically significant. “At 20-year follow-up, [estrogen plus progestin] compared with placebo significantly increased breast cancer incidence” by 28 percent, the study showed. If taking estrogen alone, there was a slight decrease in breast cancer risk, but that was a statistically insignificant finding.

The bottom line: The overall risk of developing cancer from HRT is small and is more significant in older women. That is why the WHI investigators still suggest short-term HRT for women under 60 is an appropriate therapy for relieving menopause symptoms if they aren’t already at risk of developing heart disease or cancer.

Debate over HRT isn’t the only medical arena where Makary takes sides on controversial issues based on studies that are far from conclusive. Water fluoridation “may be affecting our intelligence,” Makary warns, citing a Canadian study that compared IQ test results in young children in two communities: one with fluoridated water and one without. This matched cohort study measured the IQs of just 512 children in the two communities. It found a statistically significant decrease of four IQ points in boys aged 3 to 4 but no decrease in girls.

One doesn’t have to be a contrarian to know any number of confounding variables may have skewed the results of this small study. Yet Makary concludes, “We should be open to reversing this practice” of fluoridating water.

The book is peppered with definitive statements about medical outcomes based on such sketchy evidence. In a chapter on childbirth practices, he appropriately condemns America’s extraordinarily high rate of C-section deliveries. He also criticizes induced labor by pointing to a randomized controlled trial published in the New England Journal of Medicine that showed women with low-risk pregnancies who had labor induced at 39 weeks (full-term) had fewer complications than those who waited beyond their due date for labor to begin. “The study made its claim of superiority by adding unrelated outcomes together — outcomes that were not statistically significant by themselves,” he writes.

But then, he laments how these “cold medical practices” (excessive use of C-sections and induced labor) have soured expectant mothers on modern medicine and caused thousands to turn to home births. Parents who “glamorize home births and medical-free deliveries ignor(e) the real risks such decisions entail… Home deliveries triple the risk of infant mortality.”

That shocking claim, which would certainly turn me off to birthing at home if I were an expectant mother, sent me rushing for the footnotes. There were none. So, I searched the medical literature and found a 2010 meta-analysis (an analysis using pooled data from a group of studies on the same subject) in the American Journal of Obstetrics and Gynecology that made that claim. It reviewed data from over one-half million planned hospital or planned home deliveries. However, only 1 of the 12 studies used for the meta-analysis was a randomized controlled trial. The rest were observational studies, some with some without matched cohorts. The low quality of the evidence was blasted by letter writers to the Journal.

I also found a subsequent review of that meta-analysis that warned, “the authors’ conclusions should be treated with some caution as they did not reflect all the evidence presented in the review.” In an echo of Makary’s critique of the Women’s Health Initiative, the critique pointed out that the meta-analysis showed no statistical difference in the two groups in perinatal infant mortality (deaths up to 7 days after childbirth).” The alleged “tripling” was only in neonatal infant mortality (deaths up to 28 days after childbirth), which logic suggests would include more deaths not associated with childbirth itself. The critique also pointed out that the data on neonatal infant deaths came from trials that included fewer than 50,000 births — less than a tenth of the meta-analysis’ total review population.

Makary goes to great lengths throughout his latest book to appear as a voice of reason. He asks government officials, guideline writers, and practicing clinicians to be more humble when making limited evidence recommendations. He wants NIH to fund more research on practices that challenge conventional wisdom. He questions the peer review practices at medical journals, pointing to the 10,000 annual retractions identified by Retraction Watch (Full disclosure: its founder, Dr. Ivan Oransky, has edited magazine articles I’ve written). He laments the absence of respect for contrarian researchers who challenge “groupthink.” “Today, more than ever,” he writes, “organized medicine is finding ways to limit and stifle scientific debate.”

Science is always contested terrain. But today, despite the backlash against the Covid-era shutdowns and the growth of vaccine hesitancy fed by disinformation about safety, the primary contest is not between skeptical contrarians and the medical establishment. It is between scientists backed by companies with a financial interest in the outcome of medical research and their regulators.

Industry and the self-interested physician specialists it funds play an outsized role in generating medical evidence and writing clinical practice guidelines. Industry-funded research dwarfs that of the NIH. Outcomes and conclusions that ought to be based on an objective interpretation of facts can be biased by any number of factors, ranging from the researchers’ preconceived ideas to the study’s structure to who funded their efforts.

Moreover, best medical practice is an always-changing target, hopefully for the better. New paradigms can and often do replace yesterday’s conventional wisdom. But those changes usually come slowly and only when more rigorous investigations follow up studies whose statistical validity only hints at the need for change.

It is those higher standards of evidence that the FDA has traditionally adhered to when approving new technologies, issuing guidelines and warnings, or removing unsafe products from the market. The 18,000-person watchdog agency needs its next leader to adhere to those standards. Based on Blind Spots, Dr. Makary still needs to show he will follow those standards when he appears before the Senate for confirmation.

The post The Trouble with Trump’s Pick to Run the FDA appeared first on Washington Monthly.

When asked if health care is on the ballot this November, most voters immediately respond yes and have strong opinions about the issue. Either they are for reproductive health rights and elective abortions and are voting for Kamala Harris, or they are against both and are voting for Donald Trump.

Most people don’t know or are dimly aware that Harris has also proposed the most significant Medicare expansion since adding a prescription drug benefit in 2003. Her plan would be wildly popular if more people knew about it. Nor do they realize that a second Trump presidency, especially if Republicans also win control of Congress, will result in millions of people losing their health insurance coverage or seeing their benefits sharply reduced.

In early October, Vice President Harris, surrounded by the hosts of ABC’s The View, announced plans to add a home-care benefit to Medicare. It would provide financing for in-home aides to help with the daily living tasks of infirm elderly and disabled family members struggling to stay out of nursing homes. Most of that care is provided by unpaid relatives unless the beneficiary qualifies for Medicaid, which requires exhausting one’s assets first.

Citing her own struggles with helping her mother while she was dying of cancer, Harris pledged to help the sandwich generation that finds itself taking care of both young children and an elderly parent. “Giving that support to your family members means losing as much as you can to be able to go on Medicaid or having to leave your job,” Harris told cheering supporters at a recent rally. “That means cutting off a very important part of your income just to give the people in your life the dignity and support they deserve.”

Recent polling shows 75 percent of U.S. adults support a program to help pay for long-term care, which European countries and Japan provide through a mandatory requirement to purchase long-term care insurance, taxpayer-financed programs, or a combination of both. Like health insurance, the U.S. is the only advanced industrial nation that doesn’t have a universal long-term care program. Yet, among Americans, “two-thirds support a government-administered long-term care insurance program, government funding for low-income people to receive long-term care in their homes, or Social Security earnings credit for providing care to a loved one,” the 2022 Associated Press-NORC Center for Public Affairs Research poll on long-term care found.

The need for such a program is enormous. Nearly 50 million Americans, or 20 percent of all households—up from 15 percent a decade ago—provide unpaid care for loved ones living at home when they need help with the basic tasks of daily living like dressing, bathing, toileting, and feeding. That number will grow substantially over the next two decades as the Baby Boomer generation moves through its final years. The potential beneficiary population includes not just the elderly incapacitated by dementia and other diseases but also younger family members with severe mental and physical disabilities.

The strain of working what is essentially a second job—taking care of someone at home, a labor that falls to a woman 65 percent of the time—can take a huge toll on the caregiver’s health. They lose touch with friends. They’re emotionally exhausted. They too often wind up ignoring their health. About a third of caregivers skip routine physical or dental care because they are consumed with caregiving duties, according to the 2018 poll by AP-NORC. Nearly 40 percent have their own physical or mental problems.

A universal at-home care program will be costly. Providing in-home aides to help the helpers will cost Medicare an estimated $40 billion a year, according to a recent Brookings commentary. Issued just three weeks before Harris announced her plan, its authors included Jonathan Gruber, a key architect of the Affordable Care Act, and Wendell Primus, who served for many years as chief health care policy staffer to Representative Nancy Pelosi, the former Speaker of the House.

Their plan called for a means-tested program free to low-income people, including escalating co-pays for those with higher incomes. In addition to Medicaid, the home health aide industry relies on wealthier families paying out-of-pocket when employing in-home health aides for their loved ones.

While the benefit could be paid for by general taxation, an Urban Institute report issued six years ago called for funding a long-term care program with a surcharge on the Medicare payroll tax, currently set at 2.9 percent of income split evenly between workers and employers. The surcharge wouldn’t kick in until workers turned 40.

On the campaign trail, Harris said she would pay for the program through the savings from negotiating lower drug prices, one of the major health care accomplishments of the Biden-Harris administration’s first four years in office. However, the Congressional Budget Office estimates drug price negotiations over the next ten years will only save about $100 billion, which is only a quarter of what the Brookings authors estimate a home-care benefit will cost over a decade.

Yet the CBO’s bean-counting approach fails to consider the financial gains from a home-care benefit. Studies of pilot programs from the Centers for Medicare and Medicaid Services that provide caregivers with in-home aid show they reduce emergency room visits, hospitalizations, and admissions to nursing homes. Employers benefit from more productive workers who are under less stress and no longer need time off to care for loved ones. State budgets benefit from Medicare taking over Medicaid’s home care program, which frees up resources for other state programs or tax relief.

Recognizing any home health program’s potential popularity, Republicans updated their 2024 party platform to include a short section promising to “protect care at home for the elderly.” However, their proposed solutions, which are to “shift resources back to at-home senior care, overturn disincentives that lead to care worker shortages, and support unpaid family caregivers through tax credits and reduced red tape,” ignore basic facts.

There is no Medicare at-home benefit that had resources taken away from it. Care worker shortages are due to ridiculously low pay, which Republicans have enabled by refusing to raise the federal minimum wage or Medicaid rates in the states they control. And tax credits are mostly useless to the less well-off who pay little or no federal income tax. They will go mainly to the well-off since the modest taxes paid by people in the lower half of the income distribution are far less than the cost of an in-home health care aide.

Meanwhile, the Republican platform and Trump have been purposely silent about the biggest health care issue that will confront millions of Americans next year: the expiration of the expanded subsidies for individual and family health insurance plans sold on the Obamacare exchanges. Over the past three years, they helped lower the uninsured rate to about 8 percent—the lowest in U.S. history.

Should Trump return to office, those subsidies will be on the chopping block next year to help pay for the renewal of his 2017 tax cut, which went mainly to the wealthy and large corporations. Experts say that without those additional Obamacare subsidies, millions will forgo purchasing insurance because it is no longer affordable—something that happened during Trump’s first term when the uninsured rate went up.

Trump also never mentions plans by the architects of Project 2025, who are likely to fill key positions at his health care agencies, to return to policies that undermined the quality of health insurance. They include the sale of short-term insurance plans that leave purchasers with huge bills when they get sick and don’t meet current regulatory standards like free preventive services and guaranteed issue (no discrimination for pre-existing medical conditions); a sustained push for turning Medicaid into block grants, which will result in colossal service cuts in many states; and turning Medicare entirely over to the private insurance industry, which already enrolls over half of beneficiaries at a cost that is higher for taxpayers than the cost of those who remain in the traditional program.

When Harris says, “We’re not going back,” she’s not kidding. Her healthcare plans preserve the gains rendered by Obamacare and build on them through her new home care benefit. Trump—and those who hope to ride into office on his coattails—plans to go back by reversing the gains made under the Affordable Care Act and returning to the era when one in six Americans went without coverage and tens of millions were left with skimpy coverage that left them in medical debt.

The post Harris Wants Medicare to Cover Home Care While Trump Will Roll Back Obamacare appeared first on Washington Monthly.

During the vice-presidential debate, Senator J.D. Vance issued a thinly veiled promise to the nation’s insurance industry that after a Donald Trump win, the GOP will move aggressively to destroy Obamacare and open the door for junk insurance purveyors. He did so while also asserting that the former president had “salvaged” Obamacare while in office—a claim so audaciously absurd, yet delivered with such banal wonkery, that millions of average viewers might well have believed him.

It’s worth quoting his claim that night in full:

Donald Trump has said that if we allow states to experiment a little bit on how to cover both the chronically ill, but the non-chronically ill, it’s not just a plan. He actually implemented some of these regulations when he was President of the United States. And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I think this is an important point about President Trump… A lot of what happened and the reason that Obamacare was crushing under its own weight is that a lot of young and healthy people were leaving the exchanges. Donald Trump actually helped address that problem, and he did so in a way that preserved people’s access to coverage who had pre-existing conditions

That entire statement is a lie. First, his administration backed the GOP-run Congress’ attempt to repeal the Affordable Care Act. Only John McCain’s courageous thumbs-down vote saved the program. Then the Trump administration made a series of regulatory changes that threw millions of people off the insurance roles. He also promoted alternative plans certain to leave them with unaffordable co-pays and deductibles and huge medical debts when they became seriously ill. Finally, Trump encouraged some young people to forgo insurance by eliminating the individual mandate in his 2017 tax-cuts-for-the-wealthy act.

Kamala Harris’ running mate, Tim Walz, did a good job reminding debate viewers about the GOP’s nearly successful attempt to repeal Obamacare during Trump’s first two years in office. Unfortunately, Walz failed (perhaps because the debate’s format gave the candidates so little time) to highlight how much enrollment fell during Trump’s first three years in office. More importantly, he didn’t counter Vance’s “salvaged Obamacare” lie. He might have listed the numerous steps Trump took to undermine the program. They include:

• Shortening the enrollment period from 3 months to 6 weeks.
• Cutting the advertising budget during the ACA enrollment period by 90% and sharply curtailed funding for the navigators who help people sign up.

• Eliminating cost-sharing reduction payments to insurers so low-income enrollees would have lower out-of-pocket costs.
• Eliminating the individual mandate, which the Congressional Budget Office estimated decreased enrollment by 3 to 6 million people and increased plan costs by about 10%.
• Allowing greater use of “association” plans for small businesses and self-employed individuals, These plans exclude ACA-mandated benefits and
• Backing the legal challenge to the ACA which Trump appointees to the Supreme Court partially endorsed in 2020, allowing states that refuse to expand Medicaid to continue receiving federal funds.

The cumulative effect of those administration moves reduced overall enrollment in Obamacare by over two million people. Trump didn’t salvage the program. He savaged it.

The Trump administration also succeeded in “lessening the regulatory burden” on insurers by expanding access to short-term health plans with limited benefits. How? By lengthening their maximum duration from 3 months to 3 years. These plans provide less comprehensive coverage than ACA-compliant plans by eliminating free access to highly-rated prevention services like flu shots and mammography. They also can include very high out-of-pocket costs.

The Biden/Harris administration has executed a 180-degree reversal of the Trump changes with overwhelmingly positive results. Through higher subsidies included in the 2021 American Rescue Plan Act, which were extended by the 2022 Inflation Reduction Act, more than 10 million additional people have purchased health plans on the Obamacare exchanges, a near doubling of the final count during the Trump era after his changes had caused millions of people to drop coverage. The nation’s uninsured rate under Biden/Harris fell to 7.7%, down from 9.2% in 2019, the year before the pandemic.

Vance said Trump’s “concepts of a plan” for the future of the ACA would allow insurers to sell these skimpy plans on the exchanges, which is currently forbidden. This would allow younger and healthier people to buy low-cost plans with high deductibles. This would force older and sicker people into separate, higher-risk, and therefore more expensive pools. To repeat what Vance said: Trump wants to “allow states to experiment a little bit on how to cover the chronically ill but the non-chronically ill.”

As Walz pointed out, bifurcated risk pools were essentially what existed in the individual plan market before Obamacare. Such plans were widely judged a complete failure. They had extremely high premiums, leaving their sicker clientele with unaffordable co-pays and deductibles. They contained annual and lifetime limits on coverage, which was a disaster for the sickest patients with multiple chronic conditions. They also allowed for exclusions based on pre-existing conditions.

Even if Trump left the federal pre-existing conditions in place, which Vance promised, it would only apply to exchange plans. Allowing states to “experiment” with skimpy plans would encourage millions of younger, healthier people in those states to flee the exchanges. This would make useful coverage under the ACA unaffordable for older, sicker people or require massive increases in federal subsidies for what the ACA would become: a national high-risk pool. How likely is a GOP Congress to support that?

Ironically, neither vice presidential candidate mentioned the biggest threat facing the ACA’s insurance expansion under the Biden/Harris administration. The 2021 American Rescue Plan Act and Inflation Reduction Act lowered the percentage of income a person had to pay for silver plans on the exchanges. It also removed the income cap for subsidies, which had been set at 400% of the federal poverty level. These expanded subsidies were largely responsible for the rapid expansion of Obamacare in the past three years, to October of 2025.

But with their expiration set for a year from now, who controls Congress and the White House next year will largely determine Obamacare’s fate. Will Congress vote to maintain the expansion and thereby fulfill Obamacare’s promise to end the enduring stain on America’s reputation as the only country in the advanced industrial world that fails to provide universal health insurance? Or will coverage decline as it did under Trump when he held the highest office in the land? Based on what J.D. Vance told nationwide viewers this week, a GOP win will ensure that the U.S. continues to be an outlier nation with little concern for the sickest and poorest among us.

The post Vance Lied to Conceal Trump’s Plan to Destroy Obamacare appeared first on Washington Monthly.

Click here for the Monthly‘s Presidential Accomplishment Index and more essays comparing Trump and Biden’s achievements in office.

Health care reveals the chasm between the two major presidential candidates as much if not more than any other issue. As president, Joe Biden has successfully advanced the Democratic Party’s 75-year-long campaign to use government to ensure that everyone has health insurance. During his four years in the White House, Donald Trump led a traditional GOP effort to roll back such coverage—and failed. Trump’s response to the coronavirus pandemic was shambolic and disastrous, except for his vaccine development efforts. Biden’s was orderly and successful, though it may have erred in not recommending an end to school lockdowns sooner. Biden signed legislation that, for the first time, negotiates some drug prices and caps most senior citizens’ out-of-pocket prescription drug costs. Trump rhetorically supported similar efforts but accomplished little. Trump appointed Supreme Court justices who overturned Roe v. Wade, and in so doing created new risks to the reproductive health of American women. Biden is working to minimize those risks while maximizing the chance that GOP politicians, including Trump, pay a price. Reviewing Biden’s and Trump’s accomplishments and failures while in office leaves little doubt where either man will take the country over the next four years when it comes to health.

Insurance coverage

Trump came into office vowing to repeal Barack Obama’s Affordable Care Act (ACA), which had lowered the uninsured rate from 17 percent to 9 percent—the biggest insurance expansion since the creation of Medicare and Medicaid in 1965. Trump promised to replace Obamacare with “something terrific.” His never came up with the promised replacement plan. And his hopes for repeal were dashed with a thumbs-down vote by a dying Senator John McCain in July 2018, which prevented passage of a bill that would have gutted the law.

That failure didn’t stop Trump from making it harder for people to sign up for ACA plans, which are heavily subsidized for low-to-moderate-income families and individuals. His Health and Human Services Department (HHS) cut advertising and funding for Obamacare exchange navigators during the enrollment period; it cut the enrollment period in half; it cut subsidies for insurance companies that experienced large losses on their plan offerings; and it expanded access to short-term and employer association plans that did not meet ACA coverage requirements like guaranteed issue, allowing kids to stay on plans until age 26, and mandatory coverage of preventive health care. He also signed a 2017 tax bill that repealed the individual mandate that required people to buy health insurance or face a tax penalty. 

Those actions halted the program’s momentum, at least for a while. Signups on the exchanges fell steadily during his first three years in office, and the uninsured rate rose. But when the pandemic hit, some eligible people finally saw the wisdom in finding coverage either on the Obamacare exchanges or through Medicaid. By the time Trump left the White House, the uninsured and ACA participation rates were back to where they had been before he entered it. 

When Biden took over, he and congressional Democrats reversed most of those Trump-era policies, although it never restored the individual mandate. The American Rescue Plan and Inflation Reduction Act authorized major enhancements to government subsidies for low-and-moderate-income people signing up for plans, which sharply reduced their out-of-pocket costs and provided a powerful incentive for signing up. Biden refunded the navigator program and resumed nationwide advertising.

Finally, in an unheralded but somewhat successful program, his Centers for Medicare and Medicaid Services (CMS), led by Chiquita Brooks-LaSure, worked closely with state Medicaid agencies, including in Republican-run states, to switch people losing Medicaid coverage onto exchange-based plans. The end of the COVID emergency reinstated the requirement that everyone on Medicaid be recertified annually to ensure that they still quality for the program.

The Biden administration’s efforts galvanized the individual market. An estimated 21 million people signed up for Obamacare plans during the recently concluded enrollment period—a 30 percent increase over 2023, which held the previous record for signups. The biggest surges came in Texas and Florida, which never expanded Medicaid. 

What happens during the next administration will depend on which party controls Congress. If Trump wins the White House and Republicans win back the Senate while maintain a majority in the House, they will likely succeed at their second attempt to repeal Obamacare. The uninsured rate will soar back to levels not seen since the early 2010s. Even if Democrats control Congress, it won’t prevent Trump from taking the same types of administrative actions that resulted in a gradual rise in the uninsured rate and a deterioration in the quality of coverage for millions of Americans. 

If Biden wins, coverage will continue to expand, but only through the end of 2025, when the enhanced subsidies in the Inflation Control Act expire. It’s unlikely even a Democratic Congress will be able to overcome a Republican filibuster in the Senate of legislation renewing those subsidies. During the final three years of Biden’s second term, the onus will be on his HHS team to come up with creative solutions for maintaining existing levels of coverage.

Coping with COVID

Trump’s mismanagement of the pandemic’s first year was so egregious that it may have cost him the 2020 election. He initially downplayed the virus’s risks; refused to roll out a national testing program; failed to coordinate a national response; contradicted the advice of public health professionals; promoted the use of unproven drugs; and allowed profiteering and hoarding of personal protective equipment, ventilators, and other scarce supplies.

His idea of setting an example was to refuse wearing a mask in public for the first six months of the pandemic. This behavior was rewarded one month before the 2020 election when he came down with COVID, which landed him in Walter Reed National Military Center for a three-night stay.

His one victory was Operation Warp Speed, a federal effort to speed up the development of COVID vaccines. Launched in May 2020, the program led to the first of several vaccines receiving emergency authorization from the FDA in December, less than a year after its genetic code had been identified. He left office, however, without having set up a system for mass distribution of vaccines.

That job fell to the Biden administration, which promised to administer 100 million doses in its first 100 days. Mission accomplished within 58 days, in part because officials quickly jettisoned its early reliance on mass vaccination sites in favor of using retail pharmacies, which were more accessible. By fall, almost half the population was fully vaccinated (that is, had received at least two doses), which the Commonwealth Fund estimated saved a million lives and 10 million hospitalizations. By the end of 2021, 62 percent of the U.S. population was fully vaccinated, with 73 percent having been administered at least one shot. The administration also took steps to facilitate global distribution of the vaccine, although some public health advocates argue that it didn’t go far enough. Still, what some call the biggest international public health campaign in human history resulted in nearly 2 billion people receiving at least one shot within eight months, which researchers say saved 2.4 million lives in 141 countries. 

The Biden administration also successfully rolled out a national testing program and strongly encouraged masking, social distancing, and economic and school lockdowns—thus rejecting the herd immunity strategy being pushed by some scientists, many of whom were aligned with conservative think tanks. These latter policies remain controversial, especially when it comes to schools, where in the eyes of many the learning setbacks affecting millions of children was too high a price to pay to prevent the deaths of the 1,289 children 19 and under who died from COVID during the pandemic.

Prescription drug prices

During his 2016 campaign for president, Trump promised to negotiate prices directly with drug companies—a position that put him in the same camp with Bernie Sanders, who was then challenging Hillary Clinton in the Democratic primaries. In his Time magazine Person of the Year interview shortly after getting elected, he said, “I’m going to bring down drug prices. I don’t like what has happened with drug prices.”

But given the lack of interest among the Republican majority on Capitol Hill, nothing moved on the legislative front. His appointment of Alex Azar, a former Eli Lilly executive, to run HHS closed off new initiatives through regulation, especially after PhRMA, the industry’s trade association, launched a successful public relations and lobbying campaign to shift blame for high prices onto pharmacy benefit managers.

After Democrats won control of the House and introduced legislation in 2019 allowing Medicare to negotiate prices on 250 drugs, Trump signaled his opposition (and echoed Big Pharma’s line) in a tweet: “FEWER cures! FEWER treatments!” During the 2020 election year, he administratively took action on a few high-profile issues, like capping Medicare beneficiaries’ out-of-pocket monthly costs for insulin at $35 and requiring all pharmacy discounts on insulin and epinephrine pens be passed along to low-income consumers.

Late in his term, the CMS finalized rules that allowed states to import drugs from Canada (in January, Florida became the first state to receive FDA approval to do so). It also proposed a rule weeks before the insurrection that would set prices Medicare paid for 250 drugs at the lowest level paid by a handful of other advanced industrial economies—arguably the most radical price control measure ever issued by Medicare. The Biotechnology Innovation Organization immediately filed suit and won an injunction.

Where Trump failed, Biden succeeded. In August 2022, he signed the Inflation Reduction Act (IRA), which gives Medicare the right to negotiate the price of its 10 most costly drugs beginning in 2026, growing to 40 by 2028 and another 20 more in succeeding years. The Congressional Budget Office (CBO) estimates that negotiations will save taxpayers almost $100 billion over the next decade. This effort, too, faces court challenges by the pharmaceutical industry, but thus far the Biden administration has succeeded in blocking injunctions—or, as happened in a federal district court in Texas in February, had a case dismissed. 

The other major victory for pharmaceutical consumers in the IRA capped out-of-pocket spending on Medicare prescription drug plans at $3,250 this year and $2,000 next year. The bill also slapped a limit on future price increases on existing drugs. Drug companies will have to pay rebates to Medicare if their prices rise faster than inflation. This one provision alone will save the federal government $62 billion over the next decade, according to the CBO.

Abortion rights & reproductive health

On October 19, 2016, during the third and final debate between Trump and Hillary Clinton, the Republican nominee vowed to appoint Supreme Court justices who would overturn Roe v. Wade, the landmark 1973 decision that legalized abortion throughout the U.S. He did. Then they did, despite having pledged fealty to stare decisis during their confirmation hearings.

Since the June 2022 Dobbs v. Jackson Women’s Health Organization decision overturned Roe, nearly two dozen states have imposed abortion restrictions. They range from a total ban on the procedure (including in cases of rape or incest) to setting time limits that are long before fetal viability (23 or 24 weeks) or, in some cases, even before a woman knows she is pregnant. Republican-run states and courts have also attempted to give fetal rights to frozen embryos, ban the importation of morning-after drugs, restrict women’s health clinics, and make criminals of medical professionals and their patients who include abortion as part of their reproductive health care. The U.S. has joined Malta and Poland as the only countries in the 38-member OECD that ban abortion within their borders. 

While these victories have solidified Trump’s hold over the nation’s anti-abortion vote, his party has paid a political price. Every time abortion has been on a statewide ballot, protecting abortion rights has won. Most analysts agree it was the reason why Republicans won only a bare majority in the House in the 2022 midterms, when the opposition party usually makes major gains.

Yet in this election cycle, Trump is doubling down with a proposal that would impose restrictions on abortion access in every state in the union. In February, The New York Times reported that the presumptive Republican candidate now backs a national ban on abortions after 16 weeks with exceptions for rape, incest, and to protect the life of the mother. If Republicans win control of Congress, he will be able to impose that limit on the 30 states that still allow abortions after 16 weeks. It would also open the door to further national restrictions. 

Biden, on the other hand, has promised to sign legislation that protects abortion rights. If he faces a Republican Congress, he says he will veto any legislation that includes a national ban. Though his single nominee to the Supreme Court, Justice Ketanji Brown Jackson, arrived after the Dobbs decision, she has already penned a dissent in a Missouri case where the high court reversed a lower court decision that said a minor had the right to seek an abortion without parental consent.

With abortion rights in blue states at stake and the likelihood that there will be at least one and possibly more openings on the high court over the next four years, abortion access will be the number one health care issue on the November ballot—including at the top, where voters have a precise picture of where both presidential candidates stand based on their records.

There are a few areas where the Biden and Trump administrations have been on the same page when it comes to health care. Both have been more rigorous than previous administrations in enforcing antitrust laws. Both mounted challenges to hospital and insurance company mergers. Both supported the bipartisan No Surprises Act, which put an end to patients receiving bills from out-of-network providers working at in-network facilities. That law also required hospital and insurance company price transparency. Trump signed the law a few months before leaving office, and the Biden administration has raised compliance each year it’s been in effect. However, compliance remains incomplete, the data is hard to access, and many of the posted prices are not user friendly.

However, the areas where they disagree are wide and unbridgeable. Health care policy, whose future direction is very much on the ballot this November, will remain one of the major causes of the deep divisions within this country for the foreseeable future.

The post Trump vs. Biden: Who Got More Done on Health Care? appeared first on Washington Monthly.