Given that history, I thought it fitting to republish the following story from KFF Health News, which appeared today:

By Brett Kelman and Rachana Pradhan

NASHVILLE, Tenn. — Four years ago, Tennessee became the first state to allow adults to buy the antiparasitic drug ivermectin from a pharmacy without first seeing a doctor. Pharmacies can use a pre-written, blanket prescription to sell to just about anyone who walks through their doors.

The drug is now marketed and sold across the state in roadside shops and small-town strip malls with little oversight from health authorities. Highway billboards advertise ivermectin as “Available Without a Prescription in Tennessee!” while dozens of pharmacies offer highly concentrated pills, sometimes at 10 or 20 times the potency of a standard tablet.

Ivermectin is a Nobel Prize-winning, generally safe drug approved by the FDA for treating parasitic diseases in humans, which can generally be done with a single dose of three or four prescription-strength tablets. It is also used as a dewormer for horses and other livestock.

Its popularity surged during the pandemic as fringe doctors and anti-vaccine activists promoted it as a treatment for covid. Clinical trials have shown that ivermectin is not effective against covid.

Nonetheless, it has since become a symbol of resistance against the medical establishment among conservatives and followers of the Make America Healthy Again movement, championed by Health and Human Services Secretary Robert F. Kennedy Jr.

Timothy Caulfield, a professor at the University of Alberta who studies health misinformation, said ivermectin became an “ideological flag” during the covid pandemic, opening the door for influencers to push the drug for other ailments to a “captured audience” even without proof it works for those conditions.

“This is really about profit. This is about political identity. This is about creating distrust in the existing biomedical community. This is about money,” Caulfield said in an interview with ABC News, which partnered with KFF Health News to report on ivermectin.

After a hantavirus outbreak on a cruise ship earlier this year, unproven claims that ivermectin is effective against the virus have been spread by some popular social media accounts and right-wing figures, including former congresswoman Marjorie Taylor Greene. The World Health Organization says it has seen no research that shows ivermectin is an effective hantavirus treatment.

Tennessee’s ivermectin bill was shepherded by a Republican supermajority in 2022. Its passage blindsided state medical officials and handed a victory to medical groups that spread covid misinformation.

Some pharmacy websites now offer the drug as a treatment for covid, “long haul vax symptoms,” diabetes, or cancer — despite no evidence of its effectiveness for those purposes — while the new law largely gives pharmacists immunity from lawsuits or professional sanctions related to ivermectin.

The law was also a harbinger of legislation to come: More than two dozen states have since considered look-alike bills that would make the politicized medication available without a requiring a doctor visit.

John Mafi, a UCLA internal medicine physician who has studied the rise of ivermectin among cancer patients, worries it will lure people away from proven treatments. He co-authored a new study identifying a sharp increase in prescribing rates for ivermectin and another antiparasitic drug, particularly in the South. The rise followed a January 2025 episode of the Joe Rogan Experience podcast in which actor Mel Gibson claimed ivermectin and other drugs cured three friends with stage 4 cancer.

“It’s going back to 19th-century quack science,” Mafi said about off-label use of ivermectin. “It is alarming that I’m seeing this really unproven therapy being touted to so many potentially vulnerable Americans.”

The FDA says ivermectin can be dangerous in large doses. Tennessee has seen a small but concerning rise in signs of overuse. The Tennessee Poison Center, which fields calls from people exposed to drugs or toxic substances, received more than 60 calls for possible ivermectin poisoning in 2025, the most since 2021. They included reports of vomiting, blurred vision, neurological problems, and difficulty walking.

“People are taking this because they just feel unwell. It’s almost like a panacea now,” said Rebecca Bruccoleri, the poison center’s medical director. “I’ve heard rumblings on the internet of using ivermectin for an alternative cancer treatment, and we’re seeing it definitely in here.”

Pharmacist Paul Hughey has dispensed ivermectin under the new law at two Tennessee pharmacies: Mt. Juliet Pharmacy and Compound Rx. He estimated that “up to 20 people in a week” are buying ivermectin but that peak demand was double or triple that amount.

For years, Hughey said in an interview, customers have relayed emotional “testimonies” about the drug healing the sick, “especially with the cancer patients.”

“I’ll get a doctor call in and they say: ‘Guess what. So-and-so is cured.’ And it’s just amazing to hear that. So anybody who doubts that,” Hughey said, “I don’t really know that they’re practicing medicine. I think they’re just following the narrative.”

‘I’ve Taken Bucketloads of This Stuff’

The linchpin of Tennessee’s ivermectin market is Denise Sibley, a conservative doctor who was instrumental to the creation of the 2022 ivermectin law. She has inked agreements with pharmacies across the state empowering them to sell the drug.

Tennessee’s law allows pharmacies to dispense ivermectin without a specific prescription for each patient, through a “collaborative pharmacy practice agreement” with a doctor who provides what is functionally a pre-written, nonspecific prescription for all potential customers.

In podcast interviews, Sibley has said she has made as many as 40 of these agreements with Tennessee pharmacies, which she said forward her the paperwork on each ivermectin customer. Before selling the drug, pharmacies are required to ask customers questions about medical conditions and medications that could cause complications if taken with ivermectin. Afterward, the collaborating physician also is expected to receive a record for each person who purchases ivermectin.

“We literally have folks coming from all over the world to get our ivermectin,” Sibley said on the Common Sense MD podcast in February 2025. “As the collaborator for these pharmacies, I get every person’s sheet.”

“They’re from every state,” she said. “They’re from Canada. They’re from Europe.”

Sibley did not respond to requests for comment.

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KFF Health News has independently confirmed that Sibley signed agreements with at least 10 pharmacies. The agreements say pharmacists shall dispense ivermectin only in Tennessee, where Sibley is licensed, although one of those pharmacies said friends and family in Tennessee can “facilitate sending the medication.”

Hughey, the Tennessee pharmacist, said Sibley had prescribing agreements ready to go when the law was enacted. He credited her with advancing ivermectin sales throughout the state.

“Had Dr. Sibley not stepped in and really pushed forward, there’s no telling how hard it would have been,” Hughey said. “It would have been a lot less widespread.”

Sibley also works with Children’s Health Defense, the Kennedy-founded group that has become one of the nation’s most influential anti-vaccine organizations. In podcasts, Sibley has referred to the covid vaccine as a “bioweapon” and “the most toxic substance that’s ever been produced.”

Separately, she testified before Tennessee legislators in 2024 about an alleged plot to change the weather and block sunlight. The New York Times then included her in a story about conspiracy theorists.

Sibley has said in podcast interviews that she was told by God to treat covid patients. She said she has advocated for ivermectin ever since.

“God agrees with what I’m doing,” Sibley said in 2023 on the podcast Tomi Lahren Is Fearless, which is recorded in Nashville. “I wake up every day and I say: ‘Yes, sir. I’m reporting to duty.’”

In legislative and government hearings throughout 2022, Sibley testified that she had treated around 4,400 people with ivermectin, including some Tennessee lawmakers, all without taking payment. Sibley described ivermectin as “a wonder drug” and said making it more available “would help me to save lives.”

“I’ve taken bucketloads of this stuff myself,” Sibley said in one such hearing. “I feel like I’ve been a good test subject.”

Sibley has said she dispenses ivermectin using treatment guidelines developed by Paul Marik, who in 2020 co-founded the Independent Medical Alliance, a medical group that has promoted ivermectin as an effective treatment for covid, flu, RSV, and cancer.

Some Tennessee pharmacies now follow those protocols, too. The protocols recommend patients take 1.5 to five times as much ivermectin as is normally prescribed to treat parasites, with the dose taken for days or weeks instead of just once.

Marik and other ivermectin proponents sued the FDA in 2022 after it discouraged the use of the drug for covid by tweeting: “You are not a horse. You are not a cow. Seriously, y’all. Stop it.” The agency settled the lawsuit with no admission of wrongdoing and deleted the viral tweet in 2024.

The American Board of Internal Medicine has revoked Sibley’s and Marik’s board certifications but declined to explain why. Sibley still holds a Tennessee medical license; Marik is based in Virginia and is not licensed. Sibley and Marik each opposed the internal medicine board’s actions.

In response to questions from KFF Health News, Marik, through an Independent Medical Alliance spokesperson, said medical science benefits from “open discussion of ideas and treatments.”

“Many independent doctors have reported that treatments like Ivermectin, in conjunction with traditional treatments, are showing promise. These ideas should be explored,” alliance spokesperson Lynne Kristensen said in an emailed statement.

Marik testified in favor of Tennessee’s ivermectin legislation in 2022, telling lawmakers that it is necessary because people would otherwise buy animal-grade ivermectin in stronger dosages meant for livestock.

“They’re buying ivermectin from farm stores. We don’t know the quality,” Marik said at a March 2022 legislative hearing on the Tennessee bill. “So this would prevent that from happening.”

Tennessee Does Not Track Its Ivermectin Market

Arkansas, Idaho, Louisiana, and Texas enacted similar laws in 2025, and legislation that makes ivermectin available without the need for a doctor visit has been introduced or debated in at least 24 other states, according to a KFF Health News analysis. That means half the country could be following Tennessee down an unlit path, because no one knows the full scope of its ivermectin market.

Tennessee does not effectively track which pharmacies offer ivermectin this way, and the state government has been unable to produce some foundational documents that pharmacies are legally required to file before they sell the drug, according to a KFF Health News investigation.

Doctors and pharmacies are required by law to notify the Tennessee Department of Health when they sign agreements that allow ivermectin to be dispensed without patient-specific prescriptions, although it is not clear whether this consistently occurs.

In response to a KFF Health News public records request for those ivermectin notifications filed by pharmacies, the agency over three months produced records from only 12 pharmacies, half of which have agreements with Sibley. The agency said it did not locate records related to at least 13 others that KFF Health News has identified as selling ivermectin without requiring individual prescriptions.

Department of Health spokesperson Dean Flener said the agency would not answer questions about whether or how it regulates ivermectin or the pharmacies that distribute it.

Tennessee has said it does not track how much of the drug is sold in the state, and the amount is not well captured by federal or insurance data sources. That’s because the drug is often sold at compounding pharmacies, which make customized medications that are not FDA-approved and rarely covered by insurance. Drugmakers and wholesalers did not respond to questions about how much ivermectin they supply to pharmacies in the state.

Even the Independent Medical Alliance, one of ivermectin’s biggest cheerleaders, says it doesn’t know how much is flowing through Tennessee.

States are getting pressure from clinicians ”who have had success with the use of ivermectin,” said IMA President Joseph Varon, a physician based in Houston. “That’s what happened in Texas, and that’s what happened in Tennessee.”

‘An Unproven, Potentially Unsafe Drug’

Once signed by Tennessee Gov. Bill Lee, the state’s ivermectin law took effect immediately — even before the state’s physician and pharmacy licensing boards created rules to guide the process, which Tennessee law also requires.

Some board members were shocked.

“We’re talking about an unproven, potentially unsafe drug,” Shant Garabedian, a doctor on the state’s Board of Osteopathic Examination, said of off-label ivermectin use during a 2022 meeting. “It’s already law. Somehow it passes without our sort of input.”

In meetings that followed, at least five members of Tennessee’s medical boards voiced concerns about the law beyond safety and efficacy. Some said pharmacists could overcharge for a drug that normally costs pennies per pill. Some worried that a loosely regulated, cash-based ivermectin market might attract shady characters, especially because the law also shields prescribers from ivermectin-related civil lawsuits.

“This involves no clinical engagement,” Melanie Blake, then-president of the Board of Medical Examiners, said during a 2022 meeting. “If they’re exempt from liability as well, I hate to think of things that individuals could do just to make money, but this would be one.”

The boards eventually enacted regulations affirming that ivermectin could be dispensed without any diagnosis. Board members said the law left them no choice.

“This is more of a situation where, legally, the legislature has decided for us,” John McGraw, another board member, said in a 2023 meeting. “This has sort of tied our hands in a lot of ways.”

The first known sale under the new law occurred in May 2022 in Sibley’s home of Johnson City, a city of about 74,000 people in northeastern Tennessee. According to a news release, Sibley entered into a collaborative agreement with pharmacist Josh Harrison at The Compounding Lab, which dispenses drugs for people and animals.

The first customer was Bernadette Pajer, an anti-vaccine activist who has worked with Children’s Health Defense. In a 2024 episode of the Nashville podcast Rebunked With Scott Armstrong, Pajer said Sibley was a medical adviser for the group and described the first ivermectin sale.

“On that day, she was the doctor, he was the pharmacist making the sale, and I was the first customer,” Pajer said. “So that was pretty cool.”

Ivermectin pharmacies have spread across the state. In the suburbs of Nashville, Roman Pharmacy advertises ivermectin on at least four billboards along Interstate 65, and its website is mostly focused on the drug. Outside Knoxville, Fresh Pharmacy allows customers to order ivermectin for multiple sclerosis and Parkinson’s disease, or “to use it to detoxify.”

Roman Pharmacy did not respond to interview requests. Fresh Pharmacy declined an interview.

In Chattanooga, the Medicine Counter pharmacy says on its website that ivermectin should be taken “only as prescribed by your healthcare provider.” And yet the pharmacy sells some of Tennessee’s most potent ivermectin available without a prescription from a doctor — up to 21 times as strong as a standard tablet, for nearly $19 per pill — according to the KFF Health News analysis.

Himanshu Patel, Medicine Counter’s head pharmacist, declined to be interviewed. He said in an email that the pharmacy operates in a “very competitive market” and that its strongest pills were below the maximum dose for humans evaluated by the FDA for safety purposes.

And then there is Compound Rx, which, in addition to selling ivermectin in its store, has built a website in preparation to ship buy-one-get-one-free pills nationwide. The site, which is in “test mode,” cannot currently make any sales. It also asks customers how they heard about the pharmacy, with a dropdown menu of answers that features right-wing figures such as Donald Trump Jr., Steve Bannon, Laura Ingraham, and Kevin Sorbo.

Who is not listed as an option? Your doctor.

Hughey, the Compound Rx pharmacist, said he wasn’t involved with the website, which he said may never launch.

The highly concentrated pills are a concern for Tennessee state Sen. Richard Briggs, who worries lawmakers have created a “dangerous” ivermectin market rife with “misleading advertising” about what the drug can actually do.

Briggs, who is a surgeon and the only Republican who voted against the ivermectin bill in 2022, said he planned to introduce legislation to rein in the sale of ivermectin when lawmakers reconvene in 2027.

“But it may be a hard sell, because with the anti-vaxxers and some of these other folks,” Briggs said. “We don’t base a lot of things that we do on science, data, or facts. To a lot of folks in the legislature, the facts are just an inconvenience.”

‘Enough Trouble With Ivermectin’

Lawmakers in at least seven states have considered ivermectin legislation this year, including Alabama, Florida, Oklahoma, and South Carolina. If enacted, these bills would allow people to obtain ivermectin without an individual prescription, like in Tennessee, or make it available over the counter.

Kennedy praised such legislation at an event in Texas last August.

“I think it’s a really good bill,” he said of Texas’ ivermectin legislation, according to The Texas Tribune. “I think Americans should have the choice.”

But proponents have hit roadblocks. A Utah bill failed to advance out of the state House this year. In Oklahoma, some lawmakers have put up a fight.

“I’m a scientific person. I need to see some research and some data that shows what we’re treating,” Oklahoma state Rep. Cynthia Roe, a Republican and nurse practitioner who opposes the state’s ivermectin bill, said in an interview. “And God forbid somebody start giving it to their kid.”

Back in Tennessee, one of the medical boards that was alarmed when the law was enacted in 2022 started to distance itself from ivermectin altogether.

In January, the Board of Medical Examiners grappled with how to punish Ricky Lee Jackson, a doctor who was licensed in Tennessee and had been sanctioned and fined by Washington state’s medical commission. The Tennessee board normally mirrors punishments from other states without hesitation. But the Washington case centered on Jackson prescribing ivermectin for covid, which in Tennessee no longer required a patient to see a doctor.

After a debate, the board voted to reprimand Jackson — but told its staff to ensure the public record made no mention of ivermectin.

“This board has been in enough trouble with ivermectin,” member Keith Anderson said, according to a meeting recording. “Maybe we ought to just leave that out.”

Nashville Public Radio journalist Blake Farmer and Tennessee Lookout reporter Adam Friedman contributed to this report.

It usually includes three options. First, there is a preferred provider plan, which pays most of the bills, has few limits on provider choice, and has the highest paycheck deduction. Second comes a mid-priced health maintenance organization plan, where provider networks are limited, prior authorization rules are strict, and co-pays and deductibles are moderate. Finally, there is a high-deductible plan, which has the smallest paycheck deduction, but can leave an individual or family with large, unaffordable bills when anyone covered by the plan requires hospitalization or expensive treatment.

The employer share for any one of those plans (the average family plan cost is nearing $30,000 a year) usually hovers around 75% of the total cost. Workers pick up the other 25% through a payroll deduction. In the decade after passage of the Affordable Care Act, the annual increase averaged around 6-7% or about the same rate as economic growth after inflation was taken into account.

But during the pandemic, health care cost began a rapid ascent to around 8-8.5% annually. Now, it has taken another upward lurch.

A new survey of health care actuaries by PwC (formerly known as Price Waterhouse Coopers) found private health insurers medical claims costs are rising at a 9% clip this year and are expected to rise by a similar rate next year. Last year’s survey pegged this year’s expected cost increase at 8.5%.

“Health plans are projecting the highest medical cost trend in nearly two decades,” the consulting group said in its analysis. “Payers and employers face mounting pressure to act.”

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This could prove a financial fiasco for people on employer-based plans, which cover about 160 million workers and their families. They will likely face co-premiums, co-pays and deductibles in their 2027 plans that are rising at nearly three times the rate of inflation.

And it could be a lot worse than that. As actuaries inside the insurance companies map out their costs, they will have to take into account the additional price increases levied by hospital systems due to rising utilization, AI-enabled billing tactics, and what’s likely to be a rapid rise in unpaid bills.

The sharp cutbacks in Medicaid contained in the One Big Ugly Bill signed by President Trump last year will hit in full force in 2027. Well over ten million impoverished Americans are expected to lose coverage due to their inability to leap over the bureaucratic hurdles erected to enforce the legislation’s work requirements.

Millions more are dropping coverage and falling into the ranks of the uninsured due to the Republicans’ refusal to extend the expanded subsidies in ACA plans enacted by Democrats during the Biden administration. Both cuts will trigger a huge increase in uncompensated care at the nation’s safety net hospitals that serve low- and moderate-income communities.

Like all hospitals, safety net hospitals must provide emergency treatment for anyone who lands on their doorstep thanks to the 1986 Emergency Medical Treatment and Labor Act, which was signed into law by President Ronald Reagan. Unlike their suburban counterparts, who face far fewer cuts because they serve mostly the privately insured, these safety nets have fewer resources and small or no endowments to fall back on.

The final rates will be determined by medical actuaries inside the insurance firms over the next few months. The rates for 2027 are usually unveiled in mid-October.

How will employees respond if they see their paycheck premiums rising at a near double-digit rate? Many more low-income workers will opt into high-deductibles plans, which will leave many with unpayable medical debt because they can’t afford the out-of-pocket expenses when someone in the family gets sick. More middle-class workers will opt into HMOs with their network limitations and prior authorization restrictions to save on their upfront costs.

The nation’s employees with employer-sponsored coverage will be making those decisions starting on November 1, the traditional date for open enrollment for the ensuing year. That’s two days before the mid-term elections.

As he points out, you can’t blame the Baby Boom (the first post-WWII generation) for the shortfall. That was fixed in 1983 when Congress raised the payroll tax to its current level of 12.4%, which is split evenly between wage and salary workers and their employers. Congress also raised the retirement age.

The fix also renewed the cap on wages subject to the tax. Its level was set to tax about 90% of total income, which an annual inflation adjustment was meant to hold steady. The cap is currently $184,500.

Unfortunately, things didn’t work out that way. Today, the Social Security payroll tax only covers about 82% of total income. What happened over the intervening four-plus decades to cause the level of income taxed to fall?

It’s simple. The share of total income above the cap went from 10% of all income to 18% as upper income individuals, especially the very rich, grabbed a larger and larger share of the nation’s salary pie. As Reich pointed out, the total share of income for the top 1% of earners (it takes at least $700,000 a year to make it into our Second Gilded Age elite) has risen to more than 20% of total income compared to 11.6% in 1983.

Congress could instantaneously eliminate the shortfall by eliminating the cap. It would even generate enough revenue to raise everyone’s benefits by $200 a month. This would be a huge boon to lower-income retirees without other retirement income. The average beneficiary, who receives $2,071 a month in 2026, would get a nearly 10% raise. The beneficiaries with the highest incomes during their working years, who are more likely to wait until 70 so they can get the highest monthly payouts, would only receive a 3.9% increase on their $5,181 maximum benefit.

This is most Democrats solution to the Social Security shortfall. Legislation introduced by Democratic senators Bernie Sander and Elizabeth Warren would eliminate the cap for those earning over $250,000. They would also give everyone a $200 monthly raise.

Separate bills, sponsored by Sheldon Whitehouse (D-RI) in the Senate and Brendan Boyle (D-PA) in the House, would eliminate the cap for those earning over $400,000. Their bill doesn’t increase benefits. Both bills would guarantee trust fund solvency for at least 75 years.

As for Republicans, House Speaker Mike Johnson (R-La) announced their approach earlier this week. The current majority, if returned to Congress, will introduce its plan next year, he said.

“Entitlement programs like Medicare, Medicaid and then things like Social Security … have to be adjusted and fixed,” he reportedly said on the Moon Griffon show, which is a Louisiana-based podcast filled with rightwing, anti-gay, anti-trans, anti-environment and pro-war diatribes. I stopped listening for the exact Johnson quote after the host accused Democrats of being communists.

Given the GOP’s steadfast opposition to raising anyone’s taxes and fixation on giving endless tax breaks to the rich, Johnson was essentially signaling that they will either cut benefits or do nothing. The latter is essentially the same thing as cutting benefits if Republican remain in charge since the Social Security trust fund expiration date is now just six years away.

Rising inequality’s impact on Medicare

Income inequality is also eroding the Medicare trust fund, although not in the same way since the Medicare payroll tax, 2.9% equally split between worker and employer, has no cap. It is levied on all wages and salaries.

But what that tax misses (and this is true for Social Security as well) is that corporations are capturing a growing share of national income at the expense of their salaried and hourly workers. Corporate profits are not subject to the payroll tax. That means the relative size of the pie subject to the payroll tax is shrinking.

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Two charts from the Federal Reserve Bank of St. Louis capture this shift:

The first chart shows the total share of income going to workers has dropped by four to five percentage points between 1983 and today. Over the same time period, the total share of income going to corporate profits has increased by four to five percentage points.

To sum up, the trust funds are levying their payroll taxes on a shrinking share (due to growing income inequality) of a shrinking pie (a greater share of total national income going to corporations).

This has a larger immediate impact on Medicare than on Social Security. Retirees are more or less guaranteed that their government pension benefit will rise at the rate of inflation. That is, they don’t suffer a loss of purchasing power.

The Medicare trust fund, on the other hand, pays for hospital care (the government’s share, not seniors’ out-of-pocket expenses). Hospital costs, like health care costs as a whole, have been rising at two times the inflation rate or more over the past four decades. There’s no way a flat payroll tax on a shrinking wage-and-salary pie could keep up with that kind of cost growth.

Finally, I would be remiss if I didn’t point out that unearned or so-called passive income like interest, carried interest for hedge funds, rents and dividends, also are not subject to payroll taxes. These, too, mostly go to the well-off.

Add it all up and what you have today is more than half of national income exempt from the taxes that support our two main retirement programs.

The tax cuts contained in the One Big Ugly Bill passed last year will hand out about $2 trillion to corporations and the well-to-do over the next decade. This will only make things much worse for the Social Security and Medicare trust funds, not to mention federal income tax collections and state income tax collections that are hitched to the federal tax code.

One can only hope Democrats on the campaign trail this year will make tax reform a major issue. Everyone’s financial security in retirement, whether old or young, depends on it.

The overall inflation rate ratcheted up 4.2% last month, driven largely by fast-rising gasoline and diesel prices that are entirely due to Trump’s ill-conceived, undeclared and unwinnable war against Iran. If you take out food and energy, inflation was up “only” 2.9%. That’s still nearly a full percentage point above the Federal Reserve Board’s target level.

But dig a little deeper into the numbers and you find medical inflation, which many Americans consider their most pressing concern, rose 3.6% over a year ago, faster than the core inflation rate. Prices for hospital services were almost entirely responsible for the jump — up 5.7% year over year.

The second largest component of health care services — physician fees — grew at a much slower pace, up 2.8% or about the same rate as core inflation. Drug prices fell 2.1% over the past year.

The drug price component of the consumer price index is somewhat misleading since the Bureau of Labor Statistics measures the change in existing drugs and generics, not the price of new drugs coming to market. Big Pharma introductory prices for new drugs like the popular GLP-1s have reached sky-high levels, which often come down somewhat after launch to attract more customers.

Novo Nordisk’s Wegovy, for instance, came to market at $1,349 a month, but now can be purchased for as little as $350 a month. That shows up as a major price decline in the index, even though many consumers still can’t afford it because their insurance companies won’t pay for it.

Speaking of insurance companies, the New York Times reports their prices fell 6.4% over the past year, which is hard to understand given the rising prices for almost all of the services they finance with the premiums collected from employers and consumers. I also don’t know where the Times got that data since I couldn’t find it in either the Bureau of Labor Statistics press release or the agency’s detailed data tables.

I suspect at least some of the decline in health insurance prices reflects what individuals pay for plans sold on the exchanges, where millions of people are switching to bronze plans from pricier silver plans to lower their upfront premiums. Unfortunately, when they use their insurance, they will have much higher out-of-pocket costs.

This isn’t a price decline. It’s a cost-shift. I suspect some health care economists will insist cost-shifting doesn’t exist, claiming it reflects consumer preference for the cheaper item.

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None of this is good news for the nation’s hospital leaders, who have launched a major media campaign to shift the blame for rising health care prices onto health care’s other special interests. The American Hospital Association’s March report “The Cost of Care” blamed the surging cost of drugs, labor and supplies for their price increases.

Some of that is true, but the document offers a classic inside-the-beltway manipulation of data to make its case. The AHA report used a consulting firm’s data to show that “advertised salaries for registered nurses have grown 26.6% faster than the rate of inflation over the past four years. These increases are essential to maintain staffing levels but also contribute to the overall financial challenges hospitals face.”

Let’s take a closer look at that claim. The cumulative inflation rate between May 2022 and May 2026 was 13.8%, an average of about 3% a year before compounding. A 26.6% increase brings that to 17.5% over four years, or an average of about 4% before compounding. If anything, the AHAs data shows nurse wages have gone up about a percentage point faster each year than underlying inflation, which is what you might expect from a sector of the economy with a large union membership. Hospital prices, on the other hand, have gone up about two to three percentage points faster than inflation.

Higher wages for nurses can actually be a good thing for hospitals, which frequently hire traveling nurses to staff unexpected surges in patient load or temporarily fill open positions. The staffing firms that provide those nurses (like publicly-traded AMN Healthcare) impose huge mark-ups on the underlying nurse salaries, which make their cost considerably higher than hiring permanent staff. The same is true for many of the support staff occupations inside hospitals. If hospitals paid adequate wages and provided decent working conditions for their permanent staff, perhaps they wouldn’t have to rely on high-priced staffing firms to keep their facilities running.

Meanwhile, the House Energy and Commerce Committee today held a hearing on Capitol Hill to promote greater hospital and insurance company price transparency, an issue for which there is bipartisan support. The assumption is that greater transparency will promote competition and allow health care “consumers” to shop.

This ignores the economic realities of health care. First, only a small portion of health care services are shoppable. Second, there is little or no competition in most markets. Third, even where competition exists, most patients are locked into networks and hospital systems that offer a closed loop of primary care and specialty physician providers. More than half of all doctors in the country now work for either hospitals or insurance companies.

“The monopolization with regard to hospitals and so many health care interests exists and is getting worse,” Rep. Frank Pallone Jr. (D-NJ), the ranking member of the committee, said in his opening statement. “So, let’s not forget that … to use transparency more effectively …, we have to also look at the competitive environment to make sure it truly is competitive.”

I’m not holding my breath for Republicans to endorse greater antitrust enforcement. But it is disappointing that Democratic leaders are putting all their marbles on competition policy to bring down hospital prices, which under the best of circumstances will take years of court battles to bring results.

I didn’t get a chance to listen to the hearing today, but I bet not a word was said about putting hospitals on budgets, putting physicians on salaries and giving administrators the freedom to deploy their financial resources in ways that deliver better health outcomes. The American people are ready for meaningful change. So far, such proposals are missing from this year’s health care debate as we head into the mid-term election season.

Several replied with ringing defenses of their editorial practices. “As practicing physicians, our editors recognize our responsibility to doctors and patients. We use rigorous peer review and editorial processes to ensure the objectivity and reliability of the research we publish,” NEJM editor Eric Rubin wrote Martin. “We support the editorial independence of medical journals and their First Amendment rights to free expression.”

Critics warned the letters true intent was “to send a message to academic publishers to avoid crossing the Trump administration and push them to publish viewpoints more favorable to the current administration,” STAT reported at the time.

The Health and Human Services Department under Robert F. Kennedy Jr. subsequently canceled much of the research into racial health disparities, reproductive health and the social determinants of health, branding such studies as “woke” and a waste of taxpayer money. A Trump administration HHS spokeswoman said, “Spending billions on divisive, politically driven D.E.I. (diversity, equity and inclusion) initiatives that don’t deliver results is not just bad health policy — it’s bad government.”

Kennedy sent clear signals prior to his confirmation that he intended to attack science. During his run for president, he threatened to prosecute medical journals under federal anti-corruption statutes for allowing drug companies to influence their editorial decisions. His anti-vax organization’s research, which claimed vaccines caused autism, never made it past journal editors and peer reviewers. The one study published over a quarter century ago that found such a link had been retracted as fraudulent.

“There is a substantial resentment that they’ve not been able to get traction for these heterodox ideas within the scientific community itself,” Carl Bergstrom, an evolutionary biologist at the University of Washington and a frequent critic of low-quality science, told Stat. “So, they are willing to tear down the fabric of science in order to try to impose these ideas on the community.”

Kennedy’s group wasn’t the only Trump coalition faction seeking to force changes in the scientific publication process. Christian conservatives have frequently attacked the American College of Obstetricians and Gynecologists (ACOG) and their publications for promoting abortion, LGBTQ rights and birth control access.

Just two weeks before the interim district attorney letter was sent to Obstetrics and Gynecology (ACOG’s flagship journal), the Alliance Defending Freedom, a Christian conservative advocacy law firm, demanded the HHS secretary cut funding and investigate the group. “Paying ACOG to spend taxpayer dollars (is) inconsistent with this administration’s policies on the biological basis for sex, ending racial discrimination and ‘equity’ programs, and preventing taxpayer funding for the promotion of abortion,” its letter said.

A new assault on science

This week the Trump regime escalated its war on science by attacking the independence of the vetting process for studies appearing in medical and scientific journals. For the most part, the process relies on independent peer review, both at the agency level when making grants and at the journals after study results are submitted for publication.

The Office of Management and Budget proposed a rule that will subject every federal research grant to a second political review. The rule, which is open for public comment until July 13, essentially gives political appointees at agencies like the National Institutes of Health, the National Science Foundation and the National Oceanographic and Atmospheric Administration veto power over grant proposals.

The proposed rule also allows political appointees to summarily cancel already-awarded grants; use what an editorial on the Science Magazine website called “vague criteria” for giving favored institutions preferable treatment; and subject every grant that involves spending money abroad to political review. “This bureaucratic hurdle would effectively prevent most if not all (international) partnerships from moving forward,” an editorial in Science said.

Even before releasing this proposed rule, the regime’s editorial intimidation strategy, and the publicity surrounding the initial letters sent to journal editors, triggered a dramatic slowdown in publication of articles on the subjects that Trump’s most avid supporters find objectionable. This week, I conducted a small research project measuring the number of articles catalogued on the National Library of Medicine’s PubMed website that mention various hot-button issues in either their title or abstract.

Here’s what I found: Over the first five months of 2026, when compared to the similar period a year ago, there was a 24% drop in articles and research studies published about abortion and LBGTQ health; a 23% reduction in articles published in the medical literature that include the terms “race” or “racial” and “health disparities”; and a 15% decline in articles mentioning the “social determinants of health” and “health disparities.”

The reductions in published research in those four areas far exceeded the general slowdown in published new studies, which through May 30 was about 9% below the comparable period a year ago. Public health experts say a number of factors are driving the overall slowdown: Cuts in research spending; the time it takes to “scrub” publishable studies to avoid topics or phrases that might get researchers or the publications in trouble; and disruptions to the peer review process. Beleaguered researchers in every scientific field have less time under Trump for conducting peer reviews as they struggle to maintain funding for their own projects and labs.

“If you can’t get reviewers, there is going to be a slowdown in getting stuff published and that’s across the board,” said Nancy Krieger, a professor of social epidemiology and an American Cancer Society clinical researcher at the Harvard T.H. Chan School of Public Health. “My university had a total blockage of grant funding for a period of time, no matter what kind of research you were doing. If you were doing a clinical trial or a genetic study that had nothing to do with health equity, your lab was affected.”

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All science under attack

The attack on science isn’t just affecting medical research. The National Science Foundation’s Social, Behavioral, and Economic Sciences (SBE) division, which funds more than 60% of all psychology, sociology and economics research, is threatened with closure. The NSF, whose budget is just a sixth of NIH’s $48.5 billion annual budget, has also ended all support for doctoral-dissertation research in archaeology, linguistics, geography and anthropology. Six weeks ago, it fired the 22 members of the agency’s board.

The Atlantic reported last month that the NSF has awarded just five social science grants this year. In a typical year, it makes about 250 grants. A White House spokesperson told the magazine’s reporter the administration will fund “advancements in hard sciences, not in ideologically driven social sciences.”

What that ignores are the advances in NSF-funded social science that help improve the nation’s health. In the 1990s, NSF financed the economics research that created major improvements in the kidney-donor-matching system. The SBE division is the primary funder of three major social-science surveys, including the world’s longest running survey of families, child poverty and economic mobility. At least nine federal agencies rely on its data.

The Trump regime’s unceasing attacks on “woke” science, coupled with its demands that prestigious journals pay more attention to quack theories, has an historical precedent. During the 1930s, Joseph Stalin promoted an obscure agronomist named Trofim Lysenko to be the Soviet Union’s top scientist based on his rejection of genetics and natural selection. Lysenko claimed acquired traits could be passed along to children. Many of the scientists who opposed his views wound up in Stalin’s Gulags. Some were shot. Russia never recovered, having yet to play a major role in the biological sciences.

The Trump regime’s science overlords, when the media come calling, have downplayed their embrace of quack science by characterizing studies of racial disparities in health outcomes, the social determinants of health and reproductive and LGBTQ health as “waste.” Their spokespersons claim “billions” of taxpayer dollars are being frittered away on diversity, equity and inclusion-motivated research.

Yet during 2025, the total number of articles, studies and commentaries mentioning those terms in their titles or abstracts (7,798) accounted for less than one-half of one percent of all studies listed in PubMed for the year (nearly 1.9 million). Given that the average NIH grant ($622,000) generates an average of about 6.5 published articles, the total amount spent on “woke” research can be roughly estimated at about $766 million — not the “billions” claimed by HHS spokespersons. “To say there is a waste of funding on this kind of research is empirically false,” Harvard’s Krieger said.

If the U.S. truly wants to reduce health care spending and make it more affordable for everyone, it needs to step up its investment in researching the causes of racial disparities in health; the role the social determinants of health (food, housing, poverty, social stress) play in driving health outcomes; and the various roadblocks subcommunities of Americans face in addressing their health needs and achieving better health.

Congress has historically defined NIH’s mission as both identifying the causes of disease as well as developing cures. It cannot come up with cures for the chronic diseases plaguing this nation unless it addresses the social factors that are its primary cause. That requires more research into those social factors, not less.

The Trump regime’s proposed rule will set back that kind of scientific research for years. That’s probably why the editors of Science issued a clarion call for political action this week, something one rarely sees in the academic literature.

“Higher education and its associations need to firmly oppose these changes, which would create a massive morale and financial problem in addition to curtailing important research,” Editor-in-chief H. Holden Thorp wrote in the editorial. “The scientific community needs to flood OMB with responses during the public comment period. Universities and associations must speak out as a united front to mobilize Congress and be ready to file lawsuits once the regulations are finalized.

“I was sympathetic to members of the scientific establishment who played it carefully during last year’s budget negotiations. Getting the budget deal done was crucial. But that was then,” he wrote. “The red light is now flashing. All hands, report to stations.”

The ruling Republican regime is making things worse. Not only has it launched a full-scale attack on Medicaid, which covers nearly a third of all Americans, the latest White House initiative allows the insurance industry to sell low-cost plans on the Affordable Care Act exchanges that will pay only a fraction of the bills people receive after being hospitalized. If the regime gets its way, comprehensive insurance — the previous requirement for all Obamacare plans — will become unaffordable for almost everyone but the well-to-do.

Democratic Party-oriented think tanks and commentators continue to crank out proposals for making insurance more affordable. A new report from the Searchlight Institute, first reported by Jon Cohn of The Bulwark, calls for limiting private equity’s role in health care; limiting insurers’ ability to abuse prior authorization or hide profits at their wholly-owned physician practices; and wielding antitrust law to bust up hospital and pharmacy benefit manager monopolies.

Last week, Nobel laureate and substacker Paul Krugman laid out his path forward for dealing with the affordability crisis. His three-part explainer started by laying out “why universal healthcare is a desirable objective, and why some type of government intervention is essential to achieve it.”

His second installment described the ongoing Republican assault on Obamacare and its successes. But his final piece, rather than offering a bold or unique plan, or even something like the European countries to which he unfavorably compared the U.S., repeats most Democrats’ long-standing plea for including a public option on the exchanges.

A public option would allow people to buy into Medicare. Progressive groups have been advocating this for decades. The House-backed version of the Affordable Care Act in 2009 included a public option. He imagines many employers would encourage their employees to avail themselves of this new option (presumably providing them with some or most of the cost of the buy-in). “If they like what they get, which they probably would, we could transition over time to a single-payer system without forcing Americans into it,” he wrote.

Shortcomings

Krugman fails to address the virulent opposition that would be mounted against the public option by the hospital, insurance, drug and medical device industries, and the many other types of providers (nursing homes, hospice, ambulatory surgical centers, etc.) that make up the medical industrial complex. Nor does he take into account the main reason employers resist jettisoning their role: It keeps many employees from job-hopping.

Krugman assumes public anger over rising costs will overwhelm their opposition, a dubious proposition in my view even if the Democratic Party wins control over both houses of Congress and the White House. Why do I say dubious?

It is well known that health care accounts for 18% of gross domestic product, far more than other industrialized countries. What is less well known is the fact that direct health care provision accounts for 12% of all employment in the U.S. It is the largest or second largest employer in almost every city and town. In at least one recent month, the nation would have shed jobs had it not been for growth in the health care sector.

If you throw in employment in the health insurance industry, manufacturers of drugs, medical devices and durable medical equipment, and the small army of consultants, medical educators, think tankers and other health care hangers-on, about one in six American jobs flows from our bloated health care sector. Moreover, they are evenly distributed throughout the country, constituting a powerful voice in every Congressional district.

Reformers need a way to win providers — not the hospital system administrators, not the insurance company executives, not the nursing home operators; but the physicians, nurses and nurse aides, support staff, and more — to their side.

That’s why I am committed to a strategy that provides the health care sector with an off-ramp from its unproductive and wasteful ways. The system is tremendously successful at generating new technologies and treating highly complex cases. But it stinks at almost everything else that the general population needs.

It consumes more societal resources than any country on earth. It doesn’t cover everyone. Its multi-payer complexity requires enormous administrative overhead. Its specialty-driven, fee-for-service payment system delivers more pricey tests and operations than people need. It shortchanges primary care and prevention. It generates worse outcomes than other countries whether measured by longevity, infant and maternal mortality or chronic disease levels. And those lousy outcomes are extremely unfair, with minority populations suffering far worse outcomes than their white fellow-countrypersons. (I will address this issue in my next article.)

I agree with Krugman that the Obamacare exchanges need a public option for the uninsured and for any employer that wants to join. But the details, which he doesn’t address in his article, matter. Its pricing will have to be set at a percentage somewhat larger than what Medicare pays, which is what Washington state did when it became the first state to roll out a public option in 2021 (at 160% of Medicare prices). Colorado and Nevada have followed suit with their own higher-than-Medicare priced public options.

Providers need a guaranteed off-ramp. They and their millions of employees can’t absorb the sudden shock to the system required by the mass migration to the public option at Medicare rates, which, according to the Medicare Payment Advisory Commission, are somewhat below breakeven rates. Therefore, in addition to creating the public option, providers need to be regulated through government-set budgets that are set at current levels and guaranteed to grow, but only at a slower rate than the rest of the economy.

Over the past several decades, health care spending has risen faster than the rate of economic growth, ballooning from 13% of GDP at the start of this century to 18% of GDP today. If budgets are allowed to grow at one to one-and-a-half percentage points above inflation (that’s about half the economic growth rate), U.S. health care spending will gradually decline to international norms.

Invest in health

What else would guaranteed budgets accomplish? It would free hospitals, physician practices, clinics and other provider organizations from the treadmill of fee-for-service medicine, where the more you do the more you make. It would free up resources to invest in the nation’s woefully underfunded primary care and behavioral health providers.

It would encourage provider organizations to invest in community outreach to underserved populations suffering from undiagnosed and untreated diseases (think hypertension, pre-diabetes, obesity, and drug, alcohol and tobacco addiction). If we treat disease before its complications set in, people will spend less time in the emergency room, where care is costliest, and often comes too late to affect the trajectory of their chronic condition.

In short, the nation’s health care system needs to transform itself into one that promotes health, not one that profits when more people get sick. The Make American Healthy Again movement has that part right. Reformers on the left should grab that page from their playbook by providing a positive vision for how to produce healthier individuals as well as a plan to reduce how much the public has to spend.

Both those facts piqued my curiosity about the announcement made Monday by Donald Trump with Mark Cuban, who runs Cost Plus Drugs, at his side. They were touting adding 602 generic drugs, including statins and blood pressure control meds, to TrumpRx, the government website that directs consumers looking for lower cost drugs to Cuban’s company, GoodRx and Amazon Pharmacy.

Who will actually benefit from TrumpRx, I wondered, which is touting mostly generic drugs. And how much will they actually save?

First, I looked up what I could save by buying my generic statin from Cost Plus. Under my Medicare supplemental plan, which comes through my retired wife’s former employer (a public school system), CVS Caremark manages the pharmacy benefit. The PBM requires I pay a $20 co-pay at the pharmacy counter to obtain a 90-day supply of 20-milligram rosuvastatin, the generic name for Crestor.

Cuban’s Cost Plus mail-order website says it would charge me $7.85 for a 90-day supply plus a $5 shipping fee, thus saving me $7.15 for each refill or $28.60 a year. However, Cost Plus also tacks on a $5 pharmacy handling fee. It was unclear from the website if that was part of the $7.85. If not, adding that $20-a-year into the total cost would wipe out most of any savings for me.

I then called CVS Caremark to inquire about their savings should I decide to jump off their plan for those meager savings. I use the phrase “their savings” cautiously. I have no idea if my wife’s former employer or its plan’s medical insurer hires the nation’s second largest PBM, or how much either pays to CVS Caremark. Moreover, how much the PBM profits from the ultimate payer — the taxpayers behind the public employee retirement system — is unknown. So is the price it pays the generic manufacturer and any other middlemen that may have stuck their hands into the honey pot.

In any case, the call center operator told me the total cost to the PBM was $60.86 every 90 days. But that was before I paid $20 every three months at the pharmacy, so the cost reduction for everyone else would be about $164 a year, at least six times more than me. As noted above, how those savings would be divvied up between the PBM, the medical insurer and the employer-payer is safely contained in someone’s black box.

Will it benefit the uninsured?

How about the alleged major beneficiaries of TrumpRx — the uninsured who have to pay for any health care out of their own pockets? Their ranks are growing daily due to this year’s massive increase in rates for Affordable Care Act plans triggered by the regime’s handmaidens in the Republican-run Congress, who allowed the Biden-era increase in plan subsidies to expire.

When ACA-insured, the people dropping plans paid nothing for their cholesterol and blood pressure control medications, even if their plan had deductibles. All preventive services rated “A” or “B” by the U.S. Preventive Services Task Force must be offered free of charge under the ACA. Statins are rated “B.”

But under TrumpRx, those dropping coverage (or those that never had a plan in the first place) will have to pay the full cost. If they turn to Cost Plus Drugs, that would be at least $52 a year with maybe an additional $20 for the pharmacy fee.

Of course, both groups could run into trouble when renewing their prescriptions if they no longer have or never had a primary care physician. When signing up for Cost Plus Drugs, which I did today, I had to provide the name and contact information for my prescribing physician.

Even if they can get past that hurdle, people who are uninsured are usually pinching pennies. They no longer have a primary care physician. They don’t go in for routine checkups, which might identify when they have high blood pressure or dangerously elevated cholesterol. They are less likely to adhere to diets with less salt and less processed foods, which promote better heart health.

The ACA had it right. Drugs that have been proven to prevent serious diseases should be entirely free of charge to the consumer/patient. They are a wise investment that pays off in reduced hospitalizations and reduced complications from chronic diseases, which in turn reduces long-term health care costs. Plans like my supplemental should eliminate their co-pays entirely for such drugs, especially when they are generics like most statins and blood pressure meds.

TrumpRx sets up a financial barrier to access. It will decrease the population taking these important interventions. It is a public relations stunt designed to look like the regime is doing something about the high cost of drugs, which is entirely driven by the cost of new drugs coming to market and the high prices on those that remain on patent, not the extra fees PBMs tack onto prices.

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Paying for value

One final thought: The regime is stepping up its pressure on European countries to raise their drug prices, which are substantially less than what is paid in the U.S. Why? Other advanced industrial countries are effective drug price negotiators. They refuse to pay more than the carefully calculated medical value of a prescription.

The U.S., on the other hand, insists that foreigners pay their “fair share” for innovation instead of using the same negotiating and value measurement tactics. Big Pharma’s argument — that the high cost of drugs is driven by the high cost of research and development — never held much water and has grown increasingly shallow given how much innovation has moved to China in the wake of the regime’s immigration policies and gutting of NIH funding.

This Trump regime’s attempt to impose so-called reference pricing is, in essence, a strategy to maintain as much revenue as possible flowing to Big Pharma. It provides no long-term brake on rising costs. The U.S. would pay slightly less; other industrialized countries would pay slightly more; less developed countries would continue to go without the latest therapeutics; and the drug industry would maintain the status quo on profitability.

Here’s a sampling of the analyses offered by public health experts over the past week about the evolving hantavirus situation:

“Hantavirus is not spread by people without symptoms, transmission requires close contact, and the risk to the American public is very low.” — Jay Bhattacharya, interim Director of the Centers for Disease Control and Prevention, quoted in The Hill

“It’s important to understand this is not Covid. No matter how this virus plays out, its transmissibility is going to be very different than Covid. I don’t see a large, global pandemic coming out of this.” — Dr. Ashish Jha, Senior Fellow at the Harvard Kennedy School and Covid coordinator during the Biden administration, on the PBS NewsHour

“Andes (the name given the hantavirus strain first identified in Argentina) has mitigating characteristics that distinguish it from influenza or SARS-CoV-2, and prolonged, close personal contact is required for transmission. All in all, large-scale outbreaks are now unlikely given the control measures in place.” — Gregg Gonsalves, PhD, associate professor of epidemiology, Yale School of Public Health, writing in The Nation

"There is no chance this will become a pandemic. You have no risk of contracting hantavirus, unless you decide to sweep mice droppings in New Mexico.” — Dr. Vinay Prasad, fired from the Food and Drug Administration, writing on the Sensible Medicine Substack

However, there is at least one cautious dissenter:

“From the moment this latest outbreak hit the news last month, public health officials have been claiming that this virus is spread through ‘prolonged close contact.’ The evidence is not nearly so reassuring… This outbreak is not likely to spark a pandemic, mostly because the hantavirus is less contagious than influenza, measles, and SARS-CoV-2. But given just how little experience we have with this virus, any certainty is hubris.” — Joseph Allen, professor, Harvard School of Public Health writing in The Atlantic

Allen based his conclusions on a “meticulously documented” study of an outbreak in a remote Argentine village in 2018-19, which appeared in the New England Journal of Medicine. The report’s conclusions, written in 2020 by scientists from Argentina, the U.S. military and Centers for Disease Control and Prevention, contradict claims that “prolonged close contact” is required for transmission.

Allen is an expert in indoor air quality. In 2020 he chaired the Lancet’s Covid-19 Safe Work, Safe School, and Safe Travel task force, which modeled the early 2020 outbreak on the Diamond Princess cruise ship that brought Covid to the U.S. The task force was among the first to report that 90% of the spread on the ship was through aerosols, not contaminated surfaces. The CDC didn’t update its guidance until late 2020, long after the disease had spread through the general population.

“I am alarmed to see the same pattern playing out now,” he wrote in the Atlantic this week.

Allen interviewed the physician on board the MV Hondius who treated infected passengers after the ship’s official doctor got sick after coming in close contact with the first patient. But the others who got sick, three of whom died? “They had merely shared space in the dining room and the lecture hall and had not had close contact,” he reported. “We’re now at 10 confirmed cases from the ship, which aligns with the prior outbreak dynamics (as reported in NEJM): one person infecting many, no close contact required.”

I read that NEJM study about the Argentine outbreak yesterday. Here’s a direct quote from its conclusions:

“On the basis of both the epidemiologic and genomic investigations of person-to-person transmission events, it appears that inhalation of droplets or aerosolized virions may have been the routes of infection. … The super-spreading capability of the (Andes) strain shows a facility for sustaining continuous chains of transmission if no control measures are enforced.”

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Now, it wouldn’t be fair to say no control measures are being enforced by the current administration in Washington and two agencies primarily responsible for responding to infectious disease outbreaks, the CDC and the National Institutes of Health. They moved quickly to airlift and isolate the exposed Americans.

Europeans have taken similar precautions. According to EuroNews, 26 Dutch passengers have been quarantined either at home or in facilities; 14 Spanish passengers and 5 from France were airlifted to hospitals in their home countries, with at least one having been confirmed as catching the disease on board the ship. They all face up to seven-week quarantines where they will be continuously monitored with PCR testing.

Why seven weeks? The Andes hantavirus, the only variant known to spread from humans to humans, can take that long to generate the respiratory disease that can prove fatal. The Argentine strain had a reported fatality rate of 30% to 40%, but that number is highly suspect. The dominator in the percentage is based on those who tested positive for the virus. The real rate is unknown because many more people in the remote village may have been exposed yet never developed symptoms and were never tested to see if they carried the virus.

Are we ready?

After my brief review, I came away somewhat concerned about the prospects for a broader hantavirus outbreak but generally agree the prospect of a population-wide pandemic is unlikely. However, thanks to a good summary provided by Gonsalves in his Nation article, here’s the state of U.S. preparedness for the next viral threat that reaches U.S. shores — an inevitability in our warming world:

• The White House eliminated the Office of Pandemic Preparedness and Response Policy;

• The Trump administration closed 10 Centers for Research in Emerging Infectious Diseases that study zoonotic pathogens that jump from animals to humans, like the hantavirus;

• The Trump administration gutted the STOP Spillover Project, a USAID-funded network that tracked “menacing animal viruses across seven countries”;

• The Trump administration paused research on high-risk pathogens at the Integrated Research Facility in Frederick, Maryland;

• The CDC has an acting director without medical experience as does the Division of High-Consequence Pathogens;

• The administration has wound down NIH research on mRNA vaccines, which could be used for a hantavirus vaccine;

• The president’s 2027 proposed budget sharply cuts state and local preparedness grants to health departments and hospitals around the country; and, in a final irony,

• Its DOGE cuts from a year ago eliminated the CDC’s cruise ship inspectors and port health workers.

Bhattacharya, in his public statements, has repeatedly said the U.S. is cooperating fully with international agencies in the current outbreak. Yet the U.S. no longer belongs to the World Health Organization, which, as Gonsalves points out, “leaves us flying solo without a key source of international collaboration and coordinated planning.”

Is the U.S. prepared for the next serious emerging viral threat? I think the answer is obvious.

Don’t let that composite number for health care fool you. If you dig into the numbers, you’ll find that rising hospital prices are mostly to blame for current medical cost inflation, as they have been for the past decade (see the chart below). Every other sector — pharmaceuticals, physician services, medical commodities — are rising on average at or below 2% or what Federal Reserve Board chairman Jerome Powell and previous Fed chairs have considered the ideal target for price growth.

A slight caveat: The prescription drug price increases reported by the BLS may understate its contribution to overall medical inflation. The agency calculates its year-over-year increase mostly from the price increases on existing products, which is usually modest.

The most significant factor driving increased drug spending is the price placed on new products entering the market, which these days can range into hundreds of thousands of dollars per year for new cancer drugs and over $2,000 a year for the latest weight-loss GLP-1s. One in 12 Americans are already taking those drugs to lose weight, according to a Kaiser Family Foundation survey, while a third of adults say they are interested in taking them.

I’ll do the math for you. Current usage translates into a total cost of about $44 billion a year (that’s calculated at the low price for the pill forms now entering the market; many people and/or their insurers are still paying over $10,000 a year for the first-generation GLP-1s, which are injected). Tripling uptake, which surveys suggest could happen, will cost nearly as much money as the Pentagon says it needs to fight President Trump’s war against Iran.

But even that level of new drug spending will pale besides the rapidly rising cost of hospital care. Average prices for hospital care today are more than 50% higher than where they stood a decade ago, according to the BLS. Since hospitals account for a third of all health care spending (more than twice what is spent on drugs), hospitals now generate about 40% of the year-over-year increase in the total health care tab.

Higher prices lead to higher profits

Those rapid price increases are now showing up as outsized profits for major hospital chains, which last year dwarfed the profits made by insurers. We don’t hear much about the profits generated by hospital systems because more than three-quarters of all hospital beds in this country are controlled by non-profit systems, which don’t report to the Securities and Exchange Commission. They include religiously affiliated systems, major academic medical centers and high-prestige outfits like the Mayo and Cleveland clinics.

Their executives invariably repeat a slogan I heard for the first time at a conference I attended shortly after becoming editor of Modern Healthcare in 2012. “No margin, no mission,” they’d say when questioned about the “surpluses” reported on the income statements that they send to bond rating agencies.

Their missions varied depending on the locations of their hospitals and background of the system. They included healing the sick, research, providing free care, and helping the community. They are required to report those “community benefits” to the Internal Revenue Service each year to maintain their non-profit status. (Most systems inflate their community benefits by including the difference between Medicaid reimbursement and what they claim is the actual cost of care; but that’s a different story.)

There have been years when average hospital surpluses have been quite narrow, close or even less than the 5% target used by most for-profit insurance companies. But when I pulled the 2025 annual filings for 17 large hospital systems (accounting for over a half trillion dollars in revenue), I was stunned to see they earned an average of an 8.5% return last year.

As you can see from the next chart, margins at eight of the non-profits surpassed the most profitable publicly-traded company, which is HCA. All reported dollar amounts are in billions:

Meanwhile, health insurers’ after-tax profits dipped well below their 5% target:

What is to be done?

The policy wonk world has largely turned to antitrust as the solution to rapidly rising hospital prices. Recent studies conducted by the KFF and Families U.S.A. show that nearly every hospital referral region is dominated by one or two major hospital systems. (There are over 3,400 cities and towns with at least one hospital, but only 306 major hospital referral regions, defined by their ability to offer comprehensive medical services.)

There has been a tremendous amount of consolidation over the past two decades, with major chains gobbling up struggling independent hospitals or merging with other major chains. They’ve also scooped up independent physician practices, ambulatory surgical centers, and established numerous satellite clinics that feed patients into their hospitals when in need of surgeries, tests and chronic disease care.

After passage of the Affordable Care Act, such consolidation was rationalized as necessary to create vertically integrated delivery systems capable of providing greater care coordination that could deliver higher quality care and better outcomes at a lower price. The Centers for Medicare and Medicaid Services launched numerous pilot projects aimed at training health care systems to deliver what became known as accountable care.

Alas, most of those pilot projects failed to save money. Those that did never led to widespread adoption. Hospitals resisted moving away from a fee-for-service model where the more services they delivered, the more revenue they generated, and the more margin they earned to invest in fancier facilities or store in their growing endowments.

Insurers, most of which are now for-profit, saw no reason to tamper with the system since the more hospitals charged them, the more they could charge their employer and individual customers. Since their profits depended on total revenue, the more they were charged, the more they could turn around and charge in premiums, and the more they could make.

Insurers also talked about using population health management techniques to lower costs for the patients. Yet their primary tools turned out to be abusive prior authorization techniques and rampant claims denials, which only served to alienate patients, physicians and hospital administrators without improving health. Indeed, it may have made outcomes worse, even as it increased profits in the short run. When those tools drew massive resistance (they are now being scaled back), it led to rising utilization and a profit collapse, suggesting all their talk about population health management was precisely that — talk.

Many political leaders — ranging from single-payer advocates on the left to the White House on the right — still blame insurance companies for rising costs, and see eliminating them or reining them in as the solution. Given insurer’ abuse of prior authorization, narrow networks and their high overhead, it’s not an unreasonable position, as Larry Levitt pointed out in a commentary published in JAMA Health Forum on Monday. “Removing health insurance companies from the equation—for example, in a Medicare for all system—would reduce administrative costs and profits,” he wrote.

“But the biggest drivers of health spending growth—hospital prices, care that is not always grounded in evidence, and new drugs and medical technologies—would remain,” he concluded. “Some entity must address what health care needs to be covered and at what price. The question is, who do we trust to do that most effectively and fairly?”

As I’ve written repeatedly in recent months (see here, here and here), doctors who work in and within hospitals are best positioned to make decisions about what needs to be done to treat their patients. Couple that with putting hospital administrators under government-run price regulation tied to annual budgets, and you have a recipe for the short-run cost control and long-run affordability that will make universal coverage, which is necessary to eliminate uncompensated care from the system and deliver better population health, possible.

For the FDA, whose jobs include the approval of new drugs, vaccines and medical devices, the gold standard meant requiring rigorous clinical studies to prove that experimental products were both efficacious and safe. That usually means a manufacturer has to submit at least two trials, both of which are placebo-controlled and double-blinded (neither patients nor their physicians know if they received the real thing). Patients in the trials are randomly assigned to one group or the other — hence its name, the randomized controlled trial or RCT.

The Center for Disease Control and Prevention is charged with monitoring the extent and seriousness of health threats in the U.S. Its gold standard is different because it involves epidemiological studies, where researchers measure the extent of a disease and its outcomes in the population by mining medical records or conducting surveys drawn from well-matched cohorts. It often relies on data collected by state and city public health agencies.

In recent weeks, the press has reported that both agencies’ staff scientists have had studies withdrawn from medical journals (the FDA) and an in-house publication (the CDC). On Tuesday, the New York Times reported that “In October, (FDA) scientists were directed to withdraw two Covid-19 vaccine studies that had been accepted for publication in medical journals. In February, top F.D.A. officials did not sign off on submitting abstracts about studies of Shingrix, a shingles vaccine, to a major drug safety conference.”

Two weeks ago, the Washington Post and other publications reported top officials at the CDC refused to allow publication of a study showing the effectiveness of the Covid vaccine in reducing hospitalizations. It had been scheduled for publication in Morbidity and Mortality Weekly Report, the agency’s well-regarded in-house journal.

Jay Bhattacharya, who runs the National Institutes of Health and is the interim head of the CDC, defended his decision to deep-six the study in a Post op-ed. “I raised specific concerns about the statistical methodology chosen for the study in question,” he wrote. “These concerns about the test-negative design used go directly to the validity of the study’s conclusion.”

I’ll have more to say on test-negative design in a moment.

A new journal for CDC

Bhattacharya also announced plans for the agency to launch a peer-reviewed journal “to elevate scientific rigor across all CDC publications,” he wrote. “Peer review remains the gold standard because it subjects findings to independent scrutiny, forces transparency about limitations and strengthens confidence in the results.”

The peer review panels for this new journal, when chosen, will definitely warrant “independent scrutiny.” Should they follow in the footsteps of how the CDC has remolded its vaccine advisory committee, it should provide plenty of grist for the Retraction Watch, which monitors medical and scientific journals for published retractions. The RW website database lists tens of thousands of incidents where peer reviewed failed to catch factual errors, deliberate falsifications and other misfeasance and malfeasance in the academic journal publication process.

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I have served on several peer-review panels. I will never forget the note I received from one author after I made a number of pointed suggestions for improving his study’s conclusions. He thanked me for giving him one of the most comprehensive reviews he had ever received, one that was very helpful in improving the manuscript.

I don’t offer this anecdote to pat myself on the back. It confirmed something I’ve often heard said about peer review. A better name for the process might be “colleague review,” or “friendly review,” or even “ideological fellow-traveler review.” It would be out of character (and I will be pleasantly surprised) if the Trump regime’s CDC sets a higher standard.

Bhattacharya, who trained as an economist and physician at Stanford, has never worked as an epidemiologist or as a practicing physician. But he emerged as an expert during the Covid pandemic by co-authoring the Great Barrington Declaration, which called for allowing the general population to opt out of vaccination while adopting special measures to protect seniors, who were most vulnerable to the disease. The one country that tried that approach (Sweden) quickly abandoned it due to mounting mortality among its working-age population.

His demand for something better than “test-negative” design sounds to me like obfuscating jargon that could be used to call into question most epidemiological research. “The core problem” with that approach, he wrote, “is that, to measure the effectiveness of a vaccine in keeping people out of a hospital (for instance), this method throws away all data about people, vaccinated or not, who are never hospitalized. Instead, it replaces data with unverifiable assumptions, leading to bias. Factors such as prior infection, behavioral differences and who shows up for care can all skew results in ways that are hard to adjust for.”

Yes, all epidemiological studies that compare outcomes among two groups that haven’t been randomized have unmeasured factors that might skew the results. And there’s lots of junk science in the medical literature that makes no attempt to adjust results for unmeasurable factors. Here’s one: Martin Makary’s most recent book (he now runs the FDA) cited a study that “proved” fluoride reduce intelligence by comparing the average IQ scores in two Canadian communities, only one of which had fluoridated water (and slightly lower IQ scores among its school age children).

But most studies, especially those published in reputable journals, attempts to adjust for those unmeasured factors. The Times in its story pointed out that the “test-negative” design has been used in numerous CDC studies over the years and is well accepted in the peer-reviewed medical literature. It was used in a 2021 study on Covid vaccine effectiveness that was published in the New England Journal of Medicine, and in numerous peer-reviewed studies published in journals like JAMA Network Open, the Lancet and Pediatrics.

The Post, in its story two weeks ago, quoted Michael Iademarco, who directed the CDC center that publishes MMWR from 2014 to 2022, which included Trump’s first term in office. “I cannot recall CDC stopping an MMWR report in the publication phase after scientific clearance and editorial review,” he said.

That is, not until contrarians like Bhattacharya and Makary and the anti-science, anti-vaccine Robert F. Kennedy Jr. took over the agencies that are charged with protecting the public’s health. Now, science is whatever they say it is.

I wish I could say there is a lot of action in the states. Unfortunately, passage of major payment and delivery reforms that can serve as a model for other states and/or the nation are in short supply.

Just two states (Rhode Island and Delaware) have implemented price growth caps to control year-over-year growth in insurance premiums, according to a recent policy brief from the Georgetown University Center for Health Insurance Reforms. A few states have adopted reference pricing for hospitals, where reimbursement rates are tied to a benchmark like Medicare prices.

Washington state, for instance, caps hospital prices for a state-run public option on its Affordable Care Act exchange to 160% of Medicare prices. Oregon and West Virginia do something similar for the plans they offer their state employees.

Last year, Vermont and Indiana became the first states to enact hospital price caps for the entire commercial market. “They did so by capping the prices that hospitals can charge, rather than the amount that insurers can reimburse hospitals—thereby bypassing federal restrictions on states’ ability to regulate self-insured plans,” noted the authors of a recent article in Health Affairs.

But few of those measures tie cost control to improved quality and outcomes, or free up providers to spend their money in ways that improve their populations’ general health. Nor has any state attempted to replicate the Maryland Total Cost of Care model, which puts every hospital in the state on a global budget (it covers both in-patient and out-patient services) and ties that to an all-payer pricing system, where every commercial payer pays the same price for the same service at any particular hospital.

As I’ve noted in a number of articles and GoozNews posts (see here, here, here and here, for instance), I firmly believe this is the most promising approach short of adopting a single-payer, Medicare for all system for both bringing overall health care spending under control while improving care quality, patient outcomes and the individual patient’s experience with the health care system.

Progressive legislators in a few states (like my home state of Illinois) are pushing bills that almost exactly replicate the Maryland model. Yesterday, the Illinois Senate Appropriations - Health Committee held a first hearing on a bill sponsored by Sen. Lakesia Collins with co-sponsors Graciela Guzman, Javier L. Cervantes, Mary Edly-Allen, and Rachel Ventura, all Democrats from Chicago and its northern suburbs.

I presented testimony in favor of the bill. I was limited to three minutes. Here are my remarks:

Good evening, Chairman Aquino and members of the committee:

I am Merrill Goozner, the former editor of Modern Healthcare, a former Chicago Tribune and Crain’s Chicago Business reporter, who now write a newsletter on health care issues with over 13,000 subscribers.

The first section of Senate Bill 3900 offers a comprehensive payment reform program that puts hospitals on budgets and equalizes pricing for commercial payers. It is that section of the bill I wish to address today.

This payment program is about affordability. It has demonstrated that it can bring health care costs under control without jeopardizing patients. In fact, it sets the stage for creating a better health care system by detaching funding from how much sick care is provided.

One state has led the way. Maryland is the only state in the country with a system like the one outlined in SB3900. Since fully implementing the system in 2014, Maryland’s hospital use of unnecessary services – both in-patient and out-patient – grew more slowly than the rest of the nation, even as key quality measures improved. It has saved payers, both public and private, billions of dollars. The state’s 30-day readmission and preventable admission rates were significantly reduced compared to other states.

Why has the Maryland system been so effective?

• Equalizing commercial pricing, where every insurer pays the same price for the same service at any individual hospital, substantially reduces wasteful administrative costs for both hospitals and insurers, which reduces spending and frees up dollars for clinical care.

• Putting providers on budgets empowers hospitals and providers to deploy their resources more effectively. When they are not dependent on the volume of services delivered, they have the freedom to invest more on prevention, primary care, care coordination, behavioral health, and community outreach. These are key to better health. All are woefully underfunded. This investment will not only improve overall population health, it is key to achieving the long-term cost control that patients, consumers, employers and taxpayers want and need.

• Global budgets, if appropriately adjusted for special needs, will stabilize financing for the state’s struggling safety net, community and rural hospitals; and

• For employers, who finance about three-fourths of private health insurance, it will lay the groundwork for making the system fairer, one where employers with older and sicker workers are not forced to pay an oversized share of the state’s total health care bill.

SB3900 is a long-term cost control program. The equal pricing system, when coupled with global budgets that grow more slowly than the rest of the economy, will allow state regulators over time to bring commercial prices more in line with Medicare pricing. This will reduce the growth rate in employers’ and employees’ premiums. It will leave more money in peoples’ paychecks. It will lower employers’ costs, and therefore, make Illinois more competitive.

We live in a time when people are looking for bold solutions to pressing problems. Passing this legislation will put Illinois in the forefront of how to deal with the nation’s health care affordability crisis. I hope you will give it serious consideration.

Thank you.

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And it’s true. If you don’t measure what is happening now, how will you know if a change made to solve a problem has the desired effect? Comparing a new now to the old baseline provides the tell.

But what does measurement achieve if an organization fails to make changes? There is no new now. There’s only the same old thing.

That is precisely what happened after the Trump administration’s Health and Human Services Department last year imposed a new rule requiring insurers disclose data on prior authorization. The initial disclosure, released at the end of March, showed what share of provider claims are denied by insurers; what share are appealed; and what share of appealed denials are overturned.

Dr. Archelle Georgiou, who a quarter century ago served as UnitedHealth’s chief medical officer, took a close look at the data on her most recent substack post. Her findings are disturbing, to say the least. Denial rates average 10% for the six insurers in her sample. Two-thirds of those denials are overturned on appeal.

The most frustrating finding is that just 7% of denials are appealed. Few patients or their providers are willing to go through the long and complicated process of filing an appeal. They simply accept the denial of care.

By applying the same two-thirds overturn rate to the much larger claims-denied-but-not-appealed cohort, Georgiou estimates that four of the six insurers (two did not disclosure the actual volume of denials, only the rates) pad their profits by $100 million to $500 million a year.

A recent review of 23 studies associated greater claims denials with higher rates of hospitalization and lower rates of disease-free survival, she wrote. She questioned the Trump administration expanding prior authorization to the traditional Medicare program in six states through its WISeR (Wasteful and Inappropriate Service Reduction) pilot project.

“Why are we accepting a prior-authorization system that causes demonstrable harm?” she asked. “Why are we now running it at scale, with AI, before fixing the incentive structure underneath it?” (The WISeR model uses AI to flag questionable service requests, which are then thrown over to a private contractor to decide. That private contractor earns a fee or a portion of the savings from any denial.)

Unfortunately, the former insurance industry executive failed to offer a meaningful solution to the literally hundreds of millions of people in privately-run Medicare Advantage, Medicaid, employer-based and individual plans that use prior authorization. She merely called for greater disclosure and, until that happens, greater vigilance on the part of providers and patients.

Appeal every denial, she advised. Here’s how, she wrote:

• 1. Get a written copy of the denial letter and look for the specific reason cited for the denial.

• 2. Appeal every denial in writing. Provide specific information that counters the reason they cited.

• 3. Ask your physician’s office to submit an appeal on your behalf and get a copy for your records. This is not duplicative; your appeal letter is complementary to your physician’s.

• 4. Track deadlines aggressively. Both initial decisions and appeal reviews are subject to regulatory time frames that insurers are required to meet.

• 5. If your appeal is denied, escalate to your state insurance commissioner. Regulators notice patterns.

To which I respond, good luck with that (as if you didn’t have something better to do with your life, like dealing with your disease after being denied necessary care).

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A better way

As I wrote a little over a month ago (“Can prior authorization be fixed? Should it be?”), I believe we need to take prior authorization entirely out of the hands of the insurance industry. For-profit insurers (and surplus-maximizing non-profit insurers like many Blue Cross-Blue Shield plans) have a structural conflict-of-interest. The more they deny, they more profits they make.

One way to end prior authorization is to put all providers on budgets and give them the flexibility to decide how to deploy their resources in the most health-improving manner and at the lowest possible cost. When on a budget, keeping people out of the hospital makes an organization more profitable (or generates more surplus in the case of non-profit providers).

At-risk insurers get their payments on a monthly or annual per capita basis. Why can’t they turn around and do the same with providers? Let’s put clinical decision-making in the hands of the people who are supposed to be making those decisions — clinicians.

It is the job of provider organizations’ managements to determine if there is wasteful care in the system. When they are constrained by capped annual budgets, they are incentivized to perform that vital function. They no longer profit from allowing physicians to pad their personal income by ordering unnecessary procedures or the most expensive drug when something cheaper and equally efficacious is available.

It is a physician’s job to first do no harm. Unnecessary care is, by definition, unbeneficial care. And where there is no possibility of benefit, there is only the possibility of harm. Physician organizations that have measured the choices and patient outcomes for individual physicians and shared that data within the organization have found that those doctors who most closely adhere to accepted clinical practice guidelines have the best outcomes. When shown that data, physicians rapidly adjust their own decisions to more closely adhere to the best-performing physicians within the practice.

Why is that? Physicians are trained to follow the data. When shown the data, they change. On the other hand, when they are told they can’t do what they think best (with no data or explanation from either the insurer or their organization), they rebel. When repeatedly told no, they burn out and quit. Putting organizations on budgets and physicians on salaries contributes to solving a host of problems.

Of course, putting providers on budgets and physicians on salaries is the long-term solution. In the short run, rather than asking physicians and patients to appeal every prior authorization denial, insurers who want to deny a claim should be required to kick the claim over to an independent board comprised of independent, salaried clinicians to rapidly make a final decision. Clinicians and patients should have the right to appeal. These independent boards should be funded by a small per capita tax on every insurance plan, operate as non-profits, and have absolutely no financial stake in the outcome of their decisions (no shared savings with insurers).

I’m a great believer in transparency. The decision-making process at independent boards should be totally transparent. But it is no substitute for radically changing the rules under which they operate.

Using that habit of mind to drive journalism is a bad idea. People will be misinformed. Using it to drive the practice medicine is worse because people will get hurt.

This past weekend, I read a recent story in The New Yorker about “the seductive world of unapproved peptides,” written by Dhruv Khullar, an outstanding medical journalist. The physician-writer visited several clinics run by board-certified physicians pushing these protein snippets on gullible people looking to heal ailing muscles, improve memory and live longer lives, among other alleged benefits.

The testimonials offered by physicians promoting various peptides defied every standard of medical evidence developed since Founding Father Benjamin Rush gave up bloodletting. Charleston, S.C.’s Craig Koniver, trained in family medicine, called one peptide used for tissue healing (BPC-157) “supersafe” and said “almost everyone I could think of” will benefit from it. A few paragraphs later, he says, “I’m not a big vaccine guy. A lot of them don’t have the data.”

What’s the data behind BPC-157? There are exactly two clinical trials for that peptide in the federal government’s clinical trials database. One is an early-stage safety trial of unknown scope and status that is taking place in Tijuana. The second is an efficacy study based in Shenzhen, China, which is still recruiting patients. Vaccines, on the other hand, have undergone extensive testing and they’ve gained FDA approval, which means there are reams of data documenting both their safety and efficacy.

Koniver goes on to say “anecdotal data means a lot to me. Two days after a vaccine, someone has a stroke. Two days later they’re dead. … You see enough of that, it makes an impression.”

There’s no shortage among his 1,000 patients, who pay $15,000 a year for the services of his concierge medical practice (it doesn’t take insurance), willing to attest to peptides’ benefits. After all, wait long enough and most tissue tears eventually heal. Koniver (is a Charles Dickens doppelganger now the resident fact-checker at the New Yorker?) has 6,000 people on his waiting list.

Many of the people lining up to spend their hard-earned money on peptides may have heard the siren call of the ultimate peptide guru, Robert F. Kennedy, Jr., who sits atop the Health and Human Services Department. He frequently claims he benefited from injecting peptides to cure injuries sustained during body-building exercises.

He appeared earlier this year on the Joe Rogan podcast (the world’s most popular with 11 million listeners). Rogan frequently touts peptides on his show. The field also received an unexpected boost from the FDA’s approval of semaglutide (Ozempic, Wegovy, Zepbound), a peptide for diabetes and weight loss. If that one works, won’t they all?

Semaglutide is the exception, not the rule when it comes to data on peptides. There is almost no evidence beyond individual anecdotes that most of the peptides now in circulation, mostly produced by compounding pharmacies, actually benefit patients or are safe.

Earlier this year, Kennedy removed the limited regulation of unapproved peptides that had been put in place during the Biden administration because their manufacturers failed to submit data to the FDA proving they could be safety injected in patients. The Kennedy reversal hurled peptides back into the regulatory vacuum enjoyed by dietary supplements, where the only rules that apply involve purity (does it contain what it claims to contain) and a ban on making medical claims (which is routinely violated by industry advertising).

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Good data on peptides, whether for efficacy or safety, requires someone conducting randomized clinical trials that test whether the products are better than a placebo or the current standard of care. The tests need to be in a sufficiently large population to show statistical significance in any outcomes differences between the two groups. Absent clinical proof of efficacy in such trials, there will only be the risk of harm or unpleasant side effects.

The Biden administration upheld evidence-based medicine when it required most peptides undergo such tests. The Trump administration via Kennedy opted instead for allowing money-hungry physicians and compounding pharmacies to conduct what amounts to an uncontrolled science experiment on gullible Americans, where no one takes a measure of the outcomes except the individuals and families who will be harmed both physically and financially.

The peptide craze is following the same trajectory of the anti-vaccination movement (also championed by Kennedy); the evisceration of National Institutes of Health research into the many social causes of disease; and the degradation of the Centers of Disease Control and Prevention’s ability to promote population health. It is anti-science, pitch perfect for a society addicted to addictions, promoted by someone who admits he once snorted cocaine off a toilet seat, who now jabs needles in his body in the evidence-free pursuit of faster healing and better health.

Peptide proponents claim it is their right to try unapproved substances based on claims made by family, friends or their concierge physician. It’s my body. I willingly take the risk. Whom else does it harm?

Actually, everyone. Who pays when you end up in the hospital and wrack up huge treatment bills? Two people fell desperately ill during an Las Vegas “anti-aging” event after injecting peptides and had to be intubated. Widespread allergic reactions to the shots, some of which were life-threatening, forced regulators in Australia to issue a safety alert. Health Canada has issued a warning that unauthorized peptides can cause blood clots and liver and kidney damage.

The U.S. used to have a regulatory agency that the rest of the world awarded a gold medal for how to manage the entry of medical products into the marketplace. Today, under this government, it isn’t even in the race.

Americans frequent hear that Medicare is going broke. They rarely hear that the Medicare payroll tax only pays for hospital care, which accounts for only a third of seniors’ health care bills. The rest depends on income tax collections, which are being eroded by the massive tax breaks handed out to the wealthy and large corporations in last year’s One Big Ugly Bill.

Few Americans know that the top income tax rate was 90% between 1944 and 1963. Yet those were the years when America was so “great” that our current leader would like to take us back there.

It was a time that labor economists Claudia Goldin and Robert Margo dubbed the Great Compression, when the ratio of CEO to average worker pay was below 20 to 1, not the 281 to 1 that it is today. It was a time when income inequality reached historic lows; and when the U.S. spawned a large and growing middle class.

In the days and weeks leading up to this year’s Tax Day, I didn’t see a single media account of how last year’s tax bill exacerbated the nation’s already record-breaking income inequality, or how the growing concentration of income in upper class hands has affected income tax collections and, therefore, social programs.

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Social Security provides a good example. Less than 10% of U.S. employees earn more than the current cap on income subject to the payroll tax. But a growing share of total income is being concentrated in that narrow group’s hands. If the the Social Security tax cap were lifted, according to calculations by Rep. John Larson (D-Conn.), it would raise close to $500 billion a year and extend the system’s ability to pay 100% of benefits for decades.

To pay for some of the $2 trillion in tax cuts for the well-to-do and corporations in the One Big Ugly Bill, the Republican Congress cut $1 trillion over the next decade from Medicaid. Privatized Medicare Advantage plans just received a 2.5% bump from the Centers for Medicare and Medicaid Services, which is run by Dr. Mehmet Oz, who frequently touted MA plans on his television show before joining the Trump administration. Insurer-run MA plans already receive $80 billion more per year than if their beneficiaries had remained in traditional Medicare.

“It’s not possible for us to take care of day care, Medicaid, Medicare, all these individual things,” Trump told a private lunch at the White House a month after launching his undeclared war against Iran. “They can do it on a state basis. You can’t do it on a federal. We have to take care of one thing: military protection.” Trump’s 2027 budget asked for $1.5 trillion for the military, a more than 40% increase.

Food assistance, subsidies for Obamacare plans, and funding for every non-military function of government are being cut by Trump. Yet the taxes that pay for them are being cut by a far greater amount, thus exacerbating the already sky-high deficit as well as the already outrageously high level of income inequality.

The second gilded age

To be fair, the trend toward greater income inequality began long before Trump took office. The charts below document just the past quarter century’s shift of national income toward corporations and the well-to-do, and how lower tax rates and lower tax collections have fostered that shift.

If we’re going to begin reversing the trend toward greater inequality, we need to put progressive tax reform on the agenda. As President Teddy Roosevelt put it in 1910, a few years before the 16th amendment ushered in the federal income tax and inheritance tax:

“The really big fortune, the swollen fortune, by the mere fact of its size, acquires qualities which differentiate it in kind as well as in degree from what is possessed by men of relatively small means. Therefore, I believe in a graduated income tax on big fortunes, and in another tax which is far more easily collected and far more effective—a graduated inheritance tax on big fortunes, properly safeguarded against evasion, and increasing rapidly in amount with the size of the estate.”

Wage earners make less …

While corporations make more …

… and corporate taxes stagnate

But CAP, like the rest of the Democratic Party establishment, proved incapable of blocking the malevolent second Trump administration from imposing its destructive will on the nation’s health insurance safety net. Rather than seeking outright repeal, which could be blocked in the Senate, the ACA’s Congressional enemies in the GOP followed the playbook drawn up by the Heritage Foundation’s Project 2025. They undermined the legislation with a few well-targeted hatchet blows.

The result now playing out across the land is the biggest rollback in publicly-subsidized health insurance coverage in U.S. history. This year millions of families dropped ACA plans made unaffordable by elimination of the expanded subsidies passed by the Biden administration. Millions more face elimination from the Medicaid rolls over the next few years as the $1 trillion in cuts contained in last year’s tax cut legislation roll out.

Employer-based private health insurance, which covers more than half the population, faces its own crisis under Trump. The premiums that companies and their workers pay to cover the cost of care plus insurance industry profits and overhead are rising as fast or faster than inflation and wage increases combined.

To reduce the upfront drain on their paychecks, more and more workers are opting into plans with high deductibles and co-pays, only to find they can’t afford the extra bills they receive when they get sick. The Bureau of Labor Statistics reports 42% of adults under 65 are now in high-deductible plans with a mean upfront deductible of $2,750, which means 50% pay at least that much or more before their insurance coverage kicks in. In a nation where 43% of the public says it doesn’t have enough money saved to cover a $1,000 expense, that’s not affordable.

Voters’ biggest worry

The January KFF tracking poll found two-thirds of the public now considers health care affordability their number one financial worry. It ranks ahead of rising costs for food and groceries, utilities, housing and fuel (although that ranking may shift somewhat in the months ahead thanks to Trump dragging the nation into the Iranian quagmire). The silver lining for Democrats is they still out-poll Republicans by 13 percentage points when it come to whom voters trust to manage the issue. Moreover, 4 in 10 independents say health care costs will play a major role in determining their vote this fall.

Those poll numbers suggest voters will be open this fall to big, bold solutions that address their number one economic concern. Democrats need to run on reversing the cuts to Medicaid and ACA plans, of course. But those programs affect less than a third of the population. They need a plan that helps everyone; and that is easily understood, implementable within a relatively short period of time, and directly addresses the biggest problem that is faced by almost everyone: unaffordable out-of-pocket expenses that come in the form of co-premiums, deductibles and co-pays.

Alas, that’s not what CAP offered in its initial election year foray into the health care policy debate, which it released last week. Dubbed “A Patients’ Bill of Rights To Lower Health Care Costs,” the plan promised “immediate relief on premiums, deductibles, and insurance denials.”

While it would achieve some of that for some people, their plan falls far short of a comprehensive approach to reining in the provider prices that drive insurance premiums. It fails to set strict limits based on income on what people must pay when they get sick.

Most of its proposals, while sound, fall safely within the incrementalist tradition that has long dominated mainstream liberals’ approach to health care reform. Unfortunately, that doesn’t offer “immediate relief.” Most of CAP’s reforms will take years to show up in peoples’ paychecks.

A new incrementalist agenda

The plan touches on all the major issues. It starts by offering a prescription for reining in drug prices by expanding the number of drugs subject to government negotiation, which began during the Biden administration. It would incorporate international pricing into those negotiations, which has been proposed by the Trump administration; and bans most mark-ups by pharmacy benefit managers, which is under consideration by the current Congress. It also applies the Medicare caps on some drug prices (like insulin) to the commercial insurance market.

To address soaring commercial insurance rates, CAP calls for creation of the public option on the exchanges for both individuals and employers, which has been a long-standing goal of many Democrats in Congress. They would set provider payment rates for the public option at 200% of Medicare rates for hospitals and 130% for physicians. Currently, commercial rates average about 250% of Medicare rates, which would make the public option highly competitive in many markets and lower premiums for employers and individuals with ACA plans who make the switch.

The plan would impose both insurer and provider price regulations to further reduce rates. It would set an “affordability standard” for future insurance premium increases by having the government measure the average increase nationwide in spending per private plan enrollee, and require state regulators or the federal government (in states without rate regulation) to roll back premium increases that rose above the benchmark.

According to the report’s own estimate, this would only affect 14 states’ ACA plans and 11 states’ employer-based plans. The reported pointed to Rhode Island, where a model affordability standard reduced overall premiums by 9% or $1,000 a year. But they set their annual increase at 1% above inflation, which in our current environment would allow a 3.5% increase. Even if opposition from hospitals in those states could be overcome, it would have no impact on the majority of states, where increases for private plans have averaged 6-7% in recent years.

The CAP proposal would also set a maximum provider price for any service at 300% of Medicare rates. This would rein in prices, but only for extreme outliers among hospitals and physician practices since the average price compared to Medicare is 50 percentage points below that target. They also call for returning those savings to workers in the form of lower deductibles, which, the reported estimated, would cut the average deductible by $933 or nearly in half. But, again, this would only be for plans paying extremely high prices and not affect anyone near or below the average.

The plan seeks to address the broader market by placing additional price caps on insurers and providers. For insurers, it would limit overhead to the level used by the Federal Employees Health Benefits program, which is about 40% of usual commercial rates for profits and administrative costs.

It would also disallow mark-ups for internal transfer pricing, where insurer-owned physician groups and other closely-held providers charge exorbitant prices to their insurance arm in order to drive up premiums and thus profits an employers’ and employees’ expense. As a final gesture, the plan also called for banning insurance company ownership of providers, a move that the plan recognized “would take years to wind through the courts.”

Hospital price controls would be placed in the hands of the states, and only imposed when hospital prices exceed the statewide median. The cap for those hospitals would be set at inflation plus 1%. Given that nearly every hospital service region is considered highly concentrated with either one or two hospitals controlling the entire market in half the regions, the rule would probably affect a solid majority of U.S. hospitals. The CAP report authors estimated this would save premium payers over $1,300 a year, the most significant cost control measure in the report

Finally, the CAP plan would ban prior authorization. Instead, it would substitute “independent clinical review … grounded in evidence-based clinical guidelines and ‘appropriate use criteria.’” Taking those decisions out of the hands of insurers makes a lot of sense.

It calls on physician groups to develop clinical decision support tools that “physicians could voluntarily query at the point of care to check whether a planned test, procedure, or treatment aligns with evidence-based criteria.” Such tools already exist (Up to Date, for instance). Why they aren’t used is a separate question. For a separate list of “costly and widely overused services,” insurers could submit claims to an independent review board for adjudication within 48 hours.

Projected savings from the CAP plan:

Help everyone instead

The CAP approach to the current affordability crisis violates what I’ve come to think of as the Robert Reich rule. In a post last fall on his substack, the former Labor Secretary cautioned would-be reformers not to push 10-point plans that few will read and fewer will understand. If people have a problem, he said, address it directly with something that is easily understood. That is what succeeds politically. Complexity doesn’t.

Almost all the proposals in the CAP plan are complex and not easily understood by average voters. They will be hard to explain when they are attacked by providers and insurers with their expensive advertising campaigns about how it will destroy what people have, which is inevitable for any reform that asks the medical industrial complex to give up something without getting anything in return.

The CAP authors also failed to offer direct relief to householders in the working age population. The benefits are indirect. Moreover, they do not deal at all with the affordability issues facing low- and moderate-income seniors who live on Social Security alone — about 40% of the elderly.

Focusing only on the prices paid by employers creates another problem. There’s no guarantee any subsequent premium declines will be shared with employees. Except for small number of workplaces with unions, it is employers who determine how those savings will be shared.

Employers have historically required employees pick up 25% of family plans and 20% of individual plans. In recent years, employees have been asked to pick up a growing share of the total premium, which has driven more people to choose their employers’ high deductible plans to save money.

I did not find in the CAP plan any proposal that guarantees premium savings will be shared fairly between employers and their employees. There is an insurance regulation that could assure that: Setting a cap on what any household pays for health care out of pocket for all co-premiums, deductibles and co-pays.

Some advocacy groups have proposed setting a fixed cap on out-of-pocket expenses of $5,000 a year. That is still far too high for anyone in the bottom half of the income distribution. The better way to go, which I included in my plan released last December, is to set the cap at a percentage of household income that any household has to pay for health care in any given year.

That, too, would require legislation to regulate how employer-based insurance plans (and government plans like Medicare) are structured. But, unlike a $5,000 cap, it solves the problem for everyone. It would not depend on price controls or premium savings that will only impact 11 or 14 states; or be limited to plans paying for outlier prices at individual hospitals; or only affect some drug prices; or several of the other half-measures in the CAP plan that inevitably would be applied unevenly across the country, and, as a result, not solve everyone’s out-of-pocket cost problem.

The CAP plan also does little to bring hospitals, insurers and physicians to the table, which if I read Jonathan Cohn’s book The Ten Year War correctly, was crucial to getting the Affordable Care Act passed. Everyone had to give up something to get something, which in the ACA’s case, was turning no-pay patients, a major contributor to uncompensated care and rising insurance premiums, into paying customers.

The CAP plan is all pain, no gain for the entrenched special interests that make up the medical industrial complex. In one sense, that fits our populist times. But as a practical matter, it isn’t a winning strategy.

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I’ve proposed something that is more radical yet holds out the possibility of building a new, broad-based coalition for major reform. The permanent, income-based cap on out-of-pocket expenses benefits everyone, making it — like Social Security and Medicare — easily saleable and politically unassailable once enacted.

Equalizing prices that providers can charge any payer dramatically lower premiums for employers and employees alike, which has the potential to win support from business groups, especially those with an older, sicker workforce. This requires government to pay more so that the privately-insured can pay less. But this could be achieved through either progressive taxation (like reversing many of the Trump era tax cuts) or by capturing some of the savings through the Medicare payroll tax levied only on the employer side, not on workers.

At the same time, the government, operating either through state regulators or at the national level, should put providers on a budget that grows more slowly than in the past. CAP would impose a dramatic cut, but only on outliers, by limiting price increases to inflation plus 1%. I would peg the growth in budgets to something less than economic growth, which would allow providers to adjust over time to slower spending growth and provide them with the freedom to deploy their financial resources in ways that promote better health and better outcomes so that the slower growth doesn’t result in a stinting on care or rationing.

Providers can be brought to the negotiating table if reformers give them and their organizations an off-ramp of a budget that is slower growing but guaranteed. They will no longer be incentivized to to deliver unnecessary care, or depend on the quantity of services delivered to achieve their annual budgets.

Politicians needn’t worry about how to sell provider payment reform to their constituents. That is something they will need to work out with medical industrial complex behind closed doors once the political will to make changes exists. The CAP plan is no different in that regard.

But what an out-of-pocket cap based on income enables them to say is something that can’t be said about the CAP plan: No family will ever again pay more than a low percentage of their income for health care. That to me sounds like a winning slogan.

Maryland’s decade-old experiment with statewide hospital budgeting has dramatically reduced hospital admissions and expensive operations compared to other states.

A new study published in Health Affairs this week found Maryland hospitals reduced utilization by shifting care from out-patient facilities to ambulatory surgical centers and physician practices, where care is less costly and can be delivered just as safely as in a hospital or at hospital-owned clinics and physician practices.

The study relied on medical claims data collected by public and private payers from across the country between 2013 and 2023. It found greater reductions in hospital use in Maryland compared to other states in every age group, not just seniors. That translated into lower increases in insurance premiums for the state’s working-age population and their employers compared to the rest of the country.

The Center for Medicare and Medicaid Services had previously reported the state’s unique all-payer pricing system, where public and private payers are charged similar amounts for the same service, and its post-2014 “total cost of care” budgeting model saved Medicare more money for than any other experimental cost control program — more than $1.6 billion over a decade’s time. This is the first study that evaluated whether putting hospitals on budgets helped private payers as well as the government.

The study found hospital use (measured by admissions and patient-days on a per person basis) declined 11 percentage points more in Maryland compared to other states (down 17% in Maryland compared to 6% elsewhere). Much of the decline came in a shift in care delivery sites.

The decline in hospitalizations (in-patient care) was roughly equivalent (down 19% in Maryland compared to down 16% elsewhere). But services delivered in Maryland hospitals’ out-patient settings saw a decline of 15% compared to a 4% increase elsewhere.

“Utilization shifted from budget settings to non-budget settings,” said Timothy Bulat, a senior consultant at Actuary Research Corporation, which conducted the study for the Maryland Health Services Cost Review Commission. “That’s not necessarily a bad thing. Ambulatory centers are a more efficient place to do services because it’s lower cost.”

In-patient hospital use has been on the decline for years as many tests, procedures and operations became less invasive and capable of being performed in out-patient settings. Many hospitals held onto that business by building or buying clinics and ambulatory surgical centers on or near their campuses. Government policy enabled the move by paying hospitals in-patient rates at their out-patient facilities. Ambulatory surgical centers (ASCs) are paid at a significantly lower out-patient rate.

The mainstream of the health care policy world has focused on two possible solutions to this discrepancy. The Medicare Payment Advisory Commission has repeatedly recommended that Medicare pay hospitals the same out-patient rate as ASCs — so-called site-neutral payments. The Congressional Budget Office estimated in December 2024 that site-neutral payment for all out-patient services would save Medicare $160 billion over the next decade.

The other approach comes from the antitrust advocacy world. Their solution would bust up hospitals’ vertical monopolies by making them divest their ASCs and physician practices. Such break-ups would take years, while implementing site-neutral payments would be an immediate fix.

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But encouraging greater use of ASCs or physician-run clinics for less invasive procedures isn’t a perfect solution. As a companion commentary in Health Affairs argued, spending outside the budgets set for hospitals grew by 3.1% in Maryland under its total-cost-of-care model, even as spending at hospital declined by 6.1%. “It highlights the model’s inability to control the total cost of care outside a regulated hospital environment,” wrote lead author Amit Jain, medical director of value-based care and an associate professor of surgery at Johns Hopkins Medicine in Baltimore.

While he backs repeal of certificate-of-need laws that prevent physicians from opening more ASCs, he argued it should be accompanied by monthly payments to primary care and specialty physicians, who should be held directly responsible for health outcomes. “The model struggled to incentivize independent clinicians—whose pay in Maryland remains among the lowest in the nation—to focus on the chronic disease management needed to truly lower the total cost of care,” he wrote me in an email. “The current architecture (limiting budgets to hospitals alone) risks incentivizing volume reduction over patient access and clinical engagement.”

There was concern raised in both the study and Jain’s critique that wait times in Maryland hospital emergency rooms went up after the onset of budgeting. “Global budget models should be paired with incentives and comprehensive monitoring mechanisms to protect quality and access,” Bulat wrote.

The CMS Innovation Center is encouraging other states to follow Maryland’s lead. Last fall, it announced its AHEAD model (Achieving Healthcare Efficiency through Accountable Design) will move forward over the next decade in six states (Maryland, Connecticut, Hawaii, Vermont, Rhode Island and New York). It expects to add two more states in July. Adoption of hospital budgeting is expected to be the centerpiece of the state programs. It will be interesting to see if any states try expanding budgeting to physician practices, ASCs and other outpatient settings, and post-acute care.

Legislators in some states are attempting to move forward on their own. Here in Illinois, where I live, progressive Democrats in the Senate are pushing legislation (S.B. 3900) that would put the state’s 200-plus hospitals on global budgets.

In the current environment, where there is little hope for help from the federal government, all states would do well to take a close look at Maryland’s most recent experiences. They should consider bringing payments to physician practices into the global budgeting framework. They need to give special payments for primary care and prevention.

People are crying out for a more affordable health care system. Legislator running for office this fall who want to address affordability should take a close look at how Maryland is handling the issue.

The Biden administration’s first pandemic relief bill had temporarily lifted the maximum credit to $3,600, which had the salutary effect of dramatically lowering the childhood poverty rate to 5%, the lowest ever recorded. But the expiration of the increase after 2022 caused the child poverty rate to surge back to previous levels – more than 12%. Unless the new GOP-run 119^th Congress acted, the credit would drop to $1,000 from $2,000 due to a sunset provision stuck in Trump’s first corporate tax giveaway, which passed in 2017.

“For every Republican who has hailed the new working-class majority that President Trump has delivered, now is the time to deliver,” Hawley proclaimed. “Delivering results in this body is the acid test.”

Last July, Hawley’s resolve disappeared faster than Washington’s cherry blossoms in spring. He voted, along with all but five members of the GOP, for the $2 trillion tax giveaway to corporations and the rich known as the One Big Beautiful Bill. It did not include his $5,000 child tax credit. Instead, Trump and the GOP, in their search for revenue to offset a tiny fraction of the tax cut, limited the increase in the child tax credit to $200, which didn’t even make up for the past four years’ inflation.

Support for child tax credit has long been a bipartisan affair. It has received renewed attention from the GOP in recent years with the political ascendancy of the Christian right. Groups like Susan B. Anthony Pro-Life America, Eagle Forum, and the National Association of Evangelicals see it as government support for natalism, a part of their anti-abortion and family values agenda. Some Christian Nationalists support it because it provides support for “biblical” families where men work and women focus on cooking, cleaning and raising children.

Of course, few families in today’s economy, especially those in the bottom half of the income distribution, can afford to raise children with a single wage earner. Both parents work in 66% of the 33 million two-adult households with children (this data comes from the Bureau of Labor Statistics for 2024). In the 10 million households with single parents (three-quarters headed by women), 76% hold down full- or part-time jobs. For single fathers with kids, it is 85%.

Clearly, most of the parents taking the child tax credit (CTC) at tax time are more likely to spend the extra cash on day care as support their desire to send a young mother back to the kitchen. But the fact that it is a cash grant allows each family to make that choice and gives politicians on both sides of the aisle arguments for supporting its expansion.

Recognition of the underlying economic realities led Hawley to call for a big increase in the CTC. He also wanted it extended to families expecting children, and included in every paycheck throughout the year, not given as a lump sum at tax time. People living paycheck to paycheck don’t need an enforced savings program, they need the cash now.

How would he accomplish that? By basing the credit not just on federal income taxes, which are low to non-existent for most low- and modest-income families, but also on Social Security and Medicare payroll taxes, which take 7.65% out of every dollar they earn.

Democrats have very different reasons for supporting a big expansion of the CTC. They see it as an essential part of the social safety net, and a component of a growing movement to create a guaranteed family income in the U.S., which has strong backing from urban mayors. It also could help offset a small part of the more than $1 trillion in cuts to food assistance and health care contained in the Trump administration’s One Big Ugly Bill.

The roots of income supplements

The Republican Party’s support for income supplementation traces its roots to the late 1960s when Daniel Patrick Moynihan, the centrist academic then serving as President Nixon’s chief domestic policy adviser, proposed a negative-income tax for low-income families with children. He argued that providing string-free cash to poor families was more empowering and administratively simpler than forcing them into the hands of separate government bureaucracies doling out housing, food or welfare subsidies.

Moynihan’s Family Assistance Plan also tied benefits to work – a forerunner of today’s GOP imposition of work requirements in Medicaid and the Supplemental Nutrition Assistance Program (colloquially known as food stamps, although today it comes in the form of a debit card). Such requirements never lead to alleged shirkers seeking work. Rather, they erect bureaucratic barriers that keep underpaid workers from receiving benefits that by law should be theirs.

The first cash subsidy tied to work became law in 1975 when Congress passed and President Ford signed the Earned Income Tax Credit (EITC), whose maximum benefit today is twice as large as the CTC. Later, after becoming the Democratic Senator from New York, Moynihan continued to push for a CTC to provide extra support for low-income families with kids. Though President Reagan endorsed the idea, nothing came of it during his or George H.W. Bush’s time in office.

House Speaker Newt Gingrich included the CTC in his mid-1990s Contract with America, which became law with President Clinton’s signature in 1997. The original $400 credit was gradually increased by succeeding Congresses (again with bipartisan support) to keep pace with inflation.

Things changed in the current MAGA-controlled Congress, however. In last year’s massive tax break bill, which passed six months after Hawley’s fiery speech, most of the tax breaks again went to the wealthy and corporate America. The GOP failed to include Hawley’s $5,000 credit. Instead, it increased the CTC to $2,200, which in inflation-adjusted dollars is less than where in stood when Trump left office in 2021. Hawley voted yes on the bill, flunking his own acid test.

The CTC’s flaws left unaddressed

The One Big Ugly Bill also left each of the CTC’s well-documented flaws intact. An estimated 21 million low-income households do not qualify for the maximum credit because they don’t earn enough money. An estimated 2 million children live in households that receive nothing at all because they make so little they have no taxes to offset.

The GOP also ignored Hawley’s plea to restructure how payments are made. The money is still doled out at tax time in a lump sum, not over the course of a year when it would be most helpful in paying monthly bills or buying school supplies and winter clothes for their kids.

“A check at tax time is a very paternalistic approach to policy,” said Jane Waldfogel, a professor of social work at Columbia University. “We’ll enforce savings, and then, once a year, we will give you a check you can use for something big like furniture for the kid’s bedroom or getting your car on the road.”

Her recent book, “Child Benefits,” analyzed child support programs in the 38 countries belonging to the Organization for Economic Cooperation and Development. “All the wealthy countries have them,” she said. “In some countries, they’re scaling them back for wealthy families. Perversely, in the U.S., we’re doing the opposite. We now include all the middle- and high-income families but exclude the lowest income families.”

Pilot projects proliferate

This disparity, and the lack of federal action amidst massive cutbacks in safety net programs like Medicaid and food assistance, has led many local governments and some states to experiment with their own cash assistance programs, many with help from charitable foundations. Over 150 local officials belonging to Mayors for a Guaranteed Basic Income report there are more than 200 pilot projects underway in the U.S. They offer low-income residents as much as $1,000 a month to supplement their meager incomes.

One in Chicago and Cook County where I live was launched in 2022. It used $42 million in Covid relief funds to provide $500 a month to 3,250 households for two years. A survey completed early last year found 75% of recipients reported feeling more financially secure; 94% said they used the program to deal with financial emergencies; and 70% said the program improved their mental health. Based on those findings, Cook County government last November appropriated $7.5 million to continue the program for another year on a more limited basis.

The Family Health Project in the Boston area focuses on low-income, single, expectant mothers with children or about to have their first child. Since 2022, it has provided $400 a month for three years to two cohorts of 15 mothers. The cash arrives on a debit card each month on the same day as their baby’s birth. “It underscores that this is about the baby, not about the mom,” said Joe Knowles, the CEO of the non-profit Institute for Health Metrics, which helps hospitals develop the community needs assessments required by the IRS to maintain their non-profit status.

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He began the Family Health Project after speaking with Jeffrey Madrick, the author of The Invisible Americans: The Tragic Cost of Child Poverty. Said Knowles: “In it, he posits a direct cash benefit program is a way to begin to control poverty and help make it go away. It turns out that poor people aren’t lacking motivation, intelligence, or integrity or know-how. Poor people lack money,” he said. “A big piece of this is trust philanthropy. Don’t give mom services. Give her the money and she’ll know what to do in almost all cases.”

His small organization tracks the results through in-depth interviews with the mothers. When asked how they spent the money by relationship manager Kelly Journey, the mothers invariably say it is on things like diapers, toys, and clothes. “The biggest thing I see is that these moms get the assurance that somewhere someone believes they’re going to be a good mother. It’s powerful,” she said.

There is little question that extra cash helps the financial, physical and mental well-being of adults caring for small children. A research review conducted by Megan Curran of Columbia University in late 2022 found the expanded CTC, which had just expired, was mostly spent on basic needs. It reduced food insecurity and did not lead to less employment – a frequent charge by right wing think tanks opposed to the program.

But whether the CTC makes a difference in the life of the baby remains an open question. In recent years, researchers like Jack Shonkoff, who runs the Center on the Developing Child at Harvard School of Education, and advocates like former Kaiser Permanente CEO George Halvorson, whose book, Three Key Years, was published by the Institute for InterGroup Understanding, have focused on the importance of the first three years of a child’s life in determining their long term prospects. Income support in the form of direct cash transfers, according to Shonkoff’s Pre-natal-to-3 Policy Impact Center’s literature review, “improve household resources, child health and development, and parent health.”

A flawed study

But in the largest randomized controlled trial testing that claim, researchers found few positive impacts after four years of monthly payments to mothers of small children. The study, called Baby’s First Years and partially funded by the National Institutes of Health, recruited 1,000 mothers and their newborns from hospitals in Minneapolis/St. Paul, New Orleans, New York and Omaha. The researchers provided 400 moms with a monthly debit card worth $333 and 600 moms with a card worth $20.

The trial lasted four years, with recruiting beginning in 2018 and ending in 2023. The follow-up measured maternal depression, anxiety and body mass index, and whether the babies in families with larger cash infusions were more likely to develop language skills or avoid developmental delays. The researchers even used EEGs to measure brain activity, which can signal greater cognitive development.

In each case, there was little difference between the two groups. “The families with higher cash subsidies spend more on their children, on books, toys, and things like that,” said Lisa Gennetian, a professor of public policy at Duke University. “They’re reporting they spend more time with their children, reading, playing, activities.”

But, she said, “the cash otherwise is not having a lot of impact on family life. No impacts on mom’s subjective well-being, their happiness, their lifestyle satisfaction, their emotional well-being. We’re not finding impacts on measures of material hardship like food or housing security. We’re not finding this modest amount is changing things for family,” she told me in a telephone interview.

The researchers admit several issues may have confounded the study. First and foremost, the Covid pandemic struck in the middle of the study period, which disrupted everyone’s life and low-income people most of all. In addition, the amount offered the new moms was small – about equal to the expanded CTC – which mothers in both arms of the trial received. The fact that everyone received some money – there was no null set – may have biased the control arm participants toward being grateful for what they’d been given, no matter how small, and that may have affected their self-reported results.

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“Everyone in all the studies tells you how helpful the money has been,” said Gennetian. “It increases autonomy and agency. That’s what we’re hearing from our families.”

One of the lead authors in the study, Greg J. Duncan, a distinguished professor in the Education Department at the University of California, Irvine, says the next follow-up with the children and their moms will begin in July with results expected in 2029. He also co-authored a National Academies study released two years ago that reviewed all policies aimed at reducing intergenerational poverty.

That report concluded that other forms of income support had a far greater effect on improving the life prospects of children raised in poverty than the limited CTC. “We had studies backed by strong evidence that showed when kids and their families received support from the earned income tax credit, Medicaid and SNAP, the kids benefited in the long run. The CTC has not yet shown long-run improvements.”

He hopes the next follow-up on Baby’s First Years will. He recalled how one Minnesota mom took pictures of a winter coat she purchased with the money. Before that, her child had piled on sweaters and was socially castigated for not having money in her family.

Getting a coat “won’t improve her vocabulary scores,” Duncan said. “Providing a normative childhood for their kids isn’t the kind of thing that changes electrical activity in the brain.” But it might improve relations between the child and the mother and lead to better relations with their peers. “That might support differences at age 8 and 10,” he said.

He has postponed appointing someone to run the flailing Centers for Disease Control and Prevention, where the sands seem to be shifting. Its interim director Jay Bhattacharya, who also oversees the shrinking National Institutes of Health, on Wednesday morning told what’s left of the CDC staff, “I think it is vital that every kid in this country get the measles vaccine. Absolutely vital.”

In the wake of her confirmation hearing last month, various media reports claimed Casey Means’ nomination to become the nation’s next Surgeon General is in trouble. Sen. Bill Cassidy (R-Louisiana), a pediatrician, backs vaccines and she didn’t. Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), the GOP’s designated fence sitters, said they still have questions. Sen. Thom Tillis (R-North Carolina), who is retiring, told the Associated Press he’s leaning against voting for Means should her nomination reach the full Senate.

Yet, given anti-vax sentiment within MAHA and the group’s role in grass roots GOP politics, it’s way too soon to count Means out.

Who is Casey Means? She made her fortune as co-owner of Levels, which sells an app for continuous glucose and blood monitoring. The firm’s subscription plans (costs range from $288 to $1,999 annually) are marketed primarily to the worried well to “help you fuel better and feel more balanced.” (That cheeky description comes directly from the company website.)

Two years ago, the FDA approved the over-the-counter sale of a glucose monitor that Levels promotes for its corporate partner, Dexcom. That company used a regulatory process for approving medical devices that doesn’t require submission of clinical trial data proving that it leads to better outcomes.

Dexcom also does business with Means’ brother Calley, a top health care adviser to the Trump administration. He is co-owner of Truemed, which encourages consumers to use health savings accounts to buy supplements, fitness equipment, red light therapy and saunas from its manufacturing partners.

A year ago, just two months before Casey Means was nominated for surgeon general, the Means siblings appeared at a supplements industry trade show. Their message, according to an Associated Press account of the Natural Products Expo: The goals of the Make America Healthy Again movement will help your bottom lines.

The head of MAHA’s political action committee, which pushes for anti-science policies in state legislatures and nationally, told the same conference: “It blows my mind that I'm going to watch the Republicans carry the supplement industry and the holistic health industry and chiropractors and the acupuncturists into the promised land.”

The supplements and wellness industries do not need another Moses, although they could get one in Means. Those fast-growing, largely unregulated businesses took up residence in the land of milk and honey when the late Sen. Orrin Hatch, a Republican from Utah, shepherded the 1994 Dietary Supplement and Health Education Act through Congress. That law officially exempted supplements from meeting FDA efficacy requirements, and limited safety oversight to manufacturing purity, not prevention of physical harm. Even the good manufacturing practices guidelines allowed under the bill are non-binding.

No wonder the supplements industry grew from 4,000 products when the DSHEA passed to about 90,000 today. It has become a $70 billion-a-year industry in the U.S. — twice the size of the European Union, which has about the same number of people.

Today, grocery stores dedicate entire aisles to supplement sales, as do a few large retail chains like GNC (General Nutrition Corp., now owned by the Harbin Pharmaceutical Group of China). Analysts estimate the industry will grow by 50% over the next five years.

Conflicts-of-interest disqualify thee, but not me

In most accounts of her career, Means lambasts the medical profession for being in bed with the pharmaceutical industry. She dropped out of her medical residency in otolaryngology (ear, nose and throat doctors), claiming the field was rife with conflicts of interest.

She says (with some justification) that many of its practitioners prefer seeing more patients needing their skills than focusing on prevention. Like Kennedy, her champion, she repeatedly attacks the drug industry, vaccine makers and mainstream medicine for their conflicts of interest.

Yet the MAHA movement and the Trump regime ignored her conflicts of interest (and her brother’s) before appointing them to high government positions. Casey Means’ financial disclosure, released last September, showed that over the past five years she received “newsletter sponsorship and partnership fees (of) $12,000 from herbal remedies firm Apothekary; $27,431 from algae supplements company ENERGYbits; $16,461 from fiber supplements company Florasophy; $27,000 from probiotics company Pendulum Therapeutics; $46,000 from supplements company Pique; $536 from prenatal vitamin company WeNatal; and $16,104 from basil seed supplements company Basil Seed Works. Means received a total of more than $130,000 in sponsorship fees from supplement company Amazentis, including a $55,000 book tour sponsorship.”

Mehmet Oz, who runs CMS for the Trump regime, and top adviser Calley Means have also profited from their ties to the supplements industry.

The false promises of most supplements

The supplements industry is a case study in how to use marginal, company-sponsored science, heavy advertising and political muscle to peddle useless products to the American people. As more than one industry critic has pointed out, the industry is responsible for Americans having the most expensive urine in the world.

Their lobbyists have successfully fought every legislative attempt to impose either efficacy or safety requirements on supplements — the standard applied to drugs. Supplement makers are not required to submit placebo-controlled clinical trials to the government. Yet many in their advertising make carefully worded statements about health benefits that to the average consumer sound like it has been scientifically proven, something that the FDA is supposed to prevent.

Prevagen — widely advertised as improving “brain health” — is the poster child for this improper marketing and failed regulatory oversight. The FDA began raising safety concerns as early as 2007 and sent its first warning letters to Quincy Bioscience, its maker, in 2012. The Federal Trade Commission and New York State filed suit in 2017 to stop Prevagen’s alleged illegal marketing. It took seven years of litigation before a federal court finally issued an injunction against the company to stop making the claim that Prevagen improved brain function.

Despite that 2024 ruling, late night television is still filled with Prevagen ads aimed at seniors and the worried well wanting to stave off dementia. Today, instead of the company making the claim, they use older adults testifying that the product helped them.

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In defending her nomination, administration spokespersons have touted Means’ stellar academic credentials. Means is a 2014 graduate of Stanford Medical School. She received advanced training in otolaryngology, her specialty, at Oregon Health & Science University.

But she dropped out in 2018 to launch her wellness career after seeing how little organized medicine did to prevent the need for surgery. She launched Levels a year later with $12 million in venture capital funding. By 2024, she was deeply involved with Kennedy’s presidential campaign and co-wrote with her brother a New York Times 2024 best-selling book called “Good Energy: The Surprising Connection Between Metabolism and Limitless Health.”

Jumping in front of the MAHA parade

As the New Yorker reported in its book review, the publicity blitz for the book included appearances on the Joe Rogan podcast and Tucker Carlson show on Fox. She told Carlson her sacred texts included the Bible and Ayn Rand, clearly an attempt to endear herself to the Christian Nationalist and Libertarian wings of the 2024 Trump coalition.

She allied herself with Kennedy, too, although many in the MAHA movement remained skeptical of her blind ambition. “Nicole Shanahan, who was Kennedy’s running mate during his 2024 Presidential bid, posted on X that ‘there is something very artificial and aggressive about them (referring to both Casey and Calley Means), almost like they were bred and raised Manchurian assets’,” the review noted.

Her ties to Kennedy, himself a late convert to Trumpism, led to her nomination to become the nation’s 22nd Surgeon General. At 38, she would be the second youngest person to hold that post after Dr. Vivek Murthy during President Obama’s first term.

Like some previous Surgeons General, she would come to the office without the government or professional experience that would qualify her to supervise the 6,000-plus uniformed physicians and other public health professionals who serve in government agencies. But unlike most previous Surgeons General, she has eschewed becoming a practicing physician, choosing instead to engage in entrepreneurship, part-time teaching, political advocacy and politics.

Often called the nation’s doctor, Surgeons General usually make their mark by focusing on a single public health problem. Many have been steeped in controversy.

In 1964, Luther Terry ignored tobacco industry opposition to issue the first official warning that cigarette smoking causes cancer. During the Reagan presidency’s AIDS crisis, which the White House ignored for nearly his entire two terms in office, C. Everett Koop mailed a brochure to every American household explaining the viral (not moral) causes of the disease and how to prevent it. In the 1990s, Joycelyn Elders focused on sex education and adolescent sexual health, making her a target for conservative culture warriors.

Means, during her prolonged nomination process (it was put on hiatus last year during her pregnancy), has sought to make the fight against chronic illness the centerpiece of her tenure — a worthy endeavor that would require taking on (at the least) the processed food, chemical and agriculture industries. During her opening testimony at her confirmation hearing last month, she blamed Americans’ “ultra-processed diet, industrial chemical exposure, lack of physical activity, chronic stress and loneliness, and overmedicalization” for making the U.S. “the most chronically ill high-income nation in the world.”

She wouldn’t be the first to express those concerns. Richard Carmona under George W. Bush and Regina Benjamin under Barack Obama also targeted chronic disease, which they blamed on rising obesity, unhealthy diets and a lack of exercise. Nor is there much controversy in that stance. Sen. Bernie Sanders, the Vermont independent socialist who caucuses with Democrats, praised that aspect of her presentation during the hearing.

A vaccine two-step in the offing?

But her nomination is in trouble for one reason and one reason only: Casey Means refuses to separate herself from the Robert F. Kennedy Jr.-led war on vaccines.

At last month’s hearing, she refused to directly endorse the childhood MMR vaccine (measles, mumps, rubella) despite a multi-state measles outbreak, triggered by the declining vaccination rate, that has sickened thousands and taken at least two children’s lives. Instead, she called for parents to discuss the issue with their doctors.

“You’re the nation’s doctor,” Sen. Cassidy, chairman of the Senate committee, said. “Would you encourage her to have her child vaccinated?”

“I’m not an individual’s doctor,” she replied. “Every individual needs to talk to their doctor before putting a medication in their body.”

When Sen. Tim Kaine (D-Va.) pressed her to confirm that the flu vaccine saved lives, she demurred.

“This is an easy one, doctor, this is an easy one,” Kaine said.

“I support the CDC guidance on the flu vaccine, and I will always be working with the CDC and ACIP,” she replied.

That would be the same ACIP that was hand-picked by Kennedy; that has scaled back its childhood vaccination recommendations without offering scientific justification; and which a New York federal court last week ruled was illegally appointed.

Means also refused to rule out vaccines as a cause of autism, instead calling for more research because science is never settled. But at the present moment, the scientific literature not only overwhelmingly rejects that thesis, but the first major study suggesting there was such a link, which was published in the prestigious Lancet, has been retracted for data fraud with its primary author banished from the practice of medicine in Great Britain, his home country.

Is Dr. Means unqualified to become the next Surgeon General? You betcha. Will she? Betting markets reportedly put her chances at less than 50% with a sharp drop after last month’s hearing. Given the GOP’s latest election losses, including in Trump’s hometown of Palm Beach, they’re probably even lower today.

I’m usually in the Yogi Berra camp when it comes to predictions, but I’ll go out on a limb here. I predict Means will make private assurances to the reluctant four-some in the GOP-controlled Senate and win confirmation to become the least qualified Surgeon General since the post was established in 1871.

The 38-year-old wellness influencer and entrepreneur, who doesn’t practice medicine, even in her spare time, is nothing if not ambitious. All she has to do is follow Bhattacharya’s lead and do an about face on some aspect of vaccine policy. The big guy and the GOP-controlled Senate — desperate for some good news on the electoral front — will notice.

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While it’s unclear from the initial news reports whether this is a one-year or multi-year appropriation, the size of the request suggests this war is going to drag on a lot longer and involve far more manpower and firepower than President Trump and Secretary of Defense Pete Hegseth have let on. The now 2 1/2-week-old war of choice has already left 13 soldiers dead and more than 140 wounded. It has already cost over $12 billion, according to reported estimates.

Let’s put that cost and this latest request in perspective. The $12 billion already spent is enough to have extended the Affordable Care Act subsidies for close to six months.

Instead, over two million or 9% of people in ACA health insurance plans last year dropped them for this year (the first without the expanded subsidies) because they couldn’t afford the huge increase in their premiums, according to a new survey released today by KFF, a health care think tank. That’s nearly a 10% increase in the ranks of the uninsured, which alone will bring the uninsured rate close to 10%.

And many more will drop coverage in the years ahead, given ACA marketplace purchasers’ concerns about their ability to pay the new, higher rates without subsidies.

The $200 billion the Pentagon is requesting is sufficient to extend the ACA subsidies for over five years. Where did I get that estimate? The failure to extend the subsidies helped pay for the $7.7 trillion in tax cuts for the wealthy and large corporations in last year’s One Big Ugly Bill (OBUB). It reduced health care spending by about $350 billion over ten years, an average of $35 billion a year. $200 billion ÷ $35 billion = 5.7 years.

The same math applies to the alleged Medicaid “savings” in the OBUB. Imposing work requirements (a lexicographic subterfuge for erecting bureaucratic barriers that will make it difficult for qualified Medicaid beneficiaries to re-certify their eligibility) will cut an estimated $326 billion from the program over the next decade, according to the Congressional Budget Office. Cuts to the federal share of aid to state Medicaid programs will “save” the federal government another $300 to $400 billion. The two together add up to at least $65 billion a year ripped from Medicaid.

To sum up: Cuts in ACA subsidies and Medicaid in the OBUB will average over $100 billion a year over the next decade. At the rate the Trump regime is spending on the war against Iran, the Pentagon will eat that up in two years.

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This accounting doesn’t take into consideration the long-term costs of U.S. involvement in overseas quagmires of its own making. The Iraq War, which began in 2002, cost close to $1 trillion in direct military spending. The long-term cost of caring for the wounded, veterans’ special health care needs, and related spending has been estimated to cost an additional $2 to $3 trillion.

Those of us old enough to remember the Vietnam War will recall the “guns and butter” debate that accompanied President Lyndon B. Johnson’s slow descent into that quagmire. LBJ’s advisers assured him the U.S. could do both.

Wrong. Inflation began escalating by the late 1960s, throwing the country into a recession by December 1969. During the decade after regular combat began in 1965, prices rose by a total of 176%, twice the rate of inflation during the previous decade. The biggest increases were triggered by soaring oil prices due to an Arab oil embargo after the 1973 Middle East war.

President George W. Bush tried his hand at guns and butter in 2003 when, to bolster his reelection chances amid widening opposition to the Iraq War, he pushed through an unfunded Medicare drug benefit and pushed further deregulation of the financial sector. By the end of his term in office, the resulting housing bubble and sub-prime lending crisis led to the worst economic downturn since the Great Depression.

While looking up some of the specifics of that history, I stumbled across the origination of the phrase “guns and butter.” It wasn’t a 1960s coinage. It was popularized during the 1930s by German Reich Marshall Hermann Goering, who defended Germany’s huge military build-up by saying, "Guns will make us powerful. Butter will only make us fat."

It was Theodor Reik, a Jewish intellectual who fled Nazi Germany, who in 1965 took issue with the idea that history repeats itself. “This is perhaps not quite correct,” he said. “It merely rhymes.”

What does the Trump regime’s escalating military spending amid evisceration of social spending rhyme with? (I invite readers to comment below.)

Now in other news …

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Dem Senators working on health plan sans Sanders

A dozens Democratic Senators led by Ron Wyden of Oregon are laying down principles for a massive health care reform bill they hope to introduce next year, Stat reported this morning. Though the group includes several Medicare for All advocates, the initial iteration sounds more like incrementalism on steroids than a bold effort at comprehensive reform.

The focus will be on reining in the insurance industry by standardizing the offerings in private-sector plans (“make it simple”); increasing the amount that has to be spent on health care, not on profits, marketing and administration (raising the medical loss ratio for the wonks in my audience); and “giving all Americans access to Medicare-type choices for health,” which sounds like they want to create a public option at the federal or state level to compete with private insurers in the employer-provided and individual markets.

The other senators in the group include Mark Warner (Va.), Jon Ossoff and Raphael Warnock (Ga.), Lisa Blunt Rochester (Del.), Tammy Baldwin (Wis.), Sheldon Whitehouse (R.I.), Jeffrey Merkley (Ore.), Elissa Slotkin (Mich.), Elizabeth Warren (Mass.), Tina Smith (Minn.), and Peter Welch (Vt.).

Notably missing from the group: Sen. Bernie Sanders of Vermont, whose advocacy for a single-payer, Medicare for all will have at least one more adherent in the Senate next year. Illinois Lt. Gov. Juliana Stratton, who on Tuesday won the Democratic primary to replace retiring Sen. Richard Durbin, made strong support for M4A a centerpiece in her campaign. Her election in November election is not in doubt in deep blue Illinois.

From the “Can You Ever Trust a Billionaire?” Dept.

Shark Tank personality and serial entrepreneur Mark Cuban, who launched his Cost Plus Drugs platform in 2022, is now praising his competitor, TrumpRx, which has been roundly criticized in the health care press for its few offerings and meager (and sometimes non-existent) savings. “Reality is, it’s saving patients money on IVF and a few other drugs. A lot of money,” he wrote on the social media platform X.

The TrumpRx website currently lists only 54 drugs (there are more than 10,000 FDA-approved medicines). Many are already generic or their manufacturers have created patient assistance programs to help with patients’ out-of-pocket expenses (thus continuing to stick a huge bill on private insurers and Medicare). I wrote my critique of TrumpRx on the eve of his state of the union address.

NBC News yesterday asked Geoffrey Joyce, director of health policy at the University of Southern California Schaeffer Center for Health Policy & Economics, to weigh in. He came to a similar conclusion.

About half the drugs on the site already have generics that are often much cheaper and available through other discount sites, he said. “In its current form, it’s of limited use to uninsured consumers. If they got rid of all the ones that had generic equivalents, you’re looking at a site with 22 drugs. And it’s basically a roundup of the usual suspects. It’s some IVF, some GLP-1s. It’s not a broad scope.”

Cuban went on to praise the CMS staff working on standing up TrumpRx. Is he angling to get the contract?

Cost Plus Drugs is now a leading player in the mail order discount pharmacy business, offering over 2,500 medications in its catalog. It sells mostly generic drugs at the cost of acquisition plus a 15% markup, a $5 pharmacy service fee, and $5.25 for shipping.

But recent news reports indicate the company, which is privately held, has seen its revenue level off at slightly over $100 million a year. That’s a rounding error compared to the more than $400 billion in annual retail sales racked up by the pharmaceutical and biotechnology industries.

The reality is that low-cost generic drugs already account for 90% of all prescriptions. Insured patients have very low or no co-pays when they choose generics. They have no incentive to go outside their insurance to buy drugs because they would have to pay the full, generic-plus price. Even if it is lower than what pharmacy benefit managers are charging their insurers, it would still cost the patient more.

Patients’ real problem is with branded drugs. It’s hard to imagine the industry giving up its monopoly pricing power for drugs still on patent, except perhaps in a few high profile situations like the GLP-1s, the popular weight-loss drugs sold by Novo Nordisk and Eli Lilly, and IVF treatments.

In both cases, many insurers refuse to include the costly medicines in their plans. TrumpRx sends desperate customers directly to cooperating manufacturers with coupons that provide some discount from the list price.

Measles outbreaks are raging in four Red states. The Center for Disease Control and Prevention has dramatically scaled back its vaccine recommendations. Vaccination rates among young children are plummeting, especially in the South and rural West. Manufacturers are backing away from developing new vaccines.

In recent months, the Trump administration’s CDC, under the thumb of Health and Human Services Secretary Robert F. Kennedy Jr., has stopped recommending six routine childhood vaccines, including the flu, hepatitis A, rotavirus and meningococcal shots.

It will take years to undo the damage this already has done and will continue to do to public health until those policies are reversed. Here’s hoping this week marks the beginning of a turnaround.

Yesterday Massachusetts federal judge Judge Brian E. Murphy forbade the CDC’s newly-appointed Advisory Committee on Immunization Practices from taking further action to dismember U.S. vaccine policy. He ruled Kennedy violated federal law last June when he summarily fired the standing 17-member Advisory Committee on Immunization Practices (ACIP) and appointed eight replacement members, most of whom are avowed vaccine skeptics or critics of the Biden administration’s Covid policies. Another two appointed in January are similarly biased.

That’s not how Kennedy described his action nine months ago. He called the standing committee “a rubber stamp for industry profit-taking agendas.” He promised his hand-picked replacement committee would follow “unbiased science—evaluated through a transparent process and insulated from conflicts of interest.”

Kennedy violated both of those legal requirements, the judge ruled in a suit filed last year by the American Academy of Pediatrics and the American Public Health Association. “There is a method to how these decisions historically have been made—a method scientific in nature and codified into law through procedural requirements,” the 45-page order said. “Unfortunately, the Government has disregarded those methods and thereby undermined the integrity of its actions.”

He continued: “The Government bypassed ACIP to change the immunization schedules, which is both a technical, procedural failure itself and a strong indication of something more fundamentally problematic: an abandonment of the technical knowledge and expertise embodied by that committee.”

A law Nixon signed

The Federal Advisory Committee Act, signed into law in October 1972, requires agencies vet potential members of outside advisory committees for bias and conflicts of interest. It also requires the public be allowed to review and comment on the nominees. If an agency chooses someone with a conflict of interest, which can include a demonstrated intellectual bias, it must issue a waiver that documents why that particular person’s expertise is necessary before allowing them to serve.

(Full disclosure: I spent 2004 to 2009 at the Center for Science in the Public Interest monitoring science-based federal advisory committees’ compliance with FACA. I also served on Food and Drug Administration advisory committees. I am familiar with the law.)

Kennedy did none of that, drawing a black curtain around his promised “transparent process.” There was no public input before Kennedy made his choices. And there is no evidence (the FACA database, operated by the General Services Administration, has been non-operational for months) that any received waivers despite clear evidence that many had preconceived notions about the direction the committee should take.

Lawyers for the plaintiffs hailed the judge’s ruling. “This is a tremendous victory for science, for public health, and for the rule of law,” Richard Hughes IV, a partner at Epstein Becker & Green, told Stat News. A spokesperson for HHS said the agency would appeal.

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‘Not reckless’

The vice chairman of the new ACIP committee is Robert W. Malone, a physician and adjunct professor at Louisiana State University who has posted numerous articles on his substack expressing doubts about current vaccine policy. He claimed in his post yesterday that “Kennedy’s reforms are not the work of a reckless ideologue (but) represent a serious effort to apply rigorous scrutiny to vaccine recommendations that have gone largely unquestioned for decades.”

Rigorous scrutiny? The evidence presented at the early December meeting of the reconstituted ACIP compared the U.S. to Denmark, a small, homogeneous country with far fewer health problems. It elevated patient and parental “choice” to a core principle of vaccine policy, not adherence to medical science.

The committee recommended the CDC scale back its vaccine recommendations. The administration formalized that action in a long memo a month later when acting CDC head Jim O’Neill unilaterally reduced the number of recommended childhood vaccines from 17 to 11. That step was taken “without public comment, and without initial review of the evidence by designated advisory bodies,” according former public health officials now at Manatt Health, a consulting firm. (The CDC only makes recommendations; states are free to set their own policies when it comes to public health.)

It’s likely Trump administration lawyers will find a friendly appeals court to lift the order. Any formal reversal in the destructive vaccine policy that is now official will have to await a change in administration, if and when it comes.

I’ll leave the last word to Families USA executive director Anthony Wright. “When politics override science, our children pay the price. Today’s decision helps ensure that medical evidence – not ideology – guides how we protect kids from preventable diseases. With this decision, patient and consumer advocates will continue to advocate for clear, evidence-based advice and access to key vaccines, fully covered without cost-sharing or other barriers…

“We commend the court for this ruling, but families should not have to depend on litigation to ensure their child can receive a routine vaccine. Evidence-based medicine keeps children alive and in school. Preventing disease should be the foundation of any healthcare system serious about confronting the next disease outbreak or finding the next cure.”