The Trump regime’s attempt to impose political controls over research funding will affect every branch of government that relies on grants to outsiders for properly researched information to guide their decision-making. A federal rule, now under consideration by the Office of Management and Budget, would give the Trump regime’s political commissars the right to veto any grant that doesn’t meet their ideological agenda. The rule has drawn hundreds of thousands of protest comments from scientists, professional societies, research groups and the general public.

The news is especially disturbing when it comes to health care, the subject of this Substack.

KFF Health News reported today that the Agency for Healthcare Research and Quality has effectively been shut down, awarding just 4.5% of the $345 million Congress appropriated for an agency that is "estimated to have saved thousands of lives and billions of dollars over the past 27 years by improving medical practice.” About 75% of its staff has left since January 2025.

AHRQ’s major focus over the years has been hospital safety and flaws in the medical delivery system. “When you think about everything Americans hate about our healthcare system — that it costs too much, that you can’t get in to see a physician, that the treatment isn’t right, that the records contain wrong information — all that is what AHRQ studies,” said Dr. Aaron Carroll, chief executive of AcademyHealth, a health services research group, many of whose members depend on AHRQ grants.

Becker’s Hospital Review reported on the latest broadside in the Health and Human Services Department’s attack on all research involving genetic manipulation aimed at changing an organism’s behavior — so-called gain-of-function research. A July 20 guideline essentially ended funding for such research if it were deemed dangerous, a decision that will be left up to political appointees when the new science overlord rule goes into effect.

The American Society for Microbiology points out that there are major legitimate uses for gain-of-function research. It has been helpful in developing new therapies for cancer, cystic fibrosis, diabetes and cardiac pacemaker repair; developing vaccines for coronavirus and dengue fever; and developing treatments for bacterial infections affecting crops, a rising concern in an age of rapid global warming. The paper notes that experiments raising biosafety concerns are “an extremely small subset” of the field.

A new report from the Kaiser Family Foundation documents the decimation of U.S. support for HIV prevention and treatment around the world. Total funding from all donor countries declined by $2.1 billion or 25% in 2025 from the previous year. It was the lowest level of donor government support since 2007. All of the decline was due to sharp cutbacks by the Trump regime during its first year in office.

“Congress has continued to appropriate funding for HIV at steady levels, meaning that additional funding remains in the U.S. pipeline, although the extent to which those funds will be fully spent remains uncertain,” the report noted.

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Meanwhile, Anthony Fauci, the former head of the National Institute for Allergy and Infectious Diseases, used the fifth amendment’s protection against self-incrimination to refuse to answer any question posed by Sen. Rand Paul (D-Ky.) at his oversight committee hearing this morning. HHS Secretary Robert F. Kennedy Jr. told Fox News over the weekend that “if he lies again, he could be subject to perjury prosecution.”

Paul apparently leaked Fauci’s diaries that had been subpoenaed by his subcommittee. Besides the unflattering self-aggrandizing comments contained in the diary, which have received substantial media attention, there were a few statements that indicated Fauci believed there should be further investigation of the theory that the COVID-19 pandemic was started by an escaped virus from a Chinese lab doing gain-of-function research on coronaviruses with U.S. grants. He later dismissed this theory.

Paul also attacks Fauci for endorsing the Covid-era lockdowns, which Paul claims cost more lives than the virus itself. This claim has been repeatedly debunked in the medical literature. One early study showed that the lives lost due to economic lockdowns totaled a maximum of a quarter of a million, while lives saved with the lockdowns could have been as high as 1.7 million. The minimums in the estimates were 60,000 and 866,000 respectively.

“The Covid lockdown, however, could never have been inflicted without you aiding and abetting the crime,” Paul said at the opening of the hearing. When Fauci’s lawyer attempted to make a statement, he was ejected from the hearing room. “There will be repercussions to your refusal to testify today,” the senator told Fauci.

According to Stat News, Gary Peters (D-Mich.), the ranking member of the committee, opened the hearing by calling the legitimacy of Paul’s efforts into question, saying the oversight efforts were not bipartisan as usual. He said the pandemic response was only being relitigated to support “a pre-determined conclusion that was reached years ago.”

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That axiom will be put to the test after the agency’s Pharmacy Compounding Advisory Committee yesterday approved four untested peptides for manufacturing and sale. The 12-member committee, half of whom will financially benefit from the recommendation, will consider another three today.

None meet the FDA’s standards for safety and efficacy. Indeed, according to the FDA’s professional staff who reviewed the medical evidence behind the drugs, none have even been tested for either of the two requirements that have been the twin touchstones for agency drug approvals since 1962.

The committee contains eight new members handpicked by Robert F. Kennedy Jr.’s Health and Human Services Department. None have been vetted for conflicts of interest by FDA staff, who traditionally perform that task. Six of the eight have crude conflicts in that they run wellness, longevity and regenerative medicine clinics that prescribe peptides.

The roster also includes Robert Harshbarger, a Republican state senator from Tennessee. His mother, Rep. Diana Harshbarger (R-TN), is a pharmacist who last year introduced legislation that would, among other things, “remov(e) outdated labeling restrictions” on manufacturing facilities that mass produce peptides.

An entire industry has grown up around the manufacture and sale of peptides, small protein building blocks that allegedly perform miracles like wound healing, muscle building and promote longer life. They’ve become mainstay treatments at medical clinics and spas across the country where people with money to burn (no insurance will cover them) go for treatment, and are easily available through telehealth firms where medical professionals (perhaps licensed, perhaps not, who knows?) “prescribe” them for “patients” they’ve never seen, who self-describe their symptoms over the phone or online.

Peptides are being promoted by online influencers like Joe Rogan. They have a champion sitting atop the Health & Human Services Department. And they have received kind words from the paragon of ill-health (physical as well as mental) sitting in the White House. For more background on peptides, see this article on GoozNews published three months ago.

Today, let me address one simple fact. The FDA is not required to follow the advice of this illegally constituted advisory committee.

Why illegally constituted? The Federal Advisory Committee Act (FACA), signed into law by President Richard Nixon in 1972, prohibits any scientist, official, consumer or patient representative from sitting on a federal advisory committee if they have a financial stake in the outcome of its deliberations.

The sole exception is if their expertise is crucial to carrying out the committee’s charge and cannot be obtained elsewhere. In that case, the agency constituting the committee may issue a waiver outlining why their expertise is necessary. The agency issuing those waivers must post them on the government website that lists the committee rosters (there are hundreds across the federal government).

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Where are the waivers?

The General Services Administration website that hosts the searchable FACA database is currently non-operational. In 2018, the first Trump administration outsourced management of the database to Salesforce, the software giant based in San Francisco that manages sales for corporations. Instead of maintaining a searchable database, Salesforce began posting Excel files with the data. The company has not updated the files on the GSA website since 2024, that is, since the start of the second Trump administration.

Some enterprising journalist might consider making a Freedom of Information Act request to GSA and HHS for a copy of the waivers issued when this new committee was created.

Yesterday’s recommendations, and three more certain to follow today, will present a major challenge for acting FDA commissioner Kyle Diamantas. Prior to Trump’s appointment to run the food division at the agency in 2025, the 38-year-old lawyer worked at the legal giant Jones Day representing food, beverage and tobacco industry clients. It is highly unusual for a non-physician or scientist to run one of its key divisions, much less the entire FDA.

Yet, when Diamantas was chosen in May to replace Marty Makary, he received high praise in the trade press that covers the FDA for his one-year tenure at the food division, whose staff had been decimated by DOGE. Its previous director issued an angry resignation letter after the mass layoffs.

Here’s what Stat reporter Lizzy Lawrence had to say:

Leaders in the food industry, public health groups, and FDA career staffers have found that Diamantas exceeded expectations. As Diamantas takes the reins at the FDA, STAT spoke with more than 10 of these stakeholders, as well as former FDA commissioners and Diamantas’ former colleagues. They all described him as thoughtful and serious, someone who does his homework before meetings and listens to the experts in the room. Crucially, Diamantas has earned the trust of key career staff.

The career staff did its best yesterday to lay the facts before the stacked committee. The seven peptides under consideration for being legalized for production by compounding pharmacies have never been tested for medical efficacy in human beings. Virtually all of the safety testing has been done in animals, not humans.

In other words, the physicians or other medical personnel offering these alleged medications are not engaged in the off-label prescribing, which is allowed. There are no labels.

The long briefing monographs prepared for the committee for each of the seven peptides couldn’t have been more clear. The summary statements near the top stated in each case:

We have evaluated publicly available data on the physicochemical characteristics, historical use, safety, and effectiveness in compounding of these substances. For the reasons discussed below, we believe the evaluation criteria weigh against placing (name of peptide) on the list of bulk drug substances that can be used to compound drug products.

Attorney Diamantas. The ball’s in your court.

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The Chicago Tribune reported today that PM2.5 pollution (the most dangerous since small particulate matter from wildfires, internal combustion vehicles and industrial pollution easily enters the lungs and bloodstream) tripled the city’s previous high, which was already deemed hazardous to health. Some northern suburbs saw their previous highs quintupled.

Those previous recorded highs were set during the 2023 Canadian wildfire season, the worst until this year. Summer has been cancelled, one headline said, as public health officials warned everyone in the upper Midwest, Northeast and mid-Atlantic states to remain indoors.

Cancelling summer is depressing. Cancelling life is more important.

As yet, there has been very little reporting about the immediate health effects of the hazardous conditions suffocating central Canada and the north and northeastern third of the U.S. Studies of previous PM2.5 wildfire seasons estimated at least hundreds and probably thousands of people died prematurely from acute asthma and cardiovascular attacks. Longer term, the studies projected thousands more will die prematurely from increased cases of lung and other cancers, heart attacks and strokes.

The Associated Press this morning reported on some of the research behind those estimates. To quote from its story:

On average 24,100 people died each year in the Lower 48 states between 2006 and 2020 due to long-term exposure to tiny particles from wildfire smoke, according to a study this year in the journal Science Advances. A Stanford study projects that U.S. wildfire smoke deaths will increase with climate change and by midcentury hit an annual cost of $244 billion in terms of the economic value the government puts on each life.

On a global scale, wildfire smoke particles cause 677,745 deaths annually, with almost 39% of them children under age 5, according to a 2021 study that combined observations, studies on how the body responds to the particles and computer models to calculate the toll.

That AP story arrived just as I was concluding my own brief review of the medical literature. Here are just a few of the studies I found:

• A Canadian study in Geohealth of the health effects in Canada from wildfires between 2019 through 2023 found immediate deaths increased anywhere from 49 to 400 per year. Increased deaths from chronic exposure ranged anywhere from 660 to 5,400 deaths per year. Canada’s population is one-eighth that of the U.S.

• A U.S.-led study in Environmental Science & Technology Letters of the effects from the 2023 Canadian blazes found a three-fold increase in attributable deaths from smoke exposure.

• An Australian study in the American Journal of Obstetrics & Gynecology found asthmatic mothers-to-be exposed to at least 10 days of wildfire smoke in the first five months of pregnancy (compared to those with less or no exposure) resulted in four times more low birthweight babies, three times more pre-term babies, and five times more babies requiring neonatal intensive care.

Each of those studies was published earlier this year.

Whom should we blame?

How has the majority party in Washington responded to this unprecedented outbreak of forest fires in our northern neighbor? They’re blaming Canada for an alleged lack of response.

Sen. Bernie Moreno (R-OH) announced last Friday he plans to introduce the CANADA FIRE act (Countering Atmospheric Nuisances Arising from Drifting Airborne Foreign Incendiary Residual Emissions Act”). “My bill will declare an emergency, sanction all Canadian officials responsible, and study a victims compensation fund driven by imposing additional tariffs,” he said in a prepared statement.

Blaming political opponents for the increasing devastation from wildfires has become the go-to Republican trope for deflecting attention from the overwhelming consensus that greenhouse gas emission-driven global warming is entirely responsible for the unsurprising escalation in forest fire ferocity. President Trump took the lead last year when he accused California Gov. Gavin Newsom’s environmental and water management policies for the Palisades and Eaton wildfires, which led to 41 immediate deaths, another 440 health-related deaths, destroyed over 18,000 structures and forced over 200,000 from their homes.

Those charges were immediately debunked on the PolitiFact website. “Regional water reservoirs in Southern California are at historical highs,” the Poynter Institute’s factchecking organization noted. “Hydrants ran dry during recent firefighting because the city’s water infrastructure was not built to respond to fires so large.”

The real culprit

The Atlantic magazine environmental reporter Joshua Partlow yesterday offered a brief summary of why this year’s Canadian forest fires are shaping up as the worst ever.

When the boreal forests of Canada catch on fire, no one can do anything about it in many cases. The forests are part of Earth’s largest land biome, a greenbelt of wilderness that encircles the globe, and they’ve been suffering from the planet’s thermostat being jacked up. Wood-boring pests that flourish in milder climates have swept north and east, through tens of millions of acres. Droughts and dwindling snowpack have stressed the trees. They are ready to burn.

Trees are not just innocent victims of global warming. They are our most important allies in the fight against it. Why? Because trees take in carbon dioxide and through the miracle of photosynthesis pump out oxygen.

The majority of the earth’s arboreal forests lie in the upper reaches of the northern hemisphere. That fact is aptly reflected in the following chart. The downward-sloping portions of the saw-toothed line reflects the decline in atmospheric CO2 concentrations during the northern hemisphere’s spring and summer months.

Bottom line: Climate change’s impact on Canada and Russia matters a lot.
The vast forested lands of those two countries are the largest component of the planet’s lifeline. They are being assaulted daily by the warming temperatures caused by fossil fuel emissions. When they burn, it’s like puncturing a hole in our life preserver.

And who deserves the most blame for those fires when we look around the world? It is the current U.S. government and its environmental policies — not malfeasance by the Canadian government for failing to contain the growing number of forest fires in its 1.4 million square miles of forest land, which is more than twice the size of Alaska and constitutes 9% of the world’s total.

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Let us now review current U.S. policy as pertains to global warming:

• The current president calls global warming a hoax.

• His government supports more coal-fired plants and less renewables like wind and solar to produce electricity.

• His Supreme Court majority in 2022 severely limited the government’s ability to regulate CO2.

• His Environmental Protection Agency initiated at least 70 actions to roll back rules designed to protect the environment and limit global warming.

• He withdrew the U.S. from the Paris Agreement on fighting global warming.

• His science agencies de-funded research into the causes and effects of global warming.

• His Interior Department has opened federal lands, including national treasures like the Arctic Wildlife Preserve, to fossil fuel exploration.

• His State Department has destroyed the Agency for International Development, which provided crucial assistance for less developed countries that wanted to combat their own contributions to global warming.

If Americans want to become part of the fight against the health harms of global warming, the place to start is in Washington, D.C., not Ottawa, Canada.

Who was Trofim Lysenko? He was the political hack Josef Stalin put in charge of Soviet science in the 1930s because the dictator agreed with his theory rejecting Mendelian genetics in favor of his pet theory that learned behaviors could be inherited. Russia’s contributions to medical and biological science never recovered.

An Office of Management and Budget rule proposed in late May would require all federal grants (including the National Institutes of Health, the National Science Foundation, and virtually every agency of the federal government) gain approval from political appointees at the granting agency. The regime’s attempt to impose political control by executive order was rejected by the courts for failing to follow the federal law that requires rulemaking with public comment to make such a change.

An administration spokesperson gave Axios this boilerplate explanation for the proposal: "Federal grants were politicized under the last administration to promote a far-left DEI (diversity, equity and inclusion) agenda.… That ends now."

The unspoken agenda is the Trump regime’s desire to fund pseudo-scientists who back quack theories opposing vaccines and water fluoridation, and support scientists who claim efficacy for drugs and devices never subjected to clinical trials.

Significantly, Big Pharma has finally weighed in on the gutting of science that is the basis for their entire industry (something it has so far failed to do regarding the regime’s undermining of the Food and Drug Administration, which regulates its products). “The proposed changes to research funding decisions could introduce a level of unpredictability that would weaken the scientific ecosystem,” a spokesperson for PhRMA, the industry trade group, told Axios.

“At a time of intense global competition, creating uncertainty in research funding risks driving talent, discoveries and investment to other countries, ultimately slowing the development of lifesaving treatments for American patients and ceding U.S. leadership.”

The comment period remains open until next Monday, July 13. You can weigh in by clicking here: https://www.federalregister.gov/documents/2026/05/29/2026-10817/regulation-for-federal-financial-assistance.

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Talk about the pot calling the kettle black.

Here are the first four examples of alleged political advocacy in the 162-page report’s indictment:

1. Advocacy for extending citizenship to illegal aliens;

2. Partnership with illegal alien activists who campaigned to oust a North Carolina Sheriff from office;

3. Indoctrinat(ing) middle and high school students into opposing the enforcement of federal immigration law;

4. Created a video highlighting protestors demanding to “abolish ICE.”

Indeed, nearly half the 28 examples of alleged political activism lodged against the Smithsonian involved alleged support for “illegal immigration” and “illegal aliens.” The remainder included “rejecting biological reality, “anti-woman activism,” “turn(ing) America’s youth into anti-gun activists,” and transforming its museums “into anti-white institutions.”

In other words, this White House wants an American history purged of all references to its diversity, its proud immigrant tradition (of which most of us owe our citizenship), and any references to the equity promised in the original Declaration of Independence. They would rewrite that document to say all white men are created equal, which is what the original Constitution guaranteed since most states placed property restrictions on the right to vote in the early years of the Republic.

One of the alleged incidents of anti-white bias involved the Smithsonian forming a partnership with the Southern Poverty Law Center, which the report claimed was “found to be manufacturing racism to justify its existence.” The footnote “proving” this allegation cited an April 2026 Justice Department press release from acting attorney general Todd Blanche and FBI director Kash Patel, which touted their grand jury indictment in Alabama accusing the SPLC of encouraging the Ku Klux Klan, Aryan Nations, the American Nazi Party and the other hate groups to engage in violate acts in order to facilitate fundraising.

The paragraph started by accurately stating it was an indictment. But then used language that claimed they had already been “found” guilty. For the record, SPLC pled not guilty in May. Its interim CEO Bryan Fair said: “The charges against the SPLC are provably wrong; they are based on inaccurate facts and a misapplication of law. Our informant program was successful in accomplishing its purposes: Threats and attacks were prevented, criminal activity was stopped, and information was gathered to dismantle the efforts of hate and extremist groups.”

It appears innocent until proven guilty (the 5th Amendment) is no longer operative in Donald Trump’s Washington. However, there are exceptions. For instance, the anti-vaccine organization previously run by HHS Secretary Robert F. Kennedy Jr. remains steadfast in its willingness to use this bedrock American legal principle to maintain its pre-existing beliefs.

The New York Times reported this morning that an Idaho mother of twin toddlers who were found dead in their beds over a year ago was indicted for murder last week. The alleged crime was “either premeditated or taken in the course of aggravated battery.”

Three days after their deaths, in an interview with Children’s Health Defense, RFK Jr.’s anti-vaccine non-profit, the mother, 23-year-old Andrea Renee Shaw, claimed childhood vaccines were responsible for her kids’ deaths. Shaw went on to become the group’s lead plaintiff in its lawsuit against the American Academy of Pediatrics, which alleges the doctors’ group lied when it endorsed FDA findings that the vaccines were safe.

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What’s now PC at Smithsonian Mag

But let’s move on to another example of whitewashing American history that hasn’t made news. Ironically enough, it comes from different arm of the Smithsonian Institution. My shrink-wrapped copy of the summer edition of Smithsonian magazine, appropriately entitled “Celebrating America at 250,” arrived in the family mailbox two weeks ago. I didn’t get around to opening it until this week.

Its 144 pages appropriately celebrated the many achievements of American scientists, technologists (including Benjamin Franklin), writers, artists, civil rights activists and more. Its opening essay by Smithsonian Secretary Lonnie G. Bunch III focused, as did many of its more than three dozen essays, on America’s innovative spirit.

The nation’s greatest presidents weren’t ignored. They included George Washington, Thomas Jefferson, Abraham Lincoln, Theodore Roosevelt, William McKinley and John F. Kennedy. Neither of the thumbnail sketches of the first two founding fathers mentioned slavery. Lincoln was touted as the only president to have earned a patent for conceiving “a nifty way of freeing boats when they ran aground.” No mention of his role before and during the Civil War. McKinley earned recognition for being the first to use campaign buttons while running for office, not for launching U.S. imperialism with the Spanish-American War.

The editors bestowed the longest single profile of an American president on Woodrow Wilson, whose first-term legislative record “reflects the progressive agenda at flood tide.” Achievements mentioned included the creation of the Federal Reserve system, the Federal Trade Commission, the Clayton Antitrust Act, the curtailment of child labor, and the introduction of the eight-hour day for railroad workers. His negatives, also mentioned, included segregation of the federal workforce, the gross violations of civil liberties during WWI, and his “stubborn refusal to compromise with Senate critics” that kept the U.S. out of his own brainchild, the League of Nations.

What most amazed me about this hagiographic edition was its total omission of the achievements of the only president to have served more than two terms. Franklin D. Roosevelt, elected four times to the White House, gets mentioned exactly once — in the Wilson profile that notes that president’s achievements foreshadowed the New Deal (without giving FDR credit for that political slogan).

Why would there be no mention of America’s longest serving, president, clearly the greatest political leader of the 20th century? You’d think a Trumpified Smithsonian might worship the ground he rolled on. After all, he was a rich white man with substantial legislative achievements.

Let us recount a few of them: The 1935 Wagner Act enabled a third of the workforce to become unionized and the same year created Social Security. Both set the stage for the creation of the largest middle class the world has ever known. He ended the depression and led the U.S. during its war against fascism. He banned racial discrimination in defense industries. And his socially empathetic and activist wife, Eleanor, redefined what it meant to be a First Lady.

A balanced profile could also have emphasized FDR’s downsides: How he rigorously enforced the nation’s 1924 anti-immigration law that prevented millions of Jews, desperate to leave Europe, from entering the country. Or, how his maintenance of a rigidly segregated military engendered the anger among returning black GIs; how many majority black occupations were excluded from labor rights protections and black communities excluded from housing subsidies; and how those indignities led the postwar generation of African Americans to launch a world-shaking civil rights movement that would secure equal rights for all.

I grew up in a town named after FDR, one of the few in the U.S. It was built during the 1930s as a model community containing 200 single-family homes for unemployed garment workers. Its curving streets and pleasant cul-de-sacs surrounded a school in the center of town — its only public building. The farm and factory failed, but the spirit of that tiny central New Jersey village lived on in the hearts of its 1,000 or so inhabitants, and the millions of Americans who still venerate the achievements of FDR’s New Deal.

So, I, too, am upset with the Smithsonian for leaving out the history of white Americans — in this case, the president who helped more Americans achieve middle class status than any other, and whose achievements the oligarchy that now rules our country is destroying bit by bit, day by day.

The Associated Press reported Friday that nearly 3 million people dropped Obamacare health insurance plans during the first two months of 2026. That’s a 13% fall from the 22.1 million people who purchased individual or family plans on the exchanges in 2025.

That’s already 40% of the total the Congressional Budget Office projected would drop coverage for the entire year because the GOP-run Congress refused to reauthorize those Biden-era subsidies during last year’s budget negotiations. That left millions of low-wage workers whose employers don’t provide coverage with out-of-pocket premiums they can no longer afford without the extra help.

The end to people dropping coverage is nowhere in sight. The CBO conservatively estimated 7.5 million people would drop Obamacare coverage this year. If the first quarter average holds for the rest of the year, that number will soar to more than 10 million.

Add to that the millions of people being thrown off Medicaid due to the new work requirements and bureaucratic hurdles thrown in their way, the ranks of the uninsured will likely see its largest increase in years when data for 2026 is released next year. Last May, the CDC reported 28 million people or 8.3% of the population did not have health insurance in 2025. With the Trump regime adding another 10 million people or more to the ranks of the uninsured, the uninsured rate is likely to jump to more than 11%.

(That’s my calculation: Put 38 million uninsured over a population projected to grow to 344 million this year and you get an 11% uninsured rate.)

How about the rest of us?

What will that mean for the 156 million or so people with employer-based coverage? Their rates will be jacked up by insurance companies to pay for the uncompensated care hospitals deliver to the uninsured in nation’s emergency rooms, where, when they get sick, they turn for care since ERs legally cannot turn them away. Moreover, they will likely be far more costly to care for since ERs are the most expensive place to get care, and they will have waited until their conditions had worsened to the point where they had to seek care.

We’re already beginning to see evidence of the premium price spikes to come. Nona Tepper of Modern Healthcare reported last week that health insurers’ preliminary filings with state regulators for individual plans sold on the exchanges will show big premiums increases next year. Employer surveys showing next year’s premiums usually aren’t released until the late fall.

Leaving people uninsured is about the stupidest and inhumane policy any society could adopt, especially one that can afford to ensure than everyone has coverage. But, as Forrest Gump liked to say, stupid is as stupid does.

GoozNews will be taking the rest of this week off to attend a theater festival in Canada.

The first was the abolitionist movement that ended slavery and provided African-Americans with equal rights under the law. It took a civil war — still the bloodiest conflict in our history — and the rewriting of the U.S. constitution to accomplish those goals, albeit for men only.

The second was the women’s rights movement, which began in earnest in the 1840s. Generations of activists fought for the right to vote, which wasn’t won until 1920; and the right to reproductive freedom, tentatively won in 1965 through 1973 (partially repealed by the reactionary Roberts Court in the 2022 Dobbs decision). That movement continues today, not just in efforts to restore reproductive health rights, but in demands to narrow the yawning gap between women and men in compensation and economic opportunity.

The third was the rise of the progressive, populist and nascent trade union movements of the late 1800s and early 1900s. During the first Gilded Age, when monopolists seized control of the newly industrialized nation’s economy and politics, those organizations succeeded in passing federal laws establishing the nation’s first regulatory agencies. They broke up trusts, regulated banks, taxed exorbitant incomes and inheritances, established the first rules for food and drugs, established national parks, protected federal lands, and helped farmers. States passed laws providing limited insurance for workers enduring unemployment and when injured on the job.

These measures, always limited in scope due to the economic elite’s intractable opposition, proved inadequate to the challenges posed by the Great Depression, which began with the unregulated stock market’s crash in October 1929. The ensuing economic collapse was worsened by unaddressed wealth and income inequality, wrong-headed tariffs, and the ruling Republican Party’s refusal to embrace government intervention.

That economic catastrophe triggered the fourth great social movement in U.S. history — the rise of industrial trade unions. The pitched battles of the 1930s eventually gave way to institutional acceptance. At their peak in the 1950s, unions represented one-third of the American workforce. They succeeded in winning higher wages, better working conditions, longer vacations, and greater benefits, including pensions and health insurance, both for their members and the broader society. Labor economists dubbed the post-WWII era “the great compression,” a time when income inequality was greatly reduced and prosperity broadly shared.

But not for all, which was the economic backdrop for the fifth great social movement in U.S. history — the Civil Rights Movement. African-American soldiers, who had fought abroad to preserve democracy, returned to a country that denied it to them. Southern states, in reaction to gains made after the Civil War, had legally imposed a segregated and inferior education system on the families of former slaves. They were denied access to public facilities and denied the right to vote and participate in civic life. Southern states enforced their apartheid regime through extralegal terror: public lynchings that took the lives of more than 4,000 souls in the first half of the 20th century.

Led by preachers and lawyers, the broad-based civil rights movement succeeded in winning the support of a significant share of the white population. A Democratic Congress in the mid-1960s passed laws restoring and enforcing the legal, voting and equal access rights that had been eliminated after Reconstruction. Higher education and corporate America began accepting previously excluded groups, which diversified and enlarged the middle class. Expanded government programs reduced poverty among those left behind, both white and black. The Civil Rights movement also inspired the anti-Vietnam war and environmental movements, many of whose leaders had participated in the lunch counter sit-ins and voting registration drives of the early 1960s.

But, during the 1970s, a decade marred by three recessions and two bouts of oil price shock-led inflation, progress stalled. Previous gains were threatened and then lost. Corporate America abandoned its social compact with the communities that had spawned them. To avoid unions, they moved their factories to the largely non-union south, the precursor to moving abroad.

The corporate assault on broadly shared prosperity began in earnest after Ronald Reagan was elected president in 1980. They demanded and won lower corporate taxes to bolster profits. They rigged the income tax code to favor the well-to-do. They defeated almost all new environmental, food, drug, and worker safety regulations; and rolled back many already on the books. They defeated higher minimum wage laws that would have helped the low-wage workers in the service economy rapidly replacing the manufacturing economy. Their consultants, with connivance from an industry-controlled National Labor Relations Board, devised ever more devious ways of defeating union organizing drives among the growing service worker underclass.

Is it any wonder than we now live in an economy dominated by a small handful of billionaires? Is it any wonder we are living a level of income and wealth inequality that surpasses the first Gilded Age? Is it any wonder that the ultra-rich dominate the nation’s political system through dark money contributions and their corporate political action committees, both facilitated by the Supreme Court’s 2010 decision in Citizens United v. FEC? Our political system is far more corrupt today than it was nearly a century-and-a-half ago when New York’s Republican senator William Stewart strode onto the Senate floor with wads of cash to solicit votes from his confreres.

Trump the destroyer

Many centrist Democrats running for Congress this fall are portraying the current occupant of the White House as an aberration. Implicit in this characterization is the idea that things will miraculously return to normal once he leaves office and the current out-party is returned to power. I wish that were true.

Such thinking underestimates the serious damage that Donald Trump has done to American institutions. The media focus endlessly on how he uses the White House to financially benefit his family, those who kiss his ring, and the billionaire class that has flocked to his side. His personal incompetence amid all this corruption — the Lincoln Memorial reflecting pool fiasco being the latest example — provides comic relief.

But an end to the grift won’t correct the damage done by his losing war against Iran, which has inflicted serious damage to the U.S. economy and shredded whatever good will the country retains in the eyes of the rest of the world. Our military, which has seen dozens of its senior leaders forced out for no reason other than their sex, the color of their skin or their temerity to ask questions, has been institutionally weakened in unprecedented ways. The feckless television talking head that poses as Secretary of War is demanding $80 billion to restore its depleted armaments. (I should add, since this is usually a health care blog, that the request is twice as much as is needed to restore the lost Obamacare subsidies.)

When he leaves office, Trump will leave behind a U.S. government in shambles, incapable of carrying out many of its core functions. Thousands of competent lawyers, accountants, foreign policy experts, scientists, engineers, physicians, epidemiologists, investigators, economists and more have left DOJ, the State Dept., USAID, NIH, FDA, CDC, EPA, OSHA, NOAA, CFTC, SEC, CFPB and more. These agencies weren’t built in a day. It will take years, some say decades, to hire, rehire and train competent people willing to work for a government that pays less and, as this administration has repeatedly proved, offers less job security than what they can find in the private sector.

A quarter century ago, Grover Norquist, the pro-corporate, anti-tax Republican operative, told NPR that “I don't want to abolish government. I simply want to reduce it to the size where I can drag it into the bathroom and drown it in the bathtub.” Under Trump, the plug is in and the water is running. It will take more than pulling that plug to restore young professionals’ belief in the value of public service, a must if we’re going to rebuild the agencies that protect the public from private sector predators like Elon Musk, Jeff Bezos, Mark Zuckerberg and their ilk.

Movements for change

In the decade-and-a-half since the 2008-09 financial crisis and Great Recession, we’ve seen several movements spring up among young Americans who saw the nation galloping down the wrong path: Occupy Wall Street, Me-Too, Black Lives Matter. There’s also been an upsurge in pro-union sentiment. Support for single-payer health care has never been higher. In many left-leaning areas of the country, the socialism of Democratic socialists like New York Mayor Zohran Mamdani is no longer a dirty word.

The Sanders-AOC-Mamdani wing of the Democratic coalition is not proposing anything out of the mainstream of U.S. political history. Free buses and single-payer health care are simply the modern manifestations of the “sewer socialism” that bloomed during the Progressive era, another time when private sector failure led to the election of socialist leaders in many cities and states. They created municipality-owned water, sewer and electricity utilities, infrastructure projects and farm co-ops, most of which are still around today.

But in order to create lasting change, Democrats need a broader vision. They need a set of principles that inspire people to form and sustain a movement that unites the many disparate groups pushing specific programs and policies. That broader vision should be something like the economic security message FDR proposed in his second inaugural address. “We must find practical controls over blind economic forces and blindly selfish men,” he said. It could mirror his four freedoms speech issued on the eve of WWII, which included freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear.

I must admit I am stumped when I try to articulate the principles that will inspire people to build a unified, mass movement that calls for:

• * Guaranteed economic, social and personal security (universal adequate pensions, guaranteed annual income, universal and affordable health care coverage, family leave and daycare, the right to abortion and reproductive health services, safe communities with no gun violence);

• * A return to legality with deference to democratic norms in governance, and an end to money’s domination of politics;

• * An end to the proliferation of greenhouse gas emissions that cause global warming, and a preserved environment;

• * Equal justice and opportunity for all people, no matter their race, gender, age, physical limitations or sexual orientation;

• * Turning the U.S. into a force for peace by putting an end to nuclear weapons and withdrawing support from authoritarian regimes; and

• * Becoming a leader in the fight against global disease, poverty and hunger.

If history teaches us anything, it is that only movements, united around basic principles and active over long periods of time, are capable of generating the demands for change that politicians cannot ignore or deflect. It is important to elect leaders who offer verbal support for progressive programs. But given the political realities of a divided nation, those elected leaders will not be able to achieve significant change without a movement pushing those principles forward and convincing a majority of Americans of their wisdom.

As we approach the 250th anniversary of the nation’s founding, I invite my readers, most of whom will probably be averting their eyes from the Trump regime’s mass spectacles, to suggest what should go into a four freedoms-style speech for the rest of the 21st century. Put them in the comments section or write to me personally, and I will later elevate them through a separate blog post.

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.