January 17, 2025
Dear Interested Readers,
It’s a New Year, a New Government, and a Very New Day Coming
The New Year is slowly building some momentum. As there is increasing certainty about who will populate the Trump cabinet, we will have more clarity about how efforts to improve the social determinants of health will fair over the next four years. There is no question that DEI efforts have stalled and will fade over the coming four years. Indeed, George Floyd may have died in vain.
We don’t yet have a clear indication of how Medicare, Medicaid, and the ACA will be managed, but I have yet to hear any statements coming from the incoming Trump administration that his “concepts of a plan” is evolving toward anything that will improve access for those who have none or improve the coverage of those who are technically insured, but are underinsured and experience substantial barriers to care. One big unknown is whether Robert F. Kennedy, Jr. will be confirmed as the Secretary of Health and Human Services. It may well be that Trump promised him the nomination while betting that Republican pro-life forces and those Senate Republicans who resent his history as a Democrat will vote against his confirmation. The same reasoning could be applied to Tulsi Gabbard who is even more controversial as the nominee for Director of National Intelligence.
A month ago the Kaiser Family Foundation published a list of all the health-related executive actions that Trump could and may likely take no matter who heads Health and Human Services. If you care about improving the cost, quality, and access to healthcare, you may want to take some benzodiazepine meds–say Valium or Ativan– before reading the article. I will just give you their list. If you are interested in knowing more click on the article above and then scroll down to the item of interest to you where you can “click” to learn more details. Since many of these actions could “save” the government money while advantaging those invested in for-profit healthcare and appeasing the “religious right” you can imagine that Elon Musk, Vivek Ramaswamy, healthcare-related businesses, and fundamentalist religious leaders will be pushing Trump to sign many of these potential executive orders.
Affordable Care Act
Continue to implement hospital and health plan price transparency requirements.
Make changes to ACA Marketplace enrollment processes.
Limit or eliminate funding for Affordable Care Act consumer assistance and outreach programs.
Require separate payments for abortion coverage in ACA Marketplace plans.
Approve or reject state waivers.
Reinstate expansion of short-term, limited-duration health plans (STLDs).
Reinstate expanded access to association health plans (AHPs).
Revise guidance implementing section 1557 of the Affordable Care Act (ACA), removing LGBTQ protections.
Abortion
Direct the FDA to revoke the approval of mifepristone or revert to older dispensing protocols under the REMS.
Enforce the Comstock Act to ban the distribution of medication abortion pills and other supplies in all states.
Stop enforcing the Emergency Medical Treatment and Labor Act (EMTALA) for emergency abortion care.
Rescind HIPAA regulations to safeguard abortion privacy.
Rescind guidance to retail pharmacies about nondiscrimination obligations.
Revoke rules authorizing access to abortion care under the Veteran’s Administration.
Revoke support for active military troops and their spouses who seek abortion or fertility care.
Exclude abortion from the protections of the Pregnant Workers Fairness Act.
Bar the use of NIH funds for research involving fetal tissue derived from abortions.
Require separate payments for abortion coverage in ACA Marketplace plans.
Approve waivers that exclude Planned Parenthood clinics and other providers from the Medicaid program.
Reinstate Mexico City Policy and potentially expand it further.
Contraception
Reinstate limitations to the Title X Family Planning Program.
Overturn recently expanded contraceptive coverage regulations.
Medicaid
Delay implementation or issue new regulations to undo final regulations streamlining Medicaid enrollment and renewal processes.
Approve waivers that include work requirements as a condition of Medicaid eligibility, premiums, and other eligibility restrictions.
Delay implementation or issue new regulations to undo final access and managed care rules.
Approve waivers that exclude Planned Parenthood clinics and other providers from the Medicaid program.
Immigration and Health
End the Deferred Action for Childhood Arrivals (DACA) program and associated ACA Marketplace coverage expansion.
Reinstate changes to public charge policy to include health coverage programs.
Carry out mass detentions and deportations of millions of immigrants.
End birthright citizenship for children of some immigrants.
Reinstate “Remain in Mexico” policy.
Limit entry of humanitarian migrants.
LGBTQ Health Policy
Revise guidance implementing section 1557 of the Affordable Care Act (ACA), removing LGBTQ protections.
Issue executive orders limiting LGBTQ protections, including in health care.
Limit access to gender affirming care for minors and, potentially, adults.
Public Health
Change Federal Vaccine Recommendations and Regulatory Processes
Influence water fluoridation practices through federal recommendations and regulation
Racial Health Equity and DEI Initiatives
Eliminate equity-focused initiatives and issue anti-diversity, equity, and inclusion (DEI) executive orders.
Global Health
Reinstate Mexico City Policy and potentially expand it further.
Cease U.S. engagement in pandemic treaty negotiations.
Halt funding for and withdraw from the World Health Organization (WHO).
Rejoin Geneva Consensus Declaration on Women’s Health and Protection of the Family.
Invoke the Kemp-Kasten amendment to prevent U.S. funding for UNFPA.
Prescription Drugs
Reinstate executive order on manufacturing essential medicines in the U.S.
Fentanyl
Impose tariffs on Mexico, China, and Canada.
Deploy U.S. military to the southern border to combat drug trafficking.
Intensify domestic law enforcement efforts related to fentanyl.
Expand federal coverage for faith-based treatment and flexibilities for protected leave during addiction treatment.
Long-term Care
Relax regulations governing nursing facilities.
I doubt that everything on the list will happen, and perhaps there are a few potential executive orders on the list that you might think would be good, but I doubt that many of the people who voted for Trump because they did not like the current price of eggs ever gave much thought to the potential damage that their vote might cost them in other sphere’s of concern to them. For a large part of the electorate, a vote for Trump may have felt like the right thing to do based on their cultural worldview, their anger about the economy, or their enhanced fear of illeagal immigrants that was cultivated with stories about immigrants eating their pets, but they had no idea they were really voting against their own best economic and healthcare interests.
Did we get to where we are because we lacked the courage, insight, and coordination to defend and advance the issues that would have offered real hope to middle and lower-class Americans? Throughout the run-up to the election, I read about the strategic importance of the “blue wall” of Wisconsin, Michigan, and Pennsylvania. Based on the states that were solidly red or blue, the winner of the electoral college votes in these three states would be president. Now that we are facing many changes, I have asked ChatGPT what Trump’s margin was in these three critical states. My bet was that he won them by about 200,000 votes. I was not far off. The answer may surprise you. I asked:
By what total vote margin did Trump win Wisconsin, Michigan, and Pennsylvania in 2024? ChatGPT said:
In the 2024 U.S. presidential election, Donald Trump won the key battleground states of Wisconsin, Michigan, and Pennsylvania by the following margins:
- Wisconsin: Trump secured a victory with a margin of 0.87%, amounting to 29,397 votes.
- Michigan: He won by 1.41%, which translates to 80,103 votes.
- Pennsylvania: Trump’s margin was 1.71%, equating to 120,266 votes.
Summing these figures, Trump’s total vote margin across these three states was 229,766 votes.
As they say, close only counts in horseshoes. You might imagine what would have happened if Trump had won the popular vote as Hillary Clinton did in 2016, but lost in the Electoral College. The invasion of the Capital on January 6, 2021 would have been only a preview of the party that would have followed a second Trump loss. Perhaps, we should be happy that we avoided a second Civil War.
Why are progressive ideas such a challenge to present and sell? I recently read an interesting column in my hometown paper the Valley News entitled “Why do we cling to our healthcare system?” The article was written by an older journalist, Willem Lange, who has a recurrent byline, “A Yankee Notebook.” Lange is a fixture in New England journalism. He is a naturalist who for eighteen years has had an outdoor recreation television program called Windows to the Wild, aired on New Hampshire Public Television, that features hikes in the White Mountains and other environmental subjects and adventures. It was a big surprise to me to see that he was expanding his sphere of interest to include healthcare. The column is short, but as usual, I will annotate his interesting thoughts. It’s too bad that the article did not come out in “blue wall states” last October. He begins with a story:
I was checking out at the supermarket the other day, and as usual fell into conversation with the checkout person, an elderly woman. She was sharing a bagger with the next lane over. When the bagger — another elderly lady — joined us, I noticed a pretty heavy limp. Happily afflicted as I am with the condition called “age-related disinhibition,” I naturally asked her what was wrong. [Lange will be 90 in May.]
The problem was a deteriorated hip joint. It’d been getting worse for years, and now was seriously debilitating. I asked why she didn’t get it replaced; it’s a fairly easy and quite successful operation. She couldn’t afford it, she said. She was covered by Medicare, but it didn’t cover nearly enough of the cost to make it possible. She was clearly resigned to her situation. It wasn’t hard to see what was coming. The hip would get worse, and her debility would cost her the job, such as it was. And then…?
And then? That is a key question as we face four years of MAGA mania. He continues:
It was a reality check for me; I haven’t gotten a medical bill in almost 25 years. I recall now that prior to my 65th birthday in the year 2000, the medical insurance (if we used it) for just my wife and me cost us $14,000 annually: $8,000 for our premiums, and $3,000 deductible apiece. What a relief it was to give that up for government coverage, even though adding Part B cost about $200 a month for each of us.
Later, when my wife’s health began to fail, we added Medicaid (an incredibly complicated process for a senior citizen, though assisted cheerfully and competently by Vermont state advisers, who led me through the routine). The Medicaid premium was based on our income, and at the time cost just over $1,000 per month for nursing home care that would have cost us at least $10,000 otherwise. You may conclude that I’m a big fan of government health care insurance.
I am often envious of the 650,000 people who live in the “People’s Republic of Vermont.” Besides the natural beauty that surrounds them, it is “Bernie Land” and many of the senator’s progressive ideas have been beneficial in the effort to make healthcare services more affordable and equitable. Although there have been some failures, I believe that like Massachusetts, Vermont has been a learning lab or pilot where ideas can be tried.
Lange’s positive experience in Vermont leaves him asking questions about what is happening elsewhere now which is beginning to make him apprehensive about what might eventually happen to him.
… I’m mystified that we here in the United States seem to cling so tightly to our so obviously illogical system of health care. We claim that it’s the best in the world, but statistics prove otherwise. I have no problems with it myself, but I’m one of the lucky ones who can afford the supplementary premiums and the cost of prescriptions. What about the millions of my fellow Americans who can’t?
As an aside it is interesting to note how frequently those who care about the environment and issues like Global Warming, also care about equity and the quality of healthcare available to everyone. He genuinely cares about the older woman who is still bagging groceries for a small wage on a hip which is a constant source of pain. He begins to offer some analysis and then his opinion. Bernie Sanders could have written what comes next.
The notion that private health care insurance is superior to government-run insurance is philosophically attractive, but in practice laughable. The goal of any business is to provide a service or product and show a profit. Any health insurance business shows its investors the healthiest profit when it manages to pay the least in benefits. The recent fatal shooting of a health insurance company chief executive officer seems to have had its roots in this phenomenon. Reaction to the murder on social media has been interesting. While twisting themselves into knots to deplore the murder itself, commenters have surrounded the shooter with the aura of a Robin Hood.
As we read on, I am delighted that Willem and I share a lack of admiration for Ronald Reagan, the high priest of self-interest and the scapegoater-in-chief of all of our woes being traceable to the government.
It’s not hard to see where the public-private schism first took root. Ronald Reagan, who spent his professional life reading scripts written by others, slipped into his 1981 inaugural address the notion that government was not only incapable of solving people’s problems; it was the problem. That root has grown and blossomed into today’s general mistrust of government; and private corporations, including many in the health care insurance industry, have made the most of it.
He takes a short self-deprecating aside, and then continues with a less than laudatory analysis of us all…
Almost all of us Americans have been raised to believe that our country is the greatest in the world and that in any dispute we are the virtuous party. Those are demonstrably false assumptions. Pick any category — literacy, life expectancy, infant survival rates, even geographical knowledge — and we rank well down, or even off, the list. I can vouch from experience that the average Cuban schoolkid knows American geography better than most American adults.
I could add to his less-than-laudatory analysis of our national character and aptitude that the last election is evidence that he is correct. He is not accepting that we have no way out and can’t mend our ways.
There are no doubt many arguments against doing away with our current system of health care insurance. To claim the government is too clumsy or bloated to manage it is a gross canard. To accept with resignation that the system is too entrenched to change is bogus. To claim that government control is a step toward Communism — can’t we someday get over that old bogeyman? It should have been buried with Joe McCarthy and J. Edgar Hoover. We need to catch up with the rest of the world. As Woody put it so memorably, “If you stick together, boys, it won’t be long.” [ I think that is a reference to a line from the animated movie, Toy Story. Woody was “voiced” by Tom Hanks.]
I think the combination of age and long walks in the woods have made Willem Lange a true philosopher whose words we should consider. Moving on to another voice for these times I will transition by returning us to the moment. This last week several of President-elect Trump’s cabinet nominees have had their hearings with the Senate committees that coincide with the responsibilities for which they have been nominated. With a majority of fifty-three to forty-seven, it now seems likely that many controversial nominations like Pete Hegseth for Secretary of Defense will be endorsed by committee votes along party lines. It is also my guess that only a few will get votes from Democratic senators when the full Senate votes on them.
I am still hoping that Robert Kennedy has been tricked by Trump, and the pro-life forces will block his nomination. I am certain that we are beginning the first year of a minimum of four years of emotional challenges for me which is why I was delighted to see another thoughtful and encouraging blog post coming from Joseph Betancourt, The President of the Commonwealth Fund. Dr. Betancourt entitled his offering Looking to 2025: Changing Health Care, and the Need for Courage. After a few introductory words promising that the Commonwealth Fund will stay the course toward its mission of promoting a high-performing, equitable health care system for everyone, he begins to describe the current need for courage. He writes:
It is clear that 2024 provided much to reflect on, and three themes really rose to the surface. A common thread among these themes is the need for courage — courage to implement commonsense and well-known solutions to pressing and longstanding problems; courage to challenge the deeply entrenched interests that preference the status quo to change; and courage to hold ourselves accountable to produce better health outcomes.
His themes are not new, but the emphasis on the need for courage is a recognition of the difficulties that lie ahead for those who resonate with the Commonwealth Fund’s mission. He has three areas where he wants us to focus. Maybe he has been on a recent winter hike with Willem Lange. I have bolded some of his points.
First, health care in this country is increasingly prioritizing revenue and profits over patients —and people are angry. Most notably, the UnitedHealthcare tragedy led to a tirade of public outrage and frustration about the business-as-usual practices of health insurers that can result in delayed or denied care, with financial and, sometimes, life-and-death consequences.
I can relate to the anger over “delay, deny, defend,” because following my carpal tunnel surgery, I was diagnosed with amyloidosis and ATTN-CM. Click on the link for a terrific three-minute presentation of the problem. I am told that I most likely have the “wild type” or “senile” form of amyloid. As depicted in the video, I have peripheral neuropathy and amyloid in my heart. There is medication that can slow the progression of this problem. It costs about $300,000 a year or $25,000 for thirty 61 mg doses.
My wife and I are covered by Federal Employee Blue Cross because she worked for many years as a nurse practitioner in cardiology at the West Roxbury Veterans Hospital. I have been denied twice by Blue Cross for the medicine, and I am currently awaiting the outcome of a second appeal. You can never tell when other people’s problems will become your own.
Dr. Betencourt continues:
But we saw the profit motive play out in other ways: there was the collapse of Steward Health Care, the nation’s largest for-profit hospital system. This event — a quintessential case study of private equity’s extraction of financial value at the expense of quality, safety, and patient care — destabilized the care of patients in multiple states and drew the ire of state leaders, and even a bipartisan coalition of congressional leaders.
Furthermore, evidence continues to mount that consolidation of large health systems doesn’t yield improvements in quality, safety, or control of costs. At the same time, health care providers, in unprecedented fashion, are organizing and unionizing as a counterweight to what they feel has been a move to prioritize the business of health care over the importance of patient care. Given the power of these forces, it will take courage, from many stakeholders, to turn this tide.
Second, people — even many people who have health insurance — can’t get the care they need because of costs or because they simply do not have access to the providers they need in their communities. Despite more people having health care coverage than ever before, our research found that nearly a quarter of working-age adults had insurance but were underinsured — that is, enrolled in health plans with high out-of-pocket costs that make it difficult to afford care. We see people skipping needed care, avoiding specialist visits, not filling their prescribed medications, and making heartbreaking choices between needed treatments and necessities like food or rent. At the end of this chain reaction are poorer health outcomes that are completely preventable.
Strengthening the Affordable Care Act will be critical going forward, and a real reckoning and repair of employer-sponsored insurance — which provides coverage to 172 million Americans — is necessary…
And third, here in the United States we spend the most — far more than other developed countries — but somehow have the least to show for it. We have lower life expectancy, higher infant mortality, more chronic disease and health disparities than counterpart nations across the globe. In addition, we have wide disparities across states in the U.S., in terms of health outcomes, access to care, quality, and equity…
Dr. Betencourt reminds us that depending on where you live your access to care and the quality of the care you receive can vary substantially. If you checkout the “scorecard” on the link below you will see that the worst care is usually in “red states.” Go figure.
Public policy and health policy matter when it comes to health outcomes. This is true not only in our global comparisons but also bears out when we look at our Scorecard on State Health System Performance and our State Health Disparities Report. Commitments to a strong safety net, universal coverage, and quality and equity separate the top from the low performers across the states — in outcomes, access, quality, and equity.
Our miserable results may be a function of our deficient system of primary care.
Another key differentiator is investment in primary care. Other nations devote 15 percent of their health care spending to primary care, but we commit a paltry 4 percent. …
…Changing course will require following the evidence, looking at other proven models, and ultimately courage from all stakeholders in the health care system: leaders, providers, patients. In the meanwhile, many wonder what the new administration’s health care priorities will be. Will Medicaid remain the program we know today, protecting our most disadvantaged neighbors? How will the growth of Medicare Advantage affect seniors’ access to care? Will there be fundamental changes to — or a dismantling of — the Affordable Care Act?
Dr. Betencourt blames our politics as a major reason for our miserable system, and he offers the promise of emerging technology to help improve care.
And then, there are forces at work bigger than the U.S. political system. For one, technological advances, including AI, remote patient monitoring, wearable health technology, and genomics are rapidly changing health care — and hold promise [to] make it more efficient and effective. But we must address the financing and implementation of these tools — and ensure they are not solely benefiting one group or population at the expense of everyone else. Public health, climate change, behavioral health, and maternal health remain fundamental challenges that will also require our resolute attention…
I want to look past Dr. Betencourt’s or Willem Lange’s descriptions of the problems we face in 2025 or our need for courage. I find myself asking how we will settle on an effective strategy for progress toward promoting a high-performing, equitable health care system for everyone. I have no confidence in the coming administration’s ability to move us toward that objective. Until we develop consensus on our own “concepts of a plan,” I see little hope for progress. We have the expectation of courageously treading water until those who were feeling unappreciated and unhappy with the cost of eggs begin to realize that metaphorically they shot themselves in the foot by casting their votes for a GOAT, a conman who is the Greatest Of All Time.
Monday Is A Big Day
On Monday you may spend some of the day watching the peaceful transfer of power. I won’t because the day is more important to me for two other reasons. It is the Martin Luther King Jr. holiday. I wonder whether MLK will get any attention while DJT is busy telling us how he will rescue us from all the problems he invented and sold to a majority saying that he could fix them quickly. I hope he did not oversell himself. I am looking forward to seeing all those promises being kept. What I am looking forward to for the weekend is a visit from my youngest grandson. His first birthday is on Monday!
The picture that I am using as the header for this letter requires some explanation. It is another screenshot from the beautiful work of my neighbor, Peter Bloch. He has been “studying” ice in a series of videos. You may remember that in the summer he gave us some remarkable underwater videos. He has now given us an “under-ice” video in what he calls “ANOTHER WORLD” UnderIce #1. Click on the title for a real treat. The video was made in one of our partially frozen creeks which means that in some shots, like the one I chose, the camera is looking up from underwater through a field that is past some ice looking toward the forest along the banks of the creek.
I hope that you have something relaxing planned for the long weekend. I am sorry that my memory of a truly great American will be encroached upon by an event for which I have no interest. I hear that Presidents Clinton, Bush, and Obama are passing on the inaugural lunch, but that there will be plenty of billionaires sharing the stage for all of the ceremonies. I guess those billionaires who bend a knee to Trump are the oligarchs that President Biden warned us about in his farewell speech on Wednesday night. Ytump should understand the former presidents skipping his lunch. Remember, Trump was the first president since Andrew Johnson to skip the inauguration of his successor. I am sure that something interesting will be said or done in Washington on Monday. I will just wait to read about it in the newspaper because I don’t want to spoil an otherwise terrific weekend. I hope that whatever you choose to do your weekend will be terrific!
Be well,
Gene
