Healthcare Musings For October 3, 2025

October 3, 2025

Dear Interested Readers,

 

Slipsliding Away: Healthcare’s Impending Decline in a “Failing Democracy”

 

I imagine that many of my readers are tired of my comments about politics and the threat that President Trump poses to continuous improvement in our nation’s health and its culture of democracy. I am also tired of writing about his assaults on progress, but to my ear, he is turning up the volume of his threats to our privilege of free speech. He is aggressively deconstructing thirty years of effort to move toward universal access to equitable healthcare. 

 

I am tired of the president’s references to “the radical left Democrats” and the “vermin” among us. I fear the outcome of his pandering to those who favor Christian Nationalism, which is an affront to my own sense of the importance of the strict separation of church and state.

 

I want nothing more than to celebrate our advancement toward the Triple Aim. Still, we are left scrambling to defend and preserve fragments of previous accomplishments, such as the Affordable Care Act, which was the product of years of effort and collaboration. Perhaps, someday I will write my last letter warning of further losses to his MAGA movement, but that day seems to be a distant aspiration. 

 

So, it is with regret that again I must remind you that we have had another chaotic week in the midst of a decline in our democracy. The president is driving the country toward a “far-right kleptocracy” verging on becoming an autocracy. His effort is supported by lies and policies that represent an unprecedented abuse of a significant portion of the population who have been drawn to the fascination of his self-congratulatory disregard of all the norms that are foundational to a Democracy. 

 

For a democracy to survive, most of us must voluntarily abide by the unwritten social norms that include the acceptance of individual rights, including fair treatment for everyone, including “illeagal immigrants,” under the rule of law,  allegiance to the spirit of the Constitution, and a culture of respect for individuals, no matter their social status or political point of view.

 

I am stretching the definition of kleptocracy just a bit. But the self-dealing that Trump does for himself, his family, and those from whom he demands loyalty is close to the concept as defined by Wikipedia:

 

Kleptocracy (from Greek κλέπτης kléptēs, “thief”, or κλέπτω kléptō, “I steal”, and -κρατία -kratía from κράτος krátos, “power, rule”), also referred to as thievocracy, is a government whose corrupt leaders (kleptocrats) use political power to expropriate the wealth of the people and land they govern, typically by embezzling or misappropriating government funds at the expense of the wider population. One feature of political-based socioeconomic thievery is that there is often no public announcement explaining or apologizing for misappropriations, nor any legal charges or punishment levied against the offenders.

 

If you want to quibble over what we do have at the moment, I would argue that the best description may be a “failing democracy” with emerging characteristics of a kleptocratic autocracy. I contend that this week, we have seen the most significant evidence yet that our democracy is on the brink of failure. We will likely still have elections in 2026, although they are likely to be flawed by gerrymandering and a raft of new state laws and court decisions that are undermining the progress made under the Voting Rights Act of 1965.

 

Our Congress fails to function as designed. The judicial branch appears to be functioning in the lower courts, but the Supreme Court is enabling rather than checking the executive branch’s expansion of its powers far beyond the concept of the founding fathers as described in Article II of our Constitution. We see the president weaponizing the Department of Justice for revenge against those who have opposed him or his policies. The defunding of programs and agencies is undermining healthcare progress through executive order, budget cuts, and the obstruction of independent responsibilities of agencies that Congress previously approved. He and his appointees, such as Robert F. Kennedy Jr., are redirecting the mission of key research efforts and agencies responsible for public health.

 

Perhaps of all the things that have happened over the last eight months, the action that is likely to harm the most people in the near future was the passage of the president’s One Big Beautiful Bill (OBBB) that diverts hundreds of billions of dollars from various components of our social services safety net toward more tax breaks for the wealthy.

 

Since last January, it has been excruciating to watch the reversal of decades of progress toward better medical science, improved access to care, and the erosion of gains to improve the Social Determinants of Health. Those of us who believe that the future health and success of the nation have been confused about the options available to push back against the destructive actions of the president, which seem to increase with each passing day. There were many on “the political left” who felt that Senate Democrats missed a push back opportunity last March when Senate Minority Leader Chuck Schumer convinced enough of his colleagues to vote with him for a temporary continuance of the budget and avoid a government shutdown. 

 

Schumer contended at the time that there was more to lose from a government shutdown than to gain from blocking the passage of a “continuing resolution.”  He feared the potential pushback against Democrats from the public. He contended that Democrats were making progress in protecting critical programs through court actions. The last six months have proven that Schmer’s hope for improvement in the courts has been a disappointment. No one knows now which party will get the most blame from the public for a shutdown. Still, now, he has urged Senate Democrats to oppose the continuing resolution bill passed by the House, primarily because as many as 15 million or more people will lose their access to care. Millions more will need to pay as much as double to keep what they have through the ACA when market subsidies end at the end of December. 

 

The millions who will lose access to care will also result in financial difficulties for some of our more vulnerable hospitals and practices that serve the people who will lose their coverage. The Democratic “ask” is simple. They want Republicans to repeal the parts of the One Big Beautiful Bill that undermine Medicaid, SNAP, and other critical programs for people with low incomes among us, and to extend the subsidies to the ACA marketplace policies. The Nobel Prize-winning economist Paul Krugman explained it all very well in a post earlier this week before the shutdown. His succinct summary was:

 

Many people will face massive increases in their insurance costs. The effects on the risk pool will magnify these increases, as some healthy people will drop out, raising premiums for those who remain.

In other words, millions of Americans will soon be screaming about unaffordable health care.

In a way, I’m surprised that Republicans didn’t decide to keep the enhanced Biden subsidies in place for another year, to delay the pain until after the midterms. But they didn’t, probably because they have such a strong aversion to helping Americans in need that they couldn’t even bring themselves to play cynical politics on the issue.

This aversion to doing anything decent is why the government is likely to shut down on Wednesday. Republicans need Democratic votes to keep the government open, and Democrats have made retaining enhanced subsidies their price for cooperating.

What will happen then? I have no idea. However, I believe the Democrats made the right choice when they made health insurance premiums — rather than, say, tariffs — their primary demand.

 

We are now in the midst of the government shutdown, which is a hopeful strategy by Democrats that could preserve access to care for millions of Americans. I am not optimistic that a miracle will occur and that Republicans will grant the demands of the Democrats, which would allow the preservation of the modest gains in access to care that have been accomplished through the ACA. The next few days and perhaps weeks will be a nightmare for us all. It will be excruciating for federal workers, and some may even lose their jobs. If you have travel plans, you may experience delays at the airport. No one knows what will happen, but what we do know is that many vulnerable people will face certain losses if the One Big Beautiful Bill is not modified and the support for the ACA ends.

 

If the Democratic resistance holds and access to healthcare is preserved for millions, it will be more than just a victory for healthcare; it may mean that, despite being crippled, our democracy is not dead yet. Unfortunately, pushing back in the Senate won’t remove all the concerns about the health of our democracy that recent events have heightened. An objective review of American history suggests that political violence has been a recurrent theme. The violence is often a manifestation of frustration or anger. I can’t remember any positive changes that violence has effected that could not have been accomplished more effectively by other approaches.

 

It is too early to write the history of the ultimate impact of the shooting of Conservative activist Charlie Kirk. Still, that event did lead to an attempt at suppressing freedom of speech, as demonstrated by the temporary cancellation of Jimmy Kimmel’s late-night comedy show. Part of the “suppression” involved the threatened misuse of regulatory power by FCC Chairman Brendan Carr to intimidate the Disney Corporation and its Chairman, Robert Iger. The fact that widespread pushback and the threat that the Disney Corporation would lose business on the air and at its theme parks suggested that a government shutdown is not the only way to resist oppressive actions from a government. 

 

The government shutdown and the attempt to silence Kimmel may be positive over time. Still, I see the controversial indictment of James Comey on trumped-up charges of lying to Congress as the latest reason for concern about the future of our democracy. With the action against Comey, the president demonstrated his willingness to weaponize the Justice Department to exact revenge against those who opposed him or had failed to pledge their loyalty. Comey did both. In anticipation that Comey won’t be the last Trump target, I asked Google for a more complete list of Trump’s targets:

 

Individuals Trump has publicly pushed for the Justice Department to prosecute or has otherwise targeted include:

• New York Attorney General Letitia James: James successfully led a civil fraud lawsuit against Trump and his business empire, resulting in a verdict of over $450 million. Trump has repeatedly called for her to be prosecuted and jailed.

• Senator Adam Schiff: As a former House Intelligence Committee chair and lead impeachment manager during Trump’s first impeachment, Schiff has been a frequent target. Trump has publicly pushed for his prosecution for alleged mortgage fraud and labeled him a “traitor”.

• George Soros and other liberal funders: Following the death of activist Charlie Kirk in September 2025, Trump issued a presidential memorandum directing federal agencies to investigate foundations and activist groups he linked to political violence. He has specifically singled out Soros and his son.

• Members of the January 6th Committee: Trump has called for the members of the House committee that investigated the January 6th Capitol attack to be prosecuted for “fraud and treason”.

• Mark Milley: The former Chairman of the Joint Chiefs of Staff has been accused of treason by Trump for making back-channel calls to China at the end of his first term. Trump has repeatedly suggested Milley should face severe punishment.

• Alvin Bragg, The Manhattan District Attorney who secured Trump’s conviction on 34 felony counts in 2024, has been called for prosecution by Trump.

• Former FBI officials: In addition to Comey, Trump has targeted other former FBI officials involved in the Russia investigation, including Andrew McCabe and Peter Strzok.

• Former Speaker Nancy Pelosi: Trump has called for Pelosi to be prosecuted, specifically referencing her response to his 2020 State of the Union address.

• Hillary Clinton: A longtime target of Trump’s, Clinton has faced repeated accusations related to her use of a private email server and the 2016 election. Trump has amplified calls to “lock her up”.

• Joe Biden and family: Trump has repeatedly accused Biden and his family of corruption and has vowed to appoint a special prosecutor to go after them. 

 

If the thought of even some of these individuals following Comey into indictment worries you, you might want to gauge the health of our democracy. I decided to ask ChatGPT to describe the characteristics of a failing democracy. So I asked:

 

What are the signs of a failing democracy?

ChatGPT said:

Great question — and a vital one, especially in today’s climate. Political scientists, historians, and democracy scholars (like Steven Levitsky & Daniel Ziblatt in How Democracies Die, Yascha Mounk, and Larry Diamond) have identified warning signs that democracies are weakening or sliding toward authoritarianism. While each country has its own trajectory, there are common markers:

Signs of a Failing Democracy

1. Erosion of Democratic Norms

• Leaders undermine the legitimacy of elections (claiming fraud without evidence, refusing to accept results).

• Politicians violate unwritten rules of restraint, compromise, and fair play.

• Expansion of executive power at the expense of checks and balances.

2. Weakening of Institutions

• Courts, legislatures, and independent agencies (like election commissions, watchdogs, or regulators) are captured or politicized
• Attacks on the free press and civil society groups.

• Declining respect for the rule of law (selective enforcement, immunity for allies, harsher treatment for opponents).

3. Disenfranchisement and Inequality

• Voting rights are restricted through gerrymandering, voter suppression, or discriminatory policies.

• Political and economic power concentrate among elites, while marginalized groups lose influence.

• Deepening polarization fractures society into hostile camps, making compromise impossible.

4. Normalization of Corruption & Disinformation

• Government transparency declines; corruption is tolerated or excused.

• Disinformation campaigns (often amplified on social media) undermine shared truth, replacing fact with propaganda.

• Citizens lose faith in the possibility of objective reporting or trustworthy institutions.

5. Persecution of Opponents & Minorities

• Opposition parties are smeared, harassed, or legally restricted.

• Minority groups become scapegoats for societal problems, stoking fear and division.

• Laws or norms protecting civil liberties and human rights are weakened.

6. Violence or Threats in Politics

• Political leaders tolerate or encourage violence against rivals or critics.

• Militias, extremist groups, or partisan security forces intimidate citizens.

• Peaceful transfers of power become uncertain.

7. Loss of Public Trust

• Citizens disengage, believing the system no longer represents them.

• Low voter turnout, rising apathy, or alternatively, increased protest movements signal legitimacy crises.

• People begin to see authoritarian alternatives (a “strongman,” military rule, or populist demagogues) as preferable to democratic compromise.

Metaphor from History

Democracy rarely collapses overnight. More often, it’s a gradual decay, like termites hollowing out a wooden house: the structure looks fine from the outside until it suddenly crumbles. Democracies often fail not from a single coup, but through incremental erosion of trust, fairness, and accountability.

✅ Summary:
A democracy is in danger when leaders weaken institutions, citizens lose faith in fair play and truth, political rivals become enemies, and violence or corruption replace compromise. The most reliable early warning sign is when those in power stop respecting the rules that limit their own authority.

 

ChatGPT is good at asking follow-up questions, so I was not surprised when it asked:

 

Would you like me to map these warning signs onto the U.S. today, showing where scholars believe the country is most at risk right now? 

 

There was only one answer for that question, I said, “Yes!”

 

ChatGPT said:

Alright — let’s map the warning signs of democratic decline onto the current U.S. context (as of Trump’s second presidency, 2025). Many scholars, journalists, and watchdog groups (Freedom House, Brookings, Carnegie Endowment, etc.) argue that the U.S. shows several symptoms of democratic backsliding, even if its institutions remain resilient compared to weaker democracies.

Warning Signs of Democratic Decline in the U.S. Today

1. Erosion of Democratic Norms

• Election Legitimacy: Donald Trump and allies continue to cast doubt on the validity of elections, even after certified results, eroding trust in democratic transfer of power.

• Rule-breaking as routine: Norms like respecting judicial independence, avoiding conflicts of interest, and maintaining professional civil service are being ignored or actively dismantled.

2. Weakening of Institutions

• Courts: Increasing efforts to reshape federal courts with ideologically loyal judges.

• Independent Agencies: Agencies like DOJ, EPA, HHS, and even the Department of Education are increasingly politicized, reducing their independence.

• Checks and Balances: Congress is less able to constrain executive power due to extreme partisan loyalty.

3. Disenfranchisement and Inequality

• Voting Rights: Stricter ID laws, purges of voter rolls, and limitations on mail-in/early voting disproportionately affect minorities, younger voters, and low-income populations.

• Gerrymandering: Redistricting continues to distort representation.

• Economic Inequality: Tax and budget priorities tend to benefit the wealthy, while safety nets (SNAP, Medicaid, LIHEAP) face cuts — leaving poor and working-class families with less voice and security.

4. Corruption & Disinformation

• Disinformation: State-aligned media outlets and partisan platforms push narratives that delegitimize political opponents and blur truth/facts.

 

One current example of political lying is that the president, Vice President J.D. Vance, House Speaker Mike Johnson, and other Republicans are claiming that the Democrats are throwing the government into a shutdown to preserve access to the ACA for illeagal immigrants. Illeagal immigrants have no access to the ACA.

 

• Transparency Decline: Limits on public data, cancellation of certain research grants, and restrictions on government scientists speaking freely weaken accountability.

• Normalization of Corruption: Ethical scandals that once might have ended careers now barely register, signaling desensitization.

5. Persecution of Opponents & Minorities

• Targeting Universities & Press: Attacks on elite institutions like Harvard, Columbia, and independent media outlets undermine spaces for dissent and academic freedom.

• Immigrants: Immigration crackdowns, cuts to asylum protections, and anti-immigrant rhetoric position immigrants as scapegoats for economic and social problems.

• DEI Bans: Executive orders banning diversity, equity, and inclusion programs curtail civil rights protections and increase vulnerability for marginalized groups.

6. Violence & Intimidation

• Rhetoric of Violence: Political language often portrays opponents as enemies, fueling polarization.

• Extremist Groups: Militia-style groups and online radical movements feel increasingly legitimized, posing risks of political intimidation or sporadic violence.

• January 6 Legacy: The precedent of political violence to challenge election results remains unresolved, with some political leaders minimizing or even justifying it.

7. Loss of Public Trust

• Polarization: Americans increasingly distrust institutions (Congress, media, courts, even the military).

• Civic Cynicism: Many voters feel the system no longer serves them, leading either to disengagement (not voting) or attraction to strongman politics.

• Democratic Satisfaction: Polls show declining belief in democracy as the best system, especially among younger and more economically insecure Americans.

What This Means for the Social Determinants of Health

• Healthcare, education, housing, and social safety nets are highly sensitive to political choices. As federal programs are cut, inequality deepens, worsening outcomes for low-income families.

• Academic restrictions limit research into public health and social policy, undermining long-term problem-solving.

• Polarization makes bipartisan reform almost impossible, stalling progress on urgent issues like primary care shortages, climate resilience, and healthcare costs.

✅ Summary:
The U.S. today shows many classic warning signs of democratic backsliding: erosion of election legitimacy, weakened institutions, voter disenfranchisement, disinformation, scapegoating of minorities, and declining trust. While democracy remains intact, the trend lines suggest growing fragility, with direct consequences for healthcare, education, and social well-being.

 

Apparently, ChatGPT did not know that the president suggested this week during a bizarre conclave of generals and admirals that the military use dangerous cities [presumably those with Democratic majorities] as “training grounds.”  

 

I have no reason to doubt or deny that we are living in a failing democracy. When I encountered a patient with behaviors that I thought posed a risk to their future health, I felt it was imperative to offer a warning and all possible support that could preserve the patient’s health. It seems logical that I should apply the same approach to my concerns about our collective health, which is at risk due to a failing democracy. It has become true that when I open my computer each morning, I am afraid of what I might see. The concern doesn’t go away, and often, as has happened several times over the last few weeks, my concerns increase. So, I will continue to point out how I fear that tolerating a failing democracy will compromise the future of our healthcare. What we have built is “slipsliding” away when we should be capitalizing on years of experience and a tradition of government under the rule of law and our Constitution to continue efforts to improve the health and opportunity enjoyed by every American.

 

Fall Is Here

 

We have had a week of gorgeous fall weather. I snapped the picture that is today’s header on Tuesday. It shows some early color. Since I took the picture, we have been seeing even more color. It seems to increase by the hour. I have also seen a few buses filled with “leaf peepers” rolling by. The colors are pretty, but this year they seem muted. It is reported that the duller colors and the earlier appearance of color in our leaves this fall are a result of our drought.

The drought we are experiencing is reportedly another manifestation of global warming, which our president denies is a reality. If things are warmer, he claims there is no connection to our use of fossil fuels. He is rolling back our attempt to utilize renewable energy sources at the behest of the oil and coal producers. I don’t believe in hell as a possible afterlife experience. Still, it seems likely that our grandchildren may experience hell on earth, and the early appearance of fall color may be just a subtle warning of what is to come.

 

On Wednesday, my wife and I joined the flow of leaf peepers heading north to see friends who had just completed a new home in Littleton, New Hampshire, near Mount Washington. As you go North, through Franconia Notch, the colors are better, and there are many more peepers. It appears to me that we are about a week away from peak, but even if it is a little early, the trip is worth the effort. 

 

In New Hampshire, we need the tourist dollars of leaf peepers. Canadian visitors are a big source of income for our economy, and they are treating us as if we have a highly contagious infectious disease. They may be right. 

 

Trump does have more potential impact on the future of “fall” than either you or I. His lack of concern, and even denial, about the reality of global warming almost certainly will lead to more droughts in our future, along with duller fall colors. My advice is to get out and enjoy the muted colors and balmy weather, even though we may be previewing a future with continuing drier, warmer, duller fall days.

 

If it seems that I am in a down mood, it is in part because the Yankees have eliminated the Red Sox in the first “wild card” round of the playoffs. If, by accident of birth, geography, or just poor judgment, you are a Yankees fan, good luck in the next round. 

Be well,

Gene