September 5, 2025
Dear Interested Readers,
Trump Chaos Puts Clouds on the Future of Healthcare in America
The disturbing circus at the Senate Finance committee hearing yesterday featured verbal conflict between the Secretary of Health and Human Services, Robert F. Kennedy, Jr., and Democratic committee members, plus a couple of Republican Senators who are physicians, Bill Cassidy, M.D., a gastroenterologist, and John Barrasso, an orthopedic surgeon. It was the latest bizarre event that demonstrates the current turmoil and pitiful impending decline of American Healthcare while Donald J. Trump is president. Ironically, Mr. Kennedy owes his position to the reluctantly delivered vote for confirmation by Senator Cassidy.
After the bluster and the dust settled, as reported by the New York Times, nothing had changed. The ranking Democrat on Finance is Senator Ron Wyden of Oregon. His comment described the reality of the moment:
“It’s been obvious from the start that Robert Kennedy’s primary interest is to take vaccines away from Americans,” said Senator Ron Wyden of Oregon, the committee’s ranking Democrat. “His actions reveal a steadfast commitment to elevating junk science and fringe conspiracies.”
I didn’t expect any change in direction after the hearing. In the aftermath of the hearing, I found myself going back in my mind to last fall and the run-up to the election of President Trump. Despite Trump’s assertion that he had a concept of a plan for healthcare, I had no confidence that, whatever his plan was, the health of America would be improved. Whatever his plan was, I thought that it was unlikely that it would expand access to care, improve health equity, lower the cost of care, or improve the quality of care.
I suspected that the best predictor of the future of American healthcare and indications of any progress or not on our journey toward health equity or improvement in the Social Determinants of Health could be discerned by careful attention to the healthcare and social services comments presented in Project 2025. I was partially right. Now seven months into Trump’s second presidency, there is ample evidence that everything in Project 2025 is going to be tried, but the situation is even worse than one would have predicted after a careful reading of the document. With Robert F. Kennedy, Jr. leading HHS, we are headed to someplace that is worse than what a careful reading of Project 2025 would have predicted.
Perhaps beyond Kennedy, the reason that things are worse than one could have imagined last September or October is the complexity of the relationship of healthcare to every aspect of our domestic and foreign policy. Any part of a complex economy that is almost 18% of GDP can’t be modified without impacting every other aspect of our national agenda. Everything is ultimately connected in some way to our health, from foreign aid to predicting the weather, combating global warming, providing disaster relief, and supporting social programs that are critical to disadvantaged populations. Coupling the future of healthcare to the persistent demands to lower taxes, gut the “deep state” of the federal government, establish an autocratic presidency, cleansing the country of immigrants, and waging an internal culture war against “wokeness” leaves limited opportunities for such dated and discarded ideas as the Triple Aim and health equity.
Before the election, who could have understood the vulnerability of medical research to anti-DEI sentiment, trumped-up charges of antisemitism in our greatest universities, and misinformation about vaccines? In his introduction to a recent podcast entitled “MAHA Is a Bad Answer to a Good Question,” Ezra Klein comments:
Earlier this month, the Department of Health and Human Services, under the leadership of Robert F. Kennedy Jr., announced it would be cutting nearly $500 million in funding for mRNA vaccine development.
And it’s not only mRNA vaccines.
His cuts to scientific funding and grants and institutions broadly have thrown a huge amount of possibly lifesaving research into chaos.
Is any of this really going to make America healthy again? Obviously, I doubt it.
But what it does do is reveal what Make America Healthy Again is really about. I feel about that movement the way I felt about the Department of Government Efficiency: I’m fundamentally sympathetic to what it is promising to do. A department of government efficiency, an effort to make America healthy again — these are good ideas. Somebody should actually try them.
But MAHA, like DOGE, isn’t even attempting to do what is promised in the name. So what is it attempting to do? What are its actual ideas?
Those are great questions that get thoroughly discussed in the podcast that follows that introduction. My short take is that the focus Mr. Kennedy has brought to the chronic diseases of childhood and the imagined threats of vaccinations provides Trump with small gifts to give to part of his coalition of the unhappy and misinformed, who prefer agendas that avoid our community responsibilities to one another and proceed along a path that is labeled libertarian, even as it reduces many of our guaranteed liberties and is ultimately nihilistic. If you can’t make it better or if it offends someone in your loyalty club, blow it up, seems to be the theme of the day.
Last fall, my concerns for the future of healthcare began with the 8-10 percent of the population that still had no access to care. The majority of those disadvantaged individuals lived in the ten “red states” that had not accepted the federally funded expansion of Medicaid offered in the ACA. My next concern was for the quality of care for those who did have access. It was a concern to me that the increasing corporatization of healthcare had made the bottom line of practices and systems of care, whether non-profit or for-profit, more of a concern than the care of the individual patient. In this week’s New England Journal of Medicine, Amitabh Chandra and Mark Sheppard, two medical economists at Harvard, write:
…health care is exceptional among U.S. markets in that profits and value often don’t align.
First, patients may not be able to accurately assess the quality of medical care, so firms can make money by cutting corners, with little fear of affecting demand. Second, firms may engage in corporatization simply to build market power, which drives up prices. Third, many medical products and services are fundamentally unprofitable because people who could benefit from them cannot afford them. Society may value lifesaving HIV medicines, neonatal intensive care, transformative gene and cell therapies, or psychiatric services, but patients may have little ability to pay market prices for them. When quality is hard to assess, market power is sizable, and patients are vulnerable, corporatization carries the risk of increasing prices or reducing quality.
My first concerns were for access and quality, but the cost of care, and especially the increasing out-of-pocket costs of care, were troubling to me before the election. Remember, last fall, I had just learned that I had a potentially fatal disease, wild-type amyloidosis (ATTR-CM) (click here for a 3-minute video that explains the disease). I have early cardiac symptoms and debilitating symptoms of peripheral neuropathy that will probably force me to walk with canes for the rest of my life.
For a while, I was quite upset about my healthcare costs because the only medicine for my condition at the time was Vyndamax from Pfizer, which I was told would cost at least $225,000 a year, and my insurance had twice denied coverage. The price in England a few years ago was somewhat less at about 130,000 pounds or about $175,000, according to Google’s AI, but then why we pay more is another story. I did find that pharmacychecker.com currently suggests that the lowest “coupon” price for a daily dose of Vyndamax in the US, which has a two-page ad in the current issue of the NEJM, is $712.46. That would be $260,047.90 for a years supply.
Like many Americans, I was “fully covered” and still facing outrageous expenses. Indeed, before the election and since, I have been very focused on the cost of care, even though after two denials, I now get my Vyndamax for $65.00 a month through my insurer. I wonder how others with ATTR-CM are getting their meds. Despite my “good fortune,” I don’t see either Mr. Trump or Secretary Kennedy talking about the cost of care or the real problems that patients face. I also suspect that my disease isn’t getting much funding or attention, as they are busy dismantling medical research.
Since my earliest days of practice, I have been concerned about the stress associated with providing care. Improving the practice environment was one of the chief motivating factors in my decision to become the leader of the physician organization in my practice, then its board chair, and eventually its CEO. If you read these notes regularly, you know that I have continuing concerns about the joy of practice for all clinicians, and the shared stresses that clinicians carry with other healthcare professionals. My concerns about professional burnout, “compassion fatigue,” and moral injury for all healthcare providers have always been second only to my core concern about our service to patients. In an earlier article in the “Corporatization” series in the NEMJ, which I have previously reviewed, the focus was on the impact of corporatization on individual providers and practices. The future of practice and the stress felt by every healthcare professional were definitely core concerns for me before last year’s election.
I will admit that I may have taken the future of healthcare research for granted. Who could have predicted the current damage being done to the NIH, the CDC, and our academic centers of medical research? We are learning that you can undermine eight decades of progress in medical science in a few seconds with an executive order. Perhaps it is a gross exaggeration, but in my mind’s eye, the current state of our research establishment resembles the landscape in Gaza, a vista of rubble. Estimates that I have read suggest that Gaza will be a seaside resort before we can fully reestablish our research efforts. We have lost opportunities to search for effective cures for cancer and a host of other diseases to the foolishness of a quack who was empowered by a sociopathic narcissist who demands loyalty over talent or accomplishment.
And then there is our public health and our ability to track the status of infectious diseases around the world. In 2015, Bill Gates warned the world that a pandemic like COVID-19 could occur. We obviously didn’t pay much heed to the warning, and over a million Americans died. It is amazing that in yesterday’s hearing, Mr. Kennedy said that he did not know how many of us died in the pandemic. Secretary Kennedy also doesn’t know that it is estimated that 3.2 million lives were saved by COVID-19 vaccines. Just as Gates was predicting a pandemic in 2015, competent authorities suggest we can expect another pandemic at any time. It is not if, but when.
Perhaps the greatest irony of the two Trump presidencies is that Operation Warp Speed, which produced the COVID vaccines in an amazingly short time, is considered by many to be the greatest accomplishment of his first term. Now, that progress is being discarded. It seems likely that Secretary Kennedy and the president have already compromised our ability to quickly create an effective vaccine when the next predicted pandemic occurs.
I hope that I am wrong, but the Kennedy-Trump tag team never had a concept of a plan to Make America Healthy Again, and it seems unlikely that they have an effective plan in mind now. While Secretary Kennedy and the president dismantle healthcare and tell us that any day now they will have another analysis that will be a road map to preventing chronic diseases in children, they are ignoring the fact that guns are the number one cause of death for children. I wish my concerns were wrong, but I fear that just as I could not fully imagine last fall how much damage could be done in the first seven months of Trump’s second term, I can only partially imagine what lies ahead as we roll through the rest of his term. Chances are, he will exceed my expectations.
We Are Dry
The picture in today’s header looks like it is only a pile of rocks, when it is really the dry bed of the creek that carries water from my lake a short distance to a small pond that gives up its water over a falls to another short creek before it flows into a small lake that gives up its water to Lake Sunapee. Eventually, the water that flows from our lake finally gets to the Connecticut River, and from there, our outflow water heads to the Atlantic Ocean. Our lake is a little low; previously submerged rocks are visible, but the pond below us that gets its water from us is not much more than a mud puddle. We are in the midst of a drought.
We are hoping for a little rain this weekend. It’s strange, but if you are in a draught, it can look like you are having a long string of very pretty days. I wonder if many of those who proclaim loyalty to the chaos of the president think that they are enjoying sunny days when, in fact, we are all in a collective drought headed for a medical famine.
Enjoy your weekend. In times like these, when the weather and politics are both a bit dry, it is best to take life one day at a time. The long view is depressing.
Be well,
Gene
