Healthcare Musings For September 25, 2026

September 25, 2026

Dear Interested Readers,

 

Election Anxieties and Other Issues of Interest

 

It’s less than six weeks until the midterm elections, and  I am getting very nervous. The surprise of 2016 was a trauma from which I have never completely recovered. My candidate won in 2020, but he was never free of harassment despite trying hard to make a difference within his capabilities and against a very difficult COVID environment loaded with economic challenges. When the tables turned in 2024, I wasn’t surprised, but was nevertheless devastated because I knew the outcome would be a disaster for democracy in general and healthcare in particular. It has been much worse than I dared to imagine. 

 

Most of what I read suggests that a significant majority of voters want a change and that the Democrats have a statistically significant measured advantage in the polls. As the president’s behavior becomes increasingly unhinged, there are now suggestions of an impending “blue wave” that will give Democrats control of both the House and the Senate. I wish that I could believe it.

 

There are others like me who are beginning to believe that the more we despise the president for his attacks on reason, order, decorum, and progress based on science, the stronger he gets with his core voters, who loathe the things we value and try to defend. How all of the currents will interact with the desperation of an increasingly unhinged leader remains to be seen. With this man, the unexpected must always be included in your analysis of the possible.

 

If you followed the last link, you discovered a conversation about the president between Frank Bruni and Bret Stephens, two opinion writers at the New York Times who are usually a little more conservatively inclined than I am. The common ground we share is our disdain for the president and the damage that he has done to both the physical structures that have been symbols of our democracy, like the White House, and the plans that he has pushed for symbols that are at variance with our traditional approach to national pride, like his proposed arch, which in reality is more an attempt to honor himself in perpetuity than a symbol that will ever foster a positive image of our inherent struggle to become a pluralist society that offers a positive vision to the world. A positive monument to our nation’s greatness and a national monument to diversity, equity, and inclusion has stood at the harbor gateway in New York since 1886. 

 

The article is presented as a conversation, and during the conversation, Bruni comments:

 

The arch, the ballroom, the gutting of the Kennedy Center — they’ve helped me understand something I didn’t fully appreciate before. Though Trump is constantly called a builder, he’s the opposite. He’s a destroyer. Every edifice he creates or renovates (which is too kind a term) is a middle finger to what came before, a mockery of established taste, an insult and belittling of the people he dislikes. That’s why his fans don’t reject his architectural escapades as pure vaingloriousness. In giving physical form to his own contempt, Trump indulges and satisfies theirs.

 

Insights like this lead to important considerations as the midterms approach:

 

Here’s a serious question, Bret, because we haven’t gotten this right yet and the midterms are less than six weeks away and there’s no better time for us to finally figure it out: How do we — meaning not just the news media but also the voters who go to No Kings rallies and the Democrats vying for House or Senate seats — decide which outrages to scream about and which to ignore? Trump counts on our swinging at every pitch (what is it with me and baseball metaphors today?), because that blurs the crucial distinction between his grossest misconduct and his mere grossness.

 

Their conversion leads them to suggest a new strategic approach to contending with the president and, presumably, securing meaningful change from the midterm elections. Bret Stephens comments:

 

The people who won’t shut up about the president’s weight or hair dye or skin tone — especially when they are the same people who stayed mum about Joe Biden’s physical deterioration — are only helping him by feeding the very cultural resentments that fuel his base. But I also think the mainstream news media could help itself a lot if it just pruned every tendentious adjective from every story it writes about Trump. Those of us who believe in architectural understatement when it comes to our monuments should practice rhetorical understatement when it comes to our presidential criticism. Not because we are trying to mute our point, but rather because it’s a much more effective way of being heard.

 

That is probably good advice, but it is hard to accept. Their conversation is aligned with my anxieties about the election. Part of my anxiety is a consequence of what I see on television every night. I don’t like any of the political ads from candidates in both parties in my state that I see every evening along with the local and national news. All of the ads from both Democrats and Republicans are very negative or consist of statements that are lies at worst or distortions of the truth at best.

 

A good example of distortion is an ad from John Sununu, the Republican candidate for our open Senate seat. In the ad, Sununu claims that Chris Pappas, currently the Congressman from our first Congressional District, has voted against lower taxes for hard-working New Hampshire citizens for his own benefit as a millionaire businessman. (His family has owned a popular restaurant in Manchester for decades.) It is true that Pappas, like all Democrats, voted against his own personal best interest when he voted against the “One Big Beautiful Bill,” which was a great boon to wealthy Americans and denies real benefits like Medicaid and SNAP to millions of lower-income Americans. Sununu never names the tax-lowering bill he claims Pappas voted against, nor does he acknowledge that he personally benefited from the bill that Pappas voted against to his own disadvantage. I imagine that Sununu made out like a bandit when he gained the tax advantage offered to wealthy Americans through the OBBB.

 

It is distressing for me to see how far our political norms have sunk. I have heard no legitimate policy statements. What surprises me is that, even though “the elephant in the room” is the president’s performance and the failure of the Republican-controlled House or Senate to defend their role as described in the Constitution, that is never expressed in any of the ads. I just wish that someone would say, “Elect me to help the Democrats control the House and Senate so that we can begin to cut our losses and try to hold the president accountable for the damage that he has done and prevent the continuing damage to our economy, position in the world, and our healthcare.” The future of healthcare in America is a central political issue in this election.

 

Unfortunately, as Mr. Sununu continues to demonstrate, healthcare is such a complex issue that a candidate with the help of creative and misleading advertisements can present himself as an advocate for better care while consistently supporting an administration that is systematically defunding and dismantling the healthcare achievements of the last seventy-five years. The perfect example of this point is Sununu’s ad, in which he insinuates that the ACA is the problem and calls healthcare an expensive mess. He may be right about the state of healthcare, but he doesn’t own the reality that his party has done much of the damage and is promoting actions that will increase the number of people without access to healthcare and substantially increase the dysfunction and expense of healthcare for those who are theoretically covered.

 

He suggests that if he is elected, that will be the first step toward affordable healthcare. I wish that it were true, but I doubt other Republicans have just been sitting on their hands for the last several years waiting for Mr. Sununu to return to the Senate. He was elected to the Senate in 2002 and defeated in his reelection bid by Jeanne Shaheen in 2008.  Shaheen is now retiring. Now that she is retiring, Sununu is asking for a second chance, and, to my utter dismay, the race is essentially a toss-up.

 

As I mentioned above, coupled with his impossible claim that he will improve healthcare, he claims that the Democrat Chris Pappas has added costs to care and supported tax policy that takes money out of the pockets of patriotic and sensible New Hampshire residents. It is a trumpeting of the winning New Hampshire strategy. He promises lower taxes while claiming expertise he doesn’t have, and blaming his opponent for outcomes he did not cause. 

 

There are several other things besides deceptive political ads that make me apprehensive about this election.  My primary concern is the president’s willingness to disregard political norms and the Constitution, which means he could once again deny the results of the election after announcing before the fact that the election will be tragically flawed and stolen. The more he plants distrust before the election, the better positioned he is to deny the losses his party will incur. Secondly, the Republicans and the president’s billionaire bros in high tech, crypto, energy, and finance are taking full advantage of the Citizens United decision of the Supreme Court and spending hundreds of millions of dollars in races like the Senate race in my state. Thirdly, there is the lack of a coordinated message coming from the Democratic Party. Finally, the 41 days remaining before the election are plenty of time for some unexpected election-distorting reality, some domestic or international circumstance, to emerge that I can’t even imagine at this point.

 

I hope that I am wrong, and that Democrats will achieve a unification of voice around plausible policies, and find a way not only to win a substantial number of independent voters, but also say and do things that draw some of the committed MAGA supporters into a position of doubt about the sincerity of their dear leader. I know it is hard to admit that the man you trusted has made a fool of you for his own egotistical and self-serving purposes. If they can’t stomach voting for a Democrat, maybe the best alternative position is just to stay home on election day. 

 

This morning I began my day as usual by reading my newspapers and the opinion pieces I follow on Substack. It is often true that I find something at the last minute that bolsters the concern I am discussing in that day’s letter. So it was today, when I saw a New York Times piece entitled “How Worried Should We Be About the Midterm Elections? And how we learn to trust elections again.”

 

I won’t review it extensively, but I highly recommend that you listen to the 45-minute conversation or read the transcript, as I did, of the ideas that were presented by Sarah Isgur, an attorney, journalist, and former Republican operative, and Rick Pildes, an attorney and professor at NYU’s law school, who has argued election cases before the Supreme Court and is a student of the history of how our elections have changed over time. In the link above, we can read his qualifications:

 

His work in this field systematically explores legal and policy issues concerning the structure of democratic elections and institutions, such as the role of money in politics, the design of election districts, the regulation of political parties, the structure of voting systems, the representation of minority interests in democratic institutions, and similar issues. He has written on the rise of political polarization in the United States, the transformation of the presidential nominations process, the Voting Rights Act (including editing a book titled The Future of the Voting Rights Act), the dysfunction of America’s political processes, the role of the Supreme Court in overseeing American democracy, and the powers of the American President and Congress. 

 

At the end of their very interesting conversation, we read:

 

 

 

Bill Barr is no longer at the Department of Justice to operate as a restraint on the president’s impulsive expressions of his anger and autocratic tendencies. Now we have Todd Blanche, a known enabler of some of the president’s most outrageous actions, as Attorney General. Professor Pildes seems cautiously optimistic about the election, but his cautious optimism leaves me feeling anxiously pessimistic. If you yearn for a reversal of the decline in America’s system of care, medical education, public health, and medical research, there is nothing more important for you to do over the next 41 days than to get involved in the effort to curb Trump’s continuing attacks on healthcare and our nation’s place in the world as a positive influence for human rights and as an advocate for a stable world order than by working for candidates that will be part of a Democratic majority in the House and Senate.

 

Shifting gears, I would like to report on my wife’s post-CVA progress over the past week, since so many of you have expressed concern after I mentioned her stroke in last week’s letter. I am happy to report that she has made substantial improvement since her small stroke that temporarily paralyzed her left arm and hand. She is not back to “normal,” but her progress has greatly reduced her limitations, and she continues to improve. What isn’t resolved is the concern about how vulnerable she might be to another event.

 

Most of her outpatient workup has been completed. There remains ambiguity about the origin of her CVA, and what constitutes the best long-term treatment given her age and associated Parkinson’s. I am just relieved to see her getting better. The most likely cause was a small embolism. A much less likely explanation is that vascular disease and subsequent occlusion of a small vessel was the cause. There is no evidence of a “brain bleed.” Her treatment for the risk of vascular disease has been optimized. Her hypertension is improved with a recent change in her antihypertensive medications. A statin has been added to bring her LDL, which was already below 100, much lower. She is also taking both Plavix and aspirin. 

 

The questions that persist are whether she has had occult atrial fibrillation that should be treated with anticoagulation or whether she had a paradoxical embolus through her patent foramen ovale, which was confirmed on an echo last week with a positive bubble study that showed right-to-left flow when her right atrial pressure was increased with a valsalva.

 

One might ask, “Why not just put her on a long-term course of anticoagulation?” The answer is that she is 80 years old and, from her age and concurrent Parkinson’s disease, she has a fall risk. Closer of the PFO seems like over-treatment. I have great sympathy for her new stroke specialist who must help her resolve these ambiguities. Once again I am reminded that much of the practice of medicine is about helping patients navigate uncertainty, and that task is very difficult when the time per patient is compromised by workforce shortages and compromised finances.

 

All of this ambiguity was reviewed during our meeting with the “stroke neurologist” this Wednesday at Dartmouth Hitchcock Medical Center. I was delighted when the neurologist asked if he could use the AI program on his cell phone to document our visit. Once that was in place, his only need to use the computer was to look up recent and past studies. He also demonstrated evidence that he had thoroughly reviewed the events of her hospitalization prior to our visit. 

 

My wife’s event clearly demonstrates that healthcare finance remains a significant concern. The notices for the cost of her 36 hours at the hospital, along with some of the post-hospital tests and consultations, are showing up in a series of emails. So far, the total prior to our visit on Wednesday was a little north of $33,000. Our share of the expense so far is about $1000. I expect both numbers will continue to rise. 

 

Wednesday was also an important medical day for me. I had a 10 AM appointment at DHMC for my first injection of a new medication for my amyloidosis. My appointment was at 10 AM, and hers was at 2 PM. I have had my own healthcare finance shock and relief recently. As I have previously reported. I was diagnosed about two years ago with wild-type amyloidosis. My symptoms have been the symptoms of congestive heart failure, which are fairly well managed with a combination of lisinopril, hydrochlorothiazide, spironolactone, low-dose aspirin, and dapagliflozin (Farxiga), an SGLT2 inhibitor, plus prn furosemide. After my workup about two years ago, I was started on tafamidis (Vyndamax), which is effective at reducing CHF hospitalizations and improving longevity in amyloidosis by stabilizing transthyretin protein in the periphery. After some delay in the approval process for this expensive drug ( $250,000 to $300,000/year), Blue Cross gave it to me for $65.00 a month. I was delighted. I was even happier when, a few months later, I received notice from Pfizer that I could be enrolled in a program that would provide it to me for free. 

 

At my last visit with my cardiologist, my primary complaint was my peripheral neuropathy, also caused by amyloidosis, which greatly limits my mobility. I don’t leave the house without at least one crutch, and on most of my walks I use two. My median nerve symptoms were improved with carpal tunnel surgery, but now I am having more frequent symptoms from ulnar neuropathy. My cardiologist reported that peripheral neuropathy symptoms could possibly be improved with a newer, different medicine, Amvuttra (vutrisiran), an RNA inhibitor that reduces amyloid production by blocking the liver’s production of transthyretin, the protein that misfolds to create amyloid. Amvuttra also shows benefit for the cardiac manifestations of amyloidosis. There have been no studies comparing Amvuttra and Vyndamax, nor any studies examining combination therapy. Treatment consists of an injection every three months that is done at the hospital so that it is treated as a procedure rather than a drug for the purpose of insurance coverage. Each injection costs $125,000, so a year of treatment costs $500,000. I was warned that there would be a risk of denial. The initial request to Blue Cross was met with a demand for the same information confirming my clinical status and diagnosis that they required before approving the request for Vyndamax. Based on the positive attitude of the nurse practitioner who assisted me with the application and who will administer the drug, my first injection was scheduled a month ago for last Wednesday, even before I was approved.

 

When Monday arrived without any notice from Blue Cross, and the first treatment was scheduled for Wednesday, I decided to fight the phone tree at Blue Cross. I was delighted that, after about an hour of back-and-forth with a clerk, she told me I had been approved. I was relieved. Ironically, when I went to the post office to pick up my mail on Monday afternoon, I found a letter from Blue Cross saying I was approved. 

 

There is no medical contradiction to taking both Amvuttra and Vyndamax. No study has ever looked at the potential benefit of combination therapy, and I was told that there were no plans to do so and no plans to assess which drug is better. It would be bad business for the companies to allow a study to answer the question of which therapy was best, the production blocker, or the stabilizer. I have decided to use both meds until I am told that I must choose one. I was told that some patients took both, while others chose one over the other.

 

What seems to determine treatment is what Medicare, Medicaid, or commercial insurance will pay, or what your cardiologist recommends. Mine is open to my using both therapies. Until I am told by Blue Cross to choose one over the other, or my cardiologist changes her opinion, I will take both and accept the uncertainty and ambiguity about optimal management, since research into combined therapy is unlikely to occur in my lifetime. 

 

With the new treatment, I am focused on the hope that my peripheral neuropathy will stabilize or improve. I do reflect on the high cost of my treatment. When I looked at the little pre-filled syringe from which I was about to get an injection, it was hard to imagine that the cost of that little bit of medicine was $125,000. When I feel a little greedy about my own healthcare, I rationalize that there are others with similarly expensive therapies for a whole host of diseases that we can now treat, but for my disease and probably other diseases with new and expensive treatments,  business and political reasons prevent us from studying what constitutes the best practices that deliver the best outcomes for the most people. 

 

Like other patients, my wife and I value life and our continuing relationships with family and friends. We talk a lot about the issues of aging and mortality. The “unexpected” is an aspect of the uncertainty and ambiguity present at any moment in life, and, logically, should decrease with age, but paradoxically seems to increase as age makes you more aware of the time limitations we all share. We were shocked recently to learn of the unexpected death in a car accident of one of my medical school classmates and his wife just a couple of weeks after enjoying a meal with them at our class reunion.

 

We want to continue contributing, and we are grateful that research may extend our lives. We are also cognizant that for political reasons what we enjoy is not available for everyone, even though as a nation we collectively do have the national expertise and wealth to do the research that would reduce the uncertainty and ambiguity about best practices and probably lower the cost of care while extending the benefits of the new knowledge to everyone.  We do live in strange times, where ambiguity and uncertainty exist not only in managing complex medical conditions, but also in knowing with any certainty how much we are each entitled to receive.

 

It’s Fall, But Hints of Summer Linger

 

This week, fall arrived. On most days, the sky was almost cloudless. It was beautiful, but on the chilly side. During our nights, the temperatures dipped to the low forties. During the day, the highs were in the mid-sixties. The ferns along the road to my house are turning brown, and many of the trees are transitioning from green to their fall colors. The prediction for this fall is that it will be one of the most colorful in several years. Maybe you should plan a weekend trip to New Hampshire, but not this weekend since we are expecting heavy rain all weekend from a “nor’easter. “

 

Eighteen years ago, when we bought this property, the yard was small, and what yard we had was crowded by fairly dense woods. I imagined playing with my grandchildren in the front yard, so we cleared some of the trees to make the yard larger. Later, we imagined that some of the area we had cleared should be planted in native wildflowers. That didn’t go as well as planned, so we reverted most of the area back to grass, but there has been a persistent ring of wildflowers between the wooded part of our property and the yard. 

 

This week, I was struck by the beauty of a persistent rim of goldenrod and purple Joe Pye Weed and decided to take some pictures. While I was taking my pictures, a beautiful Monarch butterfly flitted from flower to flower. There were also several bees taking advantage of the nectar in the flowers. The scene was unique. Sunlight, clear skies, beautiful flowers, and a butterfly that was probably preparing for a long trip to Mexico came together for just a few minutes to make my day. I felt it was a special gift. 

 

As I mentioned, we are expecting heavy rain this weekend. We are the last stop of a vicious storm coming up the East Coast. Rainy days are a challenge for me, and I will be looking for a short break in the weather during which I can get in a couple of miles. If the break doesn’t come, I will just get wet and hope to be rewarded with something unexpected, like a butterfly in the fall. Enjoy the early fall. None of us have long-term guarantees, so make every day an adventure. 

Be well,

Gene