Healthcare Musings For November 22, 2024

November 22, 2024

Dear Interested Readers,

 

To Survive the Next Four Years, Think Globally and Act Locally

 

I am tired of reading about the election. I have been both entertained and horrified by President-elect Trump’s announcements of the people that he will nominate for his cabinet. He seems to nominate people with employment histories that include Fox News or have appeared frequently on Fox. High-level expertise in the areas they will potentially manage seems not to be a prerequisite that the president-elect is using to make his selections. I have heard that loyalty to Trump and his myths and a nominee’s TV appearance trump subject matter expertise and perhaps loyalty to the Constitution. No matter what the explanation, he did win the election, and I must wait and see what it will be like for Robert F. Kennedy, Jr. to be Secretary of Health and Human Services and Dr. Oz to be CMS Administrator.

 

After Matt Gaetz withdrew his nomination for Attorney General, I was delighted until I heard a commentator suggest that perhaps Trump nominated Gaetz as part of a strategy. As the theory was described, Trump knew that many of his nominations would be atypical and insight resistance from the Senate. The theory proposes that he nominated Gaetz knowing it would enrage several Republican senators. Gaetz would withdraw. The senators would feel good about defending the Senate’s “advise and consent” responsibilities with the Gaetz nomination and then rubber stamp all the rest. I am not sure the president-elect is that strategic, but I hope that will not be how things play out because there are several nominations— Gabbard, Hegseth, and Kennedy to name three—who I would hate to see confirmed.  

 

So far, the cabinet selections that Trump is making seem consistent with strategies outlined in Project 2025. You might remember that during the campaign and before the election Trump claimed that he didn’t have any connection to the Heritage Foundation’s Project 2025, and he declared that Project 2025 was not a document that he would follow. His claim was confusing because the people behind Project 2025 were some of his most loyal MAGA activists who were advocating for a radical restructuring of the government and how Washington works. I thought I would check this impression with my Chatbot buddy and see how the president-elect’s healthcare leadership selections might be in sync with Project 2025, so I asked:

 

Please review the healthcare recommendations in Project 2025 and how the selections of RFK, Jr. as Secretary of Health and Human Services and Dr. Oz as CMS Administrator might facilitate these recommendations. 

 

The Chatbot responded to my request with an analysis that referenced an article from the American Public Health Association entitled “Project 2025–A Threat to Public Health”, and an article from Media Matters entitled “Former Project 2025 director suggests RFK Jr. should run the CDC, HHS, or FDA in a second Trump administration.” It wrote:

 

Project 2025, developed by conservative organizations led by the Heritage Foundation, offers a blueprint for a significantly restructured federal government with major implications for healthcare. If Robert F. Kennedy Jr. and Dr. Mehmet Oz were to lead the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) respectively, these appointments could potentially align with the recommendations outlined in Project 2025.

Key Healthcare Recommendations in Project 2025:

• Restructuring Public Health Agencies:

• The plan advocates splitting the Centers for Disease Control and Prevention (CDC) into two separate entities: one focused on data collection and another on policy recommendations. This would reduce the CDC’s authority to issue prescriptive public health guidance, such as vaccine or mask mandates.

• It also suggests limiting the role of the CDC to evaluating health-related costs and benefits, excluding social factors from consideration.

• Restricting Reproductive Health Access:

• The document recommends restricting access to abortion services, including ending the use of medications like mifepristone and curbing “abortion tourism.” It also seeks increased state-level abortion reporting and reduced funding for organizations supporting abortion access.

• Revising Vaccine and Health Policy:

• It proposes reducing federal influence over vaccine mandates and opposes the use of vaccines developed using certain technologies, aligning with RFK Jr.’s past criticisms of vaccine safety and mandates.

• Medicaid Overhaul:

• The plan supports adding work requirements and capping Medicaid benefits, which would particularly impact low-income populations and those with chronic conditions.

• Rollbacks on Equity Initiatives:

• Project 2025 targets the removal of diversity, equity, and inclusion programs within federal health agencies and calls for the dismantling of initiatives focused on LGBTQ+ health and gender-affirming care.

• FDA Reform:

• It recommends overhauling the FDA’s drug approval processes and implementing stricter limitations on certain medical treatments and technologies.

 

Potential Roles of RFK Jr. and Dr. Oz:

 

• Robert F. Kennedy Jr.: As HHS Secretary, RFK Jr. could champion many of these reforms. His history of vaccine skepticism and advocacy for medical freedom aligns with Project 2025’s proposals to limit vaccine mandates and shift authority over health decisions from federal agencies to individuals and states. His leadership might also emphasize reducing corporate influences in medical research, an issue he has frequently criticized.

• Dr. Mehmet Oz: As CMS Administrator, Dr. Oz could play a critical role in reshaping Medicaid and Medicare policies. Project 2025’s push for work requirements and capped benefits would fall under CMS’s purview. Dr. Oz’s public health platform, which has included alternative and preventative medicine, may align with efforts to overhaul traditional healthcare delivery methods.

Implications:

The proposed policies could reduce federal oversight in healthcare, potentially increasing state autonomy but also raising concerns about health equity and access. Critics argue that such changes might exacerbate disparities, particularly for marginalized groups, while proponents claim they would promote individual choice and limit government overreach.

Overall, these appointments could pave the way for significant shifts in how healthcare is regulated and delivered in the U.S., aligning closely with the conservative agenda laid out in Project 2025. However, the practical implications for public health outcomes and healthcare equity remain highly contentious.

For more detailed insights into Project 2025 and related issues, you can explore sources like the Heritage Foundation and analyses from public health advocacy groups.

 

I was surprised that the Chatbot gave me two responses. I chose the one that did not depend on Wikipedia for most of the analysis. Although there were formatting and literary differences between the two answers, there were no substantive differences between the two essays.

 

I have resigned myself to the reality that over the next four years, if not for a lot longer, the progress that has been made toward universal access to quality healthcare will be threatened and largely reversed. It is hard to imagine how many economically disadvantaged people who have had access during President Biden’s term will not be able to get healthcare as the federal government reduces its support of Medicaid and states impose more stringent requirements for work. As more of the policy decisions are pushed down to the states through new financing mechanisms designed to cut federal expenditures, there will be more and more inequality as “blue” states endeavor to make up for lost federal support, and “red” states see an opportunity to further reduce their budgetary contributions to marginalized populations. Remember that there are still ten “red states” that have not opted for the Medicaid extensions and additional funds offered by the ACA.

 

 I remember a New England Journal of Medicine article from the nineties that compared the threshold for Medicaid eligibility in all fifty states. Medicaid support to the states that have not accepted the ACA is a fifty-fifty partnership. The feds match what the state does. If I remember correctly, Minnesota was the most generous state. In Minnesota, a person could qualify for assistance if their income was 400% of poverty. Arkansas had the highest barrier to participation. A person’s income had to be below 17% of the federal poverty level to qualify for Medicaid in Arkansas at the time. I hope my memory is wrong, but the point is that there is huge variation from state to state and therefore the potential for great inequity when Medicaid policy is primarily controlled by the states without the federal oversight associated with a state accepting the greater federal funding of the ACA. It seems that a major trend across all of Project 2025 is to send as many policy decisions as possible back to the states. One specific example of this philosophy is the idea of closing the Department of Education and sending education funding and policies back to the states. 

 

Project 2025 calls for the repeal of the ACA which would impact much more than Medicaid. Individual participation in the exchanges is supported for all Americans who fall below 400 percent of poverty. All of us benefit from provisions in the ACA that preserve and protect insurability and establish standards of care. Now that Republicans control the presidency plus both houses of Congress that is possible. House Speaker Mike Johnson is on record of favoring  “massive overhaul” of the ACA. In 2017 “repeal and replacement of the ACA” was prevented by the votes of John McCain, Susan Collins, and Lisa Murkowski. McCain has gone on to his reward. Republicans now control the Senate by a 53 to 47 margin. That means that Collins and Murkowski could vote to preserve the ACA, but a bill to abolish the ACA could pass the Senate. The vote of the Vice President could cause repeal even if there was one more Republican willing to vote to preserve the ACA. 

 

After a vote to repeal the ACA in the Senate, Johnson would be delighted to do his part to modify it beyond recognition or repeal it. With repeal or modification of the ACA, we may again see people have prohibitively high insurance expenses or be denied insurability based on “preexisting” conditions. The withdrawal of any or much of the public support of healthcare finance and the encouragement of commercial sources of coverage will surely be associated with substantial reductions in the numbers of people covered as well as the possibility of reducing the compensation available to clinicians and institutions. I predict that we will see a lot of change in access and the finance of healthcare over the next four years while we await the emergence of the “concepts of a plan” that will “Make America Healthy Again.”

 

It occurred to me earlier this week that I needed to back off with my concerns. The only leverage that we have is our vote. The voting is over, and like it or not Trump is claiming a mandate. I sense that many of the votes that gave Trump his mandate came from people who did not understand the potential harm that they were doing to themselves and future generations, but that makes me sound like an “elitist,” and pundits like David Brooks tell us that one reason for the outcome was a pushback against elitists. 

 

While pondering the disappointments and reversals that we are likely to endure for at least the next two years until the midterm elections, my mind wandered to the phrase, “Think globally, but act locally.” I have heard Don Berwick use the phrase and make sense of the strategy, but it is attributed to others in the environmental movement of the seventies. No matter its origin, I think it applies now. You can try to lead your practice, your hospital, your medical school, or just your friends and neighbors to try to practice behaviors that support equity in healthcare and the support of those who are likely to see their position in relationship to the social determinants of health slide over the next few years. For my part, I am involved in the activities of two non-profit organizations, one ongoing study, a health center, and my church that seek to support and help the underserved and financially challenged members of my community. I will find refuge in this work.

 

I am sure that if you look around you will find places where your service will be appreciated. If I was younger and more energetic, I would get involved in local politics. Republicans have been gaining influence at the local level over the last forty years by a focus on positions at the local and state levels. It is time for those of us who advocate for the principles of the Triple Aim to make similar efforts. It will be a long road and success will probably not come in the few years before I “shuffle off this mortal coil,” but wiser people have said that just because you won’t see the completed project is no excuse for not trying to start it. 

 

While on a bike ride this week, I was listening to a conversation between Ezra Klein and Anne Applebaum of The Atlantic magazine. Applebaum is a journalist who writes about the drift toward authoritarians around the world. At the end of the conversation, Applebaum offered a variation of my “think globally, but act locally” survival strategy. Click here to hear the podcast or read the transcript. I have copied the important dialogue below. Klein’s comment and question to which Applebaum responds is in bold lettering. In Applebaum’s response, I have bolded points I want you to notice. 

 

Klein said:

If somebody is listening to this, and they’re terrified, what should people do? People not on board with the idea of America sliding down in this direction [toward an authoritarian state] and who want to do something more than read news stories and follow social media posts about it.

What is effective in the sort of international scenarios that you’ve seen, and what isn’t?

 

Applebaum responded:

The worst result or the worst consequence of this kind of government, if that’s what we’re going to have, and of course we still don’t know yet, is that people become apathetic. They say: This is all so overwhelming, it’s so huge. I don’t even know what’s true and what’s not true anymore, and I’m just going to stay home.

Try to overcome that. And it almost doesn’t matter what it is that you do. Involve yourself in a local group, a discussion group. Join a political party. Run for local office. Try to be present in your community in some way. Do something that makes you active. And that makes you feel that you’re taking part in the governance of your country.

Democracies were always meant to be political systems that involved ordinary people in all kinds of ways. And I think one of the other reasons our system has declined as far as it has, is that that has atrophied. Along with all kinds of other institutions. There’s the famous thing about Americans not being in bowling clubs anymore and not joining the Rotary Club and not participating in real-life institutions because they’re at home watching TV or playing video games. But there’s also been a decline in civic activity and civic engagement.

And even if it’s just for your mental health, Even if it’s just to make sure that you don’t feel that you are isolated and alone and unable to affect anything, try to join some group or work with some group that is making change in your community, either politically or even apolitically. And that seems to me to be the best antidote.

 

I agree. I won’t stop complaining, but I will be active. I invite you to be active as well. I think being active in our communities helping others and practicing the sort of behavior that we would like our leaders to demonstrate is the best response available to what will be a difficult future. 

 

Finding Comfort In The Holidays 

 

I am really looking forward to the holiday season. The holidays should be about memorable moments with family and friends. I am quite lucky that those I am likely to see during the holidays see politics and current events the same way my wife and I do. There will be good food and no arguments at the dinner table. 

 

Much of our attention will be on the newest member of our family who was ten months old this past Wednesday. If any food gets thrown it will probably be by him, and we will all laugh. I know that I am lucky because there will be dinner tables where families will be divided over the recent election or the wisdom or intent associated with some of the recently announced cabinet positions. I have decided to be amused rather than terrified or angry, and I am counting on some combination of a few principled Republican Senators and an active press to save us from some of the worst nominees, but all that will play out long after the holidays. So, why fret now and spoil the holidays?

 

I got very excited about the upcoming holiday season earlier this week when I noticed that our Christmas cactus had its first bloom of the season. I was so excited that I decided to share it with you as the header for this week’s letter. My close inspection of the cactus revealed that many tiny buds will soon follow the first brave bud. I will enjoy watching them come to life as the holidays progress. 

 

Our Christmas cactus is sort of a family heirloom. My mother and grandmother, both had a house full of plants. I can imagine that many of my mother’s plants came from cuttings that she got from my grandmother. My grandmother’s favorite house plant was the African Violet, and there is one in the picture with the Christmas cactus, but she also had Christmas cactuses.

 

I can imagine that the plants that my mother and grandmother enjoyed were grown from cuttings from my great-grandmother who was born in 1871 and died at the age of 91 in 1962. Her husband and son were country doctors in North Carolina. After my mother died in early 2013, two months shy of her 94th birthday, my sister sent me cuttings from my mother’s plants. So, now my Christmas cactus with its first bloom sits next to an African violet on a lovely hand-carved antique walnut table that has probably been around in my family since the time of the Civil War. Like the plants, it has been passed down from my great-grandmother to my grandmother, to my mother, and now to me. Every holiday season brings back warm memories of holiday seasons of the past, and the bloom on the Christmas cactus gives me notice that another wonderful holiday season is coming soon. 

 

The holidays take a lot of energy, and sometimes they can be lonely. I can remember a couple of Thanksgivings when we had no family present, but we were lucky to have been invited to enjoy the day with friends. There was one Christmas when only one of our sons was able to join us. We made the best of it. 

 

I have been reading my father’s journals. This week I was reading what he wrote in his journal around Thanksgiving in 2005. That Thanksgiving my parents were alone, but they prepared the turkey, baked the pies, got out the best linen tablecloth, and lit candles in a silver candelabra. They carried on as if we were all there. It turns out that we weren’t there because we were all coming on the first weekend in December to celebrate Dad’s 85th birthday.  So, in his journal, he was looking past Thanksgiving toward the expectation of us all coming the next week. It is always good to be anticipating something good in your future. I’ll try that strategy for the next four years. 

 

I hope that you are looking forward to a holiday season that will bring you in contact with many family members and friends. Forget politics. Don’t watch too much football. Take some walks. Enjoy the moment. 

 

I know that some of my readers may be on call or even working in the hospital over the holidays. There were many holidays over my years in medicine when I had to work. It takes a little effort, but look past what you may be missing and focus on the benefit you are bringing others. If you are working caring for others, you are one of the people for whom the rest of us are thankful. 

Be well,

Gene