Lies and cowardice screwing almost everybody's health care coverage

There is usually more than one way to look at a situation. Often referred to as “point of view”, it is good to consider this, particularly in personal relationships, as the way you see things might not be the way the other person does. In the Trump years most of us have become more aware of a different basis for disagreement, not based on different interpretation of the facts but upon different facts. This is not just a difference in emphasis-- you and I both believe X and Y are true, but I think X is more important than Y and you think Y is more important than X.

We are in a situation in which a large portion of the population believes lies are facts, believes that things that are not true are true. Of course, this has always been the case, like when most folks thought that the Earth was flat, or that the sun and stars revolved around the Earth. These were definitively disproved, we know the truth, and yet there are other just as ridiculously incorrect beliefs (and, here, I except, for brevity, religion) that many people still cleave to. Heck, there are still flat earthers! I doubt that most of the leaders of the Republican Party or members of the administration in Washington – or even Fox News commentators -- actually believe most of these falsehoods (except Donald Trump, who seems too demented or stupid or isolated or all three to know), but they find them convenient ways of keeping the public’s attention focused away from what they are doing to benefit themselves and their buddies. This could be called the “Wizard of Oz” technique, and misdirection is a core part of most magic acts, but it is also a core component of fascist tyrannies.

These outright lies in the Era of Trump are incredible, both in number and the real impact on people. In the area of health, the focus of this blog, they have been amazing in terms of their scope and impact. Vaccines, among the few actual preventive things that medicine can do, have been attacked and criticized and completely wrongly said to cause worse problems than they solve. Not to put too fine a point on it, this is pure evil coming from RFK, Jr. and his team of loons. Yes, there are individual people who should not get one or more individual vaccines, because of a serious prior allergic reaction, or even worse a rare effect like Guillain-Barre, but for the vast, vast majority of children and adults vaccines are all good. They basically eliminated smallpox from the world, and essentially eliminated terrible killers like measles in this country – until a new movement endorsed by the Secretary of HHS brought them back. Your measles as a kid wasn’t too bad? Neither was mine. But lots of kids got sick. A bunch died. You never had measles because you’re too young? Because even your parents are too young? And you all had vaccinations? Sadly, maybe you’ll see it in your children. Mumps made people deaf and infertile, meningococcus dead or brain damaged, H influenza the same. Polio made people dead or paralyzed, in wheelchairs or in iron lungs. When I was a medical resident, we saw H influenza meningitis and epiglottitis, meningococcal disease, even some measles and polio. All eliminated by vaccines. Until we stop using them.

    

Smallpox                                Measles               Polio (in iron lung)

There are many, many other health disasters promulgated (it seems on purpose) by this administration. Eliminating or cutting back infectious disease surveillance – cyclospora, E. coli, salmonella -- anyone? Enjoying that? How about animal diseases? And funding for medical research – being heavily cut back especially for researchers that the administration doesn’t like.

But one HUGE area is health insurance, financial coverage for our medical care. I have written about the terrible US health care non-system which is designed to make money for private corporations (insurance companies, big hospitals and health systems, Pharma) instead of being designed to deliver the best actual health care for our people, and how it needs to be replaced by a system of covering everyone, as in every other wealthy country – improved Medicare for All. People need financial coverage because all those big corporations are owned by investors who demand ever-increasing profits, so the costs of the overall system (highest in the world by far), and to individuals, keeps going up.

Under the current administration, the opposite is happening. In a recent editorial in the NY Times, the cuts to coverage are enumerated and documented. The most dramatic of these are cuts to the Medicaid program and the subsidies for purchasing individual insurance on the marketplace created by the Affordable Care Act (ACA, “Obamacare”). The Medicaid cuts target the most vulnerable and needy, the poor and disabled, and the cuts to the ACA subsidies means that the poor-but-not-quite-poor-enough-to-qualify-for-Medicaid population that was finally insured through ACA will lose it. (If you want to know how poor you must be to qualify for Medicaid, you can look it up by state, but it is always very poor. When you look it up, remember that while many states tie eligibility to about 135% of the Federal poverty level, many others have much lower qualifying incomes.) This is really bad because it is going to kill people, is going to strain many physicians and hospital systems – especially those that cannot afford it, like rural hospitals – and create a lot of misery.

There are several other bad things related to health coverage that the Times does not even address. One of these is the aggressive promotion of Medicare Advantage (MA) plans for Medicare eligible people. These plans are not actually Medicare, a federal government run program, but private insurance products that use Medicare money (and gets paid more per patient than traditional Medicare, TM). On the one hand, if you get a good, comprehensive MA plan it can save you money (with TM you probably need to pay for a Medicare supplement and Part D plan as well as the Part B premium taken from your Social Security payment). But it can also have bad results because the insurance companies that run it can, and often do, deny payment for your care, just as they do for regular insurance.

Another health insurance problem the Times does not address is the fact that even in the best situations (in those states that chose to expand Medicaid and before Trump), the ACA did not cover everyone. Both this and Medicare Advantage are also areas not addressed by those making policy for the Democratic Party. It is not coincidental that the Times and that portion of the Democratic Party called (depending on where you stand) “centrist”, “moderate”, “Wall St.” or “right-wing” are similar, because both share a similar ethos. This is to be better than the GOP on a lot of social issues affecting individuals but to not threaten the basic status quo: corporate America making a lot of profit, and enriching its investors, at the expense of the rest of us, particularly but not only the poor, who get screwed out of medical care and/or bankrupted by the bills. Oh, and, by the way, if you one of the majority of people who have employer-sponsored health insurance, you’re still not safe. Costs for insurance to employers (with much or all of the increase passed on to employees) is expected to go up 11% in 2027!

The “centrist” branch of the Democratic Party does not support eliminating or strictly regulating Medicare Advantage, not to mention Improved (covering everything) and Expanded (covering everybody) Medicare for All. The same tired and inadequate reasons are given: “we can’t afford it” --- ridiculous given that every other wealthy or middle-income country does -- when what they mean is “we don’t want to alienate the billionaires who continue to support us”. They say that they need to “be moderate” because they don’t want to turn off independent voters, which results in policies that do not significantly help most regular people. Like Improved and Expanded Medicare for All (see the Jayapal House, HR 3069, and Sanders Senate, S 1506, bills) would.

We should be terrified of what the Trump Administration and GOP are doing, especially trying to disenfranchise voters before the election, and the huge cuts to our health care. But voters are not going to be excited by “Republican lite”; they need to hear about bold programs that will change their lives for the better.

"Take this, it's good for you!" Or maybe it isn't.

“Take this, it’s good for you!”

 You probably heard this growing up from your parents, or grandparents, or others, about lots of things. Medicines, foods, supplements, and even activities (“Do this, it’s good for you!”). You probably have continued to hear this from other people even if you are now grown: friends, family, people you have just met, and that most reliable of all sources, random posts (I was going to say “random people” until I realized that many or most of them could be bots) on the internet! So, should you take it? I mean, is it good for you?

I know my answer is going to be shocking: “It depends.”

On what? On a whole lot of things.

The whole idea that there is a general concept of things that are “good for you”, whoever you are and what you are hoping to achieve, is nonsense. What is good for one person – say an infant or a toddler – may well not be good for a middle-aged or older adult, and vice versa. And, of course, the most important question is “good for what?” What do you seek to have happen to you that this nostrum is “good for?” Do you even share the interest in achieving the end goal that the recommender presumably does? Lower cholesterol, lower weight, more muscle mass, stronger bones, having better balance or more stamina, improved sexual function, looking younger, better bowel movements, avoiding a deficiency disease like rickets, scurvy, or pellagra? Sometimes even cheap and easily available things from which big corporations or influencers do not make a lot of money, and that in fact do work well, are also unnecessary. Parents and grandparents may push things that their parents and grandparents told them were good for them, and they might have been, back once, but are not now. Back then, when our diets were often lacking in essential vitamins, scurvy, pellagra, and rickets were real issues in the US (and may still be in some parts of the world), but are not, generally, here now. In the not-too-distant past parents gave their kids castor oil, either as a treatment for a condition that the child might or might not have, like constipation or worms, but there are much better, safer, less unpleasant, and more effective treatments for both now. (That is not considering those who gave it as punishment!)

After you have answered the question of “good for what?” and decided that that “what“ is something you want to achieve or more toward, the next set of questions are “will it do that, does it actually work?”, “does it work for everyone the same or are there some groups of people (based on age, gender, health status, etc.) for whom it works better or not as well, and “what are the untoward effects that may, or even are likely to, happen, which may be far worse than the benefit?” Anabolic steroids, for example, do work to increase muscle mass, endurance, and power (see: sports stars) but also cause serious bad things (liver disease, testicular shrinkage, and a host of others). If it is legal and you are not competing in a sport where it is banned, it is up to you to decide whether the risk:benefit ratio is one you are willing to take (provided you are an adult, since in this area as many others, teens are poor judges of risk:benefit and do not have a good long view). Psyllium seed powders can be good for your bowels, lowering cholesterol, and helping to control your appetite, but some people have problems with the side effects. Testosterone, now being pushed by the Secretary of War who is competing with the Secretary of HHS and the President for being the administrations most macho ignoramus, can be good for some people who are deficient who should not be, but is far from a panacea that turns regular people into mindless Orcs (many medical professionals disagree, Doctors question evidence behind Pentagon testosterone plan). By the way, this is a good time to note the intrinsic contradictions in the “men’s health” movement. Its two big issues are prostate disease (especially cancer) and “low T”. Testosterone will not only make prostate cancer (or even benign prostatic hypertrophy) worse, blocking endogenous testosterone is the mainstay of treatment for prostate cancer. Oh, well, let’s see what it does for Pete Hegseth.

Some things generally are good for you. For example, age-appropriate vaccines are good for almost everyone (except those with known allergies to its components or previous severe reactions, by which I mean things like Guillain-Barre Syndrome, not a sore arm or short-term fever). Virtually all vaccines for children and adults (MMR, DTP, meningococcus, chicken pox, H. flu, influenza, Covid, shingles, polio, etc.) are really wonderful miracles that save thousands (sometimes millions, see: “Covid” and influenza) of lives, even more thousands or millions saved from serious morbidity, and with a very low rate of any significant negative effect. This is true. If you hear different information from your favorite TikTok star or Facebook friend, or Secretary of HHS, they are wrong.

Some things are generally bad for almost everyone, like taking dangerous drugs for unapproved indications (e.g., ivermectin for Covid), not to mention drinking or injecting bleach! The internet is full of recommendations for magic bullets that will cure whatever ails you or doesn’t even ail you but tells you it will or might if you don’t buy their solution. These claims are no more reliable than the clothes, makeup, hardware, and amazing items that will solve all your household worries. That is, some may be of value, for some people, in some circumstances, but often are not and even are dangerous, but all make money for those selling them (or in the modern world, selling their ability to influence others to the companies that make the products).

A big issue, it seems, is whether to take drugs, especially prescription drugs, manufactured by big, evil, pharmaceutical companies and heavily advertised by them, or to take “natural” over-the-counter drugs made by any-old-person or company and pushed by – any-old-person (or bot). Pharmaceutical companies are evil, as are most huge for-profit corporations (and they are usually the most for-profitable!) because their profits, not your health, is their main function. This does not mean that their products (or at least all of them) are not effective or safe when “used as directed”. They have two important characteristics non-prescription, even “natural” remedies, do not. First, they are tested, and approved after an extensive process, by the FDA (or were, before the FDA was decimated by the administration), which other remedies are not. Second, the doses are standardized, so you know what you’re getting. Even when plants (natural) are the basis for the drugs – say willow bark for aspirin – dosing is an issue. How much willow bark? From how old a tree? Growing in what setting? An aspirin tablet is standardized. Taking unregulated medication is akin to taking street opiates – you cannot be sure what, and how much you are getting. Plus, remember “natural” is not intrinsically good, safe, or protective. There are at least as many natural poisons as beneficial substances. If something you ingest, “natural” or manufactured, has a biologic effect that you desire, it also can (and likely does) have biologic effects that you do not desire (“side effects”, a term meaning biologic effects you don’t want). Testing and standardization are keys. Not that this in any way excuses the rapacious profit-taking of Pharma, but neither does it of those selling unregulated nostrums.

Finally, and I have said this before and will say it again, when thinking about whether something is “good for you” and whether you should take it, anything that sounds too good to be true probably is.

Aging, suffering, and the inevitability of death: Let's keep it real, and ignore the quacks

My friend Paul Taylor, longtime journalist and former executive at the Pew Trusts, has just published a new book called “This Is Getting Old: Two Boomers and Their Generation at Dusk”. It has two main topics. The first is an often-disturbing analysis of the impact of the “Boomer generation” as a whole, focused on their (our) massive accumulation of money, fighting for society’s resources to be directed to us, and shockingly, away from those who need it most, children. There are clearly many different indviduals in this generation, as well as subgroups (since boomers were born 1946 to 1965, the usual characterizations of us in our youth, activism in the late 1960s, obviously are only about the older part of that cohort). He makes the point that not only did this generation, as many before, get more conservative as they aged, but that only a portion of them were ever progressive. And the contrast between their generosity to their own children and grandchildren, and their parsimony toward most of society’s children is, at least coincidentally (as he states it), or definitely (as I think) about the color, race, and ethnicity of the majority of today’s children. Did I say this was shameful? If not, I do!

The other focus of the book is the aging of his, their, and our generation, focusing particularly on one couple (a terrific, impressive, warm and active couple), but also full of data on what is happening to all of us. Which is the same thing that happened to everyone before us, getting old and eventually dying. We may be dying older, and dying of different things, and (many of us) having more healthy and productive years before we die, but we all die. And for many of us, perhaps most of us, as all through history, that dying will be preceded by a period – which can be short or be many years – of suffering, of being sick, in pain, losing our mental faculties, or all of these. Guaranteed. While billionaires are being quite successful in avoiding (at least for themselves) the other of that famous pair, taxes, avoiding death is, even for them, only a science fiction cryogenic dream for them that has not yet happened. Thank goodness. If there are any people that the future does NOT need preserved for them to deal with, it is the billionaires most assiduously working on it!

So, we need to remember not only the inevitability of death, but the suffering that so often precedes it. We boomers have been watched it in our parents, our older relatives, and, sadly, many of our peers. It is well to remember the myth of Tithonus, who was granted eternal life by Zeus, but not eternal youth. He continued to age, alive and living sicker and more decrepit. A more modern self-deception: a few decades ago, I was the only physician in a health policy class. Each week one student had to make a presentation to the class on a particular topic. The student who addressed the issue of “long term care” did present data, but then added that in their opinion the need for long-term care would decrease because people were taking better care of themselves, exercising and eating better and not smoking. I pointed out that this would obviously increase the need for long-term care, as people would less often die young from heart attacks and more often live older and older (if not eternally, like Tithonus) with more and more care needs. I suspect I even said something like “if you want to decrease the need for long term care, have people smoke, drink, eat poorly, not exercise and drop dead in the 40s and 50s”.

But that student, and others, were young. Somehow, they conflated living a more healthful lifestyle, and having better health in the near and medium term, with not ever confronting getting old, sick, and dying. That is purely wishful thinking. While living more healthfully is a good idea, it cannot prevent the inevitable. And yet, many people, even today, believe this that somehow they can and (more venally and evilly) are selling it to others. Some of these ideas are commonly associated with folks like Secretary of Health and Human Services Robert F. Kennedy, Jr. (how painful to associate that name and that title!) and the MAHA (Make America Healthy Again) movement. Like the MAGA (Make America Great Again) of Donald Trump, the key point is the “again”. In the case of MAGA, it depends on what your definition of “great” is – probably America was if it means slavery, racism, subjugation of women, and constant wars, with military budgets making up the biggest part of public spending, the funding of which comes disproportionately from those with lower incomes.

In terms of MAHA, while there may be a bit less subjective flexibility about defining “healthy” than “great”, there is definite disagreement about the road to health. For example, a recent study by the Edelman Trust Barometer produced the table below. About a quarter to a third
of Americans believe each of these falsehoods, and 70% believe at least one, with a whole bunch of folks who “don’t know”. Edelman calls these claims “false or unproven”, which is generous. To a greater or lesser degree, they are all false. The most dangerous are the claims about vaccines, which are good, and to a large degree the reason that boomers and others are likely to live as long as they are. As a t-shirt I have seen correctly asserts “Vaccines cause adults”!

 

 

Unpasteurized (ie, raw) milk has in fact caused lots of deaths because of bacterial contamination. Testimonials from dairy farmers who drink it all the time are not valid for urbanites who are consuming it days after milking, when the bacteria in it that would have been killed by pasteurization has had time to multiply, The other false claims may not cause death, but sure can cause suffering; I suffered a lot of dental cavities as a kid before our water was fluoridated. Fluoride is definitely helpful to dental health (excessive amounts can cause unsightly, but NOT dangerous, mottling of teeth). Avoiding acetaminophen in pregnancy can cause pain. And on animal protein: it is not more healthful than plant protein, it is in fact, generally less healthful. As is animal fat (e.g, tallow, lard). 

These false claims are relatively easy to refute, although it is not easy to convince people who believe them that they are wrong; these are two different things. But what of the amazing plethora of other magical health claims, today’s equivalents of snake oil (in promises for great health, not to mention quackery). Early in his book, Taylor writes 

Don’t pick up this book expecting to find the magic formula for staying forever young. I ain’t got one. You’re better off cruising TikTok, where a bustling industry of anti-aging influencers serves up a bottomless banquet of science and quackery. They treat aging as a curable condition, death an avoidable fate. 

Sigh. It would be wonderful if these nostrums could keep you healthy and keep you from dying. But they don’t. That doesn’t keep them from being a “bustling” (and profitable!) industry.

Three points:

1) Natural is not necessarily better or safer. That is a fallacy. Anything that actually has biologic effects can have the ones you want, and the ones you don’t (side effects). If it doesn’t have any biologic effect, it’s not helping either.

2) Don’t be a sucker. Yes, Big Pharma is evil, but there is much better data on whether and how its products work than those of the MAHA-hood.

3) If it sounds to good to be true, it probably is.

Pay primary care more: Kennedy may be getting this one right!

I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!

Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.

But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).

Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).

So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!

The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.

The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.

We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!

"It was the best of times, it was the worst of times": Threats to the public's health from Medicaid cuts, MAHA, and others

“It was the best of times, it was the worst of times…” begins Dickens’ “A Tale of Two Cities”, and people have used that phrase to describe all kinds of times in the 150+ years since it was published in 1859. But maybe not today. In some ways, I guess, it could be the best of times for some privileged people in wealthy countries; never in history have so many people been able to enjoy things like enough food to eat, shelter, air that is breathable, water that is clean, heat in the winter, A/C in the summer, travel for long distances by plane, for many distances by private car, etc., etc. In every way, often ones that seem to us to be mundane, a lot of us enjoy a standard of living that could not be imagined even by the wealthy of Dickens’ time or earlier. Of course, that is only for some of us in the world, it is likely the majority in wealthy countries, even those working people living paycheck to paycheck.

But even in those wealthy countries we see too many who do not enjoy those benefits, who are living on the streets, who sleep in shelters or sewer grates or parks, who are freezing in winter and roasting in summer, who do not have enough to eat, who cannot get basic health care for their needs, and often have additional needs related to mental health or alcohol or drug use. We see children being abused and neglected by parents who do not have the wherewithal or support they need. We are, some of us, outraged and angry, some of us at them, and others of us at the system in which they live. Because we have a society that actively chooses to make the lives of many people worse so that the most privileged can have more.

And, once we leave wealthy countries such as the US, it becomes phenomenally worse. The number of people starving or suffering in wars and armed conflicts is incredible. Gaza is one obvious example, and it is horrific – the government of Israel using the all too real fact of centuries of oppression and anti-Semitism to destroy another people, the Palestinians, killing tens of thousands, displacing millions from their homes, destroying what infrastructure they had stingily allowed to be built – this is not wrongly called genocide. And there is Somalia and South Sudan and Ukraine in wars, and whole continents of people whose best days are the ones on which they get something to eat.

So, is it the worst of times? The policies being followed by the US government under President Trump and the bootlicking GOP Congress and the Supreme Court to which he appointed a disproportionate number of members, are leading us steadily downhill in virtually every part of the public arena. But the fact that they keep getting worse indicates that we have not yet reached bottom, we are not yet in the Europe of the late 1930s and 1940s even. But it does keep getting worse, in the US and across the world. It hits on so many fronts – the economy, basic human rights, climate, war – that it is difficult to even keep up.

And health and health care? The focus of this blog? Still lots of bad things, starting with the cynical, opportunistic, and dangerous policies being implemented by the Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr., the director of the Centers for Medicare and Medicaid Services (CMS), Dr. Mehmet Oz, and others in the administration, which become more and more outrageous. And, of course, the negative impact of the President’s “Big, Beautiful Bill” on those dependent on Medicare and Medicaid will be dramatic. STAT News recently reported that the Congressional Budget Office (CBO) estimates 11 million people will lose their health coverage as a result of Medicaid cuts. That is a lot of people, and only a very tiny percentage are the “boogeymen” cited by the GOP as deadbeats, adults capable of working but not seeking work. In fact, most people on Medicaid are children and their mothers, and most Medicaid dollars are spent on caring for seniors and disabled people in long-term care, and most able-bodied adults receiving Medicaid are already working, sometimes at more than one job, but making less than the standard (often 138% of the Federal Poverty Level). In my state, Arizona, that is less than $22,000 a year for a single person, and it is similar for families and in other states. The outrage is not that there are people receiving Medicaid who should be able to work, but rather that people working full-time can be paid so little that they qualify for Medicaid and other federal benefits. Many of these folks are working for high-profile (and high-profit!) corporations such as Walmart and McDonald’s, as reported by CNBC in 2020 (and probably is worse now!) Medicaid, by the way, is not a benefit paid to individuals (such as welfare or SNAP) but rather is paid to medical facilities for providing care to eligible individuals. To the extent that there is fraud, it is more likely to be on the part of those providers than the individuals. And cutting Medicaid threatens the continued existence of many of those providers, particularly rural hospitals which are, because the population that they serve has a higher percent of poor, disabled, and elderly people, more dependent upon Medicaid payments.

Medicare is also being harmed, in less obvious ways than the cuts to Medicaid, largely by encouraging the movement of Medicare recipients into private, insurance company-run plans called Medicare Advantage. I have often discussed the details (e.g., Open Enrollment Season for Medicare and Medicare Advantage: What you should know, Oct 7, 2024) but, in brief, insurance companies get paid more than Medicare spends on “traditional Medicare” (TM) recipients, and use some of it to provide benefits that are attractive, especially if you are not really sick. Of course, it is not then Medicare, but an insurance package, a PPO or HMO paid for with Medicare dollars, and the insurance company can (and often does) deny claims, as they do for their non-Medicare insurance packages, which TM does not.

And what about RFK, Jr., and his MAHA (“Make America Healthy Again”) campaign, including his disparagement of vaccines and advocacy for unproven (and sometimes proven-to-be-dangerous) treatments such as unregulated use of stem cells, and other “alternative” treatments, including saying “‘Charlatans’ Are No Reason to Block Unproven Stem Cell Treatments” even though “some methods have resulted in blindness, tumors and other injuries”? I’d say there is great cause for concern, but would also recommend reading the sympathetic and balanced discussion of MAHA supporters by Katelyn Jetelina, “Your Local Epidemiologist”. She distinguishes between leaders of the movement, like RFK, Jr., about whom she says “I don’t believe RFK Jr. is acting in good faith. His record is riddled with contradictions and falsehoods. His tactics often erode trust under the guise of restoring it. Treating him as a serious partner would be a mistake,” and the grass-roots. Many of these people feel that they are not getting accurate information (often they are not), many (appropriately) distrust Big Pharma and associate the mainstream medical and public health disciplines with it, and some are advocates for the magic benefits of “alternative” treatments such as stem cells. But a big issue that she identifies is their desire for “autonomy”, to make their own decisions on health care (where to go and what to do, what treatments to use, etc.) rather than be forced into using vaccines, or taking pharmaceuticals when they don’t want to. This is a big issue. In many areas, particularly infectious disease, individual autonomy that says “we don’t want vaccines” can lead to big disease outbreaks (like the ones we’ve recently seen of measles, which include deaths of unvaccinated children). The issue of individual autonomy vs. the public good is a longstanding tension, and of particular potency in the US.

So, what is there to say? I say do get vaccinated. Vaccines do not cause autism. Childhood vaccines, as is often stated, cause adulthood – because children do not die of polio, measles, or influenza, or epiglottitis and meningitis from H. influenza B, and hepatitis, and all the other conditions which at best cause significant suffering even when they do not lead to permanent disability or death. Vaccines are a good thing.

Swimming in polluted water, as RFK, Jr., has done is a bad idea. Taking your grandchildren along with you, as he has also done, is a really bad idea.

And yes, cutting millions of people, most of whom are hard-working, off of Medicaid, is another really bad idea.

 

 

For a balanced description of the terrible abuses that were carried out in the name of medicine and public health by Nazis, Americans, and others, see the excellent podcast “Doctors Gone Bad: Physicians, Dictatorships, and Warrior Cultures” by Dr. Martin Donohoe, part of his outstanding podcast series “Prescription for Justice”.

Vaccines and autism: "Culture eats data for lunch"

A common saw in the business world is that “culture eats data for lunch every day”. The lesson is supposed to be that in trying to create organizational change, it is important not to assume that people do what they do simply because they are ignorant of the facts, and that these simply need to be presented to them and change will occur. This is also the case in many other areas, including public health, and it seems it is often easier to create change by presenting simple “facts” (even if they are wrong) that are easy to digest and concord with pre-existing belief systems than more complex or nuanced facts that are actually right.

Recently, in a Facebook “discussion”, I was informed of a couple of things by a friend-of-a-friend whom I do not know. One was that vaccines are bad because pharmaceutical manufacturers make lots of money on them, and they are evil. Indeed, I had acknowledged that I think that they are evil, and the “discussant” asked (rhetorically, I assume) how I could then trust them? I didn’t respond (who needs to waste time arguing with folks who will never be convinced) but it is a logical fallacy. Drug companies are evil, in that they systematically exploit every method they can to make money, and even more money, but this does not mean everything that they do or make is evil. They are happy to make lots of money selling drugs (or vaccines) that in fact work well; their evil is in hiding when they don’t work well, or have bad effects (think “Sackler” and oxycontin) and grossly overpricing them when they do. Vaccines do work, and incredibly well, some better even than others. There have been rather rare side effects (beyond local soreness or slight fever) associated with them, but the one getting the most play is their association with autism, especially measles (or measles/mumps/rubella, MMR) vaccine. They don’t cause autism as shown by many studies, some of which are cited below and all are available by searching PubMed (National Library of Medicine) or Google Scholar.

Or maybe not. The other thing that this discussant noted was that there are over 200 studies showing that it does cause autism, which was news to me. They didn’t provide the citations (it was, after all, just a Facebook post) but I presume they have them. The only other explanation I can think of is that it is a number that they heard of read somewhere and are repeating (something which most of us are, at least sometimes, guilty of). In any case, I haven’t been able to find them. I am not going to go into great detail here about the absence of a link between autism and measles vaccine, as there are already many good discussions available, two of which are a review of Vaccines and Autism by the Children’s Hospital of Philadelphia and Vaccines Don't Cause Autism. Why Do Some People Think They Do? From the Johns Hopkins Bloomberg School of Public Health. This article in StatNews also reviews the evidence. If you are interested in some of the studies done that showed no association between vaccine and autism, one big one was from Denmark that looked at over 650,000 children and was published in the Annals of Internal Medicine in 2019, Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. There are dozens of others, which have looked at over 3 million children, and are easily found on searches on either NLM or Google.

If not 200, however, there are at least 2 studies, by the same author, Andrew Wakefield, that purport to show that measles vaccine causes autism. The first, published in the Lancet in 1998, Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children, studied 12 children. It not only didn’t prove that the vaccine caused autism, but was so deeply flawed it could not have, and the Lancet retracted the paper (which you will see in a notification when you search it or follow the link above). Several of Wakefield’s co-authors removed their names from this paper. There was a second study published in 2002, using a different, but also flawed, methodology.

However, despite the vast preponderance of evidence, the Secretary of Health and Human Services, Robert F. Kennedy, Jr., is not convinced and is commissioning a new study of the link, to be done by David Geier, long associated with the movement to associate vaccines with autism, (who was not a doctor but practicing under the license of his father -- who had HIS revoked for experimenting on autistic children). I wonder what it will find?

In 2025, so far in the US, there have been almost 900 cases of measles, with 3 deaths, the most of both in many decades. Given that the mortality rate for measles is about 1/1000, it suggests an under-reporting of cases. 97% of those affected were unimmunized. This means that parents who choose to not immunize their children are risking disease and death from measles. And doing so for a “benefit” (not getting autism) that is unrelated. This is sad, but people believe what they believe for a variety of reasons, and act on those beliefs. There is also no shortage of papers studying and reporting on why this is so, e.g. Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy.

Historically, and today, the prevalence of measles is higher in communities of lower socioeconomic status, for a variety of reasons discussed, for example, in Measles Outbreak in Socioeconomically Diverse Sections: A Review. Of course, many diseases are more common in communities of lower socioeconomic status, for the same reasons, prominently including lack of access to health care. What is concerning about the current measles outbreak is that it is so closely tracking, in the main outbreak in West Texas and adjacent New Mexico, low levels of immunization that result from belief that vaccines are bad, not because they are inaccessible.

Taking things on faith and not on evidence is a cornerstone of most religions, but belief in things like vaccines causing autism, and other evidence-free ideas, should not be on the same order as religious beliefs. However, it may be that being used to accepting some of the most important things on faith conditions one to being willing to accept others. Also, while the autism/vaccine question is pretty specific, it is easy to accept simplistic guidelines to guide a person as to what is “good” or “bad”, without the (unfortunately ubiquitous) subtleties. One example is “natural”; things that are “natural” are good, and things that are manufactured or modified are not. So, vaccines, being manufactured, could be bad. Of course, this idea is pretty dangerous; lots of natural things are poisons, and many beneficial natural things (like plants that help with certain conditions) are actually not as good as the standardized and purified forms made by those evil pharmaceutical companies. Aspirin is derived from willow back. But how much willow bark is good for my arthritic pain? In what season? What microclimate? How much will be too much and cause stomach ulcers? If something seems too good to be true it usually is; similarly using a single touchstone (e.g. “is it natural”) it is too simple and often wrong.

I used to be very concerned with people ignoring science and good research and believing, well, what they wanted to believe, for whatever reason. Now I am even more concerned about the seeming pride that they take in not believing science, as if that were a good thing, that in not believing what the evidence shows they are asserting their loyalty to a cause and victory over an enemy.

This is the much more important thing to believe in: US mortality is high, and strongly linked to wealth! Let us work on addressing that.