Because they are not subject to political micromanagement, medicare advantage plans can attract enrollees by cutting wasteful expenditures and using the savings to reduce out-of-pocket costs, waive premiums for prescription drug coverage and add coverage for dental care.

But Medicare’s traditional public option can still serve a valuable purpose by focusing on a new role: guaranteeing a safety net of access to essential services from a broad network of providers and quantifying the public subsidy that is needed to ensure this.

Under the traditional Medicare benefit, the federal government pays medical providers directly for each service they deliver to elderly and disabled beneficiaries, regardless of cost-effectiveness. Alternatively, beneficiaries can opt to receive benefits through Medicare Advantage, which pays private insurers a pre-fixed amount to purchase whatever medical services enrollees need during the year.

This has encouraged Medicare Advantage plans to provide additional preventive services to enhance the management of chronic conditions, avoid costly hospitalizations and improve clinical outcomes. It also enables them to reduce costs by establishing networks of preferred providers, ensuring that the most cost-effective therapies are employed and cutting out fraudulent reimbursement claims. As a result, Medicare Advantage plans bid to deliver the basic Medicare benefit at 14 percent less cost than the traditional federally managed benefit — generating savings worth around $2,000 per beneficiary, which they have been able to use to attract enrollees. 

Whereas the traditional Medicare benefit requires beneficiaries to pay 20 percent of Part B costs out-of-pocket (typically exceeding $20,000 for new cancer drugs), Medicare Advantage plans capped total out-of-pocket costs at an average of $4,972 in 2022. Whereas traditional Medicare enrollees must pay additional annual premiums averaging $478 for prescription drug coverage and between $564 and $617 for dental insurance, Medicare Advantage makes free drug coverage available to 99 percent of beneficiaries, while 94 percent receive dental benefits as part of their plans.

Some politicians have argued that Medicare Advantage’s larger benefits result from plans being “overpaid” relative to traditional Medicare, and estimates suggest that Medicare Advantage plans receive 5 percent more from taxpayers to cover beneficiaries with equivalent medical needs. But Medicare Advantage plans must also do more work to qualify for payments, with 2.4 percent of their revenues contingent on compliance with a host of process regulations.

Nonetheless, overpayments to Medicare Advantage plans are dwarfed by those resulting from traditional Medicare supplemental insurance plans, which beneficiaries can purchase to eliminate cost-sharing designed to control inappropriate utilization of Medicare services. One study estimated traditional Medicare supplemental plans increased the cost of Medicare by 22 percent; another found they drove up costs by 24 percent, with the spending increase concentrated among healthier beneficiaries. 

Whereas most Medicare Advantage enrollees pay no additional premium, supplemental Medigap plans typically charge an additional $2,000 per year. The additional cost to taxpayers resulting from traditional Medicare supplemental enrollment, therefore, goes largely to wealthier seniors. Unlike Medicare Advantage plans, traditional Medicare supplemental insurers can, in 46 states, refuse to cover individuals with preexisting conditions. 

A simple principle of parity in subsidy and regulatory burden across Medicare coverage options is clearly appropriate, and Medicare Advantage provides the appropriate framework for this. To the extent that richer beneficiaries wish to purchase supplemental coverage to reduce their out-of-pocket cost exposure while maintaining access to a broad network, they should pay the full additional associated cost through a Private Fee-For-Service plan. Firms purchasing supplemental coverage for retired workers should do similarly with an Employer Group Waiver Plan.

So, does Medicare’s traditional public option still serve a purpose? 

Some scholars have suggested making the highest quality Medicare Advantage plans the default source of coverage. But this would likely distort competition in Medicare Advantage, by making plans compete for the favor of bureaucrats rather than that of beneficiaries. It could also likely invite a regulatory blowback upon Medicare Advantage, as enrollees find they are in narrower networks than they expected. Furthermore, it would likely provide large windfalls to insurers assigned beneficiaries who (for unanticipated reasons) consume few or no Medicare services.   

The relative merits, benefits and costs of alternative Medicare plans should certainly be made clearer to beneficiaries signing up, but the traditional public option therefore remains appropriate as a default.

While it doesn’t make sense for the government to micromanage the procurement of medical care for most beneficiaries, traditional Medicare can still play a valuable role in determining the benchmark payment for the basic package of Medicare benefits which are to be funded by taxpayers. By setting prices at levels needed to maintain access to essential healthcare services, traditional Medicare can ensure that Medicare continues to guarantee a robust benefits package while checking whatever tendency Medicare Advantage plans may have to unduly narrow access to care.

In the long run, the role of defining and guaranteeing a core package of benefits is likely to become increasingly important. The federal government cannot afford to keep expanding the program to every new medical service that is developed, regardless of its additional cost or effectiveness. 

By maintaining the current benefits package and selectively adding high-value new services, a public option can ensure that Medicare’s benefit expands without absorbing all available federal revenue, even while Medicare Advantage can allow beneficiaries who wish to pay more for broader access to less-effective new services to do so. 

Chris Pope is a senior fellow at the Manhattan Institute.

A health care program meant to help vulnerable communities has ignited intense controversy in recent years, but most of the focus has been on hospitals. A new study finds that federally supported clinics are exploiting the system, too. 

Called 340B for a section of a 1992 law, the program had good intentions, but its design has encouraged maximizing profit over helping patients in need. Many of the 55,000 hospitals and clinics in the program have become heavily dependent on 340B. They have a huge incentive to leverage the flawed structure to resell as many discounted drugs as possible to insured patients, not the low-income, uninsured Americans who were supposed to be the beneficiaries. 

The program has quintupled in seven years, and a large part of that growth came from “grantees,” such as clinics that treat HIV/AIDS, sexually transmitted diseases and hemophilia. But in most discussions of 340B, the role of these grantees has been ignored — until now, with the release of a study that shows grantees earn far bigger profit margins from 340B than hospitals. 

First, understand how 340B works: Hospitals and grantees buy prescription drugs at a big discount and are then reimbursed by insurers, including Medicare and Medicaid, at the full price of the drugs. The difference, or profit, has become a major revenue source for providers. For example, in a 2022 annual report, one Florida 340B clinic reported that 94 percent of its $300 million in revenue stems from such 340B savings. 

The deficiencies of 340B, now the second-largest prescription drug program after Medicare,  have been documented for at least a decade. “The financial benefits of the 340B discounts are accruing almost entirely to hospitals, clinics, and physicians; and patients’ out-of-pocket costs and total cost of care are being increased,” concluded a 2013 article in JAMA by Rena Conti of Boston University and Peter Bach of Sloan Kettering.  

But 10 years ago, clinic participation was just in its infancy. Recently, a study by Eleanor Blalock for the Berkeley Research Group found that grantees now account for $21 billion in reimbursements and the grantees’ profit margin is much higher than that of hospitals — an incredible 73 percent, compared with 25 percent to 50 percent for hospitals. 

Overall, drug purchases under 340B in 2021 totaled $45 billion, and reimbursements were an estimated $110 billion. Most of the $65 billion gap goes to hospitals and grantees and to the contract pharmacies that these providers use to dispense outpatient medicines.  

Some 80,000 pharmacies now have arrangements with grantees — a figure that has tripled since 2017, producing profits estimated at $10 billion annually; 91 percent of the pharmacies are part of just three large for-profit chains: CVS, Walgreens and Wal-Mart.  

Just who are these clinics and pharmacies serving? New research, published in the peer-reviewed American Journal of Managed Care found that 91 percent of pharmacies weren’t even in the same zip code as the grantee that contracted with them and that the average pharmacy’s zip code had household incomes 33 percent higher than that of the zip code of the grantee.  

The role of 340B grantees has been largely overlooked in the past, but it’s now time to take serious action to remedy a government program run amok. Fixing the program would not be difficult. To begin, grantees need to account publicly for how they are spending their windfall from 340B discounts — especially because, unlike hospitals, about 70 percent of the grantees’ drug margin is attributed to public payers, mainly Medicare and Medicaid.  

The use of far-off contract pharmacies in much wealthier neighborhoods could be reined in through regulation or legislation. Conti and Bach recommended a decade ago that discount rates apply “only to those patients who are poor and uninsured” rather than to anyone treated at a 340B hospital or grantee institution.  

They also suggested that hospitals and grantees “be required to pass on their savings from drug purchases to patients and their insurance providers, including Medicare,” or, better yet, have insurers “recoup some 340B profits from hospitals and physicians and pass those profits back to their beneficiaries.” 

This system could be much simpler than the 340B contraption. An IQVIA study last year found that using a “340B discount card” reduced patient out-of-pocket costs by 93 percent, but such cards were only used in just 1.4 percent of 340B claims.  A new study by a small Kansas hospital system looked at a program where 340B treatments for chronic obstructive pulmonary disease were given directly to patients, saving them $335 a month. The result: “A significant reduction in the composite mean number of all-cause hospitalizations and emergency department visits,” saving $1,013 per patient. 

The House Energy and Commerce Committee has advanced legislation with new requirements that both hospitals and grantees would have to report “by location the total number of patients who receive 340B drugs by payer, payments, total cost and savings.” This is a step in the right direction. 

Advocates for people living with HIV/AIDS and other conditions addressed by grantees have special reason to support 340B reforms. In an opinion piece in POZ, two such advocates, Brandon M. Macsata of the ADAP Advocacy Association and Guy Anthony of the Black, Gifted and Whole Foundation, stressed that “stronger accountability and transparency are urgently needed so that the [340B] program can begin to work as intended, and patients don’t continue to be left behind.”  

Their concern is that, if reforms are not enacted, a government program that is so poorly implemented could trigger political action to pare it back or end it entirely. “Inaction will — not could but will — very soon have serious ramifications on the care that our community receives,” they wrote. 

It’s clear that if 340B is ever fixed, policymakers must direct reforms not merely at hospitals but also at grantees. 

James K. Glassman, a former American Institute fellow and undersecretary of State, advises health care companies and nonprofits. 

And why are our intelligence agencies so divided as well? The Department of Energy and the FBI think there is some likelihood it came from a lab, whereas others say no. 

The answer is twofold. First, there is clearly a political overlay in China that is obscuring pure investigation. Second and more importantly, we are talking about a powerful foreign country that has a history of obscuring public health truths from the world at large, including the first SARS outbreak two decades ago. Why should this time be any different?

Despite the fact that Dr. Anthony Fauci (whom I have interviewed multiple times and have great respect for) and others have spent many years working on establishing and building an international consortium of scientists, we must consider that scientists in these countries (including China) must report to their governments. It could well be significant that the Chinese military was involved with the Wuhan Institute of Virology soon after the pandemic began. 

Under these circumstances, it was never a correct position for any American scientist to assume against, suppress, or marginalize the lab-origins hypothesis. Yet many did. At the same time, there is no reason to assume automatically that scientists are lying, doing things for money or out of fear of losing National Institutes of Health grants. 

I recently interviewed Kristian Anderson, a professor in the Department of Immunology and Microbiology at Scripps Research. He strikes me as a scientist of integrity, whom I believe when he says that the more he studied the virus the more he thought it came from nature. 

I believe him, but that doesn’t mean he is automatically correct.

During the congressional hearing earlier this month, Anderson said several times that this was clearly not a bioweapon, but he also couldn’t rule out that it leaked from a lab or wasn’t in some way genetically edited. 

Bioweaponry is highly improbable in this case because it would likely spawn a much more deadly weapon than COVID-19, but several scientists, including former Centers for Disease Control and Prevention director and virologist Dr. Robert Redfeld, have expressed concern to me that the lab could have been working on a defensive strategy where the virus was made to help produce a vaccine vector to protect both military and civilian populations.

Anderson also acknowledged that genetic editing could well be conducted without leaving a trace, or what I call a “seam.”

The fact that Ralph Baric, a virologist and distinguished professor in the Department of Epidemiology at the University of North Carolina has worked together with Dr. Shi Zhengli of the Wuhan Institute of Virology on bat coronavirus research and generating new viruses known as chimeras is also not proof that the virus came from a lab. But the fact that COVID-19 started in Wuhan and that the lab there was working on modifying bat coronaviruses (COVID-19 clearly has a bat origin), plus the reports that lab workers were getting sick in the late summer and early fall of 2019 and that the labs had been cited for multiple safety violations, are all eyebrow-raising, to say the least. 

But it is also significant that there were at least two cohorts of humans sick with COVID-19 coming from the wet market. Though there were no bat coronaviruses there, it is clear that this market was a node of significant spread. If the virus didn’t come from here, it certainly spent time here. 

Michael Worobey, a respected evolutionary biologist and the head of the Department of Ecology and Evolutionary Biology at the University of Arizona, pointed out a potential connection to me on Doctor Radio on SiriusXM. He said that raccoon dogs that were found in the wet markets (and that showed the genetic signature of the virus) can live in close proximity to bats and could be the intermediate creature between bats and humans that scientists have been looking for since early 2020. But most bats infected with these viruses live a long way from Wuhan.

The truth of COVID-19's origins is important in preparing for the next pandemic. If it came from nature, we must be more wary than ever of zoonotic spillover. If it came from a lab, we must be even more vigilant in policing gain-of-function experiments as best we can. 

But most of all, the lesson to be learned from the ferocious debate over COVID-19 origins is that we must work together to find answers, not suppress ideas or alternate explanations. That’s actually supposed to be the main difference between our society and societies like China.

Marc Siegel, MD, is a professor of medicine and medical director of Doctor Radio at NYU Langone Health. He is a Fox News medical correspondent and author of the new book, “COVID; the Politics of Fear and the Power of Science.”

Poor diet drives up health care costs across the nation. In fact, it accounts for almost 20 percent ($50 billion) of annual U.S. health care costs from heart disease, diabetes and stroke, according to a federally funded study. Diet-related disease affects all Americans, including SNAP recipients. With that in mind, federal policymakers need to ensure that SNAP focuses more attention and resources on the diet quality of recipients, making their nutrition and health a higher program priority, similar to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program and the National School Lunch Program.

Policymakers have a golden opportunity to do so this year when the White House and Congress work to reauthorize SNAP as part of a new five-year Farm Bill, which lawmakers plan to craft in the coming weeks.

Some 41 million Americans — about 12 percent of the population — participate in SNAP each month. Nearly half are children, two-thirds are in households with children and over a third are in households with older adults or nonelderly adults with disabilities. Improving the nutritional quality of SNAP-funded meals not only would improve the health of SNAP recipients, but it also would put Washington more firmly behind better nutrition and health in America. 

As part of a Bipartisan Policy Center task force, which we co-chaired in 2018, we proposed eliminating sugar-sweetened beverages from the list of items that can be purchased with SNAP benefits given the potential health benefits and cost-savings to public insurance programs such as Medicaid. Research has shown that combining incentives for healthy food and disincentives for unhealthy food has the potential to generate the greatest health benefits and health care cost savings. 

A recent Morning Consult poll conducted by the Bipartisan Policy Center found that nearly six in 10 SNAP participants, Republicans and Democrats equally and by a 2:1 margin, support a combined approach of additional benefits for the purchase of healthful items along with a reduction in benefits if unhealthy foods are purchased.  

Nutrition has already become a higher priority for most food assistance programs. Food banks are increasingly serving fresh produce and ensuring that canned and processed foods are low in sodium and added sugars. Agriculture Secretary Tom Vilsack has made nutrition security a key objective in all USDA-administered programs, especially school meals.

To make nutrition a more central focus of SNAP, policymakers should take at least the following four steps.

To start, they should make diet quality a core, statutory focus of SNAP. Legislation from Sens. Cory Booker (D-N.J.) and Marco Rubio (R-Fla.) — the SNAP Nutrition Security Act of 2023 — would not only provide a statutory focus on nutrition within SNAP but craft a robust data collection strategy to identify opportunities to improve nutrition in the program.

Policymakers should also improve the Gus Schumacher Food Insecurity Nutrition Incentive Program (GusNIP), which provides competitive grants to programs that encourage good nutrition through incentives to low-income consumers to buy fruits and vegetables, and prescriptions from health care providers to direct patients to eat more fruits and vegetables. Policymakers on both sides of the aisle have expressed support for the program, and they should consider boosting GusNIP funding and reducing matching fund requirements for grantees as they consider improvements moving forward.

While not in the current policy proposals, Congress should empower and encourage states to create multiple, rigorous demonstration projects in SNAP to evaluate different innovative approaches to reduce hunger and improve nutrition at the same time.

Finally, they should strengthen the SNAP Nutrition Education and Obesity Prevention Grant Program, which provides nutrition education to low-income households, better integrating it with other federal and state nutrition and obesity prevention programs so that it reaches more people and has a more positive effect.

Poor diet leads to all-too-many cases of premature death and disability and to higher health care costs. SNAP can help reverse those trends by empowering its tens of millions of participants to buy and eat more nutritious meals.

Dan Glickman and Ann M. Veneman, who served as secretary of agriculture under Presidents Clinton and George W. Bush respectively, also are co-chairs of the Bipartisan Policy Center’s Food and Nutrition Security Task Force.

Although the coverage of contentious debt negotiations could leave one feeling pessimistic about the possibility for legislative action, I am forever an optimist. And I’d encourage any members on Capitol Hill looking for such opportunities to pick up the baton and carry forward the work to address an issue that continues to be a struggle for American families: lowering the cost of prescription drugs. 

In my 40 years in Congress, I saw how hard-entrenched interests pushed to keep prescription drug prices high. Without congressional leaders acting, those who profit from unaffordable medications will continue to make that push and lead in the race. I was proud to work with my colleagues to make important medicines more accessible for American families. Together we advanced bipartisan legislation like the Hatch-Waxman Act that gave rise to the generic drug industry, saving the American people well over $1 trillion and making it easier for them to get the drugs they need without breaking the bank. 

My colleagues and I then passed the baton to a new generation of leaders, who continued that progress by enacting the Inflation Reduction Act (IRA) last year, an historic milestone in the race to drug affordability. The IRA’s signature drug policy achievement — requiring the federal government to negotiate prices for certain high-cost drugs covered under Medicare — will finally start to bring American drug costs more in line with our international peers, who have long been negotiating with pharmaceutical manufacturers. The IRA includes many meaningful drug pricing advances, including requiring drug makers to pay rebates to Medicare if they raise prices faster than the rate of inflation, limiting the Medicare out-of-pocket cost for insulin to no more than $35 per month, and eliminating cost-sharing for lifesaving vaccines covered under Medicare Part D. 

Looking ahead, the law will also help close the “donut hole” for beneficiaries facing high out-of-pocket costs once their coverage limit kicks in and will expand eligibility for full Part D Low-Income Subsidies to help the most vulnerable afford their medications.

But the data show we have more to do.

A concerning report issued by the Federal Reserve showed a recent uptick in the number of Americans who avoided necessary medical care because of the cost, and prescription medicines were one of the most skipped treatments. Just last month, the Centers for Disease Control and Prevention (CDC) released new data showing that more than 9 million Americans aren’t taking their medications as prescribed due to the cost. It’s clear the American people need additional relief.

We are entering a new leg of the race to lower prescription drug costs, and patients across the country need the 118th Congress to grab the baton as we’re picking up momentum. The American people are cheering on from the sideline in a near-unanimous uproar, with a majority of both Democratic and Republican voters agreeing that more government action is needed. Congress would be wise to listen.

First and foremost, that means ensuring the IRA is fully implemented. With 89 percent of the public supporting government negotiation of lower drug prices, members of Congress would be wise to partner with federal agencies to ensure a robust implementation of the law. As they head home for the summer recess, members and their staff should also consider opportunities to help constituents understand the benefits this legislation will have for them, their families and friends, to make clear their needs are being heard and addressed.

Second, Congress should bring to the floor and enact legislation to build upon this work. Congress has an opportunity this year to help bring affordable generic drugs to market faster and make it easier for people to access the medications they need. Already, the Senate Health, Labor, Education and Pensions (HELP); Commerce; and Judiciary committees and the House Energy and Commerce Committee have advanced bills this year that would ease the processes for generic companies to make less costly alternatives for expensive medicines and make it harder for brand name companies to block competition from generic drugs.  

Together, these bills represent a key opportunity to advance a fairer and more affordable prescription drug market. For the sake of the people’s pocketbooks and their health, the 118th Congress must continue momentum on lowering drug prices and get us closer to the finish line of achieving affordable health care for all. 

Henry A. Waxman represented California’s 33rd Congressional District from 1975 to 2015. He now chairs Waxman Strategies, a public interest firm working on health care and environmental policy.

Our job as emergency physicians is to diagnose the patient promptly and to provide appropriate treatment. When we do not know the patient — which is virtually all the time — and when they cannot tell us about their medical history, the challenge is especially daunting.

Electronic Health Records (EHRs) have been an important advancement in providing complete and accurate patient information; in fact my colleagues and I have been vocal advocates for their implementation and use. The days of literally calling the medical records department so that you can view a paper record are thankfully gone forever. 

Current medical histories help us establish an accurate working diagnosis and treatment plan. With a patient’s medical history in hand, we can learn if a patient with chest pain has ever had heart problems, whether a patient with gastrointestinal pain has chronic digestive issues and whether a patient is taking a drug that may be contraindicated with drugs being considered as part of the treatment plan.

The importance of physicians having access to patients’ medical histories is well-recognized on the national level. The U.S. Department of Health and Human Services (HHS) has made significant efforts to make medical information more accessible. The HHS Office of National Coordinator for Health Information Technology (ONC) website says, “When health care providers have access to complete and accurate information, patients receive better medical care. … With EHRs, providers can have reliable access to a patient's complete health information. This comprehensive picture can help providers diagnose patients' problems sooner.”

Therefore, it is difficult to understand why the ONC is proposing rules that would allow medical information to be hidden from physicians. In a new rule, the ONC is proposing to require clinicians the ability to redact discreet pieces of medical information from the medical record created on a prior encounter, if requested by the patient. This proposal is essentially legalizing tampering with the legal medical record and therefore decreasing transparency — and increasing risk during subsequent care events. 

While the proposal is a well-intentioned effort to give patients more control over the confidentiality of their own medical histories, the practical effect will be to increase the likelihood of an inaccurate diagnosis and treatment plan.

For example, if a patient hides their past opioid use, how can an emergency physician (or any physician) know to avoid prescribing opioids? If a patient hides their past violent behavior, the emergency team could be at risk. If a patient hides their mental health history, a physician might prescribe an anticonvulsant unaware that the patient is already taking drugs that could interact. ONC’s proposal could even halt automatic systems in the EHR, such as flagging harmful drug-drug interactions, if the patient has requested a prescription be hidden.

Given the many variables in medical treatment, the possible risks to patients are endless when a physician does not have access to complete medical information. Further, rather than reducing stigma, this policy could instead encourage it by reaffirming that a history of depression or a sexually transmitted infection is something that should be hidden.

As physicians, we have an obligation to keep patient information confidential. Not only is it a matter of law that includes fines, it is central to our oath as a physician to do no harm. For emergency medical teams (or any physician), limiting access to a patient’s complete medical history can only result in delayed diagnosis and treatment at a time when quick diagnosis and treatment is critical. Hiding medical information can easily lead to less effective outcomes for the patient.

Over its history, the ONC has taken several steps to create a culture of enhancing transparency and the value of EHRs. While the bipartisan 21^st Century Cures Act has recently made huge advancements in making patient information available to clinicians, this regulation takes steps in the opposite direction and should be reconsidered, modified or — preferably — deleted. Giving patients an option to hide some of this information from physicians is a step backward for sound emergency and medical care.

Dr. Kevin Baumlin is chief medical affairs officer at the University City Science Center in Philadelphia. He is a former professor of emergency medicine at Penn Medicine; professor and chairman of the Department of Emergency Medicine at Mount Sinai Beth Israel; and associate medical information officer at Mount Sinai Health System. He is Board Certified in Clinical Informatics and Emergency Medicine.

They’re no longer actively sick and in need of daily medical interventions — they simply have no place else to go. One main culprit is the structure of Medicaid.

After suffering traumatic brain injuries, many patients are left permanently cognitively impaired, requiring lifetime assistance with daily activities and permanent round-the-clock caregiving. Even for wealthy individuals, it’s a strain on finances and families.

Thus, they can’t be discharged, lingering in medical limbo too healthy to need acute hospitalization yet too disabled to go home. They occupy acute-care beds while patients needing urgent attention pile up in ER hallways or have surgeries canceled because the hospital is full. Acute care nurses are asked to assist these patients with meals, hygiene and supervision, exacerbating nursing shortages.

This is because post-acute care options for patients who cannot discharge home are few. Inpatient rehab facilities can help patients cope with new disabilities but are temporary. Rehab facilities won’t take a patient if there’s no eventual location to discharge to. Thus, patients with few social supports typically need a skilled nursing facility.

How does one finance a lifetime of care?

Medicare and private health insurance typically fund short-term rehab or nursing facility stays, not long-term care, which is funded by private assets, private long-term care insurance or Medicaid. Since most individuals lack the necessary assets or private insurance, Medicaid funds most long-term care. These Medicaid benefits — encompassing post-acute care, nursing homes and home-based community support services — are collectively known as long-term services and supports. Collectively, long-term services and supports take up nearly one-third of Medicaid spending.

States have much leeway in structuring Medicaid. One major variation is offering fee-for-service versus third-party managed care organizations. In fee-for-service, doctors or hospitals submit bills directly to state Medicaid offices for services rendered and get paid their fees. In managed care organization models, private entities receive monthly sums per enrollee, provide care for all enrollees from that pool of funds and keep the balance (or are on the hook for the loss).

States may offer beneficiaries either one or a combination of the two models. Complicating matters, some services might be in one model with others carved out into the other. When long-term services and supports are in a fee-for-service model, this can lead to the disastrous situation traumatic brain injury patients face.

Medicaid fee-for-service typically reimburses at or below cost for skilled nursing facility services. With too many Medicaid patients, a skilled nursing facility can’t pay its staff. A nursing facility can’t be forced to accept patients just because a hospital is overcrowded. A hospital may want a bed freed up but has no recourse. However, when a managed care organization is responsible for all costs associated with a patient’s care, it’s motivated to get the patient out of unnecessary acute care and into post-acute care.

Utilizing managed care puts these incentives to work on the problem. To protect costs, managed care organizations have contracts in both skilled nursing facilities and rehab facilities. Multiple options for medially stabilized patients mean better outcomes. As long as the managed-care market is competitive and patient choice prevails (unfortunately not always the case), they must ensure quality. A reputation for using subpar providers means fewer enrollees.

Ideally, more Americans would already have private long-term care insurance. Medicaid is meant as a safety net for the disabled and destitute, not as the default payer for long-term care. When a patient reaches their private or Medicare coverage limit, they’re left having to use private assets to pay for continued care. They can deplete these assets to “spend down” and qualify for Medicaid, but many protect assets in trusts or property, qualifying while still holding substantial wealth.

State Medicaid agencies should recover these assets more aggressively, reserving Medicaid for the poor. This would encourage broader uptake of private long-term care insurance while leaving Medicaid with more funding for long-term services and supports. This, combined with greater managed care organization long-term service and supports coverage, would increase overall access to post-acute and long-term care services for the old and the young and the temporarily disabled.

More access to post-acute care means more medically stable patients discharged and fewer lingering for months waiting for skilled nursing facility beds. This would free up hospital resources, allowing nurses and doctors to focus on acute patients.

It would improve morale and patient care. I know our clinical team would appreciate it.

Anthony DiGiorgio, DO, MHA, is a neurosurgeon, assistant professor at the University of California, San Francisco School of Medicine, senior affiliated scholar with the Mercatus Center at George Mason University, and the author of a new study, “Traumatic Brain Injury: A Case Study in Failed Incentives to Address the Needs of Medicaid Patients in California.” He is also affiliated faculty at the Institute for Health Policy Studies at UCSF.

A new report by a working group that we co-chaired at the National Academy of Social Insurance indicates that the safety net was surprisingly resilient in some areas, but that the pandemic also reinforced existing inequalities and revealed system shortcomings. To be ready for the next crisis, America should act now to streamline program administration, increase responsiveness and reduce disparities.

Despite the closing of many government offices, dedicated workers ensured that programs remained operational, albeit with disruptions and delays. Social Security and Unemployment Insurance benefits continued to be paid, and Medicare and Medicaid continued to finance health care. 

Surprisingly, COVID did only limited financial damage to Social Security and Medicare. Because the economic recovery was unexpectedly fast, the dip in payroll taxes to fund these programs was briefer and shallower — and program spending was lower — than projected. COVID reinforced the downward trend in claims for Social Security Disability Insurance benefits, as office closures hindered new applications. Medicare spending also fell, as patients delayed non-urgent care. Despite the spike in COVID-related admissions, overall hospital admissions dropped 30 percent.

Beyond the existing safety net programs, Congress took further actions to mitigate the financial and health calamity. It increased and extended unemployment benefits and provided sizable lump-sum benefits to most Americans. Together with the Child Tax Credit (now expired) and increases in Supplemental Nutritional Assistance Program benefits, these changes helped cut poverty in 2021 by 15 percent overall and by 46 percent for children. Changes in Workers’ Compensation provided income assistance and health insurance coverage. Eviction moratoriums mitigated the risk of homelessness for many. Fears that such generous assistance would undermine workers’ incentive to seek new jobs proved largely unfounded, as employment rebounded faster than anticipated.

Congress also extended health care coverage, increasing the share of Medicaid costs borne by the federal government for states that maintained enrollment and liberalizing refundable tax credits for health insurance exchange plans. Between these provisions and the faster-than-expected rebounding of employment-based health insurance, the proportion of non-elderly Americans without insurance in 2021 fell to 10.3 percent, a historic low. Because Medicare and Medicaid typically pay providers less than private insurers, Congress shored up hospital finances by creating a fund to offset the influx of COVID patients covered by these programs (though the fund was not particularly well targeted to struggling hospitals).

Overall, our social insurance programs did what they were supposed to — though, without congressionally enacted changes, there would have been much greater financial distress. Although the targeting of benefits to those most in need was imperfect, enough cash and in-kind assistance went out to sustain consumer demand, supporting a U.S. economic recovery that was faster than that of many other countries. 

Despite these successes, serious failures meant that millions of people suffered much more dire financial as well as health consequences than they might have. The failures of our public health system — from lack of sophisticated monitoring, data, and infrastructure supporting rapid deployment of resources to shortages of supplies addressing foreseeable needs — are well documented, and were major contributors to the shocking 1.3 million deaths due to COVID in the U.S. The death rate of Medicare beneficiaries in nursing homes was thirteen times that of Medicare beneficiaries living elsewhere, and disproportionately higher for African Americans and Hispanics than for whites.

Our social insurance infrastructure was also woefully lacking — particularly the management of unemployment benefits. Archaic computer systems, lack of data and overworked staffs resulted in delays in the delivery of aid to the tsunami of new applicants. Confusion about eligibility rules and lack of information (such as for those not filing tax claims) led to many not receiving benefits for which they were eligible. Insufficient data also meant that aid could not be targeted based on past earnings or economic hardship. Thus, while congressional actions helped mitigate financial hardship, they were often poorly timed and poorly targeted.

The pandemic illustrated once again that those who are least well protected against adverse events in normal times suffer the most during emergencies. Those from low-income or underserved areas suffered disproportionately, as did those from racial and ethnic minority groups. There were not only unconscionable disparities in mortality and adverse health outcomes, but also in access to financial support.

The National Academy of Social Insurance report not only documents the performance of the system under COVID, but presents practical and practicable ways to prepare for future health (or economic, environmental or geopolitical) emergencies.

Many of the crucial steps undertaken by Congress could be implemented in a more streamlined and effective way if automatic triggers were enacted now, such as additional Medicaid financing for states that maintain enrollment during emergencies or extended unemployment insurance benefits. Other temporary measures could be made permanent, such as changing regulations about telemedicine or scope-of-practice restrictions.

All of these options could be better supported by modernized infrastructure to allow efficient program administration and the collection of data to allow better benefit targeting. The digital divide further amplified health and access disparities during shut-downs. Adequate internet communication is an essential element of both health and safety net systems.

Our social insurance programs provide a vital safety net at all times, but never more crucially than during national emergencies. COVID revealed how very important these programs are to health and economic survival — and also ways that we can shore them up before the next emergency arrives. It behooves us to do so.

Henry J. Aaron is the Bruce and Virginia MacLaury Chair and senior fellow in the Economic Studies Program at the Brookings Institution. Katherine Baicker is provost of the University of Chicago and the Emmett Dedmon Professor at UChicago’s Harris School of Public Policy. They serve as co-chairs of the National Academy of Social Insurance’s COVID-19 Task Force Policy Translation Working Group.

Affirmative action is not a system of quotas. It is an admissions tool that considers how race may have shaped an applicant’s experiences and the lens through which they view and experience the world. Studies show that people who are underrepresented in medicine cannot achieve enough education or money to overcome the ills of systemic racism that lead to worse education and health outcomes. This is one reason why the American Medical Association filed an amicus brief urging the court to “take no action that would disrupt the admissions processes the nation’s health-professional schools have carefully crafted.”

Even with policies that take race into account, medical schools reported that just 12 percent of matriculants in 2022 were Hispanic, compared with 19 percent of the overall population. Black people, American Indians and Alaska natives were also underrepresented. Diversity in medical school is essential for future doctors of all races: Research shows that students who train in diverse settings are more adept at caring for diverse patients. Affirmative action ensures an increase in the diversity of the medical student pipeline, creating better physicians from all backgrounds and leading to better health outcomes for all patients. 

Research shows that culturally competent care matters. Numerous studies suggest that “concordance” (when patients and doctors share race or other identifying factors) improves patient health. For instance, a 2021 study in Oakland found that racial concordance between patients and doctors increased patients’ interest in prevention, and argued that more Black doctors could “reduce the black-white male gap in cardiovascular mortality by 19 percent.”

Meanwhile, we know that racism in medicine hurts patients in obvious, documented ways. The more physicians we have from marginalized backgrounds, the more protections we have against these biases. For instance, Black patients’ pain is undertreated relative to white patients. In my own work as an emergency medicine physician, I’ve seen how biases in pain management affect patients. I’ve heard patients suffering from the painful effects of sickle cell disease, which is far more common in Black people, referred to as “sicklers” who just want a “fix.” I’ve seen how Black victims of gun violence are slower to receive pain management than white victims with less severe injuries. Meanwhile, recent evidence shows that even high-income Black women are more likely to die in childbirth than white mothers.

We already have too few people of color in health care. We can’t afford to close off more pathways, as this Supreme Court decision will do. 

If preventable maternal deaths and inequitable treatment of Black patients isn’t a strong enough argument for affirmative action and its impact on health provider diversity, then perhaps money is. A recent metastudy found that diverse healthcare teams correlated with higher quality health care and the financial performance of health organizations. This may be due to greater cultural understanding. For instance, a physician savvy enough to ask if a patient can afford healthy foods and medications could stave off a costly emergency department visit for a stroke. But with affirmative action outlawed, undermining the diverse workforce and curriculum it seeks to uphold, doctors may lack the cultural competence to ask questions pertaining to the social drivers of health — the conditions in which people live and work that affect health care outcomes.

We need more of these culturally informed conversations, and more diversity in health care, not less. When patients’ social barriers to care aren’t addressed — issues that a diverse medical team may be more likely to spot — they often end up in the hospital. Such costs are absorbed by all of us. While inequitable health outcomes disproportionately affect a fraction of the population, we all literally pay the price.

Overturning race-based affirmative action will increase preventable deaths and health inequity overall. Affirmative action is about more than just moving students of color into the nation’s ivory towers. It is about creating a diverse pipeline for fields like medicine serving a growing number of diverse and vulnerable people. 

Katrina Gipson, MD, MPH is an assistant professor of Emergency Medicine at Emory University School of Medicine. She practices at Grady Memorial Hospital and is a thought leader in health advocacy as a Public Voices Fellow of Academy Health in partnership with The Op Ed Project.

Bream’s pursuit of such clarity is, sadly, rare in her field. Around the first anniversary of the Dobbs decision overturning Roe v. Wade, newspaper headlines and television chyrons have largely clung to the familiar narrative that the consensus among Americans favors radical abortion policies like those generally espoused by Cardin and his party. 

This couldn’t be further from the truth. 

Even after 50 years under Roe, the American public strongly embraces protections for human life before birth. One major reason is that scientific advancements since the 1970s have given rise to greater understanding of babies' development during pregnancy.

Today, more than ever, Americans recognize the humanity of the child in the womb. For instance, medical advancements have demonstrated that babies need anesthesia for surgery in utero as early as 15 weeks. Certainly, these tiny humans deserve protection from brutal life-ending procedures. 

The idea of protecting children in the womb from pain is not controversial. It is a belief most Americans share. Marist polling has been tracking opinions about where to draw the line on abortion for over a decade. In that time, opinion hasn’t changed much, as indicated in the 2023 findings showing that almost seven in 10 Americans support limiting abortion to the first three months of pregnancy at most.

And despite the media narrative to the contrary, this poll is not an outlier — in fact, Marist's results track with recent Gallup, NPR, Harvard-Harris and Associated Press polls.  

When asked for their specific views — in terms of weeks or trimesters — Americans consistently express a desire to protect the unborn throughout most of their nine months of gestation.

The media generally frame their coverage in a way that lines up with Democratic messaging, labeling any protections for the unborn as an outright “ban.” Even laws that allow for abortions for any reason for five full months get the absurd misnomer “20-week ban.” In case they missed it, the dictionary definition of “ban” is “to forbid someone to do something.” In no state are all abortions forbidden. 

Every state that has enacted life-affirming laws makes some exceptions.  

The partisan press further takes a side on this issue by blacking out references to the humanity of children inside the womb, including scientifically observed milestones such as their heartbeat, fingerprints, development of unique facial features, and capacity to feel pain. The Associated Press even instructs journalists to use the cold and clinical “cardiac activity” instead of "heartbeat."

This framing is a key component of the Democrats’ political strategy. It comes straight out of their carefully poll-tested messaging playbook.  

Between the Dobbs decision and the 2022 midterm elections, Democrats’ top strategists conducted detailed polling to investigate what media messages would resonate best with voters. This research yielded a “clear conclusion” that the “most potent messaging for Democrats was to keep the conversation broad by casting Republicans as supporting a national ban on abortion and avoid a discussion over the details about gestational week limits,” the New York Times has reported. 

As longtime Democratic pollster Celinda Lake, who has conducted some of the post-Dobbs surveys, put it: “Debating weeks is not where we want to be [because] people are terrible at math and terrible at biology.” 

I disagree. In fact, Americans are far more knowledgeable about prenatal development today than they were in 1973, when Roe was decided. Recent generations have grown up observing babies in pregnancy through 2D, 3D and 4D ultrasound images. More and more Americans know someone who underwent surgery in utero, which routinely requires anesthesia, not only for the mother but also specifically for the child patient. 

What is true is that Democrats know their position of taxpayer-funded elective abortion through all nine months of pregnancy is not only inhumane, but also polls only up to 20 percent on a good day — and generally far lower than that. The media’s avoidance of this fact is an example of bias, a gift to the Democrats. 

It’s time to bring honesty and clarity to our national conversation about abortion. If the mainstream media are willing to return to impartial journalistic ethics, we’ll see a very different story. It will be abundantly clear that Americans are reasonable and compassionate and overwhelmingly want pro-life protections for both mother and child.  

Marjorie Dannenfelser is president of Susan B. Anthony Pro-Life America.

Biden’s proposal would eliminate consumer protections, throw sick patients out of their health insurance, and leave them to face sky-high medical bills without insurance for up to one year. 

Under current law, consumers can purchase renewable short-term health insurance at premiums up to 60 percent less than plans available through the ObamaCare exchanges. Plans can last up to 36 months. Enrollees can renew their plans for even longer, providing secure coverage for acute and even chronic care episodes.  

Biden hopes to limit the maximum length of such plans to four months, to prohibit renewals, and to preserve rules that forbid patients who lose such coverage from enrolling in an ObamaCare plan until the following January.  

Under Biden’s proposal, consumers who buy a short-term plan then fall ill would lose their coverage when their plan expires within four months. When that happens, they would be unable to re-enroll in new insurance for up to a year. Biden’s proposal would turn what would have been insured medical conditions under renewable plans into uninsurable preexisting conditions.

Similar rules left 61-year-old Phoenix resident Jeanne Balvin with nearly $100,000 in unpaid medical bills. In 2016, over the objections of insurance regulators, President Barack Obama briefly imposed similar rules limiting short-term plans to three months and banned renewals.  

In April 2017, Balvin purchased a short-term plan. That June and July, she required multiple emergency surgeries and hospitalizations for diverticulitis. Her short-term plan paid her claims promptly and in full — until Obama’s three-month clock ran out at the end of June. When that happened, she lost her coverage and she could not enroll in another plan. Obama's three-month rule had turned her diverticulitis into an uninsurable pre-existing condition, and Obamacare would not take her until January under its rules for open enrollment.

In short, Obama’s rules limiting short-term plans left her sick, uninsured, and with $97,000 in medical bills.

So much for Biden’s campaign promise that, under his presidency, “If you like your…private insurance, you can keep it.” His proposal would mandate the very practice of stripping coverage from the sick that he had promised ObamaCare would end.

Overall, the Congressional Budget Office estimates such rules would oust 1.5 million people from their current plans, of which 500,000 would lose coverage entirely. 

What’s happening is that renewable short-term plans compete with ObamaCare. Indeed, for many families, they are the better option. Biden wants to force people into ObamaCare by crippling the competition.  

ObamaCare is offering increasingly low-quality — one might even say "junk" — coverage with sky-high premiums. Coverage for many expensive conditions is growing ever-thinner. Choice of providers and health insurers is dwindling. In 2021, when the average ObamaCare family premium exceeded $17,000 annually (despite average deductibles near $8,000), Democrats grew so nervous, they extended premium subsidies to households earning up to $600,000 per year. The average family premium currently exceeds $18,000.  

In contrast, “short-term, limited duration insurance” offers broader provider networks and as much coverage as consumers want. According to the CBO, they do so at premiums “as much as 60 percent lower” than the lowest-price ObamaCare plans. They can do these things because Congress explicitly exempts short-term plans from the regulations that are dragging down ObamaCare. The CBO and other non-partisan groups estimate that short-term plans reduce the uninsured by between one million and 2.3 million. 

In 2018, the Trump administration clarified that federal law leaves consumers free to purchase short-term plans that last up to 36 months, to purchase multiple consecutive policies in advance, and to purchase renewal guarantees.

Renewal guarantees let enrollees keep their health plans — and keep paying affordable, healthy-person premiums — well after they get sick. They can even reduce ObamaCare premiums by keeping sick patients out of ObamaCare’s risk pools.  

If Biden really wants to protect ObamaCare, he need only sit back and let that happen. Instead, he hopes that limiting short-term plans to four months, banning consecutive policies, and banning renewal guarantees will force consumers into ObamaCare.  

Federal law creates no authority for a president to limit, much less ban, insurance renewals or renewal guarantees. In 2020, the U.S. Court of Appeals for the D.C. Circuit rejected a challenge to current rules for short-term plans, ruling that “nothing in [federal law] prevents insurers from renewing expired [short-term] policies.”

Indeed, the whole purpose of the regulatory scheme Biden is purporting to implement is to shield sick patients from re-underwriting, not to expose them to it. But the latter is what his proposal would in fact do. If Biden ultimately adopts this proposal, it will be vulnerable to legal challenge. 

Michael F. Cannon (@mfcannon) is director of health policy studies at the Cato Institute. 

As a public health and community advocate in Oregon, my nonprofit encourages fairness for workers, including farm workers and others who work in heavy-duty environments, often without access to air conditioners. Working in hot conditions results in significant harms, including heat exhaustion and death. The 2021 heatwave in Oregon resulted in the death of two workers (a farm worker and a construction worker). Despite attempts by certain industry groups to block the legislation, Oregon passed worker protections that include mandatory water and shade breaks in high heat and require employers to provide respiratory masks in exceptionally smoky conditions. 

To date, only three states require heat breaks (California, Oregon and Washington) for outdoor workers. Two others have partial protections: Minnesota has a rule setting standards for indoor workers, and Colorado’s heat regulations only cover farmworkers. 

As temperatures reach new extremes, we need to start treating heat deaths as a public health issue. The World Meteorological Organization projects the world is set to reach an increase of 1.5 degrees Celsius (2.7 degrees Fahrenheit) by 2027, bringing heat waves to unprecedented levels. 

If we consider high heat to be a public health and human rights crisis, we would view access to water and shade through a different lens. Especially as climate conditions continue to become more extreme, we need to focus on:

Improving policies that mandate water and shade breaks

There are laws against leaving children and animals in hot vehicles. In other words, animals are treated better than laborers. The work of laborers — construction workers, agricultural workers, utility workers and others — is the foundation of the economy, but they are often the most vulnerable. Ensuring their well-being requires passing laws that add protection rather than remove rights.

Better training for employers and employees on worker rights

During the Oregon heatwave, employers partially blamed the death of the workers on the workers themselves, arguing that common sense would have indicated that they stop and take a break. Oregon’s courts rightly denied the company’s argument that they should not pay a fine for failure to supervise and train employees about breaks.

Mandating that employers partner with local community organizations and leaders to provide proper education, outreach and information on worker rights during a heatwave improves employer-employee relationships and overall health outcomes. We strive to ensure that workers will never die from a heatwave because they did not access water or know they were allowed breaks.

Better data collection methods to track heat-related deaths

Public health requires data. Many deaths associated with extreme heat are misidentified or not coded properly due to complexities associated with heat-related illnesses, which can worsen a person’s underlying conditions. These deaths are classified as cardiovascular or from other causes. Studies indicate the actual number of deaths due to heat is twice as many reported.

Without access to proper reporting measures, heat-related deaths are underreported, often representing underserved communities. Underreported heat deaths severely affect public health and the population’s health.

Today, our nation continues to fail to treat laborers — often immigrant laborers — as equal human beings. Perhaps this is because anti-immigrant and anti-labor forces advocate for reducing rights, despite how much our country relies on these workers. Such attitudes and actions lead to more preventable deaths among our most vulnerable people. 

Jackie Leung is an assistant professor of public health at Linfield University. She is a public health researcher and writes about public health policy as a Public Voices Fellow with AcademyHealth in Partnership with the OpEdProject.

But cancer survivors face steep challenges unrelated to the disease itself. Among the approximately 4 million breast cancer survivors in the United States, those who have had mastectomies had to decide whether to undergo breast reconstruction and, if so, whether to do so using implants or tissue transplanted from another part of their body.

One such method, known as DIEP (deep inferior epigastric perforator), in which abdominal tissue is transplanted to the chest without using abdominal muscle, may soon be less available. Why? The Centers for Medicare and Medicaid Services (CMS) is planning to eliminate the billing codes for this and other specialized breast reconstruction procedures on Dec. 31, 2024. This should not be the case: women facing breast cancer need all the best reconstruction options readily available.

This is deeply personal for me.

My son was just shy of his second birthday in 2011 when I was diagnosed with a precursor to invasive breast cancer in my left breast. I was just 36 years old and terrified. I went ahead with a mastectomy. Then, I faced the question of whether and how to reconstruct my breast. I wanted reconstruction but was concerned about the potential downsides of implants: discomfort from a “foreign body” in my chest, implant leakage, and the need to have procedures every decade to replace the implants. These were all daunting. Reconstruction using my own tissue seemed like a better approach for me. According to my plastic surgeon, I was a good candidate for DIEP-flap reconstruction.

It was then that I first learned about the Women’s Health and Cancer Rights Act of 1998. This legislation mandates that insurers that cover mastectomies provide coverage for all stages of breast reconstruction. Through my insurance, I had options and could choose the reconstruction that was best for me. In hindsight, choosing the DIEP flap approach was one of the best decisions in my life. My reconstructed breast feels and looks much like a natural breast and has enabled me to lead an active, exuberant and fulfilling life — even bench pressing at the gym with my now 14-year-old son.

The detrimental effects of the proposed coding changes have caught the attention of U.S. senators, representatives, patient advocacy groups and professional organizations, who have written to CMS urging them to retain the specialized billing code for DIEP-flap surgery. The elimination of certain billing codes by CMS means that it wants to revert to a lower-paying billing code for these special flap procedures, generally used for less complex and less expensive reconstruction options. Though it may appear only as a procedure coding change, the consequences would be profound.

Fewer women will likely be offered DIEP flap reconstruction if surgeons are not reimbursed adequately for this more complex procedure. This could make it more difficult for women to obtain DIEP flap reconstruction, including those who have had breast radiation, for whom it is a critically important option. At a time when we are grappling with disparities in access to care, a decision like this would further perpetuate health inequities. More women will be asked to pay for the advanced procedure, many of whom simply cannot afford it. Yet, women report increased quality of life — a major goal of healthcare — with DIEP-flap reconstruction.

In a glimmer of hope, on June 1^st 2023, CMS held a hearing soliciting input on their decision to discontinue the codes, raising the possibility that the there is still a chance to reverse this process.

Just weeks ago, I was diagnosed with breast cancer again, this time in my other breast. DIEP-flap reconstruction was no longer an option for me because it was used previously. Nevertheless, I knew that I wanted to use my own tissue. I was able to have reconstructive surgery using my inner thigh tissue through a delicate microsurgical procedure. After many hours in the operating room, I recovered listening to the Doppler machine capture the melodic sound of blood supply flowing through my new breast, a sound reminiscent of a fetal heartbeat. It filled me with optimism for the future and hope of a prompt return to my favorite activities.

Having breast cancer is hard enough. Believe me. Let’s make sure that every woman is able to share the same optimism and outcomes that I had by ensuring access to the breast cancer reconstruction method that is best for her.

Katerina Politi is associate professor of pathology and internal medicine at the Yale School of Medicine.

A growing number of countries, including some of the most progressive in Europe, are rejecting the U.S. “gender-affirming” model of care for transgender-identified youth. These countries have adopted a far more restrictive and cautious approach, one that prioritizes psychotherapy and reserves hormonal interventions for extreme cases.  

In stark contrast to groups like the American Academy of Pediatrics (AAP), which urges clinicians to “affirm” their patient’s identity irrespective of circumstance and regards alternatives to an affirm-early/affirm-only approach “conversion therapy,” European health authorities are recommending exploratory therapy to discern why teens are rejecting their bodies and whether less invasive treatments may help.  

If implemented in American clinics, the European approach would effectively deny puberty blockers and cross-sex hormones to most adolescents who are receiving these drugs today. Unlike in the U.S., in Europe surgeries are generally off the table before adulthood.  

Why are more countries turning their backs on what American medical associations, most Democrats and the American Civil Liberties Union call “medically necessary” and “life-saving” care? The answer is that Europeans are following principles of evidence-based medicine (EBM), while Americans are not.

A bedrock principle of EBM is that medical recommendations should be grounded in the best available research. EBM recognizes a hierarchy of information. The expert opinion of doctors, for example, even when based on extensive clinical experience, furnishes the lowest quality — meaning, least reliable — information. Slightly higher on the information pyramid are observational studies. Systematic reviews of evidence, meanwhile, furnish the highest quality evidence. They follow a rigorously developed, reproducible methodology. They do not cherry-pick studies with convenient results, but instead consider all the available research.  

Most importantly, systematic reviews don’t merely summarize the conclusions of available studies on a question of interest. Instead, they assess the strengths and weaknesses of these studies to determine the reliability of their findings. To do this, systematic reviews typically use the GRADE system (Grading of Recommendations, Assessment, Development and Evaluations) and rank the quality of evidence as “high,” “moderate,” “low” or “very low.”  

Systematic reviews by EBM experts in Scandinavia and the United Kingdom have concluded that there are serious gaps in the evidence base for sex modification in minors. The U.K. systematic reviews found the available research to be of “very low” quality — meaning that there is very low certainty that an observed effect, like reduced suicidality, is due to the intervention, and therefore the studies’ claimed results are unlikely to represent the truth.  

Importantly, even the famous Dutch study that is said to be the “gold standard” of research in this area received a rating of “very low” due to serious methodological problems. Sweden’s National Board of Health and Welfare has said that the risks of treating gender dysphoric minors with hormonal interventions “currently outweigh the possible benefits.”  

Last year, Florida’s health authorities commissioned what is known as an “umbrella review,” or a systematic overview of systematic reviews, from independent experts at McMaster University, home of EBM. Unsurprisingly, that overview came to the same conclusion: There is no reliable evidence that youth transition improves mental health outcomes.  

Because U.S. medical groups don’t always use EBM, their conclusions can be based on studies whose fatal flaws are overlooked or ignored. Consider, as an example, a study done at Seattle Children’s Hospital and published last year. The study’s authors reported that use of puberty blockers and cross-sex hormones was associated with 60 percent lower odds of depression and 73 percent lower odds of suicidality. Leading mainstream publications, including Scientific American and Psychology Today, celebrated the findings. More recently, major U.S. medical associations cited the study in federal court proceedings.  

But a careful look at the study’s data shows that the kids who received hormonal interventions did no better by the end of the study than at the beginning. The researchers’ claim about improvement was based on the fact that the kids in the control group, who received psychotherapy but not hormones, got worse relative to the hormone group. But even this isn’t accurate, as 80 percent of the control group dropped out by the end of the study, and a likely reason for this dramatic loss to follow-up is that many or perhaps all of the non-hormone-treated kids improved without “gender-affirming” drugs. It’s quite possible that if the researchers had followed up with all the participants, we’d see this study become Exhibit A in the case against pediatric sex changes.  

Similar problems exist in studies purporting to show a rate of transition regret of less than 1 percent. The true rate of regret is not known and won’t be known for years to come. The claim that gender dysphoric teens are at high risk of suicide if not given access to “gender-affirming” drugs and surgeries is likewise baseless and irresponsible. In February, Finland’s top expert in gender medicine emphasized this point to the country’s liberal newspaper of record.

The American Academy of Pediatrics’ main statement on gender medicine, authored by a single doctor while still in his residency, is not a systematic review. The author himself has conceded as much. A later published peer-reviewed fact check found the AAP statement to be a textbook example of cherry-picking and mischaracterization of evidence.

The World Professional Association of Transgender Health (WPATH) says in its latest “standards of care” that a systematic review of evidence is “not possible.” Instead, WPATH used a “narrative review,” which has a high risk of bias according to EBM because it doesn’t utilize a reproducible methodology. England has broken from WPATH, and the director of Belgium’s Center for Evidence-Based Medicine has said he would “toss them [WPATH’s guidelines] in the bin.” In the U.S., WPATH’s standards are widely accepted as authoritative.

The U.S. Endocrine Society has relied on two systematic reviews in developing its own guideline. But these reviews were not for mental health benefits, and in any case the Endocrine Society ranks the quality of evidence behind its own recommendations as “low” or “very low.”

All other U.S. medical groups cite these three sources when assuring the public about “gender-affirming care,” thus creating an illusion of consensus around “settled science.”  

Earlier this year, an investigative report in the prestigious British Medical Journal concluded that although pediatric gender medicine in the U.S. is “consensus-based,” it is not “evidence-based.” Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario, and one of the founders of EBM, recently called American guidelines for managing youth gender dysphoria “untrustworthy.” 

Consensus can be produced by misguided empathy, ideological capture or political pressures. Consensus can also be manufactured. The new president of the American Medical Association (AMA) has said there should be “no debate” when it comes to offering kids “gender-affirming” drugs and surgeries.  

Yale School of Medicine’s Dr. Meredithe McNamara calls the questioning of the evidence behind pediatric sex changes “science denialism.” Her protest is ironic. Science is a process of ongoing inquiry and debate, not a set of predetermined conclusions. Science depends on skepticism, especially about sensitive subjects. True science denialism means restricting rational, evidence-based debate — exactly what McNamara and the AMA’s new president want to do.  

Their calls are bearing fruit. Just this month, gender activists successfully pressured a medical journal to retract a paper whose conclusions they found inconvenient. The ongoing campaign to suppress scientific debate allows a pseudo-consensus to emerge around “gender-affirming care.”  

Put simply, pediatric gender medicine in the U.S. is out of control. Medicalization of gender diversity in children is a fast-growing industry that shows no signs of self-correction. Doctors and therapists who practice “affirmative” medicine consistently demonstrate ignorance about EBM principles and deceive the public about the grim realities behind the euphemism “gender-affirming care.”  

A Reuters investigation last year interviewed providers at 18 pediatric gender clinics and found that none were doing comprehensive mental health assessments and differential diagnosis. Those who promote and practice “gender-affirming care” themselves tell us that their approach is child-led. “Gatekeeping” of medical transition, they insist, is pointless, even “dehumanizing.”

The author of the AAP’s position paper on gender medicine has said that a “child's sense of reality” is the “navigational beacon to orient treatment around.” The director of the gender clinic at Boston Children’s Hospital has admitted that they give out puberty blockers “like candy.” Even the founding psychologist of that clinic has warned that kids are being inappropriately “rushed toward the medical model.”

Why the U.S. has become an outlier on pediatric transgender medicine is a complicated question, but at least part of the answer is that European welfare states have centralized health bureaucracies and public health insurance. Before medicines can be approved for state funding, their evidence base needs to be evaluated. The American health care system is more vulnerable to profit motives, activist doctors and political pressures. Medical associations claim to advocate for patient health but can have other motives as well.

The situation is so dire that when pediatric gender medicine experts in other countries want to defend their practices before a skeptical public, they sometimes say that at least they are not as bad as the Americans. That is one kind of American exceptionalism we can do without.   

Leor Sapir is a fellow at the Manhattan Institute. 

I wrote a few years ago in these pages that Congress should be mindful of the Americans with Disabilities Act (ADA) when addressing assisted suicide public policy. Assisted suicide laws violate the landmark legislation that codifies disability as a protected class.

In the health care context, that means if you provide a certain standard of care to people — say, suicide prevention care — you cannot provide different or lesser standard of care to others based on disability.

Despite more than 30 years of the ADA being on the books, physician perceptions of the lives of people with disabilities remain abysmal. A recent Harvard study reports, “In [a] survey of 714 practicing U.S. physicians nationwide, 82.4% reported that people with significant disability have worse quality of life than nondisabled people. ... [T]hese findings about physicians' perceptions of this population raise questions about ensuring equitable care to people with disability. Potentially biased views among physicians could contribute to persistent health care disparities affecting people with disability.”

As we saw in the pandemic, states across the country promulgated Crisis Standards of Care, the triage rationing protocols put in place for medical professionals to know how best to mete out the limited resources. Multiple complaints were filed with the HHS Office for Civil Rights due to these policies systematically deprioritizing people with disabilities for life-saving medical resources, based on a misguided utilitarian view that non-disabled lives are worth more than the lives of people with disabilities.

Assisted suicide laws take the “less worthy” premise to the next level — “better off dead.” In their report, "The Dangers of Assisted Suicide Laws," the National Council on Disability, a nonpartisan federal agency, reports, “Demoralization in people with disabilities is often based on internalized oppression, such as being conditioned to regard help as undignified and burdensome, or to regard disability as an inherent impediment to quality of life. Demoralization can also result from the lack of options that people depend on. These problems can lead patients toward hastening their deaths — and doctors who conflate disability with terminal illness or poor quality of life are ready to help them.”

In every medical appointment nowadays, doctors ask, “Do you feel safe at home?” and “Have you considered self-harm?” Whenever patients express a desire to harm or kill themselves in a medical setting, the standard of care is to initiate harm and suicide prevention care and services.

In most states, if medical professionals react to those same warning signs by saying instead, “Sure, I can help you with that,” and their patients kill themselves with their help, those caregivers would be prosecuted in criminal court, likely sued by patients' families in civil court, and lose their licenses to practice medicine.

If, however, you happen to live in a jurisdiction where assisted suicide is legal, and you have a condition perceived by your doctor as limiting your life to six months or less, then both the standard of care and the usual criminal, civil, and professional protections afforded to everyone else are out the window for you. You, along with all other supposedly terminal patients, are shunted into the “better off dead” funnel, so long as doctor death is “acting in good faith.”

Every underlying condition qualifying a person for lethal drugs under assisted suicide laws also qualifies the same person for protection under the ADA. In many cases, these disabilities or conditions would not be at all life-threatening with proper medical care or long-term services and supports, yet they still can qualify for lethal drugs.

Some of the disturbing examples straight from the Oregon report include such treatable, non-life-threatening disabilities as diabetes, HIV, anorexia, arthritis, complications from a fall, hernia, and medical care complications.

Have we devalued some people so much that we are ready to waive protections in law and medical practice for vulnerable young people with eating disorders or mental health disabilities? Instead of helping them to live, society is all too ready to help them die by suicide, with state governments seemingly eager to pay for it.

The ADA was prescient and remains powerful. But it is only enforced through litigation. People with disabilities and the organizations that represent them can only hope for the fulfillment of its promise by fighting for it.

That’s why my organization has joined other organizations and individuals who filed a lawsuit in California Federal Court to overturn California’s assisted suicide law as an inherently discriminatory violation of the ADA, Section 504 of the Rehabilitation Act, and the Due Process and Equal Protection clauses of the 14th Amendment. To add assisted suicide as an “option,” but only for people with life-threatening disabilities, is just eugenics disguised to appeal to a deep cultural hunger for autonomy.

Neither the plaintiff group nor those endorsing this case are here to tell you what to do with your body. In fact, many in these groups are ardent advocates for reproductive rights. Most take no position on the moral or ethical implications of taking one's own life.

This lawsuit doesn’t attempt to punish people for killing themselves — no state in the union criminalizes suicide, and we have no objection to that.

In our fight for health care equity, however, it has become abundantly clear that California’s assisted suicide law disproportionately affects people with disabilities, funneling medically expensive people away from real healthcare and providing just one “treatment” to which we all have equal access — death.

Matt Vallière is executive director of the Patients’ Rights Action Fund and Institute for Patients’ Rights, as well as a volunteer emergency medical services first responder.