On Health Care Price Transparency

(from the comments)...

A doctor on billing practices:

Generally such figures do not reside within the physicians’ office. On our side of the table we do some procedure with multiple specifications and generate some CPT code(s) (e.g. a lap cholycystectomy is 47562, add on a common bile duct exploration and it becomes a 47564, and if you just do cholangiography it becomes a 47563). Generally, we couple that with an ICD-10 code that specifies your exact disease (K80 for simple stones, K81 for cholecystitis, etc.). We then dump those codes into a computer.

Can either of those change? Absolutely, we find a bunch of friable neovasculature around the gallbladder, congrats you likely have cancer which means this surgery is now both a different CPT code and a different ICD-10 set. Maybe only one does – we find the gallbladder lacks an obstructing stone, but does have transmural inflammation then you get a new ICD-10 code. If we find that you actually have multiple obstructing stones and we need to go deeper into the biliary tree, then those are different CPTs.

Regardless, we do what is medically indicated, document the codes used.

At this point, unless your physician keeps billing fully in house, those get handled by a processer. Often, bills from multiple providers get handled by one processor who in turn gives insurance companies bills to their specifications. Often this involves a bunch things – where was the surgery done (through very complicated rules, critical access hospitals, for example, can charge more for the same surgery because the government wants to keep them solvent lest a bunch of people lose their local emergency room and OR), who was doing it (e.g. there is a different rate if you have medical trainees involved), and of course stuff about you (e.g. complex patients get reimbursed at higher rates with the expectation that, on average, the higher rates cover higher complication rates and insurance doesn’t incentvize surgeons to make all their complex patients drive for hours and hours). Then we get to the big buys – buyers. For Medicare, there are some committees that appear to be overwhelmingly ignorant of actual medical practice but they set baseline reimbursements for these CPT/ICD-10 combos. Those then get adjusted to account for regional costs, equity concerns, and only God knows what all else. These are normally set near the break even point on national average. Medicaid, typically, uses those rates as a baseline and then cuts them (hence why many physicians won’t take new Medicaid patients, the reimbursement rates often leave folks at a net loss). Private insurers add another layer of negotiation where they use their monopsony power to extract lower rates while, allegedly, assuring physicians of volume. The range of these negotiations can be exceedingly wide – insurers can have modifiers for quality of care (e.g. how many folks come back in the perioperative period), timeliness of care, and so on and so forth.

Okay, so somebody has haggled set a rate and we just assume that get the bog standard lap chole we have a price?

Of course not.

See that is just what has agreed, in theory, these medical services will be reimbursed at. Actual reimbursement involves a non-negligable risk on non-payment (e.g. insurance denies and the patient cannot or will not pay), delayed payment (and having to utilize credit lines to cover payroll when a large insurer has an IT glitch and doesn’t pay for two weeks is quite expensive), and of course variable legal and compliance costs. You might also be hit with clawbacks, partial payments, and a host of other payment uncertainty.

Okay, but’s lest assume a single CPT/ICD-10 setup, a prenegotiated rate that is paid on time without further processing costs, and everything is chill there. We got a price yet?

Of course not.

See all of the above is for just the surgeon’s professional fees – i.e. what is being paid for use of his hands. The OR itself? That’s a completely different bucket of money that has its own set of billing and negotiations. Facility fees make the professional fees look straight forward and simple.

But we are done now? Right?

Of course not.

See those were the professional fees for your surgeon. You also need an anesthesiologist (and/or his minions). And guess what, yep completely different bucket of money and price negotiation.

But we are done now?

Well, no. There may be different negotiations for lab fees (e.g. where does the CBC get billed), for tissue pathology, for any post-operative hospital services, and of course medications (which are billed completely differently if outpatient or inpatient) to name a few of the more common options.

There isn’t “a” price for a surgery. There are, potentially, a dozen diferent prices that can be combined in a multitude of ways with some buckets covered by one payer and other parts covered by another (and things get crazy fun when you have overlapping payers).

But aren’t there cash only surgical places with listed prices? Yes. And they have an extremely limited set of procedures with everything owned in house – i.e. a setup that is pretty much illegal to set up de novo post Obamacare.

Why does everyone have all these bizarre negotations. Why don’t you just pay the surgeon everything and then he pays the hospital, the anesthesiologist, the pathologist, etc. from that cut? Because that is an invitation for your surgeon to be charged with a crime. It is federal crime to underbill or to underbill when it comes to government monies (and in many states, private insurance monies). We are required not just to I Pencil up a price, but to make that price transparent to regulators. If a hospital wants to grant me cheaper OR time because I have reliable stream of patients, keep the OR cleaner (reducing turnaround time enough to fit another case per day in), and don’t create ancillary malpractice risk at the going rate … the hospital risks being tagged with inducement. If I negotiate a cheaper rate with the lab for my patients’ tests, it is considered prima facie evidence for kickbacks and I then have a positive burden to prove that I am not getting clandestine remuneration from the lab.

Separate, disjointed, billing through bureaucratic negotiation is legible. It is legible to the courts, to regulators, and to malpractice insurers.

But doesn’t all this massive change efficiency of care delivery?

Not that I can easily see. I have personal experience with IHS, TriCare, Kaiser, the VA, and for-profit, non-profit, and even prison care; full Beveridge like IHS is often the least efficient.

So where do cash prices come from? Outside of cash only practices, those are overwhelmingly fictions that somebody pulled out of their nether regions in a likely futile attempt to BS the counterparty to an insurance negotiation.

Why is this all so complicated:

1. Principle agent. The patient has a wildly different incentive structure than the collective payer (insurance or government) and American healthcare is insanely deferential to the patient compared to alternatives. The folks with the most direct control feel at most a small fraction of the price pain have near zero incentive to economize for anything big.
2. Taxes. The original sin of American healthcare was making insurance, rather than medical procedures themselves, tax deductible. This creates very strong incentives for people to bundle non-healthcare into insurance premiums in hard to define manners (e.g. is a health insurer offering a rebate for gym membership incentivizing exercise, allowing folks who would already have gym memberships to pay pre-tax, or just selecting for healthier patients).
3. People are terrified of physician abuse. Most folks, even other physicians, have a very hard time knowing if their physician is taking them for a ride. So they turn to something powerful to regulate physicians. But, not knowing what actually matters, these folks find it extremely hard to navigate market transactions. Healthcare would far rather have 100 unattributable deaths and 2x costs than to have 1 attributable death that regulation could avoid.
4. A complete disconnect between what folks experience for prices (e.g. my tape easily costs 10x more than department store specials, my EMR internal word processor is an order of magnitude more expensive than MSWord let alone Emacs or the like) and how medical expenses run.
5. A failure to appreciate the costs of having things on standby. We have folks ready incase a simple IR procedure perfs the vessel walls. We have countless folks handy in case your infusion leads to anaphylaxis. Or your blood transfusion moves on to TRALI. Just opening the doors typically means that we need to have a few dozen physicians and their support staff available at all times. I’ve seen a simple gallbladder turn into a massive transfusion with staging, SICU, and the whole works. I have seen STD treatment turn into a catastrophic emergency of the sort that gets Derm to come in at oh ass hundred.

None of those go away if we post prices. And a lot of people will be upset – somebody will decry us pricing differently for different patients – everyone deserves the same care at the same cost. Somebody will decry us for not pricing differently enough – people should be reward for making good decisions.

Long run, healthcare is going to get more expensive. I expect it will eventually be on part with mortgage payments (you know you live in your body 24/7). But there is an evergreen fantasy that … if only … then we could reduce prices.

You can’t. You can, maybe, make them rise more slowly, normally for harsh tradeoffs Americans won’t stand. And just about every significant intervention that really moves the price needle … is either selection (e.g. health share ministries have wildly healthier populations because they are heavily selected about drugs, promiscuity, and the rest) or given entirely back by the patient dying later. And the handful of things to do pass muster (e.g. HPV vaccination, Hep C treatment) … it becomes yet another morass of how much to pay whom.

Healthcare is not a normal market. We should stop pretending it could be one.

[ed. Hence single payer, or Mediare for All. It won't solve everything, but having the government and all its various compliance mechanisms working to cut costs can't hurt.]

***

Comment: There is plenty of data from which to compute averages and provide a published estimate against which performance can be tracked. That's what consumers of professional services do in actual free markets. Making every transaction in this sector a Persian rug bazaar involving third parties with no input from the actual consumer is not how you lower costs.

Response:

It is, however, one of the more common ways to comply with regulations, liability mitigation, and uncompetitive negotiations.

The other alternative is to vertically integrate a market under and a mono(dou)poly and put all the service lines and fee sources under one roof. This has the advantage that one entity on the provider side does have all the costs and profits on one balance sheet ... but so far it is, at best, a complete bust for lowering prices (and at worst actively raises them through local monopoly power).

There is one set of constraints on healthcare that makes this a hash. It is the nature of payments, the nature of regulations, the nature of malpractice risk, and a heavy dose of inertia.

But with no single problem we also see no hope for one singular quick fix.

If you want me to lower costs (in the short term): let me own a hospital with 50 fellow physicians, allow us malpractice liability protection provided we hit prespecified milestones (and I largely don't care what you pick as long as the traditional hospitals have to meet them too), create financial incentives for patients to economize, and allow us to charge patients more aggressive for different risk and cost profiles.

Long run, all of those will fall, but our healthcare billing system wasn't built for efficiency or even naked profit maximization. It was built for regulatory compliance and navigating the insurance premium tax exemption from WWII.

***

Comment: Wait a minute here. The reason some engineering project can't be estimated in advance is because it's hard to know how many people it will take and how long. It's because it is estimating an unknown that might take 4 years or 4 months. A SURGERY should be easier to estimate. Yes, you might cut open the patient and decide the problem is cancer and not gallstones. Or they are a woman and not a man, but the surgery isn't suddenly going to take 4 years longer.. It's not going to take 4 days longer either. Of course .... if the GOVERNMENT is involved then they might get wildly different costs. But it isn't the complex nature of surgery that makes the estimate difficult. And you might say, well finding out it's cancer means a whole new cost structure .... yes it does. But THAT given surgery shouldn't change so vastly in price because of it. The new diagnosis is an entirely new issue. My MECHANIC can figure out how to call me an give a new estimate if he's there to change the oil and finds out the engine block is cracked.

No. The problems with pricing have been CREATED by massive government regulations.

Engineering projects don't have to change workforces halfway through. I have seen a surgical procedure swap successively from IR to vascular surgery to cardiothoracic surgery to neurosurg to transplant (this did not end well for the patient).

And that is part of the thing. If your mechanic encounters a cracked engine block, he waits, orders a new one, and then recommences work at leisure. Your surgeon, is diagnosing the car, while is going 80 down the freeway, has to fix the crack (because replacement parts are generally unavailable and insanely expensive for OEM if they are) without slowing down while the engine is running, and then has to make certain that his method of repair won't compromise the running of the car.

Mind you running through different surgeons often means calling in different teams (surgical assists very often specialize de facto if not de jure). And the bills mount quickly. Last time I saw the numbers, each marginal minute of OR time works out to ~$100 of extra costs (most of which is labor). And that is excluding the cost of bumping somebody off the schedule; if you are the penultimate case of the day and the system doesn't have slack to run later into the night you might well run 80 minutes over and then force us to scrub a three hour, high cost procedure which then mucks up even more OR times the following day.

Like the OR is the hotel problem are crack. Hospitals generate massive revenue by keeping ORs in constant use (spread the overhead over more patients) and a quadrupling of OR time is not going to quadruple the cost of a surgery to the system - it will often cost far, far more than.

And there are other margins. We get a bit leery about undertaking certain, technically "elective" procedures when the SICU is too full. If we are short on anesthesia folks that can bump out other patients too. If this is not a trauma I, surgical novelty can mean burning through our blood product inventory, and if that gets bad enough that means putting the ED on diversion (in which case we are paying for a lot of ED staff who are generating no revenue).

For stuff like OR, hospital efficiency is only as good as the weakest leak and because everything is often on a tight timetable with little margin (because margin costs more money) small failures can cascade to far bigger costs.

Which, generally, is not such an issue for the engineers. After all, if work halts on building one dam, it frees up labor and resources for another.

Can we just build that into the prices? Yes. And that is what vertically integrated shops do and they average the truly horrific cases over a lot of surgeons.

But for a single surgeon's office? Yeah, no. If they quote you the full range of possible costs it will likely span three orders of magnitude for the cheap stuff.

Which is part of why separate billing works. If you go in and they find you need a different surgeon, it isn't like folks have prenegotiated every possible permutation of who else needs to take care of you. They find something wonky, they call in the cavalry, and then separate bills are generated for each.

Like I've worked with engineers to build a hospital. The number and interactions of their own unknowns was simply an order of magnitude or two lower.

***

If people want wildly cheaper healthcare they already know how to do it: don't smoke, exercise, eat not complete garbage, get married, have lots of sex, have kids, go to church, hang out in person with friends, sleep soundly with a steady schedule, get educated/earn lots of money, don't do drugs, drink no more than one standard drink a night (and like just one or two a week), don't engage in crime, get car with a bunch of safety technology, live close to work/get a remote job, don't gamble ... like all of these have good correlational data and when you do two-thirds of them you almost invariably end up having a way cheaper life course expenses (e.g. most of the above are correlated with lower odds of needing institutional memory care). Some of it is given back because you live longer ... but people know this. They just have a hard time giving up vices (i.e. things where the immediate reward is too tempting for them to hold out to get their preferred long run payout) or actually prefer the less healthy habits.

via: Marginal Revolution

[ed. What a system, eh? Everyone in the business of billing medical reimbusement is incentivized to make it as complex and opaque as possible. Every major medical procedure now risks financial catastrophe.]

Into the Wood Chipper

The destruction of USAID was just as dumb as it seemed

On February 5, 2025, after USAID’s name had been taken off the building, after most of its staff had seemingly been placed on leave (it was hard to be sure—HR couldn’t confirm because they were also largely locked out of the system), Nicholas Enrich was called in to justify the agency’s global health programming to the Trump administration’s newly-appointed USAID leadership.

According to Enrich, he spoke for about five minutes about USAID’s lifesaving health work: diagnosis and treating HIV and malaria, immunizing children, responding to emerging pandemics. His presentation was met by silence, which senior official Ken Jackson eventually broke. “Wow, there really is so much that USAID does that we never knew,” Jackson said.

Joel Borkert, USAID’s Trump-appointed acting chief of staff, agreed: “I had no idea you did all this. As a Republican, when I think of what USAID does in global health, I assumed it was just, you know, abortions.”

Adam Korzeniewski, the White House liaison to USAID, was similarly enlightened, and he had an idea. To help raise attention to the importance of programs to fight drug-resistant tuberculosis, “he suggested that [they] draft a simple, ‘Barney-style’ set of slides to help the political leadership grasp the dangers, referring to the purple dinosaur of children’s television.”

Korzeniewski acknowledged that most of the relevant officials weren’t “health people,” but he didn’t think that applied to him—he had recently read a book on smallpox. Enrich writes that Korzeniewski had another idea, too:

“One thing I thought of while you were talking,” he added, gesticulating wildly with his hands to conjure the image in his mind. “If you can make one of those maps like they have in Outbreak, where it shows the red growing over time as the disease spreads? You know, like the zombie apocalypse? That would be great, very effective.”

Much of Nicholas Enrich’s new book proceeds like this, describing a process so surreal that it verges on the comical until you remember that millions of lives were in the balance. Into the Wood Chipper: A Whisteblower’s Account of How the Trump Administration Shredded USAID follows the 42-day spell that took Enrich from a relatively anonymous USAID worker to its highest-ranking health official to the author of a widely-reported memo detailing the deadly consequences of the destruction of USAID.

Into the Wood Chipper occupies the somewhat unique genre of civil service thriller, only to then verge into horror. More than anything, it was a 206-page reminder that what happened was so, so murderously dumb.

by Tim Hirschel-Burns, Together But Apart |  Read more:

Image: uncredited

[ed. See also: Everyone is misunderstanding what happened to USAID (TBA):]

***

The problem is that the development sector’s reckoning with the destruction of USAID has been largely unmoored from what actually happened. The post-mortems have tended to follow a similar recipe: a dash of lamentation and a spoonful of self-flagellation, topped with one cup of the author’s pre-existing policy preferences—all of which bear a tenuous relationship to what actually doomed USAID...

When Trump took office and DOGE went into USAID, even they didn’t plan on destroying it. But two weeks later, USAID was functionally dead. In the end, the administration terminated 83% of USAID projects, shuttered USAID as an independent agency, and kept on just 300 of USAID’s over 10,000 staff in the State Department.

Why Your Job’s Complexity Level May Affect Your Risk of Dementia

Getting an education is important for a lot of reasons, but there might be one reason you haven’t heard — it could lower your risk of dementia later in life. Decades of research have supported this claim, with one study showing that each additional year of formal education lowers the risk of Alzheimer’s disease or other types of dementia by 7 percent.

Now, a growing body of evidence suggests that the jobs we hold throughout our lives may matter just as much or more than years of education. Having a job that involves high levels of decision-making or creativity, rather than repetitive or manual tasks, could help keep the mind sharp and active.

“Many studies suggest that, if people are working in complex jobs during their lifetime, they have a lower likelihood of developing dementia in later life,” said Jinshil Hyun, assistant professor of neurology at Albert Einstein College of Medicine.

Roles like managers, teachers, lawyers and doctors are considered high complexity jobs, while clerical, transportation and assembly line work have lower complexity. The findings are consistent with the idea that taking part in mentally stimulating activities throughout the lifespan can help preserve late-life brain health and boost cognitive reserve — the brain’s ability to cope with age- or disease-related changes.

But don’t worry if your job doesn’t meet the criteria — there are other things that you can do to improve your cognitive reserve, such as reading, socializing and volunteering.

Why work might be linked to dementia risk

“We spend most of our day in work, at least eight hours a day. So that’s like, a third of our time engaged in work, sometimes more,” said Naaheed Mukadam, professor of psychiatry at University College London. “That’s a large part of what our brain is engaged in and therefore will have a large contributory effect on cognitive reserve development.”

In a recent study, Mukadam and her colleagues investigated which factors could be influencing education’s protective effect against dementia. Their analysis included 384,284 participants and took note of health behaviors like drinking, smoking and exercise; medical conditions like hypertension and diabetes; occupational complexity; and income. The results uncovered that occupational complexity is actually the biggest reason more education tends to lower your risk of dementia, accounting for more than 70 percent of that link.

“We found that occupational complexity explained the biggest proportion of that relationship between education and dementia,” she said. “People who have more education tend to get into better paid, more complex jobs. Then, the benefits for their physical and cognitive health compound in that way.”

Multiple studies have found that those with higher income have a lower risk of dementia, and the researchers speculate that job complexity likely plays a major role in that relationship as well.

Similarly, Hyun and her colleagues found in a 2021 study that occupational complexity is predictive of later-life dementia, independent of education. They looked at the effects on dementia-free survival time, or how many years a person lived before being diagnosed with dementia, in 10,195 participants from six countries. As expected, high school graduates had a 26 percent increase in dementia-free survival time compared to people who only completed middle school or less.

After controlling for education, high occupational complexity, compared to low occupational complexity, was associated with a 19 percent increase in dementia-free survival time. Hyun speculates that the greater mental stimulation of a complex job builds cognitive reserve, which helps people resist cognitive decline and stay mentally sharp for longer, even in the presence of harmful plaques seen in Alzheimer’s-affected brains.

“The cognitive reserve hypothesis suggests that, if people are doing cognitively enriching activities, then their brain has a more efficient network,” Hyun said.

by Meeri Kim, The Washington Post/Seattle Times |  Read more:

Image: iStock

[ed. Or just develop a life long love of learning. Eric Hoffer would be a good example (longshoreman/philosopher). What'll happen when more people offload their thinking to an AI assistant?]

Intraventricular CARv3-TEAM-E T Cells in Recurrent Glioblastoma

In this first-in-human, investigator-initiated, open-label study, three participants with recurrent glioblastoma were treated with CARv3-TEAM-E T cells, which are chimeric antigen receptor (CAR) T cells engineered to target the epidermal growth factor receptor (EGFR) variant III tumor-specific antigen, as well as the wild-type EGFR protein, through secretion of a T-cell–engaging antibody molecule (TEAM). Treatment with CARv3-TEAM-E T cells did not result in adverse events greater than grade 3 or dose-limiting toxic effects. Radiographic tumor regression was dramatic and rapid, occurring within days after receipt of a single intraventricular infusion, but the responses were transient in two of the three participants. (Funded by Gateway for Cancer Research and others; INCIPIENT ClinicalTrials.gov number, NCT05660369.)

***

Glioblastoma is the most aggressive primary brain tumor, and the prognosis for recurrent disease is exceedingly poor with no effective treatment options. Chimeric antigen receptor (CAR) T cells represent a promising approach to cancer because of their proven efficacy against refractory lymphoid malignant neoplasms, for which they have become the standard of care. However, the use of CAR T cells in solid tumors such as glioblastomas has been limited to date, largely owing to the challenge in targeting a single antigen in a heterogeneous disease and to immunosuppressive mechanisms associated with the tumor microenvironment. 

In a previous clinical trial, we found that peripheral infusion of epidermal growth factor receptor (EGFR) variant III–specific CAR T cells (CART-EGFRvIII) safely mediated on-target effects in patients with glioblastoma. Despite this activity, no radiographic responses were observed, and recurrent tumor cells expressed wildtype EGFR protein and showed heavy intratumoral infiltration with suppressive regulatory T cells. To address these barriers, we developed an engineered T-cell product (CARv3-TEAM-E) that targets EGFRvIII through a second-generation CAR while also secreting T-cell–engaging antibody molecules (TEAMs) against wildtype EGFR, which is not expressed in the normal brain but is nearly always expressed in glioblastoma. We found in preclinical models that TEAMs secreted by CAR T cells act locally at the site where cognate antigen is engaged by the CAR T cells in the treatment of heterogeneous tumors. We also found in vitro that these molecules have the capacity to redirect even regulatory T cells against tumors. On the basis of these data, we initiated a first-in-human, phase 1 clinical study to evaluate the safety of CARv3-TEAM-E T cells in patients with recurrent or newly diagnosed glioblastoma. Here, we report the findings from a prespecified interim analysis involving the first three participants treated with this approach. [...]

Discussion

This study shows that antitumor CAR-mediated responses can be rapidly obtained in patients with glioblastoma, even in those with advanced, intraparenchymal cerebral disease. This finding contrasts with a previous report of a complete response that was observed in a patient with recurrent leptomeningeal disease who received treatment with 16 intracranial infusions of monospecific interleukin-13 receptor alpha 2 CAR T cells. It was hypothesized by the investigators of that study that the involvement of glioblastoma in the leptomeninges may have rendered the disease more responsive to intraventricular therapy. Our experience in the current study suggests that even a single dose of intraventricularly administered living drugs such as CAR T cells also have the capacity to access and mediate activity against infiltrative, parenchymal glioblastoma.

by Bryan D. Choi, M.D., Ph.D., Elizabeth R. Gerstner, M.D., Matthew J. Frigault, M.D., Mark B. Leick, M.D., Christopher W. Mount, M.D., Ph.D., Leonora Balaj, Ph.D., Sarah Nikiforow, M.D., Ph.D., Bob S. Carter, M.D., Ph.D., William T. Curry, M.D., Kathleen Gallagher, Ph.D., and Marcela V. Maus, M.D., Ph.D. NIH, National Center for Biotechnology Information |   Read more:

Image: via

[ed. Only three patients (so far) and it appears sustained treatments are needed to prevent recurrence. But still, pretty interesting.]

Millions of Americans Are Going Uninsured Following Expiration of ACA Subsidies

Nearly one in 10 people who had Affordable Care Act plans last year dropped health insurance altogether, after premium costs rose sharply because of the expiration of federal subsidies, according to a new survey.

Most of those who remained in ACA plans reported larger out-of-pocket healthcare expenses in the form of higher copays, coinsurance or deductibles, according to the survey from health-research nonprofit KFF. About one-sixth of those who still have ACA coverage, or 17%, weren’t sure they would be able to afford their new premium payments for the entire year, indicating more people might drop insurance as the year goes on.

The survey is the broadest look yet at the fallout from the end of enhanced ACA subsidies, which lapsed at the start of this year, increasing premium bills for millions of enrollees. The higher healthcare costs have forced many ACA policyholders to make hard choices at a time when grocery and gas prices are also rising.

In February and early March, KFF polled 1,117 people who had ACA plans in 2025 and found that the most common reason people cited for dropping insurance was cost. Last year, more than 20 million people had ACA policies.

“Not only is there significant coverage loss, but there could be more to come,” said Cynthia Cox, a senior vice president at KFF. She said the survey results were “about on target” compared to what had been expected.

Of those surveyed, 69% still have ACA policies this year. Beyond the 9% who said they are uninsured, 22% of respondents now have some other type of coverage, such as Medicare or employer-sponsored insurance.

Kelly Rose, 59 years old, who lives near Orlando, Fla., became uninsured this year because she couldn’t pay the roughly $1,700 monthly bill to keep the ACA plan she had in 2025. “It’s more than my mortgage,” she said. The cost is a huge jump compared to 2025, when she got help from a subsidy, she said.

Though her job at a bank offers health insurance, she said she missed the enrollment window in the fall because she had planned to keep the ACA plan, not realizing how much it would cost.

Rose is now turning to a Canadian pharmacy to get her asthma medication, which costs $800 a month in the U.S. [...]

The ACA changes, which were the subject of a political battle that led to the longest-ever government shutdown last year, are likely to become a flashpoint again in this fall’s midterm elections. Democrats have blamed Republicans for failing to renew the expanded subsidies, and for growing healthcare costs. Republicans have argued the ACA is flawed and needs to be changed.

by Anna Wilde Mathews, Wall Street Journal |  Read more:

Image: Nate Ryan for WSJ
[ed. Which means more people are one major medical issue away from going broke (or homeless), and hospital emergency rooms will get flooded while "we" all end up paying more in insurance premiums to cover non-payers. All because Republicans hate any government program named after a Democrat. Insane. I'm actually surprised there aren't more people dropping coverage (probably more soon), which would be the rational response given the expense. See also: How New Mexico Became an Obamacare Success Story (NYT). Hint: state subsidies.]

Please Hold

She called 911 for an ambulance. She got a nightmare instead.

When Pamela Hogan phoned 911 from her Seattle apartment, she was suffering from knee pain so intense she couldn’t stand up. She had been trapped in her bed all day, unable to eat, drink or get to the bathroom. Worried and alone, Hogan thought an ambulance would come quickly and take her to the hospital.

She was mistaken.

Seattle no longer is capping ambulance wait times for certain 911 patients, tracking those waits or penalizing its ambulance contractor when they run long.

Rather than send Hogan help right away, the Fire Department routed her to a nurse in Texas who determined her crisis didn’t need immediate attention.

So the 71-year-old, a retired executive assistant who loved cooking casseroles, watching “Judge Judy” and listening to The Pointer Sisters, waited one hour for a nurse-ordered ambulance, according to call recordings and court documents.

Two hours. Three hours. Four hours, phoning 911 back several times and telling the Fire Department about a heart condition. Ten hours.

By the time an ambulance arrived at Hogan’s building, it was the middle of the night and she wasn’t answering her phone. The ambulance left without her.

Weeks later, her body was found decomposing on the floor of her bedroom.

It’s not clear Hogan’s wait is what killed her, but her estate has sued and her experience raises questions about Seattle’s relationship with its for-profit ambulance contractor, American Medical Response, which also provides the city’s 911 nurse line.

“More checks and balances and accountability need to happen,” said Josephine Ensign, a professor emeritus at the University of Washington School of Nursing who called Hogan’s case concerning and upsetting. “Seattle can do better.”

Seattle and AMR have denied the lawsuit’s wrongful death allegations and say the nurse line is generally working as intended. They say it’s reducing strain on hospitals and ambulances by diverting low-level patients to more appropriate care.

But most Seattle callers triaged by the nurse line are still being sent to hospitals in AMR ambulances, rather than being diverted, program data reveals. And officials have exempted those nurse-ordered rides, like Hogan’s, from city standards that normally require the company’s ambulances to arrive on time.

It’s possible that Hogan’s experience was an aberration. But the city stopped tracking ambulance waits like hers in 2022, so officials have no way to know. [...]

***

Hogan’s wait started when she dialed 911 on the afternoon of April 8, 2022.

“I’ve got really bad knees because of rheumatoid arthritis and there is damage to them as well, and I’ve gotten to the point where I can’t get up,” she told the Fire Department dispatcher who answered, according to a recording of the call obtained through a public records request. “I’d like to go to the ER and have them look at my knees.”

Hogan had used 911 for emergencies before, assuming this time would be the same. Instead, her call was transferred to the nurse line operated by AMR’s parent company, Global Medical Response, from a call center outside Dallas.

“I’m going to bring the nurse on the line here and let them kind of help figure out the best course of action,” the Fire Department dispatcher said.

Hogan told the nurse she had been stuck in bed all day and had completely filled an adult diaper, according to a recording disclosed by AMR in the Hogan litigation. She described her pain intensity as 10 out of 10.

“I will get someone out to you,” the nurse said. “To get you to the hospital.”

Then the nurse ordered an ambulance, recommending care within four hours, according to another recording disclosed in the Hogan litigation. An AMR dispatcher in Seattle said it would take three to four.

Neither of them told Hogan, who was no longer on the phone.

Strained system

In the years before Hogan’s emergency, the Seattle Fire Department and AMR were dealing with a mounting number of 911 calls from patients with low-level needs, said Michael Sayre, the Fire Department’s medical director.

A sore throat. Anxiety. A stomachache. Patients who don’t really require emergency transport and care. The city received 44% more low-level medical calls in 2021 than in 2017, according to Fire Department records.

Few 911 patients receive lifesaving interventions and most emergency room visits are for nonemergency issues, national research has shown. People sometimes dial 911 not because they’re in imminent danger but because they’re not sure whether they’re sick or not, Sayre said.

These patients put pressure on the Fire Department’s dispatchers, who work long, grueling shifts. Such calls often involve homeless people or other patients without regular doctors, noted Ensign, whose decades of Seattle-based work has focused on health and social inequities.

“They don’t know what else to do, so they call 911,” Sayre said.

For acute 911 calls, the Fire Department sends its own highly trained crews. They can transport patients in red Medic One ambulances or hand the patients off to AMR emergency medical technicians in white ambulances.

For less-acute calls, the department may simply send AMR. One way or another, the company handles most of Seattle’s ambulance responses, approximately 50,000 annually. [...]

New program

Like other cities that use ambulance contractors for 911 callers, Seattle allows AMR to bill patients. In return, the company must meet standards for patient care: For years, its ambulances were supposed to arrive within 11½ minutes for more-urgent calls and one hour for less-urgent calls, at least 90% of the time.

But in the wake of the COVID pandemic, AMR was struggling with ambulance staffing in Seattle, arriving late for many of its 911 patients and paying a price, Fire Department records show. The city assessed the company almost $1.4 million in contract penalties for ambulance delays in 2021.

Enter the Nurse Navigation program, which Seattle and AMR leaders said would relieve that strain and improve ambulance response times in the city by diverting low-level callers to cheaper, better solutions. When it launched with fanfare in February 2022, then-Mayor Bruce Harrell called it “a strong example” of how to make a system “more efficient and ensure better care at the same time.”

The idea wasn’t new: King County had been using a 911 nurse line on a smaller scale for years, and cities across the world were experimenting. When implemented well, these programs can deliver real benefits, many experts say.

Seattle preferred not to hire its own nurses, said Sayre, the medical director, citing the costs involved. So the Fire Department turned to AMR, which agreed to triage the city’s callers almost for free. AMR had launched Nurse Navigation in Washington, D.C., in 2018 and had been attracting positive attention. [...]

Requirements removed

Before Nurse Navigation, patients like Hogan could expect assistance in under an hour. That changed in 2022 with an amendment to AMR’s contract that gave nurse-ordered ambulances a reprieve from any response-time standards.

Seattle and AMR officials say this made sense, because the nurse line is allowing ambulances to prioritize critical patients over stable ones. The company is no longer incurring late penalties for its Seattle responses still subject to time standards, a representative said, citing the nurse line and better recruiting.

But the city removed a significant guardrail when it removed standards for an entire category of ambulance rides, experts contend. Last year, more than 4,600 rides ordered were completely exempt from time standards and contractual penalties.

“Your community’s leaders may think 10-hour waits are OK,” said Matt Zavadsky, a nationally recognized health care administrator who managed a 911 system and helped start a nurse line in Fort Worth. “If your community’s leaders are not OK with that, you need a contract that prevents that.”

Instead, Seattle has left itself in the dark. Response times for nurse-ordered ambulances are excluded from AMR’s monthly reports to the Fire Department, so the city doesn’t know how long patients like Hogan are waiting.

by Daniel Beekman, Seattle Times |  Read more:

Image: Jennifer Luxton / The Seattle Times

The Plastic Surgeon Summit

We’re in a plastic surgery “renaissance period.”

Dr. Yannis Alexandrides: It is busier than ever. There’s a remarkable year-on-year demand increase that we see in surgical procedures, especially for the face, but also for the body. This is a trend that we have seen through the pandemic, but it has accelerated the last year.

Dr. Akshay Sanan: I think plastic surgery is in a renaissance period right now because of people publicly talking about it. Plastic surgery is now part of your wellness armamentarium. People used to flex what gym they went to, that they had a trainer, and now plastic surgery is part of that flex. People love to rock that they had their eyes done or their face and neck done or their body done. It’s just part of the cultural shift that we’re seeing.

Dr. Jason Champagne: This is where social media comes into play, camera phones and Zoom meetings. You see yourself from all these different angles nowadays that maybe you didn’t notice in the past.

Dr. Emily Hu: I find it very generational: Those who grew up in the social media era with a lot of sharing and openness are also very open about telling their friends [about the work they’ve had done].

Sanan: There’s a shift in consumer or patient habits. More people in their late 30s, early 40s, they’re choosing surgery earlier to age gracefully instead of waiting until things are advanced. They’re like, “I’m not going to wait until it drops down further. I just want to be hot in my 40s.”

Dr. John Diaz: It used to be that not everyone had access to a plastic surgeon. That was reserved within the realm of the elite. Well, not anymore. I have celebrities, executives, and business owners come in — but also teachers and waiters. There’s this democratization of attractiveness.

Dr. Paul Afrooz: Patients are very educated these days. They know what they’re looking for, they know what realistic results are, and they have the ability to do a lot of background research and understand who does things at an elite level. [...]

Let’s get into it: Why are we talking so much about facelifts this year?

Diaz: Facelifts have absolutely exploded for a few reasons. A lot of women see celebrities and influencers suddenly looking incredible, and they want to know how. Think about Kris Jenner — she had a huge impact when her pictures came out. And now it’s brought awareness to the fact that we have the technology to be able to take a young-looking woman and make her look better with surgery, without making her look fake. That was a real challenge 20 years ago.

Alexandrides: Kris Jenner was a very hot topic the last few months. Definitely a lot of the patients I see here take her as, let’s say, a model on how they want to look, because she looks fresh, but she doesn’t look pulled. She looks younger, and she looks happy, and you cannot see the scars, at least not in these pictures that we see.

Hu: I can’t tell you how many of my patients are like, “Yeah, my mom had a facelift. She was so scary. I’m never doing a facelift.” I mean, that was their response because they see their mom all bruised and scary looking.

Dr. Mark Murphy: Facelifts historically had a stereotypical “plastic surgery” look. Now people have realized, “I can look like myself 15 years ago and not have to look like a circus freak for it.” It’s become very digestible for patients. Social media is a huge driver behind it. Well, that, and the techniques are better.

So what’s actually new or changing about facelifts?

Dr. Mark Mani: We call it the golden age of facelift surgery. It’s primarily because of the success of the deep plane facelift.

Dr. David Shafer: There’s nothing new about [the deep plane facelift] as a procedure. It’s just very sophisticated marketing that’s being done now, and there are refinements to the procedures. But it’s not some plastic surgeon who’s marketing it now as some magic procedure that he came up with that nobody else does.

Mani: [A version of] the first deep plane lifts was performed in the late 1960s by a surgeon named Tord Skoog in Sweden [though the name came later]. I have his textbook and can show you results that would stand up to the best deep plane surgeons today. It’s not the procedure, it’s the surgeon, and facelift surgery, among all surgeries in plastic surgery, is an art form.

Afrooz: A surgeon named Sam Hamra — he just passed, but a wonderful human being, an extraordinary thinker, an extraordinary surgeon — first coined the phrase “deep plane facelift” in a 1990 paper and laid out some building blocks of the procedure. Just like everything else in plastic surgery, we stand on the giants before us.

Dr. Michael Stein: There are two main facelift techniques: deep plane and SMAS plication. The deep plane facelift is where you cut the layer under the skin called the SMAS, dissect underneath it, and tighten it in addition to the skin. In the SMAS facelift, instead of cutting and elevating the SMAS, you suture it to itself to tighten it from over top.

Dr. Amir Karam: The majority of surgeons, up until recently, have been doing the traditional SMAS technique, which is more or less horizontally pulling the face sideways, and that was leading to a very unnatural look.

Mani: I was the surgeon who wrote the most-read facelift academic article that convinced other surgeons to do deep plane facelifts. It was an article in Aesthetic Surgery Journal in 2016, where I detailed the specific anatomic reasons that deep plane is better.

Stein: The people who only do deep plane facelifts say they have a more longitudinal result, and vice versa. But the truth is, a good result is a good result. It depends more on the surgeon versus technique. A good facelift is a good facelift.

Facelifts aren’t done evolving.

Karam: The consumer is driving surgeons to create better and better results. So there’s been a massive increase in interest for surgeons to level up their strategies surgically and learn new techniques that are not new but new to them.

Afrooz: Even my facelift today is better than my facelift was one year ago. When you hone in on one thing as your career, you’re just constantly looking for ways to improve. It’s the cumulative effect of small subtleties over time and practice that you notice nuanced improvements to your results. One might assume that a deep plane facelift in one surgeon’s hands is the same as it is in another’s, but I’m here to tell you that it’s very much not the same.

Dr. Daniel Gould: There are new layers that we’re adding into the surgery. We’re recognizing the importance of the mid-face and volume position there. I’m recognizing adding fat to the mouth and the areas around the mouth, the chin, because all these areas have been neglected. We are now nailing all the low-hanging fruit: We’re nailing the neck, we’re nailing the face, we’re nailing the temple and the brows. Now it’s time to move forward and continue to innovate and push the limits of what we can really do in facial rejuvenation.

Mani: What I’ve developed is called the scarless lift, and it’s basically a deep plane facelift without a scar in front of the ear, with an endoscope. The endoscopic procedure involves a hidden incision within the hair, a short one behind the ear, and sometimes one under the chin. I still do about 60% open [non-endoscopic], but a good percentage of my facelifts are scarless endoscopic. The results are more beautiful because you don’t have to worry about the scar, and the vectors of lifting are better.

Alexandrides: I don’t think this will be now, “OK, let’s forget about facelifts, let’s move to something else.” What will probably happen is that people will discover intricate little different techniques and say, “You have the facelift that is done like that.” I have patients who ask me very technical questions: How do you design your scar around your ear?

Stein: Facelift surgery has survived the test of time. Every year there are new machines designed to tighten skin, and for some patients with mild laxity, they may see nice results. The truth is though, if you have jowls or droopy skin of the face and neck, the only thing that’s really going to give you the best bang for your buck and directly address your laxity is a facelift.

by Bustle Editors, Bustle |  Read more:

Image: uncredited

Tomorrow’s Smart Pills Will Deliver Drugs and Take Biopsies

One day soon, a doctor might prescribe a pill that doesn’t just deliver medicine but also reports back on what it finds inside you—and then takes actions based on its findings.

Instead of scheduling an endoscopy or CT scan, you’d swallow an electronic capsule smaller than a multivitamin. As it travels through your digestive system, it could check tissue health, look for cancerous changes, and send data to your doctor. It could even release drugs exactly where they’re needed or snip a tiny biopsy sample before passing harmlessly out of your body.

This dream of a do-it-all pill is driving a surge of research into ingestible electronics: smart capsules designed to monitor and even treat disease from inside the gastrointestinal (GI) tract. The stakes are high. GI diseases affect tens of millions of people worldwide, including such ailments as inflammatory bowel disease, celiac disease, and small intestinal bacterial overgrowth. Diagnosis often involves a frustrating maze of blood tests, imaging, and invasive endoscopy. Treatments, meanwhile, can bring serious side effects because drugs affect the whole body, not just the troubled gut.

If capsules could handle much of that work—streamlining diagnosis, delivering targeted therapies, and sparing patients repeated invasive procedures—they could transform care. Over the past 20 years, researchers have built a growing tool kit of ingestible devices, some already in clinical use. These capsule-shaped devices typically contain sensors, circuitry, a power source, and sometimes a communication module, all enclosed in a biocompatible shell. But the next leap forward is still in development: autonomous capsules that can both sense and act, releasing a drug or taking a tissue sample.

That’s the challenge that our lab—the MEMS Sensors and Actuators Laboratory (MSAL) at the University of Maryland, College Park—is tackling. Drawing on decades of advances in microelectromechanical systems (MEMS), we’re building swallowable devices that integrate sensors, actuators, and wireless links in packages that are small and safe enough for patients. The hurdles are considerable: power, miniaturization, biocompatibility, and reliability, to name a few. But the potential payoff will be a new era of personalized and minimally invasive medicine, delivered by something as simple as a pill you can swallow at home. [...]

Targeted drug delivery is one of the most compelling applications for ingestible capsules. Many drugs for GI conditions—such as biologics for inflammatory bowel disease—can cause serious side effects that limit both dosage and duration of treatment. A promising alternative is delivering a drug directly to the diseased tissue. This localized approach boosts the drug’s concentration at the target site while reducing its spread throughout the body, which improves effectiveness and minimizes side effects. The challenge is engineering a device that can both recognize diseased tissue and deliver medication quickly and precisely.

With other labs making great progress on the sensing side, we’ve devoted our energy to designing devices that can deliver the medicine. We’ve developed miniature actuators—tiny moving parts—that meet strict criteria for use inside the body: low power, small size, biocompatibility, and long shelf life.

Some of our designs use soft and flexible polymer “cantilevers” with attached microneedle systems that pop out from the capsule with enough force to release a drug, but without harming the intestinal tissue. While hollow microneedles can directly inject drugs into the intestinal lining, we’ve also demonstrated prototypes that use the microneedles for anchoring drug payloads, allowing the capsule to release a larger dose of medication that dissolves at an exact location over time.

In other experimental designs, we had the microneedles themselves dissolve after injecting a drug. In still others, we used microscale 3D printing to tailor the structure of the microneedles and control how quickly a drug is released—providing either a slow and sustained dose or a fast delivery. With this 3D printing, we created rigid microneedles that penetrate the mucosal lining and gradually diffuse the drug into the tissue, and soft microneedles that compress when the cantilever pushes them against the tissue, forcing the drug out all at once.

by Reza Ghodssi, Justin Stine, Luke Beardslee, IEEE Spectrum |  Read more:

Image: Maximilian Franz/Engineering at Maryland Magazine

Embryo Selection Company Herasight Goes All In On Eugenics

Multiple commercial companies are now offering polygenic embryo selection on a wide range of traits, including genetic predictors of behavior and IQ. I’ve previously written about the methodological unknowns around this technology but I haven’t commented on the ethics. I think having a child is a very personal decision and it’s not my place to tell people how to do it. But the new embryo selection company, Herasight, has started advocating for eugenic societal norms that I find disturbing and worth raising alarm over. Because this is a fraught topic, I’ll start with some basic definitions.

What is eugenics?

Eugenics is an ideology that advocates for conditioning reproductive rights on the perceived genetic quality of the parents. Francis Galton, the father of eugenics, declared that eugenics’ “first object is to check the birth-rate of the Unfit, instead of allowing them to come into being”. This goal was to be achieved through social stigma and, if necessary, by force. The Eugenics Education Society, for instance, advocated for education, segregation, and — “perhaps” — compulsory sterilization to prevent the “unfit and degenerate” from reproducing:

A core component of defining “the unfit” was heredity. Eugenicists are not just interested in improving people’s phenotypes — a goal that is widely shared by modern society — but the future genotypic distribution. The genetic stock. This is why eugenic policies historically focus on sterilization, including the sterilization of unaffected relatives who harbor genotype but not phenotype. If someone commits a crime, they face time in prison for their actions, but under eugenic reasoning their law-abiding sibling or child is also suspect and should be stigmatized (or forcefully prevented) from passing on deficient genetic material.

A simple two-part test for eugenics is then: (1) Is it concerned with the future genetic stock? (2) Is it advocating for restricted reproduction, either through stigma or force, for those deemed genetically inferior?

Is embryo selection eugenics?

I have publicly resisted applying the “eugenics” label to embryo selection writ large and I continue to do so. Embryo selection is a tool and its use is morally complex. A couple can choose to have embryo screening for a variety of reasons ranging from frivolous (“we want to have a blue eyed baby”) to widely supported (“we carry a recessive mutation that would be fatal in our baby”), none of which have eugenic intent. Embryo selection can even be an anti-eugenic tool, as in the case of high-risk couples who have already decided against having children. If embryo selection technology allows them to lower the risk to a comfortable level and have a child they would otherwise have avoided, then the outcome is literally the opposite of eugenic selection: “unfit” individuals (at least as they see themselves) now have an incentive to produce more offspring than they would have. In practice, IVF remains a physically and emotionally demanding procedure, and my guess is that individual eugenic intentions — the desire to select out unfit embryos with the specific motivation of improving the “genetic stock” of the population — are exceedingly rare.

Is Herasight advocating for eugenics?

While I do not think embryo selection is eugenic in itself, like any reproductive technology, it can be wielded for eugenic purposes. The new embryo selection company Herasight, in my opinion, is advocating for exactly that. To understand why, it is useful to first understand the theories put forth by Herasight’s director of scientific research and communication Jonathan Anomaly (in case you’re wondering, that is a chosen last name). Anomaly is a self-proclaimed eugenicist [Update: Anomaly has clarified that this description was not provided by him and he requested that it be removed]:

Prior to joining Herasight, Anomaly wrote extensively on the ethics of embryo selection, notably in a 2018 article titled “Defending eugenics”. How does Anomaly defend eugenics? First, he reiterates the classic position that eugenics is a resistance to the uncontrolled reproduction of the “unfit” (emphasis mine, throughout):

Darwin argued that social welfare programs for the poor and sick are a natural expression of our sympathy, but also a danger to future populations if they encourage people with serious congenital diseases and heritable traits like low levels of impulse control, intelligence, or empathy to reproduce at higher rates than other people in the population. Darwin feared that in developed nations “the reckless, degraded, and often vicious members of society, tend to increase at a quicker rate than the provident and generally virtuous members”

Anomaly goes on to sympathize with Darwin’s position and that of the classic eugenicists, arguing that “While Darwin’s language is shocking to contemporary readers, we should take him seriously”, later that “there is increasingly good evidence that Darwin was right to worry about demographic trends in developed countries”, and that we should “stop allowing [the Holocaust] to silence any discussion of the merits of eugenic thinking”.

Anomaly then proposes several potential eugenic interventions, one of which is a “parental licensing” scheme that prevents unfit parents from having children:

The typical response is for the state to step in and pay for all of these things, and in extreme cases to remove children from their parents and put them in foster care. But it would be more cost-effective to prevent unwanted pregnancies than treating their consequences, especially if we could achieve this goal by subsidizing the voluntary use of contraception. It may also be more desirable from the standpoint of future people.

The phrase “future people” figures repeatedly in Anomaly’s writing as a euphemism for the more conventional eugenic concept of genetic stock. This connection is made explicit when he explains the most compelling reason for supporting parental licensing:

The most compelling reason (though certainly not a decisive reason) for supporting parental licensing is that traits like impulse control, health, intelligence, and empathy have significant genetic components. What matters is not just that some parents are unwilling or unable to take care of their children; but that in many cases they are passing along an undesirable genetic endowment.

What are we really talking about here? Anomaly has proposed a technocratic rebranding of eugenic sterilization: instead of taking away your reproductive rights clinically, the state will take away your reproductive license and, if you still have children, impose “fines or other costs” (though Anomaly does not make the “other costs” explicit, eugenic sterilization is mentioned as an example in the very next sentence). How would the state decide who should lose their license? Anomaly explains:

For a parental licensing scheme to be fair, we would need to devise criteria that are effective at screening out only parents who impose significant risks of harm on their children or (through their children) on other people.

A fundamental normative principle of our society is that all members are created equal and endowed with unalienable rights. What Anomaly envisions instead is a society where the state can seize one of the most intimate of human freedoms — the right to become a parent — based on innate factors. How does the state determine whether a future child imposes significant risk on future people? By inspecting the biological makeup of the parents and identifying “undesirable genetic endowments” that will harm others “through their children”. This is a policy built explicitly on genetic desirability and undesirability, where those deemed genetically unfit are stripped of their rights to have children and/or fined for doing so — aka bog-standard coercive eugenics.

Today, Anomaly is the spokesperson for a company that screens parents for “undesirable genetic endowments” and, for a price, promises to boost their genetic desirability and their value to future people. It is easy to see how Herasight fits directly into the eugenic parental licensing scheme Anomaly proposed. Having an open eugenicist as the spokesperson for an embryo selection company seems, to me, akin to hiring Hannibal Lecter to do PR for a hospital, but perhaps Anomaly has radically changed his views since billing himself as a eugenicist in 2023?

Herasight (with Anomaly as first author) recently published a perspective white-paper on the ethics polygenic selection, from which we can glean their corporate position. The perspective outlines the potential benefits and harms of embryo selection. The very first positive benefit listed? The “benefits to future people”. While this section starts with a focus the welfare of individual children, it ends with the same societal motivations as classical eugenics: the social costs of the unfit on communities and the benefits of the fit to scientific innovation and the public good: [...]

When eugenics goes mainstream

Let’s review: eugenics has as a goal of limiting the birthrate of the “unfit” or “undesirable” for the benefit of the group. Anomaly describes himself as a eugenicist and explicitly echoes this goal through, among other policies, a parental licensing proposal. Anomaly now runs a genetic screening company. The company recently published a perspective paper advocating for the stigmatization of “unfit” parents who do not screen. Anomaly, as spokesperson, reiterates that their goal is indeed eugenics — “Yes, and it’s great!”. With any other person one could argue that they were clueless or trolling; but if anyone knows what eugenics means, it is a person who has spent the past decade defending it.

I have to say I am floored by how strange this all is. My personal take on embryo selection has been decidedly neutral. I think the expected gains are limited by the genetic architecture of the traits being scored and the companies are mostly fudging the numbers to look good. As noted above, I also think a common use of this technology will be to calm the nerves of parents who otherwise would have gone childless. So I have no actual concerns about changes to the genetic make-up of the population or genetic inequality or any of the other utopian/dystopian predictions. But I am concerned that the marketing around the technology revives and normalizes classic eugenic arguments: that society is divided into the genetically fit and the genetically unfit, and the latter need to be stigmatized away from parenthood for the benefit of the former. I am particularly disturbed by the giddiness with which Anomaly and Herasight have repeatedly courted eugenics-related controversy as part of their launch campaign.

Even stranger has been the response, or rather non-response, from the genetics community. Social science geneticists and organizations spent the past decade writing FAQs warning against the use of their methods and data for individual prediction and against genetic essentialism. Many conference presentations and seminars start with a section on the sordid history of eugenics and the sterilization programs in the US and Nazi Germany, vowing not to repeat the mistakes of the past. Now, a company is openly advocating for eugenics (in fact, a company with direct connections to these social science organizations) and these organizations are silent. It is hard not to conclude that the FAQs and warnings were just lip service. And if the experts aren’t raising alarms, why would the public be alarmed?

by Sasha Gusev, The Infinitesimal |  Read more:

Image: Anselm Kiefer, Die Ungeborenen (The Unborn), 2002

[ed. With neophyte Nazis seemingly everywhere these days, CRISPR advances, and technocrats who want to live forever, it's perhaps not surprising that eugenics would be making a comeback. Update: Jonathan Anomaly, director of scientific research and communication for Herasight and whose articles I criticize here, responds in a detailed comment. I recommend reading his response together with this post. Anomaly’s role in the company has also been clarified. See also: Have we leapt into commercial genetic testing without understanding it? (Ars Technica).]

I Regret to Inform You that the FDA is FDAing Again

I had high hopes and low expectations that the FDA under the new administration would be less paternalistic and more open to medical freedom. Instead, what we are getting is paternalism with different preferences. In particular, the FDA now appears to have a bizarre anti-vaccine fixation, particularly of the mRNA variety (disappointing but not surprising given the leadership of RFK Jr.).

The latest is that the FDA has issued a Refusal-to-File (RTF) letter to Moderna for their mRNA influenza vaccine, mRNA-1010. An RTF means the FDA has determined that the application is so deficient it doesn’t even warrant a review. RTF letters are not unheard of, but they’re rare—especially given that Moderna spent hundreds of millions of dollars running Phase 3 trials enrolling over 43,000 participants based on FDA guidance, and is now being told the (apparently) agreed-upon design was inadequate. [...]

In context, this looks like the regulatory rules of the game are being changed retroactively—a textbook example of regulatory uncertainty destroying option value. STAT News reports that Vinay Prasad personally handled the letter and overrode staff who were prepared to proceed with review. Moderna took the unusual step of publicly releasing Prasad’s letter—companies almost never do this, suggesting they’ve calculated the reputational risk of publicly fighting the FDA is lower than the cost of acquiescing.

Moreover, the comparator issue was discussed—and seemingly settled—beforehand. Moderna says the FDA agreed with the trial design in April 2024, and as recently as August 2025 suggested it would file the application and address comparator issues during the review process.

Finally, Moderna also provided immunogenicity and safety data from a separate Phase 3 study in adults 65+ comparing mRNA-1010 against a licensed high-dose flu vaccine, just as FDA had requested—yet the application was still refused.

What is most disturbing is not the specifics of this case but the arbitrariness and capriciousness of the process. The EU, Canada, and Australia have all accepted Moderna’s application for review. We may soon see an mRNA flu vaccine available across the developed world but not in the United States—not because it failed on safety or efficacy, but because FDA political leadership decided, after the fact, that the comparator choice they inherited was now unacceptable.

The irony is staggering. Moderna is an American company. Its mRNA platform was developed at record speed with billions in U.S. taxpayer support through Operation Warp Speed — the signature public health achievement of the first Trump administration. The same government that funded the creation of this technology is now dismantling it. In August, HHS canceled $500 million in BARDA contracts for mRNA vaccine development and terminated a separate $590 million contract with Moderna for an avian flu vaccine. Several states have introduced legislation to ban mRNA vaccines. Insanity.

The consequences are already visible. In January, Moderna’s CEO announced the company will no longer invest in new Phase 3 vaccine trials for infectious diseases: “You cannot make a return on investment if you don’t have access to the U.S. market.” Vaccines for Epstein-Barr virus, herpes, and shingles have been shelved. That’s what regulatory roulette buys you: a shrinking pipeline of medical innovation.

An administration that promised medical freedom is delivering medical nationalism: fewer options, less innovation, and a clear signal to every company considering pharmaceutical investment that the rules can change after the game is played. And this isn’t a one-product story. mRNA is a general-purpose platform with spillovers across infectious disease and vaccines for cancer; if the U.S. turns mRNA into a political third rail, the investment, talent, and manufacturing will migrate elsewhere. America built this capability, and we’re now choosing to export it—along with the health benefits.

by Alex Tabarrok, Marginal Revolution |  Read more:

Image: Brian Snyder/Reuters

[ed. See also: F.D.A. Refuses to Review Moderna Flu Vaccine (NYT); and, Trump official overruled FDA scientists to reject Moderna’s flu shot (Ars Technica).]

The Questionable Science Behind the Odd-Looking Football Helmets

The N.F.L. claims Guardian Caps reduce the risk of concussions. The company that makes them says, “It has nothing to do with concussions.”

The first time Jared Wilson, a New England Patriots offensive lineman, is seen on the Super Bowl broadcast on Sunday, some viewers may wonder why he has such a big helmet.

It’s called a Guardian Cap, and Mr. Wilson is among about two dozen National Football League players who have worn the helmet covering in games this season. Not for comfort or style. Even the company that makes the cap acknowledges that it’s bulky and ugly. Rather, Wilson and others have worn it for its purported safety benefits.

The N.F.L. claims the cartoonish caps reduce the risk of getting a concussion, convincing some players that they are worth wearing. The company that designed and manufactures Guardian Caps, though, makes no such claim.

“No helmet, headgear or chin strap can prevent or eliminate the risk of concussions or other serious head injuries while playing sports or otherwise,” the product’s disclaimer warns. Instead, the company says its caps blunt the impact of smaller hits to the head that are linked to long-term brain damage.

“It has nothing to do with concussions,” said Erin Hanson, a co-founder of Guardian Sports, the Atlanta-area company that makes the cap. “We call concussions ‘the C word.’ This is about reducing the impact of all those hits every time. That’s all that was.”

The disconnect between the N.F.L.’s claims about the Guardian Caps and what the company promises is emblematic of the messy line between promotion and protection, and the power of the N.F.L. to sway football coaches and players trying to insulate themselves from the dangers of the sport.

An endorsement by the N.F.L., the country’s most visible and powerful sports league, can generate millions of dollars in sales for equipment makers, including Guardian Sports. The N.F.L.’s embrace of the caps, beginning in 2022, has led to a surge in orders from youth leagues to pro teams. About half a million players at all levels now wear them, Guardian Sports said.

“Anything I can do to save my brain, save my head,” said Kevin Dotson, an offensive lineman on the Los Angeles Rams who has worn the cap in games since last season.

The league claimed that the Guardian Cap had helped reduce concussions by more than 50 percent, which has put the company in the awkward position of embracing the spirit of the endorsement while distancing itself from the facts of it. Further complicating the situation: The model worn by pro and college players, the NXT, is not the same as the company’s mass-market product, the XT, which retails for $75. That model has less padding than the NXT, and may be less effective at limiting the impact of hits to the head, studies have shown.

Ms. Hanson said the company had struggled with whether to promote the N.F.L.’s claims about concussions. It decided to do so because the N.F.L.’s boasts might persuade young players to use the product, even if the benefits are not comparable. (...)

Guardian Caps are the latest in a wave of products that have emerged since researchers linked the sport to the progressive brain disease known as chronic traumatic encephalopathy, or C.T.E. Scores of companies have introduced equipment that purports to prevent head injuries, from a silicone collar worn around a player’s neck, known as the Q-Collar, which is promoted as a way to give the brain an extra layer of cushioning, to G8RSkin Shiesty, a head covering that is worn under helmets and promises to significantly reduce concussion risk.

Independent neurologists are generally skeptical, if not outright dismissive, of the benefits of any product claiming to reduce concussions because few rigorous studies have been done to demonstrate their effectiveness.

Few products have received as much publicity as the Guardian Cap, though. Sales of the caps, which were introduced in 2012, took off after the company won the N.F.L.’s HeadHealthTECH Challenge in 2017 — two years after the league settled a lawsuit brought by more than 5,000 former players who accused the N.F.L. of hiding from them the dangers of concussions.

Guardian Sports received $20,000 from the league for additional testing, but the N.F.L.’s endorsement was priceless.

Orders for the caps from colleges, high schools and youth teams poured in. Nearly every college team in the top ranks practices with the caps. In 2021, researchers, including some affiliated with the N.F.L. and its players’ union, published a paper that said Guardian Caps reduced “head impact severity” by 9 percent.

That year, Guardian Sports introduced its NXT model, with an extra layer of padding for bigger, stronger players. The N.F.L. required linemen, tight ends and linebackers to wear them in training camp. In 2023, the mandate expanded to all contact practices, and running backs and fullbacks were added. Starting in 2024, wide receivers and defensive backs had to wear them in practices, and players could wear them in games. (...)

Researchers at Virginia Tech, which runs a well-regarded helmet-testing laboratory, found that players who wore the NXT version of the Guardian Cap experienced a 14 percent decline in rotational accelerations — basically, the turning of the head — and that their concussion risk was 34 percent lower than for players who wore only helmets.

The benefits were significantly lower for players who wore the XT, the model worn in youth leagues and high schools. Rotational acceleration was only 5 percent lower, and the concussion risk was reduced by 15 percent.

Stefan Duma, who leads the lab, said the smaller reductions, combined with better helmets and fewer full contact practices, suggested that the benefits of wearing the XT were negligible.

“We tested it thoroughly, and the benefits are just not there,” Dr. Duma said. “It’s all noise, no statistical difference in youth.”

Most parents and coaches, though, do not read research reports from testing labs, and there is little information on the Guardian Sports website that explains the difference in performance between the XT and NXT models. But looking at the testimonials on the website from Mr. Goodell and other N.F.L. luminaries, parents and coaches might believe they were buying the cap worn by the pros.

by Ken Belson, NY Times |  Read more:
Images: Audra Melton, NYT; Cooper Neill/Getty

What Actually Makes a Good Life

Harvard started following a group of 268 sophomores back in 1938—and continued to track them for decades—and eventually included their spouses and children too. The goal was to discover what leads to a thriving, happy life.

Robert Waldinger continues that work today as the Director of the Harvard Study on Adult Development. (He’s also a zen priest, by the way.) Here he shares insights on the key ingredients for living the good life.

via:

[ed. Road map to happiness (or at least more life satisfaction). Only 16 minutes of your time.]