Coffee Break: Health Care Digest

Part the First: Profit in Medicine. In a report that will tug at the heartstrings of everyone, STAT tells us that HCA warns of lower profits in its future as more patients go uninsured because ObamaCare subsidies have gone by the wayside: The country’s biggest hospital chain lowered its 2026 profit outlook on Tuesday after treating more uninsured patients than expected in the second quarter. Many of those uninsured patients had dropped their Affordable Care Act plans after losing enhanced subsidies, HCA Healthcare said, an early indicator of the fallout from the expiration of ACA enhanced premium tax credits in January. All in, HCA now expects the increase in uninsured patients stemming from the end of those subsidies to lower its income by between $1 billion and $1.2 billion this year, up from an earlier projection of a $600 million to $900 million hit. HCA still expects to generate nearly $15.8 billion in adjusted earnings before interest, taxes, depreciation, and amortization — a form of profit known as EBITDA — this year at the midpoint, but that’s down from the $16 billion it had projected in January. The company’s stock price fell roughly 7% midday following the early morning announcement, which included a preview of HCA’s second-quarter earnings. “We remain confident in our ability to navigate through this dynamic environment, maintain our focus and investments on improving patient care, and execute on our strategic plan to digitize and grow our healthcare networks,” HCA CEO Sam Hazen said in a statement. No one disputes that medical care in not free, but those of us of a certain age see something we never thought would happen. Back in the day, those with health insurance (a category mistake that is now coming home to roost) had very little to worry about. And those without still received the care they needed. As a close colleague who is a physician put it, back then doctors got paid 90% of the time, and when we didn’t that didn’t matter. And the public hospital overseen by the local Hospital Authority composed of business and civic leaders certainly did not go after the poor people who couldn’t afford their hospital bills. Members of the Authority knew these people, or just as likely they remembered family members in the same situation. Here is a recent ranking of 105 health care systems by annual revenue. They include nominal non-profit, public, and private systems. My family is currently involved of necessity with one of the Top-10. For what should be a simple surgery, the health system will bill the employer health plan ~$100,000, depending on how non-simple the surgery turns out to be this morning. As I wrote Wednesday, our contribution is not insignificant to us and seems to be growing. We are privileged to be able to pay our part. But if this had happened to a data clerk in the bursar’s office, not so much, because what we have paid would be one month or more of that salary. Some of you will remember my previous quotation(s) from Aneurin Bevan, who organized the National Health Service in less than two years immediately after WWII, when Great Britain was still rationing food: “The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health.” Not much more to be said about that, except to remember Herb Stein again: If something cannot go on forever, it will stop. Mr. Stein was one of the good guys who served in the Nixon Administration. There were actually more than a few of those. The question is what happens next, universal health care (public; no cost at the point of delivery) or further hardening of Lambert’s Laws of Neoliberalism: (1) Because markets! (2) Go die! Part the Second: Don’t Mess with Chris Deacon. More on the Blue Cross Blue Shield in our modern world, This whistleblower took on a health insurance giant and a political machine. She’s not stopping there: It should have been a triumphant moment for Chris Deacon. Last November, Horizon Blue Cross Blue Shield, the insurance giant that manages health benefits for 750,000 New Jersey state workers, family members, and retirees, paid $100 million to wipe away allegations that it knowingly overpaid hospitals and doctors and fraudulently won its state contract. At the press conference, then-New Jersey Attorney General Matthew Platkin touted it as a “historic” action. “Today’s settlement makes a very clear statement: We send a message to Horizon and to the entire insurance industry that they cannot take advantage of the state,” Platkin announced from the dais, surrounded by his staff. “They cannot make us all illegally pay more for health care.” Deacon was a driving force behind the settlement. She caught Horizon’s alleged behavior as the top official overseeing New Jersey’s health plan. But rather than celebrate, she was torn apart by a mix of emotions as she watched Platkin and his team from her home office. She felt some satisfaction that a public display of justice was unfolding. But she also felt disgust, anger, and sadness as officials completely erased her role in uncovering the misconduct and glossed over their own culpability in allowing it to happen. “You try to do the right thing, and this is what happens,” Deacon said. “I’m at peace with it. But to be not even a footnote was like their final ‘fuck you’ to me.” As the story is told, the settlement was contingent upon Chris Deacon being left out of the settlement. But she is now in independent lawyer and consultant. The big health plans might have f*cked up: People at the highest levels of government and the private sector are noticing. Deacon has testified in front of Congress twice in the past year, advised leaders on state health care legislation, and inspired more employers to scrutinize their insurance contracts. “I’m a huge fan,” Mark Cuban told STAT in an email. The billionaire and former “Shark Tank” investor has turned into a regular critic of health insurance companies and pharmacy benefit managers and urged his 8.4 million LinkedIn followers to read what Deacon has to say. “She is fearless, focused, and does the work to have an impact. Which she is having.” One health system at a time, until she runs out of time. Part the Third: The Future of Robotic Surgery. Modern medicine has gotten better as technology has improved: X-ray versus MRI and CT scan, scalpel and retractors versus a camera and loop plus a cauterization needle. A simple cholecystectomy (gall bladder removal) is frequently an outpatient procedure with a recovery time measured in days. Not so long ago it was an invasive procedure that left a substantial scar and required weeks for a full recovery. This was also true of an appendectomy. I have seen more than a few of those scars in a lifetime in locker rooms and they are not small. Today they are unnoticeable. Aurélien Guéroult has written Surgery and the limits of the robotic ideal for Engelsberg Ideas: Clinical medicine is perhaps the most literally ‘human’ profession. Surgeons aim first to understand, and then manipulate human biology. Will medicine and surgery be the final frontier for full robotic automation? Robotic surgery, or more accurately robot-assisted surgery, has been used for around 20 years and is routinely practised worldwide, including in the UK National Health Service (NHS). In the 1990s, robotics scientists developed machines with the ability to translate continuous input from an operator into movement in real-time. This opened the door for the development of surgical robots, which replicate with high fidelity the movements of a surgeon’s hand during operations. The US-developed da Vinci surgical robotic system is one of the pioneers in the field (FDA-approved in 2000), although equivalent Chinese and EU systems have been released to market. These robots are not autonomous, and the operating surgeon remains in full control of the three or four robotic arms, which they manipulate through a console. Surgical robots’ role in routine clinical practice remains restricted to very specific operations. Throughout the latter half of the 20th century, all surgical specialities have strived to make operating as minimally invasive as possible, reducing risk of surgery and shortening post-operative recovery times. Cue video-assisted ‘keyhole’ operating. This has been a game changer and, in many cases, has superseded the original ‘open’ techniques. Many specialities have embraced keyhole techniques, virtually a revolution in clinical practice, partly because of patient preference, partly because of faster recovery. Internal camera video ‘stacks’ are commonplace in the theatres of abdominal, thoracic and gynaecological surgeons; cardiologists and vascular surgeons similarly deploy devices such as stents inside the heart and blood vessels through incisions barely a centimetre across under X-ray guidance. Dr. Guéroult’s conclusion, stated in the tagline, is that “Robot-assisted surgery is already routine practice. But the dream of a machine operating alone underestimates the practical judgement, learned over decades, that makes a surgeon a surgeon.” He is correct. The precision afforded by a surgical robot maintained by an excellent technical representative and controlled by a competent surgeon is revolutionary. But over-reliance on the technology is only the extension of the flawed engineering ideal of biology to clinical medicine. I wrote of my conversations with Dr. B earlier this week. He is an engineering graduate and seems enamored with ChatGPT’s apparent ability to “make” a diagnosis from a lab report. The problem is that the lab report is not the patient, or even a reasonable facsimile thereof, sitting before the physician or surgeon in real time. That which is spewed by ChatGPT cannot see the patient and therefore cannot know the patient. This is not a difficult concept, except for a madding crowd that would astonish the Thomases Gray and Hardy. I’m reminded of a saying I hear in medical schools: “The surgeon knows nothing and does everything, while the internist knows everything and does nothing.” I am not a clinician, but this has superficial validity at the margin, and surgeons, internists, and medical students laugh at it. But, all art and all science require deep knowledge, the intuition that comes out of that knowledge, and technique appropriate to the problem or project. There can be no shortcuts here. Any given eructation of ChatGPT is information (of uncertain provenance) but it is not knowledge, however much it appears to be, and the information depends on the training set (usually stolen and used uncritically) and the LLM/AI prompt. The surgical robot, despite its precision, will remain dangerous without intuition and knowledge of what “looks right” and what doesn’t. Despite the hype, AI as currently known will not “take over” any human discipline. The question is whether the powers that be, including various and sundry screeching tech bros and their acolytes, physicians, scientists, and politicians recognize this before it’s too late. This is at best only a 50:50 proposition. Artists rightfully have no doubt about correct answer. Part the Fourth: The War on USAID and Its Consequences. The United States Agency for International Development (USAID) was created during the first year of the American Camelot, the Kennedy Administration. It was an appurtenance of the deep state and had a Kiplingesque “white man’s burden” tinge, but at the same time it was the legitimate extender of American soft power throughout the world. There is no doubt USAID did good things where needed despite its underlying political, imperial, and military uses. There is also no doubt there was a bit of “waste, fraud, and abuse” within USAID. However we should put to its final rest the idea that “waste, fraud, and abuse” was the purpose of DOGE. Like the dog that didn’t bark, DOGE was content to go after USAID and the National Science Foundation (with a contract security guard at the door) rather than the Pentagon, where there are sergeants armed with an M4 carbine or equivalent at each door. The New Yorker can be, well, as provincial as any outlet in flyover country, but David Remnick has interviewed Atul Gawande about USAID and what it did in the world in The Cost of Doge’s WAR on U.S.A.I.D.: In 1988, Richard Rhodes, a historian and a journalist who wrote a definitive study of the creation of the atomic bomb, published an article in the Journal of the American Medical Association called “Man-made Death: A Neglected Mortality.” Rhodes argued that demographers and public-health officials ought to take greater care to account for deaths caused by war, neglect, privation, and other effects of policy. His emphasis was on deliberate acts—artificially induced famines, for example, and the willful dismantling of public-health aid and infrastructure. Atul Gawande, who was a leading administrator at U.S.A.I.D. until the Trump Administration’s DOGE initiative, led by Elon Musk, set about defunding and destroying the agency, is a surgeon and a longtime New Yorker contributor. In our latest conversation for The New Yorker Radio Hour, Gawande uses Rhodes’s concept to help describe the colossal human cost that Musk and DOGE have exacted on the world. Gawande, backed up by recent academic studies, says that the decimation of U.S.A.I.D. around the globe has been responsible for some seven hundred thousand deaths, and that number will likely ascend into the seven figures. The policy is not only immeasurably cruel, Gawande argues; it is also stupid, badly undermining what remains of American soft power and prestige, from Africa to Latin America. Elon Musk, former trillioinaire, disputes the numbers of deaths that have and will result from the DOGE obliteration of USAID. But Mr. Musk is mistaken. The archived link is worth the read in its entirety. One thing that is not covered if I remember correctly is how USAID and its contacts on the ground could have sounded the alarm early about the current Ebola outbreak in Central Africa. What, me worry? Alfred E. Neuman, apparently he is immortal. Part the Fifth: The Secretary of War and Testosterone. Or, I can’t even. In an effort to make our war fighters even more lethal, the current Secretary of War (the projection, it burns) wants soldiers, sailors, airmen, and Marines under 30 to be tested for Low-T, while Henry L. Stimson continues to spin at 300 rpm in his grave. It occurs to me that I have not seen one of those Low-T commercials in ages (NSFW; “real commercial” here), and since I rarely watch only sports on TV, they must have disappeared? Anyway, come to learn that Hegseth announces new policy to test troops for low testosterone. This is completely daft, but it certainly fits in with the MAHA zeitgeist. The reasoning behind this is that “normal” testosterone levels are essential, according to Secretary Hegseth, for a soldier to be, well, a soldier. Of course, normal testosterone levels are essential, period. As are estrogens. In men and women. At some level one cannot help but wonder if this story is related to Secretary of War’s testosterone initiative: Opportunities Narrow for Women as Hegseth Blocks More Promotions. Women do generally have less testosterone than men, after all, but explaining endocrinology…never mind. Perhaps a more “effective” policy would be to go all-in and back to the future with nandrolone. Be done with it and let the roid rage loose. I digress, but when I was a teenager, isometric exercises were said to be the best way to improve strength and muscle mass. According to my anthropology teacher who was the expert in the Indians of Southeastern North America, native American infants who are carried in cradle boards walk earlier than those who are not. So, isometrics do work, and especially well with anabolic steroids, which were the key in those particular gyms of my youth. Or we could just stop with our all-war-all-the-time jones to be the one hegemon in the unipolar world of our nationalistic fever dreams and achieve the country we have yet to become, but could. Thanks for reading! Comments, criticism, and snark welcome. I hope you enjoyed Bastille Day earlier this week: Liberté, Égalité, Fraternité. See you next week. “Lambert’s Laws!” Love ‘em, but has Lambert launched his new enterprise? I thought he was ready 6 months ago. Yes he has. The jackpot blog, it is fantastic. So much to consider with this post. 1. RE testosterone. Dr. Oz said that Trump has the highest testosterone of any man his age that he has ever seen. Clearly this means that Trump is taking supplements. Roid rage? Do his physical reports include a list of medications and supplements. RFK Jr. has admitted taking human growth hormone. 2. Horizon Blue Cross. Again, massive fraud and stealing from a public program. As always, no jail time. Street crime = jail. Suite crime = rewards. 3. USAID is a JFK Cold War program. The Peace Core is another of his Cold War programs. The world has changed much since. Is it still relevant. I saw that they have expanded the program to eastern Europe. Testosterone feeds prostate cancer, declining levels are protective. Supplementation will lead to increased morbidity and mortality. Thank you, Rui. Very true and one of the first things, as a senior citizen, I thought about. Of those parties who have felt the need to approve this ridiculosity (i.e., kowtow to perceived authority), not one has mentioned prostate cancer and anti-androgen therapy. Think of this as slow-growing prostate cancer on steroids in early middle age, which is something Dr. Hegseth of Princeton could understand if he cared to. Somehow the idea of taking extra testosterone when the male body is winding it down in usage does not strike me as a great idea. Hegseth says that he wants troops to have extra testosterone to be more “lethal” but this strikes me as some sort of sweaty, MAGA fantasy. Maybe next he will want troop to pump themselves up with steroids to be more lethal here as well. But it is not just Hegseth. US pilots have been forced to use amphetamines if they want to continue their careers for decades now. In Afghanistan, a US pilot bombed and killed a bunch of Canadian troops and his defense team argued that it was his amphetamines usage that made him more aggressive. Go figure. As for ‘The surgeon knows nothing and does everything, while the internist knows everything and does nothing’, wasn’t there another saying that said that ‘a GP knows less and less about more and more until he knows nothing about everything while a specialist knows more and more about less and less until he knows everything about nothing?’ Most reporting on Obamacare plans is about the dropped subsidy and the premiums. But another observation is that the Bronze Plan annual out-of-pocket maximum for an individual is $12,000, and for a family, $24,000. What percentage of households can pay that? https://www.kff.org/affordable-care-act/in-preliminary-rate-filings-aca-marketplace-insurers-largely-propose-double-digit-premium-increase-for-2027-following-a-steep-climb-this-year/ In Preliminary Rate Filings, ACA Marketplace Insurers Largely Propose Double-Digit Premium Increase For 2027, Following a Steep Climb This Year Oh, joy. I can hardly wait. Demand destruction for healthcare by pricing people out is the new Public Health. Priced out at the “destination of funds” end, and thrown out (of work, if the AI enthusiasts get their way) at the “source of funds” end. Perhaps shares in these companies should not be trading at multiples of present earnings. Perhaps this is what will lead to Medicare for All at some point, as a bail-out of the for-profit health-related-services provision industry.