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Jeffrey A. Singer


Earlier this week, the Food and Drug Administration issued a draft of proposed guidelines for clinical researchers conducting trials on psychedelic drugs. Even though the Drug Enforcement Administration categorizes psychedelic drugs as Schedule I (meaning that the law enforcement agency has determined they have "no currently accepted medical use and a high potential for abuse"), clinical researchers have known for decades that psychedelic drugs can help treat a variety of mental health disorders.
Government‐​approved Phase 3 clinical trials of the psychedelic MDMA* (colloquially called "molly" or "ecstasy") show the drug can be effective in treating post‐​traumatic stress disorder (PTSD). News reports claim the FDA is expected to approve the drug for PTSD treatment later this year. Regulators in Australia approved it last February. The FDA recently approved a clinical trial using MDMA to treat schizophrenia. Psilocybin, the psychedelic found in "magic mushrooms," has been shown helpful in treating tobacco addiction, depression, and suicidal ideation, particularly in patients receiving palliative end‐​of‐​life care. Research dating back to the 1950s finds that LSD (lysergic acid diethylamide) shows promise in treating anxiety, depression, addiction, and psychosomatic diseases. Of course, none of this matters if the DEA doesn't agree to reschedule these drugs and continues asserting they have "no currently accepted medical use." Accepted by whom?
Generally, when the FDA approves a controlled substance for medical use the Secretary of Health and Human Services must next formally request the DEA reschedule the drug. The DEA then has 90 days to issue an interim final rule. But the DEA doesn't have to follow the health care agencies' recommendations.
In 1985 the DEA placed MDMA on Schedule I as an emergency action. Clinicians and clinical researchers challenged the decision and, in a 1986 hearing, provided mountains of scientific evidence that convinced administrative law judge Francis L. Young to conclude:
If the Administrator of DEA carefully considers the entire record now provided in this proceeding, there is no reason why he cannot come to the informed decision the law requires of him as the Agency head. Needless to say, nothing in this opinion is to be taken as being in any way critical of the Agency's emergency scheduling of MDMA which became effective on July 1, 1985. That action was taken pursuant to certain statutory authority with which this proceeding is not concerned. That action was wholly unilateral, reflecting a view based on evidence then available to the Agency but without opportunity for the presentation of countervailing evidence or argument. This proceeding, a wholly separate process, has provided that opportunity. A complete record, with input from different perspectives, has now been assembled for the benefit of the Administrator, the head of the Agency. The record now assembled contains much more material about MDMA than the Agency was aware of when it initiated this proceeding by publishing a notice almost two years ago.Based upon this record it is the recommended decision of the administrative law judge that the substance 3, 4‑methylenedioxymethamphetamine, also known as MDMA, should be placed in Schedule III.Dated: MAY 22 1986 Francis L Young, Administrative Law Judge

Judge Young vacated the DEA's decision to place MDMA on Schedule I, placing it on Schedule III ("moderate to low potential for physical and psychological dependence"). One month later, Acting DEA Administrator John Lawn overruled the administrative law judge and moved MDMA back to Schedule I, stating that, though expert clinical researchers presented over 200 cases of MDMA‐​assisted psychotherapy at the hearing, none of them had been published in medical journals.
Think of all the research that has been stifled, and all the lives that could have been saved or improved, if Administrator Lawn had not made that fateful decision.
And it's not just psychedelics. Who can state with a straight face that cannabis has "no accepted medical use?"
Thus, even if the FDA approves MDMA to treat PTSD and other mental health disorders, clinicians and patients will still have to wait for a law enforcement agency to sign off on the decision. And this is not just a federal law enforcement decision. Each state has its own controlled substance system patterned after the federal system. According to the Multidisciplinary Association for Psychedelic Studies (MAPS), 27 states have laws that require parity with the federal controlled substances schedule. In those cases, the states automatically reschedule controlled substances to conform with a DEA rescheduling. But the remaining 23 states require lawmakers or regulators to make their controlled substance schedules conform.
Recently Representatives Dan Crenshaw, Morgan Luttrell, and Jack Bergman–all military veterans– introduced the "Mike Day Psychedelic Therapy to Save Lives Act," which would provide federal grants for research into using MDMA to treat PTSD and traumatic brain injury patients. It is gratifying to see lawmakers begin to appreciate the potential benefits of psychedelics.
But law enforcement is in command of the war on drugs. Unless Congress acts, we will continue to see cops practicing medicine. And the people—veterans and non‐​veterans— will continue to suffer.
*3,4‑methylenedioxymethamphetamine

In Members of the Medical Licensing Board of Indiana v. Planned Parenthood, decided Friday, the Indiana Supreme Court (in an opinion by Justice Derek Molter, joined by Chief Justice Loretta Rush and Justice Mark Massa) concluded that the Indiana Constitution's protection of "life, liberty, and the pursuit of happiness" "protects a woman's right to an…

Can a reliable ride to the hospital improve your health? In the world of health care, where every moment is crucial, missing out on essential medical care simply because of transportation can be life-threatening. This is the reality for the 3.6 million Americans who live with health-related transportation insecurity, according to the American Hospital Association's […]

When Maryland Governor-elect Wes Moore was 3 years old, he watched his father collapse in front of him. Losing his father at a young age greatly impacted Moore's life. He acted out at school, was sent to a military academy by his mother, and later confronted what he called the inequitable policies influencing his life, including his father's inability to receive adequate medical care. Governor-elect Moore talked with David about his path to public service and gubernatorial victory, his time serving in Afghanistan and studying at Oxford, how leadership transformed his outlook on his capabilities and himself, his governing philosophy, and the future of Maryland.
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My name is dr. Dániel András Karsai. I am a human rights attorney. I am also terminally ill. In August 2022, I was diagnosed with ALS. ALS is a so-called motor neurone disease. ALS leads to an extremely humiliating life situation, increasingly depriving you of independence. For reasons unknown to medical science, this disease causes nerve cells that move the muscles to deteriorate, leading to muscle atrophy and ultimately complete paralysis. At the end of the disease, respiratory functions also cease, resulting in death by asphyxiation. The final stage of the disease is virtually a vegetative existence, without any possibility of conscious activity or communication. For me, this form of existence is devoid of all meaning and dignity. In this situation, I firmly believe in the arguable claim to demand the right to end my life with dignity instead of enduring meaningless suffering.

What is it about liberalism that makes its
adherents go to the mattresses to preserve the infrastructure that allows minors
to have irreversible medical interventions performed on them that many children
later will regret, an attitude in sharp contrast with medical practice
worldwide outside the U.S.?

Currently, the fate of HB 648 from
the recently-concluded Louisiana Legislature regular session hangs in the
balance. The bill would disallow prescribing of drugs or surgery designed to
alter the physical sex of a minor.

The state of science at
present on the issue notes that of the small but growing proportion of all children
who begin medical interventions to alter their sex about 30 percent within a few
years want to stop, if not reverse, it. Unfortunately, the effects are irreversible,
causing major psychological trauma for those who want to stop the transition
and major physical trauma even for those who don't that has significant
psychological impacts as well.

Additionally, there is a significantly higher
proportion of mental disturbance among those wishing to transition that
suggests the desire to transition is an outgrowth of underlying mental states unrelated
to identification by sex, so interventions treat symptoms, not the disease.
Further, there is still much unknown about this phenomenon, and much of the
research that purports to support the view that any expressed uncomfortableness
with physical sex by children must initiate medical interventions to change this
has significant validity problems that severely limits its use.

Those are the scientific facts that lead objective
observers to support extreme caution in allowing humans lacking physical and
emotion maturity to have hormonal manipulations and radical surgery performed
on them. Yet leftist ideologues, as they are doing in Louisiana including Democrat
Gov. John Bel Edwards,
are putting up fierce political resistance to measures like HB 648.

That's because of the core tenets of liberalism.
In the area of personal conduct, conservatism posits that over the epochs of
human existence there has become recognized an optimal set of values by which
to organize society and reflected in individual behavior. Conceptualized as a
set of universal truths often reflected in religious belief, government is to
codify these into law.

By contrast, liberalism declares all "truths" contingent
on individuals and their contexts in time or space, or that there are no
universal truths – an inherent self-contradiction since that very statement
itself articulates a universal truth. To use another social issue as an
example, conservativism believes the truism that life begins at conception and
so people cannot decide whether to abort an unborn human unnaturally as that
violates another universal truth, that the taking of life intentionally outside
of self-protection violates natural law. But liberalism believes whether abortion
is murder is up to the individual to decide, given her unique placement in the
universe.

Liberalism, then, is an exercise in denying fixed
realities. And, along with the other genetically-defined trait of human existence
of race/ethnicity, sex is as fixed and immutable as one can find in a human. Sexual
characteristics that stubbornly resist alteration mocks liberal faith that
truths are what people choose for themselves, not things that simply are that
we must adjust to.

Thus, in organizing human interactions, the left
insists we use "gender" rather than sex as one of its concepts, where physical
sex must bend to the will of the psychological gender. And, as a bonus, with children
this process attacks what the left sees as a retrograde and rival force in
preventing imposition of itself onto the polity: the family. No other
institution so effectively resists leftism's indoctrination attempts, so it
supports vigorously any sociological superstructure that cuts out the family
such as having
schools propagandize gender identity among youth to unmoor the fixed.

Therefore, despite the harm that too often results
from medical interventions to change a minor's sex that includes a significant
portion who regret it, involving people not emotionally developed enough to
give informed consent, the left is full steam ahead on facilitating this and
willing to go to fanatical lengths to support its continuance despite the
self-evident harm that occurs. After all, to the left human welfare always is secondary
to fulfilling its ideological imperatives.

In fragile states, democracy needs, even more, strengthening in times of pandemics as citizens and institutions are exposed to increased vulnerabilities. In some cases incipient dialogue and reconciliation networks may break down as social groups turn inward as a self-protection reflex, cultural barriers might exclude women and other marginalized groups from receiving healthcare, and armed groups might exploit the situation to increase their influence. In addition to the extraordinary effort of medical personnel providing life-saving health services, governments, civil society, and citizens alike need to do their part.
Trust in institutions is key to citizens' compliance with measures that restrict individual liberties. Extraordinary measures, such as declaring a state of emergency, restricting movement, and mobilizing emergency funds, come with an increased need for government leadership and responsibility. The government's response needs to be measured and expenses appropriate, though. More than ever, the executive branch of the government should allow parliamentary control over policy implementation, because lack of proper and functional oversight mechanisms may lead authorities to abuse—or be seen as abusing—their powers.
As multiple priorities will compete for limited resources in the coming weeks and months, political parties should build political consensus not only on ways to manage the current health crisis but also on a path to socio-economic recovery over the coming months.
Strengthen social solidarity. The distribution of resources to treat medical cases—and to protect communities at large—should be and viewed as being fair; a sense of inequity can lead to deteriorating social cohesion due to perceptions that some regions or ethno-sectarian groups are getting more than their fair share. Encourage cross-group networks of solidarity that complement government efforts.
Demonstrate effective leadership and communication. Political leaders have a duty to make tough decisions, but also reassure citizens and inspire those in the frontlines of the fight against the coronavirus. Leaders should explain the strategy, and show empathy, letting experts tackle medical and legal details. The government should communicate often, with "one voice," and with clarity. Always tell the truth—misleading information or manipulated statistics tend to avenge quickly, especially in an age when everyone can easily share information using smart devices. Also, keep in mind that preexisting socio-economic and political issues will not disappear during this time; constituents still need access to services, jobs, safety, etc.
Media and citizens need to exercise good judgment and critical thinking to avoid creating panic and inflicting unnecessary suffering on the already stressed population. Deliberate disinformation is meant to sow confusion, distrust between social groups, between citizens and their government, and lead eventually to doubt that democracy can delivery in times of crisis.
Have a positive outlook—acknowledge the effort and give hope. People need inspiring models, and strong characters are forged in difficult times. Moreover, fragile countries need positive stories of challenges to overcome together to spawn a sense of resilience and pride. All should praise the hard work and commitment of first responders and try to instill the same values of self-sacrifice, discipline, and resilience across the public sector and the society at large. Last but not least, decision-makers should project hope and explain how the country and the society will be transformed and made stronger, how it will be more cohesive, through a rediscovered sense of common purpose.


Credit: Ibrahim Naji

Democracy (General), Countries: Iraq

Marc Joffe


With so many people obtaining Medicaid coverage in the wake of the Affordable Care Act and during the pandemic, it is worth investigating whether this expanded eligibility is improving health outcomes. Overall, decreases in the proportion of uninsured individuals over the last decade are not being matched by improved life expectancy. Indeed, life expectancy at birth in 2021 was lower than it was when the Affordable Care Act passed. But this fact tells us little about the benefits of Medicaid coverage since the decline has been driven in large part by COVID-19 deaths among elderly patients (often not on Medicaid) as well as increased mortality from accidents and drug overdoses.
To better gauge the benefits of Medicaid, it is necessary to look at more specific health indicators. The federal Center for Medicaid and CHIP Services (CMCS) compiles a large variety of healthcare quality measures that could help us analyze outcomes. Unfortunately, most of these measures are not available for all states and all years, making it difficult to assess performance in a systematic way.
One indicator that is generally available is the rate of low birth weight, which is the percentage of newborns weighing less than 2500 grams, or about five pounds eight ounces. Low birth weight (LBW) babies have "a higher risk of morbidity, stunting in childhood, and long‐​term developmental and physical ill health including adult‐​onset chronic conditions such as cardiovascular disease." Consequently, reducing the incidence of LBW should improve public health, but Medicaid services are not achieving this outcome.
A 2019 study in JAMA found no correlation between Affordable Care Act Medicaid expansion and LBW. The authors used administrative records to obtain rates of LBW (and some other adverse birth outcomes) before and after Medicaid expansion in states that accepted the expansion and those that did not. The change in LBW rates in expansion states was not significantly different than that in non‐​expansion states. The authors did find some improvement for Black infants in expansion states, but not for white or Hispanic infants.
Overall, the US is not among the countries that have had the best success in minimizing low birth weight. A 2015 World Health Organization analysis ranked the US 64th among 146countries, with such less affluent nations as Albania. China, and Cuba performing better. Poor US outcomes have been attributed to the use of fertility drugs (which increases the likelihood that a mother will give birth to twins or triplets) and the high rate of Caesarian sections.
According to data from the CDC WONDER Database, 8.3% of US babies born in 2019 were low birth weight. The LBW rate among Medicaid patients was substantially higher, coming in at 9.8% (WONDER also has 2020 and 2021 data, but I chose 2019 data to avoid any pandemic‐​related affects).
In the District of Columbia, the LBW disparity between Medicaid‐​financed births and those with other types of coverage is especially stark. In 2019. DC's overall LBW rate was 9.9%. For Medicaid births, it was 12.7% and for non‐​Medicaid births it was only 7.4%. And, it does not appear that this disparity is caused by a lack of access to government‐​paid medical services: the Medicaid and CHIP Payment and Access Commission (MACPAC) reports that (in 2018) 99.3% of DC Medicaid births took place in a hospital and that 91.7% were attended by a physician, with almost all of the remainder attended by a Certified Nurse Midwife.
The risk of low birth weight can be minimized through proper nutrition, not smoking, and avoiding narcotics. These risks can be controlled with non‐​medical interventions. For example, at‐​risk mothers can be accommodated at maternity homes, where their diet and substance use can be carefully supervised. The widespread use of maternity homes in Cuba may explain the low rate of LBW in that country (although Cuba's health statistics have been subject to criticism).
WONDER provides statistics on tobacco use in pregnant women. In DC, the LBW rate among Medicaid tobacco users was 23.7%. Unfortunately, data are not available for other types of substance abuse or malnutrition, however Wallethub recently ranked DC's drug use fifth among all states (plus DC).
Some states are devoting Medicaid resources to the "social determinants of health", funding non‐​medical services such as housing and nutrition that are intended to address health inequities. DC has an Office of Health Equity that supports "projects, policies and research that will enable every resident to achieve their optimal level of health — regardless of where they live, learn, work, play or age." But these added efforts are not making a dent in LBW.
Despite spending over $3 billion on Medicaid annually, DC (like other parts of the US), has pregnancy outcomes that are on a par with or even below those of developing countries. It appears that providing costly pregnancy services cannot substitute for the basic health precautions we hope all expectant mothers will take.

Missing its most important ingredient, the televised Louisiana gubernatorial
debate sponsored by media outlets and interest groups provided few useful
glimpses into the contest.

Republican Atty. Gen. Jeff Landry, the inarguable front
runner, didn't participate over concerns the Urban League as a sponsor which has
demonstrated outright hostility to some actions he has taken in his job. Five
others lined up: Democrat former cabinet member Shawn Wilson who is the only candidate
within shouting distance on Landry in the polls, independent lawyer Hunter Lundy, and Republicans state
Sen. Sharon Hewitt, Treas. John Schroder, and former gubernatorial
assistant Stephen Waguespack.

Without Landry, it's pointless to compare and
contrast candidate issue preferences uttered. Instead, winners and losers in
certain aspects will be described.

Best performance: Waguespack. A former Republican Gov.
Bobby Jindal adviser, he came off as a paler and slightly-slower speaking
version of his old boss, meaning he packed a lot of information into making
salient and convincing points.

Least impressive: Lundy. Maybe he's good in court,
but not so much on the political stage. He came off as, even for a politician, making
overly simplistic and broad statements, unaware that viewers will catch that
his promising so much stuff means quite a bit higher taxation levels than he's
willing to admit.

Most botched issue: teacher pay increases. All
pledged this, which at the level would cost about $200 million annually, but the
state faces starting
in fiscal year 2025 the headwind of deficits approaching $500 million yearly.
Where will the money come to pay for this, especially as the Republicans
essentially argued for no net tax increases, including not renewing the 2016/18
sales tax hike of 0.45 percent?

Least credible answer: Wilson came off fairly
polished, but anybody knowing his history knows he has no credibility in saying
he wouldn't back a gasoline tax hike after
he stumped for one for the past few years.

Biggest mistake: Schroder, after over more than
one answer touting the need for a better business climate, then torpedoed his credibility
when he said a minimum wage hike that destroys jobs and impairs commerce was in
order.

Best turnaround: Perhaps the most ridiculous
question of the night (see below) asked the candidate's response to the NAACP's
declaring a fatwa on Louisiana's tourism industry, warning visitors
away, after the Legislature – overriding
Democrat Gov. John Bel
Edwards' veto – enacted a law protecting children from irreversible and
often harmful medical interventions to produce a sex change, often the product
of transitory feelings of immature children bolstered by adult ideologues. The
Republican candidates batted that away, Hewitt the most effectively, in emphasizing
the law was to protect children and didn't deal with adults who for whatever
reason wanted to alter surgically or chemically their sex.

Most disappointing: Differing from all the others,
Wilson, who appeared comfortable in placing blame for the fatwa on the
Legislature rather than leftist ideologues, backed expanding legal abortion in
describing it as a choice to be decided among the unborn's mother, her family,
and medical confidants. Conspicuously absent from that was consideration of the
life that an abortion would kill, which says much about his lack of character.

Biggest tool: That wasn't earned by any
participant, but generally by the organizers who paraded several loaded, if not
stupid, questions such as about the fatwa, and specifically WWL-TV New
Orleans reporter Eric Paulsen, who not only shilled for these but also at times
felt compelled to add his own commentary that in one instance lasted longer
than any candidate was given to answer it.

This week another debate, which Landry will
attend, will occur. It's unlikely to be as meaningless as this one, yet also
not likely to be too much more informative.

A standard argument in favour of government doin' stuff is that government is eternal - therefore they're the only people able to take a long term view of matters. To be able to deal with those decades long, even generational, matters that individual lifespans, or corporate ones, simply won't bring to salience. Well, OK, it's a theory, Like all theories - or at this stage of the scientific game, hypothesis - this needs to be tested. The way science works is that we deliberately look around for the evidence which disproves the contention. If we find such evidence - we need only the one piece - then the hypothesis fails. Repeated attempts to disprove that do not disprove gradually move the hypothesis over to being a theory at which point it becomes a useful working assumption for how we deal with the world. Until, if ever, that disproof does arrive. So, doctor training: Ministers have dramatically stalled plans to double the number of doctors being trained in England by 2031 in a move that has caused dismay across the NHS, as well in medical schools and universities, the Observer can reveal.In June last year, ministers backed a long-term plan to expand the NHS workforce and pledged, amid great fanfare, to "double medical school places by 2031 from 7,500 today to 15,000, with more medical school places in areas with the greatest shortages to level up training and help address geographic inequity". Labour is also committed to raising the number of doctors to 15,000 by 2031.But a leaked letter written jointly by health minister Andrew Stephenson and the minister for skills, apprenticeships and higher education, Robert Halfon, to the independent regulator the Office for Students, says they will fund only 350 additional places for trainee doctors in 2025-26.Now, we have noted this before around here. That glorious - and yes, it is glorious - economic liberation of women has led to some run on problems. Female entry into the professions - part of that glorious economic freedom - then runs into things like maternity leave and a predeliction for part time working while the snot-machines are awaiting primary school. Now, because we're all in with the economic liberation part this isn't something to bemoan, it's simply something to deal with.Over recent decades doctoring has become a majority female occupation - economic liberation again. Huzzah!Government also takes to itself the power to determine how many doctors are trained each year - or even each decade given the time it takes to train. An average doctoring working life is some 30 years - out of training at around 30, hitting the pensions cap and retiring at 60. Say, about. Add maternity and part time working to give a decade of less than full time work over that three decades and what's the result? Other than the wholly welcome result of that economic liberation? The answer is that we need to be training more doctors. More more doctors than an ageing population requires, more more doctors than a growing population requires. We gain fewer doctoring working hours out of each doctor trained therefore we require more doctors trained. As we say, this is not a problem it's simply an effect and one that has to be dealt with. This all became obvious some 30 years back. Government did not increase the number of doctor training places 30 years back. Government's not a good manner of doing those long term things. Then it gets worse. Obviously, finally, they agreed that more training places needed to be financed. But now it's being limited for whatever short term - we assume financial - reason. Which is the whole point of passing those long term problems over to government, that long term things get dealt with in a long term manner, not subject to the short term buffeting of events Dear Boy, events.We've just found our disproof of the contention - hypothesis - that government deals well with long term issues. Therefore the hypothesis fails.A beautiful theory killed by ugly facts. Again. Now note how science works here. Repeated assertions that sometimes the hypothesis holds don't matter. All we need is the one disproof. As science doesn't actually say but does mean after all even the blind squirrel sometimes finds a nut. Government is good at dealing with long term problems fails as an assertion if we find the one example of government not being good at dealing with a long term problem.Which does, of course, mean that Mazzonomics is tosh but then we all knew that anyway.

Michael F. Cannon


Earlier this week, the press shop at the U.S. Department of Health and Human Services (HHS) spent taxpayer dollars to host a live‐​tweet, in the voice of the HHS building, to respond to press reports that HHS's building is the ugliest in in Washington, D.C.









Someone actually thought this was a good idea.
If I worked in that shop, I too might spend taxpayer dollars on gimmicky stunts to distract attention from the harms the Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and Centers for Medicare & Medicaid Services (CMS) do to patients.
When I read the live‐​tweet, it was even worse than I expected. HHS staff made the shameless claims that the department recently "insured a record number of people with quality, affordable health care coverage" and "provided the tools to fight COVID for free." These claims are a jaw‐​dropping mockery of the hundreds of millions of patients whom HHS has harmed and whose earnings the agency has wasted.
"Quality…health care coverage"?
They can't mean Medicaid. The most reliable evidence that exists on the quality of Medicaid coverage comes from the Oregon Health Insurance Experiment (OHIE). The OHIE was a randomized, controlled trial, which means that if you believe something other than what it shows, you should abandon that belief. The OHIE "did not find evidence that Medicaid coverage improved physical health," even though "the[] physical health measures were chosen explicitly because clinical trials have shown that they can respond to medication within this [study's] time frame."
They can't mean Medicare. As I detail elsewhere, Medicare has repeatedly shut down life‐ and cost‐​saving quality innovations. Medicare's price‐​control commission—officially, the Medicare Payment Advisory Commission, or MedPAC—has complained for decades that the program penalizes high‐​quality care and encourages low‐​quality care:
2003: "[Medicare] generally fails to financially reward higher‐​quality plans or providers. Medicare's beneficiaries and the nation's taxpayers cannot afford for the Medicare payment system to remain neutral towards quality. Change is urgently needed…[Medicare] is largely neutral or negative towards quality. All providers meeting basic requirements are paid the same regardless of the quality of service provided. At times providers are paid even more when quality is worse, such as when complications occur as the result of error."
2006: "Evidence shows beneficiaries do not always receive the care they need, that too often the care they do get is not of high quality, and that in some places where they receive more care there are also poor outcomes…Patient safety also continues to present a troubling picture."
2021: "There is also substantial use of low‐​value care…that has little or no clinical benefit or care in which the risk of harm from the service outweighs its potential benefit. We estimate that, in 2018, between 22 percent and 36 percent of beneficiaries in traditional FFS Medicare received at least one low‐​value service…Low-value care has the potential to harm patients by exposing them to risks of injury from inappropriate tests or procedures and can lead to a cascade of additional services."

They can't mean ObamaCare. Its supposed preexisting‐​conditions provisions are encouraging "poor coverage" for patients with costly illnesses, costing them thousands. As I report elsewhere:
Economic research provides evidence that these "protections" are forcing insurers to engage in such discrimination against patients with multiple sclerosis, infertility, substance abuse disorders, hemophilia, severe acne, nerve pain, and other conditions. Patient advocacy groups have alleged such discrimination against patients with cancer, cystic fibrosis, hepatitis, HIV, and other illnesses. Across all Obamacare plans, choice of doctors and hospitals has grown narrower, and drug coverage has gotten skimpier…
Indeed, this form of discrimination against preexisting conditions is arguably worse than the kind it (mostly) displaced. Unlike discrimination in pricing and enrollment, discrimination in plan design harms all consumers. It not only "undoes intended protections for preexisting conditions" but creates a marketplace where even "currently healthy consumers cannot be adequately insured." Patient‐​advocacy groups insist discrimination in plan design "completely undermines the goal of the ACA."

They can't mean short‐​term plans. The Congressional Budget Office (CBO) says short‐​term plans often "have lower deductibles or wider provider networks than plans in the [Obamacare] market." HHS is currently trying to reduce the quality of short‐​term plans by forcing insurers to cancel them after four months, leaving sick enrollees with no coverage for up to one year. The CBO estimates HHS's proposal would leave half a million U.S. residents with no health insurance at all.
"Affordable health care coverage"?
They can't mean Medicare. Despite the trillions HHS spends on Medicare, effective medical care is still unaffordable for many enrollees. As I report elsewhere:
11 percent of Medicare enrollees overall, 20 percent of enrollees "in fair or poor self‐​assessed health," and 23 percent of Black enrollees report "delaying getting medical care because of cost, needing medical care but not getting it because of cost, or problems paying or inability to pay any medical bills."

Medicare is so unaffordable, Congress has had to increase the Medicare tax 28 times since its inception. That's an average of one tax increase every two years.









Medicare won't require any more tax increases, though, right?
It still hasn't been enough to keep up with runaway Medicare spending. How do we know?
They can't mean Medicare or Medicaid. These two programs are almost solely responsible for the federal government's long‐​term debt problem. They are the only major category of federal spending consuming a rising share of GDP. Net interest on the federal debt is rising as a share of GDP because Medicare and Medicaid are growing.









Source: Congressional Budget Office
Most of that growth is Medicare. The CBO writes, "Spending on Medicare is projected to account for more than four‐​fifths of the increase in spending on the major health care programs over the next 30 years."









Source: Congressional Budget Office
They can't mean ObamaCare. ObamaCare plans are so expensive, Congress is subsidizing enrollees earning up to $600,000 per year. No, that's not a typo.
They can't mean short‐​term plans. The CBO says short‐​term plans provide lower deductibles and wider provider networks than ObamaCare at premiums "as much as 60 percent lower than premiums for the lowest‐​cost [ObamaCare] plan." HHS is trying to destroy quality, affordable health insurance and force people into low‐​quality, unaffordable health insurance.
"Provided the tools to fight Covid‐​19"?
They can't mean the FDA. For several months in 2020, the FDA blocked the use of safe, effective COVID-19 diagnostic tests. Epidemiologists called the move "insane."
They can't mean the CDC. When the FDA finally stopped blocking all COVID-19 diagnostic tests, it approved only one: the CDC's. The CDC promptly contaminated its test kits with the coronavirus, rendering disease containment efforts "useless."
Conclusion
When HHS boasts about its track record of quality and affordability, remember Colette Briggs.









Photo credit: Katherine Frey/​The Washington Post
Colette is a little girl with cancer. If HHS had just left her alone, she would have had affordable, secure health insurance coverage. Instead, we saw headlines like, "Parents of 4‑Year‐​Old with Cancer Can't Buy ACA Plan to Cover Her Hospital Care." Why?
The benevolent U.S. Department of Health and Human Services cancelled the Briggs family's health plan, forced them into an ObamaCare plan, increased their premiums, and pushed the providers Colette needed out of their ObamaCare plans. What happens inside the HHS building left Colette's well‐​to‐​do family desperate and scrambling to get a little girl with cancer the medical care she needed. The flaks who staged this live‐​tweet stunt should try explaining to Colette and her parents how HHS offers "quality, affordable health care coverage." I would be happy to arrange the meeting.
The outside of the HHS building is ugly, but not as ugly as what happens on the inside.

Gene Healy


Last week, the New York Times ran a front-page story admiring President Biden's political acumen on culture-war issues ("Biden Sidesteps Any Notion That He's a 'Flaming Woke Warrior'", NYT, July 4, 2023). You've got to hand it to him, apparently: Biden has "deftly avoided becoming enmeshed in battles over hotly contested social issues" like transgender rights. "At a moment when the American political parties are trading fierce fire," we're told, "the president is staying out of the fray."
The claim is pure malarkey. In fact, Biden has repeatedly engaged the full powers of the presidency in an attempt to impose a forced settlement on issues where the American people are deeply divided.
The analysis, by Times reporter Reid Epstein, is entirely style over substance. Being elderly and somewhat out of touch is the president's secret superpower on social issues, the argument goes. Biden is "white, male, 80 years old, and not particularly up-to-date on the language of the left"; Epstein writes; "the president has not adopted the terminology of progressive activists," and sometimes seems confused by it.
To be fair, it's tough even for non-octogenarians to stay abreast of the ever-proliferating jargon in this area. Last month, Biden's Secretary of State, Anthony Blinken, warned unsuspecting Americans of the perils of "biphobia" and "interphobia,"; and last week brought new "health equity" guidance from the Centers for Disease Control and Prevention (CDC) on "chestfeeding" infants. (Epstein got a little confused himself; the original version of the article included this perplexing sentence: "[Biden] also does not always remember the words most American politicians use to describe same-sex people.")
But even if, as the Times piece insists, "Mr. Biden has never presented as a left-wing culture warrior," what the president is actually doing with the weapons of executive power ought to count for something. For example:
the president's proposed Title IX edicts would give him the power to make national rules about which kid gets to use which bathroom and who gets to play on the girls' team for every K-12 public school and practically every college in America;
a rulemaking put forward by Biden's Department of Health and Human Services would require doctors and hospitals to provide "gender-affirming care"— puberty blockers, cross-sex hormones, and "top" and "bottom" sex-change surgeries—including for minor children. Private insurers—and the taxpayer, via Medicaid—will be required to foot the bill;
and in the president's June 2022 "Executive Order on Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals," he proposes sending the Federal Trade Commission (FTC) after doctors practicing "conversion therapy," which may be defined broadly enough to include psychologists who resist immediately forking over puberty blockers.
"Staying out of the fray"? C'mon, man.
Millions of Americans believe that medical intervention for trans-identifying minors is compassionate "gender-affirming care"; millions more believe it amounts to experimenting on children in the midst of social contagion. The state of the medical evidence here is "worryingly weak"; but even if it wasn't, the debate's not likely to be settled by telling people to shut up and "trust the science."
Biden's attempt to force a settlement on transgender issues points to a larger problem with "the deformation of our governmental structure" toward one-man rule. The original constitutional design required broad consensus for broad policy changes, but as law professors John O. McGinnis and Michael B. Rappaport warn in an important recent article, "Presidential Polarization":
"now the president can adopt such changes unilaterally…. Domestically, Congress's delegation of policy decisions to the executive branch allows the President's administration to create the most important regulations of our economic and social life. The result is relatively extreme regulations that can shift radically between administrations of different parties."

Florida Governor Ron DeSantis is running for president, and he has his own views on medical treatment for gender dysphoria: he says it amounts to making children "guinea pigs" and "mutilating them." If elected, he'll certainly take inspiration from Biden's FTC move—maybe he'll even encourage a few creative prosecutions under the federal Female Genital Mutilation law.
Alexander Hamilton supposed that "energy in the executive" would lead to "steady administration of the laws." In the service of presidential culture-warring, that energy can mean whipsawing between "compulsory" and "forbidden" in four to eight-year cycles, depending on which party manages to seize the White House.
Worse still, as McGinnis and Rappaport note:
The imperial administrative presidency also raises the stakes of any presidential election, making each side fear that the other will enjoy largely unchecked and substantial power in many areas of policy.

That fear encourages the dangerous sentiment that every election is a "Flight 93 Election": charge the cockpit, do or die. The relentless growth of federal power—and its concentration in the executive branch—has made our government a catalyst of social strife.
Having a president who actually stays out of the culture-war fray isn't just a worthy goal: under current conditions it may be essential to the "domestic Tranquility" our federal government is supposed to ensure. But unless we expect them to refrain out of the goodness of their hearts, we'll need structural reforms that limit their power to intervene.

My government does not believe that its purpose is to be re-elected. It is instead to improve the life and liberties of the people of this realm. Accordingly, it has set forth an agenda to achieve that. I commend these proposals to Parliament.1. We intend to achieve energy independence by authorizing the use of hydraulic fracturing to release the treasure-trove of natural gas under our land. We will compensate those locally affected with cash sums and reduced fuel bills if ever tremors above the raised allowable limits occur. 2. We intend to improve the NHS by establishing a link between the medical procedures its personnel perform and the pay they receive. Doctors will be paid for each consultation with a patient, with greater remuneration for appointments in person than for telephone consultations. Hospital staff will be paid for each procedure they perform. Patients will be free to choose which doctors and which hospitals they wish to be treated by, and the state's funds will be directed accordingly. We will use the tax system to encourage widespread use of additional private insurance.3. My government will empower and encourage local councils to purchase non-verdant land on the green belt, including non-verdant agricultural land, and give such land planning permission for housing. Those affected by the new developments will be offered financial compensation in addition to the improvement of local infrastructure and services. Current restrictions on the size of houses and the square footage inside them will be removed.4. State schools in England and Wales will be given their independence and freedom to determine their own budgets and their curricula. They will be required to teach a basic national curriculum in reading and writing skills, mathematics and the sciences.5. We will ensure that no foreign court shall have authority over the highest court in the UK. The UK will no longer be subject to the European Court of Justice or the European Court of Human Rights in any area.6. Recognizing that domestic tariffs are paid by UK consumers, my government will establish the principle of free trade wherever possible, and will seek to negotiate reciprocal free-trade agreements that encourage our trading partners also to recognize the principle of free trade.7. My government will establish a Council on Competitiveness. Its purpose will be to report the likely effect on UK competitiveness of any regulations and requirements that may be proposed or requested.8. My government will similarly establish a Council on Freedom. Its purpose will be to report the effect on personal liberties of any regulation that is proposed. It will examine in particular the effect of any attempts to direct the lifestyle of UK citizens.9. We will take steps to ensure the free speech prevails on our university and college campuses, and will withdraw state funding from any such institutions that do not act to uphold free speech.10. We will appoint a body to investigate the spread of non-elected quangos and will dissolve those that claim legislative and regulatory powers that more properly belong to this Parliament.

Should intellectual property laws upheld by the WTO be waived during a COVID-19 pandemic? I almost forgot to post this one, but it's better late than never, I guess. There have been endless allusions to the idea that, rich or poor, the countries of the world are all in this fight against COVID-19 together. However, when push comes to shove, it appears the reality of the matter is rather different: A few weeks ago, large developing countries put forth the idea at the WTO that intellectual property rights on COVID-19 medicines should be abrogated while a global pandemic is going on. Perhaps unsurprisingly if regrettably, European and American countries indicated not being willing to go along. Since a consensus would have been required for an IP waiver on COVID-19 medicines to come into effect at the WTO, this effort was admittedly a long shot from the start: Wealthy nations [...] reiterated their opposition to a proposal to
waive intellectual property rules for COVID-19 drugs, three trade
sources said, despite pressure to make an exception to improve access to
drugs for poorer countries. Supporters
of the waiver say existing intellectual property (IP) rules create
barriers on access to affordable medicines and vaccines and they want
restrictions to be eased, as they were during the AIDS epidemic.But
opposition from the European Union, the United States and some other
wealthy nations at a meeting on Friday, means the proposal set to go
before the World Trade Organization's (WTO) General Council next month
is likely to fail."If
rich countries prefer profits to life, they will kill it by tying it
down in technicalities." said a delegate supporting the motion who
attended the closed-door meeting. The 164-member WTO body usually has to agree by consensus unless members agree to proceed to a vote, which is exceptional. Populous developing countries India and later China pushed for lifting IP restrictions on COVID-19 medicines, although you have to wonder if they have competing commercial interests since they too have production capabilities in making these medicines should IP be waived. Then again, the current WTO head Ngozi Okonjo-Iweala (this article was written before she became its Director-General) also supported the initiative:The proposal
was first raised by India and South Africa in October. Since then,
China, which has five COVID-19 vaccine candidates in late-stage trials,
has voiced its support, as have dozens of other WTO members, mostly from
developing countries.The
World Health Organization says it supports tackling barriers to access
to COVID-19 medicines, as does Nigeria's Ngozi Okonjo-Iweala, selected
by a panel to be the WTO's next director-general.You have to wonder though if some developing countries might want to declare medical emergencies that compel them to waive such IP on COVID-19 medicines under "compulsory licensing" procedures allowed by the WTO:In 2001 — at the height of the AIDS crisis and under pressure from
governments whose citizens were dying because they could not afford
life-saving medicines — the World Trade Organization waded into the battle between intellectual property and public health. The resulting Doha Declaration ruled
that the Agreement on Trade-Related Aspects of Intellectual Property
Rights "should not prevent members from taking measures to protect
public health."It confirmed that governments retained several mechanisms for guaranteeing affordable access to medicines, including issuing compulsory licenses,
which allow them to use an invention without the patent holder's
consent in extraordinary circumstances. This applies not only to new
drugs but also to existing medications whose patents have been extended
because pharmaceutical companies made minor changes to formulations or
discovered a new use for the medication.Given the uncertainty
over access to treatments for COVID-19, several countries have been
laying the legislative groundwork to issue compulsory licenses for
products that patent holders refuse to make accessible.I think developing countries will first observe whether they can avail of more COVID-19 medicines they believe they need under the COVAX initiative. If that avenue proves unfruitful, then don't be surprised to see "compulsory licensing" claims start appearing. Make no mistake that our world remains riven by North-South divides even amidst a global pandemic. 

Vanessa Brown Calder


Late last year, Congress passed the Pregnant Workers Fairness Act (PWFA) as part of the sprawling 2023 Consolidated Appropriations Act. The PWFA requires that employers provide reasonable accommodation to pregnant workers, and in June, the Act went into effect.
Ensuring pregnant workers are accommodated appears a worthy goal, and Democrats and many Republicans supported the legislation. Nonetheless, there are some reasons to worry about the legislation's effects.
Pregnancy discrimination is already illegal due to the 1964 Pregnancy Discrimination Act, but the PWFA goes a step further and requires that employers provide accommodations to pregnant workers. In this way, PWFA is similar to the Americans with Disabilities Act (ADA).
The PWFA even uses the same "reasonable accommodation" definition as the ADA. Under this definition, reasonable accommodation requires employers and employees to engage in an "interactive process" to determine what constitutes an acceptable accommodation to the employee. It is subsequently unlawful for the employer to accept an alternative arrangement.
The similarity between the substance of the PWFA and ADA is significant because evidence suggests that the ADA's reasonable accommodation language has harmed, rather than helped, its target population. For example, research suggests that the ADA reduced the employment of disabled men and women, with one study estimating ADA reduced employment rates for men with disabilities by 7.2 percentage points.
Additional research finds further adverse effects on employment. One study finds that the passage of the ADA was "associated with lower relative earnings" and "slightly lower labor force participation rates" for people with disabilities, and more recent research finds that the ADA reduced the firing of disabled workers but also reduced disabled workers' ability to find a job.
What drove these unintended effects? One study indicates that the reasonable accommodation requirement in the ADA is particularly problematic and resulted in initial employment declines, with the requirement producing an estimated 10 percent decline in disabled employment in the years following its enactment. This is especially worrisome given PWFA includes the same reasonable accommodation requirement. Yet another study examining the ADA 20 years after its passage concluded that "unclear expectations on what constitutes appropriate accommodations for people with disabilities is likely having a chilling effect on the employment prospects of the disabled population… Reflecting an all too common irony in social policy, the ADA might be having the exact opposite effect of the intent of the legislation."
Despite ADA's initial effects, employment has been ticking up and unemployment has been ticking down for disabled workers in recent years. Unfortunately, that positive development is unlikely to have much to do with ADA, which is now more than thirty years past. Instead, improvements in the broader post‐​pandemic labor market recovery and the increasing availability of flexible or remote jobs are likely driving this effect. For example, remote jobs allow people with disabilities to avoid lengthy or inaccessible commutes, manage their work environment, and meet medication or other medical needs privately, among other advantages.
Ideally the PWFA will not result in adverse employment effects for pregnant workers, but evidence on the consequences of ADA suggest uncertainty. For pregnant workers, policies that support a strong labor market and permit flexible and remote work are a much better bet to increase opportunity and improve work life.