“Meet the old boss, same as the new boss.”

– We Won’t Get Fooled Again, Pete Townshend, Performed by the Who, 1971

With the elections over and the cabinet filling out, the house of medicine is sounding the alarm on the president-elect’s picks for Secretary of Health and Human Services, FDA, Surgeon General, and head of CMS.  The brokenness of the current healthcare system as of this moment has never been more obvious.  Health care costs are skyrocketing, insurance premiums have been raised aggressively, and doctors are still in the crosshairs of cost-cutting measures.  Physicians are slowly opening their eyes to the potential of their agency and simultaneously how much territory we have ceded. 

Many people are saying it was a landslide victory for the former president, and in some ways it was.  While garnering just over 2 million more votes than his opponent, his electoral vote count was significant. And that is our system. 

The Affordable Care Act as legislation has not achieved its goals.  Part of this was likely lack of transparency and foresight in the way insurers operate and the other part was asymmetric enforcement of regulatory structures.  Many opponents of the ACA rightfully place the blame on lawmakers and regulatory agencies.  We have seen almost a half dozen instances where insurers bilked the public and the government out of billions of dollars and the cases are settled for a pittance or dismissed outright.  The spend on healthcare has gone up, even while doctors’ reimbursements have been cut.  The great paradox espoused by healthcare policy wonks and their masters, the insurance cartel, which stated that the reason healthcare was too expensive was doctors made too much money.  Since this has been proven to be false, physicians have called for accountability.  None has come.  Some in the medical policy world have called for the dissolution of the Act. 

The remove and not replace plan which to some might serve as an “I told you so” moment for the Obama Administration.  One of the unintended effects will likely be thousands, maybe a few million people being kicked off their insurance plans under the exchange with no replacement plan as the insurers sunset them immediately.  Plan prices might increase as there is now no longer medical loss ratio to contend with.  Lastly, the numbers of people pushed into under-funded, under-reimbursing Medi-Cal plans and the swelling of ERs with uninsured patients would certainly be a potential scenario. 

The other concern many have voiced is the picks for healthcare administration.  The current nominees for the top jobs in American Medicine have caused quite a lot of consternation in the medical community.  The American Association of Pediatrics has preemptively put out statements (https://www.aap.org/en/patient-care/immunizations/vaccination-recommendations-by-the-aap/#:~:text=The%20American%20Academy%20of%20Pediatrics,preventing%20disease%2C%20disability%20and%20death)  about the efficacy of vaccinations in anticipation of Mr. Kennedy’s confirmation as head of the Department of Health and Human Services.  Mr. Kennedy has trafficked in statements about vaccinations causing autism, blaming it on Thimerosal.  He joined the board Children’s Health Defense, a 501(c)(3) group, in 2015.  The group opposed children’s vaccinations, the fluoridation of drinking water, and traffics in misinformation.  As an example, a pamphlet from their site seems to link childhood asthma, ADHD, allergies, and a legion of other illnesses to routine vaccinations .  3 large retrospective trials clearly refute the link with asthma (https://www.chop.edu/vaccine-education-center/vaccine-safety/vaccines-and-other-conditions/asthma-allergies). The causation of vaccines and autism has been widely debunked.  Mr. Kennedy, who resides in Los Angeles, is currently on leave from the board.

Dr. Mehmet Oz, who was dismissed from Columbia University’s faculty in 2022, has been nominated for head of CMS.  He was a practicing cardiothoracic surgeon who became famous after being touted by Oprah Winfrey on her show.  He obtained his own television show, and began to tout products as cures for a multitude of illnesses.  As early as 2015, calls were made for him to resign from the faculty of Columbia.  He also spoke extensively on hydroxychloroquine as a COVID cure, (https://www.nytimes.com/2021/12/26/us/politics/dr-oz-medical-advice.html) after extensive evidence showed it did not work in vivo, and along with many others who seemed to benefit directly or indirectly from hydroxychloroquine sales, did not talk about the risk of the fatal heart arrhythmia, torsade de pointes that can cause sudden cardiac death.  He unsuccessfully ran for senate of Pennsylvania, losing by a margin of about 5%.  Dr. Oz is a notable proponent for Medicare Advantage plans, that have been shown to be extraordinarily wasteful, and involved in illegal upcoding, and making United Healthcare one of the most profitable companies in the history of medical insurance.  To the doubting eye, this seems the opposite of making healthcare more transparent and valuable,

Dr. Marty Makary, a Johns Hopkins surgeon, was recently tapped to head the FDA.  Dr. Makary is a transplant surgeon and has served at the WHO Patient Safety program, served in the National Academy of Medicine, and is an adviser to the Paragon Health Institute.  He notably claimed the US population would reach herd immunity from COVID-19 by April 2021 (https://www.wsj.com/articles/well-have-herd-immunity-by-april-11613669731).  He also made controversial claims about myocarditis and COVID vaccinations in children.  He developed the surgical checklist that was later taken up by Dr. Atul Gawande and turned into a book.  Dr. Makary is also on the board of a weight-loss compounding company, Sesame (https://sesamecare.com/team?srsltid=AfmBOoqvQITnTfB1dSKCwfPQczn3GoLuWMdUZkOTlfmxxraW1q99HlKX). 

The reality of these people is that it is very likely they will be in these positions of power.  Their advice to the president-elect could shape health policy for decades to come.  For bad or for good, physicians will need to contend with whatever happens.  It is important that doctors preserve knowledge and remain strong in their opposition to bad science.  It is also important to listen to our patients if they come to us with bad or dangerous information, even that put out by large institutions like the FDA.  Using common sense, providing accurate information, and remaining a trusted source is all one can do.  My hope is that more than century of efficacy of virology, microbiology, immunology, pharmacology, and neurophysiology are not chucked in the name of “just asking questions.”

A common technique used by anti-establishment forces is asking Socratic dialogue questions.  For instance, during the peaking of COVID, a Facebook friend of mine, a lawyer, as trying to argue bleach was an antibiotic.  I patiently discussed with her that antiseptics are toxic to ALL organisms, not just bacteria.  She doubled down, of course, and again, without dropping the “I am a doctor” flex, stated it was not, because antibiotics are designed to be given into a human being whereas bleach, if given to a human, is a poison, the exact opposite of the intended effect of an antibiotic.  Here “what is an antibiotic” was the germane question. 

Another aspect of the questions that we may be asked are: “who are we to decide xxx is a good treatment?” or “is it out place to put xxx policy in place?”  The answer to that is, we are experts in our respective fields and are qualified to try to do our best in the interest of public health.  We are physicians who have taken an oath to do our best and it is incumbent upon us to treat our patients as if they were our family. We debate, we discuss, we fight.  However, we reach a point where it becomes clear

It is important to us, as stewards of healthcare, to impart knowledge, protect public health, and not facilitate dangerous information.  There will always be those, even among us who will ask “who determines what is dangerous information.”  And I think it is incumbent upon us to answer the question with a question (as is the custom of my people): would you advise your children, your parents the same thing?  Frequently the response will be to defer, distract, or even accuse.  And while the dialogue can devolve, it is important to stay focused.  There will be a moment, as with any interactions these days, when it is important to disengage.  There is a point where as physicians, we will have to let things take their course.

In the social media sphere, we have seen a significant exodus of healthcare professionals to alternative sites to the Musk-run X.  Sites such as Linked-In, Facebook, BlueSky, and Mastodon have become a welcome alternative. There medical groups have already formed sharing data, studies, and concerns about public health and the house of medicine.  Some notable controversial personalities in medicine have attempted to make inroads and, for better or worse, have been shunned, or blocked.  No alternative is perfect, but certainly we all seems to have our respective soapboxes.

In truth, none of us can control or contest what happens next.  All we can do is to keep doing our job, even against those who “are just asking questions” and may not have our patients’ (or our) best interests in mind.  We need to can the outrage and get to work.  If the incoming administration fixes things, kudos.  If they can create an actual free market with real competition with no one behind the scenes pulling the strings to profit, I am all for it.  

And if the system does implode, and once unheard-of outbreaks happen, rates of myocarditis and bran abscesses from dental infections, and children born affected by TORCHes organisms, then the same folks who espoused the views should wear the shame and accountability as equally as they would have worn the victory medal. 

We will see what happens and if the adults in the room will prevail, whoever they may be.