Health policy that is neither big nor beautiful

During my second and third years of residency (2002-2004), I periodically volunteered to see patients at a bare-bones clinic at a homeless shelter in Lancaster. We had limited amounts of donated supplies and medications and mostly treated acute problems. One evening, a patient with diabetes came in. He had been taking oral medications but could no longer afford them and was instead giving himself shots of insulin whenever he could afford a few vials. His hemoglobin A1c level was 15, meaning that he was walking around with an average blood sugar level of around 400 and was one mild illness away from a health catastrophe. I asked him to come see me in my faculty supervised clinic at the hospital and referred him to a social worker. Miraculously (in those pre-Affordable Care Act days, Medicaid eligibility was much less generous for single "able bodied" working adults without children), it turned out that he qualified for Medicaid. By the time I graduated, his diabetes, blood pressure, and cholesterol were well-controlled and he had saved enough money to move into his own apartment.

Like every major medical and hospital association in the United States, I lobbied against the budget reconciliation bill that squeaked through the House and Senate and that President Trump signed on July 4th. I send multiple e-mails to my representatives in Congress and encouraged others to do the same. The cuts to Medicaid and the USDA's Supplemental Nutrition Assistance Program (SNAP), totaling $1 trillion over the next several years, don't even come close to filling the $4.3 trillion budget hole created by extending tax cuts that overwhelmingly benefit people like Elon Musk, Jeff Bezos, and Trump himself.

When some health policy researchers got wind of the options being considered to reduce federal Medicaid spending, they published a timely analysis in the Annals of Internal Medicine that projected the impacts of various cuts on Medicaid enrollment and the uninsured. The bill then being considered by the House was estimated to reduce the number of people with Medicaid by more than 10 million and increase the number of uninsured persons by nearly 8 million (because some people would be able to obtain another form of insurance due to increased income or becoming eligible for workplace coverage).

These estimates were horrifying enough, but the Senate version of the bill - the one that President Trump signed on America's 249th birthday - cut even deeper. 11.8 million people are expected to become uninsured, and (outside of the bill, due to Congressional inaction) an additional 5 million will lose private marketplace coverage due to no longer being able to afford to pay the premiums.

Medicaid is just the tip of the iceberg. As a fellow Pennsylvania physician observed, Medicaid cuts will hurt all American children - not just those publicly insured, since pediatric hospitals and health systems rely heavily on Medicaid rather than the relatively more generous Medicare payments that fund adult health care. States will either try to stretch reduced Medicaid funds to cover the same number of people, lower payments to doctors and hospitals, or both. Hospitals will be forced to close, leading to mass layoffs and more people with few insurance options other than Medicaid. Similarly, SNAP cuts will hurt American farmers and grocery stores in underserved areas where people will have less to spend on food. The Commonwealth Fund estimates that by 2029, the bill's impacts will include 1.2 million jobs lost nationally, depressing collective state gross domestic products by $154 billion and state and local tax revenue by $12.2 billion.

By then, a new administration will have been inaugurated that will need to clean up one big, ugly mess that the federal government created.

AI: augmenting the intelligence of family physicians

In a recent editorial, Dr. Joel Selanikio discussed how 24/7 access to generative artificial intelligence (AI) tools such as ChatGPT empowers patients to retrieve health information and self-manage low-acuity conditions that would have previously involved visiting a clinician. By embracing the capabilities of AI to reduce administrative burdens and improve clinical outcomes, Dr. Selanikio argued that practices can demonstrate “the unique and irreplaceable value doctors bring to health care.” Another opinion envisioned the rise of “AI-augmented generalists” who integrate the knowledge base of subspecialists and use large language models (LLMs) as “active cognitive collaborators.” New competencies required for the AI era include “AI system proficiency,” “collaborative problem-solving,” and “contextual adaptation.” Recently published and ongoing research provides several real-world examples.

A 2025 Graham Center Policy One-Pager synthesized information from online peer forums and vendor websites to compare costs and pros and cons of commercially available AI scribes. A study funded by the Agency for Healthcare Research and Quality is interviewing primary care clinicians and patients to identify barriers and facilitators to successful adoption of ambient digital scribe technology and to develop a prototype implementation guide for diverse primary care settings.

In addition to office notes, LLMs can be used to generate hospital discharge summaries. A study from the University of California, San Francisco, evaluated the accuracy and quality of LLM-generated discharge summaries for 100 randomly selected inpatient stays of 3 to 6 days’ duration. A team of blinded reviewers that included hospitalists, primary care physicians, and skilled nursing facility (SNF) physicians rated LLM and physician-authored summaries on comprehensiveness, concision, coherence, and errors (inaccuracies, omissions, and hallucinations). Overall, LLM narratives contained more errors but were rated as more concise and coherent than physician-generated narratives. Of note, primary care and SNF physicians—the end-users of discharge summaries—had more favorable views of LLM narratives than did hospitalists.

AI is being evaluated for its potential to assist clinical decision-making. In a single-center study of virtual urgent care visits for respiratory, urinary, vaginal, eye, or dental symptoms, AI-generated recommendations agreed with physician recommendations in 57% of cases and were more likely to be rated as optimal:

Our observations suggest that AI showed particular strength in adhering to clinical guidelines, recommending appropriate laboratory and imaging tests, and recommending necessary in-person referrals. It outperformed physicians in avoiding unjustified empirical treatments. … Conversely, physicians excelled in adapting to evolving or inconsistent patient narratives, … [and] also seemed to demonstrate better judgment in avoiding unnecessary ED referrals.

However, the AI in this study reported that it had insufficient confidence to provide a recommendation in 21% of cases.

Finally, a randomized trial examined the diagnostic accuracy of 50 US-licensed physicians who responded to clinical questions about a standardized chest pain video vignette featuring either a White male or Black female patient before and after receiving input from ChatGPT-4. This study showed that physicians were willing to modify their initial decisions based on suggestions from ChatGPT and that these changes led to improved accuracy without introducing or exacerbating demographic biases (eg, being less likely to diagnose the Black female patient with acute coronary syndrome).

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This post first appeared on the AFP Community Blog.

On chronic disease prevention, RFK Jr.'s actions speak louder than words

Secretary of Health and Human Services Robert F. Kennedy, Jr.'s agenda, he says, is chronic disease prevention. He wants Americans to eat fewer ultra-processed foods; to decline long-established childhood vaccines against diseases like the measles, which we never see anymore; and to drink public water supplies without fluoride, apparently as a boon to the dental profession. HHS recently announced that it will spend $10-20 million on a "Take Back Your Health Campaign" that is intended to "alert Americans to the role of processed foods in fueling the diabetes epidemic and other chronic diseases, inspire people to take personal responsibility for their diets, and drive measurable improvements in diabetes prevention and national health outcomes."

Diabetes is a big problem. I'm all for preventing diabetes through healthier eating. But the longest-running longitudinal study of diabetes prevention, the Diabetes Prevention Program Outcomes study, was terminated in March when the Trump administration froze hundreds of millions of dollars in federal health grants to Columbia University, where the study coordinating center is located:

The lapse in funding means that the Diabetes Prevention Program Outcomes Study can no longer continue to collect patient data as planned; it can no longer pay staff to do blood work, collect urine samples, scan brains, or conduct neurocognitive tests. Even worse, the study’s existing data are at risk. Scientists need funds to properly store and retrieve samples; they need money to pay for computer servers and to hire statisticians and analysts, who clean and curate the data.

HHS has traditionally relied on panels of non-government experts to guide its work in prevention, and after the DOGE-driven cuts that resulted in the departure of 20 percent of its workforce, it needs outside help more than ever. For decades, five independent scientific advisory panels made evidence-based recommendations on clinical preventive services, community preventive services, newborn screening tests, infection prevention, and immunizations. Two of these panels have already been dissolved, and the remaining three are on life support.

I wrote a Medscape commentary about current threats to the U.S. Preventive Services Task Force (USPSTF), which include the hobbling and proposed elimination of its convening agency (AHRQ) and a lawsuit that the Supreme Court should decide any day now. The USPSTF's sister panel, the Community Preventive Services Task Force, which "evaluates evidence and recommends effective interventions to improve health in the community, home, school, work, and health care settings," hasn't been convened at all this year.

The Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC), which since 2003 had been making evidence-based recommendations about a list of conditions for which every newborn should be screened, was disbanded by HHS in April for no particular reason. As a result, states have been left on their own to evaluate new screening tests:

Each year, newborn screening identifies about 14,000 infants with serious conditions that benefit from early intervention. Early detection can prevent death or irreversible harm in disorders like metabolic diseases, immune deficiencies, and muscular atrophies. Eliminating the ACHDNC creates a dangerous vacuum in the nation’s newborn screening system, stalling progress on adding life-saving tests to the RUSP and increasing the risk that diagnoses will be delayed or missed for some babies—with potentially tragic results.

The same fate befell the Healthcare Infection Control Practices Advisory Committee (HICPAC), which was created in 1991 to advise the Centers for Disease Control and Prevention (CDC) on critical infection prevention and control practices. Over the past three-plus decades, HICPAC "advised and worked with the CDC to develop clinical guidelines, training resources, and expert guidance that were subsequently widely used throughout health care settings." Chronic diseases that can be prevented by reducing the risk of transmission in health care include HIV, hepatitis B and C, tuberculosis, and long COVID. HICPAC was dissolved by HHS at the end of March.

Finally, there is the Advisory Committee on Immunization Practices (ACIP), which RFK Jr. first bypassed by making unilateral changes to the COVID-19 vaccine recommendations for children and pregnant women, then remade by firing the entire committee and replacing them with a group that includes a physician who proudly identifies as an anti-vaxxer. This morning, 6 former chairs of the ACIP wrote an Op Ed in STAT that warns about millions of Americans losing access to safe, effective vaccines and the ability to develop new ones in response to future infectious threats:

Without transparent, evidence-based processes, vaccines may become inaccessible, unaffordable, or unavailable. Public trust will erode, innovation will stall, and lives will be lost unnecessarily. The systematic unraveling of our vaccine infrastructure endangers our freedom to protect ourselves and our communities. We urge congressional leaders to reflect on how these fragmented decisions collectively dismantle our ability to prevent disease and save lives.

Public health advocates frequently bemoan political obstacles to investing in evidence-based initiatives aimed at preventing chronic diseases. Today we have an HHS Secretary who is clearly interested in chronic disease prevention, but equally uninterested in evidence or established mechanisms for translating evidence into policy. As a former ACIP member recently told STAT, the message is clear: "Scientific expertise is no longer of use" unless it happens to align with what RFK Jr. already believes to be true. His terrible actions speak louder than words.

Pathways to primary care for underserved communities

Several past colleagues in the family medicine department at Georgetown recently published an informative scoping review of specialty disrespect in the medical learning environment. As they point out, specialty disrespect (also known as bad-mouthing) is common, based on "stereotypes, biases, and perceived specialty hierarchies," and play a significant, but not dominant, role in specialty choice. Although I don't recall experiencing overt disrespect when I told residents and attendings at my subspecialist-oriented medical school that I planned to practice primary care, unspoken assumptions about what I'd need to know as a family doctor sometimes led to my being assigned to patients with less challenging medical problems or greater social needs. Most family physicians have at some point heard the old saw "jack of all trades, master of none," which I have come to view as less insulting than is usually intended. (Wouldn't most people prefer to hire a single handyman to make several miscellaneous home repairs rather than a bunch of specialists in each area?)

A research study in Health Affairs charts "physicians' trajectories from medical school graduation through postgraduate training into primary care specialties" for MD, DO, and international medical graduates from 2001-15. The authors term "primary care yield" as the percentage of physicians who start training in primary care and complete it in primary care. So, a family physician who does a geriatric fellowship would count as positive primary care yield, while a physician who starts training in internal medicine and ends up a gastroenterologist would not. Unsurprisingly, they find that 97% of physicians who enter family medicine residency programs become primary care physicians, while the corresponding figures for internal medicine and pediatrics are 35.5% and 54.4%. Schools with primary care pathway programs that send a majority of students into non-family medicine residencies may not be creating future primary care physicians.

It's well documented that schools that are ranked highly by U.S. News & World Report produce a lot of subspecialists, while schools ranked highly by social mission graduate relatively more primary care physicians. A research letter in JAMA Network Open reported that in 2015 and 2020, graduates of U.S. News's top 20 medical schools were less than half as likely to be practicing in socioeconomically deprived areas compared to other medical graduates, and among physicians, family and emergency medicine were the most likely to practice in these areas. 

At the residency level, federal investments in rural and federally qualified health center (FQHC)-based programs have resulted in significant training expansions in underserved settings. Another Health Affairs study documented that the percentages of residency programs with rural and FQHC training sites rose from 6.2% and 3.6%, respectively, in 2008-09 to 14.3% and 11.2% in 2023-24. Training health professionals in FQHCs is essential to staffing those FQHCs and improving community health in the future; when community health centers close, county-level mortality increases, as illustrated in another study. Of note, the Trump administration's HHS reorganization plan and the "one big, beautiful bill" passed by the House of Representatives would eliminate the agency that funds, and most of the funding for, these training programs.

Health professionals speak out against the new nuclear arms race

During the Cold War, the United States and the former Soviet Union amassed nuclear weapon stockpiles with a collective destructive power hundreds of thousands of times that of the two bombs that obliterated the Japanese cities of Hiroshima and Nagasaki in August 1945. After peaking at more than 70,000 in 1986, the absolute number of weapons gradually declined from the implementation of various arms control treaties to 12,331 today. However, as stated plainly in a recent editorial published in more than 120 medical journals worldwide, “This does not mean humanity is any safer.” The authors urged readers to make the elimination of nuclear weapons an urgent public health priority, reiterating a 2023 editorial on similar themes:

Any use of nuclear weapons would be catastrophic for humanity. Even a “limited” nuclear war involving only 250 of the 13,000 nuclear weapons in the world could kill 120 million people outright and cause global climate disruption leading to a nuclear famine, putting 2 billion people at risk. A large-scale nuclear war between the US and Russia could kill 200 million people or more in the near term, and potentially cause a global “nuclear winter” that could kill 5 to 6 billion people, threatening the survival of humanity.

The last of the nuclear arms accords, the New START treaty between the United States and the Russian Federation, is set to expire in 2026. Both countries are spending enormous amounts to modernize their existing arsenals. A 2024 editorial in Science, noting rising tensions between the United States and Russia, China, and North Korea, observed that “the risk of nuclear war has not been so high since the Cuban Missile Crisis.” The historical events depicted in the Academy Award–winning film Oppenheimer are no longer just history; at New Mexico’s Los Alamos National Laboratory, for the first time in decades, the United States has resumed building plutonium cores. Despite safety precautions, factory workers and bystanders will be at high risk of radiation exposure and subsequent cancer, lung, and kidney problems.

The world is woefully unprepared for the health consequences of the use of a single nuclear device, much less a nuclear war. In 2024, the New York City Department of Health held a series of workshops on hospital emergency responses to an improvised nuclear detonation by a nonstate terrorist actor. Health professionals who survive a nuclear explosion (90% of those in Hiroshima were killed instantly) would likely face a catastrophic loss of communications, impassable transportation routes, and “risk their lives amid destroyed infrastructure, dangerous radioactivity, and limited healthcare facilities and supplies.”

At last month’s World Health Assembly, the World Health Organization (WHO) overwhelmingly passed a resolution to update Cold War era reports on the health and environmental effects of nuclear weapons and war by 2029. (The United States was absent, having withdrawn from the WHO in January.) Doctors have been at the forefront of campaigns against nuclear weapons since 1961, when Physicians for Social Responsibility was founded. The organization, which later expanded its list of “gravest threats to health and survival” to include excessive military spending, fossil fuels, and climate change, provides education on the health effects of nuclear testing and reality checks on government messages (eg, duck and cover) that suggest that nuclear war could be survivable. A current exhibit at Harvard University’s Countway Library highlights the social activism of former medical school and public health faculty.

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This post first appeared on the AFP Community Blog.

Lung cancer screening in primary care: more pragmatic research needed

The US Preventive Services Task Force, the American Academy of Family Physicians, and the American College of Chest Physicians recommend annual low-dose computed tomography (CT) screening for adults 50 to 80 years of age who have at least a 20 pack-year smoking history and currently smoke or have smoked within the past 15 years. A 2020 meta-analysis of eight randomized controlled trials (summarized in a POEM in American Family Physician) concluded that low-dose CT screening prevents one lung cancer death for every 250 people screened. A 2023 Cochrane for Clinicians article found similar benefits but also noted that for every 10,000 people screened, 363 unnecessary invasive tests are performed. Despite private and public insurance plans fully covering lung cancer screening in the United States, only 10% to 30% of eligible individuals in were receiving it in a recent state-by-state survey.

Barriers to implementing findings from lung cancer screening trials into typical clinical practice include the nonrepresentative nature of research participants (younger, healthier, and less racially and geographically diverse than the target populations) and the superior infrastructure and clinical support available to them. Although an analysis of the National Lung Screening Trial suggested that the eligible people in the United States would experience similar benefits as trial participants, questions about the generalizability of other studies remain.

In a research paper in the January/February 2025 issue of the Journal of the American Board of Family Medicine, Dr. Erin Hirsch and colleagues rated lung cancer screening trials and the nonrandomized Veterans Health Administration Demonstration Project with an established tool that evaluated each study through a primary care lens. Domains included eligibility, recruitment, setting, organization, flexibility of delivery, flexibility of adherence, follow-up, primary outcome, and primary analysis. The investigators scored studies on a 5-point scale, with 1 being completely explanatory and 5 being completely pragmatic. The mean study scores ranged from 2.12 to 3.33, indicating that even the most pragmatic studies fell well short of simulating conditions in community settings.

A lack of pragmatic research may explain why interventions intended to increase lung cancer screening rates have had mostly disappointing results. A systematic review and meta-analysis of intervention studies identified five randomized controlled trials and one prospective observational study. Interventions included patient navigation, outreach calls, and decision aids; control groups received usual care or informational materials. Only two of the studies found statistically significant increases in participation in the intervention group, and a meta-analysis found no difference overall (relative risk = 1.30; 95% CI, 0.74-2.29). A subgroup analysis suggested that multistep interventions targeting multiple barriers may be more effective than single-step ones.

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This post first appeared on the AFP Community Blog.