Upcoming article on mental health disorders during the Civil War

 

State and federal support for primary care: meaningful but insufficient

For a clear-eyed view of the U.S. health system factors that have collectively conspired to cripple primary care, the five-part New England Journal of Medicine series "The Primary Care Puzzle" by cardiologist and medical reporter Dr. Lisa Rosenbaum is a worthwhile read. Although I would usually frown on a subspecialist writing a pessimistic view of the problems in my field of medicine (family medicine comprising the majority of primary care in Lancaster and elsewhere), Rosenbaum has interviewed all of the key informants and gets most of the story right.

Since it has become clear that primary care is a common good, like law enforcement and public libraries, it's fair to ask what state and federal governments have been doing to support high-quality primary care. A systematic review in JAMA Health Forum discussed 5 federally-supported programs in primary care "transformation" from 2011 to 2021: 4 demonstration projects in paying primary care practices prospectively and EvidenceNOW Advancing Heart Health, which focused on improving cardiovascular outcomes. The numbers of participating practices ranged from 500 to nearly 3000. None of these programs was a failure or an unqualified success (improving health outcomes, the patient and clinician experience, or saving the system money).

The Trump administration has shown little interest in supporting primary care beyond allowing persons to use health savings accounts to pay membership fees to direct primary care practices. This change will help some access primary care, but huge funding cuts to Medicaid and premium subsidies for health insurance marketplace plans will result in millions more losing access to their doctors. (Further damaging to primary care are the hostile takeover and suspension of activities of the Advisory Committee on Immunization Practices and the U.S. Preventive Services Task Force, respectively.)

States have taken different approaches to better resource primary care. Oregon, Delaware, Colorado, and California recently passed legislation aiming to gradually increase the proportion of all health care spending on primary care from 5-7% to 11.5% to 15% over the next decade. Delaware and Rhode Island have combined primary care spending targets with caps on overall health care spending increases.

In September, the Milbank Memorial Fund published a policy menu for states looking to strengthen primary care, organized by 5 priority areas and spotlighting examples of policy actions taken by states that are diverse geographically and ideologically:

1. Make and Keep Primary Care a Top Policy Priority

2. Pay Primary Care More and Differently

3. Make It Easier for People to Access Their Primary Care Clinician

4. Expand and Support and Current and Future Primary Care Workforce

5. Build Provider Capacity to Provide Patient-Centered, Whole-Person Care

These initiatives are a good start, but they are not nearly enough to close the gap between the inadequate primary care workforce we have and the one we need to make the lagging U.S. competitive internationally in health care spending and outcomes.

Hepatitis B vaccine birth dose protects infants against lifelong health consequences

Since 2018, the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) have recommended universal hepatitis B vaccination of medically stable newborns weighing at least 2,000 grams within 24 hours of birth. After the unprecedented wholesale dismissal and replacement of the ACIP membership in June 2025, the American Academy of Pediatrics posted a fact sheet on its website emphasizing the significance of the hepatitis B vaccine birth dose and infant series in preventing acquisition of chronic infection. Although the U.S. Preventive Services Task Force recommends screening for hepatitis B virus at the first prenatal visit, a recent study found that more than 1 in 7 pregnant patients are never tested; some women do not receive any prenatal care or become infected later in pregnancy.

Perinatal hepatitis B infection has lifelong health consequences; 90% of infected infants develop chronic hepatitis B, and 15% to 25% of those die from cirrhosis or liver cancer in adulthood. In addition to being vertically transmitted from infected mothers, hepatitis B virus can also be passed on to infants through incidental contact with blood or body fluids of infected household members. The birth dose thus functions as a safety net for thousands of children who, before 1990, were being overlooked by risk factor–based vaccination strategies. Since its implementation in the United States, the birth dose has not only been associated with higher completion rates for the full hepatitis B vaccine series but also higher odds of receiving all recommended vaccines by age 19 months. A study of birth dose use in Washington, DC, found that vaccine refusals declined from 12.1% in 2017 to 4.1% in 2020 and remained below 4% in 2021 and 2022.

Nonetheless, when the reconstituted ACIP met in September 2025, it came close to voting to delay the first dose of hepatitis B vaccine to 1 month of age in infants born to hepatitis B surface antigen-negative mothers. This occurred despite the presentation of a systematic review by CDC staff that found no increased risk of any serious safety outcome when the vaccine was administered within 24 hours of birth. As highlighted in an in-depth analysis of the meeting by former ACIP members, the new committee repeatedly ignored its established processes for evaluating evidence and deliberating recommendations. Family physicians and former ACIP workgroup members Doug Campos-Outcalt and Jonathan Temte observed in a JAMA Viewpoint: “The evidence-based processes used by the ACIP were adopted to prevent exactly what happened at the first 2 meetings this year: presentation of anecdotes, selective quoting of single studies, and a lack of in-depth evaluation of some of the evidence presented.”

Ultimately, the ACIP deferred its vote on hepatitis B vaccine, preserving access to the birth dose for now. But in October, nearly all of the CDC staff that provided logistical support and subject-matter expertise to the ACIP was laid off, imperiling production of the 2026 vaccine schedules and making future departures from evidence-based recommendations more likely.

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This post first appeared on the AFP Community Blog. The Vaccine Integrity Project has announced that it plans to perform an independent review of data on the efficacy and safety of hepatitis B vaccine at birth.

Flood preparation, prevention, and an epidemic of short-term thinking

On July 4th, a flash flood in Kerr County, Texas killed 27 young girls and counselors at Camp Mystic, a Christian girls' summer camp whose staff alumni included former first lady Laura Bush. The campers and more than one hundred other local residents who also perished in the flood reacted too late, or not at all, to the National Weather Service's flash flood warning and emergency text alerts issued at 1:14 and 4:30 A.M., respectively. According to an article in the New Yorker, "many people simply ignored the warnings, or had their phones silenced or turned off." The article mentioned that after a flood in 2015 that killed 13 people, Kerr County officials decided against installing a $1 million siren system that would have warned upriver towns when a flood was coming.

In Vermont, which also experienced devastating flash floods in 2023 and 2024, the political response was different. In order to reduce the risk of recurrent floods, legislators passed a Flood Safety Act that gave the state broad jurisdiction over all of its waterways:

Beginning in 2028, when the new regulations take effect, Vermont’s rivers will be managed not as channels but as “corridors,” which will comprise all the land within the river’s natural meander pattern, plus fifty feet of riparian borders on both banks. The river will have the freedom to move and reconnect to floodplains. Riverside property owners will no longer have the automatic right to armor banks; in some cases they must allow the river to meander, even if that means it meanders through their land.

What does preventing and preparing (or not) for flash floods have to do with health care? Our federal government is trapped in cycles of short-term thinking. Even before the current shutdown, it had been nearly 30 years since Congress last passed the dozen annual appropriations bills that collectively constitute the federal budget prior to the October 1 start of the fiscal year. Most of the time, it passes "continuing resolutions" (CRs) that maintain spending at current levels and kick the can a few months down the road. (H.R. 1, aka the "One Big Beautiful Bill Act," which in large part precipitated the current legislative standoff, was an omnibus bill that also bypassed the normal budget process.)

Without action, the enhanced health insurance marketplace premium tax credits that Congress initially passed in 2021 and extended in 2022 will expire on December 31. Not only will the rollback of the tax credits place additional burdens on working class people and jeopardize small businesses, it is projected to lead to 340,000 jobs lost in 2026, the majority in states that voted for President Trump in the 2024 election. Trump may not care, since they can't vote for him again in 2028, but the Republican Party should, and their myopia will likely result in lost seats in next year's midterm elections.

The Department of Health and Human Services has ceased planning for long term health threats. Layoffs have decimated key staff at the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ), two organizations that are essential to carrying out any coherent strategy to address the epidemic of chronic diseases. The U.S.'s exit from the World Health Organization means that the CDC has been receiving far fewer samples of circulating influenza viruses that are essential to selecting strains for next year's flu vaccine. The U.S. Preventive Services Task Force, which AHRQ last convened in March, had its second meeting in a row canceled. HHS officials are publicly blaming the shutdown, but the government was open when the previous meeting was canceled in July (no explanation was ever given).

It's plausible that the Trump administration and its health officials are of the mindset that the COVID-19 pandemic was a once-in-a-century event, like the "superstorm" that inundated a large swath of lower Manhattan in 2012. But a better analogy than hurricanes is the periodic flash floods in Kerr County and neighboring Kendall County that have given their collective valley the moniker "Flash Flood Alley." Due to an epidemic of short-term thinking, a flash flood of preventable disease and deaths is barreling right toward us, with phones silenced, no early warning siren, and no way to evacuate to higher ground.