GENERAL MEDICAL LITERATURE
We in this section offer commentaries on a broad survey of recent articles. These articles are mostly chosen for two reasons: their potential translational value for immediate clinical practice or to help in determining where clinical practice might evolve to. Today’s subjects are of general medical interest.
The private health insurance market continues to lack competition
An article in Medscape Medical News under the section "Business of Medicine" recently reviewed the status of competition in the private health insurance market in the country, reaching somewhat contradictory conclusions (1). On the one hand, government data clearly demonstrate declining competition among insurers since 2011; but the data also show that this trend appears to have slowed, and in some states, it may even have reversed.
At the same time, the American Medical Association (AMA) considers a large majority of insurance markets to have remained stubbornly concentrated, with mergers further lessening competition. Especially in major metro areas, concentrations are very significant: In 47% of major metro areas, one single insurer dominates at least half of the market. Medicare Advantage markets were highly concentrated in 97% of metro areas.
Not to be forgotten—though not addressed in the article—concentration of economic power is observed not only in the insurance market. Provider functions are also increasingly concentrated through mergers of healthcare systems and the purchase of physician practices by these healthcare systems. Neither is, of course, good for physicians, and therefore, nobody can be surprised that private practice medicine, which used to be the backbone of U.S. healthcare, is quickly disappearing.
With physicians having mostly lost even the little influence they once had within hospitals and in determining fees in the insurance market, the new antagonists are the large regional healthcare systems and the major insurance providers in their geographic region. Mutual dependency has so far mostly kept the peace, but sooner or later, the core conflict between these two behemoths—the pricing of services—will reach a crisis point. With expected decreases in Medicare, Medicaid, and other federal government reimbursements for medical services, as recently suggested in The New York Times (2), one can expect these clashes to be around the corner, because healthcare systems have been subsidizing government-paid healthcare for decades through higher payments from private insurance. And they—understandably—have started to object!
References
1. Dotinga R. Medscape Medical News. https://www.medscape.com/viewarticle/competition-remains-elusive-private-insurance-market-2025a10001tn?form=fpf
2. The New York Times. Anti-Poverty Programs. January 31, 2025; pA13
And Private equity in healthcare continues to get attacked
In The Reproductive Times, a steady subject, we never tire of reading “bad stuff” about private equity in all of healthcare. A recent article in The Wall Street Journal, therefore, unsurprisingly attracted our attention when it described a recent bipartisan Senate report as “blasting” the role of private equity in healthcare (1). The report, indeed, went so far as to state that these kinds of investments are putting the entire U.S. medical system at risk.
Our antipathy toward private equity, of course, largely stems from its heavy involvement in the infertility field; but that is a separate subject, to be addressed elsewhere.
Reference
1. Cumming C. The Wall Street Journal. January 8, 2025. https://www.wsj.com/articles/senate-report-blasts-private-equitys-role-in-healthcare-b77d711f
Have you heard about William Ackman?
William Ackman, MBA and wife Neri Oxman, PhD
If you don’t know who William Albert Ackman, MBA (Harvard), is yet, you are clearly in a small minority because, especially since the October 7 events, he has become very visible beyond the business community, where he was already well-known. He is an American billionaire hedge fund manager who is the founder and chief executive officer of Pershing Square Capital Management, a hedge fund management company. He is married to Neri Oxman, PhD, who was a professor at MIT and now owns her own company. The couple also heads a private research foundation through which they donate millions for medical and basic science research.
Though we have mentioned Ackman before in The Reproductive Times regarding his activism against university and college administrations for not doing enough to fight antisemitism on campuses after October 7 (Ackman was especially outspoken about what happened in those early days at his alma mater, Harvard), none of these issues are why we are bringing him up here. The reason for this short commentary is his announcement that he would like to merge his company, Pershing Square, with Howard Hughes Holdings in a move that would transform the company, which is principally a real estate firm, into another modern-day Berkshire Hathaway, as an article in CoStar News recently reported (1).
And why does this have relevance to medicine? Because this company controls the Howard Hughes Medical Institute (HHMI), one of the leading science philanthropies in the world with the mission of advancing basic biomedical research and science education for the benefit of humanity (2). In other words, should this merger go through, Bill Ackman, who already heads a major medical and science philanthropy, may—along with HHMI—become a philanthropic powerhouse comparable in size to the NIH, and with it, one of the nation’s most important scientific voices. And just as an aside, Ackman, in a very interesting recent interview, publicly announced his availability for public office, should the country call.
References
1. Carlisle C. CoStar News. January 13, 2025. https://www.costar.com/article/1369487906/bill-ackman-seeks-to-transform-howard-hughes-holdings-into-modern-day-berkshire-hathaway
2. https://hhmi-curt.cornell.edu/about/howard-hughes-medical-institute/
More on gender transition treatments
Now that President Trump has signed an executive order restricting gender-affirming treatments for minors, U.S. hospitals have been suspending what The Guardian calls “healthcare for transgender youth” (1). But that is, of course, not what the executive order said: The order very clearly does not suspend healthcare for transgender youth; it only suspends gender transition treatments for minors and individuals up to age 19 under the threat of withholding federal funding for hospitals providing such gender-affirming care.
But this imprecision in choosing words in the headline of an article is, of course, not accidental, because a rather astonishing portion of legacy media outlets in the U.S. still appear to support gender transition treatments for minors. Other headlines document this fact: “Things to know about how Trump’s policies target transgender people” was, for example, a headline from NBC News based on a release the Associated Press sent out on February 3 (2). And PBS, of course, already two days earlier shared this opinion, following another Associated Press article by Geoff Mulvihill with the headline, “6 ways Trump’s executive orders are targeting transgender people” (3).
And this is, of course, astonishing—as we have extensively documented here in The Reproductive Times—especially following the Cass Review document in the UK, which, for all practical purposes, ended these treatments across Europe. Among very few news outlets, with The Free Press leading the charge in the U.S., only the similarly minded, recently reborn New York Sun pointed out the hypocrisy prevailing in the U.S. press and the U.S. medical community (in contrast to most European colleagues) in maintaining the orthodoxy that such treatments are safe and effective for gender-distressed minors. They, of course, aren’t, and to say otherwise is truly shameful, especially when the argument comes from the medical community. An article in The New York Sun recently pointed out that prominent U.S. professional societies, such as the American Academy of Pediatrics and the American Medical Association, have indeed aggressively supported such treatments in the past and—falsely—described them as effective and even lifesaving in preventing suicides (4).
And, remarkably, the medical and legal establishment in the U.S. continues to, to a significant degree, line up in defense of continued medical practice that allows gender transition treatments for juveniles (5).
But, most remarkably, New York Attorney General Letitia James (of the over $500 million verdict in the Trump trial!) issued, on February 3, 2025, a formal warning to New York hospitals that they would be in violation of state discrimination laws if they complied with President Trump’s executive order that outlawed certain sex-change treatments for minors (6).
New York Attorney General Letitia James
By advising New York hospitals that they must defy the President’s executive order, James is very clearly reemphasizing her original election message as Attorney General—that she considers herself the leading political voice in New York State in opposing Trumpism, which now, of course, includes the second Trump administration. Could this statement, therefore, be the start of her campaign for governor?
It certainly demonstrates her continued intent to wage war against Trump, even though—and maybe exactly because—he once again resides in the White House.
References
1. Betts A. The Guardian, February 3, 2025. https://www.theguardian.com/us-news/2025/feb/03/trans-youth-healthcare-hospitals-trump
2. The Associated Press. February 3, 2025, https://www.nbcnews.com/nbc-out/out-politics-and-policy/trump-policies-transgender-people-rcna190424
3. Mulvihill G. The Associated Press . February 1, 2025, https://www.pbs.org/newshour/politics/6-ways-trumps-executive-orders-are-targeting-transgender-people
4. Ryan B. The New York Sun. Updated January 24, 2025. https://www.nysun.com/article/new-research-raises-more-doubts-about-safety-and-benefits-of-gender-transition-treatments-for-minors
5. Aaron DG, Konnoth C. N Engl J Med 2025;392(6):526-527
6. Walker C. Tuthout. February 4, 2025. https://truthout.org/articles/ny-ag-letitia-james-tells-hospitals-they-must-defy-trumps-anti-trans-order/