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Predicting Your Health Arc

Aug 4 • 12:00 PM EDT • Health • erictopol.substack.com

Debt Digest | Federal Debt is a Health Care Problem

Welcome David Ditch to the Debt Dispatch! We are pleased to announce a new regular contributor: David Ditch will be joining the Cato Institute as a Policy Analyst for Budget and Entitlement Policy later this week. David has more than a decade of experience in fiscal policy issues, with a particular focus on federal spending. He previously worked at the Senate Budget Committee, the Heritage Foundation, and the Economic Policy Innovation Center. David’s areas of expertise include appropriations, transportation, agriculture, federalism, grantmaking, and policy options for deficit reduction. Originally from the Rochester, N.Y. area, David has a BA in Economics and Political Science from the University of Rochester and a MA in Political Management from George Washington University. David currently lives in Arlington, VA. You may have enjoyed his earlier guest posts: CBO: New Highway Bill Has More Spending, Taxes, and Deficits Trump Administration’s Proposed Changes to Federal Grants Highlight Problems of Big Government Here are this week’s reading links and fiscal facts: The federal debt is largely a health care problem. In a new report, the Congressional Budget Office and Joint Committee on Taxation find that “In 2026, federal subsidies for health insurance, net of related payments to the government, are projected to equal $2.4 trillion, or 7.4 percent of gross domestic product (GDP). In CBO and JCT’s projections, those subsidies grow by 65 percent, reaching $3.9 trillion, or 8.4 percent of GDP, in 2036. Subsidies for Medicare contribute most to that overall growth, increasing by $900 billion. Over the entire 2026–2036 period, federal subsidies for health insurance total $33.6 trillion.” Cato’s Michael Cannon emphasizes, “The long-term federal debt problem is a health care problem. […] Only two categories of federal outlays will grow faster than gross domestic product (GDP): health care subsidies and interest payments on the debt. The former is, therefore, the primary driver of the latter.” The bond market fears deficits, not the loss of tariff revenue. Responding to a New York Times essay claiming tariff revenue has grown too important for a future administration to unwind, Cato’s Kyle Handley argues: “Bond investors are not attached to customs duties as a line item revenue source. They care about the government’s overall fiscal position.” He continues, “tariff revenue is a side hustle. And the Trump administration has already promised to dole out the funds through schemes like tariff dividend rebates, farm subsidies, and pay-fors on tax cuts or other spending.” Furthermore, “tariff revenue is simply not large enough to transform the government’s fiscal trajectory.” Take net interest for example: it “reached $970 billion in fiscal year 2025, absorbing 18.5 percent of federal receipts. Customs duties accounted for only 3.7 percent of receipts—and that was before refunds (see Figure 2).” Handley concludes, “The real bond-market concern is a large and growing interest bill, persistent budget deficits, and a political system unwilling to bring spending and revenue into alignment.” Medicare’s spending growth is driven by more volume and utilization. A Congressional Research Service report finds that Medicare spending “grew at an average annual rate of 7.3%” from 1985 through 2025, and the trustees project health care expenditures will keep rising “faster than gross domestic product (GDP) in most future years.” Citing CBO, the report attributes Medicare’s projected 2026–2036 spending growth to “23% from higher enrollment, 31% from inflation, and 47% from the growth of inflation-adjusted spending per beneficiary. In other words**, the largest single driver of Medicare spending growth during the next decade is expected to be higher volume and intensity of health care services.”** Boccia and Thakur explain: “as the economy grows, Medicare spending tends to grow at least as fast—and often faster—because the program automatically pays the bill for more and more healthcare consumption by seniors, even as prices rise.” The Fed has little control over market interest rates. Cato’s Jai Kedia documents that the Fed has held its rate target steady since December, yet “nearly every rate Americans actually borrow at has climbed over the same stretch.” Kedia continues, “The Fed did nothing, and the cost of credit went up anyway. […] Markets spent these months repricing macroeconomic events such as sticky core inflation, a volatile energy market driven by the conflict in the Middle East, and global trade disrupted by tariffs, among others. None of that required a policy change to show up in borrowing costs because markets, not the FOMC, set prices.” He concludes, “Accurately priced borrowing rates will come from credible disinflation and disciplined budgets and from a Fed content to follow the economy rather than pretend it leads it.” Nearly half of US farm income comes from taxpayers. Former Reagan OMB director David Stockman notes that “in the most recently completed full year (FY 2025) farmer incomes in the US totaled $97.8 billion, but fully 42.7% or $41.8 billion of that amount came from taxpayers, not the marketplace. Nor is this some kind of one-year aberration. If we look at the most recent decade as a whole, total farm income posted at nearly $708 billion, but, as indicated, fully $322 billion or 45% of this came compliments of US taxpayers.” Cato’s Chris Edwards explains why so little of that income is market-earned: “Farmers are businesspeople, but the government shields them from just about every type of weather and market risk. Furthermore, just about every part of the agricultural industry is subsidized, including insurance, loans, marketing, research, export sales, and land improvements.” The Debt Dispatch is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. Subscribe

Aug 3 • 8:33 AM EDT • Health • debtdispatch.substack.com

Q&A: Rufus Edmisten on how Watergate compares to today's politics, civility

At age 85, Rufus Edmisten has had one of the longest and most colorful careers of any living figure in North Carolina politics. As a young aide to U.S. Sen. Sam Ervin, he delivered the subpoena for the Nixon tapes in the Senate’s Watergate investigation. Then he came back to North Carolina and served as attorney general and secretary of state.

Jul 31 • 4:30 PM EDT • Politics • wunc.org

Does public health *need* MAHA?

Last week, our friend Dr. Craig Spencer sparked an ongoing volatile discussion with his Atlantic article “Public Health Needs MAHA.” Some have come out in strong dissent, others are cheering, and others are simply lamenting that we find ourselves in such a divided world to begin with. We will dare to dip our toes in these controversial waters, too. Does public health need MAHA? We think in some ways yes, and in other ways, no. MAHA leaders versus the everyday MAHA supporter The vitriol in this debate mostly comes from one collapsed distinction: the leadership of MAHA is not necessarily the same as the people who support it. Say “MAHA” and most people picture RFK Jr. Fair enough, as he coined the term and holds most of the power. And, yes, some MAHA followers treat Kennedy as something close to a saint. But talk to the grassroots, and it’s not a monolith. They’re Republicans, Democrats, and Independents. People who distrust vaccines and vaccine supporters. It’s a wide, eclectic coalition. The data backs this too: 4 in 10 Americans support the movement—that’s a lot of people! But according to polls, vaccines and medical choice (the issues most tied to Kennedy personally) are cited by only 4% as their reason for supporting the movement. For many, the motivations are much broader. Many MAHA supporters are signing up for the idea that “something needs to change” with health in this country. They’re asking good-faith questions about corporate influence on our health systems, health care costs, nutrition, chemicals, and clean air and water. These are all questions that plenty of public health professionals recognize as legitimate and also care about very deeply. Blurring the lines between the leadership and grassroots does real damage in two important ways: It hands the 4 in 10 exactly the narrative already fed—that the health ecosystem doesn’t listen, doesn’t care, and paints every critic with the same brush. It gives the actual bad actor more power. RFK Jr. has done irreparable damage and can’t be trusted. What the MAHA movement gets right A healthy population is something the public health field was literally built on, and many of these topics are things we have dedicated our lives to. Yet the MAHA movement has captivated nearly half the country in a way the public health establishment has failed to achieve. So that means MAHA is doing something right. Some of it may be timing (after a Covid-19 pandemic and deep frustration and mistrust with institutions). The movement also does three other things really well: 1. It gives a new, louder voice to system failures. While MAHA is not a monolith, one theme stays consistent across their stories: the system failed them. For some, it was the system that flooded their communities with opioids and then walked away. For others, it was the system that let their business collapse during Covid with no safety net in sight. For others still, it was the system that failed to help them manage a complex chronic illness, bouncing them from physician to physician without any real answers. And in many ways, our health ecosystems are failing Americans. Why are medical bills so incomprehensible? Why do some kids get a healthy school lunch and others don’t? Why do an epidemiologist and a MD/PhD student have to start newsletters in the middle of the biggest public health emergency in a century, just so people can get straight information? Because the systems failed. This deep-seated frustration driving many Americans to search for solutions elsewhere needs to be recognized. 2. MAHA has brilliant comms central to their efforts. MAHA figured out something most health institutions still have not: the information landscape changed. It’s participatory now, not top-down; influence runs through many nodes in a community, not one institution; and storytelling and telling audiences “what you really think” moves people more than data dumps do. MAHA goes where audiences are listening, using podcasts, social media, and memes in ways most health institutions would scoff at—but it works. 3. They are very good at organizing. A MAHA meeting feels like a rally: energy, speakers, music, and most importantly, an action for everyone. Someone’s writing the next policy brief, someone’s seeding a narrative, someone knows the next legislative deadline, someone’s sending the text messages for a campaign. None of this is new (ask the civil rights movement), but MAHA knows it works and has capitalized on it. What MAHA gets wrong This list could be much longer, and this newsletter has spent a lot of time covering it, but here are a few things: Poor use of scientific evidence. This is the fundamental problem with many MAHA policies: the hype outpaces the science, and experts are often villainized for pointing this out. MAHA leadership has traded real solutions for cheap wins. For example, instead of taking on the powerful food industry and passing real reforms, it has celebrated french fries made of beef tallow and taken out artificial dyes from still very sugary children’s cereal. These changes won’t move the needle on America’s diet. MAHA leadership has tried to dismantle vaccine access in the U.S. While many MAHA supporters emphasize other issues, the effort to change vaccine policy has become MAHA’s signature effort. This is not surprising given RFK Jr.’s extensive track record campaigning against vaccines. It has rallied behind the wrong leader. RFK Jr. has a decades-long track record of villifying doctors, scientists, and public health workers, well before he became HHS secretary. He is known for his decades-long work sowing distrust in vaccines as well as life-saving treatments like antiretroviral therapy for HIV. This is not a serious person who can move the needle on health in the U.S, and he has already done serious damage. Public health needs more than defense Defending the evidence is absolutely necessary so health in the U.S. doesn’t move further backward. The public health establishment is very good at defense. The problem is this defense often sounds like defending the status quo, which has failed many people. Public health needs to offer an alternative to RFK Jr.’s MAHA—one that is rooted in evidence, truly listens to and addresses people’s frustrations, and has innovative solutions and the courage to change the systems. How do we get there? Find common ground. Do you know what most people care most about? The abysmal cost of healthcare. Start there. Fight for the human loudly. Too often, communications and engagement center on science with a capital S, funding mechanisms, or the CDC/FDA/NIH. Not the person. So the public doesn’t see themselves in it. Instead, they see people fighting for the very powerful systems that they feel negatively impact their health and well-being. Let the public feel and hear that you see their frustrations, you get it, and you’re fighting for them within the system. Recognize when pro-science messages are alienating people. Facts absolutely matter, but angrily venting only alienates people further. Our friend Elisabeth Marnik recently wrote a New York Times article about her experience growing up unvaccinated and how listening and empathetic conversation are the only ways to reach people that really work (a position backed by communication science). Her comments section was full of hateful comments from pro-vaccine individuals attacking her for daring to suggest we approach vaccine-hesitant individuals with empathy. It is possible to both stand firm behind scientific evidence and empathize with people who don’t trust it. Lean into politics smartly. Often, public health has shied away from politics: Don’t touch it, lest you get burned. But this fails to recognize that the third rail is what fuels the train: who is elected determines our budgets, our priorities, and our authority. Being political means being very savvy in strategy on both sides of the aisle, knowing your audience, and recognizing that political capital is as scarce as financial resources and needs to be allocated accordingly. Bottom line So does public health need MAHA? That’s not really the right question. Public health has a responsibility not to dismiss 40% of the country who feel heard by this movement and are frustrated that the system has failed them. And it has a responsibility to stick to the evidence and recognize MAHA leadership for what it is: a danger to our nation’s health. Both can, and should, be done. Love, YLE and KP A big thanks to Craig Spencer, who had the courage to put his neck out there to start a much-needed discussion at such a critical moment—one that is determining the identity of an entire field. Kristen Panthagani, MD, PhD is completing an emergency medicine residency and research fellowship focusing on health literacy and communication. In her free time, she writes the newsletters You Can Know Things debunking health myths and rumors and The Public Health Roundup. Views expressed belong to KP, not her employer. Your Local Epidemiologist (YLE) comprises a team of experts, ranging from physicians to immunologists to epidemiologists to nutritionists, working together with one goal: to “translate” ever-evolving public health science so that people are well-equipped to make evidence-based decisions. The YLE suite of newsletters reaches over 475,000 people across more than 132 countries. This newsletter is free to everyone, thanks to the generous support of fellow YLE community members. To support the effort, subscribe or upgrade below: Subscribe

Jul 31 • 6:30 AM EDT • Health • yourlocalepidemiologist.substack.com

Cerberus, former Steward Health Care private equity owner, settles with creditors

The resolution provides a measure of restitution for the financial backers of Steward, who took substantial dividend payments even as the hospitals struggled.

Jul 30 • 8:21 PM EDT • Health • bostonglobe.com