We’re at the beginning of a long timeline

Yesterday, EPA Administrator Lee Zeldin said microplastics in drinking water are now a top federal health priority. At the same time, HHS Secretary Robert F. Kennedy Jr. and ARPA-H Director Alicia Jackson announced a $144 million research initiative to study how microplastics build up in the body, which particles may be most harmful, and whether exposure can be reduced or removed.

Taken together, these moves signal something specific: microplastics have crossed from a research topic into a federal policy concern.

They have not crossed into regulation.

The EPA has added microplastics to the Contaminant Candidate List. This is a list of substances the agency may eventually regulate after more study, better measurement, and further analysis. It shows attention, not limits.

Here’s what happens next:

1. Scientists need standardized ways to measure microplastics. Right now, labs can produce very different results.

2. National data is needed to show how much microplastic contamination is in drinking water across the country.

3. Clearer evidence is needed to link typical exposure levels to specific health harms.

4. The EPA must decide whether regulating microplastics would meaningfully reduce health risks.

5. The agency must also run a cost-benefit analysis to decide whether the public health benefits justify the economic and technical costs.

Only after all of this can enforceable limits be proposed. That process can take years. Moving from “emerging contaminant” to an enforceable standard often takes a decade or more. Even then, regulation is not guaranteed. The bar is high.

Exposure is widespread

Microplastics have been found in blood, lungs, placenta, breast milk, and stool.

They are in our drinking water. They are in our food. They are in the air.

Indoor air may be a major source, especially in spaces with synthetic fabrics and dust.

Researchers can detect microplastics in human tissues and see cellular effects like inflammation, oxidative stress, and DNA damage. But linking those findings to real-world health risk is much harder.

What we don’t yet know

There is no agreed-upon exposure threshold at which harm begins.

There is no consensus on whether smaller particles, especially nanoplastics, pose greater risk because they can cross cell membranes and reach organs.

There is no clear dose-response relationship linking typical environmental exposure to specific diseases.

Microplastics are not a single substance. They vary by size, shape, polymer type, and chemical additives, each with different possible biological effects.

The problem is straightforward: We know exposure is widespread. We know there are plausible mechanisms of harm. But we do not yet know how much exposure translates into measurable disease risk.

Until those questions are answered, regulation moves slowly.

Industry incentives

Most plastics are made from oil and natural gas.

As demand for gasoline declines, plastics have become a stable growth area for the fossil fuel industry. The International Energy Agency projects that petrochemicals will account for a large share of future growth in oil demand. The OECD estimates that plastic production could nearly triple by 2060 without stronger policy.

Reducing microplastic exposure ultimately means reducing plastic production, and that directly conflicts with the interests of the fossil fuel industry.

Those incentives shape how policy is framed and what gets prioritized, and this is why plastic policy tends to emphasize waste, recycling, and individual behavior.

It focuses less on production.

This is a stable pattern across U.S. policy discussions and international negotiations, including the UN Global Plastics Treaty.

Production limits are debated, then softened. Recycling is presented as the primary solution, despite low global recycling rates and known technical limits. Waste management becomes the central frame.

At the same time, new plastic production capacity continues to come online.

What actually reduces exposure

As plastic production increases, more material enters the environment and breaks down into microplastics. These particles then accumulate in air, water, and food.

To lower exposure in a meaningful way, plastic production and use have to decrease.

There are a few ways to do that at scale:

• Limits or fees on new plastic would slow how much enters the system. Less plastic in, less plastic breaking apart later.

• Require companies to pay for the waste they create. That gives them a reason to use less plastic and design better products.

• Bans on high-exposure uses, like certain food packaging or products that shed easily, would cut off major sources of what we eat and breathe.

• Stronger product design rules could reduce how much plastic sheds during normal use, like from packaging, textiles, and tires.

• Reuse systems (refillable containers, return systems) would reduce how much plastic moves through the system overall.

These approaches work because they act upstream, before plastic becomes waste, and before it breaks into microplastics.

What does not reduce exposure

Some widely discussed solutions do little to reduce microplastics overall.

• Recycling, as it works today, does not reduce how much plastic is made. Most plastic is never recycled, and new plastic keeps being produced at high levels.

• Bioplastics are often marketed as safer, but many still break apart into small particles in similar ways.

• Waste management, like landfills and cleanup, deals with plastic after it’s already been made. By that point, some of it has already broken down into microplastics.

These approaches have value, but they mostly work downstream, after the problem has already started.

The fossil fuel industry, which supplies most plastic feedstocks, tends to support these approaches — recycling, cleanup, and new materials — because they do not limit how much plastic is made.

These approaches address waste after production, rather than reducing how much plastic enters the system in the first place.

That matters because as long as production keeps growing, microplastics exposure will keep growing too.

What individuals can do

The uncomfortable truth: we don’t yet know how much individual behavior can meaningfully reduce health risk. But we do have early signals on where exposure is coming from and what might lower it.

Diet appears to play a role, based on early evidence.

In one small study, researchers found microplastics in every stool sample tested, with concentrations up to ~3.5 particles per gram. What stood out wasn’t a single food. It was how food was processed and handled.

Higher microplastic levels were associated with:

• Highly processed foods

• Food packaged in plastic

• Plastic use during cooking and storage

That points to a practical, if imperfect, strategy:

Reduce contact between food and plastic, especially heat + plastic.

What that looks like in practice:

• Favor fresh or minimally processed foods over ultra-processed options.

• Limit plastic packaging, especially for ready-to-eat meals.

• Avoid heating food in plastic containers (e.g. microwave, hot liquids).

• Use glass, stainless steel, or ceramic for cooking and storage.

• Avoid bottled water.

There are also non-diet exposures:

• Microplastics shed from textiles and indoor air may contribute to what we ingest.

• Food can be contaminated during processing, transport, or preparation.

You can improve indoor air with HEPA filters. But even strict personal changes won’t eliminate your exposure to microplastics.

The limits of individual action

Individual actions can reduce exposure at the margins, but key sources remain:

• Food supply chains

• Packaging infrastructure

• Indoor air

And critically, the study did not find a consistent, predictable drop in exposure across “low plastic” vs “high plastic” scenarios. That’s a warning sign: the signal is real, but the system is noisy and hard to control at the individual level.

Changing the system

Microplastics are in the air, our drinking water, our food, and our soil. You can’t opt out of exposure.

That makes this a systems problem, not a personal one.

Individual choices matter at the margins. But meaningful change happens when exposure pathways — packaging, manufacturing, food systems — are altered upstream.

We’ve seen how quickly norms can shift when organized groups focus attention and create consequences. Parent-led advocacy groups have shown that coordinated pressure can force change faster than formal regulation. By sharing information, mobilizing networks, and targeting companies and school systems, they’ve pushed action on food additives, product safety, and environmental exposures.

Not all of their claims are scientifically grounded. But their effectiveness comes from something else: they change incentives.

When individuals act together, they can:

• Pressure companies to change materials and packaging

• Push for safer products and packaging

• Accelerate policy action by raising the political cost of inaction

• Shift what is seen as acceptable or normal

Regulation rarely leads. It responds to pressure.

If microplastics exposure is going to decrease in a meaningful way, it will not come from individual choices alone. It will happen when widespread plastic use becomes harder to justify, economically and politically.

A more convenient option

A new obesity treatment comes as a standard pill.

No injections, no refrigeration, no fasting requirements. It fits more easily into daily routines.

GLP-1 drugs work

They reduce appetite, lower blood sugar, and produce meaningful weight loss.

Some, including semaglutide (Ozempic, Wegovy), also reduce the risk of heart attack and stroke.

Foundayo (orforglipron) simplifies dosing: one pill, no timing constraints.

Which GLP-1 pill is better?

Two main options are emerging:

• Foundayo: no food restrictions

• Wegovy pill (oral semaglutide): must be taken on an empty stomach

Each has advantages.

In type 2 diabetes trials, Foundayo produced greater weight loss and better glucose control than lower-dose oral semaglutide.

In obesity trials, the Wegovy pill showed slightly greater weight loss, and fewer patients stopped treatment due to side effects.

A general pattern:

• Cardiovascular outcomes: semaglutide has stronger evidence

• Weight loss and glucose control: orforglipron is competitive and sometimes leads

• Convenience: orforglipron is simpler to use

Medicare coverage

If you have Medicare, you can get a pharmacy benefit card to buy Foundayo for $50 a month.

Historically, Medicare has not covered GLP-1 drugs for obesity at all. Coverage has been limited to other indications, such as:

• Diabetes

• Heart disease

• Sleep apnea

That is starting to change under a new CMS program called the BALANCE model, which will allow Medicare Part D plans to offer coverage for obesity medications with standardized criteria and negotiated prices.

Starting in July, Medicare will also cover these drugs for more people:

If your body mass index (BMI) is 30 or higher, and you have:

• Heart failure

• High blood pressure that isn’t controlled

• Moderate to severe kidney disease

Or if your BMI is 27 or higher, and you have:

• Prediabetes and heart disease

Commercial and employer-sponsored insurance

If you have commercial or employer insurance, you may qualify for a savings card that can lower your cost to about $25 a month. But that’s only if and after your insurance approves the drug, and almost all plans require prior authorization.

To get prior authorization for coverage, your doctor must show that you meet certain criteria, such as your BMI and other health conditions. They often have to submit proof that you’ve tried other approaches and treatments first. And even if you qualify, prior authorization is not guaranteed.

If your insurance does not approve Foundayo, you will likely have to pay the full price, even if your doctor prescribes it.

Many insurance companies are pulling back on GLP-1 coverage

Meanwhile, many insurers, including some state Medicaid programs, are limiting or even dropping coverage for weight-loss drugs because of cost.

The healthcare system is struggling to absorb these costs.

Doctors determine medical need, but insurers determine access.

In practice, that means rationing.

Even if prices go down, the need is still huge. Millions of people on Medicare could qualify for obesity treatment, but at today’s prices, only a small proportion of them could get the drugs without raising total costs.

We’ve turned a medical breakthrough into a financial filter.

Uninsured or if insurance doesn’t cover

If you don’t have insurance or your insurance won’t cover Foundayo, you would have to pay the cash price, which starts at $149 for the first month and rises to between $299 and $349 per month with longer-term use.

That is slightly below the cash price of drugs like Wegovy or Zepbound, which can range from $199 to $449 per month, with the amount you pay largely depending on your prescription drug coverage, if you have it.

This might all sound affordable, but it adds up over the long term.

According to Federal Reserve data, about a third of Americans can’t cover a $400 emergency expense. That tells you even “lower-cost” medications will still be out of reach for many Americans.

A medical breakthrough, trapped behind cost

The science is no longer the issue. Effective weight-loss treatments exist.

Even under optimistic policy scenarios, lower drug prices may expand access to hundreds of thousands or a few million people, but still leave the majority of eligible patients untreated.

Foundayo makes treatment easier to take, but not easier to obtain. A daily pill still depends on insurance approval and the ability to pay.

Polls show cost is the main concern for most Americans, not whether these drugs work, but whether they can afford them.

Breakthroughs tend to arrive first in American healthcare. Access may come later, if it ever comes at all.

• The advice is clear, and it works

• The patients we still miss

• Not all heart attacks look the same

The Advice Is Clear, and It Works

Diets with more fruits, vegetables, whole grains, and plant-based proteins are associated with a lower risk of heart disease. Whole grains include whole wheat, brown rice, barley, and quinoa. Plant-based proteins include beans and lentils, nuts and seeds, and soy foods like tofu.

You don’t have to go fully vegetarian. Even just a few plant-based meals a week can make a big difference. What you eat affects your blood pressure, cholesterol, and blood sugar. Over time, that can lead to plaque building up in your arteries, and that can reduce your risk of heart disease.

The patients we still miss

Meanwhile, a lot of people are getting this wrong: heart attacks don’t just happen to older men.

We’re seeing a real pattern: younger women, especially premenopausal women, are being misdiagnosed or diagnosed late when they come in with heart attack symptoms.

Part of the problem is a long-standing assumption that they’re “low risk.” But that’s not actually true, and it’s creating a care blind spot.

These women often show up with symptoms doctors think are due to anxiety, acid reflux, or muscle pain, and they get sent home.

But more commonly, women come in with classic symptoms of a heart attack, like chest pain, jaw pain, nausea, and shortness of breath, and even then, doctors don’t always think “heart attack,” especially in younger women. They don’t fit the stereotype of an older man. When doctors do not expect heart attacks in younger women, diagnosis slows down. Testing and treatment may be delayed. Some patients are sent home. Time is muscle. The longer someone waits to get treatment for a heart attack, the more the heart muscle is damaged.

And it’s not just missed diagnoses. Younger women are actually more likely to die from their first heart attack than men the same age.

Not all heart attacks look the same

There’s more. Women’s heart attacks may have different causes from men’s heart attacks. About half are caused by the usual buildup of plaque, which can block the arteries feeding the heart muscle. The rest come from other problems, like artery tears or spasms. That makes diagnosis harder.

Doctors may diagnose her with “MINOCA” — myocardial infarction with non-obstructive coronary arteries — meaning she had a heart attack, but her arteries don’t show the a major blockage. But MINOCA isn’t a final diagnosis. It’s a starting point.

As one cardiologist put it: As Dr. Harmony Reynolds, MD told the Journal of the Medical Association: “You’d never just stop and say, ‘Oh, you’ve got a fever.’ You’d figure out what it’s from.”

These types are more common in younger women, especially during or after pregnancy, when hormones are shifting.

If you’re old enough to get pregnant, you’re old enough to have a heart attack. Yet in younger women, heart attack symptoms are still often missed or misdiagnosed. Women with these symptoms should always be taken seriously, especially during and after pregnancy.

https://kffhealthnews.org/news/article/cdc-jay-bhattacharya-acting-director-search-nomination-staff-cuts-morale/

• Leadership Vacuums and a Fraying Workforce

• From Brain Drain to Burnout: The Cost of Workforce Instability

• Between Trust and Skepticism: The Administration’s Vaccine Agenda

• Soundbites from Dr. Jay Bhattacharya’s CDC All-Staff Meeting

Leadership Vacuums and a Fraying Workforce

President Donald Trump will soon nominate a permanent director for the Centers for Disease Control and Prevention, its acting chief, National Institutes of Health Director Dr. Jay Bhattacharya, told agency employees at a Wednesday staff meeting.

According to a recording of the all-hands meeting that was shared with me, Dr. Bhattacharya at one point suggested to CDC staff that Trump could name a new leader for the agency as soon as Thursday. “But if not, I don’t think much will change,” he said.

Though his official position as acting director was set to expire yesterday, Dr. Bhattacharya will continue to lead the agency until the top spot is filled. Meanwhile, news outlets including Axios and The Washington Post reported that the administration was postponing filling the permanent director job amid the challenges of gaining Senate confirmation and other political pressures.

Dr. Bhattacharya opened the meeting by acknowledging the struggles the beleaguered agency has gone through over the past year. Workers faced waves of job losses, and a gunman attacked the CDC’s Atlanta campus in August, killing a police officer and causing significant property damage. “I want to acknowledge very honestly that I know that it has been such a difficult year for the CDC and for every single one of you here,” Dr. Bhattacharya said.

He said the agency has begun to fill its leadership gaps. During his first meeting with the agency’s top leaders, he said, “I noticed almost every single one of them is acting.”

“We’ve made progress in filling key roles across the agency,” he said. “Leadership stability is essential to delivering our mission.”

The aim, he said, is to leave the agency in “a solid, secure place” so it can do its work “without so much of the turmoil that we’ve seen the last year.”

Dr. Bhattacharya invited questions from the CDC staffers, who repeatedly asked about staffing losses, morale, and their job security, as well as Trump’s decision to withdraw from the World Health Organization.

“The politics of WHO withdrawal are above my pay grade,” Dr. Bhattacharya said. “What I do know is that without the CDC, the world will be in much worse health.”

From Brain Drain to Burnout: The Cost of Workforce Instability

One employee told Dr. Bhattacharya the agency had lost a “huge amount” of “internal capacity and expertise in the past year” and it “continues to be very challenging for staff to do their jobs,” adding that “certain conditions are a bit demoralizing.”

The CDC can “function without leaders,” another speaker said. “We function without directors. And this entire team will make CDC run without you if you’re not here.”

Schedule F, an effort to reclassify certain federal employees in policy-related roles and reduce their civil service protections, drew some of the strongest statements from the staff. While it’s not fully implemented, the policy could make it easier for Trump to fire thousands of federal workers.

“What’s scaring the hell out of us right now is Schedule F,” an employee said. “We are terrified that ‘at will’ means you’re gone, you’re not here, you’re fired.”

“The Schedule F fight’s above my level,” Dr. Bhattacharya replied. He said his focus is on making sure the “work is supported.”

He said the agency should seek to “depoliticize what we do fundamentally” so that “every American sees us as working for their benefit.”

“When I say ‘depoliticize,’ I don’t mean you can’t say the hard or talk about the hard things,” he added. “I mean that you’re free to talk about the hard things without fear that you’re gonna be retaliated against.”

On hiring and operations, he pointed to ongoing efforts but acknowledged delays. The Department of Health and Human Services, which oversees the CDC, is “moving at the speed of bureaucracy,” he said, adding that he’s trying his best. “We have to move past the last year, and I think we now have an opportunity really to do that.”

Between Trust and Skepticism: The Administration’s Vaccine Agenda

On vaccines, Dr. Bhattacharya said one of the first things he did in his role as acting CDC director was to record a video “strongly encouraging parents to vaccinate their kids from measles.”

He said rebuilding trust requires engagement. That means working with communities without denigrating them, and respecting how “they think and their values,” he said.

Dr. Bhattacharya said he would like the NIH and CDC to coordinate more, particularly on HIV prevention. He described his approach as “an implementation science strategy so that we can use these two pieces of the HIV tool kit to actually end the HIV pandemic.”

The search for a permanent CDC director is being led by HHS officials on behalf of the White House and Health and Human Services Secretary Robert F. Kennedy Jr.

Dr. Bhattacharya said he’s friends with Kennedy and called “the caricature of him that I’ve seen in the press” unfair. Kennedy “really does have a deep desire to make America healthy,” he said.

For now, Dr. Bhattacharya said, he expects to stay in place at the CDC, as “either acting director or acting in the capacity of the director, whatever the heck that means.”

He joked about the ambiguity: “It’s like an Office episode, you know?”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

• A policy whiplash

• What does the law say about following process

• Back to the old schedule

• What should parents do? (speak with my AI avatar for education)

• The ongoing fight

A policy whiplash

Since coming into office, the Trump Administration has changed the U.S. childhood vaccine schedule.

A court reversed it this week.

Not because the science changed.

But because, the court says, HHS Secretary Robert F. Kennedy Jr. didn’t follow the law.

Kennedy said kids were getting too many vaccines. He said the system needed a reset.

So he dismissed prior members of the Advisory Committee on Immunization Practices (ACIP), which advises the CDC on its vaccine schedule, and selected new members who were aligned with his point of view.

What does the law say about following process

This is the part most people miss.

Kennedy bypassed FACA (Federal Advisory Committee Act), which sets rules for expert groups that advise the government.

The law says these groups must:

• Meet in public

• Share their data and decisions

• Follow a clear, science-based process

• Include a balanced group of experts

The goal is simple: no secret decisions. The public should be able to see how important health policies are made.

The court found he likely did not follow these rules. Instead, the court says, Kennedy:

• Changed the vaccine advisory group without proper process

• Avoided the usual open, expert review

• Made big vaccine policy changes without going through the full public, scientific discussion

FACA says the government needs to use experts, follow the scientific process, and do it in the open.

The judge said Kennedy likely skipped those steps and made decisions on his own.

Back to the old schedule

The CDC’s 2024 childhood vaccine schedule is back. These vaccines have been studied for years and are continuously monitored.

It is still supported by pediatricians, the American Academy of Pediatrics, the Infectious Diseases Society of America, the American College of Obstetricians and Gynecology, and other professional medical societies.

The schedule includes immunizations against:

• Flu

• RSV

• Rotavirus

• Hepatitis A and B

• Meningitis

ACIP is on pause.

What should parents do?

Talk to your child’s pediatrician for personalized advice.

And if you’re still confused, speak with my AI avatar for education on the guidelines and schedule.

The ongoing fight

For now, everything has snapped back to where it was.

The Trump administration is expected to appeal the judge’s ruling.

So the childhood vaccine schedule may change again.

• How AI is used in healthcare billing and insurance

• Why medical claims get denied

• What the data shows about denials and appeals

• How AI can delay patient care

• Why the system works this way

• What this means for patients

How AI is used in healthcare billing and insurance

So far, AI is being added to healthcare mainly to handle paperwork.

Hospitals use it to turn doctor visits into notes and billing codes. Insurance companies use their own AI to review those claims.

The process now looks like this:
visit → AI notes → AI coding → AI review → approval, delay, or denial.

Because both sides use AI, some describe this as “AI versus AI.”

The system is faster — at both approving and denying claims.

Why medical claims get denied

These systems depend on documentation.

If something is missing or unclear, a claim can be denied, even if the recommended care was appropriate.

Many denials are not about whether care was needed. They are about how the information is written and submitted.

This makes small paperwork issues very important.

What the data shows about denials and appeals

In Medicare Advantage, more than 80% of denied prior authorization requests are approved after appeal.

This suggests many denials are not final judgments about care.

They are decisions that often get reversed, but only after more time and effort.

Not every patient appeals. Not every provider has the time.

So the first decision often shapes what happens next.

How AI can delay patient care

AI speeds up decisions, including denials.

If care needs prior authorization, it cannot move forward without approval. If it is denied, the next step is an appeal.

That creates delays, even when the denial is later overturned.

The sequence is simple:
care is recommended → approval is required → denial → appeal → delay.

AI makes this sequence faster, but it does not remove it.

Why the system works this way

The issue is not the technology. It is the incentives.

Hospitals are paid to document and bill more. Insurers are paid to control costs.

AI helps both sides do this more efficiently.

The U.S. spends about 18% of its economy on healthcare, with a large share going to administration.

AI is speeding up that system, not changing it.

What this means for patients

Most AI in healthcare isn’t yet visible to patients, but it affects their access to care.

Patients can ask why a claim was denied and file an appeal. Some tools can help review bills or draft appeals.

But the basic structure remains the same.

Care depends not only on medical decisions, but on whether those decisions are approved.

• What “early-stage” actually means

• One stage, many diseases

• The many paths after the same diagnosis

• The incomplete promise of early detection

• The infrastructure behind survival

• Treating the tumor, accounting for the patient

• When treatment fits into a workday

• The most reassuring cancer diagnosis is the one found in time.

When Susie Wiles said she has early-stage breast cancer and plans to keep working, the message was simple: the cancer was caught early, her outlook is strong, and treatment will move forward.

What “early-stage” actually means

Early-stage breast cancer, usually stage I or II, means the tumor is still small. It is in the breast and may have spread only a little, if at all, to nearby lymph nodes.

This is when care can feel organized. A scan finds something unusual. A biopsy confirms cancer. Lab tests study the tumor. Doctors choose treatment step by step.

One stage, many diseases

But “early-stage” does not mean just one kind of cancer.

It is a group of different diseases that all have one thing in common: they were found before spreading far.

Some tumors grow slowly and respond to hormones like estrogen and progesterone. Others grow faster and act more aggressively. Doctors test for things like hormone receptors and HER2 to understand this.

Two people can have the same stage and need very different treatments.

Early detection makes the tumor easier to find. It does not make all tumors the same.

The many paths after the same diagnosis

Treatment often starts with surgery to remove the tumor.

After that, some patients get radiation. Some take hormone-blocking pills for years. Some need chemotherapy or targeted drugs.

Not everyone needs every treatment.

Doctors decide based on the tumor and the patient’s health. This is called personalized care.

It is precise, but it can also make things sound simpler than they really are.

The incomplete promise of early detection

It is true that finding cancer early leads to better outcomes.

But that is only part of the story.

Outcomes improve because the cancer is smaller and has not spread far. This makes treatment easier and more likely to work.

Doctors can aim to cure the cancer, not just control it.

The infrastructure behind survival

Early detection works only if the system works.

People need access to screening. They need to be able to get a mammogram without delay. If something is found, they need fast follow-up tests. A biopsy has to be scheduled, performed, and read accurately. Treatment has to begin without long gaps. And patients need the time, money, and support to complete it.

When all of this lines up, outcomes are excellent. Survival rates for early-stage breast cancer are often above 90-99% at five years.

But the system does not work the same way for everyone.

Some women are screened regularly. Others are screened late or not at all. Insurance status, geography, and health system access shape who gets routine mammograms and who does not.

Even after an abnormal result, delays are common. In some settings, patients wait weeks to months for follow-up imaging or biopsy. These delays are not random. They are more likely in under-resourced clinics, for patients without stable insurance, and for those navigating complex health systems without support.

Diagnosis is also not uniform. High-quality pathology and biomarker testing — such as estrogen and progesterone hormone receptor and HER2 status — are essential for choosing the right treatment. But access to these services can vary by hospital, region, and resources.

Treatment follows the same pattern.

Some patients receive care in well-coordinated centers where surgery, oncology, and radiation are tightly linked. Others move between disconnected providers, with delays at each step.

Some women can take time off work, afford medications, manage side effects, and return for repeated visits. Some can’t.

These differences show up in outcomes.

Black women in the United States, for example, are more likely to be diagnosed at later stages and have higher mortality rates, even when controlling for some clinical factors. Part of this reflects differences in tumor biology. Much of it reflects differences in access to timely, high-quality care.

Rural patients face longer travel times and fewer specialists. Lower-income patients are more likely to experience delays or incomplete treatment. Older patients may be undertreated, not because of biology, but because of assumptions about tolerance or life expectancy.

In this way, stage at diagnosis begins to reflect the system as much as the disease.

Early-stage cancer is where medicine works best. It is also where systems quietly decide who gets to arrive there.

Treating the tumor, accounting for the patient

At age 68, treatment decisions include more than just the cancer.

Doctors also think about overall health, other conditions, and how well a person can handle treatment.

Many older patients live long lives and may die from causes other than cancer.

This shifts the goal from the most treatment possible to the right amount of treatment.

When treatment fits into a workday

Susie Wiles saying she will keep working.

Most doctors aren’t surprised. Modern breast cancer care often allows it.

But it depends on the cancer being found early and treated under the right conditions.

https://kffhealthnews.org/news/article/organ-donor-state-registries-consent-authorization-optn-opo-raven-kinser-virginia/

When Raven Kinser walked into a Virginia Department of Motor Vehicles office two summers ago, she completed a driver’s license application that included the option to register as an organ donor. The form provides a checkbox to opt in, but not one to opt out. Kinser left the donor registration box unchecked, reflecting her decision to reverse an earlier donor registration. Six months later, after she was declared dead at Riverside Regional Medical Center in Newport News, Virginia, her parents say, they learned that her decision did not prevent organ procurement.

Raven’s case reveals a little-known gap in the U.S. donation system: There is no clear, nationally binding way to opt out — or to ensure a later “no” overrides an earlier “yes” in a different state.

This gap, along with a range of other issues related to the organ procurement system, has become a point of bipartisan congressional concern. Late last year, the House Ways and Means subcommittee on oversight held a hearing examining what members described as shortcomings, including alleged consent failures.

The panel’s scrutiny of organ procurement organizations, or OPOs, and their consent practices is a first step toward a more meaningful accountability plan that could help maintain trust across the system, according to some committee staff members.

The trust in our organ procurement and transplant system “has been eroded,” said Rep. Terri Sewell of Alabama, the panel’s senior Democrat, calling for stronger transparency and oversight to rebuild public confidence.

“Respect for autonomy — our ability to make our own decisions (self-determination) — allows for both ‘yes’ and ‘no’ decisions and for changing one’s mind,” Margaret McLean, a bioethicist at Santa Clara University, said in an email.

“Medical decision-making is not well served in a context of ambiguity,” she said.

And if a donor revokes consent, she added, “revocation by that person should carry the same ethical and procedural weight as the initial authorization, perhaps more.”

Raven Kinser Changed Her Mind

Raven was 25 when she died. Her parents, Jeff and Jaime Kinser, were at home in Michigan when they received the phone call that shattered their world. They drove through the night to the Newport News hospital, where they learned Raven’s disposition had been referred to LifeNet Health, the region’s federally designated OPO. LifeNet is rated a failing OPO by the Centers for Medicare & Medicaid Services, meaning it doesn’t meet the government’s standards for how well it finds donors and recovers usable organs for transplant compared with other organizations.

Under federal law, hospitals are required to refer deaths and imminent deaths to OPOs, which take responsibility for donation-related decisions and discussions.

OPOs occupy a hybrid position in the health care system, as private nonprofit entities that hold exclusive, federally authorized contracts to recover organs within defined regions. They are regulated by CMS and overseen by the Health Resources and Services Administration, but that oversight occurs primarily through certification standards, performance metrics, and periodic audits rather than routine public disclosure requirements. With donor registries largely managed at the state level and no unified federal reporting requirement for removals, comprehensive national data on revocations is elusive.

OPOs are meant to separate bedside care from organ procurement decisions — to help prevent conflicts of interest and preserve the trust that decisions about life-sustaining treatment are made solely in the dying patient’s interest. But the policy can be fraught, leaving families unsure who is in control if and when conflicts arise.

The Kinsers, for instance, felt their daughter would not have wanted to go through the donation process, but, at the time, had no evidence. Jaime remembers telling her husband that Raven would have been mad at them for letting it happen. In an effort to stop it, Jaime inquired about whether she would be asked to sign a consent form. But a LifeNet staff member told her that wasn’t an option because donation was Raven’s “living will,” Jaime said. Meanwhile, Raven’s parents said, her personal effects, including her Virginia driver’s license, which bore no donor designation, had not yet been turned over to the family, leaving them no meaningful way to challenge LifeNet’s determination in real time.

Jaime struggled with this outcome, even mentioning in Raven’s obituary that she was an organ donor. “How would you try to make peace with something that you felt was so wrong but had no proof?” Jamie said.

Two months passed before the Kinsers gained possession of the license, which, as they had expected, showed that Raven had not opted to be an organ donor.

According to the Kinsers, LifeNet staff told them that Raven’s status as a registered donor was established by her designation on her older Michigan license.

An emailed statement attributed to Douglas Wilson, LifeNet executive vice president, said the OPO follows federal law on organ donation, the Uniform Anatomical Gift Act, and queries applicable state donor registries, relying on time stamps and governing law to determine the most recent, legally valid expression of intent. Under that framework, a prior donor authorization remains enforceable unless a valid revocation is recorded in the regional OPO’s donor registry.

Because of privacy laws, Wilson said, LifeNet could not comment on the specifics of any individual case.

Raven Kinser’s choice not to be a donor when she applied for a Virginia license in July 2024 was not reflected in the registry LifeNet consulted, according to her parents, who said that is what the organization told them. According to Lara Malbon, executive director of Donate Life Virginia, which manages the state’s organ donor registry, if someone changes their donor status while completing a Virginia driver’s license or ID transaction, “that information is sent to our registry, and the registry is updated daily to reflect those changes.” Malbon also said Virginia’s registry includes only people who have “affirmatively said ‘yes’ to becoming an organ, eye, and tissue donor, and it retains records solely for those who have made that decision.”

The Kinsers said they were never told why Raven’s Virginia DMV record was insufficient, or how an older yes from Michigan could outweigh a newer no in Virginia.

In December, the Kinsers filed a complaint with the Health Resources and Services Administration, urging federal regulators to investigate LifeNet’s actions and require OPOs to provide families with documented proof of the donor’s current status at the time of referral. They also called for OPOs, which operate as federally designated regional monopolies but are structured as private nonprofits, to be made subject to public records laws.

When Opting Out Doesn’t Stick

Such confusion is not unique to the Kinser family. It is a consequence of the organ donation consent process in the United States.

“I have also wondered that: why there’s not just one” registry for organ donation, Jaime said. “If you go to get a firearm, you have one federal place.”

Here’s how the system works: Americans typically register their organ donation intentions when they apply for driver’s licenses through state DMVs, and that decision remains governed largely by state law. That has led to 50 different sets of rules and very little federal regulation of what has become an over $5 billion industry in the U.S.

In some states, a donor checkbox is a binding legal document. In other states, the same choice may have different rules about when it takes effect, what it covers, and how it can be revoked.

Those differences can be big. State rules determine whether a person’s “gift” is limited to transplantation or also includes research and education. They determine whether the donation authorization includes tissue. And they can determine what counts as a valid revocation and when it is legally recognized.

Because of the system’s fragmentation, though, signals can cross when someone changes their mind, like Raven; it’s not always reflected from one state system to another.

Under state versions of the Uniform Anatomical Gift Act, a donor’s most recent legally valid expression of intent is meant to control.

“Personal autonomy is paramount to everything,” said Adam Schiavi, a neurointensivist who studies end-of-life decision-making. “If I say I want to be a donor, or if I say I don’t want to be a donor, that has to take precedence over everything else.”

But states differ in how revocation must be recorded and which registry is considered authoritative if someone has lived in more than one state. Those inconsistencies can create uncertainty when records conflict across jurisdictions.

“It has to be the most recent expression, not the most recent yes,” Schiavi said.

In Michigan, a change to someone’s donor status is reflected immediately in the secretary of state’s system, but only affirmative “yes” registrations appear in the registry. Removal information remains in internal motor vehicle records. In Virginia, the state registry includes only those who have affirmatively said “yes,” retaining records solely of donors, creating potential gaps if someone believes a DMV change alone is sufficient.

Elsewhere, processes and volumes differ sharply. New Mexico updates driver records in real time but does not transmit status changes to its donor registry. Instead, donor services receive restricted search access. The state logged nearly 15,000 removals in late 2021 and almost 30,000 in 2022. Florida, which maintains formal removal records through weekly DMV data files, reported 356,161 removals in 2020, more than 1.5 million in 2023, and over 1.2 million in 2025. Kentucky processed 847,371 donor registrations from 2020 to 2025, but only 16,043 icon removals, with registry withdrawal handled separately. In 2025, more than 570,000 Texans opted into the registry, while over 31,000 individuals requested removal.

According to a federal official who asked not to be identified for fear of professional repercussions, OPOs have been highly effective at lobbying states to broaden the definition of consent and authorization — shaping how those terms are applied, whether those statuses must be renewed, and how easy or difficult it is for someone to opt out.

In subsequent correspondence with federal officials, the Kinsers have urged reforms to prevent OPOs from relying on older registry entries when a more recent state DMV record exists, and they have called for criminal penalties in cases in which consent is knowingly misrepresented. Federal regulators have not indicated whether such proposals are under consideration.

Congress Takes a Closer Look

Ethicists have long cautioned that consent must be more than a checkbox and must remain grounded in respect for the donor-patient. In an October position paper on organ transplantation, the American College of Physicians emphasized that clinicians’ primary duty is to the patient in their care, and that maintaining trust requires transparency and safeguards to prevent conflicts of interest from blurring that “bright line.”

Advocates say those steps leave unresolved the core problem raised by the Kinser family: the lack of a clear, legally binding way for people to say “no” and for that decision to follow them across state lines.

The Association of Organ Procurement Organizations said it “supports strengthening donor registries and enhancing registry interoperability to ensure that an individual’s documented donation decision is honored.” But OPOs have also argued that current policies protect donation as a legally enforceable gift and prevent families from overriding a loved one’s “yes” in the midst of grief. They argue that stronger, more durable consent helps reduce missed donations and saves lives.

Congress and federal regulators are considering changes to the nation’s organ donation system, including how consent is recorded and what should happen when a donor changes their mind.

Sen. Ron Wyden (D-Ore.) proposed legislation last year to create new federal standards for patient safety, transparency, and oversight of organ transplants, including a formal authorization for hospital or OPO staff to pause harvesting if there is any “clinical sign of life.”

HHS press secretary Emily Hilliard said the agency is “committed to holding organ procurement organizations accountable” and to “restoring integrity and transparency” to organ donation policy, calling reforms essential to informed consent and protecting donor rights. CMS issued related new guidance March 11, but it does not address the problems highlighted by the Kinsers’ case.

Critics of the organ transplant system say it is difficult for families to obtain documentation or independently verify how consent determinations were made in disputed cases.

HRSA has launched a sweeping modernization of the Organ Procurement and Transplantation Network, the national system that oversees organ allocation and transplant policy. Federal officials have described the overhaul as the most significant restructuring of the transplant system in decades, aimed at breaking up a long-standing contractor monopoly, strengthening patient safety oversight, and replacing aging technology infrastructure.

Central to that effort is modernizing the OPTN’s data systems: improving interoperability, audit trails, and transparency in how decisions are documented and reviewed. A more modern federal data architecture could make it easier to trace which registry was queried, what time stamp controlled, and how a consent determination was reached in disputed donations that span multiple states. But the modernization effort would not change the underlying state-by-state legal framework for donor authorization and what counts as a valid “no.”

Meanwhile, Donate Life America, a national nonprofit that supports state donor registries, also runs the National Donate Life Registry, a central database that allows people to sign up as organ donors directly. Unlike many DMV systems, the national registry lets people log in at any time to view, update, or remove their registration and print proof of their decision. The group is also starting a project to let participating states send registrations directly into the national system, creating one place to track donor sign-ups and removals across state lines.

Malbon of Donate Life Virginia says, “There are no plans to provide a ‘no’ to registering as a donor box at this time.”

Each of the proposals comes with trade-offs, and both advocates and OPOs have raised concerns about how they would work in practice.

“Just doing a dump truck dump of information is not going to do much unless you really apply it through checking and auditing,” said Arthur Caplan, a professor of bioethics at New York University’s Grossman School of Medicine. “It could be like the IRS. They don’t have to audit everybody. Just do a spot audit once in a while.”

The Kinsers aren’t opposed to organ donation itself. They celebrated Raven’s donation in her obituary, and in their complaint to federal regulators, they wrote, “We are NOT anti-organ donation, and we will never take away the gift of life our oldest daughter gave to others. However, that was not LifeNet’s choice to make.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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When the economy reaches the health department

After the 2008 financial crisis, U.S. public health departments lost about 50,000 workers.

Epidemiologists. Public health nurses. Community health workers.

These layoffs did not make national headlines. But their effects became clear a decade later, when COVID showed how fragile many health departments had become.

This newsletter examines how policy decisions and economic forces shape the public health systems we rely on.

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I remember that time well. I was an Assistant Commissioner at the New York City Department of Health and Mental Hygiene. I was asked to prepare plans to lay off about 20% of our staff in one year, with more cuts in subsequent years.

That experience taught me something important. Economic crises do not only affect markets or government budgets. They can quietly reshape the systems that protect public health.

Now, another economic shock may be forming.

The war between the United States and Iran has disrupted oil flows through the Strait of Hormuz. This narrow waterway normally carries about one-fifth of the world’s oil supply. Oil prices have already risen above $100 per barrel, and analysts warn they could climb much higher.

If oil reaches $150 per barrel, gas prices in the United States could rise above $5 per gallon. When gas gets that expensive, households often cut spending elsewhere in the economy.

After the 2008 recession, public health spending in many places fell by 15-20%, adjusted for inflation. Researchers later called this period a “lost decade” for the public health workforce.

If economic pressure grows again, the same pattern could repeat. The effects might not become clear until the next public health emergency.

When recessions weaken public health

The 2008 financial crisis did more than disrupt markets. It also weakened the systems that prevent disease.

As tax revenues dropped between 2008 and 2010, state and local governments faced large budget gaps. Public health departments rely heavily on these funds, so they were hit especially hard.

Between 2008 and 2012, real public health spending fell in many places. Budget cuts soon led to job losses. By 2014, local health departments across the United States had lost about 50,000 employees.

Many of the jobs lost were key public health roles:

• epidemiologists

• public health nurses

• laboratory scientists

• environmental inspectors

• health educators

These workers investigate outbreaks, track diseases, and run vaccination programs.

When these jobs disappear, health departments lose both staff and expertise. In some places, agencies were left doing only basic regulatory work, such as inspections, instead of prevention programs.

At the same time, recessions create new health risks.

After the 2008 recession, mental health problems increased. Depression and anxiety rose as unemployment grew. Suicide rates also increased in several countries.

Economic stress was also linked to rising opioid use and alcohol-related deaths. The opioid crisis grew fastest in regions that lost many jobs during the recession.

Financial strain also changed everyday health behavior:

• people delayed medical care

• prescriptions went unfilled

• preventive visits declined

• food insecurity increased

• housing became less stable

These problems build slowly but can harm population health for years.

In short, recessions hit public health systems from both sides. Governments cut prevention programs at the same time that health risks in the population increase.

At first, these changes may go unnoticed. After 2008, the damage to public health systems received little attention.

But the effects became clear a decade later. When COVID arrived, many health departments were already struggling after years of budget cuts, hiring freezes, and reduced preparedness programs.

Why the Iran war raises economic concerns

The question now is whether another economic shock could start the same cycle again.

The current crisis involves a familiar risk: an energy shock.

When oil prices rise quickly, it works like a tax on households. People spend more on fuel and less on other goods.

Several past recessions followed oil shocks, including:

• the 1973 Arab oil embargo

• the 1979 Iranian revolution

• the 1990 Gulf War

• the 2008 oil price spike

The pattern is similar each time. Energy costs rise, inflation increases, consumer spending falls, and economic growth slows.

It is still unclear whether the current disruption will cause a recession. But economists are watching closely.

Why public health and prevention funding disappears after crises

Public health holds a strange place in government budgets.

Prevention programs create large long-term benefits by keeping people healthy. Yet they are often treated as optional spending.

Some critics, including voices in the “Make America Healthy Again” movement, argue that public health has failed at prevention. Prevention has always been the core of public health. The problem is not that we fail to understand prevention. It’s that governments and taxpayers repeatedly choose not to fund it. These are the programs they cut first.

The result is a repeating cycle: investment grows during emergencies and fades once the crisis passes.

The question we should be asking

The United States is not yet in a crisis like the one in 2008.

Domestic oil production is higher today, and banks are more tightly regulated.

Still, warning signs are visible: geopolitical conflict, rising energy prices, slowing economic growth, and large federal deficits.

If these pressures lead to a recession, the budget choices made in the next few years could shape public health systems for the next decade.

Having lived through layoffs in a health department, I know how quickly economic shocks become real. Budget crises soon turn into hiring freezes, program cuts, and fewer people working to stop disease outbreaks.

Public health systems rarely collapse all at once.

They weaken slowly — budget cycle by budget cycle — until the next epidemic shows what years of quiet cuts have taken away.

Question for readers

If another economic downturn happens, what should governments protect first: short-term fiscal stability, or the prevention systems meant to protect us from the next pandemic?

Let me know in the comments.

The simple scan that can predict your risk of a heart attack

Heart disease is still the leading cause of death in the United States.

But heart attacks don’t come out of nowhere. The damage that causes them often begins years, often decades, earlier as plaque slowly builds inside the arteries.

Today, doctors can detect plaque long before symptoms appear using a simple CT scan called a coronary artery calcium (CAC) scan that can detect plaque inside the arteries.

Yet most Americans never receive this test.

Many preventive cardiologists believe this scan is one of the most powerful and underused tests in medicine.

New guidelines from the American College of Cardiology and the American Heart Association may change that. The updated recommendations encourage doctors to look for heart disease risk earlier and treat high cholesterol more aggressively when needed.

The goal is simple: stop heart disease before it starts.

Heart disease starts earlier than you think

Heart disease develops slowly over time.

When LDL cholesterol, often called “bad cholesterol”, circulates in the bloodstream, some of it can stick to artery walls. Over many years, this forms plaque.

Plaque narrows the arteries and increases the risk of heart attacks and strokes.

Scientists now know that lifetime exposure to LDL cholesterol is one of the biggest drivers of heart disease. The longer someone lives with high LDL levels, the higher their risk later in life.

That is why the new guideline encourages earlier action.

Healthy habits are still the first step. Doctors recommend:

• healthy eating

• regular exercise

• maintaining a healthy weight

• avoiding tobacco

But if cholesterol levels remain high, doctors may consider medication sooner than they did in the past.

Lower cholesterol for longer periods provides stronger protection against heart disease.

A better way to estimate risk

The new guideline also introduces a new tool to estimate heart disease risk.

It is called PREVENT, short for Predicting Risk of Cardiovascular Disease EVENTs.

Doctors use this calculator to estimate a person’s chance of having a heart attack or stroke in the next 10 years.

It uses common information from routine checkups such as:

• cholesterol levels

• blood pressure

• age

• smoking status

• other health factors

Doctors use the calcium score to help predict heart attack risk and decide whether cholesterol-lowering medication is needed. Calcium in the arteries is a sign that plaque in the arteries has already started to form.

“With this new assessment tool, we can better estimate cardiovascular risk using health information already obtained during an annual physical,” said Dr. Roger Blumenthal, chair of the guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease.

Doctors can also personalize the score by considering additional risk factors.

Clear targets for cholesterol

The new guideline also restores clear LDL cholesterol targets.

For many patients:

• Moderate risk → LDL below 100 mg/dL

• Higher risk → LDL below 70 mg/dL

• Known heart disease → LDL below 55 mg/dL

“In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke,” said Dr. Pamela Morris, vice-chair of the guideline writing committee.

Clinical trials have shown that lowering LDL cholesterol reduces the risk of heart attacks and strokes.

The scan that can reveal hidden heart disease

A coronary artery calcium scan is a quick CT scan that measures calcium in the arteries of the heart.

Calcium is a sign that plaque has already formed.

The result is given as a calcium score.

Doctors often interpret the score like this:

CAC score: 0
No calcium detected. The risk of a heart attack is very low.

CAC score: 1–99
Early plaque is present.

CAC score: 100–299
Clear plaque buildup.

CAC score: 300 or higher
Significant plaque in the arteries.

This information can change treatment decisions.

Instead of estimating risk using cholesterol levels alone, doctors can see whether plaque is already forming inside the arteries.

A powerful test few people get

Despite strong evidence, CAC scans are still not widely used.

One reason is insurance coverage. Many insurance plans consider the scan a screening test and do not pay for it.

Patients often pay out of pocket, though the cost is usually $100 to $200.

Another reason is awareness. Many patients, and even some doctors, are unfamiliar with how useful CAC scans can be for people whose risk level is unclear.

The new cholesterol guidelines emphasize CAC scans as a helpful tool in these situations.

For preventive cardiologists, the scan offers something powerful: a direct look inside the arteries.

Most heart disease can be prevented

Cardiologists say one of the most important facts about heart disease is that much of it can be prevented.

“We know 80% or more of cardiovascular disease is preventable and elevated LDL cholesterol is a major part of that risk,” said Blumenthal.

Lifestyle changes remain essential. But the guideline reflects a growing understanding that medication may sometimes be needed sooner.

“If lipid numbers aren’t within the desirable range after lifestyle optimization, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago,” Blumenthal said.

Lower LDL levels for longer periods offer stronger protection against heart attacks and strokes.

“People who maintain low levels of LDL cholesterol at earlier ages are much less likely to develop atherosclerotic disease decades later,” Morris said.

Question for readers

Have you ever had a coronary calcium scan, or has your doctor recommended one?

Let me know in the comments.

Nearly half of Americans say they have skipped taking medicine because of the cost.

That means millions of people are making a choice doctors never want patients to make: protect their health or protect their wallet.

A new national poll shows the problem may be getting worse. And while a new federal program called TrumpRx promises to lower prescription drug prices, it may only help a narrow group of patients.

Here’s what the data shows.

Millions of Americans are skipping their prescription drugs

Every month, millions of Americans face the same quiet decision at the pharmacy counter: fill the prescription, or save the money.

Too often, the choice is not what their doctor recommended.

A new national poll from KFF shows why. Nearly six in ten Americans say they worry about being able to afford their prescription drugs, and 43% say they skipped taking medication as prescribed in the past year because of cost.

These numbers reveal more than a moment of sticker shock at the pharmacy. They point to a deeper problem in the U.S. health system: medicines exist, but many patients still struggle to pay for them.

What patients do when medicine is too expensive

If these concerns were only theoretical, the debate in Washington might look very different.

But the poll shows the consequences are already shaping how people take their medications.

According to the survey, 43% of adults say they did not take a prescription drug as directed in the past year because of cost.

Patients cope in different ways.

Some never fill the prescription at all. Others stretch their medication by cutting pills in half or skipping doses so the medicine lasts longer. Some turn to over-the-counter drugs instead of the treatment their doctor recommended.

Doctors warn that these choices can carry serious health risks. Skipping blood pressure medication can increase the chance of heart attack or stroke. Missing diabetes treatments can lead to long-term complications.

In other words, the debate about drug prices is not just about policy. For many Americans, it determines whether they can follow their doctor’s instructions at all.

Subscribe for clear, data-driven explanations of the policies shaping American health care.
New posts break down the research, polling, and politics behind the headlines.

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Americans want the government to lower drug prices

Despite deep political divisions in the United States, prescription drug prices are one issue where many voters agree.

The poll shows about 72% of Americans believe the government should do more to limit drug prices.

That support crosses party lines. Majorities of Democrats, Republicans, and independents say the government should play a larger role in controlling drug costs.

One reason for the frustration is simple: the United States is unusual among wealthy countries.

In many other nations, governments negotiate directly with pharmaceutical companies to set drug prices. In the U.S., companies largely set their own prices, and the system of insurers, pharmacy benefit managers, and discounts can make the final cost hard for patients to understand.

What TrumpRx is supposed to do

The Trump administration recently launched TrumpRx, a website designed to help consumers find lower prices for certain prescription drugs.

The platform allows patients to compare prices and purchase some medications directly from drug manufacturers or pharmacies without using insurance.

The idea is simple: if patients can see prices more clearly, they may be able to shop for better deals.

But awareness of the program is still limited.

Only about one-third of Americans say they have heard of TrumpRx, and just 7% say they have used it to compare drug prices.

Who TrumpRx could help and who it won’t

Even if TrumpRx expands, its benefits may be uneven.

The people most likely to benefit are Medicare patients, especially seniors who take expensive brand-name medications. These patients often face high out-of-pocket costs each year, so even modest price reductions could make a noticeable difference.

But many Americans may see little change.

People with employer-sponsored insurance often already receive negotiated discounts through their health plans. For them, using insurance may still be cheaper than paying the cash price through TrumpRx.

Uninsured patients may also struggle to benefit. Even a discounted price can still be out of reach for someone paying entirely out of pocket.

The bigger healthcare cost problem

Prescription drugs are one of the most visible health expenses Americans face.

But they are only part of the system.

Hospital care and physician services make up a larger share of total health-care spending in the United States. That means lowering drug prices alone will not solve the broader problem of rising medical costs.

Still, prescription drugs remain a daily reality for millions of patients.

Every refill, every skipped dose, and every pharmacy receipt keeps the debate over drug prices alive.

If you found this useful, consider sharing it with someone interested in health policy.

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Questions for readers

Prescription drug prices affect millions of Americans, but the experience can look very different depending on insurance, income, and the medications someone needs.

I’m curious about your experience:

1. Have you ever skipped filling a prescription, delayed taking medication, or searched for discounts because of the cost?

2. If you take prescription medications regularly, have you noticed prices going up in recent years?

If you’re comfortable sharing, I’d love to hear your experience in the comments. Stories like these often explain the drug pricing problem better than any statistic.

https://kffhealthnews.org/news/article/quartz-countertops-silicosis-workers-lung-disease-crystalline-silica/

César Manuel González, 37, used to work with stone that was engineered to endure: dense, polished slabs designed to outlast the kitchens in which they were installed.

Engineered quartz countertops have surged in popularity in the home renovation market, with industry analysts estimating the global engineered stone market at around $30 billion. It’s continuing to expand as quartz surfaces replace natural stone in kitchens in the United States and worldwide.

When González was working, the dust that rose from his saw didn’t look extraordinary. It settled on his clothes, in his hair, across the shop floor. In a small countertop fabrication shop, he cut marble and granite before shifting to engineered stone after the 2008-09 recession, when demand for cheaper quartz countertops surged.

But the crystalline silica released while the engineered stone was cut and polished also settled into his lungs, scarring them beyond repair. What began as breathlessness hardened into silicosis, an irreversible disease that stiffens the lungs until even ordinary movement becomes effort.

A lung transplant was his path forward. The procedure can extend survival, but it redraws the boundaries of a life: anti-rejection drugs every day, constant monitoring, vulnerability to infection, the knowledge that breathing depends on the fragile acceptance of another person’s donated organ.

González, who was diagnosed with silicosis in 2023, is not alone in dealing with a disease that once was associated with miners at the end of long careers. It’s now prevalent among the much younger, often Hispanic men who work in this industry, physicians and public health officials say.

In the United States, cases are appearing in countertop fabrication shops from California to Texas, Florida, and the Northeast. Because silicosis is not a nationally reportable disease and surveillance varies by state, no comprehensive national count exists. But clinicians who treat occupational lung disease say the number of workers — often men in their 30s and 40s — diagnosed after cutting engineered stone has risen sharply over the past decade.

As of early March, California had identified 519 confirmed cases of engineered-stone-associated silicosis and 29 deaths since 2019. The median age at diagnosis is 46; at death, 49.

Doctors don’t debate whether working with engineered stone can scar lungs.

Manufacturers argue, though, that proper ventilation, wet cutting, and respirators can make fabrication safe. Workers, physicians, and plaintiffs’ attorneys counter that a material composed almost entirely of crystalline silica may be impossible to handle safely at scale.

“This is comparable to the tobacco industry saying cigarettes are safe,” said epidemiologist David Michaels, an assistant labor secretary under President Barack Obama who led the Occupational Safety and Health Administration.

More than 370 lawsuits have been filed by workers who say engineered stone manufacturers failed to warn employees about the risks or sold a product that cannot be fabricated safely. At the same time, members of Congress are considering legislation that would largely shield manufacturers from liability in those cases, turning a workplace health crisis into a national debate over regulation, responsibility, and the limits of civil litigation.

Gustavo Reyes, 36, is part of that debate. Like González, he spent the early years of his career cutting marble and granite before shifting to engineered stone, a quartz-based material that can contain up to 95% silica and generates far more hazardous dust when cut.

In the shop, he said, cutting was done with water to control the dust. But finishing work — sanding and shaping — generated heavy dust. He said he wore disposable respirator masks or a reusable elastomeric respirator with filters. A door was kept open. Fans ran overhead.

When he was diagnosed in 2021, he did not know what silicosis meant. The doctor told him that there was no medication and that he had three to five years to live. He received a lung transplant in 2023.

Asked who he believes is responsible, Reyes answered: “The industries who created the artificial stone, the product.” Manufacturers dispute that characterization. Major companies say engineered stone can be fabricated safely when employers follow OSHA dust controls, including wet cutting, ventilation, and respirator use.

An Old Disease, Reengineered

Silicosis is not new. It was synonymous with mining disasters and sandblasting, most notoriously in the Hawks Nest Tunnel tragedy, when hundreds of workers drilling through silica-rich rock in West Virginia in the early 1930s developed acute silicosis after months of unprotected exposure to dust. In 1938, Labor Secretary Frances Perkins advised that the disease could be prevented if dust controls were conscientiously applied.

What is new is the industry in which it has resurfaced.

Engineered stone, often marketed as “quartz,” is typically composed of crushed quartz bound with resins and pigments. Unlike marble, which contains little crystalline silica, engineered slabs contain very high levels of the substance.

Cutting changes the material.

“When you grind it, when you cut it, you’re pulverizing it,” said Robert Blink, an occupational and environmental medicine specialist who treats patients with advanced silicosis in Chicago and is a member of the Western Occupational and Environmental Medical Association. “You’re weaponizing the silica.”

Power tools fracture the surface into respirable particles small enough to lodge deep in the lungs. Repeated exposure triggers inflammation and fibrosis. Once scarring begins, it doesn’t reverse.

What Happens When You Look for It

In California, physicians say the pattern emerged gradually.

Robert Harrison, an occupational medicine physician at the University of California-San Francisco, helped identify the first cluster of engineered stone silicosis cases in California in 2019 after several workers from the same countertop fabrication shop died or were diagnosed with the disease. He described the crisis as “the largest outbreak of silicosis in decades.” What initially appeared as isolated cases of unexplained lung scarring in young men resolved into a recognizable occupational epidemic once work histories were examined.

Jane Fazio, a pulmonologist at UCLA, recalls seeing advanced fibrosis in otherwise healthy workers. “They have families. They were working full-time,” she said. Some experienced respiratory failure within a few years.

When doctors compared work histories, the pattern became unmistakable: Many of the men had worked in small shops cutting and polishing engineered stone countertops.

Sheiphali Gandhi, an occupational and environmental pulmonologist at UCSF, warned that the true burden remains uncertain. “We’re missing cases,” she said. “There’s no national surveillance system for this.”

California designated silicosis a reportable disease in 2025. Since 2019, statewide surveillance has identified hundreds of cases linked to engineered stone. The numbers probably underestimate the toll, though California’s dashboard makes the illness visible.

Outside California, there is no comparable tracking.

Early Warnings

California was not the first place this happened.

The earliest modern alarm came from Israel. Caesarstone, a company founded on a kibbutz in the late 1980s, helped popularize quartz countertops globally.

Israeli physicians began documenting aggressive silicosis in young countertop workers as early as 1997.

“We had never seen this before,” said Mordechai Kramer, a retired pulmonologist who previously worked at Rabin Medical Center in Israel. “In classic silicosis, you expect long exposure, decades. Here, it was much shorter.”

Several patients required lung transplantation.

Despite the warning signs, the market continued to expand.

Australia confronted the same pattern in the late 2010s.

Rather than wait for sporadic diagnoses, Australian regulators launched systematic CT-based screening of artificial-stone workers. Disease prevalence was far higher than anticipated.

Ryan Hoy, a respiratory physician and occupational health researcher at Australia’s Monash University, described severe disease in workers with relatively short exposures.

Authorities examined whether wet cutting, ventilation, and respirators could reduce exposure sufficiently. They ultimately concluded that even with controls, fabrication of high-silica engineered stone posed unacceptable risk.

In 2024, Australia prohibited the manufacture, supply, and installation of engineered stone containing high levels of crystalline silica. Manufacturers pivoted toward lower- and zero-silica formulations.

In the United States: Who’s To Blame?

Fabrication in the U.S. continues under OSHA’s silica standard, which relies on exposure limits, wet cutting, ventilation, and respiratory protection. Manufacturers argue that compliance works and that the problem lies with shops that fail to follow the rules.

OSHA first adopted silica limits in 1971 based on research from mining, quarrying, and foundry work. Although the agency updated the rule in 2016, it regulates crystalline silica broadly and does not distinguish between natural stone and high-silica engineered quartz.

The regulatory debate has now spilled into Congress. The Protection of Lawful Commerce in Stone Slab Products Act, introduced in September by Rep. Tom McClintock (R-Calif.), would largely shield manufacturers and distributors of engineered stone from civil lawsuits arising from the manufacture or sale of their products. McClintock’s office did not respond to a request for comment.

The bill was the subject of a January House Judiciary subcommittee hearing.

Supporters of the measure argue that manufacturers should not be held liable for injuries caused by employers who fail to follow OSHA standards. Opponents warn that removing litigation pressure would eliminate one of the few mechanisms capable of driving product reform if the material itself cannot be safely handled.

Michaels, the former OSHA official, sees the stakes as historical. “Litigation drives change,” he said, pointing to past battles over asbestos and tobacco.

Plaintiffs’ attorneys argue that compliance with the OSHA silica standard does not eliminate risk.

“It’s not a few bad actors,” said Raphael Metzger, a product liability attorney who has filed roughly 200 silicosis-related injury cases and a class action seeking medical monitoring. He said the issue is the product’s composition, not isolated regulatory noncompliance.

James Nevin, a tort attorney representing workers in silicosis cases, framed the congressional debate as a fight over accountability. “When it comes to causation, there’s no question,” he said, arguing that the wave of cases explains why manufacturers are now seeking what he calls “a manufacturer bailout.”

In mid-2025, Caesarstone US introduced its first products containing less than 1% silica. In response to questions, Irene Williams, a spokesperson for Caesarstone, said, “The company is not responding as these are matters of pending litigation.”

The U.S. engineered stone market is dominated by a handful of large brands — including Caesarstone, Spain-based Cosentino, and U.S.-based Cambria — while the volume of slabs imported from Asian manufacturers is growing.

Cosentino, too, is moving to low-silica products: “One third of the portfolio, including most new collections, contain less than 10% of crystalline silica,” said Kamela Kettles, a Cosentino spokesperson. “Cosentino will not be providing additional commentary at this time,” she said.

Commenting on behalf of Cambria, Mark Duffy, a communications consultant for the company, wrote, “Reckless employers are criminally violating the law, exposing workers to deadly working conditions.” He added that engineering and administrative controls, when properly used, are effective in reducing exposures below OSHA limits and said Cambria maintains exposures below the OSHA Action Level in its own facilities.

While Caesarstone and Cosentino are headquartered overseas, Cambria is based in Minnesota. Its chief executive, Marty Davis, has been a major Republican political donor, contributing millions of dollars to President Donald Trump’s election campaigns as well as to other Republican candidates and political action committees, according to federal campaign finance records. Davis has also contributed to the campaign of Rep. Brad Finstad (R-Minn.), a co-sponsor of the legislation. Finstad’s office did not respond to a request for comment.

Nevin, the attorney, said the bill would give manufacturers “free rein” from civil liability.

He also questions whether regulatory enforcement alone can address the problem. Even before the Trump administration’s funding and staffing cuts, “you had a better chance of being struck by lightning than being visited by OSHA,” he said, arguing that inspections are too infrequent to prevent disease in an industry composed largely of small shops.

Breathing on Borrowed Time

For González, the debate arrives after the fact. The dust he inhaled has already reshaped his life.

And Reyes’ transplanted lungs may last years, but not decades. The median survival time for transplanted lungs is about eight years, UCSF’s Gandhi said.

Reyes said he hopes people shopping for countertops understand that buying artificial stone “will harm the worker. The one who cuts it, the one who manufactures it.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

A difficult lesson in government staffing

About 15 years ago, I was an assistant commissioner at the New York City Department of Health and Mental Hygiene. I led a bureau of about 250 people.

The city was facing budget cuts following the 2008-2009 financial crisis. Because of those cuts, my bureau was told we might need to lay off about 20% of our staff, with additional layoffs projected in later years.

Layoffs are difficult under any circumstances. They affect people’s lives and families and can disrupt an organization’s work. But the process was especially challenging because I had limited control over how the layoffs could be carried out.

Civil service rules determined many of the decisions about who could be laid off and who could not.

In many government systems, layoffs follow seniority rules, sometimes called “last in, first out.” Employees who have worked in an agency the longest often have stronger protections, while newer employees are more likely to be laid off first. These rules are meant to make the process consistent and protect workers from favoritism.

However, they can limit managers’ ability to consider job performance, specialized skills, or program needs when deciding which positions to eliminate.

Leadership during budget cuts requires difficult tradeoffs. Leaders must protect an organization’s core mission while operating with fewer resources. In many organizations, managers can restructure teams or shift resources to protect the most important work.

In government, that flexibility is often limited.

Public-sector leaders frequently face a basic paradox: they are responsible for results but have limited control over staffing, structure, and resources.

That experience changed how I think about government hiring and employment systems.

How the Great Recession affected city budgets

The cuts we faced were part of a broader economic downturn. Tax revenues fell sharply beginning in late 2008 as the financial crisis spread through the economy.

Because most states and cities must balance their budgets, many governments responded with spending cuts and hiring freezes.

New York City faced large budget gaps in the years after the financial crisis. City agencies were asked to reduce spending and eliminate positions.

Public health programs were among those affected.

But budget cuts were only part of the challenge.

Another challenge was the structure of the civil service system.

How civil service hiring works

Even when we knew what expertise we needed, hiring the right person could take a long time.

Many government jobs are tied to specific civil service titles. Candidates often must take a civil service exam and be placed on an eligibility list. Agencies then hire from that list.

This process can take months or even longer. In my own case, it took nearly two years to be hired into my position.

Civil service systems also limit how easily managers can reorganize staff. Job classifications are rigid, and employees may not easily move between roles.

As a result, staffing changes during budget cuts can make an organization less efficient rather than more.

When exams and expertise do not match

Civil service exams are meant to measure merit and fitness for government jobs. In theory, they help ensure that hiring is based on merit rather than politics.

In practice, exams do not always measure the skills needed for the job. Written tests may focus on memorization or general knowledge rather than real-world experience or specialized training.

A candidate who scores well on an exam may not necessarily have the strongest background in the specific work required.

Another constraint is that agencies often must hire from the top of an exam list. Even if another applicant has more relevant experience, the agency may not be able to hire that person.

In specialized fields like public health, this can create a gap between the formal hiring process and the expertise agencies need.

In my experience, the rules of the system did not always align with who was contributing the most to the work.

Why civil service rules are hard to change

Civil service hiring rules in New York are not just administrative policies. They are written into the New York State Constitution.

Article V, Section 6 states that government jobs must be filled based on “merit and fitness.” In most cases, this is determined through competitive examinations.

These rules were created in the late nineteenth century to replace the spoils system, in which government jobs were often given to political supporters.

Civil service exams were designed to reduce political favoritism and create a more professional public workforce.

Courts have generally interpreted these requirements strictly.

One example comes from a case involving Long Beach, New York, a city on Long Island. Local officials attempted to fill certain jobs outside the competitive civil service system. The courts rejected that effort, ruling that governments cannot bypass competitive hiring simply because it is faster or easier.

Because these rules are written into the state constitution, major changes would likely require a constitutional amendment. That process involves approval by two successive state legislatures, followed by a vote by the public.

Staffing challenges in modern health departments

Civil service rules shape how government agencies hire and manage their workforce.

Public health agencies also face additional structural constraints.

Many programs are funded through categorical federal grants tied to specific activities, such as immunization programs, disease surveillance, or maternal and child health services. Funding from these programs often cannot be shifted easily to other priorities.

As a result, leaders may have funding for one program but not for the staff needed elsewhere.

Many public health positions are also supported by time-limited grants. When funding ends, programs and positions can disappear quickly, and experienced staff may leave.

At the same time, public health programs often cannot simply pause. Surveillance systems, laboratory networks, and vaccination programs depend on continuous staffing and infrastructure.

When hiring systems move slowly, filling specialized roles can take months or years.

During public health emergencies, those delays can affect how quickly departments can expand their response.

What the experience taught me

My experience at the New York City health department gave me a closer view of how these systems work in practice.

Civil service protections serve an important purpose. They were created to prevent political favoritism and ensure that government hiring is fair.

At the same time, the system can create real management challenges, especially during periods of budget cuts.

Public health departments today face complex problems that require specialized expertise and rapid response.

But during the recession, the hardest decisions were not about strategy or policy. They were about people.

As a manager, I was responsible for protecting the bureau's work and the services we provided to the public. Yet many of the decisions that shaped those outcomes were governed by rules I could not change.

Looking back, that experience helped me understand something about public-sector leadership: leaders are often held responsible for results while operating within systems that limit their control over the tools needed to achieve them.

During those layoffs, that reality became very clear.

Is Tylenol linked to autism?

A new analysis in JAMA Pediatrics, based on more than 2 million births in Taiwan, is the latest to revisit the question.

If you only read the headlines, you might think the science has suddenly changed.

It hasn’t.

Like a massive Swedish study published in JAMA in 2024, the new paper finds small associations that disappear once researchers account for family factors.

Which is another way of saying: the data still don’t show that acetaminophen causes autism or ADHD.

What the Taiwan study brings to the table

Three things stand out.

First, the scale. Researchers analyzed 2,092,926 births in Taiwan between 2004 and 2015. That’s a lot of babies.

Second, the familiar pattern. When researchers compared unrelated children, they saw a small statistical association between acetaminophen use during pregnancy and ADHD or autism. But when they compared siblings born to the same mother, that association disappeared.

Third, a new puzzle. When the researchers dug deeper into the sibling analysis, the results flipped depending on which sibling was exposed. That kind of reversal usually signals bias in the data, not a drug effect.

The small signal that keeps showing up

In the Taiwan study, children whose mothers were prescribed acetaminophen during pregnancy had slightly higher rates of:

• ADHD (about a 12% relative increase)

• Autism (about a 6% relative increase)

Those numbers may sound alarming.

But in epidemiology, small associations like this often turn out to be confounding. In other words, something else explains the relationship. And in this case, there’s an obvious candidate.

People don’t usually take acetaminophen during pregnancy for fun. They take it because they have:

• fever

• infection

• migraines

• pain

Some of those conditions may themselves affect fetal development.

This is called confounding by indication, one of the oldest headaches in drug safety research.

Trying to separate family factors from drug effects

To try to untangle that problem, researchers sometimes compare siblings born to the same mother.

The idea is simple. Siblings share a lot:

• genetics

• home environment

• parental traits

• socioeconomic background

So if one sibling was exposed to a medication during pregnancy and the other wasn’t, that comparison can help remove some sources of bias.

This approach has become central to the Tylenol debate.

What the Swedish study already showed

In 2024, researchers in Sweden published one of the largest sibling studies ever done on this question. They followed 2.48 million children.

At first glance, the results looked familiar. In standard population analyses, acetaminophen use during pregnancy appeared linked to slightly higher risks of autism, ADHD, and intellectual disability.

But when researchers compared siblings, the associations essentially vanished. The hazard ratios hovered around 1.0. In plain English: no meaningful difference.

The Swedish researchers concluded that the earlier signals likely reflected family-related factors rather than the medication itself.

The Taiwan study finds the same pattern

The new Taiwan study reaches almost the same conclusion.

When researchers compared unrelated children, they saw small associations.

When they compared siblings, those associations disappeared.

But the Taiwan researchers went a step further. And that’s where things got interesting.

When the data stop making biological sense

The researchers separated families into two groups: families where only the older sibling was exposed to acetaminophen, and families where only the younger sibling was exposed.

If the drug truly increased risk, the direction of the association should stay the same. But it didn’t. When the older sibling was exposed, the association looked positive. When the younger sibling was exposed, the association flipped negative. That’s not how biology usually behaves. But it’s exactly what you might expect if bias is still lurking in the data.

Possible explanations include:

• changes in autism and ADHD diagnosis over time

• differences in follow-up between siblings

• birth-order effects

• pregnancy-specific health differences

The authors themselves concluded that the contradictory results likely reflect unaddressed sources of bias.

In other words: the data are messy, which is pretty normal for large observational studies.

The sibling-study debate

Sibling studies are often seen as one of the stronger tools we have in observational research. But they’re not perfect. NIH Director Dr. Jay Bhattacharya has pointed out several limitations.

First, sibling analyses include only families in which exposure differs between pregnancies — so-called discordant siblings. Those families may not represent the broader population.

Second, restricting the sample this way shrinks the dataset, which can reduce statistical power.

Third, sibling designs control for family-level factors but not pregnancy-specific ones, like infections or fever — the very reasons someone might take acetaminophen.

And finally, acetaminophen is widely taken over the counter, which means medical records may miss some exposures.

These are reasonable concerns. But they apply to many observational studies, not just sibling designs. And when multiple large studies from different countries show the same overall pattern, that matters.

The Texas lawsuit over Tylenol

While scientists debate how to interpret these findings, the issue has also moved into the courts.

Earlier this year, Texas Attorney General Ken Paxton sued Johnson & Johnson and Kenvue, the company that now sells Tylenol.

The lawsuit claims the companies misled consumers by failing to warn that taking acetaminophen during pregnancy could increase the risk of autism or ADHD.

A Texas judge recently rejected Kenvue’s motion to dismiss the case, allowing the lawsuit to move forward.

But the legal question is different from the scientific one. Courts focus on whether companies disclosed potential risks. Scientists focus on whether a causal relationship has actually been proven.

Most major medical groups — including the American College of Obstetricians and Gynecologists (ACOG) — say the current evidence does not establish that acetaminophen causes autism or ADHD. ACOG reaffirmed in 2025 that acetaminophen remains one of the safest options available to treat pain or fever during pregnancy.

Still, lawsuits can shape public perception. For many families, seeing a lawsuit filed can sound like proof that the science is settled. In reality, it isn’t.

What pregnant patients should know

Acetaminophen remains one of the most widely used and best-studied medications during pregnancy. It’s often taken to treat fever or severe pain — conditions that can themselves pose risks to the baby if left untreated.

The new study does not show that acetaminophen causes autism or ADHD.

Instead, it highlights something less dramatic but more important: when scientists study very small risks in very large datasets, the results can be messy. That’s the nature of observational research.

Progress tends to come slowly, across many studies, rather than from a single headline-grabbing paper. Which may not be exciting. But it’s how science works.

The limits of fixing diet through medical education

On Thursday in Washington, federal health officials announced a push to teach doctors more about nutrition.

“Today we mark an historic announcement,” Health and Human Services Secretary Robert F. Kennedy Jr. said. “Fifty-three medical schools across 31 states… will require every medical student to complete 40 hours of nutrition training.”

The move targets a long-recognized gap: many physicians receive little formal training in nutrition despite treating diet-related disease every day.

More training is overdue. But doctors alone cannot fix America’s diet. The real driver of chronic disease is the food environment itself, dominated by ultra-processed foods and added sugar.

Medical schools already face hard choices

Medical schools have finite time and an expanding list of subjects.

Students must master genetics, pharmacology, infectious diseases, surgery, and communication with patients. New topics, like artificial intelligence, are also competing for space.

Every new topic pushes another aside.

Nutrition is one clear gap. Many physicians receive fewer than 20 hours of nutrition education in medical school, and surveys show many feel unprepared to counsel patients about diet, obesity, and metabolic disease.

Doctors consistently report needing more training in practical skills like dietary counseling and obesity management. Medical training has traditionally emphasized diagnosing disease more than preventing it.

Surveys of medical students and doctors also show gaps in training on physical activity counseling, sleep, stress, and behavior change — all central to chronic disease prevention.

Ironically, medical students often struggle with healthy habits themselves. Long hours and stress mean poor sleep, little exercise, and irregular diets.

Other under-taught areas include mental health, addiction, women’s health, social determinants of health, health policy, and communication skills.

Doctors do not have to carry all expertise alone. Dietitians and other clinicians also play critical roles in helping patients improve their diets. They often have more time to spend with patients and can provide this care more effectively and at lower cost.

Lessons from tobacco control

Public health experience shows that education alone rarely shifts population health.

Smoking offers the clearest example.

Doctors advising patients to quit helped. So did nicotine patches and counseling.

But the biggest declines in smoking happened after major policy changes:

• taxes on cigarettes

• limits on advertising

• warning labels

• smoke-free laws

These policies changed the environment around smoking.

Ultra-processed foods dominate the American diet

More than half of the calories Americans consume come from ultra-processed foods, and the proportion is even higher for children.

These industrial products combine refined starches, added sugar, unhealthy fats, salt, and additives.

They are engineered to taste good, last on shelves, and be eaten quickly.

They are heavily marketed and everywhere.

Sugary drinks: a major source of added sugar

Sugar-sweetened beverages are one of the largest sources of added sugar in the American diet.

These drinks include:

• soda

• sports drinks

• energy drinks

• sweetened teas

• other flavored beverages

Liquid calories behave differently than solid food. They don’t create the same feeling of fullness. As a result, people often drink these calories in addition to their meals.

Research has linked sugary drinks to a higher risk of:

• obesity

• type 2 diabetes

• heart disease

• fatty liver disease

The American Heart Association recommends limiting added sugar to 25 grams per day for women and 36 grams per day for men.

A single sugary beverage may contain most, or even more than, a full day’s recommended limit in one serving.

Because they are widely consumed and easy to measure, sugary drinks are a major focus of public health policy.

Policies that change behavior

Researchers have studied several ways to reduce sugary drink consumption.

The strongest evidence comes from taxes on sugary drinks.

Several U.S. cities — including Philadelphia, Seattle, San Francisco, Oakland, and Boulder — have implemented these taxes.

After the taxes were introduced:

• prices rose about 33%

• purchases of sugary drinks fell by about one-third

Researchers also found consumers did not appear to travel to nearby cities to avoid the tax.

Other policies, such as improving beverage standards in schools or making water the default drink in kids’ meals, can also help shift habits.

Doctors need training, but the food system needs reform

Improving nutrition education in medical school necessary.

Doctors should understand how diet affects chronic disease and feel comfortable discussing nutrition with patients.

But doctors alone cannot overcome a food system where ultra-processed foods dominate grocery shelves and sugary drinks remain cheap, heavily marketed, and easy to buy.

Solving America’s chronic disease crisis will likely require broader changes, including:

• reducing added sugar in foods and drinks

• limiting marketing to children

• improving school nutrition standards

• using pricing policies that discourage sugary drinks

Doctors need better nutrition training. But fixing America’s diet will require changing the food system itself.

An old drug, a new spotlight, and a sudden shift in autism treatment

For years, Mason Connor’s parents wondered if their son would ever speak. Mason was diagnosed with autism at age 2½ and struggled to communicate despite years of therapy.

Then something unexpected happened.

Three days after Mason started taking a little-known drug called leucovorin, his parents say he said his first word.

I first reported Mason’s story for CBS News in February 2025.

Now, a new study in The Lancet suggests stories like Mason’s may help explain a sudden rise in prescriptions for the drug across the United States.

After a White House press briefing in September 2025 highlighted leucovorin as a possible treatment for autism, prescriptions for the drug among children jumped more than 70% above normal levels, according to the study.

The findings show how quickly public attention can influence the way doctors prescribe medicines.

When a presidential briefing moves the medical needle

Changes in medical treatment usually happen slowly. Doctors often wait for large studies and official guidelines before using new treatments.

But the White House briefing appeared to speed things up.

During the event, the president and federal health officials warned about possible links between acetaminophen use during pregnancy and neurodevelopmental disorders. They also spoke about leucovorin as a promising treatment for some children with autism.

Speakers described the drug as “an exciting therapy that may benefit large numbers of children who have suffered from autism.”

Some autism researchers warned that the evidence for leucovorin is still early and that larger studies are needed.

Still, many doctors soon began hearing from parents asking about the drug.

For families searching for ways to help their children communicate, even early signs of a possible treatment can bring hope.

Mining medical records for evidence of change

To understand what happened after the briefing, researchers looked at a large national medical database called Cosmos. The database includes health records from more than 294 million patients treated at hospitals and clinics that use Epic electronic medical records.

Researchers compared prescription trends before and after the White House briefing.

They found that prescriptions for leucovorin in children ages 5 to 17 rose sharply. In the weeks after the briefing, new prescriptions were 71% higher than expected.

The biggest jump happened during the first month after the announcement, when prescriptions nearly doubled.

Out of curiosity, I asked the researchers to see if there was a similar bump in leucovorin prescriptions after my CBS News story originally aired in February 2025. Here’s what they found:

Between February and November 2025, there was an increase, albeit slower, in leucovorin prescriptions.

The White House press briefing also appeared to affect another medication.

Emergency departments gave acetaminophen to pregnant patients about 10% less often than before. This suggests doctors may have been reacting to warnings about possible risks.

Researchers stressed that acetaminophen is still widely considered safe when used as directed, including during pregnancy.

They also found no similar changes in several other medicines, suggesting the shift was tied to the White House briefing.

Crucially, the researchers found no similar changes in several comparison drugs, indicating the shifts were likely tied specifically to the briefing and related public messaging.

Why researchers are studying leucovorin for autism

Leucovorin has been used for many years to help reduce side effects from some chemotherapy drugs.

But scientists are now studying it for another reason.

Some children with autism appear to have a problem called cerebral folate deficiency. This means their brains may not get enough folate, a type of vitamin B that helps the brain develop and function.

In some cases, the body makes antibodies that block a protein that normally carries folate into the brain.

Leucovorin can enter the brain through another pathway. Scientists believe this may help restore folate levels in some children.

Several clinical studies suggest the drug may help improve language and communication in certain children with autism, especially those who test positive for these antibodies. Some experts would go so far as to say that these children don’t have autism but rather a newly recognized neurodevelopmental disorder that used to be lumped in with autism.

The studies of leucovorin so far have been small. Researchers say larger trials are needed to know which children might benefit most.

The promise and the limits of early evidence

Mason’s story helps explain why interest in leucovorin has grown so quickly.

Doctors sometimes prescribe drugs “off label,” meaning they use them for conditions that are not officially approved by the Food and Drug Administration. Experts estimate that 20% to 30% of prescriptions fall into this category.

Autism is one area where families and doctors are searching for better treatments.

While some medications can help with symptoms such as irritability, none are approved to treat the core social and communication challenges of autism.

The new Lancet study shows how quickly attention — from the media, government leaders, or advocacy groups — can affect medical decisions.

But experts say new treatments should still be tested carefully in large studies.

For now, leucovorin remains a promising but still developing area of autism research.

And for families like the Connors, the search for answers continues.

Matching breast cancer screening to risk

For decades, many women in the United States have followed a simple rule: start getting a mammogram at age 50 (and more recently, at age 40) and repeat it every year. The message was clear and easy to remember. But medicine is starting to ask a harder question: What if not every woman needs the same screening schedule?

Breast cancer is the most commonly diagnosed cancer among women in the U.S. In 2026, experts estimate that over 320 thousand women will be newly diagnosed with invasive breast cancer, and more than 42 thousand will die from it. The average woman faces about a 1 in 8 lifetime risk of developing breast cancer. Screening can help find cancer early, when it is easier to treat. But screening also has downsides, including false alarms and unnecessary biopsies. A major national study, known as the WISDOM trial, tested whether tailoring screening to a woman’s personal risk could be just as safe as annual mammograms. The results are helping reshape the debate over how often women should be screened.

How yearly mammograms became standard

Mammograms came into wide use starting in the 1970s. Over time, studies showed that screening could lower the risk of dying from breast cancer. As a result, many guidelines recommended regular mammograms based mainly on age.

Age-based screening is simple. Breast cancer risk rises as women get older.

But age is only one piece of the puzzle. Two women who are both 45 years old can have very different risks. One may have a strong family history of breast cancer or carry certain genetic changes. Another may have no known risk factors at all. Yet under annual screening rules, both women would get the same test at the same frequency.

Screening also has harms. Mammograms can find spots that look suspicious but are not cancer. These “false positives” can lead to stress, extra imaging, and biopsies. Screening can also lead to over-diagnosis: detecting slow-growing cancers that might never cause harm during a woman’s lifetime.

A personalized approach to mammograms

Risk-based screening tries to match the intensity of screening to a woman’s personal risk of developing breast cancer.

Doctors can estimate risk using models that include factors such as age, family history, breast density, and certain genetic variants. In the WISDOM trial, researchers used a detailed risk model that combined clinical information with genetic testing.

Women in the study were placed into four risk groups. Those at the highest risk were advised to have mammograms and breast MRI scans every six months, alternating between the two. Women at elevated risk were advised to get annual mammograms starting at age 40. Women at average risk were advised to get mammograms every two years starting at age 50. The lowest-risk women under age 50 were advised to delay screening until their risk increased or they turned 50.

The goal was simple: provide more screening to women most likely to benefit and less to those least likely to benefit.

Is risk-based screening safe?

The WISDOM trial included more than 28,000 women ages 40 to 74 from across the United States. They were randomly assigned to either annual screening or risk-based screening. Researchers followed them for a median of just over five years.

The main question was safety: would risk-based screening miss dangerous cancers?

The answer: risk-based screening was “non-inferior” to annual screening. In simple terms, it was just as safe as annual screening in detecting more advanced cancers.

However, one hoped-for benefit did not clearly appear. Researchers expected fewer biopsies in the risk-based group, but biopsy rates were not significantly lower. But women in the risk-based group had fewer mammograms, especially among women at lower risk of breast cancer.

Can personalized screening work in real life?

Even though the results are promising, experts say there are challenges.

In the WISDOM trial, many women did not strictly follow the screening schedule they were assigned. Some women in the yearly screening group got extra imaging. Some women in the high-risk group did not get as much MRI screening as recommended. When screening does not happen the way it was designed, it becomes harder to judge how well a new approach truly works.

There is also a bigger issue. When screening recommendations are not clear or consistent, confusion can grow. If different groups recommend different starting ages or different schedules, doctors and patients may not know which advice to follow. In busy clinics, complicated rules can lead to missed conversations about risk. Some women may be told to wait. Others may assume they are not at risk. Over time, people can fall through the cracks.

Personalized screening depends on knowing a woman’s risk. That often requires detailed questionnaires, breast density information, and sometimes genetic testing. Not all women have equal access to these tools. Women with less access to health care, less time off work, or less insurance coverage may be less likely to complete risk testing. If personalized screening is not built into routine care, it may widen gaps rather than close them.

Still, the trial shows that personalized screening can be done on a large scale. Researchers mailed genetic testing kits to women across all 50 states and successfully used those results to guide screening recommendations. The next challenge is making sure that any new system is simple, consistent, and easy to follow so that no one is left out.

The future of mammograms

The debate over annual versus risk-based screening is not about whether mammograms matter. They do. Screening has helped reduce deaths from breast cancer over time.

The real question is how to get the most benefit with the least harm.

Risk-based screening recognizes that women are not all the same. A woman at very high risk may benefit from more intensive screening, including MRIs. A woman at very low risk may safely wait longer between mammograms.

For now, national guidelines still vary, and annual screening remains common. But studies like WISDOM suggest that the future of breast cancer screening may be more personal, more precise, and more focused on matching care to each woman’s unique risk.

Esserman LJ, Fiscalini AS, Naeim A, et al. Risk-Based vs Annual Breast Cancer Screening: The WISDOM Randomized Clinical Trial. JAMA. 2026;335(9):763–774.

Baxter NN, Phillips KA. Unlocking the Potential of Risk-Based Screening for Breast Cancer: From Detection to Prevention. JAMA. 2026;335(9):758–760.

Keating NL, Pace LE. Risk-Based Screening for Breast Cancer: Time to Focus on Implementation. JAMA Oncol. Published online February 26, 2026.

The latest research

A new study published in the Journal of the American College of Cardiology found that both low-carbohydrate and low-fat diets can lower the risk of heart disease, but only when they emphasize high-quality, largely plant-based, minimally processed foods, such as whole grains, fruits, vegetables, nuts, and healthy fats. The study followed nearly 200,000 adults for up to 30 years. Diets built around refined carbohydrates, added sugars, or processed and animal fats were associated with a higher risk of heart disease.

Heart-healthy eating made simple

• 1/2 of your plate: vegetables and fruits

• 1/4 of your plate: high-quality carbs

• 1/4 of your plate: healthy proteins and fats

Your grocery shopping list (print me!)

Non-starchy vegetables (fresh or frozen)

☐ Leafy greens (spinach, kale, arugula, arugula)
☐ Cruciferous vegetables (broccoli, cauliflower, brussels sprouts, bok choy)
☐ Colorful vegetables (bell peppers, tomatoes, carrots, eggplant)
☐ Green beans, zucchini, asparagus, celery, cucumbers, mushrooms
☐ Onions, garlic, leeks, shallots

Whole fruit (fresh or frozen)

☐ Berries
☐ Apples
☐ Oranges, grapefruit
☐ Pears
☐ Kiwi
☐ Grapes

Protein

☐ Beans (dry/canned, but soak/rinse first: black, chickpeas, lentils, kidney, cannellini, navy, pinto)
☐ Fish (fresh/tinned salmon, sardines, trout, mackerel)
☐ Tofu or tempeh
☐ Unsalted nuts and seeds

Whole Grains

☐ Old-fashioned oats
☐ Brown rice
☐ Quinoa
☐ Barley
☐ Farro
☐ Bulgur
☐ Millet
☐ Buckwheat (kasha)
☐ Whole-grain pasta
☐ 100% whole-wheat bread

Healthy Fats

☐ Olive oil
☐ Avocado oil

Tip: Shop mostly around the perimeter of the grocery store.

Why women’s heart risk Is rising, and why the clock starts earlier

Heart disease is often framed as a problem that strikes later in life: men first and women later. But across the U.S., the trend line for women is moving in the wrong direction: more high blood pressure, more obesity, more diabetes, and more women living long enough for those risks to turn into heart disease and stroke. That slow build, year after year, is what makes the American Heart Association’s warning about the next few decades so alarming.

American Heart Association (AHA) researchers forecast that by 2050, nearly 6 in 10 U.S. women will have at least one type of cardiovascular disease. The AHA projects that high blood pressure in adult women will rise from 49% in 2020 to 59% in 2050; obesity, from 44% to 61%; and diabetes, from 15% to 25%.

The most urgent lesson may be about timing. Cardiovascular risk is building earlier, and pregnancy is a major hinge point. Complications like preeclampsia and gestational hypertension can be early warning signs for future heart disease; at the same time, underlying cardiovascular risks can make pregnancy itself more dangerous. In plain terms: the relationship is bidirectional, and ignoring either is how the forecast becomes reality.

At first, it can feel like a small thing: a cuff on your arm, a few seconds of squeezing, and a number on a screen. But that number, especially blood pressure, is one of the biggest reasons the AHA now says the future of women’s heart health in the U.S. could look so rough.

Longer lives, more time for risk to accumulate

A key reason the total burden rises is simple: women generally live longer than men, and heart risk rises with age. The AHA notes that women make up about half of new and existing cardiovascular disease cases and, because women tend to outlive men, the long-term burden and costs are especially high.

This creates a tough paradox. Medicine can help more women survive earlier problems, but if prevention is weak, more women will live long enough to develop chronic heart disease later.

Pregnancy as an early warning system for heart disease

The AHA’s forecast is not only about older women.

One reason experts are paying closer attention to younger women is that pregnancy complications can act like an early warning sign. Hypertensive disorders of pregnancy — like gestational hypertension and preeclampsia — are linked to a two-times higher risk of later cardiovascular disease, even for women who did not have major risk factors before pregnancy.

This matters because it changes the timeline. Heart disease is not just a “later in life” issue. For many women, the earliest red flags show up in their 20s and 30s, when there is still time to prevent a lifetime of problems.

Who bears the brunt: race, geography, and access to care

The AHA projects American Indian/Alaska Native or multiracial, Black, and Hispanic women will be hit hardest by these trends.

They also point to “deep inequities” tied to race and ethnicity and describe how overlapping barriers, like poverty, low health literacy, rural residence, and chronic stress, can stack on top of one another and worsen heart outcomes.

The path forward: treat pregnancy history like a heart health vital sign

Prevention is the most efficient and least costly path forward, but it has to happen both in clinics and in communities.

In the clinic, the biggest wins are still basic, even if they are not easy: finding and controlling high blood pressure, preventing and treating diabetes, and treating obesity with effective tools that people can actually access.

Pregnancy needs to be treated as part of heart care, not a separate lane. A history of hypertensive disorders of pregnancy should trigger real follow-up, because it can signal higher cardiovascular risk years before a heart attack or stroke.

Outside the clinic, the public health answer is that healthier communities make healthier hearts. That means neighborhoods with safe places to walk, affordable healthy food, stable housing, less chronic stress, and accessible and affordable healthcare.