The US, the World Health Organization, and the Global Health Infrastructure, JAMA Health Forum, March 14, 2025, by Sandro Galea, M.D., Dr.P.H., Editor in Chief

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The US has, in the Centers for Disease Control and Prevention, one of the premier public health agencies in the world. In addition, state and local health departments add a further level of public health action that serves the country well in tackling public health challenges. And yet, it has been amply documented that the US spends less money on public health than it should for a country of its size and complexity, and that ongoing cuts to public health funding pose a threat to population health. This was perhaps most evident during the COVID-19 pandemic, when public health systems were frequently threatened and had a difficult time keeping up with a rapidly changing infectious threat. More than 1 million individuals died of COVID-19 in the US. This death toll plus the estimated $16 trillion cost of the COVID-19 pandemic in the US are a sobering reflection of the underinvestment in public health that exposes the country to risk.

The COVID-19 pandemic is also a recent reminder of how difficult it is to separate the work of public health domestically from the work of public health globally. COVID-19 amply showed that pandemics do not respect national boundaries, and that global coordination is a key element of global disease control. However, in recent years, US engagement in global efforts to control disease has been challenged by its domestic political changes. In 2020, under the first Trump presidency and during the COVID-19 pandemic, the US withdrew from the World Health Organization (WHO), only to return in the first few months of the Biden Administration. The second Trump Administration similarly withdrew from the WHO during its first week in office. This immediately threatened the function of the WHO. The WHO Director-General subsequently issued a hiring freeze, and noted a range of consequences that US withdrawal may have on the capacity of the WHO to carry out its mission.

Academic analysis has also noted a range of harmful consequences that may follow the US withdrawal from the WHO. These include, but are certainly not limited to, having less access to surveillance data needed to anticipate outbreaks and losing influence on what remains the world’s most important health agency. The global consequences may be even more severe given the funding cuts, threatening the organization’s ability to function effectively, particularly during global health crises. Therefore, the US finds itself at a worrisome inflection point in its alignment with global health infrastructure. Time will tell whether the anticipated consequences—for the US and global health—of disengagement from the WHO will emerge, but if they do, they will be an unfortunate and self-inflicted undercutting of US leadership in global health.

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Comment:

By Don McCanne, M.D.

The World Health Organization? In the first Trump administration, the underfunding of public health, and especially the termination of our participation in the WHO, contributed significantly to the death of more than one million individuals in the United States, not to mention the other world-wide suffering and deaths in the COVID-19 pandemic. And this is only one of the many crucial functions of the WHO. More than one million US deaths!

Though the Biden administration renewed our participation in the WHO, did the voters in our last presidential election really ask Trump to withdraw us again from the WHO? The media tells us that their minds were on immigration and the price of eggs. But it was also quite clear that people thought that Trump would be more effective in reducing taxes (though primarily for the top 1% of incomes) and would reduce government spending (believing that those reductions would be in waste, fraud and abuse, but not in programs such as Social Security and Medicare). Very little thought and discussion was given to other programs such as WHO (not to mention USAID, education, CDC HIV prevention, diabetes prevention, food security – especially for children, and federal employment opportunities). Although half of the nation still does not recognize the potential impact of these reductions in spending on important government programs, the other half does, and that recognition is increasing. As people begin to feel the impact of reductions in government services, and the impact of price increases because of Trump’s tariffs and other flawed economic policies, it is likely that they will recognize the emptiness of Trump’s promises and be ready for policies that will meet their needs.

But right now, most recognize that we do not want these attacks on our health and well-being, and we do want the health of our country and of the world protected. Those who are informed know that we do want the WHO and USAID protected and supported, and those who don’t realize that need to be educated to find out what these programs do and support them to protect us and our families and friends at home and throughout the world. We don’t have the luxury of waiting to see how much harm terminating these programs will do since the cost in suffering and lives will be too great. We need to let our legislators know now (as we are already doing in their town hall meetings), and they will let the president and his administration know. Preserving the health of all citizens of the world is not selfish and not all that expensive. We certainly cannot stand by and watch the wealthiest man in the world tear these systems apart.

https://healthjusticemonitor.org…

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Cuba Sends Doctors, the US Sends Sanctions, JACOBIN, March 8, 2025, by Helen Yaffe

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The United States calls Cuba’s medical internationalism “human trafficking” – but it’s really an internationalist lifeline for the Global South.

On February 25, US secretary of state Marco Rubio announced restrictions on visas for both government officials in Cuba and any others worldwide who are “complicit” with the island nation’s overseas medical-assistance programs. A US State Department statement clarified that the sanction extends to “current and former” officials and the “immediate family of such persons.” This action, the seventh measure targeting Cuba in one month, has international consequences; for decades tens of thousands of Cuban medical professionals have been posted in around sixty countries, far more than the World Health Organization’s (WHO) workforce, mostly working in under- or unserved populations in the Global South. By threatening to withhold visas from foreign officials, the US government means to sabotage these Cuban medical missions overseas. If it works, millions will suffer.

The predominant global approach, exemplified by the United States, is to regard health care as an expensive resource or commodity to be rationed through the market mechanism. Medical students “invest” in their education, paying high tuition fees and graduating with huge debts. They then seek well-paid jobs to repay those debts and pursue a privileged standard of living. To ensure medics are well remunerated, demand must be kept above supply. The World Economic Forum projects a shortfall of ten million health care workers worldwide by 2030. But the Cuban investment in medical education raises the supply of professionals globally, thus threatening the status of physicians operating under a market system. Critically, the Cuban approach removes financial, class, race, gender, religious, and any other barriers to joining the medical profession.

The key features of the Cuban approach are: the commitment to health care as a human right; the decisive role of state planning and investment to provide a universal public health care system with the absence of a parallel private sector; the speed with which health care provision was improved (by the 1980s Cuba had the health profile of a highly developed country); the focus on prevention over cure; and the system of community-based primary care. By these means, socialist Cuba has achieved comparable health outcomes to developed countries but with lower per capita spending — less than one-tenth the per capita spending in the United States and one-quarter in the UK. By 2005, Cuba had achieved the highest ratio of doctors per capita in the world: 1 to 167. By 2018, it had three times the density of doctors in the US and the UK.

Today Cuba is in the midst of a severe economic crisis, largely resulting from US sanctions. The public health care system is under unprecedented strain, with shortages of resources and of personnel following massive emigration since 2021. Nonetheless, the government continues to dedicate a high proportion of GDP on health care (nearly 14 percent in 2023), maintaining free universal medical provision, and currently has 24,180 medical professionals in fifty-six countries.

Revolutionary Cuba was never solely concerned with meeting its own needs. Between 1999–2015 alone, overseas Cuban medical professionals saved 6 million lives, carried out 1.39 billion medical consultations and 10 million surgical operations, and attended 2.67 million births, while 73,848 foreign students graduated as professionals in Cuba, many of them medics. Add to that the beneficiaries between 1960 and 1998, and those since 2016, and the numbers climb steeply.

The beneficiary nations have been the poorest and least influential globally; few have governments with any leverage on the world stage. Recipient populations are often the most disadvantaged and marginalized within those countries. If Cuban medics leave, they will have no alternative provision. If Rubio and Trump are successful, it is not just Cubans who will suffer. It will also be the global beneficiaries whose lives are being saved and improved by Cuban medical internationalism right now.

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Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

The world community respected the United States for its humanitarian support via USAID which helped to meet the medical needs of countries that lack the resources to do so on their own. One of the first major actions of the Trump administration was to slash the resources and functionality of USAID such that the nations we served were stripped of life-saving medical prevention and care, and further denied food resources to prevent starvation, especially in children. USAID was moved to the State Department wherein Secretary Marco Rubio was set to supervise the degradation of this important agency.

Fortunately, Cuba has made it a national priority to try to fulfill these unmet health needs. Though not as wealthy as the United States, the extent of their success has been phenomenal.  Millions of lives saved; massive suffering and grief averted.

As we abandon the humanitarian mission of USAID, what approach have we taken to honor the work of Cuba in providing these valuable services? None. We don’t honor Cuba for meeting needs that we have abandoned. Instead, we place restrictions on visas for government officials in Cuba and others worldwide who are complicit with Cuba’s overseas medical-assistance.

What? We not only lay waste to our own humanitarian efforts, we try to slow Cuba’s? Hard to fathom, unconscionable.

People of good will in the US have been trying for decades to provide affordable, broad health care for everyone here, while offering meaningful support to poorer nations with even greater needs. President George W. Bush, in his most noble act, founded and fostered the PEPFAR program for foreign health assistance in HIV, and thus super-charged global health assistance. Strong foreign aid in health has been a bipartisan consensus (albeit still just 1% of the US federal budget). Now, in 2025, not only does the new Trump administration want to undo our own programs, it plans to punish a country whose offense is to fulfill the unmet medical needs of poverty-stricken nations.

We ask what kind of government leadership is it that we have elected that would drive us in the direction voiced by Trump, Musk, Miller, and now Rubio? We’re sure that the actions are illegal and impeachable. We also recognize that such outcomes are all but impossible in the foreseeable future.

For now, we ask you to link the ongoing fight for US Health Justice via universal publicly financed health insurance (single payer) to the ongoing fight for global Health Justice via foreign assistance. Write to your representatives and senators, donate to organizations that are advocating for USAID programming and staff, and for Cuba, and participate in public protests. Unified outrage is the only appropriate response.

https://healthjusticemonitor.org…

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Republicans Once Wanted Government out of Health Care. Trump Voters See It Differently, KFF Health News, Feb. 27, 2025, by Noam N. Levey

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Government regulation of health care prices used to be heresy for most Republicans. GOP leaders fiercely opposed the 2010 Affordable Care Act, which included government limits on patients’ costs.

But as Trump begins his second term, many of the voters who sent him back to the White House welcome more robust government action to rein in a health care system many Americans perceive as out of control, polls show.

Republican voters strongly back federal limits on the prices charged by drug companies and hospitals, caps on patients’ medical bills, and restrictions on how health care providers can pursue people over medical debt.

Even Medicaid, the state-federal insurance program that Republican congressional leaders are eyeing to dramatically cut, is viewed favorably by many GOP voters.

Skepticism about government lingers among rank-and-file Republicans. And ideas such as shifting all Americans into a single government health plan, akin to “Medicare for All,” are still nonstarters for many GOP voters.

But as tens of millions of Americans are driven into debt by medical bills they don’t understand or can’t afford, many are reassessing their inclination to look to free markets rather than the government.

In a recent national survey, Fabrizio Ward and Hart Research, which for decades has polled for Democratic candidates, found that Trump voters were more likely to blame health insurers, drug companies, and hospital systems than the government for high health care costs.

Three-quarters of Trump voters back government limits on what hospitals can charge, Ward’s polling found.

Mike Perry, who’s convened dozens of focus groups with voters about health care in recent years, said the support for government price caps is all the more remarkable since regulating medical prices isn’t at the top of most politicians’ agenda. “It seems to be like a groundswell,” he said. “They’ve come to this decision on their own, rather than any policymakers leading them there, that something needs to be done.”

Other forms of government regulation, such as limits on medical debt collections, are even more popular. About 8 in 10 Republicans backed a $2,300 cap on how much patients could be required to pay annually for medical debt.

As Trump and his allies in Congress begin shaping their health care agenda, many Republican leaders have expressed more interest in cutting government than in expanding its protections.

“There is oftentimes a massive disconnect,” Ward said, “between what happens in the caucuses on Capitol Hill and what’s happening at family tables across America.”

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Comment:

By Don McCanne, M.D.

The important message here is that it is not only Democrats who are concerned about health care costs so much that they want the government to take action—it is Republicans as well, including those who voted for Trump in 2024. In fact, many Trump supporters think he would do a better job in controlling their health care costs.

Yet there is still significant opposition to single payer / Medicare for All. This is despite numerous studies showing that such a model would be more effective in controlling costs while ensuring access to comprehensive, high quality care for all, affordable for each one of us. They want the government to help, but they remain uncomfortable with the single payer model. So what is going on here?

Most of all, the private insurance industry has been very effective in marketing their products. A predominant example: people on Medicare believe that private Medicare Advantage plans will provide greater benefits at a lower cost than traditional government-managed Medicare. When the insurance product is marketed to them, it seems like that is true. They get a few additional, nominal benefits that are not offered in traditional Medicare, and the up-front costs are lower than premiums in the traditional program especially if including Medigap plans needed to fill coverage holes.

But the financial advantage is illusory. The purpose of health insurance is to provide better access to necessary health care while controlling costs that they would otherwise be exposed to when they need to access that care. Is that the way private Medicare Advantage plans work? No. When beneficiaries need to use their plans, they usually have a limited choice of providers because of the narrow networks covered; they face prior authorization requirements; and they often have greater out-of-pocket expenses because of the deductibles and copays required by the plans, often creating financial hardship. At that point, they might want to return to the greater choices and more affordable coverage of traditional Medicare, but the Medigap plan may no longer be available because of pre-existing conditions (which are ignored at the time of original enrollment).

Actually, what patients want at the time of medical need would be choice of providers, truly comprehensive benefits, with elimination of cost-sharing at the time of service. The way you would get that is through a single payer system, an improved Medicare for All.

Paying for it? This would happen via a public insurance program which would be progressively financed through taxes with those in poverty paying nothing, and increasing with income, with the billionaires paying significantly more than the actual costs. This would be the most equitable method, with no person suffering a financial hardship (when unaffordable costs happen to be one of the greatest sources of dissatisfaction with today’s health care system).

Of course, Republicans have heavily opposed single payer since they greatly favor further reduction in taxes for the billionaires while having the masses fund care through reduced benefits and greater financial contributions. They currently support a privatized Medicare Advantage for All that would do this: fewer paid benefits for lower income individuals and greater cost sharing at the time of service – the opposite of what our system should be providing.

We see that the public broadly does want the government to be involved in fixing our system, providing better care at lower costs. But we really need to do this through the more humanitarian single payer model, rather than through tweaking a system designed to shift our health care dollars to wealthy private investors and away from care.

Our task now is to explain to everyone (including Trump voters!) that they can have the government controls that they want, but that the system needs to be designed so that it works for the people, all of us, rather than being designed to increase the wealth of the private investors at a cost to the average citizen of affordability and access to the care that they need.

Once they understand the system, that’s what they’ll want.

https://healthjusticemonitor.org…

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FLASH BREAKING: Major news on Republicans CUTTING healthcare, YouTube video (8 min), Feb. 25, 2025, by Brian Tyler Cohen

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Liberal Redneck – On Gutting Medicaid and Food Stamps to Cover More Tax Cuts for the Wealthy, YouTube video (8 min), Feb. 26, 2025, by Trae Crowder

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“I was a poor kid, I know gross, but I was I was on all these programs. Food stamps subsidized my education all through college; don’t know what I would have done without them and in the intervening years since I have paid back far more in taxes than I ever got for the government. So the point is stop looking at these programs as an endless money glitch for a bunch of freeloaders, and look at them instead as an investment in one of our most vital resources: each other. I am walking breathing talking proof that the ROI can be pretty damn good. We can use these programs to lift up countless other Americans out of poverty.”

“All right, look, giving these rich people even more money is not going to work. You know how I know? Cuz we’ve been doing it for more than 40 goddamn years. If the Blessed urine of our betters was ever going to trickle down to us, I think we’d have felt a drop or two by now. All right so I’m imploring you — wake up stop tongue-polishing the boot that’s on your throat, and recognize the value of investing in your fellow Americans.”

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The Debate Over Federal Medicaid Cuts: Perspectives of Medicaid Enrollees Who Voted for President Trump and Vice President Harris, KFF (Kaiser Family Foundation), Feb. 25, 2025, by Amaya Diana, Jennifer Tolbert, & Robin Rudowitz

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• Many Trump and Harris voters said that … they did not recall hearing about changes to health care programs (including Medicaid) during the campaign. Most participants said the government has a role to play in making health care more affordable and accessible … both Trump and Harris voters [said] that state verification procedures prevent individuals from defrauding the program on a large scale …

• … Participants opposed cutting Medicaid funding to pay for tax cuts that they did not believe would benefit them. Both Trump and Harris voters expressed fears that these changes would jeopardize the program, take away access to health care, result in worse health outcomes, and increase out-of-pocket costs. A few Trump voters did not believe Trump would follow through on the cuts to Medicaid because they believed he understood their financial struggles.

• Both Trump and Harris voters valued their Medicaid coverage and the access to health care services, mental health services, and medications for themselves and their children it provides. Participants also valued Medicaid because it helps to protect them from financial disaster, alleviates stress, improves health outcomes and often supports their ability to work. Participants said losing Medicaid would “be devastating” and lead to serious consequences for their physical and mental health and exacerbate pre-existing financial challenges.

• If work requirements were introduced to Medicaid, participants who were working generally felt confident in their ability to meet the requirements; however, they worried about the burden of monthly reporting requirements when those were described to them. Many participants across parties noted that access to treatment for chronic conditions, including prescription medications and mental health treatment, were key in helping to support their ability to work. More Trump voters supported a work requirement but some who were not working were convinced they would qualify for an exemption. Other participants, including both Trump and Harris voters, who were not currently working felt they would face challenges in meeting the requirements. Those who were not working said they wanted to work (and many had been previously working for many years) but were generally unable to because of disability or because they were caring for young children or a sick parent.

• Both Trump and Harris voters wanted policymakers to focus on improving Medicaid instead of cutting it. For example, some participants said they would like to see enhanced dental benefits, increased doctor availability, and fewer prior authorization requests. Focus group participants wanted policymakers to consider the implications of federal cuts to Medicaid for people, their health, financial stability, and ability to be productive members of society.

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Comment:

By Jim Kahn, M.D., M.P.H.

This week’s House budget resolution sets targets for subsequent detailed appropriation bills. The two largest priorities: cut Medicaid for the poor, and slash taxes (predominantly) for the rich. Net result: an increase in debt of nearly $3 trillion – that’s $8500 per person, >$25,000 for a family of three, while growing the ranks of the uninsured.

These strategies are widely unpopular, including the Medicaid cuts, as heard by KFF in their bipartisan focus groups.

The $880 billion in Medicaid cuts is about 10%. Where will that come from? Payment rates are already dangerously low. Benefits are slim. A GOP Congressman in the Tyler Cohen video, when repeatedly asked if he’ll vote against “cuts to Medicaid”, robotically intones with a smirk: “No benefit cuts.” What does that mean? How is that possible? Presumably: the budget cuts will arise from restrictions in eligibility (who qualifies), without removing benefits for those covered. So what’s better, less for the same number of beneficiaries, or excluding millions of beneficiaries? Cruel either way, IMO. But for the GOP rep, it’s all political subterfuge.

I do appreciate that economics was highlighted in both of these decidedly non-economic forums. Brian Tyler Cohen presents the Center for American Progress graphic summary of the budget proposals. And Trae Crowder talks about “return on investment” – his taxes as a worker far exceeding what the government invested in his healthy growing up.

Progressives have been losing the social media wars. With entertaining and whip-smart presenters like these YouTubers, we are making up lost ground!

But what’s most encouraging to me is how much a wide swath of voters like and rely on Medicaid. Not that it’s a perfect program, far from it. Despite its limitations. Just imagine how they’d feel about lifelong universal health insurance, with broad benefits, paying fair rates to providers, and no significant cost-sharing. It would be heaven. It’s called single payer. It’s an important way to unite left, middle, and right against the billionaires (but they’d be covered too).

https://healthjusticemonitor.org…

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