Author: Evan Rose

Medicare Advantage Is Giving Away Billions To Corporate Insurers. It’s Time We Put A Stop To It

Posted on November 17, 2023

Physicians and policymakers are, in different ways, both responsible for the health and well-being of patients. While physicians care for patients to the best of their ability, policymakers ensure that the structures that make up the health care system are effective and equitable. Whenever and wherever there is a threat to these goals, both groups have a role to play in recognizing and combating it. That is why we are speaking out on the need to make fundamental changes to the Medicare Advantage (MA) program.

MA as it exists today is a threat to patient care, to health equity, and indeed to the integrity of our public health infrastructure. A new report from Physicians for a National Health Program, an organization of doctors working to reform the health care system, shows that for-profit, corporate MA insurers are overpaid anywhere from $88 to $140 billion a year. That’s money coming out of patients’ and taxpayers’ pockets.

MA is the privately-run version of the traditional government-administered Medicare program. Instead of paying directly for care, the government instead pays insurers to “manage” patients’ needs. Enrollment in this program has grown significantly over the past two decades, with over 50 percent of eligible beneficiaries opting for an MA plan in 2023. Unfortunately, growth in the program has not led to better care for beneficiaries or a better deal for taxpayers — just the opposite, in fact. Tens of billions of taxpayer dollars are being siphoned off as profit by insurance companies that don’t even provide necessary care. That money doesn’t just cost our government, it costs seniors. For example, premiums paid for Medicare Part B, which covers most medical services outside of hospitalization, totaled $131 billion in 2022. With the amount of extra money that corporate insurers get from the government, we could totally eliminate Part B premiums and still have money left over.

Where is all this money coming from? It’s complicated, the result of a tangled web of loopholes, policies, and practices that are difficult for an individual beneficiary or physician to see. Even so, scholars and regulators have identified a few major factors that lead to overpayments. For example, insurance companies in MA tend to enroll patients that are healthier and therefore cost less than average but still get paid as if their patients were much sicker. This is called favorable selection, and by some estimates, it could cost as much as $75 billion a year in extra payments.

Because Medicare gives additional money to MA insurers for patients with more severe or more numerous diagnoses, another source of overpayments are all the irrelevant or old conditions that insurers record on patient charts. This practice is known as upcoding; these conditions aren’t being actively treated, so they don’t cost the insurance company anything, but they do lead to as much as $20 billion in extra payments. These methods only scratch the surface of all the ways in which MA insurers take advantage of the system, but the bottom line is clear: these companies are pocketing billions of dollars that belong to Medicare beneficiaries.

Of course, it isn’t just about the money; it’s also about patient care. Medicare Advantage plans tout their low premiums and extra benefits, but often these are only worth it as long as you’re healthy. If you get sick and need complex or significant care, plans start to show their true colors. Difficult authorization processes and narrow networks can make getting treated under an MA plan a nightmare. In fact, high-need patients with chronic conditions and patients in their last year of life are substantially more likely to switch out of MA and back to traditional Medicare, tired of having to justify each and every needed procedure or medication to their insurance company.

In our roles as a member of Congress and a practicing physician, we see different but equally concerning manifestations of these problems. Constituents call in with stories of being lured into an MA plan, and then denied care or prevented from seeing their doctor. Cancer patients, for whom an early diagnosis and treatment plan is imperative to survival, face weeks of delay because of onerous pre-authorization requirements. In fact, some of these patients have ended up needing emergency surgery or aggressive radiation that could’ve been avoided if insurers hadn’t gotten in the way. MA doesn’t just take billions in taxpayer dollars; it makes it harder for doctors to do their jobs, and harder for patients to get well.

With the money that we spend on corporate giveaways, we could entirely fund Medicare’s prescription drug benefit, establish an out-of-pocket maximum in traditional Medicare, or even provide dental, hearing, and vision benefits to everyone on Medicare and everyone on Medicaid. This doesn’t need to be a partisan issue. We should all agree that programs paid for by the people should benefit the people. It’s time to crack down on overpayments in MA and use those resources to improve Medicare for all patients.

Voters Aren’t Green About Climate Change Threats

Posted on November 15, 2023

This November’s election results should be a wake-up call to any politician who was unsure of Americans’ desire for robust climate action and support for a green economy. In states and counties that are red, blue and everywhere in between, voters favored forward-looking candidates who embraced both the need for and the economic benefits of aggressive climate action.

As much of the reporting on this election cycle has already pointed out, reproductive freedom was clearly a heavy driver of Democratic performance on Election Day. That shouldn’t overshadow the fact that, in marquee races, well-funded attacks against strong climate policies from the far right and fossil fuel interests were ignored or rejected by the voters they hoped to sway. And the emphasis on reproductive freedom doesn’t diminish the role that issues like clean energy and a healthy future for our planet and our communities played in galvanizing voters.

The climate crisis is here. It’s not politely knocking at our door; it’s banging it down. Americans in every corner of this country are hyperaware of it, especially after the dangerous and deadly heat waves and wildfires many of us experienced this year. What we’re seeing in our backyards is connected to a larger, global crisis that is affecting all life on this planet we call home. Just-released research shows that the past 12 months were the hottest on record.

This fight has always been about our future, but increasingly it’s also about our present. Voters get it.

This was especially evident in Virginia, where voters forcefully denied the Republican governor’s bid for full control of the state government. The electoral rebuke of Gov. Glenn Youngkin and his views — in which Democrats didn’t just protect their state Senate majority but also gained control of the state House — effectively ends his push to undo the climate progress enacted under his predecessor.

Youngkin sought to roll back emissions standards aimed at moving Virginia away from the sale of new vehicles with internal combustion engines as of 2035. And he has been waging an effort to withdraw Virginia from the Regional Greenhouse Gas Initiative cap-and-trade program.

LaTwyla Mathias, who leads Progress Virginia and worked to mobilize voters in this year’s election, said that among her organization’s digital ads this cycle — which were shown to voters of color, young voters and women — the ads focused on climate were the top performers.

“Our research shows that climate voters care about freedom: the freedom to breathe clean air, the freedom to live in a healthy environment, and the freedom to make decisions for themselves,” Mathias said. “Black and brown voters showed up on Tuesday because they know we’ve fought too long and too hard to let special interests take these freedoms from us.”

“By electing climate champions, we can fight back on growing health risks and pollution in marginalized neighborhoods, defend our neighbors with severe medical conditions, make sure that our communities have an opportunity to get trained in new jobs so that the transition to clean energy doesn’t leave anyone behind, and protect the progress we’ve made with the Regional Greenhouse Gas Initiative,” Mathias said.

So, as we discuss all the fundamental rights that were on the ballot this year and will be in 2024 — abortion, the right to vote, gender equality, workers’ rights and more — let’s not forget that the results of the Nov. 7 elections prove that the right to a clean environment and a habitable planet is a major election issue for an ever-growing number of Americans — especially those who live in communities on the frontlines of the climate crisis.

The Supreme Court’s New ‘Code Of Ethics’ Changes Nothing

Posted on November 14, 2023

This latest pathetic attempt at pacifying the public will do little to reverse the sharp decline in public confidence in the nation’s highest court.

Yesterday, the Supreme Court announced an ethics code for the justices. But the code is utterly empty. It has no enforcement mechanism and no mechanism for the public to lodge complaints of misconduct.

It’s public relations pablum.

The court effectively admitted this, saying that “the absence of a Code… has led in recent years to the misunderstanding that the justices of this court, unlike all other jurists in this country, regard themselves as unrestricted by any ethics rules.”

The new code has no system for the public to lodge complaints or for any outside review of alleged ethical violations.

Misunderstanding? I’m sorry, but the public understands quite well that the justices regard themselves as free to do whatever they wish, in terms of ethics.

In April, ProPublica documented years of undisclosed luxury travel enjoyed by Justice Clarence Thomas, including private jets and trips aboard a super-yacht courtesy of a Texas real estate magnate and conservative donor, Harlan Crow. Since then, other undisclosed gifts to Thomas have been revealed, all from powerful friends—including a motor coach, private school tuition for a grandnephew the justice was raising, and the justice’s mother’s home in an undisclosed real estate deal.

Thomas has also come under fire for failing to recuse himself from cases related to attacks on the 2020 election results—given that his wife, Virginia Thomas, worked to overturn the 2020 election results in the weeks leading up to the Capitol attack.

Other justices, including Samuel A. Alito Jr. and Neil M. Gorsuch, have also failed to disclose their connections to wealthy people with close ties to the court. Alito did not report a 2008 trip on the private jet of Paul Singer, a hedge fund billionaire who later had cases before the court.

Alito defended his conduct in an op-ed published by The Wall Street Journal, writing that he had “no obligation” to recuse himself from the cases involving Singer’s business, and did not have to report the travel and lodging because the jet constituted a “facility” exempt from reporting requirements. He claimed that the justices “commonly interpreted” hospitality to include accommodations and transportation for social events that did not have to be reported as gifts.

In addition to Thomas and Alito, Gorsuch did not disclose that the head of a major law firm had purchased a Colorado vacation property that he co-owned. Justice Sonia Sotomayor’s staff pushed public entities hosting her to purchase her books; she failed to recuse herself from cases involving her book publisher.

The new code would have had no effect on any of these instances and will have no effect on future ethical lapses.

The new rules don’t require any changes in how the justices conduct themselves.

The new code has no system for the public to lodge complaints or for any outside review of alleged ethical violations.

In the absence of any enforcement process, the document states that Chief Justice John Roberts has directed court staff to do a review of “best practices” based on systems already in place in the lower courts. It didn’t provide a timeline for that review or what action the court might take in response.

What prompted the court to put out this piece of PR pablum now?

Probably the fact that the Senate Judiciary Committee has scheduled a vote on Thursday for issuing subpoenas to Republican megadonor Harlan Crow and conservative legal activist Leonard Leo as part of its ongoing investigation into the Supreme Court.

As Senator Sheldon Whitehouse, chair of the Judiciary Committee subcommittee overseeing the federal courts, explained:

We need to develop information about how systemic this was. This isn’t just a random gift here and a random gift there. It’s always the same individuals, the same front groups. It’s—there’s a network effect here that we need to understand… What you have is billionaires with a demonstrated pattern of trying to influence the Supreme Court through a whole variety of groups by giving donations and participating, who are at the same time also giving enormous, massive, secret gifts to justices. Just on its face, that merits investigation. And if it happened in any other court in the United States, it would have been investigated. There would have been fact-finding, and there would have been a result and consequences. It’s only the Supreme Court that is living outside the bounds of the rules.

The Supreme Court’s new “Code of Ethics” changes nothing. The court is still living outside the bounds of rules.

Ultimately, I blame Chief Justice John Roberts. The court’s chief justice is supposed to maintain public trust and confidence in the court, but Roberts has done everything possible to avoid a Code of Ethics with teeth. This latest pathetic attempt at pacifying the public will do little to reverse the sharp decline in public confidence in the nation’s highest court.

At his nomination hearing in September 2005, I testified against Roberts becoming the next chief justice. I had no confidence in his ability or willingness to put the public interest above the interests of individual justices. Sad to say, I’ve been proven correct.

The Hidden Cost of Fossil Fuel Exports

Posted on November 14, 2023

Oil, gas, and coal exports are not counted when countries tally their greenhouse gas emissions under the Paris Agreement. This allows wealthy nations to report progress on emissions reduction goals, while shipping their fossil fuels — and the pollution they produce — overseas.

When the world convenes in the United Arab Emirates later this month for the next round of the endless climate slog, much attention will be paid to the pledges of individual nations to cut their emissions. This has been the basic scorecard of climate talks almost since the start. But it’s a wildly incomplete scorecard, in ways that are becoming ever clearer as we enter the endgame of the energy transition. We’ve been measuring it wrong.

That’s because a country’s exports of fossil fuel don’t count against its total. But it’s those exports that are driving fossil fuel expansion around the world, coming as they do from some of the most diplomatically powerful and wealthy nations on Earth.

To give the most obvious, and largest, example: the United States is, fitfully, cutting back on its carbon emissions; its envoys will be able to report, honestly, that the Inflation Reduction Act should soon actually be trimming our domestic use of oil, gas, and coal, as we subsidize heat pumps and build out EV charging networks. But at the very same moment, the U.S. production of fossil fuels is booming. That means, of course, that much of that supply is headed overseas.

And the numbers are truly staggering. If the liquefied natural gas (LNG) buildout continues as planned, for instance, by 2030 U.S. LNG exports will be responsible for more greenhouse gases than every house, car, and factory in the European Union. The emissions, under the U.N. accounting system, will show up on the scorecards of the EU and the dozens of mostly Asian nations that will buy the gas. But if you could see them in the atmosphere, they would be red, white, and blue.

Exactly the same thing is true of a handful of other nations — in fact, some are even more grotesque in their hypocrisy, if not their impact. Norway has, arguably, done as good a job as any country on earth on moving past oil and gas; almost every new car in the country runs on electricity. But it’s planning one of the dozen biggest expansions in national oil and gas production, almost all of it for export. Canada and Australia fall into the same basket. Indeed, a remarkable new report from Oil Change International (OCI) found that those four countries (the U.S., Canada, Australia, and Norway), along with the U.K., account for just over half of the planned expansion in oil and gas between now and mid-century. In most cases the project licenses have already been granted, and unless officials intervene, the damage (enough carbon and methane to take us past the Paris climate targets) is locked in.

But this means that if other nations and the climate movement could figure out how to pressure these countries to turn the spigot to the right, we could staunch much of this flow of greenhouse gases into the air. If five countries account for half the expansion problem — and if those five countries are rich and have diversified economies that allow them freedom of choice about their futures — then some of the main targets are clear. All of them, remember, have made the right noises about the need for urgent climate action; they just haven’t been willing to face down their exporters.

Canada continues to approve and/or subsidize new pipelines and LNG export projects, while permitting new oil and gas fields, putting it on track to become the world’s second-largest producer of oil and gas. Australia, the world’s third-largest fossil fuel exporter, has given the green light to major new coal and gas projects. Norway, Europe’s largest oil and gas producer, has awarded 47 new licenses for oil and gas projects in the Norwegian Sea and is permitting expansion into the Barents Sea in the Arctic. And the current Conservative government in the U.K. has adopted a policy to “max out” fossil fuel development in the North Sea.

As for the U.S., the OCI report makes clear it plans by far the biggest expansion of its oil and gas industry — about a third of the global total. Basically, this is a result of the invention of fracking, which beginning in the early 2000s allowed the rapid expansion of oil and gas production. We literally have more of the stuff than we know what to do with — so we needed to find other people to sell it to.

That would have been largely impossible prior to 2015 — since the oil shocks of the 1970s, the U.S. had had a ban on crude oil exports. But in one the great historical ironies of all time, Congress, under great pressure from the fossil fuel industry, lifted that ban the very week that the world was in Paris wrapping up the global climate accords. A few of us were fighting (with our laptops, from Paris cafes) to keep the ban in place; I coauthored an op-ed then that criticized congressional leaders as “politicians who simply don’t understand the physics of climate change.”

As it turns out, I didn’t understand the true scale of the disaster unfolding. Because it wasn’t just crude oil that was going to be sold abroad; until 2016 the U.S. had been a net importer of natural gas, but that year things began to turn. And it’s LNG that has truly turned America into an export monster. Enormous terminals — seven of them — have been built, mostly along the Gulf Coast, with 24 more planned; their business rationale is simply to take the excess gas produced by the fracking spree and send it overseas. And the numbers are astonishing. Remember the anger that President Biden brought upon himself (and the damage with young voters) when he stupidly approved the Willow oil complex in Alaska in March? Well, the next export terminal up for approval — CP2, in Cameron Parish, Louisiana — would be associated with 20 times the greenhouse gas emissions of the Willow project.

The Obama administration, of course, loved fracking — it seemed like an easy way out of both the climate and economic predicaments it inherited, jumpstarting the economy with cheap fossil fuel and, since natural gas produces less carbon than coal when its burned, allowing America’s CO2 emissions to fall. But on closer examination, it was a devil’s bargain: methane leaking from the natural gas production chain balanced out those carbon gains, and so it was unclear if total U.S. greenhouse gas emissions had even budged. But that didn’t slow the push for more — which accelerated after the Russian invasion of Ukraine, when the fossil fuel industry grabbed at the chance to expand natural gas production as an altruistic response. Whatever you think of that argument, we’ve already more than met the needs of the EU; it had enough gas for last winter, and more to come this year. There is definitely no need to build new terminals, which would lock in huge increases in production for the next 40 years.

That’s especially true since the old argument for exporting gas — it was cleaner than the coal being burned in Asia — no longer makes sense. Since sun and wind now produce the cheapest energy on earth, we’re no longer talking about transition fuels. The whole point of net zero emissions is that we have to move fast to the actually clean stuff.

And it’s especially true because we’ve been learning that exporting this stuff is even more dangerous than using it at home. A new paper from Cornell’s Bob Howarth (the dean of methane science) that I first reported on in the New Yorkerlast week has truly shocking implications. It showed that when you put LNG on a boat and send it off around the world, large amounts leak out in the process. In the best-case scenario, it is 24 percent worse for the climate than burning coal; in the worst case (old ship, long voyage) it’s 274 percent worse. This is mind-boggling and soul-sickening, and it makes the calculations in, say, the OCI report much more ominous.

Yet Biden could limit the damage. Though his administration has already approved too many of these projects, he could stop the ones that remain. Under federal law, the Department of Energy needs to grant an export license for each new terminal, certifying that sending it to countries with which we don’t have a free trade agreement is in the national interest. And clearly this isn’t; standing up here could help him regain some of the ground he lost with the Willow calamity. And it would be hard for the other side to demagogue. Because exporting natural gas clearly drives the price up here at home — that’s how economics works. Indeed, Biden could even reinstate the ban on crude oil exports lifted in 2015.

The most important decision any of these leaders — in the U.S., Canada, Australia, Norway, or the U.K. — could make is simply to say, “We won’t be the hydrocarbon equivalent of the narcotics cartels.” If they did, some of the slack would be taken up by other nations, like the United Arab Emirates, erstwhile host of the upcoming COP. But some of it would also be taken up by the switch to renewables; with the biggest suppliers leaving the market, prices would rise, and the spreadsheet would change. Again, that’s how economics works.

But the real question here may be, how do politics work? The fossil fuel industry demonstrated its firm grip on power in the U.S. in 2015 when it got the export ban lifted. Now the industry is flush with cash: Exxon reported a quarterly profit of $9.1 billion last month. It’s using its cash to buy up even more fracking real estate; clearly it concludes it has the political juice to enable it to face Biden down and keep on pumping gas for the planet.

And Exxon and the U.S. are not alone in this arrogance. In Canada, for instance, Prime Minister Justin Trudeau keeps talking a good game on reducing emissions — but at some level, who cares? There aren’t enough Canadians to produce that much carbon (indeed, the wildfires across the nation will produce more than twice as much as the people this year). Canada’s huge contribution to our global crisis is its exports. Trudeau quite honestly summed up his nation’s position in 2017 in a talk to Texas oilmen, when he told the truth about the country’s vast tar sands complex: “No country would find 173 billion barrels of oil in the ground and just leave them there.” Canada couldn’t burn 173 billion barrels of oil if everyone in the country kept their car idling 24 hours a day, and they couldn’t burn the enormous quantity of natural gas that’s been found further north in Alberta if they all turned their thermostats to 115 and wore bathing suits all winter. That’s why they’re busy building pipelines to take the oil and the gas to the Pacific.

I could do the same math for Australia or the U.K. or Norway. No matter what they stand up and say in the UAE over the next month, remember: They’ve decided to hold a fire sale at the end of the world.

Making Connections That Can Help Save the Planet

Posted on November 8, 2023

If we’re going to realize the climate benefits of historic federal support for clean energy and jobs approved in the past two years, connections are the key. And I’m not just talking about electrifying homes and buildings.

We need to connect people to the benefits spread throughout the 2022 Inflation Reduction Act (IRA) and the 2021 Bipartisan Infrastructure Act. We do that by connecting people to others in the communities where they live and with the individuals, local units of government, and non-profits who can help them take advantage of a lengthy list of tax credits and rebates for everything from electric cars to more energy-efficient windows and doors.

The need is clear. Seven in 10 Americans say they know little or nothing about the IRA by name. The same is true for specific parts of the package like tax credits for home solar panels and heat pumps.

Bobby Foley of Elephant Energy, a climate tech start-up in Colorado, sees the information gaps and hears the questions up close. “We are on the ground, scoping out a heat pump with homeowners and installing it.”

Foley can help that homeowner use rebates from a local utility and the city of Denver, alongside state and federal tax credits, to cut the cost on a new $20,000 electric heat pump to heat and cool their homes by more than half. He can install heat pumps in homes without ducts and in places where temperatures drop below zero. The result is far less carbon and 300% greater energy efficiency than a furnace and air conditioner at substantially lower monthly cost to the customer, he said.

But the people Foley meets already know enough to at least inquire. There are more than 100 programs scattered through the $370 billion in the IRA that aim to assist individuals, businesses, and state and local governments. Projections show that if we can use all that money thoughtfully and equitably, we can cut greenhouse gas emissions by 40%.

There’s a good deal of evidence to show that people need help to connect. The National Council on Aging, for example, estimates seniors leave $30 billion of potential government assistance for food, housing, and health care unclaimed. There’s often a lack of awareness or misconceptions about the difficulty of applying. The non-profit Code for America, which works to make government more effective and accessible, found that even the words used to offer programs like tax credits and food assistance to Americans makes a difference in their response rate.

For clean energy incentives, many states also have stepped in with their own support that can significantly improve the attractiveness of acting to switch to a cleaner product. That means the opportunities can vary a lot from place to place.

To help fill the gap, the Sierra Club is making a national push to recruit, prepare, and offer volunteers across the country — Community Advocates — to help people and their communities get the support that’s available to protect the planet.

Bekah Ashley has worked with Utah school districts to apply for funds from the infrastructure package to transition their transportation to electric school buses. Communities can share $1 billion a year. School buses account for the largest public bus fleet across the country, but school systems “often get overlooked in climate action,” Ashley noted.

School board members might have sticker shock — electric buses can cost more than two times new diesel buses, Ashley said. But the federal incentives and the far lower operating costs change that perspective.

Communities recognize the need and favor of government support for a cleaner economy It’s something most of us believe in. But we need to ensure that support doesn’t stay written on the pages of legislation. We need to learn more — preferably from using the incentives ourselves — and share that knowledge with others who can benefit from it.

Mexico Tried To Regulate Tony The Tiger. Here’s What Happened Next

Posted on November 7, 2023

In 2019, the Mexican government instituted a new rule that took mascots like El Tigre Toño off of high-sugar foods. The food industry fought back. And now a similar fight may be coming to the United States. Abdul reflects on the role of marketing in our food environment. Then he speaks with Nick Florko, a reporter at STAT News, about Mexico’s struggle to cage the tiger.

The following is a transcript of America Dissected episode 209. The full podcast is available at Crooked Media.

Dr. Abdul El-Sayed, narrating: Infant mortality in the United States increased in 2022, the first time in two decades. The American Medical Association considers supporting single payer health care. Health care activist Ady Barkan dies of complications of ALS at 39. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Saturday morning cartoons, remember those? Among the many reasons I’m grateful to have grown up in the nineties was that hallowed Saturday morning ritual observed by millions of children like me. I’d be up at like eight before anyone else in the house. I’d turn on that tube television with 47 channels and I’d fix myself a bowl of cereal. Mom wouldn’t let me eat the sweet stuff on weekdays, but weekends? [sigh] My time. It was Cocoa Puffs or Cinnamon Toast Crunch for me. As I devoured those little sugar bombs, their commercials would intersperse my cartoons featuring either Sonny, who was, of course, Cuckoo for Cocoa Puffs or the Cinnamon Toast Crunch chefs virtually guaranteeing that they’d be a regular part of my breakfast every Saturday. All was right in the world. Only it really wasn’t. I didn’t realize it, but the millions of us were unsuspecting victims of an elaborate scheme to convince us and our parents that the main line sugar we were eating was, quote, “part of a balanced breakfast.” That scheme hinged on the industry’s ability to do a couple of basic things. Feed us cheap ingredients at marked up prices and guarantee that we’d keep buying it. It starts with the first ingredient in Cocoa Puffs, corn. Corn is artificially cheap in America, a byproduct of a decades old public policy in this country that has us subsidizing its production by factory farms. Those subsidies have helped drive the consolidation of agribusiness, displacing family farms nationwide. And those corporate farms sell directly to multinational food corporations that rely on our artificially cheap corn supplies to manufacture the very cereals I and millions of other kids were eating. But if all I was eating was subsidized Iowa corn, I probably wouldn’t be so excited to eat it. It’s that second ingredient that got me and millions of other kids hooked, the sugar. I have to admit that I’m still at almost 40 years old cuckoo for Cocoa Puffs. It’s not just the fact that there are little sugar balls. There are lots of ways to get a sugar fix, after all. It’s a fact that they embody the nostalgia of childhood. That’s because for decades, the company that sells them, General Mills, made sure that they literally became the taste of my childhood. That has nothing to do with the puffs themselves. It’s a product of the marketing that the company put into them. Cocoa Puffs have been around since 1956. Their avatar, Sonny, he’s been around since 1962. He’s gotten a couple of redesigns and some new voices. But he’s still the same old Sonny and he’s still, well, cuckoo for Cocoa Puffs. And because of Sonny, whenever I hear Cuckoo for, I think Cocoa Puffs. Chances are love him or hate him, you do, too. And that brand, that’s powerful. And the companies that have been feeding American kids like me cereal for decades have put a lot of time and effort into making sure those brands associations stick. Let’s try something. Name the avatar for each of these children’s cereals. Frosted Flakes, Froot Loops, Cap’n Crunch. Okay. That one’s literally in the name. If you named Tony the Tiger, Toucan Sam and, well, Cap’n Crunch, a.k.a. Horatio Magellan Crunch. Their marketing worked on you too. Now, look, I’m not one of those finger waggey public health people that believes there’s no room to live a little. I still enjoy a bowl of sugary cereal every once in a while. Though, my tastes have evolved a bit. Along with Cocoa Puffs I also enjoy a bowl of Reese’s puffs nowadays. And if you haven’t had one, I’m not recommending it, but I’m just saying. But when I enjoy it, I enjoy a bowl for dessert once in a while. The fact that millions of children around the country and around the world because of our country eat this stuff every morning as breakfast, that’s wild. The recommended serving of Cinnamon Toast Crunch has the equivalent of three added teaspoons of sugar. And let’s be clear, most folks don’t eat the recommended serving. They eat a lot more than that. What’s the upshot? Rates of pediatric diabetes are higher than they’ve ever been. And for that reason, in 2019, the Mexican government decided to fight back against the cereal industry. They forced manufacturers to put warning labels on products with excess sugar or fats. Worst still for the manufacturers, if their products contained a warning label, they were banned from promoting their products with their ubiquitous mascots. So that meant that Kellogg’s, manufacturers of Frosted Flakes and Froot Loops could no longer include Sam el Toucan and el Tigre Tonio on their boxes. And let’s just say they went cuckoo. I learned about Mexico’s efforts to protect the kids from marketing designed to normalize diabetes causing foods in a recent article from Nick Florko at STAT News, and I knew I had to have him on the show to share more about what Mexico did, how the manufacturers responded, and what it means for similar regulations that may be coming around the pike here in the US. Here’s my conversation with Nick Florko.

Dr. Abdul El-Sayed: Can you introduce yourself for the tape?

Nick Florko: Sure. My name is Nick Florko and I’m the reporter on the Commercial Determinants of Health at STAT.

Dr. Abdul El-Sayed: So I um I wanted to reach out and talk to you because I have mixed feelings about Tony the Tiger or El Tigre Tonio, as uh as he’s called in Mexico. And on the one hand, he was like the character of Saturday morning cartoons and like, you know, when I was five, they really were great. And the problem is, is that I’m like a lot older than that now. And um I I very much understand that they’re not that great. And uh and and that’s why regulators are trying to do something about it. So I want to step back here and just give give some context. Um. Can you talk a little bit about labeling laws? Like what do they do? Why do they exist uh and and do they actually work?

Nick Florko: Sure. Um. So in the US, right, we really only have one true sort of food labeling law when it comes to nutrition, which is the nutrition facts label, which is what you see like on the back of a package of food. Um. It’s interesting that actually has only existed since the 1990s. Um. And I have to admit, I was a young kid back then, but my understanding is that was actually created really in response to consumers growing interest in nutrition and the subsequent rise of food companies making nutritional claims about their products and really the confusion that that created for consumers. Uh. You know, in preparation for this, I was looking back at some history, and the former head of the federal health department in 1990 gave this quote, which I have to read, “the grocery store has become a Tower of Babel, and consumers need to be linguists, scientists, and mind readers to understand the many labels they see.” So that’s where we were just you know three decades ago. Um. And to your question of do food labels work? Uh the research that I’ve seen says, yes, they do. I mean, there’s this new experiment going on, which I’m sure we’re going to talk about, which is uh adding a warning label to the front of a food package. The idea being the consumer is making a split second decision, trying to decide, should I buy this cereal or this cereal? They see a warning on the front of one of them and says, hey, there’s excess sugar. They might not buy it. They might go to another one. We’re still gathering data on sort of the actual impacts of that. But that’s sort of the new frontier in food labeling and what a bunch of countries around the world are doing and what the US is actually toying with doing as well.

Dr. Abdul El-Sayed: So I want to talk a little bit about that because, you know, when we’re talking about about food labeling, particularly when you’re talking about the warnings, you’re talking about high uh macronutrient dense, uh micronutrient poor foods that are highly processed in um or super processed in the in the language of of one of our previous guest here. And you’re talking about stuff that one should not be thinking about eating all too often as a as a part of a regular diet. Um. And there are a lot of countries that have gone far further, far faster than we have. To give us context, though, in order to you know to think about labeling as a as a public health intervention, you have to understand how the corporations that manufacture these foods try to market themselves. Can you give us some some context about that? What is the way they market? How do they try and push themselves into the eyes and ultimately into the guts of consumers, particularly our youngest consumers?

Nick Florko: Yeah. I mean, you already mentioned it at the start to be honest. El Tigre Tonio as it’s known in, he’s known in Mexico or Tony the Tiger here in the US. Um. I mean that’s a big way that food companies do market their products is is using mascots sort of making sure that those mascots get in front of of younger people. And there’s there’s really interesting research actually coming out, sort of looking at what the long term impact of things like that are. Um. So, for example, I mean, there’s there’s a study that showed that if you have a positive association with um, you know, a mascot on a unhealthy food as a kid, you’re more likely to sort of have a biased view of of how healthy that food is as an adult. Um. And what we really know is that when you try to take away those sorts of marketing tactics from food companies, they will fight pretty darn hard to keep them. I’m happy to go into it. But the experience in Mexico with them trying to ban mascots on their products is really one clear example of sort of what happens when you try to take away Tony the Tiger.

Dr. Abdul El-Sayed: And I want to get to that, um but it’s actually kind of crazy when I think about the foods that were pushed as like breakfast when I was a kid. I don’t know if they still exist now, but like, to me, the craziest one was Cookie Crisp. Like the notion that very small cookies that are in bite sizes that you can then mix with milk should be like eaten for breakfast, and that the industry got away with marketing small cookies as breakfast made absolutely zero sense to me. But I can think about all of these breakfast cereals that are extremely high in sugar, very low in protein, and were marketed as a part of a balanced breakfast. I think that was the term they always used. Um. Can you explain you know, you talked a little bit about the connection between childhood and adulthood. Um. Can you explain you know particularly why breakfast became this way to, like, really jam kids full of sugar at the beginning of a day and like, why breakfast cereals tend to be so marketed in this particular way?

Nick Florko: I think one of the ways that that folks got away with putting so much sugar, frankly, in breakfast cereals is “sugar science,” quote unquote, has been hotly debated for for decades. And we now know that industry played a big role in that. Um. So there was documents uncovered a few years back that found that in the 1960s, food companies were intentionally funding research that downplayed the role of of sugar in coronary heart disease and purposely focused the debate on fat. Um. And we still see a lot of these arguments happening today of added sugar is not the problem. Excess any macronutrient is the problem. Why are we focusing on added sugar when we’re not focusing on total sugar like [?] sugar you’d find in fruit? What we’ve seen is like decades of this debate over whether sugar is good or bad, and we’ve ended up in this country with a with looser restrictions around around sugar than other potentially unhealthy substances, like if you look, for example, at sodium, at least in the US, there’s a voluntary goal for manufacturers to lower their sodium in food. It’s voluntary, but it exists. That doesn’t even exist for sugar. Um. So we are just like when we think about what we should be limiting in our diet. Sugar has sort of been like the last issue to be addressed.

Dr. Abdul El-Sayed: Hmm. I really appreciate that you start at the, you know, the science debate level. Right? If you can make something controversial that uh really on its face should not be, you can tie up any effort to regulate it simply by pointing to what ends up being somewhat bunk science to to to substantiate your point. There’s a difference of opinion here. And, you know, that’s a playbook that a lot of the Covid deniers uh used far later on. Um. I I want to now turn to the Mexico example. Right? And uh we can talk about El Tigre Tonio here. Um. So the Mexican government decides to take a stand against what is largely American corporations selling um straight sugar to kids, in effect, and they take this stand in 2019. Can you tell us what they did?

Nick Florko: Yeah. Uh. Essentially they required warning labels on the front of packages that look like stop signs um that say excess sugar. [laugh] If a food has excess sugar there’s a warning label on it that says excess sugar. If there’s if there’s excess sodium, it says excess sodium, if there’s excess fat, it says excess fat. It honestly sounds really simple, um but it ended up prompting a multi-year just all out brawl with uh with food companies and especially the folks that were pushing food, you know, ultra processed foods with lots of sugar.

Dr. Abdul El-Sayed: And and where does uh Tony the Tiger or El Tigre Tonio come in?

Nick Florko: [laughing] Well, interestingly, one of the pieces of the Mexico law was that if you have a warning label on your product, you can’t also use a mascot or any sort of cartoon. And the idea being here that you don’t want kids getting attracted to this food uh that is potentially unhealthy for them just because they’re seeing a mascot that they like and they’ve seen commercials. What we saw was that there was just food companies got very, very creative. Specifically, Kellogg got really creative in figuring out ways to get around uh that requirement. Uh. My favorite is that they it might it’s sort of the one I like to focus on is that they basically launched this campaign in Mexico that translated to Always With You. Where these mascots were featured in all different forms of media. So, Tony the Tiger was curating Spotify playlists. He was on [laughter] commercials alongside soccer announcers. And then, I mean, my favorite and I think the one that really has just stuck with me the most is that essentially Kellogg paid to have a drone show above Mexico City where they use drones to sort of draw all the characters in the sky. Um. So the goal, of course, of all of this is to sort of not erase the mascots from consumer memory and to keep using them, even if they can’t actually use them on certain food packages.

Dr. Abdul El-Sayed: You know it’s an interesting approach here because it’s one thing to have a mascot. It’s another to have a mascot that tries to sell the good when by definition, you can’t associate the mascot with the good. And what that tells you is that they have so burnt in what that mascot stands for through decades and decades and decades of marketing that even when they cannot put Tony the Tiger or Toucan Sam in this in the same case on their packaging for the good that those mascots are associated with, they believe that they can continue to sell their product simply by making you think about Tony the Tiger and Toucan Sam.

Nick Florko: It really speaks to the uh the impact that these mascots must actually have on sort of their their bottom lines. And well I’m sure we’ll talk about sort of the US and what the US is considering. But the US doesn’t have or isn’t isn’t considering a sort of ban on mascots. At least public information suggests that at this point they’re not considering a ban on mascots. And it sort of raises the question of like was Mexico sort of on to something here? Um. Is this something that actually could have a potential public health impact if the food companies are just so aggressively trying to fight and so openly trying to fight it?

Dr. Abdul El-Sayed: Yeah, I mean, there’s there’s sort of a principle here where if you’re trying to regulate an industry that you know has a set of externalities that include obesity, diabetes, heart disease, etc., or in the in the tobacco case, uh lung cancer, heart disease and stroke, you kind of want to hit them where it hurts and they’ll tell you where it hurts by how how loudly they scream. And so, you know, you wouldn’t necessarily think that punching them in the mascot would have such a huge impact. But if their response is to go, like, absolutely, truly apeshit or in this case tiger shit to to put their mascot everywhere, it tells you that there’s something really deep about their marketing and that the ability to associate your food with a cartoon character really does create, you know, a level of almost loyalty that that increases the probability that kids are and then adults are going to continue to buy this good. And so, you know, it must be effective if they’re that upset about it.

Nick Florko: Yeah. I mean, I have to admit that. I mean, I went to Mexico for this story, but I didn’t have the foresight to actually go there to report the story. I was sort of just had the privilege to be there. And I had known about this policy and sort of honestly had sort of just wondered like, you know, what is the big impact going to be? How big of a deal is this? Like I had heard the U.S. was doing something similar and uh it was really eye opening how quickly talking to advocates in uh in the country, sort of how aggressively the food companies fought this and how big of a deal it was for them. Because it doesn’t it sounds pretty basic and uh not super controversial to add a little bit of information about, uh you know, a food’s health effects on the front of a label and maybe it restricts the marketing, but it really, really has prompted a response.

Dr. Abdul El-Sayed, narrating: We’ll be back with more of my conversation with Nick Florko after this break.

Dr. Abdul El-Sayed: One of the other things that they did was they started to use artificial sweeteners so they could get by the the sugar regulation. Can you speak to their use of of of allulose in particular to try and get past this?

Nick Florko: Yeah, um it’s funny. I discovered this by actually sort of walking through a Wal-Mart in Mexico City um and I looked at a package and saw a box of cereal and it was reformulated. It still had Tony the Tiger on it, or actually in this case, it was Toucan Sam and the label said it had one gram of added sugar. And the first time I I saw this, I sort of went home and I I mulled it. And I was just sort of like, how could a Froot Loop have that little sugar without just tasting completely different? I mean I should have–

Dr. Abdul El-Sayed: It’s just one fruit loop in the whole thing.

Nick Florko: Yeah, [laughter] right. And I I should have just went home I should have went and bought it in that moment. Um. But I was so confident that there must be this new version because actually Mexico has a rule that if a product uses an artificial sweetener, it also has to include a warning on the package that it has an artificial sweetener and this one didn’t. So I was totally confused. And eventually I went back to that Wal-Mart and looked even closer. And what I found was that the product listed [?] or allulose as an ingredient. Um. And Allulose is a is a sugar free sweetener. Um. But it’s one of the few that’s technically not considered by Mexico as an artificial sweetener. And there’s reporting to suggest that, you know, the food industry did sort of lobby the the Mexican government to not have allulose classified as an artificial sweetener. And so Kellogg’s basically found a way to sell its product you know without an added sugar warning by reformulating it. But then they were also able to avoid the warning that was meant to uh warn consumers about the the reformulation. And I think the other interesting thing here, since we already talked about mascots is that by doing this, they’re also able to keep their mascots in the stores because that new product doesn’t have any warnings on it, which means Toucan Sam can be on the package. So essentially, when you walk around the grocery store aisle, you see you know the warning label version, which is a plain box, and then you see the one with Toucan Sam, the reformulated. And that means that the mascots are getting into the into the grocery stores and into the cereal shelves just as much and kids are seeing it. So you know it’s a really it sort of it benefits them in multiple ways.

Dr. Abdul El-Sayed: Wow. So they went as far as to lobby the government to leave one of these artificial sweeteners off so they could put it in their cereal so that they could keep putting their mascots on their cereal. Like that’s I mean, that’s like a that is a long game. That it just takes a lot of foresight.

Nick Florko: I mean, I should say uh I don’t know if we have that clear of a line all the way through at this exact moment. Like I would you have to see sort of exactly when they lobbied around Allulose. But um yeah, I mean, there’s some skilled lawyers in figuring out you know what product they could use to avoid having to have the warnings and and still be able to sell their you know their product.

Dr. Abdul El-Sayed: See, the crazy thing is these are children’s cereals. And the reason non-sugar sweeteners work is because these are molecules that continue to bind to your sugar receptors on your tongue but are not picked up in your small intestine and digested. Allulose is technically a rare sugar. It’s not a sugar alcohol, it’s what’s called a monosaccharide. Um. But your your tongue, your tongue recognizes it, so you taste the sweetness, albeit with more uh what we call avidity meanings it meaning it binds a lot stronger to your tongue. That’s why a lot of these sweeteners taste saccharine like they’re they just artificially sweet. Like not as not like sugar, which is just the right um taste for our our uh taste buds. But your gut doesn’t recognize them. So they they flow on into your large intestine. But here’s the thing about it. In your large intestine, because they are undigested molecules, they pull water into your colon and they cause diarrhea. And so you can imagine, right, like I remember when I was a kid and I used to eat these sugar sweetened cereals, I wouldn’t just have a bowl. I’d have like three or four bowls. So you can imagine a bunch of kids, unfortunate children who saw Tony the Tiger, Toucan Sam, decided to buy this sugar or like push their parents to buy the sugar, ate three bowls and then just had diarrhea for the rest of the day. And it’s just like it’s like an awful thing that these these manufacturers know is going to happen. Like they they know that’s going to happen. And there’s like no indication that this is any different than the usual cereal, except for it looks like the cereal used to look.

Nick Florko: So the US doesn’t have a restrict or a requirement to warn about artificial sweeteners on their packages. But interestingly enough, the group that’s pushing for more disclosures of or add of artificial sweeteners is the sugar industry, uh and they’re petitioning the FDA to require companies to sort of more clearly state when a product has an artificial sweetener and to block companies from from claiming that their products are lower in sugar without also noting they have artificial sweeteners. But the reason I bring this up is because on the Allulose front, they’ve actually specifically petitioned the FDA to require companies that use Allulose to have a warning that says it may cause a laxative effect.

Dr. Abdul El-Sayed: [laughter] You can’t make this shit up. [laughter]

Nick Florko: It’s pretty remarkable the infighting you see in the food industry. Yeah.

Dr. Abdul El-Sayed: Wow like [laugh] I’m just at this point, I’m really just like my heart goes out to these poor kids in Mexico who are just like, Yo, what happened today? I was just busy minding, I was eating my cereal watching my cartoons, and I don’t know what happened. [laugh] Um. I want to ask you, you know, obviously, this battle is still ongoing. Where do you think this ends up? Where are the the legal teams for Kellogg um and the Mexican government going next? What what do you think this evolves into? Do you feel like they’ll be able to repeal some of these laws? Do you feel like they’ll just, you know, put up with it? Where does this go next?

Nick Florko: So I’m not a lawyer, but I will say in the Mexican case, things are looking pretty good actually. Um. So the food industry threw everything at challenging this legally as well. I mean, the Mexican legal system is is different than the U.S. system. So these numbers you know wouldn’t be the same if it was in the U.S. But there is like estimates of 70 to 100 lawsuits filed against this. Um. And a bunch of those have already made it up to sort of their appeals level courts. And those courts actually do put out sort of um draft opinions before they decide on what they’re going to do. And those seem to suggest that they are going to uphold the law. And the Mexican regulators that have been behind this have been really steadfast in, you know, throughout the regulatory process that the food companies have you know tried to make tweaks along the edges to this. And they’ve been um you know very skeptical of those and really push forward with what they were they were intending to do. Honestly, the bigger legal uh fight might be here in the U.S., because the US is considering a similar food labeling policy, one that’s a little bit weaker, to be honest. But here in the U.S., I mean, even when I talk to the most enthusiastic supporters of this, they acknowledge that our rules around sort of when the government can regulate a corporation’s speech, they’re going to be a problem. And the food companies are already sort of making very thinly veiled threats around like potentially suing over any sort of mandatory front of package labeling here in the U.S. I mean, that’s really where the fight’s going to be. In Mexico, it’s actually looking pretty good. I mean, it’s survived thus far. And um I mean, there’s no indication at this point that you know it’s going to be thrown out.

Dr. Abdul El-Sayed: Can you tell us a little bit more about what’s being proposed here in the U.S.?

Nick Florko: Yeah. Happy to. Um. So it’s in very early stages first of all. The FDA is currently at the stage where they are studying the sorts of labels that they might use. So they’re not even in sort of like the formal proposal stage. Um. But basically what they’re thinking about is less uh maybe striking warnings than in Mexico. So not like the stop sign that says excess sugar or excess fat, but something relatively similar. So like some of the designs they’re they’re testing kind of look like stoplights where it would be like, you know, green food, you know, low in low in sugar, red food, high in sugar. Um. And so they’re deciding above, I think it’s six labels right now, sort of which one they’re thinking about. Um. And but the the policy won’t include sort of things, at least thus far it hasn’t included things like artificial sweetener warnings. It’s also um they’re not thinking about this as sort of a warning. Um. You know, folks have said like you need to be putting warning labels on products and essentially they’re saying, no, we’re going to say the products are high in sugar or high in fat. We’re not going to warn around it. And then it’s not going to include things like mascot bans, for example, at least not yet. I mean, like I said, it’s really early stages. Anything could change. But all indications suggest that they’re going to go with something a bit simpler that essentially just says, hey, this food is high in sugar.

Dr. Abdul El-Sayed: And what’s what is the timeline on this that’s been considered?

Nick Florko: Oh, that’s a good question. It’s always dangerous to try to predict FDA regulatory timelines or any regulatory timelines. Um. What I can say is that uh I believe at this point they should be actually doing the formal studying now. Uh. When I talked to the FDA commissioner, he did say to me that this was something that he wanted to do during his last stint in the administration because he was also the FDA commissioner in the Obama administration. Uh. And he so he feels really passionate about this like it’s pretty clear. Um. And this is also part of a larger strategy that the Biden White House is pushing because they had this large summit on nutrition and health a few months ago. And so, I mean, this overall is clearly a priority. I don’t think this is the sort of thing that’s going to get slow walked at the agency. But I mean, it’s going to be a slow process like I mean, the way this works is they’re going to do these studies. They’re going to review the studies. They’re going to put out a proposed rule. They’re going to take comment from the food industry. They’re going to get so many comments you won’t believe. They’re going to have to go through them all really carefully and address them all because they’re going to bring up brought up in litigation eventually. Then they’re going to finalize it, and then there’s going to be you know probably an implementation period, which could be you know it could be months, it could be years. So, I mean, it’s it’s going to be a while is the short answer.

Dr. Abdul El-Sayed: Hmm. And you talked a little bit about how the industry is gearing up here. Obviously, we’re a much bigger market. And, um you know, we are the we’re the home of a lot of these these large corporations. Kellogg is based not 100 miles from from from where I’m sitting right here in Michigan. Um. You know, in so many ways, as you talked about, our public policy tends to be a lot more sympathetic to large corporations and a lot more sympathetic on on speech grounds. What I’m hearing you say is that they would have to put a warning label on their product, which of course has a lot of precedent in the setting of tobacco. Um. Can you talk a little bit about how that precedent applies or maybe doesn’t apply here?

Nick Florko: That’s a good question. So the un– the understanding that I have is essentially the fact that these labels can be considered an– the issue is that they’re if they’re sort of interpretive, uh as I understand it, so the food industry is essentially arguing that they can’t be forced to say something that uh is not sort of uh you know indisputable fact, essentially. That’s how I sort of understand what their arguments that they’ve thrown at thus far has been um. In terms of the the connection to tobacco warning labels. I mean, I’ll just note that those have also been repeatedly challenged in litigation. I mean, so, you know, in both cases, these sorts of things, any time you get into you know compelled speech, you almost always in the US get a lawsuit and it gets fought out. Um. The other interesting thing I’ll just say is that the policy argument here is is kind of interesting because the food companies are essentially arguing we’re already doing this and there’s a less burdensome way that we can do this ourselves, um which I think will eventually sort of feed into their legal argument. But essentially, you’ve probably if any you’ve been to the grocery store, you’ve probably seen that some foods do have some sort of information on the front of them that says this has this much sugar, this has this many calories. Um. That’s what the food industry calls facts up front. It was their voluntary effort to sort of uh address this issue. There’s a lot of differences, though, between those labels and what we actually see in terms of what the FDA is studying, um because those labels for example, will say like five grams of added sugar or five grams of total sugar, and it won’t say high in sugar, for example. So the average consumer looking at that isn’t getting anything to sort of interpret is this good or is this bad? They’re just getting the same information that they saw on the back, on the front. Um. And basically the food companies argue that like, hey, we can do this. You can’t demand us to do this thing where you say, you know, you set a guardrail on or a guideline on what is high amounts of sugar, and then we have to put it on our food because you think our food is high in sugar.

Dr. Abdul El-Sayed: Mm hmm. You know, it’s an interesting question right now, but what actually drives a lot of the consumption and I happen to be one that says that, you know, as far as food labeling unto itself is better than not food labeling. When I think about the value of food labeling versus a lot of the agricultural policy around subsidies, for example, that disproportionately dropped the price of sugar. Right. A lot of the sugar we’re talking about isn’t actually sugar. It’s high fructose corn syrup. And that corn syrup comes out of corn that is highly subsidized in the American marketplace. And, you know, you think about the ways that that drives the economics of being able to put sugar everywhere and make a lot of money off of it. I wonder how valuable it is relative to other things. And at the same time, I think about is this is an example of the industry just being willing to push back as hard as it possibly can on any regulation? Or is it the industry really believing that this is going to take a hit relative to some other policies? Or is it the fact that in the United States we’ve just been so piss poor at regulating the food industry at all in a positive way? You know, you cover the commercial determinants of health and I’d love to hear your thoughts on the kind of public policy we should be seeing if we truly, really wanted to reduce the burden of diabetes, for example, in our society. What would we be doing to regulate the foods? [?] Is it this is it something else? Is it some combination of some of these policies?

Nick Florko: So, I mean, I’ll say is that any good reporter, that I’m not in the business of making policy recommendations but sort of reporting on their impacts. Um. So with that framing, I’ll say in terms of what we know sort of has shown some potential benefits, like one of the policies that I think is worth bringing up that has generated quite a lot of controversy in this country is um the so-called tax on sugar sweetened beverages to dissuade consumption. So the so-called soda tax and we’ve seen those enacted on a local level with some some you know pretty encouraging results. There was a study that came out of Oakland, for example, um that found that sugar sweetened beverage purchases declined by more than a quarter in Oakland after the tax versus a neighboring city that didn’t have a tax. Uh. One of the other really interesting policies that we’re seeing tried, but I don’t think we really have great results on yet um is simply just banning the sale of sugary products to kids. Uh. The state of Oaxaca in Mexico has actually tried that, um and it’s actually pretty funny to contrast that to sort of what we see here in the US, because you know covering the commercial determinants of health, I often end up covering these sort of food fights for lack of a better term. Um. And you know one of the things that the USDA is considering right now is simply uh limiting the amount of of chocolate milk that can be served in schools. So they’re considering either banning chocolate milk in elementary school or allowing schools to sell chocolate milk so long as they sell a low sugar version. Uh. And if you’re you know concerned about like added sugar, a policy like that makes sense because there’s a good amount of added sugar in chocolate milk. But you wouldn’t believe the level of vitriol that uh sort of has has come out of that regulation. I mean, I would never have thought about that when talking about chocolate milk. So like you can’t get something like a chocolate milk restriction here in the US for elementary school kids. Uh. You know, it’s hard to imagine sort of a policy like banning the sale of all uh you know sweet products to kids, but it’s definitely like an experiment that I’m really watching right now because it is, you know, relatively uh innovative.

Dr. Abdul El-Sayed: You know it frustrates me as as someone who is very much in the business of trying to make policy recommendations. I find that the industry is very good at chameleon-ing when it comes to different value sets. So for example, they would say that a ban violates the freedom of choice that we value so highly in America. How could you ban anything from anyone? Right in this country we believe that everyone has the freedom to choose and that uh we can educate, but we cannot ban. And then when it comes to something like food labeling, which is entirely about saying we are not going to take any option off the table, we are just going to educate consumers about what options are less and more healthy. Then it becomes an entire fight about freedom of speech, right? So it’s like the freedom of choice versus the freedom of speech. And what tends to really be the case is that these companies do not want to have to bear any of the costs of the externalities that they put out in the world. And I know that’s a fancy economics term, but it basically means when, you know, you sell a product, the consequences of which bear out on society in some pretty important but not direct ways that you should have to bear the cost of those outcomes. And that means some sort of regulation to force you uh to engage in. And what’s worst of all is that our taxpayer dollars, not only are we not regulating, but we’re actually subsidizing um the production of a lot of these goods. You know, as you think about where the American mind is on these things, which of these arguments do you think makes the most sense? You know, do you think that there’s sort of a um an easier time to make an argument about freedom of choice with like clear education and compelled speech? Or um are are are you know, is the average American more willing to support something where there’s a ban? I have you know, I have my I have my my my opinions on this, but I’d love to hear yours or someone who is closer to this evidence.

Nick Florko: You know, I’m sort of making an educated guess here, but my my thought from covering these these issues would be that, you know, a policy that just gives consumers more information is a lot less likely to be controversial. Like any time I’ve ever covered anything that resembles a ban or limits choice in the US, it uh it generates some backlash. But I mean, I haven’t seen besides the food companies, right. I haven’t seen the same level of backlash to something like including more information on the front of a food package that says, hey, this is unhealthy. The question. Right. And probably the question more for you then for us for me is which one of those is actually more effective from a public health perspective? Like, I can I can tell you which one is probably more helpful just from a political messaging perspective. But the question of which one actually works the best, I don’t know if I have a good answer to that. That’s a harder question.

Dr. Abdul El-Sayed: Yeah, I think your I would tend to agree with you about where the average American would sit. I think people get real uncomfortable with the idea that somebody takes away a choice of theirs. But I think people are more nonplused about the idea that you’re going to give them more information. Right and I mean, and it really just comes down to the question of giving you something versus taking something away.

Nick Florko: But look at the New York fight over over big sodas. I mean, you remember that from a few years ago.

Dr. Abdul El-Sayed: I do.

Nick Florko: I mean, that sort of tells you everything you need to know about how the public sometimes responds to these sorts of restrictions.

Dr. Abdul El-Sayed: Yeah, I think the the question of of efficacy to me, I’ve just really been a big supporter of the idea that we should fundamentally rethink our food subsidy policy. You know, I think I think there’s there’s so many opportunities to support farmers that does not mean growing mono crops that end up turning into either sugar or gasoline or fattening up an animal. Right. Um. And so many of the crops that we do subsidize tend to promote uh corporate farming. They tend to promote these mono crops, and um they tend not to promote the kind of diversity of farming that we really, um I think need to have and would really like to have and most importantly, could benefit our health in a pretty profound way. And then I think, you know, once you do that, then there’s the the question of trying to guide somebody uh around choice making. I also think that, you know, even in science curricula, we don’t do a really good job mapping the basic science that we teach folks to choices that they can make every day. Right. So like, you know, similarly with math, you want to explain why math is important, to explain compounding and investment. Right. But like we don’t really do that. So we tell you about how compounding works in like complete abstraction, but we don’t explain why compounding is probably the single most important thing that should dictate how you store your money, right? Um. Similarly, we’ll tell you a lot about the Krebs cycle, um but we don’t really explain how that then maps to um, you know, what you’re eating and help you make good decisions. So I really think that it’s not just, you know, red for bad or green for good. It’s also like, let’s give folks a little bit more ownership of the choices that they make um and do so by really trying to orient baseline curricula early on to some of these really big important choices that people are making every day. I really appreciate you joining us um to share a bit more about your reporting uh and uh and the effort to to defang and El Tigre Tonio in uh in Mexico. Our guest today was Nicholas Florko. He is a health reporter for STAT where he covers commercial determinants of health. Nick, we really appreciate your time. Thank you.

Nick Florko: Of course. Thanks for having me.

Dr. Abdul El-Sayed, narrating: As usual here’s what I’m watching right now. Infant mortality, literally a measure of the number of babies who died before their first birthdays increased in 2022. That’s the first increase in decades. We’ve done a couple of episodes on infant mortality here. And that’s because in America, more babies die per capita than in 53 other countries in the world. Our infant mortality rates are higher than they are in Latvia and Bosnia and Herzegovina. Infant mortality is a complex outcome, a measure of a number of factors that affect a womb before a fetus is ever conceived. The health of the person carrying the fetus, the circumstances affecting the birth and the environment that shapes the infant’s life for the first year. All of this is shaped by circumstances that are a lot bigger than simply health care. Remember, these numbers are for 2022, meaning these infants were most likely conceived in 2021. And if you remember, 2021 was the single most deadly year of the COVID 19 pandemic. But COVID deaths are the tip of the iceberg. It’a also all the ways COVID shaped the mental and physical health of folks leading up to pregnancy. That includes everything from isolation, diet and physical activity, access to in-person health care. It also includes the readiness to get pregnant in the first place. Remember, COVID created a, quote, “baby bump,” which means that a lot of folks who would have been able to avoid pregnancy, ended up getting pregnant. And getting pregnant when you don’t want to be pregnant implies that by definition you aren’t in your best place to carry a pregnancy to term or care for the infant after they’re born. Which brings me to the question of choice of when, where, and with whom to carry a pregnancy. Quote, “Pro-Life” folks think they really are, quote, “saving lives” by denying abortion access. What they don’t really realize is that when people can’t control their own fertility, it creates circumstances where they’re forced to carry a pregnancy and care for an infant when they don’t feel prepared to do so. Those circumstances are terrible for the health of the parent and for the health of the infant. And sadly, I worry that because of the fall of Roe v Wade, we’re going to see these numbers simply continue to climb. For a long time, the American Medical Association has claimed to speak for physicians despite falling completely out of step with where physicians are today. In the past, physicians mainly worked for physician owned practices. They owned their own businesses and usually contracted with hospitals that used to be actual nonprofits, focused mainly on providing health care to the local communities rather than maximizing their bottom lines. Look, I wish we lived in a world where all physicians cared simply for the best for their patients and not money or autonomy. But that’s simply not the world we live in. So it made sense, at least economically, that physicians in the past might not support single payer health care in that world. But let me remind you how much health care has changed over the past two decades. Rather than truly nonprofit hospitals of yore, today’s hospitals might as well be for profits if they aren’t already. And they’ve been buying up physician practices left and right. As of 2019, the median physician no longer worked for a physician own practice. Instead, they worked for a large health care system. And guess what else changed? The median physician also supported single payer health care or Medicare for all, which makes it all the more confusing that the AMA still opposes single payer health care. But that all might change. See, some heroes have been organizing within the AMA to shift its positions, and they might just move the organization. But the last time the AMA’s House of Delegates debated the question was in 2019 and that effort to shift the tide and force the AMA to support single payer health care was led only by the medical student section. They failed by just 6%. But this time they’ll be joined by a coalition of practicing doctors from New England. We’ll keep you posted. Finally, the world lost a giant this past week. Ady Barkan was an activist, organizer and leading voice for the health care system we deserve. He was also my friend and my brother in that work. Ady campaigned for me in Michigan when I ran for office. He wrote the foreword to my first book, Healing Politics. He died of complications from ALS at 39 years old. He leaves behind two children, Carl and Willow and his incredible wife, Rachel, who will continue his legacy. You can donate to support his young family. We’ll leave the link in the show notes. Ady’s was a vivacity, born out of a righteous fight for the rest of us. When he was diagnosed with ALS. He could have resigned to spend the rest of his days with his family. Nobody would have blamed him. Instead, he used the final moments of life to remind us how much life was actually worth and what it meant to protect it. I loved Ady for his passion, his grit, his joy, his wit. But most of all, because he loved all of us. I want to leave you today with inspiration from Ady’s interview way back in 2019, when I asked him what the solution to our health care brokenness should be.

The first most important solution is Medicare for All. The solution is building a society where every single person, rich or poor, has access to excellent quality medical care. Because we believe that healing shouldn’t just be available to CEOs. The solution is a society where we believe fundamentally that health care is a human right and not a commodity like a car. No more getting on the phone trying to convince your insurance company to cover something. It’s all covered. This is personal for me. One of the things I’ve come to deeply understand over the course of this diagnosis is that our time here is the most precious resource we have. Should we really be spending the limited amount of time we have on the earth on the phone with Aetna? Why does it have to be that way?

Dr. Abdul El-Sayed, narrating: I’ve been asking myself that question too. That’s it for today. On your way out, don’t forget to rate and review the show. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked Store for some America Dissected merch. [music break] America Dissected is product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production Support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me, Dr. Abdul El-Sayed. Your host. Also a very special thanks to Michael Martinez, for whom this will be his last show with Crooked Media. Thanks, Mike. Good luck with your next endeavor. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.

Technofeudalism As Explained By Yanis Varoufakis

Posted on November 4, 2023

It’s a thought everyone has had while scrolling through social media.

“How did it know I wanted to buy that?”

For Yanis Varoufakis, a “maverick” economist and former Greek finance minister, this change of how we consume products marks the death of capitalism.

In his new book, Technofeudalism: What Killed Capitalism, Mr Varoufakis argues that through the emergence of cloud technology we have undergone an epochal shift that means the traditional capitalist market is no more.

Feudalism refers to the medieval-era social system that dominated Europe. Its basic idea is that peasants (also known as serfs) served their lords through farming and labour and in return, got to live within their kingdom. Technofeudalism is the notion that we serve our big tech overlords (Amazon, Google, Apple and Meta) by handing over data to access their cloud space.

Technofeudalism suggests our preferences are no longer our own, they’re manufactured by machine networks — commonly known as the cloud. It’s underpinned by the theory that the cloud has created a feedback loop that removes our agency. We train the algorithm to find what we like and then the algorithm trains us to like what it offers.

Referencing the television program Mad Men, Mr Varoufakis told The Drum that the market is no longer a “one-way street” with advertisements.

“Don Draper had a great idea on how to convince you [the consumer] to eat a burger you didn’t really need, or a billboard could implant in your heart the desire for a Mercedes-Benz,” he said.

“And then if the ad was successful, you would have to physically go to a Mercedes-Benz dealer or to a burger joint and actually buy the stuff from the actual maker or seller of that commodity.”

We are ‘cloud-serfs’

Mr Varoufakis said by scrolling and browsing digital media we are acting as ‘cloud-serfs’ — working as unpaid producers of data to disproportionately benefit our digital overlords.

“When Amazon suggests books to me, they’re usually books I want to read, similarly with Spotify or Netflix. They know me pretty well because of this dual process of feedback between me, you, and the machine.”

The second important factor to Mr Varakoufis is how the likes of Amazon circumvent the traditional analogue market.

“Once you want something, as a result of interaction with a machine, the machine sells it to you directly,” he said.

“You don’t have to go to the Mercedes-Benz dealer or the burger joint outlet to buy it. You just click on a button and Amazon ships it to you. Amazon has replaced the market.”

“Some people think of Amazon as a big marketplace because they have lots of sellers and buyers. But it’s not. There are a lot of sellers and buyers, but it’s the algorithm that matches them in a way that has nothing to do with any notion of the market as we know it.”

Mr Varoufakis said that a lack of understanding by governments and banks of the cloud and big tech is making our financial crisis “permanent”.

“Cloud capital is not like industrial robots or telephone systems. It’s not like electricity grids. It is there not to produce, but it is there to modify your behaviour,” he said.

“It’s a new form of capital, it’s a produced means of behaviour modification.”

More accountability needed over those who own the algorithms

Ethics Centre Fellow Gwilym David Blunt said policy makers need to do more to hold tech billionaires, such as Jeff Bezos, Elon Musk and Mark Zuckerberg, accountable.

“The curious thing about these people is that you often find the term “libertarian” associated with [them],” Dr Blunt said.

“But they’re not libertarians, they’re very much authoritarians, they’re not interested in freedom for everyone

“They’re interested in themselves from over-regulation — they’re overlords, wanting to be free of constraint like feudal overlords of the past as divine right of kings.”

Dr Blunt warns that society is too wedded to cloud technology, in a way that only rewards the tech billionaires.

“They view themselves arbitrarily as geniuses [and] we are buying into it one click at a time, affirming their power,” Dr Blunt said.

Dr Blunt said that we give online marketplaces “the power to shape our desires” by agreeing to their “terms of social cooperation”.

Blunt argues that these algorithms are shaping the way we interact with each other which ultimately erodes democracy.

“All these things are shaping the way we interact with each other and there’s no accountability,” he said.

“Power is slowly centralising in the hands of a few people … this is crushing the bases of democratic society, because we are creating a hyper-concentrated source of economic power that can’t be checked by the state because it’s transnational.”

Mr Varoufakis suggests that it’s not too late to emancipate ourselves from our cloud-serfdom status.

“What we need is social control over the algorithm. The question is — not what do they know about us, but who owns them? And how can organised democratic society take control of the algorithms in the interests of the many?” he said.

“All political problems have political solutions. The difficulty is getting organised and converting what is in our collective interest into collective action.

“But it’s always been the problem of politics since the beginning of democracy.”

Navigating Economic Uncertainty With David McWilliams

Posted on November 4, 2023

Ireland’s economy is at a crossroads, facing ‘considerable external risks’ as noted by the IMF, with its pace lagging behind fellow eurozone nations. Amidst this, a Credit Union survey reveals a third of consumers are uneasy about the economy and their personal finances. Yet, David McWilliams, economist and founder of Kilkenomics, brings a refreshing perspective.

Newsom Signs Unified Healthcare Financing Bill SB 770 Into Law

Posted on October 10, 2023

Gov. Gavin Newsom signed a unified healthcare financing bill, Senate Bill 770, into law on Oct. 7th. California has become the first state in the country to pass such a bill, paving the way towards greater healthcare equity and accessibility.

The bill requires the secretary of California Health and Human Services Agency (CalHHS) to consult with stakeholders and the federal government to pursue a waiver framework for a comprehensive package of medical, behavioral health, pharmaceutical, dental, and vision benefits. By Nov. 1st, 2025, the CalHHS secretary is required to provide the legislature and Newsom with a report of the finalized waiver framework.

Michael Lighty, president of Healthy California Now, spoke with State of Reform on the importance of SB 770 days before it was signed. The bill established a framework for California to create a systemwide unified financing approach for healthcare that is committed to guaranteeing services that are not based on profit or financial incentives.

“A fundamental principle of SB 770 is that we can create a healthcare system statewide that guarantees healthcare on an equitable basis. And so, what we’re able to do if the governor signs the bill, is initiate discussions with the federal government on how we can utilize federal money and support to create such a system.”

— Lighty

Under SB 770, patients will not have to worry about insurance copayments and deductibles—which sometimes ring up thousands of dollars before insurance kicks in. Additionally, patients will no longer face the difficulty of finding providers who are in-network.

“All those disparities between the different types of coverage would go away,” Lighty said. “There wouldn’t be an ability [for] any entity in the healthcare system to deny care or create a financial incentive to deny care that is deemed medically necessary.”

SB 770 will provide a single level of care for everyone, regardless of age, income status, employment status, immigration status, and other factors. While California continues to make changes to its Medi-Cal system, Lighty said some of the remaining issues can only be solved through systemwide reform.

“It’s very impressive—the coverage expansions that California has achieved, and it is, I think, a real testament to the advocacy of BIPOC communities in particular, to make those changes,” Lighty said. “In some ways, our achievements are so good that we may have achieved all we can within the existing system.

Therefore, a unified financing system that provides financing for all services for everyone, everywhere in California, and eliminates these disparities, eliminates the financial barriers to care, establishes a statewide commitment to equitable care, is the next logical step.”

The Healthy California For All Commission issued a report earlier this year, which found that transitioning to a unified healthcare financing system that eliminates differences between private and public health insurance would save Californians $158 billion per year in healthcare spending by 2031, while averting 4,000 deaths annually.

Lighty said small businesses in California will significantly benefit from SB 770, since many cannot afford to provide employees with employee-sponsored health insurance.

“Now, all of a sudden, they have a level playing field because everybody has health insurance. For workers, that means that money that currently goes into their health coverage, which is essentially a transfer from their employer to the insurance company, can now go into their pocket instead. Those savings will increase wages and pensions.”

— Lighty

Legislators and advocates in the state have attempted to pass bills relating to healthcare for all, but have been unsuccessful. Healthy California Now worked with CalHHS to address any concerns they had about the original version of SB 770, and Lighty said they were able to address those issues.

SB 770 requires the governor, CalHHS, community stakeholders, and the federal government to work together on implementing the new financing system. Lighty said collaboration is the heart of SB 770.

“That process will result in the best possible system of universal healthcare for California.”

— Lighty

Opposition to SB 770 came primarily from health insurance companies. The California Association of Health Plans shared a letter of opposition earlier this year, which was also signed by America’s Physician Groups, the Association of California Life and Health Insurance Companies, California Agents and Health Insurance Professionals, and CalChamber.

The letter of opposition cited how California has made strides to the healthcare delivery system, and that SB 770 “forces” Californians into a new system with no ability to opt-out.

“Studies continue to show Californians are satisfied with their healthcare and want to build on this progress, not destroy their ability to choose private coverage for their families,” stated the letter of opposition. “Moving to state-run government healthcare could eliminate consumers’ choice of physicians, hospitals, and other providers.”

In face of opposition, Lighty said there is still work to be done.

“We’ll be celebrating by getting to work,” Lighty said. “We’ve got a lot to do, but it will be an historic victory, because it really says California is going to figure out how to guarantee healthcare for everybody—that’s a big deal.”

Bernie Sanders On The Israel-Hamas War

Posted on October 27, 2023

Bernie Sanders shares his thoughts on the Senate floor regarding the horrific Israel-Hamas war and called on Israel to exhibit restraint.