Last weekend, conservative commentator Guy Benson and his partner announced the birth of their new son following the help of a gestational surrogate. A significant portion of the response in conservative circles both on Twitter and elsewhere was critical. The response mirrored the reaction to an announcement by conservative commentator Dave Rubin that he and his partner had conceived twins with the help of two surrogates last year. 

Although gay couples’ use of gestational surrogacy is often the specific focus of conservative animus, certain conservative critics are also against surrogacy in its entirety. Their complaints about surrogacy alternately focus on the alleged exploitation of gestational carriers, risks to gestational carriers’ health and psychology, and risks to children’s health and psychological outcomes. Critics have also implied that surrogate pregnancies are frequently terminated, referencing unrepresentative news stories. 

However, these criticisms exaggerate or are not in line with available facts. As described in the new study Defending Gestational Surrogacy: Addressing Misconceptions and Criticisms, common critiques of surrogacy do not reflect recent research or they indicate an unfamiliarity with the reality of surrogacy. 

Despite suggestions to the contrary, existing evidence indicates that US surrogates are not exploited based on objective measures, nor do they feel exploited. Evidence indicates that gestational carriers voluntarily enter surrogacy contracts after being informed of risks, there is little evidence of post-surrogacy regret, gestational carriers are well compensated, and many would consider becoming surrogates again.

Moreover, although pregnancy and fertility treatment are not risk-free, medical outcomes for gestational carriers resemble the general population of women utilizing IVF. Evidence indicates that both gestational carriers and resulting children experience predominantly positive long-term psychological outcomes and do well in the years following birth.

Suggestions that surrogacy results in frequent abortions may be the most off-base. Surrogate pregnancies are substantially less likely to be terminated than conventional pregnancies because they are planned rather than accidental, the product of significant time and financial investment, and frequently prescreened for major medical abnormalities.

Notably, in their quest to highlight the perceived harms of surrogacy, critics systematically minimize the substantial value of creating life. For most couples, surrogacy is the last stop on their journey after a hard-fought battle with infertility. Most children produced via surrogacy would not be alive without it. 

It is puzzling and unfortunate that critics exaggerate the risks of gestational surrogacy while minimizing the undeniable benefits. For further details on surrogacy, read more here.

On November 7, 2023, the Idaho Medicaid Managed Care Task Force shelved a proposal to move most of the state’s Medicaid beneficiaries to a managed care plan. This is a modest, but significant, win for advocates of small government in Idaho.

Back in March, Idaho approved a $4.5 billion budget for the state’s 2024 Medicaid program. (The original proposed budget was $4.7 billion; this budget was rejected by Idaho’s House, and the Joint Finance Appropriations Committee slashed $152 million from the plan in anticipation of the resumption of the redetermination of Medicaid eligibility in 2023).

The 2024 budget was a whopping 12.5 percent increase over the 2023 budget. Many lawmakers were alarmed, as the 2024 appropriations would be the largest budget ever approved by the state’s legislative branch. In response, lawmakers formed the Idaho Medicaid Managed Care Task Force to study whether managed care could control Idaho’s spiraling Medicaid expenses.

Managed care is one of the three ways by which states pay for Medicaid services. When Medicaid was first enacted in 1965, doctors were paid for each service they provided to a beneficiary. This payment model was called fee-for-service. However, from 1965–1981, Medicaid expenses rose substantially.

So, in 1981, Congress allowed states to experiment with two alternative payment models. The first alternative model was called primary care case management. In this payment model, states pay doctors a monthly fee to provide primary care to a Medicaid beneficiary. States then reimburse all non-primary care services on a fee-for-service basis. The second alternative model was called managed care, where states pay an insurer a fixed monthly premium per member to provide care for Medicaid beneficiaries.

The theory behind managed care seemed sound: the government could save money by shifting any unanticipated expenses of Medicaid care to a third-party insurer. The problem is that this usually has not worked in practice. In a 2012 meta-analysis, Columbia Professor Michael Sparer found a “paucity of evidence on cost savings from Medicaid managed care.”

A more recent 2020 meta-analysis conducted by researchers at Emory University found that “a unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state.”

Put simply, managed care is not a silver bullet that reduces Medicaid spending. Rather, the cost-savings potential of managed care depends on the specifics of each plan and each state.

This brings us back to Idaho. In 1993, Idaho enrolled most Medicaid beneficiaries into Healthy Connections, a primary-care case management plan. However, in 2014 Idaho experimented with a new plan called the Medicare Medicaid Coordinated Plan (MMCP). The MMCP was a comprehensive managed care plan for dual eligibles: individuals who are eligible for both Medicaid and Medicare. In 2018, Idaho extended this experiment by requiring most dual eligibles to enroll in one of two comprehensive managed care plans (Idaho Medicaid Plus and MMCP). After this transition, annual per beneficiary spending for dual eligibles exploded from $16,563 in 2018 to $29,092 in 2020.

Given this dire performance, there is reason to believe that extending managed care to the broader universe of Idaho Medicaid beneficiaries who are not eligible for Medicare could backfire.

The effort to stop Idaho from switching to managed care was spearheaded by the Idaho Freedom Foundation (the Idaho member of the State Policy Network), which argued, correctly, that the only way to lower Medicaid expenses is to “to reduce enrollment, use, or service costs.” (This argument is supported by Cato Institute research and inter-state comparisons. Cato research focused on the state of Connecticut, which was able to realize substantial savings after transitioning away from managed care in 2012.)

That proposal was opposed by many in Idaho’s medical community, who argued that implementing new “value-based care” elements into Idaho’s primary-care case management plan may lead to some savings. But this is unlikely, as similar programs have failed to contain expenses in Medicare. 

Ultimately, the Idaho Medicaid Managed Care Task Force made the correct decision on November 7 to stick with Idaho’s status quo.

However, if Idaho’s lawmakers are serious about reducing Medicaid expenses, they should heed the words of Idaho Freedom Foundation’s policy analyst Niklas Kleinworth:

True cost control, budget stability, and program improvement can only be achieved through lowering the cost of services, reducing the amount of use in the program, or lowering the number of people enrolled. These initiatives would require considering solutions like the repeal of Medicaid expansion, addressing program integrity and improper payments, and reducing the high use of services like prescription drugs. 

New Zealand’s newly-elected center-right government announced yesterday that it intends to scrap a planned phase-in of tobacco prohibition that would ban sales of tobacco products to people born after 2009. The plan would have also cut the number of retailers permitted to legally sell tobacco by 90 percent and ordered tobacco makers to reduce the nicotine content of cigarettes they may sell. Anyone versed in the economics of prohibition would have predicted that each of those three measures would help fuel a vibrant black market with its corresponding violent crime and corruption.

This is good news for New Zealanders, where less than 14 percent of persons over age 15 smoked tobacco in 2020. They will avoid yet another state encroachment on their personal liberty along with tax increases to fund government spending on enforcing tobacco prohibition and fighting tobacco smugglers.

UK Prime Minister Rishi Sunak should take notice. Last month, his government announced plans to clone New Zealand’s tobacco prohibition plan. Announcing his plan at Britain’s Conservative Party Conference, Sunak said, “A 14-year-old today will never legally be sold a cigarette.”

Sunak’s announcement came as both a surprise and a disappointment to tobacco harm reduction advocates, given the UK’s heretofore reasonable approach to reducing tobacco smoking. While nicotine is the addictive component of tobacco smoke, it is a relatively harmless stimulant, not very different from caffeine, as Scotland’s NHS Informs has stated. The other components of tobacco smoke are what produce harm to health.

The UK’s Royal Society of Public Health claims nicotine is “no more harmful to health than caffeine.” Public Health England has claimed that “vaping” with nicotine e‑cigarettes is “95 percent less harmful than tobacco smoking.” The Royal College of Physicians has issued the following statement:

• [T]he available evidence to date indicates that e‑cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely.
• There is a need for regulation to reduce direct and indirect adverse effects of e‑cigarette use, but this regulation should not be allowed significantly to inhibit the development and use of harm-reduction products by smokers.
• However, in the interests of public health it is important to promote the use of e‑cigarettes, NRT [nicotine replacement therapy] and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.

So far, Brookline, Massachusetts is the only jurisdiction in the United States to have enacted a tobacco ban. Brookline bans the sale of tobacco to anyone born after the year 2000. It doesn’t take an entrepreneurial genius to figure out ways to make money legally selling cigarettes to adults from the other side of the Brookline town line.

Earlier this year, California lawmakers considered making the Golden State the first in the nation to enact New Zealand’s tobacco prohibition model into law. A bill to that effect failed to advance during this year’s legislative session. Interestingly, California’s major anti-smoking and anti-vaping groups chose not to lobby for the bill. A Cal Matters report quoted Autumn Ogden-Smith, director of California state legislation for the American Cancer Society Action Network, saying, “This is not the time to tackle this. We’re trying to do the clean-up on the flavored tobacco ban. We’re having enforcement issues.”

As I wrote here, banning menthol tobacco creates its own set of harmful unintended consequences.

New Zealand’s recent about-face on tobacco prohibition will hopefully put to rest similar efforts in California and other states. Let’s hope it will also cause Sunak and his Conservative Party to reconsider their plans. The UK had the right approach to reducing tobacco smoking until now: opting for evidence-based tobacco harm reduction instead of prohibition.

Few people noticed—the press didn’t cover it much—but Coloradans in pain and the clinicians who treat them got relief this legislative session when Colorado Governor Jared Polis signed SB 144 into law last May. The bill revised an earlier statute that had placed restrictions on how clinicians treat chronic pain. The new law, which removed those restrictions, went into effect in August.

Like the majority of states, Colorado placed limits on the dosage and amount of opioids clinicians can prescribe to patients in pain, effectively enshrining in law the flawed 2016 Centers for Disease Control and Prevention recommendations for treating pain. Responding to criticism from physicians, pharmacologists, and addiction specialists who argued, among other things, that the CDC’s morphine milligram equivalent conversion tables were junk science, the CDC revised its guideline in 2022. Unfortunately, the revised pain-prescribing guideline has hardly any more basis in the evidence than the original. And though the agency stressed that it is not intended as a mandate, policymakers will likely interpret it that way.

In SB 144, Colorado lawmakers returned the clinical decision-making process to clinicians. Lawmakers also recognized the fallacy of using morphine milligram equivalent conversion tables to govern how clinicians treat individual patients. The following are among the bill’s provisions:

• A HEALTH-CARE PROVIDER ACTING IN GOOD FAITH AND BASED ON THE NEEDS OF THE PATIENT WITH A DIAGNOSED CONDITION CAUSING CHRONIC PAIN IS NOT SUBJECT TO DISCIPLINE FROM THE REGULATOR SOLELY FOR PRESCRIBING A DOSAGE THAT EQUATES TO AN UPWARD DEVIATION FROM MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATIONS OR FROM THRESHOLDS SPECIFIED IN STATE OR FEDERAL OPIOID PRESCRIBING GUIDELINES OR POLICIES.
• A HEALTH-CARE PROVIDER TREATING A PATIENT WITH CHRONIC PAIN…SHALL NOT BE REQUIRED TO TAPER A PATIENT’S MEDICATION DOSAGE SOLELY TO MEET A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD IF THE PATIENT IS STABLE AND COMPLIANT WITH THE TREATMENT PLAN AND IS NOT EXPERIENCING SERIOUS HARM FROM THE LEVEL OF MEDICATION CURRENTLY BEING PRESCRIBED OR PREVIOUSLY PRESCRIBED. A DECISION TO TAPER OR MAINTAIN MEDICATION MUST INCLUDE AN INDIVIDUALIZED ASSESSMENT OF THE PATIENT’S CURRENT MEDICAL CONDITION AND TREATMENT PLAN, THE RISKS AND BENEFITS OF MAINTAINING OR TAPERING THE PATIENT’S MEDICATION, AND A DISCUSSION WITH THE PATIENT.
• A PHARMACY, CARRIER, OR PHARMACY BENEFIT MANAGER SHALL NOT HAVE A POLICY IN PLACE THAT REQUIRES THE PHARMACIST TO REFUSE TO FILL A PRESCRIPTION FOR AN OPIATE ISSUED BY A HEALTH-CARE PROVIDER WITH THE AUTHORITY TO PRESCRIBE OPIATES SOLELY BECAUSE THE PRESCRIPTION IS FOR AN OPIATE OR BECAUSE THE PRESCRIPTION ORDER EXCEEDS A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD.
• A HEALTH-CARE PRACTICE OR CLINIC IN WHICH A HEALTH-CARE PROVIDER IS AUTHORIZED TO PRESCRIBE…SHALL NOT HAVE A POLICY IN PLACE THAT REQUIRES THE HEALTH-CARE PROVIDER TO REFUSE TO PRESCRIBE, ADMINISTER, OR DISPENSE A PRESCRIPTION FOR AN OPIATE SOLELY BECAUSE THE PRESCRIPTION EXCEEDS A PREDETERMINED MORPHINE MILLIGRAM EQUIVALENT DOSAGE RECOMMENDATION OR THRESHOLD.

While I appreciate and agree with the spirit behind the last two provisions, I don’t think lawmakers should mandate what policies private clinics, pharmacies, or pharmacy benefit managers choose to institute. However, Colorado’s lawmakers and governor deserve credit for unshackling clinicians who are trying to help their patients who are in pain and for tacitly repudiating morphine milligram equivalent junk science.

SB 144 should improve patients’ access to pain management. It isn’t the only step Colorado has taken this session to increase access to care. Earlier this year, Governor Polis signed into law HB 1071, making Colorado the sixth state to expand access to mental health care by removing barriers to psychologists prescribing.

Colorado’s lawmakers and governor deserve praise for these reforms.

Shannon Najambadi reports for the Wall Street Journal about the growing problem of “ambulance deserts.” In many parts of the US, ambulance services are so scarce that people may need to wait an hour or longer for an ambulance to arrive. According to a recent study by the University of Southern Maine’s Muskie School of Public Service Rural Health Research Center, 4.5 million Americans live in an ambulance desert, and 2.3 million in rural counties. The researchers define an ambulance desert as “a populated census block with its geographic center outside of a 25-minute ambulance service area.”

The study found that roughly 80 percent of counties in the US have ambulance deserts, but rural counties were more likely to have an ambulance desert than urban counties. The counties with the highest share of ambulance deserts were in the Appalachian regions of the South.

The Wall Street Journal article reports that more than fifty-five ambulance services have closed nationwide since 2021. In many cases, the ambulance services have had difficulty hiring people willing to train for this high-pressure job at their own expense. Adding to the problem is that the ambulance business can often be unprofitable. For example, service providers in rural areas make fewer calls per year than in urban areas, often traveling longer distances with higher fuel costs.

While not responsible for this problem, state Certificate of Need (CON) laws do not help matters. These laws require organizations that offer health care facilities or services to get permission from a state commission—usually consisting of or strongly influenced by competing incumbents— to enter the health care market.

In effect, a certificate of need is a permission slip to compete. Constitutional scholar Christina Sandefur of the Goldwater Institute refers to CON laws as a “competitor’s veto.” During the COVID-19 pandemic, many states temporarily suspended their CON laws to get the government out of the way of hospitals and other providers scaling up to meet emergency demand.

Arizona, where I reside and practice medicine, repealed its CON law in 1990. But it retained the “Certificate of Necessity” requirement for ambulance services. Arizona has a large rural population, with some towns hundreds of miles from a major town or urban center. According to the Central Arizona Fire and Medical Authority, ambulances could not respond to emergency calls 400 times in Prescott and surrounding areas during four months in 2021.

Kentucky, a state with a large rural population containing parts of Appalachia, has CON laws extending over a large swath of the health care sector. The University of Southern Maine study states that 91.7 percent of its counties have ambulance deserts.

There is no simple fix to America’s ambulance desert problem. Its causes are multifactorial. However, one way state lawmakers can help is by repealing their Certificate of Need laws so providers no longer need permission from their competitors before they can offer services to patients.

Yesterday, Ohio voters approved Issue 2, which legalizes recreational marijuana, by a decisive 57 to 43 percent vote. Issue 2 allows adults aged 21 and older to possess up to 2.5 ounces of marijuana publicly and to grow up to six plants at home. Ohio is set to become the 24^th state to legalize recreational marijuana. Thirty-eight states (including Ohio) and the District of Columbia have already legalized medicinal marijuana.

One potential fly in the ointment is that Issue 2 was a voter-initiated state statute, not a constitutional amendment. Therefore, under Ohio law, state legislators may rewrite or override much of the new statute.

Another potential problem is that the new statute imposes a 10 percent state excise tax on marijuana sales in addition to the state and local sales taxes, which will still apply. Ohio state and local sales taxes average around 7.24 percent. This means that people shopping at legal marijuana retailers may pay more than 17 percent tax on purchases.

Experience in California and other states that have legalized possessing and using marijuana should teach policymakers that overtaxing retail marijuana only serves to preserve the pre-legalization black market, as marijuana consumers who no longer fear arrest and punishment will pay less if they buy the weed from underground dealers.

Uruguay was the first country in the world to legalize marijuana production, sale, and consumption. Several European countries have decriminalized marijuana, and a number of European countries are contemplating legalizing it.

Now that the majority of the US population lives in jurisdictions that have legalized recreational marijuana use, it is long past due for Congress to act. Congress should pass federal legislation that makes growing, processing, transporting, selling, and using marijuana legal and leaves it up to states to decide on marijuana’s legal status for medicinal or recreational use within their borders.

But federally legalizing marijuana while it remains on the Drug Enforcement Administration’s schedule of controlled substances doesn’t go far enough. The DEA currently categorizes marijuana as a Schedule 1 drug: “no currently accepted medical use and high potential for abuse.” If the DEA re-scheduled marijuana to one of the remaining schedules (2 through 5), the plant would remain a controlled substance, requiring a prescription from DEA-licensed health care practitioners, whose prescribing patterns would be closely monitored and regulated by law enforcement.

Congress should require the DEA to de-schedule marijuana, i.e., remove it from the schedule of controlled substances. Alcohol, a much more potent and potentially harmful drug, is not on the DEA schedule of controlled substances. Neither should marijuana be. De-scheduling marijuana will also make it easier to do clinical research on the plant’s medicinal uses.

Surveys show bipartisan support for legalizing marijuana. A recent Gallup poll found overall support at 70 percent (87 percent of Democrats, 69 percent of Independents, and 55 percent of Republicans). As is often the case, the people are way ahead of the politicians. It’s time for leaders in Washington to jump out to the front of the parade line and wave the banner for marijuana legalization.

Last March, I wrote about a recent episode of “Cops Practicing Medicine,” in which the Drug Enforcement Administration inserted itself into the medical management of opioid use disorder by proposing telehealth guidelines that undermined Congress’ intentions when it passed the Mainstreaming Addiction Treatment (MAT) Act at the end of 2022. The act removed the onerous rules and regulations surrounding the “X waiver” that the DEA required health care practitioners to obtain if they wanted to treat addiction with buprenorphine. The DEA’s proposed rule requires that any patients initially begun on buprenorphine via telehealth must see the prescribing practitioner in person within 30 days. The rule limits the prescription to a 30-day supply. The cops are concerned that patients will “abuse” or “divert” the buprenorphine into the black market if they do not get personally inspected by the physician after 30 days. The DEA has delayed implementing the proposed rule until the end of next year.

Doctors who treat substance use disorder begged to differ from the cops and offered a second medical opinion.

Addiction specialists are concerned that the proposed rule will reduce access to buprenorphine treatment and will undermine lawmakers’ intent to make it easier for people to get treatment for opioid use disorder. Dr. Brian Hurley, president-elect of the American Society of Addiction Medicine, told STAT News, “I don’t want federal rules dictating to me when I have to cut somebody off a medication that, on the basis of the information available to me, is still appropriate for the patient.” 

It already averages 26 days to get a new appointment with a primary care provider, so there is no guarantee a new buprenorphine patient can get an appointment within the 30-day window. It might be even more difficult in rural or other areas with primary care provider shortages. The proposed DEA rule is likely to abruptly cease treatment for many patients who have just begun treatment using telehealth. Shortened or abrupt cessation of treatment will very likely cause patients to resume non-medical use of opioids in the dangerous black market.

Now, a bipartisan group of US senators has decided to go with the second opinion. Senators Sheldon Whitehouse (D‑RI), Lisa Murkowski (R‑AK), Marsha Blackburn (R‑TN), and Mark Warner (D‑VA) have introduced the Telehealth Response for E‑prescribing Addiction Therapy Services (TREATS) Act. The bill would allow providers to waive the in-person requirement. The senators argue that, in 2020, the DEA and the Substance Abuse and Mental Health Services Administration allowed patients to receive buprenorphine via telemedicine without requiring them to see clinicians in person as an emergency measure during the COVID-19 pandemic, and there is no evidence that patients abused or sold the medication on the black market.

Buprenorphine is a weak partial opioid agonist, unpopular among recreational drug users. Studies indicate that most people who buy buprenorphine on the street are self‐​administering medication-assisted treatment with buprenorphine because they can’t get appointments for treatment.

A shortcoming of the TREATS Act is that it doesn’t overrule the cops’ 30-day supply rule. Clinicians, not cops, should decide how much buprenorphine to prescribe based on their judgment and knowledge of their individual patient’s circumstances.

Senators Catherine Cortez Masto (D‑NV), Thom Tillis (R‑NC), Tim Kaine (D‑VA), Shelley Moore Capito (R‑WV), Amy Klobuchar (D‑MN), Mark Kelly (D‑AZ), and Cory Booker (D‑NJ have joined the bill as co-sponsors. Representatives David Trone (D‑MD), Jay Obernolte (R‑CA), and Brian Fitzpatrick (R‑PA) introduced the bill in the House. 

It is refreshing to see lawmakers follow the medical advice of addiction medicine specialists over the advice of cops.