Did you see the story about Marko Elez? He resigned as one of Elon Musk's tech wiz boys because of blowback from a series of racist and eugenicist rants he posted under an assumed name. Little Marko is one of Musk's raiders who burrowed into the Department of the Treasury’s multi-trillion dollar payment system and mucked about in records that included Americans’ Social Security payments, tax filings, refunds, Medicare and Medicaid payments, and other private information that has never before been broached by anyone, let alone by a bunch of teenagers and 20 somethings with no authorization or security clearance to see the information that rightfully belongs to each private American citizen.

“Just for the record, I was racist before it was cool,” Elez posted last July. In September of last year Elez wanted us to know that “You could not pay me to marry outside of my ethnicity.” In December, Elez posted this gem: "I just want a eugenic immigration policy, is that too much to ask."

Well actually it is, you worthless little incel twerp.

Within 24 hours, Vice President JD Vance was calling for his reinstatement. “I obviously disagree with some of Elez’s posts, but I don’t think stupid social media activity should ruin a kid’s life,” Vance wrote on social media. The “kid” he wants to excuse from adult responsibility is 25 years old.

Musk was already making sure it would happen by posting this poll question on his X account: “Bring back @DOGE staffer who made inappropriate statements via a now deleted pseudonym?” Within hours Musk had his answer as 78 percent of his 385,000 followers who cast votes in his poll said yes.

By Friday afternoon at his press conference with the Japanese Prime Minister, Donald Trump had jumped on board agreeing with his vice president that Musk’s techno-terrorist shouldn't suffer because he posted some stupid racist eugenicist shit on social media.

This is the Trump-Musk-Vance version of white boy DEI: They want diverse opinions from young racists to counter the libs, don't you know. So here is the brilliant future we are looking at -- they're going to come after you if you have brown skin, they're going prosecute you if you've been disloyal or mean to Trump, they're going to send you back to the kitchen to pop out babies if you're a woman, and if the genetic roll of the dice awarded you with Black skin, you'd better just start running.

The Washington Post reported this morning that Elon Musk’s “ultimate goal” is to cut so much money and so many jobs from the American government that if it is to function at all it will be AI-automated and answerable to only one man, Donald Trump.

Trumps wants to toss out the other branches of government, Congress and the courts. He thinks the founders made a mistake when they created a separation of powers between the three branches with each of them balancing and checking the other. That's not the way it worked in South Africa! It is sure as hell not the way the Trump Organization worked when The Donald sat up there in Trump Tower and was answerable to no one. What's this shit about Congress telling him how much money he can have and what he can spend it on? The Donald didn't have a Board of Governors to argue with!

But not to worry: Musk and Trump have a new idea. They'll handle all the government money with a new deal X has made for a payment system using Visa! Who needs elections when you've got online polling? Don't worry about a thing. They'll leave voter ID up to Elon and Marko Elez and the rest of Musk’s techno wiz-children.

This is what they're working on behind the scenes, a system of AI-connected totalitarianism with Trump's golfing buddy oligarchs and Silicon Valley suck-ups at the top and everybody else relegated to the ranks of the forced-loyalty masses down below.

Birthright citizenship and equal protection of the laws for me but not thee; the Ten Commandments printed everywhere from car bumpers to the backs of cereal boxes; the right to vote for the following people, and I'll give you one guess who gets to make that list.

This is bad, folks. I'm serious. The only ones who are going save us is ourselves.

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Jalalabad is the largest trading city in eastern Afghanistan. It sits right on the main trade route between Peshawar, Pakistan, and Kabul, the capital and most populous city in Afghanistan. When you first drive into Jalalabad on the road from Kabul, it’s a rather unprepossessing and modest town. Many of the businesses that line the road are wooden lean-tos or mud brick shacks open to the front, lit by kerosene lamps at night, with their wares displayed beneath makeshift tarps.

The first building you come to of any size is the Spinghar Hotel, a 35-room accommodation surrounded by rundown ornamental gardens. It opened in 1934 during the reign of Afghanistan's last royal ruler, King Mohammad Zahir Shah. When I was there, the Spinghar was the place most Westerners stayed. There weren't many Westerners at the Spinghar that week in May of 2004. In fact, the only other Westerners in the hotel were a USAID contractor and his Cambodian wife and four-year-old daughter. And thereby lies a tale.

I met him one afternoon in the garden in front of the hotel having tea with his wife. His daughter, in a flowered dress wearing little black Mary Jane style shoes with a strap over the instep, was playing with a red ball on the patchy grass next to us. I was shocked. I was carrying a bulletproof vest in the truck we had driven from Kabul earlier in the week, and here was this guy, a civilian, with a wife and a kid in an area that because of the Taliban and regular IED explosions and armed attacks on businesses and Afghan government workers was a combat zone. Hell, about five miles from us just outside of town, there was a heavily fortified U.S. Army base camp surrounded by a huge dirt berm topped with concertina barbed wire, protected by a company of infantry an Bradley armored personnel carriers and mortars.

He must have been in his late 40s, but he looked younger. His hair was graying at the temples, but his bushy mustache was black, and his smile wrinkles had not settled into his weathered face very deeply. He introduced me to his wife and daughter and called out to a waiter to bring me a cup of tea and more biscuits. The Spinghar had a vaguely British feel, and the tea and biscuits fit right in. I introduced myself as an American journalist in Afghanistan covering the ongoing war between the American army and the Taliban insurgency that three years after the American military had moved into Afghanistan was building in strength and intensity.

I asked him what he did and why he was there in Jalalabad during a time of conflict and war. He said he worked for an NGO that had been contracted by USAID and was assigned to the Provincial Reconstruction Team (PRT) that had been established by the State Department in Jalalabad.

“What kind of work do they have you doing here?” I asked him. He told me that he was a specialist in agriculture and agriculture markets and food chain hygiene.

“Boy, that's a rather specific area of specialization,” I said to him. “Well, that's what USAID does. It sends people around the world to work on problems in places where the United States has interests, and 9-11 has made Afghanistan one of them.”

He said he'd been working for USAID in one capacity or another for nearly 30 years -- sometimes as a contractor, sometimes as a federal employee, but always overseas. He had met and married his wife while serving in Southeast Asia, in Cambodia or Laos I think he told me. Since then, he had served in Turkey and for a short time in northern Iraq outside of Mosul. “They sent me here because I was nearby and we could hop a military flight to get here and save money.”

We talked for a while, and I told him I had been up the Kunar River in Asadabad trying to figure out what the hell the United States military was doing over there in Afghanistan. “Did you see any of them?” he asked me. I told him a convoy of heavily armed Humvees had passed us one day on the road, but other than that I hadn't seen much of an American presence in the border area between Afghanistan and Pakistan.

He told me he had been up to the border one day with a herder who was smuggling cattle over the border from Pakistan. “Why the hell were you doing that?” I asked him. “It's dangerous up there. Not even the Army goes up in those mountain valleys.” He said he went where the job took him. “You know how back home everything in the agricultural food chain is inspected and reinspected and regulated to make sure that by the time it gets into a supermarket it's safe to eat? Well, that doesn't happen here and in fact it doesn't happen practically anywhere, especially in the third world. And this," he said gesturing around a garden that had seen better days having been through the war against the Russian occupation in the 80’s and the Taliban’s iron-fisted rule since then, “is part of the third world."

On foot, he had followed the smuggled cattle herd all the way from the Pakistan border to the market in Jalalabad, a journey of more than 20 miles to where the cattle were slaughtered and the beef went on sale. He was trying to figure out why the local hospital, which was just up the Kabul road from the hotel was reporting so many cases of gastrointestinal disease and even death. He looked into the vegetable market and the flour that was sold in bulk to make bread and hadn't found any danger zones. But when he went into the meat market and discovered sides of beef and lamb covered in flies and often spoiled from hanging in the open air sometimes for days. He said the butchers would cut off the discolored spoiled parts with a knife and hang them back up for sale the next day. The meat was still contaminated, and he sure that he had found the reason people were getting sick.

“Well, if you could see bad meat in the market, then why did you have to go all the way to the border with Pakistan looking for the problem?”

“Because that's what you do when the problem has an apparent link to agriculture,” he explained. “You get close to the source and check out everything you can. You follow the product all the way to market, and then you explore the marketplace. I didn't find any problems with the cows or the sheep even though I suspected that's what might be problem because they were smuggled in from Pakistan. It turned out that the problem was hygiene, as it is so often in countries that are distressed. There are no refrigerated warehouses to store butchered meat in Jajalabad. There's no ice for displays in the marketplace. There's no refrigeration at all. Hell, there isn't even any electricity in the market.”

“It sounds like a problem without a solution, it's not an easy one," I said to him. He replied, “Well, there is actually a fairly easy solution with this spoiled meat that's causing so much disease and distress and death. I figure if I could get my hands on at least 11 plain household refrigerators and a couple of generators to hook them up to, we could make spoiled meat in Jalalabad a thing of the past, if I could also convince the butchers and sellers in the market to use them.”

“Did you report this to your bosses in USAID?” I asked him. “Yeah,” he said. “I took it to the guy running the Jalalabad PRT, and he sent it up the chain of command to USAID headquarters in Kabul, and we're waiting to hear back from them. It's in the bureaucracy now. That's where everything goes in the beginning, when you first figure out the solution to a problem, and that's where it comes out, if it comes out at all. I've been doing this job for decades. It's frustrating, it can drive you crazy if you let it. But over the years I have learned that it may not make much sense down here where the problem is in the field, but they're the ones with the money back in Kabul or Ankara, and they're the ones that have to okay the disbursement, and one way or another you have to deal with the bureaucracy to get anything done in this or any other world I've ever worked in.”

We sat in the garden for another hour watching his daughter gambol around. We talked about what was going on back home, and he asked me what I thought John Kerry's chances were against Bush in the fall. When we had finished with politics, we talked about rock'n'roll and the blues. He was from Chicago, and he was a big fan of Muddy Waters and wished he had seen him before he died.

I left him there in the garden of the Spinghar Hotel. I was heading back to Kabul the next day, and by the end of the week I would be on a plane to Islamabad and then back home to the United States. His contract through the NGO with USAID lasted until the end of the year. He was looking forward to home leave in August. When he returned to Kabul, he would get a new assignment in Afghanistan, but he didn't know where it would be, or what he would be doing, except that it would have something to do with agriculture markets and food chain hygiene and the stuff that kept people healthy and prevented disease and death.

I watched on MSNBC this afternoon as a worker on a cherry picker used a screwdriver to remove the metal letters that read “United States Agency for International Development” above the doorway to the headquarters building in Washington D.C. Elon Musk or somebody else working for Donald Trump announced yesterday that the administration will fire nearly all 10,000 people who work for USAID. Their plan is to leave only 290 federal employees of the agency that has done work around the world just like the man I met in Jalalabad had done for nearly 30 years.

Tonight, a judge in Washington issued a temporary restraining order preventing the Trump administration from putting the first 2,300 USAID workers on leave before firing them. There will be a hearing next week in the case against the dismemberment of USAID that Trump and Musk are attempting to carry out. If the agriculture market specialist I met in Afghanistan was still working there, he would be fired too.

This is why we should care about USAID.

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Next week Ohio's legislature will reportedly hold its first hearing on SB 34, a bill to display "certain historical documents in public schools."

The bill was sponsored by Senator Terry Johnson and co-sponsored by seven other Ohio worthies, and it at least attempts to provide some fig leaves to go with its aim of requiring school boards to post the Ten  Commandments in each classroom. The board "shall select" at least one of the following:

The Mayflower Compact
The Declaration of Independence
The Northwest Ordinance
The mottoes of the United States and Ohio
The Ten Commandments
The Magna Carta
The Bill of Rights
The United States Constitution
The Articles of Confederation

(And before you freak out, the Articles of Confederation are not from 1860, but from 1777--essentially the first attempt at a Constitution).

Again, the choice is required, and in the hands of the local board of education. Will plenty of districts choose one of the secular options? Sure they will. But for those who want to breeze past the First Amendment and do some religion establishment in the classroom, this bill provides cover. 

In fact, the local board can even erect "a monument or other marker" inscribed with one or more of these documents, and put it anywhere on school grounds. 

The district may take contributions of either funding or the actual displays. They tried this in Texas with "In God We Trust" posters, and Patriot Mobile, the Oh So Very Christian mobile phone company donated a bunch of posters. Of course, so did folks who incorporated rainbows and arabic writing, leading a huge dustup over just what sort of trust students were supposed to be tossing toward which gods. The Ohio law includes a clause that if the contributor tries to tell the school how to do their display, the school can turn them down. 

The Ohio display has to include an explanation of the historical importance of the item displayed, otherwise it would be obvious that the school had put up a religious display. This "historical importance" dodge is popular with the religious display-in-school crowd, at least until the Supreme Court finally rules that it would inhibit the free exercise of christianists not to be able to impose their religion on schools.

No word in the bill about which version of the decalogue schools are supposed to use. 

An actual Christian might be a bit put off by the way this bill equates a sacred text with some political documents, as if the founding fathers and the Great I Am are pretty much on equal footing, much like the Louisiana Ten Commandments law suggests putting up posters that equate Moses with Speaker Mike Johnson. 

Will the Ohio legislature show some sense? One never knows. Stay tuned.

This is it. This is Germany in the 1930s and what you do will be recorded in the history books. Your children and grandchildren will look back and ask what you did. Will you be able to look them in the face?

These are dark times but I will continue to tell the stories you need to hear in a clear (and usually profane) voice. If I entertain/anger/inform you, preferably all three, please consider becoming a supporting subscriber today for only $5 a month or just $50 a year $25 a year while the 9000 OMG sale is running!

🚫Do Not Obey🚫

It’s been a hectic couple of days. I wanted to write about this earlier in the week but there was so much other news dropping, I just couldn’t get to it. I love to write but there’s only so much I can pump out in a day, you know? And Wednesday I spent hanging out with the girls1 so it is what it is.

But now I have a minute to get to this so here we are, two profiles. One in courage and one in abject cowardice, both courtesy of Erin in the Morning.

By now, you should be more than aware that Trump has signed numerous executive orders targeting the trans community. They are overwhelmingly illegal and exist to further the projects of trans genocide and Trump’s lawlessness with the goal of conditioning the public to both so they will accept the atrocities Republicans are planning to commit in the near future.2

Let’s start with the abject cowardice.

But…but…mah profits!

Last week, Trump was given an executive order to sign and he did so like the mindless monkey he is. I promise you, he had no fucking idea what it was and if any reporter had the nerve to ask Trump for the details, he would have had them thrown out of the room.

Anyway! The EO, which Trump could not explain if you put a gun to his head or a dozen McDonald’s cheeseburgers on his desk, states that “It is the policy of the United States that it will not fund, sponsor, promote, assist, or support the so-called ‘transition’ of a child from one sex to another, and it will rigorously enforce all laws that prohibit or limit these destructive and life-altering procedures.” Curiously, the definition of “child” has now been extended to 19. Last I look, 18 was considered an adult. As in, they’re old enough that it’s none of your fucking business.

Then again, I’m old enough to remember Republicans spending millions on ads screaming about Obamacare getting in between patients and their doctors. Big government was evil. Until it wasn’t, I guess. My, how the times change when fascism comes a’calling…

Erin in the Morning reports that a bunch of hospitals are obeying in advance:

Throughout the past week, multiple children’s hospitals across the country have signaled their intent to comply with President Donald Trump’s executive order targeting transgender healthcare, despite the order lacking a clear enforcement mechanism beyond funding threats and conflicting with established law in many states where these hospitals operate. Internal communications obtained by Erin in the Morning reveal that University of Colorado Health has informed physicians it will cease all gender-affirming surgeries for individuals under 19 and stated that it “cannot endorse” hormone replacement therapy for this age group. Similarly, Denver Health has confirmed it will halt all surgeries for minors but has not clarified whether it will continue providing hormones.

It’s worse than it looks because many of these cowards are in blue states that have laws protecting the trans community:

A number of the hospitals pulling back on care are located in blue states that have explicitly designated themselves as “sanctuaries” for gender-affirming care. Sanctuary laws exist to provide legal protections for transgender healthcare, making bans difficult to enforce. The decisions of these hospitals to preemptively comply with Trump’s executive order stand in direct contradiction to state healthcare policies designed to protect access to care. This is a textbook case of institutions surrendering before a fight even begins, bowing to political pressure despite the lack of any immediate enforcement mechanism.

These hospitals are caving to pressure to protect their funding. Now, they could make an argument that they need that money to help the far larger number of non-trans patients. But that’s a slippery slope. Today it’s trans “kids.”3 Tomorrow it’s trans adults. Then it’s abortion. Then it’s tube ligation. Then it’s healthcare for gay men. No more vaccines because we don’t believe in those anymore.

Where do the hospitals draw the line? When does protecting their funding stop being more important than the health and lives of their patients? Or does it never end because profitability is the only metric that ever really mattered?

In the meantime, it’s become very vogue to blame the trans community for the abuse the Trump regime is heaping on them. Here’s “liberal” Brianna Wu doing exactly that:

Yeah…I don’t know who touched Wu in her No-No Box to make her lash out at the trans community like she has been for the last couple of years, but she can fuck all the way off with this. I’m just as terminally online as she is and the only way you could feel like trans rights were trying to “conquer” you is if you feel threatened by trans people in the first place. Otherwise, someone demanding equal rights and protection under the law doesn’t affect me in any way whatsoever.

As for causing the blowback? Tell that to the Haitians living and working in Springfield, Ohio. Literally no one but the people living there even knew about them until Republicans went looking for someone to hold up as a new target for their rabid base of mindless bigots to rage at. Because that’s what Republicans do. It’s what they ALWAYS do. It’s the only play they have in their playbook.

The Republican Playbook:

1. Cut taxes for the rich.

2. Gut government services for everyone else to pay for the tax cuts for the rich.

3. Blame everything on a rotating cast of marginalized groups to distract the imbeciles to win elections.

4. Repeat steps 1 through 3.

Perhaps Wu thinks the Haitians brought it on themselves? Maybe the gay community forced Republicans to target them in the early 2000s? Maybe Women forced Republicans to spend the last 50 years stripping them of their reproductive rights? Maybe Muslims forced Trump to ban them in 2017? Maybe librarians and teachers were, in fact, trying to conquer us with CRT a few years ago? That sounds plausible, yeah?

Maybe maybe maybe. The list of groups Republicans have attacked in just the last decade is longer than my arm. And I’m using a very tiny font. They can’t all be to blame, Wu. Maybe you should sit down and shut the fuck up. Go see a therapist and figure out why trans people freak you out so much?

OK, that’s enough of these jerks. On to the heroes.

Public Schools tell Trump to fuck off

When my home state of Virginia fell prey to propaganda and elected a Republican as governor in 2021 (we have off-year elections), Glenn Youngkin immediately set out to burnish his MAGA credentials by attacking trans kids. He ordered school districts to deadname students and refuse the use of their preferred pronouns and bathrooms. Most of our school districts told Youngkin to fuck off.

Trump, naturally, did exactly the same thing and the response has been…pretty much the same according to Erin in the Morning:

On Thursday, multiple school systems and representatives issued statements rejecting Trump’s executive order that directs schools to discriminate against transgender students or face legal consequences. The order, released Wednesday, labels transgender identity as an “anti-American ideology” and mandates discrimination in bathrooms and locker rooms while threatening teachers with criminal charges for supporting trans students’ social transitions. In response, school officials across the country are making it clear: they will not comply, and they remain committed to protecting the rights of their transgender students.

And it’s not that the school districts are just ignoring Trump. They’re planting a flag and saying, loudly, “Fuck you. We will not comply.”

On Thursday, Julie Yang, President of the Montgomery County Board of Education in Maryland, issued a forceful response to Trump’s executive order in a mass email to families. Representing a school district of 160,000 students, Yang affirmed that Montgomery County would continue to recognize gender identity as a protected characteristic. “We stand by our community and school system values, which include learning, relationships, respect, excellence, and equity. They guide us every day and anchor us when navigating difficult times. We intend to use all legal means necessary to uphold them… On Thursday, Julie Yang, President of the Montgomery County Board of Education in Maryland, issued a forceful response to Trump’s executive order in a mass email to families. Representing a school district of 160,000 students, Yang affirmed that Montgomery County would continue to recognize gender identity as a protected characteristic. “We stand by our community and school system values, which include learning, relationships, respect, excellence, and equity. They guide us every day and anchor us when navigating difficult times. We intend to use all legal means necessary to uphold them… We are committed to maintaining local authority over our curriculum, teaching, and learning. And we will fiercely support our teachers and staff as they implement our curriculum and policies.”

Now, one could argue that the key phrase here is “We are committed to maintaining local authority over our curriculum, teaching, and learning.” We are a fiercely independent culture and we do not like being told what to do by the federal government even under ideal circumstances.

I submit, however, that this is not what is happening here. As demonstrated by Virginia schools under Youngkin, educators understand the assignment: The children come first. And they act accordingly.

When Republicans cry “Protect the children!”, what they actually mean is, “Use the children as a cudgel against the people we hate.” We know this because when we ask them to protect the children for real, Republicans invariably respond with, “LOL! Eat shit, you little snot-nosed brats!”

• Prenatal care for pregnant women? Fuck you.

• Food, clothing, and shelter for newborns? Fuck you.

• Healthcare and education for children? Fuck you.

• School breakfast and lunch? Fuck you.

• Get guns off of the streets and keep schools safe? Fuck you.

• Raise the age of consent to 18? Fuck you.

• End child marriage? Fuck you.

• Don’t force little girls to have babies? Fuck you.

No one hates children more than a “pro-life” Republican.

But schools? Teachers? Admins and Superintendents? They do protect the children. They’ve literally taken bullets for them. There’s not a “Moms for Liberty” that would throw themselves in front of a gunman to save someone else’s child. They’re too busy quoting Hitler and trying to erase Black, Latino, and LGBTQ students.

Public schools are not motivated by ideology or by profit. They do the job because they love the children and when someone threatens them, ANY of them, the claws come out.

THAT’S what it means to protect the children. That’s what it means “to do no harm.”

Maybe the spineless hospitals obeying in advance should remember what their actual mission is. Our schools never forgot.4

Trump is coming for the Department of Education next because he’s been told to by his billionaire puppetmasters. Public education is, and remains, a threat to the Republican project to return America to the dark ages. Get ready to march because our schools have been there for the most vulnerable of us. Now it’s time to fight for them.

There are 52 days until the first Blue Wave starts in Wisconsin and 269 days until it hits Virginia and Pennsylvania. If I were a billionaire fascist, I’d think REALLY hard about getting out of the way.

I hope you feel better informed about the world and ready to kick fascists in the teeth to protect it. This newsletter exists because of you, so please consider becoming a supporting subscriber today for only $5 a month or just $50 a year $25 a year! Thank you for everything!

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After two weeks of Musk and his Tech Boys rampaging through the federal bureaucracy, the courts have finally started pulling on the reins.  Now two judges have poo-pooed Trump’s bullshit natural born executive order, and another judge today put a halt to Musk’s “Fork in the Road” demand until a hearing on Monday.  Last night, DOJ agreed to “read only” access for two “special employees” and a judge is considering that settlement now.  In the meantime, USAID remains illegal shuttered with civil servants locked out and thousands stranded in countries all over the world.

Let’s be clear, though – what Musk is doing is illegal as shit, outside of any Congressional oversight.  He’s pushing longstanding employees out, threatening others, and has even locked out thousands of employees.  He’s using the same tactics he used at Xitter, Twitter converted to X, pronounced “shitter”.  His well known tactic is to break everything, then go back and fix it later.  That’s fine when you have a private company, but when you’re fucking with 340 million Americans’ lives, the rules are, or goddam sure better be, different.

Worse, the DOJ, now under Trump acolyte, Pam Bondi, is now completely weaponized, and she’s even calling the attorneys “Trump attorneys” which the most certainly are not.  She issued a memo today announcing a plan to “root out corruption” which is translated to “make the DOJ corrupt as hell“.  So a coup is underway, stealing the US government from under the noses of the American people and none of the guardrails are even left standing.

The wheels of justice are starting turn, though too slow and too late.  The problem I see, though, is when the courts rule against Trump/Musk, (which they will) how are those orders going to be enforced against them?  It’s damn sure not the DOJ or FBI, not the Congress, and not the SCOTUS.  We are entering an absolutely lawless age in the use where the Felon is running the prison, and all the guards work for him.  This is going to take millions of people to stop and that’s going to require courage.

When it comes time to visit a doctor, it’s common to have many priorities. Maybe it’s getting relief for that aggravated pickleball injury, taming a lingering cough or finally having that weird mole checked out [you really should]. Oftentimes the risks associated with our medications are not high on the priority list, but they should be.

While any medication has risks, understanding and managing those risks is more important for some prescription medications than others. High-risk (or high-alert) medications (HRMs) are those that present extreme danger either due to patient characteristics (e.g., age, chronic disease, etc.) or misuse. As such, HRMs require prescribers and health systems to employ a number of practices and tools to evaluate and mitigate risk towards improving patient safety.

Given their prevalence, there is mounting interest about prescribing practices of HRMs and the implications for health care.

Recent Study

In a study published in JAMA Network Open, evaluators from Harvard University and Boston University compared HRM prescribing trends between traditional fee-for-service Medicare (TM) and Medicare Advantage (MA), which are privately managed plans for Medicare eligible individuals that are publicly funded through a capitated payment arrangement.

To complete their analysis, the authors compared over 13.7 million matched pairs of beneficiaries taken from samples spanning 2013-2018. The study relied on several sources to obtain data on the sample population, including the Medicare Master Beneficiary Summary file, Social Vulnerability Index, U.S. Office of Management and Budget, and the Medicare Part D Master Beneficiary Summary File.

For its primary measure, the study relies on the Healthcare Effectiveness Data and Information Set (HEDIS) and its Use of High-Risk Medications in Older Adults (DAE) metric. As a primary outcome, the authors considered the total number of HRMs that were prescribed to the qualified enrollees. As a secondary outcome, the authors looked at the proportion of older enrollees who had been prescribed at least 1 HRM per year. Other outcomes included the proportion of enrollees who had received 2 or more HRMs per year or the same HRM twice in the same year.

In addition to the primary variable of Medicare insurance type (i.e., enrollment in TM vs. MA), the study also examined a number of covariates. The researchers considered age, sex, race and ethnicity, dual-eligibility status, rurality, social vulnerability, eligibility for Medicare’s low-income subsidy, and a patient health indicator that factors the number of non-HRM medications.

The authors first used linear regressions to construct their primary model, and after accounting for covariates and other effects (fixed and random), they plotted the adjusted rate of unique HRM prescriptions. After the secondary outcomes were plotted similarly, sensitivity analyses were completed according to a range of criteria.

Ultimately, the study found that the rate of HRM use decreased in each year of the study period (2013-2018) – this was true for both TM and MA alike. Consistent with previously observed prescribing trends, HRM use in MA was significantly lower than in TM, but the gap between the two had narrowed. In the final year of the study period, the rate of HRM use in TM was still 56.9 HRMs (per 1000 beneficiaries) compared to 41.5 in MA. Similar patterns were observed in the analyses of the secondary outcome of the proportion of enrollees who had been prescribed at least 1 HRM per year. When compared with TM, MA performed better with a lower adjusted proportion of beneficiaries who had been prescribed at least 1 HRM (3.9%) versus 5.3% in TM. Relative to patient characteristics, the study observed higher rates of HRM use for certain population subgroups, including those who were female, American Indian or Alaska Native, or White.

Conclusion

The authors note several key limitations, including limiting analyses to only those medications identified by the DAE measure during the study period. The study was also unable to assess the extent that the HRM prescribing were clinically appropriate. The authors also explain that this work is limited by the use of MA as a single exposure and that only filled prescriptions were included in the analyses.

Despite these limitations, this study has implications for both medical practice and health care policy. As the study found that certain populations (female, American Indian or Alaska Native, and White individuals) received HRMs with greater frequency, there is a need to better understand how prescribers assess clinical presentation of these populations. The study’s findings also highlight how the mechanisms responsible for the overall decrease in HRM use in TM are not entirely known. The authors recommend that the Centers for Medicare & Medicaid Services explore additional avenues (e.g., tying HRM rates to reimbursement models) to narrow the gap between TM and MA relative to HRM rates.

Given their potential for harm, further research into HRM medication management strategies is an essential component of improving patient care and safety for older adults.