Health care’s colossus, bird flu, and gender-affirming surgery

Good morning, it’s the last Morning Rounds of the year! On Friday, as I closed out of the document where I draft all the items, I saw that it was 324 pages long. That’s a lot of news. Thanks for reading along, and I’ll see you next year.

Democrats want to break up health care’s colossus

Democratic lawmakers are calling for aggressive action to curb the increasing market power of UnitedHealth Group, including a possible breakup of a business empire they say is undermining competition, corrupting Medicare, and hurting vulnerable patients. They condemned the targeted killing of Brian Thompson, the CEO of UnitedHealth’s insurance business. But they said the display of resentment and rage that followed was neither new nor surprising at a time when people feel powerless to defend themselves against a company that controls their doctors, their data, and their insurance policies.

“For the sake of patients, taxpayers, and independent practices, policymakers should act to prohibit joint ownership of health insurers and their provider subsidiaries, including physicians and pharmacies,” Sen. Elizabeth Warren told STAT.

My colleagues’ investigation into UnitedHealthy this year exposed deeply embedded conflicts within its sprawling network of businesses. The latest installment finds that UnitedHealth pays some of the physician practices it owns significantly more than it pays other physician groups in the same market for similar services.

Read more about the changes lawmakers want to see.

California scrambling to understand scale of bird flu spread

California animal health authorities are now testing milk from all 984 of the state’s dairies on a weekly basis, stepping up its efforts to find new H5N1 infections in cattle. In a call with reporters Friday, California state veterinarian Annette Jones said that the new strategy was implemented two weeks ago, after the virus was found on a farm in Southern California. The majority of the state’s 659 infected herds have been concentrated in the Central Valley.

The rapid spread of H5N1 in California has nfectious disease experts questioning how well authorities understand how the virus is moving between farms. Jones said California has dozens of research projects underway to study this question. But she also noted that cows may be asymptomatic for a number of weeks—which could have contributed to infected animals unwittingly being moved to new farms during the early stages of California’s outbreak.

The unchecked spread is also leading to new human cases. The California Department of Public Health reported Friday two more H5N1 infections, both in dairy workers, raising the state’s total to 36. State epidemiologist Erica Pan told reporters that health officials have monitored about 5,000 people and tested 130 who had potential symptoms.

She also added that officials have been investigating numerous detections of H5N1 at wastewater sites throughout the state, and that at the present time, there is still no evidence of human-to-human transmission. “Almost all of our wastewater testing sites are detecting H5 now,” she said.

However, officials suspect that much of what they’re picking up is not live virus, but inactivated bits of viral RNA in pasteurized milk. “We think a lot of our wastewater detections are actually just from residential or other commercial milk dumping,” Pan said. — Megan Molteni

The renaissance of gender-affirming surgery, once again at risk

For patients who receive gender-affirming surgery, the experience can feel like a rebirth. “I decided that the old me would die on the table and then the new me would come up from it,” Wendy Grogan, a trans woman who recently pursued vocal and facial procedures, top surgery, and a vaginoplasty, told me.

Grogan is one of thousands of patients in the U.S. who receive gender-affirming surgery each year. The field has remarkably transformed in the past decade since insurance coverage started to open up. But trans people and their medical care have also become a major flashpoint in U.S. politics over the last few years. It’s not the first time trans health care has been clawed back. Gender-affirming surgeries almost disappeared in the U.S. after the country’s first dedicated clinic closed in 1966. Now, patients and clinicians alike are worried about what the future holds for a surgical specialty that’s finally beginning to come into its own.

Read more in my story on some of the most impressive and rewarding procedures in medicine. I’m still thinking about one 19-year-old patient I met, pictured above, during his first phalloplasty consultation. (And for a hint at how long it actually takes to get these surgeries — that meeting was a year ago this month, and that person still hasn’t had his first procedure yet.)

Women are supposed to be screened for incontinence. Why aren’t they?

Did you know that more than half of adult women in the U.S. live with bladder and/or bowel leaks? Here’s another fact that I didn’t know: Incontinence is a progressive condition, meaning that without treatment, it can get worse. Nearly every relevant professional medical group recommends screening women for incontinence, but it rarely happens. Why?

“The reasons are inherent to the fabric of our health care system,” write two physicians in a new First Opinion essay. And there are more consequences than shame or embarrassment: When left untreated, incontinence is associated with major negative health outcomes. Advertisements for adult diapers and other quick fixes may normalize the experience, but effective treatments exist. Read more on why the U.S. health care system needs to think differently about women’s pelvic floor.

A record-breaking kidney transplant chain

Last week, surgeons at Ohio State’s transplant center set an institutional record for a synchronized chain of kidney transplants. Over two days, they transplanted kidneys from 10 donors into 10 recipients. The “chain” begins with one person donating their kidney to an unknown recipient. Each of the recipients had a loved one whose organ wasn’t a match for them, but which did match with someone else in need of a kidney along the chain.

Nationwide, there are currently more than 90,000 people on the transplant waitlist in need of a kidney. “This kidney chain removed ten patients from the transplant waitlist, which will hopefully shorten the wait for others,” Amer Rajab, the surgical director of kidney transplantation who led the chain and performed six of the donor surgeries, said in a press release. The successful transplants from living donors occurred just days after the third completed pig-to-human kidney transplant was announced in New York.

What we’re reading

• Louisiana forbids public health workers from promoting COVID, flu and mpox shots, NPR

• They needed psychiatric care. Instead, they died after confrontations with NH corrections officers, New Hampshire Public Radio

• ‘We just dismiss people like RFK Jr.’: Infectious disease expert on how  — and how not — to rebuild trust, STAT
• ‘I thought he was helping me’: Patient endured 9 years of chemotherapy for cancer he never had, ProPublica
• How little-noticed measures to help kids with cancer became a major line of attack on GOP spending bill, STAT