A big discovery, Medicaid cuts, states removing fluoride, drug price questions, and more.
The Dose (May 19)
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There’s a lot of noise out there—outrageous theater, inflammatory comments, and attention-grabbing soundbites. I’m doing my best not to take the bait. Instead, I’m focusing on the policies behind the headlines—and what they actually mean for you.
So here’s your dose of public health context for the week, and why it matters.
Science is… so cool
Last week, a published case study revealed something extraordinary: For the first time, doctors used a new version of CRISPR—known as “base editing”—to try and fix a deadly genetic mutation inside a baby’s body.
Nine-month-old KJ was born with a rare disease (called CPS1 deficiency) that causes toxic ammonia to build up in his body. This condition often requires a liver transplant, but many babies with this condition die before they grow large enough to get one. Therefore, KJ’s doctors at the Children’s Hospital of Philadelphia used molecular tools to correct his exact mutation. This was a direct repair (not a band-aid), like editing a single typo in his DNA. It’s the first time this has been done in a living person for this condition. While we don’t know yet if it’s a cure, KJ is now hitting milestones, off some meds, and recovered from two viral infections.
This breakthrough could open the door to treating thousands of rare genetic diseases—many of which were once considered hopeless. Science, quite literally, is rewriting what’s possible. Check out Dr. Eric Topol’s deep dive into this topic.
Florida is removing fluoride from water systems. More states may follow. How big of a deal is this?
Florida recently passed a law banning fluoride from municipal water, effective this July. This follows a similar move in Utah and may signal a growing trend in other states. While fluoride decisions have traditionally been made at the local level, these state bans override that local control—effectively launching a large, uncontrolled experiment on millions of residents: remove fluoride after decades of implementation and see what happens.
(If you want more context—why we add fluoride in the first place and the science behind the current debate—check out the video below.)
The fluoride debate
Fluoride has sprung into the national spotlight in the past few weeks, and many people have great questions. Here’s the nuance to equip yourself for evidence-based discussions.
Here’s what we know about Florida (and how to think about this issue in your own state):
20% of Floridians already receive non-fluoridated water, so they won’t be affected by this new policy.
80% receive fluoridated water, including naturally occurring fluoride and added supplements. Of that, about 7% is naturally occurring, meaning 73% of Floridians may lose access to supplemental fluoride.
82% of Floridians live in Dental Health Professional Shortage Areas, meaning there are too few dentists for the population.
Of Florida’s 11,475 dentists, only 18% accept Medicaid.
The heart of the issue is this overlap: many Floridians rely on supplemented fluoride, which will now be removed, while they have limited access to dental care.
What does this mean to you: The recommended fluoride level is 0.7 mg/L. If it falls below 0.6 mg/L, fluoride supplements are recommended for children. If you’re in Florida—or anywhere—check here to see if your water is fluoridated. If it’s not, and you have a child in the home, talk to your pediatrician, as they may qualify for fluoride supplements.
One complication: the FDA has begun to remove oral fluoride supplements from market.
Time to vent a little: This data was hard to find. It took me—and several other experts—a few hours on a Saturday to chase it down, interpret it, and understand its implications. We found that anti-fluoride advocacy sites had the most useful information. If we want the public to understand health policies, our institutions need to do a better job at transparency and communication. Right now, YouTubers are winning that race, and it’s not hard to see why.
Medicaid cuts proposed for 8.6 million people. Impact will differ across states.
A recent study found that, since 2010, Medicaid expansion has reduced the mortality of the low-income adult population by 2.5%. In other words, Medicaid expansion saved more than 27,000 lives. Deaths fell not only among older enrollees (who are usually most sick) but also among those in their 20s and 30s, too. The study also found that Medicaid expansions were cost-effective.
Congress is debating a bill to cut Medicaid—even though 80% of Americans oppose such cuts. If passed, an estimated 8.6 million people could lose healthcare coverage by 2034 (out of the 71.2 million people with Medicaid). This would be the largest Medicaid cut in history.
The impact of this bill will depend on where you live. KFF outlined a few key factors:
State budgets: Each state will respond differently to the loss of federal funds. For instance, states that expanded Medicaid to cover long-term care may see that as an area to cut first.
Population needs: States with higher rates of unemployment or poorer overall health will be hit harder.
Access to care: The more limited the healthcare infrastructure in a state, the more damaging the cuts could be.
States like West Virginia and Mississippi are likely among the hardest hit. Below is a breakdown of the most affected states, depending on what factors we take into account.
What does this mean for you? Time to reach out to your representatives. Here are some tips. Dr. Emily Smith has a great Medicaid explainer if you want more information.
Note that Medicaid programs go by different names in each state, making it tricky to track how federal changes might affect your health care. For example, “cutting Medicaid” is the same as “cutting PeachCare” in Georgia or “cutting Healthy Connections” in South Carolina. Hover over the graph below to see what Medicaid is called in your state.
Opioid deaths dropped by 30,000. A big win—at risk of reversal.
Nationwide drug overdose deaths dropped by 24% last year—about 30,000 fewer lives lost. Nearly every state saw reductions in opioid- and stimulant-related deaths, except Nevada and South Dakota, where deaths went up.
Why the drop?
Survivor bias (tragically, those most at risk may have already died)
Harm reduction efforts: naloxone, buprenorphine, methadone
Changes in the illicit drug supply
Unknown unknowns
Proposed budget cuts would slash CDC’s opioid surveillance program by $30 million, and SAMHSA by $1 billion. These cuts would devastate local programs and harm reduction services, which rely on federal funding passed through to states. It’s still unclear whether these programs will be folded into RFK Jr.’s newly created arm of HHS—the Administration for Healthy America—or to what extent they’ll be preserved to avoid losing hard-won progress. At a state level, perhaps it’s time to use opioid settlement funds to pick up the slack.
What does this mean for you? Although deaths are decreasing, opioids are still the leading cause of death for Americans aged 18-44. Narcan is available over the counter, carried by EMS providers, and even stashed in vending machines in some places, like New York City.
Infectious disease roundup
There wasn’t much news in the infectious disease world last week in the U.S.
Measles. We’re now up to 1,038 cases for the year, with the West Texas outbreak still inching forward and North Dakota continuing to grow, although it is much smaller.
Interestingly, according to Truveta Research, measles vaccination for children under one year old in Texas has seen a striking increase. In March and April, 20% of first measles vaccinations were administered early, at 6-11 months. Kids are getting vaccinated eight times more in response to this outbreak than during the 2019 outbreak.
Common colds are still high, but Covid-19 is staying quiet. Most epidemiologists expect a summer wave, as we’ve had one for the past 5 years. This will likely start in July.
Question grab bag
We received a ton of follow-up questions after last week’s post on drug prices! Here are two answered.
“Can you explain exactly why the government can’t negotiate with drug makers? What is the barrier? If it’s legislative, what is the resistance to allowing Medicare/Medicaid to negotiate? Is it just the strength of the Pharma lobby? It seems like we’ve created a problem that could easily be fixed given the government's enormous purchasing power. Thank you.”
The government can’t negotiate prices broadly because of the strength of the pharmaceutical industry, which has the most extensive lobbying organization in the U.S. The Pharmaceutical Research and Manufacturers of America (PhRMA) is one of the most powerful lobbying groups in Washington. Between 1999 and 2018, the pharmaceutical and health product industry spent approximately $4.7 billion on lobbying the U.S. federal government. This substantial lobbying effort contributed to the maintenance of the status quo for many years.
When Medicare Part D was established in 2006, for example, the law included a specific clause that prevented the government from negotiating drugs under that program. Notably, the government can negotiate drug prices within the VA system, and because of that and statutory pricing requirements, the VA gets some of the best prices for drugs in the U.S.
“Is the IRA [Inflation Reduction Act] dead in the water, or is it helping to reduce the cost of medications?”
The IRA is not dead in the water—CMS successfully negotiated prices via the IRA for a slate of 10 drugs in 2024, achieving 39-78% reductions. These prices will take effect in 2026. It is currently negotiating a second slate of 15 drugs. Perhaps more importantly, the IRA capped out-of-pocket spending. However, the IRA only covers Medicare—the lower prices and caps do not apply to insurance in the private market—and it only covers a small number of top-selling drugs after a 9-13 year waiting period. Also, the IRA remains under attack from numerous drug industry lawsuits, but none of those have yet been successful.
Poll
Bottom line
Have a wonderful week!
Love, the YLE team
Your Local Epidemiologist (YLE) is a public health newsletter with one goal: to “translate” the ever-evolving public health science so that people feel well-equipped to make evidence-based decisions. This newsletter is owned and operated by Dr. Katelyn Jetelina— an epidemiologist and mom. This is free to everyone, thanks to the generous support of fellow YLE community members. To support the effort, subscribe or upgrade below:
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I'm a dentist. If you had trouble finding the recommended dosing for fluoride at different levels of existing fluoride in the water, pretty much any dentist could have helped finding the chart. Or did I miss something. This will be another live experiment and should be interesting to follow over the next several years. If, as anticipated, decayed missing and filled numbers go up, those affected don't get those years back. Reminds me of when the SBE antibiotic premed guidelines changed and suddenly the vast majority of patients with heart murmurs stopped being premedicated.
My Dad, who was also a dentist, used to say dentists were trying to put themselves out of business with fluoride, and it was a good thing.
really worried about lack of updated COVID vaccines for those who are immunocompromised and / or elderly.