It's a bad look when Robert F. Kennedy Jr. is ahead of you on scientifically sound health policies (women's health, to make matters worse), but that's exactly what happened to Gov. Gavin Newsom last week.
Oh.
In a Cabinet meeting, Kennedy groveled before Trump for more than six minutes. That's pretty standard for these increasingly bizarre gatherings, but the Secretary of Health and Human Services specifically praised the president for ending a “20-year war on women by removing black box warnings from hormone replacement therapy.”
As much as it surprises me to say it, RFK Jr. is right.
A couple of days later, appearing on stage at the New York Times' DealBook Summit, Oscar-winning actress Halle Berry unexpectedly and harshly criticized Newsom for vetoing a menopause treatment bill.
“But it's OK,” she said of Newsom repealing the Menopause Care Equity Act (AB 432), which she had pushed to pass and which had strong bipartisan support in the Legislature.
“Because he's not going to be governor forever, and because of the way he's overlooked women, half the population, by devaluing us in middle age, he probably shouldn't be our next president either,” Berry said. “Just saying.”
The two events show how complicated and controversial menopause care has become in recent years, as women not only talk about it more openly, but demand care that has, well, basically always, been denied or denigrated as unnecessary.
Looking a little deeper, this seemingly unexpected moment of menopause gets to the heart of an insurance issue that, male or female, most Americans have an opinion on: How much power should insurance companies have to deny care that a doctor deems reasonable?
Simply put, menopause is a phase that all women go through when their fertility ends, that is, 50% of the population faces it. It has specific life-altering symptoms, most of which can be treated, but often are not because many doctors are not trained in menopause care (or perimenopause, which comes first), and too often the science is overlooked or misunderstood.
The result is that too many women go through menopause without understanding what is happening to them or without knowing that there are excellent, scientifically backed treatments to help.
A prime example of this is the “black box” warning that has appeared on many hormone replacement drugs since the turn of the millennium, when a large but flawed study found that such drugs could increase the risk of cancer or other diseases.
A black box warning is the most serious precaution the Food and Drug Administration can impose on a drug, and its inclusion in hormone replacement theory (HRT) puts a severe brake on its use.
Twenty years of subsequent research not only revealed the flaws of that first analysis, but also showed important benefits of HRT. It can protect against cognitive decline, reduce heart disease, and relieve symptoms such as hot flashes, among many other benefits.
In early November, the FDA removed those warnings from many HRT medications. The result will likely be greater access for more women as doctors lose their hesitation in prescribing them and women lose their fear of using them.
“Misconceptions about risks have been exaggerated for decades, verging on dogma over real science, and have led to lost opportunities at the population level to improve the lives of our elderly women in the developed world,” Michael Rodgers, chair of the Santa Clara County Health Advisory Commission, wrote in a public comment on the change.
While Rodgers is right, insurance coverage and doctors' knowledge remain issues for women seeking care, issues that the Menopause Care Equity Act hoped to address.
The bill would have required private insurance companies to cover FDA-approved menopause treatments and would have rewarded doctors who voluntarily take continuing education classes on menopause topics. That final version had already been watered down from earlier proposals that would have called for coverage of even more treatment options (such as non-FDA-approved compounded hormones) and required doctors to be trained on menopause.
But Newsom seemed to take issue with a part of the bill that prohibited insurance companies from applying “utilization management” to menopause treatments, and this is where we agree with RFK Jr. again.
Utilization management, or UM, is basically when insurance companies decide what a patient needs and what they don't need: pre-approvals, reviews and denials, which too often seem to have more to do with cost than care.
Now artificial intelligence is entering the utilization management business, potentially meaning that it's not even a human being deciding our treatments. UM is a multibillion-dollar industry that, under the premise of keeping health care affordable, too often does so by denying care.
That's why Assemblywoman Rebecca Bauer-Kahan (D-Orinda), author of the California bill, banned UM.
“The standard is 'medically necessary'” when it comes to insurance coverage, Bauer-Kahan notes.
“When you talk about menopause, it's a very confusing term, right? I mean, I will survive in the short term without any treatment,” she said. “So what is 'medically necessary' is very vague when it comes to menopause care.”
In his veto message, Newsom said the UM ban would “limit the ability of health plans to engage in practices that have been proven to ensure adequate care while limiting unnecessary costs.”
But the truth and problem with menopause care is that it is specific to each woman. Like birth control pills, a treatment that works for one woman may cause side effects in another. There is often a lot of trial and error in finding the right path through menopause, and women should be able to have the freedom and flexibility to work individually with their doctor. No interference.
In June, Kennedy noted that prior authorization across the healthcare industry was an issue and shortly after announced that he had received a commitment from many large insurance companies to reform that process by 2026, eliminating the need for prior authorization for many treatments and procedures and streamlining the process overall.
If that reform happens, it will certainly be fantastic (I'm hopeful), but let's also wait and see. Those changes are supposed to begin in January.
Back in California, Newsom also pledged to do something about menopause coverage in January when he announces his budget proposal. In his veto message, Newsom said he would go this route, adding it to his budget package, rather than working on a new bill in the regular legislative session. This remains the plan, although no details are yet available.
Apparently someone forgot to mention it to Berry.
The budget has increasingly become a catch-all for legislation that the governor wants to do with fewer complications because the budget and its bills are always passed at some point, and it may be an easier route for him to control.
Newsom has made supporting women's rights, especially around reproductive care, a central part of his policies and presidential campaign, and equity for women is a cause championed by his wife, First Partner Jennifer Siebel Newsom.
But the governor has also long hesitated to pass legislation that has associated costs (the menopause bill could raise individual premiums by less than 50 cents a month for most private consumers). With federal cuts, rising premiums and widespread health care chaos, their caution is not unwarranted.
But also, in this case, maybe it's a mistake. The only real opposition to the California bill came from insurance companies. Imagine.
Bauer-Kahan said she has been in contact with the governor's office but remains committed to pushing for legislation that limits utilization management.
“I'm glad to know that hopefully we're going to achieve this, but it needs to be achieved in a way that really makes a significant difference in getting the care that menopausal women need,” she said.
Newsom's veto in October had little impact. Thanks to Berry's coup, his January proposal will not only be noticed, but scrutinized.
If he removes restrictions on UM, he will have to answer the broader question the action would raise: How much power should insurance companies have to override the decisions of doctors and patients?
It would be strange days if in January Kennedy and her chaotic and questionable Department of Health and Human Services offered better health care options for women than the state of California.
And it's even stranger if Newsom puts a price on women's well-being.
