Vox clamantis in deserto
‘Life has moved on’
“Canone aureo 958” (Agnes Martin) (“Golden ratio 958’’ [Agnes Martin]; detail), (acrylic on canvas), by Georgio Griffa, in his show “Paths in the Forest,’’ at the Clark Art Institute, Williamstown, Mass., through Oct. 12.
The museum says:
“Impersonal marks that belong to any hand, with thousands of years of memory” are Griffa’s subject; he follows and blurs the lines of drawing, counting, and writing. Griffa ‘interrupts’ his paintings before they are finished because, ‘in the meantime, life has moved on,’ an idea he credits to Zen Buddhism. Like the artist himself, each work remains vital: ‘Leaving the work incomplete means symbolically omitting that final point, which, like the period at the end of this sentence, fixes it in the past.”’
Hunting for a rare and beautiful plant
Bloodroot flowers
— Photo by Erutuon
A carpet of bloodroot leaves
— Photo by Myric
Excerpted from an ecoRI News article, not including pictures above
CUMBERLAND, R.I. — The hunt was scheduled to begin about the time a banker starts work. It was delayed, however, by an interrogation. Information was required from the participants. They were told they were being recorded. They responded by speaking in Latin.
The University of Rhode Island and Brown University students were armed only with outdated information, some of it going back to the 1920s. Their supervisor was also gunless. Their interrogator carried a digital camera.
The hunt covered 3 miles and took 4 hours. Typically, it’s not easy to find rare plants. This hunt proved different, at least at the beginning.
Sanguinaria canadensis (bloodroot) is a spring ephemeral native to Rhode Island’s rich, moist, deciduous woodlands. Blooming in early spring, it is highly prized for its brilliant white petals and golden center. It’s listed as a species of special concern in Rhode Island. It’s rare to find it in the wild.
Llewellyn King: A simple precaution would have prevented 9/11
WEST WARWICK, R.I.
There is a terrible truth about 9/11: It didn’t have to happen. Something as simple as a hardware store lock could have deterred the perpetrators.
The arguments against hardening cockpits were numerous, and now seem unconvincing to the point of being risible.
They included: It would cost too much; the public had to see the captain go walkabout during the flight; first responders couldn’t get to the pilots after a crash; air pressure wouldn’t be stable between the cockpit and the passenger cabin; and the pilots wouldn’t be able to go to the toilet.
Long before 9/11, airplane hijackings were a well-established tool for terrorists, asylum-seekers, extortionists, or simply those who were unbalanced.
Generally the hijackers made their way unhindered to the cockpit, with or without a hostage, and forced the pilots to fly to a country estranged from the one they started from — like Cuba for hijackers from the United States or Western Countries for Soviet defectors.
There was no mystery about hijacking and the vulnerability of pilots. What differentiated the 9/11 hijackings was the fiendish planning, complete with flying lessons and, finally, the ease with which they did their evil.
After all the deaths, the untold suffering, the billions of dollars that have gone into airport security, including the establishment of the Transportation Security Administration, the question remains why something wasn’t done before 9/11 to secure the cockpits. They are now impenetrable, they are bulletproof and can even withstand a small bomb.
A White House science adviser told me long after the tragedy, “We should have done more.”
Pilots and informed people suggested over the years that cockpits should be hardened, others went further and petitioned the Federal Aviation Administration. But the cockpits remained open, accessible and vulnerable, inviting heinous crime.
The failure to harden cockpits after early hijackings is a tragedy of multiple derelictions, from the airlines through the FAA, the White House, the FBI (which investigates terrorists and airline crime); the National Transportation Safety Board; the aviation unions, even the Occupational Safety and Health Administration — an airliner is a workplace.
The system failed because the voices from numerous places calling for hardened cockpits were too soft, too scattered, and not united. A strong statement, a loud voice, a repetitive complaint or more media coverage might have made the difference.
Since 9/11 public service announcements on public transport of all kinds have cried out, “If you see something, say something.” People saw something from many angles but said little.
General aviation is a catch-all phrase for everyone who flies everything, from crop dusters to corporate jets, from aerial-mapping aircraft to single-engine Cessnas, even those who fly cadavers overnight, a small industry.
They hangout between flights in dismal places called “pilot lounges.” In these lounges — usually a room with a few couches and vending machines for coffee and snacks — the talk is about aviation and how to fix some aspect of it.
The thing about the men and women of general aviation is that they are in a sense the heart of aviation: They fly because they would rather do that than anything else. They can’t imagine another life. And they, for assorted reasons, haven’t landed jobs with airlines or major overnight delivery services.
In these lounges, long before 9/11, there was always a groundswell of opinion about hijackers, and they all asked rhetorically, “Why don’t they lock the damn cockpits?” I heard a version of that phrase often when I was a private pilot.
Of all of those who could share some blame, the most culpable are the airlines. They didn’t want to alarm the passengers, spend the money or inconvenience the flight crew. But mostly, no airline wanted to be first.
From time to time, there was talk of doing something about the ease with which ill-wishers could penetrate the cockpit on commercial flights. Often doors were open and passengers could go to the flight deck, if they asked.
I have happy memories of being allowed into the cockpit of the French Concorde and being cheerily greeted by the pilot, who was reading Le Monde, “At 60,000 feet and Mach 2, what am I going to do?” Sensibly, he was leaving the flying to the autopilot.
We will forever mourn the 2,977 people who died on 9/11, and all those who have died in its aftermath.
Aviation is usually very safe because it prides itself on its culture of safety. On Sept. 11, 2001, that culture was absent. That culture was reduced to hoping for the best rather than locking the damn door.
On X: @llewellynking2
Llewellyn King is executive producer and host of White House Chronicle, on PBS, and an international energy-sector consultant. He’s based in Rhode Island.
Don’t be defeatist
“Last Day of Summer’’ (oil), by Karen Galanti, at Plymouth (Mass.) Center for the Arts
The sun will burn it off
“Gloucester Dawn” (oil on arist board), by Milton Avery (1885-1965), at the Cape Ann Museum, Gloucester, Mass.
Chris Powell: DEI programs are no substitute for achievement
The Samuel Wadsworth Russell House (1828), home to the Philosophy Department at the “elite” Wesleyan University, in Middletown, Conn. The building was designated a National Historic Landmark in 2001 and is considered one of the finest examples of Greek Revival architecture.
Wikipedia says: “Wesleyan evaluates roughly 90% of its applicant pool without regard to their ability to pay, but considers financial need for the remaining applicants (typically the final marginal or high-need cases) to manage its budget.’’
MANCHESTER, Conn.
In recent years American higher education has made a fetish of "diversity, equity, and inclusion," which has succeeded "affirmative action" as the euphemism for racial preferences in hiring and the award of other benefits. Since higher education is the fortress of what styles itself as liberalism -- that is, political correctness -- the Trump administration delights in attacking it, and now is proposing to revoke tax-exempt status for colleges whose policies benefit students according to their race. Many colleges have such policies to help Black, Hispanic, and other minority students specifically.
In the strict legal and moral senses the administration is right. Government should be color-blind in dealing with individuals. That's equality under the law.
But of course the country continues to suffer vast economic and social inequality, especially regarding race and class, which should be just as intolerable as racial preferences. Social harmony and justice won't be achieved until opportunity is more equal.
Racial preferences sabotage their purported objective, for they instill suspicion and resentment, impugn the qualifications of their beneficiaries, and confer a false sense of achievement.
But getting rid of racial preferences and curbing the arrogance of higher education, nice as that would be, will do little to democratize opportunity.
Fortunately democratizing opportunity doesn't require treating people according to race or ethnicity, since economic and social inequality are matters of poverty more than race and ethnicity. Higher education implicitly acknowledges this with scholarships and tuition discounts for students who are from poor families or who face other disadvantages. Favoring applicants from minority groups when all other aspects of applicants are equal is fair and won't cause trouble or resentment.
Otherwise racial preferences are clumsy and unintelligent substitutes for fairness and the country doesn't need them to elevate the poor and disadvantaged.
College scholarship programs like those run by the school systems in Hartford, New Haven, and Waterbury, cities with much poverty, elevate students without regard to race even as most of their beneficiaries come from minority groups. Under those programs students who attend school consistently, behave well, and get high grades are guaranteed substantial financial aid for higher education. The money comes from private donors, charitable foundations, colleges, and government. The program in New Haven is largely funded by Yale University, which additionally covers tuition for its own students of limited means.
Colleges today crave outstanding minority students, as they should, since the country needs them badly.
But higher education is only a secondary mechanism of elevating the poor. Indeed, much of higher education is fluff of little value.
The primary mechanisms of elevating the poor are lower education and parenting, areas in which Connecticut, while a rich state, fails terribly.
Most poor children in Connecticut are poor because they have only one parent and because the state's welfare system rewards and incentivizes childbearing outside marriage and thus impairs family formation.
Many of these children never advance far educationally because the state's schools operate by social promotion. Connecticut's schools have no requirement for students to earn advancement from grade to grade and graduation from high school by learning. As a practical matter there is no requirement for students even to attend elementary and high school, since the requirement is not enforced seriously.
So it's no wonder that chronic absenteeism is so high among students in Connecticut's poor cities -- 33 percent in Hartford, 30 percent in Bridgeport and New Britain, 28 percent in New Haven, 25 percent in Norwich and New London, and 22 percent in Waterbury. Children who can't reliably get to elementary and high school are not likely to get to college or even learn enough to qualify for more than menial jobs.
The indifference of elected and school officials to the pernicious results of welfare and educational policies underlies Connecticut's longstanding and disgraceful educational performance gap between white and minority students and the state's continuing failure to elevate the poor.
The country needs diversity, equity, and inclusion. But rewarding people for their race is mere discrimination, political patronage, and evasion, not education and achievement.
Chris Powell has written about Connecticut government, politics and society for many years (CPowell@cox.net).
Governor Sargent saved Boston
Interstate highways proposed in the 1962 Massachusetts "Inner Belt and Expressway System" plan.
—Courtesy of the Boston Public Library
On Nov. 30, 1972, Massachusetts Gov. Francis Sargent delivered an historic speech explaining why he had decided to block new superhighway construction in Greater Boston.
Central in his remarks was this:
“The problems of transportation have held us prisoner for 40 years and recently that captivity has become intolerable. You, your family, your neighbor have become caught in a system that’s fouled our air, ravaged our cities, choked our economy and frustrated every single one of us. To move ourselves, our goods and our services, we’ve built more and more and bigger and better superhighways and expressways. They seemed the easiest, most obvious answer to our multiplying needs. What we misunderstood was what those highways would create: massive traffic congestion.”
Light along the coast
“At the End” (oil on linen) by Kay Knight Clarke, in her show “Seeing Light,’’ at the New Britain Museum of American Art, through Nov. 22.
The museum says:
“Inspired by the ephemeral effects of light, color, and atmosphere along the Connecticut shoreline, Clarke’s works offer contemplative reflections on time, place, perception, and feeling. On view in the museum’s historic Landers House, the exhibition celebrates Clarke’s poetic artistry’’
A one-month season
“Sunny Autumn Day,’’ by George Inness (1825-1894), American landscape painter
“The color of September; smouldering gold, The moon goes toward the mountains and grows old.”
— Frances Frost
“September is more than a month, really; it is a season, an achievement in itself. It begins with August's leftovers and it ends with October's preparations...”
— Hal Borland
“That time of year, you know, when the summer, beginning to sadden, Full-mooned and silver-misted, glides from the heart of September, Mourned by desolate crickets, and iterant grasshoppers, crying.”
— Conrad Aiken
Julie Dobrow: How kids’ shows responded to 9/11
From The Conversation (except for image above)
MEDFORD, Mass.
On back-to-school night in 2005, I eagerly entered my youngest child’s first grade classroom. The walls were festooned with brightly colored responses to the prompt: “Draw something you remember.”
I scanned for my son’s picture and was shocked when I encountered his drawing: an airplane flying into New York’s World Trade Center.
“I saw the picture you drew up on the bulletin board,” I said to him later that night. “Do you really remember seeing planes flying into the twin towers?”
He looked me in the eyes and replied, “No, Mommy. But I do remember you crying.”
My son was not quite 2 years old on on Sept. 11, 2001. As a mother, I despaired to learn that my own reaction to that day’s tragedies had stuck with him so viscerally. As a professor and researcher of children’s media, I shouldn’t have been surprised.
My son’s memory was likely influenced not just by my emotional reaction but by the media around him that his parents and siblings consumed in the weeks and years after the attacks – a mix of TV news and content geared toward kids.
More than two decades later, children have many more ways and more platforms to encounter frightening images and stories, often without an adult nearby to help them make sense of what they see. But the ways children’s programming such as “Sesame Street” responded to 9/11 offer a useful lesson: Rather than trying to shield children completely from disturbing events, adults can help them process what they’ve seen in honest, reassuring and age-appropriate ways.
You can’t shield kids from what’s happening
Psychologist Joanne Cantor was one of the first to study what scares children about news and how they respond to it.
She concluded that what frightens children varies by their developmental stage. Younger children tend to notice and respond to stories about natural disasters and tragedies about kids or animals. Older children are afraid of stories focusing on personal injury and physical destruction, kidnapping, disease and violence. Teens express fear of stories about random acts of violence, natural disasters and foreign conflicts.
Since Cantor first published her groundbreaking research in the 1980s, kids’ media environments have changed dramatically, with more channels, screens and platforms broadcasting images and videos of natural disasters, violence and tragedies from around the world.
A child’s letter and drawing left at a memorial in lower Manhattan in the days after the 9/11 terrorist attacks. Andrew Holbrooke/Corbis via Getty Images
One study found that young children’s exposure to news is often accidental but lasting, with many children recalling distressing images long after the fact. Another one found that violent news images take a cumulative toll on children’s mental and emotional health. And an international survey of over 4,000 children from 42 countries found that over half had been scared by stories about the COVID-19 pandemic.
More recently, the children’s media nonprofit Common Sense Media surveyed hundreds of children ranging in age from 8 to 18 and found that what kids are seeing and hearing in the news frequently makes them feel scared, sad, angry or depressed.
Children’s TV takes a delicate approach
On and after 9/11, millions of children like my son either saw the images of terrorist attacks or were near adults who reacted to them.
According to “Sesame Street” producer Lewis Bernstein, when the 9/11 terrorist attacks happened, most of the episodes for the forthcoming season were already written. Yet writers and producers knew that children were not oblivious – that even the 2- to 4-year-olds comprising the core “Sesame Street” audience had some sense of what was going on.
In response, the show’s producers collaborated with experts to create additional episodes that would address children’s fears.
In 2002, Rosemarie Truglio, vice president of education and research for “Sesame Street,” explained how the show’s approach was to meet children where they were developmentally.
“Sesame Street” had already helped children process their fears through classic episodes such as “Grover’s Fear of the Dark.” Researchers knew part of what scared children on 9/11 were the loud sirens and the fact that trusted figures such as firefighters and police officers were hurt.
So the episode they developed in response to 9/11 made no mention of the terrorist attacks and instead centered on a fire at Hooper’s Store. Elmo is frightened by the noise of the fire alarm and subsequent sirens. The protective gear that the firefighters are wearing also scares him.
“Sesame Street” never mentioned 9/11 directly, but its segments addressed fears the attacks may have instilled in children.
Fortunately, a kind and kid-savvy firefighter named Bill speaks to Elmo about his fears and invites him to visit the firehouse. There, he dispels some of Elmo’s concerns and dispenses advice about what children can do if they are ever in a similar situation.
The PBS show “Arthur” took a similar approach: Its two-part episode “April 9” centers on a fire at Arthur’s school. It makes no mention of the Sept. 11 terrorist attacks but explores how Arthur, Sue Ellen, Binky and Buster each process the school fire differently.
“Zoom,” the popular PBS live-action variety show, was geared toward older kids. Just 10 days after 9/11, they aired a special half-hour episode called “America’s Kids Respond.” The seven cast members, all between the ages of 9 and 14, shared their thoughts, fears and feelings. Advisers knew their audience needed more than hearing other kids talk about their feelings. So they made sure the cast also discussed constructive things kids could do, such as helping with food donations or clothing drives for affected families.
A year later, “Zoom” followed up with another special, “America’s Kids Remember,” where cast members talked about how they had coped in the months after the attacks. They also read mail from viewers, including some letters written by kids who had been targeted by anti-Muslim slurs. The episode included a segment in which a cast member visited a girl in lower Manhattan whose school had been damaged. The girl explained how she was able to cope through her art and activism.
A promotional clip for a special episode of “Zoom,” “America’s Kids Remember,” which aired in September 2002.
What’s a parent to do?
In 2001, most children under 8 were watching approximately 3.5 hours per day of television or videos on VHS.
Today, Common Sense Media reports that the amount of time kids spend watching television or videos is similar, but their total media exposure is far greater, thanks to mobile platforms and different types of media.
In a world where extreme weather events often lead local news, natural disasters routinely take place, and school shootings and acts of political violence have become all too common, parents might naturally try to shield children from these stories.
But young children pick up on the news and on cues from their parents, even when we don’t think they do.
There are many things parents and teachers can do to help mitigate children’s fears and anxieties from what they see on the news. Recognize some of the signs your child might be feeling anxious, such as sleep problems, avoidance of activities or doomscrolling. Experts suggest answering children’s questions honestly without necessarily relaying all of the gory details. It’s also OK to say, “I don’t know.”
Some of the lessons from how children’s TV dealt with 9/11 still apply.
Young children can also benefit from adults reassuring them that they are safe, by encouraging them to process a piece of news through play or art, and helping children by giving them language to express their questions and fears.
With older children and teenagers, experts suggest avoiding labels, such as blaming something on “the bad guys.” It’s important to give kids facts and context and provide them with resources to answer their questions. Older children can benefit from outlets to express their concerns and feel agency, whether through journaling or art, or the kind of volunteerism promoted on “Zoom.”
Finally, it’s important to acknowledge and explain our own emotions to our children, as I learned on that back-to-school night nearly two decades ago.
Julie Dobrow is a teaching professor in the Eliot-Pearson Department of Child Study and Human Development, at Tufts University. She does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond her academic appointment.
‘Objects may awaken as spirits’
From Lua Kobayshi’s show “The Persistence of Memories,’’ at the Griffin Museum of Photography, Winchester, Mass., through Oct. 25.
The photographer says:
“In September 2025, I spent time moving through the greater Boston area, sitting with Japanese-American individuals and families in spaces where stories are held—living rooms, kitchens, and quiet corners shaped by daily life. Within these intimate settings, people shared personal histories, reflections on what it means to be Japanese-American today, and the objects that have traveled with them across generations. These conversations were generous and deeply moving, revealing how culture is preserved not only through documentation, but through care, trust, and the act of keeping.’’
“This project takes the form of a quiet, immersive installation centered on projection, shared memory, and a belief rooted in Japanese folklore: that objects, after a long life of use, may awaken as tsukumogami, or spirits. Within this tradition, belongings are not passive. They absorb touch, time, and emotion—carrying the presence of those who have lived alongside them.’’
Bucolic a few miles from gritty
Site of the Russell Garrison, a 17th Century fortified area in Dartmouth, Mass.
Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com
It was heartening to learn that MBTA train service connecting Fall River and New Bedford with Boston, which started just last year, has become quite popular. The line averages nearly 10,000 passengers a day, most of it on weekdays. That’s a lot of cars no longer on the still often clogged roads between the Massachusetts South Coast and “The Hub,’’ and it helps reduce air pollution. The folks taking that line almost universally say the trip is far less stressful than driving and gives them time for work and/or to snooze.
The service will be an economic boon for Fall River and New Bedford by drawing more skilled workers to live there, some of them in the many converted old mill buildings built in those cities’ industrial heyday, in the late 19th and early 20th centuries. The line will let the region become more absorbed into the Greater Boston wealth machine even as it remains less expensive than the area up north.
But some newcomers will want to live in the pricey towns nearby, especially close to Buzzards Bay, on what my friend Will Morgan calls “The Quaker Coast’’ because of the many people of that denomination who started settling there in early colonial days. Considering the density of the region’s population, there’s a surprising amount of beautiful countryside there, including vegetable farms, a few dairy farms, and some vineyards in the area’s mild microclimate. More and more people want to live there as summer folks (think The Hamptons) and as year-rounders, many of them five-day-week commuters to Boston and elsewhere.
We’ve often noted how the area looks like parts of England, with gritty cities cheek by jowl with bucolic scenes.
But will rail service sharply intensify the area’s residential-development pressures and substantially erode its beauty?
Stony show in Barre
“Ancient Deity,’’ by the late John A. Matusz, in the group show “Rock Solid,’’ at Studio Place Arts, Barre, Vt., through Oct. 24.
Studio Place Arts explains:
“This annual stone sculpture exhibit since 2000 showcases stone sculptures and assemblages by area artists. This year the show includes a group of sculptures by the late John A. Matusz, who was involved in the show for 14 years.
“View granite sculptures around downtown, historic Barre by means of the Art Stroll, a self-guided tour. Maps are available at the SPA website and in the gallery.’’
Elisabeth Rosenthal: How patients get financially hammered by ‘vertical integration,’ private equity
Though the U.S. health-care system tends to produce more innovation, it has a lower level of regulation, and almost every form of its health care costs more than in other high-income countries.
From Kaiser Family Foundation Health News (KFF Health News) (not including image above)
“Antitrust laws aren’t fit for purpose at this point, and the agencies that enforce them are under-resourced.’’
— Zack Cooper, an associate professor of public health and economics at Yale University
After a failed round of in-vitro fertilization this year, Anne Hug’s fertility doctor said she had a single polyp in her uterus that should be removed to improve the chance of pregnancy. Hug, a professor of radiology, learned that the American College of Obstetricians and Gynecologists says the procedure can be done in a doctor’s office with local numbing.
Her doctor referred her to a physician at the same hospital, which is part of a large Ohio health system. That doctor’s plan was to do the procedure in a hospital operating room, with anesthesia administered by an anesthesiologist.
Hug balked at the $18,000 estimate.
So she found an obstetrician who said he would do it in the doctor’s office. And she took the required two-week course of a hormone in preparation.
But the day before the polyp removal, the doctor’s office called to say, sorry, but he had to do it in a freestanding surgery center owned by the same system. The health system had bought the OB-GYN practice in 2025, so it called the shots. The next day, Hug recalled, “I’m in a venue I didn’t need or use, with surgical techs and OR nurses running around.”
Though she was scheduled for anesthesia or sedation, she wanted none of it. The doctor numbed the cervix and removed the polyp in a few minutes, with “a few seconds of cramping,” she said. Hug remembers watching pictures of the polyp removal and “talking to the OR crew about snorkeling.”
The estimate for the in-office procedure was around $3,000. The bill when she was forced at the last minute to switch to the surgery center was around $6,000. She now wonders, “How is it legal for these hospitals to force patients to have procedures done in a hospital when professional organizations recommend differently?”
Hug’s experience is a classic example of the predicted outcome of “vertical integration” in the health-care system, when one company owns or controls multiple parts of a supply chain and can therefore direct patients to more expensive treatment options.
KFF Health News agreed not to publish some identifying details about Hug and her health-care providers, to protect her patient privacy and ongoing relationship with the hospital system.
In any case, such health-care integration is occurring at a breakneck pace all across the nation, with endless permutations: Hospitals are buying doctors’ practices and surgery and imaging centers. Insurers are buying doctors’ practices and specialty pharmacies and sometimes merging with pharmacy chains. Hospitals are buying or creating insurers. Private-equity firms are behind many of the deals, buying practices, reorganizing operations, paring costs, then selling at a profit in a few years to a hospital or insurer higher up the health-care food chain.
And while the stated purpose is generally greater efficiency, studies have shown that for patients the net result has been higher prices and no benefit, or worse health outcomes. That’s in part because the purchases have been driven by financial efficiency, not more seamless and attentive care, said Soroush Saghafian, an associate professor at Harvard University’s Belfer Center for Science and International Affairs. What’s more, these transactions occur in a gray zone of competition law, and regulators’ tools to examine or stop them are plodding and not up to the task.
“Antitrust laws aren’t fit for purpose at this point, and the agencies that enforce them are under-resourced,” said Zack Cooper, an associate professor of public health and economics at Yale University who has sounded the alarm about the trend. The tools at the agencies’ disposal are limited — warning letters, lawsuits, and consent decrees modifying the terms of a merger to restore competition — and often slow to get results. Meanwhile, the dealmaking is galloping ahead.
Patients like Hug are often directed to a higher-priced location for procedures. They are effectively required to buy from their insurers’ specialty or retail pharmacy, which may not stock the drug the doctor prescribes or provide it at the lowest price.
The Federal Trade Commission and the Justice Department together police mergers in healthcare to protect competition and patient choice. Generally, the FTC oversees hospitals and doctors, while the Justice Department scrutinizes insurers, though their territories overlap and there are gaps. Middlemen like pharmacy benefit managers fall somewhere in between, though in recent years the FTC has taken the lead in this arena. But federal regulators are playing a tough game of catch-up.
Over the past decade, the number of doctors working for hospitals rather than in private practice has more than doubled. Today 82% of physicians are employed by hospitals, other corporate entities (like insurers), or private equity firms. For example, UnitedHealth Group’s then-CEO said in 2024 that it employed around 10,000 primary care physicians. That did not include UnitedHealth’s 80,000 “affiliated” physicians.
Many of these vertical transactions are too small for the regulatory agencies to spot. Under the 1976 Hart-Scott-Rodino Act, mergers valued over a certain dollar threshold set annually — this year it’s $133.9 million — must be reported for antitrust scrutiny. Many hospital mergers or insurer mergers exceed the threshold. But mergers involving doctors’ practices often do not, leading to consolidation and monopoly by slow accretion.
Cooper and his group, the Health Care Affordability Lab, studied hospital acquisitions of physician practices and found that over 99% of the more than 275 deals examined fell below the reporting threshold. “I’m really struggling with this,” Cooper said. “What you’re talking about is sort of like death by a thousand paper cuts.”
The FTC has brought eight actions or suits against health-care mergers and acquisitions in President \Trump’s second term. “The FTC has made health-care competition one of our top priorities,” said Daniel Guarnera, director of the FTC’s Bureau of Competition. Nonetheless, he said the agency relied on complaints and news reports to learn about smaller mergers.
The Justice Department has brought only two cases, both challenging hospital-insurer contracts rather than mergers. It has also settled a suit brought by the Biden administration that sought to block UnitedHealth’s $3.3 billion acquisition of Amedisys, a home health-care agency. The 2025 settlement required the divestiture of 164 home health and hospice locations across 19 states.
After KFF Health News requested an interview, the department’s press office replied in an unsigned email: “You’ve emailed the Department of Justice. Please reach out to FTC’s media team to set up an interview.” Further requests went unanswered.
Guarnera, at the FTC, noted that the agencies’ task is to enforce regulations, limiting the challenges they can bring.
“Some of the market distortion is caused by regulations that have anticompetitive effects,” he said.
For example, countless health-policy experts have proposed regulations mandating “site-neutral payment,” a system in which providers would get the same amount for a procedure no matter where it was performed. That would prevent predicaments like Hug’s, in which a vertically integrated system effectively backs doctors into directing patients to a more expensive venue for treatment.
Within the government, the FTC has advocated for new pro-competitive regulations, suggestions that are now under review by the White House’s Office of Management and Budget. They are not public, and Guarnera wouldn’t say whether site-neutral payment is included. Meanwhile, the Trump administration in July proposed instituting site-neutral payments for some services for Medicare beneficiaries.
The economic theory adjudicating the pros and cons of vertical integration is “nuanced,” Cooper said.
It is far easier to assess the effects of horizontal integration — when a hospital merges with a hospital or an insurer with an insurer — on patient care and cost. If two hospitals merge and become the only care provider in town, that leaves patients with less choice and can make it easier for the new monopoly to skimp on care and raise prices. There is no way “to walk with your feet” to another hospital system for care, Cooper said.
But with vertical integration, for example, a hospital merger with an insurer and doctors’ practices could in theory diminish friction, compared with a disaggregated system in which every bill is haggled over by different sectors trying to maximize their piece of the pie. Some successful and popular hospital-insurer combinations, such as Kaiser Permanente, are vertically integrated. So merely taking a “sledgehammer” to such mergers could backfire, Cooper said.
But with money on the table and business interests governing healthcare, studies have shown that cons of vertical integration — opportunities for gaming away those beneficial arrangements and raising revenue — prevail.
When Harvard researchers sought to assess the effect of hospital purchases of gastroenterology physician groups on colonoscopy care, the negative impact was clear. “It changed the way they did business,” said Saghafian, the paper’s main author.
All told, quality went down and prices as well as complication rates rose. “What improves is ‘operational throughput,’” or the efficiency with which the system could move patients through colonoscopies fastest with the least staff involvement, Saghafian said. “That’s a financial metric.”
‘It Feels Like Double-Dipping’
While health economists are studying the impacts to help regulators figure out when to act, the horse is out of the barn. All the biggest health insurers have already merged with pharmacy benefit managers, specialty and commercial pharmacies, as well as new lines of businesses that insurers require members to use to manage copay assistance from pharmaceutical companies. For example:
CVS acquired Aetna in 2018, meaning Aetna subscribers are directed to the CVS Specialty pharmacy through Caremark, its pharmacy benefit manager.
Cigna owns Accredo (a specialty pharmacy), Express Scripts (a pharmacy benefit manager), and EviCore (which does preauthorization for prescription requests).
UnitedHealth includes Optum Rx (a pharmacy benefit manager), Optum Specialty Pharmacy, and Optum Infusion Pharmacy.
So when patients change insurers, their steady access to longtime drugs at a predictable price can go out the door.
In Florida, Ari H.’s family uses three high-priced specialty drugs for chronic conditions. All three had long been subsidized by patient assistance programs from their manufacturers. KFF Health News agreed to only partially identify him, because he works for a government contractor where policy has become political and he fears retaliation.
Signing up for a $3,000-deductible plan with a new insurer, Aetna, put a new strain on his family’s finances. On his new plan, he was signed up for all Aetna’s pharmacy-related products, too. He could not choose to order elsewhere. Most importantly, his old insurance counted the copay assistance money toward his deductible, but his new insurer did not, scooping up his patient assistance money from pharmaceutical firms.
“I pay substantial premiums, and I pay my deductible and my out-of-pocket maximum — that’s all paid by me,” Ari H. said. “But now all the copay assistance goes back to them. It feels like double-dipping.”
Ethan Slavin, an Aetna spokesperson, said the company “is committed to helping members choose and use health plans that best meet their health, financial, and lifestyle needs.” He added that the insurer offers “supports that may lower out-of-pocket expenses.”
Ari H. is right, said Mark Cuban, the billionaire investor who in 2022 launched the Cost Plus Drugs site, which sells mostly generic drugs to cash-paying patients at a discount — often for less than what they would pay using insurance. “It’s crazy stuff,” he said of vertical integration. “The right pocket gives to the left pocket.”
In July the FTC reached a settlement in a suit against Caremark, requiring it to be more transparent and give patients and pharmacies more choice. It had previously reached such an agreement with Express Scripts and is working on one with Optum.
Academics like Cooper are trying to help clarify “which of these vertical deals are bad.” A clearer economic theory, he said, might help regulators make the patient experience just “a little less worse.”
Elisabeth Rosenthal (erosenthal@kff.org) is a KFF Health News reporter.
First gradually, then suddenly
“Touch of Autumn” (encaustic on panel), by Dale O. Roberts, at Portland Art Gallery.
He can’t fake it in Vt.
Strafford, Vt., Meeting House, built in 1799
“Even when I play shows, I'm more nervous to play a show in Vermont or New Hampshire than I am to play a song about New England in Missouri because they assume that I've captured the experience, whereas in Vermont, they know what this place is like.’’
— Noah Kahan (born 1997), American singer-songwriter. He was born in Strafford, Vt.
Soporific in the sun
“Bathers on Rocks” (watercolor and pencil on paper), by Herbert Mayer (1882-1960), at the University of Vermont’s Fleming Museum of Art, Burlington.
