It's not a good look when Robert F. Kennedy Jr. is ahead of you on evidence-based health policy—and worse, women's health—but that's exactly what happened to Gov. Gavin Newsom last week.
Oh.
At a cabinet meeting, Kennedy humiliated Trump for more than six minutes. That's pretty standard for these increasingly bizarre encounters, but the Secretary of Health and Human Services specifically praised the president for ending “the 20-year war on women by removing black box warnings about hormone replacement therapy.”
As shocking as this may be to me, RFK Jr. has a reasonable point.
A couple of days later, appearing on stage at the New York Times' DealBook Summit, Oscar-winning actress Halle Berry unexpectedly and sharply criticized Newsom for vetoing a menopause treatment bill.
“But that’s OK,” she said of Newsom’s repeal of the Menopause Care Equity Act (AB 432), which she lobbied for passage and which had strong bipartisan support in the Legislature.
“Since he's not going to be governor forever, and given the way he ignores women, half the population, devaluing us in middle age, he probably shouldn't be our next president either,” Berry said. “Just saying.”
These two events highlight just how complex and controversial menopause care has become over the last few years, as women not only talk about it more openly, but also demand help that, well, has 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 most Americans, both men and women, have an opinion about: How much power should insurance companies have to deny medical care that a doctor deems reasonable?
Simply put, menopause is the phase that all women go through when their fertility ends, meaning that 50% of the population experiences it. It has specific and life-altering symptoms, most of which are treatable, but often are not because many doctors are not trained in caring for menopause (or perimenopause, which comes earlier), and the science is too often overlooked or misunderstood.
As a result, too many women go through menopause without understanding what is happening to them or that there are excellent, evidence-based treatments that can help.
A prime example of this is the “black box” warning that has been present on many hormone replacement drugs since the turn of the millennium, when one large but flawed study found that such drugs could increase the risk of cancer or other diseases.
A black box warning is the strongest warning the Food and Drug Administration can place on a drug, and its inclusion in the theory of hormone replacement therapy, or HRT, sharply reduces its use.
Twenty years of subsequent research not only revealed the shortcomings of this first analysis, but also showed significant benefits from HRT. It may protect against cognitive decline, reduce the risk of cardiovascular disease, and relieve symptoms such as hot flashes, among many other benefits.
In early November, the FDA removed these warnings from many HRT medications. The result is likely to be greater access for more women as doctors become less hesitant to prescribe them and women become less afraid to use them.
“Misconceptions about risks have been exaggerated for decades, contradicting the tenets of real science and leading to missed opportunities at the population level to improve the lives of our aging women in the developed world,” wrote Michael Rogers, chairman of the Santa Clara County Health Advisory Commission, in a public comment about the changes.
While Rogers is right, insurance coverage and physician know-how remain problems for women seeking care—ones that the Menopause Equity in Care Act hoped to address.
The bill would require private insurers to cover FDA-approved menopause treatments and would reward doctors who voluntarily take continuing education courses on menopause topics. This final version had already been watered down from previous proposals, which would have required coverage of even more treatment options (such as non-FDA-approved complex hormones) and would have required training for doctors on menopause issues.
But Newsom appears to disagree with the part of the bill that prohibits insurance companies from applying “utilization management” to menopause treatments—and here we come back to agreeing with RFK Jr.
Utilization management, or UM, is essentially about insurance companies deciding what a patient needs and what they don't—pre-approvals, reviews, and denials that too often seem to be much more important to cost than to care.
Now artificial intelligence is intervening in the utilization management business, potentially meaning that decisions about our treatments aren't even made by humans. UM is a multi-billion dollar industry that, in its efforts to keep healthcare affordable, too often does so by denying care.
That's why Assemblywoman Rebecca Bauer-Kahan (D-Orinda), author of the California bill, introduced the UM ban.
“The ‘medically necessary’ standard when it comes to insurance coverage,” Bauer-Kahan notes.
“When you talk about menopause, it's a very vague term, isn't it? I mean, in the short term, I will survive without any treatment,” she said. “So what is ‘medically necessary’ is a very vague thing when it comes to menopause care.”
In his veto messageNewsom said the UM ban would “limit health plans' ability to use practices that have been proven to provide adequate care while limiting unnecessary costs.”
But the truth and challenge of menopause care is that it is different for each woman. Like birth control pills, a treatment that works for one woman may cause side effects for another. Finding the right path through menopause often involves a lot of trial and error, and women need to be able to have the freedom and flexibility to work one-on-one with their doctor. No interference.
In June, Kennedy issued a call prior authorization throughout the healthcare industry as an issue, and shortly thereafter announced that it had received promises from many major insurance companies to reform the process by 2026, eliminating the need for prior authorization for many treatments and procedures and simplifying the process overall.
If this reform happens, it will truly be amazing – I hope – but let's wait and see. These changes are due to begin in January.
Back in California, Newsom also promised to do something about menopause coverage in January when he announces his budget proposal. In his veto announcement, Newsom said he would take that route — including it in his budget package — rather than working on a new bill in the next legislative session. This remains the plan, although no details are available yet.
Apparently someone forgot to mention this to Berry.
The budget increasingly becomes a comprehensive piece of legislation that the governor wants to implement with less fuss, since the budget and its preliminary bills are always passed at some point, and it may be easier for him to control that path.
Newsom has made supporting women's rights, particularly in reproductive care, a core part of his policies and his presidential campaign, and equality for women is a cause championed by his wife, first partner Jennifer Siebel Newsom.
But the governor has also long been hesitant to pass cost-related legislation (the menopause bill could raise individual premiums by less than 50 cents a month for most private-pay consumers). Given federal cuts, rising insurance premiums and general chaos in health care, his caution is not unwarranted.
But in this case, this may be a mistaken opinion. The only real opposition to the California bill came from insurance companies. Go figure it out.
Bauer-Kahan said she has been in contact with the governor's office but remains committed to passing legislation to limit use management.
“I'm glad to hear that we will hopefully achieve this, but it needs to be achieved in a way that really makes a significant difference in women getting the menopause care they need,” she said.
Newsom's October veto caused little commotion. Thanks to Berry's blow, his January proposal will not only be noticed, but scrutinized.
If he does lift restrictions on Unified Messaging, he will have to answer a broader question that will arise from these actions: What authority should insurance companies have to override the decisions of doctors and patients?
It would be strange if in January Kennedy and his chaotic and questionable Department of Health and Human Services were offering women better health care options than the state of California.
And it's even weirder for Newsom to put a price on women's well-being.
