Science
What military doctors can teach us about power in the United States
Power is invisible, but its effects can be seen everywhere — especially in the health records of active duty military personnel.
By examining details of 1.5 million emergency room visits at U.S. military hospitals nationwide, researchers found that doctors invested significantly more resources in patients who outranked them than in patients of equal or lesser rank. The additional clinical effort devoted to powerful patients came at the expense of junior patients, who received worse care and were more likely to become seriously ill.
Military rank wasn’t the only form of power that translated into inequitable treatment. The researchers documented that patients fared better when they shared the same race or gender as their doctor, a pattern that tended to favor white men and caused Black patients in particular to be shortchanged by their physicians.
The results were published Thursday in the journal Science.
The findings have implications far beyond the realm of the military, said Manasvini Singh, a health and behavioral economist at Carnegie Mellon University who conducted the research with Stephen D. Schwab, an organizational health economist at the University of Texas at San Antonio.
For instance, they can help explain why Black students do better in school when they are taught by Black teachers, and why Black defendants get more even-handed treatment from Black judges.
“We think our results speak to many settings,” Singh said.
The disparities wrought by power imbalances are easy to spot but difficult to study in real-world scenarios.
“It’s just hard to measure power,” Singh said. “It’s abstract, it’s complicated.”
That’s where the military health records come in.
The Military Health System operates 51 hospitals across the country. The doctors who staff them are active-duty personnel, as are many of the patients they treat. Comparing their ranks gave Singh and Schwab a handy way to gauge the power differential between physicians and the people in their care.
The researchers restricted their analysis to patients who sought treatment in emergency departments, where patients are randomly assigned to doctors. That randomness made it easier to measure how power influenced the treatment patients received.
To further isolate the effects of power, the researchers made comparisons between patients of the same rank. If they happened to outrank their doctor, they were considered a “high-power” patient. If not, they were classified as a “low-power” patient.
The medical records showed that doctors put 3.6% more effort into treating high-power patients than low-power ones. They also utilized significantly more resources such as clinical tests, scans and procedures, according to the study.
Those extra resources translated into better care: High-power patients were 15% less likely to become sick enough to be admitted to the hospital over the next 30 days.
To see if they could replicate their results, Singh and Schwab narrowed their focus to doctors who treated patients within a one-year period before or after the patients were promoted to a higher rank. The researchers found that doctors devoted 1% more effort to patients post-promotion, as well as more medical resources. Those differences may have been small, but they were statistically significant, Schwab said.
Next, the pair considered what happened to low-power patients while high-power patients were getting extra attention. One hypothesis was that ordering additional tests for one patient might prompt doctors to order the same tests for everyone they treated that day. It was also possible that the decisions doctors made for their high-power patients had no bearing on their other patients.
Neither turned out to be the case. Instead, the added effort spent on high-power patients was siphoned away from low-power patients, who got 1.9% less effort from their doctors. On top of that, their risk of needing to return to the ER or be admitted to the hospital over the following 30 days increased by 3.4%, the researchers found.
“The powerful unwittingly ‘steal’ resources from less-powerful individuals,” Schwab and Singh wrote.
Outside the military, doctors and patients can’t use official rank to measure their power relative to each other, but they do contend with the effects of race and gender. That led the researchers to investigate whether the physicians in their study treated patients differently if they shared these attributes.
White doctors devoted more effort to white patients than to Black patients across the board, the researchers found. The gap was the same regardless of whether the doctor had a higher or lower rank than the patient.
However, white doctors increased their effort for high-power patients by the same amount regardless of race. As a result, white doctors treated high-power Black patients the same, on average, as low-power white patients.
The story was different for Black doctors. When they outranked their patients, they gave essentially the same amount of effort to everyone. But on the rare occasions when they encountered a higher-ranked Black patient, the amount by which they dialed up their efforts was more than 17 times greater than it was when they treated a higher-ranked white patient.
It’s not clear what accounted for this “off-the-charts effort,” the researchers wrote. They speculated that since Black service members were underrepresented among the pool of high-power patients, Black doctors were particularly attuned to their status.
The effects of gender were more difficult to ascertain, since biology dictates that men and women require different kinds of care.
Both male and female doctors invested the most effort in female patients who outranked them. But male doctors upgraded their care for high-power patients of both genders to a much greater extent than female doctors. And unlike female doctors, male doctors devoted more effort to female patients across the board.
Finally, the researchers wondered whether doctors gave preferential treatment to high-power patients because of their elevated status or because those patients had the authority to make trouble if they were unsatisfied with their care. To make inferences about this, they compared the treatment of retirees (who retained their status but had given up their authority) to the treatment of active-duty patients (who still had both).
Schwab and Singh found that high-power patients continued to elicit extra effort from doctors for up to five years after they retired, suggesting that status was an important factor.
“I think it’s really, really cool that even after retirement, you still have these effects,” said Joe C. Magee, a professor of management and organization at the NYU Stern School of Business who studies the role of hierarchy. He sees that as a strong sign that status was driving doctors’ decisions all along.
“What these folks are able to show is that it has real health consequences,” Magee said.
Eric Anicich, a professor of management and organization at the USC Marshall School of Business, called the study “impressive” and the findings “important.”
Although a 3.5% increase or a 1.9% decrease in physician effort may seem small, their cumulative impact is meaningful, especially when it comes to something as critically important as healthcare, he said.
The inequities documented in the study aren’t unique to doctors or to the armed forces, Schwab and Singh said. The mathematical model they developed to describe the behavior in military emergency rooms also helps explain why people in all kinds of situations give preferential treatment to people who look like them: It may help minimize the effects of societal disparities.
In a commentary that accompanies the study, Laura Nimmon of the University of British Columbia’s Centre for Health Education Scholarship wrote that “the ephemeral and unobservable nature of power has made it profoundly difficult to study.” But she said it’s worth the effort to make sure doctors wield their power more fairly.
The disparities reported by Schwab and Singh are “of serious concern to society at large,” she wrote.
Science
A push to end a fractured approach to post-fire contamination removal
The patchwork efforts to identify and safely remove contamination left by the 2025 Eaton and Palisades fires has been akin to the Wild West.
Experts have given conflicting guidance on best practices. Shortly after the fires, the federal government suddenly refused to adhere to California’s decades-old post-fire soil-testing policy; California later considered following suit.
Meanwhile, insurance companies have resisted remediation practices widely recommended by scientists for still-standing homes.
A new bill introduced this week by state Assemblymember John Harabedian (D-Pasadena) aims to change that by creating statewide science-based standards for the testing and removal of contamination deposited by wildfires — specifically within still-standing homes, workplaces and schools, and in the soil around those structures.
“In a state where we’ve had a number of different wildfires that have happened in urban and suburban areas, I was shocked that we didn’t have a black-and-white standard and protocol that would lay out a uniform post-fire safety standard for when a home is habitable again,” Harabedian said.
The bill, AB 1642, would task the state’s Department of Toxic Substances Control with creating standards by July 1, 2027. The standards would only serve as guidance — not requirements — but even that would be helpful, advocates say.
“Guidance, advisories — those are extremely helpful for families that are trying to return home safely,” said Nicole Maccalla, who leads data science efforts with Eaton Fire Residents United, a grassroots organization addressing contamination in still-standing homes. “Right now, there’s nothing … which means that insurance companies are the decision-makers. And they don’t necessarily prioritize human health. They’re running a business.”
Maccalla supports tasking DTSC with determining what levels of contamination pose an unacceptable health risk, though she does want the state to convene independent experts including physicians, exposure scientists and remediation professionals to address the best testing procedures and cleanup techniques.
Harabedian said the details are still being worked out.
“What’s clear from my standpoint, is, let’s let the public health experts and the science and the scientists actually dictate what the proper standards and protocol is,” Harabedian said. “Not bureaucrats and definitely not insurance companies.”
For many residents with still-standing homes that were blanketed in toxic soot and ash, clear guidance on how to restore their homes to safe conditions would be a much welcome relief.
Insurance companies, environmental health academics, and professionals focused on addressing indoor environmental hazards have all disagreed on the necessary steps to restore homes, creating confusion for survivors.
Insurance companies and survivors have routinely fought over who is responsible for the costs of contamination testing. Residents have also said their insurers have pushed back on paying for the replacement of assets like mattresses that can absorb contamination, and any restoration work beyond a deep clean, such as replacing contaminated wall insulation.
Scientists and remediation professionals have clashed over which contaminants homeowners ought to test for after a fire. Just last week, researchers hotly debated the thoroughness of the contamination testing at Palisades Charter High School’s campus. The school district decided it was safe for students to return; in-person classes began Tuesday.
Harabedian hopes the new guidelines could solidify the state’s long-standing policy to conduct comprehensive, post-fire soil testing.
Not long after the federal government refused to adhere to the state’s soil testing policy, Nancy Ward, the former director of the California Governor’s Office of Emergency Services, had privately contemplated ending state funding for post-fire soil testing as well, according to an internal memo obtained by The Times.
“That debate, internally, should have never happened,” Harabedian said. “Obviously, if we have statewide standards that say, ‘This is what you do in this situation,’ then there is no debate.”
Science
Expiration of federal health insurance subsidies: What to know in California
Thousands of middle-class Californians who depend on the state-run health insurance marketplace face premiums that are thousands of dollars higher than last year because enhanced federal subsidies that began during the COVID-19 pandemic have expired.
Despite fears that more people would go without coverage with the end of the extra benefits, the number enrolling in Covered California has held steady so far, according to state data.
But that may change.
Jessica Altman, executive director of Covered California, said that she believes the number of people dropping their coverage could increase as they receive bills with their new higher premiums in the mail this month. She said better data on enrollment will be available in the spring.
Altman said that even though the extra benefits ended Dec. 31, 92% of enrollees continue to receive government subsidies to help pay for their health insurance. Nearly half qualify for health insurance that costs $10 or less per month. And 17% of Californians renewing their Covered California policies will pay nothing for premiums if they keep their current plan.
The deadline to sign up for 2026 benefits is Saturday.
Here’s help in sorting out what the expiration of the enhanced subsidies for insurance provided under the Affordable Care Act, often called Obamacare, means in the Golden State.
What expired?
In 2021, Congress voted to temporarily to boost the amount of subsidies Americans could receive for an ACA plan. The law also expanded the program to families who had more money. Before the vote, only Americans with incomes below 400% of the federal poverty level — currently $62,600 a year for a single person or $128,600 for a family of four — were eligible for ACA subsidies. The 2021 vote eliminated the income cap and limited the cost of premiums for those higher-earning families to no more than 8.5% of their income.
How could costs change this year for those enrolled in Covered California?
Anyone with income above 400% of the federal poverty level no longer receives subsidies. And many below that level won’t receive as much assistance as they had been receiving since 2021. At the same time, fast-rising health costs boosted the average Covered California premium this year by more than 10.3%, deepening the burden on families.
How much would the net monthly premium for a Los Angeles couple with two children and a household income of $90,000 rise?
The family’s net premium for the benchmark Silver plan would jump to $699 a month this year from $414 a month last year, according to Covered California. That’s an increase of 69%, costing the family an additional $3,420 this year.
Who else could face substantially higher health bills?
People who retired before the Medicare-qualifying age of 65, believing that the enhanced subsidies were permanent, will be especially hit hard. Those with incomes above 400% of the federal poverty level could now be facing thousands of dollars in additional health insurance costs.
How did enrollment in Covered California change after the enhanced subsidies expired on Dec. 31?
As of Jan. 17, 1,906,033 Californians had enrolled for 2026 insurance. That’s less than 1% lower than the 1,921,840 who had enrolled by this time last year.
Who depends on Covered California?
Enrollees are mostly those who don’t have access to an employer’s health insurance plan and don’t qualify for Medi-Cal, the government-paid insurance for lower-income people and those who are disabled.
An analysis by KFF, a nonprofit that provides health policy information, found that nearly half the adults enrolled in an ACA plan are small-business owners or their employees, or are self-employed. Occupations using the health insurance exchanges where they can buy an ACA plan include realtors, farmers, chiropractors and musicians, the analysis found.
What is the underlying problem?
Healthcare spending has been increasing faster than overall inflation for years. The nation now spends more than $15,000 per person on healthcare each year. Medical spending today represents about 18% of the U.S. economy, which means that almost one out of every five dollars spent in the U.S. goes toward healthcare. In 1960, health spending was just 5% of the economy.
What has California done to help people who are paying more?
The state government allocated $190 million this year to provide subsidies for those earning up to 165% of the federal poverty level. This money will help keep monthly premiums consistent with 2025 levels for those with an annual income of up to $23,475 for an individual or $48,225 for a family of four, according to Covered California.
Where can I sign up?
People can find out whether they qualify for financial help and see their coverage options at the website CoveredCA.com.
What if I decide to go without health insurance?
People without insurance could face medical bills of tens of thousands of dollars if they become sick or get injured. And under California state law, those without coverage face an annual penalty of at least $900 for each adult and $450 for each child.
Science
Department of Education finds San Jose State violated Title IX regarding transgender volleyball player
The U.S. Department of Education has given San José State 10 days to comply with a list of demands after finding that the university violated Title IX concerning a transgender volleyball player in 2024.
A federal investigation was launched into San José State a year ago after controversy over a transgender player marred the 2024 volleyball season. Four Mountain West Conference teams — Boise State, Wyoming, Utah State and Nevada-Reno — each chose to forfeit or cancel two conference matches to San José State. Boise State also forfeited its conference tournament semifinal match to the Spartans.
The transgender player, Blaire Fleming, was on the San José State roster for three seasons after transferring from Coastal Carolina, although opponents protested the player’s participation only in 2024.
In a news release Wednesday, the Education Department warned that San José State risks “imminent enforcement action” if it doesn’t voluntarily resolve the violations by taking the following actions, not all of which pertain solely to sports:
1) Issue a public statement that SJSU will adopt biology-based definitions of the words “male” and “female” and acknowledge that the sex of a human — male or female — is unchangeable.
2) Specify that SJSU will follow Title IX by separating sports and intimate facilities based on biological sex.
3) State that SJSU will not delegate its obligation to comply with Title IX to any external association or entity and will not contract with any entity that discriminates on the basis of sex.
4) Restore to female athletes all individual athletic records and titles misappropriated by male athletes competing in women’s categories, and issue a personalized letter of apology on behalf of SJSU to each female athlete for allowing her participation in athletics to be marred by sex discrimination.
5) Send a personalized apology to every woman who played in SJSU’s women’s indoor volleyball from 2022 to 2024, beach volleyball in 2023, and to any woman on a team that forfeited rather than compete against SJSU while a male student was on the roster — expressing sincere regret for placing female athletes in that position.
“SJSU caused significant harm to female athletes by allowing a male to compete on the women’s volleyball team — creating unfairness in competition, compromising safety, and denying women equal opportunities in athletics, including scholarships and playing time,” Kimberly Richey, Education Department assistant secretary for civil rights, said.
“Even worse, when female athletes spoke out, SJSU retaliated — ignoring sex-discrimination claims while subjecting one female SJSU athlete to a Title IX complaint for allegedly ‘misgendering’ the male athlete competing on a women’s team. This is unacceptable.”
San José State responded with a statement acknowledging that the Education Department had informed the university of its investigation and findings.
“The University is in the process of reviewing the Department’s findings and proposed resolution agreement,” the statement said. “We remain committed to providing a safe, respectful, and inclusive educational environment for all students while complying with applicable laws and regulations.”
In a New York Times profile, Fleming said she learned about transgender identity when she was in eighth grade. “It was a lightbulb moment,” she said. “I felt this huge relief and a weight off my shoulders. It made so much sense.”
With the support of her mother and stepfather, Fleming worked with a therapist and a doctor and started to socially and medically transition, according to the Times. When she joined the high school girls’ volleyball team, her coaches and teammates knew she was transgender and accepted her.
Fleming’s first two years at San José State were uneventful, but in 2024 co-captain Brooke Slusser joined lawsuits against the NCAA, the Mountain West Conference and representatives of San José State after alleging she shared hotel rooms and locker rooms with Fleming without being told she is transgender.
The Education Department also determined that Fleming and a Colorado State player conspired to spike Slusser in the face, although a Mountain West investigation found “insufficient evidence to corroborate the allegations of misconduct.” Slusser was not spiked in the face during the match.
President Trump signed an executive order a year ago designed to ban transgender athletes from competing on girls’ and women’s sports teams. The order stated that educational institutions and athletic associations may not ignore “fundamental biological truths between the two sexes.” The NCAA responded by banning transgender athletes.
The order, titled “Keeping Men Out of Women’s Sports,” gives federal agencies, including the Justice and Education departments, wide latitude to ensure entities that receive federal funding abide by Title IX in alignment with the Trump administration’s view, which interprets a person’s sex as the gender they were assigned at birth.
San José State has been in the federal government’s crosshairs ever since. If the university does not comply voluntarily to the actions listed by the government, it could face a Justice Department lawsuit and risk losing federal funding.
“We will not relent until SJSU is held to account for these abuses and commits to upholding Title IX to protect future athletes from the same indignities,” Richey said.
San José State was found in violation of Title IX in an unrelated case in 2021 and paid $1.6 million to more than a dozen female athletes after the Department of Justice found that the university failed to properly handle the students’ allegations of sexual abuse by a former athletic trainer.
The federal investigation found that San José State did not take adequate action in response to the athletes’ reports and retaliated against two employees who raised repeated concerns about Scott Shaw, the former director of sports medicine. Shaw was sentenced to 24 months in prison for unlawfully touching female student-athletes under the guise of providing medical treatment.
The current findings against San José State came two weeks after federal investigators announced that the California Community College Athletic Assn. and four other state colleges and school districts are the targets of a probe over whether their transgender participation policies violate Title IX.
The investigation targets a California Community College Athletic Assn. rule that allows transgender and nonbinary students to participate on women’s sports teams if the students have completed “at least one calendar year of testosterone suppression.”
Also, the Education Department’s Office of Civil Rights has launched 18 Title IX investigations into school districts across the United States on the heels of the Supreme Court hearing oral arguments on efforts to protect women’s and girls’ sports.
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