• Anthony Bourdain died on Friday, with early reports indicating that the beloved celebrity chef and TV host committed suicide. Earlier in the week, Kate Spade died by suicide as well.
• Their deaths are part of a nationwide trend. Since 1999, the national suicide rate has risen by nearly 30%, and mental illness is believed to be one of the largest contributors.
• Mental-health experts expect that the country's decline in funding for mental healthcare has contributed to the rise.
• Those who can afford out-of-pocket costs for mental health services are more likely to seek them out and receive treatment.

Anthony Bourdain, acclaimed chef who explored the globe in search of the world's best cuisine, died by apparent suicide Friday morning in France, CNN said. The report followed news of fashion mogul Kate Spade's suicide earlier this week.

Their deaths come amid a larger, alarming trend happening across the US: Since 1999, the national suicide rate has risen 28%, according to the Centers for Disease Control and Prevention (CDC). Nearly every state has seen a rise over that period.

While suicide is a complex response to trauma that often involves many factors, mental illness is one of the leading contributors, according to the CDC. But for those who have a mental illness and can't afford mental healthcare, their conditions are more likely to worsen.

According to many mental-health experts, that reality makes suicide a far-reaching, systemic public health crisis. 

John Mann, a psychiatrist who studies the causes of depression and suicide at Columbia University, said several factors have likely contributed to America's rising suicide rate, including stress from the 2008 financial crisis and the current opioid epidemic. But they don't tell the whole story.

"We have a serious, national problem in terms of adequate recognition of psychiatric illnesses and their treatment. That is the single most effective suicide-prevention method in Western nations," he told Business Insider. "We're missing most of these cases. That's really the bottom line."

The larger majority of suicide victims who have a psychiatric illness — nearly 3 in 4 Americans— are not receiving treatment at the time of their deaths.

The US has made substantial cuts in mental health funding over the past decade

Making mental healthcare more affordable could help lower suicide rates in the US, Mann added. Following the 2008 recession, states were forced to cut over $4 billion in public mental health funding.

Trump's latest budget would also slash the key source of public funds for mental health treatment: the Medicaid program serving over 70 million low-income and disabled Americans.

"We have a national strategy for suicide prevention in the United States, but it's essentially unfunded and there is no government leadership in systematically implementing this strategy at the federal or state level," he said. "So we have a blueprint, but we do not act on that blueprint."

Today, many Americans simply cannot afford mental health services, which may be due to a flawed healthcare system. Of all practicing medical providers in the US, therapists are the least likely to take insurance. And only 55% of psychiatrists accept insurance plans, compared to 89% of other healthcare professionals, like cardiologists, dermatologists, and podiatrists, according to a 2014 study published in JAMA Psychiatry. 

In the US, therapy can cost hundreds of dollars per session when patients pay out-of-pocket. Prices are usually even higher in cities, which also tend to have higher rates of depression than rural areas. 

"This is a wake-up call for employers, regulators, and the [insurance] plans themselves"

Mental healthcare coverage can vary widely by state as well. In 2017, Milliman, a risk-management and health care consulting company, published a national study that explored geographic gaps in affordable mental healthcare access. 

The researchers parsed through two large databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and Washington, DC, from 2013 to 2015. In New Jersey, 45% of office visits for behavioral healthcare were out-of-network. In Washington, DC, it was 63%. In nine states, including New Hampshire, Minnesota, and Massachusetts, payments were 50% higher for primary-care doctors when they provided mental healthcare.

"This is a wake-up call for employers, regulators, and the [insurance] plans themselves that whatever they're doing, they're making it difficult for consumers to get treatment for all these illnesses. They're failing miserably," Henry Harbin, former CEO of Magellan Health, a behavioral healthcare company, told NPR in reaction to the study.

Because mental healthcare providers know that insurance companies won't adequately reimburse them, they will often require patients to pay out-of-pocket. As a result, many states do not have enough in-network therapists and psychiatrists to meet patient demand. 

"Too many people have no health insurance; there have been too many budget cuts to treatment dollars, and there are too few providers available to deliver care," Fred Osher, director of Health Systems and Services Policy at the Council of State Governments Justice Center, wrote in The New York Times in 2016. "These obstacles should lead to a call to action, not a call to further confine people with mental illness."

Correlation does not equal causation, but many other nations with universal or near-universal healthcare, like the Netherlands and Estonia, have seen declines in suicide rates, Mann said.

Following reports of Bourdain's and Spade's suicides, many Americans on Twitter shared stories of their own battles with depression and mental illnesses. A number of people also expressed worries about not being able to pay for therapy visits and/or psychiatric medications, because their insurance plans did not cover them. 

SEE ALSO: The suicide rate has risen 28% in the US in less than 20 years, according to new data

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NOW WATCH: What happens to your body when it's struck by lightning

• Pharma is getting serious about gene therapy, one-time treatments designed to modify genes to cure serious diseases.
• Novartis is the first big pharma company to make a major bet on gene therapy, acquiring Avexis for $8.7 billion in April.
• Investment in the gene-therapy space could change the way certain diseases are treated, though the treatments come with high price tags. 

One-time drugs designed to cure previously untreatable diseases by modifying human genes are starting to gain traction in the US.

These cutting-edge treatments, known as gene therapies, work by inserting new genetic code into the body to start producing a protein that is missing or deficient.

Recent mergers-and-acquisitions transactions show that big pharma is betting big on gene therapy. In April, Novartis gave an $8.7 billion endorsement of gene therapy with its acquisition of Avexis, a company working on a treatment for spinal muscular atrophy, a rare genetic condition that affects muscle movement and is the leading genetic cause of infant mortality.

Pfizer has also invested the space, acquiring a gene-therapy company called Bamboo in 2016 in a deal worth as much as $645 million.

The deals illustrate "that pharma's starting to come off the sidelines and starting to believe that there's some potential for those programs," Adam Keeney, the global head of external innovation and R&D strategy at Sanofi Genzyme, told Business Insider.

For its part, Sanofi has a collaboration with Voyager Therapeutics, which is working on gene therapies for neurodegenerative diseases. Bayer has a partnership with Ultragenyx around its hemophilia gene therapy.

"We definitely feel this is important and ready for testing primetime," Chris Haskell, a Bayer vice president who leads its West Coast Innovation Center, said in an interview. "That is, we still need to see how it works in humans. You never know until you get it into patients."

Where to start

Gene therapies have been developed to treat rare conditions that affect a small number of people — and they come with high price tags.

So far, the Food and Drug Administration has approved one gene therapy that acts on a hereditary illness. The approval, in December, was for Luxturna, a treatment for a form of blindness called Leber congenital amaurosis, which affects two or three newborns out of 100,000.

The condition is caused by a gene defect that stops the retina from making a key protein. The one-time treatment is injected into the retina, and from there, a virus carrying the corrected gene can get to work replacing the faulty one and start producing the protein.

The therapy, made by Spark Therapeutics, has a price tag of $850,000, making it the most expensive drug ever approved in the US, though some analysts had expected Spark might charge $1 million.

These sky-high prices largely fall to the government and health plans.

The price tags can also be the downfall of these therapies. For example, the world's first gene therapy, a treatment for a rare genetic disorder that causes problems with the pancreas, cost $1 million and was used only once in Germany; the physician had to prepare a submission form as thick as "a thesis" and call the CEO of a German insurer to cover the cost, the MIT Technology Review reported in 2016. Last year, Uniqure, the company behind the drug, withdrew it from the European market.

As these drugs' manufacturing improves and more treatments get closer to approval, a few areas have emerged as the best places to start when exploring just how far-reaching gene therapy can get, Keeney said.

The eye is one of them. As an organ, the eye is easy to get to, and it doesn't react as strongly to foreign objects — in the case of Luxturna, a virus carrying the gene therapy.

Next up is blood disorders like hemophilia, a group of conditions in which the body has a hard time controlling blood clotting. Shire, BioMarin Pharmaceutical, and Pfizer (in collaboration with Spark) are all working on treatments for certain kinds of hemophilia.

Gene therapy could be used in this instance to reintroduce or bolster the production of proteins known as clotting factors, which help your blood clot if you get a cut or start bleeding internally.

Elsewhere, researchers are exploring the liver and the brain as targets for gene therapies. And gene therapies are in the works to treat Parkinson's disease, a neurodegenerative condition characterized by motor symptoms such as shaking in the hands and legs and stiffness and impaired balance.

What still needs to be sorted out

For now, gene therapies seem to fit best into conditions that affect smaller groups of people and can serve as one-time treatments that, ideally, reverse it.

Beyond that, it remains to be seen how these expensive therapies might play out. For example, developing a gene therapy for diabetes — a condition that affects millions of people — may not make the most sense, because there are other ways to treat it that are less expensive and less risky.

"I think the utility outside very specific rare diseases is a question mark, and then the go-to-market and the business model of how are you going to set up an incentive system and a structure to allow those molecules to deliver commercially is still a bit of an open item," Keeney said.

For now, the treatments are expensive, so whether health plans and governments could be persuaded to pay for them remains to be seen. In the first three months of the year, Luxturna made $2.4 million in net sales, with three people treated so far since its approval.

Analysts at RBC said in May that they expected gene therapy to be used in about 32 people this year, representing $21 million in sales. That's not a lot compared with a blockbuster drug that brings in billions of dollars and treats tens of thousands or even millions of people. But the promise and the implications for the way we treat certain diseases could be bigger as more and more gene therapies make it to the market.

"Our objectives and the reason we're excited about gene therapies is because we're addressing the fundamental cause of the genetic disease," Bob Smith, the head of Pfizer's global gene-therapy business, told Business Insider.

That could mean correcting a disease at its root cause rather than treating the symptoms indefinitely.

"We have a high degree of confidence that these kinds of treatments could be truly transformational," Smith said.

FDA Commissioner Scott Gottlieb said at the BIO conference in Boston this month that he expects the FDA to approve 40 gene therapies by 2022.

And in a speech in May, Gottlieb said: "It's clear that these new technologies are going to transform medicine and human health. Gene therapy was largely a theoretical promise a few decades ago. Now we should not only expect these products to cure disease, but we also ought to demand that we reach this objective."

SEE ALSO: 'We like to think of ourselves as the lead turtle in the race of the turtles': How Big Pharma is turning to Silicon Valley to supercharge drug development

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NOW WATCH: 80% of startup money goes to 3 states — here's what one visionary is doing to help spread the wealth

• Medicare doesn't cover every health cost — retirees need to save for Medigap plans, extra health insurance policies that help pay for some of the health care costs traditional Medicare doesn't cover.
• HealthView Services provided Business Insider with average annual cost projections for Medigap Plan F, the most popular level of Medigap coverage, in every state.
• Medigap plans are most affordable in Hawaii and most expensive in Massachusetts.

Saving for retirement seems to be never ending. 

It's twice as expensive to retire today as it was 25 years ago, writes James Moore in MarketWatch. And according to one financial planner, millennials need more than $1 million saved by the time they retire.

One cost often overlooked when it comes to saving for retirement? Medigap plans. Because Medicare doesn't cover everything.

Medigap plans are extra health insurance policies sold by private companies that help pay for some of the health care costs traditional Medicare doesn't cover, such as copayments, coinsurance, and deductibles. Some Medigap plans even cover services, such as medical care when traveling outside the US.

Retirees must have Medicare Part A and Medicare Part B to have a Medigap plan.

HealthView Services provided Business Insider with the average annual cost projections for Medigap Plan F, the most popular level of Medigap coverage, across every state.

The national average cost for Medigap Plan F is $1,712 annually, which is around $143 a month. 

Medigap Plan F is the most affordable in Hawaii, with an average annual projected cost of just $1,310 a year, or around $109 a month. In Massachusetts, it's much higher: The average annual projected cost of Medigap Plan F is $1,947, which is equivalent to roughly $162 a month.

Scroll through below to see how much Medigap Plan F costs in every state, plus Washington, DC.

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51. Hawaii

Average annual Medigap plan cost: $1,310

Average monthly Medigap plan cost: $109.16

50. New Mexico

Average annual Medigap plan cost: $1,464

Average monthly Medigap plan cost: $122

49. Iowa

Average annual Medigap plan cost: $1,468

Average monthly Medigap plan cost: $122.33

• JPMorgan, Amazon, and Berkshire Hathaway have selected a CEO to run their new healthcare venture.
• The trio of employers have selected Dr. Atul Gawande, a surgeon who is also a professor at the Harvard T.H. Chan School of Public Health and Harvard Medical School.
• The venture, announced in January, is aimed at lowering healthcare costs for the companies' employees, though there haven't been many details about what that looks like.

The healthcare venture that JPMorgan, Amazon, and Berkshire Hathaway announced back in January finally has a CEO.

The three employers have selected Dr. Atul Gawande, a surgeon who is also a professor at the Harvard T.H. Chan School of Public Health and at Harvard Medical School, they said in a news release. The venture will be based in Boston.

The venture, announced in January, is aimed at lowering healthcare costs for the companies' employees, though there haven't been many details about what that looks like.

Gawande, in addition to practicing general and endocrine surgery at Brigham and Women's Hospital in Boston, is a staff writer for The New Yorker.

"This work will take time but must be done," Gawande said in the companies' news release. "The system is broken, and better is possible."

The three companies are self-insured employers, which means that when you're an employee going to a doctor's appointment, your employer, rather than a health insurer, is ultimately footing the bill for the MRI exam you receive.

"We're already the insurance company, we're already making these decisions, and we simply want do a better job," JPMorgan CEO Jamie Dimon told Business Insider in February.

The venture will be geared toward employees of the three companies rather than healthcare consumers overall in the US, though Dimon said all Americans stood a chance of benefiting.

"We said at the outset that the degree of difficulty is high and success is going to require an expert's knowledge, a beginner's mind, and a long-term orientation," Amazon CEO Jeff Bezos said in the statement. "Atul embodies all three, and we're starting strong as we move forward in this challenging and worthwhile endeavor."

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• Dr. Atul Gawande was announced on Wednesday as the new CEO of the JPMorgan-Amazon-Berkshire Hathaway joint healthcare venture.
• Gawande boasts an impressive resume that includes experience both in medicine and policy. 
• Gawande has been openly critical about problems within the healthcare system through his various written works.

The healthcare venture that JPMorgan, Amazon, and Berkshire Hathaway announced in January finally has a CEO. 

On Wednesday the trio said they'd selected Dr. Atul Gawande, a surgeon, writer, and professor, as the new chief executive of the Boston-based venture.

While the pick may have been a surprise to some healthcare industry watchers, Gawande has been on the radar of Berkshire Hathaway for a while now. 

Back in 2009, Berkshire Hathaway vice chairman Charlie Munger sent Gawande a $20,000 check for an article he'd written in The New Yorker examining the healthcare differences between two Texas neighborhoods, because of its significant social impact. The article put Gawande on the map, and he ultimately donated the check to the Brigham and Women's Hospital.

Here's what to know about Gawande, and what his appointment means for the direction the health venture may take. 

Gawande's resume

Gawande boasts an impressive resume. The son of two Indian surgeons, he grew up in Athens, Ohio. Gawande went on to complete his undergraduate degree at Stanford University in 1987. He then earned his masters in philosophy from Oxford University in 1989, his MD from Harvard Medical School in 1995 and his MPH from Harvard School of Public Health in 1999.

Gawande also took a bit of time scoping out the political arena. He was President Bill Clinton's healthcare and social policy adviser in 1992. Even today, he's very vocal politically on Twitter.

Nowadays, he's got a lot on his plate. A general and endocrine surgeon at Brigham and Women's Hospital, Gawande is also the director of Ariadne Labs, chair of healthcare NGO Lifebox, and a professor of surgery at Harvard Medical School and at Harvard's school of public health.  

He's also a prolific writer on the side. He has won in addition to his MacArthur Fellowship, two National Magazine Awards. He's been a staff writer for the New Yorker since 1998 and contributes to the Notes of a Surgeon Column for the New England Journal of Medicine. 

Gawande has done extensive research into improving surgical errors and comments frequently on the state of healthcare and his thoughts into new developments in the field.

With Ariadne Labs and Lifebox, Gawande has dipped his toes into innovation in health systems. Ariadne is a joint center between Brigham and Harvard dedicated to creating health solutions for critical moments in people's lives including childbirth, surgery and serious illness care. Their work includes BetterBirth, which focuses on research to help increase facility-based care for mothers during childbirth, and a checklist to help doctors decrease errors during surgery. Lifebox is a non-profit organization focused on making surgery safer worldwide. 

What the choice means for the direction the health venture takes

Though there have been few details about what the new healthcare venture might look like, its direction may start to take shape now that there's a CEO at the helm.

Gawande has long been an advocate for making the system smarter and more efficient. In an interview with Vox in 2016 about his book, "The Checklist Manifesto," Gawande said that "in surgery, more than half of the deaths and major complications that occurred were from failure to deliver on existing knowledge on how to do better." He also said that the healthcare system is "incredibly wasteful and disorganized."

Gawande attributes a lot of accountability to actors within the healthcare system, such as the doctor's role in contributing to the opioid crisis. He's a believer in the contribution of small acts in bettering the quality of the entire system, and is openly critical about the GOP's new health bill. 

SEE ALSO: Amazon, JPMorgan, and Berkshire Hathaway have picked the CEO to run their joint health venture

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• Employers — who pay for the healthcare of more than half of the non-elderly population in the US — are feeling the effects of high healthcare costs. 
• On Wednesday, JPMorgan, Amazon, and Berkshire Hathaway tapped Dr. Atul Gawande to lead the joint venture the three employers set up to confront those high costs.  
• Over the last year, some of these companies have started taking a more active role in their employees' healthcare plans, with one CEO who runs an on-site clinic calling them "activist employers."
  
• Instead of waiting around for costs to come down, employers are proactively testing out new technology and putting more pressure on other parts of the healthcare industry by negotiating better deals.

Healthcare's expensive. On a whole, the US spends $3 trillion on healthcare, twice as much as other developed nations, and has worse outcomes, with healthcare spending approaching 18% of the GDP. 

And for many Americans, their employers are the ones picking up the tab. More than half of the non-elderly population is covered by an employer-sponsored plan, and almost 80% of large companies are self-insured. As healthcare costs go up, employers are the ones feeling the pressure. And some are starting to get fed up.

Scott Shreeve, the CEO of Crossover Health, a startup that runs on-site or near-site health clinics for companies including Apple, Facebook, and LinkedIn, has a name for these employers.

While Shreeve been working with employers for almost 10 years, it's only been in the last year that he's seen employers become more proactive and vocal about trying to lower costs. He calls this group "activist employers." 

"They are waking up to the fact that they are the payers," Shreeve said. " These self-insured, gigantic companies are paying a lot of money and they're not getting the value."

Stepping up and speaking out

If you're an employee with a self-insured employer, it means that when you're an employee going to a doctor's appointment, your employer is ultimately footing the bill for the MRI you receive, for example, rather than a health insurer.

Insurance companies are there in the middle to handle the logistics of getting the claim from one place to another, so you might not realize your employer's footing the entire bill on the other end. It also means that employers don't always have the most direct influence on how much they spend, since they're not the ones setting up the hospital networks or negotiating the prices. 

"We always say that employers pay the bills for so much of healthcare in the US, and yet their purchasing power historically has not been equal to the size of their spend and what should be their influence in the space," Renya Spak, a partner at health benefits firm Mercer and head of the company's Healthcare Innovation Center told Business Insider. Mercer helps consult employers on how to set up and manage their health plans. While employers are the ones spending on health insurance, they haven't traditionally been able to exert that influence to score themselves better deals when purchasing that healthcare.

Already, some employers have taken action to change that dynamic. The city of Rockford, Illinois sued a drugmaker after realizing it was spending almost $500,000 on one drug. Others have formed coalitions to take on high prices using collective bargaining power.

In January, JPMorgan, Amazon and Berkshire Hathaway announced their plans to form a new independent venture aimed at lowering healthcare costs for their employees, though it remains to be seen how that shapes up. The fact that they're the ones paying for healthcare hasn't been lost on them. On Wednesday, the trio tapped surgeon and professor Dr. Atul Gawande to be CEO of the new venture, which will be based in Boston. 

"I tell people, JP Morgan Chase already buys a $1.5 billion of medical, and we self-insure," JPMorgan CEO Jamie Dimon told Business Insider in February. "Think of this, we're already the insurance company, we're already making these decisions, and we simply want do a better job."

Others are asking for the full rebates to the list prices of drugs that they're paying for. Rebates, which drugmakers pay out more than $100 billion of, is a big business for pharmacy benefit managers like Express Scripts, CVS Caremark and Optum RX. The rebates create a discount to the price drugmakers set for a particular medication. Typically, these rebates pass through the PBMs, who get a cut, and then back to the organization that paid for the drug, either the health plan or the employer. 

Mark Merritt, CEO of the Pharmaceutical Care Management Association, the lobbying group that represents PBMs, told Business Insider that about half of the clients — the employers and health plans — the PBMs work with want 100% of the rebates passed directly to them, instead of just receiving a cut. That sentiment has been growing over the last five years, Merritt's said. 

Waiting for its Uber moment 

Curbing healthcare spending isn't as simple a tacking on one program or testing out an interesting technology and calling it a day. But employers seem receptive to giving new things a try. 

"The self-insured employers are so ready for innovation now," Glen Tullman, CEO of Livongo told Business Insider. Livongo manages chronic diseases like diabetes and hypertension, working with employers as well as health plans. "They weren't always that way, but now they've gotten ready, because no one has been able to stem this increasing cost of healthcare."

While big companies may have managed other areas of their business, healthcare has evaded their control. "It's the last part of their supply chain that they haven't really managed," Shreeve said.  

Michael Rea, the CEO of Rx Savings Solutions, which works with consumers and employers paying for healthcare to help them understand their drug prices, has noticed a change in the reactions he's gotten from employers over the past few years. 

Rea said he expects the number of members covered by Rx Savings Solutions to grow in 2018 from 2.5 million to 10 million. The growth, he says, has more to do with the unrest in the market than it does his particular company. "It's less about us, it's that people are looking for something and they're starting to make decisions," he said.  

One thing's for sure: waiting around for another part of the healthcare industry to create a solution isn't an option. 

"Healthcare's waiting for its 'Uber' moment and employers have realized that they can't sit on the sidelines," Spak said. "They need to drive and shape the direction of that change in order to have greater influence and better business results."

SEE ALSO: A small but growing movement of doctors that don't accept insurance and charge a monthly fee could be a model for big employers like Amazon and JPMorgan

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• Cigna is taking a new approach to combat the opioid crisis by focusing in on communities with higher than average overdose rates. 
• The health insurer is partnering with health care providers, pharmacists and community organizations to educate, intervene and support its customers. 
• Cigna is also working with employers to develop a more comprehensive coverage plan for its customers. 

Cigna is taking a new approach to combat the opioid epidemic.

Its goal: decrease opioid overdoses by 25% by 2021 in communities around the US that have higher-than average overdose rates.

While the health insurer has taken steps earlier this year to address the epidemic by announcing a 25% reduction in prescription opioids used by its commercial customer, Cigna decided it wasn't enough.  

"We realized that there was still a lot left to do," Douglas Nemecek, chief medical officer of Cigna told Business Insider. 

Cigna's initial program will focus on areas in Connecticut, Maryland, New Jersey and Virginia and in the metropolitan areas of Chicago, New York, Philadelphia and Washington, D.C. but will expand to other communities over time. 

Cigna's commitment will include providing assistance with medical supplies and professional help to communities. Over the next three years, Cigna will partner with employers, customers, prescribing clinicians, pharmacists and community-based organizations to educate, intervene and support its customers who use prescription opioids. These include providing medication-assisted treatment, comprehensive pain management and enhanced support and counseling, and making naloxone available for overdose treatment, according to the company. 

Cigna will also continue to reinforce safe prescribing guidelines, and encourage more communication between care providers, community pharmacists and patients.

The insurer will also work with employers to help them implement health plans that include coverage for prevention and addiction treatments. 

According to Nemecek, Cigna continuously assesses all new treatments and medications that come into the market for pain to see how it can make them available to customers. It also encourages physicians to talk with patients about all other options outside of opioids for pain. 

Additionally, Cigna is delving into prevention by using data analytics to identify at-risk customers to develop intervention strategies.

There were more than 42,000 deaths attributed to opioids in 2016, and 40% of all opioid overdose deaths involve prescription opioids.

"At this point, we are the first to take this bold step to decrease overdoses in the markets," Nemecek said. "The opioid crisis is just one example that impacts too many customers, too many communities, too many families, and we want to make sure we're doing all we can to help them."

SEE ALSO: One of America’s largest health insurers has cut its opioid prescriptions by 25%

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• The CEO of the Bezos-Buffett-Dimon healthcare company, Atul Gawande, said the relationship he developed with Buffett's right hand man, Charlie Munger, after he published his New Yorker piece, "The Cost Conundrum," had paved the way for his selection.
• Gawande told STAT that he was first approached for his advice in January, but did not know when the conversation evolved into a job offer. 
• He is not giving up his positions at Harvard or Brigham and Women’s or his work as a surgeon, and plans to continue writing, although he says the healthcare venture will now become his "number one priority."
• His first decision: coming up with a name that’s less of a mouthful than the Amazon-Berkshire-JPMorgan health venture.
• Watch his full interview at the Aspen Ideas Festival Spotlight Health here.

ASPEN, Colo. — It’s hard to imagine having to endure a more exacting executive search committee than the triad of corporate chieftains atop Amazon, JPMorgan Chase, and Berkshire Hathaway.

But Dr. Atul Gawande’s selection last week by Jeff Bezos, Jamie Dimon, and Warren Buffett to run a venture with the extraordinary yet seemingly futile goal of disrupting the health care industry didn’t stem from any longstanding relationship he had with any of them. Its genesis was an article he wrote for the New Yorker nine years ago.

“That opened the door,” Gawande told STAT, providing the first explanation of how his selection came about.

Gawande, 52, the celebrated surgeon, author, and journalist, said the closest he had come to knowing Amazon’s Bezos was a fleeting hello at a TED Talk. “But I had really never met Jeff Bezos. And I didn’t know Jamie Dimon in the least.” He did catch the eye of Berkshire Hathaway’s Buffett years ago, or, rather, Buffett’s longtime right-hand man, Charlie Munger, also a businessman and entrepreneur.

In a brief interview at the Aspen Ideas Festival Spotlight Health program — in which he also said the new job would have to be his top priority —  Gawande said he had known Munger ever since he wrote a much acclaimed article in 2009 for the New Yorker, “The Cost Conundrum.”

The piece examined why health care was vastly more expensive in some parts of the U.S. than others, despite little difference in the quality of health care and the sickness of people getting it. The piece was reported from McAllen, Texas, then the most expensive health care market in the country.

“Charlie Munger I’ve known since he told me he loved, he liked, the article I wrote,” Gawande said. He then recalled the story, well-publicized at the time, of how Munger thought the article was so socially important that he blindly mailed Gawande a $20,000 check.

Gawande, a surgeon at Brigham and Women’s Hospital in Boston, said at first he sent the money back: “He sent it back to me again and said, ‘Do with it what you want.’ And so I put it into our research fund.”

Though Gawande said the Munger relationship had paved the way for his selection as CEO of the new health care company, he went on to say of Buffett, Dimon, and Bezos, “I think each of them heard about me in different ways.”

Buffett spoke publicly about Gawande long before they met. In a CNBC interview in 2010, Buffett praised the “The Cost Conundrum,” saying, “That fellow whose written on health care recently in the New Yorker — Gawande — he had an article last summer that was absolutely magnificent.”

In some ways, the McAllen article could be seen as laying out some of the challenges the new enterprise will face as it seeks to reduce health care costs. In announcing the venture in January, Dimon said, “Our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

Gawande told STAT that he was first approached for his advice in January. He said he did not know when the dialogue evolved from his offering his thoughts to being a prospect for the job.

“I started talking with them,” he said, “but they ended up talking to over 100 people for advice, so I don’t think I exactly know.”

Gawande has offered scant details about the yet-to-be-named organization (he jokingly referred to it as AJB after its corporate owners), though he said it is meant to come up with ways to reduce health care costs for the companies’ employees, as well solutions that could be applied across the entire country.

He said the intermediary who first contacted him was Todd Combs, an investment manager at Berkshire Hathaway in Omaha who was the emissary who quietly put the three billionaires together in the first place. Combs was said to have so impressed Dimon that he was named to the board of JPMorgan Chase.

No matter how efficient Gawande is with his time, his CEO role will test even his ability to multitask. Asked how much time he would devote to it when he officially begins July 9, Gawande said, “It’ll have to be 100 percent.”

But he is not giving up his positions at Harvard or Brigham and Women’s or his work as a surgeon, and plans to continue writing. He said he will transition from being executive director to chairman of Ariadne Labs in Boston, which works on solving problems in health systems around the world.

“I still have my patients and surgery booked through the summer and have my work,” he said.

Asked if most of his time will be spent in the new role, he said, “This is going to become the number one priority.”

If it were possible for Gawande to be even more of a celebrity in the worlds of health and medicine, the announcement last week has inevitably made him more in demand. He was crowded by well-wishers at appearances here Saturday and Sunday, with some thrusting his books at him for autographs.

Several leaders in health and medicine said in interviews here that while Gawande’s mission is daunting, they thought he was a prudent choice.

“He’s excited. He’s nervous. And he’s also incredibly humble,” said Seth Berkley, CEO of Gavi, the Vaccine Alliance, who met privately with Gawande in Aspen this weekend. “He’s incredibly smart and he has a great shot at being able to do this.”

Berkley said Gawande will, of course, be under great pressure from Dimon, Bezos, and Buffett. “Some of these leaders he’s working with don’t have a reputation for patience, and he knows that. He understands the risks given the oversized personalities.”

Rip Ballou, vice president and head of GSK Global Vaccines, said he was impressed after hearing Gawande speak here, saying, “He left me feeling that there are actual people thinking how do we get out of this quagmire.”

Ballou said that the billionaires who will be Gawande’s new bosses reminded him of when he worked for Bill Gates. “People who have achieved the kind of success these people have achieved — it’s not by accident,” he said. “I would expect them not to leave him to his own devices. I wouldn’t be surprised if those three bosses become very well-educated” in health care and put forward their own ideas.”

“I was very encouraged to hear that all three of his bosses said, ‘You have time — you don’t have to figure it out by next year,'” Ballou added.

Indeed, during a panel here Saturday, when he was questioned by PBS journalist Judy Woodruff, Gawande took care not to overpromise — and repeatedly noted that he hadn’t started yet. He said he understood the daunting challenge of taking on health care intermediaries such as insurers and pharmacy benefit managers.

“It is amazing to me that I would get to partner with people like Jeff Bezos, Warren Buffett, and Jamie Dimon — amazing people who have committed themselves to the long term,” he told the crowd. “But the largest concept here is that I get to have a million patients that I as a doctor get to add to my responsibility, and my job for them is to figure out ways that we’re going to drive better outcomes, better satisfaction with care, and better cost efficiency with new models that can be incubated for all. That is a tall fricking order. But what they’re saying to me is that resources won’t be the problem. Human behavior will be. And achieving scale will be.”

Gawande emphasized the nonprofit nature of the organization and made clear that he does not see himself under the thumb of Amazon, JPMorgan Chase, or Berkshire Hathaway bureaucracies — something people who know him said was important to establish before he accepted the job.

“Number 1: It is an independent entity; it is not part of those companies. Number 2: It is nonprofit; there are no dollars that go back to those companies. That’s really important.”

Asked about the range of employees at the companies, Gawande said, “This is ordinary America. They are across the entire country. So I get to have and have to worry about and learn about the life and needs of — what’s the largest employment group at Amazon? Fulfillment center workers, most of them people who probably are only there a year or so.

“So these are people who have very unstable health care … and how do you solve problems for that range of people?”

Berkshire Hathaway includes many old-line companies, he noted, “often union, Midwestern, Southern — it’s Burlington Northern Railways, with union railway workers, it is Acme Brick, it is Dairy Queen. They make stuff. And then you get to JPMorgan Chase, where their largest employment group are bank tellers.”

Sounding much like a politician, Gawande told people here that he intends to embark on a “listening tour.” His first decision: coming up with a name that’s less of a mouthful than the Amazon-Berkshire-JPMorgan health venture.

SEE ALSO: Meet the surgeon, professor, and writer tapped to run the Amazon-JPMorgan-Berkshire Hathaway health venture

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• With the opioid crisis in full force and doctors feeling pressure to cut back on the number of opioid painkillers they prescribe, chronic-pain patients aren't left with many alternatives that are as effective or accessible.
• So the pharmaceutical industry is looking to bring more non-opioid pain medications into market, with 17 drugs in late-stage clinical development and 40 drugs in early-stage development.
• One of the new types of drugs is used to block the nerve-growth factor, which can reduce pain in patients with osteoarthritis, chronic back pain, and cancer pain. The two newsworthy drugs in this category are tanezumab and fasinumab.
• Centrexion, a capsaicin-derived drug, has also received buzz for its pain-reducing properties.

Debbie Page, 66, has suffered from chronic pain for half of her life after a back injury left her with the inability to stand for more than a few minutes at a time.

"After an hour I can't think or see," she said. "The pain takes over and it's torture."

Page, a part-time occupational therapist in Boston, said oxycodone saved her life.

"I was at a point where I was seriously considering suicide or moving to Mexico. In trying everything, the only thing that ever has worked is opioids — ever," she said. "They're just magic."

For many patients like Page, opioids are the only way they're able to manage chronic pain and lead full lives. Traditional nonaddictive medicine such as a class of drugs known as nonaspirin nonsteroidal anti-inflammatory drugs, or NSAIDs, does not work for everyone.

But with the opioid crisis in full force, doctors are feeling pressure to cut back on the number of opioid painkillers they prescribe, even among patients using them responsibly. This means the more than 100 million Americans suffering from chronic pain aren't left with many options that are as effective or accessible.

For patients looking for alternatives to opioids, it can be hard to get them paid for by insurance companies. Treatments such as radio-frequency ablation, which uses radio-frequency waves to disrupts the ability of nerves to send pain, steroid injections and nerve-blockers, which are locally injected temporary anesthetics, are often labeled as "experimental" and "investigational" by insurance companies, effectively making them ineligible for reimbursement, despite being heavily recommended by many pain specialists.

So even when new technology, such as neuromodulation shows effectiveness, it can still be difficult for patients to get access to it. An increasing number of lawmakers are opening up to the concept of using marijuana as an opioid alternative, especially as a new study published in the Journal of the American Medical Association found that states with medical marijuana laws had lower opioid-associated deaths.

At the same time, drug companies and doctors alike are on the hunt for new ways to tackle the complexities of managing chronic pain. Some of the new approaches look to lifestyle fixes and cognitive therapies, while others look toward more medical-related interventions such as surgery and alternative medications.

'No doctor will take me'

There were more than 42,000 deaths in the US attributed to opioids in 2016, and 40% of all opioid-overdose deaths involved prescription opioids, according to the Centers for Disease Control and Prevention.

State lawmakers and some health systems, in turn, are putting measures in place to cap the number of opioid prescriptions that doctors dole out.

As a result, the number of opioid prescriptions nationally fell 22% between 2013 and 2017, according to a recent study from the IQVIA Institute for Human Data Science.

Page said she was already feeling the effects.

"I'm concerned every month ... no doctor will take me," she said. "I've had to travel three hours one day to fill my prescription. Everyone's out."

The problem is opioids are hard to beat when it comes to initial pricing, convenience, and immediate effectiveness.

Margaret Fitzpatrick, 52, was doing acupuncture daily to manage her chronic pain but had to cut back because the treatment wasn't covered by her insurance company after she exceeded 13 visits a year.

"Not having access to good therapists or acupuncture or massage is really frustrating especially with the opioid crisis and doctors not prescribing them when alternatives aren't covered by insurance," she said. Fitzpatrick was a teacher for many years, but had to stop working two years ago because of her pain.

"For those of us who are disabled, we don't have a lot of income, and you're taking away the alternatives that would work," she said.

For the most part, opioids work to reduce pain for a large number of people with different types of pain conditions, and there are usually minimal side effects if the patient has no history of substance-use disorder, said Cindy Steinberg, national director of policy and advocacy at the US Pain Foundation.

Opioids work by impersonating chemicals in the brain called endorphins, which act like messengers between nerve cells. The endorphin molecules bind to corresponding receptors on cells that exist in both the brain's pleasure center, and also on nerve cells that reside within the body's pain network.

These mock endorphins are far more potent than the natural ones produced by the body, so as they do their magic, they can elicit a wash of intense euphoria along with pain relief. But the body does become tolerant to this, and with every hit it needs more the next time to achieve the same response. Stopping entirely makes the body sick from withdrawal.

"Withdrawal is extremely painful," Page said. "I have to take the pill. The torture that people have to go through when they're suddenly reduced or kicked off is inhumane."

Finding alternatives

Dr. Janet Pearl, who runs a pain center outside Boston, described the pain she treats as a spectrum. Some types of anti-seizure medications and a class of antidepressants are effective at managing pain, while regenerative medicine is also an exciting area to tap into. For some patients, the body's wear and tear and genetics can make pain worse. For others, cognitive behavioral therapy works wonders. Patients need to be evaluated on a case-by-case basis, Pearl said.

Julie Morgenlender, a 39-year-old personal-finance consultant who's struggled with chronic pain for 20 years, has tried myriad treatments, including acupuncture, naturopathic medicine, and disease-modifying drugs like Plaquenil. She also suffers from autoimmune thyroid disease, for which she takes a drug called Nature-Throid.

"I have pain from each of these different things, and each one is just one piece of the puzzle," she said.

According to a Bio Industry Analysis published in February, pain accounts for a greater amount of direct US healthcare costs compared to diseases like cancer, diabetes, or cardiovascular dysfunction. Four times as many Americans suffer from chronic pain than diabetes.

Yet pain conditions are on the tail end of receiving venture funding. There are 11 unique types of drugs in the US approved for pain outside of opioids, easily eclipsed when compared to the 93 unique types of cancer drugs in 2017.

Pharma companies are just starting to invest more in drugs targeting chronic pain. There are 17 pain drugs in late-stage development to treat forms of chronic pain, as well as about 40 drugs in earlier human clinical trials.

The types of formulas used to create pain medications needs to be expanded, and there needs to be wider discussion and increased legislation to provide access to these medications, said Neel Mehta, medical director of pain medicine at Weill Cornell.

“This is changing, but there was a time where if you wanted to use an alternative treatment, you had to establish failure of an opioids, purely because of cost," Mehta said.

One of the main approaches researchers are looking into is a class of drugs that work with nerve growth factor. NGF is important in developing babies' nervous systems, and they evolve to play a huge part in how adults feel pain.

"It stimulates peripheral nerves, and thereby you end up with a barrage of pain signals from the skin or muscles up through the body up through spinal cord into the brain where it’s interpreted as pain," Ken Verburg, a senior vice president for development at Pfizer, told Business Insider. He's leading the development of tanezumab, one of the NGF inhibitors. Tanezumab blocks the effect of nerve-growth factor and lessens the sensation of pain.

The Canadian Agency for Drug and Technology in Health in February listed the approach as one of the emerging non-opioid drugs for management of chronic noncancer pain. It's one of the two major NGF-binding drugs that have surfaced in the pharmaceutical world.

• Pfizer and Lilly, tanezumab: In 2017, the FDA fast-tracked the drug, which was altered to a lowered dosage during its late-stage studies and was used to treat osteoarthritis, chronic low-back pain, and cancer pain.
• Regeneron and Teva, fasinumab: A rival drug to tanezumab, it was halted during its phase 2b trial in 2016. In May, the company ditched the higher dosage of the drug. It also targets low-back pain and osteoarthritis.

NGF blockers haven't always had a storied past. Fulranumab, an anti-NGF pain drug, was returned by Johnson & Johnson to Amgen in 2016 after a late-stage clinical trial because of safety concerns and has since been discontinued.

There's also a group of capsaicin-derived drugs that target the caspacin receptor (TRPV1) in the body to inactivate local pain fibers that transmit signals to other neurons. Capsaicin is a chemical extract from peppers. Repeated exposure to it cause substance P, a protein that transmits pain signals, to be used up, which reduces pain.

• Centrexion, CNTX-4975: In a phase 2 study, the drug kicked in within a few days and lasted about six months. “What our product does is it quiets down just the ends of pain fibers like giving a haircut,” Kerrie Brady, chief business officer of Centrexion, told Business Insider in January. “And that stops the connection and stops the pain signaling going forward.”
• Acorda Therapeutics, capsaicin 8% patch: It was approved by the FDA in 2009 to manage neuropathic pain. The patch is undergoing a late-stage trial with osteoarthritis patients.

Of the drugs in development, there are a couple of promising new candidates like Angiotensin II signaling that has a role in pathways of peripheral neuropathic pain, and EMA401, an old antagonist being repurposed by Novartis to treat neuropathic pain from diabetes.

Cornell's Mehta says that while these new drugs are promising, more needs to be more done about educating pain patients.

“Patients are open to it, but there are patients out there who are more apprehensive about it. We need to be cognizant of that. We need to do a good job of counseling, to be understanding of patient concerns, and encourage trials of other medications," he said. "We also need to understand with the new therapies coming in who is best suited for that."

Although Steinberg is waiting until all the clinical trials are done and the drugs formally enter the market, she holds out hope for the future of drug innovation in treating pain.

"If a drug can be as effective as opioids without the risk of addiction for those with substance-use disorder," she said, "it is worth the investment."

Lydia Ramsey contributed reporting.

SEE ALSO: 'We're treated like drug addicts': As US fights opioid addiction, the healthcare system is failing people who live with chronic pain

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• AstraZeneca's drug, Lynparza, helped women with ovarian cancer live longer without worsening their disease.
• Deutsche Bank analysts said this could represent around a $1 billion incremental sales opportunity for the drug, on top of its existing approved second- and third-line use, while Jefferies put it at $1.6 billion.
• The drug is far ahead of any competition, with its closest competitor being Tesaro, expected to report results next year.

LONDON (Reuters) - AstraZeneca's oncology business received a boost on Wednesday as results of a clinical trial showed its drug Lynparza helped women with ovarian cancer live longer without their disease worsening when given as a first-line treatment.

The result should pave the way for expanded use of the medicine, which is being developed and marketed with Merck & Co under a deal struck last year.

Lynparza is already approved for later use in patients with so-called BRCA genetic mutations. Its success in first-line therapy could expand the number of women with newly diagnosed ovarian cancer who are suitable for the drug by 30-50 percent, AstraZeneca believes.

Lynparza - abandoned at one stage by AstraZeneca but revived by CEO Pascal Soriot when he took over in 2012 - became the first drug in a class known as PARP inhibitors to reach the market when it won U.S. approval at the end of 2014.

It now faces competition from rival products made by Tesaro and Clovis Oncology.

Based on the strong results seen in the latest Phase III study, known as SOLO-1, AstraZeneca and Merck said they would talk to regulators about approving the earlier use of the medicine in women with BRCA mutations, which can drive tumor growth.

"It is the first time that we see a significant and clinically impactful improvement in progression-free survival in the first-line maintenance setting for women with BRCA-mutated ovarian cancer treated with a PARP inhibitor," said Sean Bohen, chief medical officer at AstraZeneca.

Deutsche Bank analysts said this could represent around a $1 billion incremental sales opportunity for the drug, on top of its existing approved second- and third-line use, while Jefferies put it at $1.6 billion.

A spokeswoman said AstraZeneca viewed competitors as 18 months behind in generating similar clinical data. The closest rival is Tesaro, which is expected to report first-line ovarian cancer results next year.

(Reporting by Ben Hirschler, editing by Louise Heavens)

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• Amazon on Thursday announced plans to buy the online pharmacy PillPack, marking its latest push into the healthcare industry.
• The announcement reverberated through the pharmacy supply chain, with the stocks of pharmacies and drug wholesalers getting hit hard.
• This is just the most recent example of Amazon's ability to disrupt an industry with a single action.

Amazon on Thursday announced it had signed an agreement to acquire PillPack, an online pharmacy.

PillPack's business is built around customers who take multiple daily prescriptions. It offers medications in presorted dose packaging, coordinates refills, and handles shipments.

The $1 billion cash deal marks Amazon's latest push into the healthcare industry. In January, the company announced a collaboration with JPMorgan and Berkshire Hathaway meant to reduce healthcare costs for US workers.

"PillPack's visionary team has a combination of deep pharmacy experience and a focus on technology," Jeff Wilke, Amazon's CEO of worldwide consumer, said in a release. "PillPack is meaningfully improving its customers' lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier."

Pharmacy stocks in the US market dropped on the deal announcement, most notably those of CVS (-8.1%), Rite Aid (-3.1%), and Walgreens Boots Alliance (-9.2%).

The damage also spread through the pharmacy supply chain, with drug wholesalers seeing deep losses. Shares of Cardinal Health, AmerisourceBergen, McKesson, and Express Scripts all dropped more than 3% on the news.

Amazon's ability to rock an industry

Pharmacy shareholders will perhaps find solace in the fact that they're not the only industry to have billions in market value erased by a single Amazon announcement. The trend has been playing out repeatedly over the past year, with grocery stores, athletic-apparel retailers, and package-delivery services among the afflicted groups.

The reasoning is simple: Amazon has a ton of cash and an unparalleled logistical network, and when it looks poised to enter or expand its position in a market, traders get scared and bail out of holdings in competing companies.

And if Amazon's torrid stock performance in recent months is any indication, the company's shareholders love the deal activity, among other fundamental drivers. The firm's shares have spiked 435% since the beginning of 2015, more than 14 times the return for the benchmark S&P 500 over the same period.

Getting one up on Walmart

Amazon's acquisition of PillPack is sure to rankle the business-development team at Walmart, which was reportedly looking at buying the pharmacy startup in early April.

As Business Insider's Lydia Ramsey has pointed out in the past, the two rivals are locked in a battle to reach the elderly market, which by 2050 is expected to double from where it was in 2012.

An aging population means we'll see an increase in health concerns and chronic conditions like heart disease, neurodegenerative diseases, and cancer that can be costly to manage. It also offers a business opportunity for those companies best placed to meet the healthcare needs of this growing population.

Based on Thursday's news, Amazon appears to have the leg up, at least for now. Stay tuned for the latest twists and turns as the nation's largest corporations battle for healthcare supremacy.

Now tell us what you think!

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• PillPack, a digital pharmacy startup founded in 2013, is being acquired by Amazon.
• PillPack simplifies the process of managing medications for customers who take five or more prescriptions daily by pre-sorting, packaging, labeling and delivering the medications at the start of every month. 
• The service delivers to anywhere in the US except Hawaii and Puerto Rico, and they also work with Medicare plans. 

TJ Parker had worked in and around pharmacies his whole life.

He grew up in a family that owned and operated a pharmacy, then ended up going to pharmacy school himself. Living in the Boston area, he met co-founder, Elliot Cohen, while running hackathons to find solutions for healthcare problems at MIT. It was there that they first stumbled upon the idea for digital pharmacy PillPack, and by the beginning of 2013, the startup had hit the ground running. 

"When I started PillPack there was almost no startup activity in pharmacy," Parker said in an interview in early June. "Now there's a ton of activity and that's super exciting, it's a $400 billion market domestically, and I think there should be a number of different solutions for different types of customers."

On Thursday, Amazon announced its plans to acquire PillPack for an undisclosed amount. 

Pharmacy stocks in the US market dropped on the deal announcement, most notably CVS (-8.1%), Rite Aid (-3.1%), and Walgreens Boots Alliance (-9.2%).

PillPack simplifies the process of managing medications for customers who take five or more prescriptions daily. It sorts and packages the medication then delivers them to the door of the customer. Prior to PillPack, these customers would need to go to the pharmacy three or four times a month. 

Customers can keep track of their medications further on the PillPack mobile app, where they can also get reminder texts and chat with a pharmacist. 

PillPack has a physical pharmacy located in Manchester, New Hampshire, and they mail all their medications to anywhere in the US except Hawaii and Puerto Rico. The company also works with Medicare plans. 

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• Walgreens Boot Alliance shares surged in premarket trading after the company released strong quarterly earnings and authorized $10 billion in buybacks.
• Those gains were quickly erased, and the company dropped more than 10%, after Amazon announced it was buying a pharmacy startup called PillPack.
• Watch Walgreens Boot Alliance trade in real time here.

Thursday started off with a bang for Walgreens shareholders.

When the company reported quarterly earnings at 7 a.m. ET, investors apparently liked what they saw, and the stock rallied as much as 1.5%. They were most likely enticed by the $10 billion buyback authorized by Walgreens, as well as by a reported jump in prescription sales.

The good times in the premarket lasted less than 90 minutes, however, thanks to Amazon's latest foray into a new industry. When the Jeff Bezos-led juggernaut announced it would buy PillPack, an online pharmacy, Walgreens shares dropped immediately. They're now trading about 10% lower on the day.

Investors in Walgreens weren't alone. The damage was felt all along the pharmacy supply chain, with the likes of CVS, Rite Aid, Cardinal Health, AmerisourceBergen, McKesson, and Express Scripts all dropping on the news.

On a broader basis, the pharmacy space is just the latest area to feel the disruptive force of Amazon. Industries as varied as grocery stores and athletic-apparel retailers and package-delivery services have also seen billions in market value erased in the past year by single Amazon announcements.

If Walgreens' stock is to recover, the company will have to contend with Amazon's vision for healthcare, which is increasingly coming into focus. Once the deal closes, Amazon could start selling prescription drugs directly through its site, delivering them via mail and skipping retail pharmacies.

That's bad news for Walgreens.

After Thursday's losses, Walgreens is trading 18% lower for the year.

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• Amazon's $1 billion acquisition of pharmacy startup PillPack is the most recent in a long list of instances where Amazon has taken huge bites out of entire industries.
• Nearly $15 billion of market value was wiped out from Walgreens Boots Alliance, CVS, and Rite Aid, an outsized impact relative to the deal price.

When Amazon announced plans to buy pharmacy startup PillPack, the reckoning across the entire industry's supply chain was swift and brutal.

Drug wholesalers like Cardinal Health, AmerisourceBergen and Express Scripts experienced deep losses. Meanwhile, Walmart — another mega-cap retail with designs on entering healthcare — also saw shares fall.

But no area of the market felt the pain worse than pharmacies themselves. Losses in Walgreens Boots Alliance, CVS, and Rite Aid exceeded 10% at their worst, with nearly $15 billion of market value wiped out.

What transpired was the most recent in a long list of instances where Amazon has taken huge bites out of entire industries. And what's notable about this particular case is the outsized degree of the market cap erased, relative to the price Amazon paid for PillPack.

If Amazon can carve a $15 billion chunk out of just three companies with a $1 billion deal, just think of the damage it could inflict once it starts throwing around more money. After all, the Jeff Bezos-led juggernaut had $25 billion of cash on its balance sheet at the end of the first quarter — and it could amass more if it ever decides to spend less on corporate reinvestment.

In a conference call with analysts on Thursday, Walgreens CEO Stefano Pessina seemed nonplussed about the damage coursing through his company's stock, saying he's "not particularly worried" about the one-day move.

"The pharmacy world is much more complex than just delivering certain pills or packages," said Pessina. "I strongly believe that the role of the physical pharmacy will continue to be very, very important in the future."

It wouldn't be unprecedented for a stock in one of Amazon's target markets to recover. For evidence of that, look no further than Kroger, which found itself at the center of a previous Amazon-driven industry scare.

Kroger dropped as much as 19% in a single day in June 2017 after Amazon announced a $13.7 billion acquisition of Whole Foods, and then experienced a fresh bout of weakness two months later after price cuts were announced. The stock has since rallied as much as 30%, climbing back near the levels seen before Amazon's mega-deal.

So while Amazon's influence isn't necessarily a deathknell for a stock, it's undoubtedly a short-term inconvenience, at the very least. Stay tuned for the next round, which could very well catch a whole new industry off-guard.

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• China has warned citizens traveling to the US of "frequent" shootings, expensive medical care, and the risks associated with running into border patrol agents. 
• The Chinese Embassy in Washington issued a notice warning travelers that "shootings, robberies, and theft are frequent," and urged citizens to remain calm and hold onto evidence if they feel they are being discriminated against by border agents. 
• Last year the US saw a drop in foreign tourism, which at the time was dubbed the "Trump Slump."

The Chinese Embassy in Washington issued a notice on Saturday telling its citizens to take caution when traveling to the US over summer. 

"First, the United States medical expenses are expensive," the notice said, encouraging its citizens to organize health cover in advance of travel. 

The notice also warned that "US law and order is not good, and shootings, robberies, and theft are frequent."Gun violence is a leading cause of death in the US.

"You should be on alert to suspicious people around you and avoid going out alone at night," the notice also said. 

China has issued warnings against the high rate of gun violence in the US in the past.

In 2017, the Chinese consulate in Los Angeles published a guide for citizens on how to respond to an active-shooter situation. And in April, the Chinese Foreign Ministry issued an advisory on popular messaging platform WeChat urging citizens to "be careful and prepare for the possibility that gun crimes may occur at workplaces, schools, at home and at tourist sites," the New York Times reported. 

The embassy notice issued on Saturday also discussed US border policy, and notified tourists that border patrol have the right to inspect travelers and to check their nationality and purpose of entry without a search warrant. But it also advised citizens to be vigilant.

"If the parties involved believe that the law enforcement officers have engaged in improper law enforcement or discriminatory practices, please keep the relevant evidence and ask to make a complaint to their superiors in person," it said. "Sparking controversy with on-site law enforcement personnel is not helpful for resolving the obstruction of entry, and may even lead to a deterioration of the situation."

The US has come under international scrutiny over the Trump administration's tightened border security measures, including its "zero-tolerance" policy, which has seen more than 2,300 migrant families separated. Several videos have also surfaced this year showing border agents patrolling bus stations and asking travelers for identification.

Last year, the US saw a drop in foreign tourism, which some dubbed the "Trump Slump." According to Travel + Leisure, the US welcomed 72.9 million foreign visitors in 2017, down from the previous year's 75.9 million, though the decline was only about 4%.

Under the Obama administration, the US saw record high numbers in 2015 with 77.5 million foreign visitors, Travel + Leisure added. 

In 2016, nearly 3 million Chinese tourists visited the US and spent $33 billion, more than tourists from any other country.

SEE ALSO: The US evacuated 9 diplomats from China after they experienced strange auditory sensations

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• On June 5, American vlogger Alyne Tamirposted a video about how she saved money on healthcare by having medical procedures abroad.
• Every year, millions of Americans leave the country in order to save money on exorbitant medications and surgeries — a phenomenon called "medical tourism."
• Many Americans have saved thousands of dollars by getting dental work, undergoing surgeries, picking up prescription medication, and even giving birth in other countries.
• According to American healthcare providers, there are a myriad of factors that are responsible for driving up the cost of healthcare in the US.
• Most Americans who travel for medical procedures claim that, despite the low cost of health services in other countries, the quality is comparable — or even superior — to that of the US.

The American healthcare system is known for being notoriously expensive. It doesn't help that, according to data collected in 2017 by the Gallup-Healthways Well-Being Index, 11.3% of Americans are not able to afford health insurance.

Even those who do have health insurance often find themselves struggling to pay sky-high medical fees. For example, a Reddit user went viral in 2013 when he posted a photo of the hospital bill he received when he was treated for appendicitis. The total charges came to over $55,000, and even with health insurance, he had to pay over $11,000 out of pocket. 

This story is nothing new. Compared to the rest of the world, people in the US pay much higher prices for medical services such as hospitalization, doctors' visits, and prescription medication.

In June, American vlogger Alyne Tamir posted a video about how she saves money on healthcare by having medical procedures abroad.

An American vlogger born in Santa Monica, California, who has been traveling full-time for over two years, Tamir has been documenting her experiences abroad through a blog and Facebook show, Dear Alyne.

On June 5, she posted a video about how "a simple toothache" opened her eyes to a "whole new world." In the video, Tamir explained it would have cost $1,500 to fix her tooth in the US. Instead, she had her root canal done in Egypt. 

"A nice hotel in Egypt costs around $70 a night," she told INSIDER. "And the actual root canal was only $120. This was at a fancy dentist too; you can definitely get it for way cheaper somewhere else in Egypt."

Tamir said that the Egyptian dentist did an "amazing job" fixing her tooth. She told us that when she got her teeth checked again in Australia, the dentist there commented that the Egyptian dentist had done a particularly fine job.

Every year, hundreds of thousands of Americans travel abroad in order to receive medical procedures at a much lower cost — a phenomenon called "medical tourism."

According to a 2015 report by the US International Trade Commission (USITC), between 150,000 and 320,000 Americans travel abroad every year to receive healthcare.

Given the high cost of healthcare in the US, Americans cite savings as the most common reason to travel abroad for health treatment. For Americans without health insurance, the difference in cost can be staggering. The USITC study claimed that, while uninsured Americans can expect to pay $30,000 for a knee replacement in the US, they could get the same surgery for $12,000 in India.

And even for Americans who are insured, most health insurance policies do not cover everything. According to America's Health Insurance Plans (AHIP), most medical insurance plans do not cover dental work, cosmetic surgeries, and many prescription medications. Even giving birth in an American hospital can be prohibitively expensive. As a result, many Americans would need to pay hundreds or thousands of dollars out of pocket to receive these medical services.

Some Americans accidentally discover that medical services abroad are much more affordable when they sustain an injury or illness on vacation.

Patrice Raplee, a Seattle-based travel photojournalist and editor, was on vacation in Florence a few years ago when she said she bit down hard on a nut embedded in her roll. She said it split her tooth right down the center and caused her to bleed profusely from her mouth.

Raplee said she went to a hospital in Florence to get an emergency medical procedure. She told INSIDER that the doctors spent a few hours administering painkiller and repairing the tooth. At the end of the procedure, she said she asked if her health insurance would be able to cover the cost of everything.

"I remember thinking, 'Oh my god, how much is this going to cost me?'" Raplee said.

However, the emergency medical procedure, which Raplee estimated would have cost at least $1,000 in the US, ended up costing her 15 euros — the equivalent of $17.43. And the anti-inflammatory medication that she picked up later at the pharmacy cost her three euros, or $3.49. In total, Raplee spent around $20.92 for the entire medical treatment she received.

Melissa Wright claimed she had a similar experience after being mugged and hospitalized in Spain. After spending eight hours in the emergency room and getting treated by six different specialists, she said she received a bill for 108 euros, or $125. According to Wright, when she previously visited the emergency room in the US for a kidney infection, she was charged over $4,000 after she spent two hours in the hospital and had a five-minute consultation with a doctor.

Many Americans take advantage of the lower costs of healthcare abroad to save money on cosmetic surgeries and dental work that are not covered by their health insurance in the US.

Since dental work and cosmetic surgery is not usually covered by most health insurance plans in the US, many Americans find that they are able to save thousands of dollars by traveling abroad for these costly procedures.

According to Physicians for a National Health Program, an estimated 108 million Americans have no dental insurance simply because most insurance companies do not offer dental coverage for adults. And dental work is not cheap in the US. According to Authority Dental, basic dental exams can cost between $50 and $200, X-rays can cost anywhere from $25 to $250, and cleanings can go from $75 up to $200.

As a result, many Americans simply do not visit the dentist at all. According to a Gallup poll conducted in 2014, about one-third of Americans did not visit a dentist even once in the past year.

But dental work can be much less expensive abroad. Nina Ragusa, the author of travel blog Where in the World is Nina? who has been traveling full-time since 2011, told INSIDER that she received a dental exam, X-ray, and cleaning from a dentist in Bangkok for $50. When she traveled to Mexico, she did the same thing for $25, and also got a night guard — which typically costs around $300 to $500 in the US — for $25 while she was there.

Cosmetic surgery, which isn't covered by most American health insurance, can also be very costly. In the US, for example, the average cost of LASIK eye surgery is $2,088 per eye. Ragusa, however, told INSIDER that she received LASIK in South Korea and paid a total of $1,400 — including all of the check-ups before and after the surgery, the surgery itself on both eyes, the medicine, and all future care for life. 

Travel writer and editor Olivia Balsinger told us she had a similar experience when she got veneers in Colombia for a fraction of the cost she would have paid in the US. For eight veneers and three crowns — a procedure that would have cost around $15,000 in the US — she paid $4,000.

"The best part was that after the procedure, I wasn't going to wallow in pain in my New York City apartment," Balsinger said. "Instead, I was on the beaches of Cartagena."

Some Americans, especially those with chronic illnesses, need to travel abroad in order to access medical treatment that they simply would not be able to afford in the US.

Sarah May Grunwald is an American citizen living with severe Crohn's disease, a chronic illness that necessitates frequent hospitalization, surgeries, and medication. However, she said she had trouble receiving adequate healthcare in the US. She told INSIDER that her medical bills from the US have landed her deep in debt. And her monthly medication, which costs about $500 a month, is simply "impossible to afford."

Now that she is living in Italy, Grunwald said she is finding it easier to maintain her health. She said that she pays about five euros, roughly $5.79, every month for her medication. And the medical procedures that used to cost her thousands of dollars in the US, she said, now cost "so little" that she cannot even recall the exact cost. She estimated that she pays "under 20 euros" for every hospital visit. 

Even colonoscopies at private hospitals abroad are cheaper, according to Grunwald. She said that they cost her 400 euros, the equivalent of $463, in Italy; at her old doctor in the US, Grunwald claims the exact same procedure would cost around $3,200.

American freelance writer Rease Kirchner told INSIDER that she went on vacation in Colombia to access the medication she needed to treat her chronic dry eye. Although she had health insurance coverage, the prescription for Restasis eye drops would have cost her $500 per month in the US. Since she needed at least a year's worth of Restasis, it would have cost her $3,000 in total. After doing some research online, she said she found that the same medication was available in Colombia for $50. Kirchner said she flew to Colombia, spent 10 days exploring four different cities, purchased a year's supply of Restatis, and still spent less than $3,000.

And some Americans have even opted to give birth abroad to save money.

The Guardian reported in January that the US is the most expensive nation in the world to give birth. A 2013 study from Childbirth Connection found that American hospitals charge an average of $32,093 for an uncomplicated vaginal birth and newborn care, and $51,125 for a standard Cesarean section and newborn care. And while health insurance does typically cover most of these costs, American families are still left to pay thousands of dollars out of their own pockets.

It's no wonder, then, that some Americans choose to give birth in other countries.

Amanda Ponzio Mouttaki, an American blogger and expat living in Morocco, told INSIDER that she had her baby three weeks ago through Caesarean section. Mouttaki said that even though she did not have health insurance, she had to pay $1,100 for the delivery, doctor, a private room in the hospital for two nights, and medication. In total, including the cost of all the prenatal appointments, blood tests, and ultrasounds, she said she spent around $2,000.

Mouttaki said that her sister gave birth in the US, also via Ceasarean, and had a $100,000 hospital bill.

The cost of giving birth also appears to be lower in some parts of China. Charlotte Zhang, an American citizen living in China, said that she had no insurance coverage when she gave birth to two babies in a public hospital in Renqiu, a small city in China's Hebei province. Each time, she said, cost her less than $200.

According to American healthcare providers, there are a myriad of reasons why healthcare in the US is so expensive compared to other countries.

America's Health Insurance Plans (AHIP), a national organization that advocates for the health insurance community, described in a recent brief that health insurance premiums are likely to rise in 2019. A major factor that drives up the cost of health insurance, according to AHIP, is the price of prescription drugs — a whopping 95% of specialty drugs cost more than $10,000 per patient per year. 

Amanda Guarniere, a nurse practitioner who graduated from the Yale School of Nursing, told INSIDER that another reason why the cost of healthcare is so high in the US is because there is very little competition in the healthcare market in the US. 

"If you are eligible for an employer-sponsored plan, you are likely going to choose that plan over one in the marketplace," Guarniere said. "There's not much of a choice, if any, in terms of what your plan offers."

Guarniere said that American physicians tend to have a higher salary expectation compared to those in other countries. She acknowledged that this is "partly cultural." However, she said that part of it also stems from the fact that American healthcare providers are expected to "pay an obscene amount of money" to receive their education. A higher salary, she said, is often necessary in order to pay off student loans.

However, according to Dr. Mary Jane Minkin, an OB-GYN at Yale New Haven Hospital, most physicians don't earn high enough salaries to explain the incredibly high cost of healthcare. "Physicians aren't making a lot of money these days," she told INSIDER. "Who the heck knows where all the money is going?"

Minkin said that another factor that is driving up the cost of healthcare in the US is malpractice insurance. She said that, unlike other countries where medical malpractice cases are judged by panels of experts, in the US these cases are often reviewed by juries comprised of laypeople who don't necessarily have a medical background.

As a result, American doctors face a real financial risk from patients' lawsuits. And even if they do end up winning the case, doctors still need to spend money on hiring lawyers to defend themselves in court.

According to Minkin, this fear of getting sued leads doctors to adopt other cost-driving practices. Unwilling to take the chance that something goes wrong and the patient decides to sue them, doctors will often perform unnecessary  Caesarean sections and order many expensive tests for their patients, she said.

"All of these things translate into higher cost of care," Minkin said. "You have to embed these costs into health insurance, and this forces patients to pay higher premiums."

The main problem, according to some healthcare providers, is that healthcare is a profit-oriented system in the US. Some believe that the way to improve healthcare in the US is by transitioning to a single-payer system. According to Physicians for a National Health Program, single-payer national health insurance would be funded by public taxpayer money and would provide full medical coverage for all residents of the US.

"It's not a panacea," Minkin told us. "But it would get around a lot of the issues with health insurance that people deal with."

Although healthcare providers told INSIDER that they understand why patients would be tempted to pursue medical tourism, many said that there are risks associated with it.

"I understand why people do it from a financial standpoint," Dr. Hillary Brenner, a podiatrist in New York, told INSIDER. "But what if something goes awry?

Brenner raised several concerns. "How clean are these instruments?" she said. "Here, they run tests about sterilization. And how are doctors in those countries trained, as opposed to our training here? I'd be petrified."

Minkin also questioned the safety of the blood supply at hospitals abroad. "Many surgical procedures need a transfusion," she said. "The blood supply they are using might be good, but the thing is, we don't know for sure."

According to Brenner, the risk seems to exceed the benefit. 

"You go there to save a buck," Brenner said. "But if an instrument is wrong, or not sterilized properly, then that might end up costing you more money in the long run. It's better to get it taken care of properly the first time around."

Guarniere told us that medical tourism could be a wise option, especially for patients seeking elective-type medical care such as joint replacements and cosmetic surgeries. "That being said, I would want to make sure that the facilities had appropriate patient care and safety standards," she said. 

Most of the Americans INSIDER spoke to, who have traveled abroad for medical reasons, said the quality of healthcare in other countries was excellent — though some reported having a less favorable experience.

Raplee said she was initially "rather fearful" when she walked into the hospital in Florence, and she was worried that she would receive substandard care. But she said she was pleasantly surprised to find that the hospital had modern facilities and the doctor had been trained in the US.

Despite charging her 15 euros for the emergency operation, she said the Italian doctor fixed her broken tooth so well that "the repair lasted for years." According to Raplee, her doctor in the US called it "brilliant" and said he couldn't believe it cost so little.

For Grunwald, one of the major differences between American and Italian healthcare in her experience was not only the drastic difference in affordability, but also the level of care.

"In America, doctors are much more inclined to not listen to women in pain," she said. She said that before she was diagnosed with Crohn's disease, her doctor suggested that she was depressed and hysterical — even though she claimed to be experiencing bloody bowel movements.

"In Italy, I have never been patronized as a woman," Grunwald told us. "They take my illness seriously and treat me with respect."

People have reported good experiences in other countries as well. Mouttaki said that her experience giving birth in Morocco was "top notch," despite costing a fraction of what she would have paid in the US. "I would say that the quality of care I received in Morocco was equal to or surpassed what I got in the US for my previous children," she said.

American freelance journalist Kira Zalan said that her experience seeing an endocrinologist and an orthopedist in Bangkok was also positive. "The customer service, efficiency, and cost were beyond anything I'd experienced in the US," she said. And she said she paid around $65 to $80 per visit. 

Zhang, however, said she had a less favorable experience giving birth in a Chinese hospital. She described the experience as "very cold and sterile," and she had difficulty communicating with the doctors. Her Chinese-speaking husband, who was not allowed inside the room, had to resort to "yelling his translations" at the door.

Despite these challenges, Zhang decided to give birth to her second child in China. For her, the low cost outweighed the inconveniences and discomfort.

Many of these Americans said that they intend on traveling abroad to receive affordable and high-quality medical care in the future.

Gigi Griffis, an American writer who has been traveling full-time for the past six years, told INSIDER that she has used healthcare services all over Europe and does not intend on returning to the US anytime soon.

Griffis cited expensive healthcare costs as one of the main reasons why she does not plan on living in the US. "I would never ever choose to have a procedure done in the US," Griffis said. "Paying five or more times as much for the same or worse care? No thanks."

Even Americans who do have health insurance said they find that it's less expensive to access medical care abroad. Wright said that she refuses to use her health insurance in the US. "I can barely afford the co-pays and it only covers 70% of the cost of most visits," she said. She intends to move to Germany, where she said the healthcare is just as good and much less expensive. 

Grunwald has no intention of returning to the US either. "Americans will say it is more expensive here because of malpractice insurance, but that's not true," she said. "It's because in most parts of the world, healthcare is a basic human right."

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• Regeneron's CEO, Leonard Schleifer, once criticized arbitrary drug price increases by pharmaceutical companies.
• But in July, the company's eczema drug price increased by 3%.
• Regeneron said Sanofi had final decision-making authority on pricing for the drug. 
• Sanofi defended the price increase, saying it is below the rate of medical inflation and will be the only price change this year. 
• The increase comes a few weeks after the Trump administration debuted its drug-pricing plan and President Donald Trump said he expected to see "massive" price cuts taken by drugmakers. 

Regeneron CEO Leonard Schleifer once stated in a heated debate between pharmaceutical executives that he was not a fan of price hikes on prescription drugs. 

"You can’t say you’ve set a drug at a fair price [when it’s launched] and then have price increases. You can’t have it both ways. It’s covering up for a lack of innovation," Schleifer said during the panel in December 2016. 

But at the start of July, the price Dupixent, an eczema drug made by Regeneron and Sanofi increased by 3%. The drug now has a list price of $37,000 a year compared to when it was first cleared at $30,000 a year. 

In a statement, Regeneron reaffirmed its position, pointing to Sanofi for the decision to increase the price:

"Regeneron is committed to pricing our innovative medicines responsibly and to working with all stakeholders to ensure access and affordability for patients. Sanofi has final decision-making authority on pricing matters for Dupixent and has increased the US wholesale acquisition cost (WAC) by 3%, which is lower than medical inflation. Please contact Sanofi for comment."

Sanofi said the decision to increase the price of Dupixent was within the bounds of the pricing policy it set, in which it commited to not raising the price above the rate of medical inflation. 

"This is the first increase for Dupixent since launching last March, and is the only planned increased for 2018," Sanofi said in an emailed statement. 

Regeneron's not the only pharmaceutical company that increased their drug prices as of July 1. The Financial Times reported on Monday that the average price increases at Pfizer for Viagara and another 100 products were around 9%. 

These come after President Donald Trump's announcement in May of a plan to lower drug prices in the US. These include proposed changes in things like pricing negotiations with Medicare Part D plans and rebates for patients. So far, there hasn't been much activity in this area aside from a couple of officials speaking out against drug pricing.

But Trump has said that he expects drugmakers to lower prices to their drugs. 

"I think we’re going to have some of the big drug companies in in two weeks, and they’re going to announce because of what we did, they’re going to announce voluntary massive drops in prices," Trump said during a bill signing at the end of May. 

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• The US delegation to the World Health Assembly shocked the world when it refused to agree that breast milk is the best possible meal for newborn babies, ignoring decades of research.
• Scientific studies have shown that breast milk is the healthiest thing new mothers can feed their growing babies, with very few exceptions.
• The World Health Organization and the American Academy of Pediatrics recommend that mothers feed their children breast milk exclusively for the first six months of life, unless they are HIV-positive or active drug users. 
• But formula makers have long sought to downplay the health benefits of breast milk.

The US shocked the world earlier this year when the country's delegation to the World Health Organization's World Health Assembly refused to go along with language that champions a mother's breast milk as the best possible meal for a newborn. 

According to The New York Times, the US delegation even threatened to withdraw military aid to countries that didn't back down from the resolution.

President Trump took to Twitter on Monday to support the US' position.

"The U.S. strongly supports breastfeeding but we don’t believe women should be denied access to formula," Trump's tweet read. "Many women need this option because of malnutrition and poverty."

The resolution wouldn't have denied anyone access to formula — it was simply a public-health recommendation. In his tweet, however, President Trump touted the same argument that many formula companies recited in the 1970s and early 80s to market their drinks to women around the world. 

The claims are so egregiously false and dangerous that in 1981, the WHO developed an international marketing code to keep formula companies in check. The rules mandated that formula containers state "the superiority of breastfeeding" clearly on their packaging.

Today, doctors and researchers agree that the benefits of breast milk are unequivocal.

"The public-health evidence that supports that is pretty irrefutable," Dr. Joan Younger Meek, chair of the American Academy of Pediatrics Section on Breastfeeding, told Business Insider.

There are very few exceptions to the rule that breast is best. While formula can be a convenient option when a mother's milk isn't available, no infant formula could ever fully replace all the nutritional benefits of breast feeding. 

"Breast milk is really a living substance," Meek said. "It has whole cells. It's not something that you can pour out of a can."

Yet the Trump administration's stance embraces the interests of formula manufacturers, according to the Times' report. And dangerous formula marketing practices still persist in many places around the world today.

Here's the established science on how breast milk boosts a newborn's health:

• The American Academy of Pediatrics encourages breastfeeding exclusively for an infants' first six months of life. Yet only an estimated 22% of women in the US do this, according to CDC surveys. Researchers estimate that if 90% of Americans breastfed their babies exclusively for the first six months of life, more than 900 lives and $13 billion would be saved every year. 
• Breastfeeding rates are lower among people with lower incomes. While low-income moms breastfeed at a rate of around 67.5%, roughly 84.6% of mothers who make more money (and are not eligible for food stamps) breastfeed. "One of the major purchasers of infant formula is the US government, because it's used and distributed thru the WIC program [food stamps]," Meek explained.
• The very first milk a mother gives her child after he or she is born is called Colostrum. This milk is like a super-fuel elixir for babies. Colostrum is high in antibodies and infection-fighting immunoglobulins, which enter the baby's intestinal tract and make their way into the infant's bloodstream. The milk protects the baby from diseases, reduces his or her risk of infection, and protects against diarrhoeal diseases.  
• A mother's breast milk produces targeted antibodies if she's exposed to an infection, so babies who drink their mothers' milk are essentially lapping up preventive care that can keep them from getting sick. "There's really no way you can replace that, in terms of putting those health [benefits], those whole cells, and those immune factors into a can of formula," Meek said.
• Infants who are fed breast milk are less likely to develop all kinds of severe illnesses. These include respiratory tract infections, pneumonia, and serious colds. Babies who get breast milk are also less prone to ear, throat and gastrointestinal infections, including the potentially deadly necrotizing enterocolitis that can destroy the walls of an infant's intestines. When they do get sick, breastfed children's illnesses are less severe — bronchitis cases in breastfed infants, for example, are 74% less severe. 
• Babies fed breast milk are less likely to develop asthma or long-term skin problems like eczema. 
• Breastfeeding also helps protect against obesity and diabetes. In one study that compared more than 400 sibling pairs, the body-mass indexes of babies who were breastfed were .39 standard deviations lower than their bottle-fed brothers and sisters, on average. That amounts to a predicted 13-pound weight gain for a 14-year-old kid raised on formula. 
• Breastfed kids are less likely to develop childhood cancers such as leukemia and lymphoma.
• There's no evidence that breastfeeding might malnourish a child. In fact, the opposite is true. "Malnutrition in developing countries occurs more frequently in children that are formula fed than in children that are exclusively breastfed," Meek said. "Even if mother doesn't have adequate calories herself, she will still produce good quality breast milk for her baby."
• Breastfeeding mothers don't have to worry about sickening their babies in places without clean drinking water. Formula and bottles, on the other hand, could be contaminated by water from dirty drinking sources. According to a 2018 report from Save the Children, 823,000 child deaths around the world could be avoided every year in low- and middle-income countries alone if mothers opted for breast milk. Another problem with bottle-feeding babies in the developing world is that some moms who can't afford to buy enough formula dilute the concentration of powder to save money, making the mix much less nutrient-rich.
• Breastfeeding isn't just good for babies — it also helps mothers stay healthy. Breastfeeding reduces postpartum recovery issues like dangerous hemorrhaging, while also providing some long-term protection against breast cancer and ovarian cancer.

There are few cases where breastfeeding is not recommended, however: 

• Women who are HIV-positive can transmit their infection to their children through breastfeeding, so they're generally advised to avoid breastfeeding. However, even mothers who are HIV-positive may feed their children breast milk with a relatively low risk of transmission if they've been on anti-retroviral drugs for their entire pregnancy and feeding period.
• The HIV-relative human T-lymphotropic viruses can also can be transmitted in breast milk, so women with HTLV shouldn't breastfeed (though the disease is not common in the US).
• A rare genetic disease called galactosemia makes an infant unable to metabolize galactose, one of the milk sugars in breast milk. These babies need to be fed a special lactose-free formula.
• Women with untreated tuberculosis should not breastfeed directly until their condition has been treated, since the baby has to stay a safe breathing distance away. But they can pump their milk and have it fed to the baby. 
• Women with active herpes lesions on their breast should not breastfeed, and should not feed their baby breast milk from the infected breast. But if a woman has a herpes outbreak on one breast, it's ok to feed the child from the other nipple. 
• Finally, moms who are actively using illicit drugs (like cocaine, heroin, or meth) shouldn't breastfeed. Mothers with a history of drug use who are not currently using, however, can feed their babies breast milk safely. 

Meek said that with these rare exceptions in mind, most mothers should be feeding their babies breast milk exclusively for the first six months of life, then start introducing other foods as desired and continue to breast feed for one to two years.

That's also the recommendation from the World Health Organization, and it's what the American Academy of Pediatrics says, too. Both base their recommendations on decades of scientific studies. 

"It would certainly be nice if our policies were supportive of what we know from our scientific and evidence base, in terms of what's best for public health," Meek said. 

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• A new study published in Nature Medicine found that a drug used to treat high blood pressure could help patients with type 1 diabetes stabilize blood sugar levels. 
• Verapamil, a calcium channel blocker, was found to slow the loss of insulin producing beta cells in patients with type 1 diabetes. 
• Taken in conjunction with insulin, patients reduce risk of over overcorrecting blood sugar levels and require less insulin overall. 

Finger pricks and daily insulin injections are currently the leading regimen for those with type 1 diabetes, a condition in which the body's insulin producing cells beta cells are destroyed. And it's not foolproof. 

Patients can often face risks over overcorrecting their blood sugar levels, which can potentially lead to hypoglycemia — low blood sugar — and coma. 

Insulin is responsible for regulating the amount of sugar in the blood, and dysfunctions with it can cause diabetes. There are two types of diabetes, type 2 diabetes, in which the body becomes insulin resistant and can't effectively use it, and type 1 diabetes, in which the immune system destroys large portions of the beta cells responsible for making insulin in the pancreas. In 2015, the Centers for Disease Control and Prevention reported that over 30 million people in the US had diagnosed diabetes, and about 5% of them had type 1 diabetes. 

Scientists sought to remedy this by repurposing an old drug to do new tricks. A new study published in Nature Medicine found that verapamil, a drug used to treat high blood pressure, could also be effective at stabilizing blood sugar levels in patients with type 1 diabetes by improving beta cells survival and function.

Dr. Anath Shalev, an author of the study and a professor of Endocrinology, Diabetes & Metabolism at the University of Alabama-Birmingham, said they found previously that an elevation of a key protein called TXNIP in response to increased calcium ion flow into beta cells was a key factor that was present in both type 1 and type 2 diabetes. Verapamil, which blocks calcium channel activity, was also shown to reduce TXNIP levels, stopping the loss of beta cells in patients with type 1 diabetes.

"This is the first indication that we have of something in hand now that acts very differently from any currently available diabetes treatment, and allows us to improve the patient's own insulin producing beta cell function," said Shalev. "This is the only one that targets this process because so far, most of the treatments are designed to replace the insulin or really squeeze the cells to secrete insulin."

A clinical trial conducted in 24 adult patients who had developed type 1 diabetes in the past three months showed that if verapamil was taken alongside insulin, patients required less insulin daily, had fewer episodes of hypoglycemia, and maintained good blood sugar control. Verapamil has been on the market for over 30 years, and according to Shalev, it's been very well tolerated and has little to no side effects.

Shalev said that since the drug will be used off label, meaning that it will have to be used to treat conditions others than it's intended for, doctors and patients with type 1 will have to discuss whether it makes sense for them to include the new drug into their treatment plans. Shalev said that although verapamil is only FDA approved for lowering blood pressure, it is inexpensive and widely available to the public. According to goodRx, a 30 capsule of 240mg pills will cost around $26. Verapamil should still be used with insulin, but it will require less insulin. 

There has been past studies showing that the drug might improve conditions of patients with type 2 diabetes as well, Shalev said. Moving forward, Shalev and her team want to expand the study to include more patients, especially younger children. 

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• President Donald Trump nominated Brett Kavanaugh to replace Justice Anthony Kennedy on the Supreme Court.
• Experts and politicians are questioning how Kavanaugh could rule on cases involving Obamacare.
• Some conservatives say Kavanaugh will not go far enough to dismantle Obamacare, citing a dissent from 2011, while other conservatives believe the judge would rule against the law.
• Democrats and liberals are almost all fearful of Kavanaugh's possible rulings on Obamacare.

President Donald Trump's nomination of Brett Kavanaugh to replace Justice Anthony Kennedy on the Supreme Court has legal scholars and politicians carefully parsing the judge's previous decisions for clues about the future of US policy.

One of the biggest issues on which Kavanaugh is expected to have a say is the future of the Affordable Care Act, or Obamacare. The landmark healthcare law has been the subject of a series of intense legal battles, and many observers expect more decisions on the ACA's future to make it to the Supreme Court during Kavanaugh's tenure.

Given Kavanaugh's conservative bent, many Democrats are up in arms about the future of Obamacare should the judge be confirmed. But conservatives are also concerned about the future of the law under Kavanaugh.

Conservative concerns

The crux of the conservative disagreement over Kavanaugh's Obamacare record comes from a single decision in 2011.

When ruling on Seven-Sky v. Holder, Kavanaugh dissented from the majority opinion that the law's individual mandate — which compelled every American to have health insurance or face a fine — was constitutional.

According to conservative healthcare expert Chris Jacobs and other conservative writers, the reason behind Kavanaugh's dissent opened the door to solidifying the ACA's legal footing.

"Even as he avoided a definitive ruling on the merits of the case, Kavanaugh revealed himself as favorably disposed to the mandate," Jacobs wrote at The Federalist. "Worst of all, in so doing, he cultivated a theory that ultimately led Chief Justice John Roberts to uphold the mandate."

In essence, Kavanaugh argued that he could not rule on the case because the Anti-Injunction Act of 1867 did not allow judges to rule on the legality of a tax before it was imposed. Since the mandate did not kick in until 2014, he wrote, the court could not render an opinion.

Jacobs wrote that Kavanaugh's use of the century-and-a-half-old law validated the Obama administration's argument before the Supreme Court that the mandate was legal since it was a tax. 

Combined with other sections of the dissent, Jacobs said Kavanaugh gave the "road map" for the Obama administration's legality argument and Roberts's decision.

But other conservatives reject Jacobs's suggestion that Kavanaugh's dissent presented a legal basis to uphold the ACA by pointing to other sections of his argument.

In the dissent, Kavanaugh said the mandate was "a law that is unprecedented on the federal level in American history" and called the penalty for people not buying insurance "jarring."

Justin Walker, a law professor at Louisville University and a former clerk for both Kavanaugh and Kennedy, wrote that the dissent was ultimately more an argument against the mandate than in favor.

"Kavanaugh’s thorough and principled takedown of the mandate was indeed a roadmap for the Supreme Court — the Supreme Court dissenters, justices Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito, who explained that the mandate violated the Constitution," Walker said.

Liberals worry Kavanaugh puts 'healthcare protections in jeopardy'

While conservatives debated the semantics of Kavanaugh's decision, Democrats and liberal activists were overwhelmingly alarmed by the nomination.

"Judge Kavanaugh should not be allowed anywhere near our nation’s highest bench," a post on the Democratic Party's official blog said. "Let’s be clear: a vote for Kavanaugh would be a vote to rip health care from American families and deny women their constitutional right to make their own health care decisions."

Democrats and pro-ACA activists are worried Kavanaugh could weaken key tenants of the ACA, given new legal challenges to the underlying thesis of the law.

While experts are dubious the new challenges have standing, in no small part because Chief Justice John Roberts sided with the liberal members of the court in 2012 to uphold the law, Democratic senators have hinted healthcare will be a core piece of their opposition to Kavanaugh's nomination.

"He’s demonstrated a hostility to the Affordable Care Act that the Trump administration is continually working to undermine," Democratic Sen. Booker said in a statement following the nomination announcement.

Senate Minority Leader Chuck Schumer said during a press conference on the steps of the Supreme Court on Tuesday that Kavanaugh's selection would put healthcare protections in the ACA, such as protections for people with preexisting conditions, "at grave, grave risk" and said people should demand a justice to "protect our healthcare, not strike it down."

SEE ALSO: Brett Kavanaugh is the latest high-level Trump appointee to come from a single Washington, DC-area high school

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