PNHP

Will the Market Cure Our Health Care System?

Will the Market Cure Our Health Care System?

What does AI tell us about the competing theories of free-marketism and a leading government role in paying for health care? An exploration of the philosophies of Kenneth Arrow, Milton Friedman, Elon Musk, and Bernie Sanders.

CAPITALISM AND FREEDOM, by Milton Friedman, The University of Chicago Press

“The United States has continued to progress; its citizens have become better fed, better clothed, better housed, and better transported; class and social distinctions have narrowed; minority groups have become less disadvantaged; popular culture has advanced by leaps and bounds. All this has been the product of the initiative and drive of individuals co-operating through the free market. Government measures have hampered, not helped this development.”

UNCERTAINTY AND THE WELFARE ECONOMICS OF MEDICAL CARE, by Kenneth J. Arrow, The American Economic Review

“The failure of the market to insure against uncertainties has created many social institutions in which the usual assumptions of the market are to some extent contradicted. The medical profession is only one example, though in many respects an extreme one.”

Comment:

By Don McCanne, M.D.

The United States has by far the most expensive health care system in the world, and yet its performance is amongst the poorest of industrialized nations.

There is a wide difference of opinion as to what we should do about this. We have a mixture of government programs such as Medicare and Medicaid and private programs such as individually purchased and employer-sponsored private insurance. The mixture of public and private is quite complex, but obviously our high costs and poor performance confirm that we do not have a viable combination. Which way should we go?

It’s time to take an objective look at the contrasting views of two of our most noted economists – Milton Friedman and Kenneth Arrow – each the recipient of a Nobel prize in economics. Although neither totally dismissed private markets or a government role in the health system, they did definitely disagree on the degree of control that private markets should have. Friedman believed that the free market should predominate, whereas Arrow believed that in health care the laissez-faire solution is intolerable due to tne difficulty consumers have in making optimal choices, with severe consequences for errors in judgment.

We would certainly like to know their thoughts on the topic today, but since they are no longer with us, we will have to rely on an alternative source. Artificial Intelligence (AI) has made stunning advances, even with the potential for abuse. Rather than thinking of AI as a digital source of independent production of new concepts, we should consider it an accessible source of encyclopedic information to shed light on a subject as we frame it. Thus, it can be immensely helpful in providing structured summaries of complex ideas otherwise available only in long books or articles. Of course, we must note possible biases in the sources that AI relies on. In other words, we can use AI if we assess its validity based on the components we know. We then use this accessible information to advance our values, such as social justice. Such is my approach today: use AI to remind me (and us) of major contrasting economic philosophies on health insurance.

With this in mind, I submitted several questions to AI “large language models” (LLMs). This is a long post, but I think worth perusing and contemplating. I offer my interpretation at the end.

Part I

I started with a ChatGPT inquiry: “How do Milton Friedman’s concepts compare to Kenneth Arrow’s as a basis for providing health care to everyone?”

Core Philosophical Difference:

Kenneth Arrow: Health care is not a normal market because of:

  • uncertainty
  • information asymmetry
  • ethical obligations
  • social expectations of equity

Conclusion: Market forces cannot reliably or efficiently provide universal health care; public intervention is both justified and necessary.

Milton Friedman: Health care should be treated as a normal market. The main problems is U.S. health care come from:

  • government interference
  • insurance distortions
  • third-party payment
  • overregulation

Conclusion: Less government, more market choice; universal access should be achieved through individual responsibility and market-driven efficiency

What They Believe About insurance:

Arrow: Insurance is essential because illness is unpredictable. But private insurance markets fail due to:

  • adverse selection
  • moral hazard
  • risk-based pricing
  • profit motives that conflict with access

This leads naturally toward:

  • universal compulsory insurance
  • government regulation
  • single payer or NHS-like models as most coherent

Friedman: Insurance is overused and misused:

  • third-party payment drives up spending
  • employer-based insurance distorts the market
  • people should pay directly for most care
  • catastrophic insurance should be minimal and private

He opposed:

  • Medicare
  • Medicaid
  • employer tax subsidies
  • regulation of insurance markets

He favored:

  • Health Savings Accounts
  • high-deductible catastrophic coverage
  • competitive private insurance

How They Think Universal Coverage Should Be Achieved:

Arrow: Universal coverage requires:

  • compulsion (the healthy must subsidize the sick)
  • government as a primary insurer or regulator
  • community rating and standardized benefits

Single payer aligns best with his logic:

  • largest risk pool
  • lowest administrative waste
  • removal of profit-driven selection
  • protects access as a social good

Friedman:

Friedman opposed government-guaranteed universal insurance. He argued universal access could be achieved by:

  • reducing regulation
  • lowering prices through competition
  • giving individuals cash transfers or vouchers if needed

His model is:

  • universally enabled, not universally insured
  • Everyone would have access to a competitive private market, not a public guarantee

Ethics and the Role of Society:

Arrow:

Medical care is a social obligation. Society views relieving suffering as a collective moral duty. This justifies:

  • universal entitlements
  • regulated prices
  • public financing

Friedman:

Medical care is a consumer service. Equality in access is not a social right but an aspiration. The role of society is limited to:

  • charity
  • voluntary philanthropy
  • targeted subsidies

He rejected health care as a “right.”

Bottom Line:

Arrow: Health care is inherently non-market – needs universal public funding.

Friedman: Health care should be a market – government financing distorts incentives.

Part II

Next, I turned to Gemini (Google’s AI) to explore the contrasting views of a modern free-marketeer and a democratic socialist. The richest man in the world, Elon Musk, noted for his strong belief that manipulating society to bring greater personal wealth, might be expected to support markets as a method to fund health care. In contrast, a popular senator, Bernie Sanders, has been quite outspoken in support of single payer as a means of making health care accessible to absolutely everyone at a price each can afford.

Hence, my Gemini inquiry: “Contrast the outcomes of our health care system in the United States that we would see under the guidance of a person such as Elon Musk who values wealth as a determinant in our outcomes as opposed to Bernie Sanders who values social justice in our outcomes.”

Wealth-Driven Outcomes (Elon Musk-aligned Values):

Access and Equity:

Highly stratified access. Premium, personalized, and rapid care for the wealthy; basic, minimized, and technologically lean care for others.

Worsening health disparities. The poor and low-income populations would see reduced coverage for non-essential or high-cost care (e.g., long-term care, some chronic disease management).

Quality of Care:

Elite, high-tech quality for those who can pay. Focus on disruptive technology (AI diagnostics, novel therapies, bio-engineering) accessible primarily to top-tier clients.

A two-tiered system where the most advanced life-saving treatments are a luxury item, not a basic right.

Cost and Efficiency:

Driven by a push for extreme efficiency and cost-cutting in government programs (like Medicare/Medicaid) through technological solutions, aiming to eliminate “waste” and “fraud.”

Lower overall government spending but higher out-of-pocket costs for the majority. Increased financial stress for low- and middle-income families facing medical crises.

Innovation:

Rapid, commercially viable innovation focused on high-profit-margin specialities or luxury-level concierge medicine.

Research and development would be highly concentrated in areas with the clearest path to monetary returns, potentially neglecting low-profit public health issues.

Overall Health:

Increased life expectancy and health for the high-income bracket, potentially widening the gap with lower-income groups.

Poorer population-level health outcomes as preventive care and treatment for social determinants of health (housing, nutrition) are defunded or minimized.

Social Justice-Driven Outcomes (Bernie Sanders-aligned Values):

Access and Equity:

Universal access and comprehensive coverage (e.g.,dental, vision, mental health) for all residents, aiming to eliminate financial barriers to care.

Reduced health disparities across income and race/ethnicity. Poorer Americans and those in rural areas would gain access to services currently unaffordable or unavailable.

Quality of Care:

A single standard of high-quality care for everyone, from primary care to specialty treatments. Focus on preventive care and addressing social determinants of health.

Improved average health and longevity across the entire population as people seek care earlier and manage chronic conditions better.

Cost & Efficiency:

Driven by systemic cost control through federal negotiation of drug prices and standard reimbursement rates for providers, eliminating the fragmented, high-cost private insurance overhead.

Significant reduction in medical bankruptcy and overall household healthcare spending for most families. Higher taxes for wealthy individuals and corporations.

Innovation:

Innovation would be focused on what improves public health and is cost-effective for the entire system, potentially including streamlined processes and primary care improvements.

Drug and device development might be slower or focused less on blockbuster drugs and more on essential, widely accessible medicine.

Overall Health:

Decreased infant mortality, reduced rates of treatable chronic disease, and a narrower life expectancy gap between the richest and poorest citizens.

Improved national health statistics that align more closely with other developed nations that have universal healthcare systems.

Central Contrast: The Guiding Principle

The core difference lies in the guiding principle of the system:

Wealth-Driven: Individual liberty and market efficiency are paramount. The market is seen as the best allocator of resources, and health outcomes are ultimately the individual’s financial responsibility.

Social-Justice Driven: Equality and equity are paramount. Healthcare is a social responsibility and a fundamental right, and health outcomes should be decoupled from an individual’s financial status.

Back to the original question: Will the market cure our health care system?

There is no question that a well-designed single payer system would cure the problems we see, making our system comprehensive, universal (covering everyone), and affordable for each one of us. The evidence from wealthy nations definitively supports Arrow & Sanders: the best-performing systems, on efficiency and outcomes, rely on universal insurance (a single payer or mandated standardized coverage).

What about the free market? Our current system is highly dependent on the market, and, except for the wealthy, it fails on almost every measure, in spite of being by a large margin the most expensive in the world. The only logical conclusion is that we can no longer cite “the Market” as the solution to repairing our highly dysfunctional health care system. Friedman’s and Musk’s predominantly free markets don’t work well in health care.

We need to oppose solutions that are designed primarily to increase the personal wealth of those who are already wealthy, and move to solutions wherein we all take care of each other – solutions wherein we all get the care we need at a price each of us can afford. The market is not and cannot ever be crafted to accomplish that. Single payer would do precisely that.

Market enthusiasts: Silence!

Health care justice advocates: Get to work!

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Dismal Health Care Experience Across All US States

National polling of adults finds, remarkably and sadly, that all 50 states and DC get Cs and Ds for the health care experience – cost, quality, and access. Every one. The problem is pervasive, and demands a national solution.

The 10 states with the best health care, according to patients, Medical Economics, November 18, 2025, by Austin Littrell

A West Health-Gallup survey of nearly 20,000 U.S. adults finds large differences in health care affordability, access and quality across the country.

#1. Iowa

Iowa ranks first in the nation for overall health care experience, earning an overall grade of C+, with D+ for cost and C+ for both quality and access.

Iowa is among the states where fewer than 21% of residents say they skipped a recommended medical test or procedure in the past 12 months because of cost, compared to rates above 40% in  several bottom-ranked states. In addition, 12% of Iowans report that someone in their household could not afford prescription medications in the past three months, one of the lowest rates highlighted in the analysis and well below the national figure of 20%.

#51. Alaska

Alaska sits last in the national rankings at 51st, with an overall grade of C-, and receives a D for cost. C for quality and C- for access.

Alaska is grouped with other bottom-ranked states like Texas, New Mexico and Nevada that report “widespread challenges,” including higher rates of delayed or foregone care, more difficulty accessing services and lower confidence in available care.

Although national-level figures show affordability pressures rising everywhere, Alaska’s combination of weak cost and access grades within the Scorecard helps explain why it trails the rest of the country on overall health care experience.

Comment:

By Don McCanne, M.D.

West Health and Gallup have a reputation for developing reliable surveys in health care. This one, which ranks the health care systems of the fifty states and D.C., is remarkable because the first ranking state and the last one are strikingly similar in their performance grades: Cs & Ds.

It is not that the lowest ranking state ranked nearly as high as the highest one, instead the highest one ranked nearly as low as the lowest. It’s stunning. All states are bunched together with very high costs and extremely poor performance.

Many advocate for enacting health system reform state by state, just as Canada did by starting in one province (Saskatchewan). The fact is, we need comprehensive reform in all states, and prior experience demonstrated that many state governments will be unresponsive to the needs of citizenry (none will be, according to this survey).

Thus reform should be universal, including all residents in the nation, regardless of state of residence. A well-designed single payer program does precisely that. It would be simple, generous, equitable, efficient, and health enhancing – for everyone. As this West Health-Gallup survey indicates, no state should be left out. And we need to do it now.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Dr. Claudia Fegan U.S. Senate testimony

PNHP national coordinator Dr. Claudia Fegan testified before the U.S. Senate Committee on Health, Education, Labor, and Pensions on December 3, 2025. The topic of the hearing was “Making Health Care Affordable Again: Healing a Broken System.”

“The U.S. health care system does not work,” said Dr. Fegan. “It does not meet the needs of the American people.”

“An expanded Medicare for All system would solve many of our problems related to the cost of health care,” she continued. “We could have high-quality, trustworthy, universal health care that is free from profit-driven conflicts of interest and delivers better health outcomes for Americans.”

full hearing: https://help.senate.gov…

Parkinson’s disease patients and scientists alike worry about their future

The Trump administration’s cuts to biomedical funding could have big repercussions for people focused on a cure.

By Mike Fitzgerald
St. Louis Magazine, Dec. 1, 2025

Mary Eagan, 71, stares at the body-height punching bag, her delicate hands buried in a pair of giant red boxing gloves. On this warm August morning, Eagan waits along with the rest of the Rock Steady Boxing class for instructor Brent Meyer to bark the next set of commands.

“Double hooks!” Meyer shouts. “Double hooks!”

Eagan leans in, then eagerly slams both fists into the bag, over and over.

The other class members enrolled in Rock Steady Boxing—four women and five men, all north of 60, all diagnosed with Parkinson’s disease—also punch away.

Meyer orders them to stop. Breathing hard, the class members drop their arms to their sides. “We’re gonna do our power move now,” Meyer says. “Knock it down!”

Eagan and her classmates commence punching. As they thump away, the bags topple over. “All the way down,” Meyer shouts. “Then we pick it back up and knock it back down.”

The class, held in the basketball gymnasium at The Lodge in Des Peres, is winding down.  Nearly 60 minutes of boxing and agility exercises have left the class members tired but exhilarated. In a world of uncertainty and frustration, there’s just something about letting it all out by smacking a punching bag with everything you’ve got.

Eagan pulls her right arm back and drives it straight into the bag. It hits the floor with a convincing thud. A look of triumph crosses her face. “That felt good,” she says later.

Parkinson’s disease is a progressive neurological disorder that affects movement. It occurs when the nerve cells in the brain that produce dopamine, a neurotransmitter, gradually degenerate. Its symptoms: frozen facial expressions, memory loss and confusion, tremors in the hands and legs, balance problems, and difficulty walking. The disease affects about 1 million Americans, and at least 10 million people around the globe.

Eagan was diagnosed with Parkinson’s in April 2023, after noticing she was shuffling her left foot. That led her to a physician who specializes in movement disorders.

“I asked him, ‘What can I do to help my body,’” she recalls. “He said, ‘Exercise, exercise, exercise.’”

Now, three times a week on average, she travels to the gym in Des Peres to box. Intense and unrelenting, Rock Steady Boxing focuses on developing participants’ coordination and balance.

“We work on everything that Parkinson’s takes away,” her instructor, Meyer, says. “While there is no cure, we try to make it as bearable as possible.”

Participating in Rock Steady takes grit. But what also enables Eagan and other class members to take part are medicines such as Rytary, a medication that works to boost dopamine levels in the brain to help manage motor symptoms.

Rytary stands out among a growing list of medicines and treatments that have sparked optimism that one day a cure can be found for Parkinson’s.

Several of the most promising drugs, such as the inhaled levodopa drug Inbrija and the selective dopamine receptor agonist Tavapadon, which is still being tested, were developed with significant federal funding and under the auspices of the National Institutes of Health and the Parkinson’s Research Program — one of dozens Congressionally directed medical research programs “aimed at advancing paradigm shifting research,” according to its mandate.

Until the second Trump administration began in January, N.I.H. was a biomedical research behemoth, a crown jewel the rest of the world admired, producing breakthroughs patients grew to rely upon. With an annual budget in 2024 of $48.3 billion, the N.I.H. accounted for 80 percent of the world’s investment in biomedical research.

About 84 percent of that amount was awarded to non-governmental research institutions such as universities and medical schools, according to Unbreaking, a website chronicling changes to the federal government under Trump. Such robust federal research funding has paid off for American consumers: Out of 356 new drugs approved in the United States between 2010 and 2019, 354 were made possible by government funding, according to Unbreaking.

Eagan knows the difference these drugs make. ”If it weren’t for these advancements they made in medications, in treatments, I’d be sitting at home,” she says.

Scientists now know more than ever about the causes behind Parkinson’s —a combination of a person’s genetic predisposition and, in many cases, exposure to toxins in air pollution and popular herbicides used on farms and golf courses.

A study published in May in the Journal of the American Medical Association indicates that living within a mile of a golf course doubles a person’s chances of developing Parkinson’s, a correlation possibly explained by exposure to herbicides sprayed on the course that drain into drinking water. Other research has revealed the importance of healthy eating, moderate meat consumption, and intense exercise.

“I feel so much better when I’m working out,” Eagan says. “I tell myself it’s almost as if I’m in a tug-of-war with my muscles. And the more I work them, the more I maintain my strength. That is very motivating.”

Hopes for new medicines and even a possible cure for Parkinson’s disease have come crashing down in the 10 months since Trump’s return to the White House.

The Trump administration has cut or frozen thousands of research grants to universities, hospitals, and laboratories across America. For the 2026 fiscal year, the Trump White House proposes a N.I.H. budget of $27 billion—a 40 percent cut from the year before.

Those actions undermine the foundations of America’s prosperity and global leadership, says Ed Weisbart, spokesman for the Missouri chapter of Physicians for a National Health Program.

Scientific innovation and discovery “made the United States a country that everybody around the world has looked up to in one way or another,” says Weisbart, a retired family physician. “And for some reason President Trump and his cronies are determined to destroy the things that have actually made America great for generations.”

Overall, the NIH under Trump has cut or frozen 5,464 previously awarded grants worth $2.3 billion since January, with 2,860 grants reinstated, according to Grant Witness, a nonprofit tracking the termination of grants to scientific research agencies under Trump.

The administration has attacked major research centers such as Harvard University and UCLA. The White House withheld $2 billion in federal research grants from Harvard on claims the university tolerates antisemitism.  A federal judge in September ruled that the antisemitism claim was a “smokescreen” for “an ideologically motivated assault” and that the research freeze is illegal.

Despite facing no claims of antisemitism being allowed on campus, Washington University in St. Louis has been hard hit as well.  A total of 44 NIH grants were terminated or cancelled with a total of $11.7 million of remaining, unspent funds, according to university spokeswoman Julie Flory.

“Most of the terminated grants only had a year or two left and the previous years of funding had been awarded and spent,” Flory wrote in an email. Nevertheless, the university announced in early October it is cutting 316 staff positions and eliminating another 198 vacant positions.

“We’re dismantling the science that is the foundation for everything,” Weisbart says.

Eagan’s independence depends on Rytary. But though the drug is effective now, she might have to switch to another medicine to treat her symptoms as it loses its efficacy.

”I know Rytary is going to work for me for a time,” she says. “But [what happens] when it stops working in some way or other, and I call my doctor and say, ‘Now what?’”

Ellen McCloskey, who’s also part of the Rock Steady class, says classmates don’t talk much about the funding cuts. “It is what it is,” she says. “We wish he hadn’t been elected. But we live with it.”

Frank Greco, 74, was diagnosed with Parkinson’s several years ago. As a way of coping, he’s enrolled in several studies examining the effectiveness of certain medicines for the disease at BJC Hospital, conducted under the auspices of the Washington University School of Medicine.

But now, because of cuts to NIH funding, “I’m not sure they will continue studying it,” he says. “That’s my concern.”

The Center for Advanced Medicine, in the heart of the Washington University medical campus near Forest Park, is where much of the university’s NIH-funded research takes place.

CAM, as it’s called by employees, is a 14-story glass and concrete building overlooking Forest Park Parkway. On a typical weekday, it hums with physicians, nurses, visitors and patients, many in wheelchairs.

Dr. Joel Perlmutter sees patients on the sixth floor. Perlmutter is a professor of neurology at Washington University School of Medicine and a prominent specialist in Parkinson’s disease and other movement disorders. In 2020, Perlmutter received a $2.3 million grant from the National Institute of Neurological Disorders and Stroke to investigate brain changes underlying Parkinson’s and in 2024 a $3.9 million grant to study brain inflammation in Parkinson’s patients.

But since the Trump administration returned to power, Perlmutter has been frustrated by repeated delays in grant reviews, funding and management.

Part of that stems from the change in NIH policy to emphasize recruiting under-represented populations for studies to now trying to expunge all such efforts.  Dr. Perlmutter believes such recruitment is “really important scientifically and for clinical benefit and application.” Even so, he says, “I had to expunge any comment about that. Because if that was there, it could be automatically tagged by government AI, which goes back and finds these and brings that back up for potential budget cuts or elimination. That’s crazy.”

On top of that, staff cuts at NIH have left the agency overworked and slow to process grants, Perlmutter says. “That means we get delayed in being able to do our research. And it’s a real problem here at the university.”

In fiscal year 2023, the NIH funded about $253 million in Parkinson’s research, making it the largest public funder of biomedical research globally. Now the Trump administration has put a much lower cap on indirect costs, and includes, in the proposed 2026 federal budget, a 40-percent cut to the NIH, to $27 billion. What’s more, the Department of Defense saw its biomedical research funding slashed by 57 percent, erasing research dollars for Parkinson’s and other neurological conditions.

In June, MassLive published a profile of Harvard University neuroscientist Bence Ölveczky, who emigrated to the U.S. from Hungary at age of 28. Ölveczky, a leading Parkinson’s researcher, said he came to America because of its reputation for leadership in science, based on robust government funding and the tight relationship between government and research institutions.

In May, the federal government revoked most of Harvard’s research grants, dealing a direct hit to Ölveczky’s lab. “It’s made America great,” Ölveczky said of America’s scientific infrastructure. “And now we are sort of willingly giving up on that. That’s the tragic part of this.”

The cuts are having their deepest impacts on the next generation of young scientists. The funding reductions make it difficult for young scientists to find jobs to pay off student loans and perform the research vital to launching their careers in science.

Laurie H. Sanders, an associate professor in neurology and pathology at the Duke University School of Medicine, is a nationally recognized Parkinson’s disease researcher. Her lab has developed a method that can detect Parkinson’s in its early stages with a simple blood test.

Sanders called the proposed cuts in N.I.H. funding, especially as they would affect Parkinson’s Disease research “devastating,” according to the med school newsletter.

But Sanders added that her biggest concern is “not for myself. It’s for my trainees. It’s for the next generation of scientists. Looking into the face of this, how do we continue the momentum we’ve built? How do we continue our training? How do we encourage them?”

Perlmutter, the Washington University neurologist, ruefully agrees. “We’re about to lose a generation of scientists,” he says.

Erin Foster has not given up hope—despite the alarms that her fellow scientists are sounding.

“I think there is a big concern that these cuts are going to have long-term negative effects and just set us back in the progress that we’ve made, especially as it pertains to more fair, and diverse and inclusive practices,” says Foster, a Parkinson’s disease investigator at Washington University’s School of Medicine. She still believes the field can recover from the cuts.

“Not as much has happened that could happen, I guess,” she says. “So I guess it depends how far it goes. It could take a long time. It’s most definitely a setback.”

Perlmutter, the Washington University neurologist, feels less optimistic, especially since August 7, when Trump signed an executive order that gives political appointees power over billions of dollars in grants awarded by federal agencies.

Scientists contend the change will threaten “to undermine the process that has helped make the U.S. the world leader in research and development” because it allows political appointees to review federal grants so that they are “consistent with agency priorities and the national interest,” the AP reported.

Trump’s executive order is “pretty straightforward. Scientists are vilified if they disagree with the agenda of the current administration,” Perlmutter says. “The only truth is what the administration says is true.”

This story was commissioned by the River City Journalism Fund.

https://stlmag.com…

Health care in the USA: Money has become the mission

By Adam Gaffney, M.D., M.P.H.; Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.; and Danny McCormick, M.D., M.P.H.
The Lancet, Nov. 29, 2025

Summary

Despite extraordinary scientific and medical resources, the US health-care system underperforms. In this Review we consider the damage wrought by decades of market-based policies that have stimulated profit-seeking by insurers and health-care providers. Policy makers have subcontracted coverage under the public Medicaid and Medicare programmes for people with low incomes and those older than 64 years to private insurance firms—which now derive most of their revenues from those programmes—raising taxpayers’ costs and constricting patients’ care. Despite worrisome evidence of misbehaviour, firms obligated to prioritise shareholders’ interests—and, more recently, private equity firms with a single-minded focus on short-term profit—have gained control of vital clinical resources. President Biden rescinded some of Donald Trump’s most egregious first-term policies, expanded coverage for lower-income Americans, and initiated modest drug price controls. Since regaining office, President Trump has laid siege to science and public health, cut US$990 billion from Medicaid to offset tax reductions for the wealthy, and is accelerating Medicare’s privatisation. State governments can tighten regulation of profit-driven abuses, and the medical community should resist Trump’s health-harming agenda. But neither restoring the pre-Trump status quo, nor further attempts to reconcile the human rights of patients with the property claims of investors will suffice. Reforms must, instead, decommercialise insurance and care provision.

full review: https://thelancet.com…

Gratitude for Parody that Inspires Reform

The New Yorker, with its inestimable wit, published a wonderful list of absurd health insurance plans. It made me smile. But collectively they make a sadly sane point: it’s time to abandon our ludicrous health insurance mess in favor of universal publicly funded coverage.

Which of These Updated Health-Care Plans Is Right for You?, The New Yorker — Shouts & Murmurs, November 26, 2025, by Eli Grober

Thrilling news: it’s time to decide what health-care plan you’ll be opting in to for the coming year. Given the feedback we’ve received about how limited and expensive health care has become in this country, we’ve made some updates to our available offerings. Please choose from the following options.

The Basic Plan

This is our most popular plan. It covers things like breathing (allowed, no co-pay), sleeping (hint: you must pretend to sleep in order to fall asleep), and eating (you pay for your own food). No other coverage is provided. This is an ideal choice if you are immune to all diseases, and are also immortal.

The Catastrophic Plan

If the San Andreas Fault opens up, we’ll send Dwayne (The Rock) Johnson to help. Not to help you, specifically—he’ll just generally lend a hand in California. Maybe he’ll leap from one building onto another building. Very cool stuff.

The Become-a-Doctor Plan

This plan costs sixty grand a year and includes a residency at a local hospital, where you’ll learn everything you need to know in order to eventually become the primary-care physician to yourself, and everyone you know. …

The “Looney Tunes” Plan

If a piano falls on your head, or you run off a cliff, because you thought that a painting was a road, you will be tended to by a cartoon rabbit in scrubs.

The Plan Within a Plan

You have to sign up for this plan to read what the actual plan is.

(more in the article)

Comment:

By Jim Kahn, M.D., M.P.H.

This week, befitting the Thanksgiving holiday, many blogs include “Gratitude” in the title. Us too. I’m truly grateful that the New Yorker put a smile on my face with this hilarious run-down of fantastically innovative health plans … that seem almost plausible alternatives to the crazily dysfunctional insurance we actually have.

Indeed the last “plan” listed above is largely true: we don’t really know what our insurance covers until we need it. There are far too many limited networks with fictitious provider lists, over-crowded clinical practices, uncovered services, incorrectly denied prior authorizations, and huge (often unmanageable) financial obligations for beneficiaries. Ouch – too much truth.

Let’s make this kind of parody archaic, with single payer. THAT will assure an enduring smile on my face – the economist’s dream of efficiency merged with quality. Indeed, it’s everyone’s dream of health care when you need it, without financial barriers. THAT will justify a truly grateful Thanksgiving, every day of the year, for all the years in our lives.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Deepening U.S. Healthcare Crisis Demands Radical Transformation, Not Band-Aids

Interview with Dr. Diljeet Singh

Counterpoint, Nov. 26, 2025

The longest government shutdown in U.S. history came to an end on Nov. 12, when both the House and Senate voted for a continuing resolution signed by President Trump that will keep federal agencies open through Jan. 30, 2026. Eight members of the Senate Democratic Caucus broke ranks to vote for a deal that failed to win a renewal of subsidies for the Affordable Care Act, overcoming the 43-day congressional impasse. That means without further congressional action some 24 million Americans will likely see their health insurance premiums double or triple, beginning in 2026, with 5 million unable to afford health insurance coverage.

The federal budget passed by the Republican-controlled Congress and signed into law by Trump in July, cut more than $1 trillion to Medicaid and Medicare over the next decade. These largest cuts to healthcare programs in U.S. history won’t take effect until after the November 2026 midterm election.

The dramatic cutbacks in funding for health programs highlights a long running crisis that an increasing number of Americans view as a failure of our nation’s healthcare system. Between The Lines’ Scott Harris spoke with Dr. Diljeet Singh, president of Physicians for a National Health Program and a practicing gynecologic oncologist. Here she reviews the many failures of the U.S. for-profit healthcare system and her group’s advocacy for adoption of a universal, comprehensive single-payer national health insurance program.

https://btlonline.org…

Dismantling Health Insurance = Increasing Support for Real Reform

GOP cuts to ACA subsidies and Medicaid are stoking widespread fears about the affordability and dependability of health insurance. Their tentative solutions are unworkable. We can, indeed must, use the crisis to grow support for public, universal health insurance.

Republicans Will Never Find a Health Care Replacement, The American Prospect, November 18, 2025, by Ryan Cooper

Republicans, for once, are sounding downright squeamish about onrushing massive cuts to Obamacare subsidies, with premiums on the exchanges expected to more than double on average starting next year. GOP House committee chairs are reportedly having some “brainstorming sessions” about what to do, and House Speaker Mike Johnson claims that they will “be rolling out some of those ideas” at some point.

So far, the genius idea in the lead is Trump’s pitch to reroute subsidies from health insurance companies to the American people, so they can buy health care. (House Republicans have already filed a bill that looks like this.) When asked whether people wouldn’t then just use that money to buy health insurance, Trump replied, “Ahh … some may. I mean, they’ll be negotiating prices.” Congratulations, folks, you now get to be your own private dealmaker with the health care system, and with your purchasing power and risk pool of one household, I’m sure you’ll get the best price!

The stupidity is the point. For decades now, the Republican Party has been dedicated to the proposition that rich people are too highly taxed and the working and middle classes get too many benefits from the government. With the passage of the One Big Beautiful Bill, they have finally caught the car. Medicaid and Obamacare have been slashed to free up budget headroom for tax cuts heavily slanted to the wealthy. Republicans don’t have a “health care plan” per se because this is their plan: to take your health care funding and give it to Elon Musk, Donald Trump, and the rest of the fascist billionaire class. …

But it’s a much more practical problem for a Republican trying to write a health care policy. Health insurance is straightforwardly impossible to square with capitalist morality for reasons a child can understand. Most obviously, people routinely get very sick or injured through no fault of their own, and require care that is far more expensive than they can afford out of pocket. Sometimes people have chronic conditions that cost many multiples of what they could ever possibly earn. Therefore, unlike the market for car or home insurance, where each person is charged exactly what they are statistically expected to claim (plus a margin of profit), any functioning health insurance scheme must have systematic transfers from the young and healthy to the elderly and sick. …

Their replacement “ideas” consist of either shifting the [ACA premium] subsidies to people, who will then find out that they’ll have to use the money to buy health insurance. As some Freedom Caucus members recently floated, that could translate into pre-Obamacare fake insurance, which does nothing for people when care is actually needed.

Panic Tears Through U.S. as Health Insurance Costs Spike, The American Prospect, November 21, 2025, by Whitney Curry Wimbish

Open enrollment is under way for 2026 insurance coverage, and millions of Americans are facing extreme sticker shock thanks to the end of expanded Affordable Care Act subsidies, which capped Obamacare premiums for a “benchmark” insurance plan at 8.5 percent of income. Twenty-two million people relied on that funding, at a cost of about $35 billion annually.

With the expanded subsidies set to expire at the end of the year, reverting back to a less generous subsidy level last in place in 2021, patients around the country are facing premium increases that are so extreme, they’re either reducing health insurance coverage or dropping it altogether. Some are facing price hikes many multiples higher than they paid last year; those whose costs only doubled told the Prospect they considered themselves lucky by comparison.

A retiree in Colorado, Jeff Rowan, described how this year’s open enrollment is driven by a sense of fear. His 2026 premium for a health plan on the state insurance exchange went from $350 a month to around $900. So he switched to a plan offered by his pension, which is $700, still a 100 percent increase. Last year, Rowan concluded that was “an outrageous amount.” Not anymore.

At one point, Rowan seriously contemplated dropping health insurance completely, he said. “But the fear of something unexpected happening and my moderate savings being wiped out is forcing me to pay the piper. It’s a completely fear-based decision.” …

Republican lawmakers are reportedly coming up with a fix, such as giving people money directly via flexible savings accounts or health savings accounts, which they would then use to “negotiate prices” with health care companies. Fellow Prospect-er Ryan Cooper notes that this won’t work. Even Trump himself acknowledged that most people would send that money right back to insurance companies, the only entities in the economy with the leverage to negotiate with hospitals under the current system.

THE END OF ACA SUBSIDIES WITH NO PLAN IN PLACE means that people who believe they’re healthy will simply not get coverage, said Dr. Vikas Saini, president of the Lown Institute, a nonpartisan think tank focused on the health care system. The remaining population on insurance will be sicker on average, a condition that doctors and economists sometimes refer to as a worse “risk pool.” That makes it costlier for companies to insure the average policyholder. So the result of millions dropping unaffordable health insurance, as the Congressional Budget Office has forecast, will be that insurance subsequently gets more expensive.

What happens on ACA exchanges doesn’t just stay there. Because major insurance companies are the ones providing the ACA coverage, this means one way they’ll make up the loss caused by the worse risk pool is by raising premiums on their clients who get their insurance through their employer. …

Like others navigating the horror show, Sam said the cost-of-living crisis is frightening. He wonders, if Republicans are going to make health care unaffordable, will they also roll back other Democratic policies, like allowing insurance companies to deny coverage because of pre-existing conditions? Indeed, one of the options Republicans are pitching for patients without insurance is enrolling in “short-term” or “junk” insurance plans, which are not required to cover pre-existing conditions. Officials in five states have barred these products. But the Trump administration relaxed the rules governing them in August.

Comment:

By Jim Kahn, M.D., M.P.H.

Two articles in “The American Prospect” describe vividly how recent federal funding cuts are driving ACA insurance premiums to unaffordable levels and reducing Medicaid coverage for low-income populations. They also highlight the unworkability of GOP ideas to offer a few thousand dollars to individuals to negotiate with insurers for policies that likely will no longer comply with fairness rules instituted by the ACA.

It is, to adopt a slightly profane formulation, a cluster-f*ck. The changes will increase the ranks of the un- and under-insured by tens of millions, and shortchange other critical household needs to scrape up insurance premiums and out-of-pocket costs.

I hate it, for the inhumanity. The silver lining is that many voters – including in the MAGA base – are harshly affected, and know where to cast the blame.

Taking away something good – i.e., ratcheting back health insurance – is easier to recognize than never having received that good in the first place. So, those losing insurance or paying far more for it understand what’s going on and how it’s causing them pain. And they know whom to blame.

And … they will be increasingly open to permanent solutions built on a foundation of (familiar refrain now) – public, universal health insurance that is simple, generous, equitable, efficient, and health-enhancing. Single payer.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Health System Insanity Explained to Epidemiologists

A short primer for experts in health and disease (epidemiologists) describes the fundamentally poor health of our health care system. Underlying cause: an excess of monetary incentives. Cure: expunge those incentives.

5 ways our health care system has become utterly insane, Your Local Epidemiologist, Nov. 12, 2025, by Katelyn Jetelina & Hayden Rooke-Ley

To me (KJ), the debate in Washington is far too small. The real story isn’t just whether subsidies stay or go – it’s how completely insane our health care system has become, and whether there will be a serious effort to address underlying costs in the system.

I know juuusssttt enough to get in trouble, so I partnered with the incredible Hayden Rooke-Ley, who is a leading national policy expert in this area, to break down the five ways the entire system has gone off the rails.

1. Costs vs. wages: A 20-year disconnect.

Over the past two decades, the cost of employer-sponsored health insurance has skyrocketed. Premiums, deductibles, and out-of-pocket costs have all soared – far faster than wages. More than half worry they’ll fall into debt any time they use the health care system.  More than 60% of those in medical debt have insurance.

2. We pay the most and get the least.

Outcomes: Despite record spending, Americans live shorter, sicker lives than peers. We underinvest in prevention, such as primary care and social supports like housing and nutrition.

Access: More than 100 million Americans live in a primary-care desert, while almost 60 million live in a pharmacy desert.

Clinician workforce: Health care workers are burning out or leaving the profession altogether.

3. Americans don’t “over consume” health care. Prices and private bloat drive costs.

Americans don’t visit the doctor more, we don’t go to the hospital more, and we don’t stay in the hospital for longer. The real difference is price.

Our system is drowning in private-sector bloat and bureaucracy, more so than any other country. Roughly one in four dollars spent on health insurance goes to something other than care, like marketing, billing, profits or middlemen.

4. Corporate and financial firms have taken over care.

Perhaps the most underappreciated transformation of the past 40 years is the corporate consolidation and financialization of medicine.

Private-equity firms now own everything from nursing homes and hospices, to emergency departments and physician practices. Their model is simple: buy up fragmented practices, cut labor costs, raise prices, and resell for profit.

5. Existing approaches have failed – and the latest proposals are more of the same.

The idea was to embrace more free market principles in health care.

  • Private insurers compete for patients: managed competition, pharmacy benefit managers, etc.
  • Over-reliance on economic incentives: pushing physicians into value-based care, and patients rationing through higher deductibles
  • Commercialization – converting public hospitals to for-profit chains

The current debate recycles the same logic: more private control, higher out-of-pocket costs, and less regulation of prices or profits. The latest idea is that deductibles need to be higher and patients don’t pay enough. … This approach has failed for 40 years. …

Bottom line

The U.S. health care system is uniquely dysfunctional. A different approach is entirely possible – if we have the will to boldly govern the health care system in the interests of patients, clinicians, and taxpayers. That means directly tackling prices, eliminating middlemen, and breaking up behemoths. It also means returning ownership of care delivery to clinicians and communities and pursuing a strategy that builds the workforce and capacity to meet America’s needs.

Health care touches everyone, and we need a system that works for us, not one that makes us work for it.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Epidemiologists are sophisticated in thinking about the prevalence and spread of disease. However, they don’t understand much about health system financing and function. So this essay is a terrific primer for them. It’s an insightful status check on the unhealthy state of our health system. Impression (a medical term): Imbalanced, with excess money and a care deficit – especially for those short on money. High costs and poor performance make it obvious that we need a transformed approach. Treatment plan: Radical shift from money focus to medical care.

It’s clear what policies are needed — providing access to care for all, while keeping the system affordable overall and for each of us. This will require major shifts in approach. Ownership should be shifted to improve access and affordability for everyone, instead of increasingly guiding profits to the wealthy while impairing access and affordability for those with lower incomes – workers and especially the indigent.

The policies we need seem obvious, so it is consensus and collective action that is needed. We actually mainly share core values. We almost all agree that everyone should have the health care that they need. Likewise, that a financing system should be distributed to ensure that the system is affordable for everyone, even if this means that the very wealthy pay a larger amount (that they would never miss), in order to avoid extracting sums from lower income individuals that are needed to meet their most basic needs.

Step back and think about it. If we worked together, we could meet the goals of accessible, affordable health care for everyone without anyone suffering adverse consequences. We are not asking the wealthy to suffer the pains of poverty.

Hayden Rooke-Ley (this time with Katelyn Jetelina) explains how to get the health system to work in favor of everyone. Isn’t it time that we listened to them, to all of the other advocates for health care justice for all, and indeed to our clear collective values?

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Change in health care market a good thing

By George Bohmfalk, M.D.
Aspen (Colo.) Daily News, Letters, Nov. 8, 2025

Editor:

I was delighted to read Mr. Neubecker’s letter (“Seniors in ‘Happy Valley have few health care choices,” Nov. 6, Aspen Daily News) about the discontinuation of Medicare Advantage plans in Garfield County; I hadn’t known that UnitedHealthcare/Rocky Mountain Health had withdrawn from this market. Rather than mourning it, this change should be celebrated.

Most seniors who have been hoodwinked into joining an MA plan do not appreciate its many pitfalls. Sure, it seems free, and you might even go to a Silver Sneakers gym once or twice. And it may cover the inexpensive drugs you take today, if not more costly ones you may need next year. But at least two enormous red flags should give any senior pause before signing up.

First, all MA plans are run by private, for-profit insurance companies, not the government. They are not in it to serve seniors, but to take in — by various hooks and crooks — much more money and to pay out far less in actual health care costs than the original, government-administered Medicare. Their primary tactic in this is across-the-board, even AI-generated, demands for prior authorization and denials of care.

UHC is pulling out of markets like Garfield County because, even with these fraudulent tactics, they still can’t make enough profit to satisfy Wall Street’s expectations. They are doing this only to shore up their stock price.

The other major red flag is that while your present providers may be in their network, the doctors and hospitals you may need next year may not be, and you’ll be on the hook for huge out-of-network co-pays.

MA is great insurance, as long as you don’t get sick and need it. Yes, Medigap plans can cost a lot, but you may find a high-deductible one for under $50 per month. The real answer, to all of our health care problems, is for Trump to realize that his “concept of a beautiful plan” should be Improved Medicare for All, which would immediately solve all of this.

https://aspendailynews.com…