PNHP

Excise middle-men from Hawaii Medicaid

Excise middle-men from Hawaii Medicaid

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, Dec. 21, 2025

Thanks for the excellent articles in the Star-Advertiser’s Dec. 14 Insight section, on proposals to save primary care practices in Hawaii, especially on the neighbor islands. I agree with the three doctors who co-authored the Island Voices piece, “Support Hawaii’s primary care providers,” that we need to direct a much higher percentage of health care spending to primary care.

We also need to reduce unnecessary administrative burdens that now result in practice overhead costs that are squeezing primary care take-home pay well below what it costs to live in Hawaii, especially on the neighbor islands. Those unnecessary burdens include abusive prior authorization polices, especially by Medicaid managed care plans, and also detailed data reporting required by HMSA’s “value-based” payment policies imposed on primary care over the past decade. Administratively costly payment systems also raise the cost of Medicaid and HMSA premiums for taxpayers and purchasers of insurance.

Hawaii turned Medicaid over to private insurance plans in 1994 and 2009, and the managed care plans added ever-increasing prior authorizations and formulary restrictions, with the result that doctors began to refuse new Medicaid patients. Financing Medicaid through capitated private plans also adds administrative costs of around 13% of total Medicaid spending — and the real figures are likely higher because poor oversight by MedQUEST, incomplete data reporting from the plans, and use of multiple subcontractor costs reported as “health care” enable plans to disguise substantial administrative costs as “health care.”

Removing the middle-men from Medicaid could relieve administrative burdens imposed on primary care practices due to abusive prior authorization policies and also free up money from the state budget to improve payment and support for primary care.

Like Hawaii, Connecticut privatized Medicaid in the 1990s, but in 2012 that state fired the managed care middle-men and started paying primary care doctors extra to manage care instead of expecting insurance companies to do that. Connecticut’s Medicaid spending promptly fell by about 13% due to administrative savings. Connecticut used 3% of the budget to improve primary care pay and add community-based support for high-risk patients. Improved pay and relief from burdensome managed care restrictions resulted in 33% improvement in physician participation in Medicaid from the first year. Increased access to primary care led to decreasing emergency room and hospital spending, and by five years out, Connecticut was spending 15% less per Medicaid beneficiary than in 2012.

Hawaii’s current Medicaid managed care system is quite similar to that of Connecticut in 2012, and a detailed study on Medicaid managed care by Physicians for a National Health Program in September estimates savings for Hawaii from similar reforms would be in the range of $85 million to $145 million per year.

Further reduction in both practice overhead for primary care and in the administrative cost of health insurance could be achieved if HMSA were to abandon primary care capitation and “value-based” payment with its high administrative overhead, and return to a simpler and less costly form of fee-for-service that includes payment for time required for documentation and care coordination.

The Democratic Party of Hawaii Health Committee has drafted a bill to remove the middle-men from Hawaii’s Medicaid program, following the policies that have proven so successful for Connecticut. Passing the bill in the 2026 legislative session would go a long way toward helping save primary care in Hawaii. Large administrative savings would also enable the state of Hawaii to weather impending cuts in federal support for Medicaid a year from now that will otherwise have devastating effects on our entire health care system.

Dr. Stephen Kemble, a retired psychiatrist, served on the now-inactive Hawaii Health Authority, charged with designing a universal health care system for Hawaii residents. He is a national board member of Physicians for a National Health Program.

https://staradvertiser.com…

Surging Voter Support for Single Payer

Amidst skyrocketing ACA premiums and looming Medicaid cuts, coupled with rising economic anxieties, support for “Medicare for All” is growing and robust among voters – revealed in focus groups and quantitative polling.

“To the question of healthcare …” with Sarah Longwell, The Focus Group podcast, The Bulwark, Dec. 6, 2025

Sarah Longwell (1:03:53): “I’ll say on the question of healthcare. So obviously I was a Republican like 20 minutes ago. So I’ve never been like a you know Medicare for All type at all. I think that’s where it’s headed though. I mean just the frustration with health care costs and affordability in general. Like this is where Democrats I think are going to find themselves.

They’re going to have to rediscover how to be a party for the middle class and a party for people who are squeezed across all these different economic vectors and that’s not going to be just gas prices and it’s not going to be just college .. like it’s all these things and I think … people are in the mood, the voters are in the mood for politicians that are going to take big swings …”

Medicare for All Is Popular — Even When Put Up Against Attacks, Data For Progress, Nov. 26, 2025

Comment:

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

Are we approaching the “perfect storm” that brings single payer to life as a politically viable policy option, after eight decades of futility? (for the geeks: Is the Overton window opening?) Maybe so …

Nearly one year into the second Trump administration, several critical factors are aligned to support transformative change: Federal ACA premium subsidies from the COVID era are expiring, and general ACA premium levels are jumping by up to 25%. Massive cuts to federal Medicaid funding will be implemented in 2027. Budget deficits created by massive tax cuts will decrease funding for Medicare. And broad economic anxiety is growing, with ongoing inflation and job losses.

Voters favor a real solution, say key experts. Sarah Longwell is producer of The Bulwark (former GOP political operatives now never-Trumpers) and host of the Focus Group podcast with voters who switched between Trump and Dem candidates 2016-2024. She concludes that voters are in the mood for Dems who take a big swing on healthcare – Medicare for All. Voters care about affordability, and medical care is now front and center for that issue. She is, as she says, not a Medicare for All advocate, but seems to regard its rise as an acceptable part of the Dem come-back.

Quantitative polling tells a similar story. When voters are presented pro-and-con arguments, 58% support Medicare for All. This is consistent with other polling in recent years – suggesting that popular support for single payer remains robust. Congresswoman Pramila Jayapal found similarly that “54 percent of voters nationally and 56 percent in battleground districts back Medicare for All.” (from Politico here).

Senator Bernie Sanders makes the case for single payer, noting that voters recognize how “fundamentally broken” our system is. (Brian Tyler Cohen podcast – here) The system is “wildly expensive” and underperforms. He describes his Medicare for All bill – coverage and benefit expansions, and the financial viability. There are also single payer efforts in various forms and stages in individual states.

These are fraught times. From crisis comes opportunity and real reform. Stay the course.

https://healthjusticemonitor.org…

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Murray pushes to halt federal pilot adding AI to Medicare approvals

By Elise Takahama
The Seattle Times, Dec. 15, 2025

U.S. Sen. Patty Murray plans to introduce legislation Monday in an effort to halt a federal pilot program that would add AI reviews to Medicare approvals in some states, including Washington.

The bill, co-sponsored by Oregon Sen. Ron Wyden, follows companion legislation filed in November by U.S. Rep. Suzan DelBene, D-Medina, and five other congressional Democrats, who slammed the program for its potential to exacerbate delays in care for some Medicare enrollees. Patient advocacy groups, physicians and hospital leaders have also raised concerns about bringing in artificial intelligence tools to review pending Medicare procedures, particularly because AI companies will have a financial incentive to deny care.

“The Trump administration is gearing up to use AI to delay and deny Medicare benefits for seniors — this is outrageous and should be a national scandal,” Murray said in a statement to The Seattle Times. “Make no mistake: this is a backdoor effort to privatize Medicare and cut benefits.”

The Centers for Medicare and Medicaid Services announced the new model — known as the Wasteful and Inappropriate Service Reduction, or WISeR, program — in June. CMS Administrator Dr. Mehmet Oz said at the time the goal of the pilot is to protect patients from being given “unnecessary and often costly procedures” by testing a “streamlined prior authorization process” in original Medicare plans, the federal insurance program for people 65 and older, and many younger people with disabilities.

The program is expected to run for six years starting Jan. 1, 2026 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

If passed, Murray and Wyden’s bill would prohibit the federal government from implementing the model.

According to CMS, the model would work with third-party tech companies to decide the medical necessity of certain procedures deemed “vulnerable to fraud, waste and abuse,” including some nerve stimulators, steroid injections, spine surgeries and skin and tissue substitutes. The program would not review emergency services or inpatient stays, according to CMS.

Health care providers would still look over final denials, government officials have said.

When Robby Stern, a retired gas fitter, first heard about the federal pilot, the Seattle resident immediately felt it would be a “big deal.”

“Holy moly, this is really bad news,” Stern, 81, said he remembers thinking. “We have chosen traditional Medicare because we wanted the primary relationship to be between us and our provider of choice. Not have private corporations be inserted.”

Stern is a past president and active member of Puget Sound Advocates for Retirement Action, and quickly started helping organize presentations at senior living facilities and other community centers to educate other Medicare enrollees about the WISeR pilot.

“People were horrified,” Stern said.

According to the state, Washington has about 1.6 million Medicare enrollees. About half have traditional Medicare plans, while the other half are enrolled in Medicare Advantage, private plans financed by the U.S. government.

Several Washington physicians, both retired and practicing, have also spoken out against the program, and questioned why our state was chosen as one of the pilot sites.

CMS has not been clear about why these six pilot states were selected. According to the Federal Register, the states were chosen based on several criteria, including geographic diversity and types of claims.

CMS did not immediately respond to a request for comment.

Dr. Matt Hollon, president-elect of the Washington State Medical Association and an internal medicine and primary care physician in Spokane, called the federal program “incredibly unfortunate” and said the Murray legislation is an “important step to take.”

“We know prior authorization overall is a significant barrier for patients to adequate care,” Hollon said. “This is not allowing physicians to practice medicine; it’s allowing insurance companies to obstruct medicine.”

Hollon and other providers are well-versed in how prior authorization practices can slow care for significant medical conditions and sometimes result in more expensive treatment, he said. Dana Iorio, a retired primary care provider who worked at Harborview Medical Center, said one of the reasons he left the field in 2019 was because of the excessive documentation required by insurance providers to prescribe certain tests or medications, primarily for his patients with Medicare Advantage plans.

“It would take inordinate amounts of time,” Iorio said. “I once spent over an hour and half with a Medicare Advantage program on a particular patient, just trying to justify getting an ultrasound.”

According to a January report from the American Hospital Association, a survey found that 62% of Medicare Advantage patients had care delayed because of their insurance provider in the past two years. About 43% of patients reported their health worsened as a result.

A 2022 report from the U.S. Department of Health and Human Services’ Office of Inspector General found that about 13% of Medicare Advantage prior authorization denials actually met Medicare coverage rules, but were denied inappropriately.

Denials can not only lead to consequences for patients, but also mean an increased administrative burden and ethical concerns for health providers, said David McLanahan, a retired surgeon who worked for Pacific Medical Center.

“It’s going against physicians’ ethics — they couldn’t do for their patient what they knew the patient needed,” said McLanahan, who co-founded the Washington chapter of Physicians for a National Health Program, an advocacy organization that pushes for a universal single-payer health system.

Hospital leaders, too, are worried about the looming start date of the federal program, and still have a range of questions about how it might affect providers’ day-to-day workload.

“We already have a huge burden with [prior authorization] — that is already something that our hospitals have to hire for specifically,” said Jacqueline Barton True, vice president of advocacy and rural health for the Washington State Hospital Association, which also opposes the WISeR pilot.

“Any expansion of that is really concerning,” she added.

While the pilot is starting fairly small, Barton True said, it’s unclear what the next steps for the program might be. For example, there’s the possibility the model expands to review other types of procedures, she said.

“It starts as a pilot, but where does it go?” she said.

Stern, of Puget Sound Advocates for Retirement Action, acknowledged the desire to reduce “waste, fraud and abuse” in Medicare plans, but said the government should instead be targeting reform in Medicare Advantage plans, where there’s been more evidence of massive overpayments to health insurance companies.

“We all share concern about waste in the system,” he said. “But if you’re really concerned about waste, fraud and abuse, why aren’t you focusing on where the greatest amount of it is?”

https://seattletimes.com…

W.Va. doesn’t know what’s about to hit it

By Dan Doyle, M.D.
Charleston Gazette-Mail, Commentary, Dec. 12, 2025

There are two rural health transformations afoot in West Virginia. One is an innovation transformation being led by Gov. Patrick Morrisey. The other is a devastation transformation brought about by $911 billion in Medicaid cuts in the so-called One Big Beautiful Bill passed by Congress this summer.

As a family physician who has served Fayette County for more than 45 years, I am concerned about the impact that both transformations will have on health care in our state.

As it pertains to what I call the “innovation transformation,” Morrisey announced the concept at a news conference on Nov. 5 and has been touting it ever since. When Republican members of Congress realized the devastation that Medicaid cuts would bring to rural hospitals and rural people in their states, they demanded and got a $50 billion fund intended to prevent rural hospital closures in their state.

The idea is that every state, including West Virginia, gets $100 million per year for five years. The first check should arrive around Dec. 31. The West Virginia application calls for a variety of tech innovations hailing them as great break-throughs. Strangely, almost none of the money goes directly to struggling rural hospitals that the fund was supposed to help in the first place.

For me, this “innovation transformation” is window-dressing designed to distract attention from a greater and much more dangerous “devastation transformation.”

Nationally, the One Big Beautiful Bill cuts $911 billion from Medicaid funding over the next 10 years. About $137 billion of that will be cut from Medicaid for rural states and communities. West Virginia will lose $1 billion per year in Medicaid funding permanently going forward.

According to a study by the University of North Carolina, this puts 700 of 1,800 rural hospitals in the U.S. at risk of closure. Seven of those hospitals are in West Virginia towns and cities:

  • Grafton
  • Grantsville
  • Logan
  • Montgomery
  • Philippi
  • Ripley
  • Welch

The effect will be to create more hospital deserts throughout West Virginia.

The OBBA also cut support for Marketplace health care coverage. This affects 15,000 West Virginians starting now. Over the next decade, 55,000 more West Virginians will lose Medicaid coverage due to the OBBA. Many are ironically referring to this shift as “Capito Care,” since all four West Virginia members of Congress voted for this in July and have been praising it as progress ever since.

So, the devastation transformation takes away $l billion per year from rural health care in our state and the innovation transformation gives back $100 million per year. You do the math. It’s a bad deal for the family that loses their health care coverage. It’s a bad deal for the community that loses their rural hospital. It’s a bad deal for local economies all over the state.

In October, I dusted off my stethoscope and went to work as a volunteer at Beckley Health Right, a free clinic for people without health insurance. I’m afraid a lot of people don’t yet know what’s about to hit them.

Dr. Dan Doyle practiced family medicine in Fayette County for 45 years. He is currently senior organizer for the West Virginia chapter of Physicians for a National Health Program.

https://wvgazettemail.com…

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…

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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…

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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…