By Stephen Kemble, M.D.
Counter Punch, May 22, 2025

Privatization of publicly funded Medicare and Medicaid, managed care, and “value-based payment” (1) have failed to reduce cost or improve population health despite over 30 years of trying, and a new paradigm for health policy is needed. This article summarizes key health policy concepts and the implications of different payment systems and offers recommendations for design of an optimally cost-effective system enabling universal high-quality care at lowest cost.

Key Concepts

1. Should Health Care be Financed as a Public Good or with Market Competition?

Public funding is appropriate for essential public services necessary for everyone—funded by taxes and paid for with budgets based on cost of operations, with no opportunity for profit or loss. Examples include police and fire departments, public schools, the military, roads and bridges, and government services. Health care should be added to this list. Other industrialized countries with far more cost-effective universal systems treat health care as a public good, not a commodity.

Marketplace financing uses competition, market forces, private enterprise, and opportunity for profit and risk of loss. This works well for consumer goods, industry and manufacturing, hotels and restaurants, fuel and food production, and housing (except for those in poverty). These are appropriately subject to market forces, but health care is not.

2. Ethics: Professional vs Commercial Ethics

Professional ethics, traditional in medicine and other professions, put patient or client interests and welfare first, ahead of personal financial interests.

Commercial ethics prioritize financial interests of owner(s) or shareholders. Patients or clients (and taxpayers) are viewed as consumers from whom money can be extracted.

Reliance on professional ethics in health care is not perfect, but it works much better than commercial ethics and there are effective ways to deal with outliers who engage in unethical practices. It would be far less costly to manage outlier practitioners than to try to control mega-corporations that have amassed deep pockets at taxpayer expense.

Profiteering and the corporatization of health care, with substitution of commercial for professional ethics, is the main root cause of excessive cost and dysfunction in U.S. health care.

3. Insurance Risk:

The entity that covers the unpredictable variability in healthcare cost bears insurance risk. Direct payment of providers with fee-for-service means claims received will be variable and somewhat unpredictable, and risk is retained by the payer.

Government programs may contract payment to private fiscal intermediaries with capitation (payment per-member, per-month), as in Medicare Advantage, Medicaid Managed Care, and Medicare Accountable Care Organizations, shifting insurance risk onto the intermediary. A fiscal intermediary contracting to assume risk will always try to over-charge—usually to assure around 90% chance of profit, 10% risk of loss.

4. Excessive Cost of U.S. Health Care:

The managed care paradigm blames excessive cost on fee-for-service with its presumed incentive to provide unnecessary care and over-utilization. The solution offered is “value-based payment” (see below) or up-front funding for care of a defined population with capitation (2). But the U.S. has never had higher utilization compared to other countries that use fee-for-service and whose universal health care costs half as much per person, so fee-for-service cannot be the cause of excessive U.S. healthcare cost (3). The difference between the U.S. and other countries is in administrative cost and pharmaceutical prices, not over-utilization (4). And market financing of U.S. health care means about a third of total cost goes to administration (5,6).

Health Care Payment Systems

1. Fee-for-service (FFS)

Simple FFS is inexpensive to administer, although FFS as implemented in the U.S. is often unnecessarily complex and costly. For doctors, FFS rewards productivity—working harder means more pay. FFS is compatible with “patient first” professional ethics and it is compatible with independent private practice. FFS does not shift insurance risk onto providers of care, so it does not need risk adjustment or linking payment to diagnostic coding, and up-coding is not an issue.

However, FFS can reward unnecessary treatment. FFS is more likely to be abused when billing is separated from direct contact with the patient, allowing substitution of commercial ethics for professional ethics. Abuse of FFS is lowest with doctors in independent practice who bill out of their office, more problematic with doctors employed by a large group practice or hospital, and worst with for-profit ownership of doctors’ practices by an insurance company or private equity (7). Current trends are in the wrong direction.

For government programs, paying doctors and hospitals directly with FFS means government retains insurance risk and must cover the variability in claims received. However, the larger the risk pool the more manageable this unpredictability becomes, and reserve funds and re-insurance can manage budgetary uncertainty without shifting risk to third-party intermediaries.

2. Salaries for doctors

Salaries are inexpensive to administer, do not create incentives to over- or under-treat, and are compatible with “patient first” professional ethics. However, payment with salaries requires an employer, which can be a problem if the employer is profit-seeking and paid with either fee-for-service divorced from contact with the patient or capitation with its incentive for profiteering. Salaried doctors who can control their schedule/workload may be tempted to become less productive, but this can be mitigated with salary plus a small productivity incentive.

3. “Value-based payment” and capitation

“Value-based payment” systems hold doctors and hospitals accountable for quality and cost of care, even when cost and quality outcomes depend largely on patient characteristics that are beyond the control of care providers. “Capitation” is an advanced form of “value-based payment,” defined as up-front payment per-capita, based on the average per-person cost for a defined population of “members.” Value-based payment and capitation shift insurance risk onto care providers.

Capitation is a simple concept, that seemingly should be inexpensive to administer and provide cost control because care delivery must live within a capitated budget. But capitation is not the same as a simple budget, and in a competitive setting introduces inherent perverse incentives, requires added administrative burdens and costs, and does not assure budgetary control.

• Up-front payment per member requires members, and performance on quality metrics and cost depends heavily on which members are captured.
• Gaming the risk pool: Competition for members rewards capturing the healthy and avoiding the sick.
• Capitation requires risk adjustment, which is administratively expensive, can’t be done anywhere near accurately enough to deter risk pool gaming (8), AND…
• Risk adjustment incentivizes up-coding diagnoses to game the risk-adjustment formula. Up-coding is heavily abused by capitated, risk-adjusted Medicare Advantage (8) and Medicaid Managed Care plans, exploiting government funding.
• Capitation rewards skimping on care since less care means more of payment can be kept, but capitation deters necessary as well as unnecessary care (9).

These incentives align to raise administrative cost and worsen disparities in care, and they conflict with professional ethics, contributing to physician moral injury.

Government programs (Medicare and Medicaid) may think capitation of fiscal intermediaries is a convenience because per-member payment is fixed for a contract year. However, payer risk due to changes in enrollment remains, and predictable funding is not assured over subsequent contract periods. Capitated fiscal intermediaries can keep unspent funds, inviting profiteering by plans guided by commercial instead of professional ethics. And government contracts with capitated plans means loss of control of the budget year-to-year, because in practice plans can extract whatever raises they want by gaming financial data reported to government (10).

For doctors, payment with capitation is independent of office visits, how often a patient is seen, or even whether a “member” is seen at all. Capitated doctors were protected from loss of income when patients stopped coming to the office during the COVID-19 pandemic. In theory, capitation does not require linking every service to a procedure code, but in practice payers using capitation often require fee-for-service claims for budgeting and benchmarking purposes, precluding administrative savings. And the perverse incentives and administrative costs of capitation listed above all apply.

4. Paying hospitals and other institutional providers

Fee-for-service

Hospital fee-for-service billing is extremely complex and heavily gamed, with chargemaster fee-setting, cost-shifting across different insurance lines of business, unreimbursed care, different in-network and out-of-network fees, and data reporting for value-based payment schemes. Large savings could be realized by paying hospitals with global budgets (see below) instead of fee-for-service.

Capitation

Attributing “members” to a hospital is problematic unless the hospital is part of a closed system with members who signed up for that system (e.g. Kaiser). The perverse incentives inherent to capitation listed above apply to hospitals in capitated systems.

Global budgeting

Simple global budgeting of hospitals (as in Canada) pays hospitals with global operating budgets based on cost of operations, including salaries for employed doctors and other professionals, plus separate budgets for capital improvements based on community need. Simple global budgeting of hospitals does not involve capitation (no “members”) or risk shifting and can’t be easily gamed like fee-for-service or “value-based payment.” Hospital administrative costs per capita in Canada (in US dollars) are less than a quarter of those in U.S. hospitals (11).

Centers for Medicare and Medicaid Services has been promoting the AHEAD model (“Advancing All-Payer Health Equity Approaches and Development”) (12), which includes a version of global hospital budgets applied on top of fee-for-service with rates standardized across all payers, with claims revenue reconciled to the budget at the end of the year, plus partial capitation with attributed “members” and “value-based” add-ons. These include pay-for-performance and incentives to address inequities and social determinants that are largely not under the control of the hospital. This version of hospital budgeting has none of the administrative savings of simple global budgeting, and in fact piles on more administrative burdens and cost.

Recommendations for universal care at lowest cost

1. Health care should be publicly financed by government, and the government payer should retain insurance risk, with no sub-contracting to risk-bearing fiscal intermediaries. Risk is most cost-effectively managed with broadest possible risk pooling plus financial reserves and/or re-insurance.

2. The major focus of reform should be on reducing administrative cost and therefore prices, not “managing” utilization of care.

3. Physicians could be either in independent practice or employed, and hospitals could be either privately or publicly owned, but ownership of doctors’ practices and hospitals by for-profit corporations or private equity and the corporate practice of medicine should be banned by law.

4. “Value-based payment” introduces perverse incentives and high administrative costs that preclude real value and should have no place in health care.

5. Large administrative savings could be achieved with simplified, standardized payment of care providers. Simplified fee-for-service would be appropriate for doctors in independent practice, with all procedures reduced to professional time required and hourly rates based on required training. Fee-for-service based on time and training would be much fairer and less costly to administer than attempting to assign a relative value to each of thousands of procedure codes (13). Payment should be based on the value of the time and expertise of the professional performing a procedure instead of attributing value to the procedure itself.

6. Hospitals, other institutional providers, and community-based health services should be paid with global budgets, with employed doctors paid with salaries.

7. Pharmaceutical prices should be regulated and negotiated by government.

8. Necessary administrative functions and quality assurance may be publicly administered or contracted out to an Administrative Services Only contractor on a non-risk basis.

Healthcare Cost Implications

Savings would come from markedly reducing billing and collections costs for doctors and hospitals, reduced administrative cost for the government single-payer, negotiated pricing for pharmaceuticals and durable medical equipment, and eliminating the high administrative cost of competing private plans. Further savings would result from a much-improved practice environment for primary care that eliminated disincentives for practice in under-served rural and urban areas, expanding access to primary care in the most cost-effective settings and reducing preventable ER visits and hospitalizations.

If all these recommendations were implemented, U.S. per-capita healthcare costs would likely fall into the range of Canada and other countries with universal systems that cost at least 30-40% less than what the U.S. now spends on health care.

Dr. Stephen Kemble is a psychiatrist in Hawaii who has followed health policy for decades and is a proponent of cost-effective universal healthcare.

https://counterpunch.org…

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References

1. Rooke-Ley H, Ryan AM. A New Medicare Agenda—Moving Beyond Value-Based Payment and the Managed Care Paradigm. JAMA 2025; 333(14):1203–1204.
2. Schroeder SA, Frist W. Phasing Out Fee-for-Service Payment. N Engl J Med 2013; 369:2029-2032.
3. Himmelstein D, Woolhandler S. Global Amnesia: Embracing Fee-For-Non-Service—Again. J Gen Intern Med 29, 693–695 (2014).
4. Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA 2018; 319(10):1024–1039.
5. Himmelstein DU, Campbell T, Woolhandler S. Health Care Administrative Costs in the United States and Canada, 2017. Ann Intern Med 2020; 172:134–142.
6. Downing NL, Bates DW, Longhurst CA, Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Ann Intern Med 2018; 169:50-51.
7. Harris E. Private Equity Ownership in Health Care Linked to Higher Costs, Worse Quality. JAMA 2023; 330(8):685-686.
8. Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy. Washington DC: MedPAC; March 2024.
9. U.S. Department of Health and Human Services Office of Inspector General, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” April 2022, https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf.
10. Goldsmith J, Mosley D, Jacobs A. Medicaid Managed Care: Lots of Unanswered Questions (Part 2). Health Affairs Blog, May 5, 2018.
11. Himmelstein DU, Jun M, et al. A Comparison of Hospital Administrative Costs in Eight Nations: US Costs Exceed All Others By Far. Health Affairs 33, No. 9 (2014):1586–1594
12. States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. CMS.gov. 2024.
13. Kemble SB, Kahn J. Optimizing Physician Payment for a Single-Payer Healthcare System. Int’l J Social Determinants of Health and Health Svcs, May, 2023.

By Chloe Crawford
Spero ~ Hope for the Future, May 13, 2025

The US healthcare system lives in two realities.

It is a system home to innovative treatments, leading research, and world-class hospitals, with the highest spending on health per person when compared to similar wealthy nations.¹

However, simultaneously, it is a system where millions of Americans face barriers to healthcare. They must navigate complicated insurance rules, and a reality where an unexpected illness or accessing care without insurance can result in bankruptcy and crippling debt.

This leaves many to ask, “Why is access to healthcare in the United States so complicated and so expensive?”

To help answer this question, we spoke with Dr. Don McCanne, a retired physician, longtime health policy advocate, and Senior Health Policy Fellow with Physicians for a National Health Program (PNHP). Dr. McCanne has spent decades treating patients and fighting for reform. We explore how the U.S. got here – and with the help of Dr McCanne –  how it might set out a different path forward.

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History of Healthcare in the US

While many similarly wealthy countries began to implement national health insurance plans throughout the 20th century, the US did not.

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A brief timeline:

Early 20th Century – Independent physicians and low costs: In the early 1900s, most doctors in the United States worked independently, healthcare costs were relatively modest, and hospitals were often community-run or charitable institutions. There was a lack of country-wide healthcare initiatives or legislation. Most healthcare matters were left to states, who in turn left them to private and voluntary programs.

World War II – Birth of employer-based insurance: During World War II, wage controls prevented employers from raising salaries, so many began offering health insurance as a benefit to attract workers.³ This marked the beginning of America’s widely employer-based model of healthcare, where affordable access to healthcare became tied to one’s employment.

Post-War Era – Rise of for-profit insurance: Private health insurance was initially offered by nonprofit organisations like Blue Cross, which charged flat rates for hospital coverage.⁴ But after the war, they faced growing competition from for-profit insurers, who introduced risk-based pricing and charged more to groups with a history of higher health costs.⁵ For example, older or disabled workers faced higher rates. This laid the groundwork for systemic differences in access and affordability of healthcare.

Cold War Impact – National Health Insurance attempts blocked: While several presidents, including Truman and Kennedy, proposed national health insurance, these efforts met fierce resistance.⁶ Opponents, especially the American Medical Association and private insurers, framed such proposals as “a communist plot,” invoking Cold War fears of communism.⁷ As other wealthy nations built universal health systems after World War II, the U.S. doubled down on private-sector solutions.

1950s-60s – Tax policy and expansion of private plans: Private insurance continued to expand, partly because employer contributions to health coverage were not included in a worker’s taxable income.⁸ This tax advantage made it cheaper for employers to offer health benefits, cementing the dominance of private, job-based coverage. Meanwhile, those without employer coverage – especially retirees, the poor, and the unemployed – were often left behind.

1965 – A turning point! The creation of Medicare and Medicaid: President Lyndon B. Johnson signed the first nationwide public health insurance programs into law in 1965.⁹ Medicare provides federal health coverage for those over 65 and some with disabilities. Medicaid, a joint federal and state program, covers low-income individuals and families, but eligibility varies by state.

1980s-90s – Managed Care and Market Logic: Healthcare costs surged in the 1980s due to the introduction of new and expensive medical technologies, the use of a fee-for-service payment model (doctors and hospitals are paid for each test, procedure, or visit) which incentivised overuse, and minimal price regulation.¹⁰ In response, insurers introduced managed care models which restricted users to agreed-upon care providers and often required pre-approval to access certain services.¹¹ While managed care briefly slowed cost growth, it also limited patient choice and created frustration and confusion among both patients and providers.

2010 – The Affordable Care Act: Introduced by President Obama and often referred to as Obamacare, it was aimed at reducing the number of uninsured Americans.¹² It expanded Medicaid in many states and created online marketplaces where people could compare insurance plans. However, it preserved the central role of private insurers.

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US healthcare is now a patchwork of private insurance plans and employer-sponsored coverage. While programmes like Medicare and Medicaid have helped millions, the system remains fragmented and dependent on private insurers. Dr McCanne and many like him believe these programmes need to go further. His career saw the impact of Medicare’s introduction on his elderly and retired patients, many of whom were living only on a social security check and were “suddenly able to have essentially unlimited healthcare.”

This is an approach he believes could work for everyone. However, over time, healthcare in the US has solidified itself as a for-profit industry, rather than a basic necessity for the benefit of everyone.

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The Current US Healthcare System

Today, about half of Americans get insurance through work. Around 9% have no insurance at all, and many more are underinsured.¹³ The current system is costly, complex to navigate, and corporatised.

Insurance doesn’t always mean affordable – Most plans include:

• Deductibles: What you pay before insurance kicks in
• Copays: Fixed fees for services (like $40 to see a doctor)
• Coinsurance: A percentage of costs you must cover (e.g. 20% of a hospital bill)

This means that many people who are technically insured still incur very high upfront or out-of-pocket costs.¹⁴

Insurance networks are restrictive – Most insurance plans use provider networks, approved doctors, and hospitals that have contracts with your insurer. If you go out-of-network, you’ll pay much more (or sometimes everything!) yourself.

Drugs and treatment are expensive! – Drug prices in the U.S. are much higher than in other countries.¹⁵ For example, insulin can cost almost 5x more in the US compared to just over the border in Canada.¹⁶ A key factor in this difference is that the US doesn’t regulate drug prices when products are launched or when substantial price increases are enacted after launch.¹⁷

Covid-19 exposed the underlying issues in the system – The pandemic laid bare some of the key systemic failures of US healthcare. Millions lost their jobs and, as a result, their health insurance. Hospitals were overwhelmed. Essential workers risked their lives with minimal reward.¹⁸ The crisis amplified calls for a more resilient, equitable system, not tied to employment nor distorted by profit.

Corporate Consolidation Has Taken Over Care – Healthcare is no longer local or community-based. Now, it’s big business. Through a process known as vertical integration, insurers, hospitals, and clinics have merged into giant corporate systems. For-profit companies now own the vast majority of healthcare facilities and practices, including hospices, nursing homes, and ambulance companies. For example, UnitedHealth, one of the largest insurers in the US, uses its offshoot company Optum to control more than 1500 clinics with 60,000 doctors. McCanne and his colleagues point to this example as evidence that “Increasingly, Americans’ insurer is also their doctor.”¹⁹

This corporate consolidation means less competition, fewer independent doctors, and decisions driven by profit for shareholders, no matter the cost to patients.

The result? Medical debt is one of the number 1 causes of bankruptcy in the U.S.²⁰

Even insured patients can end up owing thousands for hospital stays, Emergency Room visits, or medications. Surprise bills, out-of-network charges, and denied claims leave many financially devastated.

Studies show:

• 41% of US residents carry medical debt.²¹
• 60% of uninsured adults delay care due to cost.²²
• Crowdfunding sites like GoFundMe host over 250,000 medical fundraisers every year.²³

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Another Path Forward

For decades, advocates like Dr. McCanne and organisations like Physicians for a National Health Program (PNHP) have championed Medicare for All – a single-payer national health insurance system that:²⁴

• Covers every American
• Is funded publicly through taxes
• Eliminates private insurance companies
• Reduces wasteful bureaucracy
• Gives doctors and patients freedom from insurance and profit-driven decisions

This doesn’t have to come at great cost to the American people. Dr McCane points to the many studies that show that comprehensive care can be provided to everyone at no greater cost than is currently being spent.²⁵

But McCanne and others now recognise that even this bold reform must go further. They want you to ask not just how care is paid for care but who owns and provides it.

As corporate control over care delivery grows, reformers argue that the US needs a National Health Service model – publicly funded and publicly owned. In this model:²⁶

• Hospitals, clinics, and other vital facilities would be owned by the people, not shareholders.
• Local communities, not corporate head offices, would control how care is delivered.
• Federal oversight would ensure quality and equity.
• The focus would shift from financial return to human well-being.

This approach would put public health back in the hands of the people, where it belongs.

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Dr Don McCanne on how to fight for better

Dr. McCanne’s story is one of lifelong commitment. Inspired by his father, a teacher who became a physician later in life, he and his twin brother entered medicine not to get rich, but to serve. They set up and ran a community practice in San Juan Capistrano where they accepted all patients, no matter their citizenship or financial status.²⁷

Now in his late 80s, despite health issues and retirement, he continues to write and advocate for change. He co-authored the long-running “Quote of the Day” column on health policy, now continued as Health Justice Monitor by his colleague, Dr. Jim Kahn. Even in today’s turbulent political climate, he still believes progress is possible:

“The injustice of our healthcare system is becoming harder to ignore. People are waking up.”

When asked what gives him hope, he points to the next generation. “At 87, I know that I won’t see it, but I still have hope for the future.”

Dr McCanne shows us the impact of showing up, dedicating time to your community and not losing hope. He still believes that the US has every potential to live up to its proclamations of being a great country for all those who live in it. Healthcare reform in the United States is not a pipe dream. It is within reach.

Dr McCanne serves as a reminder that change doesn’t start in government; it starts with people who care. Patients, doctors, nurses, and voters must stand together and demand a system that works for everyone. This sentiment rings even more true next to a backdrop of recent cuts to healthcare programmes and research.²⁸

When reflecting on his lifelong fight for more equitable and accessible healthcare in the US Dr McCanne leaves us with this: “I realise that there is so much more work left to do, and it’s going to have to be done by you. I just hope that some of us can provide a modicum of inspiration to help move the process forward. We are so close.”

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What You Can Do

Learn more about the solutions being proposed to US healthcare at: PNHP.org, Health Justice Monitor, DoctorsForAmerica.org

If you live in the US, talk to your representatives, share your own experiences and struggles with the system and vote at elections with healthcare in mind!

For those outside the US, take inspiration from Dr McCanne on how to persevere in pursuing a more just world for yourself and others.

Stay tuned at Spero to learn about other healthcare systems around the world!

https://spero-hopeforthefuture.com…

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28. Pifer, Rebecca. “Trump Releases 2026 Budget Including Heavy Healthcare Cuts.” Healthcare Dive, May 5, 2025.

By Tony Pugh
Bloomberg Law, April 29, 2025

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