PNHP

The Big Ugly Threat to Safety Net Hospitals

The Big Ugly Threat to Safety Net Hospitals

Analyzing the hospitals put most at-risk by the Republican tax and budget reconciliation bill

By Eileen O’Grady
Public Citizen, March 31, 2026

On July 4, 2025, President Trump signed a Republican budget reconciliation package into law that will decimate affordable health care for millions of Americans and risk the closure of rural hospitals. The One Big Beautiful Bill Act, which opponents of the law nicknamed the Big Ugly Law (BUL), will cut $911 billion in federal spending on Medicaid and CHIP over the next 10 years, according to estimates from the Congressional Budget Office. Draconian work and eligibility requirements for Medicaid recipients mean that millions of people will lose their Medicaid coverage.

The cuts will be devastating to many low-income and disabled individuals who rely on Medicaid. Moreover, they will have knock-on effects on hospitals that disproportionately serve these communities, deepening the financial strain already plaguing rural and safety-net hospitals and compromising their ability to deliver care, potentially leading many to close.

This report identifies and analyzes the hospitals that are most at risk of closing, reducing the medical services they provide, or laying off workers due to Medicaid cuts imposed by the Big Ugly Law.

Key findings:

  • 446 hospitals are at heightened risk of closing or reducing services due to Medicaid cuts.
  • These hospitals collectively have approximately 69,000 beds and served approximately 6.6 million patients in 2024. They employ approximately 275,000 direct patient care workers.
  • The communities served by these hospitals have a larger share of Black and Hispanic residents, as well as people living below the poverty line, compared to other hospitals. Nearly 20% of the at-risk hospitals (85) serve high-poverty areas.
  • 267 (60%) of the at-risk hospitals serve urban areas, and 176 (39%) are rural hospitals.
  • House Republicans who voted for Medicaid cuts have 196 at-risk hospitals in their districts collectively, and Senate Republicans (all of whom voted for Medicaid cuts) collectively have 146 at-risk hospitals in their states. Republicans also represent several of the congressional districts with the highest number of at-risk hospitals.
  • Five states now have over a quarter of all their hospitals at risk: Connecticut, California, New York, Massachusetts, and Washington.
  • Almost half of the at-risk hospitals have special Medicare payment designations that are typically associated with hospitals that are rural or financially vulnerable and play a critical role in the communities they serve, including Critical Access Hospital (19%), Rural Referral Center (16%), Sole Community Hospital (9%), and Medicare Dependent Hospital (4%).
  • In recent months, hospitals have initiated layoffs and reduced services like obstetrics and maternal care, citing financial strain imposed by Medicaid cuts.

The full list of at-risk hospitals is available here.

full report: https://citizen.org…

Trump May Seek Primary Care Help from Cuba

La Verdad, Trump floats “Cuba care corridor” to address U.S. primary care shortage, April 1, 2026, by Clara Desvarío

Palm Beach, FL — At a private dinner with donors last week, President Donald Trump reportedly suggested that the United States could address its growing primary care shortage by sending Americans to Cuba for routine care — perhaps as part of vacations — and recruiting Cuban primary care providers to practice in underserved U.S. communities.

According to a source present at the event, Trump raised the idea in a conversation with a Cuban American Ă©migrĂ© donor, describing Cuba’s neighborhood-based care model as “very powerful.”

“They’ve got doctors on every block—almost,” Trump said, according to the attendee. “We could learn from that. Maybe we send some patients there – beach vacation plus doctor visits. People like vacations.”

The remarks come as the U.S. faces a projected shortage of up to 48,000 primary care physicians by the early 2030s, with rural and low-income areas disproportionately affected.

A policy analyst, Dr. Elena Márquez of the Institute for Comparative Health Systems, noted that Cuba’s system assigns a physician–nurse team to roughly 600–700 residents and emphasizes prevention and home visits.

“Cuba has one of the most intensive primary care models in the world,” Márquez said. “The question is not whether it works—it clearly does on many population measures—but whether it can be meaningfully translated across political and economic systems.”

No formal proposal has been released, and administration officials declined to comment on whether the idea is under active consideration.

Comment:

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

It is hard not to read this with a mix of fascination, irony, and sadness.

Fascination, because the underlying observation is not wrong: Cuba has built a primary care system that is deeply embedded in communities, prevention-oriented, and accountable for defined populations. For decades, health policy analysts have pointed to exactly these features as missing in the U.S. system.

Irony, because the same administration now entertaining “medical vacations” to Cuba has, in practice, supported policies that weaken primary care at home—through underfunding (eg of Medicaid), fragmentation, and persistent neglect of workforce development and payment reform.

And sadness, because the idea implicitly concedes a failure: that we might need to send Americans abroad to access the kind of continuous, community-based care that should be foundational in a high-income country. And sadness, too, that the US has in recent years sabotaged Cuba’s economy including health care through aggressive oil embargoes and other actions.

Would such a primary care initiative be worth considering? I’m ambivalent.

On one hand, expanding access – by any means – has appeal, especially for underserved populations. On the other, importing care from a country whose economy we have long viciously sought to undermine raises vexing ethical and geopolitical questions. Recruiting Cuban clinicians risks exacerbating health workforce pressures there, even as we fail to fix our own.

Ultimately, the proposal underscores a more basic point: we do not lack for strong medical care models worth emulating. What we lack is the political will to implement them. Is this the start of a stunning shift – improving the US by learning from other countries?

P.S. In finalizing today’s April Fools’ post, I saw recent NY Times reporting on the dire health consequences for Cuba’s people of US oil blockade policies. That is no laughing matter; indeed it is inexcusable.

https://healthjusticemonitor.org…

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HJM Reader Ideas

Our recent request for input from HJM readers yielded varied and rich ideas. There was some consensus on current problems (costs, complexity, & profit-taking), varied views on political context (opportunities & barriers), and a profusion of strategic and tactical ideas (both contradictory and compatible). Trump got unexpected callouts for his full-speed-ahead m.o.

HJM readers are, unsurprisingly, well-informed and articulate. Our recent solicitation of ideas yielded a profusion of cogent observations and opinions. I did my best to organize them, without judgement. Thus, HJM readers can get a sense for the range of views, both widely shared and unique.

I summarize responses by category. If you want to scan all summarized comments, see below.

More input is welcome, but I can’t guarantee that I’ll report back. If you’re eager to connect with someone expressing a specific idea, I can explore linking readers 


For Most Vexing / Motivating Current Problems, the most common views were unsurprising: high costs, for individuals and employers; complexity leading to confusion and inefficiency; and widespread profit-seeking by insurers and others. The rich are doing fine, the middle class and especially the poor not so much. Critical provider capacity suffers and improvised solutions (eg value-based payment) don’t help. It’s shameful that the US lacks state-of-the-art insurance.

Current Political Context: Harm vs Advance Single Payer elicited the the central role of economic status: the governing GOP reduces taxes for the rich and cuts government programs intended to help the middle class and poor. There is some optimism in growing condemnation of this dynamic. On broader politics, some readers are pessimistic about both parties, with huge money in politics. More upbeat, one reader noted “collectivism” counteracting the famous US “rugged individualism”. For health care, the rising sense of crisis encounters extensive anti-SP efforts by the profit-makers.

And, finally, for Strategic & Tactical Ideas 
 strategic views run the gamut: step-wise (eg expanding Medicare age and state-based single payer) to all-at-once. Tactics can be summarized as lots & varied & mutually supportive, from mass movements to fireside chats, moral suasion and technical details. Trump’s chutzpah and audacity – his disrespect for normal process, get surprise mention as a model for aggressively pursuing single payer. Framing focuses on universality, cost savings, and ending profiteering. “Premiums” is preferred to “taxes”. Finally, technical suggestions focus on fee-for-service and a tiny role for private supplemental insurance.

Many thanks to the HJM readers who chimed in so thoughtfully. These views rounded out my understanding of options and choices we face on the path to health justice.

1) Most Vexing / Motivating Current Problems

Health Insurance Failures

  • High costs – for individuals & employers (esp public) – 7
  • Un- and Under-insurance
  • Difficulty navigating insurance and care
  • Care denials
  • Inequality – poor suffer, rich do well
  • Medicaid – prove poverty now 2x / year, low payments
  • Shameful US lacks state-of-the-art insurance
  • Key provider capacity loss

Causes

  • Complexity –> confusion & inefficiency – 6
  • Profit seeking (insurance, provider groups) – 7
  • Patients seen as widgets
  • False solutions eg value-based payment

2) Current Political Context: Harm vs Advance Single Payer

Central role of economic status

  • GOP cuts: taxes for the rich & government programs
  • Wealth to rich, others losing economic stability
  • Growing perception that oligarchy = theft
  • Middle / upper class must suffer to move the needle

Other political issues

  • Govt swings between extremes
  • However, both parties fail us
  • Money in politics
  • Dems in opposition must articulate vision
  • Wide fear of taxes, esp for the common good
  • The “rugged individualism” vs “collectivism” split is shifting
  • Trump shows: Exec Branch can get stuff done if it wants

Regarding Insurance

  • Growing perception of a health care crisis
  • Relative satisfaction with Medicare (& Soc Security)
  • Inevitable strong anti-SP marketing by profit-makers
  • Dem Congress may support SP

3) Strategic / Tactical Ideas

Strategy

  • None that will work (pessimism)
  • State-by-state if fed cooperation – 3
  • Lower Medicare age to 50 – 3
  • Start with universal capitated primary care
  • All-at-once, to reveal the savings – 2
  • What would employers like?
  • Inside-Outside (legislation + mass movement)
  • Outreach + marketing, fireside chats
  • Tactic (eg moral vs technical design) tailored to constituency
  • Role of SP in the broader Left
  • Trumpian chutzpah (audacity of audacity)
  • Charismatic president “ram SP down country’s throat”

Framing

  • Universal Coverage 
 One people, one plan – 2
  • Universal coverage costs less for families than now – 3
  • Americans trained to believe govt can’t deliver – 2
  • Affordability + Abundance
  • End profiteering
  • Contrast with war spending
  • Moral imperative currently weak argument
  • “Socialized medicine” trope losing shock value
  • Govt pays for health care, not for insurance – 2
  • Delink from work
  • “Premiums” not “”taxes”

Technical

  • Fee-for-service like Trad. Medicare
  • Medicare QMB for low income
  • Private Insurance – for supplemental coverage

https://healthjusticemonitor.org…

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‘Harmed by the system’ — Physicians suffer moral injury when health care chases profits, not patient care, report says

By Richard Payerchin (fact checked by Keith A. Reynolds and AC Baltz)
Medical Economics, March 24, 2026

Key Takeaways

  • Nearly half of physicians report insufficient time for optimal care, and over one-third face patient loads they view as unsafe, underscoring operational constraints with direct clinical quality implications.
  • Many clinicians recommend evidence-based interventions despite anticipating access failures from insurer utilization management, systemic barriers or patient cost exposure, fostering repeated ethical distress.
  • Moral injury is differentiated from burnout by etiology and phenotype, emphasizing guilt, shame and loss of meaning arising from externally imposed constraints rather than individual coping deficits.
  • A substantial minority are considering leaving their jobs, suggesting workforce destabilization linked to persistent financial and administrative pressures that undermine professional obligations.
  • Single-payer universal coverage is positioned as the principal corrective, though interpretation is tempered by nonrandom sampling through advocacy networks and potential underrepresentation of departed clinicians.

It’s not just burnout when patient numbers increase but doctors are not allowed adequate time and treatments for them.

The pursuit of profit, not patient health, is causing alarming levels of moral injury to physicians who want to treat patients but instead must deal with systemic constraints across U.S. health care, according to results of a new study.

Anti-burnout initiatives, such as wellness programs and resilience training, have helped some physicians cope with workplace stressors. But they don’t change the course of “health care financialization,” in which health systems and insurers prioritize income over patients’ and physicians’ health interests. Those programs also don’t address the moral injury that physicians feel when they want to guide patients toward better health but can’t due to insurance restrictions or systemic racism, according to Physicians for a National Health Program (PNHP).

“Our research shows that the system is failing both physicians and patients,” PNHP President Diljeet K. Singh, M.D., Dr.Ph., said in a news release. “Doctors enter medicine to care for people, but are increasingly forced to navigate barriers that delay or deny treatment to generate profit. When clinical judgment is overridden by financial priorities, patient care suffers.”

What the findings say

“Moral Injury in Medicine: The Human Costs of Practicing in a Profit-Driven System” is the new PNHP report based on two years of research among doctors and patients, including surveys and interviews with 1,207 physicians. The findings are grim, though perhaps not entirely unexpected for physicians fed up when the emphasis on making money supersedes needed patient care.

Among the key findings:

  • 47% of surveyed physicians say they often or always lack enough time to provide optimal levels of care to their patients
  • 35% say they are required to care for more patients than they can safely manage
  • 44% say they often recommend treatments they know their patients will not be able to access because of systemic barriers, insurer practices or financial costs
  • 41% report often feeling complicit in structural racism perpetuated by the health care system in which they work
  • 35% say administrative and insurer pressures to reduce costs affect their ability to provide the best possible care
  • 25% say they are considering leaving their job due to this distress

The report was funded by the Robert Wood Johnson Foundation, a national nonprofit devoted to improving health care and health equity.

“Across the country, physicians and patients are navigating a health care system increasingly shaped by the pursuit of profit rather than health,” Kelsy McIntosh, MPH, program associate at the Robert Wood Johnson Foundation, said in the news release. “Physicians want to deliver high-quality, evidence-based care that aligns with their values and expertise, but too often encounter barriers designed to generate profits. Shining a light on systemic pressures can support designing systems that prioritize patient health over corporate profit.”

What to do next?

The report stops short of prescribing incremental fixes, arguing that the health care industry has repeatedly demonstrated an ability to circumvent or undermine regulatory reforms. Its primary structural recommendation is the implementation of a publicly financed, single-payer universal health care program, a position consistent with the name and organizational mission of PNHP.

The report acknowledges this advocacy context as a study limitation, noting that its survey was distributed through non-random, non-probability-based sampling that included the organization’s own membership networks, which may have attracted physicians who already share its policy views.

PNHP cites factors in Oregon, a state that “has experienced rampant financialization of health care systems, with several high-profile health care buyouts by large corporate entities.” Among the players: Amazon; OneMedical, a membership-based primary care chain of five clinics; and UnitedHealth Group subsidiary Optum, which has an aggressive ownership and growth plan there.

Oregon also has enacted some of the nation’s strictest controls on corporate practice of medicine, and has been edging closer to establishing universal health care at the state level, the PNHP report said.

PNHP notes that the particulars of geography, specialty and practice setting may not be representative across the country. The sample of doctors may underrepresent those who have already left clinical practice, the report said.

Moral injury in health care

PNHP uses the term moral injury, which is borrowed from military psychiatry to describe the psychological harm that occurs when a person is forced to act against their deeply held values.

“Physician moral injury arises when physicians are prevented from delivering evidence-based, optimal patient care due to systemic constraints beyond their control — particularly those imposed by profit-driven goals of the health care industry,” the report said, citing the work of researchers Wendy Dean, M.D., and Simon Talbot, M.D., who first applied the moral injury framework to medicine in 2018.

The report argues that framing physician distress as burnout rather than moral injury has led to ineffective interventions and allowed underlying system failures to go unaddressed. PNHP distinguishes the two conditions on both cause and symptom. Burnout manifests as exhaustion, depersonalization, and diminished personal accomplishment. Moral injury produces guilt, shame, loss of meaning and erosion of professional identity. It stems not from overwork but from being systematically prevented from fulfilling one’s professional obligations.

Standard burnout frameworks locate the problem within the individual physician and prescribe individual-level fixes such as resilience training, mindfulness, reduced duty hours and wellness programs. These approaches, the report argues, have consistently failed to slow physician attrition precisely because they treat a systemic problem as a personal one.

“There’s no amount of yoga that will make me less distressed about how my patients are harmed,” one family medicine physician said in an interview quoted in the report. “My staff is harmed. I’m harmed by this system.”

https://medicaleconomics.com…

Trump Policies Harm to Lung Health

This new article highlights the myriad ways that the current federal administration’s actions harm lung health – by reducing health insurance, vaccines, environmental protections, tobacco and TB controls, and research. The time for single payer health care is now!

Implications of Year 1 Trump Administration Policies for Americans’ Lung Health, American Journal of Respiratory and Critical Care Medicine, March 3, 2026, by Adam W. Gaffney, et al

In 2025, the Trump Administration undertook multiple actions with major ramifications for the pulmonary health of Americans.

The “One Big Beautiful Bill Act” (OBBBA), signed into law by President Trump on July 4, 2025, will terminate healthcare coverage for many low-income Americans with lung disease. The administration’s rollback of environmental protections and reduction in subsidies for clean energy production will worsen air quality and accelerate climate change. Cuts at the Centers for Disease Control and Prevention (CDC) could disrupt occupational health protections and tobacco and asthma control efforts; the Department of Health and Human Services (HHS) leadership’s embrace of anti-vaccine theories will drive vaccine-preventable illness. The termination of federally-funded research grants, including some focused on respiratory diseases, could slow medical progress. And sweeping disruptions to global health aid may impede global tuberculosis control.

In this article, we assess the likely impacts on Americans’ pulmonary health, across the life course, of policies proposed or enacted in the first year of the second Trump Administration, drawing on peer reviewed studies, media reporting, Congressional Budget Office (CBO) reports, government agencies’ impact analyses, and our analyses of national survey data.

Discussion

Lung disease is a leading cause of suffering and death. Policies pursued or enacted during the Trump Administration’s first year will likely increase pulmonary morbidity and mortality, and widen already growing inequalities in lung health and care. These policies — a form of pulmonary structural violence — strip away essential measures that protect the respiratory health of all Americans, from infancy through old age: they appear set to degrade patient care, worsen air quality, accelerate climate change, increase vaccine-preventable and exposure-related respiratory illnesses, undermine tobacco control, upend global TB control, and hobble scientific progress on lung disease.

Such harms — particularly to the developing lungs of children — will long outlast the Trump Administration. In contrast, corporations facing relaxed pollution standards stand to benefit, as do wealthy individuals who are unlikely to work in dangerous jobs or live in polluted areas and who are the primary beneficiaries of tax cuts.

The pulmonary and critical care medicine community — including our already outspoken professional societies — should respond vigorously to this crisis. We must amplify the urgent message that these actions are inflicting imminent harms on our patients. Research should track these policies’ impacts and the magnitude of their harms. Finally, we should advocate for alternative policies informed by decades of research to not only restore, but improve and expand care for every patient with respiratory disease, safeguard workers’ lungs, fight tobacco use, and ensure clean air for all.

Comment:

By Don McCanne, M.D.

Hey! Have you heard that the United States has by far the most expensive health care system in the world – a system that is one of the poorest performing in the industrialized world? Of course you have. What is almost unbelievable is that we have elected an administration that is further compounding the poor performance, as exemplified for lung disease in today’s article.

This is astonishing considering that we have known for decades now how to convert to a high performance system which would be affordable to all by paying for it with progressive income and wealth taxes, which would make health care available to those with low incomes while budgets can be managed by eliminating the profound administrative waste and excess profits of the middlemen, such as the private insurance industry and private equity, that drains our health care dollars to create private wealth for the surplus, wasteful intermediaries. The increased tax assessment for the multimillionaires and billionaires would be enough to meet the deficiencies in tax revenues from lower income individuals, yet would have absolutely no negative impact on the lifestyles of the very wealthy. This would be especially fair considering the great increase in wealth disparities over recent decades.

What is different this time is that we have a window of opportunity to actually reform health care because the incompetence of the current administration has made it obvious to the majority of the public that we have to do something to make health care affordable for all, and that something requires removal of the gross mismanagement of the current administration.

If we want high quality health care that is accessible and affordable for everyone, now is the time to act. Why now? We have the midterm elections coming up shortly. We need to work together elect a Congress that will create the legislative proposal that will enact a single payer, improved Medicare for All. They will have two years at which time we can replace our dysfunctional administration with one that really cares about the people. Our current president has created a political atmosphere in which it is now obvious that a health care system for all of the people has become a mandate. This is the greatest political opportunity we have had to finally get reform right. Prior opportunities, even if well meaning, have fallen back into the false safety zone of incremental reform. Such incrementalism has left us with the most expensive system yet with miserably failing performance.

We no longer have to accept mediocrity. We can truly create a comprehensive healthcare system that is accessible to everyone, and it can be paid for (wait for this!) without creating financial hardship for anyone! NOW is the time to move forward. Don’t just sit there thinking about what we should do. We know what we need to do. The most immediate task is to select midterm candidates who, regardless of political affiliation, support beneficial policies that will get us where we need to be. Again, when is that? It’s NOW!

https://healthjusticemonitor.org…

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47% of physicians say employer puts profits over patients: Study

By Patsy Newitt
Becker’s ASC Review, March 19, 2026

Physicians across the United States are experiencing a deepening crisis of moral injury, and they believe profit-driven healthcare systems increasingly block them from delivering the care their patients need, according to a sweeping new study by Physicians for a National Health Program, an advocacy organization of more than 20,000 physicians, medical students and health professionals who support a universal, single-payer national health program.

The March 17 report, which surveyed more than 1,200 practicing physicians and included focus groups, found that nearly half of physicians often or always feel unable to provide their patients with the best possible care, with two-thirds reporting moderate or severe distress as a result.

The study draws a sharp distinction between burnout — which implies individual depletion and is typically addressed through wellness initiatives — and moral injury, which the authors define as the distress physicians experience when they know what their patients need but cannot provide it due to constraints outside their control.

Physicians in the study were pointed in their rejection of burnout framing; as one family medicine physician said, “When we talk about burnout, it makes it sound like it’s my fault or my colleagues’ fault. The term points to the person being affected. It’s a form of victim shaming.” Notably, 40% of surveyed physicians often or always felt frustrated by the wellness activities their employers offered, saying they simply didn’t help.

The survey was distributed through a non-random, multi-modal recruitment approach using PNHP’s professional networks, medical societies including the Society of General Internal Medicine and the American College of Physicians, listservs, social media, and snowball sampling. It adapted eight items from the validated Measure of Moral Distress for Health Care Professionals and added 14 new questions capturing system-level pressures, financial constraints and administrative burdens. The mean overall moral distress score was 143, compared to 96 in the 2019 benchmark study, suggesting a significant worsening over time. For 18 of 22 survey questions, the most common distress rating was “very distressing,” the maximum level possible.

Here are 10 key things to know from the survey:

1. Forty-seven percent of surveyed physicians indicated their employer often or always prioritized financial goals over best patient care, and 50% felt betrayed by a healthcare system that hindered their ability to provide good care.

2. Additionally, 62% experienced moderate to severe distress over cost-cutting pressures from administrators or insurers.

3. Of the surveyed physicians, 45% often or always felt unable to provide patients with the best possible care, and 68% experienced moderate or severe distress as a result. An additional 47% often or always felt unable to provide optimal care simply due to inadequate time.

4. Forty-four percent of physicians often or always felt that lack of insurance approval blocked medically necessary services, and 51% often or always experienced excessive documentation requirements that compromised patient care.

5. Of the surveyed physicians, 35% often or always felt required to care for more patients than they could safely handle, and 43% often or always felt required to overemphasize productivity metrics at the expense of patient care.

6. Forty-five percent often or always encountered lack of resources or bed capacity that compromised care, and 43% said leadership often or always failed to respond supportively when such failures occurred. Three in 5 physicians experienced moderate or severe distress contemplating these situations.

7. The mean overall moral distress score was 143, compared to 96 in the 2019 benchmark study, suggesting a significant worsening. For 18 of 22 survey questions, the most common distress rating was “very distressing,” the maximum level.

8. On attrition, 27% of physicians had already left a position due to moral distress, 25% are currently considering leaving for the same reason and 42% had previously considered leaving but chose to stay. The workforce consequences are tangible: physician departures have contributed to clinic closures, elimination of services, and dramatically longer patient wait times.

9. Fifty-seven percent of physicians reported moderate or severe distress from working in systems that failed to treat vulnerable patients with dignity, and 41% often or always felt complicit in the structural racism their systems perpetuated. Physicians described patterns of race-based misdiagnosis, discriminatory care based on insurance status, and the rationing of life-sustaining treatment for uninsured and undocumented patients.

10. Nearly half of practicing physicians reported often or always making diagnostic or treatment recommendations they knew their patients would not be able to pursue, due either to insurance barriers or financial toxicity, and for 7 in 10 of those physicians, this provoked moderate or severe distress.

https://beckersasc.com…

HJM Wants to Hear from You

We regularly discuss the latest news and research on problems with health insurance and prospects for single payer. We’ll keep doing that. But we also want to understand what you’re observing, contemplating, and striving for. So today we ask you to chime in.

Three open-ended questions; please provide your thoughts. Send responses to healthjusticemonitor@gmail.com.

1) What problems with current US health insurance do you find most vexing & motivating – i.e., causing the worst harms (health and/or financial), provoking the most intensive frustration with current insurance, boosting popular desire for universal public insurance?

2) How does the current broad political context harm or advance universal public insurance efforts? E.g., an aggressively conservative federal administration (including cuts to public insurance); a determined progressive response; shifting electoral terrain.

3) Your strategic / tactical ideas: What methods to promote reform will break the 60-year impasse on universal health insurance? E.g., federal vs state action; all-at-once vs incremental steps such as lowering the Medicare age or universal primary care; highlighting the moral imperative vs system design optimization?

We will summarize and synthesize the responses and report back to HJM readers. We’ll use respondent names only with permission.

Thanks!

https://healthjusticemonitor.org…

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Chicago City Council testimony in support of Medicare for All

By Claudia Fegan, M.D.
Chicago City Council, Committee on Health and Human Relations, March 10, 2026

My name is Dr. Claudia Fegan, I retired in December of 2024 after 12 years as the Chief Medical Officer of Cook County Health, and 24 years with the system. I am the National Coordinator of Physicians for a National Health Program, a national organization with over 25,000 members, based here in Chicago. I am grateful to all the members of this committee who have already signed on to Alder Cruz’s Resolution Supporting Medicare for All. While many people think access to health care is a national issue to be addressed by congress, this is a crucial issue for Chicago, and I’m thankful for the opportunity to address you today and explain why it is so important to address now, prior to the midterm elections.

As the resolution points out, the city of Chicago spends over $600,000,000 annually to provide health insurance to city employees. Think for a moment what the city could do with those funds if we had universal health care, if employers were no longer expected to pay for their employees to have access to health care. Employers are not expected to be responsible for the education of the children of their employees or guarantee their access to police or fire protection. What could Chicago do with an extra $600,000,000?

A poll of voters from November 2025 showed 90% of Democrats and the majority of independent voters support Medicare for All. Voters want to regain control of their health care and lower costs. We are the only industrialized country that does not guarantee access to health care for everyone living within our borders. Not just every citizen, everyone living here. We already spend enough on health care; we spend more money per person than any other country in the world. We allow patients to be denied access to care they need to maximize the profits of the insurance industry.

There has been a lot written about burnout among people in health care. This past year PNHP partnered with the Robert Wood Johnson Foundation to assess that burnout. Surveying over 1100 practicing physicians, we found what has been labeled as physician burnout is often moral injury inflicted by the financialization of the practice of medicine in this country. We found it has harmed the morale of the entire health care workforce, leading to increased shortages and decreased access to care as professionals retire early, cut back on their hours or leave the practice of clinical medicine altogether. Tragically, there are increasing totals of suicides among physicians. More and more, physicians are frustrated by their inability to offer patients the most appropriate care. They are stymied by required prior authorizations that issue inappropriate denials of care, make treatment recommendations their patients cannot pursue and create conflicts between health goals for their patients and the financial goals of the institutions that employ them.

It would be life-changing for Chicago to take the lead here and make a statement by supporting Medicare for All. If the city that sent the first Black woman to the Senate, that first sent Barack Obama to the Senate and then to the White House could send the message that health care is important for everyone, it would have a tremendous impact and continue our local tradition of initiating progress.

The tide is going to turn in this country. We need to build our power and be prepared to take what we need when the opportunity presents itself. We must be represented by people who have the courage to support our agenda. Medicare for All is something representatives have to be willing to fight for. We have a Congress that has acquiesced its power to a president who doesn’t believe in checks and balances. We will not get universal health care while Donald Trump is in the White House. We must be prepared for when Trump is gone. In 3 years, we must be prepared to seize the opportunity when it presents itself.

Last year, one-third of Americans delayed getting care they needed or skipped care entirely. That is the highest number since Gallup started asking questions about this 30 years ago.

I am reminded of a woman I admitted to the hospital one night a few years ago. Both of her breasts were rock hard. They were infiltrated with cancer with palpable lymph nodes in her axilla. She worked as a hairdresser, owned her own shop but had no health insurance. She was sitting at home waiting to die. She believed she had no other choice. She knew she could not afford her care. Her daughter made her come in. Remarkably we were able to get a dramatic response with treatment. No one should ever have to sit at home waiting to die in this country, when we have treatments that can be lifesaving.

Families are desperate for solutions to their everyday health care problems, skyrocketing drug prices, rising copayments and deductibles, surprise medical bills; and are tired of having to switch doctors because of the revolving door of job-based health insurance.

The United States has struggled with the effects of ‘For Profit” Health Care for decades. The country has never embraced access to health care as a basic human right.

In the United States, we know some 28 million people or 8% of the population are uninsured and that 45,000 people die each year as a direct result of not having insurance.

If there is a lesson for the rest of the world to learn from the United States, it is the lesson of the private insurance industry. The insurance companies have a fiduciary responsibility to make as much money as possible for their shareholders. They also determine which patients have access to which care. There is an inherent conflict of interest here. By eliminating the waste and greed of private insurance, we can afford to cover everyone in our country for all necessary care, and end the scourges of surprise bills, skipped medications, and medical bankruptcy. Medical illness or medical debt is the number one cause of bankruptcy in this country, even though the majority of people who declared bankruptcy had insurance at the time of their precipitating illness.

There will always be limitations on how much money is available to spend on health care. Those decisions need to be based on societal need, cost effectiveness and population health, not profits and financial yields.

We already spend enough money on health care in this country; we just allow too many people who do none of the work of delivering health care to take profit from it. I am asking the Chicago City Council to have the political courage to lead the way and to tell our nation that health care needs to be a right for everyone. Thank you so much.

Read the full Chicago City Council resolution HERE.

Sky High ACA Deductible Highlights Need for Universal Insurance

The Trump administration is dismantling financial protections offered by the Affordable Care Act, proposing a $31,000 family deductible. This attack on the economic integrity of families is registering, boosting support for single payer.

New A.C.A. Plans Could Increase Family Deductibles to $31,000, The New York Times, Feb. 26, 2026, by Reed Abelson

The Trump administration’s proposed new rules for Obamacare plans next year would shift more health care costs to Americans, with much higher deductibles that could lead to greater medical bills.

Under the proposal, people who rely on the Affordable Care Act for their health insurance coverage could choose plans with much lower monthly premiums. But that could leave them exposed to medical expenses totaling thousands of dollars more than A.C.A. plans do now before their insurance would kick in.

Dr. Mehmet Oz’s new proposal would allow one kind of health plan to raise the annual deductible to more than $15,000 for an individual and $31,000 for a family.

The proposal involves a type of plan known as a catastrophic or skinny policies. Amitabh Chandra, a Harvard health economist who has studied high-deductible plans, said, “It’s going to be a really cheap product that nobody wants.”

“There’s no doubt that we have an affordability crisis. As we move forward to shifting more of the burden to patients, there’s a chance to really exacerbate the crises,” said Dr. Joseph R. Betancourt, the president of the Commonwealth Fund.

The proposal could also erode other consumer protections. Overall, the rules could result in up to two million people dropping coverage in 2027, according to the administration’s own estimates.

Selected quotes from the NYT reader comments:

  • “This won’t work without price controls for health care, which is best achieved by a universal health care system run by the government.”
  • “
it is time for universal health care.”
  • “Grow up USA – figure out how to do a nationalized health care.”
  • “Medicare for All please.”
  • “— we need UNIVERSAL HEALTH CARE.”
  • “America desperately needs universal health care.”
  • “Can’t we just provide single payer health care
”
  • “There’s no winning the health insurance battle until we get universal health care.”
  • “Why not look at other countries that have universal health care and build our own similar system?”
  • “Medicare for All, now.”
  • “I’m a 75 year old retired Canadian who hasn’t paid out of pocket for any of my medical care and several surgeries over the years. Health care in my opinion is a human right.”

Comment:

By Don McCanne, M.D.

What is the leading health care concern in the United States? It is high costs + high deductibles + copays, which translates to 
 unaffordability and family economic risk.

Those least worried are the wealthy who comfortably pay for quality health plans and out-of-pocket costs. Also, those of us who remain healthy and don’t require much care are generally protected from growing personal expenses, though we all still pay taxes for public programs, such as Medicare, Medicaid, and the VA. Plus there is no guarantee that the healthy won’t eventually face truly expensive medical problems. In fact, that’s a likelihood.

The very poor may be eligible for public programs such as Medicaid. However, this is no longer assured, with recent federal cuts to coverage for the near-poor. Also: some states have declined federal funds for state Medicaid programs, and some areas lack providers who are willing to accept Medicaid. On top of this, Medicaid often underfunds essential health care services, shifting costs to the rest of us.

Moderate-income individuals and families may have employer-sponsored plans, but these costs are paid for by reductions in salaries. The costs of premiums, deductibles, and copays continue to increase. As workplace plans became less affordable, many were able to obtain plans through the Affordable Care Act. Government subsidies, especially during the Covid pandemic, made these plans more affordable. However, recently Congress split in continued support of the subsidies, and they were allowed to expire. Millions are losing ACA insurance simply because they can’t afford the premiums and cost-sharing. Thus we have an increasing crisis in the funding of health care.

Since it was primarily the Republicans who ended the COVID ACA subsidies, we should ask about their proposals to address this funding problem. However, they have been quite vague on what they do propose. President Trump mentioned very modest cash distributions to citizens so that they can place their funds in health savings accounts and use them to purchase their own insurance plans or pay for care directly. Any reasonable analysis of this proposal shows that it would be grossly inadequate to pay for the health care of anyone with significant needs. Thus, it would defeat the concept of health insurance – pooling funds to make essential, expensive health care accessible to those who need it.

This latest ACA scheme, from Dr. Oz and colleagues, would greatly increase the deductible before care is paid for. This would force funding of most routine care to come out of the pockets of most Americans – mainly individuals with low and moderate incomes. The proposed amount for the deductible for a family would be $31,000. With all other essential costs rising, how would $31,000 be handled by a family with an income of, say, $60,000? We already have the tragic answer to that: severe financial hardship and bankruptcy.

Keep in mind that a universal health care system funded with equitable, progressive taxes does not produce financial hardship for anyone.

People increasingly understand the need for broad reform. Many readers responding to the NYT article advocate for universal health care. Recent polls indicate that a clear majority support Medicare for All, especially among Democrats, but also increasingly among Independents and even Republicans. Truly, what Republican wants to see a child in bankruptcy court because a beloved grandchild was unfortunate enough to develop a serious and expensive disorder? Even $31,000 for a young family that is launching its blissful voyage through life can be a profound hardship. Surely we can agree on a program that will take care of all of us!

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.

It’s the Prices and More

A blog post in Health Affairs highlights high US prices as the cause of massive healthcare costs. There is truth in this view. However, the problems plaguing US health care are far beyond prices. And, the price problem itself would be mitigated with single payer.

The US Health Spending Problem Is Still About Prices, Health Affairs Forefront, Feb. 18, 2026, by Irene Papanicolas, Jonathan Cylus, and Luca Lorenzoni

For more than two decades, debates about why US health care spending is so high have been shaped by the insight articulated by Gerard Anderson, Uwe Reinhardt and Peter Hussey: that the United States does not use more health care than other high-income countries but pays much higher prices for it. The original “It’s the Prices, Stupid” argument was fundamentally about price levels, not price growth. That central insight remains as true today as when it was first articulated: across services, drugs, and inputs, the United States consistently pays substantially higher prices than its peers for comparable services, drugs, and inputs.

Recent estimates of US national health expenditures, produced by the national health expenditures (NHE) team at the Centers for Medicare and Medicaid Services, have reignited debate about what is driving spending growth, which is a related but distinct question. In his recent Health Affairs Forefront piece, “It’s Not the Prices, Stupid,” Michael Chernew argues that utilization and intensity, rather than prices, are the primary explanation for recent expenditure growth.

While we agree that understanding what drives expenditure growth is essential for sound policy, we worry that this framing risks conflating growth dynamics with the underlying reason the United States spends so much on health care in the first place: price levels that are far higher than those paid in other high-income countries.

Health care spending reflects the interaction of prices and volume. In practice, when researchers decompose spending growth, volume typically encompasses both the use and the intensity of care delivered, with intensity referring to changes in the mix or complexity of services per episode.

Although it is lumped together with use, changes attributed to intensity may reflect shifts in service mix, coding practices, payment design, or the adoption of new technologies—many of which operate through higher prices per episode rather than greater quantities of care.

While the NHE estimates do account separately for the administrative spending incurred by payers and insurance, they are not able to do the same for provider-facing administrative costs, such as billing, coding, and prior authorization compliance; instead, these administrative costs are embedded in estimates of provider spending.

There are real consequences of erroneously focusing policy attention on the use and intensity of care as the driver of exorbitant expenditure growth. By suggesting the use and intensity of care as the culprit, decisionmakers may perceive coverage reductions and higher co-payments as the solution to reduce demand. This will result in less access to care and worsen health outcomes, when the real cause of high spending growth is that the prices paid for care exceed the value they provide.

Health Affairs Online Comment:

By Don McCanne, M.D.

Of course, prices, utilization and intensity all play some role in the cost of health care. But limiting attention to such factors, as we now do to some extent, has resulted in the most expensive health care system in the world with performance of the system ranking near the bottom of industrialized nations. What we really need is structural reform. A single payer financing system can control costs while maintaining high performance through much lower administrative costs, stronger negotiating power, limiting profit from basic coverage while covering costs, universal risk pooling, and emphasis on primary and preventive care. It’s astonishing that we are not supporting reform that would work well for everyone and instead we support reform that enables enrichment of superfluous passive investors and private equity through diversion of our health care dollars. Isn’t it time for Health Affairs to expand its coverage to such patient-friendly models that would greatly improve efficiency and value for our health care spending?

https://disqus.com…

Comment:

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

The renewed emphasis on prices in medical care brings back thoughts of free markets in health care as preached by Milton Friedman. But in a previous HJM post we highlighted that a universal, publicly financed and publicly administered program, as advocated by Kenneth Arrow, will bring us universal coverage, low administrative waste, removal of excess profits, and protected health care access as a social good – features not found in a free-market based system.

The Arrow model relieves us of the need to be concerned about prices because the legitimate costs are already built into the health care delivery system. Thus price shopping is an unnecessary feature that can be omitted from consideration when accessing health care. Rather than being concerned about prices in the marketplace, the patient’s concern is only about access since the payment has already been made through progressive taxes based on the ability to pay. Thus health care is always readily available to everyone without having to face the potential hardship of market prices since they will have been addressed by our public negotiators, as the growth in utilization and intensity will have been similarly addressed on our behalf. After all, negotiators representing all of us should certainly have a greater impact than any of us negotiating on our own. And for those worried about government negotiated expenses, remember that the savings come from reducing waste that is currently going to the investors, private equity and superfluous administration.

P.S. from Jim: The article states “NHE estimates 
 are not able to [quantify] provider-facing administrative costs, such as billing, coding, and prior authorization compliance 
”. Hence costs attributable to administrative bloat imposed by complicated insurance are not highlighted. However, provider billing and insurance-related (BIR) administrative costs have been quantified. I’ve done much of that work with colleagues. The excess (and hence avoidable) provider BIR burden is ~10% of all spending. E.g., see a 2014 review here. It seems to me that if we need to discuss prices (and we do), we must highlight the wasteful BIR portion, which of course disappears with 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.

When Oh When Real Reform?

Health insurance reform has taken a decades-long, winding, and pot-holed road. Most recently, Obama’s Affordable Care Act grew private insurance & Medicaid, yet affordability worries are worse than ever. 2025 saw cuts to these modest gains. Are conditions coalescing for real reform?

How Much Longer Will Americans Wait for Real Health Reform?, Health Care un-Covered, Feb. 20, 2026, by Trudy Lieberman

Kudos to Merrill Goozner, former editor of Modern Healthcare, for spotlighting a grim but important story on his Substack column GoozNews. “A year spent degrading health” is a damning picture of the U.S. health care system 


Below is an excerpt:

  • Two snapshots of a health care system in precipitous decline: First, the latest Kaiser Family Foundation tracking poll shows Americans’ number one pocketbook concern is now the cost of health insurance and out-of-pocket health care expenses. Fully two-thirds of the public are more worried today about health care costs than food, housing, utilities or gasoline.
  • Second, the Centers for Medicare and Medicaid Services reports that 1.2 million households dropped health insurance coverage during the 2026 sign-up season, a direct result of the Republican Congress ending the enhanced premium subsidies for Obamacare plan purchasers. The missing 1.2 million came from just 30 states that use the federal exchange.


 Now Medicaid, which was passed in the mid-1960s along with Medicare for the elderly, is in jeopardy because of provisions in President Trump’s One Big Beautiful Bill Act that reduced funding for the program.


 Will Americans pay medical bills for the rest of their lives while the profit concerns of big companies continue to overshadow the needs of ordinary Americans who just want a health system that takes care of their medical needs?

Comment:

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

This is, as a colleague aptly characterized it, a “cri de coeur” – a painful and plaintiff cry from the heart, lamenting our dire situation. Who could have foreseen that Obama’s reforms and expansions to public and private insurance would leave hundreds of millions so deeply worried about health care costs? Many single payer advocates (myself included) said that the ACA tweaks were insufficient, costly and complex. But we (or at least I) failed to anticipate the worsening of health care financial woes.

As we’ve often written in HJM, other wealthy nations (in the OECD) use a well-proven and clear strategy: a standardized comprehensive benefit package, with affordable cost-sharing, overseen by a public payer or a network of private insurers acting under not-for-profit rules. That’s the formula. It works.

Why don’t we follow that model? As Trudy Lieberman writes, because of the interests of large corporations. They make tens of billions in profits, and impose many times that in administrative complexity. Hence decades of insurance tweaks at the margins. And with the new administration, retrenchments. More people are uninsured, and many more are under-insured, with sky-high deductibles and cost-sharing.

Yet, I’m optimistic. The pain so many of us feel with high health care costs and worsening insurance is registering widely as evidence of the abject failure of our current system. The collaborative response to the current administration’s excesses is building coalitions and empowerment. Progressive political candidates are surging. Several states are designing universal health plans.

This isn’t a post about technical insurance details (always time for that later). Instead, it’s about staying the course, seeking and creating action openings. Health care reform bringing affordable universal coverage is in our future. It is for us to manifest through values and determination. And change strategy – another technical topic, coming soon.

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.

The Birth and Death of Single-Payer in the Democratic Party

In 1988, Jesse Jackson ran for president on a platform of uniting workers and pushing universalist policies like single-payer. His success terrified neoliberals in the Democratic Party.

By Vicente Navarro
Jacobin, May 5, 2020 (accessed Feb. 17, 2026)

In 1984, I became the health adviser to Jesse Jackson’s presidential campaign after Dr Quentin Young, one of my best friends and a well-known progressive physician in Chicago, suggested that the three of us meet. Quentin knew Jesse very well. Besides serving as Jesse’s personal physician, Quentin had developed a close working relationship with Jackson. Jesse had (and has) a very engaging personality, and Quentin was known for his persuasiveness. I accepted their proposal to advise Jesse in the Democratic Party primaries — an experience that became my baptism of fire in American politics (I had arrived in 1965 as a political exile from Franco’s Spain).