PNHP

Government Shutdown Pivots on ACA Premium Subsidies

Government Shutdown Pivots on ACA Premium Subsidies

The federal budget stalemate and associated government shutdown are pivoting entirely on the role of the government in supporting ACA health insurance premiums. The Dems and voters say yes; the GOP says no. Is health reform building a big head of steam?

At Stake in the Shutdown Fight: Obamacare Prices That Could Rise by Thousands of Dollars, The New York Times, Oct. 1, 2025, by Margot Sanger-Katz & Alicia Parlapiano

Democrats say they will not vote to end the government shutdown unless Congress extends extra Obamacare subsidies that are set to expire next year. Republican leaders have said the subsidies shouldn’t be a part of legislation to reopen the government, though several individual lawmakers are open to the idea.

Should the extra subsidies expire, how much more will people with Obamacare plans pay?

The subsidies, first passed in 2021 and extended in 2022, make health insurance less expensive for nearly all those who buy their own coverage. Since the subsidies’ creation, enrollment in Obamacare markets has more than doubled.

Extending the subsidies would cost the federal government … about $350 billion over the next decade, according to estimates from the Congressional Budget Office. But, without them, many Americans will face much higher costs before the midterm elections next fall — in some cases, increases of more than a thousand dollars per month.

Despite Budget Concerns, Three-Quarters of Public Say Congress Should Extend the Enhanced ACA Tax Credits Set to Expire Next Year, Including Most Republicans and MAGA Supporters, KFF, Oct. 3, 2025

7 in 10 Marketplace Enrollees Say They Could Not Afford Coverage if Their Premiums Doubled; 4 in 10 Say They Would Expect to Be Uninsured

More than three-quarters (78%) of the public say they want Congress to extend the enhanced tax credits available to people with low and moderate incomes to make the health coverage purchased through the Affordable Care Act’s Marketplace more affordable, a new KFF Health Tracking Poll finds. That’s more than three times the share (22%) who say they want Congress to let the tax credits expire.

Comment:

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

For the last two weeks, my focus has been on a major medical issue facing my wife, so HJM has paused. We restart with this post on a health insurance issue currently central to US national politics, and will aim to maintain a steady flow moving forward.

In recent weeks, health insurance has been THE driving issue in the federal government shutdown, which was precipitated by a stalled budget bill for the 2026 fiscal year (started October 1). The sticking point is that the GOP failed to extend COVID-era Affordable Care Act premium subsidies benefiting 13 million individuals. The Democrats in the Senate – whose votes are needed to pass the bill – insist on maintaining the subsidies. They are convinced that highlighting this policy debate will harm the GOP, which appears indifferent to premium jumps of 100% or more. Public opinion polling suggests overwhelming support for extending the subsidies — 92% among Democratic voters and 59% among Republicans. If the budget passes without ACA subsidies, the GOP likely will be blamed for the jump in premiums, which will occur in January 2026 (years before Medicaid cuts passed earlier in 2025), perhaps influencing the 2026 congressional elections.

This is remarkable – a major showdown on federal government subsidies for health insurance. Unlike much of current US politics, it is actually a policy issue: Should the government broadly subsidize health insurance? The message from voters is an adamant “yes.” The GOP seems indifferent; the Dems seem determined.

Is this a pivotal moment where health insurance tips the political scales? It’s too early to say. In the short term, we don’t know who will win the budget bill fight, or what a compromise might look like. And we don’t know how the battle over subsidies will influence the 2026 congressional midterms. Or the 2028 presidential election.

Nonetheless, I’m quite encouraged by the stand that some politicians are taking in favor of broad health insurance, and the public’s extremely supportive reaction.

In an upcoming post, I’ll review how politicians are talking about health insurance. Lots of creative efforts there.

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.

Missouri can save money and improve care by cutting the middleman out of Medicaid

By Ed Weisbart, M.D.
Missouri Independent, Oct. 21, 2025

What would you say if I told you it’s possible to cut $250 million from the Missouri Medicaid budget while also improving the health of people on Medicaid? All we need to do is cut out the middleman by not renewing our state contracts with insurance corporations like Centene, Blue Cross and United Healthcare.

Over the past decade, the corporations running Medicaid nationally averaged an astronomical overhead rate of 13%. On top of that, Missouri spends untold millions of dollars overseeing these corporations.

All this waste disappears if we switch to an enhanced form of the fee-for-service model that Missouri Medicaid currently uses for our aged, blind and disabled people. Other states, such as Connecticut, have cut out the middleman and run their Medicaid programs with a total overhead of 4-6%. Since 2012, that tiny state has saved $4 billion.

Connecticut did this without a significant increase in state agency staffing by outsourcing much of the work to private commercial businesses called “Administrative Services Organizations” that are paid a flat fee for a defined service, avoiding the conflicts of interest inherent in so-called “managed care” organizations.

States like Missouri that allow insurance corporations to run their Medicaid program have consistently seen higher and more rapidly growing expenses. Between 2004 and 2015, counties that outsourced their Medicaid program to insurance corporations had their costs rise $1,584 per person per year above what was being spent in comparable counties that avoided this trap.

By switching to enhanced fee for service, we would have to absorb some of the administrative functions done by insurers, but we would also stop spending anything on insurance company overhead and oversight. On balance, we could expect a modest increase in administrative expenses but save between 10-17% of total costs.

In total, after accounting for the portion of savings that would go back to the federal government (they fund the majority of Medicaid), our state would save between 152 and 258 million dollars per year, in 2023 dollars.

We’re not the only state in this position. Nationwide deprivatization of Medicaid would annually save all states combined as much as $34 billion and the federal government as much as $43 billion, for a total of $77 billion for the country.

To be clear, that’s not enough to completely mitigate the recent federal cuts to Medicaid funding – but it would go a long way. Without this approach, we face a range of unpalatable alternatives.

We could instead cut the “optional” Medicaid benefits like pharmacy, dentistry, physical therapy, occupational therapy, and hospice care. Sadly, many states facing a budget crisis decide to cut long-term home health services, a self-defeating strategy as these are the very services that keep people from being institutionalized at even higher costs to the state.

Or we could cut more people from Medicaid.

Or we could cut back on what we pay doctors, though many people on Medicaid already have difficulty finding a physician who accepts Missouri’s paltry Medicaid fee schedule.

Or we could cut back on what we pay hospitals, but Missouri already has too many hospitals at risk of closure. Cutting their funding would accelerate the crisis, particularly in rural communities.

Or we could reduce state funding for other essential services, like education.

Or we could raise taxes.

None of these choices are acceptable. Removing managed care organizations from Medicaid would protect the entire healthcare system while saving us hundreds of millions of dollars per year.

As striking as those numbers are, it’s not just about money. Removing the insurance industry’s barriers to care has been shown to attract more physicians into Medicaid, increase early diagnosis of cancer, and improve overall health.

I worry about people like my 31 year-old patient with juvenile diabetes who works as a self-employed roofer. Before Missouri expanded Medicaid, he frequently resorted to taking his insulin every other day. No physician wants to see people go back to rationing a life-saving medication.

The politics seem daunting, given the prominence of large insurance corporations in Missouri. But remember, Connecticut found a way to do this in 2012, and that state is often considered “the insurance capital of the world.”

If they could figure out how to make it happen, Missouri can, too.

Dr. Ed Weisbart is a retired family physician in Olivette and board secretary of Physicians for a National Health Program.

https://missouriindependent.com…

We’re the Lucky Ones

Health insurance in America is fantastic … for me and a few others. It can and should be for everyone.

Comment:

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

My wife just got a very serious medical diagnosis.

We’re lucky:

  • World class clinical care at UCSF (with no network restrictions).
  • No financial worries. We have great insurance – $0 deductible, minimal copays.

Shouldn’t it be that way for everyone?

We know it’s affordable, as demonstrated repeatedly.

Let’s overcome the avarice and cruelty.

(This of course led to the HJM pause; will resume shortly.)

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.

German Hospital Reform—Going Global

Germany, facing high hospital costs and overcapacity, recently passed a law shifting payment from solely patient diagnoses to primarily global budgets. The US can learn from this shift, especially since single payer anticipates hospital and overall global budgets.

Germany begins major reform of its hospital sector, DW – Health Germany, Nov. 22, 2024, by Ben Knight

The German parliament has passed a law aiming to reorganize the health sector, slashing the number of hospitals, boosting clinics and digitalizing bureaucracy. [Now former] Health Minister Karl Lauterbach called it a “revolution” … with gradual implementation starting January 2025 and ending in 2029.

The two-pronged hospital reform will change the way German hospitals are financed and impose new care standards.

Germany has the highest number of hospital beds per capita in the European Union, at 7.9 beds per 1,000 inhabitants, compared to the EU average of 5.3. But maintaining these is expensive. According to Lauterbach, this has left many hospitals on the brink of bankruptcy. The result is that patients are being kept in hospital unnecessarily so hospitals can charge health insurers extra money — which in turn drives up the whole country’s health costs and insurance contributions.

The reform means that hospitals will no longer be paid per treatment — instead, they will get a guaranteed income for making certain services available. This, it is hoped, will alleviate the financial pressure on hospitals to pack in as many operations and treatments as they can, even if they are poorly qualified to carry them out

This measure is supposed to ensure that patients needing complex treatments are referred to specialists earlier. This, according to the Health Ministry, will reduce health costs in the long run, as patients stand a better chance of being cured and are less likely to fall victim to mistakes, as hospital staff will be less rushed and overworked. Lauterbach has claimed this reform will save tens of thousands of lives a year.

Lauterbach: Hospital Reform Law Will Save Rural Hospitals, Kommunal.de, July 31, 2024

[Now former] German health minister Karl Lauterbach:

“It is precisely the goal of the reform to protect care in rural areas. Without the reform, many rural hospitals would not survive because of rising personnel costs and inflation. We are currently experiencing the steepest cost increases in the hospital sector ever in German history. All that, despite the fact that 30% of the beds sit empty. If we do not pass this reform, the precarious financial situation of many hospitals will only get worse. Then it is foreseeable that two out of three hospitals would face deficits, as it now almost is. With the reform, the necessary rural hospitals will stay solvent. I therefore predict that the majority of rural hospitals will remain.”

Comment:

By Thomas Lane 

Last year, Germany’s parliament passed a landmark hospital payment reform to shift from a purely diagnosis-based system to mainly global budgets. This addresses serious problems similar to those facing US hospitals – high costs and the financial viability of rural hospitals. Remove the references to Germany in the Lauterbach interview, and it could be about the US. Despite having universal healthcare, Germany relies on a multi-payer system (albeit which provides standardized broad coverage and generates no insurer profits). There are important structural parallels between the US and Germany, such as how hospital stays are compensated. The strategies which Germany uses to control costs offers lessons for the US quest for single payer.

Germany has more hospital beds per capita than most wealthy nations, so a key problem is wasteful spending on hospital overcapacity. Before the reform, Germany’s countless small local hospitals were funded solely via patient-level DRG (diagnosis-related group) payments. In pursuit of patient volume to stay financially afloat, many would treat complicated health issues for which they were inadequately equipped. It’s not hard to see how the new law was quite controversial. Reducing overcapacity means allowing some allegedly unviable or excessive hospitals to close. However, the law simultaneously protects hospitals in underserved areas (mainly rural regions) by replacing the current DRG payments with a mixed 60% global budget and 40% DRG scheme. Perhaps surprisingly, Germany’s government seems set to mostly continue with the reform despite the elections and change in governing coalition that occurred after the law’s passage.

What might we learn from watching Germany’s hospital reform law as it is implemented? The U.S. has far fewer hospital beds per capita than Germany, and I am not trying to imply that the US has too many hospitals. But we do share a misallocation of hospital resources in common with Germany. Wealthy, often suburban regions tend to have the most and best hospitals in America, while our rural hospitals are constantly on a knife’s edge, and many urban safety net hospitals are similarly struggling. To maximize the benefits of single payer, we will need to think about this allocation issue in addition to accomplishing the main goal of efficiently funding necessary care for all. After all, handing out Medicare cards to people in areas without a nearby hospital doesn’t help them much! This has become even more important given the looming cuts to Medicaid and the wave of safety-net hospital closures that will likely follow.

The most recent Medicare for All bill in Congress wisely puts hospitals on global budgets to protect our struggling facilities in underserved areas.  At the same time, global budgets can prevent already well-resourced areas from capturing new resources that are better used elsewhere, as they require hospitals to explain everything they are doing and make choices about what to fund (or not) with their now predictable but limited budgets. By observing how the Germans handle this transition, noting successes and problems, we prepare for how to best implement single payer in the U.S.

https://healthjusticemonitor.org…

Thomas Lane is a master’s student in the health economics, policy & management program at Sweden’s Karolinska Institute, and an analyst at the Swedish Dental and Pharmaceutical Benefits Agency, the government agency tasked with keeping pharmaceutical costs affordable. He graduated in 2024 with a bachelor’s degree in economics and German from Dartmouth College in New Hampshire. He spent several years working in state-level health reform with PNHP in his home state of Minnesota and in New Hampshire, where he was a member of the Granite State PNHP steering committee. The views expressed in HJM are his own.

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.

Preventable Deaths – Does Magnitude Matter?

A right-wing political leader, Charlie Kirk, was assassinated last week. We do not condone political violence. Nor should we accept the far greater human toll exacted by failed “free-market” health insurance and other fraught societal choices.

Deaths in US (annual) Sources
An assassination 1
Assassinations 9 Durbin 2021
Mass murders 722 (2023) Pew Research 2025
Medicaid cuts 2026 budget 8,000 – 24,000 Gaffney 2025
Gun murders 17,927 (2023) Pew Research 2025
Gun suicides 27,300 (2023) Pew Research 2025
Lack of insurance 45,000 Wilper 2009, Woolhandler 2017
Gun deaths 46,278 (2023) Pew Research 2025
Drug overdoses 105,000 (2023) NIDA 2025
Lack of & Under-Insurance 195,000 HJM 2024

Comment:

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

One murder is too many. I disagreed often with Charlie Kirk, finding many of his statements reprehensible – inaccurate and demeaning. But I certainly never wished him dead, and do not condone his assassination.

Still, I find the aggressive public mourning from conservatives out of step with the scale of the loss. I am baffled that preventable deaths on a magnitude one to tens of thousands times higher are routinely accepted as the price we must pay to preserve favored American values, such as unrestricted gun ownership and a profoundly failed free market in health insurance.

I provide today’s table as a service to myself and HJM readers, to have close at hand the hard numbers – hard in the sense of quantitative, and hard in the sense of troubling.

Please let’s continue, indeed redouble, our quest for a just and efficient health system and other social changes that drastically reduce these painful numbers.

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.

Here’s how many Granite Staters may die due to Congress’ Medicaid cuts

By Thomas Lane and Don Kollisch, M.D.
New Hampshire Bulletin, Sept. 10, 2025

There are a lot of confusing statistics about health insurance, health care costs, access to care, and other features of our complex health care system circulating around right now.

Unfortunately, the actual health of our country’s people and communities is often lost among these mostly financial metrics. One of this column’s authors, Don Kollisch, is a doctor who has practiced family medicine in New Hampshire for more than 40 years. He has worked at medical schools and Veterans Affairs (more commonly known as just “the VA”), but his clinical heart is in the rural North Country of our state, where he worked for many years.

Dr. Kollisch was a believer in prevention and worked hard to control the blood pressure, diabetes, and cholesterol of his patients. One day, covering the ER of his small critical-access hospital, he admitted a man in his 60s who had a stroke that was most likely caused by untreated high blood pressure. The patient lost some speech and some of the use of his right arm and leg. Dr. Kollisch realized, with dismay, that the man lived in a small house near Dr. Kollisch’s own clinic, which he ran 8 miles up the road. The man never came in for treatment of his blood pressure because he worked for a small company and didn’t have health insurance. Food and electricity had to be higher priorities.

If Dr. Kollisch had any doubts previously about the need for everyone in his community to have health insurance, they were permanently dispelled. He became an advocate for expanding publicly funded health insurance to cover everyone, and he is dismayed that current political trends are moving in the opposite direction, toward people losing rather than gaining insurance coverage.

Congress passed and on July 4 President Donald Trump signed the “One Big Beautiful Bill Act,” the largest ever cut to government health care funding in U.S. history. The Congressional Budget Office projects Trump’s “One Big Beautiful Bill Act” will push about 10 million Americans off of health insurance while growing the deficit by $3.4 trillion over the next decade. When combined with the looming expiration of enhanced subsidies for health insurance plans under the Affordable Care Act (more commonly known as “Obamacare”), that uninsurance figure rises to 14.2 million Americans, according to nonpartisan health policy news and analysis organization KFF.

Health economists like author Thomas Lane have studied the link between health insurance and health outcomes. Their work allows us to estimate how many more preventable deaths may occur as health insurance coverage declines, among other outcomes. For example, in a study called the Oregon Health Insurance Experiment, a lottery was run for people on a waiting list to join Medicaid, and the outcomes of those selected were followed over time and compared to those not selected. By combining the results of studies like these with KFF’s projection of the number of Granite Staters who will lose their health insurance due to the OBBBA and related policy changes, Thomas can project its health impacts.

After doing the math, discomforting results quickly become apparent. New Hampshire can expect to see an extra avoidable death slightly more often than once a week, as well as thousands of other residents cut off from necessary care and medications. Over 5,000 may join the already swollen ranks of those in medical debt.

Make no mistake, however. The craziest part of all of this should not be these figures themselves. It’s the fact that they can mostly still be prevented from coming to fruition by our state Legislature.

KFF estimates that the OBBBA will cost New Hampshire about $230 million per year over the next decade, leaving a big hole for our state legislators to fill. Although some of these harms are caused by Congress’ imposition of work requirements and paperwork burdens on Medicaid beneficiaries that the state cannot do much about, most of the damage comes from the funding cuts.

Funding cuts are something the state can definitely do something about. It just needs to come up with roughly $230 million on its own.

How exactly can the state find such a large sum of money? Despite the protests of budget hawks, it’s not actually that complicated. Currently, the state runs Medicaid through private third-party administrators, called managed care organizations (MCOs). MCOs are a product of the 1990s, when the public policy world thought the problem with health care was that people were using too much of it, and health care needed gatekeepers. This is an evidence-free claim. Americans actually use less care than people in Europe and Canada despite spending far more per capita, all while living shorter, less healthy lives. If anything, we don’t use enough. Nonetheless, the MCOs still run New Hampshire’s Medicaid program, adding significant administrative expenses onto the state budget while doing nothing to make health care better.

Connecticut got rid of these wasteful MCO contractors in 2012, instead opting to run its Medicaid program itself. Unsurprisingly, they saved lots of money doing so. Nonpartisan health policy research and advocacy organization Physicians for a National Health Program estimates that New Hampshire could save up to $81 million annually from the removal of MCO contracting alone, but changes like this cascade through the Medicaid system and lead to other beneficial effects, too.

It’s possible to roughly guess what this total effect might look like by simply comparing the difference between what New Hampshire and Connecticut spend on Medicaid per beneficiary. That difference comes out at around $307 million in lower costs annually if New Hampshire’s program had the same costs per beneficiary as Connecticut’s.

That $307 million in potential savings is far more than enough to fill the health care-related $230 million hole in the state budget. With that money, the state can ensure tens of thousands of Granite Staters get the care they need while preventing closures of the countless New Hampshire hospitals and nursing homes that depend on Medicaid for funding.

Other states are starting to consider legislation that would cut out these unnecessary and wasteful Medicaid middlemen. For example, there was a bill in the previous session of the Minnesota legislature called the Patient-Centered Care Act that would more or less copy what Connecticut did (SF1059/HF255). One of us previously wrote a column in support of it, explaining why MCOs are so unhelpful from just about everyone’s perspective, no matter where you fall on the political spectrum.

Back then, it was admittedly still uncertain whether Congress would actually pass a massive budget cut package, but it did, and now there are no more excuses.

Our state Legislature can quite easily alleviate most of the financial problems Congress has passed onto it and thereby save lives. All New Hampshire has to do is copy what Connecticut did and pass a not very big — but in our opinion quite beautiful — bill to cut wasteful MCO middlemen out of our Medicaid program.

Thomas Lane is a health economics, policy, and management master’s student at the Karolinska Institute in Stockholm, Sweden. He recently graduated with a bachelor’s in economics and public policy from Dartmouth College in Hanover, New Hampshire. There, he was a member of the steering committee of Granite State Physicians for a National Health Program.

Dr. Don Kollisch is a family physician who still practices in a free clinic for uninsured people. His career began in private practice in the North Country of New Hampshire, where he had a clinic, worked in a hospital, and served as a deputy medical examiner. He then moved into academic medicine at a number of medical schools, and ended his full-time practice at the VA in White River Junction, Vermont. He still teaches at the Geisel School of Medicine and at Dartmouth Health. He is the Convener of the New Hampshire chapter of Physicians for a National Health Program.

https://newhampshirebulletin.com…

The Social Mission

An article in the NEJM series on the Corporatization of US Health Care proposes that abandoning the central role of corporations in health care is impractical and potentially irresponsible. Without offering solutions. We urge focus on social mission for both social and business ventures.

The Corporatization Deal – Health Care, Investors, and the Profit Priority, The NEW ENGLAND JOURNAL of MEDICINE, August 30, 2025, by Amitabh Chandra and Mark Shepard

Because of health care’s essential nature, many observers have viewed the growing influence of large companies in the industry, known as “corporatization,” as odious, akin to privatization of fire and police departments. The corporatization of health care often evokes images of rapacious companies that prioritize profits over patients, since corporations operate according to the logic of business, emphasizing efficiency and financial returns, whereas medical institutions have traditionally operated as professional or charitable enterprises.

Although some critics yearn for a return to a purely professional ethos in health care, such a reversal is impractical and potentially irresponsible.

Comment:

By Don McCanne, M.D.

In the current installment of NEJM’s series on the Corporatization of US Health Care (introduced in HJM here), the authors do us a favor. They start by characterizing a reversal of corporate health care in the US as impractical and potentially irresponsible. In so doing, the authors relieve us of the chore of needing to read any of the rest of the article. As a dear friend said, the rest of the article is mealy-mouthed. However, if you are curious as to why an astute observer would label this as “mealy-mouthed,” feel free to read the full article.

The article in its entirety represents how some in the academic community fail to realize precisely what is wrong with our current health care system, and fail to proffer meaningful solutions to its vast deficiencies.

This made me think about what our personal goals should be when we interact professionally with the community. In my interactions, I was able to view our responsibilities from two angles: as a primary care physician and as chairman of the board of a community bank.

As a physician, the primary mission should be to take care of the health care needs of patients and the community. Secondarily, the role should be to produce enough income to pay for the resources needed to fulfill the primary mission and to take care of the basic needs of my family with a modest amount to make life more comfortable.

As a banker with strong interests in the business of the community, the primary mission should be to make as much money as possible to create greater wealth for the investors in the bank. Secondarily the role should be to meet the operating expenses of the bank so that it can serve customers and the banking needs of the community.

These two roles suggest contrasting primary missions: fulfilling a societal need in medicine, versus providing a financially successful business in banking. But is this mission-inspired distinction really true? Let me give you a more nuanced perspective.

First, health care. In South Orange County, California, my brother and I practiced for decades with a mission of trying to meet the health needs of the patients and of the community at large. Being close to the Mexican border, we had a wide variety of patients, ranging from undocumented agricultural workers, gardeners, cooks, household employees for the very affluent, to members of the Western White House. We accepted all patients regardless of ability to pay. We included uncomplicated obstetrics in our practice and one of us was always available, 24 hours a day, for emergenceis. Needless to say, we worked very extended hours, with office hours six days a week and rotating office hours on Sundays. Our income? It was enough to meet the resource needs of our practice and to provide basic needs for our families with some extra to provide some modest comforts. But our basic mission was to meet the health care needs of our patients and the needs of the community.

What about banking? Was that to make a lot of money? Well, I was invited by a close friend, who was also a progressive like me, to serve on the board of a new bank that he was forming. Up front, I want to say that our primary mission was to meet the banking needs of our customers and the banking needs of the community. Our secondary mission was to meet the resource needs of the bank and to provide generous compensation for our employees. As far as compensation for the Board of Directors, we provided very modest directors’ fees that amounted to no more than token compensation. We made a deliberate decision to not declare dividends for the shareholders (who were the directors of the bank), but rather to keep all funds within the operations of the bank, specifically so that we could excel at meeting our mission of taking care of bank customers and the banking needs of the communities (eventually three branches).

This proved to be a very successful tactic. The bank rating organization gave our bank a special award for being the only bank in the US rated as a Premier Performing Bank for ten consecutive years. Needless to say, we became an acquisition target.

Sadly, my good friend, the Chairman, developed a lethal disorder. The vice president, who was destined to take his place, was the only member of the board who wanted to distribute the assets to the shareholders (I.e., himself). The Chairman led the board in creating a new position on the board, the Vice-Chairman, who would be the successor, and the board elected me.

By then the board members were aging, and we were ready to turn the bank over to another community bank with philosophies that matched ours. We were compensated with stock in their bank plus a large cash bonus. That bank was also an acquisition target and sold to a subsidiary of a highly respected national bank founded by a noted religious leader – for a cash buyout of the stock and another large cash bonus.

Thus we fulfilled our primary mission of meeting the needs of the bank customers and the community. But what about the secondary role – making a profit. Yes, we were successful in that as well, but wouldn’t it have been better if the bank were a community asset, provided to the community by public provisioning, as described by Hayden Rooke-Ley for health care? Then it would belong to all of us, whether by public ownership or through a non-profit.

The point is that we are making a mistake in lining up our various services and products as either a public good for serving individuals and society, or as a private profit-making entity to serve the very affluent. We can construct society to serve all individuals and the community whether a social service function like health care or a private business like banking. For us, that means that health care should be provided to take care of everyone. That can be best accomplished by establishing a well-designed, publicly funded and publicly administered single payer system, and not by some mealy-mouthed hodgepodge that operates under a primary mission of providing profits for the affluent, with a secondary mission of meeting only a portion of health care needs for only a portion of the community.

In a time of profound political turmoil, increasing corporate influence in government, and a public safety net under attack, please keep this pro-social perspective in mind.

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.

How the US Achieved Health Security in 2035

A new online book thoroughly reviews the myriad problems plaguing US health care and leading to its predicted overhaul: massive cost growth with siphoning of care dollars to corporations, yawning coverage gaps and pervasive provider burnout. Our thoroughly broken system is sparking renewal.

Affordable high-quality health care for all Americans is the easiest problem to fix in the US, Ch 1 excerpt: HOW THE U.S. WON HEALTH SECURITY FOR ALL – A NOTE FROM 2035, by Alan Sager, PhD, Health Reform Program, Boston University School of Public Health

The Easiest (2025) online access here

A number of large accidents and mostly well-intentioned but unpredictably unfortunate choices had combined to shape U.S. health care in 2025. That care was widely believed to be ineffective, unaffordable, unsustainable, and unequal. It was anarchic, unaccountable to anyone for anything, and prone to gross inefficiency and substantial theft.

But it was also well-entrenched and very hard to change. It had support from many of those patients able to afford and obtain good care, from many doctors and other caregivers, from insurance companies, and from those suspicious of reforms who could not see a path forward to anything better.

Its critics were mainly those who could not afford care or sought reform in coverage, cost, caregiver availability, and equity that other rich democracies had achieved in recent decades.

In 2025, roads to health care reform seemed blocked. Political progress was difficult. Congress was not willing to vote for changes that lacked strong backing. No useful reforms had that strong backing. Few state governments were competent to put their arms around health care problems or devise and implement remedies. The very notion of relying on politics to substitute for markets to fix health care was rejected by many Americans and their representatives. Support for covering all people, removing financial barriers to care, and containing health care costs was broad but generally shallow and disorganized.

How, then, did Americans choose to reform health care financing and delivery so thoroughly and, apparently, so successfully—at least, so far?

The military, political, and economic cataclysm of World War I swept away czars, kaisers, and sultans. It challenged established ways of thinking, acting, working, and governing.

No such single change evoked the U.S. health care reforms of the past decade.

Rather, the accumulating external and internal threats were responsible.

Cracks in the foundations, a leaking roof, broken windows, widely-disseminated lead paint, termite infestations, and a failed heating plant forced a choice between demolition/replacement of the health care edifice and its thorough rehabilitation.

Some internal threats included the human and financial dislocations that began during the Covid years from 2020 through 2023 but persisted subsequently. These included burnout of many professional caregivers; resignations and retirements; staffing shortages; and revenue growth that was often insufficient to cover growth in expenses.

Other internal threats included suppression of access in hopes of containing cost, the steady melt-down of primary care, the closing of needed rural and urban hospitals, the crisis of unaffordable meds, and the rapidly growing need for long-term care as the U.S. population over age 65 exceeded 20 percent by 2030.

This book posits that reform also stemmed from a series of threats from outside health care— threats from other nations, economic challenges, social problems, and the collision between rising health care costs and an unsustainable federal deficit.

The crisis leading to reform was sparked by the political fights over the size of the federal deficit, the quarter-trillion-dollar yearly rise in health care spending that crowded out other valuable things, and Congress’s decision to freeze spending on Medicare, Medicaid, and ACA subsidies.

The dried brush and logs that caught fire were inside health care itself. Hospitals, doctors, nursing homes, and other caregivers were frightened. So were their workers. Employers paying health care for one-half of Americans feared that hospitals and doctors would try to offset the federal freeze by raising prices paid by insurance companies acting for those employers. Patients were afraid they’d be blocked from obtaining needed care by higher OOPs or premiums, by loss of primary caregivers, by hospital bankruptcies and closings, and by shortages of nursing home beds.

All parties were furious about the wasted health spending that impoverished health care amidst financial plenty.

Payers, caregivers, and patients saw opportunities to do much better by squeezing out fat from existing spending and recycling it as clinical bone and muscle.

But doing that required action to cover all people solidly, contain cost by capping spending, paying caregivers in ways that oblige them—and allow us to trust them—to spend money carefully.

All this obliged abandoning reliance on competitive free markets or traditional government action, mostly reaction—both of which failed health care for decades.

It’s not easy, even with hindsight, to chart the precise path taken to reform health care.

But it’s certain that U.S. health care was spiraling downward both financially and clinically. Our people long deserved medical security. Our nation couldn’t afford to permit health care to continue to act as The Sponge, absorbing money that is badly spent inside health care and is desperately needed for more important purposes outside health care.

And that made it essential to get ready. Ready to act to fix health care when it became politically and financially impossible to continue to paper over health care’s problems.

Comment:

By Don McCanne, M.D.

This new book by Alan Sager is an excellent review of the problems we have with health care, how we got there, and what we can do to ensure that everyone has the health care that they need in a system that is affordable for all. It is invaluable for those who are still not well informed on the policies of health care reform, and it is especially helpful as a review for us old-timers who can stand a refresher course on where we’ve been and where we are going.

The excerpt above, from 2035, obviously is not a precise historical description of the future, but, like the rest of the book, it gives us hope that we really will eventually meet our goal of health care justice for all.

What is really unique about this book is that, of all of the serious problems society faces today, this, almost unbelievably, is the easiest one to fix. Alan Sager explains how.

The Easiest is being posted chapter-by-chapter on this website. You can sign up to receive notices of new chapters, and download them at no charge to share with colleagues and friends who can use them to educate the nation on the fact that there really is hope for effective, sensible, comprehensive health care reform.

There has not been much coming down the pike that offers me more hope about the future of our health care system, but this one does!

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.

National Polling Reveals Widespread Cost & Access Concerns

A national poll on health care from late 2024 yielded three fascinating findings. First, no surprise – concerns about cost, access, & quality are high and enduring. Second, cost and access are considered the most urgent issues, above specific diseases. Finally, Republican views (much less so Democratic) are sharply influenced by who the president is.

View of U.S. Healthcare Quality Declines to 24-Year Low, Gallup Poll, December 6, 2024, by Megan Brenan

Evaluations of U.S. healthcare quality among Republicans … are down sharply since President Donald Trump left office in 2021. Currently [late 2024], 42% of Republicans and Republican leaners rate healthcare quality positively, compared with 65% to 68% from 2017 to 2020. …

Positive ratings of healthcare quality among Democrats and Democratic-leaning independents have been less variable since 2001 and typically lower than ratings among Republicans.  …

Partisans’ ratings of U.S. healthcare coverage have followed a similar trajectory as their views on quality.

An open-ended question measuring Americans’ views of the most urgent health problem facing the country finds that two issues related to the healthcare system — cost (23%) and access (14%) … are mentioned most often.

Comment:

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

This US poll is a bit dated (a colleague it sent it to me this week), but revealing and thought-provoking. Here are the main takeaways, as I see it:

(1) Unsurprisingly, concerns about cost, access, & quality are high and enduring over more than two decades. Efforts to improve health insurance have failed. This includes the ACA, with its bolstering of coverage at the expense of rising under-insurance (e.g., large deductibles). Thus, we can add recent health care policy innovations to the venerable list of failed efforts to remedy the underperformance of our fragmented, profiteering health insurance approach.

(2) When respondents are asked about the most urgent health issues, cost and access top the list, above specific diseases. This is astounding if you think about it: people are more worried about health insurance problems than widespread often fatal health problems. Curing disease is tricky. Fixing health insurance isn’t – as we know from scores of other wealthy nations.

(3) Republican views (much less so Democratic) are sharply influenced by who the president is. In the graphic above on coverage, notice how the red line jumped up 25% while Trump was president, and then fell under Biden. Let’s be clear: coverage did not actually improve 2017-2020, the perception changed. I’m confident that perceptions in the current Trump term will not follow the same pattern – because many adults, Republican and Democratic alike, are aware that the federal budget bill slashed health programs, and they are likely to feel those effects – e.g., when kicked off Medicaid or losing ACA premium subsidies. Nonetheless, it’s a lesson we must incorporate into our health policy advocacy: messaging matters in perceptions of current problems.

I continue to believe that the growing frustration with Trump as he deconstructs US health insurance (along with public health), combined with inspirational young progressive voices, will provide a historically unique opportunity for true health insurance reform: 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.