PNHP

The Great Healthcare Plan Hoax

The Great Healthcare Plan Hoax

A page of vague and disproven ideas is not a serious health reform plan. The Trump strategy is nonsense, unworthy of serious consideration.

The Great Healthcare Plan, The White House, President Donald J. Trump, January 2026

Lower Drug Prices

Slash Prescription Drug Prices: Lower prescription drug prices for all Americans by codifying the Trump Administration’s Most-Favored-Nation deals to get Americans the same low prices for prescription drugs that people in other countries pay. This would build off President Trump’s landmark actions that made insulin more affordable in his first term and the successful voluntary negotiations following his recent executive order to lower drug prices. Voluntarily negotiated deals with HHS/CMS will be grandfathered in.

Allow More Over-the-Counter Medicines: Make more verified safe pharmaceutical drugs available for over-the-counter purchase. This will lower healthcare costs and increase consumer choice by strengthening price transparency, increasing competition, and reducing the need for costly and time-consuming doctor’s visits.

Lower Insurance Premiums

Send the Money Directly to the American People: Stop sending big insurance companies billions in extra taxpayer-funded subsidy payments and instead send that money directly to eligible Americans to allow them to buy the health insurance of their choice.

Fund Cost-Sharing Reduction Program: Fund a cost-sharing reduction program for healthcare plans which would save taxpayers at least $36 billion and reduce the most common Obamacare plan premiums by over 10%.

Cut Kickback Costs: End kickbacks from pharmacy benefit managers to the large brokerage middlemen that deceptively raise the cost of health insurance.

Hold Big Insurance Companies Accountable

Create the “Plain-English Insurance” Standard: Require health insurance companies to publish rate and coverage comparisons upfront on their websites in plain English—not industry jargon—so consumers can make better insurance purchasing decisions.

Publish Costs of Overhead vs. Claim Payments: Require health insurance companies to publish the percentage of their revenues that are paid out to claims versus overhead costs and profits on their websites.

Display Claim Denial Rates: Require health insurers to publish the percentage of insurance claims they reject and average wait times for routine care on their websites.

Maximize Price Transparency

Post Prices on the Wall: Require any healthcare provider or insurer who accepts either Medicare or Medicaid to publicly and prominently post their pricing and fees to avoid surprise medical bills.

Comment:

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

This is it! President Trump’s plan for reforming healthcare in America! In a single page. Specifics deemed irrelevant. But, as the wise saying goes, “the devil is in the details”.

Lower drug prices? By Executive Order? How much? How to enforce?

Lower insurance premiums? This would just shift costs elsewhere, eg deductibles and cost-sharing.

Hold insurance companies accountable? Sure, but it’s gloss. To really eliminate waste, eliminate this money-extractive industry

Price transparency? Sick people are terrible price shoppers. Market mechanisms don’t work in health care (Ken Arrow, Nobel Prize 1972). Recent price disclosure rules for hospitals failed miserably.

The problem, of course, is that Trump left out virtually all the reforms that we actually need to make the system perform as it should: universal (cover everyone), comprehensive (all appropriate health care), and affordable (for society and each of us). Let’s not be fooled by a 1-page list of unarticulated and untested (or disproven) ideas, and instead follow the successful real-world examples of scores of wealthy nations.

In a way, this nonsense “plan” is good news because Trump has left to us, the people, the task to demand from our legislators to enact a program that will work: a single payer, improved Medicare for All. Funding the system with progressive income and wealth taxes would ensure that those with low and modest incomes do not suffer from financial hardship, and for the billionaires it will be painless since they will not even know what they are paying without checking with their accounting firms.

At the midterms we must elect legislators who understand what real reform is, and should be able to enact it by the time we have in place a compassionate president who cares about the people instead of the billionaires.

(Just out – a thoughtful critique of Trump’s “plan” by Jonathan Cohn here.)

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.

With Medicaid & ACA Cuts, Counties Face Daunting Care Challenge

With huge reductions in federal funding for health insurance programs, leading to a surge In the uninsured, local jurisdictions in many states will be required to fill the gap. This poses massive, highly burdensome or infeasible, funding challenges.

On the Hook for Uninsured Residents, Counties Now Wonder How They’ll Pay, KFF Health News, by Christine Mai-Duc and Claudia Boyd-Barrett, January 6, 2026

Health Officials in California’s Placer County and across the country are bracing for an estimated 10 million newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by more than $900 billion over that period.

This is the moment where a lot of decisions have to be made about who gets care and who doesn’t,” said Nadereh Pourat, director of the Health Economics and Evaluation Research Program UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”

It’s an especially thorny challenge for states like California and New Mexico where counties are legally required to help their poorest residents through what are known as indigent care programs. Under Obamacare, both states were able to expand to include more low-income residents, alleviating counties of patient loads and redirecting much of their funding for the patchwork of local programs that provided bare-bones services

“Most of the infrastructure that we had to meet those needs is gone,” said Rob Oldham, Placer County’s director of health and human services. “This is a much bigger problem than it was a decade ago and much more costly.”

“State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts,” said Scott Graves, a director at the independent California Budget & Policy Center.

Reviving county-based programs in the near term would require “considerable fiscal restructuring“ through the state budget, the Legislative Analyst’s Office said.

Health advocates fear that, absent major state investments, Californians could see a return to the previous patchwork of county-run programs with local governments choosing whom and what they cover and for how long.

Before the ACA, many uninsured people who needed care didn’t get it, which could lead to them winding up in ERs with untreated health conditions or even dying. Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that “it created a very unequal, maldistributed program throughout the state.”

Comment:

By Don McCanne, M.D.

The United States is the only industrialized nation that does not guarantee accessible and affordable health care to essentially all of its residents. Because we have attempted to correct these deficiencies through fragmented, incremental programs, we ended up with the most expensive system on earth, with deficiencies that place us at the bottom of wealthy nations in the performance of our health care system.

With recent Republican control of Congress and the White House, the situation has worsened. Low-income individuals will see a dramatic reduction of coverage from Medicaid. The government also failed to extend premium subsidies for the Affordable Care Act, which will leave millions of individuals and families unable to pay for insurance plans in the ACA exchanges. In addition, Medicare funding will likely suffer, due to budget deficits. These cuts will cause financial hardship or even bankruptcy for far too many, and, worse, inability to obtain care to prevent disabilities and even death. These problems are on top of the serious insurance deficiencies we already have.

Before programs were established to provide health insurance for much (if not all) of the population, medical care was often provided for the indigent through government facilities such as county hospitals and community health centers. As insurance coverage expanded, especially through the Affordable Care Act, these publicly-funded facilities were scaled back or even disappeared. But with the new austerity measures being put in place, there is a desperate need to replace such facilities and programs. That process will be quite complex, partly because funding will need to come from local, county, state and potentially federal sources. Also, regions controlled by conservatives will likely be stingier in providing the needed resources.

Republicans have indicated that they may change their mind and make ACA subsidies more available again. However, they have said that they will do this only if Health Savings Accounts are made part of our health care financing. The problem is that HSAs are designed to benefit wealthier, healthier individuals and families who can afford to fund them and can take advantage of the tax benefits designed for those with higher incomes. HSAs help purchase high-deductible health plans which will not adequately cover the health care costs of those with expensive illness and more modest incomes. Although the previous system offered poor performance at high cost, the most the Republicans offer now will set us further back in trying to bring a high performance health care system to everyone.

Conservatives tell us that a single payer system, such as Medicare for All, would cause prolonged waiting times for health care with inadequate resources to provide needed care. Unfortunately, that is true in some settings, where countries with universal health care systems have, in recent years, been controlled by conservative governments that deliberately under-resource their systems, partly to force a shift to private, market-driven systems. This shift drives more health care dollars to profits for middlemen (private insurers, private equity, etc.) by using funds that should go to patient care.

So what is the solution? A well-designed single payer insurance program that is comprehensive, equitably accessible, and funded based on ability to pay by using progressive income and wealth taxes. Ownership of the system should be by public provisioning – either government or nonprofit providers (eg community health centers and hospitals). Also the legislators and government administrators we put in place must believe in the moral and ethical concepts that would make affordable, comprehensive care accessible to everyone. Taxes should pay for legitimate costs (providing care!) while eliminating the middlemen who serve only to create personal wealth.

Simple. Elect legislators and a president who, deep down inside, truly believe that everyone should have high quality health care when needed. Design, enact, and implement a single payer, improved Medicare for All. Continue to keep in office government officials who sincerely believe that they are there for the people, rather than for the billionaires.

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 Physicians View Our Health Care System and What The Numbers Say

Interview with Dr. Diljeet Singh

By Rep. Pramila Jayapal
The Power You Have Podcast, Jan. 9, 2026

PNHP president Dr. Diljeet Singh spoke with Rep. Pramila Jayapal (lead sponsor of the Medicare for All Act) about why physicians are getting active in the fight for a single-payer national health program.

“For those of us who came into this work just to take care of people, it seems like we have no choice but to get engaged,” she said. “Otherwise we’re not going to be able to provide people with the health care they need and deserve.”

This episode concludes a three-part series on Medicare for All (part one HERE, part two HERE).

https://share.transistor.fm…

Threats to US Health: Vaccine Denialism + For-Profit Health Insurance

A recent New York Times Op-Ed critiques federal health agency abandonment of scientific evidence for vaccine benefit. Quote of the Day & HJM stalwart Don McCanne points out an even greater threat: private for-profit health insurance, generating ~900 reader endorsements.

We Don’t Seem to Be Making America Healthy Again, New York Times, Dec. 28, 2025, by Benjamin Mazer

As a physician and medical journalist, I have spent years watching, with both fascination and concern, as anti-vaccine groups honed their persuasive techniques. …

As secretary of health and human services, Robert F Kennedy Jr has spent the last year not only remaking federal immunization policy but shifting the national dialogue about this essential public health tool.

I never predicted that a fringe conspiracy theorist like Mr. Kennedy would one day become leader of the health care system, but it doesn’t surprise me. Anti-vaccine groups have developed into a potent force. They have learned to stoke suspicion of authority with masterful precision, they have become adept at applying a veneer of scientific legitimacy to their ideas, and they’ve prepared a superficially compelling response to seemingly every argument that doctors make to encourage immunization. These rhetorical tactics were first worked out at dinky conferences and obscure media outlets, but now the government itself has become a propaganda organ for the movement. This makes confronting vaccine skepticism much more challenging — and, amid growing measles outbreaks nationwide, far more urgent. …

Take the false idea that vaccines cause autism. The Centers for Disease Control and Prevention once plainly declared that they didn’t. Mr. Kennedy instructed the agency to take a different position: “The rise in autism prevalence since the 1980s correlates with the rise in the number of vaccines given to infants,” the C.D.C.’s website has been updated to read.

Most parents, for the time being, seem to trust their doctor’s advice. Childhood immunization rates remain relatively high in the United States. But it has taken only a slight decline in vaccine confidence to set off the disease outbreaks we are seeing. It is easier for anti-vaccine groups to chip away at public trust than it is for the medical community to rebuild it. …

Vaccines may be safe and effective, but just saying so is no longer enough. We’re only one year in, and how physicians and public health experts respond will shape what happens next.

Comment:

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

Jim: Dr. Mazer is absolutely correct to challenge the anti-scientific drift of US vaccine policy. Abuse of scientific methods in this realm is inexcusable, indeed deadly. But as Don highlighted with his online comment (below) and its highly enthusiastic reader response, the even bigger problem is the failure of our disjointed, heavily privatized and profit-ized health insurance. Each year, it wastes hundreds of billions of dollars and causes tens of thousands of excess deaths.

Don: My response to this NYT op-ed on vaccine denialism received the highest number of reader recommendations – 882 as of January 5th. This reflects the increasing popularity of Medicare for All.

Don McCanne
San Juan Capistrano, CA
Dec 28, 2025

As an 88 year old physician, I’ve had some exposure to our health care system. Watching some of our more serious diseases conquered by immunizations has been rewarding. On the other hand, watching our health care system evolve into one of the poorest performing systems of the industrialized world, while being the most expensive, has not been a matter of questionable judgement of the care we provide, rather it has been a matter of distributing our health care dollars to the very wealthy middlemen (insurers, private equity, etc.) when we really need to offer health care to everyone and pay for it through an equitable tax system based on ability to pay. Health care reform advocates will recognize that as a well-designed single payer system, or an improved Medicare for All. Let’s redirect our attention to where the real problem is.

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 shouldn’t take luck to stay healthy in Maine

By Grace Lee
Bangor Daily News, Jan. 3, 2026

I grew up helping my immigrant parents sort through insurance letters and medical bills long before I could understand the language printed on them. Now, as a medical student, I still hear the same fear in people’s voices: “I’m doing everything right. So why is health care still so expensive?”

Across communities throughout Maine — especially in rural towns — I hear the same worry. In a state with an aging population and long travel distances to care, those costs and gaps can quickly become barriers to staying healthy at all.

A recent AP-NORC poll found that Americans across political lines agree on one thing: health care is becoming harder to afford. Some describe it as a “privilege,” echoing a very human fear that resources are limited and someone else might take advantage of the system. That fear is understandable. Scarcity makes people defensive, not selfish.

But if withholding care truly solved our cost crisis, the United States would already have the least expensive health system in the world. Instead, we spend more per person than any other wealthy nation and still leave millions uninsured or underinsured. People are trying their best, yet the system is failing them.

Even those with “good insurance” run into barriers. One clear example is screening colonoscopies. Under federal law, these are supposed to be fully covered. But if a doctor finds and removes a polyp — something no patient can predict — the procedure may be reclassified as diagnostic, leaving people with unexpected bills. Patients who take preventive steps end up paying more for doing the right thing.

As a medical student, I’ve watched people ration medications, delay check-ups, or turn down tests because they fear the cost more than the diagnosis. I’ve seen families try to figure out which appointments they can afford. These are not failures of personal responsibility; they are failures of policy design.

There are steps states and communities can take right now:

Expand coverage and close remaining gaps. Ensuring more complete insurance coverage would prevent many avoidable medical and financial crises.

Strengthen protections around surprise billing. Closing loopholes that turn preventive care into unexpected expenses would protect people from being blindsided.

Invest in primary and preventive care. Every dollar spent upfront saves multiple dollars in emergency or hospital care later.

But conversations I’ve had with patients, community leaders, and clinicians point to a larger truth: small fixes can only go so far.

The most effective long-term solution, used by every other wealthy country, is universal health insurance. Countries that guarantee coverage through single-payer systems, hybrid models, or tightly regulated private insurers consistently achieve better outcomes at lower cost. More importantly, people don’t lie awake wondering whether a refill or a routine appointment will destabilize their finances.

No one should need luck to stay healthy — not the families I grew up around, not the patients I meet in a clinic, and not anyone in our Maine communities.

Health care shouldn’t depend on the right job, the right ZIP code, or the right timing. It should be a reliable foundation that helps people build stable, productive lives.

We have the knowledge and the tools. What we need now is the commitment to build a system that treats health care not as a gamble, but as a guarantee.

Grace Lee grew up in Maine and is now a medical student studying health equity and patient-centered reform.

https://bangordailynews.com…

There is a solution to healthcare in the United States

By Joshua Freeman, M.D.
Arizona Daily Star, Dec. 30, 2025

A headline in the Star on Dec. 27 is “Out-of-pocket pain means skimping on care.” The story is from KFF HealthNews, and you already know what it says. We all know. In the rare cases where we or our families or close friends haven’t experienced it ourselves, our newspapers and other media are full of such stories. Every day, we read about how people delay or forgo care, get sick, and even die because of costs: co-pays, deductibles, and other surprise charges, all in addition to the premiums they pay, which increase yearly. This is in addition to the other obstacles to care: prior authorization requirements and outright denials of care by insurance companies, and lack of access because of a shortage of healthcare clinicians.

Does it have to be this way? Is there no way out? Many politicians seem to take the same position as Representative Jeff Van Drew (R-NJ), who said, “Other than world peace, honest to God, health care is the toughest issue ever. It is really hard, but I think it behooves us to come up with something.” The last part is true, but not the first. There is a way, not only in theory but one that has been tested and retested all over the world. It is the system used by every wealthy country, and many with fewer resources: Universal health coverage. Really. It’s true. It is done in different ways, but they all cover everybody, for low, or no, out-of-pocket cost, funded by taxes. They are not all perfect, but the other thing that they have in common is that no country that has adopted universal health coverage has gone back. Ever.

Could it be done in the United States? Sure. The “Medicare for All Acts” (S. 1506 and HR. 3069) would do exactly that, expand the Medicare system to include us all. Everyone. Birth to death. No patchwork system, no falling through the cracks. Everybody in, nobody out. Medicare has served as a single-payer universal health care program for seniors and people with disabilities since 1965, so the structure is there. Just add the rest of us. These bills would also improve Medicare, by covering everything, including mental health, vision, hearing, long-term care, and the full cost of hospitalization (not 80% as now). It’s all good.

But how could we afford it? Wouldn’t taxes go up? They would, for some, but then all these other costs – premiums, co-pays, deductibles, etc. — would go away, and most people would see a net financial benefit, especially those who cost and pay the most — those who are sick. Most of the additional cost of providing healthcare to everyone would be made up for by eliminating insurance company administrative costs and profits. It is thus doubly good; not only does it save money, it creates a system whose goal is providing health care for the American people rather than making a profit for insurance and private equity companies. Imagine that! The current U.S. health “non-system” not only costs a lot more per capita than other comparable countries, but leads to worse health outcomes.

So why would the American people not support this? Actually, they do, in poll after poll. A recent one from Data for Progress shows 65% of us do, including about 75% of Democrats and Independents, and about 50% of Republicans! What about politicians? Why are there not more senators and representatives supporting the Medicare for All bills? You can guess, but let’s say that a system designed to make huge profits for insurance and other private companies provides them with the resources and incentives to make large donations to congresspeople; perhaps that’s part of it.

Time for them to hear from us. Sen. Gallego supported Medicare for All when he was in the House, as did the late Rep. Raul Grijalva. Write to our senators, Gallego and Kelly, and our representatives, including Rep. Ciscomani, and tell them what you think and demand that they sign on to the Medicare for All bills.

It’s time to have a health system that serves the people.

Dr. Joshua Freeman is a family physician and retired professor and department chair of family medicine. He is the author of the book “Health, Medicine and Justice: Designing a fair and equitable healthcare system,” and of the blog Medicine and Social Justice.

https://tucson.com…

The Ultimate Gift We Owe Ourselves: End Private Health Insurance

An article in the LA Progressive succinctly summarizes the core problem plaguing our health insurance: the pervasive role of corporations. Support for a public solution – single payer – is robust among voters and progressive politicians. We deserve this ultimate gift.

Healthcare Beyond 2026, LA Progressive, Dec. 16, 2025, by Sharon Kyle

You first have to understand how healthcare policy making in the U.S. has been systematically bought by powerful corporate interests, especially the health industry lobby.

This isn’t just political influence. It’s institutional leverage over our health, our wallets, and our democracy. In every wealthy democracy besides the United States, healthcare is considered a public responsibility.

When the ACA was passed in 2010, it was sold as a corrective to the broken system. And it did expand coverage, but the ACA’s survival was only possible because it protected private insurers’ core business – mandating participation, subsidizing customers with public funds, and setting up exchanges that funneled taxpayers’ dollars directly into private plans.

Rather than displacing the industry, the ACA made insurers bigger and more dependent on federal policy. It created a system where billions in public money go straight to companies’ bottom lines.

Temporary “enhanced” ACA subsidies introduced during the COVID pandemic – which masked the true cost of premiums for millions – are expiring at the end of 2025. When those subsidies disappear, what people actually pay out of pocket is expected to increase dramatically.

Add to that insurers filing rate increases of 18-26% on average before subsidies – a projected hike that would be the largest in years – and you have a perfect storm of higher costs by design.

And because insurance remains a private commodity nearly unique among wealthy nations, millions could drop coverage, destabilizing risk pools and triggering yet more increases – a feedback loop predictably triggered by policy choices, not economic necessity.

Universal healthcare isn’t radical. It’s common sense in every other wealthy industrialized democracy.  What’s radical in America is a democracy where an industry can veto fundamental reform indefinitely.

Why would a profit-driven industry tolerate the loss of millions of customers who will be priced out of coverage in January 2026? The answer is simple, if unsettling: insurers are not in the business of maximizing coverage – they are in the business of maximizing margins.

Many of the people expected to drop coverage when premiums rise are lower-income, higher-need enrollees who rely heavily on subsidies and use more care. From an insurer’s perspective, these customers are expensive to manage and often yield thin profits. When subsidies expire and premiums rise, insurers are not just reacting to costs – they are effectively pricing out the customers they least want.

Higher premiums act as a sorting mechanism. Healthier, wealthier, lower-utilization customers are more likely to stay. Sicker, poorer, higher-cost customers are more likely to leave. The Affordable Care Act prohibits denying coverage outright, but it does not prohibit pricing people out of the market. That distinction matters.

Insurers also know something the public rarely hears out loud: the individual ACA marketplace is not where they make their real money. The most lucrative growth areas are elsewhere: Medicare Advantage, Medicaid managed care, large employer plans, and vertically integrated healthcare empires that now include pharmacies, pharmacy benefit managers, and care delivery systems.

History has taught insurers that instability works in their favor. When premiums spike and coverage drops, public outrage grows. Congress comes under pressure. And insurers re-enter the conversation not as villains, but as “partners” asking for renewed subsidies, reinsurance payments, regulatory relief, or other forms of public stabilization. In short: they expect the government to blink – because it always has.

Universal healthcare is not radical. It is normal. What is radical – and uniquely American – is allowing a profit-driven industry to decide who gets care, at what price, and for how long.

Comment:

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

The Affordable Care Act was supposed to fix our health care system by placing uninsured individuals into exchanges of private insurance plans so that everyone would be covered. Well, it didn’t work. Many remained uninsured, and more than ever insurance plans expose them to unaffordable out-of-pocket costs. High prices and profits still permeate the system. Thus, the US still has by leaps and bounds the costliest system in the world, and despite that sits near the bottom in performance (access and longevity).

The crisis we face as 2025 ends is that COVID-era government subsidies for the Affordable Care Act plans are expiring. Skyrocketing premiums and cost-sharing will leave millions more with inadequate coverage. Despite considerable political pressure to extend the subsidies to avoid financial hardship for patients, the party in control has refused to do so.

Still, this issue is a distraction. Renewing the subsidies would help, to be sure. Yet our insurance would remain the world’s most expensive while perversely, pervasively under-performing.

Other proposals, such as health savings accounts, are much worse because they would make health care even more unaffordable, further impairing access to care and increasing exposure to financial hardship when care is mandatory due to medical urgency.

The great irony is that we already know how to provide comprehensive care for everyone at a price that is affordable to each of us. That, of course, is a well-designed single payer system that would be a refined version of Medicare; that is, improved Medicare for All.  We can’t enact and implement it in January 2026. But, as we’ve written, the public is informed on this insurance model and a majority of voters support it. Even a significant plurality of the party that has been opposed now wants to see Medicare for All.

Watching the politicians squabble over grossly inadequate solutions to tweak our health care system is intensely frustrating when we know how to really fix it. There are paths forward: two federal single payer bills, and several meaningful state initiatives. Progressive politicians are gaining in popularity and visibility.

Is 2026 the year when (finally!) the US does the right thing in health care, after the oh-so-many false starts? THAT is the holiday gift we all deserve.

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.

Excise middle-men from Hawaii Medicaid

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

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

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

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

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

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

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

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

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

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

https://staradvertiser.com…

Surging Voter Support for Single Payer

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

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

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

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

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

Comment:

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

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

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

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

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

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

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

https://healthjusticemonitor.org…

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Murray pushes to halt federal pilot adding AI to Medicare approvals

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

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

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

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

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

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

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

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

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

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

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

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

“People were horrified,” Stern said.

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

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

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

CMS did not immediately respond to a request for comment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://seattletimes.com…