Prescription for Healthcare—Save Medicaid by Removing the Middlemen
Interview with Dr. Ed Weisbart
By Rob Stone, M.D. and Karen Green Stone
WFHB Community Radio (Bloomington, Ind.), Oct. 3, 2025
PNHP board secretary Dr. Ed Weisbart discusses the urgent need to deprivatize Medicaid, in response to massive federal cuts to the program, on the Oct. 3, 2025 episode of the Prescription for Healthcare podcast.
Dr. Weisbart details the findings of PNHP’s blockbuster new report, “Removing the Middlemen from Medicaid: A Blueprint for Better Care and Lower Costs.”
Across the country, “we estimate anywhere from a 10 to 17% reduction in the Medicaid managed care budget,” he says, “and by the way, as physicians, we are here to tell you with complete confidence that you will be improving the health of people on your Medicaid program.”
full interview:
https://wfhb.org…
Medicare for All makes sense for the U.S.
By Elmore Rigamer, M.D. and Marc Lavietes, M.D.
State Affairs, Sept. 29, 2025
Some 377,000 Louisiana residents have no medical insurance. And while we do not have data for Louisiana, 40 percent of Americans have medical debt.
Residents of other industrialized Western countries don’t have medical debt because those countries have some form of a universal and regulated healthcare delivery system. Some, such as Germany or the Netherlands, use a regulated capitalistic format. Great Britain, on the other hand, uses a socialist model with government ownership of physicians‘ practices and medical facilities.
The premise of a recent column, that competition would cure our doctor shortage, is flawed. If someone wishes to purchase a sofa or a refrigerator, he is an informed consumer. He is familiar with his available choices, and his need to replace these items is usually not immediately urgent.
On the other hand, when he awakens vomiting blood or feeling excruciating chest pain, he is not an informed consumer. He has no leisure time to investigate available services, and his ability to evaluate the pros and cons of commercially available healthcare plans is limited.
And with increasing consolidation within the hospital and pharmaceutical industries, competition becomes ineffective.
Expanding Medicare Advantage will not solve the problem. Medicare Advantage is private insurance, not Medicare, and the advantage goes to the insurance industry, not to the patient or physician.
If a person chooses an MA plan, the government pays a yearly lump sum from the Medicare trust fund to the private insurer, who then assumes all responsibility for that patient’s health care. Any money not spent on the insuree’s health becomes insurance industry profit.
Industry profits further by adding co-pays and by denying claims. For every 100 claims an insurance company denies, 15 would have been covered in full by traditional Medicare. This leaves the Medicare Advantage customer with considerable medical debt.
By this mechanism, insurance companies take billions of dollars yearly from the trust fund, diverting that money intended for medical care into corporate profit. Advantage plans are popular, until the insuree is stricken with illness and must use the plan.
Since we already have a viable Medicare system in place, Medicare for All is a reasonable choice for us. In a way, this would be a compromise between the Netherlands and Great Britain. The physician is free to practice as he chooses, while the patient is free to choose the physician of their choice. There are no networks, and there is only one payer: a national trust fund. Fees are determined by collective bargaining.
At present, our Medicare system is flawed. Dental, hearing and visual care are not included, nor is long term care.
What we need is not Medicare, but rather an improved Medicare for All.
Dr. Elmore Rigamer is medical director for Catholic Charities Archdiocese of New Orleans, while Dr. Marc Lavietes is an associate professor at Rutgers-New Jersey Medical School. Both are members of Physicians for a National Health Program.
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…
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Medicare for All Explained Podcast: Episode 127
Where to Get Reliable Medical Information
Sept. 14, 2025
Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.
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.
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…
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Dr. Jessica Schorr Saxe on WBTV Charlotte
PNHP national board member Dr. Jessica Schorr Saxe spoke to WBTV (the CBS affiliate in Charlotte, N.C.) for a news segment that aired September 4, 2025.
Dr. Saxe was part of a contingent of Medicare for All supporters that attended the Mecklenburg County Commissioners meeting where the board voted unanimously in support of federal single-payer legislation.
“It’s bad enough when you’re sick,” said Dr. Saxe, “but [the U.S. is] the only place where it’s a double whammy: you’re sick, and then you worry about your bills.”
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…
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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.
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Medicare Will Require Prior Approval for Certain Procedures
A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.
By Reed Abelson and Teddy Rosenbluth
The New York Times, Aug. 28, 2025
Like millions of older adults, Frances L. Ayres faced a choice when picking health insurance: Pay more for traditional Medicare, or opt for a plan offered by a private insurer and risk drawn-out fights over coverage.
Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. This practice, known as prior authorization, has drawn public scrutiny, which intensified after the murder of a UnitedHealthcare executive last December.
Ms. Ayres, a 74-year-old retired accounting professor, said she wanted to avoid the hassle that has been associated with such practices under Medicare Advantage, which are private plans financed by the U.S. government. Now, she is concerned she will face those denials anyway.
The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.
The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.
The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.
The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.
Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.
Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.
The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.
But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers.
The program, called the Wasteful and Inappropriate Service Reduction Model, is already drawing opposition from Democratic lawmakers, former Medicare officials, physician groups and others.
Patients are also leery. “I think it’s the back door into privatizing traditional Medicare,” Ms. Ayres said.
People enrolled in traditional Medicare who live in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington State will be included in the experiment, which is expected to start in January and last for six years.
Dr. Vinay Rathi, an Ohio surgeon and an expert in Medicare payment policy, warned that the experiment could recreate the same hurdles that exist with Medicare Advantage, where people enroll in private plans. “It’s basically the same set of financial incentives that has created issues in Medicare Advantage and drawn so much scrutiny,” he said. “It directly puts them at odds with the clinicians.”
Typically, these A.I. models scan a patient’s records to determine if a requested procedure meets an insurer’s criteria. For instance, before authorizing back surgery, the system might search for proof that a patient first tried physical therapy or received an MRI showing a bulging disc. Many companies say human employees are involved at the final stages, to review the A.I. evidence and approve the recommendations.
Insurers defend these tactics as being effective in reducing inappropriate care, such as by preventing someone from getting back surgery at tremendous cost instead of another treatment that would work just as well.
Government officials said that any denials would be done by “an appropriately licensed human clinician, not a machine.”
Mr. Sutton also emphasized that the government could penalize companies for inappropriate decisions.
A group of House Democrats, including Representative Alexandria Ocasio-Cortez of New York, warned in a letter to government officials in late July that giving for-profit companies a “veto” over care “opens the door to further erosion of our Medicare system.”
Private plans under Medicare Advantage have become increasingly popular, with a little more than half of older Americans and people with disabilities eligible for the program and some 34 million enrolled. But many, like Ms. Ayres, are willing to forgo some of the additional benefits the private plans offer, like dental checkups and gym memberships, to avoid having to jump through numerous hoops to get care.
“It’s really surprising that we are taking the most unpopular part of Medicare Advantage and applying it to traditional Medicare,” said Neil Patil, a senior fellow at Georgetown and a former senior analyst at Medicare.
The American Medical Association wrote in a letter that doctors view prior authorization “as one of the most burdensome and disruptive administrative requirements they face in providing quality care to patients.” Most patients who appeal are successful, but a vast majority never appeal.
Democrats and Republicans in Congress have supported legislation that would curb some of the insurers’ most troublesome practices. The Biden administration enacted some new rules, and the Trump administration was eager to take credit for pushing insurers to pledge to a series of reforms just a few days before unveiling this new program.
In announcing the new model, Dr. Mehmet Oz, the administrator of the Medicare agency, said the goal was to root out fraud, waste and abuse.
“It boils down to patient harm,” Mr. Sutton said. The model is expected to save several billions of dollars over the next six years, although it could save more if it were expanded.
There are clear-cut examples where Medicare has wasted billions on questionable medical care. The agency came under scrutiny earlier this year for spending billions of dollars on expensive “skin substitutes” of dubious value. The pilot program would require patients to seek prior authorization before getting a skin substitute.
But if the algorithm used to authorize those procedures proves to save the government money, Dr. Rathi fears C.M.S. may feel justified in broadening the program to include services that are not such “low-hanging fruit.”
“You’re kind of left to wonder, well, where does this lead next?” he said. “You could be running into a slippery slope.”
How insurers make their decisions remains opaque. A spokesman for Health and Human Services, which oversees the Medicare agency, declined to identify which companies had submitted applications for the contract.
Contractors hired by the government are supposed to watch over payments to ward against inappropriate or wasteful coverage. Those reviews generally happened after someone had received a treatment, though the Biden administration instituted a modest pre-approval program that did not use A.I.
The new model relies on an additional set of private companies for traditional Medicare that have a very clear incentive to deny care.
The companies represent “a whole new bounty hunter,” said David A. Lipschutz, the co-director for the Center for Medicare Advocacy, one of the groups that has urged government officials to abandon the program.