PNHP

The Social Mission

The Social Mission

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

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

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

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

Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

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…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

National Polling Reveals Widespread Cost & Access Concerns

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

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

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

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

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

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

Comment:

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

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

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

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

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

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

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

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.

https://nytimes.com…

Law threatens health care

By Betty Keller, M.D.
The Barre-Montpelier (Vt.) Times Argus, Letters, Aug. 27, 2025

Medicaid pays for the health care of some 119,000 Vermonters. Vermont Agency of Human Services estimates 45,000 of them will end up uninsured as a result of the misnamed “One Big Beautiful Bill Act.” The impact on those people is obvious: avoiding doctor visits as long as possible, while their condition worsens, frequently resulting in emergency room visits, higher costs, worse outcomes, and even avoidable deaths.

The impact on the rest of us is less obvious. Think Medicaid has no impact on you if you aren’t on it? That’s a serious misconception. The $2.3 billion Medicaid feeds into Vermont’s health care system amounts to 27% of all health care spending in the state. Some 62% of that currently comes from the federal government. If that essential funding stops for 45,000 people, health care providers won’t get paid when all those now-uninsured people seek care. To compensate, most will likely raise prices for everyone else, including you. That’s not a sustainable solution.

These cuts will add serious strains to our already strained hospitals, which are already dropping services they deem unprofitable. What additional services will become unavailable, at which hospitals, affecting everyone, including people who do have insurance?

Did the people who concocted these new rules understand the consequences beyond those for the individuals losing coverage? Perhaps that is why they timed them to take effect after the midterm elections, so voters would be lulled into thinking all the naysayers were exaggerating or even making up the harms.

Please spread the word. Tell your friends and relatives, especially those in states where their elected officials voted for this huge disaster. Do what you can to push our elected officials to fix this.

Dr. Keller is president of Vermont Physicians for a National Health Program.

Our Commitment to Help Those Who Have Too Little

President Franklin Delano Roosevelt said that progress is helping those in need. President Donald Trump by words and actions advocates for the wealthy. Today’s progressives are enthusiastically received when advocating for helping everyone, yet the Democratic party often favors the wealthy. We must commit to helping those in need via programs that support us all.

Second Inaugural Address of Franklin D. Roosevelt, January 20, 1937

The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.

Second Inaugural Address of Donald Trump, January 20, 2025

Instead of taxing our citizens to enrich other countries, we will tariff and tax foreign countries to enrich our citizens.

We will restore the name of the great president William McKinley to Mount McKinley, where it should be and where it belongs. President McKinley made our country very rich through tariffs and through talent. He was a natural businessman.

The Democratic Party Faces a Voter Registration Crises, The New York Times, August 20, 2025, by Shane Goldmacher with Jonah Smith

Of the thirty states that track voter registration by political party, Democrats lost ground to Republicans in every single one between the 2020 and 2024 elections – and often by a lot. That four-year swing toward Republicans adds up to 4.5 million voters, a deep political hole that could take years for Democrats to climb out from.

Comment:

By Don McCanne, M.D.

Since I was a small child, I always believed in the principle that my father taught me that was so well expressed by President Roosevelt: we always take care of each other.

Currently we are operating under a principle expressed by President Trump: we strive to further enhance the wealth of those who have much, while taking away from those who have little.

This contrast in principles correlates with the respective political parties of Presidents Roosevelt and Trump. Yet, we now see a shift wherein the Democrats seem to be joining the Republicans in placing more value on personal wealth than they do in supporting a government that would ensure that those who have too little would be adequately cared for.

How can this be when polls show majority support for social programs such as single payer Medicare for All? Rallies, such as those of Bernie Sanders and AOC, have record-breaking attendance when they promote programs that would enable all of us to meet basic needs in life. And the Republicans who hold town hall forums in their districts are met with boos and catcalls when they boast about laws they supported that would enhance the wealthy while ignoring the needs of those who are struggling.

Where should our loyalty stand? Should it be in support of social justice which takes care of everyone – including those who have too little? Or should it be for personal wealth creation that benefits only the most affluent amongst us? I certainly have my answer to these questions, and I fail to see why a majority of us would choose the other answer. Votes should not blindly follow arbitrary loyalty to a political party. They should be based on respect we have toward fellow humans.

If someone can present me with a moral argument of why I might be wrong, I would certainly like to hear it, though I am prepared to counter any such argument. I will never accept that personal wealth is more important than our individual and collective souls.

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.

Trump’s Big Bill Will Make It Harder for Doctors to Give Patients the Care They Need

Work requirements for Medicaid don’t encourage employment; they punish illness and make recovery harder.

By Hridaya Shah and Toby Terwilliger, M.D.
Common Dreams, Aug. 22, 2025

Like most bright-eyed medical students entering the wards for the first time, I was eager to give my patients the best that modern medicine could offer. This is far from the reality that I was confronted with—one’s insurance status dictated care as much as any guideline, evidence, or well-intentioned physician ever could.

I cared for patients whose chronic illnesses forced them to stop working, only to be told that without a job, they no longer qualified for Medicaid. The logic is cruelly circular: Lose your health, lose your job, lose your care. Work requirements for Medicaid don’t encourage employment; they punish illness and make recovery harder.

Alongside countless peers and healthcare professionals, I was incredibly disheartened on July 4, 2025 as I watched US President Donald Trump sign into law the most sweeping healthcare overhaul since the Affordable Care Act. The 870-page One Big Beautiful Bill Act (OBBBA) is projected to strip health coverage from 11.8 million Americans, leading to an estimated 24,000 preventable deaths each year—driven largely by drastic changes to Medicaid’s administration.

The current administration has long touted work requirements as a fix to Medicaid, having approved 13 Medicaid Section 1115 demonstrations with work requirements in its first term. Unfortunately, it has ignored the failures of these waiver programs and doubled down, making ineffective work requirements the law of the land.

The Majority of Medicaid Recipients Are Already Working

President Trump and his administration have repeatedly stated that the integrity of the Medicaid program needs to be restored, promoting narratives of Medicaid waste, fraud, and abuse. As such, work requirements for “able-bodied” Medicaid recipients were a key provision in the OBBBA. However, in reality, 92% of Medicaid beneficiaries are already working, caring for family, attending school, or living with a disability. Only 8% are “able-bodied” adults not seeking employment.

States Have Tried Work Requirements, They Don’t Work

Arkansas was the only state to have a statewide Medicaid work requirement waiver approved. The results were catastrophic; over 18,000 beneficiaries lost coverage in the four months before a judge ruled that the program could not continue. While enacted, the waiver failed to increase employment; instead implementation was associated with increased Medicaid churn, medical debt, and loss of health coverage.

For other states, like Michigan and New Hampshire, the path to work requirements was mired with legal challenges. Both states proposed work requirements, which would have resulted in nearly 80,000 and 17,000 beneficiaries losing coverage, respectively, had the programs not been suspended before taking effect.

As of July 2025, Georgia is the only state with active work requirements through the Pathways to Coverage program. Results of this program are similarly underwhelming, with only 8,000 enrolled as of June 2025 after two years of rollout and millions spent in administrative costs. Enrollment falls far short of the projected 64,000 enrollees or the 300,000 to 400,000 Georgians who would qualify for coverage under full Medicaid expansion.

The OBBBA Doubles Down on Failed Policy

The OBBBA will require all states to follow Georgia’s path by 2027. Based on Congressional Budget Office (CBO) estimates, the federal government will save $900 billion in Medicaid spending over the next decade, with work requirements accounting for a third of the reduced spending. These savings come at an enormous cost—approximately 5 million individuals are projected to lose access to Medicaid by 2034, 1.22 million jobs in the healthcare sector will vanish in the next decade, and unemployment will rise by 0.8%. The consequences of this bill will be devastating.

Medicaid Expansion is a Job Promotion Program

Overwhelming evidence suggests Medicaid expansion has reduced uninsurance rates, increased access to healthcare and pharmaceutical care, and improved health outcomes. Moreover, hospitals in expansion states have seen increased Medicaid revenue, decreased costs of uncompensated care, and states themselves have experienced reductions in disease-related deaths, and gains in life expectancy. Importantly, overwhelming evidence shows expansion has no negative effects on workplace engagement, and rather may help increase workplace success.

If the ability to work remains a prerequisite for care, I will spend my career watching patients suffer—not because I lack the skills to help them, but because the system forbids it. Practicing medicine under those rules doesn’t just make my job harder; it risks our patients losing faith in the system altogether.

The evidence is clear, we should be expanding Medicaid, not restricting it, for the good of our patients, our hospitals, and our country.

Hridaya Shah is a medical student based in Georgia passionate about expanding access to health insurance and addressing health disparities in her community.

Dr. Toby Terwilliger is an Atlanta-based hospitalist who serves as cochair of Georgians for a Universal Health Program and currently serves as a National Board Member of Physicians for a National Health Program.

https://commondreams.org…

Trump’s Pervasive Assault on America’s Health

The recent federal budget bill slashed $1.5 trillion from Medicaid and Medicare. Yet the Trump administration’s attack on health regulations and research extends much further, undoing decades of proven capacity to save lives and reduce disease. We must harness discontent with this assault on health to rebuild and improve the system.

The Dismantling of American Health Care, NY Review of Books, July 8, 2025, by Adam Gaffney, David U. Himmelstein, and Steffie Woolhandler

On July 4 President Donald Trump signed into law a piece of legislation that amounts to a declaration of war on the working-class and the sick. The “One Big Beautiful Bill Act” will slice more than $1 trillion from Medicaid over the next decade, stripping health coverage from more than 11 million lower-income Americans by 2034 and sending tens of thousands to an early grave—all in exchange for tax reductions for corporations and the wealthy. Despite Trump’s promises to the contrary, the law will also cut nearly $500 billion from Medicare over the same period by making the deficit surge past a point at which the Office of Management and Budget “is required to order a sequestration to eliminate the overage.”

This assault on the nation’s major public insurance programs is only the latest front in an ongoing right-wing campaign against health. On April 1 Trump’s hammer fell on the Department of Health and Human Services (HHS), the sprawling agency that encompasses the Centers for Disease Control and Prevention (CDC), the Centers for Medicaid and Medicaid Services (CMS), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA), among other health-focused agencies. Having already forced out 10,000 HHS personnel earlier in his term, the Trump administration terminated 10,000 more on dubious legal grounds, devastating entire teams focused on major public health problems like tobacco control and occupational health. Altogether 25 percent of HHS’s workforce was dismissed. Since then a minority of the fired employees have been reinstated in the face of political pressure—but the depth and capriciousness of these chaotic cuts is without precedent. Disease surveillance, outbreak investigation, vaccine uptake, violence prevention, infection control, food safety, and opioid overdose prevention will likely suffer.

Meanwhile the nation’s biomedical research enterprise—in large part conducted by publicly financed scientists employed at universities— has been facing a sustained attack. NIH research grants that address important but now illicit health issues—like HIV/AIDS, racial health inequities, vaccine hesitancy, and LGBTQ health—have been wiped out in recent months. Not all of the cuts stem from specific bêtes noires: the administration has broadly decimated funding by canceling more than $1.8 billion in existing NIH grants in less than a month and a half (although some have been temporarily reinstated by court orders), reducing the issuance of new grant awards by 28 percent, and attempting to slash the “overhead” payments that cover universities’ costs for space and utilities via a now-stayed order that would have reduced grants from multiple federal agencies, including the NIH. This is on top of the funding blockades that the administration has imposed on many elite universities to bring them to heel—including all of the Ivies except Dartmouth and Yale.

The three fronts of this assault—on tax-funded medical coverage, public health, and medical research—have overlapping aims. The campaign to slash Medicaid—relied on by the poor since its establishment in 1965—follows a long neoliberal tradition of prescribing austerity for the working class and largesse for the rich. Trump and his allies seem to view public health, for its part, as waste that can be excised (DOGE-style) to fund tax cuts, as a source of regulatory excess that constrains profit-making, and as a locus of “woke” ideology and inconvenient facts. The assault on medical research is driven by similar concerns, with the added benefit of dominating rival centers of power like universities and the professions.

Yet such economic and ideological motivations do not explain the full measure of the administration’s agenda. It rests, too, on a Dark Ages disdain for science, part and parcel of Trump’s claim to be the arbiter of facts and truth. …

It seems difficult at present to resist Trump’s regressive anti-health juggernaut, much less to envision something better for tomorrow. But the medical community, which still wields considerable power and influence, appears to be reaching a boiling point. Colleagues fear seeing their coworkers and patients deported; academic freedom is threatened; medical decision-making is constrained by political fiat and managed care restrictions; research funding has disappeared; public health protections have been eviscerated; access to vaccinations has been curtailed; and charlatanism is displacing science at the highest level. Health professionals, having watched Congress slash the public insurance programs on which their patients and institutions rely, are soon to witness the needless suffering and death that will predictably follow. All these assaults are also breeding disaffection among voters. As many polls indicate, health is perhaps Trump’s weakest suit with the general public; most Americans favor more funding for science and public health, as well as universal coverage.

Comment:

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

This article is a tour-de-force review of the myriad ways that the Trump administration is undermining health care (especially public insurance), public health, and medical research. These are all areas that have yielded benefits to health over three-quarters of a century. The funding cuts have been massive, rapid, sometimes targeted, and often seemingly arbitrary. The cuts and their justifications often conflict or fail to withstand scrutiny. Further cuts are looming. As the article says, the actions bespeak a “Dark Ages disdain for science.”

For those interested in a survey of the anticipated effects of the budget bill on public insurance, in the context of health insurance trends, read Adam’s testimony to a Congressional committee.

At the end, Gaffney et al note that both the medical profession and voters dislike the broad assault on health care and science. We must hope that that this discontent will grow, and as political power shifts, we will soon have historic opportunities to rebuild, doubling down on our commitments to the public’s health, even – or especially – when that goal collides with the imperatives of maximizing shareholder value.

https://healthjusticemonitor.org…

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Corporate Profit Trajectory Undermined US Health Care

In the latest installment of NEJM’s series on the Corporatization of US Health Care, a historian reviews the trajectory launched half a century ago that led to big business profits permeating our health system, to the great detriment of patients.

A Gilded Age for Patients? The Broken Promises of Profit-Driven Medicine, From the Series: The Corporatization of U.S. Health Care, The New England Journal of Medicine, August 2, 2025, by Nancy Tomes

Between the 1920s and the 1960s, the American medical profession developed a new doctor-controlled business model of care delivery, dependent on continual investment in new drugs, technologies, and procedures. That model created the profit opportunities that enticed corporate stakeholders to invest in health care in the 1970s and 1980s. But as the corporate presence increased, physicians lost control of their business model.

Hospitals had to function in a more efficient, businesslike fashion. That ethos spread to private practice as well. This financialization led to dynamics whose negative consequences persist to this day. Even the middle-class patients, who were expected to benefit most from medicine’s new model, found the costs hard to budget for and the world of medical specialization difficult to navigate. These discontents created the opening for new business partners: insurance companies, which in the late 1930s figured out how to profitably pool savings for unpredictable expenses.

The “merger movement” in hospital and physician services enabled health care organizations to benefit from economies of scale while minimizing direct price competition. Hospitals and physician practices slowly fused into chains.

Although it may seem obvious that health care doesn’t work like a restaurant chain, many powerful health care industry stakeholders still believe allowing corporate interests freer rein will produce that “golden age for patients.” The health care economy’s fragility suggests otherwise.

No market solution has arisen for the most critical determinant of poor health and health care outcomes in the United States: extreme income inequality. The Trump administration appears intent on blowing up our fragile health care system in the name of an unrestrained “free market” and corporate profiteering. Many people will suffer if the system collapses completely, but perhaps a more sustainable health care system can be built from the rubble.

Comment:

By Don McCanne, M.D.

With Trump’s affinity for gold Rococo, it seems like he may believe that this is “the golden age,” but not for patients, just for the billionaires. For patients, he would perpetuate “the most critical determinant of poor health and health care outcomes: extreme income inequality.”

There is no need to further elaborate on why we have the most expensive but poorest performing health care system. Historian Nancy Tomes provides a succinct summary. But based on decades of inertia in producing the reforms that would reverse the high cost/poor performance ratio, there is a clear need to reinforce the public’s understanding that there is a well-documented model of reform that would provide high quality care for absolutely everyone at a cost that each of us could afford. Need we say it? Of course that is a single payer national health program, sometimes referred to as an improved Medicare for All.

Isn’t it about time that we got with the program?

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.