PNHP

Premier Medical Journal Scrutinizes Corporatization of US Health Care

Premier Medical Journal Scrutinizes Corporatization of US Health Care

The highly regarded New England Journal of Medicine just launched a series on the corporatization of US health care. Today’s for-profit health care conglomerates combine insurance, care delivery, and pharmaceuticals to serve the interests of shareholders over patients. On July 4th, it is appropriate to envision our independence from corporate control.

Defining Health Care “Corporatization”, The New England Journal of Medicine, June 28, 2025, by Erin C. Fuse Brown

In Paul Starr’s seminal 1982 work, “The Social Transformation of American Medicine,” he observed the corporatization of health care proceeding along five dimensions: the shift from non-profit and government organization to for-profit companies; horizontal consolidation of locally controlled entities to nationally or regionally controlled corporations; the shift from state single-unit and single-market firms to conglomerate enterprises; vertical consolidation among levels of care delivery and payers; and increasing concentration, size, and scope of organizations. In the four decades since the publication of this work, the U.S. health care system has progressed further along every one of these dimensions toward greater corporatization.

Insurance conglomerates, such as UnitedHealthcare and CVS-Aetna, now control physicians, home care, pharmacies, and pharmacy benefit managers. Vertical consolidation was spurred by the rise of managed care and its value-based progeny, particularly as private insurance companies have assumed a growing role in publicly financed health programs. The term “corporatization” now refers to the general trend throughout the health care industry toward higher levels of integrated control by consolidated profit-seeking enterprises.

Two key elements of this definition are worth highlighting. First is the elevation of profit generation as the primary goal of health care enterprise. Embedded in the term “corporatization” is the concept of shareholder primacy, advanced by neoliberal economists, that the primary duty of the corporation is to maximize shareholder profits. Shareholder primacy subordinates the interests of other stakeholders, such as patients, the health care workforce, or the community.

The second key element of corporatization is consolidation. The sheer size of conglomerate health entities makes them systemically critical and “too big to fail.”

Recently, the term “financialization” has been used to describe the growing involvement of financial institutions, such as private equity firms, using financial tactics to extract wealth from health care companies for investors.

Although profit motive has always existed in medicine, the control that large profit-seeking conglomerates have over the people and entities engaged in health care delivery has intensified and spread to every corner of the health care system. Corporatization has produced a system that is incredibly profitable for investors but increasingly unaffordable, inaccessible, and uncaring for everyone else.

Public satisfaction with the health system is low. Future health policy efforts must confront the fundamental question of whom our health care system is meant to serve: corporate giants or the members of our society as a whole.

Comment:

By Don McCanne, M.D.

The New England Journal of Medicine just released the first article in its series on the corporatization of US health care. Excerpts appear above. Since you, as a reader of Health Justice Monitor, are well-informed on health policy, you likely are unsurprised for corporatization to be described as a scourge for health care.

In an accompanying editorial, Debra Malina et al state, “Despite the fact that the United States leads the world in health care expenditures, American life expectancy at birth is 4 years lower than the average life expectancy in peer countries.”

Tweaking the corporate model will not be adequate to fix this problem. We not only need to replace our private insurance model with a publicly financed and administered model (single payer), we also need to shift the expenditures for health care away from private investors and into financing the health care system itself. We can do this through mechanisms such as public provisioning of health care (i.e. public and truly non-profit ownership of the health care delivery system), and by adopting regulatory oversight that prevents diversion of our health care dollars through nefarious financial gimmickry such as private equity usurpation of the delivery system.

How are we doing? This week we witnessed the passage and signing of federal legislation that will immediately produce massive tax benefits for the most affluent members of our society while mandating reduction or elimination of medical care and other social programs desperately needed by low-income and indigent individuals. These measures will exacerbate the negative effects of corporatization on health care. The GOP knows the cuts are unpopular, and hopes to elude electoral repercussions by deferring implementation until after the 2026 mid-terms.

It is fine to follow the monthly NEJM series, but don’t wait until the end of the series to begin thinking about what we need to do. Begin immediately with the transformation of the insurance system from private to public, and start on the long and arduous path to shifting our health care dollars away from wealth creation for the intermediaries to paying for the legitimate costs of the services and resources that are needed to provide an optimal health care system for all of us.

Unfortunately, our political system has just demonstrated, once again, that we need to select our leadership based on beneficial public policies that we support rather than on whether or not you enjoy leadership led by arrogant, pompous, blowhard personalities who value their personal wealth far above the fate of the rest of us.

https://healthjusticemonitor.org…

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Atlanta doctors: We can’t let Washington gut Medicaid

By Toby Terwilliger, M.D. and Dhaval Desai, M.D.
The Atlanta Journal-Constitution, July 3, 2025

As physicians, we use the term “Against Medical Advice” when a patient rejects our recommendations. We use it to convey a belief that they are making a decision that puts their health and safety at risk. But what happens when it’s not a patient ignoring our advice, but the government itself?

That’s exactly what the so-called “One Big Beautiful Bill” (HR-1) does — it ignores doctors’ warnings and endangers millions.

This week, physicians throughout Atlanta, throughout Georgia and throughout the country took to the streets and sounded an alarm — Code Red. Just like a Code Blue for a medical emergency, we called this Code, rallied with unified values of humanity in opposition to this bill.

We are sounding the alarm because HR-1 threatens to strip health coverage from about 11.8 million Americans by 2034. According to analysis in the Annals of Internal Medicine, these cuts will lead to as many as 24,000 preventable deaths every year. They would force dozens of rural hospitals to close and worsen our existing crises in maternal health and primary care access. Every health care system and American would feel the aftermath and consequences of this bill because of the challenges that would be imposed on an already over-saturated and fragile infrastructure. Health care systems would be challenged and burdened to keep doing more with less.

We see Medicaid for what it is: a lifeline. It keeps the child with asthma breathing comfortably. It helps grandparents stay safe and independent. It ensures pregnant mothers get lifesaving prenatal care. It supports people with disabilities in a world not designed for them. And it helps working Americans manage chronic conditions so they can stay employed and support their families.

Time and time again, physicians see the deadly consequences when patients go without health insurance. From cancers caught too late, vital medications skipped, chronic, controllable diseases spiraling into preventable crises, families crushed by unpayable medical bills. Knowing that stories like these will become exponentially more common is beyond disheartening; it is utterly sickening.

Physicians have taken the Hippocratic Oath, which stands by “First, do no harm.” This bill will do nothing but harm. That’s why we, as physicians, are united in speaking out. We know that cuts to Medicaid will jeopardize the lives and livelihoods of patients. We cannot remain silent while politicians pursue policies that will do irreparable harm to an already compromised health care system. Let’s remember that Medicaid is not charity, but it’s essential and lifesaving care. Our patients need more access, not less. We need to expand Medicaid, not eliminate it.

Congress: Stop playing politics with people’s lives. This time, listen and act on the medical advice from thousands of concerned physicians around the country. Do no harm.

Dr. Toby Terwilliger is an Atlanta-based physician who serves as co-chair of Georgians for a Universal Health Program and sits on the Board of Directors of Physicians for a National Health Program.

Dr. Dhaval Desai is an Atlanta-based Internist and Pediatrician, as well as an author passionate about mental health and burnout among healthcare workers.

https://ajc.com…

Physicians call for health care for all West Virginians

By Kenneth Wright, M.D.; John Aldis, M.D.; Agnes Franz, M.D.; Mike Schroering, M.D.; Dan Doyle, M.D.; and Joseph Golden, M.D.
The (Beckley, WV) Register-Herald, July 2, 2025

We are members of the WV chapter of Physicians for a National Health Program. We treat West Virginians of all income levels: low, middle, and upper income. Low and middle income people are struggling to find a stable and financially secure home life. These are people in our communities, people with whom we work, worship, and play. Our children and theirs attend school together.

Physicians for a National Health Program advocates that high quality health care be available to all people in the United States, without regard to socio-economic status, race, or gender.

We believe this should be a public right, as it is in Canada and European countries.

Right now, we are concentrating on the attempt by the Republican majority in Congress and the President to decrease funding for Medicaid and SNAP (food assistance), as they are currently administered. This attempt is through HR1, what the President calls the “One Big, Beautiful Bill.”

If this measure passes and is implemented, it will have devastating effects here in West Virginia, one of the poorest states in the country. In W.Va. 75,000 of those receiving Medicaid, and 65,000 getting SNAP (Food Stamps), will lose this support. One in three West Virginians rely on Medicaid for their health care. Many elderly in nursing homes rely on Medicaid funding for their care. And those nursing homes rely on that income to remain open. And the nursing employees rely on those jobs to feed their own families.

The drafters of HR1 have no idea what it feels like to be poor, what it feels like to be hungry, what it feels like to choose between food or medicines, what it feels like to have a loved one rejected by a nursing home because Medicaid no longer covers this treatment.

These massive cuts to Medicaid and SNAP are being done to offset tax breaks that mostly benefit well to do families. If a family earns $556,000 or more, they get approximately $50,000 extra income for which they have no survival need. People at this level can afford health insurance, and no problem providing food for their meals. In contrast families earning $55,000 or less in West Virginia will get little or no extra income from the “tax breaks” in HR1.

Many hospitals in West Virginia, especially in rural areas, rely on Medicaid funding to pay their operating expenses, including paying their employees. Seven more rural hospitals in West Virginia risk closure if this proposed shrinkage in Medicaid funding occurs. Not only will low-income people not be able to get health care, but many current employees of hospitals and other health care organizations would be laid off.

As members of PNHP-WV, we ask all citizens to think about how loss of Medicaid or SNAP food assistance will affect their families.

Contact our two U.S. Senators Capito and Justice, and two Representatives Miller and Moore in Washington. Tell them the concerns about the consequences for themselves and their families. We look for the day of improved Medicare for All when everyone will be covered with no exclusion from needed primary care, specialist care, hospital care, or medications.

But now we must fight against going backwards. Against adding more than 11 million nationwide to the 28 million already uninsured. Against 7,000 preventable deaths per year due to lack of medical care. Against severe economic harm to our fellow citizens and our state.

Dr. Kenneth Wright is the chair of PNHP-WV; Dr. John Aldis is the treasurer; Dr. Agnes Franz is the secretary; Dr. Mike Schroering is past-chair; and Dr. Dan Doyle and Dr. Joseph Golden are active members.

https://register-herald.com…

Recent Experience Shows National Medicaid Work Requirements Would Create Enormous Administrative Inefficiencies

By Adam Gaffney, M.D., M.P.H.; David U. Himmelstein, M.D.; Danny McCormick, M.D., M.P.H.; and Steffie Woolhandler, M.D., M.P.H.
Health Affairs Forefront, July 2, 2025

The “One Big Beautiful Bill Act” (OBBB) — passed by the House on May 22 and yesterday in the Senate — would make Medicaid coverage for adults contingent on enrollees’ regularly documenting that they are working, are actively seeking work, or qualify for an exemption. The Congressional Budget Office (CBO) estimates that this “work requirement” provision would push 5.2 million people off Medicaid, including many who were already working or should be eligible for exemptions, but who would fail to properly document their circumstances. We and others have projected that those coverage losses would inflict substantial health harms, including thousands of medically-preventable deaths.

Repetitively documenting and monitoring whether Medicaid enrollees have met the work requirements (or are eligible for exemptions) would also require significant administrative expenditures by states’ Medicaid programs — red-tape costs that deserve greater scrutiny as legislation approaches the desk of the President.

Looking Back: Administrative Costs Of Medicaid Work Requirements In 6 States

The first Trump Administration encouraged states to seek Section 1115 Medicaid waivers that would — for the first time in Medicaid history — require enrollees to document work or face disenrollment. CMS ultimately approved 13 states’ applications, although only Arkansas actually disenrolled noncompliant enrollees; disenrollments in other states were stalled either by court orders or the COVID-19 pandemic. Subsequently, the Biden administration rescinded approval of all work-requirement waivers, although a federal court order later reinstated Georgia’s waiver which is now in operation.

These requirements impose new administrative costs on states, which must develop, upgrade, and maintain electronic eligibility and enrollment systems; hire and train staff to process and monitor documentation; and educate beneficiaries. In a 2019 report, the US Government Accountability Office (GAO) assessed the administrative costs associated with implementing (or preparing to implement) work requirements in 5 states: Kentucky, Wisconsin, Indiana, Arkansas, and New Hampshire. Exhibit 1 displays the GAO’s estimates of new administrative costs in each state, the number of beneficiaries subject to work requirements, and our calculations of costs per beneficiary. Administrative spending for implementation ranged from $6.1 million (New Hampshire) to $272 million (Kentucky). Administrative costs per beneficiary subject to work requirements averaged $267, ranging from $84 (in Indiana) to $463 (in Wisconsin). …

Looking Ahead: Work Requirements In The One, Big Beautiful Bill Act And New Section 1115 Waivers

Congress and President Trump look set to impose billions in new bureaucratic costs on Medicaid in order to disenroll 925,000 people not meeting the work requirements, along with 4.3 million others who would likely meet those requirements but be unable to navigate the thicket of red tape required to enroll in or maintain coverage.

Even before the OBBB, the Trump Administration has been approving Section 1115 waivers that would impose work requirements in 3 states, and encouraging waiver applications from other states. Such work requirements will harm the health and finances of millions of low-income Americans, but an even larger share of Americans will pay for the bureaucratic costs needed to operate these programs. …

full analysis: https://healthaffairs.org…

Dr. Adam Gaffney on “Democracy Now”

PNHP past president Dr. Adam Gaffney appeared on “Democracy Now” on June 30, 2025. He discussed the dire implications of the Republican budget bill making its way through Congress.

“Nearly 12 million people would lose health coverage,” he said. “We estimate [in a recently published Annals of Internal Medicine study] this translates to 1.9 million Americans losing their doctor, 1.3 million Americans going without needed medications, 1.2 million Americans being saddled with medical debt, and 380,000 women going without their needed mammograms.

Biggest of all, we estimate more than 16,500 deaths annually as a result of the coverage losses that would be inflicted by the so-called Big, Beautiful Bill Act.”

Laying out the Ill-Effects of Medicaid Cuts in the Congressional Budget Bill

A new analysis reviewing all evidence regarding the likely impact of proposed Congressional Medicaid cuts quantifies the dire consequences of slashing coverage. About 7 million individuals will become uninsured, >2 million will skip care, and annual deaths will increase by 8-24 thousand.

Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health, Annals of Internal Medicine, June 17, 2025, by Adam Gaffney, David U. Himmelstein, and Steffie Woolhandler

From the Abstract:

… Enactment of the House bill [Medicaid cuts] advanced in May 2025 would increase the number of uninsured persons by 7.6 million and the number of deaths by 16,642 annually …

Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

Comment:

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

Drs. Gaffney, Himmelstein, and Woolhandler perform a critically important service: they compile and summarize the voluminous evidence that … health insurance provides access to care, improving health and extending life. And taking away health insurance has the opposite effects, harming health and increasing deaths. Of course we know that. But when these health policy leaders quantify what to expect with the specific proposed Medicaid cuts in the Congressional budget reconciliation bill, even the two of us – seasoned health policy analysts – are stunned. The accumulated empirical evidence is persuasive, and the anticipated harms are shocking.

We’ve taken the liberty of creating a summary table with the core findings (see above). Uninsured numbers rise by 6.8 million among adults (plus about 1 million among children), with 8 – 24 thousand added deaths. For more detail, especially about reductions in access to care and general health status, check out the article. And also see the PNHP press release here and NBC coverage here.

As we’ve reported previously, most voters oppose Medicaid cuts, even among Trump supporters. And in the last couple of days, the Senate parliamentarian deemed up to 40% of the cuts unacceptable by Senate budget bill rules. So we have some hope that these efforts to slash Medicaid will wither on the vine.

But they won’t wither on their own. It is essential for opponents to speak up.

Share this information widely. People need to know.

https://healthjusticemonitor.org…

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

How To Make America Sick

The Trump administration’s plan to “Make America Healthy Again” will make Americans’ health worse.

By Donald Berwick, M.D., M.P.P., F.R.C.P.
Center for American Progress, June 26, 2025

It might seem obvious that the United States, the wealthiest country on earth, would have the best health and health care. But we do not. Not even close. So when President Donald Trump, Secretary of Health and Human Services Robert F. Kennedy Jr., and their allies in Congress propose to “Make America Healthy Again,” it’s easy to get on board. The trouble is that their plan won’t work. In fact, it will make Americans’ health worse. They are currently proposing to cut Medicaid and Medicare, decimate public health structures, withdraw support for food security and other basic needs, and harm the environment—all of which is dead wrong from a scientific viewpoint.

There is no disputing that America’s health care system needs a dramatic overhaul. U.S. life expectancy ranks 49th globally at more than four years lower than that of world’s healthiest countries. Our children’s health ranks 36th among the 38 richest nations. Not a single U.S. state has an average life expectancy longer than that of comparably wealthy nations. If the goal is to make America as healthy as other wealthy nations, it would be hard to do worse than we are doing right now. And for that terrible performance, the United States spends twice as much per capita on health care as the average wealthy country—with more than 110 million Americans struggling with medical debt.

So, yes, by all means, let’s “make America healthy.” However, unlike how the Trump administration and RFK Jr. are going about it, doing so requires following the science.

In 2015, the revered British epidemiologist Michael Marmot wrote “The Health Gap,” arguably the best playbook for making any country healthier. The book summarizes decades of research on why health varies enormously among places with ostensibly similar conditions. The gap in health outcomes can be between nations, between subgroups within nations, and even across the tracks in a single city. For example, Black Americans had a lifespan six years shorter than that of white Americans in 2021; residents of west Chicago live 14 years less than residents of the Chicago Loop; and across the city of Boston, lifespan varies by more than two decades.

Marmot sorts known causes of health gaps into buckets including early childhood experiences, education, workplace conditions, supports to the elderly, and community “resilience”; he also looks at the impact of attributes such as food security, housing security, transportation systems, clean air, compassionate criminal justice systems, and recreational opportunities. Through that lens, a scientifically guided plan for “making America healthy” is simple to devise: Invest in what drives health.

This is why what RFK Jr. and the Trump administration are doing makes no sense. Watch the administration, and it would be hard to find a better way to “make America sick.” It’s like “opposite day”: Every single component of the Marmot playbook is being not only neglected but controverted through the administration’s actions. Let’s run the list.

Kids

Healthy societies tend to place their bets on safe perinatal care, strong supports for the early years—say, from birth to age 3—and school readiness, which means not only helping children but also their parents. Contrast that with the House-passed One Big Beautiful Bill Act that instead cuts food stamps by nearly $300 billion and enacts a historic $793 billion cut to Medicaid and the Children’s Health Insurance Program, which cover 50 percent of the children in America.

Education

People in countries and regions with strong educational systems, especially those that include girls and women, tend to live longer. Overall, the U.S. education system ranks 31st in the world, and it varies widely, with many schools performing poorly and many students underachieving. This is neither the teachers’ fault nor the students’. It boils down to ensuring that all children and youth, regardless of where they live or how wealthy their families are, have access to the highest quality education. The proper response would be to pour resources into delivering on that promise. On the contrary, the Trump administration’s plan calls for slashing funding for the Department of Education, cutting support to K-12 programs, and eliminating federal subsidies for student loans.

Workers

Job security is also foundational to national health. Unionization, which has been backwatered in the United States, is one straight shot to improving worker power. So is raising the federal minimum wage far above its embarrassingly low level of $7.25 per hour, instituting stronger legal protections for workers’ rights, and establishing more equity in tax and compensation policies. The Trump administration, meanwhile, seeks to abolish the Consumer Financial Protection Bureau, hamstring the Department of Labor, reduce bargaining rights for federal workers, weaken worker protections, and cut the essential food assistance and health care programs that the working class relies on, all to give massive tax cuts to the wealthiest Americans.

Seniors

How a nation supports its aging and elderly population affects not only how long and well its older citizens live, but also the health and well-being of a country’s entire population. The Trump administration claims to want to protect Medicare—a mainstay of security for those age 65 and older in the country—but study the details of what the president and his congressional allies are doing so far, and you will find steadily weakening protections for coverage, reduced access to care, and thousands of dollars more in out-of-pocket costs. For example, Medicaid, which would be torpedoed by the House-passed reconciliation bill, is the primary payer for 63 percent of people in nursing homes. Where are the elderly Americans who rely on that care supposed to go?

Communities

Healthy communities help ensure access to nutrition, housing, safety, mobility, and opportunity for everyone. The Trump administration is already weakening every one of those things and is poised to damage them further. The administration is hurting public transportation systems and rolling back environmental controls for particulate air pollution. It is also publicly in favor of coal and against wind power, against public housing expansion, against mental health supports to help reduce violence, and has backpedaled on criminal justice reform.

Conclusion

President Trump and Secretary Kennedy can preach all they want about making us healthy again, but their rhetoric is no substitute for facts. The right way to “Make America Healthy Again” is to invest in the infrastructure, programs, and priorities that we know, based on scientific evidence, will actually improve health—the very same ones that the Trump administration seems intent on destroying.

Dr. Donald M. Berwick is a former administrator of the Centers for Medicare and Medicaid Services and a senior fellow at the Center for American Progress.

https://www.americanprogress.org…

The Case for Universal Healthcare with Dr. Diljeet Singh

With Liberty and Justice for Some Podcast, June 25, 2025

PNHP president Dr. Diljeet Singh sat down with Rep. Mark Pocan to talk about how the profit motive harms patients and physicians—and why we need improved Medicare for All.

“Profit occurs at every single step of health care,” said Dr. Singh.

“Somewhere between 30 and 35 cents of every health care dollar [goes to] profit, bureaucracy, and administration. We’re putting money into a shareholder’s pocket—and it happens at every level.”

https://open.spotify.com…

‘Medicare for All’ a better solution than ACA

By George Bohmfalk, M.D.
Aspen Daily News, Letters, June 25, 2025

At Sunday evening’s Aspen Ideas Health session I was interested to hear Nancy Pelosi and other esteemed panelists discuss how the Affordable Care Act, aka Obamacare, barely passed some 15 years ago. But I was very disappointed by her opinion that the benefits of the ACA are superior to those that would be guaranteed by an improved Medicare for All.

I appreciate that a wholesale revamping of our health care system may have been politically impossible. But there’s no way that a clearcut system like improved Medicare for All — with universal, cradle-to-grave comprehensive coverage, no pre-existing conditions exclusions, elimination of the impenetrable complexities of Medicaid and several other programs, disconnection from employment and streamlined funding and provider payment system — is not an improvement over the cat’s cradle in which we now struggle to obtain, deliver and pay for care.

The ACA accomplished many great things, but it did not cover all Americans nor protect us from medical bankruptcy and has allowed private insurance companies to profit obscenely while restricting care. The dam is going to break before long.

Aspen Ideas clip:

https://aspendailynews.com…

Public Provisioning of Services: Adjunct to Single Payer

Public financing of health care (single payer) is a long-standing progressive goal. Public provisioning of services is a well-established practice in the US, largely fallen out of favor – and a perfect complement to public financing.

Reviving public provisioning in US health care, Health Affairs Scholar, March 17, 2025, by Hayden Rooke-Ley, Dana Brown, & Colleen Grogan

Abstract:

As new approaches of political economy gain ground in some sectors, American health care still reflects many aspects of neoliberalism. In this piece, we build on proposals to reorient health care policy around a new industrial policy for health. A core component of this strategy – and our focus here – is a revival of public provisioning of medical services and pharmaceuticals. Although less prevalent today, forms of public provisioning still exist in vital ways. These models demonstrate how public provisioning can not only address urgent capacity needs – it can promote local ownership, operate as a competitive public option that bolsters worker power, and assure societal return on public investments.

Introduction:

Despite experimentation in certain sectors with new paradigms of political economy, American health care still exhibits many hallmarks of neoliberalism. The privatization of Medicare typifies an overreliance on market making and consumerism, even as it drives up costs and builds private power with public dollars. Widespread corporate consolidation, pursued in the name of efficiency, increases costs and often reduces access for low-income patients. The financialization of care delivery – instantiated by private equity, insurance conglomerates, and profit-oriented “nonprofit” hospital systems – prioritizes returns for investors and corporate management over the production of health. The broader picture is one of neoliberal “re-regulation”: it is not that the health care state has receded – indeed quite the opposite – but that it has been repurposed to empower large corporations and financial investors over popular democratic demands.

In response, calls are emerging for a new health care paradigm to join the existing ferment of industrial policy.

Core to this agenda should be a revival of public provisioning, which we define as medical care and pharmaceutical production that is owned and governed by public institutions. The decline of public provisioning accelerated with the neoliberal turn, as an ideological attraction to privatization and markets took hold. Nonetheless, as we explain here, public provisioning still exists in vital if less visible ways today. These models demonstrate how public provisioning can promote local ownership, serve as a competitive check on private industry, and assure that society benefits from public health care investments.

Public provisioning today:

Public hospitals are defined as government-owned acute care hospitals and are owned by a state, county, city, or hospital district. They made up nearly a third of all US hospitals but have since declined by 39%; meanwhile, for-profit hospitals have increased by 32% since 2009. A key driver here is public-to-private conversions. The evidence suggests privatization does not increase efficiency but instead undermines access to care. Moreover, public hospitals that privatized had higher average mortality rates compared with public hospitals not experiencing privatization. Policymakers ought to consider maintaining and upgrading existing public hospitals and a more robust role for new public hospitals through which to direct public capital financing.

Health districts represent another element of locally governed and publicly accountable care that can adapt to a community’s needs. These services are often offered in under-resourced rural areas. Investing in these models will likely require cross-subsidization at the state or federal level.

Public health centers provide an avenue for local public investment to support health centers. Yet the expansion of public health centers is constrained by the 5% cap set by Congress. To build out this “public-public” delivery model, policymakers could lift the 5% cap and enhance grant funding of public institutions at the local level.

Pharmaceuticals … there are dire shortages in the generic drug market, and policymakers are beginning to look to the public sector in response. Federally, there are proposals both for large-scale generics production and public R&D coupled with public-interest provisions on all resulting intellectual property. These public-option proposals deserve serious consideration.

Future policy directions:

Current policy limits the growth of public provisioning. Policymakers could begin to address this by lifting the cap on public entity Federally Qualified Health Centers. A “new Hill-Burton” could emphasize investment through public hospitals and health districts. Similarly, state and federal investment dollars could be channeled to build pharmaceutical capacities. Ultimately, a new health care industrial policy must prioritize a rational production and allocation of capacity – and public provisioning can ensure that these public investments deliver a return for patients, the health care workforce, and their local communities.

Comment:

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

The United States has the most expensive health care delivery system in the world, yet its performance falls far below that of other industrialized nations, leaving far too many individuals with poor access to health care, low quality care, high mortality, and crippling financial burdens.

Decades ago we realized that we could address these problems by implementing single payer financing: improving the Medicare program and expanding it to cover everyone. It would be funded through progressive taxes, affordable for everyone. But we failed to achieve that goal. Instead, costs have increased faster than in other nations, with coverage and quality lagging.

What happened? We shifted most health care payments into the private insurance system. Under public financing, the mission is to fund the health care needs of patients. In contrast, the primary mission of private insurance is to enrich investors and executives. Many of their business techniques – such as cherry-picking healthy individuals and lemon-dropping sick ones, burdensome prior authorization, upcoding of diagnoses, and excessive deductibles and copayments – are used to divert our health care dollars to their profits. Sadly, corporate insurers have been effective at privatizing public insurance, allowing massive diversion of health care funds to their purposes. Both Medicare and Medicaid operate mainly via private insurance.

Another critical factor is the transformation of care delivery by widespread corporate purchase of providers: hospitals, physician groups, and nursing homes. With private equity in particular, the goal often is to buy the health care entity, drain it of assets and funds, and then dispose of it, often via bankruptcy. With a shift in emphasis from patients to profits, costs are up while quality and access are down.

What can we do about it? Single payer is essential – to shift spending away from profit-making insurance intermediaries and toward providers. But we also need to shift to not-for-profit providers. To us – the community. That is, we need significant public provisioning of health care, building on an impressive history, as nicely reviewed Rooke-Ley and colleagues.

Public provisioning is feasible, with historical and current examples and the potential to represent best practices within a diverse delivery system. In contrast, a national health service (government owning the entire system) faces far greater resistance — it would be a monumental challenge to transfer private sector to public ownership in one step. Many voters are ideologically opposed to a system that would be entirely owned and administered by the government, dismissing it as “socialized medicine”. Instead, by establishing and expanding public provisioning options, we can imagine gradual transformation to substantial public ownership. Public providers, well-funded by single payer and without the need to extract profits, would be highly desirable to patients.

Do we have the necessary public support? Of course, politics is a challenge. One major political party has fostered “neoliberalism,” which supports a major private sector role (with profits) for public goals. A significant element within that party prefers “progressive” policies, in which the mission is public (eg patient care) while profit-oriented business interests are minimized. The other major party cuts health care spending as a source of funds to reduce taxes for the wealthy. Notably, voters of both parties want to retain Medicaid, Medicare, and other public insurance. So the path, although tricky, can build on a broad base of support.

Obviously, there is a pressing need to educate the public. But: affordable. comprehensive, high-quality care for absolutely everyone creates a much better image than billionaires using government tax policies to increase their personal wealth at the cost of reducing essential social services required by so many. The public is primed, more than ever, for a public approach.

Let’s finally end decades of delay and move forward with reform based on sound policy proposals. Public financing together with public provisioning is the potent combination!

https://healthjusticemonitor.org…

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Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health

By Adam Gaffney, M.D., M.P.H.; David U. Himmelstein, M.D.; and Steffie Woolhandler, M.D., M.P.H.
Annals of Internal Medicine, June 17, 2025

Abstract

In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years. On the basis of the Committee’s estimates of savings; Congressional Budget Office analyses; and peer-reviewed studies of the coverage, financial, and health impacts of past Medicaid expansions and contractions, the authors project the likely effects of each option and of the House bill advanced by the Budget Committee in May.

Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16 642 annually, according to a mid-range estimate. These figures exclude harms from lowering provider payments and shrinking benefits, as well as possible repercussions from states increasing taxes or shifting expenditures from other needs to make up for shortfalls in federal Medicaid funding.

Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

Congressional Republicans and President Trump seek to extend and expand tax cuts implemented during Trump’s first term, which expire this year. In January 2025, the Republican majority in the House of Representatives’ Budget Committee circulated a menu of possible spending reductions (1) that could offset the estimated $5 trillion to $11 trillion in revenue losses over 10 years from such tax cuts (2, 3). Cuts to Medicaid (4–8)—which today covers 71 million Americans (9)—figured prominently in the Committee’s menu (1). In April 2025, the House passed a budget resolution calling for $2 trillion in funding cuts, $880 billion of which would come from Medicaid and a few other programs under the House Energy and Commerce Committee’s jurisdiction (10). On 18 May 2025, the Budget Committee advanced a reconciliation bill, which the House passed on 25 May 2025, that included several Medicaid cuts on the menu (11).

Using House Budget Committee figures (1), Congressional Budget Office (CBO) analyses (12–17), and studies of previous Medicaid expansions and contractions, we project the effects of the 6 largest proposed cuts—and of the bill advanced by the Budget Committee—on Medicaid enrollment and the number of persons likely to become uninsured, as well as the impacts of those coverage contractions on health care access, financial strain, and health outcomes (including mortality).

full analysis: https://www.acpjournals.org…