Sometimes I think about old posts, and how sad it is that things have not changed in the years since I wrote them. But, as with this one, from Jan 12, 2012, I enjoyed writing it, and highly recommend the film that inspired it, Le Havre.
One thing to NOT worry about: paying for health care -- in France
I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!
Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.
But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).
Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).
So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!
The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.
The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.
We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!
Healthcare is a big industry in the US. Really big. Per a recent NY Times article, it is the largest employer in the nation, its growth demonstrated by this graphic:
The plummeting in the number of manufacturing jobs over the last few decades (it being more profitable to make things in poorer countries thanks to lower wages) and the more gradual but steady fall in retail jobs as a result of the on-line economy leading to the closure of “brick and mortar” stores, have been big contributors to this phenomenon, but the growth in the number of health care jobs is also undeniable. Indeed, as seen in the graphic below, in 1990 healthcare was the largest employer in no state, but in 2024 it is the largest in all but 11! This is an incredible change, and has incredible implications for the US economy and for the health of Americans. Unfortunately, they are not entirely positive.
While growth in employment may be good for the economy overall, and helps those who have jobs in that sector, this is only true to the extent that they are good jobs, or at least are jobs that employ people who would otherwise be unemployed. Not all healthcare jobs are well-paying, and if they are relatively poor paying jobs that have replaced better paying jobs in manufacturing, the folks who have them are not better off. It is not necessarily good for the individual who is paying for their healthcare, even when they are employed in the healthcare industry (many “lower end” jobs in this industry do not come with good, or even any, health insurance). The cost of insurance has gone way up, as has the proportion of it that is borne by the individual or household. As a third graphic from this article shows, the growth in the percentage of household expenditures that is for healthcare has also been phenomenal, now being larger than the portion spent on groceries or housing.
One big issue is that not all of these healthcare jobs are actually providing healthcare to people. They include those who do, nurses and doctors and other clinical providers, and also those providing home care services, who are often at the lowest end of both the salary and benefit scale. Many of these workers are on both Medicaid and food stamps, an indictment of the healthcare industry and a rebuttal to those (mostly Republican) politicians who justify cutting those programs by saying that they are abused by able-bodied adults who should “get a job”. In addition to clinical providers, “healthcare” jobs also include multiple levels of administrators and managers in healthcare and in the insurance industry. Indeed, many work in the artificial industry created by the conflict between the two about whether and how much insurance should pay for care, both sides engaged in an essentially socially non-productive struggle.
The growth in administrative personnel – a hold-all term for those not involved in clinical activities – is illustrated by the following chart, which looks at the increase in physicians compared to administrators/managers over time. What we see represents a towering infrastructure mainly aimed at making money, either for healthcare institutions or insurers. Even though physicians are only one piece of the clinical pie, it is a pretty impressive contrast. Nurses, and the demand for nurses, has grown more dramatically (if not as fast as that of administrators). This is in part because the number of physicians hasn’t grown as fast as the demand for clinical services, and some services previously provided by physicians are now done by nurses, including Advance Practice Registered Nurses (APRNs) such as Nurse Practitioners, Nurse Midwives, Nurse Anesthetists, and other Clinical Nurse Specialists. There are currently about 4 million nurses, with about ¾ being RNs (not counting APRNs), and 1 million physicians (State of the US Healthcare Workforce, Health Resources and Services Administration, November 2024, downloaded from https://bhw.hrsa.gov). There is some question about the degree to which the number of “primary care” physicians is all doctors who are actually practicing primary care, especially among general internists, many of whom are hospitalists (40% or greater).
So, we have both an amazing growth in the number of healthcare jobs and in the portion of a regular household budget that is spent on healthcare (including direct payments, insurance premiums, copays, coinsurance, deductibles). Obviously these are related phenomena; after all the growth in the number of jobs, as well as in the number of buildings dedicated to healthcare (see Ron Shansky and Healthcare in the US: We need more than buildings, May 10, 2025) has to be paid for somehow. The “somehow” is money spent on healthcare services, which is paid by people either directly or through their insurance premiums and other payments. While it is in large part these buildings, and these jobs, that have led many to say that the US has the “best healthcare system in the world”, it is mostly the biggest.
The argument that we have the best healthcare system would be bolstered by demonstrating that, as a result of, or even coincidentally with, this enormous physical and human resources infrastructure, the health of the American people was great, or even had significantly improved. Sadly, it has not, and doesn’t appear to be headed in that direction. Certainly, many people get great health care, particularly those who are wealthier, well-insured, and live in major metropolitan areas. But many don’t, even including people in all those groups. The overall health status of the American people not only remains lower than that of all comparable (ie, wealthy) countries, and even many “middle income” (poor by US standards) countries, but the gap is increasing, not decreasing. I included a few graphs from The Commonwealth Fund’s comparative international ranking, Mirror Mirror on the Wall, in the blog cited above, including one showing how far ahead we are in health care spending, but will reproduce here the one showing 2024 health system performance rankings.
New changes in health financing resulting from the Trump-GOP “One Beautiful Bill” will have major negative consequences, making these circumstances worse, much of which is documented in How to Wreck the Nation’s Health, by the Numbers, an excellent and thorough essay in the NY Times by long-time health services researcher Dr. Steven H. Woolf. Eleven million people will lose Medicaid coverage, and the vast majority will not be able-bodied adults who are voluntarily unemployed. Most Medicaid beneficiaries are children and their mothers. Most Medicaid dollars are spent on people in nursing homes (both those that started out low-income and those that “spent down” because of the cost of long-term care and got poor enough to qualify). A recent Commonwealth Fund study estimates significant job loss and negative impact on the economy from this bill,
In 2029, cuts to Medicaid and SNAP would cause state gross domestic products to fall by $154 billion, 18 percent more than the $131 billion they would save the federal government. The cuts would result in the loss of 1.22 million jobs nationwide, equivalent to a 0.8-percentage-point increase in the unemployment rate. States with higher rates of poverty would likely be harmed more. State and local tax revenues would fall by $12 billion.
Rural areas would be particularly affected, especially in health care. Unlike the major urban medical centers I described earlier, rural hospitals often operate at the margins of financial viability. Because rural populations are poorer, older, and sicker, they are more dependent upon Medicare and Medicaid as payers. Many have closed in the last several years, and many more are likely to as a result of the coming cuts, as documented by the Cecil G. Sheps Center for Health Services Research in North Carolina and reported in KFF Health News and the University of Arizona Center for Rural Health.
The degree to which this new law will negatively impact the most vulnerable people in our nation – the poor, rural, children, seniors – is so dramatic that it is impossible to believe this was not the intention. It is certainly consistent with the goals of Project 2025, as summarized here by the American Public Health Association. If this seems inexplicably mean and cruel, it is. Even many GOP congresspeople and senators noted this before going ahead and voting for the bill anyway (note: voting for the bill under protest is the same as voting for the bill).
We are going to have to work very hard to try to minimize the negative impact, and it will take all those healthcare buildings and jobs working, not to make profit but to make us healthy. Good luck with that.
