Yes, Rep. Van Drew, there IS a solution!

 This piece appeared in the Arizona Star opinion section, Dec 30, 2025

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

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

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

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

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

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

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

 

Refs:

Van Drew quote, NY Times Dec 18, 2025 https://www.nytimes.com/2025/12/18/us/politics/health-care-gop.html

Medicare for All Act https://pnhp.org/the-medicare-for-all-act-of-2025/#:~:text=On%20April%2029%2C%202025%2C%20Rep,costs%20for%20all%20U.S.%20residents.

Commonwealth Fund, international comparisons of cost and outcomes https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024

Poll on support for Medicare for All, Data for Progress, https://www.dataforprogress.org/blog/2025/11/medicare-for-all-is-popular-even-when-put-up-against-attacks

 

 

 

 

 

 

 

Medicare and Medicaid at 60: Need more -- and more threatened -- than at 50!

Ten years ago, on August 2, 2015, I posted Medicare and Medicaid at 50: Time to include “US” all on the 50^th anniversary of Medicare and Medicaid. I lived in Kansas City, and with local pride noted that the legislation was signed by President Lyndon Johnson on July 30, 1965 at the Truman Library in Independence, MO, just outside KC, with President Truman and Mrs. Truman present. They received Medicare cards #1 and #2. There was reason for this symbolism; President Truman had tried to pass a national health insurance program in 1945, but it failed, confronting the shameful opposition of the American Medical Association. In some major ways, his proposed program was more ambitious than even Medicare and Medicaid together would end up being, as it would have covered 85-90% of Americans (it would, however, have been voluntary; opponents could have chosen not to pay in and thus not be covered). In 1946, the Republicans took over Congress and so the proposed legislation was dead, Republicans historically (and currently) opposing anything that benefits most of the American people.

President Lyndon Johnson signing the Medicare and Medicaid Acts with former President Harry Truman at the Truman Library in Independence, MO, in 1965. Ironically, Lyndon Johnson himself never made it to Medicare age, dying in 1973 at age 64.

Medicare provided universal health insurance to seniors, who had previously lived their last years in fear that they would get sick and be bankrupt and unable to afford care, as well as people with some serious disabilities including blindness. Medicaid, a different program funded by a federal-state partnership, with the federal government paying usually more than 50% and up to 90% depending on the average state income, was meant to cover the poorest Americans. Of course, each state set both the eligibility standards (how poor you had to be, and what else you had to be besides poor) and the benefits. And, of course, many states set standards well below the poverty level and provided very limited benefits.

A few years before that 50^th anniversary, in 2010, Congress passed, and President Obama signed, the Affordable Care Act, ACA, also known as Obamacare, which significantly expanded access to health coverage. One major component of the law was the establishment of insurance exchanges where individuals who were previously uninsured could purchase health insurance at group rates, which were more affordable than had previously been available to individuals. The other important component allowed states to expand their Medicaid programs to people who made too much money to have previously been eligible. This part was supposed to fill in the gap and cover those who, despite making too much for Medicaid, still were too poor to qualify for the ACA exchanges, and this was a lot of people. Remember, Medicaid did not cover people who were just poor (even really really poor); you had to be, as stated by Dr. Bridget McCandless, the CEO of the Health Care Foundation of Greater Kansas City at that 2015 event, “poor and…”:

Poor and pregnant, poor and the mother of small children, poor and disabled, poor and in a nursing home, poor and – and the tears rolled down her cheeks – a child.

As I have noted before, despite the lying propaganda put out by Republicans before the passage of HR 1 (the “Big Beautiful Bill”) this year, few Medicaid recipients are able-bodied but unemployed childless adults. Most are small children and their mothers or disabled or in nursing homes – and nursing homes, almost all of which are privately and profitably run, account for most of the money spent. By the way, neither Missouri nor Kansas (the other state in the Kansas City region) took the opportunity to expand Medicaid, even though the federal government would have initially paid 100% and after a few years 90% of the cost, so some of its citizens simply continued to suffer and die.

However, despite this, in the opinion of most Republicans in Congress, too many people were getting health care, and it was costing too much money which could otherwise be used for more important projects, mainly cutting taxes on the wealthiest people in this country. This “problem” is being addressed by HR 1, which will, according to the Congressional Budget Office, result in about 11 million people losing Medicaid coverage. Of course, this is denied by some; Vice President J.D. Vance said “Don’t believe every false media report that you’ve heard, because our explicit goal in the Trump administration is to protect people’s healthcare.” You can either believe him just saying that based on no data, or believe the CBO, or you can wait and see. Also, many Congressional Republicans expressed great concern about the bill’s impact on Medicaid, including my Congressman, Juan Ciscomani (AZ-6), but voted for it anyway. Note: voting for a bill with reservations is the same as voting for a bill!

Medicare will also be significantly (negatively) impacted by HR 1, as discussed in detail by the Commonwealth Fund. They address primarily low-income Medicare recipients with disabilities (arguably a particularly vulnerable group!) who have been eligible for assistance programs that help pay their Part B (outpatient) and Part D (drug coverage) premiums. HR 1 makes it possible for states to create additional obstacles to becoming enrolled in these assistance programs. A lot of Republicans have also talked about the tax savings people will get from Medicare payments, but it will not be very much, and benefit few:

Tax changes for people age 65 and older. The law includes a $6,000 annual tax deduction for adults over 65 with taxable incomes up to $75,000 annually ($150,000 for those filing jointly), with smaller deductions for those making up to $175,000 ($250,000 filing jointly) for 2025–2028. Low-income older adults generally do not make enough taxable income to be eligible for the deduction, but the provision could help middle- and higher-income older adults. The CBO has not separately estimated the cost of this deduction.  [Commonwealth Fund] 

Then there are the rest of us on Medicare. Another major Republican passion is privatizing both Medicare and, indeed, Social Security. Mostly they don’t like to talk about it openly because these are the two most popular programs in the nation, but that is what they are working on. And sometimes one – often a billionaire Cabinet secretary who hasn’t the slightest idea of how regular people live (are there any others?) -- slips up and says just that. In this case it was Treasury Secretary Scott Bessent who told us that the “Trump Accounts” for children were literally a “backdoor” for privatizing Social Security. And they also come in through the front door. The “Medicare Advantage” program is one of the main mechanisms for doing this; it is not Medicare (it takes the Medicare dollars that would provide for your care and pays them to an insurance company that basically puts you in their HMO or PPO) and is only advantageous for some recipients, mostly those who are not too sick. Note that these plans can vary a lot – in general government retirees are in better plans than those from the private sector – but the key issue is that rather than being in Medicare, which has to cover you, you are in a private insurance program which can – and does – often deny your claims, as it does for the non-Medicare insured. (see for example my posts "It was the best of times, it was the worst of times": Threats to the public's health from Medicaid cuts, MAHA, and others, Jun 7, 2025, and Open Enrollment Season for Medicare and Medicare Advantage: What you should know, Oct 7, 2024).

In 1945, under President Truman, the American people needed comprehensive universal health coverage. In 1965, under President Johnson, they still needed it, and some of the most vulnerable Americans, the elderly and poor, got Medicare and Medicaid. In 2010, under President Obama, they still needed it, and got some expansion of coverage from the ACA. In 2025, under President Trump, they need it more than ever, but the coverage that we do have is being deeply eroded. 

Meanwhile, the people of every other wealthy country have universal health care, longer lives, and better health outcomes, and it costs them way less! Are we such suckers?

 

 

 

The growth of the healthcare sector in the economy is not matched by an increase in health

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.