Everything is becoming more unaffordable, but health care may lead this list!

A Mar 23, 2026 NY Times article, “When voters talk about ‘affordability’, many point to health care”, emphasizes how big a deal this is to the American people – and for those who consider this finer point -- American voters. Lots of things have been becoming increasingly unaffordable, so why should health care be different? Housing is ridiculous, and if you live in one of the larger cities in this country, it may well be out of reach. The Times had another piece the same day, “How a Family of 3 Lives on $500,000 on the Upper West Side”, and apparently it is not that easy. In most of America, a family of 3 making a half-million dollars a year, would be rich, but in New York City (and it is similar or worse in San Francisco, Boston, LA, San Diego, DC, etc.) you’re living in a one-bedroom apartment (near Central Park, though) and trying to save up for something bigger, made more difficult by the $4200/month you pay for childcare for your one-year-old, more than the $3900 yoy pay in rent. Doing the math, those two expenses come to less than $100K a year, so they should still have money left, but I guess other things cost a lot as well.

Food is another big issue; even more than housing it is a necessity (there are, sadly, too many unhoused people but no one can go too long without food) and it is a real issue. I had a friend who was from Colombia, and decades ago he observed that he could understand how people could be homeless in the US, but not hungry. Unlike in his country, where housing was cheap and food expensive, you could get a dozen eggs for $1. Well, recently in many places a dozen eggs were above $6. Whatever you think about eating meat, it has become a rare luxury for many families. And gas? Thanks to the US/Israeli attacks on Iran (I take a deep breath and don’t offer more comments) and Iran’s response, gas prices have shot up. I see articles about it being up 20-30%, but where I live in Tucson, AZ it was $2.79 before the attacks and in the same stations is now $4.45 or more (that is about a 60% increase!) The administration has also cut back incentives for non-gasoline cars as they want to push oil and gas – whoops! Since public transportation is so lousy in many places, people depend on cars to get around and get to work when they have a job.

So, with those 3 things – housing, food, and gas (4 if you add childcare) costing so much, it is pretty salient that the people in the Times article single out health care as a main concern about affordability. And, as I have often written, its unaffordability has been increasing and increasing and increasing. Health insurance premiums are up, and for those who receive it through their employers the percent that the employee must contribute is also up. Deductibles are up. Co-payments are up. And even when you pay all that – and frequently people cannot – you may well not get the care you need because insurance companies have ratcheted up their delay-and-deny game, hoping you will give up and not appeal when they deny you coverage for or require your doctor to get “prior authorization” for something you really need, keeping you away with algorithms that stymie your doctors. Or, maybe they completely deny payment because you went to the “wrong” hospital, one that is not in your (really, their) network. Maybe because you were, well, really sick!

Or you could have Medicaid and find that that, as bad as it was, is being cut. Or even more, is cutting you out entirely! Or you may have had health insurance that you could almost afford as an individual through the health insurance exchanges set up by ACA (Obamacare), but now find that subsidies have been cut and there is no way you can continue to afford it. Or maybe you live in a state that never expanded Medicaid (which was the way the ACA sought to cover those too “rich” for Medicaid but too poor to afford insurance on an exchange), and so you have been without access to care for years. Or, maybe are already dead.

Or you could have “traded in” your Medicare, a single-payer program for senior and some disabled people, for “Medicare Advantage”, an insurance company product that sounded great at the start but puts you right back in an HMO, where you have limited providers and the insurance company can deny you coverage. Or, just to be sure that we are not letting anyone out of being screwed, you can have opted for traditional Medicare and find out that the new WiSER program is allowing companies to use AI-based algorithms to deny care in 6 states (so far)!

Wendell Potter’s substack “Health Care Un-Covered” published With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave on the same day (Mar 23) helps explain the reason. While the headline is somewhat optimistic (that the state of Tennessee is trying to reign them in) the real importance is the description of that vertical integration of CVS’ empire, in which they control not just local pharmacies and the health insurance giant Aetna, but also the pharmacy benefit manager (PBM), Caremark, which is now its largest cash cow! It’s a great deal for them, as they pay themselves, and have little competition from small agencies. They do have competition from UnitedHealth, which owns the PBM OptumRx and the provider group Optum, and CIGNA, which owns ExpressScripts, (which Potter explains Just Got Sued for Racketeering), so it is not an monopoly, just an oligopoly with a small number of players. And not one of those players is at all interested in your health. They are entirely focused on their bottom lines, as I discussed on Feb 26, 2026 in The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.  

The Times article emphasizes the political conflict between Republicans, who have been responsible for all the cuts and are trying to make it worse, acting exactly as if their goal is to hurt and kill lower-income people, and the Democrats who are trying (unsuccessfully so far) to block cuts to ACA and Medicaid, and perhaps place some limits on Medicare Advantage. But most “mainstream” (read “corporate”) Democrats are severely limiting their suggestions to, basically, returning to Obama-era goals. A significant minority of Democrats in both the House and Senate have signed on to cosponsor the Improved and Expanded Medicare for All bills that would move the US into the mainstream of healthcare in all wealthy countries by completely covering everyone for everything (see Yes, Rep. Van Drew, there IS a solution!,  Dec 30, 2025)! If that happened, the US would no longer be a standout for bad, paying 2-3 times what other countries pay and having worse health outcomes – and, as described above, moving in the wrong direction.

I don’t think that most Democrats are opposed to your receiving quality healthcare at a reasonable price (not sure about Republicans) but they get lots of money from these insurers, PBMs, and health systems. They need to hear from you!

More residency slots: Good, but not going to solve the primary care shortage...

The Center for Medicare and Medicaid Services, CMS, recently announced that it will be funding an additional 440 residency positions in 135 hospitals in 37 states. This is a good thing, and a step in the direction of reducing the glaring shortage of physicians in the US. CMS already funds most of the residency positions, something which is probably not intuitively obvious to those not involved in post-graduate medical education, but it is so even if it is not clear why (as opposed to, say, Congress directly appropriating such funding). This is important because while you are a doctor (physician) on graduation from medical school, you can’t obtain a license to practice anywhere without residency training (e.g., family medicine, pediatrics, surgery, psychiatry, radiology, etc.). Thus, past efforts to increase the number of physicians by increasing the number of medical schools (or the class size in existing medical schools) fail, because the residency pipeline has been static. It has only, perhaps, decreased the number of international medical graduates filling those positions. 

CMS further states, per this piece in MedPage Today, that 2/3 of those slots will be in primary care and psychiatry, two areas in which the shortage of physicians and other clinicians is particularly acute. This is also good, but will continue to have limited impact, at least until we see exactly which specialties are getting those positions. “Primary care” is not a specialty in which there is a residency; usually the term is used to include family physicians, general pediatricians, and general internists (as well as those general practitioners who completed only one year of post-graduate training, ie., internship, when that was sufficient to receive a license). The problem is mostly with internal medicine. After completion of a 3-year internal medicine residency, the large majority (about 80%) of graduates go on to complete a fellowship in an internal medicine subspecialty (cardiology, nephrology, pulmonary medicine, endocrinology, etc.). They do not practice primary care. In addition, about half the remainder become hospitalists, caring for people in the hospital only, leaving only a small number of internal medicine residency graduates to practice primary care. While many pediatrics graduates also sub-specialize or become hospitalists, the percents are much lower. On the other hand, about 90% of family medicine graduates practice outpatient primary care. In addition, it likely includes OB/Gyn which is not primary care.*

It would be good if we could get an accurate accounting. There are “general medicine” or “primary care medicine” residency programs among the internal medicine programs which produce higher percentages of primary care outpatient practitioners -- but still not all, or even close to the 90% of family medicine. We need to know if the new CMS positions that are designated “primary care” include internal medicine; if they do, obviously the output, the number of new outpatient primary care doctors, will be significantly lower. Why should they be unclear about this? It is in the interests of many institutions to keep it fuzzy. Medical schools have long reported on the percent of their graduates entering primary care, and they have included all those entering internal medicine (and sometimes OB/Gyn or even Emergency Medicine) as well as pediatrics and family medicine, inflating the percent that is ostensibly primary care. This practice has been called “the Deans’ lie”. The Association of American Medical Colleges (AAMC), quoted in the MedPage Today piece, has a similar reason to obfuscate the truth; their members are those same medical schools (and the teaching hospitals associated with them) and their leaders, both in AAMC and in the individual schools, are overwhelmingly non-primary-care subspecialists.

One of the main reasons for the shortage of primary care physicians, and thus this purposely-inaccurate effort to paper over the dearth of them, is that, while physicians overall make much more than the average person, there is a great disparity in income between the specialties, often being 4-5 times as much for certain specialists as others. The shortage of primary care physicians and psychiatrists that this change is making a small effort to rectify is very likely because pediatricians, family physicians and psychiatrists are on the low end of the physician income scale. The table below, from “PhysiciansThrive.com”, is one example, although it may actually understate the income of the top specialties.

 

 

The lowest-paid physicians are doing well compared to most Americans, but they often come out of school with $250K + debt, which is, of course, owed with compound interest. The income gap between specialties has to be narrowed, and some studies suggest that if primary care physicians made 70% of what other specialists do, money would largely cease to be an issue in student specialty choice. But how could we do that? Isn’t it really complicated?

Well, not as much as you might think. A recent installment of the New York Times feature “The Ethicist” responds to the question from a reader “Should I Feel Bad About Joining a Concierge Medical Practice?”. This in itself is a complex, but separate, question. However, the Ethicist notes in their response that one of the reasons it is hard to find a primary care physician is that 

‘Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations.’

I was surprised to see this addressed in this column; while it is absolutely true, it is rarely discussed. The comment makes 3 points which together drive the income disparity:

1.     CMS sets reimbursement rates for Medicare, but it essentially drives all reimbursement as insurance companies use Medicare rates (or multiples of them) to determine their own payments.

2.   These Medicare rates are set by “relative value units”, or RVUs, so that some sort of equivalence can be made. For example, how many comprehensive examinations by a primary care doctor or assessments by a psychiatrist or chest x-ray interpretations by a radiologist is worth one gall bladder removal by a surgeon or joint replacement by an orthopedist? This is essentially dividing up a pie of set size; when one “gains” another “loses”.

3.  While CMS sets these RVU ratios, they usually rely upon the recommendations of a little-known group called the “RUC”, appointed by the AMA. As the Ethicist notes, this committee is overwhelmingly specialists. And, so, not surprisingly, the distribution of the pieces of the pie tend to favor those specialists, and, indeed, procedures are valued more than conversations. And “conversations” kind of minimizes the communication between people (patients) and their primary care doctors, as people’s stories greatly inform both the diagnosis and the best treatment (and the one the patient is going to accept and follow through on), and are essential for the patients to know what is going on. And presumably interactions with psychiatrists are more than simple “conversations”. (I have written about the RUC several times, including Doctors' incomes and patient coverage: both need to be more equal, Jan 26, 2014 and Pay primary care more: Kennedy may be getting this one right!, July 23, 2025.) 

So there is a clear-cut way to fix these disparities: CMS simply needs to adjust the RVU basis, increasing the value of “conversations” and really thinking and assessment and decision making relative to procedures. Of course, this means the highest-paid subpspecialists would make less than they do now, and so they are going to fight it, as are their organizations and groups like the AAMC. But really, even if they take a significant cut, they are a long way from the Food Bank!

The question is: Will CMS do this? Pressure from you, the people who can’t get into a doctor, is definitely going to help!

 

*Primary care is comprehensive care of the needs of the patient, with referral to specialists when needed; internists and geriatricians and pediatricians limit the ages of their patients but they provide comprehensive care for them. While some women only see an OB/Gyn, they only provide care for a woman’s reproductive tract, not comprehensive care.

 

Drink more? Do more prostate cancer screening? I don't think so. But be careful about falls!

If the malignant lies and disinformation coming from HHS Secretary Robert F. Kennedy, Jr. (RFKJr) and his minions, whom he regularly replaces if they are too inclined to make decisions based on truth and science (see Susan Monarez, head of CDC for less than a month) were not enough, his psycho – but totally dangerous -- baloney regarding vaccines and other health issues provides cover for the re-emergence of other potentially dangerous “health” recommendations. This is par for the course for this administration, which is entirely focused on distracting us from important issues by focusing our attention on other things, brush fires (or sometimes major conflagrations). Trump is quite willing to arrest, brutalize, imprison, and deport people, to start wars across the globe, or whatever it takes to keep the Epstein files – which must contain truly damning information about him – from being made public. 

In the area of health this re-emergence has not been of the major blaze type, certainly nothing compared to the evil of RFKJr’s opposition to, discouragement of, and even blocking vaccines, but more of “well, we have an axe to grind and let’s bring it back out now that we have cover”. Who, after all will worry so much about the issues I address below when they can worry about the return of polio, measles, mumps, whooping cough, H. influenza, Covid, etc. And maybe even smallpox! But there have been several recent articles covering health issues which should be already settled. But, heck, if vaccines are not settled, why should these be?

On Sept 2, 2025, the NY Times Roni Caryn Rabin reports that Reduced Screening May Have Led to Rise in Advanced Prostate Cancer Diagnoses,  and follows that with the subhead “Changes in screening recommendations over a decade ago may have inadvertently resulted in later diagnosis of the most common cancer in men, a new study has found.” It sounds pretty scary, as it goes on to report that Black men are the least likely to be screened for prostate cancer and the most likely to die from it. Prostate cancer is being diagnosed at a later stage and the implication – no, the direct assertion in the article – is that it is because of a recommendation from the US Preventive Services Task Force (USPSTF) which in 2012 began discouraging the use of routine screening with PSA (Prostate-Specific Antigen). The Times article, and the article it is based on, from CA: A cancer journal for Clinicians, and the comments of the chief scientific officer of the American Cancer Society and one of the article’s authors, Bill Dahut, say “The pendulum may have swung too far in one direction, where we were afraid of overtreatment, and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.” 

This conflates diagnosis of cancer at later stages with (implicitly) increase in death from prostate cancer. Well, doesn’t that make sense? Except that what makes sense is not always true. There is no data in the article that says more men are dying from prostate cancer, only that they are being diagnosed with further advanced cancer. Dr. Dahut says that finding the prostate cancer earlier would make it more curable, but if this were true, the decrease in screening would not only have led to cancers being diagnosed at a later stage, but in an increase in deaths from prostate cancer. How come it didn’t? There are basically two types of prostate cancer: the kind that kills you and the kind you die with, but not from. Medicine has yet to be able to find a test that can identify which kind you have. If diagnosing the kind that kills you earlier can make it curable, that’s great – but then we would see more deaths from prostate cancer as a result of not screening, and we don’t. What has historically happened is that the other, more indolent, kind has been treated and physicians have claimed “cures” – even though men don’t die from it without treatment. But they do suffer the morbidity of treatment (i.e., impotence, incontinence, radiation cystitis, etc.) This, along with the poor performance of PSA as a screening test for prostate cancer, is what led the USPSTF to recommend against screening. This issue has been addressed a number of times over the years on this blog (PSA Screening: What is the value?, March 21, 2009, PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009,  PSA redux: The USPSTF finally recommends NOT getting it!, Oct 14, 2011, Prostate Screening and the Public’s Health, July 12, 2015, as well as other posts on the benefits – or not – of cancer screening), and essentially, nothing has changed. It is terrible that Black men die from prostate cancer. It is terrible that anyone dies from prostate cancer. If screening saved lives we should do it. But this article presents no new evidence that lives are being lost that could be saved.

A few days later (Sept 5, 2025) the Times had an article by the same reporter titled Federal Report on Drinking Is Withdrawn with the subhead “The upcoming U.S. Dietary Guidelines will instead be influenced by a competing study, favored by industry, which found that moderate alcohol consumption was healthy.” Yup. Favored by industry. Not only were the guidelines withdrawn by HHS and thus not, as planned, presented to Congress, but HHS promotes a “competing report” by a panel of the National Academies of Sciences, Engineering and Medicine that “came to a conclusion long supported by the industry: that moderate drinking is healthier than not drinking”. Yay for the alcohol industry! Of course, “Some panelists came under criticism for financial ties to alcohol makers,” but what the heck. It is perhaps surprising, as the article points out, that RFKJr’s MAHA (“Make America Healthy Again”) campaign does not include anything about the use of alcohol – or, even more amazingly, tobacco! When we don’t like the message, we kill the message (and sometimes the messenger), especially in the current administration. But despite the fact that “Science Over Bias, an industry-supported advocacy group, faulted the alcohol intake study for bias: “The Dietary Guidelines should be guided by a preponderance of sound science, not the personal ideologies of a handful of researchers,” it is the industry’s position that is based on bias rather than on evidence. With regard to physical health (not short-term mental health), there is no amount of alcohol that is good for you, and any amount is a little bad. No alcohol is better than moderate alcohol, except for the financial interests of the industry and the scientists on their payroll.

On a somewhat different issue regarding health, not about controversy (screen or do not screen for prostate cancer? Drink alcohol in moderation or not at all?), is the Times article from Sept 7 by Paula Span titled Why Are More Older People Dying After Falls? It doesn’t provide a definitive answer, but strongly implicates prescription drug use (“Some researchers suspect that rising prescription drug use may explain a disturbing trend.”) It’s important. Falls are a major cause of morbidity and mortality in older people. You can break your hip or your head, you can get a concussion or a brain bleed or die. No joke. The association with prescription medication is legitimate, especially certain ones, called FRIDs, or “fall risk increasing drugs”, that are more likely to cause falls though inducing drowsiness, dizziness, drops in blood pressure, etc. Older people are more likely to have more diseases and be on more medications to treat them, and they are also more sensitive to the side effects of these drugs. (Note that drugs do not know which of their effects are “side effects”; we define them as the ones we don’t like!) And they are more likely to suffer serious injuries from a fall. The take-away message is that physicians should carefully review the medications that their older patients (actually all patients) are on, make sure that there is a need for them, and that there is not another less risky (less FRID) drug that could be substituted. Psychoactive drugs “like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system” should be especially assessed for need, with particular emphasis on the use of more than one drug with similar side effects that can lead to greater risk. The message should not be “stop taking my drugs because the pharmaceutical industry is greedy and trying to drug us all”. Sure, they ARE greedy, and we shouldn’t have to pay so much to them, but that is another issue. They also make drugs that are effective and in standardized doses (unlike “natural” herbs). And often it is the drugs that people like most (because they relieve pain and/or make them feel better) that are most likely to be FRIDs. Exercises to increase strength and balance are important. And, if the risks still cannot be significantly reduced, people may have to modify their lifestyles. For example, it may be necessary to stop walking a big dog.

These are 3 different issues. I included the first two, prostate cancer screening and alcohol use, because they represent efforts to peel back science-based policies that may have been deleterious to the profits of industry, which is like many of the policy changes across the administration over the last 8+ months. The falls issue is a little different; here the concern is to address the risks to the extent possible without overreacting and stopping all your medications!

Medicine and science are complex. But findings can be skewed to fit an agenda, and when that agenda is corporations making more money, a little skepticism is wise.

Pay primary care more: Kennedy may be getting this one right!

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!

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.