Protests for Gun Safety … & Health Care Justice

Interview of former Gov. John Kasich (R, Ohio) after tragic school shooting in Nashville
MSNBC
March 28, 2023
Andrea Mitchell Reports

If Americans don’t protest gun violence, politicians will continue to ‘look the other way’

Gov. Kasich:

Until people go into the streets and protest, we’re not going to see changes. In my state, had I been able to get five thousand, ten thousand people on the lawns of the state house, politicians would have passed what we wanted. I couldn’t get them mobilized. I was reading this morning about the Montgomery bus boycott. You realize that took over one year for the Supreme Court ultimately to act to end discrimination on transportation. If you don’t have the people rising up, like they did with civil rights, like they did to end the Vietnam war, if you don’t have that, the politicians are going to keep passing the buck. They’re going to listen to one group of people, and, frankly, if in fact we can have the kind of massive outpourings that we have seen in this country consistent about saving our children at this point and so many other tragic accidents then you put the real pressure on the politicians to do things that we all know that we can do while still preserving the right of the second amendment. Things can be done that can provide a safer environment for all of us in this country and most particularly our children. Without the protest, Andrea, I think we’re going to keep doing… 19 incidents, 19 incidents in school shootings this year! This is sick! I heard the lady talking about all the people she visited, God bless her, she along with all of the other people who have experienced this tragedy personally has to figure out a way to mobilize all of us to stand up and say. “Enough!”

Now what I said about those women down in Montgomery, they just kept marching. They just kept doing everything they could, and that’s what it’s going to take here. If we don’t have people to begin to get into the streets and say, “Enough of this!”… the women who were so worried about all the children… the men who say this is my family… we all have to mobilize. Without it, the politicians are going to look the other way. And it’s not going to happen in a week or two. It has to be ongoing in order to get this changed. That’s my opinion on it because I sat there trying to get things done, and I was frustrated the whole time. I did what I could with executive orders, as the president has done, but there’s a limit to it. We have to get legislative action with common sense proposals that can really make a difference.

Comment by: Don McCanne

Now that guns have replaced auto accidents as the number one cause of deaths in children, isn’t it about time we really did something about it? We haven’t acted, with Democrats blaming Republicans for inaction and Republicans blaming Democrats for attacking their second amendment rights. But here we have one of the more prominent Republicans in the nation saying , “Enough!”

Mr. Kasich makes it clear that we cannot expect a responsible response to these tragedies from the politicians, as our nation’s political history has demonstrated. But he has much more faith in us, the people. All we have to do is to go into the streets, in mass, and protest. We need to march, and keep on marching. The politicians who are looking the other way will no longer be able to do so if we stay in their faces.

Our children….
    are being slaughtered by gun violence….
    and the politicians have failed us
To the streets everyone!

But wait….

We are spending more on health care than any other nation, yet we tolerate more suffering in children and others through mediocrity in health care and through the profound prevalence of poverty. While we’re demonstrating against violence in our children, shouldn’t we be simultaneously protesting this form of violence as well, violence that is quantitatively much greater and often just as tragic.

Yes. To the streets….  “No More Guns” at the top of our placards, but “Health Care Justice for All” below that.

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

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, & 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 & Don McCanne

Drs. Gaffney, Himmelstein, & 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.

Public Provisioning of Services: Adjunct to Single Payer

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 & Jim Kahn

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!

Health Reform Review: What’s Breaking, & Breaking Through

Note to HJM readers: These are politically trying times. I’m distracted by that turmoil, and I bet you are too. Hence the brief hiatus in recent HJM posts. However, I think health insurance is a critical and integral part of democratic evolution. That’s why I undertook this status report despite, indeed partially in response to, the political struggles. – Jim

A) Proposed funding cuts

Congress’ budget reconciliation bill has morphed, far more than ever before, into an omnibus policy bill – possible because policies need funding. A budget bill is not subject to the Senate’s filibuster rule, which would empower Democratic opposition. There’s another tactical reason: the more sweeping the provisions, the less likely that opposition to specific elements will coalesce. Several health insurance provisions are important:

Medicaid cuts are the highest profile issue. Proposed changes include enrollee cost-sharing, lower federal payments for states covering or helping immigrants, work requirements, limited retroactivity of eligibility, blocking minimum nursing staffing levels, and eliminating participation by Planned Parenthood. Total federal cuts are ~$800 billion over 10 years.

Affordable Care Act (ACA) – failure to extend COVID-era premium subsidies would cut federal contributions to health care for the near-poor by $300 billion over ten years.

Veterans’ Affairs (VA) – the new VA director is eager to cut budgets, with no surgical precision in the process, threatening clinical capacity. Community medical resources are often not up to the task of picking up the slack.

Medicare is not directly affected by the budget bill. However, under the 2010 PAYGO law, rising federal budget deficits (expected with the new bill) would trigger up to 4% cuts to Medicare, totaling $500 billion. This is likely to be taken from payment levels, and thus potentially decrease provider participation.

Federally Qualified Health Centers (FQHC) are a major source of health care for lower income populations. Funding derives 40-45% from Medicaid (which will be heavily cut) and 15-25% from grants (which are currently not targeted, though the funding agency HRSA may be substantially cut).

Estimated changes in coverage & deaths – All of these funding cuts translate to large dips in insurance coverage and increases in mortality. Although many potential program effects can’t be quantified, e.g., for the VA, the Medicaid and ACA changes are likely to lead to 16 million more uninsured (10.9 from Medicaid, 5.1 from the ACA). The Medicaid contraction alone may increase deaths by 2,500 – 5,000 per year.

B) Flaws in the armor

The “armor” is, of course, the broad array of political and rhetorical defenses deployed by defenders of our profit-driven health insurance to retain the status quo – and their immense financial gains. The “flaws” are vulnerabilities: developments that can, in ways both focused and far-reaching, undermine private health insurance defenses. Several of these flaws are now appearing in a potentially synergistic fashion.

Widespread displeasure with Medicaid cuts. Polling indicates that opposition far exceeds support. Only 1 in 6 adults want reduced Medicaid spending; 42% want increases. Most (55-75%) are worried about the impacts on patients and providers. Even among Trump 2024 voters, 2/3 want Medicaid spending protected or increased.

Anger with private insurers. The 2024 murder of the United Healthcare CEO clarified – and galvanized – broad dislike of private insurers. Polling in December found that 7 in 10 adults blame the death at least partly on private insurance care denials and profits.

Stricter regulation of Medicare Advantage insurers. The Center for Medicare & Medicaid Services (CMS) is substantially bolstering oversight of MA plans. Audits of diagnostic upcoding (which bumps MA premiums by $40 billion / year) are being enhanced 50-fold. UnitedHealth (UH) is being investigated. And care denials are being restricted and scrutinized. This clamp-down is surprising with a pro-business White House, perhaps reflecting the industry’s distinct Harris tilt in 2024 election donations.

Slipping profits for MA insurers. The increase in premium rates for 2025 was 3.7%, the same as previewed by the Biden administration, despite expectations of an increase. UH 2025 profit projections dropped by 12–15% from forecasts, due to higher care use in MA and the payment level; stock prices dropped 22% in April. Other insurers also lost value. Alas, still quite profitable … but vulnerable.

Pharmacy Benefit Manager regulation. PBM pricing practices are under new scrutiny from federal agencies. And states are regulating too.

Drug pricing reform. The Trump administration, confounding expectations, is pushing to slash drug costs. But true to form, blaming other countries – for paying unfairly low prices. And demanding a “most favored nation” approach: other nations pay more and we pay less. Pharma doesn’t seem too upset, perhaps anticipating preserved profits There’s no telling where this will go.

Physicians unionizing. In the last several years, unionization level and intentions have jumped up, with a focus on physician welfare such as reducing moral injury. Many unions are pro-single payer.

Ongoing Support for Government Insurance Role. Gallup polling from Dec 2024 found that 65% of US adults say it is the “responsibility of the federal government to make sure all Americans have healthcare coverage” — the highest level since 2007. Support for a “government-run healthcare system” is 46% vs 49% for ”a system based mostly on private health insurance”. Properly described single payer (“government health insurance with mostly private providers”) would poll higher.

C) Advocacy strategy

Breaking the entrenched opposition to single payer will require large doses of determination, creativity, and persistence. With no guarantee of success, but every reason to keep trying, because so much health and peace of mind are at stake. I list a few themes, opportunities, and resources. This is far from a comprehensive strategy – which we will return to in future posts.

Highlight budget bill cuts & their effects: Tell everyone you know what’s at stake if programs are unraveled – millions more uninsured, thousands more lives lost.

Contact your senator, especially if Republican: The budget bill faces an uphill battle in the Senate – the vote margin is narrow, and public sentiment is against it. But Senators need to be reminded constantly of this displeasure, and understand the consequences of going against the will of voters.

Persuade friends and family members. Show them the stark statistics summarized above about what happens with insurance cuts. Remind them of the fundamental humanity of providing health insurance, and the cruelty of taking it away.

Eyes on the prize for Single Payer. Go beyond the critique of program cuts. Single payer is the solution that both saves money and provides universal broad coverage with generous benefits. Dozens of countries use it, with lower mortality, lower spending, and no significant medical debt. Use the cuts to Medicaid and other programs – which people heartily dislike – to offer the vision of permanent, universal public insurance.

Expand your vision to community empowerment. Single payer is essential, but a truly transformative approach should also build public health capacity and not-for-profit community providers (more on this soon).

Participate in Coalition-building. There are many opportunities. The May 31 National Day of Action for Single Payer had events in dozens of cities (full report soon). There’s a one-payer state strategy meeting in Denver (and on Zoom) on August 1-2.

Health Justice Monitor: Check out our new website, HJM 2.0, to be launched in June. Blog posts (of course), data visuals for use in talks, a list of 5-minute daily actions, a glossary, organizational descriptions and links, and to navigate all this – super-charged search capabilities including via an AI bot – ask any question, get a coherent & authoritative answer.

Saturday! National Day of Action for Single Payer

Heal This Sick Country: ‘Hands Up’ for the National Day of Action for Single Payer
Common Dreams
Apr 27, 2025
By Judy Albert, Ed Grystar, Ana Malinow, Kay Tillow, Claire M. Cohen

Event details provided HERE
Scroll down a little to “Find an Action” or click here

Today, we call on people across the country to gather on May 31, 2025, to put their “Hands Up” for:

> The recognition by our government that healthcare is a human right;

> The elimination of private health insurance and the banning of for-profit delivery of care;

> The enactment of a publicly financed, national single-payer program that would provide comprehensive coverage to everyone; and

> The transformation of care delivery from profit-seeking ventures into services organized to serve the people of our country, a system in which all caregivers are freed from corporate control.

President Donald Trump’s inauguration has introduced the prospect of severe hardships to working class and low-income people, people with disabilities, the elderly, and children with proposed cuts to Medicaid, Medicare, and Social Security necessary to fund tax cuts for the wealthy. This moment demands more than the protection of our public programs; it demands a national, single-payer healthcare program, free from profit, for everyone. One people, one plan. 

The complicity of our government in the profit-making enterprise of health insurance has been exposed once again when, on Monday April 7, the Trump administration raised payment rates for Medicare Advantage insurers by 5.1%, significantly more than the Biden administration’s proposed increase of 2.2%, which was bad enough. This rate increase has the potential to increase payments to MA by $25 billion next year.

[see article for more examples of how our insurance approach increasingly places profits over health care]

Comment by: Jim Kahn

This imminent national event is exciting!

Popular demand is an essential element of achieving single payer – the desperately needed transformation of how we pay for health care. Single payer / Medicare for All places people over profits, annually saving hundreds of thousands of lives and tens of billions of dollars (as HJM has often reported). What decreases is hassle, administrative waste, and profits for payer intermediaries.

The path to single pay is, we have found over decades, very difficult. We must redouble our efforts.

Express your demands for health care justice on Saturday! Spread the word!

See links above to find out more.

Veterans Care Under Attack

VA Secretary Collins: Indifferent to Public’s and Congressional Opposition to His Gutting Veterans’ Care
The American Prospect
May 23, 2025
By Suzanne Gordon & Russell Lemle

When Doug Collins first appeared before the Senate Committee on Veterans’ Affairs (SVAC) for his confirmation hearing, his comforting bromides about his commitment to the VA and veterans lulled Democratic members, who, with only a few exceptions, voted to confirm Collins as President Trump’s new secretary of the Department of Veterans Affairs. As one Capitol Hill insider told the Prospect, many believed that, unlike Pete Hegseth or RFK Jr., Collins was “a man they could work with.” …

Fast-forward four and a half months to May 6th, when Collins appeared for the second time in front of the Senate Committee, and May 15th, when he made his first appearance before the HVAC. Assessing his first months on the job, Democrats now clearly viewed Collins as someone working not with, but against, them—and against the nation’s veterans. They expressed anger at his firing of 1,000 probationary employees, his cancelation of hundreds of contracts with vendors that supply VA with critical resources, and his termination of VA researchers, thus interrupting clinical trials that could benefit veterans. And, of course, there was Collins’s vow to lay off 83,000 VA employees. …

As one VA observer who chose to remain anonymous observed, “Some VISN staff reductions could occur without loss of functional capability if such were done in a systematic and thoughtful manner. In doing so, however, it would be important to work with the Congress on what programmatic, reporting, and other requirements they are going to insist upon going forward.”

As for all those supposed underperforming doctors and nurses Collins wants to reassign or fire, some are chiefs of medicine, chiefs of staff, chiefs of nursing, or nurse managers who provide the kind of clinical leadership without which no hospital or health system can function. These administrative positions also require the very clinical background that Collins seems to dismiss. …

At the end of the House hearing, ranking member Takano displayed a spreadsheet in which Collins’s team had calculated the cost savings that would result from a 15 percent reduction in every VA classification. The spreadsheet, Takano said, estimated that cutting 4,000 nurses would save $1 billion, while cutting 400 psychologists would save $110 million. Why, Takano asked the secretary, had Collins requested that his team conduct this kind of analysis given that he’d promised not to cut direct-care staff?

Instead of responding to the question, Collins began yelling at the ranking member …

On the afternoon after the Senate hearing, a group of 60 members of Common Defense, a progressive veterans’ organization that has launched a nationwide campaign called “VA: Not For Sale,” joined nurses and congressmembers on the steps of the U.S. Capitol to protest Collins’s plans. Common Defense’s executive director, Army veteran Jose Vasquez … told the Prospect that Common Defense is adamantly opposed to arbitrary mass layoffs at the VA. “VA shouldn’t be firing 8, or 80, or 8,000, much less 83,000 employees. The VA needs to hire, not fire.” More importantly, Vasquez added, “instead of attacking VA doctors and nurses who contribute to our care in all kinds of ways, VA leaders should be supporting the dedicated caregivers who themselves sacrifice to support veterans like me.”

Call To Action May 31, 2025: Demand Health Not Profit!
Search “Action Sites” on the webpage for a US map – will update all week as new sites are added!

We call on communities across the country to join in a National Day of Action on Saturday, May 31, 2025, to put National Single Payer Healthcare on the nation’s agenda.

Our health care system is broken beyond repair. Insurance companies and for-profit middlemen create barriers to care and massive administrative waste. These result in unnecessary suffering and deaths. For over 60 years, piecemeal reforms have resulted in higher costs and the worst health outcomes among comparable nations.

We demand the recognition by our government that health care is a human right.

We demand the elimination of private health insurance and the banning of for-profit delivery of care.

We demand the enactment of a publicly financed, national single payer program that would provide comprehensive coverage to everyone.

We demand that health care delivery be transformed from profit-seeking ventures into services organized to serve the people of our country, a system in which all caregivers are freed from corporate control.

The National Day of Action will bring people together locally and nationally from neighborhoods, unions, faith groups, businesses, and all types of civic organizations to join the demand to remove profit from health care. We must focus our collective anger towards corporate health insurers to bring real reform: put National Single Payer on the nation’s agenda!

 

Comment by: Jim Kahn

On Memorial Day, of course our attention turns to the health care of military veterans. Only to find, sadly, that this group – which voted 65% for Trump – is being mistreated by his administration. Unlike other nominees requiring Senate confirmation, Doug Collins seemed competent and committed to the VA role, to the welfare of veterans. But, as it turns out, he’s committed most of all to cutting budgets, regardless of consequences. And when questioned on this anti-veteran approach, he bristles. Thus we find that even this highly valued group of Americans suffers from being a lower priority than the billionaires whose tax cuts are the payment due for supporting the current president’s campaign.

Single payer – with everyone served by the same public system – is the way to assure adequate funding. Indeed, it is the path to combining efficiency with generosity, by eliminating administrative complexity and intermediary (insurer) profit-taking.

An exciting national day of action for single payer is just 5 days away! Join the event nearest you. Raise our voices — demand health care justice. Louder and louder every day!

GOP Medicaid Cuts: Multifaceted, Severe, Deadly, Machiavellian

Tracking the Medicaid Provisions in the 2025 Reconciliation Bill
Kaiser Family Foundation (KFF)
Updated: May 19, 2025

Requires states to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% FPL; maintains existing exemptions of certain services from cost sharing and limits cost sharing for prescription drugs to nominal amounts. Maintains the 5% of family income cap on out-of-pocket costs. Effective Date: October 1, 2028

Reduces the expansion match rate from 90% to 80% for states that use their own funds to provide or support health coverage … for individuals who are not lawfully residing in the US. Effective Date: October 1, 2027

Requires states to condition Medicaid eligibility for individuals ages 19-64 applying for coverage or enrolled through the ACA expansion group on working or participating in qualifying activities for at least 80 hours per month. Effective Date: January 1, 2029

Limits retroactive coverage to one month prior to application for coverage. Effective Date: October 1, 2026

Delays $8 billion annual reductions in subsidies for hospitals with high uninsured and Medicaid rates to September 30, 2028. 

Blocks implementation of long term care nurse staffing requirements.

Blocks Medicaid participation for large not-for-profits providing primarily reproductive health care, i.e., Planned Parenthood.

House Republicans’ Medicaid Cuts and Associated Lives Lost
Center for American Priorities
May 15, 2025

House Republicans’ radical new budget plan proposes requiring states to implement Medicaid work reporting requirements for adults enrolled through the Affordable Care Act’s (ACA) Medicaid expansion. Under this proposal, nonpregnant, nondisabled, noncaregiver adults ages 19 to 64 would be required to document at least 80 hours per month of work or qualifying activities (such as volunteering) in order to maintain their Medicaid coverage. Otherwise, they would need to seek approval for a qualifying exemption.

Evidence from prior state-level implementations show that bureaucratic paperwork requirements do not increase employment but do result in large-scale coverage losses—even among those who are working or should be exempt from the requirements.

The consequences of such coverage losses, however, are not just administrative: For thousands of Americans, they would be deadly. New estimates from the Center for American Progress show that 6.9 million people losing coverage by 2034 as a result of congressional Republicans’ proposed paperwork requirements would lead to more than 21,600 avoidable deaths nationally each year. [Provides table of avoidable deaths for selected Congressional districts.]

 

Comment by: Jim Kahn

Medicaid cuts in the House budget reconciliation bill just passed out of committee are a marvel of multidimensionality, severity, lethality, and politically adroitness. One by one:

Multifaceted: As inventoried by KFF, the changes are far-reaching in type, including enrollee cost-sharing, lower federal payments for states supporting undocumented immigrants, a work requirement, limited retroactivity, blocking minimum nursing staffing levels finalized under Biden, and proscribing participation by Planned Parenthood.

Severe: These are huge changes, with outsized increases in state costs; impaired affordability of care for enrollees with tenuous finances; millions of eligible individuals excluded from coverage by onerous (and ineffective) work requirements; dangerous nursing levels; and loss of a highly regarded provider organization. These shifts will massively impair access to care, with millions losing coverage and millions more facing new financial barriers. It will buffet state budgets, particularly in blue states that help the undocumented get coverage.

Deadly: As excerpted above, CAP estimates 21,600 added annual deaths, based on a 2017 study of Medicaid-associated reductions in mortality. Other research supports the substantial life-saving effects of Medicaid, including a comprehensive 2021 study using national surveys and datasets, and a just-published article in Lancet. There’s no question: cutting health insurance kills.

Machiavellian: The political chatter around these expected Medicaid cuts was that they would hurt the GOP in the 2026 midterms and 2028 presidential election. We underestimated the GOP political acumen / deviousness. Note that the most obviously hurtful provisions (e.g., cost-sharing and work requirements) go into effect only in late 2028 / early 2029 – thus minimizing pain to voters and electoral harm to the GOP in the interim. Guess who’ll be blamed by the voters for late 2028 and early 2029 Medicaid cuts? The Dems, if they win. Of course the Dems can cancel the cuts, but not in time to avoid significant political damage. And with GOP tax cuts (for the rich) and the Trump-tariffs-induced economic downturn, the federal budget won’t exactly be flush with funds to restore the program.

It’s truly astounding how complex Medicaid rules, funding, and politics have become. Take an apparently good idea – provide health insurance for the poor – and ultimately what you get is a major political distraction, with the immediate losers being the poor, and the long-term losers being the country. If only, if only … we could figure out a way to pay for health care simply, efficiently, generously … whereby we could remove our medical care from the dirty domain of party politics.

Health Insurance in South Korea

Query:
Please tell me about health insurance in South Korea. What financing approach is used for the primary coverage — e.g., all private insurers (and of those, a role for profit)? all public? a mix? Is separate supplemental insurance? What % of the population is uninsured? Does everyone have the same coverage (benefits + cost-sharing obligations)? How high are deductibles? How common is medical bankruptcy / debt? How common are access to care problems for financial reasons? What is annual health care spending per capita? (Feel free to compare to the US)

ChatGPT 4o:
South Korea’s healthcare system is primarily a publicly financed, single-payer model known as the National Health Insurance Service (NHIS). It offers universal coverage with a standardized benefits package, supplemented by private insurance options. Here’s an overview comparing key aspects with the U.S. system: 

1. Financing and Structure

• Primary Coverage: Administered by the NHIS, a government-run entity under the Ministry of Health and Welfare.
• Funding:
  • Payroll Contributions: Shared equally between employers and employees.
  • Government Subsidies: Support for low-income and self-employed.
  • Out-of-Pocket: Patients contribute through co-payments and services not covered by NHIS.
• Private Insurer Role: supplemental benefits and services.

2. Universal Coverage and Enrollment

• Coverage: ~97% of population enrolled in NHIS.
• Medical Aid Program: Covers the remaining 3% (low-income unable to pay in).

3. Benefits and Cost-Sharing

• Standardized Benefits: NHIS provides a uniform benefits package, ensuring equitable access to healthcare services.
• Deductibles: No deductible system akin to the US.
• Co-Payments:
  • Inpatient Care: Usually 20%.
  • Outpatient Care: 30-60%, depending on care level & facility type.
  • Exemptions: Low-income, age <6 and >65, cancer / rare diseases, disabled.

4. Supplemental Private Insurance

• Purpose: To cover services not included in NHIS, such as certain advanced diagnostics, private hospital rooms, and alternative treatments.
• Enrollment: Many individuals opt for PHI to reduce out-of-pocket expenses and access a broader range of services.

5. Financial Protection and Access

• Medical Bankruptcy: Rare due to the comprehensive coverage provided by NHIS and Medical Aid Program.
• Access Issues: While the system provides broad access, some individuals may experience financial strain due to services not covered by NHIS or high co-payments.

6. Health Expenditure

• $4,570 per capita (2022).
• US: $13,432 per capita (2023)

Comparative Snapshot

Aspect	South Korea	United States
Coverage Model	Public single-payer (NHIS)	Mixed: Private & public
Coverage Rate	~100% (NHIS + Medical Aid)	~91% (recent)
Standardized Benefits	Yes	No; varies by insurer and plan
Co-Payments	20-60% depending on service; many exemptions	Varies; often includes deductibles & co-pays
Medical Bankruptcy	Rare	Common; significant cause of personal bankruptcy
Longevity	83.6 years	76.4 years

 

Comment by: Jim Kahn

My wife and I are in Seoul, the capital of South Korea, on holiday. Our first three days have been wonderful, in this vibrant, easy-to-navigate, safe, and friendly city. We’ve had terrific conversations with quite a few people, despite our nearly non-existent Korean. Many locals manage well in English, and love to discuss their country and ours. They seem pleased to discover that we know a bit about Korean history and culture, gleaned from reading and Korean TV dramas. As far as we can tell, the culture combines diligence about work and family obligations with a sense of calm. We see consistent evidence of high trust, with valuable items (even a vendor’s cash box) left unguarded.

Of course, I’m no sociologist, and our impressions are preliminary and tentative. Still, we like what we’ve seen so far. Of note, South Korea has a thriving, free-market economy. And a thriving democracy –a popular uprising suppressed an attempted military coup by the president in December 2024.

So, naturally, I had to inquire about how health insurance works here. I know some people are skeptical about ChatGPT and other AI large language models. However, the latest versions are, based on my scrutiny, reliable sources of nuanced information. A carefully phrased query yields a highly edifying response.

As you see in the excerpt, South Korea relies on single payer. The result is high access, low costs, and impressive longevity. I can’t prove it, but I believe that universal public insurance also contributes to the high level of friendliness, calm, and trust that we’ve seen so far. Certainly, there are no significant downsides to providing universal insurance. When, oh when, will the US learn from the myriad exemplary insurance practices around the world?

Private Equity Endangers Patients

Private equity in health care puts patients’ lives in danger, studies show
U.S. RIGHT TO KNOW
April 28, 2025
By Pamela Ferdinand

Private equity firms claim their investments in U.S. health care modernize operations and improve efficiency, helping to rescue failing healthcare systems and support practitioners. But recent studies build on mounting evidence that suggest these for-profit deals lead to more patient deaths and complications, among other adverse health outcomes.

Recent studies show private equity (PE) ownership across a wide range of medical sectors leads to: 

Poorer medical outcomes, including increased deaths, higher rates of complications, more hospital-acquired infections, and higher readmission rates.

Staffing problems, with frequent turnover and cuts to nursing staff or experienced physicians that can lead to shorter clinical visits and longer wait times, misdiagnoses, unnecessary care, and treatment delays.

Less access to care and higher prices, including the withdrawal of health care providers from rural and low-income areas, and the closure of unprofitable but essential services such as labor and delivery, psychiatric care, and trauma units.

Dr, Stephanie Woolhandler, a distinguished professor of public health at Hunter College and co-founder of Physicians for a National Health Program, isn’t surprised by the findings. 

“Private equity’s track record in health care is so consistently bad that regulators should ban new private equity purchases in the health sector and impose stringent oversight on the health resources private equity already owns,” she says.

A landmark review in The BMJ analyzed 55 studies across eight countries, primarily in the U.S. It detailed how PE ownership in health care was most often associated with higher costs to patient or payers and “mixed to harmful” impacts on quality of care.

Now, new peer-reviewed research reinforces these findings and reveals a troubling pattern, especially in the absence of effective regulation and oversight: Patients treated at PE-owned facilities, whose numbers have skyrocketed, continue to experience worse or mixed outcomes – from higher mortality rates to lower satisfaction – compared to those treated elsewhere.

In fact, no study to date has found significant improvements to health care quality, efficiency, costs, or access as a result of private equity’s entrance into health care, according to a March 2024 report from Stanford Law Review.

“The drive for quick revenue generation threatens to increase costs, lower health care quality and contribute to physician burnout and moral distress,” they say.

Another study, published last year (July 2024) in JAMA, found hospital assets decreased by 24% in the two years after private equity purchases, leaving facilities less equipped to care for patients. The loss of land, buildings, major hospital equipment, and information technology – equivalent to $28 million in total assets per hospital – means fewer resources for effective patient care, experts say. 

“It’s a very striking finding and should change the way people think about private equity in hospitals. The PE firms say, ‘We bring new capital into hospitals.’ It turns out that’s not quite true,” Woolhandler, a co-author of the study, told NBC News. “There are real dangers to the health care that people get if you deplete all of the capital from a hospital.”

 

Comment by: Don McCanne

To achieve affordable, high quality health care for everyone, the need for single payer has been recognized for decades. Our failure to act has resulted in an intolerable expansion of wasteful expenses without solving the problems of impaired access and individual financial hardship.

In recent years, the menace of private equity has crept into our health care system, greatly compounding its high costs and dysfunction. The “U.S. RIGHT TO KNOW” article convincingly demonstrates this.

Three years ago we wrote an article in The Nation explaining that mere enactment and implementation of a single payer Medicare for All program would no longer be satisfactory because entrepreneurial interests had gained too much control through provider ownership: insurance reform would no longer be enough to ensure that everyone would have access to affordable, comprehensive, high quality health care. We still need single payer, but we must also address ownership of the health care delivery system. We must agree that the system belongs to all of us — community-ownership of hospitals, clinics, and other health care resources.

What have we accomplished in the last three years? Incremental changes have had a negligible impact, allowing the status of our health care system to deteriorate even more. If we continue with our inertia, things can only get worse since private equity is a one-way street in the wrong direction.

You saw the images of the Medicare for All signs at the huge Sanders-AOC rallies. It’s time! Citizen action now!

Medicare for All Act Reintroduced in Congress

Progressive Democrats Join Sen. Bernie Sanders’s Reintroduction of Medicare for All Act
Democracy Now!
Headline
Apr 30, 2025

Democratic Congress members Pramila Jayapal and Debbie Dingell joined Vermont independent Senator Bernie Sanders on Tuesday in reintroducing the Medicare for All Act, which would provide universal single-payer healthcare based on patient needs, not industry profits. 

Sen. Bernie Sanders: “Our legislation would provide comprehensive care to all Americans — rich, poor, young or old — with zero out-of-pocket expense. It would provide full freedom of choice regarding healthcare providers: You go to the doctor or the nurse that you want to. No more insurance premiums, no more deductibles, no more copayments, no more filling out endless forms!”

Sanders, Jayapal, And Dingell Press Conference About Reintroducing Medicare For All
Forbes Breaking News
Video (47 min)
April 29, 2025

 

Comment by: Jim Kahn

Amidst the current oligarchic turn of national politics, with cynical performative gestures toward efficiency obscuring the billionaire pursuit of government largesse, it is critical to reassert our quest for Medicare for All — the powerfully synergistic combination of efficiency and generosity designed to help everyone.

M4A, aka single payer, is the magical yet real and practical strategy that would trim away hundreds of billions of dollars in profits and administrative burden, facilitating directing our massive spending on health care to … health care! (instead of executives and shareholders). Families will save money, and hundreds of thousands of deaths will be averted.

Many thanks to our progressive Congressional leaders, for again promoting this admirable vision in legislative form.

To learn more, and to urge your elected officials to co-sponsor the bills, consult the PNHP website.

And stay the course. We will, eventually, guide US policy to the commonsense solution used around the world: simple and comprehensive health insurance for everyone.

US Mortality High & Strongly Linked to Wealth

Association between Wealth and Mortality in the United States and Europe
New England Journal of Medicine
April 2, 2025
By Sara Machado et al

In the United States, there has been a massive transfer of wealth from the middle class to the wealthy in the past 60 years, which has increased wealth inequality. Other high-income countries have seen concurrent growth in wealth inequality, but these have been less pronounced than in the United States. Life expectancy in the United States is also lower than in other high-income countries, and it is decreasing. These are of key concern, particularly because increases in mortality are most pronounced among the poorest people.

[Interpretation: Survival over time among adults 50-85 years old is lower in the US than in Northern / Western Europe, with more spread by wealth level.]

From the Discussion

We found that wealth was associated with mortality across the United States and Europe and that the difference in mortality between the top and bottom quartiles of wealth appeared to be larger in the United States than in Europe. Mortality in the United States was higher than in Europe, even at higher wealth levels.

Comment by: Don McCanne & Jim Kahn

We have reported often that the US can greatly increase the access and affordability of health care by enacting and implementing a well-designed, single payer, improved version of Medicare that is provided to all.

However, as this study indicates, our health is also broadly linked with economic disparities. The well recognized problem of wealth inequality in the US is associated with reduced life expectancy, especially afflicting lower-wealth individuals, far more than in European nations. At the same time, when compared to those nations – with comprehensive universal health care systems – all US wealth levels have higher mortality, even at the top tier. So the wealthy should understand that they will gain life expectancy if the system is fixed overall. Single payer is not about trade-offs, it’s about improvements for everyone.

What does this tell us? Clearly, as we have said for decades, our nation’s overall health would improve with an improved system of Medicare for All. But it also demonstrates that we need a more equitable distribution of wealth which would be more likely if we also had an equitable system of income distribution. The study showed that life expectancy was related to wealth. However, it is very difficult to see how wealth could be made more equitable without ensuring adequate income for everyone. We also really need a progressive wealth tax if we are going to correct the profound inequities created by today’s preoccupation with the accumulation of mega-wealth.

This is not the same as calling for equal income and wealth. Instead, it is a plea for fairness and justice in income and wealth distribution instead of the creation of centi-billionaires made possible by denying middle- and lower-income workers their fair share of society’s productivity. This, of course, requires effective government oversight, unlike the inhumane, slash-and-burn administration we have today.

What can we do? In just 100 days, extensive damage has been initiated to our socioeconomic and legal systems, and much more is threatened. So reversing the current politics and policy is an emergency. Once we have control of the situation, we can move forward with changes that will let us function like our European friends, perhaps even better. Solving our major challenges would enhance our nation’s well-being and return us to a place of leadership and admiration in the world. Our progress will increase global well-being! But it’s up to the people to act.