February 27, 2026
Dear Interested Readers,
Do You Think Trump Can “Fix” Healthcare Cost, Quality, and Access?
I delayed my usual weekly writing process this week because I was interested in hearing whether the president might spend some time talking about healthcare in his State of the Union address to Congress on Tuesday evening. I was not disappointed in the expectation that whatever he might say would be gilded with falsehoods, half-truths, and exaggerations. During the president’s first term, the Washington Post kept a running total of his falsehoods. In four years, he exceeded 30,000 by the Post’s count. Now, in the second term with Jeff Bezos more obviously supporting the president, the Washington Post is no longer counting, but it seems likely that the president has upped the pace of his preverications. I thought that his most egregious falsehood in the speech related to the damage he has done to SNAP when he said:
“In one year, we have lifted 2.4 million Americans, a record, off of food stamps.”
In an article published in the New York Times that documented his lies and exaggerations during his address, we read:
The number of people who receive benefits from the Supplemental Nutrition Assistance Program, commonly known as food stamps, did decline by 2.6 million from November 2024 to November 2025, according to the latest data from the Agriculture Department.
But that decrease does not correlate exactly to decreased need. The lower numbers in November 2025 came during a government shutdown, when food stamp benefits were severely disrupted. Mr. Trump’s signature tax and domestic policy law also reduced eligibility and cut federal spending on food stamps.
I have seen the damage done to SNAP recipients that Trump reports as his success. I deliver food from our local food bank to SNAP recipients who can’t drive to our local food bank and assist a few people and families with SNAP applications through our nonprofit, Kearsarge Neighborhood Partners. These days, more people are “food insecure,” and the process of applying for or renewing SNAP has been much more difficult as a result of President Trump’s policies. Food is just one Social Determinant of Health about which our president seems to care less, is ignorant of, or is actively abusing.
The president went long on self-congratulatory misrepresentations and short on healthcare policy. The online healthcare letter, STAT, summarized the president’s healthcare comments in his speech.
The nearly two-hour speech was the longest State of the Union delivered at least since 1964, when The American Presidency Project began keeping records. Even so, the president steered away from some of the more controversial health care topics that have animated his administration and lawmakers over the last several months.
The president is facing real political uncertainty ahead in the midterm elections. There is a growing possibility that, with his job approval rating below 40 percent and more and more swing voters realizing they were duped by his promises or have become disgusted by his lies and policies, he could achieve yet another superlative: he could “threepeat” on impeachment. Against that possibility, he made the obvious Trump choice: “going long.” My guess is that if we extracted the lies, half-truths, exaggerations, and cringeworthy comments about his accomplishments, and the unwarranted and unprofessional self-promotional comments contrasting his accomplishments versus the failures of Joe Biden and other Democrats, his speech would have set a record for the shortest State of the Union speech on record, rather than the longest.
Based on last year’s very long speech and his need to try to confuse the electorate into neglecting his failures, I steeled myself for what I was sure would be a very painful experience. I convinced my wife that, instead of watching the Sunday night PBS shows we had recorded while we were away, we had an obligation to watch at least until he began telling lies about his healthcare accomplishments. My wife made it about fifteen minutes into the speech, then announced that she couldn’t take any more and would retreat to the TV in our bedroom to find something else to watch or read a book. By then, I knew that I would not make it through the entire speech without losing the meal I had just enjoyed, so I doubled down on the secondary objective of making it through whatever he had to say about healthcare. I reasoned that reporters were being paid to suffer through the whole ordeal, and I could read what they had to say about it on Wednesday morning.
I hung with his boastful and disgusting performance long enough to hear the blame he cast on Democrats, and his empty promises about what he was going to do about the rising cost of care. He obviously did not talk about the damage that he and Robert Kennedy, Jr. have already done to the nation’s healthcare. Nor did he mention that several million users of the ACA marketplace are expected to be unable to continue their coverage without the renewal of the subsidies, which expired at the end of December, which he directed his vassals in Congress not to renew.
It was also my guess that most Americans don’t realize that in late January, the president moved beyond his “concepts of a plan” to the somewhat more grandiose “Great Healthcare Plan.” Currently, there are two bills in the Senate, one from Dr. Bill Cassidy, a gastroenterologist from Louisiana, and the other from Senator Rick Scott of Florida, who made millions as a for-profit healthcare entrepreneur who co-founded Columbia Hospital Corporation in 1987. Before Trump’s State of the Union address, I had asked ChatGPT about the “Great Healthcare Plan.” Skip to the summary or just read the bold type if you don’t need all the details.
“The Great Healthcare Plan” — Trump’s Official Proposal
The Trump administration has unveiled a broad initiative called the Great Healthcare Plan, and the White House is urging Congress to enact it into law. It’s aimed at lowering health care costs and increasing consumer choice, but many key details are still unspecified.
Core elements of the plan include:
💊 Lowering Prescription Drug Prices
- Codify most-favored-nation (MFN) pricing so Americans pay no more than the lowest prices paid in other countries.
- Expand the number of drugs available over the counter to reduce the need (and cost) of doctor visits.
💰 Reducing Insurance Premiums
- Stop certain federal subsidy payments to insurers and instead send that money directly to eligible Americans so people can choose plans they want.
- Fund “cost-sharing reduction” (CSR) payments that are designed to lower premiums on plans in the ACA marketplaces (the White House claims this could reduce premiums by ~10%).
📊 Increased Transparency and Accountability
- Require insurers to publish key metrics like claims vs. overhead, rate increases, and time to care in “plain English.”
- Require providers and insurers that accept Medicare/Medicaid to prominently post prices and fees publicly.
🏥 More Consumer Choice
- Make more safe medicines available without prescriptions.
- Expand pricing transparency so people can compare costs more easily.
🧾 Key Points and Open Questions About the Plan
While the plan sets out broad goals, policy analysts note important uncertainties and potential consequences:
❓ People With Pre-Existing Conditions
- The official framework doesn’t clearly guarantee protections for people with pre-existing conditions. Analysts say it leaves open questions about whether coverage rules in ACA plans would continue or change.
💸 Premium Subsidies
- The plan proposes redirecting federal subsidies differently (e.g., direct payments), but it’s not clear if this will fully replace the current ACA premium tax credits.
👥 Coverage and Access
- It doesn’t create a universal coverage guarantee — critics point out that it focuses mainly on cost and transparency, without structural reforms to expand health insurance coverage.
📈 Impact on Costs and Coverage
- Early estimates suggest the plan may reduce premiums modestly but could also lead to fewer people insured under the ACA marketplaces unless new protections are enacted. Some nonpartisan analysts have projected about an 11% premium reduction but small coverage losses.
🔎 Broader Context and Related Proposals
In parallel with the Great Healthcare Plan, Trump has also backed other health care–related actions that affect coverage and costs:
🏥 Rural Health Funding
- A separate initiative, part of recent legislation, has directed historic funding ($50 billion) toward rural hospitals and care, aiming to bolster access where providers are struggling.
📉 ACA Subsidies and Premium Spikes
- Trump’s administration has floated proposals to extend ACA subsidies as they expire, although there’s political disagreement over how to do this.
💡 Regulatory Changes
- The administration has also proposed rules affecting ACA open enrollment periods and eligibility verification, and is seeking reform in pharmaceutical pricing programs (e.g., 340B), with mixed reactions from stakeholders.
🧠 Bottom Line — What the Plan Would Do (If Passed)
Likely effects if enacted:
✔️ Could lower some costs:
- Lower drug prices via international pricing comparisons.
- Reduce premiums modestly through cost-sharing and transparency reforms.
✔️ Could increase consumer choice:
- More OTC medicines and direct payments/subsidies rather than insurer subsidies.
- More pricing transparency.
⚠️ Unclear or potentially negative effects:
- No guarantee of preserving protections for people with pre-existing conditions.
- Premium savings might be modest; some estimates project slightly fewer people insured in the ACA exchanges.
- Proposals don’t build toward universal coverage.
🧩 Summary
President Trump’s current health care proposal — branded the Great Healthcare Plan — is a combination of regulatory and legislative ideas focusing on:
- lowering drug and insurance costs,
- increasing consumer choice and transparency,
- redirecting subsidy dollars directly to individuals, and
- not directly expanding coverage or replacing core ACA protections.
Details remain politically and legally unresolved, and many aspects await congressional action to become law.
Many Americans will never fully understand the benefits of the ACA, so-called Obamacare. The good news with Trump’s new plan is that it doesn’t directly seek to repeal the ACA, but it is vague about what to expect in the future. When the Obama administration proposed the ACA, it was working with a distinct disadvantage: the American belief that competitive markets can lower prices and improve products through competition and consumer choice. Obama built his plan by accepting market realities without explicitly believing in them, so that, over time, we might be able to move away from them or further modify a mixed system toward achieving universal access to care. Trump’s grand plan is explicitly an assertion that consumer choice in a market can “fix” healthcare. It may lower the cost of care for some consumers, but it was not designed to lower the total cost of care for the nation’s healthcare or improve the health of the population through expanded and more efficient coverage and practice.
There were other barriers that Obama encountered in his attempt to introduce a plan that would provide universal access to care, lower costs, and improved quality. The two biggest barriers, beyond the bias many Americans have toward market-based progress, were the medical establishment, represented by organizations like the AMA and the American Hospital Association, and the commercial insurance industry. Obama had studied past failures to move toward universal coverage and realized that big leaps like “Medicare for All” were politically impossible. Originally, he and his closest advisors had hoped to honor the American desire to maintain the status quo and continue the fantasy that well-functioning markets could fix healthcare if they stayed within a modified market-based model and built on the previously accepted principles of a public-private partnership that existed in Medicaid and Medicare, while adding parameters to commercial insurance that prohibited junk policies.
When Obama made the mistake of saying that people could keep the policy they had, he did not realize that many insurance products at the time would not meet the ACA’s higher standards and would be rendered invalid. Under the cover of minimal disruption to the basic chassis of market-driven care, Obamacare had offered more than tweaks to the system. The ACA offered real upgrades to insurance, such as abolishing penalties for pre-existing conditions, expanding mandated benefits for preventive care, and allowing young adults to stay on their parents’ policies until age 26. The ACA also set an upper limit on the percentage of premiums insurers could retain for overhead and profit. Obama hoped to create competition for insurers by offering a government alternative to commercial insurers, but he had to give that up to get the support of Joe Lieberman, an independent senator from Connecticut, where insurance companies like Aetna were major employers. Medicaid was expanded by moving the federal-state payment ratio from 50-50 to 90-10 for states that accepted the expanded eligibility parameters. Medicaid Advantage was made more attractive as an incentive for insurers to enter the product, a move toward value-based reimbursement. CMS was allowed to begin experimenting with ACOs as another way to move toward the Triple Aim. Key to participation was “the mandate,” a small tax on those who did not want to participate. As designed, the original proposal, on the surface, appeared quite complicated because it was built on extensive analysis of what had caused previous efforts to expand coverage, such as those proposed by Truman, Ted Kennedy, Jimmy Carter, and the Clintons, to fail.
As the process started, Obama had a filibuster-proof Senate with the combination of elected Democrats and “Independents” like Bernie Sanders and Joe Lieberman, who caucused with the Democrats. After getting Lieberman’s support by giving up the “public option,” Obama encountered a new problem: the tragic death of Ted Kennedy and the surprise election of Republican Scott Brown as his replacement. Brown’s election meant that Obama no longer had a filibuster-protected majority, forcing him to use the complicated process of “reconciliation” to pass the ACA. In reconciliation, there was no possibility of a last-minute improvement of the legislation. What is remarkable is that, over time, the ACA has survived many challenges, including a Supreme Court decision that negated the requirement that states accept the Medicaid expansion. Because of that decision, there are still ten states where Medicaid has not been expanded. There have been numerous other court challenges, and, most dramatically, an attempt by Trump to repeal the entire bill in 2017. Then, the ACA was saved by the political savvy and courage of Senators John McCain, Susan Collins, and Lisa Murkowski. Currently, its success is threatened by the failure to renew the extra support to the ACA marketplace by a bill passed during President Biden’s term. The ACA has given us the closest thing we have ever had to universal access, but it has not lowered the cost of care, nor has it moved us up from last place in measured quality or life expectancy compared to all other advanced economies. Obama had to accept the hope of incremental improvement over time. He got the best deal possible, but in doing so, he had to build on the flawed idea that a market could lower the cost of care. In retrospect, it is hard to know how much better things might have been if Joe Lieberman had not blocked a public option, thereby negating any possibility of the “market” lowering the cost of care.
If you had the fortitude to read the description of Trump’s “Great Healthcare Plan,” you know that it was not designed to expand coverage, guarantee access to care, or improve the quality of care. My impression is that it is mostly an empty box that strategically puts in place small gifts like his drug program that don’t add up to a valid effort to move toward the Triple Aim, if he even knows what the Triple Aim is. It should placate some in the insurance industry, and will be warmly embraced by conservatives and libertarians who oppose the idea that the government has any healthcare responsibilities. Trump’s proposal isn’t built on what we have learned from the ACA, and it perpetuates the flawed idea that market forces and informed, empowered consumers can somehow fix the disaster of rapidly rising health care costs.
Markets don’t work in healthcare for complex reasons. Off the top of my head, I could give you several good reasons that markets don’t work in healthcare, but I succumbed to the desire to know what ChatGPT thought about markets as a path toward the Triple Aim. I got more than I bargained for and perhaps more than you will want to read. I suggest that you may want to just scan the bold type. I asked the bot:
Why has “the market” not been able to lower the cost of healthcare, improve the quality of healthcare, and result in universal access to care?
The bot responded:
When people say “the market should fix healthcare,” they usually mean competition, price transparency, consumer choice, and innovation should drive lower costs, higher quality, and broader access.
Healthcare, however, systematically violates the conditions required for a normal market to function efficiently.
Here are the core structural reasons.
1. Healthcare Is Not a Normal Consumer Good
Unlike buying a car or a phone:
- Demand is often urgent and unpredictable (trauma, cancer, stroke).
- Consumers cannot “shop” during emergencies.
- The stakes are life and death.
- Decisions are made under stress and uncertainty.
Markets work best when consumers can delay purchases, compare prices, and walk away. Healthcare rarely allows that.
2. Extreme Information Asymmetry
In most markets, buyers can evaluate quality. In healthcare:
- Physicians and hospitals hold vastly more knowledge than patients.
- Patients cannot easily assess whether a test, surgery, or drug is necessary.
- Even clinicians struggle to compare true quality across institutions.
This imbalance weakens consumer-driven price discipline. Patients often must trust rather than choose.
[It is interesting to me that in the New England healthcare market, all the advertising is reputational, built on heavy marketing of the brand without reference to cost. When I was the Atrius CEO, we moved hundreds of millions of dollars of care away from Partners Healthcare (now Mass General Brigham), which quite successfully and vigorously advertised its system as basically the best in the world. We moved our primary relationships to the Beth Israel Deaconess Medical system after a thorough data review of our experience with Partners revealed that, across all care, they were often at least 30% more expensive and, in many areas, did not have the highest quality. They just had the best marketing. The process was facilitated by Lean management techniques and a vigorous educational campaign with our clinicians and patients.]
3. Insurance Distorts Price Signals
Modern healthcare is largely mediated by insurance:
- Patients don’t pay the full marginal cost at the point of care.
- Employers or government programs cover much of the bill.
- Providers negotiate confidential rates with insurers.
This creates:
- Reduced price sensitivity for patients.
- Cost-shifting and opaque pricing.
- Limited true consumer competition.
When the consumer is not the primary payer, classic market incentives weaken.
4. Third-Party Payment and Moral Hazard
Insurance introduces two distortions:
- Moral hazard (demand side): When insulated from full cost, utilization rises.
- Supplier-induced demand (supply side): Providers influence volume and intensity of services.
Fee-for-service payment historically rewarded volume rather than outcomes.
5. Market Power and Consolidation
Healthcare markets are often highly concentrated:
- Hospital mergers create regional monopolies.
- Physician groups consolidate.
- Insurers dominate certain markets.
In many U.S. regions, one hospital system sets prices with little competitive constraint. Consolidation has often raised prices rather than lowered them.
6. Barriers to Entry
Normal markets rely on new entrants to lower prices. Healthcare has:
- Licensing requirements
- Certificate-of-need laws (in many states)
- High capital costs
- Limited residency slots for physicians
- Patent protections on pharmaceuticals
These reduce competitive pressure.
7. Quality Is Hard to Measure
In most industries:
- Quality can be directly observed.
In healthcare:
- Outcomes depend on patient complexity.
- Benefits may appear years later.
- Metrics are imperfect proxies.
Without clear quality transparency, markets cannot reliably reward high performers.
8. Healthcare Has Public Good Characteristics
Healthcare creates externalities:
- Vaccination protects communities.
- Infectious disease control benefits society.
- Untreated mental illness or addiction has social costs.
Markets underprovide goods with strong public benefits.
9. Equity vs. Efficiency Tension
Markets allocate based on ability to pay, not need.
Healthcare, however, is viewed as:
- A social good.
- A moral right in most developed nations.
Universal access requires cross-subsidization—something markets do not naturally generate.
[Over the last several decades, we have moved away from “community rating,” which was often used in capitation, toward “experience rating,” which made care very expensive for self-insured individuals who had a prior history of medical need. In community rating, insurance rates are based on the total cost of care for a population. With experience rating, the cost is based on specific populations or individuals. Younger, healthier populations pay less. Older and sicker populations pay more. In the long run, community rating benefits us all, since we will all get older and inevitably have medical needs. Experience rating is great in the moment for employers who have young, well employees. In the long run, experience rating can make the cost of care prohibitive for our most ill individuals, and ultimately, it could be detrimental to everyone’s care. In the short run, experience rating could lead to workplace discrimination. Perhaps in a future letter, with the help of AI, I will explore the differences between community rating and experience rating more deeply.]
10. Administrative Complexity
The U.S. system includes:
- Thousands of payers
- Negotiated contracts
- Prior authorization
- Billing complexity
Administrative overhead absorbs roughly 20–30% of U.S. healthcare spending. Fragmented competition has increased transaction costs rather than reducing them.
[This is huge. I have seen the work areas where the clerks who process claims and do the management of insurance products on both the provider/hospital side and the insurance side. There are acres of cubicals with people doing work that is driven by a dysfunctional finance system that adds expense and often increases the work of clinicians and diminishes the care received by patients, but it is the status quo, and changing the status quo is a challenge to politicians.]
11. Innovation Raises Costs Before Lowering Them
Healthcare innovation:
- Often increases spending (new drugs, biologics, imaging).
- Extends life but adds years of chronic care costs.
- Is rewarded even when marginal benefit is small.
Unlike consumer tech, medical innovation frequently adds layers rather than replacing old ones.
12. Political and Regulatory Hybridization
The U.S. system is not a pure market nor a pure public system. It is a hybrid of:
- Employer-based insurance
- Medicare and Medicaid
- Private insurers
- Regulated pricing in some sectors
- Unregulated pricing in others
Hybrid systems can dilute accountability and blunt incentives without fully achieving market or public efficiencies.
The Core Economic Summary
Healthcare fails as a pure market because it features:
- Information asymmetry
- Third-party payment
- Inelastic and unpredictable demand
- Moral hazard
- Supplier-driven utilization
- High entry barriers
- Local monopolies
- Externalities
- Equity constraints
These structural characteristics prevent classical supply-and-demand dynamics from delivering lower cost, higher quality, and universal access simultaneously.
The president thinks he knows markets, and maybe he does understand real estate markets, or enough about the crypto market to use it to line his pockets, but I doubt that he understands the healthcare market any better than he understands tariffs and the complexities of diplomacy. Just as he “sold” the One Big Beautiful Bill to the current slim majorities that he holds in Congress before the mid-term elections, we must accept that he may somehow bully enough Republicans who are afraid of his power with the voters, which they need to win primaries, to get his healthcare bill passed.
So, my assessment of the state of healthcare under the control of the most corrupt, narcissistic, kleptocracy-oriented president we have ever had is not good. If the health of the nation is at increasing risk from the greed, ineptitude, and ignorance of its leader, how could the state of the union be good? If you accept his assessment that we are “winning” and that he is the answer to all of our problems, you are contributing to our collective decline. Promoting healthcare equity and advancing medical science as we practice more efficiently and effectively should be a defining issue in the midterm elections. The question is how much more damage will we sustain before we can elect a Congress willing to call him on his lies and block his self-serving agenda. In the short term, his programs harm the poor and offer generous benefits to the ultrawealthy. I am holding on day to day, through his boasts and lies, hoping that soon we will no longer have to hear his voice as we begin to find our way back toward the ideals expressed at our founding 250 years ago.
An Anniversary of Sorts
The first of these letters appeared eighteen years ago on February 22, 2008. It was published at the end of my first full week as CEO of our practice. There has been one every Friday except for three weeks in late 2013 when I announced my retirement. At the time, I did not know that those first 298 issues were being bound in leather for presentation to me at our annual awards dinner. The bound letters were the work and gift of Marci Sindel, who had been my editor, mentor, and colleague for nearly six years. The collection of those letters is entitled Be well, Gene. As best I know, there is only one bound copy, although I do have an electronic copy. The bound copy is over 1,000 pages and could make an excellent doorstop. It’s a lot longer than Moby Dick, and about the same size as David Foster Wallace’s Infinite Jest.
I now consider those first 298 issues to be Volume One. Between mid-November 2013 and early January 2015, I published the letter to a list of people, the “interested readers,” who were not Atrius employees but had requested that they be added to the distribution. By that time, there were a few hundred people on that list, which had been maintained by my very talented administrative assistant, Cheryl Livoli. It was a simple Google process. In early January 2015, with the fabulous help of Russ Morgan, one of the most community-oriented men I have ever met, strategyhealthcare.com was created, and the letter was named “Healthcare Musings.” The story of my letter underlines the reality that what we accomplish in life is usually only possible because of the generous support of others. To the list of critical supporters, I must add my son Jesse, who prepares the header each week, and my wife, who often finds typos and offers valuable insights. I really appreciate any comments offered by readers.
For the first several years, I wrote a second, usually shorter, second weekly letter, which was published on Tuesdays. A couple of years ago, I decided that twice a week was too much, and went back to the every Friday schedule. It is amazing to realize that in all forms, there are now more than a thousand letters. I am sometimes amused by researching a subject on the Internet and finding that one of my previous letters pops up. What is disturbing is that I often can’t remember having written the letter that pops up on the Internet search! Getting to enjoy things again and again as “new” is one of the joys of old age! T.S.Eliot was telling the truth when he wrote:
“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”
I continue to write, whether anyone is reading or not, because it is an activity I love that keeps me in touch with the professional journey that has given my life great purpose. I have enjoyed a life of many chapters that are all a part of the same book. Trying to integrate what I think and have learned from study and experience with what is happening around us into these letters gives me a sense of purpose, whether anyone reads my effort or not. The joy is in the doing.
I have also come to enjoy sharing the mundane events of life. For instance, there is a mountain of snow in my yard, which you can see in today’s header. Our trip home was delayed a day because of the nor’easter that we had last weekend. The storm created a pleasant surprise. During a six-hour layover in Chicago, I was approached by a lovely woman who is one of the excellent PCPs at the Wellesley Offices of Atrius Health. She tentatively asked, “Are you Gene Lindsey?” The last time I saw her was probably in late 2013, just before I retired. I never knew her well, but we share many cherished colleagues. It was great to catch up and get updates on many old pals I haven’t seen for years. Our relationships in healthcare can be like family.
Warmer weather is predicted for our weekend. I hope that you will enjoy a good weekend.
Be well,
Gene
