August 7, 2026
Dear Interested Readers,
Looking Back With Appreciation For What Has Been Accomplished, and Looking Forward With Concerns
After I had “put down my pen” on last week’s letter, I read Heather Cox Richardson’s Substack post for July 30. It was entitled “Sixty Years of Medicaid and Medicare.” If you would prefer to hear her read it, click here. The letter informed me of something that I did not know or had forgotten. As with the ACA, which was signed into law in 2010 but did not take effect until 2014, there was a delay between the passage of the legislation creating these two programs and their implementation. She begins with a review of the history:
Sixty years ago today, on July 30, 1966, Medicare and Medicaid went into effect. A year earlier, President Lyndon B. Johnson had signed the Medicare and Medicaid amendments Congress had made to the Social Security Act of 1935, establishing two national health insurance programs. Medicare used federal funds to cover seniors, while Medicaid covered people who qualified on the basis of income using federal and state funding. The programs expanded health insurance to millions of uninsured Americans.
Americans and their leaders had called for government support for healthcare since the early 1900s, but the final push to expand healthcare coverage in the United States came out of the New Deal. In 1945, President Harry Truman continued to expand the social safety net anchored by the 1935 Social Security Act signed into law by his predecessor, Franklin Delano Roosevelt.
Cox expands on Harry Truman’s central role in maintaining the idea of universal coverage, even though he failed to pass the legislation due to resistance from the AMA and a Republican-controlled Congress. Throughout much of the remainder of her letter, she quotes Truman and then Lyndon Johnson, who went to Truman’s home in Independence, Missouri, to honor him by signing the bill in his presence and presenting him with one of the pens he used.
Her letter continues:
On November 19, 1945, Truman reminded Congress that in September he had proposed an Economic Bill of Rights that guaranteed “certain rights which ought to be assured to every American citizen.”
“One of them,” he reminded them, “was: ‘The right to adequate medical care and the opportunity to achieve and enjoy good health.’ Another was the ‘right to adequate protection from the economic fears of…sickness….’”
“Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health,” he said. “Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”
One of my earliest memories of hearing about politics was my father’s frequent expression of disdain for Harry Truman. “Give ‘Em Hell Harry” seemed to him to lack the social grace necessary for a president. I often wonder what my somewhat libertarian right-leaning dad would think of the current occupant of the office. The picture Cox paints of Truman reveals him to be compassionate, logical, and progressive. In his attempt to get Congress to pass the bill, he reminded our legislators that the draft for WWII revealed that about a third of the young men and women evaluated for enlistment or draft were physically or mentally unqualified for service. In Truman’s mind, that was evidence that millions of Americans needed better medical care, and fixing this problem should be a national priority and a government’s responsibility. Cox continues:
Access to the benefits of modern medical science had never been equal, Truman said, and never would be “unless government is bold enough to do something about it. People with low or moderate incomes do not get the same medical attention as those with high incomes. The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.
“Our new Economic Bill of Rights should mean health security for all, regardless of residence, station, or race—everywhere in the United States.
“We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.”
It is startling for me to read Truman’s 1945 analysis from when I was an infant and to realize that now, as I walk with a crutch in my 80s, for about 10% of Americans, what Truman said then is still true. We have been on a very long road headed toward universal access to equitable healthcare. The length of the road is perhaps related to a national characteristic, summarized in a quote attributed to Winston Churchill, without definitive proof. The quote goes something like, “You can always count on Americans to do the right thing after they have tried all the wrong things.” In my mind, like the quote about history bending toward justice, the subtle advice is to be persistent, patient, and hopeful because someday those virtues will be rewarded.
History can also give guidance for the moment. Cox reports that one of the key points of resistance to Truman’s proposal for universal access to care through a government-funded program was that Republicans warned that it would be much like Communism. President Trump is now playing the Communism card with regularity as he tries to frighten enough voters to salvage the midterm elections and maintain Republican control of Congress.
It took 20 years to go from Truman’s proposal to the launch of Medicare and medicaid benefits. Much like the persistent resistance of ten red states to accept the Medicaid expansion of the ACA, it took Arizona until 1982, 16 years, to accept Medicaid. After LBJ signed the legislation, he presented Truman and his wife with the first Medicare cards.
Cox describes Johnson’s remarks at the presentation:
In his remarks at the signing, Johnson told the crowd: “The people of the United States love and voted for Harry Truman, not because he gave them hell—but because he gave them hope.” He told Truman that those like him—men of vision who are willing to stake their reputations and position to help others—“illuminate the life and the history of a nation.” He and his advisors had come to Independence not in tribute to Truman himself, Johnson said, but in tribute to the America that he represented. “For a country can be known by the quality of the men it honors,” he said. “By praising you, and by carrying forward your dreams, we really reaffirm the greatness of America.”
Johnson explained what the measure did. “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles, and their aunts.”
“And,” he said, “no longer will this Nation refuse the hand of justice to those who have given a lifetime of service and wisdom and labor to the progress of this progressive country.”
Professor Cox points out the staying power of the MAGA principle that America is great when it ignores the needs of a significant number of its citizens.
But now, in 2026, the Republicans in charge of our government reject the vision of a government that works to support its people. They see government regulation, taxation, and a social safety net as an attack on individual liberty.
In their One Big Beautiful Bill Act, which they passed in July 2025 with no Democratic votes, the Republicans delivered Trump’s signature economic policy. The law partially offset trillions of dollars in tax cuts by cutting $911 billion from Medicaid over ten years. Most of those cuts will begin to take effect in late 2026 and early 2027, after the midterm election.
Cox moves on to discuss new attacks by the Trump administration on Medicare drug subsidies before ending with more wisdom from Lyndon Johnson:
“History shapes men, but it is a necessary faith of leadership that men can help shape history,” Johnson said as he signed the measure creating Medicare and Medicaid. He credited FDR with beginning the process of creating a basic social safety net when he signed the 1935 Social Security Act.
He noted that FDR at the time called the Social Security Act “a cornerstone in a structure which is being built but it is by no means complete.”
It’s only nine years until a century will have passed since the passage of the Social Security Act, which was a bold but incomplete step in the right direction. One wonders whether, between now and 2035, we will strengthen our social services safety net and improve the social determinants of health by passing legislation that creates universal access to care and perhaps even a universal basic income program, or whether we will continue MAGA’s attempt to undermine the accomplishments that were a part of a bold vision to obtain and maintain greatness by using our collective resources to make better health and greater opportunities in life a reality for every American—just like Harry, LBJ, and FDR imagined was possible.
While the “primary season” continued this week in Michigan with the victory of Dr. Abdul El-Sayed, an epidemiologist and former public health commissioner of Detroit, as yet another Democratic progressive candidate for the Senate, I noted another article of interest that I want you to consider. It may explain, in part, why we have struggled with questions related to the cost and access to care for so long. Writing in the Millbank Memorial Fund’s Quarterly publication, Christopher Koller, the recently retired President of the Milbank Memorial Fund, who is a Senior Advisor for Ariadne Labs and was the country’s first health insurance commissioner, serving in Rhode Island from 2005 to 2013, published an essay entitled “What We Talk About When We Talk About Health Care Affordability.”
Koller begins with reference to a short story by Raymond Carver. In the story, there is tension between a man and a woman as they discuss their differences in opinion “about love’s precise nature” while they are sharing a bottle of gin and trying to decide how they will spend the evening. He goes on to point out:
So it is with “health care affordability” in the United States today. Although health care access and affordability now ranks as Americans’ top domestic policy issue according to a March 2026 Gallup poll, a consistent definition remains elusive. For an employee, the size of their share of an insurance premium and what they pay at the time of a medical service have consistently risen faster than wages for the last 30 years, and they have relinquished pay increases for health care benefits. For an employer, health care is a burgeoning line item in their financial statement, currently just shy of $27,000 per family per year—even as they have shifted more and more costs to employees. And for a government official, health care is the “Pac-Man” of public expenditures, now gobbling up almost 30% of both federal and state budgets and forcing budget cuts elsewhere.
Those are startling numbers, but just as high as the numbers are, when we are talking about the problem of affordability, like love, we are talking about different experiences for different people. What we do share is that everyone is impacted, whether they realize it or not. Your healthcare may be much more expensive than it was, but you may not be immediately affected — yet. I think there may be some similarity to global warming. If you live where I do, where forest fires are rare, where there is plenty of water most of the time, and where at the worst you finally decide to buy a few bedroom air conditioners for the ten days a year when the nighttime low doesn’t fall below 70, then your experience is different from someone dealing in the west with the forest fires that threaten your home, low reservoirs that look like they might go dry, and weeks and weeks of temperatures that exceed 100 degrees. If the impact of a problem on us is low for the moment, we may not have deep sympathy for those who are suffering now. So it is with healthcare. Mr. Koller wants to correct this lack of awareness that is shared by many who don’t worry much about costs now and continues by emphasizing that we are all impacted now, whether we recognize it or not.
The absence of health care affordability in the United States exerts a cost on all of us. In any given year, according to KFF reports, over a third of people report skipping or postponing needed care because of costs. Health care costs that are almost twice as high as in any other country put US manufacturers at a significant competitive disadvantage in the global economy. And public money spent on health care is money not available for other services, many of which—like public health, SNAP benefits, child care, education, and support for housing and homelessness services—can reduce the need for medical care.
Unlike the absence of love, however, the absence of health care affordability in the United States can be readily diagnosed and falls into three broad categories.
First, private sector health care expenses are rising much faster than government health care spending. Research shows that employees with job-sponsored coverage are not using more health care; they and their employers are paying more for each service or item. This is particularly true for hospital-based services and pharmaceuticals.
As costs rise faster than government payments, systems consolidate to gain leverage over payers, making care more expensive for employers and patients, who are paying larger shares of premiums and out-of-pocket costs. Drug companies are raising prices because they can. Mr. Koller points out that, with the exception of New Zealand, we are the only country where you can see an ad for a drug for stage 4 breast cancer on the evening news. I now see an ad almost every evening when I watch the local and national news for a kit pre-supplied with antibiotics that can be used in emergencies to avoid costly trips to an emergency room. There is a little booklet for guidance, or you can call for advice if you have questions. Is “do it yourself” the future of healthcare? Really? At the same time, more people are opting for just “forget it” about their symptoms until there is no longer a question to answer.
Second, since US health care is financed through myriad sources, it is much easier to shift costs than to reduce them. Like a game of hot potato, insurers look for ways to deny provider claims, and employers increase employee cost-sharing. Providers consider payment variations between private and public insurance for the same service of up to three-and-a-half times to be proof of government cost-shifting. And legislators, rather than tackling systemic costs, find it much easier to limit the number of people on government programs or subsidize the purchase of health care coverage.
Again, if you are part of the “covered majority” and well for the moment, this issue may not seem as pressing to you as gasoline at $4.09 a gallon. His third category:
Finally and foundationally, when faced with the question of whether health care is a private good to be consumed by individuals (with the resulting abundant choices and significant inequities that result from a market-based economy) or a public good available to all as a right and condition for a healthy community (with the attendant limitations and tradeoffs that result), our culture has responded with a resounding “Yes!”
I think he is facetiously pointing to our resistance to resolving the basic societal question of whether access to care is an individual responsibility or a collective concern. He continues by pointing out that our lack of agreement on the basic question of whether access to care is a “right” we all share or a privilege for those who can afford it, ends up costing us all in terms of money and health.
This inability to agree on how we place economic value on health care services leaves us reaping the worst of both options—persistently poor and increasingly inequitable health outcomes, and an inefficient, rapacious health care sector that clothes itself in virtue even as it rakes in money, becoming, as Warren Buffett once said, “the tapeworm of the US economy.”
Koller returns to Carver’s story and points out that at the end:
By the end of Carver’s story, night has come, the gin bottle is empty, bitterness has surfaced, and the characters cannot make plans for dinner, let alone agree about love.
There are questions that we may fool ourselves into believing don’t need to be answered if we ignore them long enough. Ignoring global warming will lead to hotter days, more fires, less water in some places, more floods in others, and grief for everyone. Perhaps there are those who don’t look down the road far enough to imagine the long-term impact on the strategy of Making America Great Again that tolerating increases in healthcare costs and denying support to increasing numbers will have on the utopian white Christian Nationalist paradise that they dream of achieving.
Mr Koller is an earnest and responsible former healthcare executive who is deeply concerned about our current indecision regarding healthcare affordability and its ramifications. He points his finger at the power of the status quo.
…A key barrier is that the health care sector has emerged as a powerful economic and political player in US public policy. Health care companies—hospitals, pharmaceutical companies, physician groups, insurers, and nursing homes—spent an estimated $750 million in 2025 to protect their interests and defend their revenues in Washington.
Likewise, individual states have significant influence over health care affordability, given their Medicaid and commercial health insurance oversight, as well as their authority over decisions concerning provider consolidation and capital expenses. Yet, state policymakers are also confronted by the iron law of economics that one person’s expense is another person’s revenue, and the dependence of local economies on the health care sector for employment, and academic medical centers for civic status. The temptation for magical thinking persists: even as we call for making health care more affordable, it can be an economic engine.
Is he describing a trap from which there is no escape? It may turn out that way, but he hasn’t given up hope, but the Trump administration has been going the wrong way. (I did the bolding.)
…One need not succumb to platitudes or bitterness and gin, however. A health care affordability policy agenda should acknowledge that affordability is in the eye (or wallet) of the beholder. To be both politically powerful and socially just, the agenda should first focus on solidarity: making sure that all of us have access to a basic set of health services. For many, the ACA was the first step on this path: it broadened a public entitlement and forced the question of what government could afford to finance and how it should do so. In this light, the Medicaid eligibility cuts of last year—financing tax cuts for the wealthy by cutting enrollment—constitute both a profound moral failure and a blow to a broad affordability strategy. Congress chose to cut people, rather than prioritize services or change payments.
He has suggestions for how to get out of our spiral of doom. Coverage for everyone is necessary but not sufficient. We need an “affordability agenda.” He suggests limiting “high deductible” policies to protect low-income people getting insurance from their employer as a necessary step, but goes on to say:
Finally, the agenda should focus on creating the political will for setting enforceable budgets for that basic set of services and reallocating existing funds within those budgets to prioritize those services that have been shown to have the greatest benefit for the most people, such as public health, prevention, and comprehensive primary care. These reallocation decisions should not be the culmination of personal choice by individuals with “skin in the game,” who purchase all their health care in a free market. Instead, depoliticizing Medicare’s provider rate setting process to permit more objective assessments of the costs and benefits of covered services should be the basis for these budgeting decisions.
He has a role that the states can play, but he is realistic:
A number [of states] have tried to preserve Medicaid eligibility, supplement ACA subsidies, and reallocate health care spending by limiting what employers pay health systems, increasing spending on primary care, and throwing sand in the gears of health system consolidation and private equity investments. The federal government’s authority and its role in health care financing means that even the most ambitious state governments cannot do this work alone. With the Supreme Court’s 2010 Citizens United decision, current campaign financing rules favor those with economic power and health care industry players will fight any discussion in Congress that will reduce their ability to make money.
I see his conclusion as more pessimistic than hopeful. He is probably right. There are paths to better affordability, but it is unlikely that enough Republicans will join Democrats in the effort to pass the necessary legislation. I am not even certain that a Democratic takeover of both houses of Congress through the elections this fall will even plateau the rising cost of care or fundamentally reverse much of what Trump has done to undermine the health of the nation. He would surely veto any legislation that does not pass with huge bipartisan support, which has never materialized for any healthcare proposal to expand coverage or decrease costs. I am also skeptical about healthcare professionals moving together to resolve the issues that make their work lives difficult and care prohibitively expensive for many of their patients. Koller ends with a sober clarity:
Carver’s tale is, in part, about how love is hard to define and forever flawed, though essential to being human. Affordable health care is also definitionally elusive and essential to a healthy community. Like love, talk of health care affordability—and the policies to achieve it—must be based on a respect for human dignity, a recognition of our mutual dependence, and an acknowledgment of the reality of our limitations, both personal and collective.
To explore further the current evidence of the mess we are in, let me ask you to look at an article published in the relatively conservative Wall Street Journal this week entitled “The Rising Number of Uninsured Patients Starts to Hit Hospitals: Millions of Americans dropped Affordable Care Act plans after higher subsidies expired and now struggle to pay.” The article was written by Anna Wilde Mathews, an experienced journalist who focuses on health insurance. Her writing, supported by statistics and graphs, confirms much of what Mr. Koller has described.
I Have Learned That Nature Is More Predictable Than The Future of Healthcare
I really enjoy being old and retired. The writings of the minister and novelist Frederick Buechner have been mined for his wisdom and published as a book of daily meditations entitled Listening to Your Life. For the past three-plus years, my bedtime routine has, without fail, included his meditation for the day and reading entries from a couple of days in my father’s journals. Some nights there is not much wisdom to operationalize from either writer, but then occasionally, like this Tuesday, one of them will provide me with something that I ponder for days. Buechner’s entry for August 4 is entitled “Old Age.”
He begins by referencing the overworked wisdom that old age is “not for sissies.” He notes that, for some, aging is a benign process that moves very slowly, and then, all of a sudden, life is done without much suffering. For others it is like living in a house “that’s increasingly in need of repairs.” But, he says,
The odd thing is that the person living in the [deteriorating] house may feel, humanly speaking, much as always. The eighty-year-old body can be in precarious shape yet the spirit within is as full of beans as ever.
He goes on to compare eighty-year-olds to eight-year-olds. He uses a phrase, “in their second childhood,” that I often heard from my parents in reference to an elderly person with declining cognitive function. Buechner uses the phrase to describe a sort of liberation that those of us over eighty can feel from the need “of becoming.” Eight-year-olds aren’t yet at the moment when they need to give much thought to becoming. So eight-year-olds and eighty-year-olds share the reality that there are many things they would like to do, but their bodies or circumstances won’t allow. The alternative they share is the opportunity to play. He expands the idea.
Very young children and very old children also have in common the advantage of being able to sit on the sideline of things. While everybody else is in there jockeying for position and sweating it out, they can lean back, put their feet up, and like the octogenarian King Lear “pray, sing, and tell old tales, and laugh at gilded butterflies.”
In the last paragraph he writes:
Very young children and very old children also seem to be in touch with something that the rest of the pack has lost track of. There is something bright and still about them at their best, like the sun before breakfast. Both the old and the young get scared sometimes about what lies ahead of them, and with good reason, but you can’t help feeling that whatever inner goldenness they’re in touch with will see them through in the end.
I am enjoying retirement so much that at times I feel guilty, especially when I rise at 9 AM or later on some days and remember when I had already been at my day’s work for two or three hours at that time once long ago, and that there are many who now have been at their day for hours. One recurring realization I feel grateful for is that I am no longer so busy that I barely notice the progression of the seasons or the progression of nature within a season.
We are now in late summer. My Rose of Sharon bloomed on August 1, and as you can see from the header this week, the Black-eyed Susans have joined the Coneflowers in full bloom. We are looking forward to next weekend when our youngest son, his wife, and their two boys will travel from their home in Maine to see us here on the lake. It is great to enjoy the late-life bonus of grandchildren. Life is good now, and we should enjoy it while we can, even if Trump is destroying our collective future.
Be well,
Gene
