August 15, 2025
Dear Interested Readers,
Living in Trump’s Turbulent World
In what seems to be an era of ongoing expanding and universal conflict, healthcare—the care of the individual, the collective effort to improve its delivery to everyone, its social determinants, public health, and advances through research—is in decline. I haven’t seen the multiple Oscar-winning movie Everything Everywhere All at Once, but its title reflects the way the world feels in the Trump/RFK, Jr. engineered retreat from the Triple Aim. Indeed, generalized confusion in all domains — healthcare, foreign policy, domestic policy, and the economy — is either Trump’s intentional core strategy or the natural expression of his psychopathology.
In an essay in Modern Diplomacy in March, Timothy Harper assumed that the answer was a strategy and not psychopathology. He wrote:
Compared to 2017, the new Trump administration appears better prepared, having already announced key appointments and specific plans. However, it is already predictable that the decision-making process—being centered around Trump’s personality and loyalty to him—will likely introduce elements of disorder, instability, and unpredictability into governance and policymaking.
It is expected that Trump’s second term will embrace what can be called a strategy of disruption and strategic chaos in pursuit of radical and revolutionary changes rather than gradual reforms…From this viewpoint, America is currently at a critical juncture that, according to Trump supporters, will lead to a new historical age—the so-called Golden Age of America.
If that is true, and if what we are seeing represents the initiation of a new age, then I am happy that I will probably be going on to my reward before the job is completed. Living in transition is always difficult, especially if you consider the transition to represent a series of losses over which you have very little control. The question becomes more about how to accommodate and adapt than how to resist. In retrospect, I realize that recently I have been writing more about the Political Determinants of Health than the Social or Structural Determinants of Health. It is hard to stay focused on healthcare issues alone as the president undermines the efforts for self-defense and democracy in Ukraine by sucking up to Yelsin, allows famine to exist as a plausible military strategy in Gaza, fires competent federal employees for reporting facts, and invades the Capitol with the military while “gilding” the White House to look like a high rent brothel. All this is happening while he is compromising the world’s economy with the highest tariffs since the Smoot-Hawley tariffs intensified the Great Depression almost a hundred years ago.
In his New York Times column this Wednesday, which he entitled “Why Trump Always Wants a Crisis”, Jamelle Bouie wrote:
…for reasons of both personality and political ambition, Trump needs a crisis to govern — or rather, to rule. And if the actual conditions of reality will not give him a state of exception, he’ll create one himself.
We can’t blame all of the decline in the status of our healthcare on Trump. Other issues have been developing over the last twenty-five or thirty years that could have brought us close to this moment without Trump. Trump has just accelerated the decline of the undermining of the quality and equity movement in healthcare by forces of commerce, which were already in motion before his One Big Beautiful Bill (OBBB) was passed, before he appointed a vaccine-denying crackpot as our Secretary of Health and Human Service, and before he attacked our universities and medical research infrastructure. I fear that the Triple Aim is already a curious asterisk in the decline of our efforts to improve the health of everyone here, and self-serving, associated beneficial efforts to care about care delivery and public health issues around the world.
I will be controversial and say that our decline began a long time ago, when many doctors, and especially the AMA, began to care more about their personal financial health than the care of the patient. Remember that in 1927, Dr. Francis Peabody wrote:
Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
David Blumenthal and James Marone pointed out in The Heart of Power: Health and Politics in the Oval Office (click on the link to read the NYT review from 2009 written by Robert Reich), their 2009 masterpiece on the role of presidents in the evolution of our current system of care, that it was the famous Peter Bent Brigham neurosurgeon, Harvey Cushing, one of the most powerful and influential doctors of the day in the AMA, who blocked FDR’s inclusion of universal healthcare access in the New Deal. Cushing and Roosevelt were friends. Cushing’s daughter was married to Roosevelt’s son, and they were “joint grandpas.” After much study and debate, and against vigorous pushback from the AMA, which could have undermined other aspects of the New Deal like Social Security, Roosevelt folded, and the AMA “protected” its constituents from the oppression of “socialized medicine.” The AMA was also successful in protecting the “business” of medical practice from Harry Truman’s “communistic” attempt to nationalize healthcare after World War II. In the reference of the link above, we read:
Some people even feared the program would be a “Communist” act, giving too much control to the federal government. This fear was spread specifically by the American Medical Association (AMA).
Lyndon Johnson acknowledged and honored Truman’s efforts to provide healthcare for the poor and elderly when he traveled to Truman’s home in Missouri to sign the legislation creating Medicare and Medicaid. In the link above, a 2014 PBS article, we read:
Forty-nine years ago, President Lyndon B. Johnson found himself in Independence, Missouri. Although he was surrounded by a gaggle of politicians, distinguished guests and Secret Service agents, the president was armed only with a fountain pen, a bottle of ink and a sheath of papers. Seated directly beside him, so as to accommodate the newspaper photographers and the television cameras, was Independence’s favorite son, the 33rd president of the United States, Harry S. Truman.
LBJ had traveled to the “Show-Me-State” to sign the Medicare Act of 1965 into law and to praise the 81-year-old Truman who, as Johnson drawled in his thick Texas accent, was “the real daddy of Medicare.”
You may not have been around to witness it, but I was. Up to the moment Johnson signed the bill, and for many years afterward, the AMA opposed and tried to resist the implementation of Medicare and Medicaid. What my younger readers may remember is Hillary Clinton’s efforts during her husband’s first term to introduce universal healthcare. In 1993, the AMA was a less-than-enthusiastic supporter of universal access. I am reminded of the line from the 19th-century British poet, Alexander Pope, who coined the phrase, “Damn by faint praise.” That strategy worked in 1993, but by 2009-2010, in the run-up to the passage of the ACA, the AMA’s strategy was focused on making the new law advantageous to doctors. The AMA may have been founded to dispel quackery and elevate standards of practice, but for much of its existence, its positions against public policy efforts to expand access to care have been protectionist–directed at protecting the business interests and enhancing the incomes of its members. Any concerns that the AMA may have about costs and access to care seem to always come after protecting its members from changes to the status quo.
My final bias against the AMA and one of the reasons why I never joined it or subscribed to its publications is that I blame the AMA for much of the shortage we now suffer in the number of physicians we have and our access to care problems, even for those who have health insurance. Our current disaster was precipitated in part by the ill-conceived and AMA supported concerns in the 80s of an impending “glut of doctors.” Too many doctors would have threatened the business of private practice. The reasoning appears to have been that expansion of the physician workforce or the elevation of mid-level clinicians to independent practice would threaten individual practices with declining patient numbers, so the position of the AMA appears to have been to protect the doctors of the day from too much competition in the search for patients by limiting access to medical education as the nation grew in numbers and got older. The result has been widespread physician burnout, and to some degree, the death of independent practice, and the moral injury associated with working in a system that often values the bottom line over issues of patient service and access. Ironically, much of the current distress experienced by healthcare professionals and their patients was a huge “failure to diagnose” by the AMA.
So, Trump is not the only one we can blame for the state we are in; we can blame ourselves and the perpetuation that healthcare should be a market-oriented business. Two publications this week support that idea. The first article that I will bring to your attention is from The Atlantic and was written by Jonathan Chait. His article is entitled So Much for the ‘Best Health-Care System in the World’: Republicans used to trumpet the innovation of the American medical sector. Now they’re taking a meat axe to it. He begins with a provocative statement:
Here’s a piece of Republican rhetoric that used to be ubiquitous but that you never hear anymore: America has the best health-care system in the world.
Republican politicians liked this line because it helped them dismiss the idea that the system needed major reform. American health care at its finest offered the most advanced treatments anywhere. Democrats wanted to expand coverage, but why mess with perfection? “Obamacare will bankrupt our country and ruin the best health-care-delivery system in the world,” then–House Speaker John Boehner said in 2012.
In Donald Trump’s second term, Republicans haven’t given up their opposition to universal coverage—far from it—but they have mostly stopped singing the praises of American health-care innovation. Indeed, they are taking a meat axe to it, slashing medical-research funding while elevating quacks and charlatans to positions of real power. The resulting synthesis is the worst of all worlds: a system that will lose its ability to develop new cures, while withholding its benefits from even more of the poor and sick.
If you thought that my opening remarks were a bit over the top, Chait bests me by a large margin. He continues:
The line about the world’s best health care always had a grain of truth. The United States has for decades languished behind peer systems in terms of access and outcomes. We are the only OECD country that lacks universal coverage, and the failure to provide basic care to all citizens contributes to our mediocre health. But America really was among the best countries at producing cutting-edge treatments. Those of us who have access to health insurance benefit from high-level technology and a for-profit system that generates incentives for new drugs and devices. There is a reason wealthy patients with rare conditions sometimes travel to the U.S. for care.
My sainted father frequently expounded a truth in his Southern drawl that has persisted until recently, but may not apply to healthcare per se after we experience the full effect of the dynamic duo of Trump and RFK, Jr.. When confronted with an example of the privilege of wealth, Dad would say, “Thems that gots gets.”
Chait implies that the reason we have neglected our disadvantaged is a matter of greed. I would add that to many of us, the poor have been invisible. Growing up in the Jim Crow South, it was my observation that until there was a disturbance, the miseries of life endured by African Americans were of no concern to most caucasians. We could look the other way or avoid their impoverished neighborhoods as we went about a very comfortable life that much of their inadequately compensated labor facilitated. Martin Luther King, Jr. preached against the evil of not being concerned about the poverty and pain of minorities when there was more than enough wealth for everyone to flourish. Chait says:
This was never a convincing reason that the United States could not expand health-care access to citizens who couldn’t afford it. But although the trade-off was false, the Republican Party’s support for medical innovation was genuine…Trump tried and failed to repeal Obamacare, but he also engineered a spectacular success in Operation Warp Speed, which mobilized the pharmaceutical industry with unprecedented efficiency to bring effective COVID vaccines to market.
Many political pundits ascribe to the analysis that in his first term, Trump was largely corralled by advisors who were not totally loyal to his foolishness and greed. In his remarkable political comeback, Trump has called on the “darker angels” or self-interest and greed to assemble a government composed of sycophants who are delighted to profit from association with him, and who know that their moment of power is totally dependent upon how loyal to his worldview they happen to be perceived. Minor expressions of disagreement result in expeditious exclusion and exile. Chait sees the fate of healthcare in the second term as substantially different than its near-death experience during the first term.
In the second Trump era, the party’s opposition to universal health care has, if anything, intensified. The signature legislative accomplishment of Trump’s second term thus far is a deeply unpopular budget bill that is projected to take health insurance away from 16 million Americans once fully implemented.
But now the party has turned sharply against innovation too. Trump has wiped out billions of dollars in federal support for medical research, including canceling a promising HIV-vaccine project. This week, Health and Human Services Secretary Robert F. Kennedy Jr. terminated hundreds of millions of dollars in grants for mRNA-vaccine research, one of the most promising avenues in all of medicine. The United States is going to forfeit its role as medical pioneer even as it recedes further behind every other wealthy country in access.
I might add to Chait’s analysis the question that plagues me, “To what end?” Why dismantle something that is as obviously beneficial to the rich as medical research? Why trash something that is admired at home and abroad? Chait clearly implies that, on the surface, it is the effort of a cabal of fools:
Kennedy has made the party’s pivot explicit. He does not boast about the American health-care system. Instead, he calls it a disaster. “We spend two to three times what other countries pay for public health, and we have the worst outcomes—and that’s not acceptable,” he said on Fox News earlier this year. Kennedy is not wrong about the bottom line; American health care is costly, and the results are poor. But he is almost completely wrong about the cause of this failure. There are many reasons for Americans’ poor health, and shutting down vaccines and medical research, while depriving millions of access to basic care, will make all of those problems far worse.
If you are gracious enough to explain Trump’s erratic behavior by his psychopathology, that explanation does not cover the majority of his Republican enablers in Congress and around the country in state governments. It is hard for me to understand the self-defeating nature of the “anti-science” aspects of Project 2025 and MAGA philosophy. Chait doesn’t get it either.
It’s not that the entire Republican Party has abandoned its previous support for medical innovation. To the contrary, many Republicans in Congress have complained about cuts to medical research; last week, a key Senate committee voted overwhelmingly on a bipartisan bill to increase funding for the National Institutes of Health. But the anti-science wing of the party is in control of the agenda. Two main forces have driven the shift. One is the emergence of Kennedy’s “Make America healthy again” movement, a faction of gullible skeptics that Trump has brought into his coalition. RFK Jr.’s transition from left-wing kook to right-wing kook personifies the realignment of a certain strain of modern snake-oil peddlers into the Republican tent. Although they make up only a small share of the party, their intense interest in health and medicine has given them special sway—a classic instance of a tiny special-interest group determining policy for a larger coalition.
Perhaps more dangerous than the “anti-science” faction of the Republican Party are its “culture warriors.” Again, Chait succinctly nails his point as he enlightens many who are dazed and confused by the rapid changes in public policy in the first six months of Trump II. He continues:
The second force driving this policy change is the rising power of the national-conservative movement. Natcons are a wing of almost fanatically illiberal culture warriors who believe that the Republican Party must use government power to destroy its enemies. The fact that cutting university medical research will harm the United States in the long run is, for the natcons, a minor consideration when weighed against the fact that universities and government-funded labs are full of Democrats.
The combined desire of both factions to attack the scientific elite has pushed the party into a retrograde opposition to medical innovation. Making matters worse, the unabashed corruption of the second Trump administration will further weigh down the sector’s innovation potential by elevating politically connected firms over market-competitive ones…The traditional Republican position defended cutting-edge medical innovation while denying its benefits to those too poor or sick to afford access to it. Who could have guessed that liberals would one day look back at that stance with nostalgia?
The other article that was recently published that fits with my rant in this letter is the most recent instalment in the New England Journal’s “Perspective” series on “The Corporatization of U.S. Healthcare.” The piece was written by Nancy Tomes and is entitled “The Corporatization of U.S. Healthcare: A Gilded Age for Patients? The Broken Promises of Profit-Driven Medicine.” It is not a long article, and I encourage you to follow the link and read the entire article yourself. The “Perspective” articles of the NEJM do not require a subscription. For those of you who are in a hurry but have read this far, I will lift a few of Dr. Tomes’ highlights that will augment the general points of this letter.
After noting the enthusiasm for medical innovations at a January investors conference, and the tragic assassination of UnitedHealthcare’s Brian Thompson, which was greeted with both outrage for the act and outrage about the “denial of care” strategies of many healthcare insurers, she provides a little historical perspective on this moment:
These apparently contradictory perspectives are two sides of the same set of historical developments. Between the 1920s and the 1960s, the American medical profession adopted a new doctor-controlled business model of care delivery, dependent on continual investment in new drugs, technologies, and procedures. That model created the profit opportunities that enticed corporate stakeholders to invest in health care in the 1970s and 1980s. But as the corporate presence increased, physicians lost control of their business model; the “tail” of financialization began wagging the “dog” of medical practice. That shift coincided with corporate cooptation of the language of consumerism to justify these changes as in patients’ best interests. In the process, physicians and patients lost economic autonomy over health care choices.
Let’s pause and reflect. She is ascribing this moment in the decline of the healthcare experience for both patients and healthcare providers to the continual evolution of a process where the focus of clinician attention and healthcare in general shifted from Dr. Peabody’s admonition to “care for the patient” to a central concern for caring about profits which was based on the assumption that profits from medical investments would be benefical to patients, the providers of their care, and wise investors. To me, it sounds like a fallacy not much different than Reagan’s mistake that “a rising tide lifts all boats,” to which I would add that a rising tide is likely to drown many swimmers even as it lifts a few boats.
She continues by telling us that we need to know where we came from to realize where we are.
Understanding today’s corporatization requires seeing it from this historical perspective. Starting in the 1920s, the medical profession adopted a new business model that its leaders deemed better suited to the U.S. economy. But unlike other dominant sectors, such as heavy industry and consumer goods, medicine modernized not by adopting a corporate structure but by convincing state legislatures to delegate control over medical education and licensure to its professional organizations, in particular state medical boards. This professional sovereignty, as Paul Starr termed it, facilitated increasing prestige and incomes for physicians. (A list of supplemental readings on this historical time period is provided in the Supplementary Appendix, available at NEJM.org.)
…The engine of that transformation was modernization of the hospital as the “doctor’s workshop.” Hospitals had a corporatelike structure, with boards of managers and physician-dominated organizational hierarchies, which facilitated investments in new technologies and procedures. To sustain this technology-and-innovation model, hospitals had to function in a more efficient, businesslike fashion. That ethos spread to private practice as well. Modern physicians had to see themselves as investors, first in a high-quality medical education, then in a well-equipped office. To pay off those costs, doctors had to modernize their fee-setting and bill-collection practices, eschewing the old family doctor’s lax financial habits.
Be careful of the road you are on because it might take you to someplace that you don’t want to go.
This financialization led to dynamics whose negative consequences persist to this day. The model gave young physicians little incentive to practice in poor urban neighborhoods or rural areas; instead, they preferred urban and suburban areas where middle-class patients could afford their rising fees. The model also favored specialization with its higher fee scales, triggering the slow decline of general practice. Long before the corporate era, two major weaknesses in U.S. health care — medical “deserts” in poor urban neighborhoods and a trend toward uncoordinated specialization — were well established.
Dr. Tomes continues by saying that even though this transition was increasingly expensive, the paternalistic AMA and its partner, the American Hospital Association, told consumers that they should value their health and save up for the increasing expense of care. Dr. Robert Ebert, the Dean of Harvard Medical School during my years as a student there, and the founder of Harvard Community Health Plan, gave a speech in October 1967, a month after I began my medical education, where he warned of the transitions that he was observing toward more expensive hospital and specialty care and away from many patients in urban and rural environments who were being put at risk. You can read his prescient speech by clicking here.
After giving a great historical review of our regrettable trip down the road of “corporatization” of our health care, Dr. Tomes tells us what the slowly evolving trap got us:
…the “merger movement” in hospital and physician services enabled health care organizations to benefit from economies of scale while minimizing direct price competition. Hospitals and physician practices slowly fused into chains. Today, according to the U.S. Department of Health and Human Services, 81% of Medicare-enrolled hospitals are structured as corporations or limited liability companies. Nearly 70% of American physicians are employed by such corporate entities.
The extent to which DTC [direct-to-consumer] advertising and mergers have benefited patients is hotly debated. Systematization has probably encouraged improvements in patient-centered care, such as sharing of clinical records and monitoring of safety protocols. But it has also led to “consumer satisfaction” assessments that better serve economic goals than clinical ones. If a physician’s employer gives her only 15 minutes to see a patient, how useful are data on that patient’s satisfaction? If the employer doesn’t invest adequately in emergency department and hospital resources, such that patients languish in EDs for hours, what do those patient satisfaction measures reflect?
So, has the corporatization of care been beneficial? Do most healthcare professionals and patients understand how we got to this moment when healthcare professionals feel burned out or subjected to moral injury, and patients feel neglected and increasingly damaged by rising costs and greater difficulties getting access to care when it is suddenly needed?
Although it may seem obvious that health care doesn’t work like a restaurant chain, many powerful health care industry stakeholders still believe allowing corporate interests freer rein will produce that “golden age for patients.” The health care economy’s fragility suggests otherwise. For example, the Covid epidemic revealed hospitals’ financial reliance on elective surgeries. When they pivoted from profitable surgeries to unprofitable Covid care, they needed massive infusions of government funding to survive. Similarly, recent shortages of essential but low-profit drugs, including chemotherapy agents and insulin, reveal the limits of the pharmaceutical industry’s profit-oriented approach to essential drug production. Meanwhile, the launch of new weight-loss drugs, widely advertised on television, has strained insurers’ capacity to cover their expense.
After being dubious that artificial intelligence will fix things, Dr. Tomes gets very direct. I so agree with her that I have bolded her conclusion so that you will not miss it.
No market solution has arisen for the most critical determinant of poor health and health care outcomes in the United States: extreme income inequality. Countless studies indicate that poverty is the most important health risk factor that Americans face. Yet a market-driven health care system offers limited incentives to lower that risk; little profit can be made by preventing or treating poverty-induced illnesses.
I was extremely gratified as I read the last few paragraphs of her analysis. She comes to the same conclusion that Dr. Ebert articulated in 1965 when he asked the Commonwealth Fund to support the establishment of Harvard Community Health Plan as an experiment looking for a better operating model and finance system for care delivery than the hospital and fee-for-service environment. Remember that he said:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Now sixty years later, I am no longer a pre-med student and have completed a long career in healthcare during which I have witnessed a lot of change, but many of the prorblems that Dr. Ebert recognized in the 50s and 60s persist, and as Dr. Tomes’ last words suggest, we are still looking for that optimal finance system and operating model that will provide optimally the care that is needed by everyone.
U.S. health care needs a new business model. Many physicians resist the pressures to pursue economic goals at patients’ expense, spending countless hours convincing pharmacy benefit managers and insurance companies to cover necessary care. But only more collective physician and patient action will help medicine find a more equitable, sustainable model.
Meanwhile, the Trump administration appears intent on blowing up our fragile health care system in the name of an unrestrained “free market” and corporate profiteering. Many people will suffer if the system collapses completely, but perhaps a more sustainable health care system can be built from the rubble.
She goes where Dr. Ebert never dared to go. If I read her correctly, she suggests that if caring providers and patients can hold on until after things get worse and the system we now have turns to a smoldering rubble in the aftermath of Trump’s actions, then perhaps something will be learned and we will build a more humane and efficient system. I am pretty sure that I won’t be around when that day comes. Maybe you will be.
The Heat Has Broken and We Still Have Flowers
Not only have Trump’s antics been ineffective and dangerous to the world’s stability and the underserved and vulnerable among us, but we have also had oppressive heat and humidity. As I complain, I am well aware that in Canada and the West, forest fires rage, and rivers are overflowing either from melting glaciers in Alaska or swollen rivers in Texas and many other parts of MAGA land. I guess that, as difficult as a few recent days have been here, we are in a paradise compared to other places, and I am truly grateful.
Once this week, it was too hot for a sane person to walk, so I just doubled my swim in the lake to meet the demands of the app on my iWatch fitness monitor. I love to close those rings. After my exercise, I enjoy an outdoor shower that is hidden between the flowers and shrubs along the front of our home and the woods that surround our property on all sides which are not part of the lake’s shoreline. In cooler weather, I also soak my elderly muscles and bones in a hot tub that stands near the shower. Whether I am in the shower or the hot tub, I am looking at the other side of the picture in today’s header, which reveals two of my favorite August delights, a blooming Rose of Sharon and a cluster of tall pink phlox. When the Rose of Sharon blooms and the phlox produces its buds, I know that we are in the last days of summer.
An added benefit this August is that for the first time in several years, the Red Sox look like they may be able to maintain the possibility of postseason play. We will see!
I hope that you are cool and will have a respite from the problems of healthcare over a very pleasant weekend.
Be well,
Gene
