October 30, 2026
Dear Interested Readers,
The Wait Is Almost Over
Dear reader, if you are tired of reading about my anxieties for the future of healthcare in the run-up to the midterm elections, I apologize. I must admit that, despite most political pundits’ predictions that the Democratic Party will score a “blue wave,” which would give them control of the House of Representatives for sure and could also hand them the Senate, I remain quite anxious about the election, and even more anxious about what might follow the election.
I really hope that there will be no post-election insurrection or further destabilization of our democracy after the election, and that I will be free to begin to imagine how, with the control of Congress, Democrats might end the attacks on healthcare, science, and the Social Determinants of Health that have been so obvious since January 20, 2025, when the president began his path toward auttocracy with his attacks on healthcare, academia, science, and the movement toward greater equality through DEI (Diversity, Equity, and Inclusion) by signing his first 26 executive orders of this term. By the end of the year, he had signed 232 such orders.
In my letter last week, I quoted Paul Krugman again. I have channeled several of his daily letters on Substack that focus on healthcare as a key issue in this election, a topic that has not received proper attention from the media. In summary, he said:
This ongoing healthcare disaster is all on Trump and his party. And again, voters appear to have noticed, giving Democrats a large and growing edge on the issue…
…So if there is a blue wave … it won’t just be the result of inflation and Trump’s vainglorious wars. It will also in part be the result of a quiet but massive healthcare disaster.
I think that there are a few reasons that healthcare has not received as much attention as it deserves. First and foremost, there is the complexity of healthcare. We don’t have one care system; we have several. Even within what might appear to an average Medicare-aged citizen to be a homogeneous system, like Medicare Advantage, there are differences in access and cost from state to state and often from county to county within the same state. One overriding factor in the complexity of care is the maldistribution of resources, which leaves many rural and small-town Americans with no choices and no services within a reasonable distance from where they live. In larger population areas, and in combination with commercial insurance, some have protected their access to services by paying thousands of dollars extra every year for concierge care in the hope of timely attention to their concerns.
On Tuesday this week, the headline of my local paper was, Goodlander hears from trauma doctors: ‘This is not sustainable ‘: DHMC staff share concerns as US representative seeks re-election.”The article is very short, and you can read it or hear it in just a few minutes, but it presents an undeniably dangerous situation that was never optimal but has been acutely exacerbated by the policies of our president. If you click on the link, you will discover that the trauma staff at Dartmouth Medical Center met with Maggie Goodlander, my congresswoman, to show her how inadequately funded and poorly staffed they were, with the expectation that the recent passage of the “One Big Beautiful Bill” would further compromise their ability to provide emergency trauma care for the residents of Vermont and New Hampshire, for which they are one of two trauma centers. The other level one trauma center is at the University of Vermont Medical Center in Burlington, about 100 miles and more than an hour and a half up I-89. The trauma centers in Boston are even farther south. I don’t imagine that there will ever be new trauma centers in our region, but I can imagine many deaths and avoidable permanent injuries and long-term disabilities resulting from the further compromise and decline of our currently inadequate resources.
Krugman’s wisdom and analytical abilities are exceeded only by his ability and courage to call a situation what it is. Others of us are constrained either by self-interest, a lack of understanding, or fear of being as direct as he is. He opened my eyes to my own inadequacy when he wrote:
…Trump and his party have done all they can to deny healthcare to millions of Americans. They have done this partly to save money — not to reduce the budget deficit, but to make room for tax cuts for the wealthy. They have also done it out of sheer cruelty.
There are many terrible things happening in America right now, from the debacle in Iran to the depredations of ICE. But the healthcare disaster, which will ruin many people financially and in some cases kill Americans who can no longer afford essential care, deserves much more attention than it is getting.
I nodded in affirmation and said a loud “Amen” to myself when I read those words. Trump is not constrained by “norms,” and I don’t want to be seen as norm-busting myself, but Krugman is saying that we must open our eyes to the damage that the self-serving cruelty of this president and his lackeys have inflicted on us, which will likely take decades to correct with more suffering and decline from what we could have been had he never conned and lied his way to the presidency. We will pay dearly for our collective error in judgment.
Also this week, on Tuesday, the Editorial Board of the New York Times made its most compelling case for using the midterm elections to hold the president and his Republican enablers in Congress and in state governments accountable for the damage done. I hope that you will click the link and read “Trump Has Failed. Hold Him to Account.” They begin by seconding the president’s strategic attempt to rally his base by asking them to “vote like I am on the ballot.”
President Trump has encouraged voters to pretend he is on the ballot for the Nov. 3 midterm elections, and this time we can agree with his political advice. Americans should be thinking of the Trump administration as they vote for members of Congress and state officials.
That was a tongue-in-cheek declaration. What follows is more direct and also a word of wisdom to the leaders of the Democratic Party, who were not enablers but were inadequate “defenders” of the principles that really made America greater in the past than it is now, after more than a decade of MAGA influence.
Voters should keep in mind Mr. Trump’s failure to keep his campaign promises, his attempts to undermine American democracy and his flagrant corruption. They should be thinking of the Republican Party’s acquiescence to this abuse of power, and they should hold Republicans accountable. Today’s Democratic Party has plenty of flaws, including a disappointing failure to present a coherent agenda of its own. Nonetheless, Democrats offer the only alternative this year to the damage that Mr. Trump and his party have inflicted on the nation. A vote for a Democratic candidate is the best way for Americans to repudiate the Trump administration’s performance over the past two years.
What follows is an articulate indictment of the president. With the potential “get out of jail free” decisions of the Supreme Court that have vastly expanded the opportunity Trump has had to remake the powers of the presidency as something much different than was intended by the authors of our Constitution, we probably will never see him held accountable, but as Liz Cheney predicted, history will hold those that enabled him accountable. Near the end of the January 6 investigation, she said to her Republican colleagues:
“There will come a day when Donald Trump is gone, but your dishonor will remain.”
Unfortunately, because the East Wing of the White House will be replaced with Trump’s garish ballroom, we will never be able to blot out the memory of the damage he has done.
The editors of the Times are a little more hopeful, perhaps, than I am. They try to imagine the benefits of a “blue wave” by first examining what could happen if Democrats gain control of the House.
Take a moment to imagine how Washington could change if Democrats win control of the House of Representatives. Mr. Trump’s legislative ambitions will be largely ended; he will not be able to pass more tax cuts that worsen the national debt. Democrats can instead use must-pass spending bills to restore money that was improperly cut from Medicaid, schools, scientific research and disease prevention. And Congress will finally have committee chairs who seek to exercise their constitutional duty to hold the president and his appointees responsible for their actions, through the use of hearings, subpoenas and more. Even if Mr. Trump and his aides illegally defy subpoenas, the House can summon corporate executives and others who have enabled him.
That would be good, but it will not accomplish the repair of our healthcare. At best, control of the House might block further damage to healthcare. It will not reverse the ongoing damage to healthcare access and finance wrought by the One Big Beautiful Bill. There is obviously even a greater opportunity to protect us from further erosion of science and healthcare if Democrats accomplish what was until recently deemed impossible, and gain control of the Senate. The Times editors look at that possible outcome through rose colored glasses:
If Democrats take the Senate, they will be able to do more. As the body that confirms nominees for top administration jobs and the judiciary, the Senate can stop Mr. Trump from appointing unqualified cabinet members like Todd Blanche, Pete Hegseth and Robert F. Kennedy Jr. and ideologues like Russ Vought. Senators can insist on federal judges who, while surely conservative, will uphold the law. Many judges appointed by previous Republican presidents have honorably done so in recent years, but some Trump appointees have failed to meet this basic standard. The Senate’s confirmation role will be particularly important if any Supreme Court vacancies arise in the next two years.
That is not nothing! Finally, the editors come to earth and imply that there will be continuing pain to bear until the man is gone.
Regardless, Mr. Trump will almost certainly continue to do damage in office. He will issue executive orders and conduct foreign policy, and he may defy congressional authority in ways that violate tradition or the law. Yet the difference between a government completely run by a political party in thrall to him and a government with an empowered opposition is profound. Americans now have an opportunity to register their displeasure with his conduct, and they should seize it.
Next Tuesday presents an opportunity to slow the rate of destruction and lay the foundation for significantly improving healthcare, beginning after the 2028 presidential election. This last week, Drew Altman, the President of the Kaiser Family Foundation (KFF), gave a keynote address at the National Academy of Medicine’s 2026 Annual Meeting. His topic was healthcare policy seen through the lens of chronic disease. In his opening remarks, he said he wanted to discuss three problems, but he ended up discussing four.
There are three problems I want to talk about:
- Rebuilding Medicaid and Affordable Care Act (ACA) coverage after almost a trillion dollars in cuts in federal spending in the two programs over the next 10 years, the largest cuts in coverage and federal health spending in our history.
- Reconstructing federal agencies – a task which is receiving inadequate attention and will mean daunting decisions about funding, staffing, and most challenging of all – redesigning what agency missions should be. Lest we forget, nobody was happy with the primary Health and Human Services (HHS) agencies before, but we are so unhappy with the state of affairs now we forget that.
- And third, there is a new zeal to take on health care costs. But what do we even mean by that? Have we discovered the courage we never had before to do it, and, in particular, to take on underlying costs driven mostly by hospital spending and high prices?
- Finally, a bonus theme: we can’t deal effectively with any of this unless we make some progress restoring trust in evidence and facts, and the people and institutions that convey them, especially government scientific agencies. I am more optimistic than many people about this big challenge based on our survey data, and I will touch on that.
That was a good start. As his introductory remarks continue, he says:
Two points weave in and out: 1) these challenges will compete for space on the agenda and funding. No president, secretary, or new Congress will take them all on simultaneously in a meaningful way and 2) I have written often, there is an invisible crisis of costs and affordability affecting the chronically ill and people with major diseases. And I don’t use the over-used word “crisis” lightly.
It has been my opinion for years that it is a combination of the complexity of healthcare, the energy required to overcome the inertia of the status quo, and the human tendency to hold on to what is known and not working in preference to a change that could be better but is unknown that are the principal reasons that inhibit our transition to a system of care that is better. It is sad to realize that the power to create change is largely controlled by those with the greatest incentive to hold on to what is not working for many but profitable for a few.
Change in complex systems seems to occur only after undeniable disaster. Dr. Altman is implying that as our population ages and our current treatments do allow more and more of us to coexist with chronic diseases like diabetes, cancer, and various forms of heart disease, the issues of cost and access will accelerate to levels that may be intolerable and unsustainable. My perspective is that the same issues exist in our environmental concerns. The question is whether we can marshal the energy and focus to make the much-needed changes in policy and operations before our losses become insurmountable. It is possible to act too late. The creeping rise in complexities of cost and access created by the increased prevalence of those living with chronic disease may be quite similar to the impact of gradually warming oceans that we experience through increasingly violent weather.
What will be the “straw that breaks the camel’s back?” Dr. Altman doesn’t say it outright, but we soon learn that he is no fan of the “One Big Beautiful Bill.”
The One Big Beautiful Bill (OBBB) included almost a trillion dollars in cuts in federal health spending over ten years. Then, following on the heels of that, was the failure to extend the ACA enhanced premium tax credits, which our widely cited analysis showed, on average, doubled premiums for almost 24 million enrollees, leading millions to drop coverage and driving many more into plans with big deductibles averaging 7k a year…
All told, estimates are that these cuts will result in about 14 million more uninsured people over the decade, reversing progress made in recent years and bringing the number of uninsured back up to close to 40 million. But that’s not the only effect.
And what might other effects be? Altman doesn’t say it outright, but what he describes could be called a “domino effect.”
As a former state Human Services Secretary, I can tell you that states will try to replace some but far from all of these cuts, especially blue states. When they do, something else in the state budget will have to give. It may be education or higher education or environmental protection or corrections. Few to none will raise taxes.
I was surprised that he didn’t include the financial failure of many hospitals that serve the poor and uninsured, or the poorly insured, and depend on supplemental funding from state government. I can tell you that as a former trustee of the medical group that provides the professional services for the largest DSH hospital in Massachusetts, and one of the largest in the country, the Boston Medical Center (a combination of the old Boston City Hospital and the Boston University Affiliated University Hospital) plus neighborhood clinics, that revenue from Medicaid and Medicare, and some commercial insurance, was inadequate to meet the financial needs of the system. To remain open, tens of millions of state dollars are an unsustainable necessity. The article from my local paper presented to you earlier in this letter was written as a warning about the expectation of unsustainable financial losses with subsequent clinical inadequacies at Dartmouth Hitchcock Medical Center. As that article suggests, there comes a moment when no further cuts can be made without a measurable toll on patients and providers.
Dr. Altman goes into great detail about the losses we can anticipate, and I will leave it to you to read, but then he turns his attention to the difficulty of repairing the damaged infrastructure of our clinical and scientific communities. The second major segment of his long speech was entitled “A Second Big Challenge Is Rebuilding the Federal Agencies.” Remember, he is addressing an audience that is composed primarily of individuals who have been a part of the infrastructure of healthcare under other administrations, as was he. So, after more reflection about his personal experience of being part of the federal infrastructure of healthcare he continues:
I don’t want to present a lot of data about staffing cuts, and a lot of it is fluid and unreliable or from advocacy groups. To me, these are the critical points:
- It will take a Marshall Project to rebuild the HHS agencies
- No secretary will be able to do it and do everything else he or she needs to do. (I know how daunting it will be. I have been offered that job too and looked it in the eye.)
- If plans are not made ahead of time, it will be two years into an administration before much is done, and that could be too late; likewise if it is done agency head and agency by agency over time
- For those reasons, it would be timely for some distinguished nonpartisan group (KFF, NAM, a new commission funded by foundations) to take this on now. If I were a Secretary, I would appoint, in effect, a reconstruction czar, who would focus solely on plans and proposals for the reconstruction of CDC, FDA, the PHS agencies and NIH, including mission, staffing and funding.
- How to formulate an updated commitment to equity across HHS will by itself be a daunting challenge, but it must be done.
This is a tough one because no candidate will run on restoring federal agencies, but this audience understands how essential it is.
In the third long section of his very long dissertation, Dr. Altman turns to healthcare costs. He has already predicted a severe decline in access and quality. Toward the end of this section of his tour of the mess we are in he states:
So, there are six different cost problems – national spending, people’s health costs, federal spending, state spending, employer premiums and value – and often we talk past each other as if they are the same. Often, they conflict: cut federal spending, for example, and you drive up state spending. The real challenge is to take on underlying costs but there is little evidence that the country has the stomach for that, nor do Democrats and Republicans have anything resembling agreement on how to do it except for some incremental measures that will have impact only at the margin. It means aggressively taking on hospital spending either through market forces (tough in a very consolidated industry) or government regulation, which is off the table with Republicans in charge and industry strongly opposed. For at least the next two years we are destined for “small ball” on costs, typically dressed up to sound more impactful than it is. A bright spot now is the action in several states to take on hospital costs.
By now I hope that you realize that Dr. Altman’s systematic discussion is much like that of a caring clinician who is trying to explain the complexity of the clinical challenges to a patient with an affliction that is most likely to be fatal, but for whom there is a flicker of hope and the willingness to undergo a long and painful treatment process that has more possibility of failure than success.
A good diagnostician is always looking for a root cause for a difficult problem. In complex systems, the root cause can be the negative interaction among several overlapping problems. Dr. Altman has been carefully constructing his realistic view of the mess we are in and now adds what he considers to be one of the most prominent “root causes,” which may also be one of the biggest barriers to timely improvement — chronic diseases. He continues with the last section of his challenging presentation, which in essence was a distillation of factors his audience, and you, understand well, but perhaps don’t have the courage or capability of exploring all of the interconnects which preclude simple solutions. This section of his talk is entitled “It Turns Out that Chronic Illness Is at the Heart of the Affordability and the Complexity Problems.” Once again, he has a lot of information, mostly derived from large surveys done by KFF, to give the dimensions of this problem. Since I am way past “brevity,” I will leave the reading of that section to you, but give you some of the summation:
You could simply say, sure, of course they have the most problems [those with chronic medical conditions]; they use the most care. You could also say that the most basic obligation of any health system is to take care of people who are sick and we are not doing that. If I leave you with any big message today it is this: the chronically ill are the heart of the health care affordability crisis in the country.
The problem of chronic disease makes finding a solution for the overall healthcare problem much more difficult. He goes so far as to suggest that the chronically ill are being “screwed,” and as a result we all might be “screwed.” He becomes much less academic and more straightforward:
To use a technical term, the chronically ill and uninsured are probably the most screwed group of all in our health system, and now with all the cuts, their ranks will grow.
Finally, I don’t believe we can make real progress without dealing with declining trust; in government agencies, the news media, medicine and science.
We have to have shared trust in information and science. A shared belief that government can make a difference, even if we disagree over how. And a shared understanding that access to affordable health care, and health coverage, make a difference in people’s lives.
I have been writing for several months now about how important this election is to the future of healthcare. Because of how our system of government works, I have never suggested that this election would be anything more than an opportunity to stop or slow our slide into poorer health. A real recovery can’t even begin until there is a president who has the intellectual capacity to understand root-cause issues, empathy for the plight of people other than himself and his few loyal sycophants, and the ability to work with Congress.
It Is Getting Dark
Don’t forget to turn your clocks forward on Saturday night when you go to bed. It will be great to get an extra hour’s sleep on Sunday morning, but it is unfortunate that the price for that extra hour of sleep where I live will be that it will be dark by 5 PM on Sunday afternoon.
Today’s header was lifted from a recent video production of my gifted neighbor, Peter Bloch. His presentation is called “Late Autumn Splendor.” Click here to see the whole video. Fall colors are fading fast, but Peter has captured some beautiful pictures that we can enjoy long after all the color is gone, and even as it is dark at 4:30 PM.
The good news is that we are moving into the holiday season. My hope is that by Thanksgiving one of the things for which I will be thankful is that there was a blue wave next Tuesday. If you want things to stay the way they are, I respect your right to that opinion. Let’s all exercise our right to vote on Tuesday. Collectively, we share an interest in fair elections whose results reflect the majority opinion.
Be well,
Gene
