May 1, 2026
Dear Interested Readers,
Can We Get To Universal Access To Care Without Big Changes?
Much of my free time and energy for the past two weekends has been spent in Maine around the birth of our newest grandson. He arrived at Maine Medical Center in Portland three weeks early, at 6:53 AM on April 20th, after a journey that lasted more than twenty-four hours, and left his parents totally exhausted. We had made plans to go to Maine that weekend to visit some friends in nearby Topsham and to see his older brother and parents before our new arrival made his unexpected entrance. Given the rough trip the new guy had survived, we decided to let him recover a little before our visit, so we returned home having only seen pictures.
Last weekend, we repeated the trip and met the little fellow for the first time. What a joy! Even better, his older brother was delighted by his new brother’s arrival and took great joy in introducing us to him. So far, so good in avoiding a sibling rivalry. The two boys are separated by exactly two years and three months, which is almost the same time difference between my brother and me.
I was born on July 8, 1945, and my brother arrived on September 20, 1947. One of the stories my family often tells is that, as visitors came by to see my new brother on a lovely fall Sunday afternoon, I began to act out because of all the attention he was getting and the lack of attention to me. I had enjoyed being the crown prince for over two years, and apparently, I wasn’t doing well with the attention I had enjoyed being coopted by my new brother.
My father was not one known to “spare the rod.” It was a different age, and I was well into my teens and almost as big as my father before my last episode of educational “corporal punishment” was delivered by his belt after a fight with my brother. In response to my toddler’s antics while everyone was oohing and aahing over the wonderful new addition, my father rolled up his Sunday paper and announced that I would feel it across my bottom if I didn’t “settle down.” He laid the paper down, and the show continued until I picked up the newspaper and walked over to my brother’s bassinet and whacked him on the head. The story usually ends there, but it has always made me aware that most of us have some trouble sharing attention, but that we usually get better, except for those with a persistent problem with extreme narcissism, at accepting the need to share attention with others, as over time we gain some self-control. My son and daughter-in-law have obviously done a great job in preparing their older son for the arrival of his little brother. It is good to observe cultural progress.
To minimize the stress on our son and his wife, we spent the nights of both weekends with our very generous friends in Topsham, which, as the crow flies, is probably about 20 miles north and east of Gray, Maine, where the new baby lives, and just across the beautiful Androscoggin River from Brunswick, Maine, where my granddaughter, my oldest grandchild, graduated from Bowdoin College last May. There is no easy route from Topsham to Gray. Anyway you travel, it is at least a forty-five-minute drive that can only be accomplished with navigational help from Google. It seems like every time we make the trip, Google gives us different directions. We exit Topsham on Interstate 295 for about 7 miles, and then after that, we go left and right every few miles on a different country road until we finally arrive. The trip is often extended despite Google’s help when we miss one of dozens of turns, or when we get caught in a line of cars behind a very relaxed local in an old pickup who believes in going a little slower than the posted speed limit. Invariably, I am reminded of the old “Bert and I” comedy routine, “Which way to Millanocket?” Click on the link to hear the story. It will take you only one minute and twenty seconds, and it’s good for a laugh.
If you didn’t click the link, the story is simple. A traveler pulls up to an old timer somewhere in Maine and asks for directions to Millanocket. In a very typical Maine drawl, an old man tries to give directions that involve multiple turns and different route choices. In the end, he realizes the impossibility of the task and says, “Come to think of it, you can’t get there from here.”
If you are a regular reader of these notes, you know that this is not the first time that I have used “Come to think of it, you can’t get there from here.” The line comes to me every time we try to drive from Topsham to Gray. It also comes to mind almost every time I think about our collective frustration in trying to use a system of care that evolved in the late nineteenth and early twentieth centuries, built on fee-for-service finance, and was impaired from achieving the Triple Aim by a shift from a focus on the patient to a focus on corporate profits. We are on an impossible journey, and from where we are, we can’t get to our desired destination of sustainable costs, universal access to care, and all the components of quality, including healthcare equity. When I think about the challenge of giving all Americans the care they deserve, and we are capable of providing, I often say to myself, “Come to think of it, you can’t get there from here.” If we ever do make it to healthcare nirvana, it is going to be a very complex trip on a path full of the intellectual equivalent of dirt roads, multiple detours, and unexpected dead ends, or we are going to have to build a superhighway for healthcare finance reform. Fee-for-service healthcare finance is no superhighway to better healthcare for all Americans.
The day before my grandson was born, Paul Krugman surprised me with a longer-than-usual post on his Substack platform, where he has been writing almost every day since he left the New York Times last year. I am a daily reader of the Times. I appreciate their attempt to present a balance of opinion, with columnists reflecting a spectrum of political thought, including conservative, centrist, and progressive positions, but I have been surprised by the departures from the Times of Krugman and David Brooks. On his Substack, Krugman has suggested that he was somewhat restricted and that his column was excessively edited. For somewhat similar reasons, Jennifer Rubin, another favorite columnist of mine, left the Washington Post last year after many years. She also writes now on Substack.
Krugman posts a thoughtful piece about a current issue almost daily on his Substack site. The post from April 19 is entitled “Curing U.S. Health Care, Part I.” He begins:
In 2008, much to their own surprise, leading Democrats unified around a program of major health care reform. Policy wonks had spent years developing the concepts behind what eventually became Obamacare; big Democratic victories in the 2006 midterms and the prospect of controlling both Congress and the presidency made it possible to imagine turning those ideas into reality. During the Democratic primary, Hillary Clinton and Barack Obama advocated similar plans, based on those ideas, for expanding insurance coverage. And it happened! The Affordable Care Act was enacted in 2010. When it was fully implemented in 2014, millions of Americans got health insurance.
He continues with a brief review of the world we knew before the ACA became a reality.
Before the ACA, even upper-middle-class Americans often found it impossible to get health insurance if they had pre-existing medical conditions. Many Americans were trapped in jobs they wanted to leave but couldn’t for fear of losing their employment-based coverage. Meanwhile, dire predictions from the usual suspects about runaway costs proved wrong. In fact, overall U.S. medical spending has grown much more slowly since the ACA was enacted than before. [Throughout the article, he presents graphics to prove his points.]
Fixing “covered but trapped,” or not covered because of a preexisting condition, were two of the benefits of the ACA that I find many of us forget. The benefits to all Americans in the ACA are often minimized or ignored if we just focus on the ACA marketplace or the attempt to expand Medicaid coverage to all who live below 138% of the poverty level. The ACA had much to offer everyone. It was, and even in its much-damaged form, remains a substantial, but imperiled, improvement over what we had before 2010. It was always intended to be a first step and not a final destination.
In his review, Krugman reminds us that among all advanced nations, we are the only nation that doesn’t have universal access to care. By 2024, the ACA had reduced the uninsured rate among all Americans to 8%. Since our population was 340 million in 2024, that meant over 27 million Americans were still uninsured. In November of 2024, near the end of Joe Biden’s term, The Commonwealth Fund published an update that reported:
More than half (56%) of U.S. working-age adults were insured all year with coverage adequate to ensure affordable access to care. But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to health care.
Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.
Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost; 44 percent said they had medical or dental debt they were paying off over time.
Delaying care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.
Nearly half of adults (48%) with medical debt are paying off $2,000 or more; half of those with debt said it stemmed from a hospital stay.
Those statistics suggest to me that we should redefine our goal from universal healthcare to healthcare that everyone can afford to use. Not mentioned in The Commonwealth Fund’s analysis was the percentage of insured people who still could not find a primary care provider. Even if we can give everyone a ticket to ride, we also need to make sure that there is a seat on the bus for everyone and that the bus has enough gas for the trip.
Krugman is quick to point out that where we were when Joe Biden left office is not where we are now. He reminds us that as the impact of the One Big Beautiful Bill is realized, the number of uninsured and underinsured is set to rise. The process has already begun with the withdrawal of subsidies from the ACA marketplace. The recent failure to renew the subsidies to the ACA marketplace is leading to several million people choosing not to be insured. The lead article in today’s New York Times tries to measure the impact of the failure to renew the subsidies, which appears to be much greater than was originally feared.
The days of the 100% coverage or even 80% or 75% coverage by an employer are over. 50% coverage is not unusual. If you ask Google what the average cost of health insurance for a family of four is in 2026, the answer is $27,000. If you are unfortunate enough to have an employer who covers only 50% of the cost, your payroll reduction for the year will be $13,500. That is $1,125 a month, which is a big bite from a paycheck that wasn’t covering expenses anyway in our environment, where “affordability” has become a universal concern. I know that there are some who will consider the cost and their overall resources, and will say, “No, thank you, I will take my chances being uncovered.” That will mean they receive no health maintenance care or screenings for early disease detection. It probably means that death rates will rise. The cost of care when the disease is discovered in its later stages will be higher, and the results worse. After reviewing a lot of data and presenting a few charts that you would expect from an economist, Krugman concludes:
So now may well be a good time to get behind a new push for major health reform — an effort, if you like, to finish the job begun under Obama.
Today’s primer is devoted to the economics of health reform. During his failed effort to repeal the Affordable Care Act, Donald Trump famously complained, “Nobody knew healthcare could be so complicated.” Actually, we did know — and it’s not that complicated. Health economists understand the principles very well. And because health policy varies greatly among advanced nations, we know a lot about what works and what doesn’t.
This will be the first in a series about health reform. Beyond the paywall I’ll address the following:
- Why markets can’t be trusted to deliver healthcare
- Routes to universal healthcare
- What works?
In a follow-up post I’ll discuss the pros and cons of different approaches, and possible paths forward for the United States.
Let me explain what Krugman means when he says, “Beyond the paywall.” That refers to the subscription cost to his newsletter. It’s about $75 a year. It’s like your Netflix or ESPN subscription. The first installment was free to everybody. I am a subscriber, and you may rest assured that I will be passing on what I can to you. His analysis continues, and I will bold some of his points.
Why markets can’t be trusted to deliver healthcare
No modern nation leaves the delivery of healthcare up to free markets. Granted, the U.S. healthcare system is more privatized than that of any other high-income nation. Yet even in America, government accounts for 48 percent of healthcare spending, while private insurers — who paid only a third of the bills — are both heavily regulated and extensively subsidized.
Why don’t we leave healthcare up to the market? Because while markets can be extremely effective at organizing economic activity, they are effective only under certain conditions. A classic 1963 analysis by Kenneth Arrow, a future Nobel laureate, showed that healthcare meets none of those conditions. Arrow pointed out that, unlike markets for regular goods and services, the delivery of healthcare is beset by problems of risk and “asymmetric” information…
…private insurers face the constant risk that those who choose to buy insurance are more likely to need expensive care than those who forgo buying insurance. To offset that risk, private insurers must do one of two things. They can charge very high premiums. But this drives away healthier people and makes the pool of those who want to buy insurance even worse — the so-called “death spiral.” Alternatively, private insurers can deny coverage to anyone with pre-existing conditions – in other words, deny coverage to those who need healthcare the most.
Furthermore, private insurers have every incentive to avoid paying for care whenever they can, notably by rejecting payment for treatment they claim is unnecessary…the cold logic of profit maximization strikes harder when it involves matters of life or death. Thus Luigi Mangione, who is accused of killing the CEO of United Healthcare because of his grievances over denied claims, has become something of a folk hero.
Krugman next presents something positive about Americans that creates great tension because insurance sold with an eye on avoiding risk and making a profit runs counter to our self-image.
…we are a country in which it is widely believed that the types of people that private insurers don’t want to cover — the elderly, people with pre-existing conditions, and the like — should have access to healthcare. After all, they didn’t choose to get sick or grow old. Many people, even if they have relatively conservative views about economic policy, feel that basic healthcare should be available to all a nation’s citizens.
He backs up his statement with a Pew Research Center poll. 66% of all Americans, and even 41% of Republicans, respond positively to the question: Is it the federal government’s responsibility to make sure all Americans have health care coverage?
He continues with a big “But…”
But unlike other advanced countries, we do not have universal guaranteed healthcare. Too many Americans are still uninsured or under-insured, and the numbers are growing. Why?
In the never-ending debates over healthcare policy in the United States, Republicans continue to argue that universal coverage is unworkable or unaffordable. Which is flatly contradicted by the facts: all other advanced countries provide it. Furthermore, there are three well-established ways to achieve universal coverage.
Before describing those three ways, he wants to make two more points.
First, who pays? Most healthcare must be paid for by insurance. Will the insurance be provided by a government insurance program like Medicare that is funded through taxation or by private insurers that charge premiums?
Second, who delivers the care? Will it be a system of public provision, in which the government runs the hospitals and clinics, with doctors and nurses as public employees? Or will it be a system of private provision, in which private hospitals and clinics deliver the care?
Krugman then uses another reference from The Commonwealth Fund to create a chart that presents and compares the various ways other advanced countries have addressed these questions and, in so doing, have achieved universal coverage. The implication is that there are at least three paths to success if there is a political will. The obvious conclusion is that we do not need to accept what we have. The remainder of the post is devoted to a useful overview of the three ways that provide various coverage options used by the other advanced nations to give their citizens what we don’t have. You might want to read them.
Perhaps in future posts, Krugman will venture an answer to the obvious question, “If other nations can, and a majority of Americans want universal access to care, why don’t we have it?”
If I ask myself that question, my answer is complex. It includes a cultural preference for self-reliance. It includes the power of a well-funded industry that likes and profits from the status quo. It includes a reluctance to endure the pain of redesign and transition, which creates uncertainty for everyone, even as that reluctance perpetuates misery for many and increases costs for us all. Finally, there has not been a unified voice from healthcare professionals who know that we could do better, but for some reason, perhaps burnout or compassion fatigue, can’t demand the changes that many realize will benefit their patients and ultimately be better for us all. Those changes might even improve their work environment. I am sure you could expand on my answer.
So what lies ahead? We won’t have another chance to make progress toward the Triple Aim as we did in 2009-2010 until after there is a change in control of Congress and the presidency. Perhaps there will need to be a change in the Supreme Court as well. Before we can build better, we need to curb losses, and that means a change in control of the House and perhaps the Senate, which could occur in November. One thing that the Republican Party has demonstrated over the last several decades is the benefit of a coordinated long view. Whether those of us who want equitable, affordable healthcare for every American can find ways to achieve what we might if we could create a strategy with a well-articulated objective remains to be seen.
Reflections on Passings of Note
Our TV is set to record CBS News Sunday Morning with Jane Pauley every week. We usually watch it later, several hours or even days after it is broadcast. It must be a statement about where I am in life that the part of the show I pay the most attention to is the review of the notable passings each week. It is beginning to feel like most of the notable athletes and musicians of my generation have headed toward their eternal rewards. I remain amazed that Keith Richards and Joe Namath are still with us. Willie Nelson remains “on the road” as a blessing, but Kris Kristopherson and Johnny Cash are gone.
In June, my medical school class is having a big reunion. It will be our 55th. Normally, I would have expected the next big event to have been our 60th, but COVID canceled our 50th in 2021. It seems that with some regularity, I am notified that yet another classmate has moved from retirement to eternity. I want to be in attendance at my 75th reunion, so I continue to focus on the wisdom of Dr. Oliver Wendal Holmes, the Boston physician and father of the great jurist, Oliver Wendal Holmes, Jr. When, in his late eighties, Dr. Holmes was asked by a journalist for the secret to longevity he replied, “Get a chronic medical problem and take good care of it!” I have my share of chronic problems, and I am doing my best each day to take good care of them, so another 20 years may be possible. Longevity was a gift enjoyed by most of the influential men in my life, but two of them recently died in their late 90s.
The recent deaths of Dr. Eugene Braunwald and Dr. Paul Solomon led me to ask myself to identify the most influential men in my life. Number one was definitely my father, who died about six weeks short of his 98th birthday in 2018. In chronological order, after my dad, was Professor Jack Russell, from whom I took several literature courses at the University of South Carolina, and who gave me insights into critical thinking. As far as my personal care is concerned, no one did more for me than Dr. Charles Magraw, whom I saw for counseling and psychoanalysis through most of the late seventies as I was struggling with “becoming.” For the next thirty years, he would tip his hat to me when I would occasionally see him at a Red Sox game. His Boston Globe obituary notes that he was politically active in the efforts to limit nuclear weapons. He died in 2013 at the age of 87.
I was very fortunate to have known and felt some guidance from Dr. Eugene Braunwald, who died this week at the age of 96. He became Chief of Medicine at the Brigham in July of 1972, when I was starting my junior residency. For the next two years, I was in close contact with him at “morning report,” where residents reviewed and discussed the cases admitted over the previous day. As I became a cardiology fellow, there was continued contact. After training, I would frequently get a word of encouragement from him as we passed in the halls of the Brigham. I benefited greatly from the collaboration and support Dr. Braunwald gave to my next mentor, Dr. Joe Dorsey, one of the founders of Harvard Community Health Plan, for whom I owe much, as described in one of these notes when he died at age 85 in late 2022.
Dr. Robert Ebert was Dean of Harvard Medical School during my years as a student. He was the founder of HCHP, and before he died, he blessed the departure of the physicians of the health centers out of Harvard Pilgrim Health Care into what would become Harvard Vanguard Medical Associates. Even though he was a distant mentor to me, he was Joe Dorsey’s most significant guide, which makes him feel like a grandfather to me. Joe was Dr. Ebert’s personal physician when he died of cancer at the age of 81 in 1996. My final mentor, who has now gone on, was Dr. Paul Solomon, who died on April 15, one month short of his 98th birthday. I did not become aware of his death until my wife spotted his obituary in last Sunday’s Boston Globe. There is a more expansive description of his accomplishments on the website of a local funeral home.
Paul launched my career as an “organizational politician.” In the mid-eighties, I was angry about a lot of things in our practice. I was especially angry that HCHP had lost its way from the original mission Dr. Ebert had espoused. My mentor, Joe Dorsey, had been replaced as medical director, in the first of many subsequent shufflings of leadership, and we were merging with a group of suburban physicians whom I felt did not have our focus on improving care.
The transition from a non-profit medical group to a non-profit staff-model practice within a non-profit HMO had created a voice for physicians through an entity called the “Physician Council.” I ran twice for a seat on the Council, and I was defeated twice in close elections. On my third attempt, I was unopposed. At the time, Paul was the Chair of the Physician Council. I just assumed that we were on the opposite side of several fences and that he was a puppet of management. I was wrong. In a short time, he helped me turn my anger, which I would express at almost every meeting, into an ability to be an effective spokesperson for my colleagues to management.
Paul was dedicated to practice and practice improvement through the development of effective physician voices. He gave me opportunities, such as serving as Chairman of the Compensation Committee, when I did not have the skills to negotiate with management, and then provided the support I needed to be effective.
It took me a couple of years to realize that he had identified me as his successor and was grooming me. He was remarkable in that he enjoyed being part of a positive process and the effort to develop others. He was not personally ambitious. He was ambitious about improving practice and delivering high-quality healthcare. I never saw him smirk or heard him say anything negative about anyone, even if they were not aligned with his view of what needed to be done. If you click on his obit, the smile that you will see in the picture was always on his face. One of the best things our group ever did was to create an annual leadership award in his honor. He was a master of developing leaders and leading through a positive influence on others. It was a great honor to know him and to have been a beneficiary of his grace and wisdom.
Spring Comes and Goes
During the first part of our week, we enjoyed sunny days with almost cloudless skies and temps in the sixties. As I was reveling in my first convertible ride of the year, driving up from the lake toward the business section of our little town, I enjoyed the breathtaking view of Mount Kearsarge. It is amazing that we have productive farmland in town, within a half mile of the town green. I stopped, got out of the car, and took the picture that is today’s header. What caught my eye even more than the view of the mountain was the clear sky and the recently tilled land. If you look closely, you can see that some of the land is covered to warm the soil, and there are green plants of some early crop of some sort coming up in the distance.
All of these observations are a positive offset to the many disturbing events of the past week. I encourage you to follow the advice of old Dr. Holms and take good care of any chronic disease you might have. Following his advice may extend your years. I would also add that it helps to construct temporary reprieves from stress. There is no better “reprieve” strategy than to get out on foot, bike, or even in your car to see how spring is coming along where you are.
Be well,
Gene
