I cannot help but wonder why so many not for profit hospitals are on the verge of banruptcy. Is there insufficient funding or poor management or other factors
Congressional action can create a quick and immediate fix. Mandate that hospitals be prohibited to bill uninsured and under insured patients more than 125% of approved Medicare and Medicaid negotiated reimbursements. It is not unusual for a patient to be billed for the same procedure double or triple the payment the hospital is now has reimbursed by the government. The 25% up-charge would take into account additional billing and delinquent collections costs that the hospital currently avoids with government reimbursements.
We make a mistake when some achievable reforms are ignored awaiting THE PERFECT PLAN.
Very interesting and complex. It is a good debate to have; which ideas will work best for patients? Personally, I would like to see some of the biggest monopolies broken up. If we ever have the votes, I think that I would favor putting anti-trust legislation out of the purview of the SC.
I may have pointed this out before in Cohn, but will repeat it, because it may be interesting.
Apparently, the CMS has some data on resulting large ACA coverage drops that are now showing up from the Jan 1, 2026 lapse of the ACA expanded subsidies.
The data have NOT been made public yet. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
ADDING BACKGROUND on coverage-drop data (from elsewhere than the data CMS has not yet released):
This information is part of the new data that continuously rolls in, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% coverage drop for those 24 million.)
Also, I might as well toss in unique reporting by both Charles Gaba and myself (not in the KFF or NY TImes reports) that, in order to try to get themselves under the returned 400% of Federal Poverty Level (FPL) "subsidy cliff", and avoid premium jumps of up to tens of thousands of dollars from what they paid last year, a few hundred thousand people seem to have pushed their income under the "subsidy cliff". Some will have done this legitimately, by working less or other legal means. Others of them will find, if their income is over the subsidy cliff at tax-filing time in 2027, that they have to pay the up to tens of thousands of dollars they thought they were saving back to the federal government. (A very unpleasant surprise, indeed! ; For those interested in how we figured that out , details are to be found within this comment elsewhere: https://paulkrugman.substack.com/p/unlocked-repost-curing-us-health/comment/255658440 . )
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
Anyone who has read the news in the past 17 months should immediately be able to tell you the problem with any solution that depends on a government agency undertaking any sort of watchdog function. This is *exactly* the trap Obama fell into with the ACA; the Republicans demonstrated that they had no intention of even attempting to be effective managers, but the Democrats just assumed that it was posturing and that once the plan was in place, it would be so popular that nobody would want to go against it. But it was far, far too complicated to be popular, and the Republicans don't actually care about good governance. This is one of the reasons I've gone from favoring a model like Singapore to wanting single payer; we are not serious enough as a society for anything complex.
After I finished medical residency, I moved away because one hospital system controlled every hospital and clinic in about a 60 mile radius. I thought this seemed bad for my long term career prospects.
So I took my first job halfway across the country.
And private equity bought out the clinic four months after I started. It was an absolute horror show. It cannot begin to convey the terror of being the sole provider for several thousand patients, with only a single assistant to answer phones, with an ever dwindling number of supplies and a new EMR designed to optimize billing instead of convey information. I was showing up early to salt the sidewalks, and crying myself to sleep at least three nights a week.
I know a lot of people will say "oh this doesn't go far enough" or "this is just a band aid", but both hospital system monopolies and private equity buyouts are huge issues with huge effects on patient care. I just hope dentistry and veterinarians can catch a break too.
As a critical care physician who fought these types of changes tooth and nail, I think it's worse than this article portrays. Non-profit hospital networks pay their many, many executives, most of whom have no medical training, millions of dollars. So the incentives are all wrong at non-profits as well at private equity institutions.
And if you think you still have a community hospital where you live, you'd better check. The network convinced our local board of trustees to relinquish their fiduciary responsibilities, and therefore all control, without informing the medical staff or our community.
Health care should not be run like Home Depot, yet that is what we're allowing right now. The short-term transactional values of the business world now dominate our country, including health care and academics. Much more pressure needs to be applied to our state and federal politicians, who so far have done almost nothing at this point.
People want something cheaper, If the procedure costs 798.00 and this reform produces this procedure for 726.00 IT will not register in voters mind. Wake up Democrats!
That's not the "cheaper" people want. How about $20,000 for childbirth in the US vs $0 in Canada because they have a decent healthcare system that prioritizes citizens? Or a knee replacement in India for $5,000 vs $50,000 in the US? I want real change in the healthcare system.
The 'nonprofit ' status of hospitals is a smokescreen for not being taxed on profits; which the large systems have great amounts of. The good point you made is that all the profitability aspects of healthcare need limitations. This includes Pharma, Insurance companies ,hospitals. The extraordinary salaries of CEOs in all of these parts of Health Care reflects the paradox that it awards profitability while making sure expenses(actual patient care) are held down. Healthcare is not a good place to try to make huge profits when delivering healthcare is the priority. The public would be surprised to know how few trained nurses and MDs have any say in how health systems are run; MBA's run the health systems, insurance plans and Pharma......No wonder the main interest is making a profit.
The ghouls in private equity are only after two things:management fees, and real estate.
They're set up to finagle companies into thinking that they need outside help to manage their business. They come in, companies pay exorbitant fees for them to take control of their operations, then they slowly hollow out those same companies from the inside while saddling them with debt - to the private equity groups' own banks. After awhile the *managed companies* are in a spiraling debt cycle of which the PE ghouls will foreclose on and end up with all that valuable real estate - which was the goal all along, and they tricked those companies into paying them to do it at the same time.
What a grift. No wonder so many politicians have massive investments in these groups and allow no transparency or regulations on how they operate.
Private equity is a fairly new problem and only compounds a broken system.But as someone who watched Steward devastate my state, it's a great issue. Fact is, private equity is allover health care building vertical and/or horizontal market dominance.The wheel chair industry is controlled by two players and chair-bound people wait months for simple repairtobr made on their chairs. Hospice is dominated by private equity and they soak Medicare so badly, that people actually leave hospice because they weren't dying.Midicare/Midiciad really is a cesspool of private equity fraud.
And I'll get on my grandstand asking the question: How much should a cure cost? Because, unlike the past, we delay or cure terminal diseases.Should a genetic CRISPR "edit" that cures Sickle Cell, cost a onetime $2 million? I don't know, but we sure as hellbetter start talking about the reality that cures cost a boat loa of money.
It's not either or - we need to get rid of BOTH private equity on the service side and for-profit insurance companies on the payment side. Getting rid of private equity would bring down costs of service but people would still struggle with premiums and deductibles with their insurance. Creating one national insurance plan for everyone, with premiums a percentage of income (with no ceiling) would make the insurance affordable but the overpriced services would create an incredible strain on the Medicare system. We need to go back to the not-for-profit hospitals and insurance that existed in the 50s and 60s before everything became a profit center for the morbidly rich.
For those following the influential Paul Krugman opinion,I caught a key policy recommendation shift of his this past Sunday.
Formerly, he had gone with that the ACA is the best we can do, as anything like single-payer is not in the political cards.
He's shifted, not towards full and immediate single payer, but just to adding a government option, with possible gradual expansion towards something like single-payer in an evolutionary, force-no-one-to-give-up-what-they-currently-have kind of way.
I quote from his Sunday post, which was behind a paywall:
"Single-payer isn’t a perfect system, but it is a system that has been run effectively not only abroad but in the United States. While I am by no means dogmatic about this, my view is that the next phase in U.S. health reform should involve an effort to transition away from private insurance to single-payer.
Longtime readers may recall that this was not my position in 2009-10, when Obamacare was being put in place. Nor did I support Bernie Sanders’s call for single-payer in 2016. However, like many and probably most supporters of Obamacare, I backed patchwork rather than comprehensive reform not because I believed that it was the best policy but because I believed that it was the only politically realistic way forward in 2010 and in 2016.
But it’s now 2026, and the political landscape has changed in ways that arguably put fundamental reform in reach."
… [and a bit later in the Krugman post]
"This suggests that an attempt to push people into Medicare-for-all would run afoul of concerns about change.
But it would be much less controversial, I believe, to offer a public option — allowing Americans, including employers providing insurance to their employees, to buy into a Medicare-type system. Many people surely would avail themselves of that option. And if they like what they get, which they probably would, we could transition over time to a single-payer system without forcing Americans into it.
Of course, insurance companies would hate this, and campaign furiously against it. But given their current reputation, this might even help the cause of reform.
Now, I am not offering policy specifics, partly because this post is already long but mostly because this is the point at which we need details from real experts. And I am not at all dogmatic about the path forward.
The main point is, instead, that we are approaching a point at which ambitious healthcare reform, well beyond simply repairing the damage to Obamacare, will be possible. And Democrats should be prepared to rise to the occasion."
--
A thing to note is that his allowed range of change still keeps our hyper-complex current system and ACA and expanded Medicaid, where there are numerous problems, which are often dependent on how each state messes up its administration of expanded Medicaid and the ACA (the latter if it has its own exchange).
So, very slow change. Disappointing. Things may get good, by evolution, eventually. Perhaps in 150 years. (We need a "Cathedral Mentality", more than to have those in stress and fear for themselves now to be able to count on relief.)
A public option would have been a great adjunct to ACA. But it is past its sell-by date.
We need to fully eliminate private health insurance. Those companies make their profits from the suffering and death of the insured.
I suspect the entire bit about it being "too soon" after ACA to enact any real reforms was a big part of the point of ACA. Democrats enacted a Republican healthcare proposal (requiring people to have insurance) and then complained that that was all the political system could stomach.
ACA wasn't a fix to the healthcare problem. It was a fix to a political problem.
I cannot help but wonder why so many not for profit hospitals are on the verge of banruptcy. Is there insufficient funding or poor management or other factors
Getting rid of step therapy for treatment needs to be a part of any good health plan policy
Congressional action can create a quick and immediate fix. Mandate that hospitals be prohibited to bill uninsured and under insured patients more than 125% of approved Medicare and Medicaid negotiated reimbursements. It is not unusual for a patient to be billed for the same procedure double or triple the payment the hospital is now has reimbursed by the government. The 25% up-charge would take into account additional billing and delinquent collections costs that the hospital currently avoids with government reimbursements.
We make a mistake when some achievable reforms are ignored awaiting THE PERFECT PLAN.
Very interesting and complex. It is a good debate to have; which ideas will work best for patients? Personally, I would like to see some of the biggest monopolies broken up. If we ever have the votes, I think that I would favor putting anti-trust legislation out of the purview of the SC.
I may have pointed this out before in Cohn, but will repeat it, because it may be interesting.
Apparently, the CMS has some data on resulting large ACA coverage drops that are now showing up from the Jan 1, 2026 lapse of the ACA expanded subsidies.
The data have NOT been made public yet. Further, they appear to be preparing to falsely claim the coverage drops are due to reduction of fraud on the exchange.
The source is this recent NOTUS story by former Washington Post Reporter Paige Winfield Cunningham, which post seems to access leaked information from people inside of CMS:
https://www.notus.org/healthcare/aca-healthcare-dropped-insurance-numbers-subsidies
Quoting that:
"More than one in five people who enrolled in health insurance through http://healthcare.gov/ during open enrollment and in the weeks immediately following were dropped from coverage for failing to pay their first month’s premium, according to internal Centers for Medicare and Medicaid Services, or CMS, documents obtained by NOTUS that haven’t been made public.
The roughly 21% decline in enrollment in the 30 states using the federal marketplace is significantly higher than the rate of last year, when 12% of enrollees dropped off over the same time frame.
The numbers support widespread fears that the end of extra, pandemic-era subsidies, which congressional Republicans declined to extend in December, would leave Affordable Care Act plans unaffordable for some Americans.
Faced with such a stark drop in enrollment, leadership at CMS, which is led by Administrator Mehmet Oz, is seeking to attribute a majority of the enrollment declines to rooting out fraud rather than people not paying their premiums, according to three CMS sources. The sources said it’s unlikely fraud is behind most of the cancellations."
(I and other readers of Charles Gaba's substack were pointed to the leaked information in NOTUS by his post: https://charlesgaba.substack.com/p/breaking-cms-admits-over-30-million )
Charles conclusion is that it looks like, of 24 million people who had on-exchange ACA coverage, about 3 million (12%) are without coverage as of the current time this year, due to the lapsing of the ACA expanded subsidies on Jan 1, 2026.
ADDING BACKGROUND on coverage-drop data (from elsewhere than the data CMS has not yet released):
This information is part of the new data that continuously rolls in, as initial very limited open-enrollment-period only data, which counts people auto-renewed as having coverage, even if they don't wind up paying the premium, gets superseded. (That limited initial data showed only a 4.9% coverage drop for those 24 million.)
There is 5/19/2026 KFF report that summarizes the higher post-open-enrollment-report drops, looking to be 3 to 5 million, here https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/ )
There is also an earlier New York Times article that is also reporting summarizing the drop information https://www.nytimes.com/2026/05/01/business/obamacare-enrollment-decline.html
Also, I might as well toss in unique reporting by both Charles Gaba and myself (not in the KFF or NY TImes reports) that, in order to try to get themselves under the returned 400% of Federal Poverty Level (FPL) "subsidy cliff", and avoid premium jumps of up to tens of thousands of dollars from what they paid last year, a few hundred thousand people seem to have pushed their income under the "subsidy cliff". Some will have done this legitimately, by working less or other legal means. Others of them will find, if their income is over the subsidy cliff at tax-filing time in 2027, that they have to pay the up to tens of thousands of dollars they thought they were saving back to the federal government. (A very unpleasant surprise, indeed! ; For those interested in how we figured that out , details are to be found within this comment elsewhere: https://paulkrugman.substack.com/p/unlocked-repost-curing-us-health/comment/255658440 . )
--
I might as well toss this in, for those interested. I think there is starting to be evidence of the erroneous claims coming that the coverage drops are due to the administration stopping fraud on the ACA exchanges, emanating from Dr. Oz and the Paragon Health Institute. To save space, for those interested, its in a comment elsewhere, this one:
https://econjared.substack.com/p/why-are-people-so-damn-mad/comment/261555717
Anyone who has read the news in the past 17 months should immediately be able to tell you the problem with any solution that depends on a government agency undertaking any sort of watchdog function. This is *exactly* the trap Obama fell into with the ACA; the Republicans demonstrated that they had no intention of even attempting to be effective managers, but the Democrats just assumed that it was posturing and that once the plan was in place, it would be so popular that nobody would want to go against it. But it was far, far too complicated to be popular, and the Republicans don't actually care about good governance. This is one of the reasons I've gone from favoring a model like Singapore to wanting single payer; we are not serious enough as a society for anything complex.
After I finished medical residency, I moved away because one hospital system controlled every hospital and clinic in about a 60 mile radius. I thought this seemed bad for my long term career prospects.
So I took my first job halfway across the country.
And private equity bought out the clinic four months after I started. It was an absolute horror show. It cannot begin to convey the terror of being the sole provider for several thousand patients, with only a single assistant to answer phones, with an ever dwindling number of supplies and a new EMR designed to optimize billing instead of convey information. I was showing up early to salt the sidewalks, and crying myself to sleep at least three nights a week.
I know a lot of people will say "oh this doesn't go far enough" or "this is just a band aid", but both hospital system monopolies and private equity buyouts are huge issues with huge effects on patient care. I just hope dentistry and veterinarians can catch a break too.
As a critical care physician who fought these types of changes tooth and nail, I think it's worse than this article portrays. Non-profit hospital networks pay their many, many executives, most of whom have no medical training, millions of dollars. So the incentives are all wrong at non-profits as well at private equity institutions.
And if you think you still have a community hospital where you live, you'd better check. The network convinced our local board of trustees to relinquish their fiduciary responsibilities, and therefore all control, without informing the medical staff or our community.
Health care should not be run like Home Depot, yet that is what we're allowing right now. The short-term transactional values of the business world now dominate our country, including health care and academics. Much more pressure needs to be applied to our state and federal politicians, who so far have done almost nothing at this point.
People want something cheaper, If the procedure costs 798.00 and this reform produces this procedure for 726.00 IT will not register in voters mind. Wake up Democrats!
That's not the "cheaper" people want. How about $20,000 for childbirth in the US vs $0 in Canada because they have a decent healthcare system that prioritizes citizens? Or a knee replacement in India for $5,000 vs $50,000 in the US? I want real change in the healthcare system.
The 'nonprofit ' status of hospitals is a smokescreen for not being taxed on profits; which the large systems have great amounts of. The good point you made is that all the profitability aspects of healthcare need limitations. This includes Pharma, Insurance companies ,hospitals. The extraordinary salaries of CEOs in all of these parts of Health Care reflects the paradox that it awards profitability while making sure expenses(actual patient care) are held down. Healthcare is not a good place to try to make huge profits when delivering healthcare is the priority. The public would be surprised to know how few trained nurses and MDs have any say in how health systems are run; MBA's run the health systems, insurance plans and Pharma......No wonder the main interest is making a profit.
The ghouls in private equity are only after two things:management fees, and real estate.
They're set up to finagle companies into thinking that they need outside help to manage their business. They come in, companies pay exorbitant fees for them to take control of their operations, then they slowly hollow out those same companies from the inside while saddling them with debt - to the private equity groups' own banks. After awhile the *managed companies* are in a spiraling debt cycle of which the PE ghouls will foreclose on and end up with all that valuable real estate - which was the goal all along, and they tricked those companies into paying them to do it at the same time.
What a grift. No wonder so many politicians have massive investments in these groups and allow no transparency or regulations on how they operate.
Private equity is a fairly new problem and only compounds a broken system.But as someone who watched Steward devastate my state, it's a great issue. Fact is, private equity is allover health care building vertical and/or horizontal market dominance.The wheel chair industry is controlled by two players and chair-bound people wait months for simple repairtobr made on their chairs. Hospice is dominated by private equity and they soak Medicare so badly, that people actually leave hospice because they weren't dying.Midicare/Midiciad really is a cesspool of private equity fraud.
And I'll get on my grandstand asking the question: How much should a cure cost? Because, unlike the past, we delay or cure terminal diseases.Should a genetic CRISPR "edit" that cures Sickle Cell, cost a onetime $2 million? I don't know, but we sure as hellbetter start talking about the reality that cures cost a boat loa of money.
It's not either or - we need to get rid of BOTH private equity on the service side and for-profit insurance companies on the payment side. Getting rid of private equity would bring down costs of service but people would still struggle with premiums and deductibles with their insurance. Creating one national insurance plan for everyone, with premiums a percentage of income (with no ceiling) would make the insurance affordable but the overpriced services would create an incredible strain on the Medicare system. We need to go back to the not-for-profit hospitals and insurance that existed in the 50s and 60s before everything became a profit center for the morbidly rich.
For those following the influential Paul Krugman opinion,I caught a key policy recommendation shift of his this past Sunday.
Formerly, he had gone with that the ACA is the best we can do, as anything like single-payer is not in the political cards.
He's shifted, not towards full and immediate single payer, but just to adding a government option, with possible gradual expansion towards something like single-payer in an evolutionary, force-no-one-to-give-up-what-they-currently-have kind of way.
I quote from his Sunday post, which was behind a paywall:
"Single-payer isn’t a perfect system, but it is a system that has been run effectively not only abroad but in the United States. While I am by no means dogmatic about this, my view is that the next phase in U.S. health reform should involve an effort to transition away from private insurance to single-payer.
Longtime readers may recall that this was not my position in 2009-10, when Obamacare was being put in place. Nor did I support Bernie Sanders’s call for single-payer in 2016. However, like many and probably most supporters of Obamacare, I backed patchwork rather than comprehensive reform not because I believed that it was the best policy but because I believed that it was the only politically realistic way forward in 2010 and in 2016.
But it’s now 2026, and the political landscape has changed in ways that arguably put fundamental reform in reach."
… [and a bit later in the Krugman post]
"This suggests that an attempt to push people into Medicare-for-all would run afoul of concerns about change.
But it would be much less controversial, I believe, to offer a public option — allowing Americans, including employers providing insurance to their employees, to buy into a Medicare-type system. Many people surely would avail themselves of that option. And if they like what they get, which they probably would, we could transition over time to a single-payer system without forcing Americans into it.
Of course, insurance companies would hate this, and campaign furiously against it. But given their current reputation, this might even help the cause of reform.
Now, I am not offering policy specifics, partly because this post is already long but mostly because this is the point at which we need details from real experts. And I am not at all dogmatic about the path forward.
The main point is, instead, that we are approaching a point at which ambitious healthcare reform, well beyond simply repairing the damage to Obamacare, will be possible. And Democrats should be prepared to rise to the occasion."
--
A thing to note is that his allowed range of change still keeps our hyper-complex current system and ACA and expanded Medicaid, where there are numerous problems, which are often dependent on how each state messes up its administration of expanded Medicaid and the ACA (the latter if it has its own exchange).
So, very slow change. Disappointing. Things may get good, by evolution, eventually. Perhaps in 150 years. (We need a "Cathedral Mentality", more than to have those in stress and fear for themselves now to be able to count on relief.)
A public option would have been a great adjunct to ACA. But it is past its sell-by date.
We need to fully eliminate private health insurance. Those companies make their profits from the suffering and death of the insured.
I suspect the entire bit about it being "too soon" after ACA to enact any real reforms was a big part of the point of ACA. Democrats enacted a Republican healthcare proposal (requiring people to have insurance) and then complained that that was all the political system could stomach.
ACA wasn't a fix to the healthcare problem. It was a fix to a political problem.
Large hospital chains must be broken up. Competition is essential to cut costs.
Private equity is a scourge across the economy. I support this focus and imagine it’s broadly popular.