CHA.341-Medicare-Advantage-Fact-Sheet_consumer.pdf
Monthly Archives: November 2025
Navy SEAL Turned Hospital CEO: Jeff Mengenhausen Exposes Healthcare’s Failures
Navy SEAL Turned Hospital CEO: Jeff Mengenhausen Exposes Healthcare’s Failures
https://www.buzzsprout.com/1828354/episodes/18121411
What do a struggling student, a decorated Navy SEAL, and a hospital CEO all have in common? The answer: Jeff Mengenhausen.
In this explosive episode of the Crackin’ Backs Podcast, we sit down with the only Navy SEAL in the country running a hospital—a man who’s rewriting the rules of leadership, resilience, and what healthcare should really be.
Jeff’s story is anything but ordinary. Once labeled a “poor student,” he went on to earn Navy SEAL honors, a Purple Heart, and combat commendations. Today, he’s transforming Montrose Regional Health into one of the most respected community hospitals in the nation. But his mission doesn’t stop there—Jeff is exposing the cracks in America’s hospital culture and challenging the grip Big Pharma and profit-driven systems have on patient care.
Inside this episode, we ask:
- Why isn’t the Navy SEAL ethos of “embrace the suck” translating into healthcare leadership?
- What behind-the-scenes SEAL lessons still drive Jeff’s decisions as a hospital CEO?
- Why are so many hospitals failing their patients—and how is Montrose setting a new standard?
- Has Big Pharma hijacked the direction of care in America?
- And after trillions spent on cancer and chronic disease, why aren’t outcomes improving?
This conversation isn’t just about medicine. It’s about survival, clarity under pressure, and the courage to flip a broken system on its head.
Learn more about Jeff Mengenhausen and Montrose Regional Health:
Episode 460 Navy SEAL Secrets for Healthcare Leadership with Jeff Mengenhausen
Episode 460 Navy SEAL Secrets for Healthcare Leadership with Jeff Mengenhausen
In this episode of the Lead Up Podcast, host Mike Harbour interviews Jeff Mengenhausen, CEO of Montrose Regional Hospital and Health System.
Jeff shares insights from his unique journey from Navy SEAL to healthcare executive, discussing how military leadership principles can be applied to civilian healthcare.
The conversation covers topics like maintaining team morale, the importance of culture in retaining talent, and the strategies Jeff employs to foster a winning mindset among his staff.
For anyone interested in leadership, resilience, and healthcare management, this episode offers valuable lessons and applicable insight.
If you enjoyed this episode, be sure to leave a 5-star review on your streaming platform. Mike encourages you to reach out to him through Mike@harbourresources.com to share your thoughts on this episode & to share some topics you would like him to cover in the future.
How children are treated in the One Big Beautiful Bill Act
“The true character of society is revealed in how it treats its children.”- Nelson Mandela
Elected officials of both parties have proposed new and better government support for families with children. President Trump’s One Big Beautiful Bill Act includes some of these proposals, but overall, because of the law’s benefit cuts for working class and lower-income families, it will likely end up hurting roughly as many families with children as it helps.
- Parts of the law increase help for families with children: The maximum Child Tax Credit was increased from $2,000 to $2,200 per child; however, the increase remains only partially refundable and thus will not be available to many low-wage working families. In addition, on a much smaller scale and with some questions remaining about its workability in practice, the One Big Beautiful Bill Act (OBBBA) created a new type of child savings, “Trump Accounts,” and a temporary program of $1,000 payments for each child born in President Trump’s presidential term. The adoption credit has also been improved. In each of these provisions, there are further changes that could enable these programs to help more children and more families.
- However, many of the law’s most substantial changes will reduce help to children, particularly those in working class and poor families. The law imposes new legal and bureaucratic filing requirements to previously bipartisan programs, particularly the Supplemental Nutrition Assistance Program (SNAP, formerly known as “food stamps”) and Medicaid, that will keep many families from getting benefits, including benefits for which they are eligible.
- Overall, OBBBA will likely end up reducing benefits for roughly as many families as it helps, with the greatest losses concentrated among the least well-off. By 2030 the 40% lowest-income households will experience a net loss on average, and the middle quintile will have roughly no net change; there will be ongoing net gains for the top 40% of households.
This note describes some key changes embedded in OBBBA, some related proposals by Democrats, and some improvements that might be made in the future.
Is child policy becoming bipartisan?
Politicians of both parties, who once made a show of kissing babies, have progressed to making a range of proposals to improve children’s lives and prospects. In some cases, perhaps frustrated by ongoing political polarization, they’ve chosen to support the same or similar approaches, including extra tax credits or actual payments for children and child savings accounts. For example, both Senator Ted Cruz (R-TX) and Senator Cory Booker (D-NJ) have proposed savings accounts be started for every child at birth.
Although the recently enacted OBBBA was in no way bipartisan, it included some proposals endorsed by both Republicans and Democrats. At the same time, however, the Act reduced the scope of the previously bipartisan SNAP safety net program and of Medicaid.
Furthermore, despite claims by representatives of both parties to support working families with children, the changes in OBBBA overwhelmingly help families that are already better off. After the temporary tax benefits end, roughly half of U.S. families will be worse off, with most benefits of the bill going to the top 40% of the income distribution.
Below, we discuss two kinds of assistance for families for children: those that provide immediate resources and those that support saving for children’s futures.
Money for children now: Child income tax credits, baby bonus checks
Congress has subsidized children through the tax code for at least a century, starting with dependent exemptions from income1 and following with the Earned Income Tax Credit in 1975 and the Child Tax Credit (CTC) in 1997. By far the most significant action benefitting some children in OBBBA is an increase in the CTC. However, most low-income children are excluded from these higher benefits. At the same time, the Act would dramatically reduce other previously bipartisan safety net programs that support low-income children, particularly SNAP.
Child Tax Credit
The CTC is a tax credit for families with children. It was originally conceived as an anti-poverty program, though for much of its history most of the CTC’s benefits have gone to middle class or wealthier families. The CTC phases in with earnings and the credit is only partially refundable, meaning that if the credit exceeds a filer’s tax liability, families can receive a portion of the credit as a tax refund. Approximately 60 million children benefit from the current credit. In response to the COVID-19 recession, for one year the credit provided families with as much as $3,600 per child and allowed low-earnings families to get the full benefit, but that expired and the maximum returned to the pre-OBBBA maximum of $2,000. Because of the phase-in and other limitations on refundability, an estimated 17 million children in families with low incomes receive less than the full $2,000-per-child credit or no credit at all.
OBBBA Changes
Under OBBBA, the maximum credit was raised to $2,200 per child and then indexed to inflation. Because the bill did not make any changes to the CTC’s refundability or phase-in with earnings, this change will not benefit any of the estimated 17 million children who were left out under pre-OBBBA law. Furthermore, the act’s increase in the standard tax deduction and other changes will increase the number of children whose families don’t get the full credit.
The OBBBA CTC expansion primarily benefits families with above average income. As this graph from the The Budget Lab shows, the bottom 40% receive little or no benefit.
Possible Improvements
There are many possible changes to broaden the CTC’s reach and help more children. (See Crandall-Hollick, Maag, & Jha 2025.):
- CTC “Baby Bonus”: Make the full credit available for all newborns, so that every newborn child’s family would get the full credit for their first year. This could be considered a CTC-based “baby bonus”.
- Allow full refundability as long as parent earnings are above the minimum ($2,500/year).
- Start phasing in refundability from the first dollar of parent earnings.
- Allow full refundability for families with multiple children.
Adoption Credit
Under current law, adoption expenses of up to $17,280 per child can be credited against income taxes. In practice, few families get the full credit because the credit is nonrefundable and few families have an income tax bill greater than this amount.
OBBBA Changes
Under OBBBA2 up to $5,000 of qualified adoption expenses will be refundable, thereby increasing the available adoption credit for approximately 45,000 children per year.3
Possible Improvements
Congress could broaden the benefits of the adoption credit by reducing the total credit and increasing the refundable amount, e.g., reducing the maximum to $12,000 while increasing the refundable amount to $6,000.
Direct cash grants: “Baby Bonuses,” SNAP, etc.
Some observers, concerned about declining birthrates, have proposed a cash payment for newborns soon after birth. Although President Trump has expressed support for a $5,000 “baby bonus”, the administration made no specific proposal and none was included in any version of the OBBBA. (A baby bonus could be implemented via a change in the CTC, as described above.)
Important safety net programs affecting children were cut by OBBBA
There are many federal safety net programs that provide cash or in-kind benefits to families based on having children and the number of children. The largest near-cash program, SNAP, will be cut back very substantially by OBBBA. An Urban Institute report estimated that the SNAP cuts would affect 3.3 million families with children and reduce their benefits by an average of $840 per year.
Money for children’s futures: Baby bonds & Trump child savings accounts
With multiple rationales, policymakers with varying perspectives have concluded that children and their families would benefit from starting life with a nest egg, a savings account to be created early in a child’s life, to be then held and used well in the future for education, homebuying, or other purposes. States, cities, counties, and nonprofits have started programs that both establish child savings accounts and provide a starter contribution to those accounts. According to the Congressional Research Service, over 100 such programs had been started by 2023, in addition to the education savings account programs operated by many states under Section 529 of the Internal Revenue Code.
These programs draw from work in the early 1990s by academic Michael Sherraden which proposed a national program of “Individual Development Accounts” for the poor. This led to local programs in many cities and some states. A similar approach using the term “baby bonds” was proposed by scholars in 2010 as a means to reduce racial gaps in wealth, and this proposal was adapted into the American Opportunity Accounts Act introduced by Senator Cory Booker (D-NJ) in 2018. Under those proposals every child would receive a grant at birth, with additional government grants to children in poorer families in later years. Some child investment programs, such as New York City’s RISE program also incorporate philanthropic gifts.
The approach became bipartisan this year when Senator Ted Cruz (R-TX) proposed that each newborn child receive a one-time $1,000 grant in an “Invest America Account.” Cruz’s rationale was less about reducing wealth disparities and more that such accounts would give children a stake in the future and an understanding of investment markets. In place of ongoing government contributions, he proposed that parents, employers, philanthropies, and others could contribute to the child accounts. The Cruz proposal was, with modifications, adopted in OBBBA.
What are the benefits of child savings accounts?
Advocates of these accounts see several advantages. First, they note with some evidence that having a personal account early in life that can only be accessed later substantially increases a child’s and family’s interest in education and personal betterment. Some believe that these accounts will also improve financial literacy and understanding of the economy and investment.
Other advocates, noting that disparities in wealth are associated with differences in educational opportunities, attainment, and future income and that wide racial differences in wealth persist, believe these programs could reduce wealth disparities at the start of life. The original child savings programs focused on this rationale, with payments or participation incentives that favored the poor. There is research that finds higher wealth associated with better educational and health outcomes, as well as stronger protection against material hardship following disruptive events, suggesting that policies that facilitate wealth-building could have profound effects.
OBBBA’s Trump Accounts & $1,000 contribution pilot program
OBBBA permits4 the secretary of the Treasury and/or private financial institutions to offer “Trump accounts,” savings accounts for children under 18 that offer some limited tax benefits if invested and not used until age 18. Contributions to these accounts, limited to $5,000 per year from family members, would be taxed as ordinary income. In addition, there is a 10% penalty for withdrawals before age 59½, with certain exceptions for education, home buying, adoption, disaster relief, etc. Contributions are also permitted from employers, up to $2,500 per year, and as part of a general program from government or philanthropies supporting all children in an approved geographic area.
The act also creates a pilot program of $1,000 government grants for any child born in the years 2025-28 (with a Social Security number) if the parent or Treasury elects5 and if there is an account established for that child. Although the government funds to be provided are given only at birth and are generally much smaller than the CTC, if made universally available they will reach some poor families with children that the Child Tax Credit does not.
Will Trump Accounts work?
While both Republicans and Democrats have endorsed at least the outlines of child savings accounts and a universal starting grant, there are many potential supporters who have questioned the design of Trump Accounts as enacted by Congress. A comprehensive review of child savings accounts systems undertaken by the Aspen Institute’s Financial Security Program raised a series of challenges, only some of which were responded to by the Congress. The Aspen publication noted ominously that similar program in the U.K. had been regarded as a failure and had in effect “poisoned the well” so that other efforts were unlikely to be considered for many years. That may have been a warning for Trump accounts.
Making Trump Accounts and the $1,000 per newborn pilot program work will require:
- Treasury to encourage all new parents to sign up for (“elect”) the $1,000 grant and/or the Treasury can do so itself. OBBBA does not auto-enroll children. It requires either the parent or the Treasury to “elect” newborn participation in the grant program.
- Treasury to establish and pay for the millions of accounts for all newborns. Although the law permits private financial institutions to establish these accounts, in practice they are unlikely to do so on their own. The administrative costs of setting up millions of individual private accounts will be large and, after receiving the $1,000 initial grant, many families will conclude that they cannot afford further contributions. Private firms will see little benefit in maintaining millions of individual accounts holding $1,000 with little prospect for more contributions. For that reason alone, Treasury will likely need to set up the program at least initially, perhaps by managing the funds in a single investment pool and having the individual accounts administered centrally. Treasury may also have to subsidize at least part of account administrative costs.For those families that can afford additional contributions, the existing nationwide programs of tuition savings accounts (“529 Plans”) are likely to be preferred: Investment earnings within Trump Accounts will be taxed at the ordinary income tax rate (plus a possible 10% penalty unless used for approved purposes), whereas proceeds from 529 plans if used for tuition expenses are not taxed at all.
Possible changes
Since the program has the president’s name on it, Treasury is likely to make every effort to help Trump Accounts succeed and be widely adopted and used. Some changes have already been suggested:
- Provide additional government contributions for children of less well-off working families. This could be done several ways: Under the approach proposed by Senator Booker, the government could make smaller grants annually to children in families below an income limit. Alternatively, this could be done by allowing a full refund of the Child Tax Credit regardless of income while requiring the increased refund be invested in a Trump Account or something similar.
- Ensure that child savings don’t penalize other public support. Retirement accounts and tuition assistance 529 program savings are generally not considered assets in setting eligibility for SNAP and other programs, and they are given preferential treatment in determining student loans. Trump Accounts could get similar treatment, as the Aspen Institute working group proposed for early wealth building policies.
- Consolidate the many different tax-favored savings accounts into a single account type. (Muresianu & Cluggish, 2025) Since the Trump accounts are in some respects tax-disadvantaged compared to 529 school savings and also to several retirement accounts, a way to ensure the success of the effort might be to incorporate those accounts into the Trump account program.
What’s the right balance between helping children now versus saving for the future?
Unsurprisingly, there are differences of opinion whether additional resources should be devoted to immediate financial relief (using the CTC or a child grant) or instead to child savings accounts and wealth building for the longer term. There are advocates of both approaches and both have been shown to benefit children and families. However, there isn’t yet enough experience with child savings accounts to form judgments about the appropriate balance of resources between them.
We can do better
Given the broad public support to help children and families with children, elected officials from both parties will claim their efforts do so. As the distinctly non-bipartisan experience with OBBBA shows, however, many programs fall short of the rhetoric: overall, OBBBA seems likely to harm as many families with children as it helps.
Future bipartisan efforts can and should do better, supporting all families with children, including those who are more in need.
UnitedHealth CEO Says Company is Cutting Thousand of Doctors Out of Network to Boost Profits
“Value-based care” in UnitedHealth’s Optum division apparently means fewer doctors for fatter margins.
UnitedHealth Group announced last week that it plans to cut thousands of doctors from its network, a move CEO Stephen Hemsley said will increase profits for the country’s richest health care conglomerate.
UnitedHealth assembled a network of nearly 90,000 physicians across the country as it bought hundreds of physician practices, began managing the Medicaid program in many states and became the biggest Medicare Advantage company. It also owns one of the nation’s largest pharmacy benefit managers, Optum Rx.
Of those 90,000 doctors, the company says fewer than 10,000 are currently directly employed by UnitedHealth. The company has been gobbling up a broad range of medical facilities in recent years, buying or creating nearly 2,700 subsidiaries and gaining direct control or affiliation with 10% of doctors working in the U.S. in the process.
The announcement by Hemsley came during a third-quarter earnings call with investors last week, when UnitedHealth announced it made $4.3 billion in profit in the last three months by generating revenues of $113 billion.
Read more here on how they did that. Spoiler alert: It involves raising health care premiums and collecting billions more from the Medicare Trust Fund and seniors.
Hemsley said the company’s health care services division, Optum Health, needed to consolidate its physician rolls to improve its bottom line.
He passed questions about how that will be done to Optum’s CEO Patrick Conway, who said too many doctors in the network weren’t aligned with UnitedHealth’s business model, which he called “value-based care.”
“We are moving to employed or contractually dedicated physicians wherever possible,” Conway said.
Overseeing an empire that offers health insurance, pharmacy benefits and doctors who provide care and write prescriptions, UnitedHealth has become America’s third-richest company behind Walmart and Amazon. There are 29.9 million Americans enrolled in UnitedHealthcare’s commercial plans, 8.4 million in its Medicare Advantage plans and 7.5 million in state-run Medicaid programs.
In 2024, the company brought in more than $400 billion in revenue, according to its financial filings.
Americans’ health care premiums are expected to rise drastically in 2026 after climbing as much as 6% on average this year compared to 2024.
UnitedHealth’s decision to remove doctors from networks means that many of its patients will have to find new, in-network physicians unless they change their insurers.
UnitedHealth isn’t alone in taking steps to trim its medical expenses to boost its bottom line. Both CVS Health, which owns Aetna, the PBM CVS Caremark and more than 9,000 retail pharmacies, and Cigna, which owns the PBM Express Scripts, also told investors they are implementing plans to improve earnings next year.
CVS Health is just behind UnitedHealth at No. 5 on the country’s Fortune 500 list, bringing in nearly $373 billion in revenue last year. Cigna is 13th with $247 billion in revenue.
Cartoon – Today’s Side Effect
State of the Union – Wheel of American Health Care
The Structural Flaws that Must be Fixed to Transform the U.S. Health System
Key Takeaways:
- The U.S. health system’s future is uncertain but outside forces will define its direction.
- 9 structural changes appear necessary to a transformed system of health that’s affordable, comprehensive and effective.
Last week, I had a 27-hour stay in a hospital emergency room waiting for an open bed and a morning at the food pantry loading boxes in anticipation of a possible SNAP program suspension surge. It wasn’t the week I expected. So much for plans!
Such is the case for health insurance coverage for millions in the U.S. as the federal government shutdown enters Week 6. Democrats are holding out for continuation of Affordable Care Act (ACA) insurance subsidies that enable 22 million to “buy” insurance cheaper, and Republicans are holding out for federal spending cuts reflected in the One Big Beautiful Act (July 2025) that included almost a trillion reduction in Medicaid appropriations thru 2036.
ACA subsidies at the heart of the shutdown successfully expanded coverage in tandem with Medicaid expansion but added to its costs and set in motion corporatization and consolidation in every sector of the health system. The pandemic exposed the structural divide between public health programs and local health systems, and insurance premium increases and prior authorization protocols precipitated hostility toward insurers and blame games between hospitals, insurers and drug companies for perpetual cost increases.
Having mediated discussions between the White House and industry trade groups as part of the ACA’s design (2009), I witnessed first hand the process of its development into law, the underlying assumptions on which it is based and the politics before and after its passage in March 2010. Its hanging chads were obvious. Its implementation stalled. Its potential to lower costs and improve quality never realized. It was a Plan disabled by special interests that rightly exploited its flaws and political brinksmanship that divided the country. But more fundamentally, it has failed to lower costs and improve affordability because it failed to integrate outside considerations—private capital, employers, technologies, clinical innovations and consumer finances—in its calculus.
Sixteen years later, healthcare is once again the eye of the economic storm. Insiders blame inconsistent regulatory enforcement and lack of adequate funding as root causes. Outsiders blame lack of cost controls. consolidation and disregard for affordability. Thus, while attention to subsidized insurance coverage and SNAP benefits might temporarily calm public waters, they’re not the solution.
All parties and all sides seem to agree the health system broken. For example, in my trustee surveys before planning sessions with Boards of health systems, medical groups and insurers, the finding is clear:
- 92% says the future of the U.S. health system in 7-10 years is fundamentally changed and not repeat of its past.
- 84% say their organizations are not prepared because short-term issues limit their ability to long-term planning.
Republicans think market forces will fix it. Democrats think federal policy will fix it. The public thinks it’s become Big Business that puts its interests before theirs. And the industry’s trade groups—AMA, AHA, AHIP, PhRMA, Adame, APHA, et al—face intense pressure from members adversely impacted by unwanted regulatory policies.
Few enjoy the luxury of long-term planning. That doesn’t excuse the need to address it. If a clear path to the system’s future is not built, incrementalism will enable its inevitable insolvency and forced re-construction.
What’s the solution? When comparing the U.S. health system to high performing systems in other high-income countries, these findings jump out:
- All spend less on healthcare services and more on social services than the U.S.
- All include government and privately-owned operators
- All fund their systems primarily through a combination of federal appropriations and private payments by employers and citizens.
- All pursue clinical standardization based on evidence.
- All are dealing with funding constraints as their governments address competing priorities.
- All are transitioning from episodic to chronic health as their populations age and healthiness erodes.
- All are focused on workforce modernization and technologic innovations to lower costs and reduce demand for specialty services.
- All enable private investment in their systems to increase competition and stimulate innovation.
- All facilitate local/regional regulatory oversight to address distinctions in demand and resources.
- All face with growing public dissatisfaction.
- All are expensive to operate.
No system is perfect. None offers a copy-paste solution for U.S. taxpayers. And even if one seemed dramatically better, it would be a generational surge rooted in futility that welcome it.
What’s the answer? At the risk of oversimplicity, the future seems most likely built on these 9 structural changes:
- Integrate social services (public health) with delivery.
- Create comprehensive primary and preventive health gatekeeping inclusive of physical and behavioral health, nutrition, prophylactic dentistry and consumer education.
- Rationalize specialty services and therapies to high value providers.
- Incentivize responsible health behaviors across the entire population.
- Increase private capital investments in healthcare.
- Modernize the workforce.
- Fund the system strategically.
- Define and disclose affordability, quality and value systemically.
- Facilitate technology-enabled self-care.
This will not happen quickly nor result from current momentum: the inertia of the status quo leans substantially toward protectionism not because it’s unaware. The risks are high. And while the majority of Americans are frustrated by its performance, there’s no referent to which look as a better mousetrap.
I anticipated last week would be pretty uneventful. It wasn’t. My Plan didn’t work out due, in part, to circumstances I didn’t foresee or control.
Healthcare’s the same. Outside forces seen or not will impact its future dramatically. Plans have to be made though Black Swans like the pandemic are inevitable. But long-term planning built on plausible bets are necessary to every healthcare organization’s future.
Policy Talk V: My Plan for a Better Healthcare System
America’s health care system is neither healthy, caring, nor a system.
– Walter Cronkite
Healthcare policy in America is too short-sighted and vulnerable to party-politics. We need a system that’s built to last.
As open enrollment through the ACA marketplace begins November 1, millions of Americans will soon discover their health insurance rates going up in 2026 as the direct result of ACA tax subsidies expiring because party politicians in charge of the Senate refuse to budge. If you know how much your rates will be increasing in 2026, please share so I can see the impact that this inaction will have on regular folks.
Career politicians like my opponent Mike Rounds aren’t willing to stray from the party line to make sure Americans and their families get affordable healthcare, and in the process they are causing innumerable harm to not just those Americans on ACA, but also all the furloughed federal employees and families on SNAP. Something needs to change.
As an Independent candidate who supports pragmatic solutions, I will not claim my proposals are the best or only choices, but I will claim just about anything will be overall less expensive and more effective than the status quo. The bottom line is that our dysfunctional politics have us fighting over half-measure solutions to today’s problems instead of complete solutions to tomorrow’s.
Overhauling American healthcare is a complex challenge, but that cannot let it deter us. Americans deserve access to affordable, quality care. According to a KFF analysis, healthcare accounted for 27% of federal spending in fiscal year 2024. The U.S. spends far more per person on healthcare than any of the other 37 members of the Organization for Economic Co-operation and Development (OECD). Despite spending nearly twice as much per person as similar wealthy countries, we still rank poorly on key health outcomes.
America does, however, hold a commanding lead in medical debt, accounting for between 50% and 66% of annual personal bankruptcies. Other wealthy countries clearly understand better how to set up a healthcare system that is both less expensive and produces the same or better outcomes.
Considering the immense costs and mediocre outcomes, I am reminded of the famous observation from Dr. Amos Wilson: “If you want to understand any problem in America, you need to look at who profits from that problem, not at who suffers from that problem.” Having done so, I support an incremental reinvention of the American healthcare system that doesn’t just solve immediate problems such as premium hikes, expiring ACA subsidies, or Medicare cuts, but also secures a stable and healthy future for the American people.
My plan for America’s healthcare system has three basic steps, ensuring folks can get the care they need, now and in the future.
Stage 1: Fixing the Supply Side: Regulate Healthcare Companies, Lower Drug Prices, & Encourage Preventive Care
The healthcare industry (from insurers to providers) is a functional monopoly, especially at the local/regional level, similar to electric, gas, and telecommunications companies. It deserves to be treated the same way. Drawing from how the South Dakota Public Utilities Commission (and similar entities in other states) regulate utility companies to ensure that they provide “reliable service” and “reasonable rates,” creating a regulatory framework for healthcare companies (including insurers) is a good first step in adapting our current system into one that considers the needs of regular folks. Providers shouldn’t have to butt heads with insurers to provide the services that patients need, so creating a more transparent and regulated system would benefit every level of the process.
Pharmaceutical companies have the highest profit margins in the healthcare industry. According to a RAND report, Americans pay 278% higher prescription drug prices than similar countries where the government negotiates drug pricing. The common-sense solution is for the federal government to negotiate pricing for all drugs. Doing so will yield much greater savings for both the government and consumers.
To offset reduced pharmaceutical company profits and also help more consumers, the U.S. should negotiate a treaty with the European Union and other G7 countries to establish a pharmaceutical common market based on uniform drug development/approval standards enabling the elimination of trade barriers for drugs.
RFK Jr.’s “Make America Healthy Again” (MAHA) agenda includes multiple nonsensical proposals that are likely to do the opposite, but there are a handful of beneficial ideas. A MAHA focus on preventive care that strengthens primary care, expands access to screenings, and incentivizes healthy lifestyles will lower long-term healthcare spending the same way that keeping up routine maintenance on your car prevents big repair bills in the future.
Investing in community health centers, mobile clinics, and telehealth services will make preventive care more accessible, particularly in underserved rural and urban areas. Similarly, reducing reliance on highly processed foods and ensuring government nutrition assistance programs incentivize and enable healthy foods would also pay dividends.
Many states approve the rates that insurers charge consumers, but these rates increase as the base cost of providing healthcare services increases. Holding healthcare companies, providers and insurers alike, to uniform standards and making information transparently available for comparison will remove the various pressures driving up the cost of care, keeping rates down for consumers.
Stage 2: Fixing the Demand Side: Create a Public Option, Streamline Administration, Increase Residency Slots
Profits are up 230% for the top 5 health insurance companies since the Affordable Care Act (ACA) was adopted, while family premiums have also skyrocketed. While I think it was a step in the right direction to provide folks with healthcare, it isn’t a viable permanent solution. Creating a broadly available public option would enable Americans to buy into a health insurance plan administered by the government.
A public option like this wouldn’t have a profit motive, so it would be able to offer lower-cost plans, creating a baseline for other companies to compete with. Increased competition would drive down premiums and improve quality of service across the market, even amongst private for-profit insurers.
Technology can also help lower costs by reducing the complicated bureaucracy healthcare administrators must navigate. Healthcare providers currently spend enormous time and money dealing with insurance paperwork, eligibility verification, and billing disputes. Universally interoperable electronic health records (EHRs) and streamlined billing systems would significantly reduce costs. Uniform standards for these processes and better technology infrastructure would free up providers’ time to focus more on patient care.
By 2036, the U.S. is projected to need 86,000 more physicians than it will have. The primary cause of the growing shortage is a 1997 law freezing federal support for Medicare-funded residency positions. Limiting the number of doctors in training also fosters misallocation of training slots across the country, creating a mismatch between where they train and where they are needed most. Correcting this self-inflicted shortage is essential to maximizing access.
On the subject of innovative approaches to providing healthcare, fee-for-service payment models reward volume over value, encouraging unnecessary tests and procedures. Transitioning to value-based care, where providers are paid based on patient outcomes, can lead to better health outcomes at a lower cost. Accountable Care Organizations (ACOs), bundled payments, and capitation models (in which providers receive a fixed fee per patient for a specific time period regardless of services delivered) have shown promise in reducing spending while maintaining or improving quality.
Stage 3: Use The Foundation To Build a Better System
While I believe that our leaders today should be looking towards the future with long-lasting solutions rather than scrambling for band-aid policies, I also know that we shouldn’t put the cart before the horse. I believe that Stages 1 and 2 lay the foundation for a healthier America and a more streamlined healthcare system. Stage 3 of my plan is geared towards keeping our options open for the future of American healthcare.
All OECD countries with lower per-person healthcare spending provide universal or near-universal coverage to their citizens. Various universal healthcare systems seem to be an effective way to improve access and reduce systemic costs. In particular, I think that looking to our allies such as Canada (with a single-payer system) and Germany (with a multi-payer system) would be a good place to start. In both systems, the government negotiates prices directly with providers and pharmaceutical companies, leading to significant cost savings for consumers.
Conclusion
In summary, the American healthcare system doesn’t suffer from a lack of resources but rather anti-competitive profit-seeking, inefficiency, and a lack of imagination. Creative solutions lie in addressing the supply and demand side of the healthcare industry, continuously blending technological innovation, community-based delivery, and incentivizing healthier living.
No single policy will fix the U.S. healthcare system overnight, but a combination of reforms can dramatically improve access and lower costs. Providing a public option is a foundational step that keeps options open for other innovations. In tandem, reforms such as drug price negotiation, investment in preventive care, value-based payments, and administrative simplification can deliver a more efficient and equitable healthcare system. Political will and public support are crucial, but the long-term benefits for individuals, businesses, and the broader economy make these changes not only possible but necessary.
The path forward is not and cannot be a purely partisan choice of public versus private. It must be guided solely by a simple question: What is most effective at making healthcare cheaper, faster, and more accessible for everyone? At this point, I believe a robust public option is essential, but I remain unsure whether a single-payer or a refined version of a multi-payer universal system is warranted. I’m keeping an open mind.
I am sure that Washington politicians shouldn’t be screwing over regular Americans by making their healthcare inaccessible or more expensive. As South Dakota’s Independent senator, I would be empowered to break through party-first politics to make sure people always come first.
The American healthcare is complicated, so this article leans on the longer side to try and do it justice. Thank you for reading.
Rising Health Care Costs Are the Real Reason for the Government Shutdown
https://time.com/7312361/obamacare-marketplace-health-insurance-cost-increase/
For four years, people buying health care on the Affordable Care Act (ACA) marketplace have benefited from government subsidies that made their plans more inexpensive, and thus more accessible.
Now, those subsidies have become a key point of contention between Democrats and Republicans in a government shutdown that went into effect on Oct. 1 after both sides failed to reach a deal.
Democrats want Congress to extend the enhanced premium tax credits first added in 2021; without an extension, the tax credits expire at the end of 2025 and experts say premium prices could double in 2026.
“They know they’re screwed if this debate turns into one about healthcare. And guess what? That’s just what we’re doing. We are making this debate a debate on healthcare,” said U.S. Senator Chuck Schumer, a Democrat from New York, hours before the government shut down.
Republicans say that Democrats want to extend free health care for unauthorized immigrants, a talking point that is not true but that has nevertheless been repeated many times by GOP politicians. (Democrats want to reverse health policy changes that the GOP’s tax law enacted, including limits to federal funding for health care for “lawfully present” immigrants.)
Neither side appears ready to budge, which means that as of right now, people who buy health care on the Affordable Care Act (ACA) marketplace are about to be in for some sticker shock. Monthly out-of-pocket costs are set to jump as much as 75% for 2026 because of the disappearance of federal subsidies and higher rates from insurers.
“Most enrollees are going to be facing a double whammy of both higher insurance bills and losing the subsidies that lower much of the cost,” says Matt McGough, a policy analyst at KFF for the Program on the ACA and the Peterson-KFF Health System Tracker.
KFF recently calculated that the median rate increase proposed by insurers is 18%, more than double last year’s 7% median proposed increase. But the actual blow to patients is going to be much higher. That’s because enhancements to premium tax credits are set to expire at the end of 2025.
Around 93% of marketplace enrollees—19.3 million people—received the enhanced premium tax credits, according to the Center on Budget and Policy Priorities, saving them $700 yearly on average. For some people, the tax credits meant that they wouldn’t have to pay an insurance premium if they chose certain plans. For others, it meant getting hundreds of dollars off a health plan they otherwise wouldn’t have been able to afford.
Premium tax credits helped people afford plans on the Affordable Care Act marketplaces between 2014 and 2021. Then, in 2021, enhancements to those premium tax credits went into effect with the American Rescue Plan. Before 2021, premium tax credits were only available to people making between 100-400% of the federal poverty limit—so between $25,8200 and $103,280 for a family of three in 2025. The enhanced tax credits were expanded to households with incomes over 400% of the federal poverty limit, and were also made more generous for everyone. That wide range meant they subsidized coverage for people who otherwise would not have gotten any break on their premiums.
The enhancements to the premium tax credits, which are set to expire at the end of 2025, significantly boosted enrollment in Affordable Care Act marketplace plans. More than 20 million people enrolled in marketplace coverage in 2024, according to the Center on Budget and Policy Priorities, up from 11.2 million in February 2021, before the enhancements to the tax credits.
With costs being lowered by half, individuals and families decided, ‘OK, maybe this is financially worthwhile,’” says McGough. “Whereas previously, they thought that they didn’t utilize that much health care, so it wasn’t worth it to purchase health care on the marketplaces.”
Why insurers want to increase rates
Every year, health insurers submit filings to state regulators that detail how much they need to change rates for their ACA-regulated health plans. KFF analyzed 312 insurers across 50 states and the District of Columbia; they found that insurers are requesting the largest rate changes since 2018.
They are requesting the median 18% increase for a few reasons, including rising health care costs, tariffs, and the expiration of the premium tax credit enhancements, KFF found. Health care costs have been rising for years, but insurers say that the cost of medical care is up about 8% from last year. They say that tariffs may put upward pressure on the costs of pharmaceuticals and that growing demand for GLP-1 drugs such as Ozempic and Wegovy is driving up their expenses.
Worker shortages are also driving health care costs up, according to the KFF analysis. It also found that consolidation among health care providers was leading to higher prices because those providers had more market power.
Everyone’s bottom line could be affected
When they went into effect, the enhanced premium tax credits pushed some people into the marketplace who might otherwise have been uncertain about whether to get health insurance. The tax credits were graduated so that people with the lowest incomes got the most help, but they also reached people with slightly higher incomes.
Many people don’t know that those enhancements to the premium tax credits are going away, says Jennifer Sullivan, director of health coverage access for the Center on Budget and Policy Priorities (CBPP). Her organization has been talking to people across the country about how they may be affected if Congress does not extend the enhancements, and has found that even increases of $100 or $200 a month may be enough to force some people out of the marketplace.
“It’s a huge increase in anyone’s budget, particularly at a time when groceries are up and the cost of housing is up and so is everything else,” Sullivan says.
There are other reasons the ACA marketplace may see fewer enrollees, she says. A handful of policies passed by Congress require more verification to enroll in ACA plans and cut immigrant eligibility, for example.
Fewer enrollees are bad news for everyone else. The people who are likely to drop coverage are those who don’t need it for lifesaving treatment or medicine. That means the pool of people who are still covered by ACA plans will be sicker and more expensive to care for.
“The people who are left are statistically more likely to be people with higher health care needs,” says Sullivan, with CBPP. “Those are the folks that are going to jump through extra hoops, whether it’s more paperwork or higher premiums or higher out-of-pocket costs, because they absolutely know they need the coverage.”
There are other society-wide effects to people dropping their health insurance coverage. Many uninsured people end up in emergency rooms for care because that’s their only option, and sometimes, they can’t pay. That increases the cost of health care for everyone else, says Sullivan.
Amy Bielawski, 60, is one of the people who is going to look at her options when rates for marketplace plans are listed in October and decide whether or not to enroll. Bielawski, an entrepreneur and entertainer who performs belly dancing at parties, has spent much of her life without health care.
She finally signed up for an ACA plan in 2019, and was able to go to a doctor and diagnose her hypothyroidism and uterine fibroids. Last year, because of the enhanced premium tax credits, she paid $0 a month in premiums—which will almost certainly go up.
“I’m afraid, I’m very afraid,” says Bielawski, who lives in Georgia. “I can’t wrap my head around it because there are so many things that can go wrong with my health.”
Where politicians stand now
Addressing this uncertainty is one key reason the Affordable Care Act passed in the first place in 2010. It has dramatically improved health coverage for Americans; nearly 50 million people, or one in seven U.S. residents, have been covered by health insurance plans through ACA marketplaces since they first launched in late 2013.
But it has also faced numerous challenges, and Republicans have long said that weakening or revamping the law is a high priority.
It’s unclear if the hassle of a government shutdown will make them change their tune. In September, Senate Majority Leader John Thune, a Republican from South Dakota, said he was open to addressing the expiration of the subsidies, but that he did not want to tie any of those policy changes to government funding measures. Sen. Mike Rounds, also a Republican of South Dakota, has suggested a one-year extension to the subsidies, after which the tax credits return to pre-pandemic levels.
Many Republicans appear determined to end the subsidies eventually, and their insistence on scaling back spending on health care policy seems to be having an impact.
Sullivan, with the CBPP, says that the changes to the Affordable Care Act and looming cuts to Medicaid have the potential to dramatically reduce the number of people able to afford regular medical care in the country. These cuts come at a time when key indicators like infant mortality rates and life expectancy rates are worsening.
“We are seeing a real weakening of that safety net that we spent the last 10-15 years fortifying,” she says.
HENRY KOTULA 
