What’s shaking, sports fans:

Been a minute! I’ve been busy for the past year and a half. Hope you guys have been good.

I’m in touch with some folks in Washington who are looking to hire up healthcare staffers for new Dems in the House and Senate. I know there’s a pretty good collection of health-policy-predisposed folks on this listserv. If you feel like heading to Washington for a couple of years and carrying the flame, send me your resume and I’ll pass it along.

Here’s something I’ve been thinking about. I think American health finance has been a rolling crisis for, like, decades—it is a machine lubricated with blood—but I think we’re going to see rapid and extreme escalation in the crisis over the next two to four years.

One impediment to meaningful healthcare reform, the thing that keeps the trillions of dollars flowing more-or-less unimpeded through the system, is the core idea of insurance: most people don’t use healthcare in a given year. Their primary interaction with the health finance model is their monthly premium, and most of them 18–65 have those premiums subsidized, at least in part, by their employers. You’ve got this huge chunk of the electorate for whom things are mostly fine (up until the point, as we all know, that they actually need to use their insurance). While millions of people demand, or are a least interested in, single-payer healthcare, I think this employer subsidy is the big buffer that keeps it from being urgent/emergent in most of our lives.

So far, pretty basic theory. I think this model is about to be severely destabilized in the next two to four years.

If you’re reading this, you probably already know a lot about the Trump Medicaid cuts, so I won’t belabor the point: they’re very, very bad, will make life much harder for a lot of people and will social-murder many others. We already know some of the consequences: Medicaid cuts will lead to increased volumes of uncompensated care in rural hospitals and hospitals with higher shares of sick patients. Increased uncompensated care leads to 1) facility closures and 2) consolidation — clinics take buyouts from large hospitals (or, to a lesser extent, private equity) when they can’t afford to keep the doors open. Consolidation drives price increases, and insurers are both unable and, often, unwilling to constrain them—UHC’s $80 billion in gross profit has to come from somewhere.

Providers claim that low Medicare reimbursement rates drive cost-shifting; if a hospital can’t make its unlimited simoleons from the feds, they’ll juice the prices they charge the privately insured. That’s not always correct — the observed effect is much smaller than the administrators, who use this threat to demand higher Medicare compensation, argue — but I believe that this tendency is more likely to become excruciatingly real in response to the major payor shock we’re about to experience. Healthcare industry revenue growth will come from ESI. Employers are the banana stand, and the temptation to hack away at the walls will be irresistable.

At some point, the ESI sector will no longer be able to swallow price and premium increases, and I believe this will expose workers to premium shocks that existing health politics cannot contain. We’ve had two years of double-digit ACA premium hikes, a problem exacerbated for the 7% of Americans on ACA plans by the gutting of Biden’s enhanced subsidies. While ESI isn’t nearly as exposed to healthcare costs as ACA plans are, I think this has some predictive power about other payors. More and more employers will be unable to cover their share of ESI premiums, so costs will shift more dramatically to employees — I think this instability will be the force that drives some sort of major reform.

What will that reform look like? My preferred answer, and likely yours, is a single-payer model: Medicare for All. The moderates will attempt to wheeze the juice and channel this momentum into non-solutions like Medicare for America or Medicare For All Who Want It; models that pump public money into the industry, fail to reckon with the inconvenient $$$tructural issues creating these problems, and pass the buck down the road for another few years. Conservatives will end up somewhere between removing ESI requirements, promoting a self-pay deëvolution, or building the Thunderdome.

Tuesday was a hell of a day. I think we have the opportunity to make Medicare for All one of the key issues of the 2028 election. It’s been a fallow few years for health justice, but increasingly I believe the time is now, the place is here: it’s time to, as Kid Rock said, get in the pit and try to love someone.

I’m going to try to gin up my part. It doesn’t look like going to Capitol Hill—I moved to Defector a couple months ago in order to build some flexibility in my schedule so I can, hopefully, get on the road again*—but if that’s a good fit for you, send me your resume. Feel free to pass the request around to other socialist health policy types in your life.

Until then, keep on trucking!

T-Bone

* I learned a useful term from my wife when she was working with sex workers: FMTY, “Fly Me To You;” an idiom for Instagram models and other professionally hot people who get flown out to exotic locations on dates with horny rich guys. I can’t offer the same, uh, benefits as a FMTY gal might, but as always, I am available to get flewed out to talk to your church group, med school, DSA chapter, or 250 best friends about Medicare for All and other issues in health finance. If you’re a med student in Chicago for the SNaHP conference this week, I’ll see you Thursday!