The U.S. bombing of Iran’s nuclear capability is unsettling: whether MAGA or not, hawk or dove, young or old, conservative or liberal, rich or poor—it matters. Stability at home and abroad is utopian to some but desired by all. Pandemics, mass violence, natural disasters and even election results contribute to instability and lend to insecurity. Operation Midnight Hammer might contribute to the nation’s anxiety—time will tell.
The immediate aftermath of the bunker-bombings in Iran will involve two orchestrated campaigns by government officials:
- The Campaign to Contain Middle East Tension: military, diplomatic and economic levers will be put to the test to limit escalation of the bombing and limit its consequence to the region.
- The Campaign to Win Public Support: issues of consequence like military intervention ultimately depend on public opinion that support laws, funding and subsequent actions taken in response. History teaches and political leaders understand that ‘winning the hearts and minds’ of the public is necessary to success. Predictably, justification for Operation Midnight Hammer will be messaged loudly by supporters and challenged by critics.
For the moment, the news cycle will shift to foreign policy and away from tariffs, inflation, household prices and the “Big Beautiful Budget Bill” which the Senate Republicans hope to bring to the floor this week. News media will speculate about the after-effects of the Israeli-Iran bombing and what role the U.S. plays in an increasingly complicated geopolitical landscape marked by marked by armed conflicts Gaza, Ukraine, Myanmar, Yemen and 26 and other countries.
The attention these get in traditional media and social media channels will exacerbate public anxiety that’s already high: 19% U.S. adults and 40% of the country’s adolescents suffer from anxiety disorder: “a persistent, excessive fear or worry that interferes with daily life and functioning”. But, per the National Institute of Mental Health, fewer than a third suffering from severe anxiety receive professional treatment.
In the public health community, much is known about anxiety: it’s more prevalent among women than men, in minority populations, lower income populations and in the Southeast. It’s significant across all age groups, and at an alarming level among young working-class adults facing unique issues like affordability and job insecurity. And it is stigmatized in certain communities (i.e. certain fundamentalist religious sects, certain ethnic communities) lending to silent suffering and unattended consequences.
My take:
Operation Midnight Hammer came at a time of widespread public anxiety about the economy, tariffs, inflation, costs of living and political division. I will let pundits debate the advisability and timing of the bunker-bombing but I know one thing for sure: mental health issues—including anxiety, mood and substance abuse disorders– deserve more support from policymakers and more attention by the healthcare community.
- The former requires local, state and federal lawmakers to revisit and enforce mental health parity laws already on the books but rarely enforced.
- The latter requires the healthcare community to elevate behavioral health to a national priority alongside obesity, heart disease, cancer and aging to secure the public’s health and avoid unintended consequences of neglect.
Regrettably, the issue is not new. Employers, school systems, religious organizations and local public health agencies have been mental health default safety values to date; extreme have been temporarily shuffled to in hospital emergency rooms most ill-equipped to manage them. But systematic, community-wide, evidence-based help for those in need of mental health remains beyond their reach.
The Trump administration’s healthcare leaders under HHS’ Kennedy and CMS’ Oz espouse the U.S. healthcare system should prioritize chronic disease and preventive health. They believe its proficiency in specialty care is, in part, the result of lucrative incentives that reward providers and their financial backers handsomely in these areas.
In the President’s February 13 Executive Order establishing the Make America Healthy Again Commission, its goal was laid out:
“To fully address the growing health crisis in America, we must re-direct our national focus, in the public and private sectors, toward understanding and drastically lowering chronic disease rates and ending childhood chronic disease. This includes fresh thinking on nutrition, physical activity, healthy lifestyles, over-reliance on medication and treatments, the effects of new technological habits, environmental impacts, and food and drug quality and safety… We must ensure our healthcare system promotes health rather than just managing disease.”
Nothing could be more timely and necessary to the Commission’s work than addressing mass anxiety and mental health as a national priority. And nothing is more urgently needed in communities than mainstreaming anxiety and mental health into the systems of health that accept full risk for whole person health.
Paul
PS: Before Operation Midnight Hammer over the weekend, I had prepared today’s report focused on two government reports about the long-term solvency of the Medicaid and Medicare programs. Given the gravity of events in Israel and Iran and other hot spots, and after discussions with my family and friends this weekend, it became clear public anxiety is high.
I am concerned about the future and worry about the health system’s response. It’s composed of good people doing worthwhile work who are worried about the future. I recently spoke to a group on the theme (link below): ‘the future for healthcare is not a repeat of its past.’ That lends to anxiety unless accompanied by a vision for a better future. That’s what all hope for those in Iran, Gaza, Israel and beyond, and for all who serve in our industry.
From Budget Battles to Consumer Backlash: Paul Keckley on the Future of U.S. Health Care
Resources
National Institute of Mental Health www.nimh.nih.gov
Sections in this Report
- Quotables
- Consumers
- Economy
- Hospitals
- Physicians
- Policy
- Polls
- Prescription Drugs
- Public Health
Quotables
Szyperski on mental health: “Healthcare is moving deeper into the value-based era. Metrics drive decisions, outcomes define quality, and performance data shapes reimbursement. Yet amid this transformation, inpatient psychiatry and behavioral healthcare remain the most notable outlier—excluded for a variety of reasons including stigmatization, subjectivity, and a high degree of variation in clinical operations from site to site.
Behavioral healthcare lacks the foundational standards and management models that have existed in other areas of healthcare for decades. The management models used more universally by hospitals for more predictable medical-surgical care tend to break down quickly when applied to inpatient psychiatry due to the high volatility of inpatient units. The fundamental problem is that the core measurement to assess and manage patient needs in clinical operations, patient acuity, is much more complex for inpatient psychiatry and has led to the adoption of a variety of homegrown methods for day-to-day management of staff and units.
Jim Szyperski, CEO, Acuity Behavioral Health, June 19, 2025 Healthcare’s Big Blind Spot: The Measurement Crisis in Inpatient Psychiatry
Politico on hospital advocacy: “Hospitals are not used to losing on Capitol Hill. In recent years they have successfully fought off efforts to lower Medicare payments for their outpatient clinics so they’re in line with doctors’ offices. Lawmakers on both sides of the aisle have criticized hospitals for getting paid more for performing the same service.
Hospital groups have also successfully fought off a payment cut to safety net hospitals, which serve low-income patients, that lawmakers included in Obamacare. The cut aimed to help pay for the bill. And the Democrats who passed Obamacare in 2010 expected the Medicaid expansion would make the hospitals whole. But Congress has repeatedly passed legislation to block the cuts from taking effect at hospitals’ request.
Now, the industry is working against a Senate hungry for savings to pay for the megabill, the primary purpose of which is to extend the tax cuts President Donald Trump and a Republican Congress enacted in 2017. It’s also up against conservatives’ philosophical opposition to the state taxes.”
Hospitals stunned by Senate GOP’s Medicaid plan – POLITICO June 17, 2025
Bill Frist on conservation policy: “The overwhelming majority of people believe and understand that to have a thriving planet, to have healthy soil and healthy air, and to have clean water, we must have effective policy. Policy makes conservation and climate action possible by driving systemic change at scale. Nature is common ground and common sense. Nature policy is nonpartisan.
We know people care about clean air, clean water, and access to nature. They care about hunting and fishing. They care about what happens in their backyards. And the government has a responsibility to provide these benefits to people. Supporting sound nature policy is about what future we want to leave behind for our children and grandchildren. Unlike anything else, policy shapes and defines the future.”
Nature Is Common Ground: Tennessee’s Legacy of Conservation Leadership Bill Frist’ A Second Opinion June 17, 2025 https://billfrist.substack.com/p/nature-is-common-ground-tennessees
Pew on state Medicaid spending: “In fiscal year 2023, the combination of expiring federal COVID-19 pandemic aid, slowing tax revenue growth, and rising costs for Medicaid led to an increase in the share of state revenue dedicated to Medicaid of 17.8%, or $44.4 billion, over the previous year—the largest single-year rise in at least two decades. States spent 15.1% of every state-generated dollar on Medicaid, up 2.2%from the previous year, though still about half a cent less than the 15-year average.
Individually, 17 states dedicated a larger share of their own dollars to Medicaid than they had, on average, over the previous 15 years—a sharp shift from fiscal 2022, when only Alaska exceeded its long-term average…
In fiscal 2023, only five states saw the share of their own funds dedicated to Medicaid decrease compared with the previous year, but individual state increases ranged widely. Colorado saw the largest jump, rising 5.1 percentage points to 19.6% in fiscal 2024, while Delaware had the smallest increase, up just 0.004 percentage points to 10.8%….
In fiscal 2023, states collectively allocated $294.1 billion of their own resources to support benefits for 98.2 million Medicaid recipients—up 17.8%, or $44.4 billion, from the previous year. And this sharp rise in Medicaid spending came as growth in states’ own-source revenue slowed dramatically. Own-source revenue rose less than 1% from fiscal 2022 to fiscal 2023, compared with an increase of 14% from fiscal 2021 to fiscal 2022.”
NEJM on vaccine policy changes: “On May 27, 2025, U.S. Secretary of Health and Human Services Robert F. Kennedy, Jr., announced in a video statement posted on social media that Covid-19 vaccines had been removed from the Centers for Disease Control and Prevention (CDC) recommended immunization schedules for healthy children and pregnant women. Three days later, the CDC updated its recommendation materials, removing guidance that endorsed use of the vaccines during pregnancy and altering its language regarding healthy children from a recommendation for routine administration to a statement that the vaccine may be administered if desired by parents and informed by shared decision making with their clinician.1 The CDC Advisory Committee on Immunization Practices (ACIP), the expert panel that typically develops vaccine recommendations, was not included in this work, and on June 9, Kennedy announced that all 17 members of the committee had been removed.
These changes are the most recent developments in what has been an extraordinarily turbulent period for U.S. vaccination policy. Since the second Trump administration began, federal health officials have sent mixed messages regarding the importance of measles vaccines in response to large outbreaks in Texas and other states, cancelled or postponed meetings of vaccine expert advisory committees at the CDC and the Food and Drug Administration (FDA), terminated grants from the National Institutes of Health (NIH) for research on vaccine hesitancy, announced a new regulatory framework for Covid-19 vaccines that will most likely delay the availability of updated vaccines, suggested that the CDC vaccination schedule could be responsible for rising rates of chronic diseases in children, and targeted for elimination the multibillion-dollar U.S. contribution to the global immunization activities of Gavi, the Vaccine Alliance, among other actions. Each of these moves could adversely affect vaccination efforts, and together they have created a climate of confusion and uncertainty that further threatens public health and the continued success of vaccination programs.”
Revised Recommendations for Covid-19 Vaccines — U.S. Vaccination Policy under Threat | New England Journal of Medicine June 18, 2025
Consumers
BLS: Consumer spending: In 2024, consumer spending increased across all income groups, with the most significant increases observed in higher-income households. Real average spending for low-income households increased by 7.9%, middle-income by 13.3%, and high-income households by 16.7% relative to January 2018. While higher-income households experienced the largest spending increases, their spending growth has recently slowed, with a notable increase at the very top end (above $600K).
Bureau of Labor Statistics: Monthly household spending:
Motley Fool: average household spending:
| Total | Housing | Food | Transportation | Healthcare | |
| Amount | $6440 | $2120 | $832 | $1098 | $513 |
| % of monthly spending | 100% | 33% | 13% | 17% | 8% |
| % of monthly income after taxes | 29% | 11% | 15% | 7% |
American Households’ Average Monthly Expenses: $6,440 Motley Fool February 25, 2025 https://www.fool.com/money/research/average-monthly-expenses
Consumer sentiment: “US consumer sentiment dipped to a three-year low in May amid tariff-driven anxiety that inflation will come roaring back, the Associated Press reports. The University of Michigan’s consumer sentiment index fell to 50.8, its lowest point since June 2022 and the second-lowest level in almost 75 years. The country’s biggest retailer recently acknowledged that it was beginning to raise prices to cope with new import taxes that were imposed earlier this year.
US consumer sentiment slides to 3-year lows as trade war raises inflation anxiety | AP News
JPMorgan Institute study: Rental household economics: “For renters already managing tight budgets, added housing costs translate into a meaningful loss of disposable income. Our findings show that the financial effects are both immediate and durable, as rent shocks rapidly ripple through household budgets. These increases lead to higher rent-to-income ratios, push more renters into financially strained categories, and trigger immediate spending cutbacks. Quantifiably, every additional dollar in rent compels renters to reduce non-housing consumption. In percentage terms, a 1 percent rent increase leads to a 0.27 percent decline in overall spending. These responses mirror those observed following income shocks, suggesting that rent hikes function, in economic terms, like a forced pay cut for millions of renters…
Rent inflation has tangible, everyday repercussions for over 21 million rent burdened renter households. Our report reveals that an average annual $1,032 rent increase does more than just add to financial burdens, it reverberates across many aspects of renters’ economic well-being. While recent rent growth has slowed, rents have stabilized at significantly elevated levels compared to pre-pandemic norms, creating persistent affordability challenges. The high propensity for spending displacement, particularly for Severely Burdened renters (who cut $0.54 from nondurables for every $1 in rent increase), suggests that measures aimed at alleviating rent stress such as targeted rental assistance could be effective. For these renters, a substantial portion of rental assistance would likely be reallocated to non-housing consumption, thereby supporting both renters’ stability and local economies as these funds flow directly into goods and services.”
When the rent comes due: Impact of inflation on renters’ financial security
JPMorgan Institute: Homeownership affordability: “Today’s first-time buyers face the toughest path to homeownership in decades. Post-pandemic increases in home prices and interest rates led to a rapid deterioration in housing affordability. In 2019, only one-in-five people thought that home prices would rise by 20% or more over the subsequent 5 years… Over the next 5 years ending December 2024, nationwide home price indices rose about 50% indicating how far the housing market moved relative to expectations. Meanwhile, the 30-year fixed mortgage rate rose from 3.7% at the end of 2019 to 6.9 % at the end of 2024. This combination of higher prices and rates caused monthly mortgage costs to double for would-be buyers.
Incomes have not kept up with housing cost increases—even for younger individuals, who historically have higher wage growth on average. Median income growth from December 2019 to December 2024 was 41% in nominal terms for the cohort of individuals aged 25−44 in 2019. After adjusting for overall consumer price inflation, this performance was below the pre-pandemic trend.4 The average age of first-time homebuyers rose to an all-time high of 38 years old in 2024, according to a survey from the National Association of Realtors, as individuals needed to climb further up their career ladder to afford a home…
Housing affordability reached a historically low level due to increases in home prices and interest rates relative to incomes from 2019 to 2024. Unique data used to measure income changes at the individual level more precisely capture the financial challenge facing young individuals seeking to become first-time homebuyers. To buy a comparable home, a household would have to increase its budget allocation to a mortgage payment by 45 percent as of December 2024, compared to December 2019. Lower-income individuals, who have lower rates of homeownership and stock market participation, have been relatively disadvantaged by the rise in asset prices. Geographic differences in affordability dynamics have been notable since the pandemic. The densely populated urban centers of large cities have experienced notably less home price appreciation relative to the suburbs and more rural areas.
The decline in housing affordability is feeding into disparities in financial health…”
The affordability gap: Is home ownership still within reach in today’s economy?
Economy
Fed holds line on rate cuts: “In line with forecasts, The Federal Open Market Committee announced Wednesday that it will not cut rates, holding for the fourth time this year. The decision comes as Trump’s quick-changing tariff policies with top trade partners have spooked businesses and investors for the past several months. CME FedWatch, which anticipates interest-rate changes based on market moves, had projected a 99% chance of steady rates in June.
Fed Chair Jerome Powell has expressed concern that Trump’s trade plans will negatively impact US companies and consumers, and said that the central bank is waiting to see the clear impact of these policies before making a rate-cut decision.”
Fed Holds Interest Rates Steady in June – Business Insider
B of A Fund Manager survey: The survey conducted from June 6 to June 12 with responses from 190 fund managers overseeing over $520 billion in assets: Highlights:
“The headline numbers pack a punch: 66% of fund managers now anticipate a “soft landing” for the global economy, up from 37% in April. And while 82% of respondents in April predicted weakening growth, only 46% hold that view in June. That’s the largest two-month sentiment swing since last year’s presidential election. Recession fears have diminished drastically — now, 36% of respondents think a downturn is “unlikely.”
“…diffusing trade tensions, rolled-back and somewhat stabilizing tariffs (expected by about 75% of investors to be an average of 15% or lower), and better-than-feared U.S. economic data are the big factors. While the world warms up, sentiment toward U.S. assets is increasingly bearish…
Concerns over the sustainability of U.S. fiscal policy are also prevalent, with 81% expecting recent spending bills to significantly add to national debt. Treasury yields are predicted to climb, possibly reaching 5%.”
Stock market investor sentiment bounces back from Trump tariffs: BofA survey
Medicare Trustees forecast: “Certain features of current law may result in some challenges for the Medicare program. For example, physician payment update amounts are specified for all future years. These amounts do not vary based on underlying economic conditions, and they are not expected to keep pace with the average rate of physician cost increases…
Medicare’s costs under current law rise steadily from their current level of 3.8% of GDP in 2024 to 6.2 % in 2049. Costs then rise more slowly before leveling off at around 6.7% in the projection period’s final 25 years. Under the illustrative alternative, projected costs would continue rising steadily throughout the projection period, reaching 6.7% of GDP in 2049 and 8.8% in 2099.
In 2024, Medicare covered 67.6 million people: 60.3 million aged 65 and older, and 7.3 million disabled. About 50% of these beneficiaries have chosen to enroll in Part C private health plans that contract with Medicare to provide Part A and Part B health services. Total expenditures in 2024 were $1,122.1 billion, and total income was $1,133.3 billion, which consisted of $1,122.3 billion in non-interest income and $11.0 billion in interest earnings. This $11.2 billion difference means assets held in special issue U.S. Treasury securities increased to $407.9 billion.
2025 Medicare Trustees Report June 18, 2025
American Enterprise Institute on AI usefulness in healthcare cost containment: “While many expected the modernization of health care with technology to naturally address waste, history has not borne this out. Electronic health records are a classic example: initial reports projected tens of billions in cost savings that never materialized.3 Because electronic health records were designed largely to serve as billing instruments, their broad adoption has simplified some tasks but also added friction and complexity. As long as new technologies are used to optimize revenue generation instead of patient care and experience, waste reductions will remain elusive. This principle holds true within each category of waste, tempering the promise of AI with caution…”
Artificial Intelligence and Health Care Waste—Promise or Peril? | Health Policy | JAMA Health Forum | JAMA Network June 13, 2025
Pitchbook on PE climate for healthcare: The current uncertainty surrounding US trade policy exerts significant pressure on middle-market companies. The B2B and B2C sectors—together representing more than half of all PE-backed companies—are particularly exposed…
Compounding these structural vulnerabilities, middle-market companies now confront a heightened recession risk…
PE exits in healthcare had an encouraging start to 2025 with an estimated 28 exits for an aggregate of $4.1 billion in Q1. Healthcare accounted for 20% of total middle-market exit value and count in the first quarter, a significant jump from the 10% share the sector took in 2024 and higher than the five-year average…
Going forward, healthcare exits could benefit from the sector’s lower exposure to tariff risks compared with more commodity-driven industries, and the sector will need to focus on cost-saving solutions to mitigate any impact from tariffs and high interest rates.
Healthcare exit activity in Q1 continued to build on the sector’s recovery, which had seen YoY growth in 2024 and ended two years of decline. Still, healthcare exits have a long way to go, as 2024 activity marked the second-lowest total in the past 10 years, and recent macro uncertainty may pose additional challenges. The recent increase in exit activity could also indicate that some sellers are succumbing to the prolonged holding times of their assets.
Tariff and recession risks put mid-market PE exits on the back foot – PitchBook
Hospitals
Study: site neutral payments: “Technological innovation has successfully permitted the safe and effective performance of some surgical procedures in lower-cost ambulatory surgery centers (ASCs) in place of the hospital inpatient setting. Concurrently, policy experts and the US Congress have proposed adopting site-neutral payment (i.e., paying the same amount for a service regardless of where it is performed) to promote safe and cost-effective care, with the Committee for Responsible Federal Budget estimating that site-neutral payment could save $153 billion over a decade. As procedural innovation advances, specialties can optimize procedures to improve quality, safety, and lower cost: ophthalmology is no exception.
A New Vision for Site-Neutral Policy | Cataract and Other Lens Disorders | JAMA Ophthalmology | JAMA Network June 9, 2025
Study: Site Neutral payments: Researchers analyzed 2013–20 Medicare claims data, comparing spending under site-neutral rates with spending under site-based rates and using difference-in-differences analysis to assess the effect on hospital-physician integration. “During the period 2017–20, most Medicare payments were unaffected by the Bipartisan Budget Act: Only 1.5% of outpatient department spending occurred at site-neutral facilities. Counties subject to the Bipartisan Budget Act did not show a statistically significant difference in the percentage of hospital-integrated physicians (2020 estimate: −0.2 percentage points). The act did little to reduce Medicare spending or hospital-physician integration, suggesting that site-neutral legislation could be strengthened by reducing exceptions.”
Hospital bad debt increasing: “Bad debt is rising among some hospitals, largely driven by an increased burden on patients to cover the costs of care…
As of April, bad debt as a percentage of gross revenue had increased at a median 2.9% year over year, according to an analysis from consulting firm Kaufman Hall, which pulled data from about 700 hospitals.
Many hospitals are reaping the benefits of higher volumes, but more patients do not necessarily translate into a stronger balance sheet. Much of the payoff depends on payer mix. Hospitals serving a larger portion of uninsured patients or patients covered by government payer plans tend to be more at risk for bad debt balances.”
Hospital bad debt rises as patients must cover more costs – Modern Healthcare
Study: Hospital Discharges to PAC Settings among Medicare Beneficiaries: “Between 2018 and 2022, hospital discharges to PAC settings declined overall, but discharge patterns and hospital LOS vary considerably between MA and Traditional Medicare.” Key findings:
- Hospital Discharges: In 2018, MA plans had 192 discharges per 1,000 beneficiaries, compared to 223 discharges per 1,000 in TM By 2022, the discharge rate has decreased for both MA and TM beneficiaries to 180 and 178 per 1,000, respectively
- Discharges to PAC: Between 2018 and 2022, MA hospital discharges to PAC increased by 5.6% from 338 to 357 beneficiaries per 1,000 MA discharges TM hospital discharges, however, decreased by 1.5% from 401 to 395 per 1,000 TM discharges
- Hospital Length of Stay Across all PAC settings, MA beneficiaries have consistently longer average and median LOS compared to TM beneficiaries
20250514_PAC Analysis Findings.pptx
Physicians
Study: PE Ownership in gastroenterology: “This difference-in-differences event study and economic evaluation analyzed data from US gastroenterology practices that were acquired by PE firms between 2015 and 2021. Commercial claims covering more than 50 million enrollees were used to calculate price, spending, utilization, and quality measures from 2012 to 2021. The data were analyzed between April 2024 and September 2024.
Results: Data from more than 1.1 million patients (mean [SD] age, 47.1 [8.4] years; 47.8% male patients) undergoing 1.3 million colonoscopies were analyzed…. Colonoscopy prices at PE-acquired gastroenterology practices increased by 4.5% relative to independent gastroenterology practices. The estimated price effect increased to 6.7% when considering only colonoscopies performed by gastroenterologists in PE-acquired practices with market shares above the 75th percentile (24.4%) in 2021 as treated. Colonoscopy spending per physician increased by 16.0% while the number of colonoscopies and the number of unique patients per physician increased by 12.1% and 11.3% respectively; however, these spending and utilization measures were already increasing prior to PE acquisition. No statistically significant associations were detected for the 6 quality measures analyzed.
Conclusions and Relevance: In this economic evaluation, PE acquisition of gastroenterology practices led to higher prices and spending but had no discernible effect on quality. Policymakers may be well advised to monitor PE investment in physician practices given the increase in prices and spending without a commensurate increase in quality.”
Opinion: Primary care remedy: “The fees for primary care are low. They’re set that way deliberately by the RUC (the Relative value scale update committee) which is dominated by specialists and essentially sets Medicare fees, which are then followed by most private insurers. So, most doctors tend to look at the top end of this chart rather than the bottom they are choosing their residency slots. American health care is expensive because we have too many specialists doing marginally useful care, and too many hospitals (and pharma and device companies) making bank off them…
There are 340 million Americans. We can give everyone a PCP and put them in a panel of 600 people (as opposed to the 2-3,000 typical PCP panel. That number happens to be what MDVIP and other concierge services offer. That would require 570 thousand PCPs. Which is about 60% of doctor’s post-residency in America.
So, if we converted all those currently licensed PCPs and added NPs, we could give EVERYONE in America concierge style care. Those doctors would be immediately available and help their patients navigate the system…
My contention is that we could give each PCP $2k per patient (or $1.2m per 600 patient panel), of which they could use (my guess) $300-500k to run their practice, and they could keep $700K to pay themselves.
So, my proposal is we give everyone really high-end primary care, pay primary care docs really well and save a boatload of money. And apparently we have nearly enough primary care docs to do it. For sure if they were paid $700K a year we’d soon find plenty more of them.”
How to Fix the Paradox of Primary Care – The Health Care Blog June 16, 2025
Policy
RWJ analysis of House budget bill: National healthcare spending would decline by $797 billion over the next decade.
- 36% of this decline would occur in California, Florida, Texas, and New York.
- Declines in healthcare spending would exceed $20 billion in 9 additional states (Arizona, Georgia, Illinois, Indiana, North Carolina, Ohio, Oregon, Pennsylvania, and Washington).
- Hospitals would see the biggest decline in spending ($321 billion). Physicians would see an $81 billion cut.
The United States would see a $204 billion increase in uncompensated care over the next decade.
- The largest increases in uncompensated care would be in California ($27.5 billion), Texas ($15.9 billion), New York ($13.1 billion), and Florida ($11.7 billion).
- Hospitals would face a $63 billion increase in uncompensated care, and physicians would face a $24 billion increase.
Researchers project additional provider revenue losses if Congress also allows tax credits that reduce millions of people’s healthcare premiums to expire at the end of 2025.
- Under this scenario, researchers find there would be an additional $262 billion decrease in healthcare spending.
- Demand for uncompensated care would increase by an additional $79 billion.
Reconciliation Bill Effects on States’ Healthcare Spending and Uncompensated Care
Study: Impact of House version budget cuts to healthcare: “In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years…
Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16,642 annually, according to a mid-range estimate…”
Opinion: Need for refreshed value agenda: Formal value-based payment programs have operated nationally at least since the 2008 enactment of the Medicare Improvements for Patients & Providers Act (MIPPA). The Centers for Medicare & Medicaid Services (CMS) has primarily overseen these programs for the entirety of their existence, yet 17 years later, there is still no consistent set of best practices for compensating what is considered value in risk-based healthcare arrangements—reduced demand for future services.
The Trump administration, through its Department of Government Efficiency, has been scouring the federal government to root out waste, fraud and inefficient spending. An opportunity exists at the Center for Medicare and Medicaid Innovation (CMMI); CMMI has never relied on available commercial tools and methodologies that could save the government upwards of $8 billion annually, simply by more accurately capturing the value present in reduced demand for health care services. For providers, these methods could result in significantly greater shared savings paid out.
Because CMS and CMMI employ multiple, distinct monetization methods, providers are left in the dark as to which of these two values is the correct monetary expression of value…The future of value-based care partly hinges on establishing a consistent, transparent, and objective approach to monetizing value created in delegated risk arrangements.
CMS’ Pay-For-Performance Paradox | Health Affairs June 16, 2025
Polling
AP-NORC Poll about Budget Bill: “Interviews for this survey were conducted June 5-June 9, 2025, with adults aged 18 and over representing the 50 states and the District of Columbia. Highlights:
“The public is not aligned with the priorities of Donald Trump’s “big bill” that is expected to reduce federal spending and extend tax cuts. Most people think the federal government spends too little on many of the federal benefit programs that the budget bill could cut.
A majority of adults think the federal government is already under-spending on key safety net programs including Medicare and Social Security. They also feel the country is not investing enough in education.
Roughly half the public feel spending is too low for Medicaid and food and nutrition programs like SNAP. About 3 in 10 think current spending is about right. Less than a quarter feel spending is too high.”
| Is the federal government spending for… | % Too
much |
% About the
right amount |
%Too
little |
| Assistance to other countries | 56 | 25 | 17 |
| Border security | 32 | 37 | 29 |
| The military | 31 | 37 | 31 |
| Food and nutrition assistance | 24 | 30 | 45 |
| Medicaid | 18 | 31 | 50 |
| Education | 14 | 25 | 60 |
| Social security | 8 | 30 | 61 |
| Medicare | 7 | 32 | 60 |
Few want spending reductions on federal benefit programs – AP-NORC
KFF tracking poll: Opinions about the Budget Bill:
- “The “One Big Beautiful Bill Act” that was passed by House Republicans and is currently being discussed by the U.S. Senate is viewed unfavorably by a majority of adults (64%), including large majorities of independents and Democrats. Six in ten Republicans have a favorable opinion of the bill, but this support is largely driven by supporters of the Make America Great Again (MAGA) movement, while two-thirds of non-MAGA Republicans view the bill unfavorably…
- favorability of Medicaid, the health care program for low-income adults and children is now at 83%, including majorities of Democrats (93%), independents (83%), and Republicans (74%). “
- A majority of the public (68%), including nine in ten Republicans and MAGA supporters, as well as half of Democrats support Medicaid work requirements as described in the House bill…”
https://www.kff.org/medicaid/poll-finding/kff-health-tracking-poll-views-of-the-one-big-beautiful-bill KFF Health Tracking Poll: Views of the One Big Beautiful Bill June 17, 2025
Milbank survey: Opinions about Medicaid: Researchers surveyed 1571 U.S. adults about public attitudes toward Medicaid funding cuts. Highlights:
“Medicaid has strong support across the political spectrum: There is near total opposition to cuts from Democrats (94%), but there is also very strong opposition among Independents (81%) and significant pushback from Republicans (51%). State-level patterns similarly reflect deep opposition to cuts in red states, where 74% oppose spending cuts, as well as in blue states, where 78% oppose cuts. Among Medicaid beneficiaries, for whom the stakes are exceptionally high, 88% oppose cuts. But even people who do not receive Medicaid oppose decreased Medicaid spending (73%).
Most people think that Medicaid is effective at providing coverage and protecting access to health care Americans view Medicaid more positively than political rhetoric suggests… Roughly 67% of Republicans and 90% of Democrats believe that Medicaid is effective at keeping people from becoming uninsured. Similarly, 68% of Republicans and 92% of Democrats believe that Medicaid is effective at protecting access to health care. And most Americans recognize who stands to suffer acutely in the face of cuts: 71% of Republicans and 94% of Democrats think that Medicaid is effective at protecting the health of families with low incomes.
Medicaid Cuts Are Undemocratic and Not What the American People Want | Milbank Memorial Fund
McKinsey: Consumer sentiment: “We conducted a targeted survey in May to understand how tariffs are shaping consumer concerns and behaviors. What we found was that net sentiment1 dropped 32% in May, a 9% swing from the previous quarter. While inflation remains consumers’ top concern, tariffs have quickly risen to second place. In the United States, 43% of consumers reported rising prices as their top concern, followed by tariff policies (29%). This comes as little surprise, given how much the discussions of global trade have occupied the American media and how engaged with tariff-related news US consumers said they have been (91% of consumers in the United States heard about tariffs in the news or discussed the topic with others).”
PK note: In the McKinsey Poll cited above, 22% said “the ability to make ends meet” and 16% said “cost and accessibility of healthcare” as their 3rd & 4th biggest concerns.
US consumer spending trends 2025 | McKinsey May 30, 2025
Pew on Media Preferences: The Pew Research Center media preference study is based on a survey conducted March 10-16, 2025:
“Democrats and independents who lean toward the Democratic Party are much more likely than Republicans and GOP-leaning independents to both use and trust a number of major news sources. These include the major TV networks (ABC, CBS and NBC), the cable news networks CNN and MSNBC, major public broadcasters PBS and NPR, and the legacy newspaper with the largest number of digital subscribers, The New York Times.
Republicans, meanwhile, are much more likely to distrust than trust all of these sources. A smaller number of the sources we asked about are more heavily used and trusted by Republicans than Democrats, including Fox News, The Joe Rogan Experience, Newsmax, The Daily Wire, the Tucker Carlson Network and Breitbart.”
Which News Sources Republicans and Democrats Use and Trust: Report | Pew Research Center
HealthEdge 2025 Annual Study of Health Plan Performance: Excerpts of its survey of 4500 consumers:
“51% of consumers now view their plan as a “partner in care” vs. a “payer of claims,” and those who do report dramatically higher satisfaction, lower cost sensitivity, and a more substantial likelihood of recommending or retaining their current plan. 78% of members who view their health plan as partners are satisfied with their plan’s ability to deliver a personalized experience, compared to only 49% of those who see their plan as a payer.
High out-of-pocket and/or monthly costs remain a top frustration and a top influencing factor when consumers mention switching health plans for the second year in a row. Additionally, 32% of consumers blame health insurance companies, only slightly behind the government (36%), for the high costs and inefficiencies of the U.S. healthcare system…While 1 in 3 consumers reported no frustrations with their health plan, 2 in 3 ranked costs, limited in-network providers, and confusing explanations of benefits and coverage as their top issues – the same issues as last year’s survey and consistent with their top reasons for switching health plans.
Overall, member satisfaction remains higher in some groups than others, but loyalty can’t be taken for granted. 34% of members report being extremely satisfied with their health plan today. Older adults (ages 65+) are the most satisfied, averaging 47% being extremely satisfied…However, consumer loyalty is in question, with 27% of members indicating that they are somewhat or very likely to switch health plans within the next year, down slightly from 29% in 2024.
- 57% of members have experienced a denial over the past 12 months, and 74% (almost 3 in 4) felt that the denial was unfair
- 31% say they were able to receive timely access to care only “sometimes” or “never.”
- 27% skipped or delayed care due to an issue with their health insurance plan. The top reasons members gave for delaying/skipping care were: Out-of-pocket costs or co-pays too high (31%), Trouble finding a qualified care provider in my network (21%) and Authorization was denied (17%)
- 28% reported having received a Surprise Bill and most of them either paid the bill anyway or disputed it with their insurance plan. 10% said approval timeframes for their prior authorizations were unreasonable.”
PK Note: The report does not provide methodology information useful to interpretation i.e. online or telephone data collection, sample construction and screening criteria, results from prior surveys for comparison, actual wording of questions, et al.
Consumers Split on Health Insurance as ‘Partner’ or ‘Payer’ According to HealthEdge Researchfile:///C:/Users/Owner/Downloads/2025-healthedge-consumer-study-report%20(1).pdf
Qlik AI Healthcare Survey: conducted by Censuswide Research among 2,002 employed US respondents ages 18+ between April 17 and 23, 2025 for Qlik, a data analytics company:
“69% of Americans are comfortable sharing their health data to improve their own care, only 40% are comfortable sharing that same data with tech companies for AI-driven products. Despite growing AI integration in healthcare, only 28% would accept a prescription written solely by AI, highlighting deep-rooted trust concerns.” Other findings:
- 71% reject medicine prescribed exclusively by AI.
- 50% of Gen Z adults are comfortable with government using their health data for policy, while only 36% of seniors agree.
- 41% think insurers already leverage their data.
Prescription Drugs
Propublica investigation: offshore drug manufacturing safety: “To understand how risky drugs could end up in our medicine cabinets, ProPublica spent more than a year investigating the U.S. Food and Drug Administration’s oversight of foreign factories accused of violating critical quality standards. Reporters focused largely on factories in India, a key supplier of the world’s generic drugs.
The investigation exposed how the FDA, without warning the public, allowed more than 150 drugs or their ingredients into the United States over the past dozen years even though they were made at factories banned from shipping products here. The agency did not routinely test the drugs as they were circulating in the United States or actively track whether consumers had been harmed.
The FDA and several former agency officials told ProPublica they believed the medications that were exempted from import bans were safe. They said the agency required generic drugmakers to conduct additional quality checks before the drugs were sent to the United States, including extra drug-safety testing and bringing on third-party consultants to verify the results.”
We Spent a Year Investigating How the FDA Let Risky Drugs Into the U.S. Market — ProPublica
AEI experts on CBO scoring of drug development: The experts argue that the Congressional Budget Office scoring of policy changes and resulting costs with respect to drug development inadequately consider 3 factors that might alter their forecasts:
- Post Approval Research: The CBO model only considers impacts on new drug development, not the essential role of continued development of drugs post initial approval.
- Capital Mobility and Global Development: The CBO model also assumes that if a drug candidate is expected to be profitable, even if it is less profitable after a policy change, it will still receive investment for clinical trials to receive approval. Market realities suggest otherwise.
- Health Impact: Finally, the CBO model does not measure any impact on health. The model calculates the number of new drugs that are not developed. However, if a policy deters investment in drugs with limited health benefits, it may effectively steward scarce resources. Conversely, if a policy deters investment in the clinical study of highly effective treatments for diseases without effective therapies, the negative impact is much greater.
Modeling Drug Development: Improvements Still Needed | American Enterprise Institute – AEI
Public Health
U.S. birthrate decline: “Americans in their 20s and 30s are planning to have fewer children than a decade ago, according to a Pew Research Center analysis of government data. The total number of children that women and men ages 20 to 39 planned to have, on average, dropped from 2.3 in 2012 to 1.8 in 2023. Those numbers remained stable from 2002 to 2012…
In 2023, the total number of children that men and women ages 20 to 39 planned to have fell below 2.1. This is important because 2.1 is about the average number of children, per woman, that a population needs to replace itself over time.”
US adults in 20s and 30s plan to have fewer kids than in past | Pew Research Center
Study: Impact of Medicaid expansion on health and mortality in low-income population: Researchers examined data of 37 million individuals identified by linking the 2010 Census to administrative tax data. Findings: We find that expansions increased Medicaid enrollment by 12 % and reduced the mortality of the low-income adult population by 2.5% suggesting a 21% reduction in the mortality hazard of new enrollees… These expansions appear to be cost effective, with direct budgetary costs of $5.4 million per life saved and $179,000 per life-year saved falling well below valuations commonly found in the literature. Our findings suggest that lack of health insurance explains about 5-20% of the mortality disparity between high- and low-income Americans. We contribute to a growing body of evidence that health insurance improves health and demonstrate that Medicaid’s life-saving effects extend across a broader swath of the low-income population than previously understood.”
National Bureau of Economic Research Working Paper, May 2025
