|
|
 |
Why Healthcare Is in a Death Spiral: Follow the Money December 1, 2025
If each of these is not a part of any 'reform,' than all that is being done is pouring money into a monopolizing cartel, just in a slightly different way.
Unbeknownst to those of us with little inside knowledge of the complex financial plumbing of the US healthcare system, healthcare is in a death spiral that will surprise everyone but insiders who grasp the system's unsustainability. To help us outsiders understand the death spiral, I asked a senior MD to guide us through "follow the money." Trump Blasts "Big, Fat, Rich Insurance Companies" As Lawmakers Propose Ways To 'Fix' Obamacare. Since this is the issue of the day and it falls within my expertise, here are some thoughts. Executive Summary Multiple conditions are aligning for a broad re-alignment of medical care delivery in the US, resulting in the development of a two-tiered delivery model: high-quality, efficient, innovating cash-pay for those who can pay and low-quality, wait-rationed care delivery for those who can't. If you can't afford it, don't get sick. Health systems make their money through inflated commercial real estate (CRE), sale of patient health information (PHI), consolidation of supply chains, and kickbacks in exchange for redirecting federal dollars. Absent a tiny sliver of procedures, the delivery of healthcare itself is a loss leader. It is a requirement for entry, not a source of value. As such, care delivery managed to prevent loss, not promote innovation. Most health system CEOs are financial engineers, not care delivery specialists, and compare the size of their real estate management infrastructure with their care delivery management infrastructure; the former is always much more robust than the latter. Insurers have become utilities, administering government payment programs. Their ability to bear risk as a business model was discarded with the ACA; they no longer have the infrastructure or talent to do so. You might as well ask them to make shoes. This monoculture, the corruption of monopoly and finally the response to the pandemic has crippled both. Health systems faced a profound interruption in throughput which they dealt with by tapping reserves, inflating CRE further, pushing the boundaries of PHI sales, increasing their kickback programs, and, most importantly, becoming fully dependent on the now ending government bailouts. Further consolidation and partnering with private money is their only path forward. Recent experience teaches that the private money will cut the delivery of healthcare to the bare minimum needed to maximize the other sources of value. A whole lot of administrators and c-suiters are also going to lose their jobs. After the ACA, the Insurer's only cash cow was the immensely overfunded and fraud-filled Value-Based Care (VBC) Medicare and Medicaid programs such as Medicare Advantage. The fraud is now being criminally prosecuted, the overpayments are gone, and the cost of care delayed during the pandemic and which the insurers now bear are being realized manifold. Insurers simply have no path forward other than as payment administrators. Look for massive consolidation, starting with the individual Blues. The government has been resistant, but now it's a choice of merger or bankruptcy. In 2028 probably only Coventry, United, and Centene will be left standing, no more blues. The ACA itself is in a death spiral. Envisioned as a universal mandatory risk pool, so many exceptions have been made that only the sickest and those who have no choice get their care there, the former being subsidized by the latter, the government, and ever dwindling coverage. The pandemic subsidies masked it and without them the coverage is non-sensical. Non-participation will be its end. In addition, government medical care programs have long been subsidized by suppressing payment for the resources used to obtain care delivery; clinicians, labor, administration, and even bedpans. Real wages for even the highest paying doctors working within the system haven't increased since 2010, nursing wages have gone up only because so many have become free-lancing agency workers. I got offered a locums position for $145/hour, the same as I was offered 8 years ago. All those resources are now worth more outside the system than inside. Thus, those resources are migrating to the cash-pay market. Used to be the huge government market and dependable payments was enough to overcome the difference in value between the two markets, cash vs third party. No longer. The legacy costs, management/leadership expertise and business models of current Fee For Service (FFS) health systems preclude all but the most highly branded health systems from competing in the cash-pay model. Access to the cash-pay market will vary based on jurisdiction: it's illegal in some states, hamstrung by others, free in still more. Look for policy to evolve into a high-dollar, deductible, roll-over Health Savings Account (HSA) with income-based subsidies paired with a government subsidized catastrophic care program. At least until the young and disaffected elect a socialist; then healthcare will be plentiful and affordable for all. A $2,000 direct payment to beneficiaries such as being currently contemplated is completely ineffectual, especially since it has to be borrowed and will just increase inflation that much further. True reform must include: 1.Invalidation of state and federal laws which restrict cash-pay. 2. Prohibition of not-for-profit (NFP) / Religious organizations from third-party payment programs. The competitive advantage of the tax-free business model and the inherent corruption it has engendered render their participation not in the public interest. Removal of restrictions on clinician ownership in healthcare delivery. Renewed criminal anti-trust enforcement in medical care delivery. Others can be added, but if each of these is not a part of any 'reform,' than all that is being done is pouring money into a monopolizing cartel, just in a slightly different way. No improvement will occur. It's not payments which need reform, it's delivery. And a lot of folks' paychecks depend on obfuscating that fact. Thank you, senior MD for the guided tour of healthcare's financial death spiral. I have long stated that healthcare in its current extractive-cartel form will bankrupt the nation all by itself: Why America's Healthcare (Sickcare) System Is Broken and Unfixable (July 16, 2014) Sickcare Will Bankrupt the Nation (March 21, 2011) My questions: 1. Is any of this financial plumbing actually private insurance, or is it all just sluicing government funding through a profitable skimming operation? 2. How can a 'healthcare' system that refuses to connect digital derangement, ultra-processed diet and poor fitness to 'health' possibly generate 'health' as an output? These questions are taboo because the answers would implode the entire system. Medicare costs: parabolic: 
Medicaid costs: parabolic: 
My new book Investing In Revolution is available at a 10% discount ($18 for the paperback, $24 for the hardcover and $8.95 for the ebook edition) through November. Introduction (free) Check out my updated Books and Films. Become a $3/month patron of my work via patreon.com Subscribe to my Substack for free My recent books: Disclosure: As an Amazon Associate I earn from qualifying purchases originated via links to Amazon products on this site. THE REVOLUTION TRILOGY: Investing In Revolution Ultra-Processed Life The Mythology of Progress Systemic Problems/Solutions Investing In Revolution (2025) Introduction (free) The Mythology of Progress (2024) Introduction (free) Global Crisis, National Renewal (2021) Introduction (free) Money and Work Unchained (2017) Introduction (free) A Radically Beneficial World (2015) Introduction (free) What You Can Do Yourself Ultra-Processed Life (2025) Introduction (free) Self-Reliance in the 21st Century (2022) Introduction (free) When You Can't Go On: Burnout, Reckoning and Renewal (2022) Introduction (free) Get a Job, Build a Real Career and Defy a Bewildering Economy (2014) Intro (free) Novels The Adventures of the Consulting Philosopher Intro (free) The Secret Life of an Asian Heroine First chapters (free) Become a $3/month patron of my work via patreon.com. Subscribe to my Substack for free Investing In Revolution print $18, (Kindle $8.95, Hardcover $24 (145 pages, 2025) 
Only now do we see that we've been investing in revolution for decades--not the revolutions we thought we were investing in, revolutions in technology and finance, but in the social revolution made inevitable by the extremes that we've reached in our single-minded pursuit of private gains.
The pendulum that we've pushed to an extreme will swing to the opposite extreme, and the artifices that have propped up a facade a stability for decades will accelerate the disorder rather than reverse it. We now stand at the point of decision, and this book offers a path to a reformation and renewal that serves the shared interests of us all, not just the few. Introduction (free) Ultra-Processed Life print $16, (Kindle $7.95, audiobook, Hardcover $20 (129 pages, 2025) 
Ultra-Processed Life: the substitution of a synthetic, commoditized, very profitable facsimile for what was once authentic.
Ultra-Processed Life is my term for everything that is analogous to ultra-processed snacks: attractively marketed, instantly alluring, easy to consume, addictive by design, tasty in the moment but harmful over time, its origins a black box of unknown processes, the brightly colored product bearing no resemblance to the real-world ingredients, an idealized form of what is inherently imperfect, untethered from the natural world. As with many others, the catalyst for my exploration was a life-threatening medical crisis that did not have a specific cause. This led me to wonder if our entire way of life is like an ultra-processed snack: tasty but not healthy, edible but stripped of the nutrients we need to be healthy, addictive by design. Introduction (free) The Mythology of Progress, Anti-Progress and a Mythology for the 21st Century print $20, (Kindle $9.95, Hardcover $24 (215 pages, 2024) audiobook, Read the Introduction and first chapter for free (PDF) 
What if the policies to accelerate growth are no longer working because our fix for every problem--growth at any cost--is failing? We're told Progress is inevitable as a result of technology, but everyday life is getting harder, not easier--the opposite of Progress, what I call Anti-Progress.
What if the real source of the unraveling is far deeper than economics or politics? What if the problem is what we see as the inevitable destiny of humanity--Progress--is actually a modern mythology, disconnected from the real-world consequences of growth for growth's sake? We indignantly reject that Progress is a mythology, but our need for mythology hasn't gone away because we've mastered technology; we've created a modern mythology of technology that is heedless of its own consequences. To truly progress, we need a new mythology aligned to 21st century realities. Read the Introduction and first chapter for free
Recent entries: Why Healthcare Is in a Death Spiral: Follow the Money December 1, 2025 24 Things I'm Grateful For November 28, 2025 A Stoic's Thanksgiving Gratitude November 26, 2025 The Middle Class Is Cracking November 24, 2025 Is AI a Catalyst for Growth--or For Collapse? November 20, 2025 What We've Lost November 18, 2025 Inequality Then and Now: Now It's Too Late November 14, 2025 Did the "Solution" Solve the Problem, Or Did It Just Make Somebody Rich? November 11, 2025 The Risk of AI Isn't Skynet November 6, 2025 The Inevitable Drift Down from "Can't Lose" Owning Stocks to "Can't Win" November 3, 2025
Contributions/subscriptions are acknowledged in the order received. Your name and email remain confidential and will not be given to any other individual, company or agency. All contributors are listed below in acknowledgement of my gratitude.
Mastery requires reading and doing.
Of Two Minds Site Links home musings my books archives books/films policies/disclosures social media/search Aphorisms How to Contribute, Subscribe/Unsubscribe sites/blogs of interest original music/songs Get a Job (book) contributors my definition of success why readers donate/subscribe to Of Two Minds mobile site (Blogspot) mobile site (m.oftwominds.com)
HUGE GIANT BIG FAT DISCLAIMER: Nothing on this site should be construed as investment advice or guidance. It is not intended as investment advice or guidance, nor is it offered as such.... (read more) WHY EMAIL TO THIS SITE IS READ BUT MAY NOT BE ACKNOWLEDGED: Regrettably, I am so sorely pressed for time and energy that I am unable to respond to the vast majority of emails. Please know I read all emails, but I can only devote a very limited number of hours to this blog and all correspondence.... Subscriptions to the Weekly Musings Reports Subscribers enable Of Two Minds to post free content. Without your financial support, the free content would disappear for the simple reason that I cannot keep body and soul together on my meager book sales alone. Your financial support is very much appreciated. Subscribers ($7/mo) and those who have contributed $70 or more annually receive weekly exclusive Musings Reports ($70/year is about $1.35 a week). Each weekly Musings Report offers four features: 1. Exclusive essay on an extraordinarily diverse range of insightful topics 2. Summary of the blog this week 3. Best thing that happened to me this week 4. From Left Field (a curated selection of interesting links) There are four easy ways to subscribe: Substack, Patreon, US Mail and Paypal: How to Contribute, Subscribe/Unsubscribe to Of Two Minds What subscribers are saying about the Musings: "What makes you a channel worth paying for? It's actually pretty simple - you possess a clarity of thought that most of us can only dream of, and a perspective that allows you to focus on the truth with laser-like precision." Jim S. Thank you very much for supporting oftwominds.com with your subscription or contribution.
Extra-Special Bonus Aphorisms:
"There is no security on this earth; there is only opportunity." (Douglas MacArthur) "We are what we repeatedly do." (Aristotle) "Do the thing and you shall have the power." (Ralph Waldo Emerson) "Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius and a lot of courage to move in the opposite direction." (E.F. Schumacher, via Tom R.) "He who will not risk cannot win." (John Paul Jones) "When we drink coffee, ideas march in like the army." (Honore de Balzac) "Progress is not possible without deviation." (Frank Zappa, via Richard Metzger) "Victory favors those who take pains." (amat victoria curam) "The man who has a garden and a library has everything." (Cicero, via Lee Bentley) "A healthy homecooked family meal and a home garden are revolutionary acts." (CHS) "Do you know what amazes me more than anything else? The impotence of force to organize anything." (Napoleon Bonaparte) "The way of the Tao is reversal" Or "Reversal is the movement of Tao." (Lao Tzu) "Chance favours the prepared mind." (Louis Pasteur) "Success consists of going from failure to failure without loss of enthusiasm." (Winston Churchill) "Where there is ruin, there is hope for treasures." (Rumi) "The realm of gratitude is boundless." (CHS, 11/25/15) "History doesn't have a reverse gear." (CHS, 12/22/15) Smith's Law of Conservation of Risk: Every sustained action has more than one consequence. Some consequences will appear positive for a time before revealing their destructive nature. Some consequences will be intended, some will not. Some will be foreseeable, some will not. Some will be controllable, some will not. Those that are unforeseen and uncontrollable will trigger waves of other unforeseen and uncontrollable consequences. (July 8, 2014)(thanks to Lew G. for retitling the idea.) Smith's Neofeudalism Principle #1: If the citizenry cannot replace a kleptocratic authoritarian government and/or limit the power of the financial Aristocracy at the ballot box, the nation is a democracy in name only. The Smith Corollary to Metcalfe's Law (The Network Effect): the value of the network is created not just by the number of connected devices/users but by the value of the information and knowledge shared by users in sub-networks and in the entire network. (CHS, 4/6/16) My Credo of Liberation: I no longer care if the power centers of our society--the distant, fortified castles of our financial feudal system--are changed by my actions, for I am liberated by the act of resistance. I am no longer complicit in perpetuating fraudulent feudalism and the pathology of concentrated power. I no longer covet signifiers of membership in the Upper Caste that serves the plutocracy. I am liberated from self-destructive consumerist-State financialization and the delusion that debt servitude and obedience to sociopathological Elites serve my self-interests. (Thank you, Klaus-Peter L., for reminding me) "We've become a culture of excuses rather than solutions: solutions always require sustained effort and discipline." (CHS 4/9/16) "Fraud as a way of life caters an extravagant banquet of consequences." (CHS 4/14/16) "Creativity = problem solving = value creation." (CHS 6/4/16) "Truth is powerful because it is the core dynamic of solving problems." (CHS 7/21/17) "We live in a system of human emotions that masquerades as a science (economics)." (CHS 1/1/18) "Always remember, your focus determines your reality." (George Lucas) "Diversity is for poor people. Sameness is for the successful." (GFB) "When power dissipates suddenly, it dissipates completely." (CHS 7/14/19) "Disobedience is the true foundation of liberty. The obedient must be slaves." (Henry David Thoreau) "Markets cannot price in the value of non-monetized natural assets such as diverse ecosystems." (CHS 7/14/19) "Magical thinking isn't optimism, it is folly." CHS 1/3/22) "Tune in (to self-reliance), drop out (of hyper-consumerism and debt-serfdom) and turn on (to relocalizing capital and agency)." (CHS 1/5/22) "The path to everything you desire starts here: like yourself as you are right now." (CHS 11/20/22) "There are only two signals: how many essentials you produce and share and if you're consuming less with better results. Everything else is noise." (CHS 12/17/22) "Liberation is no longer needing any confirmation or feedback from others or the world for one's sense of self. Wealth, fame, recognition, admiration, praise, prestige, approval, sainthood, martyrdom, success: none are needed, none are desired." (CHS 12/26/22) "When fame, wealth, prestige, status and glory are out of reach, you're free to pursue other more valuable things." (CHS 2/6/22) "It is the sacred duty of every activist who seeks to better their community to grow and share as much life-giving food as is humanly possible." (CHS 6/15/23) "Being anonymous, gray and unknown is the ideal state of freedom." (CHS 3/15/24) "We seem to have entered a world of anti-leisure and anti-productivity in which the unpaid shadow work demanded to keep all the complicated digital bits in motion obliterate our leisure and productivity." CHS (5/22/24) "It is axiomatic that failing systems work the best just before they fail catastrophically." Ray W. "Looking younger is mere technique; thinking younger demands creativity." CHS (10/16/24) "Tell me what's taboo and I'll tell you the truths that threaten the status quo." CHS (12/15/24) "This is the core of the Attention Economy: the ultimate addiction is the addiction to ourselves." CHS (1/28/25) "If You Seek the Truth, Look for What's Taboo." CHS (7/18/25) "My definition of self-reliance: the less you need, the easier it is to get what you need." CHS (7/26/25) "Mastery requires reading and doing." CHS (7/28/25) "The replacement of authentic value, quality, agency, choice, trust, legitimacy and experience with self-serving facsimiles is the key dynamic of Ultra-Processed Life, my term for the present-day human condition." CHS (8/12/25) "Ultra-Processed Life replaces an authentic experience with a synthetic, simulated, commoditized, highly profitable version that's superficially attractive but destructive over the long term." CHS (8/12/25) "What we see everywhere is the replacement of authentic things--including democracy--with synthetic facsimiles designed to maintain the illusion of choice and value." CHS (8/12/25) "Sometimes certainty is the enemy we don't even see and uncertainty is our most faithful ally." CHS (9/20/25) |
|
||||||||||
|
All content, HTML coding, format design, design elements, original images, videos and musical compositions
and recordings on www.oftwominds.com are protected by copyright © 2025 Charles Hugh Smith, All global rights reserved in all media, unless otherwise credited or noted.
Terms of Service:
All content on this blog is provided by Trewe LLC for informational purposes only. The owner of this blog makes no representations as to the accuracy or completeness of any information on this site or found by following any link on this site. The owner will not be liable for any errors or omissions in this information nor for the availability of this information. The owner will not be liable for any losses, injuries, or damages from the display or use of this information. These terms and conditions of use are subject to change at anytime and without notice.
Our Use of Generative AI Tools Policy:
Our Privacy Policy:
PRIVACY NOTICE FOR EEA INDIVIDUALS
Notice of Compliance with
The California Consumer Protection Act
Regarding Cookies:
Our Commission Policy:
|
|
|
|||||
| home email me (no promise of response, sorry, here's why) mirror site | |||||
