‘Murica

In August, Yale researchers led by Alison Galvani published an analysis (https://www.medrxiv.org/content/10.64898/2026.07.22.26358689v1) estimating that a Medicare-for-All-style system would cut national health spending by $1.04 trillion a year — about 20% — while covering everyone. It's a preprint, not peer-reviewed, and the savings lean on three big assumptions stacked together (drug pricing, provider rates, one billing system). Stress-test those down to something more conservative and the number shrinks a lot. It doesn't disappear, though — some real savings survive almost any reasonable version of the model, which ended up mattering more to me than the headline figure.

That's basically what the Congressional Budget Office found (https://www.cbo.gov/publication/57637) too, back in 2022, modeling five illustrative single-payer designs: results ranged from a $700B decrease to a $300B increase in national spending, depending almost entirely on how providers get paid. The financing label doesn't determine the outcome. The rules inside it do.

So which rules actually work? Maryland's been testing one answer since 2014 — every hospital paid under the same regulated rates, on a global budget instead of fee-for-service. Hospital expenditure growth has run 8.74 points below the national average, saving Medicare an estimated [$1.6B](https://www.mathematica.org/publications/evaluation-of-the-maryland-total-cost-of-care-model-progress-report), and a 2025 Health Affairs study, (https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2025.01324) found utilization dropped 11 points more than in comparable states. Nobody had to abolish private insurance. CMS liked it enough to build its new AHEAD model (https://www.cms.gov/priorities/innovation/innovation-models/ahead) directly on Maryland's template.

Put those together and I don't think the honest answer is "pass 'Medicare for All' in one vote and hope." I believe it's a sequence: fix provider prices and hospital incentives first (the biggest, best-tested levers), negotiate drug prices without betting the whole plan on it, standardize the paperwork, then build a public option that covers the people the current system already fails — and only let it expand as far as the results justify. Nobody's employer coverage gets ripped up overnight, and nobody has to win an argument about the size of government first.

I laid the whole thing out step by step, with sources: [A Step-by-Step Path to Medicare for All (https://brokenpromiseshealthcare.org/step-by-step-path-to-medicare-for-all)

A phased in approach seems better to me than betting everything on Day One. I am sure a lot of you disagree with me. I would like to hear your ideas.

I am a final-year MD student currently studying in the Philippines. Somewhere along the way, I completely lost interest in clinical medicine. I am looking for guidance on how to transition into a new career path with or without a masters and relocate to a country with better professional opportunities once I earn my degree. I am interested in administrative or health-tech roles related to healthcare, provided they do not require incurring significant student debt and offer a strong job market.

Federal efforts to increase PBM transparency are putting greater attention on whether changes to rebates and compensation ultimately lower pharmacy costs.

I saw Homer Simpson episod asking to astronaut things like this.

I applied a the major hospitals in Houston. (Methodist, MDA, Texas Children’s) Has anyone heard back about interviews? The MD Anderson website says interviews start tomorrow but I haven’t heard a thing. Feeling bummed because I got a first round interview last year. At least a rejection would end my suffering lol

The Florida suit keeps getting posted like “see PBM logos are cosplay.”

It’s Prime and Express Scripts. Pharmacies are mad reimbursement went down after a 2019 contracting deal. Fine. That’s a pharmacy payday story.

It is not “patients got robbed” and it is not “nobody competes.” Plans still shop PBMs. Prime still does its own claims. Sharing manufacturer leverage is how you don’t pay list price like an idiot.

If every bit of scale gets called co-opetition, the only PBM people will accept is one too weak to negotiate. Cool slogan. Terrible benefit.

The jobs that I was told were for Healthcare Administrators, are all now saying RN required. Im confused as to how an RN would have the background knowledge to do finance for a clinic? This has been almost every job I've seen. I can't do a fellowship as it would be a dramatic drop in pay. Im just not understanding the jobs that fit this degree.

There is something I wish more patients and families understood about what is happening in healthcare right now. Sometimes your nurse is worried about you too.

We know when we have too many patients. We know when we're being asked to do more than can reasonably be done in twelve hours, and we know when that starts creating risks for the people we're taking care of. We see the call lights waiting while we're tied up in another room. We know there's a confused patient who needs to be watched closely, somebody else who needs help getting to the bathroom, medications that need to be given, an admission coming, assessments that still need to be completed, and another patient whose condition just doesn't look quite right. All of those things can be happening at the same time.

Most of us know exactly what good nursing care is supposed to look like. That's actually part of what makes this so difficult. We know the care we want to provide, and we know when our workload isn't giving us a realistic chance to provide it.

I also want people to understand that this isn't about nurses wanting an easier job. Nursing has never been an easy job and nobody with any experience expects it to be. It isn't about wanting more money either. What we want is enough staff, enough time and enough resources to take care of our patients safely. There is a huge difference between being busy and being responsible for more care than one person can reasonably provide.

There's another side of this that patients probably don't think about very often. Your bedside nurse may not feel safe telling you any of this.

You might have a good relationship with your nurse and ask, "Do you think you have too many patients today?" Maybe you can see how overwhelmed everyone is and you just want an honest answer. The problem is that giving you an honest answer can put that nurse in a terrible position.

Suppose your nurse tells you that they're worried about the staffing. You're understandably upset, so you go to administration and say, "My nurse told me this isn't safe." Now the focus can shift away from the staffing problem and onto the nurse who said something about it.

That nurse has a family too. They have a mortgage or rent, groceries, health insurance, kids and people depending on their paycheck. Nurses shouldn't have to choose between being honest with a patient and protecting their livelihood, but that is a position many nurses are understandably afraid of being put in.

So I'm asking patients and families to help us in a slightly different way.

Please don't put your bedside nurse on the spot and ask them to declare whether the staffing is safe. Ask the people who are responsible for the staffing.

Ask the charge nurse, nursing supervisor, nursing director or hospital administration how many patients your nurse is responsible for that day. But don't stop with the number. Ask how the hospital determined that assignment was appropriate for the needs of the patients on the unit.

That second question matters because six patients aren't always just six patients. Six people who are alert, medically stable and mostly able to take care of themselves are one thing. Six people who are confused, incontinent, medically complicated, unable to transfer safely, at high risk of falling or requiring extensive assistance with basic care are something completely different. The ratio can look exactly the same on paper while the actual amount of nursing care required is nowhere close.

If you're still concerned, tell the nursing supervisor, nursing director or patient advocate: "I'm concerned that the current nursing staffing may not be adequate to safely meet my loved one's needs. I would like my concern formally documented, and I would like to know how the hospital determined that the current staffing is adequate for the patients on this unit."

You don't need to yell at anyone or accuse somebody of negligence. You don't even have to know for certain that the staffing is unsafe. You're a patient or family member asking a reasonable question about whether there are enough people available to provide the care that is needed.

If you don't feel like your concern is being addressed, ask how to file a formal patient grievance. Keep your own notes too. Write down the date, approximately what time something happened, what you asked for, how long you waited, who you spoke with and what response you received. Stick to what you actually saw and heard.

I can't promise that doing this will suddenly cause another nurse to appear on the unit. It probably won't. But there is value in patients and families making these concerns known themselves, especially through the hospital's formal channels. Staffing problems are much easier to treat as an internal employee complaint when the only people talking about them are nurses.

If your nurse is running from room to room and it takes too long for someone to answer your call light, please understand that the nurse running down that hallway probably didn't decide how many nurses would work that day. The nurse apologizing for your wait probably didn't create the staffing budget either. Sometimes the person you're frustrated with is every bit as frustrated and worried about the situation as you are.

We want to answer your call light. We want to have time to sit down and explain your medications. We want to notice that small change in your condition before it becomes a big one. We want to help you to the bathroom instead of finding out that you tried to get there by yourself because nobody came quickly enough. We want to give you the kind of care we'd want someone to give our own families.

Patients deserve safe care, and nurses deserve a realistic opportunity to provide it. If you are worried that there aren't enough nurses, don't ask the bedside nurse to take the risk of saying it for you. Ask the people making the staffing decisions to answer for those decisions themselves.

Sources and Further Reading

AHRQ: Nursing and Patient Safety

Background on staffing, workload, patient acuity and patient safety.

AHRQ: Missed Nursing Care

Explains delayed or omitted nursing care.

CMS: Find a Patient Advocate

Information about patient advocates.