Healthcare is infrastructure. Treat it like infrastructure.

Universal coverage is no longer a left-right debate in any honest sense — every advanced economy in the world has it; the United States is the outlier. The American debate is over the path. Single-payer Medicare for All would consolidate purchasing power and eliminate insurer overhead, at the cost of a transition that displaces existing employer-sponsored coverage. Public option proposals add a Medicare-like plan to the ACA marketplace, preserving choice while creating downward price pressure. State-level single-payer pilots (proposed in California, New York, Vermont, others) would create a controlled experiment but face federal preemption issues. Medicaid expansion in the remaining holdout states would cover roughly 4 million Americans currently in the coverage gap, a gain achievable without federal action. The honest framing: the question is not whether we will have universal coverage, but how long the holdouts can sustain the political fiction that we don't need it.

From the creation of Medicare Part D in 2003 until 2022, the federal government was statutorily prohibited from negotiating prescription drug prices for Medicare beneficiaries — a gift to the pharmaceutical industry that cost Medicare and seniors hundreds of billions over two decades. The 2022 Inflation Reduction Act narrowly lifted that prohibition. The first round of negotiations, completed in 2024, covered ten drugs and produced negotiated prices 38-79% below previous list prices. The next rounds expand the list each year. The substantive policy levers going forward: shorten the long market-exclusivity windows before drugs become negotiation-eligible, extend negotiated prices to private payers (currently only Medicare benefits), end evergreening abuse where minor reformulations extend monopoly periods, and cap insulin and other essential medicines at predictable prices. The political question is whether subsequent administrations will use the authority aggressively, weaken it, or repeal it under industry pressure.

Private equity acquisitions in US healthcare have grown rapidly over the past two decades: physician practices (especially specialty groups), nursing homes, hospitals, ER staffing, dialysis clinics, dental chains, autism services. The financial logic is consistent — extract immediate returns through cost cuts, debt-financed dividend recaps, real-estate sale-leasebacks, and short-hold exits. The clinical consequences are now well documented. Studies of PE-acquired nursing homes show measurable increases in mortality and decreases in staffing. Studies of PE-acquired hospitals show increases in adverse events. ER staffing chains owned by PE were central to the surprise-billing crisis. Reform options range from disclosure (require PE ownership of healthcare entities to be public, with rolling reporting on staffing and outcomes) to structural (ownership caps, mandatory minimum staffing ratios with real penalties, restrictions on real-estate sale-leasebacks that strip facilities of their underlying assets, cooling-off periods before PE-owned hospitals can be sold). The throughline: healthcare is not a product where market discipline produces good outcomes when patients can't shop.

The 2008 Mental Health Parity and Addiction Equity Act required insurers to cover mental health and substance use treatment at parity with physical health. Compliance has been chronic. Insurers maintain narrower networks for behavioral health, deny coverage at higher rates, and apply prior-authorization requirements that don't apply to comparable physical-health services. Beyond parity enforcement, the binding constraint is workforce: the US trains nowhere near enough psychiatrists, psychologists, social workers, and substance-use counselors, and Medicaid reimbursement rates for behavioral health are often well below cost. Reform priorities: meaningful parity enforcement (with penalties for repeat violators), Medicaid rate increases for behavioral health, scholarship and loan forgiveness for behavioral health workforce, and expanded community-based crisis response (988, mobile crisis units, alternatives to police-led mental health calls).

Two related collapses are happening at the geographic and demographic margins of the US healthcare system. First, more than 130 rural hospitals have closed since 2010, and many more have shuttered their labor-and-delivery units while remaining open as smaller facilities. The closures concentrate in non-Medicaid-expansion states and are driven largely by uncompensated-care costs that expansion would have absorbed. Second, the US maternal mortality rate is the worst among advanced economies and has been rising — with a roughly 3:1 gap between Black and white maternal mortality that has widened in recent decades. Both crises are reversible with policy: Medicaid expansion in the holdout states, federal support for rural-hospital labor-and-delivery service lines, the Black Maternal Health Momnibus package of bills, and Medicaid coverage extension to twelve months postpartum (now adopted in most states but not all). None of this requires inventing new ideas; it requires implementing existing ones.