This is a very brief review of Rock Health founder Halle Tecco’s Massively Better Healthcare. Halle is trying to do something quite complicated in this book. It’s really a three-part attempt to help somebody who is relatively new to health care entrepreneurship understand what the hell they are getting into. 

The first part is a brief assessment of the current US healthcare system. If you’ve been working in health care for a long time you can probably skip this but if you’re an entrepreneur coming into American healthcare for the first time, it’s a good introduction. It may though not be enough given how messed up and complex the American system is. There are of course plenty of other great books to read about that. It’s not really Halle’s aim to do more than warn you about the mess the system is here.

The second part is essentially a guide to how to do innovation and how to build a company. This is very valuable. I wish Halle had written more in this part and included more of the work she’s done with the many companies she has stewarded and invested in because there’s another book to be dragged out of her about this. ( I’m sure she would hate me for saying this having just finished this one!). But I wanted to know more about all the boardrooms and strategy sessions she’d been in and the conversation she had about company building. For me this was the best part of the book because it has a lot of great nuggets about innovation. I just wish there’d been more here and that the examples were longer and deeper.

The last section of the book is four good rules for what works and what doesn’t and that’s a lot of useful stuff in there as well. She ends the book with an impassioned plea for people to come and fix the health care system, by working on individual problems within it by taking what she calls Smart Shots. 

To me this appeal is overly optimistic but it’s also probably the only way that people can actually fix anything in health care given the current state of the system. She actually references the cranky old guard (which I think I include myself in) but I think she’s specifically talking about people who have spent a long time in big hospital systems or health plans and feel that nothing can be changed from within. Because those organizations are so rich and powerful I personally think the only way to really change health care is to have a “meteor hitting the Earth” extinction event for them, but I’ve written enough about that elsewhere. 

So all in all I think Massively Better Healthcare is a very valuable read especially for somebody coming into healthcare with intention to fix the system. But I think it will help those people make health care better incrementally rather than massively.

I think I will actually prefer the sequel, so long as what happens in that is that we get more out of Halle about the experiences she’s had and the companies she’s worked with. There is probably nobody better to deliver a real tell-all about the “warts and all” of building health tech startup companies and although we got a good flavor from her in this first book, I think that there is actually a lot more to come from her.

Matthew Holt is the publisher of THCB

By ANISH KOKA

I was listening to a conversation between two critical thinkers I respect greatly: geneticist/technologist/blogger Razib Khan and Washington Post columnist Megan McArdle. Their discussion was a freewheeling rant about the problems they see with the rise of populism on the left and right, but a throwaway comment related to the US physician shortage in the context of needing high skilled immigrant labor towards the end of the almost two-hour conversation made me realize how little people really know about healthcare in America. Of course, everyone knows certain aspects of healthcare as a consumer very well, but even if you are a high-IQ individual who can make use of the vast information at all of our fingertips, it is hard to really know what the reality on the ground is without living it / having deep knowledge. Interestingly enough, early on Megan and Razib both acknowledge the impossibility of commenting on the situation in Iran, because the Iraq war taught them the folly of making conclusions from the available information. Bottom line, it doesn’t matter how smart you are if your conclusions are based on reading Colin Powell on the weapons of mass destruction Saddam Hussein must have. The public may not realize it, but health policy has a similar problem. The vast majority of academics “covering” American health policy, and in charge of describing healthcare, are ideologues whose main goal is not to describe reality, but to fashion a story. And as any screenwriter will tell you — do not let the facts get in the way of a good story.

What follows is an examination of what happens when you pull one of the important healthcare threads that forms the bedrock of many healthcare opinions that smart people like Megan and Razib hold: Rural access to healthcare in America.

First, here’s what a Google search reveals — and notice the sources. I assure you that PubMed is not much different. Rural healthcare access in America must be bad, right?

Once we establish that healthcare access in rural America is “bad”, there are all sorts of conclusions that are downstream from that like funding of rural hospitals, and management of the physician labor supply.

But the strange thing about the rural healthcare access problem that should strike anyone over a certain age that has followed/lived healthcare is that we have been talking about this and passing legislation on the matter forever, and yet if you are to believe those who should have the most knowledge about these things, we continue to fall short.

Understanding what exactly is happening requires some knowledge of the legislative sausage that has created the current landscape. Understanding the laws and more importantly how they are implemented should quickly make the reader understand why there is a powerful incentive to maintain a certain narrative.

A brief summary of some major legislation currently on the books exposes exactly why it may be so important to maintain a certain narrative on rural health care access.

The Critical Access Hospital (CAH) designation, created by the Balanced Budget Act of 1997 after a wave of rural closures, gave over 1,300 hospitals cost-based Medicare reimbursement — meaning Medicare pays whatever the hospital reports it cost to deliver the service.

The Rural Health Care Access Act of 2025 (H.R. 771) goes further, eliminating the distance requirement that a hospital must be more than 35 miles from another hospital to qualify as a CAH, extending cost-based reimbursement to hospitals that were never remote enough to meet the original threshold.

The Rural Emergency Hospital (REH) designation allows low-volume rural hospitals to drop inpatient beds while retaining emergency and outpatient services — and receiving additional federal payments — with recent legislation proposing to extend eligibility to hospitals that closed as far back as 2014.

Congress has also allocated new Medicare-funded Graduate Medical Education (GME) residency slots specifically for rural hospitals, even though a December 2025 GAO report found that 95 percent of the hospitals receiving slots were geographically urban hospitals that had legally reclassified themselves as rural to qualify.

The Rural Health Focus Act formally authorizes the CDC Office of Rural Health with dedicated appropriations, and the Fair Funding for Rural Hospitals Act modernizes disproportionate share hospital payments with a $20 million per-state funding floor.

Perhaps most consequentially, one of the primary political shields against site-neutral payment reform — the policy that would equalize Medicare reimbursement regardless of whether a service is delivered in a hospital outpatient department or a physician’s office — a change that would save Medicare tens of billions annually comes from those arguing that this change would close hundreds of rural hospitals within six months.

Every one of these programs represents a funding line. And every attempt to close the loopholes in these programs is quickly crushed with an avalanche of moralizing about saving money on the back of the indigent. You can understand that there are a lot of interests that have much to gain by promulgating a rural health care access gap. Nowhere is the spin on American healthcare more obvious than when it falls to academics to critique it. Academic health policy wonks nationally and internationally consistently rank American healthcare as woefully inadequate relative to our peer nations that have some form of nationalized/socialized healthcare.

This narrative has a powerful institutional home. The Commonwealth Fund’s Mirror Mirror report, probably the most widely cited international healthcare comparison, has ranked the United States last or near-last among high-income countries in virtually every edition for the past two decades. The report’s methodology leans heavily on insurance coverage, administrative burden, equity metrics, and survey-based measures of patient experience. Countries with national insurance systems — the United Kingdom, Canada, and the Nordic countries — score well on the access dimension almost by definition, because universal coverage is treated as equivalent to universal access. The American system, with its patchwork of private insurance, Medicaid, and Medicare performs poorly on these metrics and gets ranked accordingly. These rankings are then cited in congressional testimony, think-tank reports, and op-ed pages as evidence that the American healthcare system is inferior — that Americans get less for more, and that a national insurance program would fix it.

But what good is a national insurance card if there is no hospital within the critical 90 minute time window when you have a heart attack? Insurance coverage and geographic access to care are not the same thing. A patient in rural Canada has universal coverage but may wait hours for an ambulance to reach a cardiac cath lab — if one is reachable at all. A patient in rural Nevada may be uninsured and be at a PCI-capable hospital in 40 minutes. The former is counted as “access” in the Commonwealth Fund framework. The latter is counted as a failure. The rankings measure the bureaucratic architecture of insurance systems, not the physical reality of whether care can be delivered, especially when it is most urgently needed.

So how about we actually try to quantify the American patchwork and compare it to one of our peer nations that is supposed to be a model for us — our Medicare for All Canadian neighbor.

Percutaneous coronary intervention — the procedure that opens a blocked coronary artery during a heart attack — is close to an ideal proxy for healthcare access broadly. It is definitionally time-sensitive: the ACC/AHA guidelines set a 90-minute door-to-balloon target for a reason, and delays beyond that threshold carry measurable mortality/morbidity consequences. It requires significant infrastructure — a catheterization laboratory, trained interventional cardiologists, a specialized team available around the clock. It is therefore not uniformly distributed across geographies. And crucially, it is a procedure where we have excellent public data on exactly where it is being performed.

Access to PCI is not a perfect proxy for access to all medical care. But if a community has a functioning PCI program within reasonable distance, it almost certainly has the broader infrastructure — emergency services, hospital beds, advanced imaging, specialist coverage — that defines a functional healthcare ecosystem. The inverse is also roughly true: communities far from PCI tend to be far from the rest of advanced care as well. PCI access is a reasonable healthcare canary.

When you measure the actual distance between where Americans live and where the nearest cath lab is — using real hospital data and population-weighted geography — what do we find?

Building the maps — and what they show

How the U.S. map was built

The foundation is a 2006 paper by Nallamothu et al. in Circulation — still the most rigorous published analysis of geographic PCI access in the United States — which found that 84% of Americans live within 60 minutes of a PCI-capable hospital. Using Medicare billing records for DRG codes 246–251 to identify 1,322 hospitals actively performing PCI, and replicating the Nallamothu methodology with updated data, I find essentially the same result. No comparable developed nation approaches this level of access — and I will get to what the closest peer comparisons actually look like below.

But a simple county choropleth — color each county by drive time — has a fundamental problem: it treats a county of 600 people identically to one of 600,000. The vast empty counties of the interior West look alarming on the map, and their sheer geographic mass dominates the visual.

The policy-relevant question is not which counties are far from PCI, but whether the people who live in those counties are far from PCI — and whether the population density in those areas justifies the kind of infrastructure investment the rural access narrative calls for.

To answer the question I built a bivariate map encoding both dimensions, population density, and distance to a PCI-capable hospital. Counties are assigned to three density categories using the 50th and 90th percentiles of the county density distribution — percentile-based thresholds rather than arbitrary absolute cutoffs.

I then defined three access bands anchored to the ACC/AHA guideline for opening a blocked artery in the setting of an acute heart attack: within 30 minutes, 30 to 90 minutes, and beyond 90 minutes. Beyond 90 minutes is an important threshold that defines the point where most individuals will have a cardiac scar or worse if they are outside this time window for artery opening.

The centroid problem — and why it matters

Creating a database of drive time from a hospital requires defining where to measure from. The United States is separated into counties, and taking the geographic center of the county (the geographic centroid) as the distance to measure from creates some meaningless distortions because the population in any given county is not necessarily clustered in the middle of the county. Large western counties where nearly all the population is clustered in one corner of a vast area explain why the simple geographic centroid fails so badly.

Click on the map to be taken to an interactive map

Reno sits in the southwest corner of Washoe County, home to Renown Regional Medical Center and St. Mary’s Regional. But Washoe County extends hundreds of miles into the Nevada desert. Its geometric centroid lands 43.5 miles from Renown, in an area where essentially nobody lives — and an earlier version of a map I made marked it red. Luckily, the Census Bureau publishes population-weighted centroids for all 3,143 U.S. counties in the CenPop2020 file, calculated from 2020 block-level data. Washoe’s population-weighted centroid is 3.8 miles from Renown. That is the correct number, and so I used population-weighted centroids for every U.S. county.

What the U.S. map actually shows

The striking finding is not about dense counties — dense counties cluster around cities, and cities have hospitals. The striking finding is about the moderate and sparse counties: even at low population densities, a surprisingly large share of the American population is within the 90-minute guideline window. But despite the enormous federal apparatus dedicated to rural healthcare access, 2.2 million Americans in moderate-density counties and 9.5 million in sparse counties — roughly 11.7 million total, or about 3.5% of the population — live beyond 90 minutes from a PCI hospital. Those are the people the rural access legislation is ostensibly built for, and after decades of CAH designations, GME slot carve-outs, Rural Emergency Hospital programs, and billions in cost-based reimbursement, that is what remains.

Click on the map for an interactive version

The peer comparison problem — the U.S. is genuinely without peers

Every international comparison of healthcare access implicitly assumes the countries being compared are meaningfully comparable. They are not — at least not for this question. The United States is the third-largest country in the world by land area and the third most populous. No high-income democracy comes close to combining both. The United Kingdom has 68 million people in an area smaller than Oregon. The Nordic countries together have fewer people than the greater New York metropolitan area spread across a landmass that is mostly accessible by road. These countries face no meaningful analog to the American geographic access problem.

The countries that do approximate the U.S. in scale — Russia, China, India, Brazil — fail so comprehensively on PCI access that no meaningful comparison is possible. Russia has perhaps 100 PCI centers for 144 million people across 11 time zones. China’s cath lab infrastructure is heavily concentrated in coastal cities. India and Brazil have dramatic urban-rural gradients at a severity that makes rural Nevada look well-served. These are not peer comparators. They are cautionary tales about what actually happens when healthcare infrastructure is insufficient at continental scale.

This is why international access rankings that place the United States alongside Belgium, the Netherlands, and New Zealand are not measuring the same thing. A country the size of Maryland with universal insurance and three PCI centers serving a compact population is not navigating the same access challenge as a country spanning four time zones with 335 million people. The Commonwealth Fund framework does not account for this, but the bivariate maps do.

Canada: the closest legitimate comparison — and a sobering one

Canada is the most defensible peer comparison — similar legal and institutional tradition, similar income level, physically adjacent, and frequently invoked by American reform advocates as a model. But making the Canadian map involved different choices than the U.S. map.

The Canadian map uses census divisions rather than counties — there are 282 of them, compared to 3,143 U.S. counties. PCI center locations were compiled from CIHI Cardiac Care Quality Indicators and provincial cardiac network directories rather than from a Medicare billing equivalent, because Canada has no public analog to the CMS procedure-level data. The 30 centers identified are the best available count, but the sourcing is less rigorous than the U.S. approach.

More importantly, the density thresholds for Canada are calculated separately from Canadian census division percentiles — sparse below 17 per square mile, moderate 17 to 213, dense above 213 — rather than applying U.S. thresholds. Canada is just so darn sparsely populated overall that applying U.S. density thresholds would classify virtually every Canadian census division as sparse, collapsing the bivariate analysis into a single meaningless category. Even with Canada-specific thresholds that are far more forgiving than U.S. ones (what counts as “dense” in Canada would be “moderate” in the United States) the comparison is still stark.

Baber et al. in Open Medicine (2011) found that 63.9% of Canadians aged 40 and older live within 60 minutes of a PCI facility, versus 84% of Americans. That 20-point gap reflects a country where 30 PCI centers serve 38 million people spread across the world’s second-largest landmass, concentrated almost entirely within 125 miles of the U.S. border. Applying the same bivariate methodology, approximately 10.9 million Canadians — 28.7% of the total population — live beyond 90 minutes from a PCI hospital. That includes:

• 4.4 million in sparse census divisions beyond 90 minutes (11.5% of population)
• 5.5 million in moderate-density census divisions beyond 90 minutes (14.4%)
• 1.1 million in dense census divisions beyond 90 minutes (2.8%) — a category that contains zero Americans

Those 1.1 million Canadians in dense-but-far census divisions represent the starkest contrast with the United States. They are concentrated in the Quebec City–Trois-Rivières corridor — a populated, accessible stretch of southern Quebec that in any reasonable sense should be well-served. And yet, remarkably, it isn’t.

I manually checked this to make sure the code was correct. Here are the four dense census divisions and their nearest PCI hospitals:

• Francheville (Trois-Rivières area, 452,604 people): nearest PCI is the Institut universitaire de cardiologie et de pneumologie de Québec — 54.6 miles, estimated 110 minutes
• D’Autray (Berthierville area, 266,948 people): nearest PCI is the Montreal Heart Institute — 53.4 miles, estimated 108 minutes
• Shawinigan (195,640 people): nearest PCI is the Institut universitaire de cardiologie — 75.9 miles, estimated 147 minutes
• Montmagny (east of Quebec City, 150,022 people): nearest PCI is the Institut universitaire de cardiologie — 47.9 miles, estimated 98 minutes

To put the overall numbers in context: the U.S., with nearly nine times Canada’s population, has 11.7 million people beyond the 90-minute threshold — 3.5% of its population. Canada has 10.9 million beyond the threshold out of 38 million — 28.7%. On a per-capita basis, Canada’s access gap is roughly eight times worse than America’s, in a country where 90% of the population lives in a narrow temperate corridor along the world’s longest undefended border. A simple framing of American rural access as a crisis that demands X while holding up Canadian Medicare as a model tells me you are either uninformed or have a dog in the fight.

So where does this leave us?

The United States is not perfect. Eleven point seven million Americans live beyond the 90-minute window for emergency cardiac care, and that matters. Every one of those people deserves better. But the honest framing of that number is that it represents 3.5% of the population of a continent-spanning nation — and that no comparable country on earth comes close to matching it. Canada, the country most frequently held up as the model America should follow, leaves 28.7% of its population outside that same window, including over a million people in densely populated (by Canada standards) areas. Rural healthcare access is a genuinely hard problem at continental scale and the headline should be that the United States has solved more of that problem than anyone else.

And yet this is not the story you will read in the Commonwealth Fund reports, or in the health policy journals, or in the congressional testimony that precedes the next round of rural hospital funding. The dominant narrative — that American rural healthcare is in crisis, that we are falling behind our peers, that the system is failing — is maintained by two groups with aligned incentives. The first is the academic and advocacy class that wants a government-payer system and needs American healthcare to look broken to justify the overhaul. The Canadian comparison is instructive: the single-payer system they want Americans to adopt delivers measurably worse geographic access to emergency cardiac care than the patchwork they want to replace. The second group is the healthcare industry itself — the health systems, the hospital associations, the administrators of residency training programs and the hospitals that are all too happy to take advantage of a Medicare funded program that gives them free physician labor. All of this is fueled by funding streams that, in part, depend on the continued perception of a rural access crisis. The Critical Access Hospital program, the Rural Emergency Hospital designation, the rural GME carve-outs: every one of these represents money flowing to institutions, and every attempt to reform them is met with the same argument — that any change will close hospitals and kill patients.

The result is a policy landscape where the problem is never defined with real metrics, the funding is never tied to measurable access outcomes, and the same institutions that absorb billions in rural subsidies also lobby aggressively against meaningful legislation like site-neutral payment reform. Health systems swallow enormous amounts of federal funding and still cannot completely close the remaining access gaps. (What they can do, and do very effectively, is drive up the cost of care for everyone else.)

There are many other levers to pull on if we want to be truly exceptional and improve rural access for the 11.7 million Americans who remain relatively underserved. I hope I’ve convinced you that the simple Canadian option offered up by many would take us backwards, not forward. There are some far more sensible options that should have wide public support.

First, it would seem a smarter and a better long term solution to solve the physician scarcity problem in rural areas by allowing for those who grow up in these communities to travel a vastly accelerated path to becoming a general practitioner. At the moment a bright young kid in rural West Virginia is much more likely to run his own HVAC shop than run his own primary care practice. Any current primary care practitioner will tell you the HVAC route is a much smarter and more lucrative path than a route to becoming a physician that has you spending a minimum of 11 years after graduating from high school and accruing mid six figures worth of debt. It wasn’t always that way — a century ago, a young person could go from high school to practicing medicine in five or six years, and many of those physicians served exactly these kinds of communities. So Megan and Razib’s comment on physician shortages and the need for high skilled immigrant labor that isn’t possible to be sourced locally has a lot of layers to it. The “shortage” is partly a function of funding a lot of residency spots in rural areas, that are then filled by overseas physicians looking for an entry point to the US health care system. This framework is a policy choice that doesn’t even do a good job of ever fixing the problem because physicians from Lahore and Hyderabad (or their children, who overwhelmingly leave medicine/ choose to practice medicine in metropolitan areas) only stay in these communities if they have no other option. If we, for instance, stopped funding rural residency slots, these hospitals that are still awash in cash from a variety of other federal programs would choose different labor options (nurse practitioners/physician assistants/pay more to local family practice doctors to help staff patients), and suddenly you would have a very different looking landscape of “need” for physicians. Bottom line: if you are going to try to engineer something — make it more attractive for local members of the community to become physicians in their community rather than massively incentivizing rural hospitals to import physicians to fill a need that you created.

Second, if we are to use American tax dollars to close the rural access gap, we need to demand better outcomes. The data exists to measure, county by county, how far Americans actually are from emergency cardiac care, primary care, and basic surgical services. Tie funding to some mix of those measurements. If a rural health system is receiving cost-based reimbursement, GME training slots, and Rural Emergency Hospital subsidies, it should be required to demonstrate what access it is providing — next-day primary care appointments, 24/7 emergency coverage, PCI capability — and lose its designation (and funding) if it cannot.

Third, since we actually need more hospitals, we should break the monopoly C-suite has on the opening of new hospitals. The physician hospital ownership ban — a product of the Affordable Care Act, lobbied for by the hospital industry — prevents the people most likely to solve rural access problems from doing so. Physicians from rural communities who want to raise capital, build facilities, and deliver care are legally prohibited from owning the hospitals they would staff. The ban protects incumbent health systems from competition. It does nothing for patients. Consider what happens where physicians can own facilities: Atlas Surgery Center in Amherst, New York — a physician-owned ambulatory surgery center built by the neurosurgeons of University at Buffalo Neurosurgery — performs same-day awake endovascular neurosurgery, carotid stenting, Gamma Knife radiosurgery, and complex spine procedures that would otherwise require multi-day hospital admissions at far greater cost. It is the first ambulatory center in the country to offer outpatient Gamma Knife. That is what physician ownership produces when the law allows it. Now imagine that model applied to rural communities that need a hospital and have physicians willing to build one. Currently, the law says no.

The entire rural access debate is premised on the assumption that only large health systems backed by federal subsidies can deliver care in underserved areas. The evidence for this is thin. What the evidence actually shows is that when physicians are allowed to own and operate facilities — ambulatory surgery centers, imaging centers, urgent care networks — they deliver care at lower cost with comparable or better outcomes. Extending that model to hospital ownership in underserved areas is the most direct path to closing the remaining access gaps without the perpetual subsidy machine that has manifestly failed to close them over three decades.

The mountain to climb is high. The first step may be the hardest: cutting through the noise of motivated academics who control most of the messaging on health policy and healthcare access. The public should have a clear understanding that the crisis narrative they have been sold is not a description of reality but a product — manufactured by those who profit from it, whether in funding or in political capital. Should we try to do it even better? Of course.

But there is little hope of getting anywhere without a good grasp of the scope of the problem that faces us.

Anish Koka is a Cardiologist in Philadelphia. He writes on medicine and health policy on his substack where this was originally published and also cohosts a weekly podcast : The Doctors Lounge

Link to PCI access US/Canada Interactive maps | More on map methodology, limitations

By MATTHEW HOLT

I know you all care, so I am giving a 7th update on the telenovela about my Labcorp bill for $34.95.

The very TL:DR summary of where we are so far is that in May 2025 I had a lab test to go with the free preventative visit that the ACA guarantees, but I was charged for the lab tests and I was trying to find out why, because according to CMS I should not have been.

For those of you who have missed it so far the entire now 7 part series is on The Health Care Blog (1, 2, 3, 4, 5 & 6). Feel free to back and read up.

Where we left it last, Brown and Toland (the IPA between my plan Blue Shield of California and Labcorp) told me that on 8/29/2025 their benefits department had finished their review and reported that the original lab test wasn’t coded as preventative lab services by One Medical, so that the co-pay of $34.95 was correct. ($34.95 was the total agreed payment for all the tests, charged at a total of $322.28. And as it was less than my $50 copay, LabCorp only charges the patient for the total, not the $50!). That call was on December 18 and resulted in update 6.

I next (well about a week later later because life, etc) requested One Medical to resubmit the bill coding it as preventative. That happened on Dec 24, 2025 and someone called Alexis working for One Medical, while exhibiting terrible life skills, replied on Dec 25 and sent it on to their billing department asking them to recode it. I followed up on Jan 15 and Alexis at One Medical confirmed that the billing department had faxed the updated codes to Labcorp. I presumed that Labcorp would resubmit the claim to Brown and Toland and I would eventually get a $0 bill from them.

However, today (4/9/26) I called Brown and Toland about a different telenova — a coinsurance I had received for a dermatology office visit. While I had the rep on the phone, I asked about the Labcorp bill from May 2025. She told me that the benefits team at Brown and Toland had decided on December 18 — that’s right, before I contacted One Medical to ask them to resubmit the claim — that the codes should have been classified as preventative and that I don’t owe the $39.94. Of course Dec 18 was the last time I called Brown and Toland when they said that I had to have One Medical resubmit the claim to Labcorp. Sounds a little coincidental that very same day their benefits team re-reviewed the claim and decided that it should change to being preventative. But who am I to complain or raise a fuss!

Just to add to the complication, on Dec 29 someone within Brown and Toland (customer service?) received that message from the Benefits team and sent it over to the “Epic team” which I assume deals with outliers, with a request to reprocess it. As of today (April 9, 2026), that reprocessing had not happened.

As it happens they may not bother. Labcorp way back when agreed not to send me to collections, and I don’t know if they care enough to go after Brown and Toland for the $39.94, or have just given up on it. More likely if the claim is reprocessed, it will probably be tossed into the capitated amount they already got paid. Which is why the “payment” for my two subsequent lab tests was $0.

So I think we may be at the end of this series. (OK, if you read part 6 there are a couple of other tests Brown and Toland think I should be paying for but no one has sent me a bill for those yet and I may just let sleeping dogs lie).

But don’t worry, there’s always more stupidity in the way Americans deliver and pay for health care, so I’ll keep talking about it. Until we blow up the system and build one that works.

Mathew Holt is the Founder & Publisher of THCB

By MIKE MAGEE

This past week, Donald Trump decided to get into a war of words with a person with dyslexia. His target was the Governor of California, Gavin Newsom, who has struggled with the learning disability since the age of 5.

The President’s action was premeditated and intended to take the potential Democratic 2028 Presidential contender down a peg. It got pretty personal pretty fast. Trump was direct as is his way. He said simply, “Everything about him is dumb.”

In response, the governor broadened the conversation to include young Americans with the condition with these targeted words of encouragement, “To every kid with a learning disability: don’t let anyone — not even the President of the United States — bully you. Dyslexia isn’t a weakness. It’s your strength.”

Trump seemed surprised by the blowback from his “dumb” remark. It drew a stern rebuke from the Yale Center for Dyslexia and Creativity which reminded the President that approximately 20% of the US population is challenged by some form of this condition.

Fellow dyslectic, author and political commentator, Molly Jong-Fast,  quickly connected the political dots to current events: “Mr. Trump is a bully, but beyond that he tries to flatten things. Sometimes voters respond to this flattening, this simplification of complicated issues, but ultimately his refusal to see nuance in things, his inability to plan ahead, to see second- or third-order effects is his undoing (see: this war he has gotten us into).”

As the Yale experts put it, “Reading is complex. It requires our brains to connect letters to sounds, put those sounds in the right order, and pull the words together into sentences and paragraphs we can read and comprehend. People with dyslexia have trouble matching the letters they see on the page with the sounds those letters and combinations of letters make. And when they have trouble with that step, all the other steps are harder.”

Neuroscientists couldn’t agree more. Language is indeed complicated.  At least five areas have been identified as role players in coordinating human capacity for language and speech.

For the dyslexic, it’s a problem with language processing. The learning issues vary widely and can include difficulties with word recognition, numeracy, spelling, writing, reading, word and symbol recognition. Taken together, these difficulties often translate into deficits in organization, motor skills, visual discernment, planning, social interaction, and short term memory. A common early flag is delayed literacy.

Gavin has been nothing short of an open book when it comes to dyslexia.  On tour in support of his new memoir, “Young Man in a Hurry: A Memoir of Discovery” last month, he revealed the challenge of being a politician unable to read a speech. In Atlanta recently, he said, “I’m no better than you. You know, I’m a 960 SAT guy.”

Ironically, Gavin’s current critic has learning issues of his own. Back in 2019, Professor Harriet Feinberg Ed.D from the Harvard Graduate School of Education took a close look at Trump’s 1st term linguistic behavior and came to the conclusion that “Dyslexia may explain a lot about the twisted behavior of the president.”

Feinberg peg’s Trump’s reading level at 5th grade – “enough to tweet and to follow a teleprompter, but not enough to comprehend a longish article in the Wall Street Journal. . . He could never have read his textbooks at Wharton School. Someone would have had to read them aloud to him or create bullet points she would grasp the main ideas.”

In Dr. Feinberg’s experience, dyslexia doesn’t predict every individual’s fate. Personality has a huge impact on future outcomes. For Trump couldn’t measure up as a child, and likely began faking it at age 6 or 7 and never stopped. Early failures were covered up, paved over, and sheltered by family wealth and connections.

Dr Feinberg summarized succinctly her evaluation during Trump’s first term. She said he likely “faked and falsified his way to fame and power and enjoys overlording it over so-called “smart” people and thwarting their hopes. I am suggesting that Trump’s lifelong experience with dyslexia, instead of increasing his capacity for compassion, has instead combined with problematic elements in his personality, including a penchant for revenge that was apparent even when he was a young adult.”

Attacking Gavin Newsom for an inherited disability that the governor had the courage to disclose has come back to bite a President already under siege. Fakery, grandiosity, and cruelty work well for a media personality. But governing a nation by shelving expertise and knowledge, rejecting deep cultural experience and diplomacy (while surrounding yourself with loyal sycophants who you enjoy publicly torturing as you once did in the schoolyard, or under the glare of your fake televised boardroom) is clearly not a recipe for success.

According to Dr. Feinberg,  dyslexia is the key to solving the mystery that is Donald Trump, a boy with a penchant for revenge. Summarizing, she explains, “Because it was so hard for him to learn from books–coupled with his unwillingness to listen to people with deep knowledge and alternative perspectives–he nurtured resentment and mistrust…he exhibits a combative complacency, a receptivity to unworkable and dangerous ideas, an admiration of dictators, and an almost savage destructive push that is causing severe ongoing harm to our democracy.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical-Industrial Complex. (Grove/2020)

By HANS DUVEFELT

(Note: Hans is rerunning some of his greatest hits. This one is from 2014 and leans right into my current and future obsession with fixing primary care-Matthew Holt)

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.

Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)

DISEASE PREVENTION AND SCREENING

You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.

My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.

I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.

What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.

(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)

Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.

Hans Duvefelt is a physician, author, and creator of “A Country Doctor Writes” where this piece first appeared.

By KIM BELLARD

If all goes well, in the next couple of days NASA will be sending astronauts on their way to the moon, for the first time since – gulp – 1972. They’re not landing, mind you, they’re just doing a fly around, something Apollo 8 first did way back in 1968. Given the advances in microchips, computing power, AI, a robust private space industry, and Elon’s grand plans to inhabit Mars, it doesn’t really sound all that ambitious, hardly a “moonshot” in the sense that we’ve come to use that term, but I guess we should be glad that NASA hasn’t entirely conceded space to the billionaires.

The Artemis II mission will send four astronauts – including, if you are counting (and many are), the first person of color, the first woman, and the first Canadian to reach the moon — on a ten day, 230,000 mile trip that won’t actually orbit the moon but just loop around it, not getting closer than a few thousand miles. “Things are certainly starting to feel real,” Christina Koch, one of the four, said during a news conference Sunday morning.

Last week NASA unveiled its “Ignition” strategy that Artemis II is part of. It includes not just the fly-by, but also a follow-up mission in 2027, a manned landing in 2028, and a permanent moon base in the 2030’s, committing $20b over the next seven years to accomplish the latter. “NASA is committed to achieving the near‑impossible once again, to return to the Moon before the end of President Trump’s term, build a Moon base, establish an enduring presence, and do the other things needed to ensure American leadership in space,” said NASA Administrator Jared Isaacman.

He added: “Today, we are providing a demand for frequent crewed missions well beyond (previously announced moon landings in 2028). We intend to work with no fewer than two launch providers with the aim of crewed landings every six months, with additional opportunities for new entrants in the years ahead. America will never again give up the moon.”

I knew Elon and Jeff were going to get something from all this.

I hope the mission goes according to plan. I hope I live long enough to see a successful manned landing on the moon and even that lunar base. Then again, President Obama launched the Cancer Moonshot in 2016, aiming to “end cancer as we know it,” and there still seems to be plenty of cancer around. Sure, much progress has been made, but we’re still seeing disturbing trends like  “skyrocketing” increases in colorectal cancer rates in young adults.  

You might call Operation Warp Speed a moonshot, developing effective vaccines against the global COVID pandemic in a matter of months, but it has had the paradoxical result of a new wave of vaccine hesitancy generally, aided and abetted by the MAHA team heading up HHS in the Trump Administration. You wouldn’t consider our measles outbreak as what we’d expect from a vaccine moonshot.   

Similarly, Alphabet has a whole “Moonshot Factory” aimed at big breakthroughs, but none of its successes have revolutionized society or even been the Next Big Thing for Alphabet. “We have a 2% hit rate,” CEO Astro Teller told a conference last fall. “Most of the things we try don’t work out, and that’s okay.” Waymo and Wing are considered its big successes, but, I don’t know about you, neither is in my market yet.

A couple weeks ago I wrote about the U.S. military seems to have failed top learn the lessons of the way in Ukraine, continuing to rely on expensive weapons systems that are ill-equipped to deal with flights of AI-driven drones. A couple days ago Simon Shuster wrote in The Atlantic about his visit to Rheinmetall, the German arms manufacturer. He told his guide about how tanks in Ukraine had changed from being killing machines to being easy drone targets, and so had been modified to have nets and other anti-drone protections. His guide was abashed. “No,” he said. “We don’t have something like that.”

The Rheinmetall CEO was dismissive of Ukrainian innovation: ““It’s Ukrainian housewives. They have 3-D printers in the kitchen, and they produce parts for drones. This is not innovation.”

I beg to differ.

I think of all this in the context of an updated KFF analysis of hospital concentration. The key takeaways:

• “One or two health systems controlled the entire market for inpatient hospital care in nearly half (47%) of metropolitan areas in 2024.
• In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75 percent of the market.
• Nearly all (97% of) metropolitan areas had highly concentrated markets for inpatient hospital care when applying HHI thresholds from antitrust guidelines to MSAs.
• Most hospital markets in metropolitan areas (80%) became less competitive from 2015 to 2024 or were controlled by one health system over that entire period.”

I first wrote in 2015 about how hospitals were the biggest source of health care spending – as they had been in 1960, and as they are today. KFF says they accounted for 40% of our national health care spending growth from 2022 to 2024. With such concentrated market share, it’s easy to see why.

This is not innovation. Those are not the result of any moonshots. That is not the future.

Hospitals, to use an overworked analogy, are the health care system’s tanks (or aircraft carriers). Powerful but hugely expensive, relatively slow, steeped in traditions of prior wars. They should not be the mainstays of 21^st century medicine.

21^st century healthcare should not be “fought” with big, expensive, slow-to-produce assets. Even aside from hospitals, I mean, how long does it take to train physicians, at what expense? And once they are practicing, how long does it take to bring the new clinical findings into their actual practice? It’s ridiculous, especially in an AI era.

Similarly, how many billions does it take to develop new drugs, leaving how many years of patent protection?  With genetic manipulation, AI-assistance, and 3D printing, why aren’t we in the era of inexpensive, more effective prescription drugs?

We need the kind of innovation that Ukraine has brought to 21^st century warfare. Those are the kind of moonshots I want to see.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor