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Physician, author, and health care reform advocate David K. Cundiff discusses his article “Accountable care cooperatives: a 2026 vision for U.S. health care.” David analyzes the severe funding crisis affecting American families where premiums have skyrocketed and millions lack access to primary care providers. He shares personal experiences with the medical system regarding back pain and criticizes the pharmaceutical industry for prioritizing profit over patient safety in drug development. The conversation outlines a bold structural solution involving member-owned cooperatives that integrate social determinants of health like nutrition and housing while freezing federal spending. David argues that shifting to a nonprofit model can drastically reduce administrative waste and improve metabolic health outcomes. Discover how a community-governed approach can stabilize the national deficit and restore affordable access for everyone.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back David K. Cundiff, physician, author, and health care reform advocate. Today’s KevinMD article is “Accountable care cooperatives: a 2026 vision for U.S. health care.” David, welcome back to the show.

David K. Cundiff: Thank you very much, Kevin.

Kevin Pho: So last conversation, we talked about accountable care cooperatives. Just to recap, give us a brief definition of what that is, and then we will talk about the KevinMD article today.

David K. Cundiff: OK. I introduced accountable care cooperatives in my book Grand Bargains: Fixing Health Care and the Economy in 2015. Now is the time that we have a crisis in health care and health care spending. So it is the time to look at this option because other options are just not workable. Accountable care cooperatives are what I have defined as private and non-governmental, although they are funded by the government. They compete, but they are self-regulating. They also take care of social services such as nutrition, housing, and employment for patients that are in the accountable care cooperatives.

Kevin Pho: All right, so tell us about your most recent KevinMD article extending that conversation. What is this one about?

David K. Cundiff: As of January 1, 2026, we are in a health care crisis in the United States like never before. My book, Money Driven Medicine: Tests and Treatments That Don’t Work, reported back in 2006 that 40 to 50 percent of the costs of medical interventions were unnecessary or harmful, wasting about a trillion dollars in 2007. From 2007 to 2025, we have spent roughly 35 trillion dollars on ineffective or harmful treatments. This is more than the entire United States gross domestic product in 2025. We are literally bankrupting the country to pay for medical tests and treatments that don’t work.

This huge waste accounts for polls showing that the medical system earns a D+ grade for affordability among the public. Out of roughly 18 million health care workers, only about 9 million treat a patient. The rest are administrators. Back in the 1970s when I was in training, one out of 40 health care workers was an administrator. Now it is one to one, and medical bureaucrats that don’t see patients average about 108,000 dollars a year.

Frontline workers in health care that see patients get 87,000 dollars on average. This may account for why 55 percent of our clinicians are considering or planning to quit.

Kevin Pho: So what are the options going forward? Before talking about the solutions, how did we get to this point? You said that, just to quote one of your statistics, we have gone from one administrator for every 40 clinicians to a one-to-one ratio now. How did we get to that point where now we have so many more administrators?

David K. Cundiff: Well, it is very complicated. That is a good question. I can’t say that I really know the answer other than there has been a continuous increase in the cost of health care. The government has just tried to throw strategies to reduce that increase. They do it by just throwing administrators in there. So they are checking everything that is ordered from Medicare. It is having Washington, DC, or other government employees just try to do things that reduce the cost of health care. It is obviously not working because the cost of health care continues to balloon.

Kevin Pho: And you are saying it is not just the government, but of course health insurers also have this administrative bloat. A lot of it is just because of the way our health care system is structured. A lot of the rules and payment structures that we have require a lot of administrators to execute them.

David K. Cundiff: Exactly. Exactly. Yeah. And what are the options going forward? Well, there is a Republican “one big, beautiful act.” What would it do? Well, it would increase health care costs. It is now 6.3 trillion dollars in 2026, and it will be 9.6 trillion dollars by 2035. That will increase the federal deficit by 3.4 trillion dollars by 2035. And that is favored by just 41 percent of voters.

Now, the Democratic public option has an effect on the federal deficit that is neutral. It won’t reduce the deficit or increase it significantly. Only 31 percent of adults favor that. The Democratic single-payer Medicare for All, which I remember back in 1990, I don’t know if it has ever been favored by more than 50 percent. It would supposedly reduce the deficit by two to five trillion dollars by 2035, but only 35 percent of adults favor it. So all of these options, Republican and Democrat, are just non-starters. We need a different system. My book, Grand Bargains: Fixing Health Care and the Economy, came out in 2015 and it introduced the accountable care cooperatives that we are talking about.

Kevin Pho: So I am looking at some of the suggestions that you make. Number one is to flip the ratio. You want to transition 5.5 million workers from administration back to the bedside. Another idea you have is to cap the panels. You want to move from the 2,000 to 3,000 patient panels primary care physicians have down to 600 to 800. Let me ask a question about that specifically. How do you propose flipping the ratio? A lot of these administrators don’t necessarily have bedside training. How can we flip some of them and transition them to bedside care?

David K. Cundiff: We wouldn’t necessarily make an administrator without medical training train to be a health care provider. But our system now has Medicare pay for interns and residents to go through their training. The money that they are using is very constricted because they have other things that they are doing with Medicare money. So we are just not training enough health care providers. Since I started in medical school, about a quarter of our physicians in the United States have immigrated from other countries, including a lot of developing countries and developed countries. Why should we be drawing in physicians? I mean, they are great physicians and health care providers, but why do we need to draw them in rather than produce our own providers and finance that training? Accountable care cooperatives would do that.

Kevin Pho: So let me ask a second issue about capping the panels. Wouldn’t capping the panels from say 2,000 to 3,000 to 600 to 800 worsen the primary care shortage when we already have difficulty finding primary care physicians for all the patients?

David K. Cundiff: No. I think we could well already, probably most primary care providers are nurse practitioners or physician assistants. We could increase those numbers pretty rapidly. It would take some time, but we have a lot of very bright young people in the United States that are interested in health care careers that aren’t going to burn you out like the current system. So we could do it.

Kevin Pho: What would be the first steps that you would implement? You did mention that both the Republican and the Democratic solutions are non-starters. If you were the health care czar and in charge of running health care in our country, tell us the first steps that you would do to implement your vision.

David K. Cundiff: Well, the first step would be to get rid of all public and private insurance schemes. This includes Medicare, Medicaid, Veterans Affairs, Obamacare, children’s care, and Indian care, all with their own administrative bureaucracies. Those people count as health care providers. We do not need that incredible amount of bureaucracy or bureaucrats. We need more health care providers. Yeah, it will take some time, but if we start now in 2026 with a bill through Congress signed by the president, it could happen as an emergency. When the Second World War was declared an emergency, things happened very immediately. This is as much an emergency right now in the United States as any of the other emergencies going on.

Kevin Pho: Probably now short of a World War, right? Realistically, what you are describing probably isn’t going to happen politically, of course. Right. So is there anything that administrations could do currently? Of course, we have a Republican administration, and even if we had a Democratic administration, what do you think are some realistic things that could happen given the constraints of our political system?

David K. Cundiff: Well, I don’t know if I agree that we are looking at our politicians in this regard regarding health care. I would rather go directly to patients and influencers like yourself about accountable care cooperatives. The politicians will listen to patients and influencers. If this gets into the conversation, I am confident that the politicians may be the last to hear about it, but they will hear about it if it gets into the conversation in the newspapers and media.

Kevin Pho: Another suggestion that you have in your notes was freezing the budget. Locking in health care spending at 6.3 trillion dollars for 2026. Again, politically, how feasible is that?

David K. Cundiff: I think it is more than feasible, but it has to be done by getting rid of all public and private insurance. That is so much of the cost of health care. So, it would all come out of that and there would be plenty left over because the United States health care system costs twice what the next most expensive health care system per capita in the world is.

So there is a lot of room there to save on the cost of health care while we are giving much more health care, long-term care, and most importantly, preventive medicine. Then these accountable care cooperatives will be competing with each other. They won’t be competing on who can gain Medicare or other insurance companies, but they will be competing with each other on who can be the most innovative in their preventive medicine and treatments to satisfy their patients and also keep the costs within control.

Kevin Pho: Now with any significant change like the one that you are proposing, there are going to be winners and losers. If we are talking about dismantling entire industries like the private health insurance industry, there is going to be a lot of resistance. People are going to lose jobs, and companies may go out of business. Right? So how do you overcome some of that status quo?

David K. Cundiff: Yeah, with any meaningful change for sure. There are people that are making great money. The insurance company and the pharmaceutical industry and other industries that are connected with health care are cleaning up. They won’t necessarily like it, but I don’t know if they all won’t like it. I think they have health care problems too. They have children and grandchildren and see that the system is not working. So, I think that if people see this option and see how bad the system is now, this will win in polls. The politicians will hear people that have read about accountable care cooperatives.

Kevin Pho: We are talking to David Cundiff, physician, author, and health care reform advocate. Today’s KevinMD article is “Accountable care cooperatives: a 2026 vision for U.S. health care.” David, let’s end with some takeaway messages that you want to leave with the KevinMD audience.

David K. Cundiff: It is up to Americans to look at this once-in-a-multiple-generation opportunity to do what I think maybe it was Truman who tried to do: change the health care system. Then Obama and several in between tried and failed. It doesn’t mean that this one will fail. Because of all the previous failures, this one is the most consequential. So I ask you to look at the KevinMD articles I have written on this and the references they lead you to, and contact your politicians and friends.

Kevin Pho: David, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

David K. Cundiff: Thank you so much.