How to fix health care without Medicare for All [PODCAST]

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Medicare for All keeps dying in Congress. So what would actually get the major players to agree on universal coverage? Health care journalist Ken Terry returns to lay out a different model, one that keeps insurance companies in the system while putting primary care doctors back in charge of basic care. This episode is based on his article “A Medicare for All alternative that keeps insurers in,” published on KevinMD. You will learn why he believes Medicare for All is a political non-starter and how a two-part financing system could split basic care from major medical coverage. He explains why rewriting corporate practice of medicine laws to free primary care doctors from hospital and corporate employers sits at the center of his plan. You will also hear how independent primary care groups competing on cost and quality could raise physician pay through waste reduction, on a five-year path from here to there. Press play to hear how universal coverage might be reached without cutting the industry out.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Ken Terry. He’s a health care journalist, and he’s the author of the new book, “Beyond Medicare for All: Cracking the Code of the Health Care Affordability Crisis.” There’s an excerpt from that book on KevinMD. Ken, welcome back to the show.

Ken Terry: Thank you very much. I’m glad to be here. I’d just like to point out that this book is the third of my three books on health care reform. And the latest book really takes a major step beyond where I was when I wrote my last book.

Kevin Pho: There’s an excerpt from that book on KevinMD, so tell us about the excerpt, and then of course we’ll talk about the book itself.

Ken Terry: As the excerpt explains, I’ve developed a new model for health care financing and delivery. In my first two books, I assumed that we’d eventually have Medicare for All, and I proposed reforms of health care delivery to make it successful. By the time I wrote my third book, however, I’d realized that Medicare for All is a political non-starter, so I came up with a model that provides universal coverage without Medicare for All.

This model includes an important role for health insurance companies while placing primary care doctors in charge of basic care.

Kevin Pho: Before we get into your model, just give us some of the reasons why you think Medicare for All is not possible today.

Ken Terry: The biggest reason why it’s not possible, and this shows up in the fact that you’ve never had more than 100 congressmen actually co-sponsor a Medicare for All bill, is that the industry opposes it. Insurance companies don’t want to be cut out, and health care providers don’t want to see their incomes cut substantially. And if you can’t get the industry behind you, you can’t have a major plan to restructure the industry.

Kevin Pho: So we’ve gotten to a point where the health care industry, among other industries in our health care system, is so powerful today that it needs to be on the side of health care reformers in order for us to have any meaningful change. Is that what you’re saying?

Ken Terry: Precisely.

Kevin Pho: In terms of the prior attempts at Medicare for All or more government involvement in health care, just give us a little bit of history in terms of what has been tried in the past and failed.

Ken Terry: There was a long history of attempts to create universal coverage going back to the Truman era, which did not pass through Congress. Back in the early 1970s, President Nixon wanted to introduce a reform essentially based on the HMO model that had proved successful in California. But the Democrats wouldn’t allow that to pass because they wanted Medicare for All.

In the 1990s, President Clinton introduced a proposal that would have had a kind of managed competition among health care plans. It didn’t really address the problems in health care delivery, but the idea was that we would reach universal coverage and that this competition would bring down prices. But Congress never even considered the proposal, so it again was a non-starter.

And then in the late aughts, President Obama proposed the Affordable Care Act, and he was very careful to sit down with all the major players in the industry and get them to agree. It was in many ways a fairly watered-down piece of legislation compared to what was originally proposed, but it still resulted in the uninsurance rate dipping to the lowest point ever. And there are some people who believe that it also restrained the growth in health costs.

Kevin Pho: Now tell us where specifically the Affordable Care Act fell short, because as you said, the Obama administration famously tried to get health insurers on their side, on the side of reformers. Speaking today in 2026, how did it fall short?

Ken Terry: It fell short because it didn’t really address the underlying growth in health costs, which meant that the cost of these Obamacare plans kept going up. Eventually the government had to provide subsidies in order to make them affordable, and that was the core of the fight in Congress last year over whether to keep those subsidies or not.

The Republicans insisted that they be retired, and as a result of that, it’s now believed that more than 5 million people will lose their health insurance because they can no longer afford to buy Obamacare plans.

I think another side of the Affordable Care Act that’s been less discussed is that it did try to improve quality and try to engender some accountability into health care through a number of different methods. I think the vast majority of its experiments failed, but a few of them, such as the Medicare Shared Savings Program, have actually reaped some benefits.

Kevin Pho: So as we stand now and as we speak today, because the subsidies have lapsed, the percentage of those uninsured is rising, right? Because the plans are getting more and more expensive. So you’re coming up with an alternative that keeps the insurers in. Tell us the basis of what you think should happen.

Ken Terry: Let me just correct one thing. This is not a new form of Medicare for All. There isn’t any Medicare for All in my model. My model actually has more in common with the current system in terms of how people are actually covered. For example, in the insurer part of the system, employers, workers, consumers, and the government would all contribute to the cost of the premiums just as they do now. But it would be on a much broader scale so as to ensure universal coverage.

The two important innovations in my model are, number one, it would be a bifurcated system of financing in which basic care would be run by primary care groups, competing primary care groups that would take financial responsibility for that care, and which would include both primary care and the lower levels of specialty care. And the groups would charge subscription fees to everyone, including people on Medicare and Medicaid, again with the subsidies from employers and the government helping everybody to buy these subscriptions.

The other half of the financing, which I call major medical insurance, although it has nothing to do with what used to be called that, would give insurance companies the ability to cover inpatient care, post-acute care, and the more expensive forms of outpatient care such as cancer care and outpatient surgery. And they would have networks just like they do now. But they would have relatively little influence over the decisions about what care to provide.

The way I would do that is, there is now a system in Maryland, which you may be aware of, that goes back several decades, in which there’s an all-payer hospital rate so that all payers pay the same amount for the same services at each hospital. And also the hospitals are on global budgets that they negotiate with the state. This system has actually worked pretty well, and the insurers and the hospitals have done well. Medicare has saved at least $1.6 billion. And it could be done in other states, as Ezekiel Emanuel and his colleagues have pointed out in Health Affairs.

The big question is, how do you get from here to there when it comes to the primary care doctors? Most, I would say, but 33 states and the District of Columbia have what are called corporate practice of medicine laws that prevent corporations, or are supposed to prevent corporations, from employing doctors. They haven’t really been used to any great extent to prevent employment of doctors by hospitals, insurance companies, PE firms, and so forth. But the laws could be rewritten so that they would prevent at least primary care doctors from being employed.

I think that’s a really important point, because as you know, primary care is in a very bad state right now. Just in the past several years, the percentage of doctors in primary care has slipped from a third to about a quarter. And that period coincides with the period in which most doctors became employees of health systems or corporations. I believe that there is a correlation.

Primary care doctors in particular have lost a lot of their autonomy. They’ve been placed on this treadmill where all they really expect to do is see more patients and make more referrals. This is definitely related to the rise in clinician burnout and early retirements. And I think that has to stop. It could stop if primary care doctors were liberated from these corporate employers, and if they could form their own privately owned groups that competed with each other on the basis of cost, quality, and patient experience, and people had the opportunity to choose a doctor in the group that they thought would do the best job for them.

Kevin Pho: I’ve actually heard some similar proposals. I had another guest talk about something similar to what you’re bringing up, having these privately owned primary care cooperatives compete against one another. So you’re proposing a system where each group would charge a subscription, and then the subscription may or may not be subsidized by employers. Just tell us a little bit more granular in terms of who exactly would fund these primary care collectives, and what the role of the patient is in terms of them paying for the subscription fees themselves.

Ken Terry: As I said, in some ways it would be similar to what we have now. People who are employed in companies with 50 or more employees would receive help from their employers in paying the premiums. And the government would also step in, both to supplement the employer’s contribution and also to cover poor people entirely, people who can’t afford to pay anything for a subscription, to ensure that everyone was covered.

Groups would set their own subscription fees based on what they believed was needed to cover their costs and provide decent earnings for their physicians. And patients would be incentivized to choose more cost-efficient groups, because if they did, their share of the subscription fee would be smaller.

This system has actually been proved to work. 30 years ago, in the Minneapolis-St. Paul market, self-insured employers did something like this with care systems that in some cases were physician groups and in some cases were hospital systems. It cost less for people to join up with a less expensive group. And they also had quality rankings to consult. Over time, people gravitated toward the less expensive, higher quality groups. So again, this is not a new idea from outer space. This is stuff that has actually been tried over the years.

Kevin Pho: And to clarify, those without jobs, the government would step in and cover their subscription fees entirely?

Ken Terry: Well, I’ll put it this way. If they had no jobs but they had other resources, then they would have to contribute. You take a look at their incomes, right, and their total financial situation. But people who are poor would not have to pay anything.

Kevin Pho: Now, one of the reasons you said earlier why some physicians may be against Medicare for All was that it would have a hit on physician incomes. So under your plan with these primary care collectives, how would that impact the incomes of physicians?

Ken Terry: The physicians in these primary care groups would have the opportunity to benefit from waste reduction. There’s a tremendous amount of waste in health care, estimated to be as much as a quarter or even a third. Now of course, the majority of this waste is in higher levels of care, not basic care, but there’s still plenty of it in basic care too, which, to reiterate, includes both primary care and the lower levels of specialty care that are involved in chronic disease care.

So essentially, by cutting that waste, number one, and number two, by doing a good job of population health management, which is the focus of a lot of the value-based care efforts right now, but there aren’t that many groups or systems in the country that are doing a good job with it. But if they did a good job with it and they reduced the amount of waste, they could charge a competitive fee and still make out pretty well. They could make more money than they do now. Specialists might not make as much, but I don’t think they would be cut back to Medicare levels across the board as they would under Medicare for All.

Kevin Pho: So if we were to get, like you said, from here to there, tell us what the first step would be, and what you anticipate are some of the obstacles that prevent your plan from coming to fruition.

Ken Terry: The first step would be for states to pass or rewrite their corporate practice of medicine laws in order to force health systems and other corporate employers to divest their primary care practices. And there would be an obstacle right there, because these employers would demand some kind of compensation, right? However, I argue in my book that hospitals and health systems should not have to be compensated, because they’re losing a ton of money on their primary care practices. Plus, if they say, “Well, if this primary care doctor was independent, they could refer to another hospital,” there’s actually a law against an employer of physicians requiring the doctor to refer to their own hospital. So they wouldn’t have much of a legal case.

The bigger problem would be with the insurance companies, the PE firms, primary care companies, and so on, that in some cases spent fair amounts of money to buy these practices. I think one way to deal with this is for the government to say, this is a scarce, vital public good. There’s a right of eminent domain, but we will pay you a fraction of what those practices are worth, and pay it out over a period of years. I think that’s one way to address it.

So the next thing, after the doctors were liberated, is they would have to start getting together and form these groups. Now, a lot of doctors are in large groups already, and they’re used to working in large groups. Many of the health system primary care groups are big enough so that you could form several primary care groups of the type I’m talking about, which have to be large enough to take financial risk. I kind of estimated in my book that the average might be about 50 doctors. So you could get a lot of them out of the existing groups. You could also get doctors who’ve formed ACOs, or that have formed IPAs or other organizations that are used to working together. They could come together.

So over a period of time, and I’m estimating it would be about two years it would take to actually form these groups and get them up and running, and then another maybe three years for them to put together the infrastructure for population health management and learn how to do what they have to do. And in the meantime, be taking progressively more financial risk, starting with primary care capitation, say. So it probably would take a good five years to change the system in the way that I’m talking about.

But this is the biggest change in the system, and it has to do with primary care doctors. Most of the rest of the system would stay more or less as it is. So it wouldn’t be as much change as some other types of reform models.

Kevin Pho: We’re talking to Ken Terry. He’s a health care journalist, and we’re talking about his book, “Beyond Medicare for All: Cracking the Code of the Health Care Affordability Crisis.” Ken, as always, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Ken Terry: I’ve explained the basics of what’s in my book. There’s much more about reducing waste, health IT, rural health care, and how to rein in expensive new technologies, which is an absolute requirement. But the essence of what I’m saying is that we can save health care in this country if we’re willing to restructure our system. It’s going to take several years to put all the pieces in place, but if we do what I propose, we’ll restore the primacy of primary care, which is essential to improve population health and reduce costs while keeping the major players satisfied. And no reform that fails to balance these elements can succeed. We have to bring the entire system together to save health care.

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

Ken Terry: Thank you, Kevin.

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