Michael Apkon
@michael-apkon.bsky.social
Health system leader, pediatrician
After your Bulwark interview - 2 thoughts about means testing: employer wage tax + revised approach to CMS tax would be reasonable. Eliminate tax benefit of emplr-sponsored coverage. Public option of M4all. Low but non-zero copay for those that can afford to manage moral hazard and excess demand.
January 1, 2026 at 12:48 PM
After your Bulwark interview - 2 thoughts about means testing: employer wage tax + revised approach to CMS tax would be reasonable. Eliminate tax benefit of emplr-sponsored coverage. Public option of M4all. Low but non-zero copay for those that can afford to manage moral hazard and excess demand.
There is recent pan-Canadian negotiation and pricing over many drugs. You are correct that out of hospital meds aren’t typically covered by govt. but there are a range of govt programs that do pay for drugs based on means, cost, and disease. Also employer-based supplemental coverage to cover meds.
January 1, 2026 at 12:38 PM
There is recent pan-Canadian negotiation and pricing over many drugs. You are correct that out of hospital meds aren’t typically covered by govt. but there are a range of govt programs that do pay for drugs based on means, cost, and disease. Also employer-based supplemental coverage to cover meds.
Interesting approach. Good luck figuring out the means testing though. It would have to be done on recurring basis since people’s circumstances and HC costs can change suddenly. Very subject to gaming. The rich have many more ways to hide assets and income than most. I worry about admin costs.
December 31, 2025 at 9:06 PM
Interesting approach. Good luck figuring out the means testing though. It would have to be done on recurring basis since people’s circumstances and HC costs can change suddenly. Very subject to gaming. The rich have many more ways to hide assets and income than most. I worry about admin costs.
Moreover, the ability to cross subsidizes reduces pressures to manage costs.
December 31, 2025 at 8:59 PM
Moreover, the ability to cross subsidizes reduces pressures to manage costs.
Big difference between Medicare and Medicaid. Medicare historically ~ covered fully-loaded costs (more than covers marginal costs) - now it’s more like 90%. Medicaid is a much poorer payer and can be as low as 50%. Commercial cross subsidizes. But we should recognize that’s a choice about fees.
December 31, 2025 at 8:59 PM
Big difference between Medicare and Medicaid. Medicare historically ~ covered fully-loaded costs (more than covers marginal costs) - now it’s more like 90%. Medicaid is a much poorer payer and can be as low as 50%. Commercial cross subsidizes. But we should recognize that’s a choice about fees.
In UK and Canada you can go to the specialist of your choice. May need a referral but there is no concept of in vs out of network. US has higher specialist:PCP ratio which costs more, has more fragmentation, and poorer outcomes. US has no constitutional right to be seen. Might be worth the trade.
December 28, 2025 at 10:23 PM
In UK and Canada you can go to the specialist of your choice. May need a referral but there is no concept of in vs out of network. US has higher specialist:PCP ratio which costs more, has more fragmentation, and poorer outcomes. US has no constitutional right to be seen. Might be worth the trade.
No program should be considered static. All will need policy updates as healthcare evolves. Offering Medicare for All (a public option) would be a good first step and among the quickest routes to UHC.
December 25, 2025 at 3:06 PM
No program should be considered static. All will need policy updates as healthcare evolves. Offering Medicare for All (a public option) would be a good first step and among the quickest routes to UHC.
It happened pretty fast. The federal cost sharing was implemented in 1966 and all ten provinces had implemented by 1971. The 1984 federal act revised the programs somewhat but only took 5 years for all provinces to design and adopt UHC. Not easy and not perfect but a lot quicker than you suggest.
December 25, 2025 at 3:06 PM
It happened pretty fast. The federal cost sharing was implemented in 1966 and all ten provinces had implemented by 1971. The 1984 federal act revised the programs somewhat but only took 5 years for all provinces to design and adopt UHC. Not easy and not perfect but a lot quicker than you suggest.
We do have a version of UHC here - Medicare. Covers virtually everyone over 65. The single payer for that is more efficient in terms of lower admin costs and has been a stronger driver of Q improvement than private insurance. Also, UHC doesn’t have to mean single payer.
December 25, 2025 at 4:59 AM
We do have a version of UHC here - Medicare. Covers virtually everyone over 65. The single payer for that is more efficient in terms of lower admin costs and has been a stronger driver of Q improvement than private insurance. Also, UHC doesn’t have to mean single payer.
Plenty of countries have govt paying for care by autonomously governed not for profit and for profit entities. Bigger threat to private companies is the pressure to control costs when govt is the payer - but isn’t that the point.
December 25, 2025 at 1:48 AM
Plenty of countries have govt paying for care by autonomously governed not for profit and for profit entities. Bigger threat to private companies is the pressure to control costs when govt is the payer - but isn’t that the point.
No reason that UHC requires appropriating private companies. May change their economics to have a single payer system but even in single payer systems, govt can fund private companies to do the work. UHC also doesn’t mean govt provided care delivery.
December 25, 2025 at 1:48 AM
No reason that UHC requires appropriating private companies. May change their economics to have a single payer system but even in single payer systems, govt can fund private companies to do the work. UHC also doesn’t mean govt provided care delivery.
Key to this working is for the networks to be broad enough to cover broad range of services that might be needed including advanced services. Your cost is still less than average per cap expenditure. Not sure how that is managed unless care delivery changes to manage costs. What about unemployed?
November 5, 2025 at 1:40 AM
Key to this working is for the networks to be broad enough to cover broad range of services that might be needed including advanced services. Your cost is still less than average per cap expenditure. Not sure how that is managed unless care delivery changes to manage costs. What about unemployed?
I've long thought that there is an opportunity for children's hospitals to formally band together to reap the benefits of scale and collaboration that the large adult-oriented centers enjoy. Great to see Tom Golisano provide the catalyst.
October 29, 2025 at 5:07 PM
I've long thought that there is an opportunity for children's hospitals to formally band together to reap the benefits of scale and collaboration that the large adult-oriented centers enjoy. Great to see Tom Golisano provide the catalyst.
Our component of govt funded HC (Medicare) has the lowest admin costs and most equitable access within our crazy system. Wouldn't want to see fully single payor but a universally-available public option would provide a lot of discipline to the system.
June 10, 2025 at 6:51 PM
Our component of govt funded HC (Medicare) has the lowest admin costs and most equitable access within our crazy system. Wouldn't want to see fully single payor but a universally-available public option would provide a lot of discipline to the system.
Not sure I agree with your thoughts about complete transparency. Not my experience in Canada compared to the US. CMS has driven more transparency here at least about outcomes than other places.
June 10, 2025 at 6:51 PM
Not sure I agree with your thoughts about complete transparency. Not my experience in Canada compared to the US. CMS has driven more transparency here at least about outcomes than other places.
Single payor is a separate issue. 340B is a federal program and could exist in single payor or not. Lots of reasons single payor leads to lower healthcare expenditures - one is that the healthcare budgets are set prospectively which leads to more creative ways to stretch the $ - and rationing.
June 10, 2025 at 6:44 PM
Single payor is a separate issue. 340B is a federal program and could exist in single payor or not. Lots of reasons single payor leads to lower healthcare expenditures - one is that the healthcare budgets are set prospectively which leads to more creative ways to stretch the $ - and rationing.
Net result is higher costs for pharmaceuticals, everyone in the chain taking their cut, and many special interests wanting the program to continue. The answer isn't reforming the individual components. The answer is in properly reimbursing care costs and not using programs like 340B as workarounds.
June 10, 2025 at 6:44 PM
Net result is higher costs for pharmaceuticals, everyone in the chain taking their cut, and many special interests wanting the program to continue. The answer isn't reforming the individual components. The answer is in properly reimbursing care costs and not using programs like 340B as workarounds.
What's evolved though is an entire industry sorting out how maximize the profits they can make by participating - hospitals working to provide medications to as many as they can, contract pharmacies helping them supply the patients, pharma figuring out pricing and rebate programs to maximize profit.
June 10, 2025 at 6:44 PM
What's evolved though is an entire industry sorting out how maximize the profits they can make by participating - hospitals working to provide medications to as many as they can, contract pharmacies helping them supply the patients, pharma figuring out pricing and rebate programs to maximize profit.
340B is an example of what happens when the industry figures out how to take advantage of what was intended to be a good thing. It was originally intended to help providers be able to address the shortfalls in covering the costs of care for people with Medicaid.
June 10, 2025 at 6:44 PM
340B is an example of what happens when the industry figures out how to take advantage of what was intended to be a good thing. It was originally intended to help providers be able to address the shortfalls in covering the costs of care for people with Medicaid.
So now they are blaming the healthcare workers for not doing enough? Maddening.
April 10, 2025 at 8:15 PM
So now they are blaming the healthcare workers for not doing enough? Maddening.
So when Republicans talk about cutting Medicaid, they are talking about taking insurance from children and the elderly.
February 25, 2025 at 7:08 PM
So when Republicans talk about cutting Medicaid, they are talking about taking insurance from children and the elderly.