“Certificate of need (CON) laws exist in various forms in 38 states and Washington, D.C. The stated goal of such laws is to keep costs down by preventing overinvestment in any single market. If regulators decide an area already has enough of any type of service, they can block new construction.
As a result, nobody in North Carolina can open or expand certain medical facilities without these regulators’ permission. Even purchasing an MRI scanner without their approval can be illegal. These restrictions prohibit Singleton from using his own clinic in New Bern for most of the surgeries he performs. He must drive two miles up the road to a competitor’s office, as it is owned by a major health care player. This unnecessary red tape increases costs and decreases scheduling options, and patients suffer.
Singleton has battled this scheme since he set up his clinic in 2024. Frustrated by a wall of bureaucracy and lack of progress, he sued in 2020 with representation from our public interest law firm, the Institute for Justice.
Getting to trial has not been easy. Wake County Superior Court tossed out his case in 2021 without discovery or witness testimony, and the North Carolina Court of Appeals upheld that decision in 2022. The state Supreme Court ruling simply allows Singleton to go back and try again.
Singleton is not alone in this struggle. The Iowa ophthalmologist Lee Birchansky fought for more than 20 years before state regulators relented and gave him permission to perform surgeries at his own clinic. In 2016, Virginia fended off a CON lawsuit from pulmonologist Mark Baumel and radiologist Mark Monteferrante. Kentucky spiked a home health care service that entrepreneur Dipendra Tiwari tried to launch in 2019. Connecticut blocked a cancer treatment center in 2022, clearing the way for political insiders to proceed unimpeded with their own cancer treatment center 45 miles east. None of these cases involved health or safety concerns.
CON laws work great for existing providers, who do not have to worry about rivals setting up shop and attracting patients with superior service. This also means existing providers can also take their doctors and nurses for granted, as CON laws keep rivals far away, limiting their ability to poach talent.
California, Texas, and 10 other states operate without CON laws. None of these states has experienced any measurable harm. In fact, multiple studies show benefits. For example, Matthew Mitchell, a researcher at George Mason University’s Mercatus Center, says states that got rid of their CON laws have more hospitals and surgery centers per capita, along with more hospital beds, dialysis clinics, and hospice care facilities.”
“Mangione never mentioned being covered by or angry with United Healthcare specifically in any social media, according to multiple reports. But Samadani, who treats patients with spondylolisthesis, notes that many insurers require patients to undergo six to 12 weeks of physical therapy before the companies will agree to cover surgery or even imaging to diagnose the condition. And for someone with severe spondylolisthesis, physical therapy can be “excruciating” and won’t necessarily help, she adds. “It’s sort of like a torture, a mandatory torture imposed by the insurance company,” Samadani says.
And that’s if they are treated at all. Samadani says she’s seen multiple young patients who were initially turned away by doctors who didn’t believe they could have chronic back pain. “In the case of this particular kid, my guess is that he was in massive pain,” she says.”
“Luigi Mangione appeared carefree while enjoying a trip across Asia just months before he allegedly gunned down UnitedHealthcare CEO Brian Thompson, suggesting he suffered a rapid unraveling in the lead-up to the brazen slaying.
One of a pair of friends who were vacationing across Asia told TMZ that they met 26-year-old Mangione by chance at a Muay Thai fight in Krabi, Thailand in April of this year. The trio quickly hit it off and decided to travel together.
After exploring Krabi together, the group parted ways when Mangione went to Phuket, while the pair of friends visited Malaysia. But they later reconnected for a road trip across Thailand, stopping off in Khao Sok and Bangkok, according to TMZ.
All the while, the source told TMZ, the software engineer did not show any signs of being a cold-blooded killer—in fact, he seemed like the typical young man enjoying the chance to explore a different country.
The source’s characterization of Mangione as a “super friendly, communicative, and open” person aligns with other accounts from people who had encountered the Ivy League graduate before he entered the public eye this week.”
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“There have been some signs, though, that in the months leading up to the shooting Mangione took a dark turn. His social media presence has revealed a suite of health struggles—as well as a penchant for radical political and social texts, including Unabomber Ted Kaczynski’s manifesto.
Loved ones had expressed concern about Mangione on social media days before the murder, and The New York Post reported that his mother filed a missing-persons report for him last month.”
““I do apologize for any strife of traumas but it had to be done. Frankly, these parasites simply had it coming. A reminder: the US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy. United is the [indecipherable] largest company in the US by market cap, behind only Apple, Google, Walmart. It has grown and grown, but as our life expectancy?””
” In most rich countries, people don’t have to worry about sifting through a dozen different health plans — and they don’t live in fear of losing their health care after losing a job, and they receive more affordable, higher-quality care than Americans do. The paradox of the world’s wealthiest nation having one of the weakest health systems among developed nations has long been a vexing policy problem — without an easy solution.”
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“American health insurance, as we think of it today, started to take shape in the 1920s, as the medical profession was being standardized and modern hospitals were being built. Some employers started offering payments for hospital-based services as a perk for their workers. Companies had large groups of employees, some in good health and some in bad, to spread the risk and make the finances work much like modern-day insurance does.
This system soon became entrenched enough that President Franklin D. Roosevelt bypassed plans to include national health insurance as part of the New Deal. Then came World War II, along with government-mandated wage controls for employees in the private sector to keep the war machine moving. Barred from offering raises to motivate their workers, companies started pumping up their health benefits — and the government agreed to exempt those benefits both from wage controls and taxes.
By the 1950s, employer-sponsored insurance had become popular among those who received it and progressive labor unions urged the government to make the tax exemption permanent. Congress agreed, enshrining in 1954 the subsidy for company health plans in federal law. Doctors and hospitals, whose industry was growing into the leviathan that it is today, became accustomed to working with private insurers rather than with the government directly.
Today, these work-based health plans still cover roughly half of all Americans.”
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“The problem with the employer-based system was it left out too many people because they didn’t work or didn’t have a job that offered health insurance. To start filling in the gaps, in 1965, Congress created Medicare and Medicaid to cover two of the biggest groups of people who lacked coverage: seniors and people in poverty.
After that expansion, we had a system that covered most Americans — which made it hard to change, because people feared losing what they had.
Those fears, supported by the medical industry’s campaign against “socialized medicine,” doomed the health care overhauls proposed by presidents Richard Nixon and Bill Clinton that would have consolidated most Americans into a national insurance scheme. Certain tendencies in American culture — consumerism and trust in private markets — made it easier to persuade the public that they’d lose under a government-run health plan.
Meanwhile, the US health care system still had obvious holes. Rather than threaten the status quo, policymakers added new patches.
CHIP was approved in the 1990s, covering children of working-class families whose incomes were not low enough to get Medicaid. (Their parents, however, were often left without any coverage at all.) The 2010 Affordable Care Act, also known as Obamacare, was designed to fill that gap by covering people who didn’t receive health insurance through their jobs but didn’t qualify for Medicaid.
Yet even after a half-dozen rounds of incremental health reform over five decades, about one in 12 people in the US lack health coverage and Americans are much more likely than people in other developed nations to say they skip medical care because of the cost.”
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“Other countries built their health care systems more deliberately.
After World War II, the United Kingdom sought to extend medical security to all its citizens, creating the National Health Service; many other European governments followed suit.
A half-century later, another wealthy island nation made the same choice. Taiwan, building a modern democracy after decades of authoritarian rule, scrapped a fractured, inequitable health system to set up a national insurance program that would cover everyone. It was a proclamation of solidarity after a tumultuous military dictatorship had come to an end.
Not all countries have opted for a single government program, but their systems are still simpler than America’s and cover the entire population. In 2006, the Netherlands opted to trade a dysfunctional two-tiered insurance system for a universal program that relied on private coverage but was nevertheless designed to insure everybody. The uninsured rate there today is less than 1 percent (some people opt out).
But the US? We’ve never paused to build a fairer, simpler, uniform health system.”
“The NIH is the world’s largest public funder of biomedical and public health research, with a budget of $47 billion, most of which is used to support research at universities and academic medical centers. The agency has long been criticized for being way too risk-averse when it comes to choosing which research projects to fund.”
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“Being informed by the best information is certainly the right goal. But RFK Jr.’s long history of anti-vaccination agitation suggests he is not a source of the best information for the safety and efficacy of modern vaccines. This includes false assertions that vaccines cause autism; that they are not tested using placebo-controlled trials; and, contradicting the previous claim, that COVID-19 vaccines killed more people than did a placebo.
Again, the CDC needs fixing, but RFK Jr.’s skepticism about the safety and efficacy of modern vaccines would further undermine what should be the CDC’s main focus: the prevention of the spread of dangerous infectious diseases.”
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“Four years into the post-COVID era, most research has found that ivermectin and hydroxychloroquine provide no treatment benefit for the infected. In April, the Journal of Infection published a report about a randomized controlled trial that concluded, “Ivermectin for COVID-19 is unlikely to provide clinically meaningful improvement in recovery, hospital admissions, or longer-term outcomes.””
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“Giving drug development and infectious disease an eight-year break seems inadvisable. After all, the death rate for cancer has continued to drop from 2016 to today, partially as a result of lower incidence stemming from lifestyle changes, but also because of better and more widely available pharmaceutical treatments. Recent calculations show the value of medicines to patients far outweigh the profits the drug companies rake in. And, as ever, infectious diseases lurk in the background waiting for us to lower our guards or seeking just the right mutation to enable them to jump into the human population.”
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“RFK Jr.’s solution to stemming the tide of chronic illnesses is better diets and physical fitness. History suggests government interventions will have little effect on either. After all, the federal government has been periodically issuing dietary guidelines since 1979 and promoting physical fitness since 1956. The Lancet authors agree with RFK Jr.’s aspirations but suggest in the meantime that “regulations need to be put in place to eliminate barriers to accessing new-generation obesity clinical treatments, ensuring the availability and affordability of these options to the broader population.””
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“The FDA needs streamlining to speed biomedical innovation, the NIH needs greater risk-taking in research, and the CDC needs to be laser-focused on preventing infectious diseases. None of these appear to be high on the agenda of possible incoming secretary of health and human services.”
“The US does have significantly fewer doctors per capita than some other wealthy nations, such as Germany and Sweden. But America’s physician-to-patient ratio is actually about the same as other developed countries — Canada, the United Kingdom, Japan, France — that still generally rank better on measures of health care quality than the US does. So aggregate numbers alone are not enough to explain the access problems that patients face, and experts disagree over whether we need to boost the overall supply of providers in the short term.
The bigger problem is misallocation in the US physician workforce, Coffman told me last year. We know that we don’t have enough doctors in certain important specialties: primary care, obstetrics, and psychiatry, for example. We also don’t have nearly enough providers in a broad swath of specialties practicing in rural and other low-income communities. Between 2010 and 2017, while large urban counties added 10 doctors per 100,000 people on average, rural counties lost three. As a result, metro regions had 125 doctors per 100,00 patients, while rural areas had 60.
America is littered with doctor deserts, areas where there are not enough primary care providers, much less specialists or hospital-level services. The federal government estimates that 80 percent of rural Americans live in medically underserved communities.
In the long term, the US will undoubtedly need more doctors in rural and urban areas alike. Groups like the Association of American Medical Colleges continue to project long-term workforce shortages, as boomer-generation doctors reach retirement age and the population of seniors requiring medical care swells.”
“Many providers like Balay see an obvious link between rising congenital syphilis rates and sparse access to obstetric care (i.e., care for pregnant people, also called maternity or prenatal care). That’s largely because, historically, prenatal care is where syphilis transmission to a fetus has been interrupted. Testing is standard in prenatal care, and all but eight states require syphilis testing during pregnancy.
The problem is simple, as Balay explains. “There just is not enough obstetric care,” she said. And as prenatal care becomes increasingly scarce, so do opportunities to catch and treat syphilis.
Balay is not alone in thinking that scarcity helps explain what’s happening with congenital syphilis, especially among Indigenous Americans.
In a recent CDC report, 37 percent of US babies with syphilis were born to parents who didn’t get timely syphilis testing during pregnancy. But that number was higher, 47 percent, when the parents were American Indian. And most of those parents who didn’t get timely testing didn’t get any prenatal care at all.
In rural states, increasingly inadequate maternity care access is making intensified mother-to-child syphilis transmission all but inevitable. That puts Indigenous women and their newborns at especially high risk.”
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“One of the most promising solutions to South Dakota’s maternal care scarcity problem got a boost last year when the state’s voters approved an initiative to expand Medicaid beginning in early 2023. The expansion means more than 52,000 of the state’s residents are newly insured, which shifts the costs of their care from IHS to a better-funded federal program. It also means that hospitals caring for these patients will get paid more for the care they provide to the thousands of tribal residents newly covered by Medicaid. And most importantly to patients, expansion will make it more financially feasible to get the care they need.”
“Mining companies offer good jobs with good benefits that can counterintuitively damage health care access. Health systems can grow dependent on those insurance plans to survive, and the benefits are in some cases so good that providers are reluctant to serve others in the community. It’s the consequence of a national health care system that feeds off employer-sponsored health insurance to turn a profit, and, as a result, warps itself to meet the needs of those who have it.
Six months of interviews with more than 90 patients, providers, retired miners, community leaders and health care experts across the U.S., including in three towns characteristic of the mining industry’s past, present and future — Williamson, West Virginia; Elko, Nevada; and White Sulphur Springs, Montana — reveal the breadth of these perils: retired and injured miners, and their families, struggling to get care; communities left with beleaguered or closed health facilities; and pricy hospital bills in towns where mines have driven up median incomes.”
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““Doctors want these big reimbursements from the very rich insurance policies that the gold mine provides. They don’t want the pennies they receive from Medicare,” said Jan Brizee, former ombudsman for the Nevada Office for Consumer Health Assistance representing Elko and other rural counties. “So you have somebody who’s retired after 25 or 30 years, and now they have nothing, having to travel out of town to get even primary care, let alone a specialist.”
Not all mining communities experience these problems, and similar issues exist in towns dependent on other industries with good benefits, like manufacturing. But mining communities face unique obstacles compared with other one-company towns — including remoteness and challenging geography — that make it difficult to attract other businesses that would diversify their health insurance landscape.
Miners also tend to be in worse health than their counterparts with other manual labor jobs, with higher rates of poor sleep and heart disease.”
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“Medicaid expansion and extra federal funding to support rural health centers and hospitals have helped in some towns. But providers bemoan stingy state Medicaid reimbursement rates that aren’t enough to pay the bills, paltry federal funding to support primary care and hospital designations that don’t meet the needs of all facilities.
For the most part, these solutions have inadequately addressed the systemic failures of employer-based health systems in these communities.”