“Tantivy, tantivy,” calling all brain cells. Trumpets required. Let us see if enough of mine will answer that I can communicate something I’ve been thinking.
In my 20’s, fresh out of business school and three classes in economics, I loved free markets. How glorious, the “invisible hand.” In my 40s, back at work in Silicon Valley, smack dab in the midst of some fairly serious technical innovation, corporate meetings felt as creative as college theater.
In short, I truly believed, nay, deeply felt, that the American system worked. Was great, even. (I hasten to add I have not become a communist, have no fear. I don’t even know what “ist” I am. But my views are changing.)
Fast forward to 2026. A series of experiences.
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- Housing Industry Without The Little Guy
- Walking my little suburban neighborhood this week I noticed the usual commotion of cranes and trucks and vans building a new house. A very very big new house. But no framing, no hammering sheet rock, no windows flying through the air. Instead, this house had been pre-fabricated elsewhere and was being installed like Lego, chunks at a time. Not cheap, BTW. The house (remember this area has very high housing prices) is listed for $5M.
- No more local general contractor guy with local craftspeople. A (privately-held, not on the stock market) corporation now controls the total profit of this house build.) Consolidation at the investor level, if you will, of a value-creating process. Not that we don’t need new housing, we do. But probably not the $5M kind replacing something that sold for half that.
- Medical Care For Whom?
- My primary care physician just quit the group I’ve gone to since I was 4. Moved on to “concierge care,” and doesn’t take insurance. The group she left behind struggles to hire physicians.
- So where we’ve always had two bands of healthcare, Medicaid and insurer-supported, a third band now comes on strong. Healthcare for the rich. Healthcare for those who don’t rely primarily on jobs for income, but on their wealth. The poor, if they can afford and are eligible for Medicaid, are administered by the government, the middle by health insurers who must make a profit, and the wealthy by small groups who (this is key) can spend more on their doctors.
- I would not presume to re-engineer American healthcare, but I’m pretty sure gutting the medical professional community to give extra special care to the rich isn’t the best path. A private option is bound to spring up in any system, but three bands of care feel like we’re duplicating administrative costs, at the very least.
- Generative AI For All?
- In the simplest terms, generative AI like ChatGPT and Anthropic allows software and data to do the work of entry-level, and maybe mid-level creators of industrial language and images. Many who were told “learn to code,” are now regretting that choice. Entry-level financial analysts, those who generated the reports mid-level investors read, are worrying. I can’t speak to young lawyers or marketers, but I don’t imagine 2026 is just like 2016 for them.
- Meanwhile, corporations fielding these AI tools are raking in investment dollars, hand over fist. And if they go public, investors will reap the value. Workers, kids out of college who had hoped for office jobs, now what? It is at this point that I start to see the appeal of a basic income program, for everyone, no questions asked. Even conservative think tanks believe. These people aren’t “not trying.” They aren’t lazy. Investors and technologists have simply taken (one might say seized) the benefits of this work for themselves.
- Housing Industry Without The Little Guy
At minimum, I believe we need strong regulation. At maximum, well, I don’t know. Ideas I’ve seen floated are Medicare for All, and Basic Income for all, no needs testing required. As recently as 10 years ago I’d have rejected both because, competition is good. But now, in a world with such wealth, and the capacity to meet the basic material needs of so many without burdening anyone–except those who dreamed of riches to build a place in history–is greed really the best driver to improve our collective lives?
I do think it used to be. On average across the entire world, the economics of greed harmed, brutalized many, but may have fed, housed and cured more than were hurt. An ugly calculus. I’m also as sure as I can be that it’s no longer true.
If you have thoughts, I’m all ears. In any case, I wish a good weekend to everyone. I hope you have shelter, healthcare, and a job if you need or want one, and thereby can find compassion to spare for others.
34 Responses
I applaud your willingness to grow and change. Even more, your willingness to openly admit to learning as facts change. What you say also reflects your values. Admirable.
You named three things I worry about. A fourth is our climate crisis. Leaving the medical issue aside (except to note that we have to be healthy to thrive), surely there are bright minds who can devise a policy that leverages the concentration of capital, the possibilities of AI for good, and our very talented workforce to address climate change.
We are not free until we are all free, not healthy until we are all healthy, and not safe until we are all safe.
So well said. And I agree that climate change is another place where the market breaks down. We ever learned about the Tragedy of the Commons in business school. Funny how it gets ignored and cost curves are tattooed into financial markets.
And thank you.
“We are not free until we are all free, not healthy until we are all healthy, and not safe until we are all safe.” So well said and so true.
The climate crisis really hits home for me too, as I live in a place that’s now gets ravaged by severe weather every week it seems during the late “winter” (when temps now frequently climb into the 80s) and spring. This never happened when I was young. It creates a constant state of fear for me now, since I lost my house and a neighbor in a tornado in 2020.
I can imagine possibilities for the use of AI for good, but I just know beyond any doubt that good is not the way it’s going to go, especially with the leadership we have. I’m terrified of what’s to come.
It’s the mark of a wise and good person to grow and change throughout life, adapting to new information and experiences. So many people never let go of the pride that prevents them from doing so. I try, at least. I’m pretty sure we’re all the good (and very rare) kind here. Have a great weekend, all. ❤
Oh, Jess, I am so sorry you lost your home. And a neighbor! The effects of climate change are no longer theoretical, and this wanton overturning of regulation makes absolutely no sense. There’s money to be in green energy, if the right regulations are in place.
I agree. The people here are the good kind. And I’m eternally grateful.
It is so important to be able to change our views over time.
The concierge medicine model is happening all around us as well. In fact, many many medical specialists in Dallas do not take Medicare patients. I’m not talking Medicaid patients here–but Medicare patients–which is MOST elderly people who. need specialists. That is why we have changed to the local medical school (UT Southwestern) for most of our medical care. They have specialists of every kind and ALL of them take Medicare.
I see private equity firms as one of the elements of our economic life in the US that has severely affected almost everyone of us. They have a LOT of money to invest and are always looking for places to put it. They buy up companies in their quest to obtain profits for their rich clients. When they acquire these companies, they do not care about the employees of the companies, or about making the companies better, or even giving good service to the customers of the company. A case in point is the rural water company/provider that service the area around our East Texas farm. For years, it was a good and reliable company. Then, it was purchased by private equity. Now, we have frequent boil notices and a substantial increase in “brown water”. This necessitates calling the company (based in Houston) and reporting–and hoping that they will fix the issues involved. This is happening more and more. A good company would get a handle on what the issues are–and make these instances infrequent. Instead, they are becoming more frequent.
The privatization of water is terrifying. So sorry you’re hit with it with such immediacy.
Private water. What, will it be private air next?
Great points Susan about private equity. Profit pursuit with no other values taking over crucial services. An effect of the extreme concentration of wealth which leads to an insatiable appetite for investment opportunities. Anonymized and unaccountable.
In my central Tx city (and in many other places), private equity is contributing to the housing shortage by bidding up the price of starter homes by as much as $75,000 to $100,000 and then marketing them as rentals. This was the experience of two of my young colleagues – I don’t know how people “get started” in such a set up.
I don’t know either. I have voiced support in my neighborhood for new housing, and the resistance is profound. Especially up in the wealthiest places like Woodside and Portola Valley.
Anonymized and wholly unaccountable. Like the “dark money” on Wall Street. Not a free market, rather one tightly held.
So important. I left business before private equity became such a big thing. But everything I read tells me you are right. It’s amazing that Dallas physicians don’t even take Medicare. The question is whether Medicare reimbursement is too low, or the money to be made from wealthy private clients is above and beyond, and possibly both are true.
I have heard from providers that medicare paperwork is *completely insane* so it effectively costs more per patient (a therapist I was seeing feels it’s unethical as well, since it requires more disclosure of private information; but she was also saying that per hour of patient time, it takes an additional hour to do the paperwork; I think this effect is reduced for non-mental-health specialties, but not eliminated). I got a glimpse of this last year, as I was on both a primary insurance and medicare for the first time, and it took 4 months to straighten out a billing quibble for a primary care doctor’s visit between primary insurance and medicare.
For people like primary care physicians, if they’ve already got regular billing set up for Medicare and have already got a sense of what tests Medicare will/won’t pay for without x, y, or z, then it’s more comparable to average (also insane! oh, hey, if you’re a PCP you can’t order Vitamin D tests anymore and reliably have them reimbursed by many private insurers, despite that being a really common and easily treated cause for an extra layer of fatigue or depression; oh, and heart calcium tests which tell you your plaque risk for $50 also aren’t covered, gotta get those out of pocket…). They still won’t all take Medicare patients, but it’s at least less of a penalty for them.
I don’t know what Medicare reimbursement rates are for specialists vs. PCPs, though; it seems reasonably likely that it’s both more of a pain and less-reimbursed, but I don’t have data.
Our regular insurance, via the university which is a large portion of the town, got in a standoff with the local hospital (and most medical practices) several years ago, and several years before that, because they refused to raise the allowed reimbursement rates with the rate of inflation and the hospital was like: look, we quite simply can’t *do* most of those things for those amounts of money. The insurance for the bigger state university, with the medical school and research facility, *also* got in a standoff with *their* university, resulting in doctors who, insurance-wise, would not have been allowed to see themselves! Anyway. It eventually got sorted in both cases, after a lot of unnecessary stress, but: we need meaningful insurance reform. No algorithms denying all <$200 claims just because most people won't bother; no "fiduciary duty to shareholders" being more important than the professional duty to the patients who have the insurance; less paperwork; better match-up with actual costs.
Sometimes the "we don't take insurance" private practices do that because it allows them to spend an adequate amount of time with each patient with complex conditions, instead of a half-hour intake and 15 minutes for followup appointments as insurance required our first primary care provider in this area to comply with. (which is *insane* for any chronic health condition or anyone who is experiencing the health complexities that come with aging or multiple medication balances)
We've also now got tiered providers within our insurance, where the ones who "don't keep costs down" – aka do tend to order tests for things – cost substantially more to see than those who rarely order testing, and this is really something when you're trying to find someone who sees more patients with your weird thing… but when your thing is weird enough that it usually *requires more testing* in general, and realize the set of perverse incentives that have been set up.
We also need to kick a lot of monopolies in the posterior.
I've been thinking about this article for a while now: https://www.theatlantic.com/ideas/archive/2024/12/food-deserts-robinson-patman/680765/ – and yes, if you have no choice, you'll commute to your grocery store. But that's evil, to deliberately steal more time/energy from people who already don't have enough money, time, or energy.
There are some basic human needs in our society that have high value and should not have sky-high profit margins for investors. I'm not sure how best to decouple these things, though. (and yes, a pox on private equity's "bleed the business and let them die" practices!)
More paperwork, that’ll solve things:(. We the patients have more too. Questionnaires before exams, and then we still have to fill out the paper on the clipboard. Questionnaires after medical visits – feedback please. They have to hire people for this “feedback,” when they really know already what we want and need.
That article on food deserts that you link to, I had NO IDEA this was linked to a refusal to enforce a prior anti-trust law. Incredible. The 1980s were in some ways the last hurrah for the middle class, weren’t they? Here we have small groceries, but they are of course luxury groceries, based on San Francisco’s Bi-Rite’s model. Lots of prepared food too. Let’s not even speak about what Amazon did to Whole Foods.
Thank you for contributing here. I always knew I had intelligent, knowledgable readers but this has been a whole new level.
I’ve also undergone a gradual, significant in my beliefs about capitalism. I did not foresee that “pro-business” policies would result in this brutal winner take all environment, that limiting regulation would result in such extreme concentrations of power and a hollowing of the middle class. It’s taken a while to recognize how modern corporate capitalism differs from the simple models I learned in college(for example the way banks package and securitize loans with little responsibly for risk management and none for community investing). To note how opportunities for small entrepreneurs have narrowed (lack of affordable health care being just one factor). And yes to the discussions above about AI, climate change, housing, etc.
I also would never have guessed that our democracy would stagger so quickly under pressure from a weirdly talented, openly corrupt populist—surrounded by ideologues like Miller and the Heritage Foundation, plus the ultra wealthy eager to protect their assets at all costs. So when and if America moves on from the current political nightmare we will need to reimagine and restructure our economy and rebuild (not just restore) our government. A huge project! I hope Americans can do it, though issues like AI and climate change will not permit a slow pace. Thanks for your thoughtful posts.
Thank you for your thoughtful and knowledgable comments today. I agree completely about bank loans. Repackaging as you point out also guts the human components of lending.
I wasn’t surprised by what Trump and Miller and Vought have put in place, probably because I am so prone to disaster thinking after COVID and the deaths in my family. Also I have a fair amount of free time. But I have been surprised by how little resistance law firms and media have offered up, and how much the brave people of Minneapolis have been willing to risk.
I was an information systems major at a business school in the early 1980s and swallowed capitalism whole. Voted for Reagan and everything.
Motherhood radicalized me. It was my first taste of power over anyone and made me realize how quickly and easily things could get dangerous. That was only a short leap to wanting the Powers That Be held to the same standards I hoped to uphold myself. (Basically I changed my mind, my attitude towards power because having it scared the **** out of me.)
There is enough for everyone. We have got to get away from the idea that people need to earn the basics of their existence. We also have to stop acting as though the obscenely astronomically wealthy are innately virtuous. Both of those attitudes are tied to an unhealthy and vile reward-based approach throughout our society towards everything from elementary education to professional management. Human beings are treated as the raw material in an extraction industry.
Yikes, that match lit fast. Thank you for opening your heart and mind to us, and giving us room to do the same. Have a wonderful weekend.
That is beautiful, Maria. Absolutely beautiful. Thank you. Motherhood can be a revelation. And yes, there is enough for everyone and there is no virtue per se in be able to amass a fortune. We’re all gathered around the fire, thanks for the kindling.
Chiming in from Canada here…we have universal health coverage (“FREE” hospital emergency visits, hospital stays, hospital tests and medications, out-patient physician visits for all ages and also many free immunizations, depending on age). Here’s the rub…”FREE” in quotations means we pay for it with our taxes…fair enough….the system has worked quite well up to now, and our standard of health care is amongst the highest in the world. Nobody goes broke in Canada (so-called medical bankruptcy) due to medical or hospital costs.
However, this previous reality is now colliding with the new reality that new treatment options cost more, in some cases – much more – think new cancer treatments, think more frequent organ transplantation and joint replacements as the population ages, and in response to the stresses/temptations of modern life, more people need addictions and mental health treatments, which also can cost a lot.
Nearly all Canadians want to keep universal, “free” health care (as shown by their voting patterns) – hence it’s important to keep a well-funded public health system – with a heavy emphasis on preventative care – going strong. But predictable events like an aging population, plus unforseen events like accidents and infectious pandemics (to name but a few), will upset the prevention/treatment balance.
The result is that Canada, like many European countries, is facing the dilemma of higher taxes vs. longer waiting lists, backed-up emergency rooms/operating rooms etc. When put to the choice, many Canadian prefer to pay higher taxes, also perhaps require people to work longer before retirement, so they pay more into the system etc. It also makes sense from our point of view to encourage immigration of foreign-trained doctors, nurses and other professionals, but that deprives their home countries of their health professionals. No easy answers!
Thank you for this. The portrait you paint here is what I had also always heard about the UK, and was one of the primary reasons I was against a full public healthcare option. It’s a very good point, and should be reiterated, that there are no easy answers to how to structure healthcare. I believe that if we can find the political and societal will in the USA, we can however do better. The issue of innovation, the new treatments that are bound to cost more in early days, and how to offer them fairly, I hadn’t considered and I appreciate you bringing it up.
Lisa writes: “My primary care physician just quit the group I’ve gone to since I was 4. Moved on to ‘concierge care,’ and doesn’t take insurance. The group she left behind struggles to hire physicians.”
You have my sympathy. Losing a close, long-term relationship like that is a shock.
My 40 year primary care MD’s new group causes him to be unavailable for appointments 3 to 4 weeks out, or more. But a same-day appointment can be had by his on-staff PA or APRN.
This is what I’m seeing here in the Southeast: Hospital groups, and other physician groups are served by one MD-per-specialty now, with PAs, DOs, APRNs seeing the majority of their patient loads.
I’m just guessing, but the group you went to since you were 4 may be under the same industry-wide pressure to hire DOs to treat patients. From scanning the medical staff personnel at nearby hospitals and hospital in-patient treatment offices online, I’m seeing DOs dominating treatment centers.
The intricacies of insurance reimbursement are over my head, but I’d point in that direction, if forced.
Thanks, Flo. In fact the story is more complicated, I just didn’t want to burden you all with details. My longtime doctor, my age, retired several years ago. She chose a top new grad to replace her. Well, the top new grad had so many patients the waiting time was as you describe. Then the top new grad took extended maternity leave – gone for a year and then back part-time. As soon as she was stable, let’s say it was about 3.5 years after she had taken the job, she quit for concierge. I wholly understand her decisions, and I still hated the results LOL. The system does not support PCPs, and supports young women even less.
I too see more nurse practitioners, physician’s assistants, and DOs vs. MDs. The MDs are heading up to concierge. Do we need an MD for everything? Maybe not. But health care is not getting well-structured by private industry, that I can see.
There was an excellent opinion piece in the NY Times a few weeks ago by a conservative economist, Oren Cass, who talked about the financialization of our economy – e.g., how banks now repackage loans instead of lending money to build railroads. It’s titled “The Finance Industry Is A Grift. Let’s Start Treating It That Way.” So you’re in good company in thinking that new approaches need to be taken. This link should allow you to read it. https://www.nytimes.com/2026/02/06/opinion/capitalism-industry-financialization.html?unlocked_article_code=1.OFA.3Pj3.-jqgsvr0x5Bs&smid=nytcore-ios-share
OMG that article is SO GOOD! Brilliant in fact. Thank you for sharing.
Twenty-five years ago I felt like the real value of investment bankers and corporate lawyers was actually anxiety reduction for the enterprises that made something and sold it, or performed services in support of those who made something. But his analysis goes so much deeper, obviously. And it dovetails, in my opinion, with what we are learning about Epstein and those he “advised.” Everything is a transaction, or a gamble on a transaction. I am so glad an economist is thinking about this, and that the NYT is publishing these thoughts. I hope the Democratic apparatus is cultivating these brains.
Maybe there is some hope that we as a country might evolve and structure a new system, one that keeps the good parts of the USA, optimism, blunt speaking, hard work, and gets rid of the fungus that has developed in the cracks. At least most of it.
Hi Lisa-
Capitalism is fine for certain arenas, but health care is not one. We should have universal coverage, not patchwork. I listened to a podcast (The Rest is Politics UK version) recently in which they were discussing
JD Vance and his book about “Hillbilly Elegies” and the huge US crisis in drug use. Their comment about the fact that with universal health care in Great Britain this is not as much of a crisis made me reflect again about our country. Yes, each country that has universal health care has issues with access, how much the tax is, but the fact is that everyone is covered and the broad statistics which indicate that health care is better (maternal death statistics, childhood mortality, and so many more) in spite of spending twice as much of GDP on health care! The recent loss of medical insurance subsidies –ugggh to Republican policies.
I trained as an internist? primary care physician in the 70’s and the above statistics were valid then. I completely understand your PCP’s decision to transfer to being a concierge MD. The fact that an orthopedic surgeon makes 2-3 times (or more) the income of an internist/PCP is difficult to observe after a while. After I retired several of my colleagues became concierge MD’s. They make tons more money and have a small patient panel. Primary care presently is very stressful and poorly organized (even by Kaiser who have been working on this for 70 years).
We could have “Medicare for all” and at least have basics available to everyone. I have enormous respect for PA/NPs who provide excellent care in most cases.
A fascinating book to read: The Healing of America by TR Reid (2010), about how various countries adopted various solutions to the health care problem. 16 years old and still brilliant. Very thoughtful post, and thanks!
Oh, thank you for contributing from your experience and expertise! I keep wondering if healthcare reform ought to start with a blank slate and define baseline care. Because everything possible for everyone most likely isn’t realistic. And I agree, some of the best care ‘s had has been by a nurse practitioner. What I really dislike is being shuttled about. My uninformed opinion is that a human relationship over time will most likely capture more info and lead to better care than segmenting a person into “care silos” and testing for symptoms. I would be fine with an NP, if she/he could offer a holistic approach. In particular, a holistic approach as I age. I have been thinking I’d apply to be transferred to a geriatrician for primary care for just this reason.
For example, what do I do when my cholesterol indicates “reduce full fat dairy” and my bones say, “MOAR DAIRY?” I think a doctor would need to hear me explain that I can be highly disciplined when I have a clear goal. How do I tell that to a DEXA scan? But enough about me. Again, thank you so much.
I think it’s also very, very hard in people-focused professions to know you don’t have enough time to give patients proper care with what insurance wants you to stick with. Half an hour isn’t really enough for a PCP intake appointment of anyone who isn’t young and mostly healthy; 15 minutes isn’t enough for followup appointments when 1. the problem continues [or the treatment has caused a different problem] and 2. the next step is not blindingly obvious; and insurance is shoving people towards telehealth appointments for anything that can be telehealthed, further reducing the points of contact and the ability to keep up with how patients are doing and what they need and what they’ve tried already (and what random unlisted supplements they might be on and that might be complicating the picture).
And then there’s all the unreimbursed time – patient messages and phone calls; straightening out prescription glitches and refilling prescriptions; paperwork, billing, checking test results, following up.
I want PCPs (and specialists, and dentists – a friend of mine had a hard time finding a dentist who wasn’t part of a Widget Dentists Private Equity Office) to be able to earn a good-enough living without being run off their feet all the time.
I also want as few layers as possible siphoning off the available pay-in/pay-out money from healthcare. But the “finance” industry sees things differently than I do, in general.
I really feel for the medical professionals. All the people I know went into this because they wanted to help people and solve other’s health problems (along with personal reasons). And how can they do that in 15-minutes slices of a day?
On -ists, political and economic labels are speed bumps deployed to delay reaching the conclusion that concentrations of money and power cannot benefit most of us.
I live in New York City, and I’ve been a protest monitor here for the last two years. In watching demonstrators, marchers, marshals, organizers, de-escalators, lawyers, federal officers, and NYPD commingle in that time for all sorts of reasons – Israel/Palestine, ICE atrocities, LGBTQ+ causes, budget battles, appointments, reproductive freedom, you get the idea – I run into DSA members and organizers a *lot.* They run a tight ship and they cosponsor a lot of mutual-aid events I attend already, but I’ll probably go listen to them at one of their events, too. I am and will likely remain a registered Democrat, as I want to be able to vote in the primaries, but I find myself thinking quite a lot about my first comparative government class three decades ago. Democratic socialism made the most sense to me then, and it makes the most sense to me now.
But again, I think fixating on labels is a waste of time; Americans are self-determining and us-and-them-ing ourselves right out of existence. I follow the on-the-ground mutual aid and volunteering connections I make back to their organizational sources, then follow those sources to the legislators advancing their proposals, and I pitch in accordingly. It helps me, and I hope it helps them.
I love this. Starting from the smallest, most immediate, truest, and moving up to the general, essentially. And I agree, labels become kind of like the ball in dodgeball, people want to possess them to throw at someone else.
I have learned SO much from this post and all of the comments. You are treasure, all.
I often think about the blatantly obvious monopolies we have now, as more and more of my favorite “smaller” businesses close, and wonder exactly when our antitrust laws stopped being enforced and how that’s allowed. Now the head of the antitrust division has been removed just in time for Ellison’s acquisition of most of what remained of television news. And as we know, most coincidences aren’t…
To be very clear here, the third band of healthcare has been strong, large and in charge for YEARS. Different and better healthcare services and providers for “top executives” in EVERY industry from A-Z, has been the “norm” for YEARS longer than I have been on this planet. Pushing 70. Boutique healthcare and giving special care for the rich has been their secured path with no-trespassing for a very, very long time. Also check with local elected officials, their generous access and benefits, and rely on your dime aren’t too shabby. Their inner circle is exquisite too.
Yes, top executives have always had better care. The thing that appears new to me, where I live, is that a concentrated number of wealthy people are demanding so much and paying so much for their care that we have a shortage of doctors who accept even standard employer care.
In a previous life, not all that long ago, at the onset of the pandemic, I worked with hundreds of individuals that were switching gears in the career to become Java developers. (I worked for a tech company.) A good number of the people dropped out of med school not just because of the cost and for some, to the dismay of their parents (!) but because they didn’t want to ultimately – in their words- be controlled by the healthcare insurance companies.
Most recently my own doctor that I only see once a year, told me that physicians he knows, and he too, are increasingly moving from general practices to specialized care- he said, “it’s just not worth it to be a GP doctor anymore.” And then walked out of the room. He is young and early in his career, that will no doubt shift into a specialized field or boutique practice that I certainly could never afford.