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More money could be saved over the long term, she added, if connecting newly released inmates to services helps to keep them out of jail and reduces visits to emergency rooms, the most expensive form of care.“The ability for us to be able to call up a treatment provider and say, ‘We have this person we want to refer to you and guess what, you can actually get payment now,’ changes the lives of these people,

as important, he said, was the chance to coordinate care for prisoners after their release.About 70 percent of prison inmates in the state have problems with addiction, he said, and 34 percent suffer from mental illness. Without health coverage, inmates leave prison with 30 days’ worth of medication and are then mostly left to their own devices.“If they go off their medication, oftentimes it can once again lead to more criminal activity,” Mr. Raemisch said. “So by keeping them medicated and keeping them mentally healthy, it really helps us in our re-entry efforts.”

As essential as health insurance is for people trying to put together their lives after being incarcerated, the challenge of getting them into treatment, when they often did not have housing or jobs, was “a whole other kettle of fish,”

With that political backdrop, Obamacare deals only indirectly with high prices. By regulating and mandating insurance plans, it seeks to create a better, more competitive market that will make care from doctors and hospitals cheaper.

With half a billion dollars spent by medical lobbyists each year, according to the Washington-based Center for Responsive Politics, our fragmented profit-driven system is effectively insulated from many of the forces that control spending elsewhere

Many health economists say we must move away from the so-called fee-for-service model, where doctors and hospitals bill every event, every pill, every procedure, even hourly rental of the operating room.

And so American patients are stuck with bills and treatment dilemmas that seem increasingly Kafkaesque.

Given that national or even regional rate-setting is out of the question, most health economists argue that the nation needs a new type of payment model, one where doctors and hospitals earn more by keeping patients healthy with preventive care rather than by prescribing expensive tests.

The Affordable Care Act generally requires patients to be responsible for more of their bills — copays and deductibles — so they will become more price-savvy medical consumers. But the deck is stacked against them in a system where doctors and hospitals are not required or expected to provide upfront pricing. Why not?

And policy makers need to address two of the biggest drivers of our inflated national health care bill: the astronomical price of hospitalizations and particularly end-of-life care.

r premiums, the Medicare cuts, the Medicaid expansion, all of it. And at that point, the plausible right-of-center alternatives to Obamacare will no longer look risky and disruptive relative to the status quo, because that status quo will no longer be one that Republican interests and voters are deeply invested in defending. Instead, those interests and voters will be looking for ways to limit the health care law’s impact, and the conservative alternatives will look more like what they actually are — proposals that spend less, regulate less, and reflect a greater confidence in markets than the president’s new law, and that would change the underlying health care system in ways that a sensible G.O.P. should support.

many women who started out with all the ambition in the world find themselves in a place they never expected to be. They do not choose to leave their jobs; they are shut out by the refusal of their bosses to make it possible for them to fit their family life and their work life together. In her book “Opting Out? Why Women Really Quit Careers and Head Home,” the sociologist Pamela Stone calls this a “forced choice.” “Denial of requests to work part time, layoffs or relocations,” she writes, will push even the most ambitious woman out of the work force.

The problem is even more acute for the 42 million women in America on the brink of poverty. Not showing up for work because a child has an ear infection, schools close for a snow day, or an elderly parent must go to the doctor puts their jobs at risk, and losing their jobs means that they can no longer care properly for their children — some 28 million — and other relatives who depend on them.

This looks like a “women’s problem,” but it’s not. It’s a work problem — the problem of an antiquated and broken system.

there’s good news. Men are also beginning to ask for and take paternity leave and to take lead parent roles. According to a continuing study by the Families and Work Institute, only a third of employed millennial men think that couples should take on traditional gender roles

we cannot do this alone, as individuals trying to make our lives work and as workers and bosses trying to make room for care. Some other company can always keep prices down by demanding more, burning out its employees and casting them aside when they are done

To be fully competitive as a country, we are going to have to emulate other industrialized countries and build an infrastructure of care. We used to have one; it was called women at home.

To support care just as we support competition, we will need some combination of the following: high-quality and affordable child care and elder care; paid family and medical leave for women and men; a right to request part-time or flexible work; investment in early education comparable to our investment in elementary and secondary education; comprehensive job protection for pregnant workers; higher wages and training for paid caregivers; community support structures to allow elders to live at home longer; and reform of elementary and secondary school schedules to meet the needs of a digital rather than an agricultural economy.

Change in our individual workplaces and in our broader politics also depends on culture change: fundamental shifts in the way we think, talk and confer prestige. If we really valued care, we would not regard time out for caregiving — for your children, parents, spouse, sibling or any other member of your extended or constructed family — as a black hole on a résumé.

“Just because a physician’s office extended its hours doesn’t make it urgent care,” Mr. Charland said. “To me, urgent care means you can do X-rays, that you can do sutures, maybe you’re open one weekend day, plus one or two evenings.”

There might be other explanations. With any infection, there are four basic questions to ask when looking at broad differences in death rates. Is the virus different here versus there? NO. Right now, there is no evidence that the virus is mutating toward a more potent strain in the US.Is one country diagnosing the virus sooner than another? YES. As above, this may be skewing German and South Korean results by identifying asymptomatic and mildly symptomatic persons unlikely to require medical care. Hospitalization rates by country, currently not tracked, would help sort out the contribution of aggressive testing to survival rates. Is the infected patient different here versus there? YES. South Korea (young patients) and Italy (old patients) are unique in the outbreak, and the characteristics in Iran are not well known. All other countries with specific information, from China to even the US epicenter of New York City, have shown the same basic distribution with respect to age, sex (more men than women) and smoking. Is the health care system different here versus there? OH YES. Health care system differences at the country level are hard to examine: information is sparse and, given the 50,000-foot view, possibly misleading. However, health care experts typically can rely on "structural measures" to determine the quality of a hospital or a state or a country.

The World Bank tracks health care information by country on three relevant structural measures (though recentness of information varies country to country), each measured per 1,000 general population: doctors, nurses and hospital beds. They and other sources also track two other relevant variables: lifespan per country and health care spending per individual. Neither of these demonstrate differences in affected Western European countries that might explain a difference in Covid-19 survival.

Among the nine countries with the highest number of Covid-19 cases, the country that has the highest nurse rate also has the lowest death rate from the disease. Germany has 13.2 nurses per 1,000 (echoing a trend for high nurse numbers throughout Northern Europe) far above the other heavily Covid-19 affected countries. This may be just another armchair epidemiologist observation of course. But higher numbers of nurses may reflect one of two beneficial factors (or both): first, that nurses, the backbone of hospital (and especially ICU) care, are essential to patient management and, ultimately, survival.

Either way, it is a reminder that Covid-19 will continue to reveal the strengths and weaknesses of health care systems across the world. The current observed differences also mandate that, when we finally are out from underneath the weight of the current crisis, we must work to determine how we can deliver better health care to large populations across the world.

their explanation begins by dismantling several others.

Was the source of the problem America’s all-too-ready supply of prescription opioids?

About a million Americans now use heroin daily or near-daily. Many others use illicitly obtained synthetic opioids like fentanyl.

As Case and Deaton note, most people who abuse or become addicted to opioids continue to lead functional lives and many eventually escape their dependence

The oversupply of opioids did not create the conditions for despair. Instead, it appears, the oversupply fed upon a white working class already adrift.

although opioid deaths plateaued, at least temporarily, in 2018, suicides and alcohol-related deaths continue upward.

Could deaths of despair be related to the rising incidence of obesity?

Case and Deaton report that we’re seeing the same troubling health trends “among the underweight, normal weight, overweight, and obese.”

Is the problem poverty?

Overdose deaths are most common in high-poverty Appalachia and along the low-poverty Eastern Seaboard, in places such as Massachusetts, New Hampshire, Delaware, and Connecticut. Meanwhile, some high-poverty states, such as Arkansas and Mississippi, have been less affected. Black and Hispanic populations are poorer but less affected, too.

How about income inequality? Case and Deaton have found that patterns of inequality, like patterns of poverty, simply don’t match the patterns of mortality by race or region.

A consistently strong economic correlate, by contrast, is the percentage of a local population that is employed

In the late nineteen-sixties, Case and Deaton note, all but five per cent of men of prime working age, from twenty-five to fifty-four, had jobs; by 2010, twenty per cent did not.

What Case and Deaton have found is that the places with a smaller fraction of the working-age population in jobs are places with higher rates of deaths of despair—and that this holds true even when you look at rates of suicide, drug overdoses, and alcohol-related liver disease separately. They all go up where joblessness does.

Conservatives tend to offer cultural explanations

People are taking the lazy way out of responsibilities, the argument goes, and so they choose alcohol, drugs, and welfare and disability checks over a commitment to hard work, family, and community. And now they are paying the price for their hedonism and decadence—with addiction, emptiness, and suicide.

Yet, if the main problem were that a large group of people were withdrawing from the workforce by choice, wages should have risen in parallel.

Case and Deaton argue that the problem arises from the cumulative effect of a long economic stagnation and the way we as a nation have dealt with it

For the first few decades after the Second World War, per-capita U.S. economic growth averaged between two and three per cent a year. In the nineties, however, it dipped below two per cent. In the early two-thousands, it was less than one per cent. This past decade, it remained below 1.5 per cent.

Different populations have experienced this slowdown very differently

Anti-discrimination measures improved earnings and job prospects for black and Hispanic Americans. Though their earnings still lag behind those of the white working class, life for this generation of people of color is better than it was for the last.

Not so for whites without a college education. Among the men, median wages have not only flattened; they have declined since 1979. The work that the less educated can find isn’t as stable: hours are more uncertain, and job duration is shorter

Among advanced economies, this deterioration in pay and job stability is unique to the United States.

In the past four decades, Americans without bachelor’s degrees—the majority of the working-age population—have seen themselves become ever less valued in our economy. Their effort and experience provide smaller rewards than before, and they encounter longer periods between employment.

The problem isn’t that people are not the way they used to be. It’s that the economy and the structure of work are not the way they used to be

Today, about seventy-five per cent of college graduates are married by age forty-five, but only sixty per cent of non-college graduates are

Nonmarital childbearing has reached forty per cent among less educated white women.

Religious institutions previously played a vital role in connecting people to a community. But the number of Americans who attend religious services has declined markedly over the past half century, falling to just one-third of the general population today.

Case and Deaton see a picture of steady economic and social breakdown, amid over-all prosperity.

climate—the amount of social and economic instability not only in your life but also in your family and community—matters, too. Émile Durkheim pointed out more than a century ago that despair and then suicide result when people’s material and social circumstances fall below their expectations.

why has the steep rise in deaths of despair been so uniquely American

The United States has provided unusually casual access to means of death.

The availability of opioids has indeed played a role, and the same goes for firearms

The U.S. has also embraced automation and globalization with greater alacrity and fewer restrictions than other countries have. Displaced workers here get relatively little in the way of protection and support.

And we’ve enabled capital to take a larger share of the economic gains. “Economists long thought that the ratio of wages to profits was an immutable constant, about two to one,” Case and Deaton point out. But since 1970, they find, it has declined significantly.

A more unexpected culprit identified by Case and Deaton is our complicated and costly health-care system.

The focus of Case and Deaton’s indictment is on the fact that America’s health-care system is peculiarly reliant on employer-provided insurance.

As they show, the premiums that employers pay amount to a perverse tax on hiring lower-skilled workers.

According to the Kaiser Family Foundation, in 2019 the average family policy cost twenty-one thousand dollars, of which employers typically paid seventy per cent.

“For a well-paid employee earning a salary of $150,000, the average family policy adds less than 10 percent to the cost of employing the worker,” Case and Deaton write. “For a low-wage worker on half the median wage, it is 60 percent.”

between 1970 and 2016, the earnings that laborers received fell twenty-one per cent. But their total compensation, taken to include the cost of their benefits (in particular, health care), rose sixty-eight per cent. Increases in health-care costs have devoured take-home pay for those below the median income.

this makes American health care itself a prime cause of our rising death rates.

we must change the way we pay for health care. Instead of preserving a system that discourages employers from hiring, retaining, and developing workers without bachelor’s degrees, we need to make health-care payments proportional to wages—as with tax-based systems like Medicare.

So far, the American approach to the rise in white working-class mortality has been to pour resources into addiction-treatment centers and suicide-prevention programs. Yet the rates of suicide and addiction remain sky-high. It’s as if we’re using pressure dressings on a bullet wound to the chest instead of getting at the source of the bleeding.

Case and Deaton want us to recognize that the more widespread response is a sense of hopelessness and helplessness. And here culture does play a role.

When it comes to people whose lives aren’t going well, American culture is a harsh judge: if you can’t find enough work, if your wages are too low, if you can’t be counted on to support a family, if you don’t have a promising future, then there must be something wrong with you

We Americans are reluctant to acknowledge that our economy serves the educated classes and penalizes the rest. But that’s exactly the situation, and “Deaths of Despair” shows how the immiseration of the less educated has resulted in the loss of hundreds of thousands of lives, even as the economy has thrived and the stock market has soared.

capitalism, having failed America’s less educated workers for decades, must change, as it has in the past. “There have been previous periods when capitalism failed most people, as the Industrial Revolution got under way at the beginning of the nineteenth century, and again after the Great Depression,” they write. “But the beast was tamed, not slain.”

Today, the battles are over an employer-based system for financing health care, corporate governance that puts shareholders’ interests ahead of workers’, tax plans that benefit capital holders over wage earners.

We are better at addressing fast-moving crises than slow-building ones. It wouldn’t be surprising, then, if we simply absorbed current conditions as the new normal.

A law passed in the wake of the 2009 financial crisis forced Italian regions to reduce annual spending on health-care workers to 1.4% below the 2004 level. While the limit wasn’t always respected, there was a sharp reduction in the number of doctors and other medical personnel employed in the national health service because those who retired often weren’t replaced.

The U.S. has one of the highest per capita rates of deaths attributed to the virus. Yet the country’s health-care spending equaled 17% of gross domestic product in 2019, according to the OECD, compared with 8.7% in Italy and 11.7% in Germany.

In just about every other consumer market you can think of, the Internet, by making prices instantly available and comparable, has resulted in prices that are lower, more uniform and more closely tied to costs. But in health care, where pricing remains opaque, prices are rising faster than inflation, faster than costs and faster than the incomes of the people paying for it

The new rules would require hospitals (and the doctors whose practices are owned by hospitals) to publish, in an easy-to-use format, their minimum and maximum rates for 300 common services, along with the amount the hospital is willing to accept from someone without insurance. The aim is to make it easier for uninsured patients, or insured patients with co-payments and deductibles, to shop around for the best value.

More controversial, however, is a second rule that would require health insurers to create an interactive website that would tell customers what their out-of-pocket cost would be for a service at any provider, whether in network or out, as well as the price it has negotiated for that service with in-network providers. The effect would be to let every hospital and insurer know the rates negotiated between every other hospital and insurer — rates that under current contracts must be kept secret.

Within minutes of these regulations being announced, the hospitals and the health insurers announced their opposition, warning the rules would result in higher prices for consumers

Their argument is that if negotiated rates were made transparent, then the hospitals offering the deepest discounts would feel compelled to stop doing so out of fear that they would be forced to offer similar discounts to all insurers. In highly consolidated hospital markets — which at this point describes two-thirds of the country — there is also concern that allowing hospitals to share price information would make it easier for them to tacitly collude and keep price competition to a minimum.

major hospital chains and insurance already have a pretty good sense where they stand relative to their competitors in terms of pricing. A number of firms — including one owned by United Healthcare, the nation’s largest insurer — already gather and analyze pricing data and sell it to both hospitals and insurers. The only parties who are really in the dark are the consumers and employers who ultimately pay the bills.

if it is true that transparency will lead the lowest-price hospitals to raise their bids, then logically it should be also true that it will lead the insurers now paying the highest prices to demand better deals. Given that the market for health insurance is now as consolidated as the market for hospital services, the possibility of collusion is high on both sides.

Indeed, if transparency has any effect on prices, the most likely outcome is to eliminate the outliers at both the top and bottom of the price range, reducing the enormous variations in prices. And to the degree that transparency causes average prices to move in any direction, the more likely direction is down, not up

Such a positive outcome is suggested from experience in New Hampshire, the first state to establish a website listing how much customers of different insurance plans would be charged at different hospitals and labs for medical imaging such as X-rays, CT scans and MRIs. Zach Brown, an economist at the University of Michigan, found that the cost of imaging declined by an average of 4 percent for insurers and 5 percent for consumers, rising to 11 percent after five years.

Statewide, the range between the highest and lowest negotiated prices shrunk by 15 percent.

In today’s highly consolidated health-care markets, the goal for hospitals and insurers isn’t so much to lower costs as to shift costs onto someone else. When dominant insurers use their market power to extract lower prices from hospitals, the hospitals’ natural response is to try to extract higher payments from smaller insurers to cover their costs and meet their profit targets.

As this cost-shifting plays itself out, small insurers and small hospitals find themselves squeezed as they are forced to pay more and charge less.

The dirty little secret is that neither side in these hospital-insurer negotiations really wants to drive down prices. What matters to either side is not what price they pay or receive in an absolute sense — in general, both hospitals and insurers profit more when prices and premiums are high. The thing they really care about is whether they are getting a better price than their competitors

The reason insurers and hospitals are prepared to use whatever legal muscle they have to fight price transparency is the same reason pharmaceutical companies and pharmacy benefit managers fought a similar proposal by the Trump administration on drug pricing — because it would expose this con game.

Given the anti-regulatory tilt of the federal courts, the inevitable legal challenge is likely to succeed. Which means the only way Americans are likely to get genuine price competition in health care is if transparency rules are written into law by a Congress not captured by business interests and free-market ideology.

“If a patient comes to the urgent care clinic but is in need of emergency care, they will be stabilized and transferred to an emergency department at another facility for appropriate care,” he said.

The pandemic has exacerbated the Indian Health Service’s decades-long weaknesses and has contributed to disproportionately high infections and death rates among Native Americans. The Albuquerque service area has a seven-day rolling positivity rate of about 14 percent, compared with 7 percent for New Mexico and about 8 percent nationwide.

The office in the Albuquerque area is one of I.H.S.’s 12 service regions and serves 20 Pueblos, two Apache bands, three Navajo chapters and two Ute tribes across four southwest states. There are five hospitals, 11 health centers and 12 field clinics serving the residents of the area.Wendy Sarracino, 57, a community health representative for the Acoma people, said that when her son broke his leg, she had to stop at two hospitals before he could receive the care he needed.

“That was kind of our lifeline,” Ms. Sarracino said of the hospital. “We didn’t have to go very far for health care. An awareness needs to be made that people do live in rural New Mexico and we need health care.”

Dr. Thomas said the agency requested an extension of the removal of the tribe’s financial shares in the hospital given the pandemic but Laguna denied that request. “We’re doing everything we can to maintain all services for the tribal communities,” he said. “We take it very seriously and want to make sure we’re there for the patients.”

It has always been difficult for I.H.S. to attract doctors and nurses to its facilities, many of which are in isolated areas. In the Albuquerque area, the overall job vacancy rate of the health system is 25 percent for doctors and 38 percent for nurses.

“There’s already so much loss that we have to deal with in term of the unavailability of goods and services because we live on the reservation,” she said, “so basically we are fighting to keep whatever we can because at this point the health of our community isn’t great enough to sustain itself on it own.”

The Supreme Court is slated to hear arguments on the latest legal challenge to the decades-old law on Nov. 10; if the court does strike down the law, the president and Congress will need to move quickly to address the tens of millions of Americans who could lose their health coverage.

Trump, who campaigned on slashing drug prices in 2016, supports enacting a faster approval process for new generic drugs to drive down prices and has signed an executive order to import drugs from countries with lower prices.

Biden, meanwhile, has proposed allowing Medicare to negotiate discounts for drugs, in part by setting up an independent review board that would be in charge of determining the value of new drugs by comparing their price tag in other countries. 

Trump has also looked to more broadly reduce health-care costs, in part by issuing a rule that forces hospitals to report the rates they strike with individual insurers for all services, including drugs, supplies, facility fees and care by doctors who work for the facility. If the hospitals fail to comply, they could be forced to pay a $300 per day fine.

Biden aims to increase competition in the health-care market by using antitrust authority to reduce consolidation among providers. The candidate has called for establishing a public health-care option, which would allow for price negotiations with providers and create leverage to obtain lower prices.

Biden frequently says that he would "listen to science" in handling the virus outbreak, contrasting himself from Trump, who frequently disagrees publicly with the nation's leading infectious experts, including Dr. Anthony Fauci.

If elected, Biden has said that he would enforce a "national mask mandate," although he's conceded that it would almost face, and likely fall to, a legal challenge. Trump does not support a mask mandate and has largely left the pandemic response up to individual states. 

"I had to pray that my insurance would approve of my transplant just in the nick of time," she says. "I had that Stage 4 label attached to my name and that has dollar signs. Who wants to invest in someone with stage four?"

After doing her research, Rafieei says she intends to vote for Joe Biden, who helped get the ACA passed in this first place.

Even ten years after the Affordable Care Act locked in a health care protection that Americans now overwhelmingly support — guarantees that insurers cannot deny coverage or charge more based on preexisting medical conditions — voters once again face contradicting campaign promises over which candidate will preserve the law's legacy.

A majority of Democrats, Independents and Republicans say they want their new president to preserve the ACA's provision that protects as many as 135 million people from potentially being unable to get health care because of their medical history.

President Donald Trump has pledged to keep this in place, even as his Administration heads to the U.S Supreme Court the week after Election Day to argue the entire law should be struck down.

And yet the Trump administration has not unveiled a health care plan or identified any specific components it might include. In 2017, the administration joined with Congressional Republicans to dismantle the Affordable Care Act, but none of the GOP-backed replacement plans could summon enough votes. The Republicans' final attempt, a limited "skinny repeal" of parts of the ACA, failed in the Senate because of resistance within their own party.

But the state's governor also embraced the Republican effort to repeal and replace the law in 2017, and now Arizona's Attorney General is part of the lawsuit — that will be heard by the Supreme Court on Nov. 10 — that could topple the entire law.

Republicans have often tried to skirt health care as a major issue this election cycle because there isn't the same political advantage to pushing the repeal and replace argument, says Mark Peterson, a professor of public policy, political science and law at UCLA.

"Not everybody, particularly Republicans, associates the ACA with protecting preexisting conditions," he says. "But it is pretty striking that overwhelmingly Democrats and Independents do — and a number of Republicans — that's enough to give a significant national supermajority."

While pursuing repeal with zeal, Republicans are far from reaching any consensus on how to go about replacing the health care law, under which more than 20 million Americans have gained health insurance.

The blueprint directs four House and Senate committees to draw up legislation.

“every American will be adversely affected" by the repeal of the health care law.

We know now that touching things, being with other people and breathing the air in an enclosed space can be risky. How quickly that awareness recedes will be different for different people, but it can never vanish completely for anyone who lived through this year

The comfort of being in the presence of others might be replaced by a greater comfort with absence, especially with those we don’t know intimately

he paradox of online communication will be ratcheted up: It creates more distance, yes, but also more connection, as we communicate more often with people who are physically farther and farther away—and who feel safer to us because of that distance.

When all is said and done, perhaps we will recognize their sacrifice as true patriotism, saluting our doctors and nurses, genuflecting and saying, “Thank you for your service,” as we now do for military veterans. We will give them guaranteed health benefits and corporate discounts, and build statues and have holidays for this new class of people who sacrifice their health and their lives for ours. Perhaps, too, we will finally start to understand patriotism more as cultivating the health and life of your community, rather than blowing up someone else’s community. Maybe the de-militarization of American patriotism and love of community will be one of the benefits to come out of this whole awful mess.

Plagues drive change. Partly because our government failed us, gay Americans mobilized to build organizations, networks and know-how that changed our place in society and have enduring legacies today. The epidemic also revealed deadly flaws in the health care system, and it awakened us to the need for the protection of marriage—revelations which led to landmark reforms. I wouldn’t be surprised to see some analogous changes in the wake of coronavirus

The second reason is the “political shock wave” scenario. Studies have shown that strong, enduring relational patterns often become more susceptible to change after some type of major shock destabilizes them

But given our current levels of tension, this scenario suggests that now is the time to begin to promote more constructive patterns in our cultural and political discourse. The time for change is clearly ripening.

The COVID-19 crisis could change this in two ways. First, it has already forced people back to accepting that expertise matters. It was easy to sneer at experts until a pandemic arrived, and then people wanted to hear from medical professionals like Anthony Fauci. Second, it may—one might hope—return Americans to a new seriousness, or at least move them back toward the idea that government is a matter for serious people.

The coronavirus pandemic marks the end of our romance with market society and hyper-individualism. We could turn toward authoritarianism.

Religion in the time of quarantine will challenge conceptions of what it means to minister and to fellowship. But it will also expand the opportunities for those who have no local congregation to sample sermons from afar. Contemplative practices may gain popularity. And maybe—just maybe—the culture war that has branded those who preach about the common good with the epithet “Social Justice Warriors” may ease amid the very present reminder of our interconnected humanity.

The first is the “common enemy” scenario, in which people begin to look past their differences when faced with a shared external threat.

COVID-19 will sweep away many of the artificial barriers to moving more of our lives online. Not everything can become virtual, of course. But in many areas of our lives, uptake on genuinely useful online tools has been slowed by powerful legacy players, often working in collaboration with overcautious bureaucrats

The pandemic will shift the paradigm of where our healthcare delivery takes place. For years, telemedicine has lingered on the sidelines as a cost-controlling, high convenience system. Out of necessity, remote office visits could skyrocket in popularity as traditional-care settings are overwhelmed by the pandemic. There would also be containment-related benefits to this shift; staying home for a video call keeps you out of the transit system, out of the waiting room and, most importantly, away from patients who need critical care.

This crisis should unleash widespread political support for Universal Family Care—a single public federal fund that we all contribute to, that we all benefit from, that helps us take care of our families while we work, from child care and elder care to support for people with disabilities and paid family leave. Coronavirus has put a particular national spotlight on unmet needs of the growing older population in our country, and the tens of millions of overstretched family and professional caregivers they rely on. Care is and always has been a shared responsibility. Yet, our policy has never fully supported it. This moment, challenging as it is, should jolt us into changing that.

“We haven’t given up on changing the American health care system,” Senator Mitch McConnell of Kentucky, the majority leader, said after a lunchtime meeting of Republican senators. “We are not going to be able to do that this week, but it still lies ahead of us, and we haven’t given up on that.”

Mr. McConnell said Republicans would move on to their next big legislative goal: overhauling the tax code, a feat that has not been accomplished since 1986.

Democrats, who have spent all year fighting to protect the Affordable Care Act, a law that is a pillar of President Barack Obama’s legacy, responded by calling for the resumption of bipartisan negotiations to stabilize health insurance markets.

“We hope we can move forward and improve health care, not engage in another battle to take it away from people, because they will fail once again if they try,” said Senator Chuck Schumer of New York, the Democratic leader.

The decision by Senate Republican leaders may prove to be a milestone in the decades-long fight over health insurance in the United States, suggesting that the Affordable Care Act had gained at least a reprieve and perhaps a measure of political acceptance.

health care is sure to be an issue in next year’s midterm elections.

For their part, Democrats have tried to use health care as a bludgeon against the few Senate Republican targets they have next year, mainly Senators Dean Heller of Nevada and Jeff Flake of Arizona.

“We know Republicans like Dean Heller and Jeff Flake won’t stop until they force Americans to pay more for less, and we will make sure voters hold them accountable for it,”

The Graham-Cassidy bill would have taken money provided under the Affordable Care Act for insurance subsidies and the expansion of Medicaid and sent it to states in the form of block grants.

instructs the Department of Health and Human Services to open a special enrollment period for the Affordable Care Act through HealthCare.gov,

"As we continue to battle COVID-19, it is even more critical that Americans have meaningful access to affordable care," a White House fact sheet reads.

His second executive action aims "to protect and expand access to comprehensive reproductive health care" by rescinding the Mexico City policy, also known as the global gag rule. This policy, reinstated and expanded by the Trump administration, bars international nongovernmental organizations that provide abortion counseling or referrals from receiving U.S. funding. Biden on Thursday called the gag rule an "attack on women's health access."

Last November, the Trump administration and several Republican-led states argued at the U.S. Supreme Court that the program should be voided, which would have eliminated popular elements of the law such as protections for those with preexisting conditions.

The Supreme Court will hear a case that could decide the legality of work requirements for Medicaid recipients.

Biden is reversing course and directing federal agencies to reconsider those work requirement rules. He is also asking agencies to review policies that undermined protections for people with preexisting conditions, including complications related to COVID-19.

The administration faced pressure to open HealthCare.gov for anyone to enroll in the Affordable Care Act in response to the pandemic, but it never did.

For decades, Democratic and Republican presidents have alternately rescinded or reinstated the global gag rule, with Democrats, such as Biden, opposing the policy. Republicans have argued that the rule would reduce the number of abortions.

However, a study released last year suggested the policy failed to reduce the rate of abortions and ultimately had the opposite effect. The study said the rate of abortions increased by about 40% in the countries studied — most likely because the funding ban caused a reduction in access to contraception and a consequent rise in unwanted pregnancies.

Under the actions announced on Thursday, the president is telling federal agencies to review a Trump-era rule that limited the use of Title X federal funds meant for family planning and reproductive health services for low-income patients. Under this program, organizations that provided abortions or abortion counseling could not have access to those federal funds. The White House said, "Across the country and around the world, people — particularly women, Black, Indigenous and other people of color, LGBTQ+ people, and those with low incomes — have been denied access to reproductive health care."

Now, as the policy is entrenched is institutionalized, people want their older kids on it, they want pre-existing conditions covered and an open marketplace, they support it.”

In a Midwestern Great Lakes Poll released in early October, that 56 percent of voters in Michigan, Ohio, Pennsylvania, and Wisconsin—the states that really matter—were in favor of the ACA with only 36 percent opposed.

The current numbers from the Kaiser Family Foundation have the ACA approval nationally running at 55 percent favorable to 39 percent unfavorable. A New York Times/Siena College poll released this week likewise shows support for Obamacare at a 55 percent to 40 percent margin. Women bump that up to 62-33 percent. The support/oppose numbers break predictably along party lines, but independent voters are very much pro-ACA, supporting it by 55-37 percent. Repeal and replace is no longer acceptable for most of the public.

Also odd is how Trump talks about health care on the rare occasions he does bring it up. “We are rounding the corner,” Trump said in Janesville. “The vaccines are unbelievable. Except for a little politics. We have unbelievable vaccines coming out real soon. And the therapeutics are unbelievable.”

Unmentioned by Trump: Any of the facets of health care that voters say are important to them: Protections for pre-existing conditions (very or somewhat important to 94 percent) Lowering of health care costs (92 percent) The future of Medicare (90 percent) Health effects from the coronavirus (95 percent) The future of the ACA (74 percent)

The ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started

Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic.

Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight

For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify

if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk

The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years

the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out.

adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time?

“All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories.

But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses.

Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm.

In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million.

It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life.

the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque.

Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.

“I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.

In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

he message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out.

although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,

that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions

Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it

She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid

By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look

The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity.

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism

But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events.

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell.

Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed.

In the meantime, thinness was coming back into fashion

In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight.

If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat.

Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now

Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies.

“The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways

When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.”

why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

crowding, especially in bigger cities, is one of the downsides of a government-run health care system. On the upside, had I managed to book a bed in one of the public wards, my birth would have been completely free, paid for entirely by the government’s Assurance Maladie. Everyone pays into Assurance Maladie through charges that are taken directly from their paycheck

From the sixth month of pregnancy to 11 days after a child’s birth, the government covers a woman’s medical expenses in full.

transparency in the price of medical care is a legal requirement in France. The government sets what they consider fair prices for all appointments and procedures, and then reimburses these for everyone at 70 percent. This is not unlike Medicare and Medicaid in the U.S., but because the French government system covers the entire population, it has more bargaining power to keep prices low

t’s not uncommon in the bigger cities, particularly in Paris, for a doctor to charge more than the government’s recommended price. But these overages, called dépassements, don’t come anywhere near what an American specialist might charge. In fact, under French law, a doctor must issue a receipt explaining any dépassement above 70 euros before beginning the test or appointment.

In the U.S., meanwhile, it’s often impossible to get a price for a delivery out of a hospital. Estimates vary by orders of magnitude: This California study of 100,000 complication-free deliveries showed that new mothers were charged anywhere from $3,296 to $37,227, with no clear medical reason for the massive discrepancy.

By contrast, for my complication-free delivery and five-day stay in a private clinic, my total out-of-pocket cost was 400 euros, or about $542.

I don’t think we should count Obamacare’s average monthly premium of $328 as a success. That’s still a lot of money for a middle-class family—and that’s before co-pays, in-network deductibles, and all manner of hidden costs. From my French-ified perspective, a single-payer system—with strong government oversight to keep the price of medical care low—seems like the only way to go.

many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital “facility fee” is tacked on. Likewise, Mr. Smith said, many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.

“From the hospital end there’s a big feeding frenzy, a lot of bidding going on to bring in doctors,” Mr. Mechanic said. “And physicians are going in so they don’t have to worry

The base salaries of physicians who become employees are still related to the income they can generate, ranging from under $200,000 for primary care doctors to $575,000 in cardiology to $663,000 in neurosurgery,

Dr. Jacowitz said that the economics drove the choice and that the only other option would have been to bring in more revenue by practicing bad medicine — ordering more heart tests on patients who did not need them

“The question now is how to shift the compensation from a focus on volume to a focus on quality,” said Mr. Smith of Merritt Hawkins. He said that 35 percent of the jobs he recruits for currently have such incentives, “but it’s pennies, not enough to really influence behavior.”