HJNO Nov/Dec 2025

WHAT’S WRONG WITH HEALTHCARE 10 NOV / DEC 2025 I  HEALTHCARE JOURNAL OF NEW ORLEANS   In this case, the ACA did succeed in expand- ing insurance coverage for many, while being nowhere close to the hyperbolic government takeover of healthcare voiced by conservatives. Regardless, this right-versus-privilege framing remains deeply embedded in our political cul- ture. Yet calling healthcare a “privilege” tends to reinforce inequality. If access depends large- ly on where one works, what one earns, or what protections one happens to have, then many are left behind — not because of lack of effort, but lack of leverage. The right-versus-privilege frame is not just a moral question; it’s a poli- cymaking one, touching eligibility, coverage mandates, and societal expectations. Public vs. Private Funding Closely tied to this moral question is the de- bate over public versus private funding. Public programs such as Medicare, Medicaid, and the VA represent collective risk-pooling — soci- ety agreeing to cover care for certain groups or conditions. Private insurance, whether em- ployer-sponsored or individually purchased, often reflects market-driven choice, with both its benefits and limitations. The U.S. has long hybridized these approaches. For example, Medicaid expansion under the ACA extend- ed public coverage to millions of low-income adults, while concurrently preserving employer- sponsored insurance as the backbone of pri- vate coverage for working Americans. Marketplace plans under the ACA offer subsidized private coverage through public regulation, but tension still persists. The new- est chapter of this saga, in the form of the so- called “One Big Beautiful Bill Act” in the Trump administration threatens to undo public cover- age for millions of Medicaid patients while also threatening the subsidies that fueled growth of marketplace plans. And so the questions remain: Should essential services — preventive care, vaccinations, maternity care — be guaran- teed by public systems, with private insurance as supplemental? Or should government re- treat to a minimal safety net, leaving markets to decide access? These competing visions define much of the modern healthcare debate. Red States vs. Blue States: Geography, Health, and Social Determinants In our last article on utilization management, we discussed how, when it comes to healthcare utilization, geography is often destiny. Politi- cal geography also matters. Whether a state is “red” or “blue” often correlates with deep dif- ferences in health outcomes. These differences stem not only from ideology but from what policies are enacted, especially around social determinants of health: poverty, education, housing, environment, and public health in- frastructure. Data from America’s Health Rank- ings’ 2024 annual report show persistent gaps. 7 States with higher health rankings tend to have lower poverty, higher educational attainment, and stronger public health investments. Mas- sachusetts, Minnesota, and Vermont regularly appear near the top. By contrast, Mississippi, West Virginia, Alabama, Arkansas, and Louisi- ana often rank near the bottom. Life expectancy data as of 2021 show that Hawaii had the highest life expectancy at birth (79.9 years) among the 50 states, while Missis- sippi had the lowest (70.9 years). 7 Here, geog- raphy, policy, and social structure intersect to produce starkly different outcomes that lead to debates about societal inequity. Medicaid expansion is one of the clearest policy divides. States that expanded coverage after the ACA saw improvements in insurance rates, earlier access to care, and in some stud- ies, reductions in mortality. 8 Maternal mortal- ity provides a sobering example. The United States already has the highest maternal mor- tality rate among high-income countries, but within the U.S., Black women are three to four times more likely to die in childbirth than white women. 9 Non-expansion states often com- pound the problem by limiting postpartum Medicaid coverage, leaving women uninsured during a critical health window. Hawaii is a unique exception that informs this discussion. Hawaii consistently ranks among the healthiest states despite pockets of socio- economic disadvantage, particularly among Native Hawaiians and Pacific Islanders. Several factors may help explain this disparity. The Ha- waii Prepaid Health Care Act of 1974 required most employers to provide health insurance for employees working at least 20 hours weekly. 10 Hawaii’s uninsured rate is consistently among the lowest in the nation, with only Massachu- setts having a lower uninsured rate. 11 I have been fortunate enough to be invited to speak in Hawaii on three different occa- sions at an annual healthcare symposium held on the big island that is self-funded by island physicians who attend. The orchestrator of that conference communicated via email with me about the culture of medicine in Hawaii, stating “There is a mindset that we are on an island and need to be there for each other. There is also a one degree of separation mindset. Folks often act on the idea that we all are connected to one another.” Culturally, Hawaii is also characterized by strong family networks, lower rates of smoking, and dietary traditions which may have histori- cally buffered against poor outcomes. So, while poverty can predict poor health outcomes, pol- icy design and community strengths have the potential to mitigate its impact. Having said that, the most innovative and sophisticated model of care in the country originated in a red state. If Hawaii illustrates how policy design and community resilience can buffer against disadvantage in a blue state, Alaska offers a compelling example of how care delivery redesign can improve health out- comes. Their Nuka System of Care, pioneered by the Southcentral Foundation (SCF), is an Alaska Native–owned and –operated health system in Anchorage. In the late 1990s, SCF assumed management of primary care un- der the federal Indian Self-Determination and Education Assistance Act (ISDEAA) of 1975, transforming health services for Alaska Native people. The system redefines “patients” as “cus- tomer-owners,” builds care around small, in- tegrated teams, and blends medical, dental, behavioral, and social services under one roof in ways driven by relationships and culture. After SCF implemented a patient-centered medical home (PCMH) model, emergency department use dropped, asthma-related ED visits declined, and customer-owners reported improved access to primary care. 12 SCF also reports large declines in hospital admissions and ER visits over time, very high satisfaction among both customer-owners and staff, and performance on many Healthcare Effectiveness Data and Information Set (HEDIS) metrics in the top quartiles. By centering care in the values and needs of its indigenous population in a po- litically conservative state, Nuka demonstrates that innovation and strong outcomes are not exclusive to blue states — but instead emerge when “we” is embraced locally. When “Me” Triumphs Over “We” Nowhere is the tension between individual liberty and collective responsibility clearer than in the debate over vaccinations. Florida’s cur-