Hi, Bulwark readers! A few weeks ago I wrote about a health care proposal from the Center for American Progress. And as I said at the time, one reason to pay attention is that Democrats and their supporters are starting to have a conversation about what kind of policies they want to enact if/when they get the ability to pass major legislation again. The proposals getting floated today might become laws tomorrow. Now we have another proposal. It’s from the Searchlight Institute, and they have given me an early look at it. Today’s edition of The Breakdown explains what they have in mind, along with its potential pros and cons. I’ve tried to hold back from opining too much, because right now I think job number one is airing out these ideas so they can get the attention and scrutiny they deserve. Serving as a forum for good faith policy debates is a big part of what we seek to do here at The Bulwark, and why the support of our Bulwark+ members is so important. Would you consider joining today at the steeply discounted rate we’re offering this week? New members can get a year of Bulwark+ for half price: –Jonathan Exclusive: Read the Newest Health Care Proposal Being Circulated Among DemsA think tank that is trying to elect more unorthodox candidates is urging them to target private equity.
A PROMINENT, DEMOCRATIC-ALLIED THINK TANK is releasing a new report on how to make health care more affordable, and it targets for-profit companies in a way that says a lot about how the politics of the issue are shifting. The report comes from the Searchlight Institute, which sees itself as a source of ideas that can deliver progress while appealing to voters who might not identify as progressive or liberal. But the report’s core recommendations seem perfectly compatible with the priorities of progressives. They include blocking the formation of hospital monopolies, limiting the role of private equity in health care, and stopping insurance companies from denying coverage arbitrarily.¹ It’s easy to imagine somebody like Bernie Sanders or AOC embracing these kinds of policies—and using some of the same language Searchlight leaders are invoking as they pitch their plan. “I think people are tired of being jerked around by big corporations that don’t have their interests at heart,” David Bowen, a Searchlight senior fellow and principal author of the report, told me in an interview. The report lands in the middle of a broad conversation now taking place among Democrats and their advisers, in the hopes of forging some kind of consensus on health care reform so they are ready to act whenever the political opportunity presents itself. The Searchlight report, which the organization planned to publish and circulate Tuesday evening, will actually be the second one the group has issued this month. The first came out a little less than two weeks ago, when the organization formally called for free primary care. The month prior, the left-leaning Center for American Progress published a health care agenda that included a call to regulate hospital prices. And that’s on top of the more ambitious overhauls that many Democrats have been floating for years, like progressive proposals for a “Medicare for All” system, that very much remain part of the debate. But the CAP and Searchlight proposals are notable because of those groups’ many ties to party leaders. And although the plans are different in their particulars and in their framing, both focus on the ways hospital monopolies have raised prices, just as both seek to curb the power of insurance companies to deny treatments. The common element here is the contempt for corporations and conglomerates who seem to be putting shareholder profits before the best interests of their patients. There are good reasons both groups have landed there, and those reasons start with all the evidence that for-profit health care companies really are having some pernicious effects. ONE OF THE BIGGEST HEALTH CARE SCANDALS in recent history was about a private equity firm that started acquiring hospitals in 2010, and within a few years had created the largest for-profit hospital chain in America. It was called Steward Health Care. The original idea had been to rescue some nonprofit hospitals that had been struggling financially by bringing in smarter management and finding economic efficiencies. But Steward racked up billions of dollars in debt. By 2024, it was beset by widespread reports that it was not paying its bills, forcing the closure of some facilities while leaving others short of staff and crucial supplies. Among the unsettling stories that journalistic and government investigations eventually produced was an allegation—which Steward strenuously denied—that supply issues had led directly to the death of a Massachusetts woman after childbirth. Doctors had wanted to perform a procedure to stop bleeding in her liver, according to reporting in the Boston Globe, but staff said they were unable to do so because a supplier had repossessed the required equipment. Steward would go on to declare bankruptcy, and there’s still ongoing litigation involving various parties associated with the company. But things worked out okay for the private equity firm and its shareholders, who together made hundreds of millions of dollars. The Steward story is an extreme example of what is now a well-chronicled phenomenon: Private equity gobbling up hospitals, physician practices, nursing homes, and other providers to build giant health systems. The promise is always the same: that the integration and consolidation will yield efficiencies. And research has found evidence of that happening . . . sometimes. But multiple studies have also linked private equity acquisition to closures, cuts and higher mortality rates. “Medicine and private equity stand at the crossroads of an irreconcilable conflict,” John E. McDonough, a Harvard health policy professor and author of a forthcoming book called America’s Wrong Turn, told me this week. “To hold public trust, medicine must embrace the value of patients first. Private equity is all about maximizing shareholder value.” Like the other researchers I interviewed, McDonough did not know about the Searchlight plan when we spoke. But it’s not hard to see the intellectual overlap between his point and the group’s proposals. Searchlight calls for curbing private equity’s influence—and preventing more sagas like that of Steward—by giving the Federal Trade Commission more power to review acquisitions in advance and to reject those that don’t serve the interests of the community. A stronger FTC is also the cornerstone of Searchlight’s efforts to stop the formation of hospital monopolies, which multiple studies have found lead to higher prices without corresponding improvement in quality or access. Another big piece of the Searchlight proposal calls for creating a “charter of consumer rights” that would limit how long insurance companies could take reviewing treatment recommendations, and prohibit reviews altogether for certain routine procedures. Here again the Searchlight proposal is drawing on academic research—in this case, evidence that insurance companies are using the review process, called “prior authorization,” in ways that delay or deny necessary care rather than simply reduce unnecessary or wasteful treatments. “There is overprescribing in the U.S. [but]. . . . the problem is that prior authorization has extended to areas of prescribing where there is not evidence of abuse,” Miranda Yaver, a University of Pittsburgh health policy professor, told me this week. Yaver, author of a new book called Coverage Denied, cited insulin and certain cancer drugs as examples of treatments for which prior authorization makes no sense, because patients clearly need them and will suffer harm without them. Bowen said he believes the problems of prior authorization are tied to the problems of market concentration, in that both are symptoms of a health system where government isn’t doing enough to check the power of for-profit companies. “I think U.S. policy has been hamstrung by the legal construct in which it works—it is less driven by the ultimate goal, which is what’s good for patients,” Bowen said. “It’s good for patients not to pay artificially high prices because a given hospital has achieved dominance in a particular area. It’s good for patients not to have what Miranda Yaver calls ‘rationing by inconvenience’ on the insurance side, where they just put up so many rules in place because they can.” WHETHER THE SPECIFIC PROPOSALS in the Searchlight report would deliver what the group promises—i.e., cheaper, more reliable health care—is a complex question of its own. Health policy is all about tradeoffs. And it’s possible, for example, that breaking up big health systems would deter coordination among primary care physicians and specialists. That could lead to more duplicative treatment and unnecessary care, or too little emphasis on prevention, any of which could drive up costs or drive down quality. And that assumes the steps Searchlight is outlining would have any significant impact at all. Bowen says inspiration for the group’s anti-monopoly efforts came from health care systems abroad, where—as he described it—“countries have a broader, and more consumer-protective approach to monopolies.” But it’s impossible to know how well the Searchlight proposals will work without more information—like precisely under what circumstances the FTC would intervene—that’s not available at this early stage of policy development, when think tanks are issuing six-page memos rather than fifty-page white papers. “Antitrust enforcement—blocking potentially harmful mergers—will stop things from getting worse,” Zack Cooper, a Yale economist who has done much of the groundbreaking work on hospital market concentration, told me. “The challenge, however, is that after two decades of consolidation, a large portion of hospital markets are already concentrated. So unless we’re talking about breaking up health systems . . . more enforcement will not prospectively lower spending.” At its best, a proposal like Searchlight’s could provide building blocks for bigger reforms, while helping to get health care costs under control and sparing patients from some of the insurance company hassles they face now. At its worst, it could draw attention away from more promising policy alternatives, including efforts to pass more sweeping reforms (like “Medicare for All”) that plenty in the party would prefer to pursue. Figuring out which description better applies to Searchlight’s agenda is precisely the sort of debate Democrats and their allies should be having. And the time to have it is now, because if they wait until they have power it will be too late. “People ask when did the work on the ACA start, and the answer is that it really started years before,” said Bowen, who as a senior committee staffer and adviser to former Massachusetts Senator Edward Kennedy was part of the effort to write and pass the Affordable Care Act. “That’s when you start getting policies out and saying what can we do. And there are a bunch of different ones out there, a bunch of good ideas, and you spend the time pressure testing them and figuring out what makes sense in the context of what you have.”
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The Searchlight proposal includes several other provisions, including one designed to make sure nonprofit hospitals deliver more charity care and another that would set up an X Prize–style competition for innovations that reduce costs and improve the quality of care. You’re a free subscriber to The Bulwark—the largest pro-democracy news and analysis bundle on Substack. For unfettered access to all our newsletters and to access ad-free and member-only shows, become a paying subscriber.We’re going to send you a lot of content—newsletters and alerts for shows so you can read and watch on your schedule. Don’t care for so much email? You can update your personal email preferences as often as you like. To update the list of newsletters or alerts you received from The Bulwark, click here. Having trouble with something related to your account? Check out our constantly-updated FAQ, which likely has an answer for you.
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