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Becker’s Healthcare Podcast
Scott Becker - The Biggest Issues Shaping U.S. Healthcare Heading Into 2026
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This is Scott Becker with the Becker Health Care Podcast. Today's discussion is a discussion of the biggest issues shaping US health care heading into 2026. And we're going to talk here about supply and demand issues, payer and power issues, the tiering of health care, other issues that watching, and some ideas for improvement in the health care system. So, so here is the. The concept as we head into 2026. I wouldn't say that healthcare is broken, but it's certainly under enormous strain. There's a lot that we do right and a lot of very big challenges ahead of us as we head into this year. We're watching a set of forces that are structural, accelerating, interconnected, that are. That are very, very challenging, that stack up to create increasing problems for healthcare over the next decade, the next several years, and increasing challenges when it comes to quality, cost, and excess. So we'll go through about eight of those concepts today, and then we'll also provide some suggestions on what we could do or should do if we were so inclined as a nation to try and fix some of these things. So the first issue is supply and demand in a physician shortage. We are no longer approaching a physician shortage for all practical purposes, and in many, many areas, we are very much in it. We now have acute shortages in behavioral health, anesthesia, surgical specialties, neurology, oncology, primary care. And there's so many examples of this. When you need to find a physician, you need to know somebody. Here's an example of a dermatologist in Minnesota who treats a population of 5 to 700,000 people. Just incredibly, that just doesn't work. We had on our podcast not long ago a neurologist in Texas that also serves an area of 5, 700,000 people. In a time of increased dementia, Alzheimer's and other brain issues, more and more places where you're seeing labor and delivery closed down because there's just not enough ob gynes. Rural America, in many places, is becoming a healthcare desert. You've got a situation with burnout, aging physicians, insufficient training. Medical education is all but broken, and it's no longer a workforce problem, just a workforce problem. It's an access, quality and safety problem and a cost problem in general. We've got about 1.1 million physicians, 345 million people in our country or more. We only produce about 25 to 28,000 physicians a year. About 10,000 retire a year. We're just at a point where the numbers just don't work. The supply and demand numbers are broken, and people could do all they want about subsidies, about Medicare Advantage, about payers, about anything you want. But if we don't fix some of these supply demand issues, we're really going to be in horrendous, horrendous trouble. The second thing I'll talk about is we have a rapidly tiering health care system. We've always had a tier health care system, but it's becoming more clearly tiered in terms of the haves and have nots amongst patients and the haves and have nots amongst hospitals and health systems as well, surgery centers and practices and everything else. We're increasingly see it split into tiers. We always had the commercial versus the Medicaid versus the inagent and different tiers of availability and access and that itself was problematic. Now you've got a situation, and partly driven by the supply and demand problems, where you're seeing more and more the evolution of, on one hand, concierge medicine, time, personalization and technology being allocated to those that can afford it, immediate access for those can afford it, and then others sitting in long, er, weights, long, long department waits, having an incredible time finding a primary care physician or finding a physician at all. Recently came across a dermatology practice that's added in the access B. Obviously a ton of physicians have gone concierge. We see it in increasingly in all kinds of specialists. Recently heard about a cardiologist who's moved to a concierge practice. Just an absolute ton of it. And what this means, unfortunately, is you've got on one hand the upper tier of patients that can afford it, getting better and better comfort and care. And those that are Medicaid, indigent, rural systems, Medicare increasingly really struggling. Then there's also this middle that's being hollowed out. So you end up in a spot where you always have these two tiers, those with commercial, those without. Now you've got a situation, those that really afford the concierge type aspects of care, those that can't, and those are really indigent, Medicaid, Medicare and so forth. This tiering has profound implications for health equity, for outcomes, for trust. Access is just really a challenge. We see the same thing playing out amongst hospitals and health systems. 60% of health systems have some margins, 40% have none. And this is of course increasingly challenging because it creates more and more vulnerability and access problems in those areas where hospitals are really struggling and can't find physicians, can't staff, can't take care of people. The third thing we'll talk about today is the unsustainable cost of health care. Cost in health care continue to surge whether subsidized or not. And in fact, one could easily argue that subsidies are causing the cost to surge. And it's an unpopular topic. But so many of the subsidies from the government end up going to the payers, they try and go to health systems and the whole thing ends up in a giant cluster of rising costs all over the place. Employer sponsored coverage for a family of four now eclipses 30,000 a year or close to it. The true average cost when you include deductibles, everything else is closer to 30, 35,000 a year. This is an abstract, these are real numbers. When a great majority of the country makes less than a hundred thousand a year, it's not abstract. It affects wages, hiring, family, financial security affects almost everything. And we're essentially pricing people to impossible corners. And you have these huge subsidies, they're leading towards more inflation. And then you've got lower and lower physician pay and not enough physicians. And the whole thing is really an incredible challenge. We'll talk in a few minutes about the power of the payers, but suffice to say, two of the top five largest companies in America are payers. Four of the largest 20 in America by revenues are payers. There's been an amazing amount of money that's flowed through to the payers that should flow through to the system. But at the end of the day it's, we've gone into the situation of the old adage of other people's money and ultimately dries up the cost. Incredibly throughout healthcare, not a popular discussion, but the reality of it. The fourth thing we'll talk about is are we losing on all three parts of the triple A? There was traditionally a belief that between quality, cost and access, you get two of these, right? You could have lots of access and lots of quality, but cost you a lot of money. Or you could have lower cost and win on that, but not have as good of quality or not have as good of access. But increasingly it seems like we're really moving in the wrong direction on all three. Higher cost access is getting a lot worse and the quality is really under strain because of access and works force burnout and not enough supply to meet the demands that we have. We would argue that you're really struggling across all three areas. Persistent access challenges, clinical exhaustion, rising cost. And the beauty of healthcare is all of us are consumers. So all of us see this. All of us know if you need to get into somebody, you got to know somebody, especially need to get somebody really good. We also often realize that the depth of strength in certain specialties is really, really weak and not nearly as strong as we'd like it to be or might appear on the surface. So incredible challenges. The fifth thing I'll talk about is artificial intelligence. AI does have incredibly positive impacts and it's really a cascading thing to see where it really takes some of the pressure off. Throughout the healthcare ecosystem, we're seeing increasing use cases quickly, clinical ambient clinical documentation, administrative simplification, revenue cycle management, predictive analytics in a lot of other areas. The thing that I'm cautioning is I think that this whole effort is one of trust plus verify. We need technology, prevention and doctors and nurses. You need all of it. There are real, real improvements, but you still need doctors and nurses to take care of people and really see between the lines and work with patients and take care of things in all kinds of places. Where I won't replace clinicians, but hopefully will supplement them. I will change health care, but it's a question of how fast and how we deploy it. There's a lot of differences between simple use cases and enterprise use cases. And there's also a huge difference in whether it really replaces physicians or whether we just need to keep on investing in physicians plus AI. And I think quite frankly, that's really the answer. The sixth thing I'll talk about is quickly the growing power of the mega payers. Again, the balance of power continues shifting towards the mega payers. More than half of Medicare is now managed by Medicare Advantage plans. Many states also turned over Medicaid management to payers. This has just driven so much dollars through the payers and it's really not led to cost improvement or reduced utilization. In fact, costs are skyrocketing. Again, you know, the open question is, does this concentration lead to lower costs? I think the answer is it does not. And what you see is physician groups, health systems, surgery centers. Everybody feels increasingly just outmatched in negotiations by the payers. The payers are just much more, you know, the, you know, are just much stronger. And this dynamics could keep on shaping care delivery for years in that we're, you know, I don't know what needs to be around this unless you take a ton of subsidies that have flown through the insurance companies away. And politically it's hard to do, even though the insurance companies aren't particularly popular because everybody sort of feeds at the bottom of that trough of those subsidies. Seventh concept is breakthroughs in pharmaceuticals. We are seeing great improvement in the treatment of diseases. Of all sorts and complex diseases. The advances in oncology, autoimmune diseases, rare conditions are just remarkable. At the same time, progress is really uneven. We still see lots of cancers that are almost untreatable and devastating brain cancers, pancreatic cancers and everything. We'll have to keep on investing in the drug development world and in pharmaceuticals. And there is hope is rising, but there's an urgency to accelerate discovery and access. And of course we pay too much for the drugs and the deliverables, but it is what it is. We'd rather have them than not. But it certainly is a challenging spot in terms of what we pay for all the drugs, the pharmaceuticals, the developments and so forth. It's kind of ludicrous that we pay more for it in our country than they do in other countries. GLP1 thinks a good example where in our country might pay 201,000amonth and another country might be paying 200amonth. And this is true across the pharmaceutical spectrum. We're just paying so much more for it here than they are overseas. The aids issue, the government's role in all of this. And this is really challenged because we're now at a spot where the government pays for more than half of health care. The federal and state policy plays an enormous role in healthcare funding and system behavior. Subsidies are essential for affordability to that huge percentage of the population that just can't afford the health across the area today. The flip side is subsidies have led to the situation where money flows through the insurance companies. Everybody's buying healthcare with other people's money. So you've got a really bastard, bastardized market that has led to insane amounts of, you know, insane amount of inflation in health care. It creates this painful paradox. They drive up prices, but we need them to allow people to have access and have coverage. No easy answers. I'm a believer that we should have coverage for all. We got to figure out how to do that and contain cost. It's a, it's a really challenging situation. So overall a really, really challenging situation. In terms of the payer health care supply demand situation, I don't see it getting better in a hurry. If I were king for the day, and thankfully I'm not, eight or ten things that we would look at. One, we would stop turning over massive government health care programs to payers. We just would stop doing that. We think that was a mistake and has led to tremendous inflation, tremendous payer. Second, drug companies would be paid us prices equal to foreign countries. We wouldn't subsidize what Every other, every other country in the world by paying inflated drug prices here. Third, a much larger share of medical education would go towards specialties. And this is an unpopular position, but I think at the end of the day, when have primary care handled by PAs, NPs and a lot of others, and in fact 90% of PAs of primary care is going to be handled by nurses, physician assistants and others. That means we need more and more specialists to take care of all the complex, challenging issues and situations through. Along with that, medical education would be shortened and modernized. Medical education now was developed prior to the Internet. So it's literally four years of college, four years of medical school, three to four years of residency and a fellowship in other countries. They're creating doctors by 27, 28, doing it by 30, 32. More and more doctors are part time by 40 or so. So the math and how we handle this is just being handled incredibly poorly. We do need to expand residency slots, you know, and Medicare Advantage has become just a complete debacle. We've ended up turning a lot of the Medicare program over to payers. It's inflated the cost versus reduced the cost and it's overall a disaster. The final thing that I talk about is if we, if I was in charge, we would aggressively continue to invest in research. I think it's very important to give the US a leader in research, technology and healthcare. So that's sort of the gist of it. Again, to go through those eight points. Again, physicians and MPs will deliver 90% of primary care medical education to be shortened and modernized Residency spots will be significantly expanded to help to meet the supply need that we have, the demand need to increase supply. Medicare Advantage would be shut down in some way or another because I don't think it's work and it's costing more than expected and doesn't seem to have any benefits other than causing more inflation. Fifth, drug companies will be paid U.S. prices equal to foreign nations. Sixth, a much larger share of medical education would go towards specialties. Seventh concept is we'll have to keep on investing in the drug development world and in pharmaceuticals. And eighth, we would stop turning massive government programs over to the massive payers. You know, none of this is simple, all of it's debatable. But I do think we need some bold changes to try and fix this. Health care is not going to be fixed through a single reform. But, but at the end of the day we are, we are facing a real challenge as we look forward at this horrendous supply and demand issue and the politicians are mostly focused on talking points but not solving the real issue, which is supply and demand. In any event, thank you so much for listening to the Becker's Healthcare Podcast. This is in preparation for a talk we're giving, so I hope that you enjoy this and I appreciate you so much listening. I would love your feedback in this. If you have feedback, feel free at any time to text Scott Becker 773-766-5322 and love your feedback on this talk. If you're the first person to text me feedback in this talk, I'm happy to send you a 100 hour Amazon gift certificate. Again, text me. You got to text me a few comments, a few thoughts, what you hate, what you what you like. Did I talk too fast? Was it, Was I listenable today? 773-766-5322 thank you so much for listening to the Beckers Healthcare Podcast.