Problem · Risks a universal system can create

Providers leave, retire, or go cash-only if pay drops

Cutting payment toward Medicare levels would reduce revenue for specialists and commercially dependent hospitals; some may retire, opt out, or close.

Evidence

Medicare hospital margins were about −13% in 2023.
Sources: Medicare Payment Advisory Commission (2025)

Who's affected

Who is hurt

People with ongoing or specialist care needs: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.
Residents of areas with too few health professionals: Provider retirements, opt-outs, and closures reduce access in affected specialties and regions.

Who gains while it lasts

Cash-pay and private care practices: Payment cuts can shift providers toward cash-only care.

Under your mix of paths

Paths that create or worsen it

Paths that fix or soften it

Using your saved plan. 0 paths picked.Edit all picks

Root causes

Revenue cuts without matching cost reductions

Related costs

Open questions

At what level should provider payment be set, and how fast should it change?

Caused or worsened by these paths

This problem only matters if one of these paths is chosen.

Set a default out-of-network rate instead of arbitrationSurprise billing and a runaway arbitration systemChosen

Benchmarks set too low weaken emergency and anesthesia staffing.

Eliminate out-of-network statusSurprise billing and a runaway arbitration systemChosen

Providers opting out can still charge patients directly.

Require non-profit hospiceHospice growth, for-profit entry, and fraudRejected

Restricting hospice provision to nonprofit or public organizations can reduce capacity when for-profit providers exit.

Solution paths (3)

Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.

Phase rate changes in over several yearsChosen

Move from today's rates to the new uniform rates in steps, so providers can cut costs instead of closing or leaving.

+Providers leave, retire, or go cash-only if pay drops

−Takes years, or money up front, before it pays off
−U.S. prices are far higher than in other countries

Strict opt-out rules for cash-only practiceChosen

Clinicians may opt out, but then cannot bill the public program for anyone for a period (e.g., 2 years).

+Providers leave, retire, or go cash-only if pay drops
+Two-tier care: a private fast lane for those who can pay

−Limits choice or applies one rule to every setting

Lower costs for clinicians, not only payChosen

Offset lower rates with less billing overhead, malpractice reform, and debt relief so take-home income falls less than gross rates.

+Providers leave, retire, or go cash-only if pay drops
+About $1 trillion a year in administrative cost

−Depends on other changes to work
−Takes years, or money up front, before it pays off