The Homefront Report: The Healthcare Is Magnificent. Access Sold Separately.

A presidential victory lap meets patients waiting for care, families losing insurance, and the price of being left out.

On Sunday, Donald Trump offered this assessment of American health insurance: “We have the best health care plans in the world. Now that doesn’t cover everybody, but it covers a lot of people.” I admire the confidence required to announce that your lifeboats are the finest ever constructed while acknowledging, almost as a courtesy, the people still in the water.

The missing people are rather central to the assignment. A healthcare system should be judged by whether people can get the care they need, including the ones without a friend in the White House. Today’s healthcare news offers a less congratulatory assessment, involving patients waiting for permission, people losing coverage, and a hospital corporation putting a dollar figure on what happens afterward.

Here on the Homefront, spirit week has reached day two, “Tired Tuesday,” and the children went to school in their favorite pajamas with a stuffy and a blanket. My daughter wore ballerina pajamas, my bonus son wore space jammies, and his younger sister on his mom’s side, who also happens to be my daughter’s best friend, wore a Stitch onesie. They reluctantly submitted to photographs. It was adorable, once again, although I do feel the school has appropriated my entire lifestyle and given it a theme.

Ezra is being a champ about the antibiotics for his pesky ear infection and the eye ointment I lovingly call eye goop. My nephew has also been here the last couple of days while my brother, our resident contractor, attempts to fix our shower drain. After everything we have already been through with this plumbing, we are once again without a shower. At this point the house and I are both waiting for someone to authorize normal bodily functions.

Progress is being made, though, which is all I can ask for. I stayed up too late again, and my sleep was hardly an award-winning institution before that. Tired Tuesday feels less like a special occasion here and more like an unusually honest calendar.

That brings me to why I wanted to spend today on healthcare. Between the news, what I am hearing from former colleagues, and the president’s remarks, this deserves our attention. I am also on attempt number three to get my insurance to cover a procedure to repair a deviated septum. I have trouble breathing properly at night, miserable sleep, and recurring sinus infections. I would like less green snot and a reasonable chance of waking up feeling as though I have actually been unconscious.

I work, pay taxes, raise babies, and would appreciate being able to breathe through my own face without assembling a legal defense for the nose. But someone who can’t work, or doesn’t pay taxes, deserves care too. Breathing shouldn’t require a résumé. Neither should the care our children need, as the headache surrounding Ezra’s MRI has already given me ample opportunity to contemplate.

I used to work in healthcare quality and compliance, so I have a particular interest in the space between a process existing on paper and that process helping an actual person. A policy can have the correct signatures, a designated reviewer, and a beautifully maintained spreadsheet while the patient is still awake at three in the morning wondering what happens next.

Consider WISeR, the federal government’s Wasteful and Inappropriate Service Reduction model. Since January, this pilot has used AI and human clinical review for selected Original Medicare services in six states, including Washington. The Centers for Medicare & Medicaid Services (CMS) says it aims to reduce unnecessary care and spending. It doesn’t apply to every Medicare service or to Medicare Advantage; emergency services are excluded. There is a legitimate job in preventing unnecessary treatment. The question is whether the machinery built to do that job also keeps necessary treatment within reach.

Records the Electronic Frontier Foundation released in September, obtained through a public-records lawsuit, describe lengthy delays and provider complaints about patients waiting in pain. One status report documented an authorization request that remained unanswered for 83 days.

CMS says licensed clinicians determine recommendations for nonpayment. That’s important: this isn’t simply a robot independently canceling everyone’s healthcare. It also doesn’t answer whether the whole review process is timely, accurate, or workable for someone who needs treatment. Having a human somewhere in the building is a beginning, rather than a patient outcome.

There’s a financial incentive to examine, too. CMS says participating companies receive a share of spending classified as avoided wasteful or inappropriate care, with compensation adjusted for performance. That makes it essential to distinguish preventing unnecessary treatment from obstructing needed treatment. They can both look like money not spent until somebody checks what happened to the patient.

I’d personally like any celebration of administrative efficiency to include the hours patients and medical offices spend trying to obtain an answer. The paperwork doesn’t become weightless because you hand it to a sick person. Neither does pain pause politely while a request makes its way through the appropriate channels.

Today, hospital operator HCA Healthcare supplied another part of the picture. In its third-quarter earnings release, the company said more patients were arriving uninsured, primarily because they’d lost coverage on the health insurance exchanges. HCA estimated that the shift reduced its quarterly pretax income by approximately $400 million.

Taking away someone’s coverage doesn’t take away their illness. It changes how they approach getting help and who’s left trying to pay for it. What appears in an earnings release as a change in the mix of insured and uninsured patients is, somewhere else, a person trying to decide what they can afford.

HCA still reported approximately $1.58 billion in quarterly profit, and it spent nearly $2.97 billion buying back its own shares during the quarter. Those are different financial measures, and they don’t describe every hospital’s circumstances. They do, however, show that this particular corporation has substantial resources while reporting the effects of patients losing insurance.

I would prefer our national healthcare conversation to show at least as much curiosity about the people who lost coverage as it shows about the corporation’s ability to absorb them. A person’s financial emergency deserves attention before it becomes an investor-relations topic.

The Commonwealth Fund’s new coverage survey, released October 22, helps put those patients in a broader context. It estimates that the uninsured share of adults ages 19 to 64 rose from 8.9 percent in 2024 to 11.2 percent in 2026. Nearly half of working-age adults, 46 percent, were inadequately insured: uninsured, experiencing a gap during the year, or insured with costs high enough to meet the study’s definition of underinsurance.

Half of working-age adults reported delaying or going without needed care because of cost. These survey findings describe a national pattern. Alongside HCA’s report, they make it considerably harder to treat people falling out of the system as a minor qualification to a magnificent success.

An insurance card and usable healthcare are related concepts that we’ve allowed to drift a remarkable distance apart. You can have the card, pay for the card, carefully keep the card in your wallet, and still need to convince a separate organization that the thing your doctor wants to do deserves to happen.

That’s where I want the accountability to be. When officials promise savings, ask whose time and money are being saved. When a company reports fewer payments, ask whether patients received appropriate care. When a president says our plans are the best, ask how he’s counting the people who can’t get one, can’t afford to use one, or can’t persuade one to cover what they need.

There are people inside healthcare trying very hard to get patients through this. I know that from my work, and I don’t want their effort buried under the failures surrounding it. They deserve systems that help them do their jobs, and patients deserve a route to care that doesn’t depend on having enough spare energy to become their own case manager.

I want my children growing up in a country where getting sick doesn’t hand you a second, unpaid job. Today they went to school with blankets and stuffed animals because someone understood that comfort is a reasonable thing to offer a small human. We should be capable of carrying that understanding a little farther into adulthood.

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The heat pump is working, the shower has resumed negotiations, and your resident writer continues her campaign for functioning indoor plumbing, both architectural and nasal. Thank you for helping us keep doing this work and building a home around it.

Take care of yourselves today. If your Tuesday requires pajamas and a blanket, I believe the children have established a precedent.