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Quantifying the Rural Access Problem: Emergency Cardiac Care as a Window into American Healthcare

By ANISH KOKA

I was listening to a conversation between two critical thinkers I respect greatly: geneticist/technologist/blogger Razib Khan and Washington Post columnist Megan McArdle. Their discussion was a freewheeling rant about the problems they see with the rise of populism on the left and right, but a throwaway comment related to the US physician shortage in the context of needing high skilled immigrant labor towards the end of the almost two-hour conversation made me realize how little people really know about healthcare in America. Of course, everyone knows certain aspects of healthcare as a consumer very well, but even if you are a high-IQ individual who can make use of the vast information at all of our fingertips, it is hard to really know what the reality on the ground is without living it / having deep knowledge. Interestingly enough, early on Megan and Razib both acknowledge the impossibility of commenting on the situation in Iran, because the Iraq war taught them the folly of making conclusions from the available information. Bottom line, it doesn’t matter how smart you are if your conclusions are based on reading Colin Powell on the weapons of mass destruction Saddam Hussein must have. The public may not realize it, but health policy has a similar problem. The vast majority of academics “covering” American health policy, and in charge of describing healthcare, are ideologues whose main goal is not to describe reality, but to fashion a story. And as any screenwriter will tell you — do not let the facts get in the way of a good story.

What follows is an examination of what happens when you pull one of the important healthcare threads that forms the bedrock of many healthcare opinions that smart people like Megan and Razib hold: Rural access to healthcare in America.

First, here’s what a Google search reveals — and notice the sources. I assure you that PubMed is not much different. Rural healthcare access in America must be bad, right?

Once we establish that healthcare access in rural America is “bad”, there are all sorts of conclusions that are downstream from that like funding of rural hospitals, and management of the physician labor supply.

But the strange thing about the rural healthcare access problem that should strike anyone over a certain age that has followed/lived healthcare is that we have been talking about this and passing legislation on the matter forever, and yet if you are to believe those who should have the most knowledge about these things, we continue to fall short.

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7th and possibly final update on the $39.94 lab test bill

By MATTHEW HOLT

I know you all care, so I am giving a 7th update on the telenovela about my Labcorp bill for $34.95.

The very TL:DR summary of where we are so far is that in May 2025 I had a lab test to go with the free preventative visit that the ACA guarantees, but I was charged for the lab tests and I was trying to find out why, because according to CMS I should not have been.

For those of you who have missed it so far the entire now 7 part series is on The Health Care Blog (1, 2, 3, 4, 5 & 6). Feel free to back and read up.

Where we left it last, Brown and Toland (the IPA between my plan Blue Shield of California and Labcorp) told me that on 8/29/2025 their benefits department had finished their review and reported that the original lab test wasn’t coded as preventative lab services by One Medical, so that the co-pay of $34.95 was correct. ($34.95 was the total agreed payment for all the tests, charged at a total of $322.28. And as it was less than my $50 copay, LabCorp only charges the patient for the total, not the $50!). That call was on December 18 and resulted in update 6.

I next (well about a week later later because life, etc) requested One Medical to resubmit the bill coding it as preventative. That happened on Dec 24, 2025 and someone called Alexis working for One Medical, while exhibiting terrible life skills, replied on Dec 25 and sent it on to their billing department asking them to recode it. I followed up on Jan 15 and Alexis at One Medical confirmed that the billing department had faxed the updated codes to Labcorp. I presumed that Labcorp would resubmit the claim to Brown and Toland and I would eventually get a $0 bill from them.

However, today (4/9/26) I called Brown and Toland about a different telenova — a coinsurance I had received for a dermatology office visit. While I had the rep on the phone, I asked about the Labcorp bill from May 2025. She told me that the benefits team at Brown and Toland had decided on December 18 — that’s right, before I contacted One Medical to ask them to resubmit the claim — that the codes should have been classified as preventative and that I don’t owe the $39.94. Of course Dec 18 was the last time I called Brown and Toland when they said that I had to have One Medical resubmit the claim to Labcorp. Sounds a little coincidental that very same day their benefits team re-reviewed the claim and decided that it should change to being preventative. But who am I to complain or raise a fuss!

Just to add to the complication, on Dec 29 someone within Brown and Toland (customer service?) received that message from the Benefits team and sent it over to the “Epic team” which I assume deals with outliers, with a request to reprocess it. As of today (April 9, 2026), that reprocessing had not happened.

As it happens they may not bother. Labcorp way back when agreed not to send me to collections, and I don’t know if they care enough to go after Brown and Toland for the $39.94, or have just given up on it. More likely if the claim is reprocessed, it will probably be tossed into the capitated amount they already got paid. Which is why the “payment” for my two subsequent lab tests was $0.

So I think we may be at the end of this series. (OK, if you read part 6 there are a couple of other tests Brown and Toland think I should be paying for but no one has sent me a bill for those yet and I may just let sleeping dogs lie).

But don’t worry, there’s always more stupidity in the way Americans deliver and pay for health care, so I’ll keep talking about it. Until we blow up the system and build one that works.

Mathew Holt is the Founder & Publisher of THCB

Tom Kelly, Heidi Health

Tom Kelly is the CEO of Heidi Health, another of the many ambient AI scribes that is spreading its wings to other roles, including bringing its own AI Open Evidence competitor! He calls it an AI care partner. Heidi started in Australia, and quickly moved to the UK and Canada, but now are in over one hundred countries. More recently they have come to the US and have now four major health systems and a lot of other mid market users. Tom think’s Heidi will soon do all the “work around the work”, and he doesn’t think it has to be deeply integrated with the EMR. He sees that as a superpower as doctors don’t want to be in the record. Is he right? Are scribes and ambient AI going to be separate? Does the scribe have to be a medical device, as it does in the UK? Will patients use it? Lots of questions about the future and Tom has lots of answers. Some might even be right!–Matthew Holt

Dyslexia Comes Back To Bite President Trump

By MIKE MAGEE

This past week, Donald Trump decided to get into a war of words with a person with dyslexia. His target was the Governor of California, Gavin Newsom, who has struggled with the learning disability since the age of 5.

The President’s action was premeditated and intended to take the potential Democratic 2028 Presidential contender down a peg. It got pretty personal pretty fast. Trump was direct as is his way. He said simply, “Everything about him is dumb.”

In response, the governor broadened the conversation to include young Americans with the condition with these targeted words of encouragement, “To every kid with a learning disability: don’t let anyone — not even the President of the United States — bully you. Dyslexia isn’t a weakness. It’s your strength.”

Trump seemed surprised by the blowback from his “dumb” remark. It drew a stern rebuke from the Yale Center for Dyslexia and Creativity which reminded the President that approximately 20% of the US population is challenged by some form of this condition.

Fellow dyslectic, author and political commentator, Molly Jong-Fast,  quickly connected the political dots to current events: “Mr. Trump is a bully, but beyond that he tries to flatten things. Sometimes voters respond to this flattening, this simplification of complicated issues, but ultimately his refusal to see nuance in things, his inability to plan ahead, to see second- or third-order effects is his undoing (see: this war he has gotten us into).”

As the Yale experts put it, “Reading is complex. It requires our brains to connect letters to sounds, put those sounds in the right order, and pull the words together into sentences and paragraphs we can read and comprehend. People with dyslexia have trouble matching the letters they see on the page with the sounds those letters and combinations of letters make. And when they have trouble with that step, all the other steps are harder.”

Neuroscientists couldn’t agree more. Language is indeed complicated.  At least five areas have been identified as role players in coordinating human capacity for language and speech.

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There Are Three Kinds of Primary Care, Not to Be Confused With Each Other

By HANS DUVEFELT

(Note: Hans is rerunning some of his greatest hits. This one is from 2014 and leans right into my current and future obsession with fixing primary care-Matthew Holt)

Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?

SICK CARE

Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.

Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.

In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.

Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?

CHRONIC DISEASE MANAGEMENT

More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.

The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.

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Oh. Another Moonshot

By KIM BELLARD

If all goes well, in the next couple of days NASA will be sending astronauts on their way to the moon, for the first time since – gulp – 1972. They’re not landing, mind you, they’re just doing a fly around, something Apollo 8 first did way back in 1968. Given the advances in microchips, computing power, AI, a robust private space industry, and Elon’s grand plans to inhabit Mars, it doesn’t really sound all that ambitious, hardly a “moonshot” in the sense that we’ve come to use that term, but I guess we should be glad that NASA hasn’t entirely conceded space to the billionaires.

The Artemis II mission will send four astronauts – including, if you are counting (and many are), the first person of color, the first woman, and the first Canadian to reach the moon — on a ten day, 230,000 mile trip that won’t actually orbit the moon but just loop around it, not getting closer than a few thousand miles. “Things are certainly starting to feel real,” Christina Koch, one of the four, said during a news conference Sunday morning.

Last week NASA unveiled its “Ignition” strategy that Artemis II is part of. It includes not just the fly-by, but also a follow-up mission in 2027, a manned landing in 2028, and a permanent moon base in the 2030’s, committing $20b over the next seven years to accomplish the latter. “NASA is committed to achieving the near‑impossible once again, to return to the Moon before the end of President Trump’s term, build a Moon base, establish an enduring presence, and do the other things needed to ensure American leadership in space,” said NASA Administrator Jared Isaacman.

He added: “Today, we are providing a demand for frequent crewed missions well beyond (previously announced moon landings in 2028). We intend to work with no fewer than two launch providers with the aim of crewed landings every six months, with additional opportunities for new entrants in the years ahead. America will never again give up the moon.”

I knew Elon and Jeff were going to get something from all this.

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Today’s April Fool is me in 2011

I randomly found this interview I had completely forgotten about on Youtube from 2011. I was younger and thinner then, even though I didn’t have much hair. And I was very optimistic that tech was going to change health care in 10 years……and that it was going to take a long time. Guess we are still waiting!

Kevin Wang, Suki

Suki is one of the original Ambient scribing, now Ambient intelligence, companies. They’re selling both to providers and to other partners using their tech in their tools and services (think telehealth, other EHR providers like Athena, and more). Kevin Wang is the Chief Medical Officer, and he told me about the evolution of ambient documentation, how it makes doctors happy, and how it’s now moving into improving coding (and billing) but will soon be moving into improving clinical decision support. We haggled a little about the ROI from Ambient and where that comes from (remembering codes), and discussed how the EMR v Ambient plays out. And we talked a little about what the impact of ambient and AI will be on medicine…–Matthew Holt

Healthcare’s Quiet Dependence on the “Possimpible”

By GANESH ASAITHAMBI

In an episode of the sitcom How I Met Your Mother (HIMYM), Barney Stinson introduces a fictional word: possimpible. The possimpible combines “possible” and “impossible” and describes the extraordinary achievements by people who refuse to accept conventional limits. In modern healthcare, the possimpible is no longer a joke; it has quietly become an expectation.

Clinicians are expected to provide care that is safer, faster, and more compassionate despite rising administrative burdens, workforce shortages, and an increasingly complex patient population. These expectations often extend beyond what existing systems were designed to accommodate. The distance between what the system can provide and what patients need is increasingly filled by clinicians.

Picture this example at the end of a clinician’s day. A physician takes a seat to call a patient’s family. The phone conversation takes longer than expected with questions about their loved one’s prognosis and hesitancy about what to do next with fear about what is to come. The physician provides reassurance and guidance. The physician hangs up, only to find that note dictations are not complete and messages are still unread. None of this shows up as productivity, but it is needed to provide quality care. There are thousands of scenarios like this that take place every day in American health care.

These moments appear routine. However, they reflect something more consequential: healthcare has become quietly dependent on clinicians to stretch beyond the boundaries of the systems they work within.

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Adventures in health care billing. My $51.96 zit co-insurance

By MATTHEW HOLT

I know my many fans love me delving into the world of why we get seemingly incorrect trivial bills in health care, and what they all mean. The long telenovella of the $39.94 bill from Labcorp is as yet stalled with One Medical apparently resubmitting the original claim with the new preventative codes on it. But even though I am continuing and expanding my role as a difficult patient this year, there are still some blasts from the past that won’t quite leave.

This particular one concerns some rather unpleasant dermatology issues. For many years I had an nasty small sore/lesion on my leg that never quite healed. Then I started getting a few more that started as zits and never quite left. My wise PCP Andrew Diamond at One Medical told me to use some antibiotic wash and referred me to a dermatologist. Unfortunately the one I was referred to was out of network for the Blue Shield HMO I was in, but one request back to One Medical and I was both sent to a dermatologist in my network and got a pre-auth in the mail from Blue Shield to go see him!

Dr Cristian Gonzalez took a quick look at my leg, decided what the problem was, and  proceeded to inject, freeze and attack my various lesions. He then prescribed a cheap topical  steroid for me to use, and basically after 4 visits over the summer and Fall, my legs went back to resembling a baby’s bottom–well more or less. 

For each specialty visit Blue Shield had a co-pay of $85 per visit, which I handed over using my HSA card. One time the front desk said I had a balance, but when I asked them what it was for they told me it was a mistake. Until this week.

Some 4 months after my last visit I got a bill in the mail for $51.96

Given that I had made a co-pay of $85 each time, this seemed a little odd. So I took a look at my Blue Shield EOBs. (BTW they are back online, you may recall they vanished when Blue Shield cancelled and then changed my plan but the Internet never forgets….)

There a curious anomaly began to play out. Each visit generated three identical claims and three more or less identical EOBs.

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