#death panels

The Bureaucracy of Denial

How privatized Medicare is quietly reshaping access to care—not through refusal, but through delay.

James B. Greenberg

Jul 31, 2025

Something underhanded is happening inside Medicare and Medicaid, and no one’s talking about it, but it’s about to change how millions get treated.

An oncologist I spoke with recently told me something that stopped me cold. Starting next year, she said, every cancer treatment she prescribes for patients on Medicare Advantage or Medicaid will require prior approval. Not just for experimental therapies or risky procedures—everything. Even the routine. The decisions are no longer hers to make. They’re deferred to remote systems, reviewed by people she’s never met, many of whom may not be physicians at all.

She didn’t use the term, but what she described sounded eerily close to what critics once called death panels. It’s probably too strong a phrase. Still, it captures something about the shift underway: the way life-preserving care is now filtered through layers of authorization, delay, and denial. None of it is accountable to the patient.

We’ve been told that privatizing Medicare would lead to innovation, flexibility, and smarter use of resources. It’s a story that’s been repeated long enough to sound like common sense. But for patients navigating serious illness, especially those living on fixed incomes, the promises vanish the moment treatment is needed. Beginning January 1, 2026, a new set of policies will require physicians treating cancer patients under Medicare Advantage and Medicaid managed care to submit for prior approval before delivering care that used to be routine. These changes aren’t theoretical—they’re already being implemented and modeled in anticipation.

What was once a matter of clinical judgment between doctor and patient is being rerouted through an administrative gauntlet. Treatment plans will be paused while paperwork moves through opaque systems. Approvals that used to be immediate will be delayed. Appeals may stretch out over days or weeks. This isn’t about rare procedures or experimental therapies. The requirements will extend to standard care. The review won’t be performed by someone with direct knowledge of the patient—or necessarily by a physician at all. The rationale won’t be medical. It will be financial.

Delay isn’t a side effect. It’s the strategy. Every treatment deferred, every procedure denied, becomes a line of surplus in a system where profit is made not by healing, but by avoiding the cost of it. The fewer approvals processed, the more money retained. These are not decisions shaped by care. They are decisions shaped by silence—by hesitation, by distance, by the absence of resistance.

This is how rationing works in a privatized state. Not through force. Through systems. Through thresholds that move. Through policies that sound reasonable until you need them to respond. And when they don’t, there’s no one to appeal to. The system isn’t broken. It’s sealed.

For those enrolled in Medicare Advantage—plans marketed as more efficient, more integrated, more modern—this is the tradeoff. Lower up-front costs come at the price of discretion. You may no longer be free to act on your doctor’s recommendation without additional steps. Those steps aren’t about safety. They’re about managing expenditures in a system that rewards denial.

This isn’t just a bureaucratic failure. It’s the cultural reengineering of care. What was once an ethic of shared protection has been repackaged as managed risk. The patient becomes a cost center. Illness becomes a data point. Survival is now negotiated—case by case, code by code.

The consequences are not evenly distributed. They follow the same lines they always have—income, geography, race, insurance class. What presents as efficiency is more often a gatekeeping device. Those already on the margins are the first to wait. The last to be approved. The easiest to disappear into the backlog.

This is power not in its spectacular form, but in its administrative mode—the kind that decides who waits and who moves forward, who receives care as a right and who receives it as a favor. It governs not by issuing decrees, but by deciding which lives can afford to be delayed. This is how life is managed, and death is administered—not by violence, but by withdrawal.

From a political ecology perspective, this is a system designed to manage vulnerability, not by addressing it, but by distributing it. It governs not through direct care, but through selective abandonment, allocating life chances through a logic of scarcity. What gets called efficiency is often just rationing by another name.

From an anthropological perspective, these systems don’t impose power from above. They embed it in routine. They normalize it through repetition. Waiting, in this context, becomes a tool of governance—an ordinary mechanism for deciding who can afford to endure delay and who cannot. It is a slow, administrative form of violence, harder to detect than force, but no less consequential.

Some argue these policies are necessary to contain costs in an aging society. But cost containment isn’t neutral. It always lands hardest on those with the least time and the fewest resources. While administrators speak of oversight and sustainability, patients are left to wait. Sometimes too long.

This wasn’t the promise of Medicare. It was supposed to be a bulwark—a collective safeguard against the precarity of aging and illness. Medicare Advantage has reframed that promise through market logic. What began as a public good is now filtered through private incentives. What was once a guarantee is now a margin call.

These aren’t simply budget decisions. They’re life decisions, managed through process. A quiet calculus unfolds in the background—who gets to live well, and who can be left to linger in the queue.

This is what happens when governance is reorganized around cost rather than care—when what we call reform becomes a mechanism of controlled exposure. The system doesn’t collapse. It tightens. It hardens. It withdraws.

This is not a malfunction. It’s the system doing exactly what it was built to do.

Suggested Readings

Foucault, Michel. Society Must Be Defended: Lectures at the Collège de France, 1975–76. Edited by Mauro Bertani and Alessandro Fontana. Translated by David Macey. New York: Picador, 2003.

Himmelstein, David, and Steffie Woolhandler. “The Medicare Advantage Scam.” The Nation, October 3, 2022. https://www.thenation.com/article/society/medicare-advantage-healthcare/.

Krieger, Nancy. Ecosocial Theory, Embodied Truths, and the People’s Health. New York: Oxford University Press, 2021.

Mbembe, Achille. Necropolitics. Translated by Steven Corcoran. Durham, NC: Duke University Press, 2019.

Raudenbush, Danielle T. Health Care Off the Books: Poverty, Illness, and Strategies for Survival in Urban America. Oakland: University of California Press, 2021.

It’s not that conservatives aren’t sometimes right — it’s that even when they’re right, they’re highly selective about it. Take the hoary chestnut that “incentives matter,” trotted out to deny humane benefits to poor people on the grounds that “free money” makes people “workshy.”

There’s a whole body of conservative economic orthodoxy, Public Choice Theory, that concerns itself with the motives of callow, easily corrupted regulators, legislators and civil servants, and how they might be tempted to distort markets.

But the same people who obsess over our fallible public institutions are convinced that private institutions will never yield to temptation, because the fear of competition keeps temptation at bay. It’s this belief that leads the right to embrace monopolies as “efficient”: “A company’s dominance is evidence of its quality. Customers flock to it, and competitors fail to lure them away, therefore monopolies are the public’s best friend.”

But this only makes sense if you don’t understand how monopolies can prevent competitors. Think of Uber, lighting $31b of its investors’ cash on fire, losing 41 cents on every dollar it brought in, in a bid to drive out competitors and make public transit seem like a bad investment.

Or think of Big Tech, locking up whole swathes of your life inside their silos, so that changing mobile OSes means abandoning your iMessage contacts; or changing social media platforms means abandoning your friends, or blocking Google surveillance means losing your email address, or breaking up with Amazon means losing all your ebooks and audiobooks:

https://www.eff.org/deeplinks/2021/08/facebooks-secret-war-switching-costs

Businesspeople understand the risks of competition, which is why they seek to extinguish it. The harder it is for your customers to leave — because of a lack of competitors or because of lock-in — the worse you can treat them without risking their departure. This is the core of enshittification: a company that is neither disciplined by competition nor regulation can abuse its customers and suppliers over long timescales without losing either:

https://pluralistic.net/2023/01/21/potemkin-ai/#hey-guys

During the Delta surge

The doctor wanted to transfer the patient to the ICU. But the unit was full.

Harkins quickly convened a video meeting of the Scarce Resources Committee. As doctors began to weigh in, the committee realized the crisis ran deeper. There were an additional four critically ill patients in other parts of the hospital who also should be transferred to the ICU.

The math was brutal: Five patients and zero beds.

The committee began the process spelled out by an allocation algorithm in Montana’s crisis standards of care guidelines. Factors like age and preexisting conditions were fair to consider, but vaccination status was not.

Harkins quarterbacked as the committee deliberated: How old? Other serious health conditions? How long in the hospital? What is the latest status?

One critically ill non-COVID-19 patient had a serious heart condition. “I feel the heart patient will not survive. How do you feel?” one doctor asked. Everyone agreed that the heart patient would not get an ICU bed and could be treated in another unit.

After about 20 minutes, the committee decided the woman in the emergency room had the most urgent need and should go to the ICU. They could make a bed available by moving a dying patient too ill to survive to another unit. But they had promised the patient’s family they would wait until everyone arrived to say their goodbyes before removing life support. One family member was not there yet. The hospital was running out of time.

Suddenly, a piercing code blue alarm sounded in the emergency room. “Wait a minute, guys,” an attending physician told the committee. “The patient is coding.”

Then, “the patient has died.”

The committee took a moment to absorb the news. Then it began deliberating again. The call lasted an hour. In the end, the terminal ICU patient’s family members were able to gather to say their goodbyes. When that bed was free, another patient discussed during the call was moved into the ICU but died a few days later.

Of the five patients who had been vying for a bed, four ultimately died.

“Under normal circumstances we would have moved all five into the ICU,” Harkins later told ProPublica. “But we just couldn’t.”

Being forced to make such profound decisions changed Harkins and others on the call.

Kimberly Pepper, the hospital chaplain who served on the committee, described seeking solace in the “thin places,” a Celtic belief that there are spots where the distance between heaven and Earth is at its slimmest. Hers was in the Montana mountains. She noticed her hikes had become longer and longer.

Harkins said hospital staff had found their “cry spots” to deal with the anguish. Hers was in an empty office. “The human psyche,” she said, ”was not built for this.”

The virus was forcing cracks in the hospital’s usual care.

Remember when idiotic Republicans like Sarah Palin were complaining that Obamacare meant that there would be “death panels” in the US?

Years into Obamacare, Palin and her crew must feel disappointed. But the right-wing resistance to mask mandates and vaccination mandates have led to a type of death lottery in parts of the country resistant to common sense pandemic precautions.

The states with the worst outbreaks in confirmed cases per capita right now — Tennessee, Kentucky, Alaska, Wyoming, and West Virginia, according to the New York Times’s tracker — have either set new hospitalization records in the last several weeks or are near their previous highs from the winter wave. All of them have vaccination rates below the national average. Throughout the South, hospitals are reporting they have more patients in need of ICU care than ICU beds available, as the Times reported on Tuesday.

America, the richest country in the world, is not supposed to be a place where patients are left at the door to die. Yet that is exactly what’s happening now — 18 months into the pandemic.

It’s not just COVID patients who are suffering from the overcrowding of hospitals. Maybe you remember the case of Daniel Wilkinson.

In Bellville, Texas, 46-year-old military veteran Daniel Wilkinson was rushed to the emergency room. He was diagnosed with gallstone pancreatitis, which is treatable but which his local hospital was not equipped to treat, according to KPRC. The doctor called all over the region — to hospitals in Texas, Oklahoma, and Arkansas, among others — but could not find a hospital that would take him.

Mr. Wilkinson finally found a hospital that would take him – but it was too late. He died of pancreatitis which could have been successfully treated on time if hospitals in Texas were not overflowing with anti-vaxxing COVID patients

Daniel Wilkinson is certainly not alone in being unable to to obtain prompt medical care.

On Monday, the Washington Post reported that a 73-year-old Alabama man died of a cardiac emergency after being turned away from more than 40 hospitals. The closest hospital that would take him was 200 miles away in Mississippi. 

In addition to the overcrowding problems caused by anti-vaxxing morons, the US has no system to serve as a clearinghouse for available hospital space.

Other countries appear to have avoided unnecessary deaths because they have a real system to coordinate care. In Britain, hospitals are currently able to handle more emergency care than the average volume prior to the pandemic, according to recent research by the Nuffield Trust, though elective surgeries are still sometimes being canceled.

“Hospitals have been incredibly stretched but have always been able to offer urgent and emergency care,” Nick Scriven, a UK doctor and past president of the Society of Acute Medicine, told me. “People were not turned away if they needed a hospital bed.”

The pandemic laid bare how disastrously disorganized the US health system is. But that’s always been true. It just usually reveals itself in more subtle ways.

We have no such system in the US because the loony right would start braying about socialism or something like that.

Too much medical and pharmaceutical care in the US is still in the hands of entities whose primary goal is to make big profits – not to cure people. We’ve seen graphically how the plague of opioid deaths in the US has been caused by greedy drug companies acting as pushers.

The people who claim that the US has the best healthcare system in the world try to get you to ignore the fact that the US still has the highest number of deaths from COVID-19. As of Thursday morning the US had 666,618 COVID deaths. We’re still ahead of Bolsonaro’s Brazil with its 588,597 pandemic fatalities.      

For now, all we can do is encourage vaccination mandates. But next year there will be an opportunity to vote Republican COVID-19 Death Panels out of office.