Privatization > death panels

[Rideback]

James Greenberg:
"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."