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Who Decides What in Your Health Care: The 2026 Midterm Vote · Doctor AI: Rebuilding Trust in American Healthcare

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Who decides what in your healthcare?
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The twenty twenty-six midterm vote.
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A map for the week before you vote
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The medical system in the United States is wrapped in complex,
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expensive, and ineffective processes.
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When I used to go to the polls, I knew the big players, governor, legislators,
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but what I didn't know was how their election would affect the health of the
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people I cared for, my friends and their families, my practice, the hospital
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system, and me through legislation.
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I also didn't have awareness of the cost to the healthcare of our state about
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the choices I was or was not making by voting for certain propositions or people.
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In medicine, I understand the choices and consequences.
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There are always trade-offs.
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But these complex areas of policy, there are trade-offs as well.
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I just frankly did not know enough to judge how to make them.
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I realize many of you are in the same boat.
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Rather than just criticizing the system we have, which is easy to do right now, I'll
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grant you, it's time to take an active role by understanding and then acting.
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Which of course, this next few weeks means voting.
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This week, I am attempting to clarify for you, the voter, why
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your vote counts so much this year.
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This is the first of four pieces before Election Day, November third.
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Today, who decides?
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Tuesday, your state, one page for each of the fifty states.
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Wednesday, seven questions to ask anyone who wants your vote.
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And Thursday, five gifts the public's already paid for.
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All of it you can find at robinblackstone.com/voteyourhealth.
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Since September, I have been writing about one thing: who gets paid
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in American healthcare, who gets heard, and who gets to decide.
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The pieces had different titles: trust, medical debt, respect, the closed
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screen, but they are one argument.
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Their purpose is education that allows you to exercise your right to
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choose your own future and health.
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Today is the map.
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Election Day is November third, and early voting is already open in
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many states, New York among them.
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Most of what will happen to your health in the next four years will
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be decided by people on that ballot or by the people they appoint.
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Here is who the players are and what they control.
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The definitions.
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One, uninsured means no health coverage of any kind.
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The official number comes from the Census Bureau's annual report, Health
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Insurance Coverage in the United States, which counts people who had
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no coverage for the entire year.
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Twenty-six point seven million people, seven point nine percent of the American
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population for twenty twenty-five.
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That is a floor.
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It leaves out everyone who lost coverage for part of the year and
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got it back or never got it back.
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The CDC asks a different question.
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They ask whether you are uninsured right now, and that
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gets twenty-eight million people.
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If you are feeling vulnerable right now, I get it
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Definition number two, Medicaid expansion.
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Forty of the fifty states took the federal offer in the Affordable Care Act,
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available since twenty-fourteen, to cover adults earning up to one hundred and
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thirty-eight percent of the poverty line.
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Under the twenty twenty-six guidelines, that is people who earn less than or at
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least twenty-two thousand twenty-five dollars a year for one person and up to
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forty-five thousand dollars five hundred and forty for a family of four, with
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the federal government paying ninety percent of the cost of covering them.
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Ten states have not taken it: Alabama, Florida, Georgia, Kansas,
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Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.
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Roughly eleven million uninsured people live in those ten states.
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Texas alone has roughly five million people with no health insurance
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Those states counts Are my arithmetic from the Census Bureau rates and populations.
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The exact 2025 state figures are released October 29th of 2026
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Definition number three, the medical board.
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Each state has one.
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It licenses doctors and takes licenses away, so it decides who may practice
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and increasingly what tools may be used.
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The medical boards are now the target of lobbying by trade groups
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and companies over the rules for AI.
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And the question on the table is whether a doctor must be in the loop
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standing between you and the answer when you ask Claude, ChatGPT, or
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another large language model about your own health Four, scope of practice.
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State law on what each kind of clinician may do without a physician's sign-off.
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It it applies to nurses, pharmacists, physicians assistants, and now software.
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Every signature the law requires that isn't about safety is a
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fee paid in money or in waiting.
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Definition five, billing code set.
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The set of codes every medical bill must use.
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For procedures and visits, it is called CPT.
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It is privately owned by the American Medical Association, and
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they make hundreds of millions of dollars from it every year.
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Everyone who bills pays that fee to the American Medical Association
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directly or inside the price of the software that sends the bill Now
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let's jump to the federal layer.
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Five bodies decide most of what happens nationally.
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Two are elected.
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Three are run by people the president appoints through the Department
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of Health and Human Services.
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One, Congress controls the money.
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It sets the Medicaid formula that decides how much Washington pays your state for
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every person covered, and it decides whether the marketplace subsidizes
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that lower the lower premiums continue.
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Last year, Congress changed both.
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The Congressional Budget Office estimates the twenty twenty-five
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reconciliation law will mean ten million more people will become uninsured
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by twenty thirty-four, and the lapse of the enhanced premium credits adds
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another four point two million people.
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Congress is partisan, and the mindset of the party in
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power governs these decisions.
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Number two, the President of the United States appoints the heads of every
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federal agency that governs health and can change policy by executive
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order without a vote in Congress
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The largest posts require confirmation by the Senate.
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All of the agencies below sit inside the Department of Health and Human Services,
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led since February twenty twenty-five by Secretary Robert F. Kennedy Jr.
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None of these people is on your ballot.
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The senators who confirm them are.
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Thirty-five of those seats are up on November third.
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Three, CMS, the Centers for Medicare and Medicaid Services, runs Medicare,
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pays the federal share of Medicaid, runs the marketplaces where people
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in the states can buy coverage, and sets the payment rules for
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every hospital and doctor lives by.
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It is led by Mehmet Oz, MD, confirmed April third, twenty twenty-five.
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It also names by federal regulation the billing code
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set the whole system must use.
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This July, in its proposed payment rule for twenty twenty-seven, it asked
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the public to describe the harms or challenges of the AMA's control of
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that code set, citing long-standing concern expressed over the federal
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reliance on a private organization with such an obvious conflict of interest.
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Thursday's piece picks that up.
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Number four, FDA decides which drugs reach you, which devices, and
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which pieces of software count as a medical device and need its approval.
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FDA stands for the Federal Drug Administration
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The part about things counting as a medical device needing
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approval now includes the question of which AI tools do.
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Its commissioner, Marty Markary, resigned in May of twenty twenty-six.
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An acting commissioner is in place, and a nominee is waiting for a Senate vote.
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Five, National Institute of Health funds the research.
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The medical literature your doctor's AI reads was paid for in large part
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by you through the NIH It is led by Jay Bhattacharya, confirmed March
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twenty-fifth, twenty twenty-five.
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Two agencies inside HSA, HHS, the FDA, and the CDC each have changed hands more than
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once since February of twenty twenty-five.
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The CDC's first confirmed director of this term was removed a month after
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her The second, Erica Schwartz, was confirmed in August of twenty twenty-six.
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The Surgeon General's chair has been empty the entire term.
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Now let's get down to the state level.
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This is where the action is for you and I.
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This is the layer most people skip, and it's the one that
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touches your life most directly.
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One, the governor appoints the state medical board, the Medicaid
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director, and in most states, the insurance commissioner.
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She signs the budget that funds the state's share of Medicaid, and
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she decides whether to expand it.
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If one person on your ballot controls your healthcare, it is the governor.
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Two, the legislature in your state sets Medicaid eligibility within federal
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rules, decides who may practice what, that's called the scope of practice,
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whether health, telehealth counts as a visit, critical for all of us,
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you might imagine, what insurance must cover, and increasingly what
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AI may and may not do in medicine.
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Eighty-eight of the country's ninety-nine legislative chambers
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are on the ballot this year.
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Number three, the medical board licenses and disciplines physicians.
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Its members are, in most states, appointed by the governor.
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Through their national federation, the boards are now drafting model rules on
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AI that works with limited or no direct physician supervision, which is to say
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on whether you may use a tool for your own health without a doctor's permission.
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That drafting is happening in a closed committee with no members of the public
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in it, and it directly affects you
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Four, the insurance commissioner approves rates, decides whether
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a plan's network is adequate, and enforces what plans must cover.
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Elected in eleven states, appointed in thirty-nine.
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On the ballot this year is California, Georgia, Kansas, and Oklahoma.
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Number five, the attorney general reviews hospital mergers, polices
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debt collectors, and enforces consumer protection against insurers and providers.
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Thirty attorneys general are on the ballot this year.
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And your city.
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Cities don't license doctors or regulate insurers, states do.
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What cities run is public health and public hospitals, which is where the
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uninsured are usually actually seen.
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New York City has its own Department of Health, a Board of Health appointed by the
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mayor that writes the city's health code, and Health Plus Hospitals, the largest
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public hospital system in the country.
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It also runs Medicaid enrollment on the ground.
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So the person who will decide whether you may use AI for your
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own health is a state appointee.
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The person who runs the hospital you'd go to without insurance is a city one.
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The pattern is the same most places.
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The state licenses, the city delivers.
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What is on the ballot on November third?
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Seven things by the official counts.
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One, thirty-six governors.
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Two, thirty-three US senate seats plus two special elections.
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Three, all four hundred and thirty-five seats in the US House.
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Four, eighty-eight of ninety-nine state legislative changers in forty-six states.
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Five, thirty state of attorneys general.
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Six, four insurance commissioners.
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Seven, and through the governors elected, the next appointments to every state
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medical board, Medicaid office, and in most states, the insurance department
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Your impact is much larger than you've been told.
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The person you choose for governor chooses the people who will decide what you are
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allowed to know about your own body and whether your neighbor keeps her coverage.
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That is one vote, and it is yours.
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Where I stand.
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I am not a member of any party.
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No party's platform was written with me in mind, and I would rather judge
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each candidate on what they will do about the things on this page than
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adopt an agenda somebody else assembled.
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This is not a paid announcement.
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I am not raising money.
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Nobody is paying me to write this.
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I'm a surgeon who took care of thousands of people with chronic disease and
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cancer in Arizona, was president of a national surgical society dedicated
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to the treatment of obesity and chronic disease, worked inside one of
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the largest health providers in the country, and finished a formal career
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inside a large medical device company.
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I've spent the last several years trying to describe a novel medical system in
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which health, not rescue, is the product.
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I have conflicts of interest, like everyone in this field.
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I founded the companies and the charity that carry that work,
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and I write books about it.
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None of them profit from how you vote
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Tomorrow on Tuesday, we're gonna give you your state, all
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fifty states, one page each.
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These are a roadmap that prepares you to vote on health.
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On Wednesday, seven questions to ask anyone who wants your vote.
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On Thursday, five gifts the public already paid for and who can give them
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I would love to hear from you.
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Please write me.
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I'm on social media.
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Thank you for listening.
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I'm Robin Blackstone, MD. Vote your health