Updated at 3:10 p.m. ET

President Trump has made price transparency a centerpiece of his health care agenda. Friday he announced two regulatory changes in a bid to provide more easy-to-read price information to patients.

The first effort targets hospitals, finalizing a rule that requires them to display their secret, negotiated rates to patients starting in January 2021. The second is a proposal to make insurance companies show patients their expected out-of-pocket costs through an online tool. That proposed rule is subject to 60 days of public comment, and it’s unclear when it would go into effect.

“Our goal is to give patients the knowledge they need about the real price of health care services,” said Trump. “They’ll be able to check them, compare them, go to different locations, so they can shop for the highest-quality care at the lowest cost.”

Administration officials heralded both rules as historic and transformative to the health care system.

“Under the status quo, health care prices are about as clear as mud to patients,” said Center for Medicare & Medicaid Services Administrator Seema Verma in a written statement. “Today’s rules usher in a new era that upends the status quo to empower patients and put them first.”

As NPR has reported, hospitals are currently required to post their “list prices” online, but that information has been very hard to use and doesn’t tell consumers much about what they are likely to pay. The new rule makes hospitals show what they really pay for services — not the list prices — and requires them to make that information easy to read and easy to access.

“I don’t know if the hospitals are going to like me too much anymore with this,” Trump said in a White House news conference Friday afternoon. “That’s OK.” He later added, “We’re stopping American patients from just getting — pure and simple, two words, very simple words — ripped off. Because they’ve been ripped off for years. For a lot of years.”

The second rule Trump announced Friday (which is a proposed rule, still subject to public comments before being finalized) affects insurance companies. It would essentially make insurers give patients their “explanation of benefits” upfront. It would require insurers to explain how much a service would cost, how much your plan would pay and how much you would owe — before the service is performed. The idea is that patients could use that information to shop around ahead of time for a better deal — assuming a better deal can be found, and the service isn’t a medical emergency.

Certainly these rules would give patients more information than they currently have. The other promise of these rules — that they will bring down health care costs — is more of an open question.

In public comments for the hospital rule, hospitals argued that having to make their negotiated rates public would backfire — if a hospital is charging less than another one nearby, it could theoretically raise its price to more closely match its competitor’s.

Secretary of Health and Human Services Alex Azar dismissed that argument on a call with reporters Friday morning.

“This is a canard,” he said. “Point me to one sector of the American economy where the disclosure of having price information in a competitive marketplace actually leads to higher prices as opposed to lower prices.”

Larry Levitt, executive vice president of the Kaiser Family Foundation, pointed out on Twitter that the penalty for hospitals that defy Trump’s transparency rule was “quite weak.”

“A maximum fine of $300 per day,” he wrote. “The technical term for that is ‘chump change.’ I wonder how many hospitals will just pay the fine.”

There’s also an open question about whether these rules will survive legal challenges. Another Trump administration proposal to show drug list prices in television ads was blocked in the courts.

“We may face litigation, but we feel we’re on a very sound legal footing for what we’re asking,” Azar told reporters.

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“Don’t read The House of God,” one of my professors told me in my first year of medical school.

He was talking about Samuel Shem’s 1978 novel about medical residency, an infamous book whose legacy still looms large in academic medicine. Shem — the pen name of psychiatrist Stephen Bergman — wrote it about his training at Harvard’s Beth Israel Hospital (which ultimately became Beth Israel Deaconess Medical Center) in Boston.

My professor told me not to read it, I imagine, because it’s a deeply cynical book and perhaps he hoped to preserve my idealism. Even though it has been more than 40 years since its publication, doctors today still debate whether it deserves its place in the canon of medical literature.

The novel follows Dr. Roy Basch, a fictional version of Shem, and his fellow residents during the first year of their medical training. They learn to deflect responsibility for challenging patients, put lies in their patients’ medical records and conduct romantic affairs with the nursing staff.

Basch’s friends even coin a term that is still in wide use in real hospitals today: Elderly patients with a long list of chronic conditions are still sometimes called “gomers,” which stands for “Get Out of My Emergency Room.”

Like any banned book, The House of God piqued my curiosity, and I finally read it this past year. I’m a family physician and a little over a year out of training, and I read it at the perfect time.

I got all the inside jokes about residency — and many were laugh-out-loud funny — but I am now far enough removed that the cynicism felt like satire rather than reality.

The House of God also felt dated. Basch and his cohort — who were, notably, all men, although not all white — didn’t have electronic medical records or hospital mergers to contend with. They wrote their notes about patients in paper charts. And it was almost quaint how much time the doctors spent chatting with patients in their hospital rooms.

It couldn’t be more different from my experience as a resident in the 21st century, which was deeply influenced by technology. There’s research to suggest that my cohort of medical residents spent about a third of our working hours looking at a computer — 112 of about 320 working hours a month.

In The House of God, set several decades before I set foot in a hospital, where were the smartphones? Where was the talk of RVUs — relative value units, a tool used by Medicare to pay for different medical services — or the push to squeeze more patients into each day?

That’s where Shem’s new book comes in. Man’s 4th Best Hospital is the fictional sequel to The House of God, and Basch and the gang are back together to fight against corporate medicine. This time the novel is set in a present-day academic medical center, and almost every doctor-patient interaction has been corrupted by greed and distracting technology.

Basch’s team has added a few more female physicians to its ranks, and together they battle a behemoth of an electronic medical record system. The hospital administrators in Shem’s latest book pressure the doctors to spend less time with every patient.

If The House of God is the great medical novel of the generation of physicians who came before me, perhaps Man’s 4th Best Hospital is the book for my cohort. It still has Shem’s zany brand of humor, but it also takes a hard look at forces that threaten the integrity of modern health care.

I spoke with Shem about Man’s 4th Best Hospital (which hit bookstores this week) and about his hopes for the future of medicine.

This interview has been edited for clarity and length.

The protagonist in Man’s 4th Best Hospital, Dr. Roy Basch, doesn’t have a smartphone. I hear you don’t either. Why not?

If I had a smartphone, I would not be able to write any other novels. I have a bit of an addictive personality. I’d just be in it all the time. … I’ve got a flip phone. You can text me, but it has to be in the form of a question. I have this alphabetical keyboard. You either get an “OK” or an “N-O.”

A big theme in the novel is that technology has the potential to undermine the doctor-patient relationship. What made you want to focus on this?

I got a call out of the blue five years ago from NYU medical school. They said, “Do you want to be a professor at NYU med?” And I said, “What? Why?” And they said, “We want you to teach.” When I first got there, because I had been out of medicine [and hadn’t practiced since 1994], I figured, “Oh, I’ll look into what’s going on.” And I spent a night at Bellevue.

On the one hand, it’s absolutely amazing what medicine can do now. I remember I had a patient in The House of God [in the 1970s] with multiple myeloma. And that was a death sentence. We came in; we did the biopsy. He was dead. He was going to be dead. And that was that. Now it’s curable.

At Bellevue, I saw the magnificence of modern medicine. But like someone from Mars coming in and looking at this fresh, I immediately grasped the issues of money and effects of screens — computers’ and smartphones’.

And it just blew me away. It blew me away: the grandeur of medicine now and the horrific things that are happening to people who are really, sincerely, with love, trying to practice it. They are crunched, by being at the mercy of the financially focused system and technology.

In Man’s 4th Best Hospital, there’s a fair amount of nostalgia for the “good old days” of medicine in the 1960s and 1970s, before electronic medical records. What was better in that era?

If you ask doctors of my generation, “Why did you go into medicine?” they say, “I love the work. I really want to do good for people. I’m respected in the community, and I’ll make enough money.” Now: … “I want to have a good lifestyle.” Because you can’t make a ton of money in medicine anymore. You don’t have the respect of your community anymore. They may not even know much about you in a community because of all these [hospital] consolidations.

Do you think anything in medicine has gotten better?

The danger of isolation and the danger of being in a hierarchical system — students now are protected a lot more from that. When I was in training, interns were just so incredibly exhausted that they started doing really stupid things to themselves and patients. The atmosphere of training, by and large in most specialties, is much better.

You wrote an essay in 2002 titled “Fiction as Resistance,” about the power of novels to help make political and cultural change. What kind of resistance today can help fix American health care?

When somebody falls down, up onstage at a theater, do you ever hear the call go out, “Is there an insurance executive in the house?” No. If there are no doctors practicing medicine, there’s no health care. Doctors have to do something they have almost never done: They have to stick together. We have to stick together for what we want, in terms of the kind of health care we want to deliver, and to free ourselves from this computer mess that is driving everybody crazy, literally crazy.

Doctors don’t have a great track record of political activism, and only about half of physicians voted in recent general elections. What do you think might inspire more doctors to speak out?

Look at the difference between nurses and doctors. Nurses have great unions, powerful unions. They almost always win.

Doctors have never, ever formed anything like what the nurses have in terms of groups or unions. And that’s a big problem. So doctors somehow have to find a way — and under pressure, we might — to stick together. Doctors have to make an alliance with nurses, and other health care workers, and patients. That’s a solid group of people representing themselves in terms of what we think is good health care.

The profession we love has been taken over, with us sitting there in front of screens all day, doing data entry in a computer factory.

Health care is a big issue for the upcoming election. What kind of changes are you hoping we’ll see?

There will be some kind of national health care system within five years. … You know, America thinks it has to invent things all over again all the time. Look at Australia. Look at France. Look at Canada. They have national systems, and they also have private insurance. Don’t get rid of insurance.

The two biggest subjects for the election are health care and health care. … The bad news is, it’s really hard to get done. The good news is, I think it’s inevitable. The good news is, it’s so bad it can’t go on.

One of the major criticisms of The House of God is that it’s sexist. It seems like your hero, Dr. Basch, has gotten a little more enlightened by the time of Man’s 4th Best Hospital. Does this reflect a change you’ve also experienced personally?

I was roundly criticized for the way women were seen in The House of God.

I remember the first rotation I had as a medical student at Harvard med was at Beth Israel, doing surgery. It got to be late at night, and I was trailing the surgeon around, and he went into the on-call room. There was a bunk bed there, and he started getting ready to go to bed. And I said, “Well, I’ll take the top bunk.” And he said, “You can’t sleep here.” So I left, and in walked a nurse. I was shocked.

Things have changed, and I am very, very glad. I don’t know if it seems conscious — I was very pleased to have total gender equity in the Fat Man Clinic [where the characters in Man’s 4th Best Hospital work] by the end of the book.

What made you feel like it was time to update The House of God?

I write to point out injustice as I see it, to resist injustice, and the danger of isolation, and the healing power of good connection. … We can help our patients to get better — but nobody has time to make the human connection to go along with getting them better.

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. You can follow her on Twitter: @MaraGordonMD.

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You’d think that as a poor country grows wealthier, more of its children would get vaccinated for preventable diseases such as polio, measles and pneumonia.

But a review published in Nature this month offers a different perspective.

“The countries that are really poor get a lot of support for the vaccinations. The countries that are really rich can afford to pay for the vaccines anyway,” says Beate Kampmann, director of the Vaccine Centre at the London School of Hygiene & Tropical Medicine and author of the review.

But, she says, “the middle-income countries are in a tricky situation because they don’t qualify for support, yet they don’t necessarily have the financial resources and stability to purchase the vaccines.”

Adrien de Chaisemartin, director of strategy and performance at Gavi, the Vaccine Alliance, agrees: “More and more vulnerable populations live in middle-income countries.” Gavi, an international nonprofit that helps buy and distribute vaccines, projects that 70% of the world’s under-immunized children will live in middle-income countries by 2030.

Brazil, India, Indonesia and Nigeria were among the 10 countries with the most children who lacked basic vaccinations in 2018 — for example, shots to prevent diphtheria, tetanus and pertussis by age 1. Each of those countries meets the World Bank’s definition of a middle-income country: an average annual income (known as the gross national income, or GNI, per capita) between $1,026 and $12,375. In Nigeria alone, 3 million kids are undervaccinated. That’s 15% of the world’s total of children who lack key vaccinations.

By contrast, vaccination rates can be high in poor countries, according to global health researchers, who say that Gavi has boosted the numbers. Rwanda, for instance, despite having a GNI of $780 per person, now has a near-universal coverage rate for childhood vaccines, on par with some of the wealthiest countries.

But in general, once a country reaches a GNI per capita threshold over $1,580 for three years, support from Gavi tapers off. And despite their improved fortunes, countries don’t always choose to fund childhood vaccines.

Angola is among the middle-income countries with the lowest vaccination rates. Diamonds and oil have helped propel the country out of low-income status, and its president is a billionaire. Yet an estimated 30% to 40% of children there did not receive basic vaccines in 2018.

The lag in vaccination rates is caused by any number of reasons. “There’s a whole list of middle-income countries, and they’re not all the same,” says Kampmann.

For example, Sam Agbo, former chief of child survival and development for UNICEF Angola, says Angola’s leadership does not fully fund immunization programs. Agbo blames a political system that he says is mired in corruption, financial mismanagement and lots of debt. So it’s hard to increase the health care budget. “Primary health care is not sexy,” he says. “People are interested in building hospitals and specialized centers rather than investing in preventive care.”

Gavi’s de Chaisemartin groups Angola with other resource-rich but corruption-plagued countries like the Democratic Republic of Congo, Nigeria, Papua New Guinea and East Timor. “These are countries where the GNI is relatively high because of their oil resources, for the most part, but that doesn’t translate into a stronger health system,” says de Chaisemartin.

Then there’s the matter of cost. Countries that buy vaccines on the open market might pay over $100 a shot.

Public attitudes also play a role. In Brazil, which is on the high end of the middle-income spectrum, an immunization program that once outperformed World Health Organization recommendations has been declining for three years. Jorge Kalil Filho, an immunology professor at the University of Sao Paulo, says public inattention and anti-vaccine campaigns, popular on social media, are undermining progress.

De Chaisemartin says the global health community needs to adjust to an unprecedented global economic shift. “Fifteen years ago, the world was divided between poor countries, where most poor people were living, and high-income countries,” says de Chaisemartin. “Now you have a lot of middle-income countries with very poor and vulnerable populations.”

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