Concentration Camps: Is the US still the "savior" or will they happen here? Fascism on the rise in health and everything else.

Recently, in Trieste, I visited the San Saba concentration camp, also known as the Rice Mill because that’s what it had been. On the scale of concentration and extermination camps of the Third Reich, it was small. “Only” 3000-5000 people, mostly Jews, were incinerated here, although others were shipped off to Auschwitz to experience a similar fate. It was my first visit to a concentration camp, and I do not know that I will ever go to Auschwitz, or Treblinka, or Sorbibor, or Belsen, but it was very disturbing. However, at one point the guide noted that it had been liberated by the Americans on May 1, 1945.* My eyes, already full of tears of sadness, teared up yet again but this time with pride. It was the same pride I have felt ever since I was a little kid, born only a few years later, every time I hear about my country, the US, standing strong against Nazism and Fascism, and liberating the camps.

But today it was a bittersweet feeling, because in just the last two weeks my country has been rapidly moving toward fascism. The separation of powers, the core structure of our Constitution has been ignored by the current President. I used to call him the Trumpenik, because it sounds very like the Yiddish word “trombenik”, defined by Wiktionary as 1. a lazy person or ne'er-do-well, or 2. a boastful loudmouth, both of which were good descriptions of him. But now he has decided to become Il Duce, another comparison that is very scary here in Italy.  And he, who was at least elected President if not dictator, hasn’t even been doing all this work himself. He has let Elon (who he sometimes calls Leon) Musk do it. Musk, not elected to anything, not appointed to anything with the advice and consent of the Senate, has taken control of the government’s two most critical functions, the funding of it and the information it possesses on all of us, including Social Security and Medicare. Medicaid has already suffered serious threats to its continued ability to help provide healthcare to poor people. As a federal/state partnership, the federal government pays from about 60-80% of the cost, higher in the poorer states – which are often also the most Republican states. The National Institutes of Health (NIH) funds health and medical research; the largest amounts are spent on cancer research, though many other conditions that affect many Americans – heart disease, stroke, Alzheimer’s disease and many others – as well as basic science research that sets the stage for discoveries on diseases we recognize. In addition to the direct funding of the research, the institutions grantees work at also get indirect funds to “keep the lights” on and to provide many of the resources that allow research to go on. The Musk lackeys see this as pork, or worse, things that “enable a leftist agenda” by, I assume, funding universities. The issue of NIH direct and indirect funding is well described by Dr. Jeff Burns, a neurologist and researcher at the University of Kansas Medical Center, in a Facebook post that unfortunately doesn’t have an out-of-FB link**.

Medicare and Social Security are the most popular programs in the country, put in place by Democratic administrations (as have virtually all programs that actually benefit a significant percent of the American people), and its recipients, mostly seniors, aren’t going to be happy to have those programs cut. It is not clear if anyone in the administration cares. Musk has his own ideas of what programs are worthwhile and what are not (often colored by his personal history and interest) and wasn’t elected to any position and is unlikely to be. Decimating the National Labor Relations Board (NLRB), which will be devastating to working people in the US, serves the interests of folks who run major corporations like himself and Jeff Bezos of Amazon. It has also been suggested that his animosity to the US Agency for International Development (USAID) may in part be a result of its support for the majority population of South Africa, from which country’s minority white former rulers Musk comes. And their investigation of his company Starlink’s contracts with Ukraine. And Trump himself is unlikely to run for election again – he got this job and will stay out of jail and make a lot of money and get his revenge on his perceived enemies. And maybe cancel future elections. But going after senior and rural people and programs that benefit red-state residents is not going to increase his popularity.

I care a lot about healthcare and the healthcare system as well as health research, but the moves toward fascism go much farther. Every agency, especially those tasked with enforcing the law and pursuing criminals (like say, felon Trump) has had its professional staff replaced with loyalists and ideologues, especially both the Department of Justice (including the FBI) and the Department of Defense. There are some glimmers of light, particularly from the federal courts, in decisions such as ‘Judge halts Access to Treasury Payment Systems by Elon Musk’s Team’, and indeed the NY Times suggests that the federal judiciary may be the last obstacle to him. But the top decision maker in the federal judiciary is the Supreme Court, to which Trump appointed three justices and has been very friendly to him. And it will be a long time before a lot of those cases get through the courts. And someone has to enforce it. And who thinks that Musk and his Gen-Z minions who have gotten access to and control of federal databases and funds will all of a sudden, even if these cases are successful, rewrite the codes to be the way they were and not leave themselves backdoors to get in? You can’t un-ring a bell.

Enough of this by me. There is plenty of detail being provided by many other sources, and almost all of it is depressing. Let us get back to my feeling of pride in the US and its fight against Nazis and Fascists, of being, on the world stage, the good guys. Of course, it was not always true that we were – plenty of countries were invaded by the US or had their governments overturned by CIA-supported coups, etc., and even in WWII there were the Allies, including the Soviet Union which lost 20,000,000 people! And there were pro-Nazis and fascists in the US, always. Even US concentration camps (if not death camps) were started by FDR, for Japanese-Americans.

But the idea that an opponent of democracy and freedom, a person who wants to be Mussolini, or Hitler, or Stalin, or Putin, or even Viktor Orban, is the President and has moved so quickly to dismantle our Constitution and has had no significant opposition? That makes me sad, and I wonder when we will re-create camps like the one I visited in Trieste, or worse?

 

*Actually, Trieste was first freed on May 1 by Yugoslav partisans. New Zealanders came May 2, and other allies (US and UK) a couple of days later.

**Jeff Burns’ FB post:

Why Cutting Indirect Rates Means Cutting Medical Research

Medical centers aren’t just buildings—they are the foundation that makes research possible. They provide specialized lab spaces, maintain infrastructure, ensure compliance with safety regulations, and handle the complex financial and regulatory requirements that keep research running. None of this is cheap, and none of it is optional.

The NIH is one of the most powerful vehicles for turning ideas into reality—funding research that directly improves lives. Securing an NIH grant is an ultra-competitive process and a gold standard for top notch research. When researchers like me win a grant, the funding covers the research itself (“direct costs”), but the university also receives “indirect costs” to support everything that makes the research possible: the facilities, oversight, administration, and ecosystem that allow scientists to do their work. Without that support, it becomes harder to do the work that advances medicine. And, NIH funding isn’t just about research—it’s an investment in people and communities, with significant downstream effects on the economy.

Cutting indirect rates doesn’t just trim a budget line—it makes research harder to conduct, slowing scientific discovery and the development of treatments that help people. For my own work in Alzheimer’s disease, this means fewer studies, fewer discoveries, and fewer opportunities to change lives. I work alongside hundreds of clinicians, scientists, students, and staff who have dedicated their careers to tackling this disease. But dramatically and suddenly cutting indirect support shakes the very foundation that allows us to take on these big scientific challenges.

This isn’t about cutting waste—it’s a massive, across-the-board budget cut to science. And the hardest hit won’t be the elite universities with massive endowments; it will be the institutions where every NIH dollar is critical. Less investment means less medical research—period. Cutting indirect rates isn’t just bad policy—it threatens innovation, economic growth, and the future of medical discovery.

"Health Care Un-covered": Covering the abuses and heartlessness of the health insurance industry is a big job!

The former health insurance executive turned whistleblower Wendell Potter provides outstanding service on his substack “Health Care un-Covered” by revealing abuses within the insurance and greater healthcare industry (well, abuses to him and to me; SOP to the companies!). Recently, Trudy Lieberman, a past president of the Association of Health Care Journalists posted there “Deny, Defend, Depose”, words made famous by being inscribed on the bullets used to kill UnitedHealthcare CEO Brian Thompson. She discusses early meetings in the 1990s when health insurance coverage was migrating from covering “major medical” to “managed care”, where the company paid for – and sometimes controlled directly – all the care you received. Managed care, as a concept if not a term, existed way back in the 1950s, when “consumer cooperatives” like HIP in New York, Ross-Loos in Los Angeles, Group Health in Seattle were established to reduce the cost of healthcare by eliminating the middleman – the insurance company – and could either provide more care to members for the same money, or similar care for less money. When, first under Nixon and then Reagan, this concept was expanded, many people (like me) were fine with it because of our positive experience with the consumer cooperative version.

Under the new version, however, a different type of managed care emerged which, rather than excluding the insurance companies, was owned by the insurance companies, often even employing the physicians and other clinicians who provided care. Thus, a third option emerged: rather than either saving consumers money or providing them with more care, these companies could provide less care and pocket the savings! She writes

New perils came with that new age of health coverage. In the quest to save money while ostensibly improving quality, there was always a chance that the managed care entities and the doctors they employed or contracted with – by then called managed care providers – could clamp down too hard and refuse to pay for treatments, leaving some people to suffer medically.

And this is what happened and continues to happen. UnitedHealth is not the only company to profit handsomely (an understatement) from this setup, but it is the largest. The three words in the title (and on the bullets) summarize the strategies used – deny claims for healthcare, defend any challenges in court (these costs being less than the profits) and depose patients, making their lives miserable.

When these changes were being instituted, there were many in the policy arena who advocated for them as a means of cost control, citing the “overuse” of healthcare by Americans as the main reason for the high cost of our health system compared to that of other countries, which needed reining in by supposedly responsible bureaucrats. They were wrong then, and they are wronger now, when it is clear that the cost to the system of people “overusing” healthcare (whatever that means) is miniscule compared to the amount of money being taken out of the rest of the economy in terms of profits for health insurance companies, and to some degree to providers (e.g., hospital systems). The cost of US “healthcare” compared to other countries has risen, although the amount of actual healthcare we get has not, has gone down, demonstrated by the lower health status and increasing mortality rate of Americans.

In a post written by Potter he describes one of the main ways that UnitedHealthcare (and others) siphons money from the public sector, Medicare, into its pockets by not only the “3Ds”.

UnitedHealth has taken a unique approach to Medicare Advantage: directly employing thousands of doctors and arming them with software that generates diagnosis checklists before they even see patients.

This is a tactic to enhance the strategy of upcoding, ensuring that they get more money by documenting every possible problem a person might have, even if not relevant to the reason that they are being seen. In Medicare Advantage (managed care for Medicare patients, in which UnitedHealth is the largest player) this is even more insidious; in MA plans Medicare pays the insurers not for the care provided but by capitation, paying more for sicker patients. Thus, documenting every potential sickness makes them more money. Of course, the theory is that sicker people cost more, and so the insurers need more money for them. That would be good, but UnitedHealth and other insurers have figured out how to get more money to go in their coffers, however, not to the care of patients, by often using extraneous diagnoses that do not increase the amount of services rendered or the care people receive.

In a related documentation of abuse by players (insurers, providers, drug companies) in the “health sector”, Becker’s Hospital Review reports on the Shkreli Awards given out by the Lown Institute. Named after Martin Shkreli, the Turing Pharmaceuticals CEO who in 2015 “acquired a 62-year-old drug called Daraprim and, overnight, increased the price from about $13.50 per pill to $750” (discussed by me in Drug prices and corporate greed: there may be limits to our gullibility, Sept 27, 2015).  I suggested that there were limits because “in 2017, he was convicted in federal court on two counts of securities fraud and one count of conspiring to commit securities fraud, resulting in a 2018 sentence of seven years in prison. In 2022, a federal judge ordered Mr. Shkreli to repay $64 million for hiking the price of Daraprim and imposed a permanent ban on his executive roles in public companies and a lifetime ban from the pharmaceutical industry. He was released early from prison that same year.”

But that was then. Based on the activities described for the recipients of this year’s Shkreli Awards, including UnitedHealthcare, which came in #2, Shkreli himself was a piker. BTW, the #1 spot went to Former Steward Health Care CEO Ralph de la Torre, MD.* So I guess the idea that there are limits to our gullibility, or to the greed of these people and corporations, and the willingness of “regulators” to tolerate or even enable it, was optimistic.

However, a positive is that the Consumer Financial Protection Bureau (CFPB) has finalized a rule that would bar medical debt from appearing on Americans' credit reports. Potter observes that

“This progress did not happen in a vacuum. Addressing the medical debt crisis has been a growing priority for policymakers, patients and organizations like Be A Hero, Undue Medical Debt and the Lower Out-of-Pockets (LOOP NOW) Coalition, which I lead.

My team and I, through LOOP NOW, had the honor of helping facilitate a White House event in which Vice President Harris and CFPB Director Rohit Chopra laid out the administration’s plans to address the crisis. That event wasn’t just about policies — it was about amplifying the stories of people like Lindsay, a single mother saddled with $50,000 in medical debt after her insurer denied coverage for her child’s life-saving brain surgery.”

Potter notes that “This single action could wipe $49 billion in debt from the credit reports of 15 million people, offering relief to individuals and families that have had their financial futures derailed by the unforgiving realities of our health care system. If you’ve ever struggled with medical debt—or know someone who has—this is a moment worth celebrating.”

And indeed it is. Until the new Trump administration reverses it, as they probably will, along with abolishing the CFPB altogether.

 

*”Lown Institute awarded Dr. de la Torre the top spot for bad behavior in 2024, which was the demise of Dallas-based Steward Health Care. The for-profit chain was on a buying spree in recent years. Four days into 2024, hospital landlord Medical Properties Trust reported Steward was $50 million behind on its rent. When The Boston Globe published local reporting on the state of affairs at Steward's Massachusetts hospitals, lawmakers and officials started to pay closer attention and the house of cards began falling apart. By May, Steward reported $9 billion in debt and put all of its hospitals up for sale. Dr. de la Torre resigned in September, days after the full Senate voted unanimously to hold him in contempt after he did not comply with a Senate subpoena.”