Saturday, March 2, 2019

Medicare for All, Compromise, and who gets left out

As the movement for Medicare for All gains steam, with the new bill, HR-1384, being introduced by Rep. Pramila Jayapal (D-WA) and 100 co-sponsors (video available on PNHP Facebook page), the attacks have, unsurprisingly, started coming. They are hard and soft, overt and subtle. The overt attacks on it from Republicans who call it “socialism” are probably the least important. They, and the folks for whom socialism is a buzzword that has them throwing up their hands in horror, were never going to support it or any effort to have universal health insurance, and are probably not going to support any less-extensive compromise. On the other hand, they could learn something by reading about the experiences of people in the all-the-other-industrialized-countries-in-the-world who have some form of universal health care. For example, the recent piece in the Washington Post by an American studying in Taiwan,  uninsured in either country, whose abdominal pain nonetheless led him to go to the ER at 3am. He was seen and given treatment in 20 minutes, had lab tests and imaging studies, was diagnosed with a stomach virus and given 2 medications, and sent off. Total cost: $80. (March 1, 2019)

The real threat, unsubtle and incredibly well-funded, is from the insurance and hospital corporations (and “non-profit” health systems) who are responsible for about 30% of all dollars spent on health care in the US being for administrative costs (including their huge profits) and not actually health care. They are a major cause of the high cost of health care in the US, and stand to lose the most if Medicare for All is implemented, because it will be funded in large part by taking that money away from them. Thus, they are highly motivated to attack any such attempt, organized to do so, and are already doing it, as clearly presented in Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, NY Times February 23, 2019. This will ultimately be the real fight, incredibly wealthy companies that would lose a lot of money will do almost anything to keep it, even though it will prevent a change in the current crazy, costly, poor-result non-system that we currently have, that would benefit the health of all the rest of us.

The more subtle attacks, or perhaps “criticisms”, are from other Democrats and ostensibly liberal media, like the Times. Senator Bernie Sanders (I-VT) sponsors a single-payer Medicare for All bill in the Senate, S-1804, and many of the current candidates for the Democratic presidential nomination are co-sponsors, including Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), Cory Booker (D-NJ), and Kirsten Gillibrand (D-NY), and Rep. Tulsi Gabbard (D-HI) is a cosponsor of HR-1384. Sen. Amy Klobuchar (D-MN) and Rep. Julian Castro (D-TX) are not. S-1804 is not quite as good or comprehensive as HR-1384 (the even-better successor to the old HR-676), but this is not the reason almost all of them (except, of course, Sen. Sanders) have stepped back a little from, or danced around, their position on a single-payer program in various interviews with the press. They worry it might go too far, and while want support from single-payer fans, they fear alienating others, or believe that Medicare for All cannot happen, and talk about compromise. Several senators have introduced another bill that would allow people over 50 to buy into Medicare ('Medicare for More', but only if they pay). The Times, however, is getting more supportive; in their February 16, 2019 editorial ‘How Much Will Americans Sacrifice for Good Health Care?’, they move to focusing on the cost and practicality, and no longer say single payer or Medicare for All is not a good thing.

Of course, other leaders of the Democratic Party do not even pretend to support Medicare for All, and cling to the falsehood that the Affordable Care Act (ACA) would be enough if the GOP had not let many of its components expire, and GOP governors had not refused to institute expanded Medicaid in so many states. The classic rendition of this song was performed by House Speaker Nancy Pelosi (D-CA), in an interview in a recent Rolling Stone. Dr. Don McCanne, in his great Quote of the Day, correctly says of Pelosi’s comments:
‘Perhaps most disappointing have been the responses of those who would prefer to continue to support the Affordable Care Act and add a public option - a Medicare buy-in for some…."All I want is the goal of every American having access to health care. You don’t get there by dismantling the Affordable Care Act." Further she says, "When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act." Has she been practicing composing Trumpisms? The Jayapal Medicare for All Act is vastly superior to ACA - absolutely no contest.’

“Compromise” is often touted as a good thing, and sometimes it is. Maybe it means you and your partner take turns deciding what movie to see or what to have for dinner. But often compromise is, as noted by business guru Stephen Covey, it is a “lose-lose”, where everyone gives up something they want. If we can find something that is “win-win”, it is of course better. Medicare for All might actually be a “win-lose”, a win for the American people (comprehensive health care for less money) but a loss of enormous profit for the big health and insurance corporations (no tears here).

The most obvious flaw in the logic of the mainstream Democrats is harping on the cost. Yes, it will cost a lot, but the average American family will pay less than they are now in premiums, deductibles and co-payments. The big saving would be in the elimination of the money being made by insurance companies, drug companies, and health systems, and apparently Speaker Pelosi is not ready to cut off their access to the trough. Already, the government pays almost 60% of all health costs (Medicare, Medicaid, coverage for government employees, tax breaks for employer contributions to health insurance, etc.) This means that, in our country, the government already pays more per capita than in most countries that cover everyone. Yes, HR-1384 would expand the benefits of Medicare (‘Improved and Expanded Medicare for All’) to be basically everything with no copays or deductibles, and this would be costly, but those of us who can afford it pay for them anyway, and those who cannot currently do without.

But there is another flaw. All of the folks advocating for less-than-universal-coverage, Medicare-for-More, buy-in to Medicaid for folks not poor enough to qualify now, let’s-not-let-the-perfect-be-the-enemy-of-the-good, are missing something. What they are missing is those people who are not covered or covered with poor insurance that won’t meet their needs if they are sick. All the compromise politicians and pundits seem to forget that these are real people, not just numbers (yes, if fully implemented the ACA covers 90%, but is that enough?). As I wrote in my very first blog post (“Universal Health Coverage”, November 28, 2008), ‘When was the last time, even in private but certainly in public, you ever heard someone say “I’m really suffering without health coverage, but don’t worry about including me and my family in your health reform plan. We don’t want to let the perfect be the enemy of the good.”?’ Those advocating for less than universal coverage need to get out there and tell us who it is that they don’t think needs good health coverage, who can be left out. You? Your Uncle George or Aunt Minnie? Your neighbor? Who are the Americans who they are advocating leaving out?

I can tell you one thing. It won’t be them or their families.

Wednesday, February 13, 2019

Medicare for All, or "Eat well, take your medications, and good luck!"

I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:
Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 
And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can not do a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!

Monday, February 4, 2019

Venezuela and Medicare for All: Don't forget who benefits!

The mainstream media is not an evil, liberal-to-radical behemoth by any means. It is, however, often a willing, and sometimes self-deluded, ally and shill for the interests of the well-to-do in society, as well as for many questionable government policies. The latter is particularly important in the drumbeat buildups to wars, and is recently apparent in the coverage of Venezuela in journals such as the NY Times. The US government is making the case not only that Venezuelan president Nicholas Maduro is illegitimate because it has decided his election was “unfair” and “tainted”, as well as an evil and violent dictator, but that it will recognize unelected self-declared Juan Guaido as president. The Times has gone so far as to publish a self-congratulatory op-ed by Guaido, and it news coverage is typified by ‘Venezuelans Opposed to Maduro Pour Into Streets for Day of Protests’ and a Sunday Review piece by a Guaido supporter called ‘Venezuela’s Very Normal Revolution’.

I do not doubt that thousands marched against Maduro or that millions oppose him (or probably that millions support him). I certainly am not saying Maduro and his government is good, or that there is not justifiable opposition to his violent repression of opponents. I am not saying that revolutions are bad. I am saying that this one is funded and supported by the US government not because Maduro is bad -- the US has supported and continues to support dozens of brutal dictators around the world. It is because he is not our dictator, not one who supports US policy, and this is critical because Venezuela is the country with the largest oil reserves in the world. As for the NY Times -- as with most leftist governments, the support for the one in Venezuela comes more from the poorest people, while those with access to the NY Times are among the most privileged.
And this is the connection to domestic health policy, and in particular coverage of the Democratic candidates for president’s positions on Medicare for All. The NY Times (and all mainstream media) is of course owned by the very wealthy, and as individuals they see the world as members of the class of which they are part. But, possibly more important, the editors and reporters are middle and often upper-middle class, and they see the world from this perspective, from that of their families, and friends, and neighbors who are – amazingly – also privileged! The people who have access to these editors and reporters are very skewed away from the most needy, or indeed most people (who are not the same as most people in an upper middle class suburb).
In specific, we get essentially uncritical coverage of the statements of billionaires like Michael Bloomberg and Howard Schultz that “Medicare for All” is unaffordable, despite the clear fact that it is the current system that is unaffordable, and that a universal health system is going to cost less. One key part of this lower cost is the elimination of private health insurance companies’ profit, and their incentive to increase it by decreasing the availability of care. Yet the Times article covering Elizabeth Warren’s increasing iffiness on the issue contains phrases like ‘would people lose the choices offered by private insurance?’ That is, your ability to choose (maybe, depending upon what their employer offers) which overpriced-to-unaffordable policy, offered by which rapacious, obscenely-profit-making insurance company, to cover you so that, even after paying the premiums and co-pays and deductibles, you find out that, whoops, it doesn’t really cover what you thought it would or should, and you’re out of luck, and either have to pay out even more money you cannot afford or go without the health care you need. Wasn’t that what the insurance you bought supposed to get you?
Nope, not necessarily, and often not at all. The first goal of private insurance companies is to make a profit. That profit has to be maintained and expanded. The two major ways of doing so are 1) by raising the prices people (and their employers, if they are lucky enough to have employers who pay offer health insurance) pay, in premiums, deductibles, and co-pays, and 2) by denying coverage for care, or paying less for it, which often results in providers not, well, providing it to you. The insurers hire “pharmacy benefit managers” to get them the ‘best’ prices on drugs, often requiring your doctor to keep writing a different brand-name drug-of-the-month (again, see Danielle Ofri, “The Insulin Wars”), with the cost to you always going up.
What would Medicare for All offer? Or, more explicitly, Improved and Expanded Medicare for All, as in the House Bill that was H676 and will get a new number this year? First, everyone would be in the same program. No more shopping around for the least bad deal among the universe of bad insurance. Everyone would get the same benefits. The benefits would include all medically necessary health care: inpatient, outpatient, nursing home, home care, drugs, mental health, dental, eye care. Even hearing aids. Nothing excluded, except perhaps truly cosmetic surgery. Providers could not refuse to accept this insurance because they would have no business. Oh, maybe some doctors and hospitals could make a living caring for Howard Schultz and Michael Bloomberg and Saudi sheikhs who pay in cash, but there aren't very many of them, and so even the supplemental insurance we now buy would be unnecessary. There would be, you see, no deductibles or co-pays. Everything would be 100% covered. It sounds good. It would be good.
And it is not unaffordable. Currently, the government funds over half of health care (Medicare, Medicaid, government employees and retirees at all levels, military), and it is about 60% if you also count the revenue lost because employer contributions to health care premiums (unlike salary) are tax-deductible. The majority of the sickest and most needy (elderly, blind, and disabled) are already in Medicare. Most vulnerable children are in Medicaid or S-CHIP. To make up the additional cost, employers and individuals would continue to pay, but in taxes rather than premiums, co-pays, and deductibles, and for most (maybe not for Schultz and Bloomberg!) it would cost them a lot less. Most estimates of the excess costs in the US health care non-system are in the 30-35% range, for profits and administrative costs in the private sector (Medicare’s are in the 1-3% range). Administrative costs include insurance companies hiring armies of workers to deny claims, while providers have other armies to fight them, and demand more. This is money spent for no health benefit for the population, but it would be a mistake to minimize the extent to which those – insurers and providers and drug and device manufacturers – who are pocketing it would go to keep it coming.
Thus the role of the mainstream media, and the mainstream Democrats – to appeal to the needs (not desires, real needs!) of most of the people for health care and at the same time not threaten the wealthy and profitable sectors that can fund campaigns for or against them. Thus the concerns of “don’t people want to have their private insurance?” and even more ludicrous their choice of insurance company (“I’ve always been an Aetna man! So what if it costs a little more and I get just as little? I’m worth it!”). Thus the nonsensical pieces on how much a single payer Medicare for All program will cost, which ignore the cost of our current arrangement. And, somehow, manage to not address the fact that this current arrangement leaves concern for people’s health to last, and so doesn’t deliver it.
I understand that people are worried about change. But the cost, in dollars and health, of the current system has moved the majority of the population to want something different, something that meets their needs and costs less.  It is available, if we seek to do it, if we can resist the pressures from the industries and billionaires who profit from the current way of doing things.
When we read about the need to overthrow foreign dictators, or hang on to private insurance companies, we always must remember to ask: cui bono?

Wednesday, January 23, 2019

Hospitals post their charges: almost indecipherable, but important!

The recent Trump administration order to have hospitals post their prices has been widely covered in the media, along with both headlines and articles that make it clear that these prices list are far from…clear! For example, Robert Pear’s article in the NY Times on January 13, 2019, titled “Hospitals Must Now Post Prices. But It May Take a Brain Surgeon to Decipher Them” , starts:
‘Vanderbilt University Medical Center, responding to a new Trump administration order to begin posting all hospital prices, listed a charge of $42,569 for a cardiology procedure described as “HC PTC CLOS PAT DUCT ART.”
Baptist Health in Miami helpfully told consumers that an “Embolza Protect 5.5” would cost them $9,818 while a “Visceral selective angio rad” runs a mere $5,538.’

The Arizona Star piece on Tucson hospitals had a more moderate title, “Hospitals post prices, but public can find it confusing”, but made the same points. As a physician (if not a brain surgeon!) I think I can figure out what most of these mean, but the point that they are making is that they are hard for almost everyone to understand. The reason, of course, is that they have simply posted online their “chargemasters”, the price list that they supply to insurers (including Medicare and Medicaid), which are based on the nationally used “procedure codes”; these are numbers which identify different treatments that are abbreviated as above. So, the charge at Baptist for a radiologist injecting dye into an artery supplying your intestines is only a little over $5,000, while Vanderbilt charges over $42,000 to do a surgical procedure to close a shunt artery in your heart that is vital to fetal circulation but normally closes spontaneously after birth. The question is, what does all this mean? And what are you and I supposed to do with this information?

Elisabeth Rosenthal, the emergency room physician turned NY Times reporter turned editor of Kaiser Health News, is more optimistic in her Times Op-Ed on January 22, 2019, “Donald Trump did something right”. She acknowledges the opacity of the posted charges to most people, but says it is a great step forward, because they are accessible, at least to those who are academic experts, and can be compared, both one hospital to another (“Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000”), and to alternative treatments (“With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon.”) Obviously, these would not be easily available on your phone now, but her hope and expectation is that third parties will develop apps that will take this nearly impenetrable information and make it easily accessible to people, as apps such as GoodRx® have done for drug prices. She emphasizes the magnitude of this change, since before now these prices have been closely-guarded secrets.

Rosenthal makes a number of other important points that illustrate the fact that this system is not only opaque, but deeply morally corrupt. Hospitals are run as businesses, to make money, even when they are ostensibly “non-profit”. Their CEOs and other executives are mostly businessmen, CPAs and MBAs – even when they are physicians, which sometimes happens, they are usually also MBAs – and are hired for their ability to run a money-making operation that happens to sell health care. And sell it, to your insurance company, at what often seems like deeply discounted prices because they are based on absurdly inflated chargemasters. “You don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges,” says one CEO. More important, it allows them to reach agreements with insurers to pay a lot less than the official “price”, which in turn allows those insurance companies to brag to you about how much money they saved you. Rosenthal notes this is farcical, raising prices to make you think that you got a discount (‘If a supposedly $1,000 TV is “on sale” for $80, it’s not really a discount. It’s an absurd list price’), and that it emulates practices in other arenas, such as airlines overestimating their flight times to make it seem like they have a better on-time percent.

At a higher level, Rosenthal points out what is wrong is that these inflated charges do make a difference. Your co-pays and deductibles, if you are insured, are based upon the amount that your insurer pays, so that if they have agreed to pay only 20% of the listed charge, $200 for the TV set instead of $1000, you still may pay more than if you bought it for $80 cash. And certainly more than if the insurer were paying 20% of the old list price, say $500. You pay. You always pay. (See, for example, how insulin manufacturers and insurance companies and pharmacy benefit managers, each following their own profit incentives, have made insulin – a life saving treatment for millions of people with diabetes – often unaffordable: Danielle Ofri, “The Insulin Wars”.)

And, of course, there is the nasty little glitch that it is the most vulnerable and most needy, those who are uninsured as well as sick, and often poor, that get charged the full list price, the $1000 for the TV, or the ostensible “uninsured discount”:
When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.

Wait. Medicare? Medicare would have paid a quarter of their list price and a third of what this uninsured person got billed with the “discount”? Yes. And that is a place to start. Hospitals – or the third-party app developers that will let you see these prices on your phone – should be required to list the Medicare-approved payment right next to what they will charge you, or your insurer. That would measurably increase the “light of day”.

Of course, some doctors and hospitals do not want to accept Medicare for this reason – they can charge more money to insurance companies, who pass it on to you in premiums (in addition to your co-pays and deductibles) while claiming to be saving you money. There is a solution to this also, although Rosenthal does not mention it. It is to have everyone in the same insurance program, a single payer, an improved and expanded Medicare for All. This would set the rates and pay them, without co-pays or deductibles for necessary services. Everyone in the same plan would mean that the better educated, wealthier, and generally more empowered would ensure that it worked for them – and thus would work for everyone else, middle-class, poor, and even homeless.

Yes, hospitals and other service providers (physicians, nursing homes, etc.) and drug companies and insurance companies would make less profit. I’m sure that your heart goes out to them (maybe the next requirement could be the posting of the salaries of the C-suite executives at hospitals…). But, after all, what the health care system should be run for, and is run for in every other developed country, is the health of the people, not the profit of corporations.

Amazing, huh? And it could be that way here!

Friday, January 11, 2019

Gangster capitalism and our health: In the US and in the World

There has been a lot written about capitalism. Karl Marx, for example, wrote a multi-volume study of it just about 150 years ago, and since then a lot of the writing has been about what he wrote, supportive and critical. There is no question that it has remained the dominant economic system in the world; it is the linchpin not only of Western “democracies” and totalitarian fascist states but also ostensibly Marxist governments like China. While capitalism has both its defenders and detractors, it is interesting to me that the defenders spend little time defending the amazingly deleterious effects that it has on the quality of life (and even existence of life!) of people, the environment, war, and (to the point of this blog) health.

The problem is that, in pursuit of profit, industries will do and have done almost anything, with no moral compass or conscience, and, worse, with no concern for future generations or the planet. Some of the most obvious and egregious examples in the US at this time include their (largely successful) lobbying of the current administration to roll back on rules to ensure clean air and water and the overall environment so that they (in this case, extraction industries like oil and mining) can further increase their unconscionable profits without worrying about the damage it does. So we have mining and extraction in and near our national parks (“near” is important; air and water do not respect boundaries!), scaling back of national monuments so extraction can take place, poisoning of the water through leaks in oil pipelines (such as Keystone), and poisoning of the air we breathe when fossil fuels are burned. Oh yeah, and the increase in global warming which has already permanently altered the climate and will eventually wipe out life on earth (starting with the lowest lying areas) if nuclear war doesn’t first.

Our health and safety is also constantly at risk from aggressive efforts by corporations to increase their profits. This can take the form of producing unsafe products either because it saves money (e.g., dangerous child toys) or costs a lot to not do (e.g., not having lead in our water or asbestos in talcum powder), or by making important and beneficial (and hopefully safe) medications unavailable to many people because of incredible price increases (for the tip of the iceberg, see “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016). We of course know about the ongoing – and largely successful efforts – of the tobacco industry to increase their profits by promoting a product that kills 400,000 people a year in just the US (mainly from cancer and heart disease), including through promoting it to children (e.g., the cartoon character “Joe Camel” – see Fischer et al, “Brand Logo Recognition by Children Aged 3 to 6 Years: Mickey Mouse and Old Joe the Camel”, JAMA 1991;266(22):3145-3148, December 11, 1991).

One of the most vicious and insidious efforts to compromise our health in the interest of profit has been carried on for more than a half-century by the sugar industry. For decades, under the table, sugar producers funded scientific research into the negative effects of a high-fat diet while ignoring the almost-certainly more detrimental effects of a high-carbohydrate, especially simple carbohydrate – sugar – based diet. Soda pop became the national beverage with incredible impact on the rate of obesity, in the US and internationally. A 12-oz can of Coca-Cola® has 140 calories, so what about that 40oz fountain drink at the convenience store? A 2-liter bottle has 812 calories. That’s a lot. So most health professionals, like doctors, tell people to not drink it, or not very much of it. This is, however, competing against the messaging of the industry, which pushes it a lot, and gets the cooperation of many nutritionists through the use of – wait for it – money! I have written about the corruption (or conflict of interest, to put it nicely) of health organizations like the American Academy of Dietetics and Nutrition (AADN) and the American Academy of Family Physicians being funded by Coca-Cola® and other sugar purveyors and having their ads on their websites (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). The ads are no longer there, but you can read about the AADN at the fooducate blog, and if you search sugar on the current AADN website, you will find some pieces on limiting sugar, but as many on the potential risks of artificial sweeteners (which, whatever your beliefs,  the FDA rules as safe) and fats.

Of course, as with the case of tobacco, efforts to limit the sugar market in the US (such as Mayor Michael Bloomberg’s failed attempt to limit the size of sugary sodas in NYC), have led the industry to branch out and increase its efforts to profit in the rest of the world, particularly the developing world. While many countries can be targeted, the biggest markets, China, India, and Mexico, have received special attention. The NY Times has an important exposĂ©  on January 9, 2019, ‘Research details how junk food companies influence China’s nutrition policy”, citing work published in BMJ (“Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China”) and the Journal of Public Health Policy (Soda industry influence on obesity science and policy in China”) on the role of the International Life Sciences Institute (ILSI):
…a worldwide organization with a Washington headquarters, funded by many of the biggest names in snack foods, including NestlĂ©, McDonald’s, Pepsi Co. and Yum! Brands as well as Coca-Cola. It has 17 branches, most of them in emerging economies like Mexico, India, South Africa and Brazil, and promotes itself as a bridge between scientists, government officials and multinational food companies.
But in China ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

Thus China’s health policy, which almost entirely focuses on exercise like “Happy 10 minutes” (good for you!) and ignores the dangers of high-calorie sugar-laden foods for obesity (and there is excellent evidence that diet is probably about 80% of the issue, with exercise critical for the other 20%).

There are those who will argue that it is not capitalism itself, but “unfettered capitalism” that is the problem. There is a lot of truth to that. The blind pursuit of maximal profit with no attention at all to the negative impacts on the world around them is not a necessary part of any profit making endeavor. Indeed, the “Wealth of Nations” by Adam Smith cautions strongly against this sort of excess, and “the only responsibility of business is to make profit for its stockholders” guru Milton Friedman sort of assumed that they wouldn’t do it.

But they do, and “unfettered” – or corporate gangster capitalism – is what is running the world. And it is not good for our health.

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