The greatest quality deficit? Physically destroying the health care system, and, oh yeah, the people it is supposed to serve

I have previously quoted from the important JAMA paper by Schiff, Bindman, and Brennan “A Better Quality Alternative: Single Payer National Health System Reform” (JAMA Sept 14, 1994, 272(10):803-808) the observation that “denial of care” is the “gravest of quality deficits”. It is generally hard to argue with this; if people are denied care they are not going to get quality care. While it can be argued that there are some forms of care that is worse than no care, this is clearly not what the authors have in mind. They are talking about the fact that people are denied appropriate care because they do not have money or insurance. More than 30 years later this still rings true, in an America that has not yet seen a health insurance system that covers everyone, as every other well-to-do country has, and indeed is even more threatened by cuts in the coverage that we do have. As I write, the federal government is facing a shutdown, with the Democrats in Congress demanding continued funding for those who received coverage from the expansion of Medicaid under the Affordable Care Act (ACA, “Obamacare”) of 2010, while the administration and Congressional Republicans steadfastly refuse to consider this, arguing mainly the high cost. This demonstrates once again their complete inhumanity and heartlessness, in no small part because earlier this year they cut more than that from the taxes of billionaires.

There are many ways to deny care, and rolling back Medicaid expansion is one. Another is closing hospitals, and many, mainly rural, hospitals, have and will close as a result of these cuts. They can also make existing insurance harder to get and more expensive, as is regularly documented in Wendell Potter’s substack “Health Care Un-Covered” and many other venues. I will talk more about this in a future blog post. But another, really effective, way to decrease access is to destroy health care facilities. Much more efficient than starving hospitals for money by discriminatory, greed-focused funding is actively blowing them up, killing the providers, and eliminating the infrastructure for providing care for anyone, insured or not. This is commonly done during a process called “war”, in which a strategy often adopted goes beyond violating the Geneva Conventions by not caring for enemy combatants, but indeed targets the elimination of the civilian health care infrastructure. The Geneva Conventions provide for not attacking health care providers, for caring for the wounded based on need, not loyalty, and certainly respecting civilian health care (some references: Rule 25 on medical providers, International Committee on the Red Cross, World Medical Association, Wikipedia (Medical Neutrality), among many others). I learned about much of this decades ago from a surgeon who worked for the International Committee on the Red Cross (ICRC) and HAD supervised one of its hospitals in Chechnya during the war there. It was this hospital which military combatants invaded, murdering four nurses. At the time, it was horrifying. Since then, such actions have become so common a practice in the 21^st century that, in itself, it almost refutes the idea that human beings have become more civilized over time.

While there are many places where combatants have used attacks on the civilian population and their health care facilities as methods of imposing their will, the attacks by the government of Israel on the healthcare facilities in Gaza stand out in their extent, persistence in the face of world opinion, lack of any sign of conscience, and contribution to genocide. I am not expert in war, but I know that you are supposed to try to not kill civilian noncombatants, and that you are not supposed to destroy medical infrastructure; these are war crimes. In Gaza both are happening; people’s houses and cities are bombed, thousands have been killed, hundreds of thousands displaced, and the facilities where they might go for care – for problems that occur in peacetime, of course, but far more for those inflicted on them by the military attack on them – are destroyed. On purpose. Repeatedly. As part of an immoral and illegal strategy to “win”, by killing or injuring as many as possible.

Israel, unsurprisingly, and its US supporters in the American Jewish Committee, deny this. They say that what they are doing in Gaza is not genocide, and that what they are doing in killing the people of Gaza as well as destroying its hospitals and other health care facilities and healthcare workers are not war crimes. Of course, what is happening is happening, but they are picking apart word, like the application of a particular term (“genocide”, “war crime”). I am also no expert on the definition of genocide (like, what percent of a group do you have to be trying to kill for it to qualify), but those who are most expert say that what Israel is doing in Gaza is genocide. No responsible independent body has even tried to justify what they are doing. The argument cannot be that “because we are Israel, what we are doing is ok, although it would be intolerable if anyone else did it especially to us”. Nor can it be that “no matter what we do, no matter how horrific or destructive, because we are a Jewish state, any opposition to it is anti-Semitism.” Of course, this position is without logic.

There can be no justification for the Holocaust, for any reason, for anyone. But just as the atrocities being committed by Israel do not mean “Hitler was right”, the fact that the Holocaust happened – and that there is serious anti-Semitism in the world today – does not justify those atrocities being committed by Israel. In true fascist tradition, the government of Israel is not only committing these atrocities, destruction of healthcare infrastructure and healthcare workers, killing civilians including children en masse and starving them, it is blocking international aid from coming to the people of Gaza. These flotillas of boats bringing aid, contrary to what Israel says, are humanitarian and the people doing it are brave and noble. The government of Israel, and those Israelis and non-Israelis who support its actions, are … not. Interested in knowing what is happening in Gaza? There are many sources, but here is a recent article from the NY Times, longstanding Israel supporter on the destruction of Gaza. Or how about the video, if you need visual evidence.

There are terrible threats to the health of the American people, longstanding and persistent threats from greedy and evil for-profit insurers and pharmaceutical manufacturers and PBMs and health systems and private equity. These have been exacerbated by the Trump administration’s hostility to covering all people, such as the cutbacks in Medicaid expansion from the ACA, an issue on which the Democrats have finally shown some spine although the GOP commitment to not spending the money in order to maintain tax cuts for the wealthiest has led to a federal government shutdown. It is a very bad situation for many Americans, especially those with the greatest vulnerability.

But this is almost nothing compared to the attacks on health in many places, and particularly in Gaza. The purposeful destruction of cities where people live, mass murder of civilians, huge displacements of people, augmented by the destruction of the very facilities that might provide some treatment and succor, is without conceivable justification.

The authors of the paper cited at the beginning of this piece were, thus, not correct in saying that lack of access is the greatest quality deficit. That is true when there is a functioning health system and some people are excluded. Actively doing what is done in many wars, and what Israel is doing in Gaza, is a much worse assault on not just quality of healthcare but on health and life itself.

The WiSER program to erode your Medicare coverage: Not WISE for you!

While much about American health insurance is infuriating, starting with it treating the healthcare system as a vehicle for making money rather than providing healthcare, “prior authorization” (PA) is one of its most infuriating, and dangerous, practices. It means that before you can get the treatment your physician has recommended, indeed often before you can see the physician you want, the insurance company must authorize it. This practice is ubiquitous in commercial health insurance, including “Medicare Advantage” (MA), a program that allow an insurance company to collect the money allocated for you by Medicare. This means that if you receive a terrible diagnosis, such as lung cancer and your oncologist recommends a specific treatment, it is entirely possible that they will deny coverage for it, especially if your cancer is rare, or requires an expensive drug. You can file an appeal, but even if it is eventually granted, the process takes time, and meanwhile you are sick and your cancer is advancing.

But if you have Traditional Medicare (TM), this has not been a problem. TM covers virtually all doctors and hospitals in the country, covers most treatments, and does not subject the individual to PA, or decide that another (usually cheaper and possibly less effective) treatment, or even no treatment might be better for you. Or that a different doctor or hospital that is “in network” (for them) would be a better choice even if their track record is inferior. The absence of PA is a major reason why many health experts recommend TM over MA. 

Back in January, 2023 I wrote about the proposed ACO/REACH program at CMS (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!), which would allow companies (many owned by private equity) to purchase primary care practices, and voilà!, all those doctors’ patients were now in the company’s ACO and subject to restrictions on their care, including PA, without having to do anything at all and thinking they were safe because they were in TM! The REACH name was dropped but the program still continues; a friend in northern NJ was just informed he is now part of an ACO because they have acquired his doctor’s practice!

And other assaults on TM and the patients it covers continue. If you live in Arizona, as I do, or in 5 other states (New Jersey, Ohio, Oklahoma, Texas, Washington), even if you have TM you will suffer the indignity and damage of PA as Medicare implements a 6-year “pilot program” called WiSER (Wasteful and Inappropriate Services Reduction). No longer will you be able to get any Medicare-approved procedure from any Medicare-accepting doctor at any Medicare-accepting hospital (ie, virtually all doctors and hospitals). Medicare will contract with private companies that will utilize artificial intelligence (AI) algorithms to decide whether you can get the treatment. As with ACO/REACH, you have no choice, as participation is “voluntary” by state, but not by individual Medicare recipient. Actually, then it is worse than ACO/REACH, which you could get out of by changing your primary care physician (provided you could find another one!); WiSER will require you to move out of state!

Maybe the AI algorithms know better than you or your doctor. After all, isn’t reducing wasteful and inappropriate services a good thing? If you believe that the high cost of health care is the result of your using inappropriate and wasteful services, you might want to consider that the companies Medicare contracts with to do the PA will be paid “based on a share of averted expenditures.” That is, they will be paid on commission, receiving a percentage of the money saved by denying your care! But that won’t affect their decisions at all, right?

In reality, the use of “inappropriate and wasteful services” by you and your family and friends is not the reason for the high cost of health care. The reason is the enormous administrative costs of the US healthcare system, including the huge amounts made by for-profit insurance companies and pharmaceutical companies (and the eight-figure salaries of their CEOs and other executives), as well as health care providers (hospitals and health systems and the physicians, usually employed by them). This is a system found nowhere else among wealthy countries, every single other one of which comprehensively covers the care of all their people at much lower per-capita cost.

Bringing PA into Medicare is not “wiser”. It is the exactly wrong way to go. What we need is the expansion of Medicare to include everyone in the US, birth to death, and the improvement of that system by covering all health needs, including mental, dental, hearing, vision, and eliminating the 20% hospital co-pay Medicare recipients now are responsible for (and must buy Medigap insurance to cover). The “administrative costs” now being taken out of the “healthcare” system by companies would more than pay for it.

We would then have a system designed to provide health care for the American people, not profit for corporations. Imagine that!

 

adapted from a piece originally written to be a guest essay in the Arizona Star, but not published 

Drink more? Do more prostate cancer screening? I don't think so. But be careful about falls!

If the malignant lies and disinformation coming from HHS Secretary Robert F. Kennedy, Jr. (RFKJr) and his minions, whom he regularly replaces if they are too inclined to make decisions based on truth and science (see Susan Monarez, head of CDC for less than a month) were not enough, his psycho – but totally dangerous -- baloney regarding vaccines and other health issues provides cover for the re-emergence of other potentially dangerous “health” recommendations. This is par for the course for this administration, which is entirely focused on distracting us from important issues by focusing our attention on other things, brush fires (or sometimes major conflagrations). Trump is quite willing to arrest, brutalize, imprison, and deport people, to start wars across the globe, or whatever it takes to keep the Epstein files – which must contain truly damning information about him – from being made public. 

In the area of health this re-emergence has not been of the major blaze type, certainly nothing compared to the evil of RFKJr’s opposition to, discouragement of, and even blocking vaccines, but more of “well, we have an axe to grind and let’s bring it back out now that we have cover”. Who, after all will worry so much about the issues I address below when they can worry about the return of polio, measles, mumps, whooping cough, H. influenza, Covid, etc. And maybe even smallpox! But there have been several recent articles covering health issues which should be already settled. But, heck, if vaccines are not settled, why should these be?

On Sept 2, 2025, the NY Times Roni Caryn Rabin reports that Reduced Screening May Have Led to Rise in Advanced Prostate Cancer Diagnoses,  and follows that with the subhead “Changes in screening recommendations over a decade ago may have inadvertently resulted in later diagnosis of the most common cancer in men, a new study has found.” It sounds pretty scary, as it goes on to report that Black men are the least likely to be screened for prostate cancer and the most likely to die from it. Prostate cancer is being diagnosed at a later stage and the implication – no, the direct assertion in the article – is that it is because of a recommendation from the US Preventive Services Task Force (USPSTF) which in 2012 began discouraging the use of routine screening with PSA (Prostate-Specific Antigen). The Times article, and the article it is based on, from CA: A cancer journal for Clinicians, and the comments of the chief scientific officer of the American Cancer Society and one of the article’s authors, Bill Dahut, say “The pendulum may have swung too far in one direction, where we were afraid of overtreatment, and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.” 

This conflates diagnosis of cancer at later stages with (implicitly) increase in death from prostate cancer. Well, doesn’t that make sense? Except that what makes sense is not always true. There is no data in the article that says more men are dying from prostate cancer, only that they are being diagnosed with further advanced cancer. Dr. Dahut says that finding the prostate cancer earlier would make it more curable, but if this were true, the decrease in screening would not only have led to cancers being diagnosed at a later stage, but in an increase in deaths from prostate cancer. How come it didn’t? There are basically two types of prostate cancer: the kind that kills you and the kind you die with, but not from. Medicine has yet to be able to find a test that can identify which kind you have. If diagnosing the kind that kills you earlier can make it curable, that’s great – but then we would see more deaths from prostate cancer as a result of not screening, and we don’t. What has historically happened is that the other, more indolent, kind has been treated and physicians have claimed “cures” – even though men don’t die from it without treatment. But they do suffer the morbidity of treatment (i.e., impotence, incontinence, radiation cystitis, etc.) This, along with the poor performance of PSA as a screening test for prostate cancer, is what led the USPSTF to recommend against screening. This issue has been addressed a number of times over the years on this blog (PSA Screening: What is the value?, March 21, 2009, PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009,  PSA redux: The USPSTF finally recommends NOT getting it!, Oct 14, 2011, Prostate Screening and the Public’s Health, July 12, 2015, as well as other posts on the benefits – or not – of cancer screening), and essentially, nothing has changed. It is terrible that Black men die from prostate cancer. It is terrible that anyone dies from prostate cancer. If screening saved lives we should do it. But this article presents no new evidence that lives are being lost that could be saved.

A few days later (Sept 5, 2025) the Times had an article by the same reporter titled Federal Report on Drinking Is Withdrawn with the subhead “The upcoming U.S. Dietary Guidelines will instead be influenced by a competing study, favored by industry, which found that moderate alcohol consumption was healthy.” Yup. Favored by industry. Not only were the guidelines withdrawn by HHS and thus not, as planned, presented to Congress, but HHS promotes a “competing report” by a panel of the National Academies of Sciences, Engineering and Medicine that “came to a conclusion long supported by the industry: that moderate drinking is healthier than not drinking”. Yay for the alcohol industry! Of course, “Some panelists came under criticism for financial ties to alcohol makers,” but what the heck. It is perhaps surprising, as the article points out, that RFKJr’s MAHA (“Make America Healthy Again”) campaign does not include anything about the use of alcohol – or, even more amazingly, tobacco! When we don’t like the message, we kill the message (and sometimes the messenger), especially in the current administration. But despite the fact that “Science Over Bias, an industry-supported advocacy group, faulted the alcohol intake study for bias: “The Dietary Guidelines should be guided by a preponderance of sound science, not the personal ideologies of a handful of researchers,” it is the industry’s position that is based on bias rather than on evidence. With regard to physical health (not short-term mental health), there is no amount of alcohol that is good for you, and any amount is a little bad. No alcohol is better than moderate alcohol, except for the financial interests of the industry and the scientists on their payroll.

On a somewhat different issue regarding health, not about controversy (screen or do not screen for prostate cancer? Drink alcohol in moderation or not at all?), is the Times article from Sept 7 by Paula Span titled Why Are More Older People Dying After Falls? It doesn’t provide a definitive answer, but strongly implicates prescription drug use (“Some researchers suspect that rising prescription drug use may explain a disturbing trend.”) It’s important. Falls are a major cause of morbidity and mortality in older people. You can break your hip or your head, you can get a concussion or a brain bleed or die. No joke. The association with prescription medication is legitimate, especially certain ones, called FRIDs, or “fall risk increasing drugs”, that are more likely to cause falls though inducing drowsiness, dizziness, drops in blood pressure, etc. Older people are more likely to have more diseases and be on more medications to treat them, and they are also more sensitive to the side effects of these drugs. (Note that drugs do not know which of their effects are “side effects”; we define them as the ones we don’t like!) And they are more likely to suffer serious injuries from a fall. The take-away message is that physicians should carefully review the medications that their older patients (actually all patients) are on, make sure that there is a need for them, and that there is not another less risky (less FRID) drug that could be substituted. Psychoactive drugs “like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system” should be especially assessed for need, with particular emphasis on the use of more than one drug with similar side effects that can lead to greater risk. The message should not be “stop taking my drugs because the pharmaceutical industry is greedy and trying to drug us all”. Sure, they ARE greedy, and we shouldn’t have to pay so much to them, but that is another issue. They also make drugs that are effective and in standardized doses (unlike “natural” herbs). And often it is the drugs that people like most (because they relieve pain and/or make them feel better) that are most likely to be FRIDs. Exercises to increase strength and balance are important. And, if the risks still cannot be significantly reduced, people may have to modify their lifestyles. For example, it may be necessary to stop walking a big dog.

These are 3 different issues. I included the first two, prostate cancer screening and alcohol use, because they represent efforts to peel back science-based policies that may have been deleterious to the profits of industry, which is like many of the policy changes across the administration over the last 8+ months. The falls issue is a little different; here the concern is to address the risks to the extent possible without overreacting and stopping all your medications!

Medicine and science are complex. But findings can be skewed to fit an agenda, and when that agenda is corporations making more money, a little skepticism is wise.

Making a profit isn't enough for Wall St.: You are going to have to pay, with your money (and maybe your life!)

Wendell Potter, in his “Health Care Un-Covered” substack, recently (Aug 6, 2025) reports that ‘As Americans Struggled, Health Insurers Made a Record-Breaking $71.3 Billion in Profits. In 2024, seven big insurers posted $71.3 billion in profits and paid their CEOs more than $146 million.’ There are several things being said in that sentence. First is that health insurance companies made a lot of profit. Second is that some people, specifically health insurance CEOs, are doing very well, thank you. Third is the assumption that Americans are struggling, presumably with their health insurance and healthcare. Let’s think about each of these.

These health insurance companies, per the chart that Potter includes, made $71.3B in profits. That seems like a lot to me. For most, it’s also more than the prior year. But not for all. Note that Humana made 33% less than in 2023, a mere $2.7B. 

Fortunately, that was enough to continue to pay it’s CEO over $15M.

At least UnitedHealth, the largest health insurer, is doing fine, right? It increased its profits 6% over the year before, and its CEO Andrew Witty (head of UnitedHealth Group, not to be confused with the assassinated Brian Thompson, CEO of UnitedHealthCare, who worked for him), is the highest-paid health insurance CEO at $26.3M, so I guess he deserves it because the company is doing so well. That shows that I (and possibly you) are not expert in the ways of Wall St. investors. It wasn’t enough for them. Just two days earlier, on Aug 4, Potter posted ‘Inside the Midyear Panic at UnitedHealth’. It makes fascinating reading, although the lessons learned by an MBA student may be different from those learned by, say, a regular person needing healthcare. As far as Wall St. is concerned, it is not enough to stay profitable; corporate profits need to continually go up so that these investors can meet their expectations for their own profit. It is important to understand that, as much as health insurance companies can be seen to be greedy parasites who produce nothing but obstruction and cost for those providing and receiving healthcare which they sell as producing “value”, private investors are a meta-level worse. They don’t even pretend to produce anything; they are, as an old family friend liked to say, “in money”. They invest and expect money back, more money all the time, and don’t care much about how the companies they invest in get it.

Nearly 500 years ago, Shakespeare wrote the “Merchant of Venice”, an excellent but anti-Semitic play about a greedy Jewish moneylender named Shylock.* Shylock has been widely decried for centuries for demanding a pound of flesh as repayment for the loan (how horrible!) But, by today’s standards, particularly in health insurance, he’d be a piker. While a lot of people, including me, could afford to lose a pound (or 20) of flesh, the health insurance companies are being spurred on by their investors (along with their own lack of values), are doing much worse. The actions that they are taking to ensure Wall St. investors make what they believe to be sufficient ROI will end up killing people. Antonio should have been happy to give up his pound of flesh! 

Of course, the financial investors in health insurance companies are not gauche enough to literally demand the killing of their clients. But they did demand changes that will undoubtedly have that result. While UnitedHealth saw an 8% increase in their Medicare Advantage plans, which they generally like because these plans allow them to do what they do with regular insurance, obstruct access, they still had to pay more out in medical claims than the shareholders were happy about. As Potter says, “Those seniors figured out how to get at least some care despite the company’s high barriers to care (aggressive use of prior authorization, “narrow” networks of providers, etc.).” Sounds good if you’re a patient, but if you’re an investor, it’s horrific. Remember what the insurance industry calls the percent of the premiums that they collect which they actually have to pay for medical care? The “medical loss ratio”! They hate it when they make less profit because they are paying for your care! Yes, UnitedHealth made $14.3 billion in profits during the second quarter, but it was less than the $15.8 billion they made in the second quarter of 2024, so something had to be done!

Potter describes what UnitedHealth promised its investors they would do:

• Dump 600,000 or so enrollees who might need care next year  [after all it is much more profitable to collect premiums from people who won’t need care]

• Raise premiums “in the double digits” – way above the “medical trend” that PriceWaterhouseCoopers predicts to be 8.5% (high but not double-digit high)[ie., you, the customer, pay more for less]

• Boot more providers it doesn’t already own out of network [when they work for you, money you pay them goes back to yourself!]

• ·       Reduce benefits [of course]

Yup, these changes most definitely will kill people.

Most insurance involves has you betting against yourself; you pay premiums to protect you if something happens that you do not want (or expect) to happen, but might. You have homeowner’s insurance, but you hope your house doesn’t burn down. You have auto insurance, but you hope you are not in a car accident. Originally, health insurance followed the same idea; it was not intended to pay for routine care, but to protect you if you had to be hospitalized and or have surgery for something you didn’t expect. But then it began covering (or hopefully covering) regular medical care, visits, treatments, and drugs. It was paying for what you wanted – regular care, not unexpected and unanticipated “major medical” care. This is different from what insurance usually is. Actually, though, insurance companies preferred as it is predictable and relatively low cost. With Medicare Advantage plans, for example, they take money from Medicare to cover seniors who are happy to have coverage for prevention, doctor visits, drugs, and even gym membership without having to pay separately for a Part D plan, a Medicare Supplement plan (to cover the 20% of hospital costs Medicare Part A doesn’t pay for), etc.

When those people get sick, however, they want their bills paid, and not infrequently United and the others were denying it. But as Potter points out, not often enough to please their investors. People were sometimes, increasingly, getting their bills paid – indeed CMS, the Center for Medicare and Medicaid Services, was requiring that they be paid. That is what infuriated investors – all that money going to pay for medical care rather than profit and shareholder dividends! So, they will reduce benefits, increase premiums, further limit the doctors you can see and hospitals you can use, and make being sick more unpleasant than it already is. Tough luck.

But that’s what you get when you have a “healthcare” system that exists primarily to make profit, not to provide healthcare. When you live in the United States. Why do we put up with this?

 

 

* Jews were moneylenders because it was an area open to them; in those quaint days Christians actually thought they had to abide on the Biblical prohibition on earning interest from lending money. It’s complicated; most of the prohibitions are actually in the Old Testament, but this was often interpreted as not lending money to other Jews; Christians were OK. Of course, they were presumably lending to other Jews when New Testament describes Jesus turning over the tables of the moneylenders in the Temple, saying per Matthew 5:42 ‘Give to the one who asks you, and do not turn away from the one who wants to borrow from you’. Anyway, both Jews and Christians lend money – “invest” – now.