Red, Blue and Purple Redux: Don't let them divide and conquer!

I wrote Red, Blue, and Purple: The Math of Health Care Spending back on Oct 20, 2009, and have referred to it several times since. It is important because not everyone is sick at the same time, so the percentage of sick people in any given year is relatively low.

I included these charts:

 

The colors represent more or less the same groups of people; in any given year 5% of the population accounts for 50% of the health care costs, while half the population accounts for only 3%. This means that, in any given year, a large percentage of our population (generally younger, and mainly healthier) does not have significant medical problems and thus does not incur significant medical expense. This is good for them, but it also can make them relatively happy with their health insurance. When you don’t need it, insurance of any kind is great, except that you continue to pay premiums. Ignorance is bliss. But when you get sick is when you find out how good your health insurance is – or is not. Does it cover the treatment that your doctor recommends? Does it say it will, but require prior authorization that, while not medically indicated, can delay your treatment. Maybe for too long ()? Does it cover your doctor? Does it cover the hospital they use? Does it cover the other doctors in the hospital you will be billed by (e.g., ER, radiology, laboratory, anesthesiology, etc.)? Does it require big co-payments? Or any?

It is also the basis for a lot of the decisions that health insurance companies make. In a recent post on the “Health Care Un-covered” substack, Ron Howrigon (Feb 3, 2026) demonstrates how insurance companies can use these numbers to their advantage (i.e, to not pay):

So, you have been named the new CEO of UnitedHealth, and you have this wonderful idea. Put policies in place to deny, delay or refuse to pay for care. These policies are going to upset 5% of your membership. The members impacted by these policies are expensive members with chronic diseases like MS, cardiac disease or cancer. Let’s say that half of those members get so upset that they leave UnitedHealth and join one of your competitors. That means you take a 2.5% reduction to your revenue but a 25% reduction to your medical expense. Profits go up and life is good. Well, unless you are one of those patients that didn’t get the medication or treatment that you needed that is.

You see? They don’t get screwed – you do. They don’t care if you leave their insurance company if you are costing them money. Ideally, insurance companies want to collect premiums from people (or their employers, or the government for programs like Medicare and Medicaid) who will never use them! Indeed, one tactic that Medicare “Advantage” (MA) plans use is urging people who get sick to consider leaving their program and going on to regular, traditional Medicare (TM). Those “free” glasses and hearing aids and gym memberships that the MA plans offer seemed great at the front end, but actually having them cover the cost of your being sick and in the hospital and needing procedures would be better.

It is too bad if people do not realize that, while they may be in the purple or even blue groups today, not needing too much health care and not costing that much, that could change tomorrow. Much of that “purple” group is made up of people with one or more chronic diseases, predominantly older, who go to the doctor a few times a year and maybe have a short hospitalization or two. But when those chronic diseases worsen, when you need surgery or other procedures, or need to be in an ICU, then you can quickly become “red”. The shifts can be even more dramatic for young, healthy people. One car accident and a teenager can need multiple surgeries and become a very high-cost patient. One premature baby who needs to be cared for in the neonatal ICU and your young family skyrockets into the high-cost group. Or cancer – a new and unexpected diagnosis can change anyone of any age into a high-cost high utilizer.

Since I wrote the original piece in 2009, many more people have cottoned to the truth of the situation, because they, or their family members, or their friends have experienced movement into the high-need, high-cost group. It may be only 5% of people in any given year, but those years mount up, and they are not the same people year-to-year. For starters, a significant percentage of those who were in that 5% last year are no longer with us this year. It is commonly noted that end-of-life care accounts for a huge percentage of the cost associated with someone’s care in their lifetime, but when that lifetime is over, others move into the 5%. The fact is that we are all in this together (well, except for the insurance company executives and really wealthy folks) and policies that don’t hurt us individually this year can hurt us very much next year.

In the substack post cited above, Ron Howrigon raises the specter of a major economic event, “correction” or recession à la the housing bubble of 2008, except maybe worse because the health sector of the economy is three times as large. The problem identified above is only one of three major problems with the health insurance industry that he identifies, as he makes the case that it is built on flawed economic assumptions just as the housing industry was. Such economic implosions are not, in themselves, good for us, but continuing the way we are is also not. For many years, the “economy” has grown, but all that growth has gone to corporations and multi-billionaires and not to regular people (indeed possibly more than all the growth, since the imbalance is worse). While there may be some hard-working people who are fine with this even though they are struggling to pay the rent and buy food and gas – it takes all kinds – most of us are not. If the health care industry “fails” and then must be rebuilt to actually take care of Americans’ health, that would be a good thing. Although, judging by the response of the government to the financial crisis of 2008-09, that would be a dubious outcome; they’d probably bail out the health insurers. Unless we all can get together to stop them!

Divide and conquer has long been a strategy used by rulers and the powerful. It still happens and, so far, it still works. On Dec 30, 2025 I published on this blog Yes, Rep. Van Drew, there IS a solution!, which had appeared 3 days earlier as an Opinion piece in my local paper, the Arizona Star. I note that Medicare for All is a solution to a huge part of this problem, that there are bills in both the Senate and House (S. 1506 and HR. 3069) to create it, and that a large majority of the American people, in poll after poll, support it.

While the people are increasingly understanding how they are being screwed for the benefit of the rich and powerful, in this important case insurance companies, legislators seem to have not gotten the message. This could be in part the result of money being given to them and their campaigns for re-election by those same companies! This cannot be understood as anything but – graft! And, to overcome this, our voices – and our votes – need to be loud and clear so they can be heard by those legislators and policy makers. Pass laws and make policies that benefit the health and pocketbooks of the mass of the American people, and do not pay attention to the enrichment of health insurance companies, their executives, or their billionaire private equity owners. In the balance between the health of the people and the wealth of corporations, the latter should get NO weight!

Write to them, tell them, call them daily!

"Values" based care: Public Health, Primary Care, and Medicare for All

Recently, a class of undergraduate freshmen I teach debated the issue “Health Care is a Human Right”. Although we later determined that most of them personally supported that statement, the “no” team did a good job marshalling the arguments of opponents, often citing those of libertarian think tanks such as the CATO Institute (originally founded as the Charles Koch Institute, in case that helps), which identifies itself as promoting "free markets and individual liberty”. This includes identifying health care as a “commodity” and opposition to health care as a right (and thus to universal health coverage) as an infringement upon individual liberty. Essentially these two concepts boil down to the idea that the individual is free to decide what kind of health care they want, or don’t want, and what kind of insurance coverage they want, or don’t want, and can use their money (or not) to purchase this commodity (health care) as opposed to another (I don’t know, say a bass boat).

The hole in this argument is wide enough, though, to drive a bass boat through. It is that not everyone has such a large amount of disposable income that they have the financial options to make such decisions. An old point about commodities having to do with cars, when most Americans bought American brand cars, is that some folks can buy Cadillacs and others Chevrolets. But of course, even if we update this to Beemers and Kias, there are a huge number of people who are buying used cars – often old “junkers” – to try to get to work and shopping. And there are those who can’t afford to buy, insure, and run any car at all and are reliant on public transportation. If there is any public transportation where they live. People without a lot of money (often despite working multiple jobs, even those making quite a bit more than the federal minimum wage of $7.25/hour -- last raised in 2009 when $7.25 was equivalent to about $9 today) make regular trade-offs on what they will spend their money on. Rent? Food? Clothes for the kids? Heat? Electric bill? Gas for the car to get to work, if they have a car? Health and medical care are rarely right up there at the top unless they are actively ill. Indeed, often even chronic diseases don’t get adequately managed, with medications for common conditions such as diabetes and hypertension stretched out. This family – and to a greater or lesser extent, this is probably true of the majority of families – is trying to figure out how to juggle absolute necessities, not luxury goods. The students arguing the “anti” position gamely tried to respond to such concerns, but learned that, outside the walls of conservative think tanks, Congress, state legislatures, and country clubs, there is a limit to the effectiveness of continually repeating “individual liberty” and “commodities”.

Paying for the cost of health care is a real juggling act for the government, although for a different reason from the one the families above are doing. It is balance between wanting to spend less money and continuing to support the profits of health care corporations such as insurance companies, hospital systems, and drug makers. The rational solution to this problem is to decide that it is not the government’s business to guarantee the often obscene profits of such private corporations, but rather to spend the money on whatever maximally increases the level of health of the American people.

This should include at least two major changes: first, a national health insurance plan (such as “Medicare for All”, recently reintroduced with major improvements by Reps. Pramila Jayapal and Debbie DIngell) that ensures that everyone is covered – everyone, all in one plan, no exceptions by age, disease, etc.), and second, a massive and continuing re-investment in public health, the need for which should have been made clear by the COVID pandemic. Historically in the US, in Democratic and Republican administrations, funding for public health is about 1% of the health budget, with the rest going to individual medical care. When we have a crisis, we bemoan the lack of public health infrastructure for a while, but then it recedes. Yet this is the most important component of keeping us healthy. Fighting an active enemy (like COVID) can garner support, while maintaining programs of prevention absent an obvious crisis gets less. How often do we wake up and say “I’m glad I don’t have cholera today because we have clean water and sewage”? And, yet, recently folks in Mississippi and Texas can count themselves lucky that their lack of water did not come with cholera or another infectious disease.

Instead of such wholesale reimagining we have had programs like “value-based care” for Medicare, adopted with the ACA (“Obamacare) in 2010. When this was first rolled out, I was enthusiastic because I misunderstood it – I thought it was about providing care based upon values, presumably decent human values. Sadly, I was wrong. It was about spending less money. Did it work? To do what? If the goal was spend less, yes, to some degree (see Austin Frakt in the NY Times Upshot Oct 9, 2019, “more singles than home runs”). One of the big goals was to substitute “value” for “volume”. Paying for volume, the number of patients seen, was the accepted way to pay doctors. But what does paying for value mean? This whole issue is reviewed by Dr. Don McCanne in his “Quote of the Day” for March 17, 2021 “Policy community hung up on ‘volume to value’”. Dr. McCanne reviews the recent article “The Future of Value-Based Payment: A Roadmap to 2030” from the University of Pennsylvania on the topic, but in his comments he notes that

“All health care has “volume” – time, effort and resources devoted to health care. Volume varies tremendously depending on the clinical situation. Think of management of a common cold as opposed to management of severe multiple injuries in an accident. Can payment schemes ignore volume? Of course not. Volume is built into the problem.”

Here is a volume/value solution that I have discussed before but will now say clearly: Revise the way that physicians (and other providers) are paid so that family physicians and other primary care doctors make at least as much as those providing subspecialty care. This is the third step to add to universal health coverage and investment in public health. When I go to a shoulder orthopedist for the pain in my shoulder, that is the ONLY PROBLEM they deal with. Not BP, not abdominal pain, not my cold -- not even the arthritis in my knees.  My PCP would deal with every problem on my – and all their patients’ -- problem list (to greater or less extent, depending upon severity and acuity), and thus rarely has enough time for any on person. If you go to the cardiologist, and mention that you have knee pain, they say "I don't do knees; here is a referral to the orthopedist". And you go to the orthopedist, they make a recommendation, you come back to the cardiologist who says "I don't do knees; whatever they said". So, for the subspecialist, referral is a time saver.

But if you come to a PC doc and say your knee hurts, they make some diagnostic and treatment suggestions. After examining your knee, maybe ordering imaging and lab, and thinking about it, if they think it might need surgery, they might refer you to the orthopedist. Then you go and the ortho says "maybe surgery", so you come back and ask your PC doc’s opinion, so they read the whole consult and review the films and think about it and discuss it with you. Result: referral for a PC doc makes MORE work.

And they get paid less.

PC docs need more time with everyone, and thus fewer patients each day/week/year. How much money should they make? I don't care, pick a number, but it should be able to be earned by seeing no more than half the number of visits that they currently do. People's complaint is ALWAYS about not having enough time with the doctor.  

So, increase funding for public health, develop a universal single-payer health insurance system, and pay PC docs at least as much per hour or patient as the highest-paid subspecialist in the outpatient setting. 

Now we begin to have “value”!

Biden: Not Medicare for All, but leadership on COVID

The defeat of Donald Trump in the 2020 election was a wonderful thing, despite the less-good news: that the “blue wave” did not appear, that the Senate (barring two unlikely upsets in Georgia) will continue to be controlled by Mitch McConnell, that the GOP gained seats in the House, and especially that 70 million Americans voted to re-elect the worst president in American history, thus supporting racist, misogynist, anti-environment, anti-union, pro-corporate and pro-billionaire policies, and bellicose macho authoritarian bluster. The election of a Black (and Asian) woman as Vice-President is historic and great. While it is possible that Biden’s uninspiring “centrist” (read “center-right”) positions gained him votes, the division in America has never been more dramatic. Cities like, most highly featured in the days following the election, Philadelphia and Atlanta (as well as New York, Los Angeles, Chicago, etc.) went 70-80%+ for Biden, while rural counties went for Trump by the same margins.

My purpose here is not to be a political commentator, but to discuss what this might mean for health care under a Biden administration. Certainly not a supporter of any kind of single payer universal health insurance, including Medicare for All, Biden further has to contend with a (probably) Republican Senate and a newly strengthened rightist Supreme Court that even as this is being written is hearing another challenge to the ACA, President Obama’s signature domestic achievement, and the scaffold on which Biden hoped to build his own health care plan by adding a “public option”.

Assuming that, despite Senate and possible SCOTUS opposition, the ACA survives and even that the “public option” becomes law, it would be a great advance in the number of Americans who had access to decent health insurance (which, in itself, may doom its chances in those two “august” bodies!) Indeed, the arguments that many, including myself, have made for the savings that could be achieved by government single-payer program (extension of an improved Medicare to everyone) would likely be somewhat achieved by a well-designed public option, since better coverage would cost less money than it does under the private, for-profit, insurance sector. Not nearly as much as would be achieved by single-payer, but enough to have a good chance of eroding the base of those who hang on to excessively costly, poor-quality private insurance.

And yet, ”Medicare for All” continues to enjoy wide public support, certainly in those “blue” cities and counties, but also within the US as a whole, including some of the “reddest” areas. People know that their health insurance is costly and that the coverage is inadequate, and that not only their lives and health are at great risk, but so (to the extent that they have any) is their “treasure”. Democrats who supported M4A were all re-elected, while many opponents were defeated. Indeed, this illustrates the difference between those in power, members of the Senate and the House (and SCOTUS) who serve the wealthy and are mostly wealthy themselves, for whom tax cuts for their patrons and corporations (under the umbrella of the scandalous SCOTUS decision in Citizens United that declared money to be speech and corporations to be people!) are the main agenda, and their constituents. The latter have poor and costly health insurance, benefit little if at all from tax cuts, and are losing their jobs right and left as US companies push more and more money to the top. For the former, Medicare for All is a bugbear; for the latter it may be a lifeline.

The most important healthcare issue in which the election of Joe Biden is likely to make a big difference, however, is the most important healthcare issue currently facing America, and the world – the COVID-19 pandemic. This second (or maybe third) wave is breaking all kinds of records for new cases, new hospitalizations, and new deaths. In my state, Arizona, we have the highest rates since July. The nation has had well over 100,000 new cases a day recently, in some of the “reddest’ counties, with rates over 200/100,000 residents in some. The reason is that the virus does not care about what you want, and apparently what we have wanted is greater opening, an end to social isolation and not going out to restaurants and bars, not having parties and funerals and visits with our relatives. We want businesses to open, we want our jobs back, we want our personal economy (not just the stock market) to improve. We bristle at the “discomfort” of masks (like the “discomfort” of seatbelts). We want to rush, en masse, onto the football field to celebrate a huge victory for Notre Dame over Clemson (oh, wait, we did that!)

The problem, of course, is that each of those things spreads the virus, and the spread of the virus means more people will die. I have often said REOPENING=DEATH and it remains true, however much we want it not to be; there is nearly a linear relationship between the degree of reopening in any city or state and the increase in the rate of cases of “the rona”. Now, as we look toward all those college students, including those from Notre Dame, returning home for the holidays, we hold our breaths as we worry about how many of their parents and grandparents will become infected and die, putting a damper on the celebrations.

Masks and reasonable social distancing will not prevent this entirely, but will help a lot; masks really decrease transmission. Having a President who wears a mask, who encourages safer behaviors, who does not encourage total irresponsibility as has the current incumbent, is likely to make a big difference. Something has to, and certainly it needs to happen soon. Most encouraging, Biden is not only willing to, but enthusiastic about accepting science as the guiding principle of the response to the epidemic. He has already named members to his COVID “panel”. It could use some more epidemiologists, some nurses, but the intent and direction are good. The increase possibility of a vaccine, especially the recent news from Pfizer, is very encouraging. With a new administration committed to making a difference by using strategies that might actually make a difference, the trajectory of the virus might be turned around.

There are, and will continue to be, great obstacles. The most vulnerable populations will continue to be the most vulnerable – including people in prison, and those immigrants in federal detention, whose rates of infection are staggering. The Pfizer vaccine requires shipping and storing at temperatures of -80 degrees, which is very difficult in many places, particularly in less developed countries where the pandemic is raging.

Add caption

But leadership from the US President can go a long way. Whatever else we might wish from him that we are unlikely to get, we can hope that Biden will provide this.

Hospitals compete for money, not the people's health. We need to stop this.

For decades, Santa Fe, NM, had only one hospital. St. Vincent’s was founded 155 years ago by the Sisters of Charity, but was taken over by the national Catholic corporation CHRISTUS in 2008. It’s a pretty good hospital with about 200 beds, for a small city of 85,000. A couple of years ago, the largest health system in New Mexico, Presbyterian, opened another hospital. It is a big building, but has only 30 beds, so its additional contribution is not primarily general inpatient care. Interestingly, while the hospital is on the far southwest side of Santa Fe, its main medical center building is directly across the street from St. Vincent’s. This is obviously not a coincidence, as it is now firmly in the center of the area in which people are accustomed to coming for medical care, establishing itself, at least for outpatient care, as a competitor.

The point that I want to talk about is not hospitals in Santa Fe specifically but rather competition among hospitals in general. This is not a problem in rural areas and small towns where the struggle is, rather, to hang on to their hospitals at all (often with just a very few inpatient beds, and almost invariably losing money). It may not be a big issue for mid-size cities like Santa Fe. It is a huge issue in the major metropolitan areas where most hospitals and doctors are, and where there are the greatest concentrations of patients (the medical term for what in English we call “people”).

In these areas, you will find that almost every big hospital (or “medical center” or “health system”) has a Cancer Center. And a Heart Center. Centers for Orthopedic Surgery and Sports Medicine are also big. And in the last decade Neuroscience centers have joined the ranks of “must-haves” for each of these centers. Of course, if they deliver babies, they certainly will have a Neonatal Intensive Care Unit. What is wrong with this? Are these not important, serious diseases that can and do kill a lot of people and need treatment? Am I advocating against treating, say, cancer?

Not at all. But while there are a lot of people with cancer, it is a finite number. Was the new Cancer Center just opened to a lot of hoopla at St. Elsewhere necessary because there were many cancer patients for whom there was not room in the Cancer Center at Downtown General, opened a few years ago, and now would have an opportunity to receive treatment? Or, just perhaps, is St. E’s hoping to attract many of the patients, and perhaps the doctors, who currently use DG to instead use their new, glitzy, state-of-the-art facility? Is it a simple matter of competition for a limited market?

If we had a medical care system that was based on the health care needs of the population, we wouldn’t have such redundancy of facilities; we would have enough for all the people who need care and not unnecessarily duplicate services. Downtown General might have centers of excellence in cancer and orthopedic sports medicine, while St. Elsewhere might be great for heart and neonatal care. And, since we are fantasizing about a system in which the driving force is the health of the people, let’s throw in primary care and mental health. But that doesn’t happen. And, in our hypothetical city, even with both cancer centers (and perhaps yet another at Doctors Medical Center), there will still be bunch of people who cannot receive care because they have no insurance or their insurance is poor (i.e., they are “underinsured”).

So, in addition to creating excess capacity, which creates major excess cost, competition in medical care services doesn’t meet the needs of all the people. The true driver of the health system, making money, creates at least three major sources of inequity:

1. The services are only for the well-insured. Entire groups of poorly-insured people are excluded. The services offered by these special centers may be highly-profitable, but only if they get paid. They don’t make money providing care to poor or uninsured or underinsured people. 
2. The services offered are those that are highly profitable, and most often this is for particular procedures. Yes, cancer is bad. So is heart disease. But the real reason for these centers is that these conditions are very well reimbursed by insurers, so the hospitals (and doctors) make a lot of money (provided the patients meet criterion #1, of course). For example, while chemotherapy drugs are ridiculously expensive, of course, making money for the pharmaceutical industry, the hospital makes money on the “administration fees” which are far in excess of the actual cost of administration. In addition, the creation of new “centers” are often driven by a single procedure. No one had big “Neuroscience” centers until the procedure for inserting a catheter into a brain artery to pull out a clot was developed. THAT is reimbursed incredibly well! All of a sudden every big hospital needed a “Stroke Center” and started competing (and paying a lot of money for) “stroke doctors” (who might be neurologists, neurosurgeons, or invasive radiologists) who could do this procedure. But poorly reimbursed services? No matter how much the people need them, don’t expect lots of new centers for primary care. Or mental health. Or even general surgery. Essentially, we discriminate not only against those who are poor or uninsured, we discriminate against those who are unlucky enough to have poorly-reimbursed diseases!
3. The third great inequity is obviously geographic. If you live in a major metropolitan area, and are well-insured, you can have your choice of which hospital is the best for your problem. You consult US News, ask your friends, read the ads. But if you are in a small town or rural area far from such a city, it’s a long trip. And not worth making if you don’t have the money.

What can and should we do? In the long term, we need to eliminate the motivation of hospitals to compete for profitable services by putting them on a global budget, which is what is done in Canada as part of their single-payer health care system, called (interestingly) Medicare. And, of course, we need to cover everyone so there are no people left out because they are poor and uninsured, a universal health insurance system, not “cover more” but “cover everybody”. And by long term, I mean as soon as possible.

In the mid-term, we must change policies to much less dramatically favor certain procedures at the expense of others. Pay more for mental health and primary care. Pay less for cancer drug administration and sucking clots out of brain arteries. Stop making it so much more profitable to do knee surgery than gall bladder surgery. The availability for any kind of procedure should be based on the need for it, not how well it is highly reimbursed. That is a totally backward motivation, and dangerous to our health. This can actually be done by federal policy simply by changing how (US) Medicare values and pays for services. Because Medicare is the largest payer, it sets the market rate. Private insurers may pay more, but it is always “multiples of Medicare”; the ratio of what is paid for one medical service relative to another is set by the federal government.

And while we’re at it, let’s eliminate the universal tax-breaks “non-profit” hospitals get for anything that they do, which are mostly things that will make them money! As evil in many other ways as for-profit hospitals are, they are at least required to pay taxes, and go to the capital markets for capital expansion. No donations to a hospital should be tax-deductible if they are going to be used for a money-making scheme. Again, in Canada capital budgets are separate from operating costs. A hospital is not motivated to increase its operating profit so it can expand and build, to better compete with others. It must apply for additional capital funds, which will only be available if they serve a health need.

In fact, this is something we can do in the near term. As citizens and donors, we can demand that the next opulent fund-raising gala for our local hospital is not for the purpose of expanding money-making services, but rather to expand those services to those who cannot currently access them. The money raised should be earmarked only for, say, providing cancer care at our great cancer center to uninsured people. That would be something for which tax-deductibility is justified.

It is outrageous that our health system in the US is structured to maximize money-making and not health. But as in so much else in our society, those making the money have a lot of it to use to exert their clout. It is going to take a massive national effort by the people to make the changes that we need to have.

 

 

COVID-19 emphasizes the necessity of Medicare for All

This will not be much of a reprise of “what should you do about COVID-19”, you know, wash your hands, use hand-sanitizer, avoid groups whenever possible, stay home if you are sick-but-not-too-sick (if you’re really short of breath, go to the ER; if you have signs of a heart attack or significant trauma, go to the ER, even though both increase your risk of infection). It will also not be much of reprise of what not to do: have big parties to celebrate the cancellation of classes, like many of the students at Cornell (https://cornellsun.com/2020/03/15/while-some-cornellians-self-quarantine-others-pack-parties-in-response-to-campus-shutdown), who at least have to “excuse” of being both young and thus less likely to die and young and thus have underdeveloped frontal cortexes (where judgement resides). Or the racquetball players at my local racquet club who had a tournament this weekend gathering at least 40 people in a relatively small space and sharing finger food like fruit and cheese and crackers (and who are decidedly NOT young! Although they may lack judgement…).

At the debate on Washington DC on March 15, Bernie Sanders emphasized the degree to which having a universal health program, a single-payer program, Medicare-for-All would help in this crisis. Yes. It would have and it will in the future, when another epidemic comes calling. It will not, by a long shot, solve all the problems that have existed in our (and other nations’) response to COVID-19, but it would have helped a lot, particularly in alleviating the still-valid fears that people have of getting crippling bills if they seek care.

This is not to minimize the incredibly incompetent, not to mention destructive, role that the federal government has played. The Executive Branch, led by President Trump, has bloviated, lied, misled, created fear, and provided incredible misinformation to the American people. This has been extensively covered by the media; criticizing the buffoonery of Trump is apparently fair game among the mainstream press. There has also been some, albeit less, coverage of the purposeful decimation of the nation’s public health infrastructure by the Trump administration prior to the advent of SARS-CoV-2. The federal epidemic response task force was eliminated by the administration. Federal support for state and local health departments was cut. Once the administration finally acknowledged that it was a big problem (one for which the President took no responsibility), the response was anemic and ineffectual.

Trump named science-denier Mike Pence to lead the effort. Jared Kushner has it added to his portfolio; he consulted his brother’s father-in-law, who is, after all, a doctor, and a Facebook group. Trump called it the “China virus”, but SARS-CoV-2 was not intimidated. Concerned about a stock market taking its biggest dive since 2008 (something that really worries him!) Trump proposed cutting payroll taxes paid by employers by $700B, both remarkably stupid (takes a long time, and cuts funding for Social Security, and helps neither the economy or the stock market) and typically directed to benefit the best-off, ignoring the plight of those most affected, the poor. The response to the epidemic, including especially the unavailability of tests for SARS-CoV-2, has been scandalous. We are at least a year from having a vaccine, but the President continued his moronic approach by apparently trying to buy a vaccine developed in Germany for use “only in America”.

But it was not just the administration. The Congress also did not demand a public health infrastructure. The states and local governments, in part because of decreased federal funding, have grossly underfunded their own health departments, which were woefully unprepared in most areas and are struggling to begin to catch up. Luckily, the health department in Seattle/King County Washington, where the virus has hit hardest in the US, was one of the ones in better shape.

So there is no question but that poor planning, addressing core health needs only when there is a crisis, focusing on tax cuts for the wealthiest and not planning for “the big one” (just as we have not planning for climate change or war) has crippled the US and its response. There is also no question that having a president who plays to his right-wing base who see him as the one “in charge”, and enablers like Fox News’ Sean Hannity, made it even worse. The system that does exist in the US has long been focused (“focus” = funded) on individual care of individual people (called “patients), and particularly on those who have money or good insurance and even more on those whose diseases (such as cancer) are very well reimbursed by those insurers. Public health suffers because, other than in epidemics (SARS, H1N1, Ebola) it is not in the public consciousness, so the government can work on tax cuts for the rich and the health system can work on making money on the insured sick. Sins of omission are less obvious; I have noted previously that people do not wake up each morning saying “thank goodness I don’t have cholera because we have a clean water supply!”

But there is another part of the story, which will become even bigger as folks get sick. This is because the US does not have universal health care, does not have a national health system. It has not even addressed who will pay for COVID-19 testing (a local university recently suggested it would charge its own students $200, until it was embarrassed out of it!), or a vaccine if it becomes available. It certainly has no reasonable plan for paying for the care of people who fall ill with disease, need hospitalization in intensive care units need to be on ventilators, but have no or rotten insurance. We hear that the VA will be a backup health system; great, if it can. When will we federalize the for-profit and “non-profit” hospitals?

We have also, of course, had policy decisions on closure made by each individual business/organization/school/local government, based on its own perception of risk (epidemiologic, financial, peer pressure) without adequate consideration of its impact on the entire social structure. Stay home from work? Work from home? What about the (generally lower paid) folks whose work depends on being there (cleaners, health workers, etc.)? What about those who don’t have sick leave? What about those who don’t get paid, or lose their jobs, if they don’t show up? What about school closures putting parents in the position of choosing childcare vs work (or calling upon grandparents, in the higher risk group)?

Planning for and implementing a response to an epidemic is different from having an organized national health system. Many European countries including Italy and Spain have their citizens all covered but are struggling terribly. But having such a system does create the infrastructure basis for national health policy and national health response; see how South Korea dramatically ramped up its COVID-19 testing, and was able to implement it because of a national health system. Spain has indeed nationalized all private healthcare to battle this crisis. Norway suggested that its citizen living abroad come home. It is urging its citizens abroad to return home, especially if they are "staying in a country with poorly developed health services and infrastructure and/or collective infrastructure, for example the USA"! We planned poorly and we won’t necessarily provide care for them, or indeed for “us”!

Much terrific insight is provided by Dr. Seiji Yamada in his terrific Counterpunch piece “Coronavirus for All”: ”These days U.S. health system is run by health care executives, with their business smarts, their lean operations (except for their compensation packages), achieving just-in-time delivery.”

Health care should be a human right. This crisis illustrates the need to have a robust, continuously-funded public health infrastructure. It also illustrates the need for a universal health care system that can take care of all of us. Bernie Sanders may not win the nomination, but the fight for universal health care for all of us must continue.

As Dr. Yamada notes:

Certainly it’s true in the U.S.A. it is easier to imagine the end of the world than to imagine the end of capitalism. On the other hand, it’s also obvious that capitalist health care is going to faceplant in the face of the coronavirus. It’s going to be a choice between Medicare for All or Coronavirus for All.