Access to healthcare: More primary care and no financial barriers for anyone

A recent study by Matthew Toth and Lauren Palmer from the Research Triangle Institute (RTI) evaluated the impact of the Center for Medicare and Medicaid Services (CMS) Financial Alignment Initiative (FAI) on access to primary care by those people who are eligible for both Medicare and Medicaid. These people are called “dual-eligibles” and represent about 13% of Medicare recipients. The FAI aimed to increase coordination of care, and the authors discovered that it did increase primary care access, to some degree, in 6 of the 9 states in which this demonstration project was implemented. In one state where it did not, Washington, eligibility for the program required people to have multiple morbidities (chronic diseases), and so the authors speculate that it increased access in other states for “healthier” dual eligibles.

There is nothing wrong with this study, or the program it studies, insofar as they go. But it raises two major issues. The first is that the program is yet another example of how the federal government continues to tinker around the edges of a completely flawed healthcare system by experimenting with one program after another that might possibly help, to some degree, a small portion of our population. This is not to say that the people who were studied, those eligible for both Medicare (by age or disability) and Medicaid (by poverty) are not deserving of better access to care and care coordination; certainly, they are. But we all are. Because we have some people who are eligible for Medicare and some people who are eligible for Medicaid and lots of people who are eligible for neither, and many people who are uninsured, and many more are grossly underinsured, we have fragmented our population and made financial access both unwieldy, far from comprehensive, and incredibly expensive. If this study (maybe) shows that the improvement in access was more for those “dual-eligibles” without multiple morbidities, is this bad? Well, it’s bad that they weren’t getting coordinated care in the first place!

Here I need to take a break, before going on to the second issue, to put in a word or two for our medical insurance companies and large hospital systems. They are not doing badly. Indeed, the outrageous excess cost of our health system, two to three times (or more) per capita than other OECD countries despite leaving large numbers of people uncovered, is due almost entirely to their profit-taking. They are doing well, thank you, along with the drug manufacturers, even while rural and inner-city safety net hospitals are going broke taking care of poor and uninsured (and sick) people, and millions of Americans go without care or receive inadequate care. The words – I’ll go with two – are rapacious thieves.

The second issue is that while financial access, being covered by adequate insurance, is very important, it is only part of the picture. The other part is having doctors (or other appropriate clinicians) who are available to see patients. This is the other area in which the US (and, in fairness, a few other countries including Canada) are failing. Have you tried to get an appointment to your primary care clinician lately? Maybe you can get in easily, but if so you are the exception. Most people have to wait weeks or months. If they go to the ER, they wait many hours, even for urgent or emergent problems. It would be good to be able to see a doctor who knows you, and knows your history, right? Instead of someone in an Urgent Care Center. I can answer all of these for people I know (or me) and the answers are not positive, and these are folks who are well insured and live in a major metropolitan area, not in a rural one or an inner-city health care desert! In Canada, there are suggestions that the way to fix the wait is to – wait – privatize health care! Hah! Come on down and see how that works here!

Why is it that people cannot get appointments to see primary care clinicians? Shouldn’t there be enough? Years ago on Saturday Night Live, Don Novello portrayed a character called Father Guido Sarducci who offered a “5-minute university”, where you were only taught what you would remember years later anyway. For Economics, it was “supply and demand”. So if there is so much demand for doctor visits, especially primary care visits, why is there not enough supply to meet it? This is, as you would guess, kind of complicated

Obviously, there are not enough primary care clinicians, either as a whole or as a percent of all physicians. If there were enough, you could call your doctor and get in today if you were sick or had a worsening problem. Like on TV (pick your favorite FP/GP show). So we don’t have enough. This is all about money. To some degree, it is about doctors wanting to make as much as they can. This results in far too small a proportion of graduates entering primary care, since they can make two or three times as much in some other specialties, which is enough to convince even many who liked the idea of primary care that, especially with their debt load, they liked anesthesiology more. We are at about half the percentage of primary care that we should be. For this I blame the system that pays other specialties so much more (or primary care so much less). In addition, the distribution is poor – not enough doctors in rural areas, or certainly poor urban areas, but all concentrated in more wealthy urban and suburban areas.

Ultimately this is all about the corporatization of health care, and the treatment of providers as widgets in a factory. Put this many in clinics, make sure that they are totally booked and have no room for anyone who needs to get in on short notice, put others in the hospital, put others in urgent care or ERs. Have no flexibility in the system because if you have the capacity to expand when needed, that means that at other times you have down time, and that is unacceptable for making maximum corporate profit. Of course, this is not good for your health, which is better when you can see a doctor who knows you, especially when you are sick and couldn’t plan two to eight weeks ahead of time (or more!) to make an appointment.

Creating doctors and other health professionals takes many years, and cannot change on a dime, but it will never change if that change doesn’t start. If we care about people’s health and healthcare, we need to dramatically decrease the difference between what primary care and other specialist income so it doesn’t discourage students from choosing primary care. We need to ban for-profit corporations (or ostensibly non-profit systems that act like for-profits) from being in our health system at all. All of health care and its components should be about ensuring better quality health for our people, not making money for businesses.

The usual pattern in the US is to have funding for public services cut by politicians who are receiving money from private corporations, to the point that they do not function well at meeting public needs. Then those same politicians say “privatize!” and they do and the cost goes way up and the public needs are still not met, because, well, that’s not what private enterprise is there for. (See this good video by Brittlestar on why privatization is not a good choice for Canadian healthcare.)

Jimi Hendrix said “Castles made of sand fall into the sea eventually”. But our health care system is not built on sand. It is built on rocks of intransigent corporate profit, and it is not going to change without a fight. You and your health don’t count as much as big business making money.  So there. Pick up the gauntlet, and fight for yourself, your family, your community.

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.

 

 

"Single Payer", "Medicare for All": Good ideas and about time!

The call for a universal health care system in the US is probably greater than it ever has been. While, of course, the Republicans, whose only firm position is completely kowtowing to billionaires and major corporations, are opposed to it, many Democrats have signed on to the “Improved and Expanded Medicare for All” bill in Congress (120 at last count). Democrats running across the country have been calling for “single payer” as well as “Medicare for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in NY (and of course Bernie Sanders) to moderate Democrats running in states and districts that Trump won. They correctly see this as an issue that cuts across traditional liberal-conservative lines, and even racial lines, and may be their path to victory.

Many Republicans (although not the Republican congressional leadership) are reading the same tea leaves, and are hedging, trying to say that they favor the things that people like about the ACA (most important, the protection against insurers denying coverage for pre-existing conditions). Of course this often requires major dissembling for those who, like our Arizona GOP candidate for Senate Martha McSally, voted to gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz Amendment” that would strip virtually all protections for people under ACA. President Trump, never one for nuance, has no difficulty having it both ways: he calls for the repeal of ACA while insisting that his health care plan will protect people’s ability to have health insurance, pre-existing conditions or not (it won’t).

It is in this context that the recent Sunday NY Times’ Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t get too excited” about Medicare for All’ becomes important. For starters, “Don’t get too excited” is not necessarily the opinion of the authors but a quotation from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one of his Nashville constituents, Dr. Carol Paris, President of the leading physician advocacy group for single payer, Physicians for a National Health Program (PNHP), that he had signed onto the Medicare for All bill. Nonetheless, the article does raise many cautions about the movement to single payer or Medicare for All, mainly about different interpretations of the meanings of this by different advocates, and incomplete and sometimes inaccurate understanding of them by regular people. The most important thing about it, however, is that it had to be written at all because there is such a movement; long-time activists, including PNHP physicians, remember that it was not too long ago that such an idea was poo-pooed, dismissed. Not now.

Clearly, the quantum step forward was the 2016 presidential campaign of Bernie Sanders. The establishment pundits of both parties were shocked at how popular and successful this old Jewish socialist from Vermont (ok, originally Brooklyn) was across the country. He didn’t win the Democratic nomination, true, but he might have won the general election against Trump. Certainly, his straight talk and the fact that he directly addressed the felt needs of regular people was the main reason for his popularity, and people’s fears about their health risks and costs were central to this (see A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care, October 16, 2018). Bernie had advocated for single payer for decades, as had great leaders before him including the late Representative Ron Dellums of California (see Ron Dellums: Loss of a great leader and a job for the rest of us, July 31, 2018), but the visibility of his presidential campaign skyrocketed the visibility of single payer.

Rosenthal and Luthra utilize a good bit of ink describing what single payer is --the government is the only payer for health care, rather than multiple private insurers; Canada is the best example of this, and Britain has a government-owned national health service. They also note that Medicare for All means exactly that, that everyone, not just those over 65 and the blind and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be single payer. They describe the misconceptions people have (“would I be able to keep my present plan?”), and also talk about other countries, such as France and Germany, that have universal health care without a single payer but with a heavily-regulated marketplace. They observe that partialist solutions do not generate the enthusiasm of single payer, but that the latter would be the hardest and thus (perhaps) most difficult to institute. Among the concerns they note are the displacement of insurance company employees and the decrease in doctors’ income.

But these are the most important points.

1.       Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43^rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
2.   Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
3. Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.

These are the core issues that need to be addressed, and what sets the US apart from all other developed countries. Yes, Canada has a single payer system such as we might have with Medicare for All (and they even call it Medicare). Britain has a National Health Service, with most hospital and health care facilities owned by, and some doctors employed by, the government. Britain, however, allows private insurance for those who can afford it, Canada does not. France and Germany and Switzerland have multiple insurers, but they are not unfettered to maximize profit by denying care. In Switzerland, for example, insurers have to be non-profit, have to offer the same benefits, and have to charge the same amount. They compete on quality of service! Can you imagine that here?

So, while Rosenthal and Luthra repeat the idea that single payer, although the most enthusiasm-generating, would involve the biggest change, it is also, in another sense, the least complicated. Trying to get to a system like that that evolved in these other countries over decades will be more complicated to understand and to implement. Many of the suggestions for incrementalism (“Medicare for More”, “public option”) will not solve the problems we have because they do not include everybody, and because they do not eliminate the incentive for making money on the back of denying care that is the core flaw in our current situation.

“Medicare for All” and “single payer” are popular among people because their core meaning is understandable, and they would address the needs that they have.

• ·        Everybody in, nobody out!
• ·        No profiteering!

Simple message. Needed solution.