"Non-profit" hospital chains join for-profits in destroying our health system

The New York Times’ latest exposé on the despicable actions of large, ostensibly “non-profit” health systems, ‘How a Sprawling Hospital Chain Ignited Its Own Staffing Crisis’, examines Ascension Health, one of the largest such systems in the US. It is definitely worth reading, although you may want to try deep breathing first. Ascension owns hospitals over a wide area of the US, mainly in the Midwest, and took a bow in 2019 when it “was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric”, saving $500M! Unfortunately, cutting the number of employees to bare bones limited the quality of care available to patients. And when the COVID pandemic hit, and occupancy rates skyrocketed, they were woefully understaffed – except that the woe was experienced by the patients who sought, and to one degree or another, received care in those hospitals. It was and remains a disaster. Among the impacts cited in the article: at one hospital “there were so few nurses that psychiatric patients with Covid were left waiting a full day for beds, and a single aide was on hand to assist with 32 infected patients”; at another “Chronic understaffing meant that patients languished in dried feces, while robots replaced nursing assistants who would normally sit with mentally impaired patients.” Think about that patient being your parent! Disgusting? Upsetting? Dangerous? How about downright evil?

But, you might think, the cost cutting was necessary. After all we read about hospitals that are on the brink, are barely surviving, needing government bailouts to keep serving their communities. Oh, wait, those are different hospitals. Those are rural safety net hospitals. Ascension has $18 Billion in the bank. $18 Billion! In a “non-profit” hospital system! Boy, I’m sure that those C-suite execs who oversaw that got big 7-figure bonuses! And now? With that much in the bank, I doubt they are going to suffer much just because people are getting terrible care and dying in their hospitals.

So how are these systems non-profit? The Times does a good summary:

In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities.

But…

The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions. Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas. And many have cut staff to skeletal levels, often at the expense of patient safety.

Oh. That doesn’t sound so good. And, to be sure, Ascension is far from the only “non-profit” hospital chain to behave in this manner; most of the big and “successful” ones do so. The West’s Providence Health System, the focus of a previous Times exposé and post on this blog ("Non-profit" hospital systems behaving worse than for-profits: No end to the scams”, October 1, 2022), ironically started by a group of nuns to care for the poor and underserved, also gets coverage in this article.

There is so much evil here it is hard to know where to start. Certainly, a key part is running networks of institutions ostensibly created to heal the sick and injured (“hospitals”) as if they were manufacturing businesses and employing au courant management strategies designed for manufacturing, such as “just in time” supply chains and cutting staff down to the bone. This is absurd; hospitals, to be effective, to be able to meet regular seasonal changes, not to mention disasters or pandemics, need to have excess capacity at all times. Running “lean and mean” is wrong on many levels. It is exploitive of the staff, and indeed puts staff in the position of providing poor-quality care to their patients, compromising their professionalism and commitment; the testimonies of the nurses at Ascension are the most damning part of the report. It makes it difficult to impossible to gear up in times of need. And it um, kills people. You cannot have a potential staff of on-again-off-again health care workers to be employed just when needed “just in time”. If you could, if such excess capacity existed in the society, it would be yet another sign of perversion, of oppressing people and their families and communities to make more money – profit for “non-profits”.

Another way that this is, to put it gently, inequitable, is described in the Times article: cutting back on services in high-need-but-low-income communities and reallocating them to wealthier neighborhoods. And, of course, emphasizing and marketing high profit-margin services (cancer care, orthopedics, neurosurgery, cardiac interventions). Again, a  morally bankrupt strategy to meet not the health needs of our country but rather the dollar desires of a board of directors!

So what do I have to add to the excellent coverage given to this issue by the NY Times? They even call it “Profits over Patients”, which it is. I think I can give the problem a name that the Times will not: Capitalism. Capitalism is the problem. And it is not just any capitalism, it is not the capitalism of mom-and-pop stores or small businesses or making a reasonable profit, it is the capitalism-run-amok, it is the capitalism of anything-for-a-buck, full-speed-ahead, don’t-care-who-gets-hurt, bigger-is-better, I-want-to-be-a-billionaire-too that we have seen increasingly over the last decades. It is the capitalism that Noam Chomsky calls “gangster capitalism”, but in many ways what these folks do worse than what gangsters do, because it threatens not only people but all of our society. Sure, a gangster may threaten or even kill you. These systems are designed in a way that will kill thousands! But you know what? That is capitalism, that is the end point of capitalism. That is the Gordon Gekko, greed-is-good, result of capitalism that is not only unfettered by government regulation (especially with the elimination of many of the best parts of the New Deal) but that is actively enabled by a government that is willing to let private companies take all the profits when they make them and bail them out when they lose. And it is arguably even more evil that the hospitals described in the Times article are large “non-profits” which behave exactly like for-profits except that they don’t pay taxes! Who would have thought I’d be arguing for for-profits? Well, I’m not; they actually providing even worse care for the community because there are almost no regulations governing what they do. But at least they pay taxes.

So what can be done? A great deal actually.

•  Ban for profit corporations, or any entity controlled by private equity, from health care delivery. Yes, hospitals, but also clinics, urgent care centers, nursing homes, etc.
• Require not-for-profit entities to behave like non-profits are supposed to, with community benefit being the SOLE criterion by which they are judged. Do not allow building of facilities, expansion, or the dissolution of “product lines” except when it can be demonstrated that this will benefit the health of the overall community. Not allow “we’re moving into/building into this prosperous expanding suburb because, you know, they will need health care” if it means there will be inadequate resources to serve the people in the most needy, sickest, and poorest communities. No cannibalizing inner-cities to feed wealthier suburbs. And while it may not be possible to directly regulate the income (salary and bonuses) of C-suite executives of non-profits, the requirements should ensure that they cannot make loads of money and build huge reserves ($18 billion! Come  on!) If they won’t do this, tax them
  
• ·Ensure that the communities most in need, especially in rural areas, have their needs met on a case by case basis. The absurd Hobson’s Choice the federal government is offering rural hospitals, crystallized in the headline of the article cited in the second paragraph, “A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care?” must be changed so that each hospital, and the larger community it serves (sometimes geographically enormous) gets support for what it needs, inpatient care, outpatient care, and usually both.

Even better, while eliminating private for-profit ownership, discourage misbehavior by non-profit owners by creating and implementing a single payer health system, such as Medicare for All, which as the sole payer would be able to with and regulate these health systems for the benefit of the health care of the people of our country.

Twenty years after 9/11: a health worker perspective

This is a guest post on the 20th anniversary of September 11, 2001, by Seiji Yamada, MD, a family physician at from the University of Hawai'i John A. Burns School of Medicine

All those of us who are old enough recall what we were doing when we heard of the attacks of September 11, 2001. Since I live in Hawaiʻi, I was awakened by a friend living on the East Coast. He called to tell me to turn on my TV. When I did so, I saw the two towers of the World Trade Center on fire. I then watched the towers collapse.

On the following day, the University of Hawaiʻi Department of Family Practice (before the name was changed to Family Medicine) held a debriefing session with all staff, residents, and faculty in attendance. We came to some conclusions that we wrote about in the medical school newsletter:

We are humans before we are healthcare workers; our humanity is still a core component of our effectiveness as healers. Thus, our presence and genuineness, in the form of compassion and, when appropriate, openness about our own feelings, are therapeutic. When we can share some of our feelings about a recent disaster, it encourages a healing partnership by making the relationship less hierarchical. . . .

 

We must seek productive ways that translate our responses to distant suffering into a medicine more responsive to the suffering before us.  In this way, we can strive to incorporate social justice, equality, and compassion into both the practice of medicine and into the political response to acts of jarring violence.  We suggest that we should feel, think, and act not as members of a particular ethnic group, religion, or nation - but, rather, as humans.[1]

One participant, a Muslim and Arab woman, was silent through most of the session, but at the end, she related that she first wanted to hear what others had to say. She told us that she had grown up with, and constantly lived with anti-Muslim, anti-Arab sentiments being expressed around her – such that she often found it most prudent to hide her ethnicity.

We wondered what the future would hold.  Would this tragedy make Americans ponder why their country is hated by many around the world?  Or would the U.S. hunker down like Israel and embody the national security state, arms pointed in every direction?  The fearful consensus was, as has been borne out, that this trial would only serve to strengthen the impetus to meet force with force.

Indeed, 9/11 was followed by much flag-waving and George W. Bush’s declaration of a “War on Terror.” As the mastermind of the September 11 attacks, Osama Bin Laden (a Saudi), and the training camps of Al-Qaeda were in Afghanistan – the U.S. military began to plan for an assault on Afghanistan.

Richard Horton, the editor of The Lancet, wrote in a commentary published on October 6, 2001, suggesting that “The war against terrorism, announced by President Bush and endorsed by western political leaders in the immediate aftermath of the Sept 11 assault on America, will fail.” He suggested instead that “health, development, and human rights” be the objectives of a public health approach to Afghanistan.[2]

The U.S. started bombing Afghanistan on October 7, 2001.

I attended the American Public Health Association in Atlanta in late October 2001. Against the backdrop of daily bombing runs projected on the megascreen of the CNN Center, I thought that I might find fellow health workers opposed to the war. After all, UN agencies such as the World Food Program and UNICEF had been drawing attention to the humanitarian crisis in Afghanistan that pre-dated 9/11. Severe drought and twenty years of war in Afghanistan had led to conditions bordering on widespread famine. Shouldn’t public health workers, who are concerned about the health and well-being of people, oppose the U.S. war on Afghanistan?

I buttonholed Victor Sidel, grand old man of social medicine, and invited him to chat over a coffee. His take on bombing Afghanistan was, “The U.S. has to do something.  It can’t stand by and do nothing.” He criticized what he saw as my pacifist stance.[3]

It has taken nearly 20 years for the U.S. to leave Afghanistan. September 11 also served as one of the pretexts for the Iraq War of 2003-2011. All told, the first ten years of the “War on Terror” took on the order of 1.3 million lives.[4]

Since September 2001, we have endured twenty years of U.S. invasions of Afghanistan, Iraq, and wherever else the U.S. deploys its Special Forces, whether it is Africa or the Philippines. Twenty years of drone attacks, reaching its height under “Hope and Change” Obama, who devoted his Tuesday mornings to choosing the week’s targets for extrajudicial assassination (“Sorry about the wedding party collateral damage”).  Twenty years of torture chambers at Guantanamo and Abu Ghraib and Bagram Air Base and those hidden black sites around the world (“Yeah, Gina Haspel, you sure did a bang-up job running that black site in Thailand - we’re going to give you the top job of CIA Director”). Oh, Julian Assange, Chelsea Manning, Edward Snowden, do you think you’re going to let the people know what’s really going on? Well, for your troubles, you’re going to be psychologically tortured and placed in solitary confinement or exiled.

One economic sector saw its stock prices jump upward after 9/11, those of the arms manufacturers. As soon as the generals who oversaw the destruction of Afghanistan and Iraq and Libya retired from the U.S. military, they moved straight onto the boards of the weapons manufacturers. Lloyd Austin went from being commander of CENTCOM to the board of Raytheon. Meanwhile, the other pillar of the U.S. economy was the gambling house of debt financialization. When the casinos (i.e., the investment banks and their insurers) couldn’t cover their own debts and crashed the world economy, the U.S. taxpayers (via Congress) bailed out the banks, and workers were foreclosed on their houses. Subsequently, the Affordable Care Act (ACA, or ‘Obamacare’), touted as expanding the social good of health care to more people, essentially turned it over to the insurance and pharmaceutical industries.

However much the fabric of U.S. society has deteriorated in the twenty years since 9/11, it does not compare with the deliberate kinetic destruction wrought on the health services, access to water and food, infrastructure, and economies of Afghanistan and Iraq. Prior to the Gulf War (1991-1992, waged by George H.W. Bush), Iraq had been a thriving society, a leader in science in medicine in the Arab world. [5] Now, subsequent to the U.S. invasion (2003-2011, started by George W. Bush and Dick Cheney), and the war against ISIS (2013-2017), Iraq is a shambles. And thanks to Donald Trump’s utter incompetence, George W. Bush is now looked upon as a statesman. We are reminded that the U.S. destruction of the Middle East has been going on for much longer than the past twenty years. As Noam Chomsky often says, massive reparations are in order.

As noted by Chris Hedges, as the U.S. leaves, Afghanistan is, like when the U.S. invaded, in the midst of another humanitarian crisis:

Things are already dire. There are some 14 million Afghans, one in three, who lack sufficient food. There are two million Afghan children who are malnourished. There are 3.5 million people in Afghanistan who have been displaced from their homes. The war has wrecked infrastructure. A drought destroyed 40 percent of the nation’s crops last year. The assault on the Afghan economy is already seeing food prices skyrocket. The sanctions and severance of aid will force civil servants to go without salaries and the health service, already chronically short of medicine and equipment, will collapse.[6]

As Hedges points out, the response of the civilized world is to freeze the assets of the Afghan central bank and deny the new government access to loans or grants.

In retrospect, it is obvious how the desire for revenge in the immediate aftermath of 9/11 has led us to where we are now. What if, instead, the pain engendered by 9/11 had encouraged us to recognize the pain of others - those who suffer from hunger, poverty, ill health, and exploitation? What if narrative and images death and destruction had prompted us health workers to demand an end to war?[7]

What if we had sought instead to alleviate social ills and sought to ensure clean water, good nutrition, education, and health? Might we not all be better for it now?

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[1] Yamada S, Maskarinec G, Bohnert P, Chen TH.  In the aftermath:  reactions to September 11, 2001.  News from the John A. Burns School of Medicine 2001 Winter;2:1-2. https://www.researchgate.net/publication/354116332_In_the_aftermath_-_reactions_to_September_11_2001

[2] Horton R. Public health: a neglected counterterrorist measure. Lancet 2001 358:1112-1113.

[3] Yamada S. On The Responsibility of Health Workers to Oppose the War. ZNet. Nov. 2, 2001. https://www.researchgate.net/publication/354116411_On_The_Responsibility_of_Health_Workers_to_Oppose_the_Afghanistan_War

[4] International Physicians for the Prevention of Nuclear War. Body count: casualty figures after 10 years of the “War on Terror” Iraq Afghanistan Pakistan. 2015 March: International Physicians for the Prevention of Nuclear War. https://www.psr.org/wp-content/uploads/2018/05/body-count.pdf

[5] Yamada S. Health workers and the Afghanistan-Pakistan War. ZNet.  December 14, 2009. Reprinted at Medicine and Social Justice. January 11, 2010. https://medicinesocialjustice.blogspot.com/2010/01/health-workers-and-afghanistan-pakistan.html

[6] Hedges C. The Empire does not forgive. ScheerPost. August 30, 2021. https://scheerpost.com/2021/08/30/hedges-the-empire-does-not-forgive/

[7] Yamada S, Smith Fawzi MC, Maskarinec GG, Farmer PE.  Casualties:  narrative and images of the war on Iraq.  Int J Health Services, 2006;36(2):401-15. http://web.mit.edu/humancostiraq/further-reading/casualties.pdf