Universal health coverage would save money. And lives. And make life a lot better for people.

Two recent Gallup polls confirm long-standing problems with the US health system. Americans Sour on U.S. Healthcare Quality finds that 

For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% -- a new high -- calling it “poor.” 

It is important to read that carefully; it does not say that “for the first time in two decades, Americans find problems with U.S. healthcare”. It says that for the first time fewer than half rate it as “good” or “excellent”. And “a new high”, 21%, say it is poor. This is very significant because the opinion one has about healthcare varies tremendously depending on whether one has needed it or not. If you, and your family, have been healthy, and have rarely if at all needed anything other than, perhaps, immunizations or checkups, then you are likely to perceive the system as better. Even then, you probably had some difficulty getting an appointment, getting through to find out the results of any tests you had, and difficulty communicating in general. And it likely cost a lot. If you were just a little sick, it can be irritating, frustrating, and even risk your health to some degree. But if you are really sick, and especially if you need to be in the hospital, it is very unlikely that your experience was even “fair”.

This is something that a lot of people, and a lot of pundits miss. When you don’t need health care, everything is fine, and your insurance is good and pays for all of the nothing you use; indeed even being uninsured is fine. It is just that pesky problem of it not being fine when you need it. Like anything; you don’t regret not having a down coat on a balmy Spring day, or an umbrella when it is dry. There is an old story about a traveler coming across someone whose roof is leaking in the rain. The traveler asks why he doesn’t fix it. The man responds that when it is raining it is too wet to get up on the roof, and when it isn’t, “my roof is as dry as anyone’s.” This is fine as a joke, but not as  healthcare strategy. When you or a family member is in a car accident, or gets a cancer diagnosis, or needs major (or even minor) surgery, or your newborn needs to be in the intensive care unit, is not the time to start to think about your health coverage.

And, yet, that is what many people do, are forced to do, to depend upon hope and prayer. While for some this could be in part an issue of distorted priorities – health insurance is expensive and I could be buying a nicer house or a bass boat –this is not the usual reason. It is more often “health insurance is expensive and I need to pay the rent and buy food and put shoes on my children’s feet”. And if their budget allows them to actually buy health insurance, it tends to naturally be the one that the buyer can afford – and is often inadequate, and have high patient responsibility (co-pays, maximums, and other costs). Thus “having health insurance” deludes you (and many pundits and policy makers) into thinking that you have taken care of this issue. Until you need it.

Which brings us to the results of another Gallup poll, released at the same time, “Record High in U.S. Put Off Medical Care Due to Cost in 2022”. “The latest reading, from Gallup’s annual Health and Healthcare poll conducted Nov. 9-Dec. 2, is the highest by five points and marks the sharpest year-over-year increase to date.” Not a surprise given the information above. You can put off going to the doctor for a checkup, or a cold, or a vaccine, or even for treatment for a significant chronic disease like diabetes, high blood pressure, heart disease – at least if is not bothering you too much – but it is not very wise, since ignoring such conditions is one way to get you really sick, and into the hospital, and maybe into intensive care, and maybe, even, die. However, since we don’t have a universal health program in the US, too many people simply cannot afford to get healthcare, especially anything that is costly. I am tempted to say that there is a price list, and, like buying a car or a house or a coat, you shop within your means. Except, of course, there is no price list, and you hardly ever know what a medical procedure will cost. And there are often no good alternatives to the expensive treatment; in this way it is definitely not like buying a perfectly functional, if less fancy, car.

A third important article was published in June 2022 in the Proceedings of the National Academy of Sciences USA. “Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic”  by Galvani, Parpia, Pandey, and Fitzpatrick, estimates that during the pandemic a universal healthcare system would have saved 212,000 lives and $105.6B from COVID alone, in 2020 alone. This would have risen to about 338,000 lives through March 2022, as reported on in the Scientific American, and would have been on top of another $438B saved from other causes besides COVID. That is a lot of money. And a lot of lives. More than 100 times the number of lives lost in the World Trade Center attack. And (see the polls from Gallup) that is not counting the people who didn’t die, but could have. Who lost their health, their ability to work, their life savings, their ability to provide for their families.

So what is this “Universal Healthcare” thing? Some kind of pie-in-the-sky dream of liberals that would bankrupt the US? No, it is what they have in every other wealthy country in the world, and many that are not so wealthy. Those countries that don’t consider health and healthcare to be a consumer luxury, that consider it to be about people’s health rather than something for the private sector to profit from. Remember, that $105,600,000,000, and that $438,000,000,000 (2020 alone) is not going into the garbage. It is going to health insurance companies, and health care providers (by which we mean not only – or even mainly – doctors, but rather hospitals and “health systems”) and their suppliers, especially drug companies. This is detailed in the latest publication on this topic (regularly updated, and rarely improving) from the Commonwealth Fund. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes” shows that the US is the only wealthy country that does not guarantee health care coverage to all its people, and still spends 2-4 times as much as those other countries. The money goes, of course, to private profit. There is a name for this: corruption and graft. And words for it. Mostly obscene.

So why don’t we do something about it? We have tried – President Truman tried to get a national health insurance system in 1948. Defeated, sadly, with support from labor unions who thought it would undermine their success in getting health insurance through negotiations with employers (there’s a quaint memory). Medicare, a national health insurance system for seniors and the disabled, was passed in 1965 under President Johnson. So was Medicaid, a state/federal partnership to provide coverage for many (but certainly not all!) poor people. In 2010, under President Obama, ACA (Obamacare) was passed, which extended health coverage to many (but certainly not all!) of those left out, who were unable to afford individual health coverage but were not poor enough to get Medicaid (and in most states that is desperately poor!).  But nothing comprehensive, nothing that covers everyone, nothing that guarantees you won’t be broke and in debt at the end. Nothing that resembles the systems in any other OECD (i.e., wealthy) country.  Why?

Because private corporations make lots of money, from you, and from your employer, and from the government, and very much do not want that to go away. Indeed, as I discussed recently (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, January 20, 2023), the private sector is expanding its leech-like sucking of public funds through privatization of Medicare by programs like Medicare Advantage and ACO/REACH. And are willing to spend some portion of that huge amount of money on lobbying – and making contributions to – members of Congress, to make sure that their profits are maintained at the expense of the health and lives of the American people, not to mention their money.

It is  that simple. The health and lives of people vs. the profit of corporations. Don’t be fooled by liars or obfuscators. It is time to end this incredibly expensive boondoggle that costs the lives and health of so many of us. Write your Congresspeople and demand Medicare for All, or any form of completely universal healthcare, now.

Or sooner.

Kansas only state to increase number of uninsured: A how NOT to do it strategy

The title of Alan Bavley’s article, “Kansas is only state to see an increase in its uninsured rate, survey says”, (Kansas City Star, August 5, 2014) kind of says it all. It could be seen as a victory by some. Four years after the passage of the Affordable Care Act (ACA), aimed at expanding health coverage to more Americans by a combination of strategies including the creation of both state-run and federally-run (for those states that chose not to run their own) insurance exchanges to match people seeking coverage with insurance companies and subsidizing premiums for the moderately low-income, and expanding Medicaid for the very low-income, Kansas has succeeded in actually reducing the number of people covered!

The adult uninsured rate in Kansas rose from 12.5 percent last year to 17.6 percent during the first half of this year, giving the state the seventh-highest rate in the nation, according to data collected as part of the Gallup-Healthways Well-Being Index…. in other states uninsured rates declined or remained unchanged. Kansas was the only state with a statistically significant increase in the percentage of uninsured residents.

One could construct a fantasy out of whole cloth demonstrating how this proves why the opponents of the ACA were right all along; that it is not increasing health care coverage because it is evil and socialist, and that the increased costs for some people, along with cuts in the number of employed folks because of policies that do not always support “job creators” (read: very rich people) have decreased our employer-based insured group. Of course, that would be incorrect, but I expect to see it anyway.

In fact, those governing my state have worked very hard to make this happen. Governor Brownback and most of the state legislature are strong opponents of Obamacare, and have done what they could to make it not succeed. When the Supreme Court ruling allowed states to opt out of expanding Medicaid, Kansas did so, eliminating the very poor (under 133% of poverty) from the method the law intended for them to receive coverage. Kansas also chose not to develop a state-run insurance exchange and pu up as many obstacles as it could to the federally-run one. One of two Court of Appeals decisions (discussed in this blog in ACA: Where are we? And where should we go?, July 27, 2014) ruled that subsidies could be available only to enrollees in state-run exchanges (which Kansas doesn’t have); it hasn’t gone into effect yet, because another district’s Court ruled the other way, so we will have to wait for the Supreme Court to decide, but if it is upheld would bolster the number of Kansans not getting insurance.

But a decrease in the number of insured? The only one? Surely that is a notable accomplishment. How did we pull that off? “’It’s eye-popping. Kansas really sticks out,’ said Dan Witters, research director for the Well-Being Index, an ongoing national poll that surveys people’s health, relationships and finances.” For starters, it could, possibly, not be exactly true, but a data anomaly of the survey somehow. This is basically the position of the state’s Insurance Commissioner, Sandy Praeger, who said

…the number “appears to be an anomaly that needs more review. To have the uninsured jump that much in one year would be unprecedented.” The uninsured numbers in Kansas have hovered around 12 to 13 percent for many years, Praeger said, adding, “We will try to find out where the discrepancy is.”

This is worth noting, as Praeger is one of the few honest, trustworthy, and non-ideological members of state government in Kansas. Note that she does not claim that it is a liberal lie, or that it is a good thing, but just that it is inconsistent with previous data and she will try to find out why there is a discrepancy. If that is the reason, I’m sure she will.

But there are reasons to think that the numbers may not be inaccurate, even if they turn out not to be quite as bad as this survey indicates. Since the election of Governor Brownback in 2010, and with the support of the legislature, taxes in Kansas have been slashed, particularly income tax rates on high-income people and corporations and business taxes. The motivation was a profound belief in supply-side economics, that tax cuts would stimulate job growth.  Unfortunately, it has not. Job growth in Kansas has been more sluggish than in the country as a whole, and the state is facing enormous deficits. Cuts in spending have been dramatic, but the problem is, in fact, on the supply side – not enough tax revenue.  People don’t have jobs, and thus often don’t have enough income to qualify themselves for the exchanges, even if subsidies are allowed by SCOTUS to continue. The state has a very large number of undocumented workers (and most are indeed working, or in families of people working) who would not be eligible for coverage by any part of ACA, and can only get it if their employers pay for it. Which many do not.

While many states with Republican governors have pursued many of the same tacks as Kansas, including limiting the impact of ACA and cutting taxes, Kansas has been in many ways a test case for these strategies, even more than Wisconsin, because of its strong Republican tradition. Americans for Prosperity has a very strong political and financial influence in the state, and it is heavily financed by the Koch brothers whose Koch Industries is based in Wichita, Kansas (where Charles Koch still lives). Cutting taxes for the wealthy and corporations, and blocking any opposition to fossil fuel expansion, is the cornerstone of state politics, not ensuring the health or well-being of its residents.

In a larger sense, however, this is more than a story about Kansas. It may be the only state with a statistically significant increase in uninsured in the last year, but it is far from the state with the largest percentage of uninsured. Many other states that have not expanded Medicaid, and cut social services, have similar situations. Sadly, of course, many of these states (particularly in the southeast) started pretty far down, much worse than Kansas did, and have dug themselves deeper in the hole. The real story, I think, is in the states that, despite being southern and conservative, have chosen to expand Medicaid, and have seen real benefit for their people.

The Gallup poll found that the 10 states with the largest reductions in uninsured rates this year had all expanded their Medicaid programs and had either created their own exchanges or partnered with the federal government on an exchange. Arkansas saw the steepest decline, from 22.5 percent uninsured in 2013 to 12.4 percent this year. Kentucky was second with a decline from 20.4 percent uninsured to 11.9 percent.

Good policies can actually help. The state with the actual highest rate of uninsured people is Texas. “Look out, Texas,” Governor Brownback stated in announcing his original tax cuts, “here comes Kansas!”  He was talking about job growth, which we haven’t achieved, but we are making much more progress on denying people access to healthcare coverage.

Health and income: "what's new?" or a good resource

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This is a guest post by Kim Kimminau, PhD, Associate Professor of Family Medicine at the University of Kansas School of Medicine and Director of the Center for Community Health Research.

I come from a family where my parents, one a first generation American and the other a child immigrant, and the first in their families to complete high school, would say to me “so, somebody actually pays you to do that?”, and the “that” was my life’s work – the study of human health through time and space (aka, biological anthropology) and to conduct research. For them and so many others, reading the titles of research grants or peer reviewed articles was an exercise in a delightfully sardonic mix of tongue-twisted, mispronounced terms, outright mockery and guessing what and why anyone would want to spend “good money” (as my father would say) to study such things.

Apparently, the time has come. I have become my parents.

In the online Robert Wood Johnson Foundation’s News Digest on public health I learned from a UPI story that a Gallup poll was recently conducted among 200,000 U.S. adults over the span of nine months (http://www.upi.com/Health_News/2010/10/18/US-health-well-being-tied-to-income/UPI-74081287460458/ ). This alone is pretty mind-boggling – a huge poll by almost any standard. I read on. What was learned from the survey was that “the more money Americans make, the better physical emotional and fiscal well being they report.” Really? Who could possibly be surprised at this finding? Using my parent’s lexicon, more importantly, who would waste good money on measuring this?

The article went on to say that poor adults are three times more likely to smoke, eat less healthy options and exercise infrequently. Those with lower incomes are more likely to report having been told they have a chronic disease and, more than their more affluent counterparts, poor Americans report being obese and having twice as many colds and flu. So I braced myself, waiting some intrinsic “blame the victim message” – if only “those people” (and yes, I detest such speech) would stop eating fast food, get a job, stop wasting their money on cigarettes and cell phones, and take care of themselves, these statistics would be very different. But wait, this information was put out by the Robert Wood Johnson Foundation….surely a more valuable lesson about determinants of health was imbedded in the UPI report? But no, the article ended.

So I did some digging. I took some time to learn that Gallup entered a 25-year partnership in 2008 with Healthways (a publicly traded NASDAQ company, headquartered in Tennessee and led by CEO Ben Leedle (who, interestingly, has ties to Wichita, KS)). They conduct a daily nationwide survey that produces the Gallup-Healthways Well-Being Index. Not only is this the largest “behavioral economic database ever created” the Well-Being Index can be used to drill down to associated state, congressional district and city level reports. Eureka! While I was busy dissing the effort, I actually uncovered a fascinating resource that monitors the pulse of the nation on a variety of indicators that I should have been paying attention to over the past two years.

The methodology being used is commendable. Each daily sample includes a minimum quota of 150 cell phone respondents and 850 landline respondents, with additional minimums to ensure representative gender within each region. Using Current Population Survey figures for the 18 year old and older non-institutionalized adult population and including Spanish language interviews, they have a 98% representative adult sample. They measure 6 domains of well-being: emotional health, physical health, healthy behavior, work environment, basic access, and a sixth called “life evaluation” (it includes 2 questions that use the Cantril Ladder scale (Cantril, 1965)). As with any rating system, our first inclination is to look at where we fall on the scale, so in this case, I clicked on “Kansas” to review the most recent summary report (the report includes data collected during 2009. You can also click on “snapshot findings” to see data collected during the most recent 6 months. What that profile tells you is that you should be happy if you don’t live in West Virginia.)

The Kansas report can be found at: http://www.well-beingindex.com/files/2010WBIrankings/KS_StateReport.pdf . (And Nebraska at http://www.well-beingindex.com/files/2010WBIrankings/NE_StateReport.pdf, and you get the drill!) You may be surprised that our state is the last state in the top quintile for overall well-being (up from 22nd in 2008). What’s more, among our three largest cities, Topeka (not Wichita or Kansas City) ranks worst on overall rank. Finally, if I were running for political office in the 1st Congressional District, I’d be worried about the fact that constituents report the worst life evaluation scores compared to the other three districts by a long shot.

But back to the bigger picture. I’d urge you to go to the well-being index home page http://well-beingindex.com/monthlyWBIreport.asp and click on the “daily pulse” tab of the dashboard. I’m a numbers person, but just looking at the daily distance between the orange line of those “thriving” and the green line of those “suffering” should give us all a reason to reflect on why poor people smoke, eat empty calories and at times feel hopeless and helpless. The distance between those doing well and not well is enormous, and the need to close the disparities gap couldn’t be clearer. I plan to return regularly to this page to review how health reform implementation begins to bend these curves, especially on the “basic access” and the “physical health” tabs for the index.

While I’m happy that I inherited the genetic predisposition of skepticism from my parents, I’m equally happy that my training has made me a data dumpster diver and that this superficial article yielded a great return of a new resource for me.

Live and learn. That was another of my parent’s favorite sayings.
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