Dark Times for Public Health and Healthcare: Will the insurance industry fix itself?

It’s an exciting time for both health care and public health! Anything goes, and almost anything is, or will in the near future! On the public health front, we have the nomination by President-elect Trump of Robert Kennedy, Jr. to the post of Secretary of Health and Human Services. Kennedy has long been what is generously called a “vaccine skeptic” and his lawyer, Aaron Siri, has sued the Food and Drug Administration to revoke the approval of the polio vaccine. Although the NY Times article says ‘Like Mr. Kennedy, Mr. Siri insists he does not want to take vaccines away from anyone who wants them. “You want to get the vaccine — it’s America, a free country." This is disingenuous. If the FDA approval is revoked, nobody will be able to get it.

I have written recently about the importance of vaccines, especially polio and measles, in preventing disease and death (Raw milk, vaccines, and RFK, Jr: Some dates worth remembering, Nov 15, 2024). A series of letters to the Times in response to the Siri article make clear the risk. Read them; they address the science, the controlled trials of polio vaccine, the experience of those who were doctors and children during previous polio epidemics, and touchingly, the experience of dancer Tanaquil LeClerq, wife of choreographer George Balanchine (short answer: no vaccine, polio, and paralysis). In regard to other vaccines, we can read in the Times ‘Tiny Coffins: Measles Is Killing Thousands of Children in Congo’ and imagine it happening in the US as a result of Kennedy’s anti-vaccine actions. Kennedy calls his movement “health freedom” and says that he will give infectious diseases a “break” (whatever that means), but in fact, as described by Gregg Gonsalves in The Nation, RFK Jr. Is Giving Infectious Diseases a Promotional Tour.

I posted on Facebook that I have heard people say “kids get too many shots”, and asked “then which preventable disease do you want your child to die of?” One comment I got from a colleague was that the problem was not that kids get too many shots, but that too many kids get shot! The most recent killings, in a Christian school in Madison, WI (15-Year-Old Girl Identified as the Shooter in a Wisconsin School) were at least the 323^rd this year in the US! THIS is an epidemic, the extent of which people in most other countries cannot imagine, and, like many of us, wonder what will be done about it. Sadly, the answer is going to be very little, if anything; we may be closing out the statistics for deaths from school shootings in 2024, but nothing suggests that 2025 will be any better.

On the healthcare front, things are not getting better. The anger at the health insurance industry exposed by the shooting of UnitedHealthcare CEO Brian Thompson was deep, broad and well-justified, as I wrote in Murder of a Health Insurance CEO: People HATE the companies and the people who run them (Dec 8, 2024). Study after study continues to appear providing evidence that more and more people have inadequate, unaffordable, or no health insurance. The Commonwealth Fund recently published a report that shows Hispanic/Latino Adults Lack Adequate, Affordable Health Insurance Coverage,

and that this led to their having real trouble accessing health care. The breadth of this lack goes far beyond Latinos.

Maybe we can come up with a solution! I think I have already indicated several – mainly instituting a single-payer universal national health insurance program. Or, until we do, capping the amount of out-of-pocket costs a person can have to a reasonable number ($1000?). And limiting the profits of health insurers, or the ways in which health care providers (e.g., hospitals mainly, but also nursing homes, doctors, etc.) act to make money, whether technically profit or “non-profit”, at the expense of people’s health.

Others have entered this discussion. In a remarkable Op-Ed essay in the NY Times on Dec 13, UnitedHealth Group’s CEO Andrew Witty (Brian Thompson’s boss, who makes more than $20M a year) wrote The Health Care System Is Flawed. Let’s Fix It. Unfortunately, what is remarkable about this article is that the Times chose to run it at all, since it makes no significant suggestion on how to “fix” it, certainly none that would threaten UnitedHealth’s profits. It mostly displays the Times’ complicity in an effort to focus away from the righteous fury of the American people with the health insurance industry.

USA Today reports on Seven reasons why Americans pay more for health care than any other nation, and it gets most of them right. (Reason 1: Lack of price limits, Reason 2: Hospitals and doctors get paid for services, not outcomes, Reason 3: Specialists get paid much more ‒ and want to keep it that way, Reason 4: Administrative costs inflate health spending, Reason 5: Health care pricing is a mystery, Reason 6: Americans pay far more for prescription drugs than people in other wealthy nations, Reason 7: Private Equity.) There are a few others, but it is a good list. Despite that, however, it doesn’t come up with a meaningful, comprehensive solution to them, or any of them. Indeed, it ends up quoting the Witty piece referenced above, "We know the health system does not work as well as it should, and we understand people’s frustrations with it,” rather than having any kind of answer. Like, say, universal non-profit health insurance, limits on hospital system (and physician) incomes, and banning private equity and other for-profit players from the health system!

Maybe it is asking a lot for insurance companies, largely the perpetrators of this massive scam that is bleeding the entire US economy, to come up with a “solution”. But USA Today, Commonwealth Fund, and others that do such a good job of identifying the problem should be able to take the simple next step to recommending the fix. In what is to me an amazingly open (if entirely disgusting and reprehensible) acknowledgment of their agenda, CNBC reported back in April 2018 that Goldman Sachs, the huge investment bank (Jamie Dimon, CEO) raised the question (discussing biotech research) ‘Is curing patients a sustainable business model?’.

!!??

Actually, it’s a good question. Maybe the answer is “no”. Most ethical physicians I know (and it is the vast majority who are ethical) have always said something like “I look forward to the day when we can put ourselves out of business”. Investment banks and other forms of private equity, and the insurance companies like UnitedHealth and the providers that they control, do not see this as a positive. Maybe it is refreshing to see such a stark portrayal of the problem? Or not.

But I, and I believe most Americans, would rather see diseases and the people who have them cured, and would be happy to see the profits of any of these profiteers, privateers, just plain ganevem, and the salaries of their C-suite execs and Boards, disappear.

What do the American people want in a healthcare plan? Not what Trump, Price and the GOP will give them

Readers of this blog are probably aware that I am a member of Physicians for a National Health Program (PNHP) and, like that organization, support the creation of a single-payer health system in the US. Sometimes referred to as a Canadian-type health system, or as in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty easy to understand, and is a system that has worked not only in Canada but, in modified forms, in most developed countries in the world. The key feature of such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out” in the title of the book by the late Quentin Young, MD, a former President and executive director of PNHP and a “tiger for social justice” in the words of his Chicago Sun-Times obituary.

Such a system would replace the bewildering, dazzling, complex, confusing mess of the current US health care system, with its hundreds of different private insurance policies with widely varying benefits, premiums, and coverage, as well as the federal programs of Medicare, federal-state partnerships like Medicaid and the ACA’s health insurance exchanges, and of course that persistent, pesky mass of 30 million or so uninsured. And the underinsured, who are effectively uninsured, because they buy the only policy that they feel that they can afford only to find out when they need it that it, surprise, doesn’t cover what they need!

Much of the defense of the ACA has been based on the fact that an insurance pool must have healthy as well as sick people. This is a core tenet of insurance, which would otherwise be unaffordable. Life insurance cannot work if it only covers people on their deathbeds; car insurance cannot work if it only is purchased at the time of an accident, homeowner’s insurance cannot work if it is only bought by people in the midst of a fire. If this were how insurance worked, there would be no need for it, for the premiums would be basically the same as paying for the cost of the services. To have it otherwise, as insurance, requires a pool of money contributed by folks, whether directly or through their taxes, who are not immediately benefiting to cover those who need it. In fact, though, understandably but impossibly, people want coverage for when they are sick, but don’t want to pay when they are not. People may not want to pay a lot when they are healthy (or think that they are) but they want coverage for their sick parents, or newborn with health problems, or when they are diagnosed with cancer, or when their adolescents are in a car wreck. These are things that don’t happen to most of us most of the time but happen to enough of us over our lives that we know enough to fear or expect it. A national single-payer system gets rid of this problem, by having the largest possible risk pool.

But the people of the US did not elect Bernie Sanders, and he did not even get the Democratic nomination. We elected (OK, the Constitutional unfairness of the Electoral College elected) Donald Trump, whose positions may be erratic and change frequently, but whose appointments to Cabinet-level posts are remarkably consistent. Most are from the most right wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite a campaign that attacked Wall Street and the support Hillary Clinton received from the financial sector, he has appointed many Wall Streeters, including several former (and current) folks from Goldman Sachs -- most recently, their lawyer whose wife still works for them, to head the SEC. Foxes guarding the henhouse abound; climate change deniers will head the EPA and Department of Energy. And in the same vein, we have, for Health and Human Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about whom I wrote recently (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters”, December 3, 2016).

Rep. Price certainly does not stand for a single-payer national health system. Nor does he stand for ensuring health care for the vulnerable, whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in the New England Journal of Medicine by Sherry A. Glied and Richard Frank, “Care for the vulnerable vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant,” which would mean that not only Medicaid, and the coverage people have received under ACA, but even Medicare which has protected seniors for 50 years, would be under threat. The article contains information about his positions on other issues, including favoring greater access to armor-piercing bullets, opposing regulations on cigars and on tobacco as a drug, opposing the reauthorization of the Violence Against Women Act and laws prohibiting discrimination against LGBT people. In terms of ensuring health coverage he is as mean as they come:

His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.

But he is the President-elect’s health guy, and we might think that the folks who voted for Mr. Trump will get what they wanted. Except they probably won’t, other than that small slice of voters representing the wealthiest providers, insurers, drug manufacturers, corporate executives, and pundits (like the Wall St. Journal’s Kim Strassel). The health situation in the US is bad, particularly for lower income whites, whose mortality rate has, remarkably, as reported by the Commonwealth Fund, been static rather than decreasing or in some cases (low income women) increasing. These are many of the same folks who voted for Donald Trump, and are presumably looking for a solution. The Kaiser Foundation recently conducted focus groups among Trump voters in states have been hard hit by job losses and were key swing states in the election – Ohio, Michigan, and Pennsylvania. The participants either had Medicaid or were covered by ACA. The results are summarized by an op-ed in the New York Times by Kaiser’s CEO, Drew Altman, “The health care plan Trump voters really want”, January 5, 2017.

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

That’s what they want. That’s what I want. It is what I believe a single-payer system would deliver. But it sure isn’t what they are going to get from Tom Price, or from whatever “replacement” the Republicans come up with for ACA.

And that’s more than a shame.  It’s a scandal.

…

Opioids and other pharmaceuticals are the tip of the iceberg: It's the profit, stupid!

The NPR program “Fresh Air”, with Terry Gross, had Anna Lembke, MD as a guest on December 15, 2016. Dr. Lembke is the author of the recent book “Drug Dealer, MD”, in which she apparently (per the discussion on air; I have not read it) implicates physicians and pharmaceutical companies in the widely discussed “opioid epidemic”. Dr. Lembke is a Stanford psychiatrist and director of the addiction medicine fellowship there, and she is able to articulately describe what is known and what is not about the neurological impact of opiates and opioids on the brain. One important point she makes is that continued use of opioids causes tolerance and a need for higher doses; in addition she describes how chronic use of opioids causes a pain syndrome of its own (decreased tolerance to pain) in some people, and how weaning them off opioids can actually decrease or eliminate their pain.

Her key issue, however, is that the epidemic of opioid use was orchestrated by the pharmaceutical manufacturers of opioid analgesics, who heavily promoted them, created the perception among doctors and the public that physicians were heartlessly undertreating the pain that their patients were in, and hooked in (mostly) well-meaning doctors to become, in essence, their pushers (“Drug Dealer, MD”) while they made huge profits. And continue to do so. And, as the reaction to this epidemic begins to form, continues to promote new syndromes that require treatment with their drugs.

An example of this is “OIC”, opioid-induced constipation, which made its first big appearance during the Super Bowl of 2016. The commercial left it a vaguely mysterious ailment, but it is a real one. Of course, the commercial was a prelude to an advertising campaign, in this case for Movantik ®, a partial opioid antagonist manufactured by a collaboration between AstraZeneca and Daiichi Sankyo designed to treat this condition. Constipation, in fact, is the only side effect of opioids that does not decrease with continued use, so as a person uses higher and higher doses of the opioids to try to control their pain, their constipation gets worse and worse, sometimes requiring surgery and occasionally death from a ruptured colon. My reaction, while understanding we would soon see a drug for this condition promoted, was that it was a cynical and disturbing attempt to “normalize” opioid addiction. “Oh, you have this problem? Well, it’s not just you! LOTS of people have OIC!” It turns out that I was not the only one with this reaction; Ahiza Garcia on in a piece on CNN Money called “Super Bowl drug ad sparks big backlash”, quotes Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing: "It's very disturbing to see an ad like that. It's normalizing the chronic use of opioids, which aren't demonstrated to be safe over the long term.”

Of course the greed and anti-social behavior of pharmaceutical manufacturers is neither new nor is it going away. Their efforts to use doctors and exploit the public as much as they can possibly get away with in pursuit of exorbitant profits continues to generate news, and occasionally, reaction by states. We have all heard about the huge price increase in Daraprim ® by Martin Shkreli and Turing (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015) and Epi-Pen® by Heather Bresch and Mylan (Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016) and maybe thought that this publicity would rein in further abuses. But not so. Reuters just reported in “US states sue Mylan, Teva, others for fixing drug prices” that “Twenty states filed a lawsuit Thursday against Mylan NV (MYL.O), Teva Pharmaceuticals (TEVA.TA) and four other generic drug makers, saying they conspired…on pricing of two common generic drugs, according to a copy of the complaint.” Lest you think that this conspiracy is just preventing these companies from being undercut by each other, we are talking fantastic price increases for common and necessary drugs. “The drugs involved in Thursday's lawsuit include the delayed-release version of a common antibiotic, doxycycline hyclate; and glyburide, an older drug used to treat diabetes. Doxycycline, for example, rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.” In case you missed it, this is a 9245% increase in the price of doxycycline! And it may well be up to the states to bring such legal action, since there is little reason to think that the federal government, led by President-elect Trump and his corporate cabinet, along with the Republican-dominated Congress, will be doing anything about it.

Which, of course, is the core problem, and has been for a long time. Corporate profit has become the be all and end all of US policy. Anything that increases corporate profit is seen as good. This certainly includes subterfuge, cheating, exploitation, and corruption. While this has long been the case, it is likely to increase under the Trump administration, with its depressing panoply of corporate exploiters and climate change deniers. We are likely to see not only tolerance of encouragement and celebration of such outrageous excesses. Of course, it is fine to make a profit, but that profit should be reasonable and honest; it should not be highway robbery, generated by dishonesty, exploitation, and trampling others.

The pharmaceutical company activities cited about are the result of an attitude that “if we can make some money honestly, look how much more we can make if we are corrupt!” that pervades virtually every industry, from fossil fuels (see Rex Tillerson, the Exxon CEO who is Trump’s nominee for Secretary of State) to financial services. After campaigning against Goldman Sachs, the largest investment bank, and its ties to Hillary Clinton (“I know the guys at Goldman Sachs. They have total, total control over [Cruz]," Trump said. "Just like they have total control over Hillary Clinton"), Trump has named at least four current and past Goldman execs to cabinet-level positions, including its #2, Gary Cohn, as director of the National Economic Council. And, should anyone harbor any illusion that the survival of Goldman in the face of the collapse of rivals Bear Stearns, Merrill Lynch, and Lehman Brothers has anything to do with their being more honest or less evil, less likely to have indulged in “the Big Short” and transferred all their toxic investments to their own clients, read the recent piece by Matt Taibbi in Rolling Stone, “The Vampire Squid occupies Trump’s White House”.

Speaking of Rex Tillerson, his close ties to Russia and Vladimir Putin are seen (by the President-elect) as major qualifications for Secretary of State. In this context, the New York Times Op-Ed by Andrew Rosenthal from December 15, 2016, “To understand Trump, learn Russian”. Rosenthal notes that Russian has two words for “truth”:

The word for truth in Russian that most Americans know is “pravda” — the truth that seems evident on the surface. It’s subjective and infinitely malleable....But the real truth, the underlying, cosmic, unshakable truth of things is called “istina” in Russian. You can fiddle with the pravda all you want, but you can’t change the istina.

The pravda will change a lot with the new administration. Fossil fuel extraction is all good, climate change is a hoax, public education is bad, getting rid of the ACA will improve access to healthcare, immigrants are the problem, Putin is good, and gays and transgender people have no rights. That putting foxes in charge of the henhouse makes sense, and that having corporate titans in direct rather than indirect control of government will benefit us all. But the growth in the gap between the wealthiest and the rest of the people has grown under both Republican and Democratic administrations and anger at it was actually one of the drivers of the vote for Trump.

The istina, though, is that making the wealthiest wealthier and destroying the earth in the process is not the answer. Attention to the common good, for all of us, is the only thing that will move us forward, as a society and as a world.