Recalling an old post: Le Havre and not paying for health care -- in France

Sometimes I think about old posts, and how sad it is that things have not changed in the years since I wrote them. But, as with this one, from Jan 12, 2012, I enjoyed writing it, and highly recommend the film that inspired it, Le Havre.

 One thing to NOT worry about: paying for health care -- in France

Concentration Camps: Is the US still the "savior" or will they happen here? Fascism on the rise in health and everything else.

Recently, in Trieste, I visited the San Saba concentration camp, also known as the Rice Mill because that’s what it had been. On the scale of concentration and extermination camps of the Third Reich, it was small. “Only” 3000-5000 people, mostly Jews, were incinerated here, although others were shipped off to Auschwitz to experience a similar fate. It was my first visit to a concentration camp, and I do not know that I will ever go to Auschwitz, or Treblinka, or Sorbibor, or Belsen, but it was very disturbing. However, at one point the guide noted that it had been liberated by the Americans on May 1, 1945.* My eyes, already full of tears of sadness, teared up yet again but this time with pride. It was the same pride I have felt ever since I was a little kid, born only a few years later, every time I hear about my country, the US, standing strong against Nazism and Fascism, and liberating the camps.

But today it was a bittersweet feeling, because in just the last two weeks my country has been rapidly moving toward fascism. The separation of powers, the core structure of our Constitution has been ignored by the current President. I used to call him the Trumpenik, because it sounds very like the Yiddish word “trombenik”, defined by Wiktionary as 1. a lazy person or ne'er-do-well, or 2. a boastful loudmouth, both of which were good descriptions of him. But now he has decided to become Il Duce, another comparison that is very scary here in Italy.  And he, who was at least elected President if not dictator, hasn’t even been doing all this work himself. He has let Elon (who he sometimes calls Leon) Musk do it. Musk, not elected to anything, not appointed to anything with the advice and consent of the Senate, has taken control of the government’s two most critical functions, the funding of it and the information it possesses on all of us, including Social Security and Medicare. Medicaid has already suffered serious threats to its continued ability to help provide healthcare to poor people. As a federal/state partnership, the federal government pays from about 60-80% of the cost, higher in the poorer states – which are often also the most Republican states. The National Institutes of Health (NIH) funds health and medical research; the largest amounts are spent on cancer research, though many other conditions that affect many Americans – heart disease, stroke, Alzheimer’s disease and many others – as well as basic science research that sets the stage for discoveries on diseases we recognize. In addition to the direct funding of the research, the institutions grantees work at also get indirect funds to “keep the lights” on and to provide many of the resources that allow research to go on. The Musk lackeys see this as pork, or worse, things that “enable a leftist agenda” by, I assume, funding universities. The issue of NIH direct and indirect funding is well described by Dr. Jeff Burns, a neurologist and researcher at the University of Kansas Medical Center, in a Facebook post that unfortunately doesn’t have an out-of-FB link**.

Medicare and Social Security are the most popular programs in the country, put in place by Democratic administrations (as have virtually all programs that actually benefit a significant percent of the American people), and its recipients, mostly seniors, aren’t going to be happy to have those programs cut. It is not clear if anyone in the administration cares. Musk has his own ideas of what programs are worthwhile and what are not (often colored by his personal history and interest) and wasn’t elected to any position and is unlikely to be. Decimating the National Labor Relations Board (NLRB), which will be devastating to working people in the US, serves the interests of folks who run major corporations like himself and Jeff Bezos of Amazon. It has also been suggested that his animosity to the US Agency for International Development (USAID) may in part be a result of its support for the majority population of South Africa, from which country’s minority white former rulers Musk comes. And their investigation of his company Starlink’s contracts with Ukraine. And Trump himself is unlikely to run for election again – he got this job and will stay out of jail and make a lot of money and get his revenge on his perceived enemies. And maybe cancel future elections. But going after senior and rural people and programs that benefit red-state residents is not going to increase his popularity.

I care a lot about healthcare and the healthcare system as well as health research, but the moves toward fascism go much farther. Every agency, especially those tasked with enforcing the law and pursuing criminals (like say, felon Trump) has had its professional staff replaced with loyalists and ideologues, especially both the Department of Justice (including the FBI) and the Department of Defense. There are some glimmers of light, particularly from the federal courts, in decisions such as ‘Judge halts Access to Treasury Payment Systems by Elon Musk’s Team’, and indeed the NY Times suggests that the federal judiciary may be the last obstacle to him. But the top decision maker in the federal judiciary is the Supreme Court, to which Trump appointed three justices and has been very friendly to him. And it will be a long time before a lot of those cases get through the courts. And someone has to enforce it. And who thinks that Musk and his Gen-Z minions who have gotten access to and control of federal databases and funds will all of a sudden, even if these cases are successful, rewrite the codes to be the way they were and not leave themselves backdoors to get in? You can’t un-ring a bell.

Enough of this by me. There is plenty of detail being provided by many other sources, and almost all of it is depressing. Let us get back to my feeling of pride in the US and its fight against Nazis and Fascists, of being, on the world stage, the good guys. Of course, it was not always true that we were – plenty of countries were invaded by the US or had their governments overturned by CIA-supported coups, etc., and even in WWII there were the Allies, including the Soviet Union which lost 20,000,000 people! And there were pro-Nazis and fascists in the US, always. Even US concentration camps (if not death camps) were started by FDR, for Japanese-Americans.

But the idea that an opponent of democracy and freedom, a person who wants to be Mussolini, or Hitler, or Stalin, or Putin, or even Viktor Orban, is the President and has moved so quickly to dismantle our Constitution and has had no significant opposition? That makes me sad, and I wonder when we will re-create camps like the one I visited in Trieste, or worse?

 

*Actually, Trieste was first freed on May 1 by Yugoslav partisans. New Zealanders came May 2, and other allies (US and UK) a couple of days later.

**Jeff Burns’ FB post:

Why Cutting Indirect Rates Means Cutting Medical Research

Medical centers aren’t just buildings—they are the foundation that makes research possible. They provide specialized lab spaces, maintain infrastructure, ensure compliance with safety regulations, and handle the complex financial and regulatory requirements that keep research running. None of this is cheap, and none of it is optional.

The NIH is one of the most powerful vehicles for turning ideas into reality—funding research that directly improves lives. Securing an NIH grant is an ultra-competitive process and a gold standard for top notch research. When researchers like me win a grant, the funding covers the research itself (“direct costs”), but the university also receives “indirect costs” to support everything that makes the research possible: the facilities, oversight, administration, and ecosystem that allow scientists to do their work. Without that support, it becomes harder to do the work that advances medicine. And, NIH funding isn’t just about research—it’s an investment in people and communities, with significant downstream effects on the economy.

Cutting indirect rates doesn’t just trim a budget line—it makes research harder to conduct, slowing scientific discovery and the development of treatments that help people. For my own work in Alzheimer’s disease, this means fewer studies, fewer discoveries, and fewer opportunities to change lives. I work alongside hundreds of clinicians, scientists, students, and staff who have dedicated their careers to tackling this disease. But dramatically and suddenly cutting indirect support shakes the very foundation that allows us to take on these big scientific challenges.

This isn’t about cutting waste—it’s a massive, across-the-board budget cut to science. And the hardest hit won’t be the elite universities with massive endowments; it will be the institutions where every NIH dollar is critical. Less investment means less medical research—period. Cutting indirect rates isn’t just bad policy—it threatens innovation, economic growth, and the future of medical discovery.

Once again, the US trails rich countries in health care -- except in cost! Why do we tolerate it?

Sometimes the news is good, sometimes it is bad (too much of the latter!!). Sometimes it is surprising, and sometimes it is not. Often it is more of the same, and sometimes this is surprising because we had thought or hoped that it had changed, preferably for the better, and sometimes it is not surprising because we knew it had not.

A good example of this is international health rankings, in which the US consistently and continually ranks at the bottom of the wealthy nations and has a health status that is in the middle of what are known as “middle income countries”. These are called middle-income because they are better off than the really poor countries, but compared to the US and similar countries, they are poor.  In 2000, the World Health Organization (WHO) published a ranking of health system performance in their member nations, based on 1997 data, in which the US ranked #37 in the world, between Costa Rica and Slovenia, on overall performance. When many were aghast that the US could be like Slovenia, the prime minister of that nation took offense and pointed out that his country had been making significant advances. In the area of Disability Adjusted Life Expectancy (DALE) the US in fact ranked #72! I had reproduced these tables in  US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, and do so again now.

Of course, 1997 is a long time ago. Maybe, since then, we, like Slovenia, have gotten better. Except we haven’t. This is the sadly non-surprising part of the news.

While the WHO has not redone that 2000 survey, in 2017 Bloomberg published its Global Health Index, and, as I said then,

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

For an ongoing comparison, the Commonwealth Fund publishes a report every few years called “Mirror, Mirror on the Wall” comparing US health outcomes and cost to other high-income countries. I have cited it, in its various editions, on many occasions (Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost, June 26, 2010, ACA: Where are we? And where should we go?, July 27, 2014, US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, Our health system: Not equitable, not effective, and not even efficient. Bad business!, March 24, 2022), and address it in detail in my 2015 book “Health, Medicine and Justice: Designing a fair and equitable health system” (Copernicus). The relative performance and ranking of the other countries varies a bit over the years, but the position of the US at the bottom of the heap, #1 only (and consistently) in cost, and worst in performance, is unchanging. The most recent report, “Mirror, Mirror 2024: A portrait of a failing US health system” has just come out, and the title provides the answer: not good. Not better. Failing. And, probably, failing worse. The study’s conclusion, in the Summary, is:

The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Here is the table of rankings:

And, if you prefer a visual portrayal about how much worse the US health system is performing:

But we do lead in spending:

And, logically, trail the pack by a lot in value for dollar spent:

This is the non-surprising non-news. But, while not surprising, it should be very concerning. It’s not getting better, and there is little reason to think that it will, if past performance is a predictor of future performance. And we’re talking more than two decades of consistent past performance. It is not a question of what the fact are, of what is true, no longer if it ever was. The US health system performs terribly as a health (or even medical care) system. Costs are enormously high, outcomes are consistently poor, and we dramatically underperform every other country that has in any way comparable resources (and many, many with far fewer resources). It is incredibly inequitable. See, for example, some of the countries grouped around the US in the 2017 Bloomberg rankings, such as Qatar, Brunei, and Bahrain – countries with money and inequitable distribution. So, the question is why are we not doing anything about it?

The answer simply requires a little re-framing of the data presented above. I, and likely you, see the incredible cost/performance ratio as a negative, something to be addressed and fixed. But all that money that is being spent is going somewhere, and certainly a large amount of it is not going to provide high-quality healthcare. It is going to profits for insurance companies and pharmaceutical companies and the Wall St. investors that own them, and for enormous salaries for the C-suite executives who run them, as well as those in the ostensibly non-profit sector (see Why many nonprofit (wink, wink) hospitals are rolling in money by Elisabeth Rosenthal (Washington Post, July 29, 2024). For them the current system is working very well, thank you, they are getting very rich. Your problem, and mine, is that we think that this system should be about providing high-quality and cost-effective care for the American people, at which it is obviously failing. But if we understand it as a cash-cow for these corporations, as a method for transferring money from the rest of the economy to them, it is working great. And, because it is working so well and they are making so much money and spending a great deal of it contributing to politicians, it is unlikely to change.

Unless YOU make it change.  There is, and has been for decades, a loud and effective rant from the corporations and individuals profiting from your health care dollars and their employees (or shall we say “beneficiaries of their largess”) in the legislative, think tank, and punditry arenas, that the Democratic party, and particularly its progressive wing, are radical socialists who are anti-American. This has been very successful. See above, we have kept to the unique American way of doing things. The one that takes money from you in premiums, co-pays, and deductibles and provides you with poor outcomes. That every other wealthy capitalist country has found a way of delivering higher quality for less money is the evidence that it is possible and will not destroy the country. But it will destroy the conveyor belt that takes your money and puts it into their pockets, and this is a terrifying thought, so that they will do anything to prevent it.

Their tactics include both painting mainstream Democrats who merely want to tinker around the edges of the system as flaming radicals, and funding organizations such as the Heritage Foundation to come up with truly radical proposals like Project 2025 (pdf of the health section here) that would institutionalize the worst, most anti-human practices going on today. The strategy is that if they can get half the country to support politicians who support those policies (whether those voters actually support those policies or not), it moves the center of the discussion to the “right” and means compromise will be much less threatening to them. But much more threatening to you.

People want good healthcare for themselves, for their families, and for their friends. They don’t want to pay ever-more for health insurance only to have the insurers deny their care, often as a matter of routine, when they need it. They deserve, as do the people of other countries, a health system that is intrinsically structured to provide the best possible health care for our people and not to make money for Wall St., big corporations, insurance companies and health systems. We know it can be done as it has been done everywhere else.

Make it the thing you vote for and let your representatives know it; you want health care, as the old saying goes, for people and not for profit!