Lies and cowardice screwing almost everybody's health care coverage

There is usually more than one way to look at a situation. Often referred to as “point of view”, it is good to consider this, particularly in personal relationships, as the way you see things might not be the way the other person does. In the Trump years most of us have become more aware of a different basis for disagreement, not based on different interpretation of the facts but upon different facts. This is not just a difference in emphasis-- you and I both believe X and Y are true, but I think X is more important than Y and you think Y is more important than X.

We are in a situation in which a large portion of the population believes lies are facts, believes that things that are not true are true. Of course, this has always been the case, like when most folks thought that the Earth was flat, or that the sun and stars revolved around the Earth. These were definitively disproved, we know the truth, and yet there are other just as ridiculously incorrect beliefs (and, here, I except, for brevity, religion) that many people still cleave to. Heck, there are still flat earthers! I doubt that most of the leaders of the Republican Party or members of the administration in Washington – or even Fox News commentators -- actually believe most of these falsehoods (except Donald Trump, who seems too demented or stupid or isolated or all three to know), but they find them convenient ways of keeping the public’s attention focused away from what they are doing to benefit themselves and their buddies. This could be called the “Wizard of Oz” technique, and misdirection is a core part of most magic acts, but it is also a core component of fascist tyrannies.

These outright lies in the Era of Trump are incredible, both in number and the real impact on people. In the area of health, the focus of this blog, they have been amazing in terms of their scope and impact. Vaccines, among the few actual preventive things that medicine can do, have been attacked and criticized and completely wrongly said to cause worse problems than they solve. Not to put too fine a point on it, this is pure evil coming from RFK, Jr. and his team of loons. Yes, there are individual people who should not get one or more individual vaccines, because of a serious prior allergic reaction, or even worse a rare effect like Guillain-Barre, but for the vast, vast majority of children and adults vaccines are all good. They basically eliminated smallpox from the world, and essentially eliminated terrible killers like measles in this country – until a new movement endorsed by the Secretary of HHS brought them back. Your measles as a kid wasn’t too bad? Neither was mine. But lots of kids got sick. A bunch died. You never had measles because you’re too young? Because even your parents are too young? And you all had vaccinations? Sadly, maybe you’ll see it in your children. Mumps made people deaf and infertile, meningococcus dead or brain damaged, H influenza the same. Polio made people dead or paralyzed, in wheelchairs or in iron lungs. When I was a medical resident, we saw H influenza meningitis and epiglottitis, meningococcal disease, even some measles and polio. All eliminated by vaccines. Until we stop using them.

    

Smallpox                                Measles               Polio (in iron lung)

There are many, many other health disasters promulgated (it seems on purpose) by this administration. Eliminating or cutting back infectious disease surveillance – cyclospora, E. coli, salmonella -- anyone? Enjoying that? How about animal diseases? And funding for medical research – being heavily cut back especially for researchers that the administration doesn’t like.

But one HUGE area is health insurance, financial coverage for our medical care. I have written about the terrible US health care non-system which is designed to make money for private corporations (insurance companies, big hospitals and health systems, Pharma) instead of being designed to deliver the best actual health care for our people, and how it needs to be replaced by a system of covering everyone, as in every other wealthy country – improved Medicare for All. People need financial coverage because all those big corporations are owned by investors who demand ever-increasing profits, so the costs of the overall system (highest in the world by far), and to individuals, keeps going up.

Under the current administration, the opposite is happening. In a recent editorial in the NY Times, the cuts to coverage are enumerated and documented. The most dramatic of these are cuts to the Medicaid program and the subsidies for purchasing individual insurance on the marketplace created by the Affordable Care Act (ACA, “Obamacare”). The Medicaid cuts target the most vulnerable and needy, the poor and disabled, and the cuts to the ACA subsidies means that the poor-but-not-quite-poor-enough-to-qualify-for-Medicaid population that was finally insured through ACA will lose it. (If you want to know how poor you must be to qualify for Medicaid, you can look it up by state, but it is always very poor. When you look it up, remember that while many states tie eligibility to about 135% of the Federal poverty level, many others have much lower qualifying incomes.) This is really bad because it is going to kill people, is going to strain many physicians and hospital systems – especially those that cannot afford it, like rural hospitals – and create a lot of misery.

There are several other bad things related to health coverage that the Times does not even address. One of these is the aggressive promotion of Medicare Advantage (MA) plans for Medicare eligible people. These plans are not actually Medicare, a federal government run program, but private insurance products that use Medicare money (and gets paid more per patient than traditional Medicare, TM). On the one hand, if you get a good, comprehensive MA plan it can save you money (with TM you probably need to pay for a Medicare supplement and Part D plan as well as the Part B premium taken from your Social Security payment). But it can also have bad results because the insurance companies that run it can, and often do, deny payment for your care, just as they do for regular insurance.

Another health insurance problem the Times does not address is the fact that even in the best situations (in those states that chose to expand Medicaid and before Trump), the ACA did not cover everyone. Both this and Medicare Advantage are also areas not addressed by those making policy for the Democratic Party. It is not coincidental that the Times and that portion of the Democratic Party called (depending on where you stand) “centrist”, “moderate”, “Wall St.” or “right-wing” are similar, because both share a similar ethos. This is to be better than the GOP on a lot of social issues affecting individuals but to not threaten the basic status quo: corporate America making a lot of profit, and enriching its investors, at the expense of the rest of us, particularly but not only the poor, who get screwed out of medical care and/or bankrupted by the bills. Oh, and, by the way, if you one of the majority of people who have employer-sponsored health insurance, you’re still not safe. Costs for insurance to employers (with much or all of the increase passed on to employees) is expected to go up 11% in 2027!

The “centrist” branch of the Democratic Party does not support eliminating or strictly regulating Medicare Advantage, not to mention Improved (covering everything) and Expanded (covering everybody) Medicare for All. The same tired and inadequate reasons are given: “we can’t afford it” --- ridiculous given that every other wealthy or middle-income country does -- when what they mean is “we don’t want to alienate the billionaires who continue to support us”. They say that they need to “be moderate” because they don’t want to turn off independent voters, which results in policies that do not significantly help most regular people. Like Improved and Expanded Medicare for All (see the Jayapal House, HR 3069, and Sanders Senate, S 1506, bills) would.

We should be terrified of what the Trump Administration and GOP are doing, especially trying to disenfranchise voters before the election, and the huge cuts to our health care. But voters are not going to be excited by “Republican lite”; they need to hear about bold programs that will change their lives for the better.

We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.

 

                                       

Health Insurance is not Healthcare: Everybody in, nobody out!

 I have long advocated universal health insurance, recently in the form of Improved and Expanded Medicare for All. What “Expanded” means is obvious – EVERYONE would be in it. As the late Quentin Young, MD, was famous for saying “Everybody In, Nobody Out!”. That should be simple to understand. The “Improved” part means “not having the limitations of current traditional Medicare”. This means also covering dental, vision, hearing, and long-term care. And, most important, to eliminate the 20% of the amount that Medicare approves that patients are responsible for paying for hospitalization (Medicare pays 80% of approved hospital charges), or at least capping the dollar amount (not %) that people have to pay out of pocket. More detail is presented in the Physicians’ Proposal by Physicians for a National Health Program (PNHP), and is essentially what is proposed in the Medicare for All act, HR 3421, sponsored by Rep. Pramila Jayapal (D-WA) in the House, and the companion Senate Bill, S. 1655, sponsored by Sen. Bernard Sanders (I-VT).

I would like to address several important issues about why EVERYBODY IN, NOBODY OUT, expanded coverage for essentially all medical care, and the different between having health insurance and having health care. First a quick review of some of the important places where health coverage was expanded, just for background.

When there was a limited amount that doctors could do for people, folks accessed medical care with cash (or chickens). When hospitalization and surgery became effective for many conditions, insurance like Blue Cross/Blue Shield were established, mainly by surgeons. These were for a long time non-profit. After WW2, because the federal government implemented wage and price controls, even though there was a labor shortage companies could not compete by paying higher wages so benefits, like health insurance, became attractive. This was embraced by organized labor, which could exhibit such insurance as a member benefit. In 1965, Medicare was implemented to cover aged and disabled people, a huge advance. Medicaid, a program for low-income people who could not afford health insurance, was also a huge advance, but as a federal/state partnership, who and what it covers varies a lot from state to state. The ACA passed in 2010 (Obamacare) further expanded coverage by making health insurance affordable for many more Americans. This is the really short course.

 

As can be seen in the graphic (from Statista®) the number of uninsured people in the US has, as a result of the programs above, dropped dramatically. There are, however, 3 big problems that continue to exist. First, 25 million is a lot of people without insurance. Second, having health insurance, in the current chaotic system, is not an all-or-nothing thing. Many “insured” people have poor quality insurance, with high deductibles, high copays, caps on coverage, and high rates of denials by their insurance for treatments recommended by their physicians. Even people with “better” (and often more expensive, and likely paid in part by their employers) health insurance find themselves confronting these same trends with costs often making getting care unaffordable. The key lesson here is “health insurance is not healthcare”; if the care you need is unavailable to you because it is unaffordable despite having some form of insurance your health is not improved. This is what I will mostly talk about below.

Third is what changes will happen with the new Trump administration. We cannot know for sure what it will succeed in doing or even try to do, but it won’t be good. He and his advisors want to get rid of the ACA. They want to further privatize Medicare by moving more people into Medicare Advantage plans, which are private insurance plans paid for with public money that can and do often deny you care. (see Such a deal! Insurance companies keep your money and deny you care! How can I get in on that?, Oct 28, 2024.) If you want to get more information, check out the Project 2025 proposals for health care and health insurance.

So, let’s get back to the second, that having health insurance is not the same as having health care. This should also be obvious, but apparently it is not to a lot of people, including politicians, pundits, and health economists. For most things we buy, we trade off quality and price, usually assuming that higher price will lead to higher quality. With health insurance, it is sort of that way, but unfortunately the price is so high that many people buy the lowest cost (and lowest quality) because that is all that they can afford. It is why so many people have high-deductible plans that, when they need to use them, are not actually useful for obtaining health care because the deductibles and co-pays are so high. It is why the lowest cost ACA plans are the most popular and deliver the least. And it is one of the main reasons why so many seniors have opted for Medicare Advantage (MA) plans rather than traditional Medicare (TM). The entry cost is lower, they cover some things TM does not (like glasses and hearing aids and dental) and it does not require purchase of a Medicare Supplement (Medigap) plan to cover the 20% of approved hospital charges that TM doesn’t pay. But when folks get sick, they may discover that the MA plan does not cover the hospitals or doctors they want and that, because they are private insurance plans and not, in fact, Medicare, they can and do deny coverage for lots of things. Oh, well. You want a lot of detail on how bad it is? Look at the Commonwealth Fund’s Biennial Survey, “The State of Health Insurance Coverage in the US”.

Why do we demand such premiums, deductibles, and co-pays? A lot of health economists have used the term “skin in the game”, implying that if people have to pay some of their own money they won’t “over-use” health care, which drives up the cost. This analogy to gambling is flawed, and wrong. There is no evidence that “over-use” is a major driver of health care costs, either in the US or, more importantly, in other countries where the direct costs to patients are non-existent or very limited with low caps on the maximum that people can spend out of pocket. It is a theoretical belief not supported by the data. And politicians, pundits, health economists, and newspeople are employed, usually with relatively high incomes, and what seems to them anecdotally to be “not so much” (a few thousand dollars?) is so high for many Americans that they forgo health care altogether.

The cost of US health care is indeed extremely high, but it is not because people over-use services. Physicians often over-use (over-order) services because they can see the benefit but not the cost, because they may make money from procedures and even more from their use if they also own, say, the imaging center, and because they fear lawsuits if they do not. But most of the excess cost of US health care compared to other countries (many of which actually use more health care per person than we do, in terms of things like hospital beds per population) is the excessive administrative cost and profit on the part of health insurers and large care providers like hospital systems.

What can we do? Well, we can eliminate for-profit insurance companies, or regulate the heck out of them so that, as in countries like Switzerland, they have to provide the same set of benefits at the same price, cannot make a profit, and have to compete on – get this – customer service! We can have one single-payer plan, Medicare for All, improved to cover everything and expanded to cover everyone. In the meantime, we can at least cap the out of pocket maximum people have to pay to, say $1000. How could we fund it? Let’s start with the $590B in overpayments to Medicare Advantage plans!

A year ago, Levitt and Altman wrote about the complexity of the US healthcare system (Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Health Forum), and included this:

 “Yet, any push for health care simplification inevitably clashes with commercial interests. The health insurance system is structured to simultaneously maximize profits, control costs, and serve consumers, which are competing goals that add to the challenge of simplifying it.” 

OK. Can any decent person even consider that the value of “maximizing profits” should have any weight compared to “serve consumers”? It might be the defining question as to whether one is a decent person!

Finally, though, we need a system to cover everyone, well, so that they can really get healthcare.

EVERYBODY IN, NOBODY OUT!