Mamdani, universal health coverage, and the scandal of profits over healthcare

First, let me offer congratulations to Zohran Mamdani and the people of New York who elected him. While the news focus is on him, and of course he merits it, it is the “them” that is more important. New Yorkers showed that they want someone who stands with and for them, for their needs, for their ability to afford rent, and healthcare, and education, and food, rather than for the developers and billionaires and financiers (overlapping groups) who have long controlled the city. It should be a wakeup call to the finance-oriented Democrats, not to mention the Republicans who only stand for the oppression of people. Maybe he will be able to deliver on his promise of universal health care in the city, and maybe not, but what he, and they, have shown is that this is something people want. People most assuredly do NOT want the interests of insurance company profit to even be in the same discussion as a value in comparison to their health and healthcare, and they shouldn’t.

What is remarkable is the number of people in positions of power who do. This can, accurately, be attributed both to the financial support insurers give to politicians (and pundits) and the fact that they hang around with each other. Polls have shown that large majorities of Americans support universal health care, and the NYC election was another important such “poll”. But, in fact, things are going in the opposite direction for healthcare and the health of the American people. The party of Snidely Whiplash (PSW) is doing everything it can to make people’s lives worse. They have made it eminently clear that they don’t think all Americans should have health coverage by keeping the government shut down rather than talk about continuing the subsidies for ACA demanded by the Democrats. 

And remember that lots of things besides healthcare coverage affect health – access to adequate food is one of the main ones. So, because, I guess, the PSW so enjoys being mean, they have cut SNAP (food stamps) benefits dramatically, so that more children can go hungry. Twirl that mustache, Snidely! In Tucson, as around the country, food banks that are already overwhelmed will see huge increases in need. We just loaded up the car with boxes of food for the community food bank donated by members of our HOA. They were particularly heavy because of the cans of beans, tuna, chicken, and peanut butter donated especially because the food bank is often out of protein. Which, you may recall, people, and especially growing children, need! You see, grants for the food bank to buy this food from local farmers, which benefitted the farmers as well, have been cut off. Just when you thought we couldn’t be meaner, har har har! 

Government policies that cut aid for food and healthcare are terribly damaging to Americans’ health. Rural hospitals are closing because so many of their patients are covered by Medicaid, which has been dramatically cut. Telehealth programs that might have helped fill that gap are ending. If anyone still believed the private, for-profit sector (as opposed to the volunteer non-profit sector, like food banks) might step into help, they are doing the opposite. Recent insurance company actions have doubled down on limiting access to care, paying for care, and of course caring. Just a few recent actions detailed by Health Care Un-covered include ‘Coverage Without Care: The Cruel Math of Health Insurance Open Enrollment’ and  ‘UnitedHealth CEO Says Company is Cutting Thousands of Doctors Out of Network to Boost Profits‘. You thought it was already hard to find a doctor? The largest health insurance company in the nation doesn’t care; it does care about making more money! Remember that when you see their ads on TV!

Many people – well, pundits, not actual people – say the problem is people need to have jobs, to contribute to the economy. Others, perhaps (?) more well-meaning suggest people need more education about how to choose and navigate the health insurance system so they are not (or are at least less) screwed. Baloney. Read this story on the KFF site about Dr. Lauren Hughes, whose car was T-boned 20 miles from her home. She had injuries including a broken ankle, but the hospital to which she was taken was “out of network” for her insurance, and she ended up with a $64K bill! Dr. Hughes is a highly-educated, knowledgeable, skilled and experienced family physician, who also leads a health policy research group at the University of Colorado. She knows way more about how the system works than most people – heck, than most doctors! And she still was screwed (not just with the ones in her ankle)! Because of her knowledge, role, and indeed clout, and the support of others she was able to get most of the insurance company decision reversed, but good luck if it is you, or someone else who has less of all of those advantages!

The KFF piece is full of phrases that should infuriate, and nauseate, any decent human being, like “out of network”, “surprise billing”, “uncovered care”, “observation status”. These are all strategies (“gimmicks” would minimize their significance) to make more profit for insurance companies by denying you health care. Another recent Health Care Un-covered piece discusses ‘Where Do Our Health Insurance Premiums Go?’, and the answer is profits, stock buy-backs, lobbying, executive salaries. Not increasing coverage or access, decreasing rates; indeed, quite the opposite: as profits go up, so does consumer cost, while access goes down! In any other country, these phrases would be anathema. Every other country that can possibly be considered “wealthy” or even “middle income” (an international classification that almost any American would still see as “poor”) has universal health care. The concept that any person, not to mention a “well-insured”, educated, professional – physician! -- would have such indignities heaped on them and not receive the care they need as a right of their citizenship (and in many countries, even non-citizens) would outrage them. I would like to remind folks of two pieces I wrote long ago, both coincidentally related to films. One thing to NOT worry about: paying for health care -- in France, is from 2012. It discusses the film Le Havre, and how amid the tribulations of being poor, worry about paying for necessary health care was not one of them. The other, from 2009, "Sick Around America": A little bit sickening, talks about TR Reid’s special “Sick around the world” and something from it that has stayed with me.

In each country he [Reid] asked how many of their citizens went bankrupt as a result of health care debts, and they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

It should be a national scandal here; indeed, it is a scandal that, for so many it is not. The American people know this, and increasingly will be punishing politicians who do not care, or who, with a total lack of not only empathy but any moral or religious compass at all, put the financial profits of insurance companies above the health of our people, when in fact it should have ZERO weight.

Back in 1958, Harry Golden, a writer, humorist, and published of the Carolina Israelite wrote the best-seller “Only in America”. At the time, reviewers’ comments focused on his being a Southern Jew, and on his support for integration (the moral issue of that age). But it is sad to think that nearly 70 years later, “Only in America” refers to the lack of a universal health care system, unique among the OECD (Organization for Economic Cooperation and Development, the rich) countries.

It is long past time to change that!

The growth of the healthcare sector in the economy is not matched by an increase in health

Healthcare is a big industry in the US. Really big. Per a recent NY Times article, it is the largest employer in the nation, its growth demonstrated by this graphic:

The plummeting in the number of manufacturing jobs over the last few decades (it being more profitable to make things in poorer countries thanks to lower wages) and the more gradual but steady fall in retail jobs as a result of the on-line economy leading to the closure of “brick and mortar” stores, have been big contributors to this phenomenon, but the growth in the number of health care jobs is also undeniable. Indeed, as seen in the graphic below, in 1990 healthcare was the largest employer in no state, but in 2024 it is the largest in all but 11! This is an incredible change, and has incredible implications for the US economy and for the health of Americans. Unfortunately, they are not entirely positive.

While growth in employment may be good for the economy overall, and helps those who have jobs in that sector, this is only true to the extent that they are good jobs, or at least are jobs that employ people who would otherwise be unemployed. Not all healthcare jobs are well-paying, and if they are relatively poor paying jobs that have replaced better paying jobs in manufacturing, the folks who have them are not better off. It is not necessarily good for the individual who is paying for their healthcare, even when they are employed in the healthcare industry (many “lower end” jobs in this industry do not come with good, or even any, health insurance). The cost of insurance has gone way up, as has the proportion of it that is borne by the individual or household. As a third graphic from this article shows, the growth in the percentage of household expenditures that is for healthcare has also been phenomenal, now being larger than the portion spent on groceries or housing.

One big issue is that not all of these healthcare jobs are actually providing healthcare to people. They include those who do, nurses and doctors and other clinical providers, and also those providing home care services, who are often at the lowest end of both the salary and benefit scale. Many of these workers are on both Medicaid and food stamps, an indictment of the healthcare industry and a rebuttal to those (mostly Republican) politicians who justify cutting those programs by saying that they are abused by able-bodied adults who should “get a job”. In addition to clinical providers, “healthcare” jobs also include multiple levels of administrators and managers in healthcare and in the insurance industry. Indeed, many work in the artificial industry created by the conflict between the two about whether and how much insurance should pay for care, both sides engaged in an essentially socially non-productive struggle.  

The growth in administrative personnel – a hold-all term for those not involved in clinical activities – is illustrated by the following chart, which looks at the increase in physicians compared to administrators/managers over time. What we see represents a towering infrastructure mainly aimed at making money, either for healthcare institutions or insurers. Even though physicians are only one piece of the clinical pie, it is a pretty impressive contrast. Nurses, and the demand for nurses, has grown more dramatically (if not as fast as that of administrators). This is in part because the number of physicians hasn’t grown as fast as the demand for clinical services, and some services previously provided by physicians are now done by nurses, including Advance Practice Registered Nurses (APRNs) such as Nurse Practitioners, Nurse Midwives, Nurse Anesthetists, and other Clinical Nurse Specialists. There are currently about 4 million nurses, with about ¾ being RNs (not counting APRNs), and 1 million physicians (State of the US Healthcare Workforce, Health Resources and Services Administration, November 2024, downloaded from https://bhw.hrsa.gov). There is some question about the degree to which the number of “primary care” physicians is all doctors who are actually practicing primary care, especially among general internists, many of whom are hospitalists (40% or greater).

 

So, we have both an amazing growth in the number of healthcare jobs and in the portion of a regular household budget that is spent on healthcare (including direct payments, insurance premiums, copays, coinsurance, deductibles). Obviously these are related phenomena; after all the growth in the number of jobs, as well as in the number of buildings dedicated to healthcare (see Ron Shansky and Healthcare in the US: We need more than buildings, May 10, 2025) has to be paid for somehow. The “somehow” is money spent on healthcare services, which is paid by people either directly or through their insurance premiums and other payments. While it is in large part these buildings, and these jobs, that have led many to say that the US has the “best healthcare system in the world”, it is mostly the biggest.

The argument that we have the best healthcare system would be bolstered by demonstrating that, as a result of, or even coincidentally with, this enormous physical and human resources infrastructure, the health of the American people was great, or even had significantly improved. Sadly, it has not, and doesn’t appear to be headed in that direction. Certainly, many people get great health care, particularly those who are wealthier, well-insured, and live in major metropolitan areas. But many don’t, even including people in all those groups. The overall health status of the American people not only remains lower than that of all comparable (ie, wealthy) countries, and even many “middle income” (poor by US standards) countries, but the gap is increasing, not decreasing. I included a few graphs from The Commonwealth Fund’s comparative international ranking, Mirror Mirror on the Wall, in the blog cited above, including one showing how far ahead we are in health care spending, but will reproduce here the one showing 2024 health system performance rankings.

New changes in health financing resulting from the Trump-GOP “One Beautiful Bill” will have major negative consequences, making these circumstances worse, much of which is documented in How to Wreck the Nation’s Health, by the Numbers, an excellent and thorough essay in the NY Times by long-time health services researcher Dr. Steven H. Woolf. Eleven million people will lose Medicaid coverage, and the vast majority will not be able-bodied adults who are voluntarily unemployed. Most Medicaid beneficiaries are children and their mothers. Most Medicaid dollars are spent on people in nursing homes (both those that started out low-income and those that “spent down” because of the cost of long-term care and got poor enough to qualify).  A recent Commonwealth Fund study estimates significant job loss and negative impact on the economy from this bill,  

In 2029, cuts to Medicaid and SNAP would cause state gross domestic products to fall by $154 billion, 18 percent more than the $131 billion they would save the federal government. The cuts would result in the loss of 1.22 million jobs nationwide, equivalent to a 0.8-percentage-point increase in the unemployment rate. States with higher rates of poverty would likely be harmed more. State and local tax revenues would fall by $12 billion.

Rural areas would be particularly affected, especially in health care. Unlike the major urban medical centers I described earlier, rural hospitals often operate at the margins of financial viability. Because rural populations are poorer, older, and sicker, they are more dependent upon Medicare and Medicaid as payers. Many have closed in the last several years, and many more are likely to as a result of the coming cuts, as documented by the Cecil G. Sheps Center for Health Services Research in North Carolina and reported in KFF Health News and the University of Arizona Center for Rural Health.

The degree to which this new law will negatively impact the most vulnerable people in our nation – the poor, rural, children, seniors – is so dramatic that it is impossible to believe this was not the intention. It is certainly consistent with the goals of Project 2025, as summarized here by the American Public Health Association. If this seems inexplicably mean and cruel, it is. Even many GOP congresspeople and senators noted this before going ahead and voting for the bill anyway (note: voting for the bill under protest is the same as voting for the bill).

We are going to have to work very hard to try to minimize the negative impact, and it will take all those healthcare buildings and jobs working, not to make profit but to make us healthy. Good luck with that.