Pandemic mismanagement: Fear, inequity and -- maybe -- hope?

Like almost everyone else, of all political persuasions, I imagine, I am furious. What and whom we are furious about or with varies, of course, with how we see the world, what we value, and whether we have a “reality-based” outlook. To a great degree our perception is affected by what we want to be true, rather than what necessarily is true, and our short-term desires rather than any long-term sense.

As a physician with a great interest in and concern for public health, I am very concerned (!!) about the horrible way that President Trump and his administration prepared for a pandemic (not at all), reacted to the first evidence of one (denial), finally moved into a response (incompetently), and have yo-yo’d (good word for them) back and forth between making tentative positive moves and stepping back. Trump’s own statements are pretty accurately parodied by a meme making the rounds with him as Captain of the RMS Titanic. But we now have a response team, headed by Ivanka and Jared, with folks like Mark Meadows, Wilbur Ross, and Steven Mnuchin, so everything should be OK. Or not. We will, as Masha Gessen tells us in the New Yorker, not know the moment when democracy dies. We can have armed rallies demanding ‘reopening of the economy’, and even calls for insurrection if he loses the election, by folks like Franklin Graham.

So far, the coronavirus does not appear to be intimidated.

Predictions for the duration of this pandemic and the way in which it will change society and human behavior in the US and around the world are both dire and probably accurate. The most distressing news has been the unsurprising degree to which it has had its greatest negative impact upon the most vulnerable: the poor, minorities, elderly, and those who cannot afford to not go to work. The most inspiring aspect has been the degree to which it has highlighted the contributions of not only heroic health care workers, but all essential workers, the majority of whom are women, especially non-white women, and are generally underpaid. Among the essential workers are NOT included CEOs, hedge fund managers, political pundits, and other mostly-male, mostly overpaid roles. Walter Scheidel gives us mixed news in his New York Times piece ‘Why the Wealthy Fear Pandemics’; back to at least the 14^th century, it brings about social disruption and tends to increase the relative power of workers to demand better wages and working conditions. However, he cautions, that while “more often than not, repression failed…none of these stories had a happy ending for the masses.”

But it is not just the far-right, the GOP, and Trump who are not responding well to this crisis. The Democrats have been much better, but that’s a low bar. They still insistently miss the point that a national health program would have put us in a much better position to respond to this pandemic, and at the very least have eliminated the probably of bankruptcy for many of those receiving treatment. It almost certainly would have decreased the number of people staying away from treatment because of fear of the cost. Bernie Sanders said this throughout his entire campaign, and has just said it again in a NY Times Op-ed:

We are the richest country in the history of the world, but at a time of massive income and wealth inequality, that reality means little to half of our people who live paycheck to paycheck, the 40 million living in poverty, the 87 million who are uninsured or underinsured, and the half million who are homeless.

These ideas are absolutely as correct now as they were before he left the race. We need a national health system.

Most recently (April 18, 2020) the case is made by economists Anne Case and Angus Deaton, who continue to be amazed at the fact that ‘America can afford a world-class health system: Why don’t we have one?’. They note that

In March, Congress passed a coronavirus bill including $3.1 billion to develop and produce drugs and vaccines. The bipartisan consensus was unusual. Less unusual was the successful lobbying by pharmaceutical companies to weaken or kill provisions that addressed affordability — measures that could be used to control prices or invalidate patents for any new drugs.

The notion of price control is anathema to health care companies. It threatens their basic business model, in which the government grants them approvals and patents, pays whatever they ask, and works hand in hand with them as they deliver the worst health outcomes at the highest costs in the rich world.

And make this blunt and totally accurate statement:

The American health care industry is not good at promoting health, but it excels at taking money from all of us for its benefit. It is an engine of inequality.

It is not good at promoting health. That is a bad thing. It is good at taking money from all of us for its benefit. That is a corrupt and inefficient, as well as bad, thing. It is an agent of inequality. For most of us, that is a bad thing.

And yet it persists. And its enablers include the Democratic leadership, which resolutely continues to refrain from challenging the profits of the insurance and pharmaceutical industries. They sometimes talk about how it’s a bad thing, but then so does Trump, and sadly it seems that Trump is often more sincere. The latest proposal for spending money on protecting people by the Democratic leadership is to pay for people’s COBRA (this is where you can continue to keep your former employment-based health insurance for a time when you are laid off by paying the whole premium yourself). A good thing if you were going to lose your health insurance, for sure, especially if now, not working, you can’t afford to pay not only what YOU were paying but also your employer’s contribution. Not a bad start. But, somehow, one would hope for a better, more proactive, more comprehensive, and most important more effective solution to this crisis than just paying money to insurance companies!

The media has talked about the Democratic Party and its presumptive nominee, Joe Biden, coming a bit closer to the universal health, single-payer, Medicare for All (#Medicare4All) proposals endorsed by Sen. Sanders; a recent NY Times article tells us that ‘Biden's new proposals include expanding Medicare, government insurance for Americans over 65, to those 60 and older.’ Bold! Not! Yes, it is good that people who are 64 years old will not have to risk their lives waiting to turn 65 – that would become the province of 59 year olds! It certainly would not begin to solve the problems of the health system that are apparent to all of us, not just to Case and Deaton. It leaves the uninsured uninsured, the underinsured underinsured, the folks bankrupted by co-pays, deductibles, and surprise bills (especially those from catastrophic costs, mainly a problem for the middle-income with employer-based health insurance, per the Commonwealth Fund) bankrupt, and the insurance companies fat and happy.

It is not a solution, and the only thing audacious about it is that Biden and his campaign even dared to put it out there. We are told, by all the candidates who have dropped out, by all the liberal pundits, even by progressives, that if we want to defeat Trump and incipient fascism, we have to all come together and vote for Biden. If we do, we need to see meaningful movement to put the interests of the people ahead of those of the healthcare-industrial complex, as leaders like Alexandria Ocasio-Cortez have called for.  We need to see meaningful proposals from the Democratic standard-bearer.

In fact, we need to see him. Anyone seen Biden recently?

"Single Payer", "Medicare for All": Good ideas and about time!

The call for a universal health care system in the US is probably greater than it ever has been. While, of course, the Republicans, whose only firm position is completely kowtowing to billionaires and major corporations, are opposed to it, many Democrats have signed on to the “Improved and Expanded Medicare for All” bill in Congress (120 at last count). Democrats running across the country have been calling for “single payer” as well as “Medicare for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in NY (and of course Bernie Sanders) to moderate Democrats running in states and districts that Trump won. They correctly see this as an issue that cuts across traditional liberal-conservative lines, and even racial lines, and may be their path to victory.

Many Republicans (although not the Republican congressional leadership) are reading the same tea leaves, and are hedging, trying to say that they favor the things that people like about the ACA (most important, the protection against insurers denying coverage for pre-existing conditions). Of course this often requires major dissembling for those who, like our Arizona GOP candidate for Senate Martha McSally, voted to gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz Amendment” that would strip virtually all protections for people under ACA. President Trump, never one for nuance, has no difficulty having it both ways: he calls for the repeal of ACA while insisting that his health care plan will protect people’s ability to have health insurance, pre-existing conditions or not (it won’t).

It is in this context that the recent Sunday NY Times’ Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t get too excited” about Medicare for All’ becomes important. For starters, “Don’t get too excited” is not necessarily the opinion of the authors but a quotation from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one of his Nashville constituents, Dr. Carol Paris, President of the leading physician advocacy group for single payer, Physicians for a National Health Program (PNHP), that he had signed onto the Medicare for All bill. Nonetheless, the article does raise many cautions about the movement to single payer or Medicare for All, mainly about different interpretations of the meanings of this by different advocates, and incomplete and sometimes inaccurate understanding of them by regular people. The most important thing about it, however, is that it had to be written at all because there is such a movement; long-time activists, including PNHP physicians, remember that it was not too long ago that such an idea was poo-pooed, dismissed. Not now.

Clearly, the quantum step forward was the 2016 presidential campaign of Bernie Sanders. The establishment pundits of both parties were shocked at how popular and successful this old Jewish socialist from Vermont (ok, originally Brooklyn) was across the country. He didn’t win the Democratic nomination, true, but he might have won the general election against Trump. Certainly, his straight talk and the fact that he directly addressed the felt needs of regular people was the main reason for his popularity, and people’s fears about their health risks and costs were central to this (see A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care, October 16, 2018). Bernie had advocated for single payer for decades, as had great leaders before him including the late Representative Ron Dellums of California (see Ron Dellums: Loss of a great leader and a job for the rest of us, July 31, 2018), but the visibility of his presidential campaign skyrocketed the visibility of single payer.

Rosenthal and Luthra utilize a good bit of ink describing what single payer is --the government is the only payer for health care, rather than multiple private insurers; Canada is the best example of this, and Britain has a government-owned national health service. They also note that Medicare for All means exactly that, that everyone, not just those over 65 and the blind and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be single payer. They describe the misconceptions people have (“would I be able to keep my present plan?”), and also talk about other countries, such as France and Germany, that have universal health care without a single payer but with a heavily-regulated marketplace. They observe that partialist solutions do not generate the enthusiasm of single payer, but that the latter would be the hardest and thus (perhaps) most difficult to institute. Among the concerns they note are the displacement of insurance company employees and the decrease in doctors’ income.

But these are the most important points.

1.       Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43^rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
2.   Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
3. Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.

These are the core issues that need to be addressed, and what sets the US apart from all other developed countries. Yes, Canada has a single payer system such as we might have with Medicare for All (and they even call it Medicare). Britain has a National Health Service, with most hospital and health care facilities owned by, and some doctors employed by, the government. Britain, however, allows private insurance for those who can afford it, Canada does not. France and Germany and Switzerland have multiple insurers, but they are not unfettered to maximize profit by denying care. In Switzerland, for example, insurers have to be non-profit, have to offer the same benefits, and have to charge the same amount. They compete on quality of service! Can you imagine that here?

So, while Rosenthal and Luthra repeat the idea that single payer, although the most enthusiasm-generating, would involve the biggest change, it is also, in another sense, the least complicated. Trying to get to a system like that that evolved in these other countries over decades will be more complicated to understand and to implement. Many of the suggestions for incrementalism (“Medicare for More”, “public option”) will not solve the problems we have because they do not include everybody, and because they do not eliminate the incentive for making money on the back of denying care that is the core flaw in our current situation.

“Medicare for All” and “single payer” are popular among people because their core meaning is understandable, and they would address the needs that they have.

• ·        Everybody in, nobody out!
• ·        No profiteering!

Simple message. Needed solution.