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?

Cui bono? Is healthcare financing about funding providers or caring for patients?

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In a recent blog, GME funding must be targeted to Primary Care, December 10, 2011, I wrote about the fact that the financial interests of hospitals lead them to choose to support residency training positions which are not necessarily (or often, or usually) in those specialties that the nation most needs. I urged that funding from the government for graduate medical education (primarily through supplements to Medicare and Medicaid) include mandates as to the proportions of trainees in different specialties, with a strong emphasis on training more primary care physicians. This is only one area, however, in which the financial incentives to hospitals, and indeed all health providers including physicians, do not always jibe with the healthcare needs of our population.

A recent spate of news articles has discussed changes in the organization and financing of healthcare services. The New York Times recently covered the conflict between the governor of the state of New York, Andrew Cuomo, and the mayor of New York City, regarding the potential conversion of Emblem Health to a for-profit company (Bloomberg Predicts Fair Deal if Health Insurer Gets For-Profit Status, by Thomas Kaplan, December 23, 2011). Cuomo wants it because it could bring as much as $1B in tax revenue to state coffers; Bloomberg is concerned because Emblem is the insurer of the majority of municipal employees and he expects such a move will drive premiums up. But, as the title of the article suggests, he thinks they can work it out. Between them. For the benefit of both the city and state governments. Not, however, for the people insured by Emblem. Emblem was created by a merger of Group Health Insurance (GHI) and Health Insurance Plan (HIP) of Greater New York, two early not-for-profit HMOs, or managed care organizations. Except they were created before either term, HMO or managed care, existed. Back in the 1950s, these were consumer cooperatives, where it was recognized that by cutting out the (for-profit) insurance company middleman, people could have more care for the same money, or the same care for less money. No wonder the majority of city employees enrolled.

Over time, rebranded by the Reagan administration with the new name of “HMO” or managed care, became the de facto standard for US health care coverage. Why Republicans could buy into this vaguely populist or socialist concept was that the new HMOs would increasingly be owned by for-profit insurance companies, which they could literally buy into as shareholders. The savings that came from managing care would now accrue to the insurer, not the patient-owner-members. Many of the long-standing HMOs of the early period (e.g., Los Angeles’ Ross-Loos) were purchased by insurance companies, but there were a few holdouts that remained consumer cooperatives (e.g., Group Health of Seattle and the groups that became Emblem). And then, as we remember, came the consumer backlash against HMOs in the late 1990s, with people furious at the restrictions these organizations put on their access to health care. The mistake, however, was thinking that the problem was the organization of care with requirements for only approved therapies, relatively “closed panels” of doctors and hospitals, and capitated payments. The problem was that they were, and are, mostly owned by for-profit corporations, which increase their profits every time care is denied. This is a very different incentive than when the owners are the patients themselves through a cooperative.

As time went on, even the non-profit HMOs and other non-profit groups like the Blue Cross / Blue Shields that are not part of the for-profit Anthem/Wellpoint, have had to act like for-profits to compete. The advantages have all been for the insurers, which remain very profitable, not for the patients, who find both many of the same restrictions they bridled at in the past, and, in addition, increasing premiums, co-payments, and deductibles. If Emblem becomes for-profit, Michael Bloomberg may be able to work a deal where the city government is spared a major premium increase, but the city workers who are insured by Emblem will not be so lucky. In a typically excellent “Quote of the Day”, Don McCanne, MD, discusses the fact that the National Business Group for Health (NBGH) is predicting major increases in deductibles for all employees. As reported in an article in the Nashville Tennesseean, “High deductible plans on the rise”, by Tom Wilemon, December 27, 2011, “Helen Darling, its [NBGH] president, predicts that by 2016 the majority of all health plans will have high deductibles.” McCanne notes correctly that the members of NBGH are the nation’s largest corporations, mostly Fortune 500 companies, which have historically had the best health insurance coverage for their employees. If these deductibles – the amount a family has to pay out-of-pocket before any insurance coverage kicks in – rise to $1500 a year, it will be much worse for those working for smaller, less prosperous companies.

McCanne also comments on reports from the AMA that Highmark, the large Western Pennsylvania Blue Cross / Blue Shield affiliate, will be purchasing its own health system, where it will be able to profit on both ends, or, at least not pay as much for care. He observes that this will enhance its financial status, but not benefit patients, who will be preferentially locked into care at West Penn. The greatest complaints are from the competing University of Pittsburgh Health System, which believes it will Iose patient revenue from such an arrangement. So the conflict here is between the benefit for one health system versus another. It is not benefit for state versus city government as in the Emblem case, but it is still not about the health of the people. It continues to be about how the money from healthcare is distributed among the various players, including as insurance companies, hospitals and doctors.

My hospital, the University of Kansas Hospital (UKH), has done very well financially. In the most recent “Book of Lists” sent to subscribers to the Kansas City Business Journal (not on line; a copy will cost you $65, or $169.95 for immediate download!), it had the greatest revenue in the Kansas City area, at over $2.5B, more than $1B ahead of #2. The physicians who staff the hospital, faculty of the University of Kansas Medical Center, are seeking a restructuring of the current affiliation agreement to share more of that revenue with the doctors. As one of them, I do not disagree with the concept that the physicians, whose work generates much of the revenue, should share more equally, but, as with West Penn and University of Pittsburgh, this is about who gets what, not about how to provide better healthcare for less money to more people.

Health industry consulting groups, such as the Advisory Board, warn hospitals that there will be major cuts to their income resulting from federal budget cuts and programs such as pay-for-performance (P4P) and “value based purchasing” (this is “value” in the economic sense, that is cheaper, rather than having anything to do with “values”, such as caring for the sick!) Hospitals like UKH worry about whether their up-to-this-point successful strategy of investing in the highest-profit “product lines” such as heart disease and cancer will continue to work in the changing reimbursement system. They sense a pressure, as do physicians, to enter into “health systems”, collaborations, to maximize efficiency and profit (or at least not make much less than they are). There is a certain irony in pressures to re-create the managed care era.

But, because that “re-creation” is still about how hospitals, doctors, and insurers can make money, not about how we can provide the best health care for the most people, it is re-arranging deck chairs on the Titanic. If, when, we hit that proverbial iceberg and the ship goes down, many people will be hurt. Sure, just as on the Titanic, it will be the poor people on the lowest decks who get hit the worst. Then, the middle class. And even some of the rich, and some of the officers will go down. But, if you are a betting person, you bet on the most privileged being the most likely to survive; you would have been right in on the 1912 sinking of the boat, and you’d be right 100 years later in health care.

One day maybe we will develop a health policy that engenders behaviors that are about providing the best health to all of our people.
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