COVID Vaccine and Privilege: When is it not about you?

Recently, an article from CNN, “A vaccination site meant to serve a hard-hit Latino neighborhood in New York instead serviced more Whites from other areas”, was posted on a medical social justice page of which I am a member. Among a number of others, I expressed my displeasure at this, but I also posted a comment in which I unfortunately said “People are scum”. It did not specifically refer to the white people who had obtained these vaccines, perhaps inappropriately, but certainly could be seen as that. I was called out for that comment, and that was appropriate. People are not scum, for better and worse. Scum is a substance that exists without intentionality. People, however, do have intentionality, and that can make them do things that are very good and very bad and everything in between. Certainly, doing something bad, or wrong, does not make a person bad; many religions have doctrines that are more or less comparable to “hate the sin, love the sinner”.

More to the point is whether the people referred to in the article did anything wrong or objectionable at all. While those quoted in the  article were very critical of this behavior, some of those posting comments on the page felt that these people (presumably people who otherwise met the current criteria in NY for the vaccine, by age or health status) were just trying to do what they could, and not trying to use their privilege to obtain vaccine intended for the minority community. They agreed that the system, and the structure for distributing the vaccine was severely flawed and probably inequitable, but that the individuals pursuing the vaccine should not be condemned. They acknowledged that some people, by virtue of education, wealth, computer-savvy, connections to other family members who may be more computer-savvy, and other characteristics, are more able to avail themselves of benefits. Even when this results in preferentially vaccinating white people rather than the minorities for whom it was intended (by placing vaccination sites in minority communities), it does not mean those individuals (many of whom are sick and elderly) are doing a bad thing, still less are bad people, or certainly scum. Nonetheless, the result is the result; the New York Times on January 31, 2021 reports that “Data showed that while 24% of city residents are Black, only 11% of vaccine recipients were. White New Yorkers received a disproportionate share of the shots.

The CNN report was not the only one critical of people “jumping the queue”. In a NY Times Op-Ed on January 28, 2021, Elisabeth Rosenthal MD, editor of Kaiser Health News, writes “Yes, It Matters That People Are Jumping the Vaccine Line”:

For weeks Americans have watched those who are well connected, wealthy or crafty “jump the line” to get a vaccine, while others are stuck, endlessly waiting on hold to get an appointment, watching sign-up websites crash or loitering outside clinics in the often-futile hope of getting a shot.

She adds, agreeing with some of the points made by the commenters on the site, “I don’t blame the lucky recipients; after all, hospitals would just offer the unused vaccine to the next person on the list,” but also notes that “The problem is that often, people are not really being “offered” the vaccine; in some cases, they are grabbing it through position, influence or deceit.” How often? I don’t know, and probably Rosenthal does not either. Or, for that matter, those who posted comments on the page, although they seem to be from NY and likely to know a lot more about the situation there than I do.

Most likely, the predominantly white recipients of the vaccine being offered in minority neighborhood represent a spectrum of people. They would include those who consciously believe that they are special and privileged and deserve to be at the head of the line, those who believe in equity but let that concern be overcome by their self-interest, and those who are appropriately candidates for the vaccine in the current phase but are desperate, confused, and, with no negative or ignoble intent, found their way to that place and time. Defending the latter, however, does not excuse the former, and there are certainly many of them. Freeman’s Law (which I should probably rename “Freeman’s First Law” so as not to confuse it with Freeman’s Second Law, to which I referred in my blog post of January 28, 2021, “Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems,”) states that in any program designed to help a group of people, no matter how narrowly defined, those with the relatively least need are most likely to benefit. Thus in a program designed, say, to help homeless pregnant teenagers with HIV living under bridges, those who have some greater resources (a bit more education, a slightly less traumatic childhood, etc.) will be the ones who are able to access it first. The larger the universe of people who are targeted, the more people who would qualify for services, the greater the disparity is likely to be. This is of course especially true in the case of COVID vaccine, where the target population is, ultimately, everyone.

Another aspect of the comments posted that was interesting to me was that they referred to those seeking to get the vaccine as “patients”. Perhaps this is understandable on a medical site, and it is quite possible that some of those involved were patients of those doctors who made the comments. I have sometimes been critical of the use of the term “patients”, noting that it was the “medical” word for what in English are called “people”, and that it could tend to diminish their humanity. I am quite sure this was not the intent of those using it, but in this context it has quite another flaw. Calling folks “patients”, especially when they are not your patients, carries a connotation of dependency, needing help from their doctor. Calling them “people” implies more that they have agency, the ability to make decisions, prioritize needs and values, and act on them. While it is often true that many people, particularly the sickest and oldest and least educated and least empowered do need help, it is also true that when the affected universe is the entire population, it includes all of us, all people, adults and children, young and old, Black and White, rich and poor, doctors and “patients”. It includes those who are the wealthiest, most educated, most connected, and most empowered, who are often find ways to get to the head of the line. Thus, prioritizing who should get the vaccine first and enforcing that is critical. Social justice is about promoting equity, which means giving more help to those who have the least and need it the most, and reducing the temptation to give in to those whose privilege or loud voice is most demanding.

Rosenthal writes:

The United States has allowed its public health system to become a hollowed-out underfunded mess, and many vaccination clinics are being run and staffed by contracted private companies. And the private sector has so far proved too vulnerable to private favoritism.

Until the supply is sufficient, the government needs to give the shots to the people and places that need it most, and find ways to ensure that the plan is followed; the system could prioritize ZIP codes that have high Covid-19 infection rates or target low-income populations who might otherwise have a difficult time securing an appointment.

She is absolutely correct, but clearly targeting certain ZIP codes is not sufficient, as the Times describes on February 2, 2021 in ‘Even in Poorer Neighborhoods, the Wealthy Are Lining Up for Vaccines’ (Feb 3 print title: ‘Where poor suffer most, wealthy find vaccines’). And a 52-year old celebrity on-line fitness trainer got the vaccine as an ‘educator’.  Meanwhile the COVID surge most hurts those in the poorest neighborhoods, as in LA. And people behaving as though the doors were opening at a department store the day after Thanksgiving is not just a NY problem. a friend in another city, on seeing the pushing and shoving, both literal and figurative, that went on when they went to get their vaccine, said “I wouldn’t want to be in a concentration camp with those people.”

The problem, if you think it is a problem, of empowered people going to poor neighborhood to get their vaccines is real and ongoing. I think that folks who do so are doing a selfish thing, a bad thing. This in itself does not make them bad people, or certainly scum. However, for the record, I personally believe that there are indeed bad people, and that doing enough bad things often enough, predictably enough, and bad enough does make someone a bad person (see, e.g.,”Nazis”).

We should have compassion for those with need, and the most compassion for the greatest need. And recognize that “me” is not the hallmark of social justice.

COVID-19 and protecting healthcare workers

The world, and the US, have entered unchartered waters in recent history as a result of the COVID-19 epidemic. Obviously, the deaths of people who would not otherwise have died is the most important. The real economy (forget the stock market) is a disaster; in this country 3.3 million people applied for unemployment insurance benefits one week only to have it double to 6.6 million the next – the previous high was less than 700,000. The responses of governments – national, state, local – to the epidemic, and the degree to which they rely on actual science, is another huge issue.  Here I seek to address one part of the crisis, one tension, the protection of health care workers, including doctors and nurses.

For starters, we have the issue of the actual health of these individuals. The reason for placing special emphasis on the protection of them is not because they are better or more important people than others, but because we need them to care for the sickest of us, those whose illness means that they cannot safely “shelter in place”, and need to come to urgent care centers, doctors’ offices, emergency rooms, and hospitals. Health care workers, particularly in hospitals, are personally more vulnerable because they have ongoing, repeated exposures to the virus. Greater levels of virus, from one or multiple exposures, increase the risk that a person will not only become sick, but become sicker, as discussed in ‘These Coronavirus exposures might be the most dangerous’ by Joshua Rabinowitz and Caroline Bartman in the NY Times April 1, 2020, and healthcare workers in hospitals have repeated exposures.

In addition, of course, we need these people to care for the sick, because they are the ones with the skills and training to do so. Thus, they need to be protected as much as possible. The news has been full of stories of this not happening, of hospitals not providing necessary Personal Protective Equipment (PPE) to its providers, and even punishing those who bring their own (with the bizarre idea that it is not fair to the other workers who do not have it). Our healthcare providers need to be protected, not punished for identifying flaws in the system (Nicholas Kristof, April 2, 2020, ‘”I Do Fear for My Staff,” a Doctor Said. He Lost His Job.’). Doctors, nurses, and other healthcare workers have often been lauded by the public (the practice of applauding out the window, begun in Italy, is especially touching), but punished by their employers. (Others, such as Capt. Brett E. Crozier of the aircraft carrier USS Theodore Roosevelt, are also being punished by their bosses for doing the right thing.) And these people are, although health professionals, also people, with families and with risk (Sandeep Jauhar, ‘In a Pandemic, Do Doctors Still Have a Duty to Treat?’. Heroes are great, but dead heroes are still dead, fired heroes are still fired, and dead or sick healthcare workers cannot provide care to others.

One of the most elementary pieces of PPE is in great shortage: the effective N-95 masks that every healthcare worker, certainly those in the hospital, should have on all the time. Some of this is because our overall national response has been anemic, and production has not ramped up quickly enough, and some is because hospitals have adopted the “just in time” approach to acquiring equipment popularized by corporations like Toyota and Ford. It may work for cars, and it may be profitable and efficient for hospitals in normal times, but like so much of our “normal” capitalist system it is fatally (quite literally) flawed when stressed by a real crisis. This fault has been augmented by individual profiteering -- well over a month ago the staff in my local Home Depot laughed when I asked about them; they told me they had all been bought up when COVID-19 began in China, by “entrepreneurs” who sold them to Chinese on eBay. True? I can’t know, but there sure were none available. One thing that the rest of us can do is to ensure that essentially ALL new N-95 masks should be available for healthcare workers, especially those in hospitals. Other people should not be wearing, not to mention hoarding or scalping them. Don’t get some to wear when you go out. Stay home. Especially if you’re symptomatic. Stay away from others. Social distancing is something we can practice, and healthcare workers cannot. What about other masks, “surgical masks”? They won’t protect you much if at all from acquiring the virus, but may help (if you can find them, or else use a bandana) protect other people from getting the virus from you if you are infected but asymptomatic. Of course, if you are symptomatic, you should not be going out at all -- unless you are so sick and short of breath that you urgently need to go to the hospital, in which case, wear a mask.

Sometimes this balance between our own self-interest (I need to go out and an N-95 mask protects me) and society’s interest (healthcare workers need the N-95 masks) is difficult, but it is decision that should not be hard. You, me, or our family members, may be the ones who would have been cared for by that doctor or nurse if they weren’t lying in the next bed because they didn’t have the mask we wore to the grocery store.

But some other decisions are harder, like deciding who should get access to a ventilator when there are far too few for everyone who needs one. In their generally good opinion piece (April 1, 2020), Protect the Doctors and Nurses Who Are Protecting Us: They need immunity from lawsuits and prosecution for triage decisions, Cohen, Crespo, and White argue for laws to protect doctors making difficult decisions protection from lawsuits or criminal charges for making them. This is a very good idea. They make two very important points. The first is that there need to be formal criteria established for triaging access to scarce resources so that we do not just have individual doctors making individual decisions, but rather following well-thought-out guidelines. The other is that those decisions need to be legally protected. They cite   

A Maryland statute [that] makes health care providers “immune from civil or criminal liability” for actions they take “in good faith” during a declared “catastrophic health emergency.” According to the Maryland Attorney General’s Office, this statute immunizes clinicians who follow state-approved ventilator allocation protocols, “regardless of the negative consequences arising from the withdrawal of a patient’s ventilator.”

This is a good idea, and one that should be adopted by all states.

But these writers also note that “Denying some patients short-term ventilation, against their wishes, will probably cause them to die when they might have gone on to live long and healthy lives with the treatment. But it will also make limited numbers of ventilators available to other patients who are more likely to survive.” Fortunately, this is not yet really the situation we are in, having to decide which “people who might have gone on to live long and healthy lives with treatment” should be left to die. But we will be, and are in places like New York, in a situation in which decisions will have to be made that deny some patients who would NOT have gone on to lead long and healthy lives ventilation to allow their use for other patients who are more likely to survive.

People who have pre-existing terminal diseases from which they would have died anyway, or those with dementia who are never going to have normal healthy lives (and cannot make their own decisions) will be, and should be, the last people to receive ventilator treatment. Hopefully, this will not be “against their wishes” (or those of their family, if their dementia makes it impossible for them to express those wishes), because they recognize the sense of this. When people have a terminal disease, and/or are suffering from dementia, coming to grips with dying and when it is time to say “enough” even if there WERE sufficient ventilators, is something that should have been addressed already, by the patient, family, and physicians. Of course, none of this argument should suggest that criteria other than pre-existing health status and the likelihood of a full recovery should be considered in allocating resources; certainly not income, wealth, insurance status, race, disability of any kind that is not associated with an expectation of dying soon, or even age in and of itself.

COVID-19 has affected, or will affect, (as the southern hemisphere enters winter) the whole world. We are all in it together. In fact, of course, we are always all in it together, but the pandemic has exposed the flaws in individualistic arguments. I am not going to write that we can “beat this” because I don’t know, but we can behave in wise and responsible ways to keep the terrible consequences a little less terrible.

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.

The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.

That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!

Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.

We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.

What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)

In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.

To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.

The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.

We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

Integrating health systems must be to improve quality, not increase cost

The February 13, 2014 article in the New York Times by Elisabeth Rosenthal, “Apprehensive, many doctors shift to jobs with salaries”, more or less just presents the facts. It notes that the medical placement firm, Merritt Hawkins, says that 64% of jobs this year are salaried as opposed to 11% in 2004, and that it expects it to go up to 75% in the next two years. She cites AMA figures that “…about 60 percent of family doctors and pediatricians, 50 percent of surgeons and 25 percent of surgical subspecialists — such as ophthalmologists and ear, nose and throat surgeons — are employees rather than independent.” In some places it is more dramatic; in Kansas City, there are no longer any cardiologists (a type of internal medicine subspecialist) who are not employed by hospital systems, and oncologists (cancer specialists) are not far behind.

So, is this a good thing? The article suggests yes, but maybe not entirely. It states that “Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test,” and I agree, and that “When hospitals gather the right mix of salaried front-line doctors and specialists under one roof, it can yield cost-efficient and coordinated patient care. The Kaiser system in California and Intermountain Healthcare in Utah are considered models for how this can work,” with which I also agree. However, not all health systems are Kaiser or Intermountain Healthcare. The article continues: “But many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital ‘facility fee’ is tacked on.”

Rosenthal has written about facility fees before, as has Alan Bavley of the Kansas City Star in his “Doctors, Inc.” series (“’Facility fees’ add billions to medical bills”, Dec 29, 2013), and I have commented on it in Changing the structure of health care delivery systems: to benefit the patient, the providers, or the insurers?, January 14, 2014. The new arrangements promise more money, or at least stable incomes, to physicians, and continue to pay the currently-most-highly-paid specialists the most money, with primary care doctors getting less. This is not because hospital systems have anything against primary care, but rather that they are following the money, and these acquisitions have occurred precisely while we are still under fee-for-service reimbursement in most locations. If cardiology or orthopedic or radiologic or neurosurgical procedures bring in great amounts of money to the hospital (“technical fees”) the hospitals like this, and are willing to share some of that money with the doctors to ensure that they keep their patients in their hospital or health system. Primary care does not generate such largesse. Relatively intelligent systems recognize that they need a locked-in “primary care base” to create referrals to their subspecialists, but will pay as little as they can, and demand “high productivity” (which could be seen as “patient churning”), and it is not just primary care: “many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.”

Bloomberg News has a more direct take on this phenomenon, stating firmly in an article by Shannon Brownlee and Vikas Saini that “Bigger hospitals mean higher prices, not better care”, February 18, 2014. They cite data from sources such as the Dartmouth Atlas of Health Care, a recent article in Health Affairs[1] which demonstrated that “On average, higher-priced hospitals are bigger, but offer no better quality of care,” and a variety of lawsuits by public agencies (such as the Massachusetts Attorney General) to demonstrate that hospital acquisitions are about market share and control of practices and, ultimately, about money, not quality. “If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.” As I have written about before, doctors control a lot of costs in the health system, by choosing the tests that they order, deciding whether to admit to the hospital or not, and where they refer. By employing the physicians, hospitals can not only control the latter, but can set criteria requiring physicians to abide by hospital policies on the others. The doctors then become, in the words of this article,  “…another cog in the corporate machine, and many physicians have told us they feel they must skew their medical judgment to keep their jobs.”

This is the nonsense that occurs when things are done piecemeal. Intermountain Health Care and Kaiser are not perfect, but they have used their status as integrated health systems to control costs and increase efficiencies. To the extent that they are also the insurer, it is in their interest to do so. Efforts by the federal government to have others emulate these models through the creation of Accountable Care Organizations (ACOs), without changing the manner of reimbursement, are bound to fail. As Paul Baladian is credited with saying “every system is perfectly designed to get the results that it gets.” If we are getting a system in which hospitals are buying up physician practices so that they can charge insurers, from Medicare to Blue Cross, more; if we are getting a system in which medical decisions are being made in the best financial interests of hospitals rather than the best health interests of patients; if we are getting a system in which we continue to favor some patient over others based upon their income, insurance status, or their type of disease (middle-aged well-insured person who needs a single joint replacement = “good”, older person with multiple chronic medical conditions and “just” Medicare or worse yet uninsured because they are under 65 or undocumented = “bad”), it is because we have perfectly designed it to be so.

Brownlee and Saini offer some suggestions for solutions. They suggest that Medicare expand its “Advance Payment Model,” a program that provides capital to small or rural physician groups, and also particularly about forming multispecialty Accountable Care Organizations driven by primary care.

“Until we give primary-care groups control over what happens to patients, large hospital systems and specialist-dominated groups -- those with greatest access to capital -- will be able to keep raising prices, even as they issue press releases about their plans to control costs and improve care.”

Sounds like a good idea to me. Combine that with a single-payer system that covers everyone, “everybody in, nobody out!” and we may be able to reverse the trend toward higher profit at the expense of lower quality.

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[1] White C, Rechovsky JD, Bond AM, “Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs”, Health Affairs, January 2014 10.1377/hlthaff.2013.0747.