Healthcare and Public Health: Issues from 2024 will continue into 2025

As we end the year and begin a new one, what can we say was the most important health-related story of 2024, and what will be the biggest in 2025? Certainly, late in 2024 a huge story was the murder of Brian Thompson on the streets of New York. This was not in any way a random killing, but an assassination of someone the killer believed was responsible for hundreds or thousands of deaths in his role as CEO of UnitedHealthCare, the nation’s largest health insurer. As I discussed in my December 8, 2024 post ‘Murder of a Health Insurance CEO: People HATE the companies and the people who run them’, Thompson was guilty of presiding over a company whose role was to make money by collecting premiums and denying care. He also was guilty of having made this problem worse by bring in artificial intelligence algorithms, which had been shown to be wrong up to 90% of the time, to deny health care to his supposed customers – I say “supposed” because the only customers health insurance companies really have is their stockholders; the people they insure could be called “victims”. 

 Although much of the mainstream media tried hard to focus attention elsewhere – on the accused killer and his personality, on self-serving nonsensical essays like the one by Thompson’s boss, UnitedHealth Group’s CEO Andrew Witty run as a NY Times Op-Ed, etc. – the real story is the outpouring of fury at the health insurance industry from the great mass and majority of the American people. While most did not applaud the murder itself, virtually no one outside themselves and their paid punditry had anything good to say about US health insurance. Probably the overall public sentiment reflected that of Chris Rock: “He actually killed a family, a man with kids. I have condolences for the healthcare CEO. This is a real person, but sometimes drug dealers get shot.”

Another huge story, which will become even bigger in 2025, is the planned nomination by President-elect Donald Trump of profound enemies of public health to the positions responsible for ensuring that health. Foremost among these, of course, is Robert Kennedy, Jr. to be Secretary of Health and Human Services. Kennedy is well-known as a vaccine “skeptic”, which essentially means vaccine opponent, and if he is confirmed as Secretary and is able to implement policies reflecting the positions he has long advocated, we will see the resurgence of many diseases long gone from American life with accompanying deaths, as I discussed on November 15, 2024 in ‘Raw milk, vaccines, and RFK, Jr: Some dates worth remembering’. Remember polio? Measles? I do, but most do not. Check out the numbers on this picture. This is an incredible threat to the public’s health.

But, ultimately, the real story of 2024 – and probably 2025, and sadly beyond – is the fact that the American people remain the only ones in the developed, rich or really even middle-income, world that do not have universal health insurance or care. This is what would prevent the crises, delays, denials, and deaths that the private health insurance industry heaps upon our population and that engenders the wrath of so many. Indeed, that wrath continues to grow because the people who are affected, either personally or through someone they love such as a family member, who realize the inexcusable evil that the actions of these companies inflict, grows over time. While only a small percent of the ostensibly insured will have a terrible event each year, with more years more people and families experience such terrible events. Also, of course, the practices of the health insurance companies become more restrictive and more draconian, leading to both more delays and denials and deaths and more out-of-pocket costs for more people. In other countries, this happens, essentially, very little or not at all. The following chart presents the dates when other countries implemented universal health care, and when they got rid of it because it wasn’t working. Look at it carefully and you might discern a trend:

The US has a higher mortality rate than many of these countries. Jim Kahn, in the Health Justice Monitor, makes an effort to quantify the extent to which health insurance (or lack of it) contributes to this. It is an estimate, but as he notes, whether 170,000 or 220,000, it is too much. And, more, we spend much more than all these other countries on what we call “healthcare” despite so much of it going to corporate profit, that the fact that there is any excess mortality due to lack of health insurance is even more intolerable.

This might come as a shock to many Americans, especially those who have yet to personally experience the delays, denials, and deaths that the for-profit health insurance industry heaps upon its victims, because we are regularly and consistently told by politicians and pundits that a universal health insurance system would be a bad idea, that it wouldn’t work for Americans. That it would be too costly. That it would limit our freedom. We need to recognize that this is not true. Few of us want to have the freedom to choose which insurance company takes our money and then tries its best to limit our access to care (although, if we can afford it, we might choose the one that does it least). What we do want is the freedom to choose the doctors and hospitals that we believe will provide us the best care for our health needs and have our insurance pay for it. Of course, this is not the freedom that they are talking about; what they mean is the freedom of insurance companies (and to be fair, many health care providers) to make as much money as possible, which is what would be limited in a universal government-run health insurance system. And, oh, by the way, provide the funds to pay for it. Imagine that our health care dollars, from our pockets and those of our employers and our government (from the taxes we pay; the large corporations and billionaires who own them don’t) could be spent on providing us with health care rather than lining corporate pockets!

There are actual examples of “single payer” health care in the US. Military retirees and families are covered by government-funded health insurance through the VA or TriCare. In the military itself, for active duty service members, health care is not only single-payer, it is government run. The other big example of single-payer available to Americans is traditional Medicare, for those over 65 or disabled. Medicare. The most popular government program since…Social Security. Under traditional Medicare, health care services are approved for people who need them and have them ordered by a doctor, not micromanaged for each individual with people (or AI!) denying them willy-nilly. In an alternative to Medicare, people can opt for enrollment in an HMO/PPO like system run by the same insurance companies that insured (and often screwed) them before they became eligible for Medicare, and have it paid for by Medicare funds. This program, misnamed “Medicare Advantage”, takes away the guarantees of traditional Medicare and puts you back a the mercy of those for-profit health insurance companies that have treated you so well before!

This is exactly what we don’t need – erosion of Medicare. We need Medicare to be improved, to pay for 100% of all needed medical care, and expanded to cover every American, cradle to grave, paid for by the money now going to insurance company and pharmaceutical and device company and health system profits. The reason to do it is because it would benefit people, remove the major cause of heartache, loss and bankruptcy in the US, and make us more secure and happy people. The reason not to do it is that these huge corporations would no longer be making their exorbitant profits by taking premiums and denying health care, and thus would not be able to make such large contributions to the legislators who should be acting, instead, for the American people.

What do you want? Maybe in 2025 it is time to let your legislators know!

 

A final thought from Bernie Sanders:

 

 

 

 

Medical errors should not be prosecuted as crimes: Systemic change is needed

As reported recently in MedPage Today, Kentucky has become the first state to pass a law shielding medical professionals from criminal prosecution for clinical errors. This is important. It is a good thing and had the support of many professional organizations. It is not about protecting nurses and doctors who actually commit crimes, as ‘it does not apply to "gross negligence or wanton, willful, malicious, or intentional misconduct."’ For example, the Pennsylvania nurse convicted of murdering patients with insulin would not be covered by this law. But mistakes happen, and while they can have very bad outcomes in the medical setting – including death – when they are not intentional they should not be prosecuted as criminal acts.

The case cited as motivating this law occurred in the neighboring state of Tennessee, and involved a nurse named RaDonda Vaught at Vanderbilt Medical Center. She mistakenly gave a paralytic rather than a sedative with a similar name to a 75 year old woman, causing her death. She did not try to cover it up but reported it immediately, and yet was charged with and convicted of reckless homicide and impaired adult abuse. The outcome, the woman’s death, was terrible, but the criminal charges were neither justified nor functional. Yes, you can bet that the particular nurse would be extra careful the next time she gives medication – although, of course, with the criminal conviction she has lost her nursing license. Maybe it could be a deterrent to other nurses and doctors making inadvertent mistakes? Think about how well this works in other areas, about, for example, how a pedestrian or bicyclist being killed by a car in your town has suddenly made all the other drivers extra careful. Right.

Doctors, nurses, and other health professionals are already careful (barring the rare truly malicious exception, who is not covered by this law). The issue is how to make it increasingly difficult to make mistakes, to make errors. A whole field of health safety and error prevention exists, originally stimulated by the work of W. Edwards Deming and Avedis Donabedian, and including such luminaries as the Institute for Healthcare Improvement (IHI) and founders Donald Berwick and Paul Batalden, and Harvard professor Gordon Schiff.  One thing that is clear is that the solution is not draconian punishment of those who have made mistakes. It is mostly (almost all) about systems, about making it difficult (and some day, hopefully impossible) to commit errors. Deming said “To find the mistake is not enough. It is necessary to find the cause behind the mistake, and to build a system that minimizes future mistakes”. Every mistake is a gem, because it offers us the opportunity to discover the cause and to develop systems to prevent that, and similar, mistakes in the future.

Many systems have been developed in many places and areas of healthcare to do this. For example, in pharmacy drug lists, similar sounding or spelled drugs are often distinguished by having the letters that are different capitalized, calling attention to it and making it less likely to prescribe the wrong one. Surgery now almost never takes place without a final “timeout” in which a checklist is gone through with all the operating team present, including “which side are we operating on”! There are many more examples. In the field of occupational health, the first choice in preventing injuries is architectural, e.g., don’t put a big window next to a place on the shop floor where slippery substances are spilled. The second choice is engineering: ok, the window is there, so let’s put up bars across it so if people do slip they don’t go through. The last choice is behavioral: tell the people who work there to be careful! If this last sounds unlikely to be completely successful, it is both the most common and the least effective. Imagine your being responsible for changing the behavior, consistently and always, of a person. Now make that everyone! Think back to drivers…

It is true that many, maybe most, healthcare facilities are and have been working to improve quality and limit the number of possible places that workers can make mistakes, but these procedures are processes and must continually be upgraded and enhanced, primarily by identifying mistakes that continue to be made and figuring out how they can be prevented. Quality improvement is not something that can be “put in place”; it is both a state of mind of individuals and most importantly an overarching commitment on the part of the institution, in all places. Yes, it costs money – but so do the lawsuits that come when it is inadequate, and that should not be the motivation.

Although making money is a strong motivation. Insurance companies, for example, are very good at instituting procedures that make them money. ProPublica recently published an article about Dr. Debby Day, who was one of the physician reviewers at CIGNA, tasked with reviewing the decisions about approving or denying coverage for people’s care, after the initial decision was made by a nurse reviewer (mostly working in the Philippines). CIGNA continually monitored the number of minutes taken for each review, and physicians like Dr. Day were sanctioned or even fired if they took too long. They took too long making decisions that could not only affect people’s health, but their life and death. Your life and death. Your family’s. How were they supposed to keep up with the speedup expectations? ‘“Deny, deny, deny. That’s how you hit your numbers,” said Day, “If you take a breath or think about any of these cases, you’re going to fall behind.”’ This makes CIGNA (and, to be fair ALL the big health insurance companies) money. The speedup is part of it, but the denials are where the real money is made. Denying ‘coverage for a cancer patient or a sick baby’. Your cancer. Your baby.

To be sure, insurance companies as such are not the actual providers of health care, like hospitals and doctors. Except, increasingly through vertical integration, they are – UnitedHealth, for example, owns Optum (and OptumRx, a pharmacy benefits manager). The thing is that they are corporations and are very good at putting systems in place to increase their bottom-line profits, even when that harms the health of – or kills – people who are their clients. So, I think, they should and can be equally effective in putting in place systems that protect and benefit those clients/customers/patients/people.

Hopefully, the type of law passed in Kentucky will become more widespread. This will make it more difficult for the prosecutors and politicians who want to make their “tough on crime” reps by such prosecutions, which is good. But also, hopefully, it will be combined with renewed efforts to strengthen the systems of quality control, and greatly limit the possibility of an individual making a mistake.

The health of people should be the goal of healthcare organizations.