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:

 

 

 

 

People are more important than profit. Period.

In his recent piece, ‘An Appropriate Anger’ on his Substack “The Reframe”, writer AR Moxon states that “All people have an intrinsic and indestructible worth that cannot be measured”.

He notes:  “That’s not true of everything, you know. If a car stops functioning properly, it’s no longer as valuable as it was when it was functioning properly…[but] It’s not that way with people who, as it so happens, are not things.”

I happen to agree with that, and honestly believe that most people do. But not everyone does. Moxon has some things to say about the businesses, and the people who hide behind the corporate logo, who clearly think that profit is more important than people and act on it. He particularly focuses on healthcare as he had a very scary event with a person close to him. But healthcare is a particularly good example of the core problem that he cites. Healthcare is a system which people want to believe, and often in the face of powerful evidence to the contrary do believe, exists to help them. In fact, it is actually an incredibly efficient and effective producer of profit for the industry, often at the expense of the health of the people it ostensibly exists to help.

What makes this worth continuing to comment upon is the ongoing, aggressive, and accelerating rate at which it is happening. No sooner can one say “well, this is bad, but at least we have X as an alternative” than X is taken away or modified into a profit-producing structure that decreases availability and quality of care for people while increasing their costs. And, as a result, harming their health. (Just in recent blogs I have written about ‘Why are we paying wealthy corporations billions to limit our healthcare?, July 23, 2023; ‘Older adults cannot afford healthcare even if they are insured: Time for a new system!’, Aug 22, 2023; ‘The problems with our US 'Healthcare' system are well documented. We need to start with the solution!’, Sept 3, 2023;  ‘Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people’, Sept 28, 2023).  The perpetrators of these evils – and they are evils -- are corporations including insurance companies, health care providers, and pharmaceutical companies, often now overlapping in a vertical integration, as for example with UnitedHealth’s ownership of the physician group Optum that now provides more income and profit than its insurance business! But the perpetrators are also the people that run those corporations and make their decisions.

Groups that study the healthcare system, such as the Commonwealth Fund and the Kaiser Family Foundation, continue to issue increasingly distressing, indeed terrifying, reports about the state of US healthcare, the access people have to it (or not), and the impact that this has upon their health. The Commonwealth Fund in particular has published a series of pieces that, although written in a calm manner, create great alarm in me because of their content. ‘High U.S. Health Care Spending: Where Is It All Going?’, Oct 4, 2023, notes that ‘The United States spends twice as much per person on health as peer nations’ and concludes that

More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.

[Note that wages for physicians and nurses is on 15% of this total!]

The ‘Findings from the Commonwealth Fund 2023 Health Care Affordability Survey’ are reflected in its title, ‘How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer’. Those findings demonstrate that they are, and it is getting worse, and although the greatest impact is in those already marginalized (particularly Black Americans and those already poor), it is affecting more than half of the US population, those insured and uninsured:

Large shares of insured working-age adults surveyed said it was very or somewhat difficult to afford their health care: 43 percent of those with employer coverage, 57 percent with marketplace or individual-market plans, 45 percent with Medicaid, and 51 and percent with Medicare.

 

Commonwealth also had a series of reports, appearing every year or two, called “Mirror, Mirror on the Wall” which compared US health care costs and outcomes to other comparable (wealthy) countries. The US always did worst (see ‘US Health Rankings remain low and #Trumpcare will make them worse!’, June 18, 2017, which includes scary data tables comparing US health system performance to others). The most recent report, from 2022, has a different title that is even scarier: U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. It includes as “highlights” (or lowlights)

·        Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.

·        The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.

Comment: These are not good things.

 It is also easy to lose health insurance. It can happen intentionally when insurance companies seek to offload high-cost individuals (ie., the sick people). This procedure (“lemon dropping”) is common in Medicare-substitute programs like Medicare Advantage and push them into regular Medicare. It is the complement to efforts to enroll only healthy seniors (“cherry picking”). The ideal insurance client, from the point of view of maximizing profit (is there another point of view?) is one who pays premiums and never uses care. Of course, if you are not yet on Medicare, you can be dropped and – that’s that. You are uninsured.

But you can also lose insurance coverage by mistake or oversight; in her Oct 25, 2023 essay ‘It Shouldn’t Be This Easy to Lose Your Health Insurance’ in the New York Times, physician Danielle Ofri describes how she lost coverage because the notification for “open enrollment” from her own HR department was collected by her spam filter, and she was put into the “basic” plan – without coverage for her family. Why does she have to re-enroll every year? And why do Medicaid patients?

The stated reason for this bureaucratic merry-go-round is that eligibility must be ascertained every year so as not to allot services to someone who doesn’t qualify. But the process of determining eligibility is highly flawed. Only some disenrolled Medicaid patients, for example, are truly ineligible; according to KFF, a health policy research organization, a majority of people (more than 90 percent in some states) were disenrolled for procedural reasons, such as missed deadlines, paperwork issues and outdated contact information. Many of these people are eligible for insurance but lose coverage because of the byzantine logistics.

Yes. Dr. Ofri was able to reinstate her coverage but not everyone can; she is not only highly educated but a physician: “For me, it took endless phone calls to fix the problem and a miserable week in which I was convinced that I’d failed my family. For millions of Americans, the system is simply unnavigable.” Especially for those Medicaid patients.

Dr. Ofri concludes with the key point:

Of course, none of this would be necessary if the only requirement for getting insurance was — as it is in many countries — being born. 

Think about that. Everybody is insured – and coverage is the same – for every person in the country. There is no enrollment or disenrollment, no coverage lapse, no inability to afford it. Everyone is covered. And it costs less – all of those countries spend less, overall and per capita, than does the US. It is administratively simpler, less costly, more effective, and results in better health status for the population. It has been adopted by every other well-to-do (and many much less well-to-do) country in the world. The US is an outlier, not in a good way, in being the only nation that doesn’t.

But American insurance companies and health care providers make huge amounts of money, money that is intended (often by the government) to be spent on providing health care but instead ends up on the positive side of a corporate balance sheet. That can be seen as a good thing, if you are a corporate executive, a completely heartless and unempathetic bastard, and, of course, you are certain that the negative impact will never affect you. We need to change that, i.e., make it affect them.

Moxon goes on at great length documenting how the “profit motive”, which can have positive effects on a society, has been so perverting by being the ONLY thing that is considered to matter (“the profit motive doesn’t care about enriching the lives of people, and it never will, any more than a garden trowel cares about the state of your garden”) that it leads to mass suffering, in health care and  “with justice, and with education, and public safety, and housing, and transport, and recreation, and water, and the arts, and elder care, and on and on and on.”

What is amazing is that so many of us have drunk enough of the Kool-Aid to believe that, while  these are not good things, we think it is inevitable and the way that things have to be. Of course, there are also those who in fact believe, either because they are ideologues or are getting rich from the corporations they control or both, or are politicians being paid from the lobbying arms of those corporations, that profit is in fact more important than people. They should voluntarily (or not) sign up on the list of people who will not get care because that would decrease profit. They are welcome to live out their principles. Until they can’t because they aren’t getting health care.

As long as the rest of us do not continue to have to sacrifice our health to their profit.

Outrageous behavior by hospitals harms Americans' health to make money

The article in the NY Times (June 1, 2023) titled “This Nonprofit Health System Cuts Off Patients With Medical Debt” carries the subhead “Doctors at the Allina Health System, a wealthy nonprofit in the Midwest, aren’t allowed to see poor patients or children with too many unpaid medical bills”. That sounds bad. It is bad. It is disgusting. It is reprehensible. But it is only one example of the extreme lengths many “non-profit” hospitals go to in order to maximize their income (their “non” profit!) at the cost of limiting care to people.

I don’t know how many hospitals, hospital chains, or “health systems” have gone as far as Allina in explicitly refusing to see patients, but most of them go as far as they think they can – and maybe tiptoe over the line. The article states that “Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.” This is, unsurprisingly, most prevalent among those that can do it, those that are wealthy, those that are in urban or suburban areas where they can make money taking care of insured people. (A different calculus informs the often-marginal rural hospital.)

It is, in theory, possible to have two different worldviews regarding this situation. One (mine) is that the main purpose of health care, hospitals, doctors, etc., is to improve the health of the population, not to make money. To the extent that the pursuit of money gets in the way of (or explicitly blocks) caring for the health of people, it is wrong, unethical, and should be condemned. Another possible view, however, is that the business of any business (making widgets, providing income tax services, flogging corporate interests on the internet) is to make money, and that healthcare is just another business, and if some people can’t afford it this is no different from someone not being able to afford a car. I do not believe this, and think it is a morally vacuous position (and, more important, one that actually hurts people), but it is popular in some circles. Folks cite the maxim attributed to economist Milton Friedman that the only responsibility a corporation has is to make profit for its shareholders.

But wait – these are NON-profits! They do not HAVE shareholders! They do have Boards of Directors and (very) highly paid management teams, but they don’t pay taxes. Because they are non-profits! The reason that they don’t is because, under the law, they are expected to provide “community benefit”. While such systems often try to claim that they are doing so by occasionally sponsoring low-cost events such as health fairs where you can get your blood pressure or blood sugar checked, that is not what the requirement actually intended. The Times article correctly states “Nonprofit hospitals like Allina get enormous tax breaks in exchange for providing care for the poorest people in their communities.” That means taking care of people who have need, and not pursuing ANY of the gross collection tactics, not to mention refusing care. “But a New York Times investigation last year found that over the past several decades, nonprofits have fallen short of their charitable missions, with few consequences.” Put simply, these non-profit hospitals are given very large benefits (no taxes) because they are supposed to care for those with need, for the poor, but then they do not. But they keep the money.

These non-profit hospitals (and systems), run by finance people and accountants, operate as if they were for-profits, seeking to maximize income just as much as the for-profits do. Not having to pay shareholders, they can pay huge salaries to management, and accumulate enormous bank balances. In fact, this is an incredible competitive advantage – if you are a for-profit, you have to pay taxes! As a result, most for-profit hospitals in large urban markets cannot, and do not seek to,  compete with non-profits, and are found primarily in niche markets, for example in subspecialty hospitals providing particular kinds of procedural care to well-insured people.

Not that I am endorsing overtly for-profit health care. It is also slimy and disgusting, meeting some needs of some people and openly refusing care to others. The pursuit of profit and money is the root of the failure of our health system to do what most of us think it is there for: to improve health. However, non-profits operating in this sector get huge government (meaning taxpayer!) subsidy for doing – things that they do not do, do not want to do, and will take every legal (and often extra-legal) avenue to avoid doing. Indeed, in addition to not paying taxes they get great financial payments from other government programs, such as the 340B drug program, often worth tens of millions (see "Non-profit" hospital systems behaving worse than for-profits: No end to the scams, October 1, 2022).

If there is anyone left who is still taking evidence-free issue with the idea that the US health non-system is a failure at providing health, take a look at this recent piece from the Washington Post by Steven Woolf and Laudan Aron. Yes, it is an “Opinion” piece, but it is full of facts (see graphic) and backed up by the work of the National Academy of Medicine in its report “Shorter Lives, Poorer Health”. Since 1980, when the life expectancy of Americans was in the lower half of wealthy countries, it has slowly dropped so that by the early 2000s it was the lowest, and well before COVID arrived, had plateaued while that of other countries continued to rise. Almost all countries took a “life-expectancy” hit with COVID, but for most it was short-lived and has since rebounded. Except the US, where it has just started to drop a little more slowly.

 

Life expectancy is not the only measure of health system function or success. However, there is no accepted measure (deaths of middle-aged people, infant mortality, maternal mortality, years of productive life lost, etc. etc.) in which the US does not lag its peers, and often poorer countries. Unless you think the provision of boutique specialty care to wealthy people (including foreigners) is somehow a measure of health system success.

Woolf and Aron cite the National Academy report which lists a number of reasons why the US does poorly:

(1) unhealthy behaviors, such as our diets and use of firearms;

(2) inadequate health care and public health systems;

(3) poor socioeconomic conditions;

(4) unhealthy and unsafe environments; and

(5) deficient public policies.

They note the last is most important, including failure to address basic human needs for food, housing, education, and jobs. The continuing effects of racism. The failure to have an adequately funded public health infrastructure.

The National Academy did not look at the fact that our gangster-capitalist system has taken over health care as a cash cow to have money extracted and only incidentally (when convenient and profitable) provide health care, but this too is a clear failure of public policy.

If hospitals, non-profit or for-profit, are not providing all the health needs of our people, rich and poor, they must be forced to do so, by public policy. They should be provided with a negotiated, global, annual budget for operations (and a separate one for capital, so they don’t milk patients to make money to expand) by a national health system. And be held to it.

Addressing the problem of greedy hospitals, the pursuit of money rather than health, will not solve our health problems. Not only does it leave the other parasites, insurance and pharmaceutic companies, it leaves all the other societal inequities cited above, that also must be aggressively acted on.

But it is a necessary step, and a good start.