Mamdani, universal health coverage, and the scandal of profits over healthcare

First, let me offer congratulations to Zohran Mamdani and the people of New York who elected him. While the news focus is on him, and of course he merits it, it is the “them” that is more important. New Yorkers showed that they want someone who stands with and for them, for their needs, for their ability to afford rent, and healthcare, and education, and food, rather than for the developers and billionaires and financiers (overlapping groups) who have long controlled the city. It should be a wakeup call to the finance-oriented Democrats, not to mention the Republicans who only stand for the oppression of people. Maybe he will be able to deliver on his promise of universal health care in the city, and maybe not, but what he, and they, have shown is that this is something people want. People most assuredly do NOT want the interests of insurance company profit to even be in the same discussion as a value in comparison to their health and healthcare, and they shouldn’t.

What is remarkable is the number of people in positions of power who do. This can, accurately, be attributed both to the financial support insurers give to politicians (and pundits) and the fact that they hang around with each other. Polls have shown that large majorities of Americans support universal health care, and the NYC election was another important such “poll”. But, in fact, things are going in the opposite direction for healthcare and the health of the American people. The party of Snidely Whiplash (PSW) is doing everything it can to make people’s lives worse. They have made it eminently clear that they don’t think all Americans should have health coverage by keeping the government shut down rather than talk about continuing the subsidies for ACA demanded by the Democrats. 

And remember that lots of things besides healthcare coverage affect health – access to adequate food is one of the main ones. So, because, I guess, the PSW so enjoys being mean, they have cut SNAP (food stamps) benefits dramatically, so that more children can go hungry. Twirl that mustache, Snidely! In Tucson, as around the country, food banks that are already overwhelmed will see huge increases in need. We just loaded up the car with boxes of food for the community food bank donated by members of our HOA. They were particularly heavy because of the cans of beans, tuna, chicken, and peanut butter donated especially because the food bank is often out of protein. Which, you may recall, people, and especially growing children, need! You see, grants for the food bank to buy this food from local farmers, which benefitted the farmers as well, have been cut off. Just when you thought we couldn’t be meaner, har har har! 

Government policies that cut aid for food and healthcare are terribly damaging to Americans’ health. Rural hospitals are closing because so many of their patients are covered by Medicaid, which has been dramatically cut. Telehealth programs that might have helped fill that gap are ending. If anyone still believed the private, for-profit sector (as opposed to the volunteer non-profit sector, like food banks) might step into help, they are doing the opposite. Recent insurance company actions have doubled down on limiting access to care, paying for care, and of course caring. Just a few recent actions detailed by Health Care Un-covered include ‘Coverage Without Care: The Cruel Math of Health Insurance Open Enrollment’ and  ‘UnitedHealth CEO Says Company is Cutting Thousands of Doctors Out of Network to Boost Profits‘. You thought it was already hard to find a doctor? The largest health insurance company in the nation doesn’t care; it does care about making more money! Remember that when you see their ads on TV!

Many people – well, pundits, not actual people – say the problem is people need to have jobs, to contribute to the economy. Others, perhaps (?) more well-meaning suggest people need more education about how to choose and navigate the health insurance system so they are not (or are at least less) screwed. Baloney. Read this story on the KFF site about Dr. Lauren Hughes, whose car was T-boned 20 miles from her home. She had injuries including a broken ankle, but the hospital to which she was taken was “out of network” for her insurance, and she ended up with a $64K bill! Dr. Hughes is a highly-educated, knowledgeable, skilled and experienced family physician, who also leads a health policy research group at the University of Colorado. She knows way more about how the system works than most people – heck, than most doctors! And she still was screwed (not just with the ones in her ankle)! Because of her knowledge, role, and indeed clout, and the support of others she was able to get most of the insurance company decision reversed, but good luck if it is you, or someone else who has less of all of those advantages!

The KFF piece is full of phrases that should infuriate, and nauseate, any decent human being, like “out of network”, “surprise billing”, “uncovered care”, “observation status”. These are all strategies (“gimmicks” would minimize their significance) to make more profit for insurance companies by denying you health care. Another recent Health Care Un-covered piece discusses ‘Where Do Our Health Insurance Premiums Go?’, and the answer is profits, stock buy-backs, lobbying, executive salaries. Not increasing coverage or access, decreasing rates; indeed, quite the opposite: as profits go up, so does consumer cost, while access goes down! In any other country, these phrases would be anathema. Every other country that can possibly be considered “wealthy” or even “middle income” (an international classification that almost any American would still see as “poor”) has universal health care. The concept that any person, not to mention a “well-insured”, educated, professional – physician! -- would have such indignities heaped on them and not receive the care they need as a right of their citizenship (and in many countries, even non-citizens) would outrage them. I would like to remind folks of two pieces I wrote long ago, both coincidentally related to films. One thing to NOT worry about: paying for health care -- in France, is from 2012. It discusses the film Le Havre, and how amid the tribulations of being poor, worry about paying for necessary health care was not one of them. The other, from 2009, "Sick Around America": A little bit sickening, talks about TR Reid’s special “Sick around the world” and something from it that has stayed with me.

In each country he [Reid] asked how many of their citizens went bankrupt as a result of health care debts, and they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

It should be a national scandal here; indeed, it is a scandal that, for so many it is not. The American people know this, and increasingly will be punishing politicians who do not care, or who, with a total lack of not only empathy but any moral or religious compass at all, put the financial profits of insurance companies above the health of our people, when in fact it should have ZERO weight.

Back in 1958, Harry Golden, a writer, humorist, and published of the Carolina Israelite wrote the best-seller “Only in America”. At the time, reviewers’ comments focused on his being a Southern Jew, and on his support for integration (the moral issue of that age). But it is sad to think that nearly 70 years later, “Only in America” refers to the lack of a universal health care system, unique among the OECD (Organization for Economic Cooperation and Development, the rich) countries.

It is long past time to change that!

Recalling an old post: Le Havre and not paying for health care -- in France

Sometimes I think about old posts, and how sad it is that things have not changed in the years since I wrote them. But, as with this one, from Jan 12, 2012, I enjoyed writing it, and highly recommend the film that inspired it, Le Havre.

 One thing to NOT worry about: paying for health care -- in France

One thing to NOT worry about: paying for health care -- in France

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I recently saw the film Le Havre, a film set in that French city and made, in French, by Finnish director Aki Kaurismäki. It was a very good film, generally well-reviewed (here is the New York Times review), and part of its appeal for me is its unabashed portrayal of working-class people as the central characters. One of the plots involves the illness of the female lead, Arletty, who suffers severe abdominal pain, is brought to the hospital, and is told that it will be terminal (although, the doctor observes, “miracles do happen”.) I don’t need to share any more of the plot, because what I found striking was really incidental to it.

Kaurismäki goes to some length to depict both the poverty and dignity of his characters. It is an imaginable working class poverty -- this is not the Mumbai of Slumdog Millionaire – but it is certainly poverty. Arletty’s husband is a shoeshine man; they live on an alley off a small street in a house that evokes the apartment of Ralph and Alice Kramden on The Honeymooners. When he sees his wife in such pain, her husband’s main concern is how he will get her to the hospital. He goes to the street to ask a shopkeeper if he can use her phone (they don’t have one), and she offers to drive them.

What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was “nothing” (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.

Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.

There was another aspect of the healthcare portrayed in the film that struck me. The hospital was simple and unostentatious. It looked a little dated, old-fashioned, like the houses and the shops and the working-class lives of the characters, even though the film and its theme are contemporary. Maybe this is also something about France. The hospital is clean, freshly-painted, with clean linen, and private rooms, and IV poles and doctors and nurses. But it is simple. The ceilings are not high, there is not expensive art on the walls, or carpets, or hallways twice as wide as they need to be. It is functional. It is not third-world, but it is basic. It is pretty unlike my hospital, or most of the hospitals that we see in the US (except some of the oldest public institutions). If someone with private health insurance saw this hospital in, say, Kansas City, they would be unimpressed. They might rather, next time, seek one that was “nicer”. Fancier. With really good hotel accommodations. This is what we look for in the US, what we expect. Surely this is what they lose in such national-health-insurance countries as France.

I checked this with a friend, who is from Canada. He said that this is the way hospitals in Canada are; clean, and functional, but not fancy. He told me he was shocked when his wife had a baby in Kansas City and there were hardwood floors. What for, he wondered? Of course, we know what they are for. They are to help to provide a competitive advantage, to make people choose one hospital over another. For the same reason that hospitals buy new MRI scanners when the hospital down the street has one that is underutilized. Why they have fundraisers to be able to support their cancer center, to attract people with cancer (and, of course, insurance!) to them, rather than to the perfectly good cancer center across town. Why, as depicted in a recent New York Times “Opinionator” by Ezekiel Emanuel and Stephen D. Pearson (“It costs more, but is it worth more?”), hospitals such as Mayo Clinic are building their own billion-dollar proton-beam accelerators to treat cancer when there are more than enough in the country to treat the relatively small number of people who require this kind of cancer therapy.

Because, in the US, healthcare provision functions much more as a business than as a social good. The “product” is healthcare for people, but the product is only of value when it can be sold to those who can pay. We have hospitals that compete for some of our people, while there are others who can barely get care. This competition model can work, just as it works for other products – vendors compete for those who can afford it and ignore those who cannot. If we want healthcare to be an industry, a business, rather than health care.

Le Havre is a very good film, and it does not shy away from social issues. In fact, it addresses many of them. But access to health care is not one, it is not Sicko! The themes I discuss here are just in the background of the film,and I imagine they are not even noticed by French audiences. Or Finnish ones. Being able to afford medical care is not an issue in those places.

Which is as it should be.