The problems with our US 'Healthcare' system are well documented. We need to start with the solution!

Many sources of news have provided information that should be shocking on the abuses of the US “healthcare” industry. They include newspapers like the New York Times, Washington Post and the Guardian, non-profit policy organizations like the Commonwealth Fund and the Kaiser Family Foundation (KFF), and many smaller podcasts, substacks, and blogs (well, like this one). The rapacious profit-taking by corporations from dollars ostensibly allocated to provide our healthcare by the federal and state governments (through Medicare and Medicaid), our employers and, not least, ourselves, is regularly siphoned off for profits and administrative costs (like multi-million dollar C-suite salaries).

That this continues to happen and is built into the way our “system” (or better “non-system”) works seems to completely mystify our government and policy wonks. Their response is a hodge-podge of regulations that seek to try in some way to limit the negative health effects of our system, and to limit the number of people who are unable to access care because they have little money, no insurance, poor quality insurance, or have been excluded for reasons such as prior disease. The obvious solution – one single-payer health insurance system that automatically includes every single person of every age – has been anathema to them, despite the overwhelming evidence of it being pretty successful in every other developed country. And, even when far from perfect, always better than the US in terms of health access, health outcomes, and cost. We presume the reason is, essentially, corruption – that, as a result of getting fat and wealthy at the public (and our private) trough, these corporations give lots of money to politicians.

Just a few recent examples of what is wrong with not having single payer:

·        The NY Times reports on a “glitch” in many states incorrectly disenrolling children from Medicaid. Whoops.

 

·        The Healthcare Un-Covered substack takes a good long look a the practices of health insurance companies.

In the “good old days”–let’s call that period pre-2008–the majority of commercial insurance was full-risk: increases came out of payor profitability rather than employers’ and consumers’ pockets, and patients were protected from high out-of-network/out-of-pocket costs. In 15-20 years, everything has changed.  A lot.

Sure has. Its “poster child”, United Health Group, makes lots of money on its insurance business per se, denying people (whether on “regular” insurance or on Medicare-substitute plans like Medicare Advantage). Even more, it is making its most money on its owned physician practice subsidiary, Optum, as well as their pharmacy benefit mangers, using what is called “intercompany eliminations” to have one of its subsidiaries pay more to another of its subsidiaries than to competitors. Plus the Optum practice groups do not have the caps and regulations affecting the insurance group.

Practically, this means UnitedHealth Networks can pay its own physicians, UCCs, ASCs and the care delivery sites it owns above market rates–through something called intercompany elimination–then starve other providers with low rates. This accomplishes two things: it makes the starving providers more likely to sell their practices to Optum, and it allows UnitedHealth to post amazing profitability and stay under federal MLR caps. This is what we call “a good problem” in business.

Good problem for United Health. Big, bad problem for everyone else, including the providers in other groups and mostly the people (that is the English word for “patients”) who seek care.

·        The administration announces the first 10 incredibly-overpriced drugs that Medicare will negotiate the prices of.  Allowing Medicare to negotiate drug prices is one of the most popular issues in the US, across party lines; KFF found ‘in a survey late last year, 89 percent of Democrats and 77 percent of Republicans said they favored the plank of the Inflation Reduction Act that authorizes negotiations.’ Pharmaceutical companies of course push back, with completely bullshit claims that it will limit the number of new drugs. What it will, of course, threaten, is not whether they make a profit, but only the incredibly amount of money these companies are raking out of the economy in grossly excess profit. One good example of the vicious, avaricious abuses is found in The Lever, “Big Pharma’s American Con”, documenting how they rip us off while charging much less in the regulated environments in other countries.

·        The new administration regulations on nursing home staffing have angered both the operators (whose costs will go up, and also have trouble finding staff – at the salaries they pay) and the patient-advocacy groups who point out that they are far too little (patients have to be seen by someone 33 min a day??).

·        And on and on.

What do all these issues – and many more -- have in common? Well, of course, they are manifestations of insatiable and unregulated greed by corporations, and the willingness of our government to allow money that is supposed to be for our health go into corporate pockets. But they also have in common the fact that they can only exist in the absence of a single, rational, health insurance system for the American people. What can we do? We can – and I have, in this post and in many others – document and decry the absolute ripoff of the American people. For example, Medicare Advantage, which is great if you are pretty healthy and doing well, but not so much if you are sick and they deny you care, that are funded (even overfunded, paid more per recipient than is given to traditional Medicare) with the dollars that you have contributed over your working life to the Medicare trust fund. Of course, it is facilitated by the revolving door with government functionaries who are supposed to be regulating them but don’t, and facilitate their greed, and are rewarded by leaving the government and going to work for them for beaucoup bucks. One example is Billy Tauzin, the former Louisiana congressmen who chaired the committee that passed Medicare Part D and included a prohibition on Medicare negotiating drug prices, who became CEO of PhRMA. Or Tom Scully, the Center for Medicare and Medicaid Service director who oversaw  the development of privatized Medicare, who went on to join a major health private-equity firm and made out like the bandits he and they are, as detailed in American Prospect. The list of what is wrong seems endless.

So, I think, it is time to stop leading with all the skullduggery, rapacious, thievery, failure of public trust, and outright killing of people, and start with the solution. A single-payer health system. Everybody in, nobody out. Birth to death. No one is excluded, and no one can be “thrown out”. It covers the same things for everyone, regardless of income. If it is something people need for their health, it is covered; if it is unneeded, frivolous, or harmful it is not. Glasses, hearing aids, mental health, dental, long-term care. No out of pocket costs.

How can we pay for this? See above, all the money going to not-health-care. It would cost much less! Do not let your legislators off the hook. For example, Phoenix congressmen Ruben Gallego has co-sponsored Medicare for All legislation for years. Now he is running for Senate against wolf-in-sheep’s-clothing Democrat-turned-Independent Kysten Sinema and whatever yahoo the GOP drags up. But this year he has not signed on to the Medicare for All bill, HR 3421. I have made it clear in response to his daily solicitations that unless he does, no more money from me.

Demand a universal healthcare insurance system. Now.

We don't need billionaires, we need a healthy population: It is time to move forward

I recently started reading Ricardo Nuila’s book “The People’s Hospital”, about Ben Taub, the largest public hospital in Houston. This will not be a book review (which can be found in many places, such as the NY Times, Washington Post, and elsewhere); I’ve just started it. What affected me was how, even in the first few pages, Nuila’s description of Ben Taub was so like that of Cook County Hospital (now John Stroger Hospital), the public hospital in Chicago where I did my family medicine residency and later practiced and taught for many years. That should not be surprising; the characteristics of large public hospitals in major cities, and especially the circumstances of the people who come to them for their health care (a major focus of the book, per the reviews) are going to be, sadly, very similar. What was most striking, and depressing, to me was the temporal aspect. Nuila is writing about recent years, including the impact of the COVID pandemic, while my years at Cook County were in the 1970s, 80s, and 90s. And yet so little has changed, especially not for the better.

Yes, medicine has changed. What we can (or, maybe more important, could) do for people is more. When I was a resident at County, CT scanners were uncommon, and didn’t exist at our hospital. If a patient needed a CT scan, it could usually be scheduled for after midnight at the private hospital across the street, if they were accompanied by the resident. Who had been up the entire previous night doing admissions. CT scans, and other imaging, are far easier to obtain now. We now have dozens, perhaps hundreds of more antibiotics, and are able to effectively treat many more infections, although bacterial resistance to them seems to grow faster than the antibiotics themselves, both because of overuse and the special breeding capacity of bacteria in hospitals where antibiotics are so pervasive. We can treat, even  cure, cancers we could not touch in the past, although the cost of chemotherapy drugs – a bonanza for not only the pharmaceutical companies but the hospitals that get paid a huge markup from insurers for administering them – makes them often unavailable to those who are poor and uninsured.

But there have been other things that have not changed. Indeed, have often gotten worse. This is the main focus of Nuila’s book, the social conditions that so many people, especially poor people, live in that have such a major negative impact upon their health. Calling them the “social determinants of health” is largely accurate, although the “socioeconomic determinants of health” would be more so, but it tends to almost make it sound trivial. It is not trivial. The socioeconomic conditions in which people live have a far greater impact upon health than anything except, perhaps, genetics. Certainly more than medical care, which accounts by most estimates for at best 10% of health, although it is where we as a society spend more than 90% of our health-related money. It has far more impact than all those diet/exercise/lifestyle factors, or vitamin/mineral/“natural supplements” that are promoted by those who are true believers as well as those who see this as their way to cash in.

It is shocking and distressing to me that conditions for poor people are not better than they were so long ago, and are in fact worse. The same groups of people who have always been pushed into this category, especially Black and Latino and Native peoples, and indeed poor white people, have been supplemented by immigrants from all over the globe who our society treats just as badly. And even more, supplemented by the NON-poor, working and middle class Americans who often have trouble getting the health care that they need – and deserve – because of limits imposed by insurance companies and health systems, which all operate as if they were for profit.

It is still surprising to me, because although I intellectually know better, much of my instinctive reaction is deep-seated and believes that history moves in a positive direction and things tend to get better. Said so much more articulately by Dr. King, “The arc of the moral universe is long, but it bends toward justice,” it resonates with me as much as I fear it is not so. My own perspective is generational; grandparents who were immigrants and low-income, parents raised in the Depression and in WWII, myself raised after the war thinking we were now middle-class (we were working class); better off than our parents were growing up. It was in that period that CEO salaries relative to average workers were “only” about 30x as much (not the hundreds of times as much as today), unions were stronger, the civil rights movement was gaining ground. See, e.g., this from the Economic Policy Institute from 2019 showing CEO salaries gained 940%  since 1978 while average worker salary was up only 12%!

But now it is much worse. It is moving backwards, except for the wealthiest – and by the wealthiest I mean the really wealthiest. Midwifed by the Republican party (but abetted by the Democrats), especially since the Reagan 1980s, we have become a society in which not just a disproportionate share (which was always), not just most, but virtually everything goes to the wealthiest. This Oxfam report (January 2023) shows that in the last 2 years, the top 1% has accumulated nearly twice as much as everyone else in the world put together!! This is what it is all about. Yes, there is racism, and sexism, and anti-LBGTQ+ ism, and they are terrible and they often make people’s individual lives terrible, and should be fought against ceaselessly. But it is the gangster capitalism (Noam Chomsky’s term) in which there is literally no limit to the greed and the amount of money a few people have, hundreds of times more than they or their descendants could ever spend.

This is the trend in our world and our nation while the people who seek health care at Ben Taub Hospital in Houston or Stroger Hospital in Chicago or their equivalents, not to mention those who live in places where there are not public hospitals, not to mention those from all the parts of the world to whom coming to Houston or Chicago seems like it would be Heaven, get sick and sicker and die. In fact, contrary to the proclamations of right-wing pundits, all of these problems can be solved with money. It should be the money now being amassed by the richest individuals and corporations, including those in health care (providers and insurers and pharmaceutical and device manufacturers) could, and SHOULD, be used to provide medical care, but more important provide the conditions necessary for health. For EVERY person to have adequate and healthful food, to have adequate and warm housing, to have an opportunity for an education as far as their drive will take them, to have a job to feed themselves and their family. There is enough money to do this, and yet it is being socked away in private pockets so deeply it will never be touched.

In 1850, the Frenchman Frederic Bastiat wrote in “La Loi” that "When plunder becomes a way of life for a group of men, they create for themselves, in the course of time, a legal system that authorizes it, and a moral code that glorifies it." They get to do this because we enable them. Directly, our politicians enable them; while Republicans and Democrats keep our attention focused on “culture wars”, both parties (except for the most progressive Democrats) depend upon and enable them. Indirectly, it is the rest of us, who do not demand that the politicians we elect fight for the interests of the people. If the 10,000 or so Americans worth $100M or more disappeared tomorrow, no one would miss them except (presumably) their families and the politicians who have become accustomed to being owned by them. If they averaged just $100M each, that would be $1 TRILLION ($1,000,000,000,000), but of course that is an underestimate since many are worth billions, or tens of billions.

It is well past time to take that, both in taxes and in other changes in public policy, and use it for the people.

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 1 (of 4 parts)

This is part one of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

“The dream of reason did not take power into account”.

--Paul Starr, "The Social Transformation of American Medicine", 1982

In 2008, the British Healthcare Commission began an investigation into conditions at Stafford Hospital, run by the Mid-Staffordshire Health Trust.[1] The investigation was prompted by patient complaints and a higher-than-expected death rate, and it and subsequent[2] investigations uncovered a pattern of both poor quality care and cover-ups by those running the hospital. It became a major national scandal. In 2014, whistleblowers began to reveal the extent of problems in the Phoenix Veterans Administration system, with long delays for appointments, inadequate care, and even excess deaths. The investigation revealed enormous cuts in services, as well as efforts to cover up the problems, similar to those in Stafford. Moreover, it turned out that the problem was far more extensive across the VA than just Phoenix.

These two events are discussed by M. Gregg Bloche in his NEJM Perspective “Scandal as a Sentinel Event — Recognizing Hidden Cost–Quality Trade-offs”[3]. The details of the two scandals differ, as do the health systems of the two countries in which they occurred, but there are disturbing similarities.

“As with the VA scandal,” Bloche writes, talking about Staffordshire, “politicians blamed individual perpetrators and one another, and the prevailing narrative highlighted lapses of character and culture…In both cases, performance standards often proved incompatible with resource constraints….The fakery was discovered, and perpetrators were punished. But the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged.”

So, while more rigorous standards were being set for performance, budgets were being cut. These cuts made it difficult or impossible to meet those standards, and administrators in both systems covered up the problems. They lied about their compliance with the standards -- and, not coincidentally, often got financial bonuses for doing so (or at least got to keep their jobs). In addition to the probably unnecessary deaths, outcomes were more generally poor care for all patients. In the British case, the excess deaths were pretty well documented, as were the stories of patients lying in urine and excrement, inadequate food, and unavailable nursing care. In the US, at the VA, proving excess deaths was more difficult, but excessively long waits, particularly for specialty services, may well have contributed to unnecessary or premature mortality, and falsifications by the administrators were very clear.

In both cases, heads rolled – local administrators, the head of the Mid-Staffordshire NHS Trust, and in the US eventually the head of the VA.  The politicians, in the US Congress and the British Parliament, who had been responsible for the funding cuts in the first place, took no responsibility and indeed used these scandals to act in a self-righteous manner, denouncing “those responsible”, while being clear that this did not include themselves. Nowhere in the discourse in the media are the budget constraints and cutbacks acknowledged as a major cause of the problem.

And, yet, the politicians were surely responsible, because it was the budget cuts that they imposed, along with the potential they built in to these systems for financial gain on the part of those directly tasked with running the operations, that led to these problems, certainly along with the collusion of the people directly in charge. The process has had two steps  – first, we are going to cut your funding and you are going to have to figure out how to cut in a way that doesn’t, at least obviously and in a manner that reflects on us, cut services. Second, we are going to tie rewards – institutional and personal (direct financial bonuses, or at least keeping your jobs) – to the degree that you can cut costs. We are also going, to a greater or lesser degree, “privatize” operations on the assumption that this will, with the motivation of profit, increase the efficiency (and lower the cost). And if we cannot privatize them, we will use “motivators” characteristic of private enterprise – again see financial bonuses. And now a right-wing group of Koch-funded consultants and legislators is creating a proposal to essentially privatize the VHA, covered by Suzanne Gordon,

“The proposal they have crafted is an exercise in incoherence, denial, and magical thinking. he group believes that private sector hospitals would be willing and able to recreate VHA Centers of Excellence and other programs like the San Francisco VAHCS’s Center of Excellence in Epilepsy or Primary Care Education or Palo Alto’s polytrauma, blind or spinal cord injury rehabilitation programs. It also believes the private sector could fulfill the VHA’s research and teaching missions. As one San Francisco VAHCS researcher told me, “Can you see my eyes rolling?”’ http://suzannecgordon.com/the-plot-thickens/

It is of more than passing interest that both of these events occurred in government agencies that were established to provide necessary care to people. In Britain, the National Health Service, established in 1948 to expand upon the National Health Insurance program that had existed since prior to WW I, is enormously popular because it provides care to everyone. Let’s think about this for a minute. 1948 was soon after the war. Britain, as most of Europe (but not the US) was in shambles, its population of young men decimated, its economy and industrial capacity largely destroyed, its streets covered with rubble from the Blitz (think the street scenes of East London in Call the Midwife from over a decade later), and the last thing that they had was “extra money”.

 
 But the National Health Service was established, not as largesse in a time of plenty, but as a way of meeting the needs of the British people. In the US, a different story unfolded; with its industrial capacity intact and the need to shift from war to consumer production, the demand for labor exceeded the number of workers. Prevented from increasing wages because of wage and price controls, large companies found offering health insurance (non-taxable) a significant inducement, and found common cause with labor unions who could then offer these benefits to their members; a win-win that led to the employer-based health system that has characterized the US since.

In Britain, the Mid-Staffordshire scandal broke under a Labor government, but the seeds were sown when the Conservatives were in control. Recognizing that the NHS was far too popular to be dismantled, the Tories, seeking to emulate the US, both cut funding and established “NHS Foundation Trusts”, like Mid-Staffordshire, which were in a sense semi-privatized and incented to save money by being offered an opportunity to keep some of the savings, which could be used both for reinvestment in the hospitals and health system and to bonus those in charge. In the US, our services to veterans have almost never (as documented by Bloche) kept up with our rhetoric about the heroism of the men and women who serve in our military, and the VA scandal was tightly linked to cuts in funding. Indeed, some of the “solutions” offered by the same Congressmen who were responsible for the cuts involved privatization; this is often proposed as a solution to not having enough money, and almost never works, at least if the goal is improving quality.

As Suzanne Gordon says in her piece on the growing efforts in Washington to privatize the VA:

‘In their document, the Strawmen [the group working on this] justify their position on total privatization by pointing to the fact that the VHA is having trouble hiring new recruits to fill many staff vacancies because of the “stigma” attached to working at the VHA.  They also argue that the current VHA workforce suffers from “poor morale” and a “culture of fear.” Of course, VHA management practices could be significantly improved.  But if there is now a “stigma” attached to working at the VHA, a “culture of fear” within it, or demoralization among its current employees, that is, in great part, due to the bashing conservatives have unleashed in the media and Congress.’

But we’ll get back to that.

(to be continued)

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[1] http://webarchive.nationalarchives.gov.uk/20110504135228/http://www.cqc.org.uk/_db/_documents/Investigation_into_Mid_Staffordshire_NHS_Foundation_Trust.pdf

[2] http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report

[3] N Engl J Med 374;11 nejm.org March 17, 2016, pp 1001-3

The business of America...or is America a business?

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“The business of America,” President Calvin Coolidge said, “is business.” His only famous quotation (after all, the guy’s nickname was “Silent Cal”), it is almost a mantra guiding the actions of Presidents, and Congresses, and state legislatures, since. It can be seen almost as a tautology, recognizing that successful businesses are essential to the economic success of the entire country, and the world. Pursued to perversion, with governments not just facilitating the success of business but doing anything businesses want, with no respect for the balance between business success and negative impact, however, it can have terrible results for society -- for many people, or, as in the recent implosion of the economy, for all people. Completely abandoning all regulation of financial derivatives, the housing market, etc., was predictably a bad idea. But, of course, those predictions were not heeded.

And are not being heeded. On the heels of the enormous public bailouts, absent any requirements that the financial industry actually do anything to help Americans (like, say, lend them money), we continue to see further deregulation. The Supreme Court will soon decide on whether to permit corporations, not just the individuals who own and work for them, to contribute to political campaigns. Many folks think that the conservative majority will say “yes”, based on the legal fiction that corporations are people, and therefore have First Amendment rights to freedom of speech.

Of course, corporations are not people, and the “founding fathers” who wrote both the Constitution and Bill of Rights had absolutely no intention of considering them as such. Indeed, given their experiences, most were quite suspicious of – often hostile to – corporations, which is why the Constitution provides for state control of them. This was because, as stated in an interesting discussion by Jan Edwards on the “Third World Traveler” website, “State governance was closer to the people and would enable them to keep an eye on corporations. In the eighteenth century, corporations had very few of the powers that we now associate with them. They did not have limited liability. They did not have an unlimited life span. They were chartered for a limited period of time, say 10 or 20 years, and for a specific public purpose, such as building a bridge. Often a charter would require that, after a certain amount of time, the bridge or road be turned over to the state or the town in which it was built. Corporations were viewed differently in early America. They were required to serve the public good.” Things, however, have changed, and this is apparently an area in which the “strict constructionists” on the Court are a little less strict.

Would this make a big difference? Well, perhaps conceptually it would, but corporations are already able to use their money to have great influence over policy. This includes the donations to candidates by the people associated with them, but more often and in greater amounts to the soft-money PACs to which they contribute. On the health care front, the New York Times recently ran an article (December 29, 2009) unfortunately titled Health Lobby takes fight to the states (I say unfortunately because, as the article makes clear, it is the lobby for the health care industry, not lobbyists for our health!) that looks at efforts in state legislatures to not participate in any health reforms that eventually pass Congress. The rationale for opposing the changes that would prevent insurance companies from denying coverage to people because of pre-existing conditions, and at least potentially extend coverage to the majority of the uninsured, is, according to author David Kirkpatrick, is based “on the grounds that it tramples individual liberty”. This is eerily reminiscent of the first point in Andy Borowitz’ December 17 piece, Senate Unveils CompromiseCare: “Under CompromiseCare (TM), people with no coverage will be allowed to keep their current plan”. Except that was intending satire; I don’t think that the 42 Florida Republican legislators pushing this plan meant to be self-satirical (but, hey, who knows?)

More interesting, and bringing this back to the influence of corporations on policy, Kirkpatrick notes that those 42 co-sponsors “…were almost all recipients of outsized campaign contributions from major health care interests, a total of about $765,000 in 2008, according to a new study by the National Institute on Money in State Politics, a nonpartisan group based in Helena, Mont.” Amazing. The suggestion is that these wealthy corporations are buying votes. A reader might conclude that these legislators, and so many others, are corrupt scuzzbuckets. But it is, probably, coincidental.

Maybe. After all, in our current political culture it takes money to get elected, money to get the word out on your positions, money to get the word out smearing your opponent, to buy radio and TV time. And it is a known fact that very rich people and corporations give much more money to politicians than poor and working people. So why would we think that they wouldn’t have an influence on the votes of these legislators, or those in Congress? Whether it is a matter the legislators “paying their donors back”, or simply of those donors funding the election of candidates who really believe in the issues important to them -- such as corporate personhood, or that trying to ensure that people get health care coverage tramples on their individual liberty. Or maybe those candidates just care more about that individual corporation than are about those cheap poor people who don’t make campaign contributions. OK, they’re corrupt scuzzbuckets.

I don’t know why, at my age and my at least moderate knowledge of history, I continue to be amazed by this. After all, one of the most corrupt Presidential administrations was that of Warren G. Harding, whose vice-president (and successor) was ol’ Silent Cal himself. I think there are a lot of Americans who actually think that their elected officials should work on their behalf, not on that of a monied corporate elite; they were responsible for the election of Barack Obama to the Presidency. Perhaps they thought that was enough, and now they could go back to watching TV, or playing on line at Facebook and Foursquare.

But they have to stay involved, because the powerful have the resources to keep coming back. If the people can defeat them once, they will try again. If the folks who voted for Obama do not keep working, inertia will lead to control staying with those who can afford to buy politicians. We cannot allow our country to be sold to the highest bidder
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