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.

The frustration of actually trying to get health care: the other meaning of access

I have written about the quality of care that people in the US receive, and about access to and the cost of care, but another very important issue is the actual process of obtaining appropriate care. This is a major source of frustration for patients and their families, and can drive anger against the system, against doctors, against insurers, against the government. People who experience this frustration and anger want it to change, and sometimes want to lash out, offering an opportunity to be intentionally misled by influential others for their political ends. The demonization of the Affordable Care Act (“Obamacare”) is a good example. Obamacare actually did lots of good things, starting with insuring tens of millions who did not previously have coverage; it also forbid insurers from charging more to those with pre-existing conditions, and allowed children to stay on their parents’ plans until they are 26. Actually, it did little or nothing bad, if the criterion is access to care. A few people saw increased premiums, mainly the healthy young and those who previously had such terrible policies that they were both cheap and essentially worthless. While the Republican congress tried to repeal it, it turned out that, surprise, people would be worse off without it.

On the other hand, frustration with the obstacles to obtaining appropriate care are real, every day, and in-your-face for patients and their families. I have recently been experiencing these from the perspective of the patient (or family) rather than that of the provider, as I work at getting care for my 92-year-old father. My experience with the provider perspective helps me to understand the situation from both sides, and hopefully to try to figure out which obstacles are rational and which are simply unnecessary.

Let me start by largely absolving any of my father’s individual providers; all those involved with him – physicians both general and specialist, physical therapists, and more recently the nurses, social workers, and nurse practitioners through the palliative care agency – are committed, caring and hard-working. They do their best to help him, to be available, to respond when a problem, minor or urgent, arises. However, there are obstacles in the way. Many services require a referral from a physician, from calling in prescriptions, to ordering lab tests or x-rays (and getting the results), to getting physical or occupational therapy, to enrolling in palliative care. While none of these individually may seem to be burdensome for the doctor, there can be many for any individual patient, multiplied by the number of patients a physician sees who need these services. While it is sometimes the specialist who makes such a referral or fills out such a form, it most often “rolls downhill” to the primary care provider. That provider has to have a very large number of patients to get by and make a living, so the phone messages and faxes and lab results pile up while s/he is spending all day actually seeing his/her patients. Rationalizing the delivery of care means trying to get nurses or other staff to deal with as many as possible, but lots of these require a doctor (or other licensed provider, such as a nurse practitioner) to interpret, approve, or sign off on.  And having more staff costs more money, and means (particularly for the primary care provider, whose reimbursement is much lower than for many specialists) having more patients. Thus, a vicious circle, often compared (from the provider’s point of view) to running on a hamster wheel; for patients, this often seems like obstructionism.

Of course, it often is obstructionism, but rarely on the part of the individual provider. The reason is, unsurprisingly, money. For the providers of care, or more usually the companies for which they work (whether for-profit or not), the issue is reimbursement by insurers, including Medicare and Medicaid. There are rules that must be followed, forms that must be filled out, referrals that must be signed, and procedures to go through, or payment will not be forthcoming. And then the provider, whether physician, nurse practitioner, physical therapist, pharmacist, or social worker, whether self-employed or working for a company, doesn’t get paid. And, depending on how often this occurs, will make less, fire staff, or go broke. In addition, insurance companies themselves often create obstacles to payment (such as the time-honored one of just refusing to pay the first time or two, because maybe the provider will give up), but this is more often true for costly surgeries than lower-cost preventive and treatment services. And sometimes the practices seem almost incomprehensible as in insurers requiring patients to use brand-name rather than generic drugs and thus have to pay more out of pocket (“Take the generic, patients are told. Until they are not”, NY Times, August 6, 2017); one word, not used in the article but clearly described: kickback.

To be fair, many of the rules that seem to be obstructions are not only about saving money; they are about both preventing fraud and even patient safety. There absolutely are major fraudsters out there, doctors and home-health companies and nursing homes and every sort of medical support provider (even hospitals), who try to and often succeed in bilking Medicare (and other insurers) out of millions of dollars in inappropriate (“do you want a scooter at no cost to you?” – but someone else is paying!) or truly fraudulent (there is no patient) care. In fact, some care, even if you want it, even if someone is willing to provide it (if they get paid), is not appropriate for you, or your family member. Medicare and other insurers do set criteria, and require that it be documented. This can actually be good, not only for all of us as taxpayers but for our health and safety.

But often it isn’t good. It sometimes makes care that is appropriate, evidence-based, and desired, hard to get. It takes a long time. It takes lots of phone calls, and hours on hold or waiting for calls back. It has messages lost in piles, or over the weekend. It should not happen, but it does. And it is frustrating. The “Triple Aim” guiding progressive health care has received a lot of attention. It is to deliver high-quality care in a cost effective manner that is satisfying to patients. To document the last, many hospitals, provider groups, and companies send out “patient satisfaction” surveys, which are at best cosmetic and at worst destructive. People don’t fill them out “right”; they tend to reflect an overall impression that leads people to mark each of the ostensibly-separate questions “great” or “terrible”. Also, in forming this global impression, folks understandably often overvalue the things that they can assess (like the quality of food or attractiveness of the facility) compared to things that they cannot (such as the actual quality of care). This is, by the way, where providing good customer service makes a big difference, and while some places are getting better, the medical care industry is generally weak in this critical area.

As in almost everything, those with the least get the least. The uninsured, the poorly insured, and the just poor, provide the least incentive to providers (getting paid) to meet their needs. Government regulations that require certain services for Medicare or Medicaid without paying for them result in greater strain on those providers who provide care to people in these groups. Many providers, especially in some fields or medical specialties or geographic areas, try to avoid them. They locate in wealthier neighborhood, don’t take folks who are uninsured (or on Medicaid, and sometimes even Medicare), or offer indulgent, wonderful “concierge” services for those who can pay a significant retainer. Thus works the “market” in health care. A terrible way to go.

A universal health insurance system won’t make all these problems go away; even with it, systems can still be poor, providers can be uncaring. But it will help a lot. Because everyone is covered, there is no “vendor lock”; the market can function well because people choose their providers based on service, not because they are forced to because they are locked in to a limited pool. Information flows between primary care and specialists and therapists and labs and imaging because if it doesn’t folks are free to take their business elsewhere. The way competition should work; competition on providing the best product and service.

And, because we would all be in it together, in the same system, the most empowered will make sure it works for them, and thus, hopefully, for us all.

Medicare Advantage plans, CMS, and providing high-quality care to -- and care for -- all people

Medicare Advantage plans, also known as Medicare HMOs, or officially as Medicare Part C, are an alternative to traditional Medicare. By enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient gets additional benefits that are characteristic of HMOs. This may include smaller (or no) copayments or deductibles, coverage for things not covered by traditional Medicare like dental care, eyeglasses, and hearing aids, and other “advantages”. There are disadvantages, also, of course, just as in other HMOs. Beyond cost, the main one is that there is a limited panel of providers – doctors and hospitals – that the person can use. This is particularly an issue for retired people who travel a lot, or may spend the winter in a warmer climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other providers employed by the HMO itself. There are fewer of these than there once were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”, where any doctor can be “approved” to be part of their provider group, but many doctors may choose not to be for reasons such as lower reimbursement or onerous regulation. Thus, it is at least theoretically possible that a Medicare Advantage enrollee could receive lower quality care from the doctors and hospitals that were part of the HMO’s network than from another doctor or hospital that might not be, but would be available to traditional Medicare patients. In addition, some Medicare Advantage plans are open to “dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying the additional premium. That such programs might provide worse care than others isnot an unreasonable concern based upon other services targeted Medicaid patients (e.g., nursing homes) and other programs targeted specifically to low income people.

Thus, Medicare has developed a rating system for Medicare Advantage plans, which assigns from 1 to 5 stars based, presumably, on carefully considered and assessed quality measures. If you want a good plan, it would behoove you to choose one with a “5 star” rating. Provided, of course, one is available in your area, and provided you can afford the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will pay for. Unsurprisingly, many plans that have enrolled Medicaid or other lower-income patients have had lower ratings, based on the outcomes of those patients. The plans argue that this is because these low-income patients are higher-risk, have more co-existing medical, mental health, and social conditions outside of the plan’s control. Others, including the Center for Medicare and Medicaid Services (CMS), which administers Medicare, have argued that considering these characteristics might “give a pass” to plans that provide lower-quality care to poor people. A similar rating system exists for hospitals, and similar arguments have been made. As I discussed in a blog from November 10, 2013, “Does quality of care vary by insurance status? Even Medicare? Is that OK?”, there are legitimate arguments to be made on both sides.

Now, however, according to a report in “Modern Healthcare” on October 21, 2015, CMS interim administrator Andy Slavitt and his deputy administrator who runs the Center for Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for Medicare Advantage plans based upon the pre-existing risk of the patients enrolled. This is important to the plans, since Medicare can drop them if they have several years of lower-than-3-star ratings. And they don’t want to be dropped, because these plans are moneymakers, in no small part because CMS treats them, financially, better than traditional Medicare plans (a result of purposeful federal policy to try experiments to “privatize” Medicare). While new criteria have not been officially announced, and would not take effect until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising because the CMS has previously downplayed the effects of socio-economic status on the ratings. The agency described the effect as ‘small in most cases and not consistently negative’ in a summary of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the (possible) change of heart is happening, it is difficult to not consider the financial and political clout of the insurance industry that sponsors these programs, and the political support that such “private” Medicare-replacement programs have.  It is worth noting that CMS has not indicated that it will consider revising the ratings for hospitals, despite the fact that hospitals that care a higher proportion of poor and socially disadvantaged people face the same issues. The financial penalty for hospitals is very direct, as Medicare is not paying for readmissions which occur within 30 days. If this seems, on its face, reasonable, consider that sometimes even when the care provided in the hospital is of high quality, people go back to their homes (or long-term care facilities) where it may not be. This is sometimes a result of lack of money, lack of social support, and other stressors, but the result is that they are more likely to be readmitted. Again, CMS has argued that it would not want to encourage hospitals providing lower-quality care for poor people (which certainly would be a bad thing). But if CMS penalizes hospitals for readmissions that are outside their control, it simply encourages hospitals to not care for low-income people, or, if they are sole providers in their community, possibly even close their doors, and that would be a very bad thing. Studies that have been done indeed show that readmissions are higher when hospitals care for lower income and Medicaid patients, and that this is not the result of poorer quality care provided when those people are inpatients. (See “Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program” from the Kaiser Family Foundation and “Socioeconomic status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to all Medicare recipients (indeed all people) by a hospital is not discriminatory or inequitable and that all patients have access to the care they need at the highest possible quality level. But unadjusted readmission rates are a very crude measure of quality, and it is unreasonable for CMS to expect that hospitals will be able to compensate for the impacts of poverty and lack of access to preventive care and early diagnosis and treatment. It is not unreasonable, however, for us, the American people, to expect that our government develop and help pay for programs that ensure that people’s basic needs for shelter, food, clothing, warmth and other social determinants of health, as well as post-hospital care (access to primary care, home health, and high-quality long-term care).

A single-payer health system is insufficient to address all of these needs. But it is a good start for some of them.