The greatest quality deficit? Physically destroying the health care system, and, oh yeah, the people it is supposed to serve

I have previously quoted from the important JAMA paper by Schiff, Bindman, and Brennan “A Better Quality Alternative: Single Payer National Health System Reform” (JAMA Sept 14, 1994, 272(10):803-808) the observation that “denial of care” is the “gravest of quality deficits”. It is generally hard to argue with this; if people are denied care they are not going to get quality care. While it can be argued that there are some forms of care that is worse than no care, this is clearly not what the authors have in mind. They are talking about the fact that people are denied appropriate care because they do not have money or insurance. More than 30 years later this still rings true, in an America that has not yet seen a health insurance system that covers everyone, as every other well-to-do country has, and indeed is even more threatened by cuts in the coverage that we do have. As I write, the federal government is facing a shutdown, with the Democrats in Congress demanding continued funding for those who received coverage from the expansion of Medicaid under the Affordable Care Act (ACA, “Obamacare”) of 2010, while the administration and Congressional Republicans steadfastly refuse to consider this, arguing mainly the high cost. This demonstrates once again their complete inhumanity and heartlessness, in no small part because earlier this year they cut more than that from the taxes of billionaires.

There are many ways to deny care, and rolling back Medicaid expansion is one. Another is closing hospitals, and many, mainly rural, hospitals, have and will close as a result of these cuts. They can also make existing insurance harder to get and more expensive, as is regularly documented in Wendell Potter’s substack “Health Care Un-Covered” and many other venues. I will talk more about this in a future blog post. But another, really effective, way to decrease access is to destroy health care facilities. Much more efficient than starving hospitals for money by discriminatory, greed-focused funding is actively blowing them up, killing the providers, and eliminating the infrastructure for providing care for anyone, insured or not. This is commonly done during a process called “war”, in which a strategy often adopted goes beyond violating the Geneva Conventions by not caring for enemy combatants, but indeed targets the elimination of the civilian health care infrastructure. The Geneva Conventions provide for not attacking health care providers, for caring for the wounded based on need, not loyalty, and certainly respecting civilian health care (some references: Rule 25 on medical providers, International Committee on the Red Cross, World Medical Association, Wikipedia (Medical Neutrality), among many others). I learned about much of this decades ago from a surgeon who worked for the International Committee on the Red Cross (ICRC) and HAD supervised one of its hospitals in Chechnya during the war there. It was this hospital which military combatants invaded, murdering four nurses. At the time, it was horrifying. Since then, such actions have become so common a practice in the 21^st century that, in itself, it almost refutes the idea that human beings have become more civilized over time.

While there are many places where combatants have used attacks on the civilian population and their health care facilities as methods of imposing their will, the attacks by the government of Israel on the healthcare facilities in Gaza stand out in their extent, persistence in the face of world opinion, lack of any sign of conscience, and contribution to genocide. I am not expert in war, but I know that you are supposed to try to not kill civilian noncombatants, and that you are not supposed to destroy medical infrastructure; these are war crimes. In Gaza both are happening; people’s houses and cities are bombed, thousands have been killed, hundreds of thousands displaced, and the facilities where they might go for care – for problems that occur in peacetime, of course, but far more for those inflicted on them by the military attack on them – are destroyed. On purpose. Repeatedly. As part of an immoral and illegal strategy to “win”, by killing or injuring as many as possible.

Israel, unsurprisingly, and its US supporters in the American Jewish Committee, deny this. They say that what they are doing in Gaza is not genocide, and that what they are doing in killing the people of Gaza as well as destroying its hospitals and other health care facilities and healthcare workers are not war crimes. Of course, what is happening is happening, but they are picking apart word, like the application of a particular term (“genocide”, “war crime”). I am also no expert on the definition of genocide (like, what percent of a group do you have to be trying to kill for it to qualify), but those who are most expert say that what Israel is doing in Gaza is genocide. No responsible independent body has even tried to justify what they are doing. The argument cannot be that “because we are Israel, what we are doing is ok, although it would be intolerable if anyone else did it especially to us”. Nor can it be that “no matter what we do, no matter how horrific or destructive, because we are a Jewish state, any opposition to it is anti-Semitism.” Of course, this position is without logic.

There can be no justification for the Holocaust, for any reason, for anyone. But just as the atrocities being committed by Israel do not mean “Hitler was right”, the fact that the Holocaust happened – and that there is serious anti-Semitism in the world today – does not justify those atrocities being committed by Israel. In true fascist tradition, the government of Israel is not only committing these atrocities, destruction of healthcare infrastructure and healthcare workers, killing civilians including children en masse and starving them, it is blocking international aid from coming to the people of Gaza. These flotillas of boats bringing aid, contrary to what Israel says, are humanitarian and the people doing it are brave and noble. The government of Israel, and those Israelis and non-Israelis who support its actions, are … not. Interested in knowing what is happening in Gaza? There are many sources, but here is a recent article from the NY Times, longstanding Israel supporter on the destruction of Gaza. Or how about the video, if you need visual evidence.

There are terrible threats to the health of the American people, longstanding and persistent threats from greedy and evil for-profit insurers and pharmaceutical manufacturers and PBMs and health systems and private equity. These have been exacerbated by the Trump administration’s hostility to covering all people, such as the cutbacks in Medicaid expansion from the ACA, an issue on which the Democrats have finally shown some spine although the GOP commitment to not spending the money in order to maintain tax cuts for the wealthiest has led to a federal government shutdown. It is a very bad situation for many Americans, especially those with the greatest vulnerability.

But this is almost nothing compared to the attacks on health in many places, and particularly in Gaza. The purposeful destruction of cities where people live, mass murder of civilians, huge displacements of people, augmented by the destruction of the very facilities that might provide some treatment and succor, is without conceivable justification.

The authors of the paper cited at the beginning of this piece were, thus, not correct in saying that lack of access is the greatest quality deficit. That is true when there is a functioning health system and some people are excluded. Actively doing what is done in many wars, and what Israel is doing in Gaza, is a much worse assault on not just quality of healthcare but on health and life itself.

Slash the VA! Make our veterans pay for increasing corporate profits!

Given the heavy-handed, mean-spirited, cruel, anti-democratic, un-Constitutional, and penny-wise (maybe) but pound-foolish actions of the current GOP/Trump/Musk administration, it is hard to know where even to begin to discuss it. Certainly many, many intelligent and well informed people, including luminaries such as politician Bernie Sanders and historian Heather Cox Richardson, as well as many news sources such as the Contrarian (established by reporters and editors fired by or resigned from Jeff Bezos’ Washington Post and the New York Times). Even in the narrower realm of health, we have outrages like the vaccine denier and proponent of ineffective and even dangerous therapies, Robert F. Kennedy, Jr. heading the Department of Health and Human Services, and Mehmet Oz, RFK, Jr’s fellow traveler, nominated to head the Centers for Medicare and Medicaid Services, presumably so those services can continue to be slashed. And even more narrowly, in health and medicine and social justice – well, all of these actions and cuts tie to social justice!

So, let’s look at the Veterans Administration (VA). The VA is tasked with providing health care for our veterans, those who have served in the military, many of whom have suffered very serious, life-threatening injuries, physical and mental (of course not counting those never got to be veterans because their lives were lost). Veterans have also had higher rates of cancers and lung diseases linked to the use of burn pits (horrific incinerators used “in country” to dispose of garbage, waste, bodies, munitions, toxic materials, using jet fuel as the source of fire, running 24/7 close to camps). The death of President Biden’s son Beau was linked to burn pit exposure, and finally during the last administration Congress passed the PACT act (Honoring Our Promise to Address Comrade Toxic Exposure) to compensate and care for those veterans whose diseases were likely caused by such exposure, often called “the Agent Orange of the Gulf wars”.

The VA was already highly stressed by underfunding and understaffing due to previous cuts made by the pro-veterans-in-words-only GOP Congress and that stress was dramatically increased by the hundreds of thousands (at least a quarter million) claims under the PACT act. Amazingly the VA clinical operation, also very short-staffed, was able to continue to provide health care to veterans. Although there were many complaints of waits and slowdowns, they were in fact much less than the routine waits and slowdowns in the non-VA health care sector (anyone tried to get a doctor’s appointment lately?) and virtually every measure of quality has shown that the VA has outperformed the civilian sector. Of course, its mission is to provide health care for veterans, not to make a profit; this distinguishes it from the civilian sector in which profit is “Job One” and accessible, quality, effective health care a distant second. The NY Times’ recent article titled ‘Chaos at the V.A.: Inside the DOGE Cuts Disrupting the Veterans Agency’ notes that the VA

…treats 9.1 million veterans, provides critical medical research and, according to some studies, offers care that is comparable to or better than many private health systems. Even Project 2025, the conservative governing blueprint assembled by Trump allies, said the V.A. had transformed into “one of the most respected U.S. agencies.

Many of the VA’s successes, as well as its challenges, are documented by journalist Suzanne Gordon in journals including these in Jacobin, Veterans Starting to Mobilize, and the American Prospect.

Then came Trump, Musk, and DOGE. Under the banner of “cutting government waste” the already far-too-lean staffing of the VA is proposed to be cut by another 80,000 jobs! This will certainly result in major delays in accessing care, in lower quality, and unconscionable disservice to our veterans. It seems like heartless cruelty, and of course it is. But the nauseating thing is that while it certainly is not about cutting waste, it is not even about the heartless cruelty. It is about one thing: transferring “government” dollars – that is, YOUR tax dollars (not Musk’s, or his companies’, they don’t pay taxes!) – to private corporations. THAT is the goal.

Think about it. Slash funding and positions from the VA, which will naturally lead to complaints about inadequate service (even the VA can only do so much when cut not only to, but deep into, the bone) and protests from veterans’ groups and maybe even GOP members of Congress. So, what will they do? We don’t even have to guess – they’ll do their favorite thing and privatize it! Contract out the care of veterans to private corporations so they can have the wonderful experiences all the rest of us have in trying to access quality care. Of course, they won’t be able to, maybe even less than the rest of us, but heck, those companies will make a lot of money!

And that is the goal. It is not saving government money, it is about transferring it to private corporations, as acknowledged by Treasury Secretary Scott Bessent. This will cost more, be less efficient, and have lower quality. This is the consistent track record of almost every government service that has been privatized – they almost never either save money or work better, they put taxpayer money in private pockets. In health care, it is even worse; it is almost impossible to think of an example where privatization has not cost far more and had worse service, accessibility, and quality outcomes. If the funding is the same, it is always worse.

But, of course, this is not an accidental outcome, it is the intention. Privatization is sold as saving money, but it always costs more, and as increasing quality but it always goes down. What it is successful at is moving public dollars to the private sector. So, it doesn’t save money by eliminating waste, it eliminates basic care and then “solves” the problem by spending even more money! The heartless cruelty is not the goal; it is simply the byproduct. It hurts our veterans, but this is not a concern to the heartlessly cruel, non-empathic (Musk thinks empathy is “destroying Western civilization”) greedheads making these decisions.

Something can be done. Veterans can rise up and protest and contact their Congressional representatives. So can the various “veterans service organizations” (VSOs) including the American Legion, VFW, and many others. Maybe even some GOP Congresspeople will take the initiative and actually do something to help veterans instead of just flapping their gums! (OK, that may be a bridge too far…)

The denominator matters: we only have a quality health care system if everyone can access it!

Denominators.

Even if you are not a regular user of statistics, you probably remember that word from arithmetic. You know, the “4” in ¼, as opposed to the “1”, the numerator. Why is this important in the current policy debate? Well, if you know, for example, that a majority of, say, Republicans (or Democrats) like a policy, it would be a mistake to assume that a majority of all people like it. In health care policy, in particular, denominators, and how they are chosen, are important, because by choosing an inappropriate one you can “prove” a point that is wrong.

I recently was present for a debate on the issue of “health care is a human right” in an undergraduate class. The students did well, and although almost all personally supported the “pro” side, the “anti” side was able to find arguments in the literature, often from organizations like the CATO Institute. To a significant degree, however, they were either philosophical objections (“what is a human right?”) or, conversely, pragmatic irrelevancies to the issue (“a lot of doctors don’t take Medicaid”). Many of the assertions are belied by the facts. For example, the Northwestern economist Craig Garthwaite, interviewed in VOX, notes that if drug companies can’t make huge profits, innovation will go down, and most of the world depends upon the innovations discovered in the US. In fact, of all New Molecular Entities (NMEs) discovered, a little over 1/3 are in the US. But even this ignores another important point – many or most of these were not originally discovered by pharmaceutical companies using their hard-earned profits on Research and Development (R&D), on which they spend much less than on marketing, but by government (National Institutes of Health, NIH) supported university research, which the drug companies skim for the most promising ones. So what is the denominator there? All NMEs, or only those funded by drug companies?

The students also cited these opponents of healthcare-as-a-right or Medicare for All who also assert that, in a similar manner, it would cause quality to decrease. If everyone has access, and hospitals and doctors can’t make more money on some, they opine, then those people will not get all the best, most modern and effective care. This is where denominators come back in. Even if it were true that there might be decreased quality for those who currently have unfettered access (very questionable), it is obvious that the quality of care would increase for those who now get little or none! Overall, when the whole population is considered as the denominator, the quality of care would absolutely go up. Denial of care, as asserted long ago by Schiff, Brennan and Bindman, is “the gravest of all quality defects”.[1] If a hospital, for example, reports excellent outcomes for people treated there for heart attack, but only those with good insurance were admitted for treatment and the overall rate of death from heart attack in the community rose, it would be painting a very skewed picture. If what you mean is “I have real privileges, and I am afraid that by spreading access out to everyone I might lose that privilege”, then say that; don’t dress it up by pretending quality would decrease!

A common assertion we hear, particularly from “moderates”, or at least from the politicians, pundits, and media who assert that they speak for moderates, is that “Most people obtain health insurance through their employers and are generally satisfied with their choice of providers, coverages and the amount they contribute to their family’s healthcare.” This may be true, or it may not be. The majority of people current have health insurance coverage through their employer, but whether they are generally satisfied is another question. The main thing is that they are much more likely to be satisfied when they are healthy and do not have to utilize health care very much or at all. Even then, the copays and other surprise costs can prove burdensome, but it is only when something happens that causes them to need to use a lot of healthcare that it becomes critical, bankrupting them and often even making that care inaccessible. When you and the members of your family are not sick, costs can be low (and you can be satisfied) but when you are sick is when all the hidden costs kick in. In this case, the important denominator might be a smaller group, those who used healthcare, rather than everyone.

These excess costs include the various legal scams described by Elisabeth Rosenthal “Where the frauds are all legal” on December 7, 2019 in the NY Times (discussed by me in Scamming Medicare: It's the providers and insurers, not the patients!, December 19, 2019), when her husband had a serious accident. They also include the “surprise bills” that come because, even though you went to a hospital that was in your insurance network and saw a surgeon who was in your network, it turns out that the ER group or the anesthesiology group contracted by the hospital, or the assistant surgeon your surgeon picked, is not in network. Boom! $10,000, $100,000 bills! No one is “satisfied” by this.

Such problems are most often faced by those with multiple chronic diseases, often older people, who have to see the doctor, be hospitalized or be operated on more often. Most people, in most years, are not in need of major or expensive care, so they are the “satisfied well”. But something bad and expensive could happen to any of us any day: Your doctor surprises you by telling you that you have cancer! You are in a car (or bicycle) accident and need big surgeries! Your baby was premature and needs to be in neonatal intensive care! We are all at risk in a system where only some people are covered, and only some of the time, and for some things, and for certain providers.

Recently, there was big news when the large Culinary Workers of America union came out to oppose Sen. Sanders’ Medicare for All plan, which the union suggests would void the excellent health care coverage that they have won for their members. The union deserves tremendous credit for having negotiated this coverage in the current and recent negative environment for unions, especially for a membership that is largely relatively low-paid, minority, female, and often non-English speaking. However, to suggest that it would be a loss for their members is deceiving. For one thing, the coverage of a Medicare for All plan would be at least equal to this excellent plan; it would cover everyone for everything. Health coverage is a great benefit, but the money that employers pay for their contribution (which unlike workers’ contributions is tax-deductible) is money that they don’t pay in wages. The benefits of M4All compared to the CWA plan are well-described in this Quote of the Day by Dr. Don McCanne. And the CWA contract is a relative outlier and not guaranteed to be as good next time; remember the many General Motors workers who were the exemplars of having “Cadillac coverage” during prior healthcare insurance debates, but who lost most of those benefits when GM “restructured” after bankruptcy – if they were not laid off altogether?

At least as important are the relatives, friends, and neighbors of those covered workers who work for small companies without good – or any – health insurance plans, or are disabled, or unemployed for longer or shorter periods. This is the “community”, the “population” that needs to be considered as the denominator. Many CWA (and other union) members realize this; while the union leadership may rightly be proud of their accomplishments in negotiating, this does not bring excellent health coverage or care to all of the people. The denominator needs to be all of us.

Only a universal single payer system, an improved and expanded Medicare for All, will do that.

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[1] Schiff GS, Brennan AB, Bindman TA, A Better-Quality Alternative Single-Payer National Health System Reform, JAMA 272(10):803-808, September 14, 1994.