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!

"Non-profit" hospital chains join for-profits in destroying our health system

The New York Times’ latest exposé on the despicable actions of large, ostensibly “non-profit” health systems, ‘How a Sprawling Hospital Chain Ignited Its Own Staffing Crisis’, examines Ascension Health, one of the largest such systems in the US. It is definitely worth reading, although you may want to try deep breathing first. Ascension owns hospitals over a wide area of the US, mainly in the Midwest, and took a bow in 2019 when it “was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric”, saving $500M! Unfortunately, cutting the number of employees to bare bones limited the quality of care available to patients. And when the COVID pandemic hit, and occupancy rates skyrocketed, they were woefully understaffed – except that the woe was experienced by the patients who sought, and to one degree or another, received care in those hospitals. It was and remains a disaster. Among the impacts cited in the article: at one hospital “there were so few nurses that psychiatric patients with Covid were left waiting a full day for beds, and a single aide was on hand to assist with 32 infected patients”; at another “Chronic understaffing meant that patients languished in dried feces, while robots replaced nursing assistants who would normally sit with mentally impaired patients.” Think about that patient being your parent! Disgusting? Upsetting? Dangerous? How about downright evil?

But, you might think, the cost cutting was necessary. After all we read about hospitals that are on the brink, are barely surviving, needing government bailouts to keep serving their communities. Oh, wait, those are different hospitals. Those are rural safety net hospitals. Ascension has $18 Billion in the bank. $18 Billion! In a “non-profit” hospital system! Boy, I’m sure that those C-suite execs who oversaw that got big 7-figure bonuses! And now? With that much in the bank, I doubt they are going to suffer much just because people are getting terrible care and dying in their hospitals.

So how are these systems non-profit? The Times does a good summary:

In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities.

But…

The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions. Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas. And many have cut staff to skeletal levels, often at the expense of patient safety.

Oh. That doesn’t sound so good. And, to be sure, Ascension is far from the only “non-profit” hospital chain to behave in this manner; most of the big and “successful” ones do so. The West’s Providence Health System, the focus of a previous Times exposé and post on this blog ("Non-profit" hospital systems behaving worse than for-profits: No end to the scams”, October 1, 2022), ironically started by a group of nuns to care for the poor and underserved, also gets coverage in this article.

There is so much evil here it is hard to know where to start. Certainly, a key part is running networks of institutions ostensibly created to heal the sick and injured (“hospitals”) as if they were manufacturing businesses and employing au courant management strategies designed for manufacturing, such as “just in time” supply chains and cutting staff down to the bone. This is absurd; hospitals, to be effective, to be able to meet regular seasonal changes, not to mention disasters or pandemics, need to have excess capacity at all times. Running “lean and mean” is wrong on many levels. It is exploitive of the staff, and indeed puts staff in the position of providing poor-quality care to their patients, compromising their professionalism and commitment; the testimonies of the nurses at Ascension are the most damning part of the report. It makes it difficult to impossible to gear up in times of need. And it um, kills people. You cannot have a potential staff of on-again-off-again health care workers to be employed just when needed “just in time”. If you could, if such excess capacity existed in the society, it would be yet another sign of perversion, of oppressing people and their families and communities to make more money – profit for “non-profits”.

Another way that this is, to put it gently, inequitable, is described in the Times article: cutting back on services in high-need-but-low-income communities and reallocating them to wealthier neighborhoods. And, of course, emphasizing and marketing high profit-margin services (cancer care, orthopedics, neurosurgery, cardiac interventions). Again, a  morally bankrupt strategy to meet not the health needs of our country but rather the dollar desires of a board of directors!

So what do I have to add to the excellent coverage given to this issue by the NY Times? They even call it “Profits over Patients”, which it is. I think I can give the problem a name that the Times will not: Capitalism. Capitalism is the problem. And it is not just any capitalism, it is not the capitalism of mom-and-pop stores or small businesses or making a reasonable profit, it is the capitalism-run-amok, it is the capitalism of anything-for-a-buck, full-speed-ahead, don’t-care-who-gets-hurt, bigger-is-better, I-want-to-be-a-billionaire-too that we have seen increasingly over the last decades. It is the capitalism that Noam Chomsky calls “gangster capitalism”, but in many ways what these folks do worse than what gangsters do, because it threatens not only people but all of our society. Sure, a gangster may threaten or even kill you. These systems are designed in a way that will kill thousands! But you know what? That is capitalism, that is the end point of capitalism. That is the Gordon Gekko, greed-is-good, result of capitalism that is not only unfettered by government regulation (especially with the elimination of many of the best parts of the New Deal) but that is actively enabled by a government that is willing to let private companies take all the profits when they make them and bail them out when they lose. And it is arguably even more evil that the hospitals described in the Times article are large “non-profits” which behave exactly like for-profits except that they don’t pay taxes! Who would have thought I’d be arguing for for-profits? Well, I’m not; they actually providing even worse care for the community because there are almost no regulations governing what they do. But at least they pay taxes.

So what can be done? A great deal actually.

•  Ban for profit corporations, or any entity controlled by private equity, from health care delivery. Yes, hospitals, but also clinics, urgent care centers, nursing homes, etc.
• Require not-for-profit entities to behave like non-profits are supposed to, with community benefit being the SOLE criterion by which they are judged. Do not allow building of facilities, expansion, or the dissolution of “product lines” except when it can be demonstrated that this will benefit the health of the overall community. Not allow “we’re moving into/building into this prosperous expanding suburb because, you know, they will need health care” if it means there will be inadequate resources to serve the people in the most needy, sickest, and poorest communities. No cannibalizing inner-cities to feed wealthier suburbs. And while it may not be possible to directly regulate the income (salary and bonuses) of C-suite executives of non-profits, the requirements should ensure that they cannot make loads of money and build huge reserves ($18 billion! Come  on!) If they won’t do this, tax them
  
• ·Ensure that the communities most in need, especially in rural areas, have their needs met on a case by case basis. The absurd Hobson’s Choice the federal government is offering rural hospitals, crystallized in the headline of the article cited in the second paragraph, “A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care?” must be changed so that each hospital, and the larger community it serves (sometimes geographically enormous) gets support for what it needs, inpatient care, outpatient care, and usually both.

Even better, while eliminating private for-profit ownership, discourage misbehavior by non-profit owners by creating and implementing a single payer health system, such as Medicare for All, which as the sole payer would be able to with and regulate these health systems for the benefit of the health care of the people of our country.