COVID-19 emphasizes the necessity of Medicare for All

This will not be much of a reprise of “what should you do about COVID-19”, you know, wash your hands, use hand-sanitizer, avoid groups whenever possible, stay home if you are sick-but-not-too-sick (if you’re really short of breath, go to the ER; if you have signs of a heart attack or significant trauma, go to the ER, even though both increase your risk of infection). It will also not be much of reprise of what not to do: have big parties to celebrate the cancellation of classes, like many of the students at Cornell (https://cornellsun.com/2020/03/15/while-some-cornellians-self-quarantine-others-pack-parties-in-response-to-campus-shutdown), who at least have to “excuse” of being both young and thus less likely to die and young and thus have underdeveloped frontal cortexes (where judgement resides). Or the racquetball players at my local racquet club who had a tournament this weekend gathering at least 40 people in a relatively small space and sharing finger food like fruit and cheese and crackers (and who are decidedly NOT young! Although they may lack judgement…).

At the debate on Washington DC on March 15, Bernie Sanders emphasized the degree to which having a universal health program, a single-payer program, Medicare-for-All would help in this crisis. Yes. It would have and it will in the future, when another epidemic comes calling. It will not, by a long shot, solve all the problems that have existed in our (and other nations’) response to COVID-19, but it would have helped a lot, particularly in alleviating the still-valid fears that people have of getting crippling bills if they seek care.

This is not to minimize the incredibly incompetent, not to mention destructive, role that the federal government has played. The Executive Branch, led by President Trump, has bloviated, lied, misled, created fear, and provided incredible misinformation to the American people. This has been extensively covered by the media; criticizing the buffoonery of Trump is apparently fair game among the mainstream press. There has also been some, albeit less, coverage of the purposeful decimation of the nation’s public health infrastructure by the Trump administration prior to the advent of SARS-CoV-2. The federal epidemic response task force was eliminated by the administration. Federal support for state and local health departments was cut. Once the administration finally acknowledged that it was a big problem (one for which the President took no responsibility), the response was anemic and ineffectual.

Trump named science-denier Mike Pence to lead the effort. Jared Kushner has it added to his portfolio; he consulted his brother’s father-in-law, who is, after all, a doctor, and a Facebook group. Trump called it the “China virus”, but SARS-CoV-2 was not intimidated. Concerned about a stock market taking its biggest dive since 2008 (something that really worries him!) Trump proposed cutting payroll taxes paid by employers by $700B, both remarkably stupid (takes a long time, and cuts funding for Social Security, and helps neither the economy or the stock market) and typically directed to benefit the best-off, ignoring the plight of those most affected, the poor. The response to the epidemic, including especially the unavailability of tests for SARS-CoV-2, has been scandalous. We are at least a year from having a vaccine, but the President continued his moronic approach by apparently trying to buy a vaccine developed in Germany for use “only in America”.

But it was not just the administration. The Congress also did not demand a public health infrastructure. The states and local governments, in part because of decreased federal funding, have grossly underfunded their own health departments, which were woefully unprepared in most areas and are struggling to begin to catch up. Luckily, the health department in Seattle/King County Washington, where the virus has hit hardest in the US, was one of the ones in better shape.

So there is no question but that poor planning, addressing core health needs only when there is a crisis, focusing on tax cuts for the wealthiest and not planning for “the big one” (just as we have not planning for climate change or war) has crippled the US and its response. There is also no question that having a president who plays to his right-wing base who see him as the one “in charge”, and enablers like Fox News’ Sean Hannity, made it even worse. The system that does exist in the US has long been focused (“focus” = funded) on individual care of individual people (called “patients), and particularly on those who have money or good insurance and even more on those whose diseases (such as cancer) are very well reimbursed by those insurers. Public health suffers because, other than in epidemics (SARS, H1N1, Ebola) it is not in the public consciousness, so the government can work on tax cuts for the rich and the health system can work on making money on the insured sick. Sins of omission are less obvious; I have noted previously that people do not wake up each morning saying “thank goodness I don’t have cholera because we have a clean water supply!”

But there is another part of the story, which will become even bigger as folks get sick. This is because the US does not have universal health care, does not have a national health system. It has not even addressed who will pay for COVID-19 testing (a local university recently suggested it would charge its own students $200, until it was embarrassed out of it!), or a vaccine if it becomes available. It certainly has no reasonable plan for paying for the care of people who fall ill with disease, need hospitalization in intensive care units need to be on ventilators, but have no or rotten insurance. We hear that the VA will be a backup health system; great, if it can. When will we federalize the for-profit and “non-profit” hospitals?

We have also, of course, had policy decisions on closure made by each individual business/organization/school/local government, based on its own perception of risk (epidemiologic, financial, peer pressure) without adequate consideration of its impact on the entire social structure. Stay home from work? Work from home? What about the (generally lower paid) folks whose work depends on being there (cleaners, health workers, etc.)? What about those who don’t have sick leave? What about those who don’t get paid, or lose their jobs, if they don’t show up? What about school closures putting parents in the position of choosing childcare vs work (or calling upon grandparents, in the higher risk group)?

Planning for and implementing a response to an epidemic is different from having an organized national health system. Many European countries including Italy and Spain have their citizens all covered but are struggling terribly. But having such a system does create the infrastructure basis for national health policy and national health response; see how South Korea dramatically ramped up its COVID-19 testing, and was able to implement it because of a national health system. Spain has indeed nationalized all private healthcare to battle this crisis. Norway suggested that its citizen living abroad come home. It is urging its citizens abroad to return home, especially if they are "staying in a country with poorly developed health services and infrastructure and/or collective infrastructure, for example the USA"! We planned poorly and we won’t necessarily provide care for them, or indeed for “us”!

Much terrific insight is provided by Dr. Seiji Yamada in his terrific Counterpunch piece “Coronavirus for All”: ”These days U.S. health system is run by health care executives, with their business smarts, their lean operations (except for their compensation packages), achieving just-in-time delivery.”

Health care should be a human right. This crisis illustrates the need to have a robust, continuously-funded public health infrastructure. It also illustrates the need for a universal health care system that can take care of all of us. Bernie Sanders may not win the nomination, but the fight for universal health care for all of us must continue.

As Dr. Yamada notes:

Certainly it’s true in the U.S.A. it is easier to imagine the end of the world than to imagine the end of capitalism. On the other hand, it’s also obvious that capitalist health care is going to faceplant in the face of the coronavirus. It’s going to be a choice between Medicare for All or Coronavirus for All.

Drug corporations from manufacturers to retailers are rotten down the line

Drugs, drugs, drugs. We hear a lot about drugs. Especially about the Opioid Crisis, which is a very serious problem in the US. But the other drug problem we hear about is also very serious: the cost of drugs and the inability of people to access the drugs that they need, not to mention to save their lives, because of the cost.

One such drug is insulin, needed by people with Type 1 diabetes to survive. Stories of people dying from, or almost dying from, lack of access to insulin, or having to go to Canada or Mexico to buy it, are both sad and galling.  It is particularly so in the case of insulin because its discoverers wanted it to be free. In 1923, Frederick Banting and his colleagues Charles Best and James Collip sold the patent to the University of Toronto for $1 each, worried that if they did not patent it drug companies would patent an inferior version of insulin (imagine that!) and people would die. The University of Toronto gave the patent royalty-free to drug companies, specifically Eli Lilly.

Unsurprisingly, that marked the end of being motivated by the public interest. As early as 1941, Lilly and two other companies were indicted for price fixing of insulin, and it has gone on from there. In 1982, Lilly was able to synthesize human insulin (previously insulin was made from beef or pork pancreas, which had a lot of reactions, although pork was closer to human and thus preferred). Of course, the price took off. With the complicity of the government, worse in administrations that believed corporate profit (especially for big donors) was more important than human lives, the price continued to rise. This has led us to story after story about people with diabetes, like Josh Wilkerson, dying because they could not afford $1,200 co-pays. Banting and Best are turning in their graves.

Yes, pharmaceutical manufacturers are greedy and evil, whether they make insulin or Epi-Pen or colchicine, or other drugs (like pyrimethamine – see Martin Shrkeli) and deserve every bit of anger, hatred, and scorn that has been visited on them. They are continually the #1 (or, sometimes, #1!) profitable industry in the US, making lots of money because, well, people need their products to live. But they are not the only part of the drug industry that is responsible for bleeding us for profit. They are complicit with insurance companies, who agree to pay the outrageous prices that they demand (because, after all, they just raise their premiums), and with our bought-and-paid-for Congress. For example, when Congress passed the Medicare Part D Drug Act in 2003 it contained a prohibition against Medicare, the nation’s largest insurer, negotiating drug prices, thus ensuring that American pay far more for drugs than people in other countries (there is a reason uninsured folks go to Canada or Mexico)! As I noted recently, the idea is often put forward that without drug company profit, innovation in pharmaceutical discovery would grind to a halt, but in fact nearly 2/3 of discoveries are made outside the US and most of those in the US are discovered through research funded by the National Institutes of Health.

But beyond the usual villains, pharmaceutical and insurance companies, we have the wholesalers, retailers, and “bundlers” of drugs also making out like bandits (they are bandits, even if, thanks to that bought-and-paid-for Congress, their schemes are often legal) from our health needs. The “bundlers”, called Pharmacy Benefit Managers (PBMs) are contracted by large insurers to negotiate for the “best prices” with pharmacy retailers. For a positive spin on what they do, see this piece from “The Balance”. However, they are also responsible for a lot of the high cost of drugs, especially for those with worse, or no, insurance. In addition, they have a lot of practices that enhance their profit at your expense, many explained in this piece from the Commonwealth Fund, such as jacking up the price charged to insurers and pocketing the difference (“spread pricing”) and pocketing rebates from manufacturers. The entire role of PBMs is complex and bewildering, but they play a critical role in the important process of profiting off of your illness.

More recently, we have seen exposure of the nefarious practices of the final link in the chain of getting you your needed medicines, the retail pharmacies themselves. Of course, the old mom-and-pop drugstore on the corner is almost a thing of the past, having been replaced by mega-chain pharmacies such as CVS, Walgreens, Rite Aid and Duane Reed. (Of course, in many big cities they are still on every corner, not just competing with each other but with themselves; in places like New York City they are more ubiquitous than Starbucks!) These chains drove out the small drugstores by underpricing them, but having been successful in that, they have adopted practices that are frequently unethical, sometimes illegal, and always guaranteed to make them more profit. Indeed, two of the largest PBMs are now owned by these chains (Caremark by CVS and Envision by Walgreens), enhancing the vertical integration of the industry.

A New York Times exposé of January 31, 2020 by Ellen Gabler tells how retail pharmacies overwork their employees, sometimes with resultant errors such as patients getting the wrong medicines and often having adverse effects. It was titled “How Chaos at Chain Pharmacies is Putting Patients at Risk”, but this headline, while accurate, does not explain the real reason for the chaos, which is that these pharmacies are using an old and dishonorable technique made famous by Henry Ford in the early days of assembly lines called “speed up”. Speed-up, increasing the expectations for “production” (in this case, number of prescriptions filled per hour) has been a target of union contracts since the 1930s, but as the influence of unions has waned (with the collaboration of pro-corporate legislatures) these practices have increased. Pharmacists may be “professionals” (like nurses and doctors) but whatever your education and training, if you work for a large corporation who sets the rules and standard and has control, you are a worker, and need the protections that all workers should have. The most conscientious of these professionals have protested, often to the state boards that regulate them, as cited in the Gabler article:

In letters to state regulatory boards and in interviews with The New York Times, many pharmacists at companies like CVS, Rite Aid and Walgreens described understaffed and chaotic workplaces where they said it had become difficult to perform their jobs safely, putting the public at risk of medication errors.

They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said — all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.

“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.

“The amount of busywork we must do while verifying prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board in February. “Mistakes are going to be made and the patients are going to be the ones suffering.

So is the problem being addressed? You can be sure that it is, by the corporations that run these pharmacies. How? The complaints of the pharmacists are being taken care of in the way that big corporations often do, that is, ignoring them and deleting mention of them from their reports. In a follow up on February 21, 2020, “At Walgreens, complaints of medication errors go missing”, Ms. Gabler writes:

Pharmacy employees at Walgreens told consultants late last year that high levels of stress and “unreasonable” expectations had led them to make mistakes while filling prescriptions and to ignore some safety procedures.

But when the consultants presented their findings at Walgreens’s corporate offices this month, there was no reference to the errors and little mention of other concerns the employees had raised.

That’s because senior leaders at Walgreens had directed the consultants to remove some damaging findings after seeing a draft of their presentation, a review of internal emails, chat logs and two versions of the report shows.

In one instance, Amy Bixler, the director of pharmacy and retail operations at Walgreens, told them to delete a bullet point last month that mentioned how employees “sometimes skirted or completely ignored” proper procedures to meet corporate metrics, according to the chat logs and the draft report.

Good for you, Ms. Bixler! Took care of that problem! You should get a nice bonus this year!

If these practice are of concern to you, they should be. So should the price gouging up and down the line in the pharmaceutical industry, the drive to profit for manufacturers, PBMs, insurance companies, and retail pharmacies to make lots of money off you, or you die. “Your money or your life!” is an old cliché attributed to highwaymen. It should be the mantra of the pharmaceutical industry in this age of unfettered capitalism.

But no highwayman ever had the reach or power or ownership of politicians that these folks do. 

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.