Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.
Medicare for All Is Not Enough, The Nation, March 31, 2022, by David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; Adam Gaffney, M.D., M.P.H.; Don McCanne, M.D.; John Geyman, M.D.
We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.
However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and â70sâthe model for single-payer reform in the United States.
But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providersâincluding by private equity firmsâhas burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.
These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nationâs vital health care assets.
Responding to the evidence of for-profitsâ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilitiesâlike the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giantsâare needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?
In both instances, a transition to public, community-based ownershipâa reform model generally labeled National Health Service (NHS), in contrast to NHIâseems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.
Such an NHS should have federal funding and oversight, similar to the Veterans Health Administrationâa publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the USâs pandemic responseâand in so doing, turn the tide of faltering health in America.
Comment:
By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.
But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physiciansâ practices, hospitals, and other health care institutions. Avaricious firms â both for-profit and non-profit â are gobbling up the vital resources needed for care, gaming even traditional Medicareâs payment incentives, and prioritizing profitability over patientsâ and communitiesâ needs. Physicians, like other health care personnel employed by these organizations, must either comply with executivesâ profit-seeking directives or be shown the exit.
Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayersâ and patientsâ dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotlandâs National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.
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