By Ravi N. Shah, M.D., M.B.A.; Obianuju O. Berry, M.D., M.P.H.
JAMA Psychiatry, September 16, 2020 (Online first)

Mental health care is ripe for innovation. Less than a third of people with mental health disorders receive treatment, and even a smaller proportion receive adequate care. The private sector has taken notice of this economic mismatch (high demand with inadequate supply) and is aggressively pursuing mental health and wellness as an investment opportunity. In 2019 alone, venture capital (VC) companies invested a record-breaking $637 million in more than 60 different mental health–oriented companies, which is more than 22.8 times the investment in 2013. This rapid rise in investment in the mental health and wellness space brings new challenges related to defining, quantifying, and assessing products and services that had previously resided within traditional health care.

Although self-guided smartphone applications and digital products have received a great deal of public attention, the financial market is dominated by companies that provide direct clinician-patient services. Most of these companies focus on anxiety, depression, and insomnia with little emphasis on severe mental illness.

Concerns Related to Private Investment in Mental Health

Physicians, caregivers, payers, and patients should have real concerns about this trend. Silicon Valley’s motto for success, “move fast and break things,” has led companies such as Uber and Theranos to break laws and cut corners. This ethos is not compatible with the Hippocratic doctrine of primum non nocere. Venture capital companies evaluate success in terms of growth of consumers and revenue, with little rigor applied to quality assessment. In fact, Pear Therapeutics is unique in achieving US Food and Drug Administration approval for a prescription digital therapeutic. The National Institute of Mental Health itself acknowledges that there are currently no national standards for evaluating the effectiveness of the hundreds of mental health applications that are available and recommends that consumers ask their health care providers for recommendations. In response, the American Psychiatric Association has developed a framework for evaluating mental health applications but still leaves the work of evaluating effectiveness up to individual health care professionals. Quality assurance is needed not just for products (eg, digital therapeutic tools) but also for services rendered by companies that connect clinicians with patients.

Other specific challenges that VC-backed start-ups must confront include privacy concerns, ability to adapt to personalized needs, applicability for individuals with serious mental illness, and payer adoption. A recent study of 36 mental health applications showed that 92% transmitted data to third parties, but only 69% had a privacy policy. Furthermore, clicking an “I accept” button on a lengthy privacy policy does not constitute informed consent to share protected health information. In addition, digital products are highly structured to facilitate scale, but this uniformity may provide overly narrow solutions for patients, for whom comorbidity is the rule rather than the exception. Few of these companies focus on serving the population with serious mental illness, creating a gap between where investment goes and where it is most needed. Without insurance adoption and reimbursement, only individuals able to pay out of pocket or those whose employers pay for these products will be able to access these innovations, further increasing the mental health equity divide.

Possible Advantages to VC-Led Innovation in Mental Health Care

Despite these concerns, VC-backed start-ups may accelerate mental health care innovation. Companies supported by VC rely on the idea of scale—the ability to grow quickly to serve a large population to maximize return on investment. In the traditional mental health care setting, dissemination of evidence-based treatments is a major challenge because treatments take place as one-on-one encounters over several months. Venture capital companies subsidize start-ups to constantly produce new iterations of their models to generate proof of concept and to refine their product or service as it evolves. This market-based, “survival of the fittest” approach means that companies only succeed if patients use and perceive benefit from these products and services. Given their consumerist mindset, VC-backed mental health companies’ strength is their transparency with diagnosis, treatment process, and costs. These are all steps forward for mental health care in the United States.

The mental health care landscape is changing rapidly, and VC-backed for-profit companies represent a significant force driving these changes. Although the value of this trend is yet to be fully realized, the rise in VC investment in mental health care offers an opportunity to scale treatments that work and address mental illness at the population level. However, quality control, privacy concerns, and severe mental illness are major issues that need to be addressed. As the demand for digital solutions to mental health concerns continues to rise, we will have to wrestle with this question: can VC-backed mental health start-ups move fast without breaking anything?

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Mental health has always seemed to be more or less of an orphan-child of medicine. Although for decades many efforts have been made to reduce inequities in mental health care, tremendous voids remain.

In my practice the affluent patients were able to afford the mental health care that they needed, but the majority of my patients were not. Maybe the acutely psychotic would be locked up for 72 hours, but then they were released to followup that frequently did not seem to exist. The Medi-Cal PPO for which I was a network provider had only one psychiatrist in its network, not in our community, though even he was not available after he was arrested on morals charges. Because I already worked extended hours throughout my career and really didn’t feel competent in providing mental health services anyway, my patients got the short shrift. As I fantasized about the nation eventually enacting and implementing a single payer national health program, I had to take satisfaction in the belief that some day soon mental health services would be available for all, though I was clearly wrong about “soon.”

In the meantime, we have witnessed a dramatic growth in the medical-industrial complex. Venture capitalists have become a major player. As this article mentions, mental health has presented the economic mismatch of high demand with inadequate supply, creating the aggressive pursuit of mental health and wellness as an investment opportunity. The article mentions legitimate concerns related to private investment in mental health, but, from a broader perspective, the culture of the business model in health care exists on a much lower ethical plane than does the culture of the professional service model. The authors state that the venture capital model can be advantageous since it can lead to greater innovation (a term that applies primarily to the business of medicine), and grow quickly to “maximize return on investment.” It is difficult to imagine a worse model of expanding mental health services – passing more health care dollars to capitalists.

The bottom line is still the same. We desperately need a single payer model of an improved Medicare for All to make all health care, including mental health services, affordable and accessible for everyone. I don’t understand why we don’t have it. Maybe I need some counseling.

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RAND, September 18, 2020

Prices paid to hospitals nationally during 2018 by privately insured patients averaged 247% of what Medicare would have paid, with wide variation in prices among states, according to a new RAND Corporation study.

The study notes a steady increase in hospital prices, rising to the 2018 average level from an average of 224% of Medicare costs in 2016 and 230% of Medicare costs in 2017.

The analysis, which includes information from more than half of the nation’s community hospitals, is a broad-based study of prices paid by private health plans to hospitals.

“This analysis provides the most-detailed picture ever of what privately insured individuals pay for hospital-based care relative to what the government pays for people insured through Medicare,” said Christopher Whaley, the study’s lead author and a policy researcher at RAND, a nonprofit research organization.

If employers and health plans participating in the study had paid hospitals using Medicare’s payment formulas, total payments over the 2016–2018 period would have been reduced by $19.7 billion, a potential savings of 58%.

“The rising gap between public and private hospital prices is a cause for concern and raises questions about the efficiency of the employer market,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, which sponsored the project. “The goal of this work is to arm employers with data so they can negotiate more effectively. Curbing excessive spending on employer health insurance is in the public interest.”

Spending on hospital services accounts for approximately 44% of total personal health care spending for the privately insured, and hospital price increases are key drivers of recent growth in per capita spending among the privately insured.

Other findings from the study include an observation that hospital costs within individual states and hospital systems vary widely. Researchers also examined whether the observed differences in prices could be explained by differences in the quality of care. However, they did not find a strong relationship between prices and two widely-recognized metrics of quality and patient safety, or that variation in hospital prices is explained by differences in Medicare and Medicaid patient populations.

A large portion of private health insurance contracting for hospitals is done on a discounted-charge basis where the insurer agrees to pay a percentage of billed charges. By contrast, Medicare issues a fee schedule that determines the price it will pay for each service, with adjustments for inflation, hospital location, the severity of a patient’s illness and other factors.

RAND researchers suggest that private insurers may want to move away from discounted-charge contracting for hospital services and shift to contracting based on a percent of Medicare or another similar fixed-price arrangement, often called reference-based pricing.

“In the case of specific high-priced hospitals, there may be justification for the unusually high prices, such as offering specialized services or a well-deserved reputation for higher-quality care,” Whaley said. “However, if two hospitals have similar quality, then any difference in prices may be harder to justify.”

https://www.rand.org…

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The full report can be downloaded at a link through this website:
https://www.rand.org…

From the Conclusion of the full report:
“Although many hospitals do face increasing costs, such as growing employment and personnel costs, increased needs for investments in electronic health records, and other technologies, the results of this study show that some hospitals are still able to charge much lower prices than other hospitals.”

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Comment:

By Don McCanne, M.D.

Hospitals pay much higher prices for privately insured care than they do for the government programs Medicare and Medicaid. This difference is not due to higher quality care, but rather it is due to hospitals’ market power in being able to contract with the private insurers for higher prices, whereas the government programs use fixed fee schedule prices. Further, this study shows that the wide variation in prices paid demonstrates that low income hospitals are still able to provide high quality care.

Also, the evidence indicates that higher private insurance prices did not correlate with lower prices paid by government programs. The report states, “the absence of a correlation between hospital prices and payer composition does not support the argument that higher hospital prices are in place to offset underpayments by Medicaid and Medicare.”

Considering our very high health care prices in the United States, and considering that the private insurers have been ineffective in controlling hospital prices, shouldn’t that make you think that we should consider changing our health care financing system? Other nations that use global budgets to finance hospitals, much like budgeting fire departments, have been much more effective in controlling excess hospital spending.

If you consider the historical health care spending curves in the United States and Canada, they were about the same until Canada enacted their single payer systems in the provinces. Canada then bent their cost curve to sustainable levels (maybe a little bit too low) whereas ours has continued on its unsustainable trajectory.

How can we continue to look at these studies and then do nothing beyond occasional tweaking while leaving the private insurance industry in control of much of our health care spending? About $600 billion is wasted on the administrative burden created by this industry while they can’t even get pricing of hospital care right. We don’t need the insurers, but we do need the hospitals. We just need to fund them appropriately.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Jessie Hellmann
The Hill, September 16, 2020

Some health insurance brokers provided misleading or false information to potential customers about whether their plans covered preexisting conditions, according to an undercover audit completed by the nonpartisan Government Accountability Office.

The audit, requested by Senate Democrats, sought to determine whether companies selling health plans exempt from Affordable Care Act coverage requirements were being honest about the limitations of the plans, which tend to be cheaper but aren’t comprehensive and typically don’t cover preexisting conditions like cancer or diabetes.

In 31 “undercover phone calls” in which employees of the GAO posed as customers looking for health insurance that covered their preexisting conditions, eight of the sales representatives “engaged in potentially deceptive marketing practices,” the agency concluded.

In those instances, representatives sold GAO employees limited benefit plans that don’t cover preexisting conditions, including memberships to health care discount programs that don’t actually qualify as insurance.

For example, the report states, one sales representative told a GAO employee they were purchasing a comprehensive health insurance plan, but instead sold them two limited benefit insurance plans that don’t cover preexisting conditions.

“During the call, we repeatedly informed the sales representative that we had diabetes and had recently been seeking treatment for the condition. However, the application filled out by the sales representative on our behalf, which we later obtained, stated that we had not been treated for or diagnosed with diabetes for the past five years,” the report states.

This indicates that the broker may have intentionally falsified information on the application, which allowed the application to be submitted and the insurance policy to be purchased, but would not allow health care services related to our pre-existing condition to actually be covered under the terms of the policy.”

Some of the sales representatives refused to let GAO employees see the policy documents before they agreed to buy it.

Insurance brokers can be paid higher commissioners for selling limited benefit plans, while they earn a flat dollar amount for ACA-compliant plans.

https://thehill.com…

GAO report (29 pages):
https://www.gao.gov…

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Comment:

By Don McCanne, M.D.

Supposedly the Affordable Care Act requires all insurance plans to cover preexisting conditions, but that is not quite true. Plans that may be exempted from covering preexisting conditions include certain grandfathered plans, short-term limited duration plans, limited benefit plans, health care sharing ministries, and association health plans. Even Medigap plans can be denied to individuals who failed to enroll when they first became eligible. Also at risk is the preexisting coverage mandated by the Affordable Care Act that will be subject to a Supreme Court hearing shortly after the November election.

The GAO report confirms that the confusion created in the insurance marketplace exposes would be buyers to unscrupulous practices that may leave them without the coverage they thought they were purchasing, or they may be left unprotected merely because of the complexity in the fragmented insurance market that creates confusion as to just what the plans do cover.

In the midterm election, the Republicans campaigned on promising to cover preexisting conditions at the same time that they supported the repeal of the Affordable Care Act which would have removed such protections from the insurance marketplace. Since they have not offered an ACA replacement plan, their support for covering preexisting conditions was a hollow promise. Although some of the Republicans still contend that preexisting conditions should be covered, they have not made it a major issue in this election since they still have no replacement plan, and they don’t want to be caught with their plans down again.

Under a single payer Medicare for All plan, this issue goes away. Everyone is completely covered forever. It is astonishing that so many Americans reject Medicare for All while accepting Trump’s support of short-term junk insurance that leaves patients vulnerable to massive medical debt. There must be some loose screws around. We’d better tighten them up.

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By Gene Bukhman, MD, Ana O Mocumbi, MD, Prof Rifat Atun, FRCP, Prof Anne E Becker, MD, Prof Zulfiqar Bhutta, PhD, Prof Agnes Binagwaho, PhD, et al.
The Lancet, September 14, 2020

We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.

Conclusion: global solidarity for NCDI Poverty and universal health coverage

Propelled by a 2001 UN General Assembly Special Session, the first decade of the 21st century saw dramatic growth in development assistance for HIV. In many cases HIV financing has had collateral benefits for those afflicted by other conditions, but it has not been sufficient. We have estimated that around 85% of the poorest billion live in countries with a per-capita GDP of less than US$1600 in 2015 exchange-rate US dollars. Simply put, these countries do not have the domestic resources to address even their most urgent health-care needs.

NCDIs have been understood by development agencies and multilateral institutions as an emerging problem associated with ageing, urbanisation, and economic growth, rather than a constituent part of the most extreme poverty. The 2011 UN High-Level Meeting on NCDs was greeted with hope for a new era of global solidarity despite the 2008 financial crisis. These hopes have not materialised. Our Commission has shown that little development assistance for NCDIs has been mobilised for NCDIs over the past decade, and that almost none has gone to the poorest countries.

The framing of NCDs that crystallised through the 2011 UN High-Level Meeting was, in part, a solution to the perceived weakness inherent in the heterogeneity of a large array of non-infectious conditions. This Commission proposes that this complexity should be recognised as an inescapable part of the NCDI burden in the poorest populations. More than that, this complexity should be leveraged to build global solidarity and to catalyse structural reforms for quality and innovations in integrated service delivery for the world’s poorest and most vulnerable people.

To begin to remedy the shocking neglect of NCDI Poverty by rich countries, this Commission is launching an NCDI Poverty Network. This Network is composed of a growing group of National NCDI Poverty Commissions and their allies. The Network will work over the next decade to catalyse financing and technical partnerships to support implementation of integrated delivery strategies for locally prioritised interventions. The Network will also work closely with The Lancet and the NCD Countdown 2030 Group to report on progress toward locally identified goals. In doing so, we hope that this Commission will elevate an emerging NCDI Poverty movement and accountability mechanism that will contribute to health and shared prosperity for all.

Addressing NCDI Poverty offers a chance for the poorest countries to build durable, high-quality health systems. It also presents an important occasion to act on the underlying social determinants of disease such as housing, household energy, food insecurity, education, and transportation. In order to be successful, these countries will require greater global commitments to health equity. Private philanthropic organisations have small resources at their disposal but can have an outsized effect on policy and research. We ask that, when funding disease-specific initiatives, these organisations consider the poorest billion and recognise the need to invest in integrated strategies that drive health system improvements.

Bilateral donors must increase their investments in health in the poorest countries. When funding NCDIs as part of UHC expansion pathways, bilateral donors and multilateral institutions must also begin with the poorest billion in mind. Prospects exist to build on existing investments and to crowd-in resources for NCDI Poverty in priority countries and populations. Financing to address treatment gaps in the poorest countries should not be neglected even as resources should also be increased to support common goods for health such as research, policy, and coordination.

We call on WHO to expand its UHC monitoring and NCD action plan after 2020 to address the diverse set of diseases and conditions recognised as NCDIs in its own Global Health Estimates; intervention priority setting at WHO to give due consideration to equity (including condition severity and distribution among the poorest) in addition to cost-effectiveness and feasibility; and WHO to strengthen its work on integrated service delivery for NCDIs, and particularly to invest in development of technical packages for first-level hospitals.

NCDI Poverty is one of the largest gaps and largest opportunities for UHC and global health equity in the SDG era. The Director General of WHO has called for one billion more people to benefit from UHC by 2023. The scope of UHC recognised by this commitment must be broadened to include NCDI Poverty. Consistent with the SDG pledge that, “no one will be left behind”, and the SDG commitment, “to reach the furthest behind first”, the next billion to benefit from this more inclusive conception of the UHC should be the poorest billion.

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

I have always been concerned about the inadequacies of health care programs in poor nations. Who hasn’t?

A few decades ago, as I was approaching retirement, I wanted to become part of a movement to ensure that the entire world has affordable access to all essential health care services. The need was so great. But first we needed to address the health care deficiencies in our own nation so that we could stand as an example to all other nations. We certainly had enough funds, but we needed to fine tune our system by improving Medicare and expanding it to cover everyone. That was the easy step that we could take immediately and then move on to addressing the rest of the world’s health care problems.

Easy step? Oh my!

The Director General of WHO has called for taking care of one billion more people by 2023, while reaching the furthest behind first. Considering the efforts of President Trump to reduce the efforts on improving health care in the United States, it is no wonder that he withdrew both funding and membership in the WHO as they embark on this international effort to provide care for the poorest one billion people in the world.

But the need is so great that we should start supporting the WHO effort now. As far as the comparatively minor effort required in the United States, we can do that simultaneously. PNHP would gladly provide guidance on Medicare for All. We should be able to complete that task in 2021, and then move on to help with the goal of expanding care to another one billion people by 2023. And they told us that Medicare for All was a tough haul. That’s the easy part.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Harry Saltzgaver
The Grunion, September 10, 2020

Mayor Robert Garcia said Thursday, Sept. 10, he and the mayor of Oakland have created an organization to promote Medicare for All in the country as a whole.

The announcement was in the form of a press release out of Garcia’s office. Oakland Mayor Libby Schaff is partnering with Garcia to create Mayors for Medicare for All (Mayors 4 Medicare).

One of the group’s goals, according to the release, is to have a resolution of support in front of the U.S. Conference of Mayors to be adopted as a policy position of that group.

The organization supports Medicare for All legislation introduced by Senator Bernie Sanders and Congresswoman Pramila Jayapal. A single-payer health care system would cover all Americans, including vision, dental, hearing, prescription drugs, mental health care and more.

“The clearest lesson from the COVID-19 crisis is that healthcare must be a right for all — and not a path to bankruptcy and deeper racial disparities,” Schaaf said in the release. “We’re mobilizing local leaders to build a national movement so the next Congress will adopt legislation that brings healthcare access to all.”

There already is a logo and a website — mayors4medicare.com — that includes a place for mayors to sign up and basic information about the group.

https://www.gazettes.com…

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Mayors for Medicare for All

Our coalition has 3 goals:

1. Create a network of mayors who will endorse Medicare for All.
2. Submit a formal resolution of support for Medicare for All to the U.S. Conference of Mayors for adoption and as a policy position of the conference.
3. Work with the next administration and Congress to adopt Medicare for All.

https://mayors4medicare.com

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Medicare for All Would Help End Racial Disparities in the South

We must take a stand against a for-profit health care system that too often devalues Black lives.

By Jason Williams, Amelia Parker
Common Dreams, September 9, 2020

The coronavirus pandemic and ongoing protests over racial disparities in the U.S. have highlighted just how broken our health care system is, especially for Black Americans.

As local elected officials, we have witnessed first-hand in our cities how our for-profit health care system fails so many of our residents.

In Louisiana, Black people account for 53% of all coronavirus deaths in Louisiana despite making up 32% of the state population, according to the Louisiana Health Department. Black coronavirus patients also made up three-fourths of hospitalization in the state.

These disparities are underscored by broader racial trends. Black children in New Orleans are 3.5 times more likely to be uninsured than white children—8.5% compared to 2.5%—and Black adults are twice as more likely to be uninsured than whites—32.3% to 16.6%.

In Tennessee, Black residents make up 12% of the population, but account for 33% of coronavirus deaths. Black Tennesseans are 40% more likely to be uninsured than White Tennesseans.

Latinx communities are also experiencing a disproportionately high rate of positive COVID-19 cases in our communities. In Knox County, Tenn. Latinxs represent 30% of the county’s positive and probable COVID-19 cases, while only representing 5% of the county’s total population. A study in New Orleans Parish, La., found that 20% of Hispanics tested positive to COVID-19 vs. just 3% of Whites. Latinx Tennesseans are three times as likely to be uninsured that White Tennesseans, and Latinx Louisianans are 3.6 times as likely to be uninsured then White Louisianans.

In this moment of reckoning on racism in so many aspects of society, we must take a stand against a for-profit health care system that too often devalues Black lives.

Our economic health depends upon our physical health. This is not a red issue or a blue issue, it’s a red white and blue issue. The future of the U.S. is depending on universal health care.

That’s why the New Orleans and Knoxville City Councils joined cities and towns across the country in passing resolutions recently in support of Medicare for All. These resolutions send a powerful signal to Congress that our cities stand with the majority of Americans who demand guaranteed health care.

Jason Williams is the New Orleans City Council President.

Amelia Parker is a Knoxville City Council Member.

https://www.commondreams.org…

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Comment:

By Don McCanne, M.D.

When you study all of the inefficiencies and injustices of our health care system, it does not take much to understand the health care issues that cities face. Although some of our larger cities are able to supply some of the basic infrastructure in health care, perhaps with the backup of counties and states if they are so inclined, the role of the federal government is essential.

If you look at the Medicare program as a model, you can easily see that it would be possible for a federally financed program to ensure health care for everyone. We would merely need to improve Medicare and then expand it to cover everyone as a single payer Medicare for All program.

Today’s articles demonstrate that some city officials do recognize that the solution for their cities’ health care deficiencies would be to establish a national Medicare for All program. We should encourage our city governments to seriously consider this approach and help them to establish a national movement of Cities for Medicare for All, or Mayors for Medicare for All, or whatever name floats. Let’s just do it.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Adam Dean, Atheendar Venkataramani, and Simeon Kimmel
Health Affairs, September 10, 2020 (Ahead of print)

Abstract

More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates.

From the Introduction

Labor unions representing health care workers perform several functions that may reduce SARS-CoV-2 transmission. Unions generally demand high staff-to-patient ratios, paid sick leave, and higher wage and benefit levels that reduce staff turnover. They educate workers about their health and safety rights, work to ensure that such rights are enforced, demand that employers mitigate known hazards, and give workers a collective voice that can improve communication with employers. In the specific context of the COVID-19 pandemic in New York, labor unions advocated for access to PPE and new infection control policies.

Study design and data sources

We conducted cross-sectional regression analyses to estimate the association between the presence of a health care worker union and COVID-19 mortality rates in nursing homes in New York State during the 2020 COVID-19 pandemic. We used publicly available data from the New York State Department of Health (NYSDOH) on COVID-19 mortality. We used proprietary data from 1199SEIU United Healthcare Workers East (1199SEIU), the International Brotherhood of Teamsters, and the Communication Workers of America (CWA), as well as publicly-available data from the New York State Nurses Association (NYSNA) to determine if a labor union represented health care workers in each facility.

From the Discussion

Among 355 nursing homes in New York State for which data on COVID-19 mortality rates were available, the presence of a health care worker union was associated with a 30% lower mortality rate from COVID-19 among nursing home residents. The findings were robust to adjustment for a range of covariates and specification checks for bias from missing data. We also found that nursing homes with labor unions had greater access to PPE and lower COVID-19 infection rates, two important mechanisms that may link unions to lower COVID-19 mortality rates.

However, more research is needed to understand the numerous mechanisms through which unions may influence COVID-19 mortality rates, such as staff training, reducing use of part-time workers, implementing infection protocols, and giving workers a collective voice in the workplace.

Our finding that unions are associated with reduced COVID-19 mortality rates in nursing homes is consistent with previous findings that unions improve safety and health standards for workers, help to co-enforce those standards with employers, and also reduce workplace injuries and accidental deaths. Health care worker unions, in particular, are also associated with improved patient outcomes.

We also found that chain nursing homes were associated with higher COVID-19 mortality rates. Previous research similarly finds that nursing home chains are associated with lower quality care.

Conclusion

Residents in nursing homes have been disproportionately affected by COVID-19. The presence of a health care worker labor union was associated with a 30% relative decrease in the COVID-19 mortality rate compared to facilities without unions in the State of New York. Health care worker unionization may play an important role in ensuring access to appropriate PPE and implementing infection control policies that protect vulnerable nursing home residents.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

“The presence of a health care worker labor union was associated with a 30% relative decrease in the COVID-19 mortality rate compared to facilities without unions in the State of New York.” Not only that, but “chain nursing homes were associated with higher COVID-19 mortality rates.”

How do health care labor unions reduce COVID-19 mortality in nursing homes? “Labor unions representing health care workers perform several functions that may reduce SARS-CoV-2 transmission. Unions generally demand high staff-to-patient ratios, paid sick leave, and higher wage and benefit levels that reduce staff turnover. They educate workers about their health and safety rights, work to ensure that such rights are enforced, demand that employers mitigate known hazards, and give workers a collective voice that can improve communication with employers. In the specific context of the COVID-19 pandemic in New York, labor unions advocated for access to PPE and new infection control policies.”

On these pages we frequently differentiate business ethic from service ethic in health care. With a business ethic, profit rules. For example, chain nursing homes are expected to manage the operations in a manner that maximizes profits for their passive investors. With a service ethic, the expectation is that everyone involved in the nursing home strives to provide the best care possible with the available resources. Professionalism on all levels drives the care provided. This study confirms that the difference is very real. Unionized health care workers save more lives.

As another example, when you see demonstrations in support of Medicare for All, the participants are frequently members of California Nurses Association/National Nurses United. They are not there to advocate for more profits for Wall street investors. They are using their own time to advocate for affordable, comprehensive health care not only for their own patients, but for everyone.

Health care unions are about professional service for the patients. We need to have them everywhere throughout the health care system. In fact, we need unions everywhere to help correct the scourge of excessive inequality in income and wealth, which is a major contributor to health care injustice and other injustices throughout our society. We can do better, much better.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.