PNHP

Medicare for All would honor our health care workers

Medicare for All would honor our health care workers

By Kent Hackmann, Ph.D.
Concord (N.H.) Monitor, July 15, 2020

New COVID-19 infections and deaths have risen alarmingly in many states. Fortunately, today in New Hampshire we are holding down both. That success is due to health care workers and to the concerted effort by individuals across the state to wear face masks, practice social distancing, and wash hands.

It is too early for a victory lap, and we must continue effective science-based practices. Containing the virus requires the continuation of proven practices across the state. We are all in it together.

Everyone applauds the professional dedication of frontline health care workers. What may go unrecognized is that those workers – from doctors, nurses, paramedics, and long-term care staff to assistants, cooks, and cleaners – are all risking their health and their lives to care for patients during the pandemic.

How can we honor those many workers in a lasting way that would make a difference?

Medicare for All would do just that. Everybody would have health coverage, regardless of age, income, or employment. Everyone would have the chance to improve health outcomes and lessen the chronic conditions that can increase risk of illness or death from COVID-19.

Medicare for All would speak to the needs of about 275,000 health workers with high-risk conditions who are uninsured, including 11% of those with diabetes, and 21% of those with chronic lung disease.

Medicare for All would speak to the needs of predominantly low-wage nursing home staff who work with a most vulnerable population. Nationally, more than 600,000 health workers have family incomes below the federal poverty line.

In fact, Medicare for All would speak to the needs of all minimum-wage workers in New Hampshire who cannot afford health insurance.

Today’s fragmented and profit-driven health system does not serve those on the front line fighting the COVID-19 virus. Nor does it serve anyone who does not have adequate health insurance or any at all.

A majority of New Hampshire doctors, I believe, agree with my diagnosis and my proposed remedy. The time is now for Medicare for All.

https://www.concordmonitor.com…

Florida and Georgia badly need universal health care

Pandemic reveals big need for universal health care

By Erica Heiman, M.D.; Jack Bernard; and Henry Kahn, M.D.
The (Jacksonville) Florida Times-Union, July 14, 2020

COVID-19 has stolen the lives of over 130,000 Americans so far with many more to come.

We think that universal health insurance coverage — such as expanded, improved Medicare for All — would have lessened the pandemic’s impact on our nation.

COVID-19 has impacted the U.S. particularly hard, with a higher number of confirmed cases than anywhere else in the world (over 3 million) and a higher mortality rate than many less-developed nations. In large part this is due to our lack of a comprehensive system of national health insurance, like Medicare for All.

Our U.S. health care financing is a clumsy mixture of public, private and employer-based insurance. As the COVID-19 calamity has shown, our current hodgepodge denies high quality care to people who are economically and socially underprivileged.

We also allow increasing numbers of Americans to fall into these deprived categories as massive job losses lead to terminations of health insurance. Prior to the pandemic, unemployment was at 3.6 percent and it is now at 13.3 percent. When statisticians include those underemployed or discouraged from seeking work, the current unemployment estimate rises to 20.7 percent.

Our number of uninsured was much too high before COVID-19, but now it has reached heights not seen since the passage of the Affordable Care Act (Obamacare) in 2010. Between May 21 and May 25, 20.5 million U.S. adults were uninsured. Rates of un-insurance in Florida and Georgia are higher than national rates.

The U.S. spends more per capita on its health care than any other developed nation, $10,586 here as opposed to other nations like France ($4,965) and Canada ($4,974) with better mortality and morbidity statistics.

No system is perfect, but more inclusive models around the world finance health care more cost-effectively. Plus, other countries have done better during the coronavirus pandemic, such as Austria, Denmark, Germany and Japan.

Protesters of all races and ages in the streets of America’s cities have shown that our country wants major systemic changes. Now is the time to design and implement a simplified U.S. health care financing system, leaving no one uninsured or underinsured.

Universal coverage will not eliminate systemic racism or erase a pandemic, but it will provide a solid platform of good health for Americans. Expanded and improved Medicare for All will prevent so many of our fellow citizens from falling through the cracks.

Dr. Erica Heiman is a general internist and medical educator based at Grady Memorial Hospital in Atlanta. She is a member of Physicians for a National Health Program (PNHP). Jack Bernard, former Director of Health Planning for Georgia, is a retired executive with a national health care corporation. Dr. Henry Kahn, also a member of PNHP, practiced primary-care medicine for nearly 40 years. He is Professor Emeritus at the Emory University School of Medicine and adjunct faculty at Morehouse School of Medicine.

https://www.jacksonville.com…

Our current system has allowed the greatest health insurance enrollment losses in history

The COVID-19 Pandemic and Resulting Economic Crash Have Caused the Greatest Health Insurance Losses in American History

Families USA, July 2020

Results in Brief

  • Because of job losses between February and May of this year, 5.4 million laid-off workers became uninsured.
  • These recent increases in the number of uninsured adults are 39% higher than any annual increase ever recorded. The highest previous increase took place over the one-year period from 2008 to 2009, when 3.9 million nonelderly adults became uninsured.
  • Nearly half (46%) of the increases in the uninsured resulting from the COVID-19 pandemic and economic crash have occurred in five states: California, Texas, Florida, New York, and North Carolina.
  • In eight states 20% or more of adults are now uninsured: Texas, where nearly three in ten adults under age 65 are uninsured (29%); Florida (25%); Oklahoma (24%); Georgia (23%); Mississippi (22%); Nevada (21%); North Carolina (20%); and South Carolina (20%). All but Oklahoma are also among the 15 states with the country’s highest spike in new COVID-19 cases during the week ending on July 12.
  • Five states have experienced increases in the number of uninsured adults that exceed 40%: Massachusetts, where the number nearly doubled, rising by 93%; Hawaii (72%); Rhode Island (55%); Michigan (46%); and New Hampshire (43%).
  • No federal COVID-19 legislation signed into law has attempted to restore or preserve comprehensive health insurance, which improves health outcomes, limits financial insecurity, and promotes economic recovery. Federal lawmakers can fill that gap in the next COVID-19 bill.

https://www.familiesusa.org…

Health Care Administrative Costs in the United States and Canada, 2017

By David U. Himmelstein, M.D., Terry Campbell, M.H.A., Steffie Woolhandler, M.D., M.P.H.
Annals of Internal Medicine, January 21, 2020

Total Costs of Health Care Administration: Health care administrative costs in the United States in 2017 totaled $812.0 billion, $2497 per capita ($2696 per insured person), or 34.2% of total spending in the categories for which data are available. The comparable estimates for Canada are $551 per capita ($593, assuming U.S. wage rates in doctors’ offices), or 17.0% of expenditures. The difference amounts to over $1900 per capita (or over $2100 per insured person), equivalent to more than $600 billion in excess administrative spending in the United States.

https://www.acpjournals.org…

Comment:

By Don McCanne, M.D.

The COVID-19 pandemic and its economic consequences have caused the greatest losses in health insurance enrollment in U.S. history: 5.4 million laid-off workers have become uninsured. However, it is important to understand that all was not well before the pandemic. Nearly 28 million people were already uninsured and tens of millions more were underinsured – unable to afford the out-of-pocket costs that were not covered by insurance.

Of major significance, these are nonelderly adults. Medicare – for those over 65 – continued to provide stable coverage after the onset of the pandemic. There would be no uninsured now had we had in place a single payer Medicare for All program.

The experience in California also provides us with some important lessons. As one of the most progressive states, California went out of its way to maximize the benefits of the Affordable Care Act and other public programs. Thus we can get a perspective of how well the financing system works when stressed. The number of workers in California who became uninsured due to job loss between February and May 2020 was 689,000. In total, 3,227,000 adults are uninsured in California. There are now about 27% more uninsured adults in California than there were in 2018.

Regardless of all of the praise ACA receives, the program clearly is not working as it should. There are proposals to temporarily fill in some of the gaps, but these proposals fall far short of the comprehensive reform that we need, and most of them would be only temporary, at the end of the pandemic defaulting to our current unsatisfactory financing system.

The primary reason given for not enacting single payer Medicare for All is that it costs too much. Yet comparing our highly inefficient health care financing system with Canada’s single payer system indicates that more than $600 billion in annual administrative waste is recoverable – more than enough to expand the provision of comprehensive health care services to absolutely everyone, permanently, without spending more in inflation adjusted dollars than we already do.

One major candidate for president would forgo this in order to perpetuate, with tweaks, our clearly inadequate health care financing system with its profoundly inefficient and costly administrative excesses. The other major candidate is supporting a repeal of ACA without offering any effective substitute, leaving us worse off than we already are.

I mean, when California has one of the very best programs and it alone has over 3,000,000 adults who are uninsured? That’s unacceptable. It’s criminal! We need to change the system: single payer improved Medicare for All. Now!

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

Health care justice will require economic justice

Rising levels of unemployment mean a loss of health insurance coverage, which is now the case for 18% of Americans.

By Hrayr Attarian, M.D.
Chicago Sun-Times, Letters, July 14, 2020

In the past three months, more than at any previous time in my 28 years as a physician, the medical community has tackled its own implicit and explicit racism. Issues such as biased laboratory norms, historic racial injustice in the field and preconceived notions about non-whites are being widely debated. The catalyst, obviously, has been Black victims of police violence and the disproportionate effect of COVID19 on minorities.

One question, nevertheless, nags at me. Can we discuss racial justice separately from economic justice?

According to the Economic Policy Institute, rising rates of unemployment during the pandemic have hurt Black Americans more than any other group. This is a health equity problem because, as the Kaiser Family Foundation reports, 49% of people receive health insurance through their work. Unemployment means a loss of health insurance coverage, which is now the case for 18% of Americans.

If the Affordable Care Act is overturned, 23 million more Americans will be without insurance during one of the worst pandemics in modern times. And this, too, according to the Kaiser Foundation, will disproportionately harm African Americans.

We must fight racism in medicine; and I, for one, feel fortunate to be employed by an organization that is on the forefront of the struggle. I wonder, however, how much more effective we would be in eradicating prejudice and bias if we also worked more for healthcare equity and economic justice.

This means advocacy for truly universal health insurance coverage, regardless of citizenship, employment, income, race or ethnicity. It means creating a system of health care that is about medicine, not profit, founded on the principle that health care is a basic human right.

We should all struggle towards that.

https://chicago.suntimes.com…

Democratic Party’s disunity problem

A Vote for American Healthcare is a Vote for Violence

By Maggie Mills
Common Dreams, July 11, 2020

A recent study by Yale epidemiologists found that Medicare-for-All would prevent 68,000 deaths a year. These 68,000 deaths are not quiet, peaceful deaths. They are gasping-for-air, writhing-in-pain, bleeding out, wasting, violent, gruesome deaths. These deaths often follow extended periods of physical pain, emotional distress, and financial ruin.

The same study found that Medicare-for-All would save the United States 45 billion dollars annually. In the midst of a pandemic-motivated corporate bailout estimated at between $6 and $10 trillion so far, the ‘’but how will we pay for it” argument has largely been abandoned. And yet, the nominee for the Democratic Party has unequivocally stated that he will veto Medicare-for-All, the Democrats in Congress have proposed a bill to bail out insurance companies that subsidizes COBRA payments rather than provides healthcare for their constituents, and 27 million Americans and counting have lost their employer-based coverage as unemployment soars. Three of the four members of Congress with the highest campaign contributions from the pharmaceutical industry are Democrats, and the healthcare lobby accounts for a third of the contributions to the DCCC in the 2019-2020 election cycle. As usual, the Republicans brazenly broadcast their disdain for the poor, sick, and disabled. Put simply, both Democrats and Republicans receive many millions of dollars from the healthcare lobby to ensure that the industry profits at the expense of human life. There is no relief in sight from either establishment party, not even in the shadow of economic collapse.

I write this not to rage against the bipartisan, healthcare and pharma lobby funded machine. Although, the American public should at minimum educate themselves as to why every developed nation on earth has managed to provide healthcare to its citizens as a right, except for the US.

I write this to appeal, hell, plead, with my fellow Americans to pay attention to the suffering that exists all around us- to recognize our well, able-bodied privilege, and to come together to tear this cruel system down.

I have MS. I have a growing Rolodex of injuries, illnesses, and disabilities. I am exhausted. My prospects are limited. I am a victim of the unwinnable battle with our healthcare system. I work full time to keep my increasingly unaffordable health insurance. Ironically, I will lose this insurance when my full time job makes me too sick to continue working full time. I cannot vote for a candidate that doesn’t support Medicare-for-All.

I have been told that I am part of the Democratic Party’s disunity problem for my decision. I have been told that I am part of the problem as if prioritizing my own ability to remain in the world is petty or immature. I have been told this by people who think millions of lives are expendable in the name of political party loyalty and who refuse to acknowledge that we cannot patiently wait for incremental change when our lives are at stake. I have only been told this by people who are well, able-bodied, or who have excellent health insurance. I am angry and indignant because people who casually vote to sacrifice the most vulnerable of their fellow citizens are the problem, and not the other way around.

Class does not prevent illness and disability, though their onset tends to push the afflicted into poverty. People with disabilities make up 12% of the US population, yet account for more than half of the population living in long-term poverty. Medical bills are responsible for an astounding 66.5% of bankruptcies. As of January, it was estimated that as many as 25% of Americans delayed getting healthcare because of cost, resulting in great physical pain, mental anguish, and death. These numbers have surely grown exponentially during the pandemic.

We should be outraged at the injustices that our fellow citizens suffer at the hands of this predatory healthcare system. We should be outraged at the violence that it inflicts on its innocent victims. We should be outraged that this violence has been normalized as if there is nothing to be done to stop it. We should not accept it, nor should we be quiet about it. We should educate our neighbors, withhold our votes, and shout that we will do so from the streets. Tens of millions uninsured, underinsured, bankrupt, suffering, and dead constitutes an unforgivable injustice. Please allies, I beg of you, demand justice.

And please, allies; recognize that by settling for anything less than universal healthcare and by voting for someone who does not support Medicare-for-All, we are committing a deliberate and willing act of violence against the poor, sick, and disabled among us.

Maggie Mills is an artist and assistant professor of art at Cedar Crest College.

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

The important message from this article is that many Democrats who emphatically support single payer Medicare for All are so disappointed in the fact that the presumed Democratic Party candidate for president is outspoken in his opposition to Medicare for All that some are considering not supporting him in the general election – the Democratic Party’s disunity problem.

What other options are there? Not showing up to vote? There are many other important issues that are certainly worthy of a vote. Defecting to the Green Party? We still have a predominantly two party system so casting a vote for a third party candidate will have a similar net impact as not voting at all, except for the personal satisfaction of having cast a protest vote. Vote for President Trump? With our highly polarized politics, without overlap in the middle, abruptly flipping on all policies would defy reason.

Many people have cautioned that if the Democrats endorse Medicare for All, President Trump may be reelected by those opposing Medicare for All, and getting him out of office is their highest priority. That is ridiculous. Even Democrats who want to keep their current health plans are not going to vote for Trump just to prevent enactment of Medicare for All. In fact, many Republicans, though not a majority, also support Medicare for All.

The disunity is not in opposed views on Medicare for All, and it is not even in opposition to the reelection of Donald Trump. Rather than disunity, the problem is disappointment in the fact that Joe Biden continues to reject Medicare for All.

The current health care situation is horrendous for many of those with significant health care needs, and that can be any of us at any given time. So what can we do? Simply, don’t let up. Continue with advocacy through education, coalitions, and grassroots efforts. Some say that is not enough, so go ahead and expand your efforts. Any and all activities that will take us beyond the threshold for action are certainly welcome. Just don’t fall into the trap of walking away because of the perception of a disunity problem.

Though PNHP does support single payer Medicare for All, PNHP does not endorse any political candidates nor political parties. Political views expressed here are those of the author and not of PNHP.

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

Walgreens and Walmart enter the fray

Walgreens strikes deal with primary-care company to open doctor offices in hundreds of drugstores

By Melissa Repko
CNBC, July 8, 2020

Walgreens Boots Alliance will soon have doctor offices inside of hundreds of its U.S. drugstores.

The pharmacy chain said Wednesday it has struck a deal with VillageMD, which will staff and run the primary-care clinics. The companies said they will open the clinics in 500 to 700 stores in more than 30 U.S. markets over the next five years.

Walgreens will invest $1 billion in equity and convertible debt in VillageMD over the next three years as part of the deal, including a $250 million equity investment completed Wednesday. Most of the money will be used by VillageMD to open the clinics and integrate its technology with Walgreens.

VillageMD will recruit and pay employees’ salaries, cover other operating expenses and pay Walgreens to use the space. Walgreens said it will own about 30% of the primary-care company after the multiyear investment.

The company wants to turn its drugstores into health and wellness destinations where people spend more time and money.

Through the new partnership, patients will be able to visit the Village Medical at Walgreens clinics for a wide range of medical services from annual checkups to walk-in appointments if they feel sick. Each clinic will have nine exam rooms, a waiting area and a four-person physician-led staff that coordinates with store pharmacists. They can also request a home visit or get care around the clock through telemedicine.

Walgreens and VillageMD will face stiff competition. Walmart has opened four primary-care clinics, with plans for more. The big-box giant’s clinics, called Walmart Health, emphasize its signature low costs and upfront pricing. Amazon’s acquisition of online pharmacy PillPack underscores its broader health-care ambitions. And CVS Health, which acquired health insurer Aetna, plans to open 1,500 HealthHUB stores by the end of 2021. The redesigned stores have a variety of health-related features such as expanded clinics, wellness rooms for yoga and more medical-related products.

“We want to be everywhere in America where people need health care,” (Walgreens co-Chief Operating Officer Alex Gourlay said). “That’s always been our position and always will be.”

https://www.cnbc.com…

Walmart quietly registers insurance business in its latest move into health care

By Melissa Repko
CNBC, July 8, 2020

Walmart is making yet another move in the health-care world: It’s getting into the insurance business.

The Bentonville, Arkansas-based retailer confirmed to CNBC on Wednesday that it will start selling health insurance plans. It has job openings listed on its careers website for “Walmart Insurance Services LLC.” In the job posts, it says it’s looking to hire insurance agents in the Dallas area to sell supplemental Medicare insurance.

Walmart currently provides insurance information at Walmart Health, its primary clinic locations, and has an education program called Healthcare Begins Here that helps people find an insurance policy.

The big-box retailer has opened primary-care clinics, made health-care acquisitions and spoken about its broader ambitions. It previously teamed up with insurer Humana to offer a Walmart-branded Medicare prescription drug plan, but this marks the first time the retailer is setting up as an insurance broker.

The retailer has opened four Walmart Health clinics in the U.S., with plans for more. The clinics offer a wide range of low-cost services, such as an annual checkup for $30 or a strep test for $20.

https://www.cnbc.com…

Comment:

By Don McCanne, M.D.

Our health care financing system is highly inequitable. In spite of being the most expensive health care system, we fall behind most other wealthy nations in leaving too many individuals uninsured or underinsured, with impaired access to care. We’ve been trying to fix that by advocating for single payer Medicare for All. But, as we have been directing our attention to health care financing, what has been happening with the health care delivery system?

Well, horizontal and vertical consolidation has changed the market dynamics in health care. The private insurance companies and the benefit managers have been moving in and becoming an integral part of the health care delivery system. The expansion of control by the medical-industrial complex has changed the nature of traditional relationships between patients and their health care professionals. Today’s articles on Walgreens and Walmart provide examples of how control of health care is shifting away from the health care professionals and institutions and more towards the investment community.

This is serious. How is a single payer Medicare for All program going to be able to manage making appropriate payments to the health care delivery system when it has become part of an amalgamation with other business interests, many of which we have been trying to remove from health care financing if for no other reason than their profound administrative waste?

Earlier this week we discussed the importance of planning in health care. Adam Gaffney stated, “We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities.”

In the future, when you are taken by ambulance to a hospital emergency department, after they ask you for your insurance card, instead of asking who your physician is, will they be asking, “Are your medical records at Walgreens or Walmart?” That might please the advocates of market competition, but it shouldn’t be about markets. It should be about patient service.

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

Biden-Sanders Unity Task Force fails to unify on Medicare for All

Biden-Sanders Unity Task Force Recommendations

Achieving Universal, Affordable, Quality Health Care (Pages 28-37)

(Excerpts)

We are going to at last build the health care system the American people have always deserved: One that finally provides universal health care coverage; reduces prescription drug prices, premiums, and out-of-pocket costs; reins in overall health care expenses; and tackles the deep-seated inequities in our health care system. We will build a health care system that is driven by the needs of patients and the people who care for them, instead of the profit motives of big corporations.

Democrats will always fight to save Americans’ lives by making it easier and more affordable to go to the doctor, get prescription medicines, and access preventive testing and treatments. Our policy agenda is designed to produce real results for the American people—not hollow platitudes. As Democrats, we fundamentally believe health care is a right for all, not a privilege for the few.

Responding to the Coronavirus Pandemic

We must start by making COVID-19 testing widely available, convenient, and free to everyone. That includes expanding programs to proactively extend testing services to populations we know are especially vulnerable, including the homeless and those living in nursing homes and long-term care facilities. We must also expand funding so state and local public health departments can hire sufficient staff to adequately conduct contact tracing for everyone who tests positive for the novel coronavirus. Only through testing, tracing, and targeted quarantining can we hope to fully understand the scope of the pandemic, contain it, and stop it.

In a public health crisis, we all have to rely on each other. That’s why Democrats support making COVID-19 testing, treatment, and any eventual vaccines free to everyone, regardless of their wealth or their immigration status.

In the midst of this pandemic, we will provide direct, increased support to states to enroll eligible adults in Medicaid, have the federal government cover a higher percentage of the bill, and add incentives for states which have not yet expanded Medicaid to do so.

For people who risk losing their insurance coverage if they lose their jobs in this pandemic, Democrats believe the federal government should pick up 100 percent of the tab for COBRA insurance, which keeps people on their employer-sponsored plans. For those who are still unemployed or do not have access to employer-sponsored health care when their COBRA eligibility period expires and are eligible for premium-free coverage, we will take action to automatically roll them over to other coverage options, so they do not experience any gap in health care. We will also re-open the Affordable Care Act marketplaces, even outside of the normal open enrollment season, and expand subsidies to make it easier for people to buy coverage.

Democrats will also make available on the marketplace a platinum-level, federally administered health insurance option with low fees and no deductibles, so that everyone will have access to this high-quality, low-cost plan. Low-income Americans will be automatically enrolled in this federally-administered option at zero cost to them.

We will keep these emergency measures in place until the pandemic ends and unemployment falls significantly.

Democrats will direct the federal government to work with private-sector manufacturers to dramatically scale up the United States’ domestic manufacturing capacity for both personal protective equipment and essential medicines.

Reinvesting in Public Health

Democrats will act swiftly to stand up a comprehensive, national public health surveillance program for COVID-19 and future infectious diseases, including recruiting 100,000 contact tracers to help state and local health departments identify people at risk of contracting or spreading the coronavirus.

We will substantially increase funding for the Centers for Disease Control and Prevention and for state and local public health departments, many of which suffered deep budget cuts during the Great Recession. And we will restore American leadership on global public health by working with our allies and partners around the world, including through the World Health Organization.

Securing Universal Health Care Through a Public Option

We will give all Americans the choice to select a high-quality, affordable public option through the Affordable Care Act marketplace. The public option will provide at least one plan choice without deductibles, will be administered by the traditional Medicare program, not private companies, and will cover all primary care without any co- payments and control costs for other treatments by negotiating prices with doctors and hospitals, just like Medicare does on behalf of older people. The lowest-income Americans not eligible for Medicaid will be automatically enrolled in the public option at no cost to them, although they may choose to opt out at any time. Everyone will be eligible to choose the public option or another Affordable Care Act marketplace plan, even those who currently get insurance through their employers, because Democrats believe working people shouldn’t be locked in to expensive or insufficient health care plans when better options are available.

For the 4.8 million adults who should be eligible for Medicaid, but who live in states where Republican governors have refused to expand the program, Democrats will make the public option available without premiums. And we will enable millions of older workers to choose between their employer-provided plans, the public option, or enrolling in Medicare when they turn 60, instead of having to wait until they are 65.

Democrats will also empower the states, as laboratories of democracy, to use Affordable Care Act innovation waivers to develop locally tailored approaches to health coverage, including by removing barriers to states that seek to experiment with statewide universal health care approaches.

We also know that finally covering every American through the public and private insurance system alone is not enough to guarantee universal access. That is why Democrats support doubling investments in community health centers and rural health clinics, including increased support for dental care, mental health care, and substance use services like medication-assisted treatment. We will expand the National Health Service Corps to address critical shortages of health care providers in rural areas, including primary care nurses, dental professionals, and mental health and substance use counselors.

Bringing Down Drug Prices and Taking on the Pharmaceutical Industry

Democrats will take aggressive action to ensure that Americans do not pay more for prescription drugs than people in other advanced economies. We will empower Medicare to at last be able to negotiate prescription drug prices for all public and private purchasers—for families and businesses, as well as older Americans—no matter where they get their coverage. We will also ensure and enforce that the price of brand-name and outlier generic drugs cannot rise faster than the inflation rate. We will cap out-of-pocket drug costs for seniors, and ensure that effective treatments for chronic health conditions are available at little or no cost.

Reducing Health Care Costs and Improving Health Care Quality

We will make it easier for working families to afford high-quality insurance in the Affordable Care Act marketplaces by ensuring that no one pays more than 8.5 percent of their income in premiums and eliminating the cap on subsidies.

We will work to increase price transparency in the health care system across all payers, and reduce paperwork through uniform medical billing.

Democrats will support policies that increase the number of primary care practitioners, registered nurses, dentists, and dental therapists, especially in rural and low-income metropolitan areas, so it’s easier for every American to access preventive and primary health care.

Expanding Access to Mental Health and Substance Use Treatment

Democrats will aggressively enforce the federal mental health parity law and ensure that health insurers adequately cover mental health and substance use treatment.

Expanding Long-Term Care Services and Supports

Democrats support measures to eliminate state waiting lists for home and community based care, including through a significant expansion of the home care workforce, and will work to develop a broader approach to eliminate the institutional bias within Medicaid.

Eliminate Racial, Gender, and Geographic Health Inequities

Democrats are committed to eliminating health disparities by race, ethnicity, gender, and geography. We recognize it is not enough to have a commitment: We must have a plan. That is why Democrats will launch a sustained, government-wide effort, with leadership at the highest levels, to eliminate racial, ethnic, gender, and geographic gaps in insurance rates, access to quality care, and health outcomes. That includes tackling the social, economic, and environmental inequities—the social determinants of health like poor housing, hunger, inadequate transportation, mass incarceration, air and water pollution, and gun violence—that contribute to worse health outcomes for low-income Americans and communities of color.

(More on Black people and Latinos, pollution, maternal mortality, data collection to understand disparities, Indian Health Service, reproductive health care services, sexual assault and domestic abuse, LGBTQ+ discrimination, and HIV/AIDS treatment and prevention.)

We will expand access to health care for people living and working across the United States by extending Affordable Care Act coverage to Dreamers, and working with Congress to lift the five-year waiting period for Medicaid and Children’s Health Insurance Program eligibility for low-income, lawfully present immigrants.

Democrats believe that gun violence is a public health crisis. We believe that expanding access to mental health care is key to confronting the epidemic of suicides-by-firearm, including among veterans. Democrats will ensure the Centers for Disease Control and Prevention have sufficient resources to study gun violence as a public health issue and support evidence-based programs for preventing gun violence.

Strengthening and Supporting the Health Care Workforce

We will invest in community health worker care-forces around the nation proven to prevent, manage and better treat chronic illness now burdening tens of millions of Americans, and empower first-time mothers with nurse home visiting. We will close provider gaps and increase diversity in the health care profession by creating a robust pipeline of talent with career ladders for work advancement. And we will also increase opportunities for community health workers to come from the communities they serve.

Investing in Health Science and Research

We will support increased and sustainable funding for federal health and medical research across agencies, including at the National Cancer Institute and other components of the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Research and Quality. We will increase the federal investment in research and development for new medications through the National Institutes of Health, and make sure that there is a return on that investment for taxpayers.

Democrats also support increasing funding for research into health disparities by race, gender, age, geographic area, and socioeconomic status, with a particular focus on how the social determinants of health contribute to differences in health outcomes.

Rep. Pramila Jayapal, Co-chair
Vivek Murthy, Co-chair
Donald Berwick
Abdul El-Sayed
Sherry Glied
Mary Kay Henry
Chris Jennings
Rep. Robin Kelly

https://joebiden.com…

Comment:

By Don McCanne, M.D.

When the neoliberals commandeered the Democratic primary process and bumped Bernie Sanders out of the running, it was recognized that Joe Biden would have to do something to reunite the Democrats since the flame of the popular progressive revolution had been extinguished, and the Democrats were left with a candidate basically representing the status quo. Perhaps the greatest disappointment was that single payer Medicare for All had been removed from the agenda.

The report of the recommendations of the Biden-Sanders Unity Task Force(s) is 110 pages long and covers many areas of policy. The ten page section on health care basically perpetuates the current health policies, led by the Affordable Care Act, while adding a public option and reducing Medicare eligibility age to 60. The most glaring feature is invisible – the total lack of any mention of single payer Medicare for All.

Single payer Medicare for All is not simply an expansion of Medicare to cover everyone. It is a comprehensive revision of the financing of health care making it universal, comprehensive, efficient, effective, equitable, accessible, and affordable for everyone, for life. The Biden-Sanders Unity Task Force proposal meets none of those criteria.

Biden has said that we cannot afford single payer Medicare for All, yet his model perpetuates much of the excessive spending in health care, failing to recover hundreds of billions of dollars in administrative waste. For administrative efficiency he suggests reducing paperwork through uniform medical billing, but we already have that in Form 1500. He also suggests price transparency as if Nobel laureate Kenneth Arrow never explained why health care markets don’t work. Biden’s proposals would significantly add to our health care spending, and thus would be much more expensive than an efficient single payer Medicare for All.

The goal of the Unity Task Force is to bring disappointed progressives back into the fold. It is likely that President Trump is going to orchestrate his own defeat, and Joe Biden will be elected by default. Regardless, it is important that progressives not give up on single payer. Assuming Biden is elected, it is imperative that we continue to educate everyone on the virtues of the single payer model. If President Biden truly understood the single payer model (and he doesn’t), he would certainly sign legislation enacting it.

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Bring Back Health Planning

We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

By Adam Gaffney, M.D., M.P.H.
Dissent, Summer 2020

When the COVID-19 pandemic hit, my life as a critical care physician in a Boston-area hospital changed quickly. Massachusetts weathered the third biggest outbreak, in total cases, in the nation. Patients who had contracted the novel coronavirus filled our intensive care units. Their lungs failed; our days started early and ran late. To expand capacity, we acquired more ventilators and brought in new staff. Our surgical recovery room was converted into an open-ward ICU exclusively for critically ill COVID-19 patients.

Another change: we began to cooperate with other hospitals in a novel way.

The ICU capacity at our region’s mid-sized hospitals could evaporate overnight with a surge of admissions of patients in respiratory failure. Much larger institutions nearby had more space and some specialized technologies, like extracorporeal membrane oxygenation (ECMO)—a sort of external artificial lung that pushes oxygen into the bloodstream and sucks out the carbon dioxide, which can help some of those with refractory lung failure. When I wasn’t treating patients, I joined daily phone meetings with physicians working throughout the greater Boston area. We shared data and learned where we could send critically ill patients when we ran out of beds. Something similar played out in New York, where the crisis, by necessity, spurred unprecedented cooperation among the state’s hospitals.

Pandemics lay bare the need for cooperation in health services. But cooperation, and planning, will be equally important after the pandemic is over, and must go well beyond meetings. We need to envision a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

Planning has been a dirty word in healthcare for decades. Competition is today’s idol. But it was not always so: in the postwar era, though the United States failed to achieve European-style reform, a “health planning” movement emerged. The Hill−Burton Act of 1946 provided billions of federal dollars to expand existing hospitals and build new ones, particularly in underserved regions. In the 1960s and 1970s, state and later federal legislation—culminating in the 1974 National Health Planning and Resources Development Act—created planning bodies tasked with assessing local community health needs, approving new capital projects, and ensuring an adequate distribution of health infrastructure. But in the absence of universal healthcare financing for patients, à la Medicare for All, the movement was only marginally effective—and the rise of a new capitalist healthcare paradigm in the Reagan era easily brushed it aside.

The consequence has been simultaneous excess and deficit in health infrastructure. Today, market forces dictate the life and death of American hospitals. The epidemic of rural hospital closures, for instance, is not the consequence of a lack of rural health needs, but of the cold reality that serving those needs is unprofitable. A large academic hospital closed in Philadelphia last year not because its disproportionately low-income and minority patients no longer needed its services, but because those patients did not generate sufficient revenue. One Journal of the American Medical Association study found that, per capita, Manhattan has the most hospital beds among the five boroughs but had the fewest COVID-19 hospitalizations. Little wonder, then, that the virus battered outer boroughs’ hospitals with such ferocity.

The lack of planning is evident not only in the mismatch of hospitals and patients but in the distribution of basic supplies. “California’s Coronavirus Testing Still A Frustrating Patchwork Of Haves And Have-Nots” ran the headline of an NPR story that described glaring geographic disparities in access to testing months into the pandemic. The logic of competition that informs our national approach to healthcare has also meant chaotic and wasteful bidding wars for testing supplies and personal protective equipment (PPE) among hospitals and state and local governments.

The Medicare for All bills in Congress, if enacted, would do much to advance planning: they mandate dedicated funding streams for healthcare capital expenditures. Adequate investment in stockpiles of PPE and other equipment—and the capacity to rapidly distribute it—could also be undertaken by such a system. But we need to think of other ways that planning could prepare us for the pandemics of the future.

Maintaining a large, unused, yet readily deployable ICU “surge capacity,” for instance, is illogical in market terms: it costs money but delivers no revenue outside of plague years. But that unused reserve capacity benefits society. We need to rethink hospital design, with areas that can be used in times of emergencies but otherwise be idled. Israel’s Ramban Health Care Campus—which has a large underground parking garage that can be converted into a 2,000-bed hospital within hours—offers one example. Similar innovations could be envisioned for the inevitable calamities of our future—and be made available to everyone on a truly equal basis.

That necessitates, of course, abandoning the market ethos that currently drives the expansion and contraction of healthcare infrastructure. It requires discarding the false promise of anarchical medical competition as the salve of our healthcare cost crisis. It does not mean returning to the last era of health planning, but instead reinventing planning for the post-COVID age.

Dr. Adam Gaffney is a pulmonary and critical care physician, a public health researcher, and an Instructor in Medicine at Harvard Medical School. He serves as president of Physicians for a National Health Program and is the author of “To Heal Humankind: The Right to Health in History.”

https://www.dissentmagazine.org…

Adam Gaffney: Reinventing health planning

Bring Back Health Planning

We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

By Adam Gaffney, M.D., M.P.H.
Dissent, Summer 2020

When the COVID-19 pandemic hit, my life as a critical care physician in a Boston-area hospital changed quickly. Massachusetts weathered the third biggest outbreak, in total cases, in the nation. Patients who had contracted the novel coronavirus filled our intensive care units. Their lungs failed; our days started early and ran late. To expand capacity, we acquired more ventilators and brought in new staff. Our surgical recovery room was converted into an open-ward ICU exclusively for critically ill COVID-19 patients.

Another change: we began to cooperate with other hospitals in a novel way.

The ICU capacity at our region’s mid-sized hospitals could evaporate overnight with a surge of admissions of patients in respiratory failure. Much larger institutions nearby had more space and some specialized technologies, like extracorporeal membrane oxygenation (ECMO)—a sort of external artificial lung that pushes oxygen into the bloodstream and sucks out the carbon dioxide, which can help some of those with refractory lung failure. When I wasn’t treating patients, I joined daily phone meetings with physicians working throughout the greater Boston area. We shared data and learned where we could send critically ill patients when we ran out of beds. Something similar played out in New York, where the crisis, by necessity, spurred unprecedented cooperation among the state’s hospitals.

Pandemics lay bare the need for cooperation in health services. But cooperation, and planning, will be equally important after the pandemic is over, and must go well beyond meetings. We need to envision a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

Planning has been a dirty word in healthcare for decades. Competition is today’s idol. But it was not always so: in the postwar era, though the United States failed to achieve European-style reform, a “health planning” movement emerged. The Hill−Burton Act of 1946 provided billions of federal dollars to expand existing hospitals and build new ones, particularly in underserved regions. In the 1960s and 1970s, state and later federal legislation—culminating in the 1974 National Health Planning and Resources Development Act—created planning bodies tasked with assessing local community health needs, approving new capital projects, and ensuring an adequate distribution of health infrastructure. But in the absence of universal healthcare financing for patients, à la Medicare for All, the movement was only marginally effective—and the rise of a new capitalist healthcare paradigm in the Reagan era easily brushed it aside.

The consequence has been simultaneous excess and deficit in health infrastructure. Today, market forces dictate the life and death of American hospitals. The epidemic of rural hospital closures, for instance, is not the consequence of a lack of rural health needs, but of the cold reality that serving those needs is unprofitable. A large academic hospital closed in Philadelphia last year not because its disproportionately low-income and minority patients no longer needed its services, but because those patients did not generate sufficient revenue. One Journal of the American Medical Association study found that, per capita, Manhattan has the most hospital beds among the five boroughs but had the fewest COVID-19 hospitalizations. Little wonder, then, that the virus battered outer boroughs’ hospitals with such ferocity.

The lack of planning is evident not only in the mismatch of hospitals and patients but in the distribution of basic supplies. “California’s Coronavirus Testing Still A Frustrating Patchwork Of Haves And Have-Nots” ran the headline of an NPR story that described glaring geographic disparities in access to testing months into the pandemic. The logic of competition that informs our national approach to healthcare has also meant chaotic and wasteful bidding wars for testing supplies and personal protective equipment (PPE) among hospitals and state and local governments.

The Medicare for All bills in Congress, if enacted, would do much to advance planning: they mandate dedicated funding streams for healthcare capital expenditures. Adequate investment in stockpiles of PPE and other equipment—and the capacity to rapidly distribute it—could also be undertaken by such a system. But we need to think of other ways that planning could prepare us for the pandemics of the future.

Maintaining a large, unused, yet readily deployable ICU “surge capacity,” for instance, is illogical in market terms: it costs money but delivers no revenue outside of plague years. But that unused reserve capacity benefits society. We need to rethink hospital design, with areas that can be used in times of emergencies but otherwise be idled. Israel’s Ramban Health Care Campus—which has a large underground parking garage that can be converted into a 2,000-bed hospital within hours—offers one example. Similar innovations could be envisioned for the inevitable calamities of our future—and be made available to everyone on a truly equal basis.

That necessitates, of course, abandoning the market ethos that currently drives the expansion and contraction of healthcare infrastructure. It requires discarding the false promise of anarchical medical competition as the salve of our healthcare cost crisis. It does not mean returning to the last era of health planning, but instead reinventing planning for the post-COVID age.

Adam Gaffney is a pulmonary and critical care physician, a public health researcher, and an Instructor in Medicine at Harvard Medical School. He serves as president of Physicians for a National Health Program and is the author of To Heal Humankind: The Right to Health in History.

https://www.dissentmagazine.org…

Comment:

By Don McCanne, M.D.

In a 2011 Quote of the Day, I wrote, “One fundamental concept that has appeared repeatedly on the pages of Physicians for a National Health Program (PNHP) is that excellence is a product of cooperation, not competition. It is not choice between private for-profit and public systems, but rather it is equity within public systems that facilitates excellence.”

Imagine all participants in the health care system working together to improve the efficiency and effectiveness of health care delivery. Obviously health planning is fundamental to this concept,

Instead, in the United States, we rely on markets and competition which shred coordinated planning and cooperation. That is not only very expensive, it creates many of the inefficiencies, deficiencies, and dysfunctions in health care delivery.

The current pandemic has been very instructive in this regard. Instead of providing leadership in a cooperative effort, the federal government has passed much of the responsibility to the states that have had to rely on competitive bidding in the markets for limited supplies, which has driven prices up, not down. When the research community needs to cooperate in developing drugs and vaccines, the United States has gone so far as to withdraw from the World Health Organization – the entity in which nations cooperate in such goals that would improve health throughout the world. The Trump administration has even promoted agreements in which they hope American firms will gain control of the world markets for these new drugs and vaccines, wherein business success trumps public health, at a cost to those on the losing end (competition creates winners and losers, whereas, with cooperation, everyone wins). They also intend to punish our colleges and universities that follow certain recommended public health standards aimed at reducing transmission of the coronavirus, by revoking the visas of international students, an important source of revenue for these institutions. Not only is this not cooperation, it is not even competition. It is simply madness.

Imagine. Working together. For the benefit of patients. Instead of competition and markets, we need cooperation and public service – features characteristic of the single payer model of Medicare for All. Planning together. We have the money. We simply need an infusion of social solidarity.

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Bill of Health

How market logic hobbles the nation's hospitals

By Adam Gaffney, M.D., M.P.H.
The Baffler, Salvos, July 2020

The intensive care units where I work as a physician were almost unrecognizable this April: doctors and nurses outfitted in head-to-toe Tyvek suits—bright white protective onesies with hoods—along with face masks, translucent face-shields, and shoe coverings. We squinted, at times, to recognize one another. As our ICUs filled up with Covid-19 patients, we improvised more space: the post-op recovery area became a Covid-only ICU that, for unclear reasons having nothing to do with geography, we dubbed “ICU North.” The regular hospital floors were filled with coronavirus patients on oxygen who were monitored closely for deterioration, or the need for intubation. If ICU patients are sick by definition, these were often the sickest of the sick: lung failure, again and again, led to heart failure and kidney failure, necessitating artificial breathing with ventilators, adrenaline-substitutes dripped into the big veins of the chest, and emergency dialysis. On the busiest days, I felt pulled from one patient to the next, from rounds with residents to assessing a tenuous patient on the hospital floor who might need intubation, then back again to the ICU, perhaps for an emergent procedure. “Codes”—CPR and other resuscitative efforts undertaken to save a patient whose heart has stopped—seemed more frequent than ever before.

Later, data would confirm what we suspected to be true: two of the working-class, disproportionately immigrant towns near Boston that our health system served, Everett and Chelsea, were among the hardest hit municipalities anywhere in Massachusetts during the first wave of the pandemic. At one point in late April, some 88 percent of our beds were filled with Covid-19 patients. Epidemics are not, as the cliché goes, “great equalizers”—they tend to exacerbate social inequality. Telecommuting and social distancing are not options that everyone can afford; the chronic illnesses that predispose people to acute disease follow social gradients; oppressive conditions weather the human frame. It was little surprise that, like other hospitals in Covid-19 hotspots, we were busy. We felt full.

But just as we found ourselves feeling busier than ever before, something strange happened to hospitals nationwide: the sector went into free fall. To prepare for a potential swell of patients with severe Covid-19, and to preserve critical supplies like ventilators and personal protective equipment (PPE), hospitals cancelled elective, often lucrative, surgical procedures across the board. Clinic visits were also cancelled so as to avoid turning physicians’ offices into coronavirus incubators. Meanwhile, desperate efforts to acquire additional supplies and staff put hospitals into bidding wars against each other. Costs rose, revenue sunk, and hospitals went into the red.

In the first quarter of 2020, spending on health services plunged by 18 percent, sinking gross domestic product with it. The health sector shed some 1.4 million jobs, according to the Bureau of Labor Statistics. Some 243,000 lost employment at doctors’ offices, about 135,000 at hospitals, and around a half million at dentists’ offices. Physicians and nurses, even in Covid-19 hotspots, faced pay cuts and job losses in the middle of the pandemic. Boston Medical Center, a safety-net hospital that provided a large amount of care to Covid patients, was expected to lose $100 million in April and May, the Boston Globe reported, and proceeded to furlough some 10 percent of its staff.

This is unprecedented: health care is a famously resilient industry in the face of economic downturn. “The data clearly show,” notes a 2018 article in the Monthly Labor Review, “that the Great Recession had little, if any, negative effect on job growth in health care”—even while unemployment soared to 10 percent nationwide. But Covid-19 is different: health services shuttered across the country at the very moment that millions of people lost income and health insurance. The consequences were absurd: in the midst of a pandemic the likes of which we have not seen for a century, the U.S. health system was, paradoxically, defunded.

In truth, this is no paradox. Covid-19 hit the health care industry with simultaneous supply and demand shocks. Hospitals’ “products”—particularly elective surgeries that command high reimbursement rates from private insurers—could no longer be sold. Wares that were suddenly more valuable—like pandemic preparation, or prolonged care for patients with respiratory failure—did not pay enough, or at all. The U.S. health finance system was functioning exactly as it was designed to: it was operating as a business, and this quarter was very bad for business. The crisis hence laid bare what happens when a health system is built on the framework of capitalism—when health care is packaged into marketable units, when some patients make money for hospitals, and others do not.

The Price You Pay

Figuring out exactly how to pay hospitals is hardly intuitive. Lucrative procedures are hospitals’ lifeblood in this era, but in the mid-fifteenth century, care was subsidized by hawking wine. In 1450, the conversion of grapes to alcohol was the single biggest source of revenue for one charity hospital located in the town of Beauvais, France; like other medieval hospitals, its revenue came mostly from agriculture and land rents. The only payments it sourced from patients themselves amounted to a mere eleven of its 766 livre budget, raised from selling off bedding and clothing dead patients had brought along when admitted. But, as William Glaser makes clear in his seminal treatise on hospital financing, Paying the Hospital, from which I’ve drawn these facts and figures, the idea that the budgets of hospitals would be funded by patient payments is a generally modern development, even as we take it for granted today.

After all, early hospitals were conceived not as places for the rich, but for the sick poor. They emerged as distinctly charitable institutions in the Byzantine Empire before spreading to the Islamic world and Western Europe. “Until quite recently,” notes historian Michel Mollat, “the poor were almost the only clients of hospital, places in which they felt truly at home.” The well-to-do, in contrast, saw hospitals as death traps to be avoided at all costs. And in an era of primitive therapy, the most useful thing that hospitals really had to offer was nursing care and housing.

With the advent of modern medicine, however, everything changed: hospital care increasingly became a service that the well-off wanted rather than feared. Alongside the usual charity cases, hospital administrators in the early twentieth century eagerly sought well-off patients who would pay for private rooms and treatment from their private surgeon or doctor. In later decades, payments for services were increasingly made by a third party, initially not-for-profit insurers in the United States (i.e., Blue Cross) that grew to cover much of the U.S. workforce in the postwar era, or the social insurance funds that expanded into universal systems in Europe. Differential treatment by class faded in Europe; in the United States, not as much.

But on both sides of the Atlantic, hospitals didn’t bother trying to calculate a precise “price” for providing care for a particular patient, whether measured in the number of dressings applied, minutes of nursing care provided, tablets of medications swallowed, or soiled bedding washed. As Glaser describes, for a century if not longer, the “daily charge” (known as the prix de journée in France, the Pflegesatz in German-speaking nations, or the sengedagstakst in Denmark—there were versions in just about every country) was the most common way hospitals were financed. The accounting was simple: hospitals divided up the total projected budget for the coming year by the total number of nights that patients were expected to sleep in their beds. Social insurance funds paid this per diem amount for each night a worker stayed within a hospital’s walls.

When Medicare was passed in 1965, it more or less adopted this practice as well, following Blue Cross, but with fewer strings attached than in European systems. Crucially, the U.S. per diem rules allowed hospitals to fold spending on expansion and debt interest into their reimbursable costs, which spurred a historic spree of debt- and profit-driven expansion, driving up health care spending. But the biggest single difference that set the American system apart was even simpler: in the United States uniquely, as Glaser notes, hospitals were allowed to retain profits.

If the per diem rate was a “price” of sorts, it was a profoundly simple one, especially in Europe: it reflected the actual cost of running the institution, divided among the patient-days. But the American pricing rules were easily gamed: in the 1970s, critics came to blame cost-based reimbursement as the cause of the nation’s rising health care costs and saw hospital payment as ripe for disruption. “I mean, it was just stupid,” said the former head of the national lobbying group of for-profit hospitals, quoted by political scientist Rick Mayes in his history of the hospital payment reforms of the 1970s and 1980s. “You don’t give people their costs, because you just give them an incentive to spend more.” In other words, when you pay hospitals whatever it cost them to provide care, they have no incentive to hold down their operating costs—whether in terms of labor, technology, or physical plant. There was no market discipline put on hospitals, no competition. This became the conventional wisdom, notwithstanding the fact that cost-based per diems, when coupled with public financing and capital controls, had proven entirely compatible with cost control in Europe.

Patients or Products?

In the 1970s, a group of researchers at Yale University believed they had come up with a solution: the DRG, or diagnosis-related group. To get to the bottom of hospital operating costs, the researchers consulted Robert Fetter, a professor at the university’s school of management. “Well, tell me what your products are,” Fetter asked one of the researchers, according to Rick Mayes’s narrative. The response was: “We treat patients.” Fetter retorted, per Mayes, with something like: “and Ford makes cars, but there’s a big difference between a Pinto and a Lincoln.” So the team crunched Connecticut-wide hospital data using a new computer program they invented, and came up with more than three hundred categories of hospital care, or DRGs. Each was a product that could have a price. For instance, if today you were hospitalized for a severe infection (“sepsis”) that required less than ninety-six hours of mechanical ventilation (MV) and that caused a major complication or comorbidity (MCC), like kidney failure, you might be billed as DRG 871, “SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC.”

A DRG is supposed to reflect the average costs for the average bundle of care needed by the average patient for a given type of hospitalization. After a brief trial in New Jersey in the 1970s, the new system was rolled out nationwide, along with a law signed by Ronald Reagan in 1983 designed to cut Medicare spending. DRGs have been hailed as a revolution, but it may be that the medicine was worse than the disease. It is true that hospitals slashed patients’ length of stay in response to being paid lump sum payments instead of per diem reimbursements by Medicare, as one might expect: annual hospital days quickly tumbled by nearly 30 percent from 1981 to 1988. That might seem like a good thing—who wants to sit in a hospital for a week after recovering from an uncomplicated appendix removal?—but the implications for patients were rather more mixed. Many patients were merely shipped off to nursing homes rather than allowed to recover in the hospital. And unlike with hospital care, conventional insurance might not cover the nursing home stay.

Cost control also proved to be a mirage. Hospitals were at least as good at gaming the DRG system as the per diems. After all, the DRG was determined by what doctors and hospital coders and billers said was the diagnosis. Hospitals brought in brigades of consultants to fine-tune billing—leading to what has been termed “DRG creep” or “upcoding.” Minor differences in how a diagnosis was worded could have enormous ramifications for how much one was paid, creating a large incentive to get the wording “right.”

The new system also changed the nation’s hospital infrastructure itself: alongside shorter hospital stays, the DRG era saw a marked decline in hospital beds. As the nation braced for the arrival of Covid-19 in early spring, many commentators noted with some surprise that the United States had so few hospital beds: just 2.8 per 1,000 people, compared to 8 in Germany, or 13.1 in Japan, according to the OECD. And while DRGs did succeed in reining in Medicare spending in the 1980s, overall costs did not go down—hospitals merely shifted them to private payers, at least as long as they were able to. Health economist David Cutler found in 1998 that every dollar of reduced Medicare hospital spending in the latter half of the 1980s was accompanied by a dollar of increased spending by private insurers. Private insurance premiums soared as the 1990s arrived, and today’s health care cost crisis was born.

In short, DRGs failed miserably to contain hospital costs, and American medicine mushroomed into more of a business than ever before. Hospitals, whether for-profit or not-for-profit, made something of a final leap into modern corporate structure during the 1980s. The Reagan administration deregulated hospital expansions; health care providers began to consolidate. Powerful for-profit corporate hospital chains, like Tenet Healthcare and Hospital Corporation of America, gained market share. And not coincidentally, it was precisely at this moment that U.S. health care costs began their historic ascent. “America was in the realm of other countries in per-capita health spending through about 1980,” noted health care researcher Austin Frakt in the New York Times in May 2018. “Then it diverged.”

If the DRG didn’t singlehandedly cause these changes, it did decisively reframe the provision of care into an (ostensibly) interchangeable commodity. Some DRGs are profitable, while others are not, and because payment for DRGs depend on the payer—the payouts from private insurers are nowadays lucrative compared to those from public insurers like Medicaid and Medicare—some patients are profitable, while others are not. In 2017, the CEO of the Mayo Clinic caused a firestorm when a leaked speech revealed that he said that the giant health system would “prioritize” those with private insurance over those with public insurance, but he was really just describing the reality of American health care. Hospitals that produce more profitable DRGs can grow, expand, and beautify; those that produce the less profitable DRGs, for poorly insured and disadvantaged people, are less well-endowed. And hospitals that can’t turn a profit at all simply go bust, like those shuttering across rural America, or the safety-net institution in downtown Philadelphia that closed last year. The story of the American hospital, up to the Covid age, is the story of inequality in America.

How the Other Half Convalesces

In May, the Covid tide ebbed at our hospital. Fewer patients were rushed to the intensive care unit from the emergency room or the hospital floors each day. I spent less time zipped up in a Tyvek suit. We closed the ad hoc “ICU North.” My pager went off less frequently while I was at home on call, permitting longer stretches of sleep. Colleagues and I began having longer lunches, albeit alone at our own tables in the cafeteria, spaced farther apart than they used to be. Some of our patients even attended follow-up appointments after weeks-long comas.

Operating rooms throughout the country began to re-open; elective procedures, many sorely needed, were again performed. Hospitals, meanwhile, sought to move out their patients with persistent respiratory failure to specialized long-term hospitals, as is the norm in the United States. It was clear that, at least for the moment, at least in Massachusetts, the pandemic was retreating. What was less clear was what would change in the post-Covid world, both within and without the hospital.

To deal with the shortfalls in hospital funding stemming from plummeting patient billing for profitable DRGs like elective surgery, Congress included some $100 billion in bailout funds in the CARES Act, a big coronavirus relief bill signed into law by President Trump on March 27 (another $75 billion came from subsequent legislation). But it was soon clear that this relief would rectify no inequalities. One formula for dispersing the funds, the Los Angeles Times reported, allocated relief based on hospitals’ previous revenues, which meant that hospitals that took in more revenue from wealthier patients with private insurance would receive far more “relief” than those that provided care to the uninsured or those with Medicaid.

A study from the Kaiser Family Foundation estimated that the hospitals likely to reap the biggest payouts were for-profit institutions and those that provided less charity care. The Hospital Corporation of America and Tenet Healthcare together took in some $1.5 billion in federal relief, according to the New York Times. Our small health system fared less handsomely: the CEO of my hospital system told the Los Angeles Times that we would see some $90 million in losses but were expected to receive only $6.7 million in relief. He noted that some of the hospitals’ work—for instance, setting up a homeless shelter for individuals with coronavirus—would not even be considered in Trump’s formula. As June approached, the stage seemed set for further consolidation and corporatization of our nations’ hospitals, and a further exacerbation of inequity amongst them.

In the five years leading up to the Covid-19 pandemic, the Medicare for All movement achieved something momentous: it helped push single-payer from the radical sidelines of American politics to the very center of the national discussion. For a brief and exciting moment right before the coronavirus careened across the nation, it even seemed that our next president might be the Vermont senator who had put Medicare for All at the center of his long political career. As cases and deaths from the outbreak continued to mount in April, we learned that this would not come to pass. But the case for Medicare for All only grew stronger.

Some 18.2 million Americans at high risk of severe Covid, whether because of advanced age or chronic disease, were uninsured or underinsured at the onset of the epidemic, according to a study that colleagues and I published in the Journal of General Internal Medicine in June. Not surprisingly, these individuals were disproportionately black, Latinx, and American Indian, and from low-income families. The specter of people going bankrupt from Covid-related care, or avoiding testing because they couldn’t afford it, proved too much even for Congress and Trump: legislation was passed that protected, albeit inadequately, many individuals from medical costs for Covid testing and treatment. Nothing, however, has yet been done for the tens of millions who are liable to be bankrupted from treatment of every other ailment or injury.

Still, the epidemic has perhaps strengthened the notion that a person’s ability to obtain medical care should not be contingent on his or her ability to pay, which is to say, as an economist might, that our “effective demand” for care should depend only on our individual preferences and medical needs—not our income or wealth. That requires universal coverage and the elimination of financial barriers to care, something only a single-payer reform would realize. But what even the proponents of Medicare for All sometimes fail to emphasize, and what needs to be understood as we begin to imagine a better post-Covid-19 world, is that health care reform must not only achieve equity in demand but must also address the ubiquitous inequities and dysfunctions in the supply of care that stem from our nation’s unique history of hospital financing.

We should recognize, for instance, that the basic philosophical premise of the DRG—that a hospitalization can be treated as a product and priced like any other commodity—is a fallacy of the neoliberal age. If every DRG was “priced” appropriately, then none would be more profitable than any other. Hospitals would have no incentive to focus on the provision of high-tech procedures over the care of those with, say, protracted respiratory failure, substance use disorders, or mental illness. There would be no “profitable” and “unprofitable” patients. But they do, and there are: prima facie evidence that this system has failed.

The DRG system, moreover, fails to fund other important things that hospitals might do, like helping to set up homeless shelters for Covid-19 patients or other community public health projects that cannot be billed to individuals. Treating hospitalizations as individual billable commodities also means that there is no incentive to maintain excess capacity—say of ICU beds or ventilators—to be ready for the next pandemic or climate catastrophe. After all, empty hospital capacity is an idled machine; it has social value but lacks utility in a system governed by market logic. So it does not exist.

Original Spin

The point is not to go backward; hospitals aren’t going to go back to making money selling wine or dead patients’ bedding, fortunately. Instead, we must move forward to full public financing of hospitals, not as commodity-producing factories, but as social institutions, with guaranteed annual global budgets that could be used for the care of hospitalized patients and the provision of community care services alike. Global budgets, long included as part of Physicians for a National Health Program’s single-payer proposals, are lump sum payments that operate similar to how public schools are typically paid. Schools receive a budget for the year to cover the cost of educating all the children who attend; they don’t issue individualized bills to each student that ostensibly reflect his or her unique educational “costs,” whether measured in the predicted frequency of interactions with teachers, the amount of wear and tear imposed on the playground, or the consumption of extracurricular activities. Global hospital budgets would not crumble in the face of disaster, for they would not be linked to the sale of individual products. Global budgets could save us money, yes, through the downsizing of the bloated billing and administrative departments, designed to maximize payments, that have been growing since the 1980s. But they would mean something more fundamental: moving to a world beyond health care products and prices.

This requires changing something even more fundamental: our health care institutions could no longer retain profits. “No law of nature,” as my colleagues (and co-founders of Physicians for a National Health Program) David Himmelstein and Steffie Woolhandler, together with Public Citizens’ Sidney Wolfe, argued in a medical journal, “requires that hospitals make profits in order to thrive.” Health care profits are our original sin; they led to unbridled expansion and waste in the 1970s, when hospitals were paid per diem, but also today, when they are paid mostly with DRGs. Although the majority of hospitals are not-for-profit legally, all must have revenue greater than costs: whether we call it a “margin” or a “profit” matters little. This difference is what hospitals use to upgrade facilities, to build new wings, and to purchase the latest equipment and machines. Those purchases, lumped under the term “capital expenditures,” are not only necessary for success, but for survival. High margins can mean technological prowess, beautiful atriums, and the latest treatments on offer. As margins evaporate, hospitals become shabby and out-of-date, abandoned by physicians and patients alike.

The consequences of this profit-oriented financing system is a combination of deprivation and excess. That kind of inequality of health care supply has a name. In 1971, the British general practitioner Julian Tudor Hart coined a phrase, the “inverse care law,” that describes it well. “The availability of good medical care,” he wrote in The Lancet, “tends to vary inversely with the need for it in the population served.” Those who need care the most, that is to say, have the least access to it. The inverse care law even operated in the United Kingdom in the age of the National Health Service (NHS), as Hart witnessed in his daily practice, where he cared for a working-class population in an impoverished Welsh mining town. While the NHS eliminated inequalities in effective demand through the realization of universal, free health care, it inherited a geography and distribution of unequal supply that had been built up over decades.

Yet the NHS, unlike a market-based system, provided the tools to unravel this inheritance. An intentional effort to achieve greater geographical equity in financing was carried out, successfully, in the 1970s in the UK. As Hart noted, the “inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” As such, the inverse care law is today in operation in the United States like no other high-income nation. But we can change that. We could fund new hospitals and new health infrastructure not from profits, but from the public purse, something that the Medicare for All bills now in Congress, particularly the House version, would achieve. Hospital expansion would then be premised on the basis of health needs, not market logic.

Inequalities in health care demand and health care supply share a single root: the only partially successful venture to build a health care system on the principles of capitalism. Today, market forces limit the ability of working-class people to obtain needed medical services, and indeed distribute those services toward those who can afford them, just as they distribute hospitals and health infrastructure by profitability, not community health needs. The hospitals of the poor and people of color shutter, or contend with paltry funding, for the very same reason that their patients are more apt to be uninsured or ration their insulin: market logic underlies both inequities of American medicine. As we move into the post-Covid age, we must fight for a just health care system that addresses both.

Dr. Adam Gaffney is a pulmonary and critical care physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance, and serves as president of Physicians for a National Health Program. He writes about issues of health policy and politics and is the author of To Heal Humankind: The Right to Health in History, published by Routledge in 2017.

https://thebaffler.com…

Lown Institute: Hospitals and civic leadership

In a new hospital ranking, doing good counts nearly as much as doing well

By Sharon Begley
STAT, July 7, 2020

You won’t find the usual suspects like Massachusetts General Hospital or the Mayo Clinic at the top of a new ranking of U.S. hospitals. That’s because the rating system relies not just on traditional quality measures, but also on a hospital’s community-minded policies and avoidance of unnecessary care.

The rankings show that those hospitals with good clinical outcomes tend to score poorly in addressing inequities that affect the health of their communities. And even when hospitals perform many low-value procedures — those that research has shown to be of limited or no benefit — their patients generally have a low risk of dying both in the hospital and after being discharged, as well as a low risk of having to be readmitted.

No previous hospital rankings use “civic leadership,” which includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. The Lown Institute, a nonprofit think tank in Brookline, Mass., incorporated both measures into its rankings of 3,282 hospitals because “it is time for hospitals to rethink what it means to be great,” said Lown’s president, physician Vikas Saini.

Civic leadership matters because the health of the people in a hospital’s community “reflect things outside the four walls of a hospital,” he said. “If one patient is going back to a community without a lot of resources, where health equity is low, and another is going back to a wealthier community, their [long-term] health will be very different even if the quality of care in the hospital was identical. Hospitals have an obligation to improve the health of the outside community.”

A number of hospitals renowned for their quality of care got A+ or A for patient outcomes but a D for civic leadership, including Massachusetts General Hospital, the Cleveland Clinic, the Mayo Clinic, and the University of Washington in Seattle. Teaching hospitals such as these do pretty well on supporting their communities, but pay equity — multimillion-dollar salaries for top executives — sinks them in Lown’s calculation of civic leadership. Not a single hospital in the top 100 for patient outcomes was in the top 100 for civic leadership, and vice versa.

Many hospitals perform high numbers of low-quality procedures, which tend to be lucrative (and waste an estimated $100 billion per year in health care spending). “The right thing to do financially isn’t necessarily the right thing to do for patients,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit backed by large employers that aims to identify and promote high-quality, high-value health care and whose hospital ratings emphasize patient safety.

She called Lown’s decision to downgrade a hospital for performing many low-quality procedures “a breakthrough” in hospital ratings. “We know inappropriate care is an extremely significant problem for the health care system,” Binder said. “It’s also a terrible tragedy for individual patients to go through an unnecessary procedure.”

Few patients are likely to reject a hospital based on how much it pays its CEO relative to its custodians. But Binder called civic leadership an important metric. “If there is anything you want out of a hospital, it’s ethics,” she said. Charity care, community support, and pay equity “are informative about a hospital’s culture.”

The American Hospital Association, however, said in a statement that the report offers consumers no “accurate and useful information,” instead offering “a hodgepodge of composite score, ranking, star ratings, and letter grades that will, at best, confuse consumers and likely mislead them.”

https://www.statnews.com…

Lown Institute – Hospitals Index:
https://lownhospitalsindex.org

Comment:

By Don McCanne, M.D.

Some hospitals are great at pleasing the principal players in the medical-industrial complex. To no surprise, many of these hospitals score high on current arbitrary measures of hospital performance, not to mention that they also have impressive financial statements. But Vikas Saini and his colleagues at the Lown Institute have studied extensively problems with the health care delivery system, and they identify another crucial factor that contributes to high performance of hospitals, and that is “civic leadership.”

Civic leadership includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. As Leah Binder of the Leapfrog Group stated, “If there is anything you want out of a hospital, it’s ethics.”

When you look at the features of single payer Medicare for All, you see that its infrastructure represents the epitome of ethics or civic leadership that stands in contrast to the mere business foundation of the medical-industrial complex. Single payer is universal, equitable, affordable for everyone, allocated efficiently, and always there when needed – ethical features that are simply not innate in a system controlled exclusively by the medical-industrial complex.

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