Summary: A communist perspective on health pushes the boundaries of reform. For many progressives, it’s too much. But it’s a legitimate and valuable part of the discussion. Let’s meet in the Town Square to see how we can reconcile our perspectives, unite our caring, and agree on a solution.

Health Communism, Verso 2022, by Beatrice Adler-Bolton and Artie Vierkant

Excerpts:

Capital has been allowed to define the meanings, terms, and consequences of “health” for long enough. We articulate how health is wielded by capital to cleave apart populations, separating the deserving from the undeserving, the redeemable from the irredeemable, those who would consider themselves “workers” from the vast, spoiled “surplus’ classes. We assert that only through shattering these deeply ingrained binaries is the abolition of capitalism possible.

Some readers may be surprised to find little attention devoted in Health Communism to the question of health insurance. We understand health insurance companies for what they are: principally, they are financial institutions, concerned as they are only with payments for services rendered and the endless, bureaucratic, deadening, management of risk. There is no place for them in society.

It is important to recognize that, even as we fight in the US for policies like Medicare for All, the task at hand is much greater than one program could capture. It is the total reformation of the political economy of health, and in so doing, the total reformation of the political economy.

Capital has emphasized and corrupted the delineations between surplus classes for its convenience; it is immeasurably threatening to capital to see a group of those it has deemed to be waste come together in solidarity.

We are each of us ripped and maimed, strangled and buried by capital, in one way or another. That entire industries exist in plain sight to see us along this vast process of endlessly iterative life chances, to then subject us to extraction when we are surplus and no longer of use, and to eke out slivers of profit from our eventual deaths, is capital’s greatest sleight of hand. We are all surplus.

The host-body relationship of health and capital can be understood through an analysis of the social determinants of health and their direct relationship to the broader political economy. It is present in each of the accounts we have demonstrated throughout Health Communism; with each stage, with every evolution of the political economy of health, capital has come to occupy and replace more and more components of its host. But capital cannot kill its host body, or it would have nowhere to hide, nothing to exploit, a barren universe. It is for this reason that capital only fears health. It is up to us to separate them.

Comment:

By Don McCanne, M.D.

There is a great need to increase communication on the concepts that will bring health care justice to all. The title and rhetoric of Health Communism may not seem like it would fall in line with this goal, but it clearly does. Understanding the views of those who sincerely care about the health of all of us is important, and so it is important for us to make a sincere effort to understand those views no matter what ideological and rhetorical frames they adopt.

What about understanding the views of those who don’t seem to care? The capitalists. Rather than not caring, it is much more likely that they communicate amongst themselves, distracted by payment methods and the like, developing modes of behavior and rhetoric that merely suggests that they don’t care. Maybe we should be having more conversations with them, asking them questions that would bring out answers to show that they really do care.

Maybe it’s time to agree to meet again in the Town Square and bring all of our ideas together so that we can develop that system that will work for all of us. Of course, if we’re all there to ensure health care justice for all, it is likely we would end up with a universal social insurance system: single payer. We would also address the social roots of health inequity. And as we have suggested before in HJM, Medicare for All may not be enough: we may need to take on capital interests more broadly. That’s a tough but necessary conversation in the Town Square.

http://healthjusticemonitor.org…

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Summary: Tuesday’s midterm elections pitted Dem efforts to build social welfare and protect abortion rights and democracy against GOP blaming Biden for inflation and crime, and advocating for limits on abortion. The Dems performed strongly, but threats to democracy loom. We explore how the fights for democracy and single payer align.

Comment:

By Jim Kahn, M.D., M.P.H. and Kenneth Colón

What the midterm election told us:

The nation averted the “red wave” endorsement of MAGA politics, with the best first midterm result for a Democratic president in decades. Voters responded to appeals to protect abortion rights and democracy, and largely didn’t blame Biden for post-COVID inflation. Yet it’s not time for complacency: American democracy remains in danger.

CNN reports that of the 34 Republican candidates for Secretary of State or Governor who rejected, questioned, or tried to overturn the results of the 2020 election, 11 are projected to win their races. The Republican National Committee has supported 70+ “election integrity” lawsuits, intending to suppress votes and systematically deprice Dems of full representation, as in the case of hyper-aggressive gerrymandering. A GOP Senate, if that happens, will obstruct Dem appointments to courts and agency oversight boards. The US House of Representatives will likely be GOP-controlled. This will likely lead to nearly nonstop hearings attacking Biden and other favorite targets of the Right to build support for a 2024 GOP presidential win. With a GOP president, traditional norms on stability of domestic and foreign policies will be jettisoned via bureaucratic subterfuge (a reclassification of civil servants as “policy making” thus depriving them of job protection, affording the president massive power to enforce loyalty over law). Meanwhile, the US Supreme Court will consider a case next month that may put control of federal elections solely in the hands of state legislatures — some of which, as a byproduct of extreme gerrymandering, deviate sharply from the views of their constituents. A Dem presidential candidate may win more votes, yet the state electors go to the GOP.

To be sure, there are encouraging signs in the mid-terms. Support was high among young Americans, who leaned very Democratic due to progressive values and favoring student debt relief – helping achieve impressive Dem overall and progressive results. We also elected our first Gen Z member of Congress. More and more, it appears that voters are recognizing and reacting to the threats to democracy. This offers hope of further broadening of resistance to GOP efforts to undermine majority rule.

Where does health reform fit in?

Small changes nudge us in a good direction, e.g. in the Inflation Reduction Act: more subsidies for the ACA, and Medicare drug price negotiations, constraints, and out-of-pocket spending limit. Yet single payer would do much better at controlling overall health care costs and save families thousands of dollars.

Beyond that, single payer is the health reform that most faithfully embodies the democratic values we’re fighting for. Equality would jump as universal, high-quality insurance replaces being uninsured, under-insured, or insured by under-funded programs for the poor. Liberty would rise by delinking work and insurance coverage, and offering real, unfettered choice of providers — not false choice among over-priced insurance plans. Small businesses and entrepreneurship could flourish as a result. Community would blossom by fostering the shared experience of access to care and elimination of medical debt. Americans could live longer, healthier, more fulfilling lives.

Is there a viable link between promoting single payer and saving democracy?

Single payer proposals engender massive attacks as “socialism” and “government takeover”. It isn’t, of course — it’s public financing of private care. Notably, even modest and inadequate reform ideas like a public option are similarly attacked, so we might as well think big, aiming for an approach that would really solve health care financing problems. Fortunately, people are increasingly recognizing the fundamental failings of our fractured insurance mess and thus the need for real reform.

So, how can we link the fight for single payer with the fight for democracy? Here are some ideas:

1. Understand the links – where do the values overlap? We started above and are exploring other shared values. But we’d like to broaden the discussion and disseminate this idea.
2. Explore alliances – convene organizations working on single payer and democracy preservation for structured discussion and mission coordination.
3. Scrutinize the idea that the Dems should focus on small-bore incremental health reforms rather than single payer, which generates vigorous attacks from the GOP interests vested in our current health system. One potential counterargument is that only comprehensive health care financing reform broadly and powerfully advances democratic values. It’s the only way to control costs globally and for families. Another is that all healthcare reforms proposed by Dems will be condemned by the GOP anyway, so Dems should not let the GOP guide their healthcare strategy.
4. Broaden political involvement. For people excited about these issues and energized by midterm results, and perhaps thinking about working with the local political party, or volunteering in elections – now is a great time to start.
5. Encourage discussion. With friends, family, neighbors, anyone who will engage. Spread the word, but also listen well to their thoughts, beliefs, and concerns.

Let’s make meaningful progress on the parallel and aligned fronts of democracy and health care justice!

http://healthjusticemonitor.org…

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Summary: A US Senate committee issued a report documenting and condemning “widespread” abusive marketing practices for the private health plans known as Medicare Advantage. This follows NYT reporting on the Medicare Advantage “cash monster.” It’s time to recognize the failure of privatizing Medicare … and instead embrace single payer.

Deceptive Marketing Practices Flourish in Medicare Advantage, November 3, 2022, by the Majority Staff of the U.S. Senate Committee on Finance

Part I: Executive Summary

The Centers for Medicare and Medicaid Services (CMS) revealed earlier this year that the number of Medicare beneficiary complaints about private sector marketing for Medicare Advantage (MA) plans more than doubled from 2020 to 2021. The Senate Finance Committee … launched an inquiry in August 2022, collected information on marketing complaints from 14 states and found evidence that beneficiaries are being inundated with aggressive marketing tactics as well as false and misleading information, such as:

Seniors shopping at their local grocery store are approached by insurance agents and asked to switch their Medicare coverage or MA plan.

Insurance agents selling new MA plans tell seniors that their doctors are covered by the new plans. Seniors who switch plans find out months later that their doctor is actually out-of-network, and they have to pay out-of-pocket to visit their doctor.

Seniors receive mailers that look like official business from a Federal agency, yet the mailer is a marketing prompt from an MA plan or its agent or broker.

An insurance agent calls seniors 20 times a day, attempting to convince them to switch their Medicare coverage.

Widespread television advertisements with celebrities claim that seniors are missing out on benefits, including higher Social Security payments, in order to prompt seniors to call MA plan agent or broker hotlines.

Each one of these vignettes represents documented instances of aggressive or deceptive MA and Part D marketing practices that this investigation found to be widespread, not isolated events. Other examples submitted by the states are documented in this report.

The Committee received evidence of fraudulent and misleading marketing practices from states and other stakeholders – painting a consistent national picture. These issues were reported more frequently with respect to MA plans compared to stand-alone Part D plans. In addition, nine of the ten states reporting quantitative complaint information found an increase in complaints from 2020 to 2021 that mirrored the trend found by CMS.

Information submitted by states demonstrates that beneficiaries are inundated with fraudulent and misleading communications across all modes of communication (in-person, television, telemarketer, and robo-calls). An egregious example submitted by the states includes marketing materials designed to look like official communications from Federal agencies. A number of states also raised concerns with the use of “Medicare” in the naming and branding of marketing companies to suggest that a marketing company is representing the Medicare program. These practices are intentionally deceptive as they blur the lines between official government communication and private health plan marketing.

The investigation also uncovered a range of predatory actions. Agents were found to sign up beneficiaries for plans under false pretenses, such as telling a beneficiary that coverage networks include preferred providers even when they do not. Of particular concern to the Committee were reports across states of agents changing vulnerable seniors’ and people with disabilities’ health plans without their consent.

The burden of deceptive and predatory marketing practices falls unequally across the already vulnerable Medicare population. The Committee heard that unscrupulous actors are targeting individuals dually eligible for Medicare and Medicaid (so-called “dual eligibles” who are allowed to switch MA plans once every quarter) as well as individuals with cognitive impairments. False and misleading marketing advertisements and fraudulent sales practices undermine access to care and the trust beneficiaries have in the Medicare program.

Comment:

By Jim Kahn, M.D., M.P.H.

As I approached my 65th birthday in May, the calls began. “This is the Medicare Medical Care Help Center” was the frequent opener. Guess what? They were not from Medicare, instead were telemarketers peddling Medicare Advantage plans. I also received – and continue to receive – numerous mailings. Lucky for me, I’m not cognitively impaired, and my University of California retirement supports a generous health plan that works for me and my family. I recognized this marketing blitz as high pressure sales, and ignored it. Reading the impressive Senate report, it turns out that CMS prohibits many of these marketing practices (such as private brokers using the “Medicare” name). Countless seniors have been fooled and harmed.

So, can we fix these problems? That’s what the Senate report recommends – better oversight. I excluded that portion of the Executive Summary, because I believe the problems with Medicare Advantage are far too pervasive and structurally embedded to be remedied with fine-tuning.

Medicare Advantage (MA) is a fundamentally flawed idea. As reported in the NY Times, MA plans overbill the federal government by tens of billions of dollars per year. Financial barriers to care for sick individuals are greater in MA than in traditional Medicare. Mortality for MA beneficiaries is highly variable, hurt by lower spending, and unrelated to quality measures. Recent letters to CMS list the problems (here & here).

Traditional Medicare is also under privatization assault. ACO REACH, despite its clever “equity” marketing, echoes the flawed MA model: it uses corporate “direct contracting entities” that will reap billions in profits as fiscal agents for capitated coverage. See here, here, and other HJM posts.

We’ve seen abundant evidence that privatization of Medicare is a disaster masquerading as a solution, to address a problem that never existed. Traditional (non-privatized) Medicare was and remains better – it is cheaper and has greater access to care.

Single payer – improved Medicare for All – is the right solution.

http://healthjusticemonitor.org…

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Summary: Evidence from around the world and in the US confirms the value of primary care for health care access, quality, and outcomes. Yet through inadequate financing we cause its shrinkage and stresses over time. Single payer would remedy this critical imbalance.

Is Primary Care in Critical Condition?, Medical Economics, October 28, 2022, by Timothy Kelley

In 2006 the American College of Physicians (ACP) declared that primary care, “the backbone of the nation’s healthcare system, is at grave risk of collapse.” That year, in a landmark New England Journal of Medicine article, Thomas Bodenheimer, M.D., M.P.H., a professor at the University of California, San Francisco (UCSF) and founding director of its Center for Excellence in Primary Care, identified “a confluence of factors that could spell disaster.” Patients are increasingly dissatisfied with their care, he wrote, and primary care physicians are unhappy with their jobs. “The quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field,” says the Bodenheimer jeremiad.

Other countries seem to get it even if the U.S. doesn’t. Study after study has shown that other wealthy countries outperform the U.S. on almost any healthcare metric you might imagine while devoting a far smaller share of their gross domestic product to healthcare. One explanation: They put more emphasis on primary care.

With an extra medical assistant on the core team working as a scribe, says Bodenheimer, physicians can see more patients because they’re relieved of many of the documentation tasks that overwhelm their days and that they often take home to work on after a long workday is over. The nonphysician members of interprofessional teams, he says, can save physicians even more time by seeing some patients themselves “if you let them do what they’re capable of doing,” he says. Some studies have shown that pharmacists can do a better job of taking care of people with diabetes than physicians and that physical therapists can do the same for people with musculoskeletal problems, says Bodenheimer.

However, recent innovations such as the accountable care organization (ACOs) and the patient-centered medical home (PCMH) have failed to transform primary care as many had envisioned …. PCMHs, in particular, get low marks from Bodenheimer: “They’ve been pretty much a flop.”

Bodenheimer notes that annual U.S. healthcare expenditures totaled more than $4 trillion in 2020, with just 5% of that spending going to primary care compared with 12% in European countries. “Primary care really should get 10% of the healthcare dollar rather than 5%,” he says. “If we do that, we’ll have enough money to hire the people — the nurses and pharmacists and physical therapists, for example — to be on teams that can help the physicians take care of their overly large panels and make life a lot better for the physician. And that would attract more medical students to go into primary care and could reverse the whole downward trend.”

So there it is. Just move $200 billion around, and you’ll get many more physicians eager to embrace what is arguably U.S. healthcare’s most crucial, most problematic — and potentially most rewarding — challenge.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

There is a consensus that we should be doing better with primary care if we want to achieve our goal of higher quality care for everyone and better outcomes. International evidence supports this. And within the US more primary care translates to lower mortality.

However, our health care infrastructure is set up with models catering more to the business of medicine rather than to the medical care of the patients.

Tom Bodenheimer suggests that the answer is in spending health care dollars more appropriately on the primary care team designed to provide optimal care rather than on service models more appropriate for building income and wealth.

He has been distributing his message for some time now. Isn’t it time that all of us become more aggressive in applying it?

Single payer would permit us to support and grow primary care through appropriate financial support and reward for this fundamental pillar of health care.

http://healthjusticemonitor.org…

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The Marx-Kahn family Halloween display.

http://healthjusticemonitor.org…

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Summary: This week three city councils in the Midwest, West, and Southeast passed resolutions backing nationwide single payer. This brings local endorsements to over 100. Combined with growing popular and physician support, are we approaching an irresistible force?

Three Cities Pass Medicare for All Resolutions in Past Week, October 26, 2022, Public Citizen

In a show of growing momentum behind passing Medicare for All legislation, Denver, Colorado, Gainesville, Florida, and Kent, Ohio all passed city council resolutions in recent days backing a nationwide universal healthcare program, sending a strong signal to Congress that their constituents care about ending for-profit healthcare.

The three cities join more than 100 localities that have endorsed Medicare for All.

During the pandemic, more than one million Coloradans – including 34% of those in Denver – saw their incomes reduced; many lost their job-based insurance, and people of color were hit hardest, according to the Colorado Health Institute’s 2021 Health Access Survey. In Denver County, the U.S. Census Bureau estimates that 12% of residents under 65 are uninsured.

In Ohio’s 13th district, where Kent is located, more than 43,000 people are uninsured, and over 117,000 people live below the poverty threshold. Kent Councilwoman Heidi Schaffer-Bish works with Coleman Health Services and encounters many people struggling to make ends meet when it comes to healthcare. “We’ve seen that government-based healthcare works, and private insurance through your employer does not,” said Shaffer-Bish.

In Alachua County, where Gainesville is located, the U.S. Census Bureau notes that 11.5% of people under the age of 65 are uninsured.

Brittany Shannahan, a Medicare For All organizer at Public Citizen, stated: “These resolutions, city-by-city, are helping to pressure our representatives to act to make guaranteed healthcare for all a reality. The chorus of voices is growing.”

Comment:

By Lily Meyersohn

Shannahan is correct in announcing that the “chorus of voices is growing” on a nationwide single payer healthcare program. This is not just three cities; this is a national movement. In recent years, support for the program has risen in the general public and among key stakeholder groups like physicians.

In Medicare for All: A Citizen’s Guide (2021), physicians and progressive activists Abdul-El Sayed and Micah Johnson write that “there is one stakeholder in American healthcare that matters most: the American public.” And “public support for M4A is high. A nationally representative Pew Research study [from 2019] found that most Americans agree “it is the responsibility of the federal government to make sure all Americans have health care coverage. And a majority of Americans support M4A as a way to achieve this goal.”

This is a sea change from prior decades: “From 1998 to 2008, the Kaiser Family Foundation conducted ten polls asking Americans whether they supported a single-payer national health insurance program. None found majority support. Between 2017 and May 2020, the same organization conducted fifteen similar polls. Every poll found majority support for M4A.”

Physicians, too, are shifting toward single payer. Sayed and Johnson note that the American Medical Association “played a central role in fighting previous attempts at national health insurance.” But now the organization’s membership is in steep decline. “Both physician preferences and power may be changing fast. Most individual physicians today support M4A.”

Recently we’ve experienced COVID fatigue: people fed up and tired of the pandemic. If the 100+ localities that have endorsed M4A – including the three cities that signed on this past week – can teach us anything, it is that people across the country are fed up and tired of our abominable health care system. Maybe we should call that “Mixed Insurance Plan Fatigue.” From fatigue comes a determination for change!

http://healthjusticemonitor.org…

Lily Meyersohn is a researcher at the Institute for Public Accuracy, where she covers pandemic policy and American health care issues. She can be reached at lilymeyersohn@gmail.com.

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Summary: Massive private equity investment has substantially transformed US health care. A highly respected health news service, KHN, highlights the trend and its downsides. The Private Equity Stakeholder Project documents these investments and resulting patient care problems. Single payer would correct the skewed health system dynamics that favor private equity.

Patients For Profit: How Private Equity Hijacked Health Care, How Private Equity Is Investing in Health Care: A Video Primer, KHN (Kaiser Health News), October 26, 2022, by Hannah Norman

See video (3 minutes)

“A common move is to ‘roll up’ a string of businesses under one more established ‘platform’ and find new ways to make money. But as a result, patient care can suffer.” (2:25)

Private Equity Stakeholder Project: Healthcare

Private equity increasingly makes up a substantial portion of investment in U.S. healthcare companies, touching virtually every sector of the industry, and is expected to continue to grow. Asset managers have record levels of available capital earmarked for healthcare investment; as of 2019, private equity firms had $29.2 billion in capital waiting to be invested in healthcare.

This is despite the fact that private equity investment in healthcare companies carries substantial risk to patients, workers, and investors. The typical private equity investment playbook—pursuing outsized returns over short time horizons while using high levels of debt—may lead to behavior that jeopardizes patient care.

For example, private equity-owned healthcare companies have seen the following issues:

• Reduced staffing, or filling beds without adequate staffing ratios
• Over-reliance on unlicensed staff to reduce labor costs
• Failure to provide adequate training
• Pressure on providers to provide unnecessary and potentially costly services
• Violation of regulations required for participants in Medicare and Medicaid such as anti-kickback provisions, creating litigation risk

PESP has studied the impacts of private equity investment in key healthcare sectors, including safety net hospitals, behavioral health, nursing homes, prisons and detention centers and dental care. We have also written about the practice of taking debt-funded dividends from healthcare companies; private equity’s role in medical debt collection; and the relationship of private equity ownership and Medicare fraud. PESP also tracks private equity healthcare acquisitions on a monthly basis, highlighting notable transactions in a variety of sectors.

Comment:

By Jim Kahn, M.D., M.P.H.

Private equity (PE) is a menace to US health care, extracting profits and leaving care underfunded and patients at risk. HJM has written frequently about specific PE issues among providers (eg, here), capitated “direct contracting” (including ACO REACH) by PE and other corporations in Medicare (eg, here), and the dangerous growing corporate ownership of providers. The broad PE critique offered by today’s sources is important.

The rising prices that plague US healthcare reflect growing provider power through corporate acquisitions and mergers – often driven by PE. Massive private health insurers are only too happy to pass along the high costs and associated high profits to payers (CMS and private employers, mainly) and patients (in the form of punishing cost-sharing and financial barriers to care). Private equity is turbo-charged exploitation enabled by our complex, fragmented, and chaotic insurance landscape.

How will single payer help? It will correct the distorted power imbalance, with a global payer that can effectively negotiate prices with large provider groups, reducing costs. It will simultaneously empower small providers (remember solo practice?) by treating them the same as the largest providers. It will simplify billing administration for physicians, removing the incentive to sell to corporations to shed the annoyingly complex paperwork. Many providers and patients prefer a non-corporate setting with greater autonomy and personalization, and will have that choice.

In short, single payer will unravel and replace the play space for aggressive corporate profit-taking. In so doing, it will support smaller providers and, of course, patients. Investor gains will yield to equitable, accessible, and affordable health care.

P.S. See the first comment — additional resources from NY PNHP

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