PNHP

Falling U.S. Longevity Largely Due to Health Insurance Failings

Falling U.S. Longevity Largely Due to Health Insurance Failings

Summary: In a sad echo of 2020, US longevity again fell in 2021 – from 77 to 76 years. Two proximate causes – COVID and chronic disease – have everything to do with insurance gaps. And rising fatal accidents and overdoses reflect a sense of desperation driven substantially by medical care inaccessibility and debt. Single payer would make a huge difference.

U.S. Life Expectancy Falls Again in ‘Historic’ Setback, New York Times, August 31, 2022, by Roni Caryn Rabin

While the pandemic has driven most of the decline in life expectancy, a rise in accidental deaths and drug overdoses also contributed, as did deaths from heart disease, chronic liver disease and cirrhosis, the new report found.

Comment:

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

Once again, life expectancy In the US fell, by a year in a year. Stunning, unprecedented. This horrendous backsliding continues an on-and-off declining trend since 2014, and follows a sharp dip in 2020. The huge two-year drop has never been seen before.

See below a graphic representation. Longevity is now far below where it was in 1999, indeed takes us back to 1995. No other nation has experienced this drastic decline. The fall is greatest among Native Americans, and longevity for Black Americans remains the lowest of any group.

What’s the role of health insurance? The NYT doesn’t say. But insurance is a prime culprit. As HJM discussed recently, at least 1/4 of COVID deaths are attributable to uninsurance. Many chronic disease deaths are due to un- and under-insurance. Our lax gun laws and opioid regulation contribute to the accidental deaths and drug overdoses, but also reflect a sense of desperation in part driven by impaired access to health care, along with rising medical bills and medical bankruptcies.

Our insurance system is failing us. Single payer would break this fall.

Figure by Charlie Swanson, except 2021 blue arrow by Jim Kahn (real health spending may have dropped due to lower elective care, hence the backward lean).

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Private Equity Hollowing Out Nursing Home Care

Summary: Private equity sees large financial returns in the nursing home business, and is willing to maximize that profit by cutting services at the expense of resident well-being. The result is a leaner and riskier existence, with higher death rates. Private equity is degrading care for our aged and infirm.

When Private Equity Takes Over a Nursing Home, The Daily Newsletter of The New Yorker, August 25, 2022, by Jessie Li

After an investment firm bought St. Joseph’s Home for the Aged, in Richmond, Virginia, the company reduced staff, removed amenities, and set the stage for a deadly outbreak of COVID-19.

St. Joseph’s Home for the Aged was once a beloved nursing home with a family-oriented ambiance, where nuns lived with residents and the waiting list for a room was three years long. There were manicured gardens, a lively aviary and an aquarium, and warm common areas with “a china cabinet here, an upright piano there,” as Yasmin Rafiei writes. Then, in June last year, the home was sold to a private-equity firm called the Portopiccolo Group. The situation is not uncommon: since the turn of the millennium, there’s been a trend toward private-equity investment in nursing homes. Researchers at the University of Pennsylvania found that, “when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent,” as Rafiei writes. At St. Joseph’s, which was renamed Karolwood Gardens, residents began eating meals alone in their rooms, nursing staff plummeted, and the home experienced a string of COVID-19 infections and deaths. Rafiei delves into the question of why deaths skyrocket in private-equity-owned homes, and tells a deeply reported story of St. Joseph’s devastating transformation.

Financial and Quality Metrics of A Large, Publicly Traded U.S. Nursing Home Chain in the Age of Covid-19, International Journal of Health Services, February 4, 2022, by David E. Kingsley and Charlene Harrington

This descriptive case study examined the structure, operations, strategies, care outcomes, and owners of the Ensign Group Inc. the second largest U.S. for-profit chain, between 2007 and 2021. Ensign, as a holding company, has a complex organizational structure that uses more than 430 corporate entities to manage its 228 nursing homes and senior living facilities. Ensign’s small board, executives, and institutional investors protected and enhanced shareholders interests rather than ensuring that its nursing homes met professional standards and regulatory requirements.

The financial power that institutional investors bring to corporate governance reinforces the agency theory of management and a philosophy that shareholder interests are the sole mission of corporations, while their nursing homes provide mediocre care at best and deadly care at worst. By protecting and enhancing shareholder interests as the summum bonum of management, excess capital is accumulating and driving governance to benefit investors rather than ensuring that NHs meet professional standards and regulatory requirements.

Comment:

By Don McCanne, M.D.

What are the two words that communicate this despicable transformation that is taking place throughout our health care system? Private equity!

What could exemplify this more than a beloved nursing home where patients are cared for as if they are family members being taken over by an entity that changes its mission to enhancing its profits by reducing as much as possible the services rendered to its patients, regardless of the deterioration in the quality of care that the patients receive? The full New Yorker article by Yasmin Rafiei provides detail on Portopiccolo Group’s takeover of St. Joseph’s Home for the Aged and related research.

The Kingsley and Harrington study provides an academic description of corporate strategies in the nursing home industry, strategies that clearly favor investors over patients.

Private equity. Whatever happened to patient service? Everywhere you turn now, it’s private equity. And it’s not as if it’s filling some unmet need. Much of our health care dollars are now being directed to shareholders, including millionaires and billionaires, when tens of millions of people remain without adequate care because of being uninsured or underinsured.

We really need to dump private equity in health care and replace those two words with the two words that we know will work for all of us: Single payer!

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

How Big Pharma makes a killing on patients’ suffering

By Brenda Gazzar
Code Wack Podcast, August 29, 2022

What happens when the cost of surviving an illness is so high, it’s simply out of reach? How does Big Pharma enjoy such outsized profits from cancer and other treatments? And what about patients who are stuck between a pharmaceutical company and their health insurer?

To find out, we spoke to Dr. David Leibowitz, hematologist-oncologist and incoming chair of Physicians for a National Health Program – California, a non-partisan voluntary organization that supports equitable access to high quality health care as a right to all people. What’s on his agenda for the California state chapter?

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

This time on Code WACK! Why are some cancer drugs so incredibly expensive? How do some drug companies and health insurance companies choose profit over patients? To find out, we spoke to Dr. David Leibowitz, who conducted lab research for about 20 years before spending another 20 as a hematologist oncologist helping cancer patients. (Hematology is the study of blood.)

Now retired, Leibowitz fights for improved Medicare for All and is the incoming chairman of Physicians for a National Health Program-California, a non-partisan voluntary organization that supports equitable access to high quality health care as a right to all people.

Welcome to Code WACK!, Dr. Leibowtiz.

Leibowitz: Thank you. It’s a pleasure to be here.

Q: It’s a pleasure to have you. So tell us a bit about yourself. Why did you decide to go into medicine and why oncology specifically?

Leibowitz: So I decided to go into medicine because it was a way to do science that I enjoyed, and it was also something that I thought would help mankind, help make the world a little better place. So I came to hematology or oncology and the way that happened, it was through the lab because when I was in medical school, I started working in a lab that was doing hematology related research, and I enjoyed that so I just kept doing it and so when it came time to do a fellowship, I did it in hematology oncology again, cuz I could continue that kind of lab work and I did lab work for kind of the first half of my career and then I decided I was tired of supervising a lab and I wanted to work more with people so I went into practice and my practice was mainly hematology, benign and malignant, but also some kind of more straightforward oncology.

Q: So after 20 years in research, you began seeing patients? That must have been quite a change.

Leibowitz: So I was seeing patients all the time that I was in the lab also, but not as often, but I had clinics during that time.

Q: Got it. So did seeing patients more often affect your understanding of the challenges they face as they cope with cancer?

Leibowitz: Absolutely. Because even having a clinic, you don’t quite get the exposure to the problems people have paying for things and that’s a big problem for a lot of people.

Q: Yeah. Can you tell us more about that? Do you have any stories of patients, for example, that you can share?

Leibowitz: One was a man who was actually a retired doctor and he had an illness called multiple myeloma. This was like about 15 years ago and there was a new medicine that was available, an oral pill, but it was very expensive. And in spite of the fact that he was a retired physician – so you might think that he should have been able to afford it – he could not afford it. It angered me because it turns out that that medicine makes people live long and relieves a lot of symptoms, so that bothered me.

Q: So what happened to this gentleman?

Leibowitz: Well, eventually he passed away from his illness. There was no way at the time that I could get the medication for him. It was just starting to be used for myeloma at the time and so it was very, very expensive.

Q: Wow. Do you remember how expensive it was?

Leibowitz: Oh, it was one to $2,000 a month. Yes. a lot of the medicines when they’re new are very expensive and for quite a long time, Medicare would not pay for oral medications. That’s changed to some extent, but for many years they wouldn’t pay for oral medications and so people were really stuck.

Wow.

Leibowitz: Cause on the one hand, we’re delighted to have an oral medicine because it means people don’t have to travel to an infusion center and they don’t have to sit for hours and get IV medications but at least at that time it also meant they had to pay for it themselves.

Q: So this patient, did he just go without medicine?

Leibowitz: He went without that particular medicine, there were other medicines we could treat him with that we did treat him with, but he probably would’ve lived longer and more comfortably if we could’ve used the expensive medicine.

Q: How did that make you feel?

Leibowitz: Well, it made me angry and sad – both of those things.

Q: Thank you for sharing that. And you mentioned another case?

Leibowitz: It’s frighteningly similar. This was a man who had prostate cancer and we’ve been very lucky in that prostate cancer in the last 10 years or so has had a bunch of new medicines come on the market, which make quite a bit of difference for patients….Chemotherapy for prostate cancer is still not terribly effective by itself, but these new medicines again were not chemotherapy. They were a brand new way of affecting the hormonal control of the cancer and they were really great, but in the same way that happened with the first person, it was an oral medicine and it was enormously expensive. It was also over a thousand dollars a month and I actually had a number of patients who could not afford it when it first came out. Again, that really is infuriating cuz I mean we are a very rich country and there are a lot of very successful companies in the world of health care and you would think that we should be able to take care of people.

Q: It’s so true. So the second patient who couldn’t afford the medicine for prostate cancer, what happened to him?

Leibowitz: You know, so we would treat him with all the other options and there are other options. They cause more side effects than the new group of medicines does and today we know also about combinations of medicines that work more effectively. But the problem is that, you know, when a medicine is new, there’s no generic equivalent and basically it’s whatever the market will bear in terms of the price that’s set.

Q: Got it. I can imagine that drug companies just wouldn’t want there to be a generic version because once there is, they’ll miss out on a great deal of money, right?

Leibowitz: Well, yeah, there are a number of great stories about how the pharmaceutical companies handle that. It’s not that uncommon that they buy the company that is making the generic and then one of two things can happen. They may continue making the generic with the company they bought or in some cases they shut down the company and so there is no generic available.

Q: And that’s legal in America?

Leibowitz: It is legal.

Whoa, that’s insane.

Leibowitz: Yes. that’s a good word for it. <Laugh> And unfortunately, you know, insulin is a great example, I mean that’s not a new medicine. That’s been around for a very long time, but suddenly the price has gone up so much that a lot of diabetics are having problems affording it so it’s not just the new medicines. And I guess the other catch is that when a medication is starting to approach the time that it would come off patent, it’s not uncommon that a company will try to make some little chemical change in the medication so that they can patent it again. There are a lot of clever ways to kind of cheat in the system.

Q: So interesting. What about your patient struggles with health insurance? Do you have any stories you can share about that?

Leibowitz: The prostate cancer story is really about that because a lot of times the insurance could cover the medication if it chose to and that gets into the whole story about authorization and preauthorization and the ways in which health insurance companies control what doctors are allowed to do in their practice, and that actually is becoming a major issue because today 60% to 70% of physicians are employed. They no longer have their own little independent practice.

They’re now employed by hospitals or healthcare corporations and the really sad part is that many of those healthcare companies are being purchased by private equity firms. So before they were purchased, they were for-profit companies. After they’re purchased by private equity, there’s really no kind of pretense that they have a benevolent motivation cuz private equity is strictly dedicated to taking as much money out of a company as possible.

But even without considering private equity, if the company is for profit, the way you make a profit in insurance is by not paying anything out and in medical insurance, that means you don’t pay for medical care. So companies try to avoid paying for expensive medications. They try to avoid paying for expensive treatments. One of the newest types of treatments for a few different kinds of cancer is a kind of specialized kind of bone marrow transplant – stem cell transplant. And you know, of course that’s just starting up and is very expensive because it requires hospitalization, which is enormously expensive in the United States and insurance companies have been doing their best to avoid letting patients have that treatment. Luckily to some extent they get forced into it if it’s very clear that that’s the best treatment for the patient.

Q: So it sounds like in some cases they don’t get forced into it?

Leibowitz: Exactly.

Q: So what happens then?

Leibowitz: The patient doesn’t get that particular treatment. They’ll get some other treatment. It may not be as good. That’s the problem with the way our healthcare system has developed. It wasn’t always quite this dramatic, but over the last 20 to 30 years, the motivation to pull money out of the system as profit has gone up dramatically. If you look at graphs, comparing a variety of different things, comparing the United States to similarly developed countries until 20 or 30 years ago, there wasn’t that much difference between the United States and all those other countries. But since then there has developed a dramatic difference in how much we spend on health care, on how long we live and how many mothers and babies die. And it’s not going in the right direction.

That’s so sad and scary to think about.

Leibowitz: Absolutely.

Q: So how would single payer Medicare for All help remedy these challenges?

Leibowitz: Well, that’s a great question. One immediate thing is that you’d eliminate the for-profit dollars and that would probably amount to about one third of what we are now paying and that money would almost pay for the single-payer system, not completely, but it’s clear that single payer would save quite a lot of money, the total expenditure and you know, it varies from one estimate to another. Some estimates say that the savings would start in the first three years. Some estimates say, you’d have to be at 10 years before you start seeing the dramatic savings, but it would absolutely stop the incredible rise in costs in our system because you get rid of profit and you also eliminate administrative waste because the administrative costs in the U.S. system, since you have a whole variety of different insurers, each of which has their own set of criteria for what they’ll pay for and how they want the claim submitted, doctors have to pay for a team of people, billing and talking to the insurance companies. Care gets delayed, sometimes with terrible consequences and that takes up about 20% of our healthcare dollars. And in most of the other comparable countries, that figure is 9% to 10%. The Medicare system in the United States, the administrative costs are only two to 3%. The estimates are that if you had a single-payer system, it would probably be around 5%. So it would not be quite as low as Medicare right now, but it would be dramatically lower than what we’re spending and it would probably be lower than most of the other advanced countries.

Q: So how would saving money and getting rid of the administrative and cost burden help patients?

Leibowitz: Ah, yes, that’s the most important part of it. So it would mean that lots more things would be covered by insurance — vision care, hearing, dental care, long term care, which is an enormous item, particularly in the United States.

Q: Like nursing home care?

Leibowitz: Exactly and also there wouldn’t be any insurance premiums. There wouldn’t be any deductibles. There wouldn’t be any copays and there wouldn’t be any costs for medication. So it would be a whole new ballgame and one of the things that this is one thing that irritates me in terms of the debate about this. Sometimes you’ll hear people say that putting together Medicare for All or a single-payer system would increase everyone’s taxes and that’s very deceptive because taxes might go up, but the actual costs for families would go way down.

Q: For health care?

Leibowitz: Exactly, exactly. Well, yes. Right. Most families would end up saving money.

Q: Good to know you were recently named chairman of Physicians for a National Health Program – California, which advocates for Medicare for All. Congratulations. What’s your vision for the chapter and what are your goals?

Leibowitz: Well, the goals of course, would be to have a single-payer national healthcare system. There is debate within the group about, you know, how happy would we be if we had a single-payer system in one state. Some people feel like we ought to just focus on a national system. I think everybody would agree that a national system is the goal, but other people would argue that that is the goal, but maybe we need to start in one state or a group of single states at a time because Canada actually started in a single province and then the system got generalized. So my goal would be that PNHP has a large enough group of doctors who feel strongly and are committed to advocating for a single-payer system. The sense is that even though doctors are not by number an enormous voting block, people do still feel that doctors know something about how health care should be delivered and so we’d like to have a large enough group of doctors advocating for single payer so that the general public believed them and came to support single payer.

Thank you, Dr. David Leibowitz.

Do you have a personal story you’d like to share about our ‘wack’ healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts.

This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

Resolution in Support of Medicaid Expansion in Georgia and Medicare for All Nationally 

Adopted by delegates to the Democratic Party of Georgia’s State Convention on August 27, 2022

WHEREAS every person in the state of Georgia and the USA deserves high quality health care; and

WHEREAS the number of Americans without health insurance before the COVID-19 pandemic was still nearly 30 million, with more than 40 million Americans underinsured, despite important gains made since the implementation of the Affordable Care Act; and

WHEREAS Georgia has a lower health system performance score than 37 other states; and

WHEREAS Georgia is among the worst performing states regarding mortality amenable to healthcare; and

WHEREAS Georgia is failing to get its fair share of ACA money and 700,000 more Georgians would be covered if Georgia fully expanded its Medicaid program; and

WHEREAS expansion of Medicaid under the ACA would create 50,000 new jobs for Georgians, and

WHEREAS ​many people delay seeking needed health care due to an inability to pay​, leading to a sicker and poorer population in the long run; and

WHEREAS the ever-increasing costs of health care, which are further elevated due to the on-going pandemic, may challenge our already strapped state and municipal budgets​​; and

WHEREAS long term ​COVID-19 related treatment could cost uninsured patients tens of thousands of dollars​; and

WHEREAS​ in order to equitably and effectively address the health care burden, we must urge the expansion of health insurance coverage to provide comprehensive coverage to every resident of the United States without any cost sharing; and

WHEREAS Medicare for All would provide national health insurance for every person in the United States for all necessary medical care including prescription drugs; hospital, surgical and outpatient services; primary and preventive care; emergency services; reproductive care; dental and vision care; and long-term care; and

WHEREAS Medicare for All would provide coverage without copays, deductibles or other out-of-pocket costs, and would slash bureaucracy, protect the doctor-patient relationship and assure patients a free choice of doctors; and

WHEREAS polls show that a majority of Americans support Medicare for All and expansion of Medicaid; and

WHEREAS Medicare for All will guarantee that all residents of Georgia will be fully covered for health care without copays, deductibles or other out-of-pocket costs, and would save millions in taxpayer dollars now spent on premiums that provide often inadequate health insurance coverage for government employees; and

WHEREAS the quality of life for the residents of Georgia will vastly improve because they would be able to get the ongoing care they need, instead of waiting until they have a medical emergency that could upend their lives as well as further burden local resources;

NOW THEREFORE BE IT RESOLVED, that the Georgia Democratic Party expresses its enthusiastic support for immediate full expansion of Medicaid in our state and urges the Georgia General Assembly to fully expand Medicaid under the Affordable Care Act with no waivers and calls upon each of our state legislators to work toward its immediate expansion.

BE IT FURTHER RESOLVED, that the Georgia Democratic Party asks Congress to enact legislation to provide universal, comprehensive health coverage with zero cost-sharing for patients and enthusiastically supports Medicare for All  as referenced in the Medicare for All  Act of 2021 (H.R. 1976 and S. 4204) and calls on our federal legislators to work toward its immediate enactment, assuring appropriate and efficient health care for all residents of the United States.

PDF version:
https://pnhp.org…

The Financial Fallout of Chronic Illness

Summary: A new study finds that privately-insured individuals with chronic illness are far more likely to have medical debt that is delinquent or in collections, and credit problems. And the debt is larger. Our insurance system is punishing people for being ill.

Association of Chronic Disease with Patient Financial Outcomes Among Commercially Insured Adults, JAMA Internal Medicine, August 22, 2022, by Nora V. Becker et al.

From Abstract: Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

From Discussion: Further research in this area is needed to determine the relative importance of these pathways, as the policy implications of each are different. If poor financial well-being leads to additional chronic disease, policy makers should consider new social safety-net policies to reduce poverty rates and should explicitly incorporate improvements in physical health—and correspondingly reduced health care spending—as a benefit of antipoverty programs. If, in contrast, chronic disease diagnoses are directly leading to adverse financial outcomes, then improving commercial insurance benefit design [JGK – For a different solution, see below.] would be warranted to provide additional protection from out-of-pocket medical expenses, particularly for conditions identified as being costly for patients. In addition, policy makers should consider expanding access to disability benefits and implementing other social safety net policies to help patients recoup income loss after illness.

Comment:

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

These findings come as no surprise – in our health insurance system with very high patient cost-sharing (deductibles, copays, and uncovered services), individuals with greater ongoing medical needs inevitably have more medical expenses, more debt, more low credit scores, and more bankruptcies.

The cost-sharing doesn’t control healthcare costs. So why do we design a health insurance system this way, to financially punish the ill?

You know the answer: it’s profitable for insurers. Costs shift from shareholders to patients. It’s also profitable for drug makers and providers who charge high prices and garner out-sized profits.

When will we adopt an insurance system that is humane – that serves and protects the ill? And that is, in the process, efficient, saving money for the healthcare system.

It sounds magical. It is. It’s called single payer.

(We also need far better income protection for individuals who are disabled by chronic illness.)

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

CMS Should terminate the Medicare Advantage Program

PNHP Comments on CMS file code CMS-4203-NC: “Medicare Program; Request for Information on Medicare Advantage”

By Physicians for a National Health Program
August 25, 2022

Medicare Advantage is a program offering private health insurance plans as options to replace traditional Medicare. Medicare Advantage plans differ from traditional Medicare in that they are paid with capitation (per member), they are required to limit enrollees’ out-of-pocket spending and can offer extra benefits (e.g. gym membership, dental benefits), they almost always offer prescription drug coverage, they use a defined and often restricted network of providers and can require enrollees to pay more for out-of-network care, they can use utilization management techniques such as prior authorization, and they can fund special programs such as rewards for beneficiaries to encourage healthy behaviors. The hope is that these differences will lead to improved care at lower cost compared to traditional Medicare.

However, capitation has serious drawbacks and introduces perverse incentives to skimp on care, game risk pools, and upcode. Payment with unadjusted capitation based on average cost would grossly overpay for the healthy and even more grossly under-pay for the sick. Capitation therefore requires risk adjustment and quality incentives to mitigate its inherent incentives to worsen disparities in care. Risk adjustment and quality incentives in turn require detailed data on diagnoses and treatment, adding administrative costs and burdens that exceed those required by fee-for-service (FFS).1,2

Capitation is justified by the common assertion that FFS incentivizes excessive “volume” (over-use) of care and that this can be corrected by shifting insurance risk onto providers of care. However, the four key assumptions – that there is widespread overuse of care due to FFS, that capitation carries improved incentives compared to FFS, that risk adjustment can be done accurately, and that the overhead cost of capitation is worth it to achieve more cost-sensitive care – are all contradicted by the evidence. There is very little evidence for the claim that “volume” of services with FFS payment, as opposed to their price, explains the high cost of health care in the US.3,4,5 It appears demonization of FFS in health policy is mainly a rationale promoted by the insurance industry to justify a central role for themselves in health care, because unlike FFS, capitation requires their capacity to handle the data demands of risk management. But the overhead required for capitation far exceeds savings from the incentive to reduce care, so patients get less care, Medicare pays more, and intermediary insurers take home large profits.

And risk adjustment cannot be done anywhere near accurately enough to avoid over-paying for the healthy and under-paying for the sick. Gaming of risk pools means capturing a population of members or beneficiaries (risk pool) with lower-than-average health risk while getting paid for an average risk pool, so as to profit from the difference. MA plans use marketing tactics6 (including variations in coverage and contracting with employers to directly enroll newly Medicare eligible retirees) that attract healthier beneficiaries, and they employ multiple tactics to deny care to the sick, including narrow networks, formulary restrictions, and prior authorization. Sicker enrollees, such as in the last year of life, who have been frustrated by denial or delay of services tend to disenroll and return to the traditional Medicare program.7 The effect of both marketing tactics (“cherry-picking”) and disenrollment of sicker beneficiaries (“lemon-dropping”) is to create for Medicare Advantage plans a healthier and less costly than average risk pool.8,9 

CMS added diagnostic categories to the HCC risk adjustment formula in 2004. This improved its predictive accuracy from 1% to only 12%,10 but linked payment to diagnosis and introduced a major new opportunity for gaming: up-coding. Up-coding means choosing more specific or severe (and more highly paid) diagnosis codes than would be required for purely patient care purposes, and fraudulently adding irrelevant or non-existent diagnoses. Up-coding has been extensively exploited by Medicare Advantage plans since soon after diagnoses were added to the HCC, apparently often to the point of fraud11,12. According to one expert estimate, the cost to Medicare of aggressive diagnostic coding by Medicare Advantage plans and the failure of CMS to correct for it will reach several hundred billion dollars in coming years.13

Medicare Advantage plans have achieved profitability largely by gaming their risk pools, up-coding, and blunt restrictions on care including issuing millions of inappropriate denials for care that met Medicare coverage rules,14 and minimally if at all by improving care. 15,16 Typical administrative costs for Medicare Advantage plans, including profits, have been in the 15-20% range1,17, compared to around 2% for Traditional Medicare prior to the Affordable Care Act.2

It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. 

These problems are not correctable within the competitive insurance business model, and the Medicare Advantage program should be terminated.

References:

  1. McDermott D, Stolyar, L, Hinton E, et. al., Health Insurer Financial Performance in 2020. Kaiser Family Foundation, May 3, 2021. https://www.kff.org…
  2. 2012 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. April 23, 2012. 
  3. Health at a Glance 2019. OECD Indicators: Number of doctor consultations per person. Hospital discharge rates, 2000 and 2017. 
  4. Deborah Korenstein, et al., Overuse of health care services in the United States: an understudied problem, Archives of Internal Med, 2012. doi:10.1001/archinternmed.2011.772. 
  5. Katz MH. Overuse of health care: Where are the data? 2012;172:178. doi:10.1001/archinternmed.2011.1253.
  6. Gilfillan R, Berwick DM. Medicare Advantage, Direct Contracting, and The Medicare ‘Money Machine,’ Part 1: The Risk-Score Game. Health Affairs Blog. Sept. 29, 2021. 10.1377/forefront.20210927.6239.
  7. Meyers DJ, Belanger E, Joyce N, McHugh J, Rahman M, Mor V, Analysis of drivers of disenrollment and plan switching among Medicare Advantage beneficiaries, JAMA Intern Med. 2019;179(4):524–532. doi:10.1001/jamainternmed.2018.7639.
  8. Brown, J., M. Duggan, I. Kuziemko, et al., 2011. How does risk selection respond to risk adjustment? Evidence from the Medicare Advantage program. NBER working paper 16977. Cambridge, MA: National Bureau of Economic Research. doi:10.3386/w16977.
  9. Neuman P, Jacobson GA, Medicare Advantage Checkup, N Engl J Med 2018; 379:2163-2172. doi:10.1056/NEJMhpr1804089.
  10. June 2014 Report to the Congress: Medicare and the Health Care Delivery System. MedPAC, June 13, 2014.
  11. Schulte F. Researcher: Medicare Advantage Plans Costing Billions More Than They Should. Kaiser Health News, Nov. 11, 2021. 
  12. Hiltzik M. The government lawsuit against Kaiser points to a massive fraud problem in Medicare. Los Angeles Times, August 4, 2021.
  13. Kronick R. Projected Coding Intensity In Medicare Advantage Could Increase Medicare Spending By $200 Billion Over Ten Years. Health Affairs 36, no.2 (2017):320-327. doi: 10.1377/hlthaff.2016.0768.
  14. Grimm, Christi A, Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. OIG Report OEI-09-18-00260. https://oig.hhs.gov…
  15. Park S, Jung J. Burke RE et al. Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage. JAMA Network Open. 2021;4(3):e211762. doi:10.1001/jamanetworkopen.2021.1762.
  16. Figueroa JF, Wadhera RK, Frakt AB, et al., Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure. JAMA Cardiol. Published online September 2, 2020. doi:10.1001/jamacardio.2020.3638.
  17. Day B, Himmelstein DU, Broder M, Woolhandler S. The Affordable Care Act and Medical Loss Ratios: No Impact in First Three Years. Int J Health Svcs, 2015:45(1);127-131. http://org.salsalabs.com…

pdf version:
https://pnhp.org…

Time to ‘correct course’ on health care access, affordability

By Howie Wolf, M.D.
Arizona Daily Star, August 25, 2022

The Aug. 18 guest opinion “Let’s stand together for health care affordability” by Pam Kehaly, president and CEO of Blue Cross/Blue Shield of Arizona, requires a reasoned response.

The premise of her article is valid in that she points out that “health care has reached a critical tipping point.” Kehaly correctly states that “rising costs are unsustainable, and it is time to correct course. Families should be able to meet their health care needs without fear of facing crushing debt.”

As a retired family doctor with over 50 years of practice, I am a member of PNHP (Physicians for a National Health Program). Our group recognizes why we rank last among six other industrialized countries on measure of quality, efficiency and access to care. The main reason is that the citizens of these countries — Australia, Canada, Germany, Netherlands, New Zealand and the UK — have access to government-run care paid for by taxes. Profiting from providing basic health care does not happen. In my practice, I frequently saw evidence of delayed care due to anticipated costs.

Administrative expenses of private insurance companies in the U.S. account for 15%-25% of total health care expenditures, amounting to $600 billion to $1 trillion per year. If you have health insurance, that is the percentage of your premium that does not pay for health care. By comparison, Medicare, the U.S. system for those 65 and older, operates at 2%-3% of administrative costs.

Proposals for a Medicare for All system in the U.S. have failed primarily because lobbyists for our private health insurance and pharmaceutical companies have influenced our senators and representatives. The last thing they want to see is a universal, not-for-profit system here.

Kehaly points out that her insurance company has an obligation to ensure that “we are good stewards of every health care dollar” and they have become advocates for families and individuals because “it is the right thing to do.” These claims ring hollow when our country has nearly 30 million uninsured and more “underinsured.” Policies with high deductibles also represent a barrier to access to care. If the first $1,000-$4,000 of medical expenses each year comes out of your pocket, it is easy to understand the reluctance to seek care. It is not surprising that medical expenses are the leading cause of bankruptcies in our country.

I would urge readers to learn more about why the richest country in the world, which spends more on health care than any other country, ranks so low in life expectancy, maternal mortality, access to care and other comparisons. If you agree, let your legislators know the time has come to “correct course” and support Medicare for All.

Dr. Howie Wolf is a retired family doctor with over 50 years of practice and a past president of the Colorado Academy of Family Physicians.

https://tucson.com…

Biden’s Plan to “Commercialize” Covid Care Will Have Terrible Consequences

The administration expects to stop buying vaccines and treatment by year’s end, handing over these responsibilities to for-profit companies that are salivating at the opportunity.

By Adam Gaffney, M.D.
The New Republic, August 24, 2022

Last week, at an event held by the U.S. Chamber of Commerce Foundation, White House Covid-19 response coordinator Dr. Ashish Jha said that the Biden administration would begin shifting procurement of coronavirus tests and treatments from the federal government to the commercial sector. “One of the things we’ve spent a lot of time thinking about in the last many months … is getting us out of that acute emergency phase where the U.S. government is buying the vaccines, buying the treatments, buying the diagnostic tests,” Jha said, adding that by 2023, “you’re going to see the commercialization of almost all of these products.”

This coming commercialization is but the latest sign that American health care, after glimpses of something better during the pandemic, is returning to business as usual—that is, back to its usual dysfunctional, wasteful, and unequal state.

So much was wrong with America’s response to Covid-19 that it can be easy to forget what was right, including notable departures from usual operating procedures in American health care financing. Covid-related care was usually covered for the uninsured, at least until the program ran out of funds and became defunct in March. Insurers waived co-pays and deductibles for Covid-related hospitalizations—for a time, anyway; average out-of-pocket payments for a coronavirus hospitalization are now around $4,000 for the privately insured. The Families First Coronavirus Response Act, the emergency package that President Trump signed into law in mid-March 2020, helped prevent states from pushing people out of Medicaid, a lifeline that will be cut once the Federal Public Health Emergency is lifted (and an estimated five million to 14 million people lose Medicaid coverage). Finally, the federal government directly procured and provided billions of dollars of Covid tests, treatments, and vaccinations—an approach that will end with “commercialization.”

Of course, the vaccines have always been “commercial”: They are manufactured and sold by companies like Pfizer and Moderna. During the pandemic, however, the United States wisely did not relegate procurement of these products to the diverse slew of public and private insurance programs that cover most Americans. Instead, the federal government spent tens of billions on vaccine R&D, while also subsidizing drug firms’ manufacturing capacity and market risk, and it directly negotiated with companies and purchased these life-saving products so it could provide them to the public for free. This had important benefits in terms of the rapid delivery of the vaccines, their cost to society, and their provision in a relatively equitable fashion (within the U.S. only, alas). But as Covid-related care becomes like all else in American health care, those benefits will vanish.

For instance, it’s a truism that Americans get ripped off by drug companies: A 2021 RAND Corporation study found that U.S. drug prices were more than double those in  other nations. But the price differentials for Covid-19 vaccines were generally much smaller. According to a Washington Post analysis, relative to the U.S., the European Union paid 24 percent less for the Pfizer vaccine and 15 percent less for Johnson & Johnson but 20 percent more for Moderna. Once they are no longer negotiating with the U.S. government but instead with our jumble of for-profit private insurers, pharmacy benefit managers, state Medicaid programs, and Medicare Part D drug plans, pharmaceutical companies will jack up prices. Moderna CEO Stéphane Bancel said as much in an interview with Yahoo Finance: “So what we are doing as a company is to get ready for a private market situation,” he said, adding that the U.S. price of his firm’s vaccine in the “public setting” was, in his opinion, quite low and that he expects to increase it in “an endemic setting.” Pfizer’s CEO has also alluded to increasing vaccine prices.

We didn’t necessarily get great deals from these firms, however. The American public is—or should be—an owner of the Moderna vaccine: Taxpayers financed its development, and NIH scientists played a key role in inventing it. Also, it’s not as if these companies didn’t turn a hefty profit from their sales to governments: Pfizer and Moderna have taken in $79 billion in revenue for Covid-19 pharmaceuticals globally. To now hand the keys over to a hodgepodge of insurance intermediaries will drive up costs, which will be borne by the public. In addition to increasing health insurance premiums, this could have the effect of squeezing state Medicaid budgets and consequently the availability of funds for other care.

But this is not only about money. We should care about the shift Jha announced because achieving universal and equitable access to Covid-related care remains critical. So far, the government has not only provided the vaccine for free but forbidden providers from charging administrative fees or discriminating based on a patient’s immigration status. Covid therapeutics like monoclonals and oral antivirals (such as Paxlovid) have also been distributed free of charge. Some municipalities took innovative strategies to improve uptake of these agents, ranging from mobile vaccine outreach teams to free home delivery of Paxlovid in New York City—programs that would have been far more costly if health departments also had to buy the products. Yes, disparities in vaccine uptake nevertheless persisted, and inadequate access to health care has remained a barrier to Covid care. In one study, for instance, my colleagues and I found that the uninsured were much less likely to have a booster shot, perhaps because of lack of a trusting relationship with a primary care physician who could provide information and counsel (and the booster itself). That’s not a surprise: Single-disease-focused “vertical” programs are no substitute for comprehensive, universal, primary care–based systems. Still, it’s hard to imagine that the commercialization of Covid care won’t lead to a worsening of disparities.

It’s still unclear how the process of commercialization will unfold and whether steps will be taken to retain some access for the uninsured: The administration is meeting with pharmacists, drug firms, and health departments later this month to work out details. Additionally, under the Affordable Care Act, most insurers are required to cover certain forms of preventive care—including recommended vaccines—for free. In all likelihood, however, bringing these products into the fold of regular American health care will reduce access. Some Medicaid patients could see co-pays for Covid vaccines once they are commercialized—or not have access to these vaccines at all, according to a report from the Brookings Institute. Provision of vaccines to the uninsured, who are at increased risk of Covid, will almost certainly deteriorate when neither administration nor the products themselves are publicly funded. And co-pays and deductibles for treatments like Paxlovid will presumably pop up for the privately insured.

The partial decommercialization of the financing of Covid care was a departure from business as usual for American health care. Many were struck by the novelty of walking into a mass vaccination site and being able to get a vaccine free of charge without an insurance card, or of being able to order free Covid-19 tests online from the government. As a pulmonary physician, I’m more confident that the sorts of patients I see with advanced lung disease will be able to get Paxlovid or a Covid vaccine than, say, an expensive inhaler for asthma. So it is unfortunate, if unsurprising, to watch Covid become yet another illness inadequately covered by a faulty and fragmented financing system.

We will experience Covid waves for the foreseeable future, probably indefinitely, which means that it will remain a public health threat for some time: It was, that is to say, inevitable that financing care for this illness would ultimately be incorporated into the fabric of the American health care system. But rather than shift the way we finance Covid care so that it resembles everything else in American medicine, we should do the opposite: realize a universal, integrated, primary care–based national health program that more efficiently provides the full spectrum of health care—including prevention and treatment of Covid-19—on the basis of needs, not means.

Dr. Adam Gaffney is a pulmonary and critical care physician, an assistant professor at Harvard Medical School, the author of To Heal Humankind: The Right to Health in History, and the immediate past president of Physicians for a National Health Program.

https://newrepublic.com…

Taiwan: “Economic Dynamism” Paired with Single Payer

Summary: Recently House of Representatives Speaker Nancy Pelosi led a delegation to Taiwan, affirming US support for the country’s continued independence as China stridently pursues reunification. She praised Taiwan’s economic vitality, but forgot to highlight the country’s fine approach to health insurance: single payer.

Letters from an American, August 20, 2022, by Heather Cox Richardson

Pelosi … championed Taiwan as a leading democracy, “a leader in peace, security and economic dynamism: with an entrepreneurial spirit, culture of innovation and technological prowess that are envies of the world.” She explicitly said her visit was intended to reaffirm “our shared interests [in]…advancing a free and open Indo-Pacific region.” “By traveling to Taiwan, we honor our commitment to democracy: reaffirming that the freedoms of Taiwan—and all democracies—must be respected.”

Comment:

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

So, what kind of health insurance does Taiwan have?

Oh, yeah, single payer, since 1995.

Seems like having universal health insurance paid by the government doesn’t cripple the economy. Vibrant capitalism, supported by a generous and efficient social welfare foundation.

Who knew? (Lots of us, of course.)

Health care costs low, equity and longevity high. Part of the formula for economic robustness.

I wish Ms. Pelosi had made this point.

http://healthjusticemonitor.org…

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Amazon Pursues Profitable Medical Care Role

Summary: Amazon just entered the medical provider business, buying a large medical firm. Their goal: to make money by finding insured, well-off, and inexpensive patients. It’s a business model, to maximize profits. What we need is a health improvement model, to … maximize health!

Amazon’s acquisition of a medical firm may not disrupt healthcare, but could disrupt your life, Los Angeles Times, August 18, 2022, by Michael Hiltzik

Amazon plainly believes that there is profit to be made from the business model of One Medical.

One Medical aims its services, which amount to providing faster appointments, “wellness” services and “routine and preventive care,” at a relatively affluent market segment. It does so partially by charging an annual fee of $199.

Then there’s the firm’s practice of geographical segregation. One Medical says it places its offices in “locations convenient to where consumers work, shop and live.” This works to One Medical’s advantage by “limiting its exposure to uninsured, poor, and costly patients.”

“Amazon may be able to make this a viable business venture that returns a significant profit to their investors,” David Blumenthal, a primary care physician who is the Commonwealth Fund’s president, told me. But “unless they substantially change the model this will just be another selective deal serving a part of the population that is already favored by the current healthcare system.”

“Most of health care spending is on sick patients and can’t be easily reduced,” Amitabh Chandra, a healthcare expert at Harvard Business School, said in an interview on the school’s website after the Amazon announcement.

Amazon’s high-profile misstep was Haven, a joint venture with Jamie Dimon’s JPMorgan Chase & Co. and Warren Buffett’s Berkshire Hathaway, launched in a blare of publicity in 2018 and humiliatingly shut down in 2021.

Haven aimed to reduce American healthcare costs by focusing on “technology solutions,” but the Bezos/Dimon/Buffett triumvirate didn’t understand what healthcare economist Uwe Reinhardt and colleagues identified in 2003 as the main reason for high healthcare costs in America, with an article titled “It’s the Prices, Stupid.”

The key flaw in the American healthcare system is the encroachment of business principles into what used to be regarded as a public service, back when Blue Cross and Blue Shield were nonprofit insurers and most hospitals were nonprofit providers.

The structure that would be most likely to bring universal healthcare to Americans at an affordable price would be a single-payer system with the government as the payer. But even Medicare, which was once the quintessential single-payer program, has been moving away from that principle, thanks to the spread of private Medicare Advantage plans.

Comment:

By Don McCanne, M.D.

Whereas quite a few individuals are being served fairly well by our current health care system, far too many are not because of deficiencies and voids, especially in the way we pay for health care. Even though we spend more than other nations, we fall below many other wealthy nations in our health care outcomes, largely because of these deficiencies.

Part of the problem is demonstrated by the proposed Amazon acquisition of One Medical. It is structured as a business deal to make a profit for private investors (concierge fees, marketing to the healthy and wealthy, avoiding care for the sick and poor) while avoiding the public service concept of health care for all.

Now even our traditional public insurance programs are also being converted to cater to private investor interests as exemplified by private Medicare Advantage and ACO REACH models. We’re clearly headed in the wrong direction.

As Michael Hiltzik states, “The structure that would be most likely to bring universal healthcare to Americans at an affordable price would be a single-payer system with the government as the payer.”

http://healthjusticemonitor.org…

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Price Transparency (Alone) Is Not Enough

Summary: The New York Times recently posted a wonderfully produced video op-ed bemoaning hospitals’ failure to abide by federal price transparency rules. But price transparency is a market tool, and health care is far from a perfect market commodity. Other cost control tools are needed.

How Much Does Your M.R.I. Cost? Buy It First to Find Out. (video), New York Times, August 2, 2022, by Martin Schoeller

A federal rule that went into effect last year requires hospitals to post prices for their services, with the aim of removing the element of surprise for patients and perhaps even spurring price competition among health care providers.

But a recent study by PatientRightsAdvocate.org, a nonprofit group that works for price transparency, revealed that only about 14 percent of the 1,000 hospitals it surveyed were complying with the new rule. …

“We depend on hospitals in our communities to take care of us,” Mr. Schoeller said. “But our hospitals are putting profits before patients.”

The solution, he argues, is in stronger government enforcement of the transparency rule and stiffer penalties for those hospitals that don’t comply.

Comment:

By Kenneth A. Colón

Price transparency is valuable, but by itself insufficient.

As a matter of principle, we deserve to know how much we will be paying for a particular good or service. This is the basis upon which all market transactions are built – learning the price for a particular item, and deciding if you are willing to pay that price.

The same must be demanded in healthcare, as long as we use a market-based system. I agree with the author, on principle, that we need stronger government enforcement and stiffer penalties for hospitals which don’t comply.

However, price transparency alone won’t produce the pressure on healthcare prices needed to bring them down.

Research shows that price transparency tools see low uptake and usage among patients when offered, with one study finding only 10% of those offered used the tools, and no overall reduction in spending. Furthermore, cost savings among tool users – where it was found at all – was limited to a few services, including MRIs/CTs and sleep studies.

This makes intuitive sense. You can shop around for prices only if the services you are shopping for are non-emergency. An MRI for your chronic knee pain? Sure, you may be able to shop around a bit. Surgery for your acute appendicitis? Not so much.

The Health Care Cost Institute estimates roughly 35% of out-of-pocket healthcare spending is spent on “shoppable” services, suggesting that roughly 65% of out-of-pocket spending would be difficult to alter.

There’s another issue. Higher healthcare prices are sometimes interpreted by consumers as a marker of high quality. This can mean that price transparency leads to higher costs.

So what’s the alternative? What should be done instead of or in addition to price transparency?

The Kaiser Family Foundation recently published a review of policy options to rein in healthcare costs. These include: price regulation (price setting, price caps, and price growth caps), global budgets, and spending growth targets. Ideally, these would be combined with a full transition to single-payer, which would shield consumers from substantial out-of-pocket costs.

Using any of these strategies alone or together is likely to have a far greater downward effect on healthcare prices and costs than price transparency alone ever could.

Kenneth A. Colón is a research affiliate at the Center for Infectious Disease Modeling and Analysis at the Yale School of Public Health. He earned his Master’s in Public Administration at the Maxwell School of Citizenship and Public Affairs at Syracuse University.

http://healthjusticemonitor.org…

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Racism in the Inflation Reduction Act: No Medicaid Expansion

Summary: As noted in HJM yesterday, the IRA contains historic advances, including first-ever drug cost controls. Unfortunately, it also perpetuates historic injustices inflicted on people of color by omitting social benefit categories most used by them; in this instance, Medicaid. Single payer would end such discrimination and harm.

The health care coverage concessions made to strike a deal in the latest reconciliation package came at the expense of Black Americans, The Incidental Economist, August 15, 2022, by Gabriella Aboulafia

The recently passed Inflation Reduction Act (IRA) of 2022 is historic and unprecedented. In addition to making the most significant investments in the country’s history to address climate change, it also includes health care provisions that will meaningfully improve the affordability of health insurance and prescription drugs for millions of Americans. But one of the massive health care coverage concessions made during the negotiation process came at the expense of Black Americans; sacrificing certain demographic groups for the sake of political feasibility is not a new feature of the American policymaking process.

In 12 states, an estimated 2.2 million people are uninsured because they have no accessible health insurance options. People in the “Medicaid coverage gap” have incomes that are too high to qualify for Medicaid, but too low to qualify for premium assistance for Affordable Care Act (ACA) marketplace plans. Advocates have been sounding the alarm about this problem since 2014. And researchers have been beating the drum for at least as long, putting out study after study that underscore the positive effects of Medicaid expansion.

Not lost on these advocates and researchers is that states that have not expanded their Medicaid programs, mostly concentrated in the south, have some of the largest shares of Black people. States decisions’ about whether to expand follow a legacy of racialized politics.

Democrats had been trying to get this reconciliation package passed for over a year. To secure Senator Joe Manchin’s (D-WV) vote, they had to prioritize deficit reduction and strike certain provisions. But the health care coverage provisions that they chose to exclude would’ve had an outsized impact on Black people in particular. In addition to excluding a fix for the Medicaid coverage gap, policymakers also dropped the permanent expansion of postpartum Medicaid coverage, which would’ve required all states to extend Medicaid coverage for pregnant people from 60 days postpartum, up to a full year. This provision had the potential to meaningfully improve life outcomes, particularly for Black birthing people, who are three times more likely to die from pregnancy-related causes (52 percent of which occur up to one year after birth) than their white counterparts.

The exclusion of Black Americans from federal policy deals, ostensibly on the basis of political and administrative feasibility, is not new. To reach a deal with southern Democrats, agricultural and domestic workers were excluded from the Social Security and unemployment insurance programs. Many of the key federal policies designed to promote economic opportunity during the New Deal era up until the modern Civil Rights Movement, like the GI Bill, gave white people a leg up and effectively left Black Americans out.

During the debate on the reconciliation bill, Senator Raphael Warnock of Georgia, where over a quarter of a million people do not have health insurance because the state has refused to expand the program, introduced an amendment to address the coverage gap. Only five senators (Baldwin, Collins, Ossoff, Sanders, and Warnock) voted to consider the amendment.

Several Democratic senators came out and said they would be voting no on any and all amendments,  because they would distract, divide, and put the rest of the bill at risk. But choosing to sacrifice the same group of people, time and time again, sends a message about who we value and who we do not. Policy decisions will always entail tradeoffs, and negotiations will always include concessions. But when policy concessions continually come at the expense of the same group of people, it’s not reasonable to conclude it’s a coincidence. It’s reasonable to consider that it’s a defining feature of the political system.

Comment:

By Don McCanne, M.D.

Ouch!  (In contrast, single payer reform would be refreshingly colorblind.)

http://healthjusticemonitor.org…

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