By Kip Sullivan, Ana Malinow, M.D., and Kay Tillow
STAT, July 26, 2022

The value-based payment crusade is now two decades old. But despite the tens of billions of dollars — perhaps hundreds of billions — spent on these programs, they have done little to improve Americans’ health or lower health care costs. It is time for proponents of value-based care to call a halt to these programs until they have an answer to this question: “Why have the vast majority of value-based payment experiments failed to improve value?”

Advocates of value-based care are not about to do that. Although some of the leading lights of the movement are willing to admit they have little to show for all the money and time sunk into accountable care organizations and kindred value-based entities, none has been willing to call for an end to continued experimentation with schemes that have clearly failed.

The concept of value-based payment became widespread among U.S. health policymakers and analysts during the 2000s. It collectively refers to interventions that offer doctors and hospitals financial incentives that, in theory, induce them to improve both components of health-care value — cost and quality — without generating the hostility provoked by managed care insurance companies during the HMO backlash of the late 1990s.

The most prominent and frequently discussed value-based payment methods — the accountable care organization and the medical home — focus on primary care doctors. An ACO is a group of doctors and hospitals that is “held accountable” by a public insurance program (such as Medicare) or an insurance company for the cost and quality of medical services provided to a defined population. The medical home is similar, but it consists only of primary care doctors. Medicare beneficiaries and policy-holders do not enroll in ACOs and medical homes. Instead, they are assigned to them based on which primary care doctor they saw the most often over a “look-back” period that is typically two years long.

The pages of the nation’s medical and health policy journals and health care blogs are filled with calls to double down on ACOs, which are by far the largest and most comprehensive of the various iterations of value-based payment reforms. The Centers for Medicare & Medicaid Services, the nation’s most influential and aggressive proponent of these programs, announced in 2021 it will redouble its efforts to push Medicare beneficiaries into accountable care organizations.

The agenda for the National Primary Care Transformation Summit, a four-day conference underway this week featuring the nation’s best known value-based care evangelists, suggests it will be a celebration of accountable care organizations, not an examination of why they have failed.

Experimentation with value-based methods, especially ACOs, accelerated rapidly after 2010, when the Affordable Care Act was enacted. This act authorized CMS to insert all manner of value-based payment schemes into the traditional Medicare program (the non-Medicare-Advantage part of Medicare). It also created an agency within CMS, the Center for Medicare and Medicaid Innovation, to run experiments testing the assumptions of value-based payment advocates. The Affordable Care Act also authorized the Department of Health and Human Services, which oversees Medicare and Medicaid, to “certify” — meaning expand and make permanent — any of these experiments that lowered costs without harming quality or raised quality without raising costs.

The Center for Medicare and Medicaid Innovation has conducted experiments with more than 50 models of value-based payment. Brad Smith, a former CMMI director, reported last year in the New England Journal of Medicine that only five of 54 models had cut Medicare costs. “[T]he vast majority of the Center’s models have not saved money,” Smith wrote, “with several on pace to lose billions of dollars. Similarly, the majority of models do not show significant improvements in quality….”

Smith’s successor, Elizabeth Fowler, confirmed Smith’s assessment in a January 2021 interview. “Now, ten years later, … there is no silver bullet. We have four models that were certified to be expanded…. I wouldn’t say they’re the most transformational: … home value-based purchasing, Pioneer ACO, but then also the recurrent non-emergent ambulance and diabetes programs.”

Fowler’s characterization of these four certified programs as not the most transformational is the understatement of the year.

• The Home Health Value-based Purchasing Model demonstration cut Medicare spending by 1% with mixed effects on quality.
• The Pioneer ACO program, which saved no more than a few tenths of a percent net, suffered an astonishing attrition rate: the number of participating ACOs fell from 32 at the beginning of the program in 2012 to nine when the program ended in 2016. CMS rushed to certify the program based on data gathered in just the first two years using a questionable methodology.
• The non-emergent ambulance prior authorization demonstration and diabetes prevention programs are not value-based programs. The ambulance program merely tested the use of prior authorization for ambulance service. The diabetes prevention program simply confirmed what previous research had shown: for individuals at high risk for developing type 2 diabetes, lifestyle changes can prevent or delay disease.

The largest of CMS’s accountable care organization programs, the Medicare Shared Savings Program, is permanent and does not need to be certified because it was created by Congress via the Affordable Care Act. It has also performed poorly, raising or lowering Medicare net spending by a few tenths of a percent depending on which year one examines and how control groups are constructed. It has also had mixed and trivial effects on quality.

The relatively few studies of private-sector experimentation with accountable care organizations and medical homes, the primary value-based payment methods adopted by the private sector, confirm the Medicare-focused research.

It’s important to note that the spread of accountable care organizations has driven up administrative costs for providers and induced further consolidation of an already highly consolidated health care industry. The final evaluation of the Pioneer ACO program reported, for example: “Approximately three-quarters of Pioneer physicians indicated that participation had required them to increase time spent on administrative, documentation, and reporting tasks ‘somewhat’ or ‘a lot’.” A 2019 report in the journal Health Affairs found “a clear association between physician consolidation and county-level ACO penetration. In counties with the highest ACO penetration, there were large declines in the number of small practices and increases in the number of large practices.”

An honest analysis of why value-based payments have failed should consider at least these four explanations:

• wrong diagnosis
• no definition of what ACOs are expected do
• requiring that ACO “members” be assigned rather than enroll
• no evidence for the assumption that price and quality can be accurately measured

Wrong diagnosis. Proponents of ACOs assume that the cost problem, be it rising costs for Medicare or for the country, is due to the excessive volume of medical services being rendered rather than excessive price (price times volume of services equals total spending), and that the fee-for-service method of paying providers induces overuse. To be sure, there are pockets of overuse in the U.S. health care system and in Medicare, but no evidence that they are caused by the fee-for-service method.

No definition. In its June 2009 report to Congress, the Medicare Payment Advisory Commission (MedPAC), a nonpartisan independent agency of the legislative branch that provides the U.S. Congress with analysis and policy advice on the Medicare program, recommended that Congress insert accountable care organizations into Medicare but “defined” ACOs only in these aspirational terms: “The defining characteristic of ACOs is that a set of physicians and hospitals accept joint responsibility for the quality of care and the cost of care received by the ACO’s panel of patients.”

What does “accepting responsibility” mean? Whatever it means, it conveys no information about what the “set of physicians and hospitals” must do differently. MedPAC has repeated this useless definition in virtually every report to Congress about ACOs since.

The lack of a clear definition makes it extremely difficult for providers to know what they’re supposed to do, and it impedes intelligent discussion about why accountable care organizations fail. At least two evaluations of Medicare’s ACO programs have commented on the vague definition problem. A 2012 evaluation of the Physician Group Practice Demonstration (an early test of the ACO concept that demonstrated it doesn’t work) stated: “The demonstration was not designed to test specific interventions; therefore, participating sites had complete autonomy in determining strategies that would provide higher quality care and expenditure savings. Since these strategies … were not uniformly designed, defined, or implemented across the ten PGPs, evaluations of interventions could not be done.”

Similarly, an evaluation of the Pioneer ACO program, which ran from 2012 through 2016, reported, “The ACO ‘treatment’ under investigation is not a prescribed set of activities or interventions.”

Assignment of ACO “members” rather than enrollment. To avoid a repeat of the backlash over health maintenance organizations, the Affordable Care Act required that Medicare beneficiaries be assigned to ACOs “based on their utilization of primary care services.” CMS measures “utilization of primary care services” by examining claims filed for beneficiaries over a look-back period. This method of populating ACOs results in high rates of leakage — the industry term for people assigned to accountable care organizations who seek care outside of their networks. Leakage rates are typically 30% annually. How are ACO providers supposed to be “accountable” for patients they never see?

Inaccurate measurement of “value.” Proponents of accountable care organizations assume that CMS and other insurers can accurately measure the cost and quality of providers and ACOs, and when financial carrots and sticks are attached to these measurements, only good things will happen.

This assumption is sheer fantasy. Measurement of cost and quality is wildly inaccurate — especially at the level of the individual doctor — and always will be. The bonuses and penalties dished out to ACOs, and to individual providers, more closely resemble white noise than useful feedback. They create incentives to deny care and to game the measurements by upcoding and teaching to the test.

Years ago, a consulting company’s blog post joked that “ACO” stands for “amazing consulting opportunity.” To understand the truth in this wisecrack, just review the list of sponsors and speakers at the National Primary Care Transformation Summit. Many hold positions in firms that supervise, own, or consult with accountable care organizations and other value-based payment entities.

The “amazing” opportunity to make a buck off the tortured U.S. health care system while rarely laying eyes on patients may be the single most important reason why health policy mavens continue to embrace value-based payment despite its miserable track record.

Kip Sullivan is a member of the advisory board of Health Care for All Minnesota. Ana Malinow is a retired pediatrician and professor of pediatrics at the University of California, San Francisco. Kay Tillow is a union activist, chair of Kentuckians for Single Payer Health Care, and coordinator of the All Unions Committee for Single Payer Health Care.

https://statnews.com…

By F. Douglas Stephenson
Informed Comment, July 25, 2022

On July 30. 1965, Congress enacted Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income or medical history. President Lyndon B Johnson signed the Medicare Act into law and created two new programs, Medicare for those who had reached the social security retirement age of 65 years, and Medicaid for those whose incomes were below specific levels. In the long history of struggles to obtain national health insurance in the USA, this was a momentous act that provided health insurance for people ages 65 and older and the disabled regardless of income or medical history. In the 57 years since, Medicare has become living proof that public, universal health insurance is superior to private insurance in every way. Medicare is more efficient than private health insurance and is administered at a cost of 3 percent to 4 percent, as opposed to private, for-profit health insurance, which has administrative costs above 15 percent.

Medicare’s costs have risen more slowly than those of private health insurance. Medicare provides better access to care, better financial protection and higher patient satisfaction. Although many have negative feelings toward government, and examples of government inefficiency and incompetence exist, the record of private health insurers is far worse. Dozens of financial profiteering scandals have wracked private insurers and HMOs in recent years. Everyone should categorically reject fear tactics about ‘Medicare for All’ that try to frighten seniors and others by telling them they will lose Medicare benefits under a new M4A program, that pointy-headed government bureaucrats will make medical decisions, determine the cost vs benefits of procedures, including age and quality of life considerations and medical personnel will be in short supply.

Beholden members of Congress want to protect the interest of insurance and Pharma — these two industries spent $371 million on lobbying in 2017 alone. Big Pharma, Big Insurance industries have literally bought most of our legislators (both Democrat and Republican). A massive disinformation/fear campaign has promoted the myth that Medicare for All would limit choice of doctors and hospitals, create unsustainable costs, and expansive, uncontrolled bureaucracy. These myths better describe the reality of our present system based on the private insurance industry.

Opposition to Medicare for All is based on irrational fears, folklore/myth and general prejudice against government programs. Fear-mongering about waiting lists, bankrupt doctors and hospitals, and socialism is exactly the same fearful/false rhetoric used in the campaign to block LBJ’s original Medicare program in 1965. The Wall Street Journal then warned about “patient pileups,” and the American Medical Association mounted a campaign featuring Ronald Reagan that smeared Medicare as creeping socialism that would rob Americans’ freedom.

Research in the New England Journal of Medicine showed that administration consumes a total of 31 percent of U.S. health spending, with much of that waste attributable to private insurance company overhead and profit. If the single-payer plan pays health care professionals, hospitals and drug companies at levels comparable to Medicare’s current substantially lower rates, premiums for all individuals and families could be so low that the public plan could consume the market and end private health insurance.

M4A is a solid investment in our country because it promotes a social service for universal access to affordable health insurance for everyone. The USA is a country where health insurance for medical and mental health care is a function of socio-economic status. Everyone knows that this inhumane system should have been corrected long ago, but the death and illness ravages of the pandemic crisis makes it impossible to any longer avoid reality. We must immediately end our moral crime of having the greatest health system in the world, but only for those who can afford it.

LET’S IMPROVE MEDICARE IN 2022

To continue our progress, it’s time to upgrade Medicare by establishing a new improved, 21st century “Medicare for All” health insurance system that covers all age groups, cradle to grave. Newborns will leave the hospital with their new Medicare card, and drop it off years later at life’s end. The U.S. Senate’s new Medicare for All Act of 2022, has been introduced by Sen. Bernie Sanders and 14 co-sponsors. In the US House, Reps. Pramila Jayapal (D, WA) and Debbie Dingell, (D., MI) introduced the modern MEDICARE FOR ALL ACT of 2021 (H.R. 1976) i. M4A 2021 is new legislation calling for a single-payer national health program in the United States that addresses decades of health/mental health-related injustices that have been made even more painfully apparent by the COVID-19 pandemic.

The list of features in common between S. 4204, and the most recent House Bill (H.R. 1976) is substantial .Each of these bills provides all residents of the United States and its territories with a nationally consistent comprehensive benefit design, eliminates nearly all copays and deductibles, is funded through an equitable tax model, protects current benefits and services for veterans and Native Americans while also including them in Medicare for All, and dedicates expanded resources towards improving equity and justice in health care/health insurance.

Covered are all medically necessary services, including primary care, medically approved diet and nutrition services, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, hearing services, long term care, palliative care, podiatric care, mental health services, dentistry, oral surgery, eye care, chiropractic, and substance abuse treatment. Patients have their choice of physicians, mental health and other providers, hospitals, clinics, and practices.

Co-pays and deductibles paid at health professionals offices are ended because payment for health insurance is fully pre-paid directly into Medicare, much like Social Security, and covered at first dollar amounts. This means the obsolete 80%/20% payment split between private health insurance companies and Medicare is eliminated, with Medicare for All now covering 100%.

All citizens are guaranteed insurance for professional health care while achieving significant overall savings compared to our existing system by lowering administrative costs, controlling the prices of prescription drugs and fees for physicians, mental health and other health care professionals, hospitals, reducing unnecessary treatments and expanding preventive care.

INSURANCE FOR HEALTH CARE ESTABLISHED AS A BASIC HUMAN RIGHT

Good health care would be established as a basic human right, as in almost all other advanced countries. Nobody would have to forego needed treatments because they didn’t have insurance or they couldn’t afford high insurance premiums and copays. Nobody would have to fear a financial disaster because they faced a health care crisis in their family. Virtually all families would end up financially better off and most businesses would also experience cost savings under Medicare for All compared to what they pay now to cover their employees.

HOW TO FINANCE IMPROVED MEDICARE

We finance our new Medicare for All by slashing administrative waste and eliminating profiteering by the private health insurance industry. The new system would be funded in part by the savings obtained from replacing today’s welter of inefficient, profit-oriented, private insurance companies, and the system-wide administrative waste they generate, with a single streamlined, nonprofit public payer health insurance system. Such savings, estimated in 2017 to be about $500 billion annually, would be redirected to patient care for all. With the advantage of risk insurance pooling that includes everyone, all beneficiaries are eligible for the same health insurance benefits, and the cost of providing those benefits is largely financed by broad-based revenue sources (e.g., progressive income or payroll taxes), completely separating enrollee health status from financing of the programs’ benefits.

Existing tax revenue would fund much of the system. According to a 2016 study in the American Journal of Public Health, tax-funded expenditures already account for about two-thirds of U.S. health spending. That revenue would be retained and supplemented by modest progressive taxes based on ability to pay, taxes that would typically be fully offset by ending today’s very high premiums paid to the for-profit private insurance industry and out-of-pocket expenses for care. The vast majority of U.S. households, one study says 95 percent, would come out financially ahead. The system would reap savings by dealing with drug and medical supply companies for lower prices. It also saves money by giving hospitals annual lump-sum (“global”) budgets to run their operations.

More than two dozen independent analyses of federal and state single-payer legislation by agencies such as the Congressional Budget Office, the General Accountability Office, the Lewin Group, and Mathematica Policy Research Group have found that the administrative savings and other efficiencies of a single-payer program would provide more than enough resources to provide first-dollar coverage to everyone in the country with no increase in overall U.S. health spending.

WHAT MEDICARE IS – AND IS NOT

Often the public is confused and fearful when the “socialized medicine” label is conflated with single-payer, Medicare-for-all, which simply is “socialized health insurance.” Whatever the pros/cons of socialized medicine, Medicare for All is not socialized medicine. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. Health-care professionals in the U.S. Veterans Administration and the armed services are paid this way. The good health systems in Great Britain and in Spain are other examples.

Most European countries, Canada, Australia and Japan have socialized health insurance, but not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Physicians and other health professionals are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage medical or mental health practices or hospitals.

PRIVATIZATION OF HEALTH INSURANCE

The U.S. subscribes to a private business model for health insurance that defines insurers as commercial entities. Private health insurers also maximize profits by limiting benefits or by not covering people with health problems. Like all businesses, their goal is to make money. Under this business model of health insurance, the greed of casual inhumanity is built in and the common good of the citizens and nation is ignored. Excluding many in the middle class, the poor, the aged, the disabled and the mentally ill is sound business practice policy since it maximizes profit.

Today we still have tens of millions of individuals without insurance, many more who are underinsured, many who have impaired access to their physicians because of insurer network restrictions, many who face financial hardship when health needs arise, and an outrageously expensive system due to the profound administrative waste of the insurers and the burden they place on the health care delivery system when immense profit is required. With millions losing their jobs due to Covid-19, the dangers of connecting health insurance to employment are painfully clear. Health insurance must NOT be tied to employment.

Almost none of these problems would exist if the government, instead of the private insurers, served us as the health insurance financing authority. It is inhumane to allow consumer-directed, moral-hazard based private health policies to erect barriers to health care for millions of citizens with minimal or modest resources.

We now have several decades of experience with the conversion of health/mental health care into a business. Our health care is being rationed, with care guidelines determined by profitability and secrecy decided in private Wall Street corporate boardrooms. To realize large profits demanded by Wall Street investors, our health system must attract the healthy and turn away the sick, disabled, the poor, many of the old, and the mentally ill.

To maintain corporate control of U.S. health care insurance, our system is privatized and unregulated. Private, big insurance companies are in the business of making money, not providing health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs (and immense profiteering ) are greater in the private health care insurance system, and even Medicare itself is weakened by having to work through the private system.

The country’s largest health insurer, UnitedHealth Group, reported its profits were $6.7bn in the second quarter of 2020 compared with $3.4bn in last year’s. Anthem’s profits rose to $2.3bn from $1.1bn for the same three-month period in 2019. Humana reported its earnings rose to $1.8bn, compared with $940m in 2019. Steffie Woolhandler, M.D., a longtime advocate of single-payer healthcare and a professor at Cuny Hunter College, said in normal circumstances she considered the billions insurance companies collect a “scandal”.
“It is particularly glaring and inappropriate in a pandemic,” said Woolhandler, a co-founder of Physicians for a National Health Program.

POLITICIANS FOLLOW 1 % DONORS DEMANDS

President Biden and many Democrats have spent their careers defending the financial sector, including big insurance and big pharma, whose leading policy is to maintain and further privatize basic health care financing and infrastructure. Distinguished classical economist Michael Hudson notes that, “Biden’s long political career has been right-wing. He’s the senator from Delaware, the country’s most pro-corporate state – which is why most U.S. corporations are incorporated there. As such, he represents the banking and credit-card industry. He sponsored the regressive bankruptcy “reform” written and put into his hands by the credit-card companies. As a budget hawk, he’s rejected Modern Monetary Theory (MMT), and also “Medicare for all” as if it is too expensive for the government to afford – thereby making the private sector afford to pay 18% of US GDP for health-insurance monopolies, far more than any other country. That means blocking governments from providing basic services at cost or on a subsidized basis – education, health care/health insurance, roads and communications. Privatized and financialized economies are high-cost.”

Although health insurance affordability for the majority of US citizens remains a very large problem, Pres. Biden’s latest health insurance plan wants to shift many more dollars into private, Wall Street insurance industry hands. The takeover of health insurance by private Wall Street entities continues apace as Democrats/Biden propose to increase taxes and give it to the private profit insurance industry – the source of our profound administrative waste, along with the costly administrative burdens they place on the delivery system. Profiteering continues unabated as private insurance sells us services we don’t need/want , such as deductibles and other cost sharing, maintenance of narrow networks, requiring prior authorization with increased administrative costs, excessive ongoing paperwork/documentation requirements, all while avoiding paying for surprise bills and other denied benefits.

SUPPORT MEDICARE — A SOLID INVESTMENT IN OUR COUNTRY

Let’s never forget that Universal Medicare for All is a solid investment in the citizens of our country. This investment simply promotes a social service for universal access to affordable health care insurance for all. Aren’t we a society that cares enough to see that everyone receive the health care they need? That’s the basic point of Medicare for All, and it’s certainly the right thing to do now with the Covid-19 pandemic.

Nobel Prize recipient Bernard Lown, M.D., of the Harvard School of Public Health summed it up nicely: “One may only hope that Winston Churchill’s quip will soon be realized: ‘You can always count on Americans to do the right thing, after they have tried everything else.’ The United States has tried any number of bad solutions for providing its people with health care/insurance. Long overdue is the recognition that medicine is a necessary social service that should be accessible to all citizens.”

Join the majority of Americans who support improved Medicare for All. Ask your legislator to celebrate Medicare’s 57th birthday by supporting legislation in the House (H.R. 1976) and Senate (S. 4204) that would establish this badly needed reform.

F. Douglas Stephenson, LCSW, is a retired psychotherapist and former instructor of social work in the University of Florida Department of Psychiatry. He is a member of Physicians for a National Health Program.

https://www.juancole.com…

By Ed Yong
The Atlantic, July 21, 2022

Jacob Bor has been thinking about a parallel universe. He envisions a world in which America has health on par with that of other wealthy nations, and is not an embarrassing outlier that, despite spending more on health care than any other country, has shorter life spans, higher rates of chronic disease and maternal mortality, and fewer doctors per capita than its peers. Bor, an epidemiologist at Boston University School of Public Health, imagines the people who are still alive in that other world but who died in ours. He calls such people “missing Americans.” And he calculates that in 2021 alone, there were 1.1 million of them.

Bor and his colleagues arrived at that number by using data from an international mortality database and the CDC. For every year from 1933 to 2021, they compared America’s mortality rates with the average of Canada, Japan, and 16 Western European nations (adjusting for age and population). They showed that from the 1980s onward, the U.S. started falling behind its peers. By 2019, the number of missing Americans had grown to 626,000. After COVID arrived, that statistic ballooned even further—to 992,000 in 2020, and to 1.1 million in 2021. Were the U.S. “just average compared to other wealthy countries, not even the best performer, fully a third of all deaths last year would have been prevented,” Bor told me. That includes half of all deaths among working-age adults. “Think of two people you might know under 65 who died last year: One of them might still be alive,” he said. “It raises the hairs on the back of my neck.”

These counterfactuals puncture two common myths about America’s pandemic experience: that the U.S. was just one unremarkable victim of a crisis that spared no nation and that COVID disrupted a status quo that was strong and worth restoring wholesale. In fact, as one expert predicted in March 2020, the U.S. had the worst outbreak in the industrialized world—not just because of what the Trump and Biden administrations did, but also because of the country’s rotten rootstock. COVID simply did more of what life in America has excelled at for decades: killing Americans in unusually large numbers, and at unusually young ages. “I don’t think people in the United States actually have any awareness of just how poorly we do as a country at letting people live to old age,” Elizabeth Wrigley-Field, a sociologist at the University of Minnesota, told me.

Although Bor’s study has yet to be formally reviewed, Wrigley-Field and five other independent researchers vouched for its quality to me. “The paper is extremely important, and the researchers who produced this know what they’re doing,” Steven Woolf, a population-health expert at Virginia Commonwealth University, told me. “It builds on, and considerably expands, what we’ve already known.”

Several studies, for example, have shown that America’s life expectancy has tailed behind other comparable countries since the 1970s. By 2010, that gap was already 1.9 years. By the end of 2021, it had grown to 5.3. And although many countries took a longevity hit because of COVID, America was once again exceptional: Among its peers, it experienced the largest life-expectancy decline in 2020 and, unlike its peers, continued declining in 2021. But Bor says that people often misinterpret life-expectancy declines, as if they simply represent a few years shaved off the end of a life. Someone might reasonably ask: What’s the big deal if I die at 76 versus 78? But in fact, life expectancy is falling behind other wealthy nations in large part because a lot of Americans are dying very young—in their 40s and 50s, rather than their 70s and 80s. The country is experiencing what Bor and his colleagues call “a crisis of early death”—a long-simmering tragedy that COVID took to a furious boil.

In every country, the coronavirus wrought greater damage upon the bodies of the elderly than the young. But this well-known trend hides a less obvious one: During the pandemic, half of the U.S.’s excess deaths—the missing Americans—were under 65 years old. Even though working-age Americans were less likely to die of COVID than older Americans, they fared considerably worse than similarly aged people in other countries. From 2019 to 2021, the number of working-age Americans who died increased by 233,000—and nine in 10 of those deaths wouldn’t have happened if the U.S. had mortality rates on par with its peers. “This is a damning finding,” Oni Blackstock, the founder and executive director of Health Justice, told me.

The crisis of early death was evident well before COVID. As many studies and reports have shown, since the turn of the 21st century, “midlife ages are where health and survival in the U.S. really go off the rails,” Wrigley-Field told me. “The U.S. actually does well at keeping people alive once they’re really old,” she said, but it struggles to get its citizens to that point. They might die because of gun violence, car accidents, or heart disease and other metabolic disorders, or drug overdoses, suicides, and other deaths of despair. In all of these, the U.S. does worse than most equivalent countries, both by failing to address these problems directly and by leaving people more vulnerable to them to begin with.

Consider how many years the missing Americans would have collectively enjoyed had they survived—all the birthdays and anniversaries that never happened. In other rich countries, the total “years of life lost” have flatlined for the past five decades. In the U.S., they have soared: In 2021 alone, the 1.1 million missing Americans lost 25 million years of life among them. That number doesn’t account for the events that preceded many of these deaths—the “years of disability, illness, and loss of human potential, creativity, and dignity,” Laudan Aron, a health-policy researcher at the Urban Institute, told me. And, especially in the case of middle-aged deaths, they left behind young dependents, whose own health might suffer as a result. The sheer number of missing Americans, and the “profound ripple effects” of their absence, are “really hard to wrap one’s head around,” Aron said.

These staggering numbers also help contextualize COVID’s toll. The coronavirus caused the largest single-year rise in mortality since World War II, becoming the third leading cause of death in the U.S., after only heart disease and cancer. But this enormous tragedy unfolded against an already tragic backdrop: The number of missing Americans from 2019 is larger than the number of people who were killed by COVID in 2020 or 2021. This isn’t to minimize COVID’s impact; it simply shows that in the Before Times, America had “very successfully normalized to an extremely high level of death on the scale of what we experienced in the pandemic,” Justin Feldman, a social epidemiologist at Harvard, told me. And when COVID drove those levels skyward, America proved that “we’ll accept even more deaths compared to our already poor historical norms,” Feldman said.

Such deaths, though obvious on a graph, are hidden from Americans with social privilege. In the summer of 2020, Bor remembers having an outdoor BBQ with a friend who grew up in a low-income housing project. “At that point, six months in, he knew six people in his close circle who had been killed by COVID,” Bor told me. “I still don’t.” The fact that half of the working-age Americans who died last year should still be alive “isn’t visceral if you haven’t lost anyone,” he said.

The current mortality crisis was long in the making. In terms of mortality, America’s peer countries—many of which had been hammered by World War II and its aftermath—began catching up with it in the mid-1970s before overtaking in the early 1980s. That was a pivotal era, when globalization, automation, and a growing service industry led to huge losses in mining, manufacturing, and other blue-collar sectors. The U.S. profoundly failed to protect its citizens from these changes. Its social safety net—state assistance for parents, or people facing job, food, or housing insecurity—was meager; its public-health system was languishing after decades of underinvestment; and unlike every other wealthy country, it lacked universal health care. These factors “privatized risk,” Bor and his colleagues wrote in their paper, “tying health more closely to personal wealth and employment.” As labor unions declined and minimum wages stagnated, more Americans had fewer resources to lean on if their health declined. Poorer Americans already lived, on average, shorter lives than rich ones, and that gulf started to widen.

Other particularly American choices exacerbated the stresses on the health of the country’s citizens, again weighing more heavily on less wealthy people. A growing mass-incarceration industry punished them. A deregulatory agenda that began with Ronald Reagan’s administration left them vulnerable to unhealthy foods, workplace hazards, environmental pollutants, guns, and opioids. “America basically says: If you’re poor, you don’t have access to safe choices,” Bor told me.

Factors like social inequalities and frayed social safety nets are the fundamental weaknesses of American society, which more specific problems like opioids, metabolic disorders, and COVID exploit. During the pandemic, for example, poor and minority groups were more likely to be infected because they lived in crowded housing, distrusted medical leaders, and couldn’t work from home or take time off when sick. And instead of addressing these foundational problems, policy makers instead focused on personal responsibility.

America’s drastic underperformance in health also stems from its history of segregation and discrimination. Racist policies have obviously harmed the health of minorities. But as the policy expert Heather McGhee and the physician Jonathan Metzl have independently argued, elites have long marshaled the racial resentment of poor white Americans to undermine support for public goods that would benefit everyone, such as universal health care. Per Frederick Douglass and other Black leaders, “They divided both to conquer each.”

COVID, for example, disproportionately killed Black, Latino, and Indigenous Americans—a trend that, when highlighted to white people, reduces their concern about the pandemic and their support for safety measures. But in 2021, young white Americans still died at three times the rate of the average resident of other peer nations, while young Black and Indigenous Americans died at rates five- and eightfold higher, respectively. “There are thousands of racial-disparity studies that compare Black people to white people—but white Americans are a terrible counterfactual,” Bor told me. They’re frogs in the same pot, boiling more slowly but boiling nonetheless. By using them as a baseline, we ignore how “everyone is harmed by the status quo in the U.S.,” Blackstock told me, while also underestimating how dire things really are for people of color. (The same problem applies to income inequality: White Americans living in the richest 1 percent of counties still have higher rates of maternal and infant mortality than the average residents of wealthy countries.)

So, “what happens now?” Bor asked me. “Are we going to have 1 million missing Americans a year, every year, going forward? Or more?” His study doesn’t suggest a reason for optimism, but it does provide a defense against nihilism. The entire concept of missing Americans is rooted in a comparison with other countries, which shows that these early deaths aren’t inevitable. The U.S. could at least start moving in the direction of its peers by adopting policies that work elsewhere, such as universal health care, minimum-wage increases, federally required paid sick leave, and better unemployment insurance.

But “the inability of our politics to generate policies that manage health threats is grim,” Bor said. None of the weaknesses that COVID exposed have been addressed; some, like the chasm-sized health gaps between rich and poor or white and Black, have been widened. Vaccines significantly reduce the risk of dying from COVID, but their power is blunted by low uptake, new variants, the lifting of almost all infection-thwarting protections, and the looming loss of COVID funding. Reactionary laws that hamstring what public-health departments can do in emergencies will make the U.S. vulnerable to the new viruses that will inevitably assault it in future years. America’s already underperforming health-care system has been badly battered by the pandemic, and weakened by waves of health-care-worker resignations. In recent months, the Supreme Court has constrained both gun and carbon-emission regulations, while clearing the road for states to restrict or ban abortions—a move that could easily boost America’s already sky-high maternal mortality rates. The climate is still changing rapidly, exposing people who have no choice but to work outside to the ravages of heat.

As much of the country returns to normal, Bor’s study makes plain what normal actually meant—and, as I wrote in 2020, that normal led to this. “A lot of Americans may be under the impression that we had a bad go of it during COVID, and once the pandemic is over, they can go back to having the best health in the world,” Woolf told me. “That is a gross misconception.”

https://www.theatlantic.com…

July 15, 2022

Podcast host Joe Sparks talks about the administrative headaches associated with U.S. medical records, and the demands these records place on patients, especially those who are seeing a new doctor or visiting a new medical facility.

He notes how entering and re-entering medical history and other data “takes quite a bit of time, and causes me to see how many cuss words I know.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com