Summary: “Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States. U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.” This says it all.

Health and Health Care for Women of Reproductive Age, The Commonwealth Fund, April 6, 2022, by Munira Z. Gunja et al

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States.

U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

U.S. women of reproductive age have among the highest rates of multiple chronic conditions and the highest rate of mental health needs.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands.

Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons. America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.

Comment:

By Don McCanne, M.D.

How is the United States doing in providing adequate health care for its residents? Let’s just look at women of reproductive age – a group that plays such an important role in family and community life and should not be afflicted by medical risks more characteristic of older age.

Compared to other wealthy nations that spend less on health care than us, our record is miserable. Not only do our insurance programs leave many unacceptable gaps in coverage, we leave ten million women with no insurance coverage at all, thus potentially unnecessarily exposed to physical and financial suffering and even death. We are already spending the funds that could prevent this, but we are spending them on the wrong health care financing system – a highly dysfunctional, fragmented system designed to benefit venture capitalists and private equity investors, with insurance and much patient care being primarily a tool to enable wealth accumulation.

We are spending enough money to do it right, but it appears that our health care infrastructure is now so distorted by capital interests that even single payer Medicare for All may not be enough to ensure adequate health care for all. Maybe all of us, as communities, need to play a greater role. For those who missed it, several HJM contributors last week published an article in The Nation how communities, not corporations, should own our most vital health care assets.

With public financing and community control, women of reproductive age would no longer have to worry about their own health care access and affordability, and also would no longer have to worry about health care for their loved ones, or for everyone else.

Maybe women are best positioned to lead the march toward health care justice for all.

http://healthjusticemonitor.org…

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Summary: An excellent review of 12-year financial trends for the largest six insurers reveals: a) skyrocketing revenue and profits, b) based mainly on growth in the public insurance sector, and c) acquisition of pharmacy benefit plans. Half of Americans are in their plans.

A decade-long look at how Big Insurance profiteers American taxpayers and the sick, Wendell Potter NOW, April 4, 2022

Those six companies–Anthem, Centene, Cigna, CVS/Aetna, Humana, and UnitedHealth–are massively bigger today than they were 12 years ago [when the ACA was passed] as a result of numerous mergers and acquisitions and a new love interest: the government. In 2010, the companies took in a combined total of $245.2 billion dollars in revenue. Last year, that number had more than quadrupled to $1.1 trillion. …

Two of those companies–United and CVS/Aetna–have grown so fast they have leapfrogged into the top five of the Fortune 500 of America’s biggest companies. Only Walmart, Amazon and Apple took in more money last year than those two companies. (Cigna, the third largest in terms of revenue and my former employer, is now the 13th largest on the Fortune list.)

The big six insurers’ profits have soared along with their revenues. Last year they made $60.7 billion in profits collectively, compared to $16.9 billion in 2010. …

Relatively little of the six companies’ growth in health plan revenues and profits has come from private paying customers. By far most of the money they now collect to administer health plans comes from us as taxpayers. That’s because all of the companies have shifted their focus away from the private sector and toward various government-funded programs: Medicare, Medicaid, federal employees and the military. …

In 2010, 16.9 million Americans were enrolled in the Medicare Advantage, Medicare supplement and Medicaid plans operated by the big six. In 2021, that number had increased by 46 million–373%–to 63 million. …

Thanks to the many mergers and acquisitions since then, one of every two of us are now enrolled in one of their health plans. (And 31.1 million of us remain uninsured.) …

AND THEN THERE IS …

The Big Three of the Big Six make more money “managing” Americans’ prescription medications than by administering our health insurance plans. Aetna supersized itself when it merged with CVS, which operates the country’s largest pharmacy benefit management [PBM] company, Caremark, in 2017. Cigna bulked up the next year when it merged with Express Scripts, the second largest PBM. And United’s fastest growing and most profitable division is Optum, which encompasses the country’s third largest PBM. Together, CVS, Cigna, and United control nearly 80% of the national PBM market. At all three companies, the PBMs now generate more profits than their health plan businesses.

Those three companies are also far bigger than the biggest company that actually makes prescription medications. Johnson & Johnson, the biggest U.S. drug company, ranks a distant 36 on the Fortune 500. To put that in perspective, J&J was #33 on the Fortune list in 2010. Cigna, which is now #13 was #129 in 2010.

Comment:

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

The Affordable Care Act will strengthen the hand of private insurers, single payer advocates said in 2010. Oh how I wish we’d been wrong.

Wendell Potter’s review highlights just how right we were. Half of us are enrolled in plans (both private and public) run by the top six insurers, with $1.1 trillion in annual revenues and $61 billion in profits. (Lest you think, oh, that’s not such a big profit margin, consider that the rate of return on real investment is 6 to 9 times higher.)

Most of the gains are for publicly funded programs, primarily Medicare Advantage and Medicaid Managed Care.

They’ve even taken over pharmacy benefit management companies (PBMs), which specialize in extracting more profits from health care.

All in all, a dismal state of affairs. Profits grow exponentially, while access to care and health outcomes plummet. Shareholders gain and beneficiaries lose.

Time for disintermediation. Seriously.

http://healthjusticemonitor.org…

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Summary: A nurse mistakenly gives an incorrect drug that kills a patient, and is convicted of homicide. Our system kills up to 100,000 a year due to un- and under-insurance, and nobody is indicted. Where is the justice and sense of proportion? Our inaction is outrageous.

Why Nurses Are Raging and Quitting After the RaDonda Vaught Verdict, KHN (Kaiser Health News), April 5, 2022, by Brett Kelman and Hannah Norman

Vaught, who worked at Vanderbilt University Medical Center in Nashville, was convicted in the death of Charlene Murphey, a 75-year-old patient who died from a drug mix-up in 2017. Murphey was prescribed a dose of a sedative, Versed, but Vaught accidentally withdrew a powerful paralyzer, vecuronium, from an automated medication-dispensing cabinet and administered it to the patient. …

Vaught was acquitted of reckless homicide but convicted of a lesser charge, criminally negligent homicide, and gross neglect of an impaired adult.

Comment:

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

A nurse in a university hospital was convicted of unintentionally killing a patient due to a medication error. She’ll likely get 8 years in prison.

Yet those who defend our dysfunctional health insurance system and extract tens of billions in profits by restricting access to care are causing 100,000 excess deaths per year. Do they know of these horrendous effects? They must; it’s plain to see in the stories and research (eg, here and here).

Where is justice? Proportionality? Common sense? Humanity?

I’m sick about our indifference to large-scale systematic harm. We punish one nurse for her inadvertent, if tragic, error. We protect and enable those who cause deaths on a massive scale.

http://healthjusticemonitor.org…

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Summary: A very surprising and hugely important announcement: US health insurers have decided to “disintermediate” – step back from their traditional position between purchasers of health care (e.g., policyholders) and providers of health care (e.g., doctors and hospitals). The implications of this change are far-reaching.

Health Insurer Trade Association Announces Disintermediation, USA Wire Service, April 1, 2022 , by Ziua Pācālelilor

Today the trade group America’s Health Insurance Plans, known as AHIP, announced that its members – scores of health insurers – voted to “disintermediate”. In a press release, AHIP explained that “disintermediation” means removing themselves from playing an intermediary role between insurance purchasers and healthcare providers, and between patients and clinical care.

The insurance companies represented by AHIP voted unanimously at the annual conference to make this drastic change in their business model. During the meeting, which was off limits to the press, one insurance CEO reportedly said, “It’s about time that we place efficiency and medical care over bureaucracy and profits. I for one am quite set financially, and would like to make this socially responsible action my swan song.”

The decision was completely unexpected. Health policy analysts expressed shock and confusion. One asked, stuttering, “But then what’s their purpose for existence, if not intermediation?”

A representative of the federal Center for Medicare and Medicaid Services, or CMS, said, “Well, that’s quite a course change. Seems like we’ll need to reinstate traditional Medicare, paying doctors and hospitals directly.”

Former insurance company executive and whistleblower, now a leading advocate for single payer universal health care, Wendell Potter said, “What? Holy shit! Really? This is transformative. Kudos to AHIP and their members. Finally, they’ve seen the light.” Mr. Potter popularized the term “disintermediation” in 2011, soon after leaving Cigna Insurance Company. At the time, he said it was the greatest fear of health insurers.

Today AHIP’s membership vigorously embraced that fear, and apparently conquered it.

Comment:

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

Whoa? For real? Health insurers voluntarily throwing in the towel on their half-century role in financing – and influencing – US health care.

The motivations of AHIP and its members are pure speculation. By adopting this position, they are abandoning their highly lucrative business model. Perhaps they have decided that the profit-taking cannot continue indefinitely, and this is a good time to get out. Perhaps, if we believe the quoted CEO, some had a change of heart regarding the purpose of health care financing – to pay for care and improve health, rather than bring giant financial returns to shareholders.

We can now look forward to settling on the details of the successor financing system – efficient, equitable, and health-maximizing single payer.

Let’s also remove corporate intermediaries on the provider side.

Alas, were it so. Today is, I remind our dear HJM readers, April Fool’s Day.

Keep working to make it real. With single payer, and community control.

http://healthjusticemonitor.org…

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Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.

Medicare for All Is Not Enough, The Nation, March 31, 2022, by David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; Adam Gaffney, M.D., M.P.H.; Don McCanne, M.D.; John Geyman, M.D.

We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.

However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.

But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.

These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.

Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?

In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.

Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.

But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physicians’ practices, hospitals, and other health care institutions. Avaricious firms — both for-profit and non-profit – are gobbling up the vital resources needed for care, gaming even traditional Medicare’s payment incentives, and prioritizing profitability over patients’ and communities’ needs. Physicians, like other health care personnel employed by these organizations, must either comply with executives’ profit-seeking directives or be shown the exit.

Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayers’ and patients’ dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotland’s National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.

http://healthjusticemonitor.org…

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