Summary: Medical debt is common and iatrogenic*, induced by un- and under-insurance. A new survey confirms that it has serious consequences, most of all for mid-life and younger demographics: Gen X (born 1965-80), Millennials (1981-96), and Gen Z (1997-2012). Boomers and the Silent Generation also feel its effects.

* Iatrogenic: Illness caused by medical interventions.

See Update below.

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One in Four Gen Z, Millennials Skip Rent or Mortgage Due to Medical Debt: Survey, HealthCare.com, March 15, 2022, by Dan Grunebaum

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HealthCare.com’s 2022 Medical Debt Survey shows about one in four Gen Zers and Millennials with medical debt skipped rent or mortgage payments because of their debt.

Close to half of Millennials and Gen Xers with medical debt say the debt harmed their credit score.

Two in three Gen Zers who have health insurance but still incurred medical debt say their health insurance plan didn’t cover the service they received.

More than half of U.S. adults with incomes below $25,000 and medical debt had their bills sent to debt collectors.

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Comment:

By Don McCanne, M.D.

Because of the nation’s refusal to replace our fragmented, inequitable system of health care financing with a universal, comprehensive, equitable single payer system, it is inevitable that many individuals will face problems when they are unable to pay their medical bills. This survey describes some of those problems.

Perhaps one of the more alarming is the need to skip rent or mortgage payments thereby threatening their housing. This is a major consequence when you consider that a well-designed, universal, single payer system would totally remove the threat to housing caused by medical debt.

Some of the other risks are the obvious: damaged credit score decreasing flexibility in the marketplace, being hounded by debt collectors, decreased ability to build capital reserves for purposes such as retirement. In other words, screwed up credit merely because of the misfortune of having medical problems in a nation that has still declined to adopt a truly universal, comprehensive, equitable, progressively funded, health care financing system that we all could afford.

How can we tolerate seeing people evicted from their homes merely because of having faced medical misfortune for which our current health care financing system will not guarantee coverage? We can fix that.

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Update:

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

This just in: credit agencies have agreed to remove paid medical debt from credit reports, thus not using it to lower credit ratings. But that doesn’t prevent the problems described in today’s post. Indeed, unpaid medical debt, and rent and credit card bills not paid due to paying off medical debts, *will* hurt credit scores. We can’t fix this broken system with band-aids.

http://healthjusticemonitor.org…

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Summary: With federal protections for Medicaid coverage during the public health emergency winding down, states are aiming for an orderly “redetermination” process. Translation: orderly ousting from public insurance. About 1 in 8 individuals with Medicaid coverage will lose it, up to 1 in 3 in some states, often due to process problems. This is a double whammy – administrative burden that worsens access to care. Instead, we need lifelong, universal, equitable coverage.

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Medicaid and CHIP Eligibility and Enrollment Policies as of January 2022: Findings from a 50-State Survey, Kaiser Family Foundation, March 16, 2022, by Tricia Brooks et al.

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Executive Summary: Enrollment in Medicaid has grown significantly during the coronavirus pandemic. Provisions in the Families First Coronavirus Response Act (FFCRA) require states to provide continuous coverage for Medicaid enrollees until the end of the month in which the public health emergency (PHE) ends in order to receive enhanced federal funding. Continuous enrollment has helped to preserve coverage and halted Medicaid churn. However, when the PHE ends, states will begin processing redeterminations and millions of people could lose coverage if they are no longer eligible or face administrative barriers despite remaining eligible. Existing state enrollment and renewal procedures, as well as their approaches to the unwinding of the continuous enrollment requirement, will have major implications for Medicaid enrollment and broader coverage. …

In 20 states able to report, it is estimated that about 13% of Medicaid enrollees will be disenrolled when the continuous enrollment requirement ends. However, the estimates range widely across reporting states from about 8% to over 30% of total enrollees. Based on available data, most states report that an increase in income will be the primary reason for the disenrollments, but several states also expect incomplete renewals or missing documentation to be a primary reason for disenrollment. If these estimates hold true, millions of people will lose Medicaid coverage in the months following the end of the PHE; however, many children will likely be eligible for CHIP and many adults will likely be eligible for Marketplace or other coverage. Successfully transitioning these individuals into those other coverage options could reduce the number who lose coverage altogether and become uninsured.

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Comment:

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

One thing we did right on health insurance during the COVID pandemic is to provide continuous coverage for Medicaid participants. That is, don’t remove the poor and near-poor from public health insurance during a public health emergency.

Now that the crisis is easing, we can return to business as usual. Which means:

— Spend a huge amount of effort and money to review eligibility, so if someone is again working (often at a low paying job without health insurance), take away their Medicaid.

— In the process, many people who still do qualify for Medicaid will lose coverage for bureaucratic reasons – missed process steps, not lack of eligibility.

— Net effect: reduced access to care and resulting illness, bankruptcies, and deaths.

Why do we torture ourselves with these burdensome and inhumane systems, when we could cover everyone with high quality insurance for their full lifetimes, while saving money?

Our system is operating with cumbersome rules and indefensible values.

The solution is … yes, you guessed it … single payer. Generous, simple, affordable.

http://healthjusticemonitor.org…

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Summary: California recently inserted a private pharmacy benefits plan into Medi-Cal, despite evidence from other states that it adds costs. Thousands of patients have suffered medication gaps. All this makes no sense, if the goal is efficient, equitable, effective medical care.

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Opinion: New Medi-Cal Rx Is Riddled with Problems, Hurting Those Who Need it Most, California Health Report, March 10, 2022, by Hector De La Torre

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Despite warnings that the health of the state’s 14 million Medi-Cal beneficiaries would be threatened, on Jan. 1, the California Department of Health Care Services (DHCS) implemented Medi-Cal Rx, the questionable fee-for-service program that stripped pharmacy benefits from health plans and handed Medi-Cal prescription drug purchasing and distribution to a private, for-profit company. Now, a month into the new program, there are reports that thousands of Medi-Cal patients have been left without their medications for days or even weeks. Physicians are concerned that someone is going to die as a result of this flawed system. Remember, these are individuals in an already underfunded Medi-Cal system, and they are the same people who were disproportionately impacted by the COVID-19 pandemic.

As a former State Assembly member, I am appalled that DHCS moved forward with Medi-Cal Rx. Last November, I offered public comment expressing concerns about the system, versions of which had already failed in 10 other states. Those states expected cost savings, like those promised with Medi-Cal Rx, but they did not materialize. And in 2019, the Menges Group released a report that showed Medi-Cal pharmacy expenditures would jump more than 19 percent if California adopted a carve-out model.

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Comment:

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

This policy looks like a classic but especially heinous example of corporate profit over all other considerations — notably health of public beneficiaries, and responsibly managing public funds.

Private Medi-Cal plans have their own serious problems. But adding a private medication plan is remarkable for insane counterproductive complexity layered on top of underlying dysfunction. It boggles the mind, after evidence from other states of serious problems with this strategy.

What could be the motivation? Here are some ideas:

1. Brainwashed faith in the magic of privatization.
2. Financial conflicts of interest, via campaign contributions and/or promises of jobs or other major monetary benefits.
3. Advice from analysts or advisors who are brainwashed and/or financially conflicted.
4. All of the above.

Time to switch cognitive and moral framework, to a “public good” approach – single payer.

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Additional Comment:

By Don McCanne, M.D.

Our editor Jim has appropriately reinforced the outrage demonstrated by former State Assembly Member Hector De La Torre. When we have a severely malfunctioning health care financing system in dire need of replacement, society is resorting to a patchwork approach that not only is inadequate, but is moving us backwards from where we need to be as far as privatization is concerned. Serving private corporate interests at the cost of patient care is outrageous. Dare I say that it is time to consider judicious citizen action to redirect our public representatives in the direction of health justice for all?

http://healthjusticemonitor.org…

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Summary: Yesterday was the end of the Roe era of federal protection of abortion rights. This is the culmination of decades of GOP anti-democratic efforts to undo majority-supported and health-enhancing reproductive autonomy.

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Texas Supreme Court Shuts Down Final Challenge to Abortion Law, New York Times, March 11, 2022, by Kate Zernike and Adam Liptak

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The Texas Supreme Court on Friday effectively shut down a federal challenge to the state’s novel and controversial ban on abortion after about six weeks of pregnancy, closing off what abortion rights advocates said was their last, narrow path to blocking the new law.

The decision was the latest in a line of blows to the constitutional right to abortion that has prevailed for five decades.

The Texas law, which several states are attempting to copy, puts enforcement in the hands of civilians. It offers the prospect of $10,000 rewards for successful lawsuits against anyone — from an Uber driver to a doctor — who “aids or abets” a woman who gets an abortion once fetal cardiac activity can be detected.

It is the most restrictive abortion law in the nation, and flies in the face of the Supreme Court’s landmark 1973 decision in Roe v. Wade, which prohibits states from banning the procedure before a fetus is viable outside the womb, which is currently about 23 weeks of pregnancy. …

Abortion rights supporters and legal scholars said the Texas law would encourage other states not only to pass similar bans on abortion, but to attempt to nullify other precedents they oppose.

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Comment:

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

Friday sadly marked the demise of Roe v. Wade, which since 1972 – half a century – protected abortion rights based on privacy protections in the 14^th Amendment to the US Constitution. The end came in the form of a Texas Supreme Court decision rejecting the last legal path to invalidating a state law banning abortion after 6 weeks of pregnancy, even in cases of rape and incest.

This is almost certain to result in a flood of similar laws in other states and further restrictions in Texas, such as prohibiting help for women seeking abortion out of state. The result will be, aside from reversal of reproductive health autonomy for millions of women, the well-documented serious psychological and physical risks associated with taking an unwanted pregnancy to term – far in excess of harms from abortion. Plus the mortality and morbidity risks from unregulated illegal abortions offered in medically suboptimal settings, often by un- or underqualified practitioners. This is a medical and health justice nightmare.

Why does the title blame “GOP subversion of democracy” for this outcome? Because for two decades, the GOP has used profoundly anti-democratic tactics to mold the US Supreme Court into the perfect anti-Roe instrument. How? By stealing elections (mainly) and ignoring long-standing governing and legal norms. Here is a partial list:

2000: The GOP (George W. Bush) steals Florida and thus the presidential election, through a combination of blocking voting for tens of thousands of mostly minority individuals incorrectly listed as having felony convictions, a horribly confusing ballot design in Palm Beach County (a Dem error), and vote recount disruptions and delay orchestrated by Roger Stone. An already GOP US Supreme Court breaks precedent in a decision removing authority over state voting from the state (contradicting conservative legal doctrine) to end the recount while Bush is still ahead.

2004: Swift Boat dirty tricks gets Bush a second term.

2001-2008: Bush appoints 2 Supreme Court Justices.

2016: In mid-February, conservative Justice Antonin Scalia dies. Senate Majority Leader Mitch McConnell refuses to allow a hearing for Obama’s nominee Merrick Garland, despite nearly a year before the next president takes office. This is unprecedented obstruction.

2016: Trump is elected despite getting 2.9 million fewer votes, and with Russian social media support that some analysts believe tipped mid-western states and thus the election to him.

2017-2020: Trump appoints 3 Supreme Court Justices, creating a 6-3 conservative majority.

2021: Texas passes the abortion law, constructed with a novel and frightening legal theory: The state can evade 14^th Amendment constraints on states taking away individual rights by delegating the enforcement of such rights limitations to private citizens via civil litigation. This has been called a “posse” or “vigilante” law – empowering individuals not working for the government to do what the government is not allowed to do. Astoundingly, the US Supreme Court (the conservative majority) permits this approach. This sets the stage for any state to circumvent any federal limits on state action, simply by delegating enforcement to the population.

Thus we see merged a heinous states-rights governing theory, harkening to the 19^th century, with conservative social values. Note: only 27% of Americans wanted Roe over-turned.

The delegation legal approach likely will be used to deny other federally guaranteed rights.

A larger and more balanced Supreme Court is appealing. It can be done.

http://healthjusticemonitor.org…

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Summary: California’s Medi-Cal expansion for undocumented immigrants is laudatory … but is just a partial fix, leaving millions uncovered. It falls profoundly short of what is needed to cover everyone with high quality insurance, while saving money and boosting the economy: single payer.

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California is expanding Medi-Cal – but hundreds of thousands of immigrants will still be left behind, CalMatters, February 28, 2022, by Ana B. Ibarra

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Experts say allowing people to sign up for comprehensive Medi-Cal coverage regardless of their immigration status is the single biggest step California can take to insure as many people as possible in the current system. Newsom called his latest planned expansion “universal access to coverage.”

But the expansion would still leave several hundred thousand undocumented immigrants uninsured. They are unable to qualify because they have jobs where they earn above Medi-Cal’s annual income thresholds for most adults.

That leaves many low-income immigrants with few viable options for health coverage. While most Californians who earn over the Medi-Cal limit can get subsidized coverage through Covered California, undocumented people are not allowed to buy insurance through the marketplace under the federal Affordable Care Act.

In 2023, after Medi-Cal expands to cover undocumented immigrants 50 and older, about 3.2 million people will remain uninsured in California, according to researchers at the UC Berkeley Labor Center and the UCLA Center for Health Policy Research. Of those, 1.16 million will be unauthorized immigrants.

Even if Newsom’s next step is approved — covering undocumented adults 26 to 49 years old as early as 2024 — that would still leave roughly 450,000 undocumented people under 65 with no health coverage.

Lack of access because of immigration status is just one piece of the remaining uninsured. Many other Californians forgo coverage despite being eligible, likely because of the cost. According to the UC Berkeley and UCLA study, 2 million uninsured people qualify for Medi-Cal, employer coverage or Covered California.

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Comment:

By Don McCanne, M.D.

Well, so we can’t have single payer reform because it is too expensive, and we can’t afford the taxes to pay for it. But at least we can fill in much of the void in California and other states by providing Medi-Cal (Medicaid) to the undocumented… or can we? Check out the numbers.

Hundreds of thousands of the undocumented in California would still be left out and millions of other Californians would remain uncovered for other reasons, primarily for lack of affordability of insurance. And worse, our highly dysfunctional, fragmented healthcare financing system that shunts much of our healthcare dollars to entrepreneurial interests while impairing access to needed care would remain in place. Defective incremental patches can never serve as an effective substitute for a comprehensive, equitable, publicly administered, affordable, progressively funded program that is truly universal for life.

The recent Nation article by Michael Lighty shows how ridiculous our concern over single payer costs and taxes has been when we could have an ideal single payer system for less money than we are paying for our current inadequate, dysfunctional system. And the recent study from the Congressional Budget Office shows us that spending on a single payer system would not only fix our healthcare financing system and bring comprehensive health care to everyone, it would also provide improvements to the economy that would benefit all of us.

Merriam-Webster’s definition 3b for insanity: “something utterly foolish or unreasonable”

Now there is an instance we can save on healthcare that doesn’t even take a psychiatrist to manage. Let’s just get rid of our current dysfunctional financing system and substitute it with a single payer system. We’ll not only cure our insanity, we’ll be money ahead!

http://healthjusticemonitor.org…

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Summary: An excellent commentary in The Nation reviews the cost advantages of single payer in California and generally, the current health care cost explosion, and the unsavory trade-off foisted on us every day: corporate profits up, family health down.

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The Plan to Save Californians $117 Billion a Year by Switching to Single-Payer, The Nation, February 25, 2022, by Michael Lighty

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Why is universal health care seen as prohibitively expensive when the status quo costs far more?

In the public debate over Medicare for All, the first casualty is always the truth about costs, savings, and taxes. And the recent struggle in California over a proposed statewide single-payer health care bill, the California Guaranteed Health Care for All Act, has been no exception. Scouring the media coverage of the bill, also known as AB 1400, you would find a multitude of statistics and figures, but nowhere would you find this simple fact: Under the current system, health care in California will cost an estimated $517 billion in 2022. …

Reports from the Healthy California for All Commission, a single-payer health care task force appointed by the state government, estimate that the present system, characterized by huge inequities, coverage gaps, restrictions on access to care, and administrative complexity, will cost an estimated $323–$496 billion more in 2031 than would a single-payer system covering everybody. …

But what about taxes, the favorite scare tactic of those who profit from the current dysfunctional system? According to a study from the Healthy California for All Commission, it turns out that the current cost of health care is the biggest “tax” paid by the middle class—ranging from 25 to 40 percent of a household’s income. Single-payer financing eliminates that burden. Replacing the cost of premiums, co-payments and deductibles with modest public tax increases on businesses and high-income individuals seems like a very good deal. (Under California’s AB 1400, households making less than $600,000 per year would see no more than a 1 percent tax increase.) …

If readers are surprised to hear about the savings from single-payer, chalk it up to the influence of the health care industry, which has been repeating the lie that we cannot afford universal health care since 1993. Because the industry can literally charge whatever it wants now, single-payer represents a direct challenge to its profits and power.

Consider the industry’s ability to set the health policy agenda. Counting lobbying expenditures and campaign contributions, the health care sector spends more on influencing lawmakers than any other industry. A study published in The Journal of the American Medical Association found that between 1999 and 2018 “the pharmaceutical and health product industry spent $4.7 billion, an average of $233 million per year, on lobbying the US federal government; $414 million on contributions to presidential and congressional electoral candidates, national party committees, and outside spending groups; and $877 million on contributions to state candidates and committees.” …

The profits of the biggest health care corporations are obscene: Kaiser Permanente had a net income of $8.1 billion in 2021, a record. The same year, HCA, the largest for-profit hospital corporation, booked $7 billion in profits, while United Health, the largest commercial insurer, reported profits of $17.3 billion. … Meanwhile, patients die for lack of insulin, and Congress has so far failed to limit the price of this decades-old drug (as it has failed to limit the price of any prescription drug, which single-payer will do).

Sifting through the scare tactics, misrepresentations, and influence buying of the health care industry reveals a pattern of profiting from human suffering and protecting financial interests at the expense of our health. California, like the rest of the United States, can both save money and address our health inequities by adopting a single-payer system. Yes, we can afford to provide the health care that we need and deserve. In fact, we can’t afford not to.

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Comment:

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

My comment is short and sweet – Michael does a stellar job of summarizing favorable single payer cost analyses, rapidly rising healthcare costs in the current system, sky-high industry profits and salaries, political influence through donations and lobbying, and a “pattern of profiting from human suffering and protecting financial interests at the expense of our health.”

This piece is a must-read.

Single payer is a must-do.

http://healthjusticemonitor.org…

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