By Linda J. Blumberg
Urban Institute, June 2020

Exploring the Five Core Questions Necessary to Evaluate the Trade-Offs Inherent in a Health Reform Proposal

Evaluating the trade-offs inherent in the answers to each of the five core questions below is critical to understanding the philosophical underpinnings and general implications of health reform proposals.

1. How broadly should the costs of the sick be shared with the healthy?
2. How important is reaching true universal coverage? How many US residents must be insured?
3. How generous should federally financed subsidies of premiums and cost sharing be?
4. How should reform options be financed?
5. Should there be regulations limiting the prices paid to health care providers of different types (i.e., hospitals, physicians, prescription drug manufacturers, medical device manufacturers), and if so, how broadly should those regulations apply, and how should prices be set?

Answers to These Five Central Questions Frame Policy Proposals

To illustrate how this five-decision framework clarifies the reforms most frequently discussed, I use three policy examples:

• Full repeal of the ACA
• Build upon the ACA with additional financial assistance and a public option
• Replace the current system with an enhanced single-payer program

(Pages 10-14 provide the author’s answers to each of the five questions for each of the three models listed. Use the link to access the report.)

From the Conclusion

Advocates of various health care reform proposals are quick to extoll the virtues of their preferred reforms. But advocates should acknowledge the trade-offs inherent in their respective approaches. An educated consumer of public policy ideas should be aware that there is no perfect solution. All reforms will yield advantages and disadvantages, gains and losses. The challenge is finding a policy that represents a broadly accepted set of trade-offs. Any one person’s preferred trade-offs will hinge on their individual values and preferences. This brief is designed to help people understand the inherent consequences of different options so readers can make more informed choices about the types of reforms they support.

https://www.urban.org…

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Comment:

By Don McCanne, M.D.

Linda Blumberg is right when she says that we should understand the trade-offs with various health reform policies. But the policies are not neutral from a health care justice perspective. There are beneficial policies and detrimental policies, and we should not grant detrimental policies an equal status just because some individuals place self-interests above the rest of us. Let’s look briefly at the three models of reform she discusses.

Full Repeal of the ACA

1. Sharing health care costs of the sick with the healthy
   • It would increase health care costs for the sick
2. True universal coverage
   • Millions more would be uninsured
3. Generosity of federal subsidies of premiums and cost sharing
   • Insurance costs would increase for individuals and families
4. Financing this reform option
   • Federal support would be reduced
5. Price regulation
   • Reduction of government price oversight

Build upon the ACA with Additional Financial Assistance and a Public Option

1. Sharing health care costs of the sick with the healthy
   • Many of the sick would still face significant costs
2. True universal coverage
   • Many immigrants would still remain uninsured, and others underinsured
3. Generosity of federal subsidies of premiums and cost sharing
   • Subsidies would be expanded but many will still face significant costs
4. Financing this reform option
   • More federal support but inequitable private spending would persist
5. Price regulation
   • Public option would be regulated, but not employer-based plans

Replace the Current System with an Enhanced Single-Payer Program

1. Sharing health care costs of the sick with the healthy
   • All costs care shared equitably through a universal risk pool
2. True universal coverage:
   • All residents are covered regardless of immigration status
3. Generosity of federal subsidies of premiums and cost sharing
   • Financial barriers to health care would be removed
4. Financing this reform option
   • Fully funded through equitable progressive taxes
5. Price regulation
   • Fair prices would be paid through rate negotiation and global budgeting

So let’s accept good policies while rejecting the bad. It’s long past time that we replace the I/me/mine selfish, uncaring policies with we/us/ours egalitarianism so that all of us can have accessible, affordable health care whenever we need it.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Jessica Silver-Greenberg, Jesse Drucker and David Enrich
The New York Times, June 8, 2020

The New York Times analyzed tax and securities filings by 60 of the country’s largest hospital chains, which have received a total of more than $15 billion in emergency funds through the economic stimulus package in the federal CARES Act.

The hospitals — including publicly traded juggernauts like HCA and Tenet Healthcare, elite nonprofits like the Mayo Clinic, and regional chains with thousands of beds and billions in cash — are collectively sitting on tens of billions of dollars of cash reserves that are supposed to help them weather an unanticipated storm. They awarded their five highest-paid officials about $874 million in the most recent year for which they have disclosed their finances.

At least 36 of those hospital chains have laid off, furloughed or reduced the pay of employees as they try to save money during the pandemic.

Industry officials argue that furloughs and pay reductions allow hospitals to keep providing essential services at a time when the pandemic has gutted their revenue.

But more than a dozen workers at the wealthy hospitals said in interviews that their employers had put the heaviest financial burdens on front-line staff, including low-paid cafeteria workers, janitors and nursing assistants. They said pay cuts and furloughs made it even harder for members of the medical staff to do their jobs, forcing them to treat more patients in less time.

But the formulas to determine how much money hospitals receive were based largely on their revenue, not their financial needs. As a result, hospitals serving wealthier patients have received far more funding than those that treat low-income patients,.

One of the bailout’s goals was to avoid job losses in health care, said Zack Cooper, an associate professor of health policy and economics at Yale University who is a critic of the formulas used to determine the payouts. “However, when you see hospitals laying off or furloughing staff, it’s pretty good evidence the way they designed the policy is not optimal,” he added.

The for-profit hospital giant Tenet Healthcare, which has received $345 million in taxpayer assistance since April, has furloughed roughly 11,000 workers, citing the financial pressures from the pandemic. The company’s chief executive, Ron Rittenmeyer, told analysts in May that he would donate half of his salary for six months to a fund set up to assist those furloughed workers.

But Mr. Rittenmeyer’s salary last year was a small fraction of his $24 million pay package, which consists largely of stock options and bonuses, securities filings show. In total, he will wind up donating roughly $375,000 to the fund — equivalent to about 1.5 percent of his total pay last year.

The chief executive at HCA, Samuel Hazen, has donated two months of his salary to a fund to help HCA’s workers. Based on his pay last year, that donation would amount to about $237,000 — or less than 1 percent — of his $26 million compensation.

Apparently anticipating a strike, a unit of HCA recently created “a new line of business focused on staffing strike-related labor shortages,” according to an email that an HCA recruiter sent to nurses.

The email, reviewed by The Times, said nurses who joined the venture would earn more than they did in their current jobs: up to $980 per shift, plus a $150 “Show Up” bonus and a continental breakfast.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Billions of dollars of taxpayer funds have been paid out to some of the nation’s largest and most successful hospital chains, supposedly to prevent job losses of health care workers, though tens of thousands have instead received pay cuts or have even been furloughed (1.4 million health care jobs lost in April – Bureau of Labor).

And the CEOs of these chains? Showing sympathy, the CEOs of industry giants Tenet and HCA have agreed to a reduction of about one percent of their incomes to assist their workers in these difficult times. It must be quite a hardship to get by on the remaining ninety-nine percent of their eight-digit incomes.

Further, HCA has created a new line of business focused on staffing strike-related labor shortages, promising nurses who join their new venture pay raises, bonuses, and even a continental breakfast. Nobody can say that these CEOs are heartless, at least not for the strike-breaking nurses who are willing to join them in their venture, if any such nurses even exist. All of the nurses I know advocate for their patients rather than for corporate CEOs and shareholders.

Another excerpt from today’s article probably reveals more about the cold, cold hearts of the HCA executives:

“Rosa Luna, who cleaned patient rooms at HCA’s hospital in Riverside, Calif., died of the virus; her colleagues had warned executives in emails that workers, especially those cleaning hospital rooms, weren’t provided proper masks. Around the time of Ms. Luna’s death, HCA executives delivered a warning to officials at the Service Employees International Union and National Nurses United, which represent many HCA employees. The company would lay off up to 10 percent of their members, unless the unionized workers amended their contracts to incorporate wage freezes and the elimination of company contributions to workers’ retirement plans, among other concessions.”

If the nurses agree to these reductions, will the executives agree to a ten percent reduction in their work force while forgoing their pensions and stock options and bonuses, along with making other concessions (oh no, not the corporate jet!)? Didn’t think so.

We are already spending $4 trillion on health care. That’s enough to take care of everyone through a well designed, single payer, improved Medicare for All. There are plenty of hospital administrators who believe in patient service, who will work for fair incomes, and who would be honored to be part of the Medicare for All team.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Fritz Heese and David Fries
Marsh & McLennan, Oliver Wyman, Accessed June 5, 2020

There are a few claims we’re making (with confidence!) about healthcare’s future. We predict healthcare’s migration to value will continue. Margin pressure and intense competitive pressure will push efficiency among incumbents (like automating and transitioning care to lower acuity environments). Industry boundaries will be challenged as digital, retail, and other companies make deeper forays into healthcare. But how fast will change happen? And who will win (and lose) profit share?

Below, we examine the range of possible scenarios.

Scenario 1: Status Quo Continues

Here, the next decade closely mirrors the last. Total healthcare costs increase before levelling off with gross domestic product growth. Value-based reimbursement models become only slightly more common. Healthcare’s still primarily fee-for-service. Government deficits continue, but Medicare and Social Security remain solvent.

Incumbents still create incremental efficiency through consolidation and process improvement. Most improvements are uniform, maintaining competitive parity without providing undue advantage to new business models. Electronic Health Record penetration reaches maturity, creating process efficiencies and modest clinical management improvements, reducing unnecessary medical costs.

Payers’ progress is evolutionary. They create simpler, more flexible products featuring integrated ancillary coverage, sculpted networks, and other cost-cutting levers. Care management programs slowly improve. Payer business models aren’t fundamentally disrupted.

Next-generation delivery models (like Iora, Amazon, and Omada) with potential for massive disruption exist, but still at the margins. Innovation happens in pockets. Nobody develops scalable, innovative solutions. Costs increase, but not faster than the system can withstand. Medicare and Social Security remain solvent. Industry economics are largely unchanged.

This scenario may seem unlikely. But if we’d written these words in 2009, it’s this scenario that would have best described the next ten years, where innovations and improvements happen in silos without fundamentally changing healthcare’s economic landscape.

Scenario 2: Healthcare As A No Profit Zone

This scenario begins like the last, but with less optimistic macroeconomics. The industry cannot drive incremental value without fundamentally disrupting existing business models. Government deficits skyrocket. Continued increase in deductibles and out-of-pocket spend oppresses patients, driving political reform. As a result, there’s a “reckoning” five years out, when rising healthcare costs become unbearable.

Medicare and Medicaid reimbursement is reduced, hitting pharma hard, as the government targets drug reimbursement parity with Organisation for Economic Co-operation and Development (OECD) countries. Annual prescription drug price increases disappear. More stringent limitations regarding comparative effectiveness limit new drugs coming to market. The government launches a “Medicare for all” single payer option which is managed similarly to Medicare Fee-for-Service, where payers play only a small, back office processing role. And thus, payers lose most of their commercially insured members to Medicare, now a direct competitor. Employers, eager to reduce costs and offer lower premiums and deductibles, contract directly with providers for the remaining commercial business, further dwindling legacy payer membership.

Incumbents’ margins are dramatically compressed. Consolidation pushes as far as regulators allow, leaving a few incumbents with razor thin margins, as price and earnings multiples enter mid-single digits. Like Scenario 1, innovative start-up and out-of-industry solutions exist in pockets, but aren’t profitable, or scalable enough to disrupt. Despite enough well-funded investors to spark competition and drive lower prices, a killer solution doesn’t thrive and prosper in the end.

Scenario 3: Triumph of Value – Incumbent-Led

Several “vectors to value” reach critical inflection points, going from pilots and silos to disruptors. Market incumbents lead the way. This creates massive consumer value and significantly expands healthcare profit pools, increasing opportunities to harness value for both incumbents and new market entrants. “Value” broadly includes supply-side and demand-side innovations driving better outcomes and lower cost of care.

(For details, use link below.)

Payers leave underwriting and risk taking for healthcare data science, behavior change, and managing an “iPhone-like” integrated healthcare experience. Highly performing providers heavily incentivized for cost and quality achieve massive gainsharing. Across these industries, incumbents hyper-aggressively acquire new innovations that drive transformation.

Scenario 4: Triumph of Value – Innovator-Led

Healthcare majorly pivots towards consumerism; the “Behavior”, “Tech”, and “Science” vectors initially dominate. Brand power, engagement, and strong consumer relationships become primary differentiators. Magnetic platform owners creating quality consumer experiences accrue value. Amazon and/or smart phone apps provide integrated consumer solutions to find doctors, purchase insurance, and change behaviors, leading to healthier lives. New market entrants capitalize on customer relationships to provide more traditional healthcare services, playing in the “Tools” and “Delivery” vectors. Increasingly, these solutions lead patients to healthcare’s “new front door” through retail clinics or virtual care owned and operated by new entrants. Incumbent business models remain largely stagnant, relegated to suppliers highly detached from customers.

Health insurers and traditional providers are commoditized, “racing to the bottom” to offer the lowest prices for services where patients use digital comparative shopping tools. Patients are loyal to the platform, not payers and providers (now secondary vendors). In an extreme case, the traditional healthcare system becomes a last resort destination as patients seek virtual care or retail clinic options, for all but the highest acuity care episodes. Low acuity care is no longer considered “healthcare”, but a consumer service provided by a mix of retail and Internet companies.

For incumbents, results mirror the “Health as a No Profit Zone,” Scenario 2 as they cede wallet share to out-of-industry players, now earning only a small profit portion in healthcare’s new market. Meanwhile, companies considered “non-healthcare” in 2019 will accumulate well over a trillion dollars in healthcare market cap by 2030.

In the future, different scenarios will increase value with highly contrasting implications for profit shares. Those who understand trends, vectors, and how to create strategic control and value will be best positioned. 2030, here we come.

https://www.mmc.com…

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Comment:

By Don McCanne, M.D.

Predicting the status of health care a decade from now is difficult because of the variables, but since the medical-industrial complex is dominating health care, the perspective of Oliver Wyman health care consultants is important since they have a better grasp than the health care professionals do as to where health care is headed.

The most likely scenario is tweaking of the status quo (though the authors state that this may seem unlikely, and that may be the case considering the plethora of capitalists swooping in to try to grab a major portion of the $4 trillion health care market). At any rate, the status quo is not satisfactory since it is failing far too many of us who need health care.

There is much talk today about replacing health care volume with value, and the authors suggest two scenarios in which that could occur: one in which the “incumbents” move from pilots and silos to disruptors, and the other in which “innovators” move in and take over. In both of these scenarios the business players take over and the traditional patient-oriented health care professionals become tools of the entrepreneurs, as the Hippocratic and Oslerian traditions fade into the background. Those who believe that capitalism should always prevail may find this approach to be great, but those supporting health care justice for all will likely find this sadly lacking.

From PNHP’s perspective, their scenario of “healthcare as a no profit zone” should interest us since it is based on their concept of how a “single payer ‘Medicare for All’ option” would transform our system (seemingly confounding a public option with single payer). They seem to be describing the changes from the perspective of a capitalistic, market-oriented entrepreneur – a sector that would be disappointed as the rewards of the system would go to the patients instead of to those who capture the market.

In sharp contrast, our vision of a well designed, publicly-funded and publicly-administered, single payer Medicare for All program would bring us the health care nirvana that we have been seeking. The problem is, they are in control. Their followers likely would prefer the innovator-led, profit-seeker approach (aka value-seeker), while leaving most of the incumbents behind and disrupting the status quo.

Think about it. Shall we just take potshots from the sidelines as the medical-industrial complex continues to transform the system to their liking? Or shall we finally get off our duffs and take over the process? Remember, we’re the ones who advocate for the patients, and that’s what the health care system should be all about. Right?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Angela P. Harris and Aysha Pamukcu
Law and Political Economy, June 4, 2020

“We’re all in this together” has become a familiar call for strengthening our sense of community and social responsibility during the COVID-19 pandemic. Although this phrase can obscure deep social inequities, this recognition of our interdependence presents an opportunity to connect economic justice and public health. COVID-19 has instilled a new public understanding that our collective health and safety is contingent on the fate of the most marginalized and least prosperous among us.

Author Anand Giridharadas has asked, “Take note today of the people who come within infecting distance of you. Are you confident they all have access to the care they need to be healthy—and keep you healthy?” We could easily expand that question: how confident are we that those around us have paid sick leave, decent working conditions, and housing where they can safely quarantine?

But even if the US strengthened its economic policies and successfully “flattened the curve” overall, we wouldn’t make a dent in the shocking disparities in mortality rates that are appearing in our daily news feeds. COVID-19 may endanger us all, but it is far more costly to some than others.

In a forthcoming article in the UCLA Law Review (see below), we — a critical race feminist and a health justice attorney — call for a campaign by public health advocates, civil rights lawyers, and frontline communities for “the civil rights of health.” We argue that policy should take a “targeted universalism” approach – working to address universal and particular needs at the same time by promoting policies that help everyone while providing the greatest benefit to the most marginalized. Although we wrote this article before the COVID-19 outbreak, we think its principles are fully applicable to our current plight.

Well-established literature on the social determinants of health shows us that individual choices determine our health outcomes far less than we think. The civil rights of health begin with a recognition that the cause of unjust health disparities is, quite simply, subordination. Based on the research, we identify three broad and interacting pathways through which subordination is written on the body: population, place, and power. COVID-19 has taken all three pathways in its spread across the US, resulting in unjust and racialized health outcomes.

Based on the incomplete data available across states, the national COVID-19 mortality rate for African Americans is 2.3 times higher than the rate for Asians and Latinxs, and 2.6 times higher than the rate for Whites.

These overall disparities were dwarfed by disparities in the nation’s “hot spots.”

These racial disparities in death rates are caused by — and amplified by — other social and economic inequities. Those who are homeless have no feasible options to “shelter in place.” People incarcerated in prisons and detention centers are prevented from practicing physical distancing safety measures. Low-wage workers are classified as essential and yet are not provided with appropriate protective equipment and paid sick leave. As the weeks pass, we are confronted with mounting examples of already-broken systems that now pose a deadly public safety threat.

We argue in our article that one way to forge an alliance among civil rights lawyers, marginalized communities, and public health advocates is to recognize that oppression is a health issue. Put simply, justice strengthens public health and injustice weakens it. Today, COVID-19 has clearly demonstrated that pandemics — and other disasters — thrive on inequality.

Not all government entities are rising to the occasion. We see actors in the federal government promoting unproven cures for the virus and using racially inflammatory language against Asian communities. Even the Centers for Disease Control and Prevention (CDC) chose to look the other way on some of the disparate effects of COVID-19, by initially only releasing location and age data regarding the pandemic while ignoring race.

In contrast, local communities across the country are stepping up.

We can build on these efforts by aligning public health data collection and interventions with a civil rights focus on eliminating oppression. We suggest that public health practitioners explicitly connect unjust health outcomes across population and place with subordination. Doing so will allow advocates to better address the root causes of poor health.

Today’s social movements are seizing the opportunity to change the underlying narratives that influence policy. For too long, health has been commonly understood to be a private good that people could enjoy by making the “right” decisions, like buying insurance, eating kale, or lifting weights. Today, with the help of public health, civil rights, and social justice advocates, economic justice is being reframed as a public good that benefits everyone’s health.

COVID-19 has demonstrated the dangers of treating the social determinants of health as private goods reserved for the fortunate few. We argue that it’s time to treat good jobs, affordable and adequate housing, clean air and water, and above all, anti-discrimination law and policy as health interventions that can both flatten the curve for everyone and close the unjust gap between the privileged and the subordinated.

Angela P. Harris is Professor Emerita at the UC Davis School of Law and the 2019-20 Visiting William H. Neukom Fellows Research Chair in Diversity and Law at the American Bar Foundation.

Aysha Pamukcu is the 2019-2020 Fulcrum Fellow at ChangeLab Solutions, where she was previously Health Equity Lead and Senior Attorney.

https://lpeblog.org…

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The Civil Rights of Health: A New Approach to Challenging Structural Inequality

By Angela P. Harris and Aysha Pamukcu
SSRN, UCLA Law Review, forthcoming, draft last revised Feb. 19, 2020

Abstract

An emerging literature on “the social determinants of health” reveals that a major driver of public health disparities is subordination. This body of research makes possible a powerful new alliance between public health and civil rights advocates: an initiative to promote the “civil rights of health.” Understanding health as a matter of justice and civil rights law as a health intervention has the potential to strengthen public health advocacy. At the same time, understanding social injustice as a health issue as well as a moral issue has the potential to reinvigorate civil rights advocacy. However, given the history of legal/public health initiatives that have reflected and even reinforced subordination, social movements are an essential advocacy partner and watchdog. This Article argues that a civil rights of health initiative built on a “health justice” framework can help educate policymakers and the public about the health effects of subordination, create new legal tools for challenging subordination, and ultimately reduce or eliminate unjust health disparities.

Conclusion

As a joint project of public health, social justice, and legal advocates, promoting the civil rights of health holds the potential to foster public and elite awareness of the systems of subordination that produce and perpetuate health disparities. We end with a word about partnerships.

Public health research demonstrates how even policies that seem far from the health arena have significant and often measurable health implications and impacts. Moreover, public health data is incredibly powerful and even predictive on a population basis — something which has yet to be effectively harnessed by the legal field, including civil rights advocates. Fully realizing the civil rights of health will require interdisciplinary and cross-sector collaboration to strategize and leverage collective resources. This work will require combined social, political and legal strategies, and much remains to be done.

One natural place to begin this collaboration is in our law schools. Within legal education, public health law is considered a “niche” subject; few faculty teach it and relatively few students are exposed to it. Properly understood, however, public health law is deeply integral to social justice, as the literature on the social determinants of health makes clear. Introducing the literature of the social determinants of health, not just to public health law faculty and students, but more broadly to students and faculty in a range of civil rights-related courses will help make clear the importance of health justice to the social justice mission. Courses that could incorporate information about the social determinants of health include poverty law, civil rights law, constitutional law, critical race theory, gender, sexuality and the law, environmental law, and international human rights law, as well as practice-related courses like legislative advocacy, public interest practice, and policy advocacy.

Finally, we note that alliances among social justice advocates and civil rights advocates have made surprising recent gains in a time of retrenchment and pessimism. Campaigns such as “Ban the Box” and the “fight for $15” have succeeded in moving the needle on mass incarceration and economic justice. The “Me Too” and “Time’s Up” initiatives have similarly reinvigorated the battle against sexual violence, harassment, and exploitation. LGBT advocates have established same-sex marriage as the law of the land and called attention to the distinctive subordination of trans and gender-nonconforming people, despite legal setbacks. Health justice builds on the work of [x] justice movements that have come before, and carries the potential to unite them in an overall concern for human flourishing.

The geographer Ruth Gilmore famously defined racism as “the state-sanctioned or extralegal production and exploitation of group-differentiated vulnerability to premature death.” It is perhaps fitting, and unsurprising, that justice makes us healthy and injustice makes us ill. With this recognition bolstered by science as well as law, we are at an important beginning of new scholarship and practice. We hope this Article will be read not as a summation, but a call to action.

https://papers.ssrn.com…

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Comment:

By Don McCanne, M.D.

We have read much about the social determinants of health and the social and economic inequities that lead to unjust health disparities. As these authors state, “justice makes us healthy and injustice makes us ill.”

At PNHP, we have long advocated for a health care financing system that will make health care accessible and affordable for everyone – the single payer model of Medicare for All. But there is so much more involved in the health of the public even before the need to access the health care delivery system. In their paper, “The Civil Rights of Health: A New Approach to Challenging Structural Inequality,” Angela Harris and Aysha Pamukcu propose that we situate “the civil rights of health” within the emergent “health justice movement,” a framework that places the empowerment of vulnerable populations at the center of action.

Quoting the authors, “A health justice approach to the civil rights of health allows for many possible alliances between legal power, scientific power, and people power. Some partnerships may be preventive in nature, such as participatory budgeting and community-based comprehensive planning; others will be necessarily reactive, such as collaborations among public health and immigrant justice advocates to provide flu shots to detained migrants at the U.S.-Mexico border. The ultimate goal, however, is what the public health world calls ‘health equity’ – a world in which your wealth, your social status, your access to power, and your zip code are irrelevant to your life expectancy or vulnerability to illness.”

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By David J. Nyweide, Woolton Lee, and Carrie H. Colla
Health Affairs, June 2020

Abstract

Both the number and the size of accountable care organizations (ACOs) in the Medicare Shared Savings Program have been increasing. The number of ACOs rose from 220 in 2013 to 548 in 2018, while the average number of participating clinicians in ACOs increased from 263 to 653. Although increases occurred for primary care physicians (from an average of 141 to 251) and medical specialists (from an average of 76 to 157), the increase for nonphysician practitioners (from an average of 47 to 245) was the largest. These differential increases changed the ACO workforce composition over time. The average proportion of nonphysician practitioners in ACOs grew from 18.1 percent to 38.7 percent, with a commensurate decline in the average share of primary care physicians from 60.0 percent to 42.2 percent. As value-based care models grow in prevalence, their evolving clinician composition may affect workforce patterns in the broader health care delivery system.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Supposedly accountable care organizations (ACOs) are designed to make physicians more accountable for quality and costs of health care. This study shows that in ACOs the proportion of primary care physicians are declining by 30% (from 60.0% to 42.2%) whereas the proportion of nonphysician practitioners are increasing by 114% (from 18.1% to 38.7%).

So far the studies of ACOs have been quite unimpressive as far as cost savings are concerned. With this large of a shift of services from higher paid physicians to less costly nonphysicians, it seems that more significant cost reductions should be in order. Can it be that the inefficiencies of the extra administrative costs of ACOs is consuming the potential cost savings? Are patients getting a better deal by switching to nonphysicians even though there is not much saved by that shift? And quality? Are patients receiving higher quality care by switching to nonphysicians?

There are plenty of reasons to believe that the ACO experiment has been a failure. The added efficiencies that should be attainable by shifting some care to nonphysicians should be beneficial from a cost perspective without impairing quality. But apparently the ACO model has been a failure on this count as well.

Let’s dump the failed ACO concept and move forward with the more efficient single payer model of Medicare for All wherein all health care professionals are serving in positions for which they are appropriately trained. That can help us actually achieve higher quality at a more affordable cost.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By The Associated Press
AP, June 2, 2020

Throughout January, the World Health Organization publicly praised China for what it called a speedy response to the new coronavirus. It repeatedly thanked the Chinese government for sharing the genetic map of the virus “immediately,” and said its work and commitment to transparency were “very impressive, and beyond words.”

But behind the scenes, it was a much different story, one of significant delays by China and considerable frustration among WHO officials over not getting the information they needed to fight the spread of the deadly virus, The Associated Press has found.

Despite the plaudits, China in fact sat on releasing the genetic map, or genome, of the virus for more than a week after three different government labs had fully decoded the information.

Chinese government labs only released the genome after another lab published it ahead of authorities on a virologist website on Jan. 11.

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On Jan. 13, WHO announced that Thailand had a confirmed case of the virus, jolting Chinese officials.

The next day, in a confidential teleconference, China’s top health official ordered the country to prepare for a pandemic, calling the outbreak the “most severe challenge since SARS in 2003”, as the AP previously reported. Chinese CDC staff across the country began screening, isolating, and testing for cases, turning up hundreds across the country.

Yet even as the Chinese CDC internally declared a level one emergency, the highest level possible, Chinese officials still said the chance of sustained transmission between humans was low.

WHO went back and forth. Van Kerkhove said in a press briefing that “it is certainly possible there is limited human-to-human transmission.” But hours later, WHO seemed to backtrack, and tweeted that “preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission” – a statement that later became fodder for critics.

A high-ranking official in WHO’s Asia office, Dr. Liu Yunguo, who attended medical school in Wuhan, flew to Beijing to make direct, informal contacts with Chinese officials, recordings show. Liu’s former classmate, a Wuhan doctor, had alerted him that pneumonia patients were flooding the city’s hospitals, and Liu pushed for more experts to visit Wuhan, according to a public health expert familiar with the matter.

On Jan. 20, the leader of an expert team returning from Wuhan, renowned government infectious diseases doctor Zhong Nanshan, declared publicly for the first time that the new virus was spreading between people. Chinese President Xi Jinping called for the “timely publication of epidemic information and deepening of international cooperation.”

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On Jan. 22, WHO convened an independent committee to determine whether to declare a global health emergency. After two inconclusive meetings where experts were split, they decided against it — even as Chinese officials ordered Wuhan sealed in the biggest quarantine in history. The next day, WHO chief Tedros publicly described the spread of the new coronavirus in China as “limited.”

For days, China didn’t release much detailed data, even as its case count exploded. Beijing city officials were alarmed enough to consider locking down the capital, according to a medical expert with direct knowledge of the matter.

On Jan. 28, Tedros and top experts, including Ryan, made an extraordinary trip to Beijing to meet President Xi and other senior Chinese officials. It is highly unusual for WHO’s director-general to directly intervene in the practicalities of outbreak investigations. Tedros’ staffers had prepared a list of requests for information.

“It could all happen and the floodgates open, or there’s no communication,” Grein said in an internal meeting while his boss was in Beijing. “We’ll see.”

At the end of Tedros’ trip, WHO announced China had agreed to accept an international team of experts. In a press briefing on Jan. 29, Tedros heaped praise on China, calling its level of commitment “incredible.”

The next day, WHO finally declared an international health emergency. Once again, Tedros thanked China, saying nothing about the earlier lack of cooperation.

“We should have actually expressed our respect and gratitude to China for what it’s doing,” Tedros said. “It has already done incredible things to limit the transmission of the virus to other countries.”

https://apnews.com…

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Comment:

By Don McCanne, M.D.

President Trump has recently condemned both China and the World Health Organization for their alleged delays and mismanagement of the COVID-19 pandemic. He has cut off US funding for WHO and has stated he would make good on his threat to withdraw from the organization.

AP’s global investigative team has described the alleged delays by China and the frustrations of WHO’s leadership which occurred in January, before the seriousness of the infectious process was recognized, and long before WHO’s March 11, 2020 declaration of the Novel Coronavirus Disease pandemic. More details can be found in the full article at the link above. Although the reporters do seem to be somewhat critical of China’s decisions, it is difficult to see significant signs of incompetence or neglect considering how early it was in trying to understand this new disease.

Compare that to the United States. This is now June, and, so far, our federal government has provided very little substantive support to combating this horrendous pandemic, while seemingly passively accepting the sacrifice of our health care workers and professionals dedicated to caring for these patients, not to mention the deaths of over 100,000 US residents. China and WHO have been far ahead of us in their response, but, instead of cooperating with them, our president wants to withdraw. The reasons are not clear, but he seems to be waiting for the development of drugs and vaccines in the private sector which he and some in his administration believe will be very successful from a business perspective if they can just beat China to the world market.

This pandemic shouldn’t simply be looked upon as an opportunity to control pharmaceutical markets and charge the highest prices the market will bear. It’s a pandemic. We should be working with the rest of the world to bring it under control, and that means that we should be working closely with the organization that exists for this very purpose – the World Health Organization. Mr. Trump, please, the world needs us to be involved.

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By Patrice A. Harris, M.D., M.A.
President, American Medical Association
AMA, May 29, 2020

“In the grip of a global pandemic that has already killed more than 100,000 Americans, severing ties with the World Health Organization (WHO) serves no logical purpose and makes finding a way out of this public health crisis dramatically more challenging. This senseless action will have significant, harmful repercussions now and far beyond this perilous moment, particularly as the WHO is leading worldwide vaccine development and drug trials to combat the pandemic. COVID-19 affects us all and does not respect borders; defeating it requires the entire world working together. In the strongest terms possible, the American Medical Association urges the president to reverse course and not abandon our country’s leadership position in the global fight against COVID-19.”

https://www.ama-assn.org…

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Comment:

By Don McCanne, M.D.

President Trump’s effort to sever ties with the World Health Organization during this horrendous pandemic seems like it screams out for nonviolent resistance. Can’t we get anything right?

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By Stacey McMorrow, Lisa Dubay, Genevieve M. Kenney, Emily M. Johnston, and Clara Alvarez Caraveo
Urban Institute, May 28, 2020

Abstract

Alarming increases in US maternal mortality have generated national attention, a search for policy solutions to promote maternal health, and an increased recognition of how important the postpartum period is for mothers’ and infants’ health and well-being. Without access to consistent, comprehensive health insurance coverage, many new mothers can face extreme challenges obtaining the care they need to support their and their infants’ health. This analysis uses 2015–18 data from the National Health Interview Survey (NHIS) to document access and affordability challenges facing uninsured new mothers and 2015–17 data from the Pregnancy Risk Assessment and Monitoring System (PRAMS), a state-specific surveillance system of pregnancies resulting in a live birth, to describe the health status of women who lost Medicaid coverage following their pregnancies. Together, our analysis provides new evidence on the access and affordability barriers that could be reduced and the health problems that could be treated if these uninsured new mothers were to gain coverage through a postpartum Medicaid extension or broader Medicaid expansion.

From the Discussion

Despite documented increases in insurance coverage for new mothers under the ACA, more than 1 in 10 new mothers remained uninsured from 2015 to 2018, and over half of those women were Hispanic and nearly two-thirds lived in the South. About 1 in 5 uninsured new moms reported at least one unmet need for medical care because of cost, and over half were very worried about paying their medical bills, emphasizing that health care affordability is a problem for many new mothers. Moreover, about half of all uninsured new mothers reported that losing Medicaid or other coverage after pregnancy was the reason they were uninsured. Thus, it appears many new mothers could benefit from the financial protection that insurance can provide and would likely benefit from the extensions of postpartum Medicaid coverage that have been proposed at both the federal and state levels.

Even if a permanent postpartum extension were adopted, however, not all uninsured new mothers would qualify. Access to postpartum coverage under current rules depends critically on state-specific eligibility criteria for pregnancy-related Medicaid coverage, based both on income and immigration status and on which women actually enroll in Medicaid during their pregnancies. These same factors will determine who is eligible for the maintenance-of-effort provisions under the Families First Coronavirus Response Act and state-specific implementation of the provisions may vary. Moreover, the economic downturn may extend well beyond the public health emergency, leaving many new mothers at higher risk of being uninsured when the maintenance-of-effort provision expires or if they lose other coverage sources because of rising unemployment. Without additional federal or state action to expand access to affordable coverage options, many new mothers may remain uninsured both during and after the public health crisis.

Our findings suggest that if new mothers were to gain coverage through an extension of postpartum Medicaid eligibility, they could experience reduced affordability problems and an improved ability to manage chronic conditions during that critical period after giving birth. However, longer-term solutions to addressing the maternal morbidity and mortality crisis would involve achieving continuous coverage and care throughout a woman’s reproductive years. A more comprehensive Medicaid expansion, for example, would allow more low-income women to identify and manage their chronic conditions, plan and support wanted pregnancies, and maintain good health to support ongoing maternal and child well-being.

https://www.urban.org…

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Comment:

By Don McCanne, M.D.

“And poor people who are uninsured? They can always get Medicaid.”

No. There are a great many reasons why uninsured, low-income individuals may not be able to enroll in Medicaid, ranging from qualifications based on their own personal situations to public policies that vary by the state in which they reside. This Urban Institute study shows that even those who may have been enrolled in Medicaid during a pregnancy can lose that coverage in their postpartum period. That certainly indicates a serious policy deficiency.

The authors suggest that the incremental reform of expanding coverage during the postpartum period can close the gap for some of them, though there will always be others who remain uninsured for various reasons.

The authors then make what at first glance seems to be an excellent suggestion of providing Medicaid coverage throughout a woman’s reproductive years. But what happens when that woman moves to a different state with different rules, or her income no longer falls within the qualifying level, or she has stuttering coverage through her spouse’s employer-sponsored plan(s), or qualifications change based on Medicaid waivers or budgetary constraints, or whatever? Also, why cover her only through her reproductive years and not in childhood and beyond menopause? And why not automatically cover the infant produced by that pregnancy? And what about other women not eligible for the Medicaid program? And, while we’re at it, what about everyone else throughout their entire lives?

Incremental reforms such as expanding postpartum coverage fail to correct the gross fundamental defects in our health care financing system such as the lack of universality, the profound, expensive administrative excesses, the lack of affordability for far too many individuals and families, and the profound inequities that should not exist in the most expensive system in the world. Most of the proposed incremental reforms add to the administrative complexity and costs while falling far short of the essential goals of universality, comprehensiveness, high quality, effectiveness, efficiency, equity, and affordability.

Instead of tinkering with postpartum coverage of Medicaid patients, the Urban Institute should look at their own study of single payer Medicare for All, correct its deficiencies (we’ll help them), and then advocate for its adoption since it would truly ensure health care for all of us, with postpartum care automatically included.

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By Arundhati Roy
Financial Times, April 3, 2020

But unlike the flow of capital, this virus seeks proliferation, not profit, and has, therefore, inadvertently, to some extent, reversed the direction of the flow. It has mocked immigration controls, biometrics, digital surveillance and every other kind of data analytics, and struck hardest — thus far — in the richest, most powerful nations of the world, bringing the engine of capitalism to a juddering halt. Temporarily perhaps, but at least long enough for us to examine its parts, make an assessment and decide whether we want to help fix it, or look for a better engine.

The mandarins who are managing this pandemic are fond of speaking of war. They don’t even use war as a metaphor, they use it literally. But if it really were a war, then who would be better prepared than the US? If it were not masks and gloves that its frontline soldiers needed, but guns, smart bombs, bunker busters, submarines, fighter jets and nuclear bombs, would there be a shortage?

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Finally, on March 19, the Indian prime minister addressed the nation. He hadn’t done much homework. He borrowed the playbook from France and Italy. He told us of the need for “social distancing” (easy to understand for a society so steeped in the practice of caste) and called for a day of “people’s curfew” on March 22. He said nothing about what his government was going to do in the crisis, but he asked people to come out on their balconies, and ring bells and bang their pots and pans to salute health workers.

On March 24, at 8pm, Modi appeared on TV again to announce that, from midnight onwards, all of India would be under lockdown. Markets would be closed. All transport, public as well as private, would be disallowed.

He said he was taking this decision not just as a prime minister, but as our family elder. Who else can decide, without consulting the state governments that would have to deal with the fallout of this decision, that a nation of 1.38bn people should be locked down with zero preparation and with four hours’ notice? His methods definitely give the impression that India’s prime minister thinks of citizens as a hostile force that needs to be ambushed, taken by surprise, but never trusted.

Locked down we were. Many health professionals and epidemiologists have applauded this move. Perhaps they are right in theory. But surely none of them can support the calamitous lack of planning or preparedness that turned the world’s biggest, most punitive lockdown into the exact opposite of what it was meant to achieve.

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What is this thing that has happened to us? It’s a virus, yes. In and of itself it holds no moral brief. But it is definitely more than a virus. Some believe it’s God’s way of bringing us to our senses. Others that it’s a Chinese conspiracy to take over the world.

Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality.

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next.

We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.

https://www.ft.com…

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Comment:

By Don McCanne, M.D.

Financial Times has made the full article available for free at the link above. It is quite provocative. In this difficult time of the pandemic and associated financial crisis, provocation seems to be right in order.

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