PNHP

You don’t need a pandemic to lose your health plan at work

You don’t need a pandemic to lose your health plan at work

Millions of Americans are about to lose their health insurance in a pandemic

Americans are about to learn something horrifying: how irrational it is for health insurance to be linked to your employment status

By Wendell Potter
The Guardian, March 27, 2020

The tragic effects of our battle with the novel coronavirus are seemingly endless. But arguably the most mind-blowing is this: the very pandemic that threatens to infect and kill millions is simultaneously causing many to also lose their health coverage at their gravest time of need.

Here’s how: the virus has caused a public health crisis so severe that people have been forced to stay home, causing businesses to shutter and lay off workers. And with roughly half of Americans getting their health insurance from their employer, these layoffs mean not only losing their income but also their medical coverage. In other words, just as our need for medical care skyrockets in the face of a global pandemic, fewer will have health insurance or be able to afford it.

America needs to finally get out of the business of linking health coverage to job status. Even in better times, this arrangement was a bad idea from a health perspective. Most Americans whose families depend on their employers for coverage are just a layoff away from being uninsured. And now, when many businesses are shutting down and considering layoffs, it’s a public health disaster.

It’s worth noting that even in good times, the employer-based model fails to cover enough of us, with the number of Americans covered through an employer steadily dropping in general. Since 1999, the percentage of those with job-based coverage has declined by nine points. And it most certainly will drop like a rock in the coming weeks and months.

https://www.theguardian.com…

Comment:

By Don McCanne, M.D.

A well designed single payer model of an improved Medicare for All would meet the health care financing needs of everyone forever while being affordable for each of us based on our ability to pay. Yet some politicians and pundits keep telling us that we want to protect our choice of continuing to be covered through private insurance, which for about half of us means keeping the insurance we receive through our employment.

But that’s a fallacy. Think back twenty years ago. Do you have the same insurance now that you had then? Likely not, unless you are over 85 and on Medicare or perhaps if your long-term employer has provided benefits under Kaiser Permanente. But most of you have not had the opportunity to continue on the plan you had twenty years ago.

Coverage under employer-sponsored plans is highly unstable. The most common reason is that, each year, over 60 million people leave their jobs and thus lose the coverage they had, if any. Though many will find other coverage through a new employer, through ACA exchanges, through Medicaid if income eligible, or through Medicare if age eligible, virtually none will be able to keep their previous plan once COBRA runs out. Also employers frequently change the plans they offer which often means changing the network of physicians and hospitals that are covered or changing the benefits and cost sharing, especially the deductibles.

Right now, job instability due to the coronavirus pandemic demonstrates how fragile coverage under employer-sponsored plans can be, as Wendell Potter describes in his article. Many of those being laid off will find that their options for health care coverage may be very limited if for no other reason than that the options may be unaffordable if the individual does not qualify for a government subsidized program.

If there ever was an opportune time to talk up single payer improved Medicare for All, that time is now. With the tremendous insecurity that so many of us are facing, it would be a relief if at least we had in place a system that would ensure health security forever, no matter what crises we may or may not face. If the people demand it, we can have it.

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Arno and Caper: What is left out in the discussion of Medicare for All

Medicare For All: The Social Transformation Of US Health Care

By Peter S. Arno and Philip Caper
Health Affairs Blog, March 25, 2020

There is a large elephant in the room in the national discussion of Medicare for All: the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.

The problem is not that these corporate entities are doing something they shouldn’t. They are simply doing too much of what they were created to do—generate wealth for their owners. And, unlike any other wealthy country, we let them do it. The dilemma of the US health care system is due not to a failure of capitalism or corporatism per se, but a failure to implement a public policy that adequately constrains their excesses.

Since the late 1970s, US public policy regarding health care has trended toward an increasing dependence on for-profit corporations and their accompanying reliance on the tools of the marketplace—such as competition, consolidation, marketing, and consumer choice—to expand access and assure quality in the provision of medical care.

This commercialized, commodified, and corporatized model is driving the US public’s demand for fundamental reform and has elevated the issue of health care to the top of the political agenda in the current presidential election campaign.

We must therefore ask: How is it that we spend more on health care than any other nation, yet have arrived at such a sorry state of affairs?

The answer is that only in the United States has corporatism engulfed so much of medical care and come so close to dominating the doctor-patient relationship. Publicly traded, profit-driven entities—under constant pressure from Wall Street—control the financing and delivery of medical care in the US to an extent seen nowhere else in the world. For instance, seven investor-owned publicly traded health insurers now control almost a trillion dollars ($913 billion) of total national health care spending and covers half the US population. In 2019, their revenue increased by 31 percent, while their profits grew by 66 percent.

The corporatization of medical care may be the single most distinguishing characteristic of the modern US health care system and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held—but mistaken—belief that the problems of US health care can be solved if only the market could be perfected have effectively obstructed the development of a rational, efficient, and humane national health care policy.

What Is The Best Approach To Reform?

It is not an exaggeration to say that no reforms except publicly financed, single-payer universal health care will solve the problems of our health care system. This is true whether we are talking about a public option, a Medicare option, Medicare buy-in, Medicare extra, or any other half-measure. The main reason is because of the savings that are inherent only in a truly universal single-payer plan. Specifically, the administrative and bureaucratic savings gained by eliminating private insurers are the largest potential source of savings in a universal single-payer framework, yet all the “option” reforms listed above leave largely intact the tangle of wasteful, inefficient, and costly private commercial health insurers. The second largest source of savings comes through reducing the cost of prescription drugs by using the negotiating leverage of the federal government to bring down prices, as is done in most other developed countries. The ability, will, and policy tools (such as global budgeting) to restrain these and other costs in a single-payer framework are the key to reining in the relentless rise in health care expenditures and providing universal coverage.

The various “option” reform proposals will not simplify our confusing health care system nor will they lead to universal coverage. None have adequate means to restrain health care costs. So why go down this road?

Conclusion

The real struggle for a universal single-payer system in the US is not technical or economic but almost entirely political. Retaining the status quo (for example, the Affordable Care Act) is the least disruptive course for the existing medical-industrial complex, and therefore the politically easiest route. Unfortunately, the status quo is disruptive to the lives of most Americans and the least effective route in attacking the underlying pathology of the US health care system—corporatism run amok. Following that route will do little more than kick the can down the road, which will require repeatedly revisiting the deficiencies in our health care system outlined above (see full article at link) until we get it right.

The US public and increasingly the business community are becoming acutely aware of the rising costs and inadequacies of our current system. It is the growing social movement, which rejects the false and misleading narratives, that will lead us to a universal single-payer system—truly the most effective way to reform our health care system for the benefit of the US people.

Peter S. Arno, PhD, is an economist and senior fellow and director of health policy research at the Political Economy Research Institute at the University of Massachusetts–Amherst and a senior fellow at the National Academy of Social Insurance.

Philip Caper, MD, is a physician and founding member of the National Academy of Social Insurance and currently serves on the Board of Maine AllCare.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Earlier this month, the National Academy of Social Insurance released a report on expanding Medicare eligibility through three options: lowering the eligibility age for Medicare, establishing a Medicare buy-in or a Medicare-like public option, or extending Medicare to cover everyone (Quote of the Day, 3/4/20). Peter Arno and Philip Caper were members of the study panel that wrote the report, but they felt that the final report missed the elephant in the room: “the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.”

They decided that it was important to issue a “minority view” in response to the NASI report that would raise alarms over the business transformation of US health care. Excerpts of their response appear above though it is highly recommended that the full article be accessed at the Health Affairs website, not only for the sake of completeness but also because the article should be distributed widely to inform the public on why our health care system requires much more than a Medicare option to fix its problems.

Perhaps if enough of you recommend the article to Joe Biden, he might actually read it. He needs to. For that matter, so does Donald Trump.

PNHP does not support any political candidates for office, but we do encourage all candidates to be thoroughly and accurately informed on health policy so that they will support health care measures that are truly in the best interests of all of us.

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

Medicare For All: The Social Transformation Of US Health Care

By Peter S. Arno, Ph.D. and Philip Caper, M.D.
Health Affairs Blog, March 25, 2020

There is a large elephant in the room in the national discussion of Medicare for All: the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.

The problem is not that these corporate entities are doing something they shouldn’t. They are simply doing too much of what they were created to do—generate wealth for their owners. And, unlike any other wealthy country, we let them do it. The dilemma of the US health care system is due not to a failure of capitalism or corporatism per se, but a failure to implement a public policy that adequately constrains their excesses.

Since the late 1970s, US public policy regarding health care has trended toward an increasing dependence on for-profit corporations and their accompanying reliance on the tools of the marketplace—such as competition, consolidation, marketing, and consumer choice—to expand access and assure quality in the provision of medical care.

This commercialized, commodified, and corporatized model is driving the US public’s demand for fundamental reform and has elevated the issue of health care to the top of the political agenda in the current presidential election campaign.

Costs have risen relentlessly, and the quality of and access to care for many Americans has deteriorated. The cultural changes accompanying these trends have affected every segment of the US health care system, including those that remain nominally not-for-profit. Excessive focus on health care as a business has had a destructive effect on both patients and caregivers, leading to increasing difficulties for many patients in accessing care and to anger, frustration, and burnout for many caregivers, especially those attempting to provide critical primary care.

As a result, the ranks of primary care providers have eroded, and that erosion continues. One of the major reasons for burnout in this group is the clash between its members’ professional ethics (put the patient first and “first do no harm”) and the profit-oriented demands of their corporate employers. Applying Band-Aids can’t cure the underlying causes of disease in medicine or public policy. Ignoring the underlying pathology in public policy, as in clinical medicine, is destined to fail. 

Many of the symptoms of our dysfunctional health care system are not in dispute:

  • An average employer-sponsored family health insurance policy now exceeds $28,000 per year, with employers paying about $16,000 and employees paying about $12,000.

We must therefore ask: How is it that we spend more on health care than any other nation, yet have arrived at such a sorry state of affairs?

The answer is that only in the United States has corporatism engulfed so much of medical care and come so close to dominating the doctor-patient relationship. Publicly traded, profit-driven entities—under constant pressure from Wall Street—control the financing and delivery of medical care in the US to an extent seen nowhere else in the world. For instance, seven investor-owned publicly traded health insurers now control almost a trillion dollars ($913 billion) of total national health care spending and covers half the US population. In 2019, their revenue increased by 31 percent, while their profits grew by 66 percent.

The corporatization of medical care may be the single most distinguishing characteristic of the modern US health care system and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held—but mistaken—belief that the problems of US health care can be solved if only the market could be perfected have effectively obstructed the development of a rational, efficient, and humane national health care policy.

There are three main reasons to pursue a public policy that embraces genuine health care reform:

  1. Saving lives: To simplify our complex and confusing health care system while providing universal affordable health care coverage;
  2. Affordability: To rein in the relentless rise in health care costs that are cannibalizing private and public budgets; and
  3. Improving quality: To eliminate profitability and share price as the dominant and all-consuming mission of the entities that provide health care services and products when that mission influences clinical decision making. Profitability should be the servant of any health care system’s mission, not its master as seems to be increasingly the case in the US.

What Is The Best Approach To Reform?

It is not an exaggeration to say that no reforms except publicly financed, single-payer universal health care will solve the problems of our health care system. This is true whether we are talking about a public option, a Medicare option, Medicare buy-in, Medicare extra, or any other half-measure. The main reason is because of the savings that are inherent only in a truly universal single-payer plan. Specifically, the administrative and bureaucratic savings gained by eliminating private insurers are the largest potential source of savings in a universal single-payer framework, yet all the “option” reforms listed above leave largely intact the tangle of wasteful, inefficient, and costly private commercial health insurers. The second largest source of savings comes through reducing the cost of prescription drugs by using the negotiating leverage of the federal government to bring down prices, as is done in most other developed countries. The ability, will, and policy tools (such as global budgeting) to restrain these and other costs in a single-payer framework are the key to reining in the relentless rise in health care expenditures and providing universal coverage.

The various “option” reform proposals will not simplify our confusing health care system nor will they lead to universal coverage. None have adequate means to restrain health care costs. So why go down this road? Is it too difficult for the US to guarantee everyone access to affordable care when every other developed country in the world has done so?

The stated reason put forth in favor of these mixed option approaches is that Americans want “choice.” But choice of what? We know with certainty from former insurance company executives such as Wendell Potter that the false “choice” meme polls well with the US public and was used to undermine the Clinton reform efforts more than 25 years ago. It is being widely used today to manipulate public opinion.

But choice in our current system is largely an illusion. In 2019, 67.8 million workers across the country separated from their job at some point during the year—either through layoffs, terminations, or switching jobs. This labor turnover data leaves little doubt that people with employer-sponsored insurance are losing their insurance constantly, as are their spouses and children. And even for those who stay at the same job, insurance coverage often changes. In 2019, more than half of all firms offering health benefits reported shopping for a new health plan and, among those, nearly 20 percent actually changed insurance carriers. Trading off choice of doctors or hospitals for choice of insurance companies is a bad bargain.

The other major objection to a universal single-payer program is cost. Yet, public financing for health care is not a matter of raising new money for health care but of reducing total health care outlays and distributing payments more equitably and efficiently. Nearly every credible study concludes that a single-payer universal framework, with all its increased benefits, would be less costly than the status quo, more effective in restraining future cost increases, and more popular with the public—as 50 years of experience with Medicare has demonstrated.

The status quo generates hundreds of billions of dollars in surplus and profits to private stakeholders, who need only spend a small portion (millions of dollars) to influence legislators, manipulate public opinion, distort the facts, and obfuscate the issues with multiple competing reform efforts.

Conclusion

The real struggle for a universal single-payer system in the US is not technical or economic but almost entirely political. Retaining the status quo (for example, the Affordable Care Act) is the least disruptive course for the existing medical-industrial complex, and therefore the politically easiest route. Unfortunately, the status quo is disruptive to the lives of most Americans and the least effective route in attacking the underlying pathology of the US health care system—corporatism run amok. Following that route will do little more than kick the can down the road, which will require repeatedly revisiting the deficiencies in our health care system outlined above until we get it right.

The US public and increasingly the business community are becoming acutely aware of the rising costs and inadequacies of our current system. It is the growing social movement, which rejects the false and misleading narratives, that will lead us to a universal single-payer system—truly the most effective way to reform our health care system for the benefit of the US people.

Health spending for the next decade

National Health Expenditure Projections, 2019–28: Expected Rebound In Prices Drives Rising Spending Growth

By Sean P. Keehan, et al, CMS Office of the Actuary
Health Affairs, March 24, 2020

Abstract

National health expenditures are projected to grow at an average annual rate of 5.4 percent for 2019–28 and to represent 19.7 percent of gross domestic product by the end of the period. Price growth for medical goods and services is projected to accelerate, averaging 2.4 percent per year for 2019–28, which partly reflects faster expected growth in health-sector wages. Among all major payers, Medicare is expected to experience the fastest spending growth (7.6 percent per year), largely as a result of having the highest projected enrollment growth. The insured share of the population is expected to fall from 90.6 percent in 2018 to 89.4 percent by 2028.

  • $4,014.2 billion – National health expenditures 2020
  • $6,192.5 billion – National health expenditures, projected 2028

National health spending is projected to increase 5.4 percent per year, on average, for 2019–28, compared to a growth rate of 4.5 percent over the past three years (2016–18). The acceleration is largely due to expected faster growth in prices for medical goods and services (2.4 percent for 2019–28, compared to 1.3 percent for 2016–18). Growth in gross domestic product (GDP) during the projection period is expected to average 4.3 percent. Because national health spending growth is expected to increase 1.1 percentage points faster, on average, than growth in GDP over the projection period, the health share of GDP is expected to rise from 17.7 percent in 2018 to 19.7 percent in 2028.

Although growth in economywide prices is projected to accelerate during 2019–28, growth in personal health care prices is expected to increase more quickly, partly reflecting faster expected growth in the wages paid to health care workers.

Over the projection period, Medicare is expected to have the highest spending growth among the major payers of health care each year and on average (7.6 percent), largely reflecting the continued shift of the baby-boom generation out of private health insurance and into Medicare.

The modest rate of growth in private health insurance enrollment is influenced both by the impact of the repeal of the Affordable Care Act (ACA) individual mandate in the early part of the projection period and by the expectation that the working-age population will continue the recent trend of enrolling in private health insurance (primarily employer-sponsored insurance) at lower rates. As a result, by 2028 the insured share of the population is expected to fall to 89.4 percent (from 90.6 percent in 2018).

The share of health care spending financed by federal, state, and local governments is expected to increase by 2 percentage points during 2019–28, reaching 47 percent in 2028. The increase is primarily due to the federal government’s share, which is projected to grow from 28 percent in 2018 to 31 percent by 2028, driven by faster growth in Medicare spending related to increasingly higher enrollment. The projected business and household share is expected to fall from 55 percent in 2018 to 53 percent in 2028.

Conclusion

As it has over the past several decades, health spending is expected to grow, on average, more rapidly than the rest of the economy in each year of the projection period through 2028 and to consume an increasingly larger share of GDP. Thus, health spending is projected to reach 19.7 percent of GDP in 2028, even with a modest projected decline in the insured share of the US population. Anticipated increases in inflation for medical goods and services are key drivers of accelerating national health spending growth, since the use and intensity of services are expected to grow more slowly than in recent years—in part because the share of the population with insurance coverage is projected to decline slightly. The government is projected to pay a larger share (nearly half) of the nation’s total health bill by 2028, as the baby boomers continue aging into Medicare and the program’s beneficiaries consume $1 out of every $4 spent on health care. Policy makers and other stakeholders will undoubtedly continue to monitor these trends and their implications for the health sector, federal and state budgets, and the economy as a whole.

(Given the timing of publication and the uncertainty associated with the impacts of the COVID-19 pandemic, those impacts are not reflected in the estimates.)

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Two important take-home points from this annual report from CMS Office of the Actuary: 1) Health care spending will continue to increase at a rate greater than the growth of the GDP, comprising 19.7% in 2028, and 2) The percentage uninsured will increase from 9.4% in 2018 to 10.6% in 2028.

Thus the Affordable Care Act has fallen short of the goals of reform, especially when you consider all of the other deficiencies of our health care financing system that will remain in place (profound administrative waste, rampant underinsurance, restrictive provider networks, job lock with employer-sponsored plans, etc., etc.).

Of course, the system could be changed in the next decade. Since the Republicans have been unable to come up with a replacement plan for the Affordable Care Act, it is likely that not much would happen under their control. It now appears that, if the Democrats were to gain control, a public option might be added, but that would have very little impact on the financing system at large. The public option would be only one more administratively-complex player added to our fragmented, dysfunctional system of financing health care.

Of course we don’t know yet what COVID-19 will do, but it may well have a major impact on the health care delivery system and its financing. The health and economic consequences could jar the minds of the political and policy communities such that it is possible that they may regret that we did not have in place a well designed, single payer improved Medicare for All program. Imagine if we enacted and implemented such a system what the following 10 year projection by the Office of the Actuary would be. Pretty good, I’d say.

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Vets Say We Need a Strong VA to Combat Coronavirus and Win Medicare for All

By Candice Bernd
Truthout,

Not many know about the Department of Veterans Affairs’s (VA) so-called “fourth mission.” In 1982, Congress expanded the VA’s role beyond providing care, benefits and burial services to the nearly 9 million veterans it currently serves. Its additional role is to provide a backup health care system in a national emergency — for example, taking on non-veteran patients in the event of a global pandemic.

The agency’s Veterans Health Administration is the country’s largest government-run, integrated health system, with more than 300,000 staffers and 1,200 medical facilities across its sprawling administration. The agency stands ready to deploy 16,500 acute-care beds, including 1,000 isolation units and at least 3,000 ventilators. Such resources could prove crucial as COVID-19 continues to spread, threatening to overwhelm hospital capacity across the nation.

In fact, according to VA Press Secretary Christina Mandreucci, VA staff are actively assisting the Centers for Disease Control and Prevention (CDC) in coordinating its emergency response, including deploying a liaison officer to the Department of Health and Human Services (HHS) secretary’s Operations Center, and deploying 16 nursing assistants to assist the CDC with screening returning U.S. soldiers.

But even as the agency prepares to fulfill this fourth mission, its leadership under the Trump-appointed Secretary Robert Wilkie threatens to jeopardize its success. Even as criticisms mounted over the agency’s prior failure to release a comprehensive plan for addressing the crisis in late February, Wilkie told legislators that the VA did not need additional resources to fight the outbreak. To make matters worse, the agency quietly deleted any mention of its fourth mission from its Office of Emergency Management page on its website earlier this month.

Yet, lawmakers are quickly recognizing the urgent need for the VA’s resources. As part of the just-reached deal over a massive economic stimulus to combat the economic fallout of the outbreak, Congress has allocated nearly $20 billion in new funding for VA hospital expansion and upgrades, testing kits, protective equipment and other resources.

Despite this expected funding increase, many veterans and experts familiar with the VA told Truthout they’re worried about whether the agency is up to the task after decades of disinvestment and more recent privatization schemes, including the administration’s unprecedented overhaul of the VA in its 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, which has funneled billions toward private-sector care for veterans.

The new stimulus bill includes $2 billion to fund private-sector care for veterans. However, VA officials announced Wednesday that the department would freeze its private care program under the 2018 MISSION Act to prevent private hospitals from being overwhelmed. Experts say that such increased funds and an end to outsourcing will be needed for the VA to do what’s necessary to take on COVID-19.

Still, the agency must fill 49,000 vacant positions — including a permanent deputy secretary position. In fact, five federal public sector unions representing nearly 350,000 VA workers are so worried that they recently urged agency leaders to put better plans and protocols in place.

Such disinvestment, outsourcing and understaffing has put the VA in a poor position to handle its role as an emergency health care provider amid the current crisis, and it remains to be seen whether or not an infusion of $20 billion can get the institution on its feet. As of publishing, the VA said it had administered 3,378 COVID-19 tests, and was tracking 365 positive veteran cases, with four confirmed deaths.

Joining President Trump in a White House press briefing last week, Secretary Wilkie said his department has 3,000 medical staff on standby, ready to deploy to areas overwhelmed by the virus. “We’re gaming out emergency preparedness scenarios, and we stand ready when the president needs us to expand our mission,” Wilkie said.

A Vulnerable, At-Risk Population

The staffing shortages and current lack of tests and other supplies at VA facilities could put older veterans — a patient population among the most vulnerable to infection due to many veterans’ service-connected, underlying conditions — at an increased risk.

Denny Riley, 75, an Air Force veteran who regularly receives VA care for his disability, is among the demographic most at risk. If he begins to have symptoms of COVID-19, he will be able to quickly call a VA doctor remotely, using the agency’s Telehealth program, and be directed from there. Even in a worst-case scenario in which Riley becomes critically ill and VA medical providers become quarantined or a VA facility is otherwise inaccessible, he can still use the VA’s Tele-ICU program, which brings remote intensive care physicians into a facility’s ICU rooms via video screens to assist localized staff in treating and diagnosing patients.

Riley understands the necessity of the VA abetting the civilian health care system as the outbreak intensifies, but says he is increasingly worried about being pushed out of the VA system and sent to a civilian hospital if the VA becomes overwhelmed.

He greatly prefers his VA care, but says even at his local VA facility, he has witnessed a reduction in staffing levels. “That’s the kind of cutback they’ve made, is in hiring people, so that staffs seem incomplete,” he told Truthout. “If you defund something so that it doesn’t work adequately for the people, then you can point at it and say, ‘See, it doesn’t work,’ and send these people to private health care, and that’s a total boondoggle.”

Another demographic at extreme risk are veterans without permanent housing and those who live on the street. Tramecia Garner is associate director for housing and residential programs at the San Francisco-based Swords to Plowshares, a nonprofit that provides housing and other social services to veterans in the California Bay Area.

Garner, who oversees 476 veteran-dedicated housing units, including two VA-funded, short-term transitional housing sites, says most of the veterans she works with are over 60, and many struggle with service-connected conditions and disabilities. The VA has tested at least three veterans involved in the program for COVID-19; all three of their tests came back negative, she said.

“Folks spending time on the streets and being chronically homeless will come to us with a number of challenges already, so of course [COVID-19] doesn’t help the situation,” Garner said. Still, she says, the VA has been responsive and crucial to her clients’ care.

A Nationalized System

Suzanne Gordon, author of Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans says the media’s depictions of the VA as a failing institution are not only unfair but also inaccurate. She points to an increasing body of research showing that VA facilities deliver care equal or superior to that provided by the private sector. Studies have confirmed such quality even after it was revealed that faulty record keeping concealed lengthy wait times at some VA facilities in 2014.

“What I think we’re suddenly realizing, and the media is realizing, after years of bashing the VA, is that it serves a very important function,” Gordon says.

Despite the agency’s dysfunctional leadership, she says, the VA may prove to be one of the few health care institutions in the country with the proper expertise to contain the outbreak. In fact, the VA has a long record of responding effectively to emergencies, including in climate change-fueled crises in Puerto Rico in the aftermath of Hurricane Maria and more recently during the California wildfires.

The VA set up command posts in both situations and actively reached out to every veteran enrolled in its system to make sure they had access to their medications. “[A national health care system] doesn’t just care for you when you book the service and come in and pay the fee. It cares for you throughout, and it reaches out to you,” Gordon says.

The very fact that the VA’s health administration is a government-run system is its biggest strength in a time of crisis, she says, as it doesn’t have to deal with the profit-driven complexities of the private sector. Because of this, its medical providers can quickly shift staff away from certain tasks to address more urgent needs.

Moreover, the VA’s research and development is not proprietary, meaning all its research toward a possible vaccine for COVID-19 is free and accessible to the public. Still, Gordon says, the agency’s health administration can’t perform any of these necessary functions if it remains underfunded, understaffed and overburdened.

“This crisis really underscores the problems, and really folly, of the MISSION Act, because [the Trump administration] paid so much attention to outsourcing veterans’ care to the private sector,” Gordon told Truthout. “You don’t want veterans going to the private sector now.”

It’s not just Trump who deserves scrutiny, however. The MISSION Act was a bipartisan effort, with Democratic Senators Jon Tester and Doug Jones signing on as co-sponsors, and the bill passing with clear majorities in both chambers. Additionally, Gordon is not very confident that 2020 Democratic presidential frontrunner former Vice President Joe Biden would steer the agency toward a better future if he wins in November.

“Biden makes wisecracks about Italy’s single-payer system, and it doesn’t bode well toward his attitude toward the VA. What’s President Biden going to do with the VA if he doesn’t like single-payer systems and doesn’t understand how they work?” Gordon says. “I would hope that the Democrats, if they get back in office after this … would repeal most of the MISSION Act.”

Paul Cox, a Marine Corps veteran and president of the Veterans Healthcare Policy Institute, agrees, telling Truthout that Democratic presidential candidate Sen. Bernie Sanders has a better track record of strengthening the VA as the former chair of the Senate Veterans Affairs Committee. In fact, Cox says, if Republicans hadn’t filibustered Sanders’s omnibus VA bill in 2014, its health administration would be better prepared to handle the COVID-19 pandemic today.

Ultimately, the question of whether the VA sinks or swims as the outbreak intensifies will play a vital role in the larger fight for a Medicare for All system in the United States. If the VA succeeds in helping to stem the pandemic’s impacts, it could serve as a key example of how a single-payer system is uniquely able to address an unprecedented public health crisis.

“The VA is being looked at right now as a sort of model for what a single-payer health care system looks like, and in a lot of ways it does a very good job of that,” says Essam Attia, an Army veteran and activist with Veterans for Peace and Common Defense who gets his care from the VA. “If the VA does get the funding that it needs to be able to respond to this crisis properly, it could be an amazing message to the country as to what a different health care system could look like. On the flip side, if it fails in a major way, it could backfire, and it could be something that is used against the idea of a single-payer health care system…. It’s a double-edged sword.”

Riley, the 75-year-old disabled Air Force veteran, is more hopeful. “I think in this particular situation, the VA will outshine private health care. I think the VA is in a better position to be a star player in this. I may be completely wrong, but I think they are,” he said.

This story has been updated to reflect additional details regarding Wednesday’s stimulus deal and its allotments to the VA, as well as the department’s announcement that it will be temporarily freezing reimbursements under its private care program.

https://truthout.org…

Spend a life-changing hour with Frances Perkins

Summoned: Frances Perkins and the General Welfare

By Mick Caouette, Filmmaker
South Hill Films

About the Film:

In the depths of the Great Depression, Franklin Roosevelt appointed Frances Perkins as the first woman on a presidential cabinet. Against overwhelming odds, she became the driving force behind Social Security, the 40-hour work week, the eight-hour day, minimum wage and unemployment compensation. “Summoned: Frances Perkins and the General Welfare” features compelling interviews with David Brooks, Nancy Pelosi, Amy Klobuchar, Lawrence O’Donnell and others while telling Perkin’s heroic story which explores the history of women in politics, Social Security, our attitudes toward immigration, poverty, Socialism, and the role of government. Without this context our current dialogue is ill-informed and diminished.

“Some of us decided that the purpose and the reason for government should be the improvement of life for all of its people.” – Frances Perkins

This link includes a six minute preview of the film:
https://www.southhillfilms.com…

“Summoned: Frances Perkins and the General Welfare” (full video – 57 minutes):
https://www.kcet.org…

Also a DVD can be purchased through PBS:
https://shop.pbs.org…

Comment:

By Don McCanne, M.D.

These are difficult times. The highly contagious nature and the lethality of Covid-19 has caused many of us to accept the advice and direction of experts in epidemics of infectious diseases to retreat and practice “social distancing.” This should give us time for contemplation and values clarification.

Somewhere in your schedule, or what’s left of it, you should be able to find an hour to sit down and watch this video. I would say that it is an imperative in that it shows how a nation, with the inspiration provided by leaders like Frances Perkins, can address the problems of our times. Although the specific issues are not all the same now as they were then, the general concept is the same: society is not functioning well even though the nation has the ability and resources to do something about it.

How are we not functioning well now? We are facing a pandemic at a time that our government stewards had elected to diminish our public health resources so that we were not adequately prepared for this. We have diverted too much of our very high national health expenditures away from patients and to administrators and passive investors, while leaving too many without access to the health care they need. We have shifted decades of the gains in productivity to the wealthy at the top while leaving workers and their families struggling just to try to make ends meet. We have continued to engage in endless, meaningless wars. We have allowed democracy to deteriorate to the point that our elections all too often no longer represent the will of the people. And the list goes on.

Viewing this will be an hour well spent, but much more important will be the contemplation that follows. That can lead to an epiphany for each of us. Dammit, we can do something about this!

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

Why are we waiting for Medicare for All?

By F. Douglas Stephenson
The Gainesville (Fla.) Sun, March 23, 2020

An old social justice chant, “Why are We Waiting,” is sung to the tune of the beautiful and inspiring Christmas carol, “O Come All Ye Faithful.” The lyrics apply to the situation today: Even with the dangerous coronavirus pandemic, big insurance and big pharma continue opposing legislation for the new Medicare for All.

We still wait because these resistant, self-serving industries have the most to lose if their huge profits are redirected to direct patient care for all. Individual and corporate predators regard democracy, government and community as obstacles to their greed and avarice, always placing profits over individual patients, families and public health. It’s no wonder so many beholden members of Congress want to protect the interests of big insurance and big pharma, industries that spent $371 million on lobbying in 2017 alone.

Dealing with the COVID-19 virus would be more life-saving if Medicare for All was in place today. A recent New York Times editorial, “With Coronavirus, ‘Health Care for Some’ Is a Recipe for Disaster,” stresses the importance of covering everyone.

Even before COVID-19 was known to humans, Northeastern University professor of public health Wendy Parmet presciently warned that the push to exclude immigrants from access to health-care services would be both dangerous and quixotic.

“None of us can be self-sufficient in the face of a widespread epidemic,” she wrote in 2018. “That is just as true for noncitizen immigrants as everyone.” In any pandemic, self-sufficiency can be self-deluding; everyone’s health, citizens, immigrants, etc. alike is only as good as our most vulnerable neighbors.

In what is truly a recipe for disaster, vested interests reject the science of public health epidemiology by asserting that only an incremental approach to health insurance reform is possible or acceptable. So, what are we willing to settle for, and should we just settle for what we can get? Should we lower the expectations, turn down the public heat and keep waiting?

Gradualism, baby steps and extending health insurance coverage to some, but not all, are the mantra of the day. “Medicare for some,” but not Medicare for All, is fawned over by politicians, profiteers and advocacy groups alike while reducing communities resources to deal with dangerous epidemics.

Virtually all the risky gradual reforms being touted would reinforce a dysfunctional health insurance system with as many standards of insurance as there are dollars to purchase them. It would further lock us into an obsolete private insurance-based model that holds everyone’s health hostage to profiteering HMOs and unaccountable big insurance companies for years to come.

For these proponents of political expediency, the question remains, who will be left behind while we wait? Every year, well over 18,000 unnecessary deaths, the equivalent of six times the number who died in the Sept. 11 attacks, are linked to lack of health insurance coverage. Pandemics can quickly increase these numbers.

Our most successful national health insurance program, Medicare, provides one of the best arguments against incremental steps. When Medicare was enacted 55 years ago, following a broad grassroots campaign, many believed the dream of a full national health insurance system was right around the corner.

Five decades later, Medicare still has not been expanded. Most of the changes have been contractions with higher out-of-pocket costs for beneficiaries and repeated attempts at privatization by big pharma, the health insurance industry and its champions in the White House and Congress.

It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for individuals and families.

American history is filled with examples of fundamental, democratic change brought about by successful mass action and public pressure against the counseling of the go slow, vested interest crowd. No more waiting! Ask your legislators to fully support Medicare For All now: HR-1384/S-1129.

F. Douglas Stephenson, LCSW, BCD, is a retired clinical social work psychotherapist. Formerly on the faculty of the University of Florida Department of Psychiatry, he is a health professional member of Physicians for a National Health Program.

https://www.gainesville.com…

Marcia Angell: Coronavirus reinforces moral basis for Medicare for All

Why the U.S. failed the coronavirus test

By Marcia Angell
Santa Fe New Mexican, March 21, 2020

The coronavirus pandemic is the best argument for “Medicare for All.” As it stands, most Americans get health care only if we have insurance that will pay for it. If we don’t or we can’t afford the deductibles and copayments, too bad. Every other advanced country provides universal health care in a predominately nonprofit system.

What happens, then, when Americans develop a fever and cough? Are they likely to seek medical help, despite the hefty bills they are sure to receive, particularly if, say, the radiologist is out of network or the insurance company refuses to pay for some other reason? The new coronavirus, while highly contagious, is usually mild, so people with minimal symptoms might simply take their usual cold remedies while they go about their business and spread the infection widely.

The problem is that we treat health care like a market commodity distributed according to the ability to pay in an uncoordinated system with hundreds of commercial insurers and profit-oriented providers. Some 30 million people have no access to health care because they are uninsured, and millions more don’t use their insurance because the deductibles and copayments are unaffordable. In addition, insurers usually require patients to get their care within a narrow network of providers and exclude certain services.

The shortage of test kits for coronavirus stems from a related problem. Since there was no commercial market for them, they didn’t get made immediately. While we’ve converted health care into a market commodity, we’ve hollowed out our public health system, so it couldn’t do the job.

For all we know, the coronavirus may already have spread widely within the United States. Although it has been in other countries for more than two months, we have not really looked for it here. Until the last week in February, our premier public health agency, the Centers for Disease Control and Prevention, limited its diagnostic testing to symptomatic patients who had traveled to China or had contact with someone known to be infected. This is akin to looking for lost keys only under a lamppost.

The CDC probably could not have done better, given its lack of funding and governmental support. But ignorance is hardly a good public health strategy. Right from the beginning, we should have made test kits available to state and local public health agencies (as was done in Italy and South Korea). The only way to deal with an epidemic of this scope is with a universal health care system like “Medicare for All” and a strong, well-funded public health network.

The political opposition to “Medicare for All” is puzzling, since Medicare is the most popular part of our current fragmented system. In fact, many 64-year-olds can hardly wait to be 65, so they will be eligible. Why, then, do opponents of “Medicare for All” seem to believe that extending this popular program to everyone would be a sacrifice? Would a 64-year-old really prefer private insurance, with its networks and variable benefits, to Medicare, with its free choice of doctors and guaranteed benefits?

It’s true that taxes would have to increase to pay for “Medicare for All,” but the taxes could be as progressive as we wanted. For most Americans, they would probably be completely offset by the elimination of premiums, deductibles and copayments. In addition, the system as a whole would be far more efficient, because of the reduction in our gigantic overhead costs and the elimination of most profits. Most important, cost inflation would slow greatly, so that in a few years we would come out well ahead.

But as important as cost control is, my reason for favoring “Medicare for All” is primarily moral. Health care is not like ordinary consumer goods that people can choose to purchase. Illness is not a choice; it’s a misfortune. So why should people have to pay for it, as if they wanted it? Providing health care, just like providing clean water or police protection or basic education, is simply what decent societies should do. And during an epidemic, it protects all of us. The coronavirus pandemic powerfully underscores the need for a coherent national health system, in which we all pull together.

Marcia Angell is a member of Harvard Medical School’s Department of Global Health and Social Medicine, and a former editor-in-chief of the New England Journal of Medicine. She will soon be a resident of Santa Fe.

https://www.santafenewmexican.com…

Comment:

By Don McCanne, M.D.

Certainly we have all had more than enough reason recently to give considerable thought to factors potentially influencing the health of all of us. As Marcia Angell makes clear, we most emphatically need a coherent national health system like “Medicare for All” with a strong, well-funded public health network. Most of us can cite many reasons for this, but, above all, the reason is primarily moral. How can we not do it?

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

America’s extreme neoliberal healthcare system is putting the country at risk

Single-payer healthcare can’t prevent a novel virus like Covid-19 but it could help us plan, coordinate and save lives

By Adam Gaffney, M.D., M.P.H.
The Guardian, March 21, 2020

At the final debate of the Democratic presidential primary on Sunday, Senator Bernie Sanders and Joe Biden clashed on the coronavirus. Sanders contended the pandemic laid bare “the incredible weakness and dysfunctionality” of the US healthcare system, and called for single-payer reform. Biden countered that Italy’s universal system had failed to protect the Mediterranean nation, and asserted that Covid-19 “has nothing to do with Bernie’s Medicare for All”. At first glance, the ex-vice-president seems right: of course single-payer can’t close the door to a novel virus, any more than it can forestall a deadly earthquake or fend off a zombie apocalypse. Nonetheless, a national health program with unified financing and governance – basically the opposite of what we have in America today – is a powerful tool in a health crisis.

The debate over Medicare for All in the age of Covid-19 is complicated by the fact that it is our public health agencies – and not the medical care system – that serve as our first line of defense against novel epidemics. In that regard, we’ve shot ourselves in the foot with a 12-gauge shotgun: year after year of underfunding of our federal, state and local public health agencies has left us ill-prepared for the Covid-19 challenge (as evidenced by the testing fiasco). How we finance medical care, however, is also critical. On the most basic level, containing the coronavirus will require those infected to seek medical care, so that they can be diagnosed and isolated. Fear of devastating ER or hospital bills, however, could keep some home – or at work. As a Taiwan government spokeswoman, lauding her country’s single-payer system for its successful containment of Covid-19, told NBC News, “Taiwan’s health insurance lets everyone not be afraid to go to the hospital. If you suspect you have coronavirus, you won’t have to worry that you can’t afford the hospital visit to get tested.”

On Wednesday, Trump signed into law a bill that would make Covid-19 testing – but not treatment – free. It’s hence inadequate, given the predicted looming surge in hospitalizations from Covid-19 pneumonia. After all, 30 million Americans are uninsured – a number that will surely grow as the economy tanks and millions or tens of millions of Americans lose their jobs. Even more are underinsured, and for these individuals, co-pays and deductibles will only become more unaffordable as disposable income falls and savings dwindle. For both groups, medical bills for an intensive care unit (ICU) stay for Covid-19 could be devastating. People, of course, will also not stop having heart attacks, cancer or traffic accidents during this outbreak – on the contrary, medical needs are likely to rise in the face of a recession, as unemployment and misery takes its toll on the nation’s health. Financial ruin from medical costs – whether it stems from Covid-19 pneumonia or the looming Covid-19 recession – is financial ruin all the same, and will compound the harm of the epidemic.

But there’s more to it than that. We need single-payer not only to protect us from healthcare costs, but to transform our healthcare infrastructure. In recent weeks, you may have heard that the US, despite our high healthcare spending, has fewer hospital beds per capita than many other wealthy nations. You may have also heard in recent years about an epidemic of hospital closures in poorly served rural areas, or the 2019 closure of a major academic safety-net hospital in Philadelphia. These hospitals closed not because they are unneeded, but because they are unprofitable. For the American hospital landscape is shaped by market forces, which largely determine where hospitals grow and where they wane.

At the same time, while our hospital bed supply is relatively low, our ICU bed supply per capita is among the highest in the world. Yet those beds aren’t necessarily where they need to be: a 2010 study in the Journal of American Medical Association, for instance, found large regional disparities in the distribution of ICU beds; the researchers concluded that in the face of a major epidemic, some areas might have empty beds, while others would have too few. Again, this distribution, far too often, is driven by market logic – not health needs.

Finally, healthcare in America is uncoordinated – and ungoverned. Since the epidemic’s onset, hospital and city and state governments have waged “bidding wars” over crucial supplies and ventilators, the New York Times noted. It’s every hospital for itself: some are resorting to pleas to the community for donations of masks; presumably, others are well-stocked – but who knows? “Respirators, ventilators, all of the equipment – try getting it yourselves,” Trump suggested to state governors on Monday, quoted by the New York Times. This is not a healthcare system – it is atomized chaos. For again, in the American way of paying for healthcare, our hospitals (or increasingly, our multi-hospital systems) are silos, some rich and some poor, each fending for themselves, locked in market competition.

This is neither necessary nor rational, leading both to excess and shortfalls, to generous overall health system funding yet care that remains unaffordable for many. A single-payer national health program would allow us to move past the market-driven status quo to remake this chaotic healthcare landscape of simultaneous healthcare plenty and poverty. It would, in short, allow us to begin to plan – not merely for this epidemic, but for the one that follows.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonary and critical care doctor at the Cambridge Health Alliance. He is President of the advocacy organization Physicians for a National Health Program. He blogs at theprogressivephysician.org.

https://www.theguardian.com…

Why the U.S. failed the coronavirus test

By Marcia Angell, M.D.
Santa Fe New Mexican, March 21, 2020

The coronavirus pandemic is the best argument for “Medicare for All.” As it stands, most Americans get health care only if we have insurance that will pay for it. If we don’t or we can’t afford the deductibles and copayments, too bad. Every other advanced country provides universal health care in a predominately nonprofit system.

What happens, then, when Americans develop a fever and cough? Are they likely to seek medical help, despite the hefty bills they are sure to receive, particularly if, say, the radiologist is out of network or the insurance company refuses to pay for some other reason? The new coronavirus, while highly contagious, is usually mild, so people with minimal symptoms might simply take their usual cold remedies while they go about their business and spread the infection widely.

The problem is that we treat health care like a market commodity distributed according to the ability to pay in an uncoordinated system with hundreds of commercial insurers and profit-oriented providers. Some 30 million people have no access to health care because they are uninsured, and millions more don’t use their insurance because the deductibles and copayments are unaffordable. In addition, insurers usually require patients to get their care within a narrow network of providers and exclude certain services.

The shortage of test kits for coronavirus stems from a related problem. Since there was no commercial market for them, they didn’t get made immediately. While we’ve converted health care into a market commodity, we’ve hollowed out our public health system, so it couldn’t do the job.

For all we know, the coronavirus may already have spread widely within the United States. Although it has been in other countries for more than two months, we have not really looked for it here. Until the last week in February, our premier public health agency, the Centers for Disease Control and Prevention, limited its diagnostic testing to symptomatic patients who had traveled to China or had contact with someone known to be infected. This is akin to looking for lost keys only under a lamppost.

The CDC probably could not have done better, given its lack of funding and governmental support. But ignorance is hardly a good public health strategy. Right from the beginning, we should have made test kits available to state and local public health agencies (as was done in Italy and South Korea). The only way to deal with an epidemic of this scope is with a universal health care system like “Medicare for All” and a strong, well-funded public health network.

The political opposition to “Medicare for All” is puzzling, since Medicare is the most popular part of our current fragmented system. In fact, many 64-year-olds can hardly wait to be 65, so they will be eligible. Why, then, do opponents of “Medicare for All” seem to believe that extending this popular program to everyone would be a sacrifice? Would a 64-year-old really prefer private insurance, with its networks and variable benefits, to Medicare, with its free choice of doctors and guaranteed benefits?

It’s true that taxes would have to increase to pay for “Medicare for All,” but the taxes could be as progressive as we wanted. For most Americans, they would probably be completely offset by the elimination of premiums, deductibles and copayments. In addition, the system as a whole would be far more efficient, because of the reduction in our gigantic overhead costs and the elimination of most profits. Most important, cost inflation would slow greatly, so that in a few years we would come out well ahead.

But as important as cost control is, my reason for favoring “Medicare for All” is primarily moral. Health care is not like ordinary consumer goods that people can choose to purchase. Illness is not a choice; it’s a misfortune. So why should people have to pay for it, as if they wanted it? Providing health care, just like providing clean water or police protection or basic education, is simply what decent societies should do. And during an epidemic, it protects all of us. The coronavirus pandemic powerfully underscores the need for a coherent national health system, in which we all pull together.

Marcia Angell is a member of Harvard Medical School’s Department of Global Health and Social Medicine, and a former editor-in-chief of the New England Journal of Medicine. She will soon be a resident of Santa Fe.

https://www.santafenewmexican.com…

Dr. Paul Song on “The Issue Is”

PNHP national board member Dr. Paul Song appeared on “The Issue Is” on March 21, 2020. He discussed the growing COVID-19 pandemic, how it threatens the health and well-being of millions, and how inequality in U.S. health care makes it harder to address the crisis. Dr. Song also discussed the rising threat of racism directed at Asian-Americans owing in no small part to President Trump mislabeling COVID-19 as the “China Virus.”

Emergency coronavirus funds for American Indians languish in bureaucratic limbo

Exclusive: Emergency coronavirus funds for American Indian health stalled

Tribes say they’ve been forgotten in Trump’s coronavirus response and are running dangerously low on medical supplies.

By Adam Cancryn
POLITICO, March 20, 2020

The Trump administration has held up $40 million in emergency aid Congress approved earlier this month to help American Indians combat the coronavirus — a delay that’s left tribal leaders across the nation frustrated and ill-equipped to respond to the fast-growing outbreak.

The number of confirmed coronavirus cases among American Indians has risen in recent days, from four earlier this week to easily more than a dozen. The Navajo Nation has recorded cases 14 alone, and on Thursday, a Cherokee Nation citizen became the first person in Oklahoma to die from the virus just a day after testing positive.

The funding has languished in bureaucratic limbo for weeks, despite increasingly urgent pleas from tribal organizations desperate to stockpile essential supplies and keep health clinics operational. Federally run American Indian health facilities are well short on hospital beds and ventilators, some frontline clinics received fewer than a dozen coronavirus tests, and federal officials have already signaled there will be little in the way of reinforcements — telling tribal leaders that all they can send right now are expired respirators.

That’s fueled alarm throughout American Indian country and on Capitol Hill, where advocates warn the administration has done comparatively little to protect American Indians as it plans drastic action elsewhere to protect vulnerable populations and slow the virus’ spread.

Pressed further on IHS’ readiness, one IHS official characterized the agency as a “shoestring operation.” At another point, (chief medical officer Michael Toedt) downplayed the threat by telling staffers that “IHS believes this virus will be slower to reach Indian country,” according to a person on the call.

Tribes rely heavily on IHS facilities, which provide many health care services to American Indians and Alaska Natives at no cost under the federal government’s long-held trust responsibility. Over a quarter of the tribal population in the U.S. is uninsured, more than double the national rate.

In a survey published Tuesday by the National Indian Health Board, just 16 percent of its tribal leaders, providers and partners reported receiving federal resources of any form to aid the response. Even fewer — 4 percent — had received basic protective equipment.

https://www.politico.com…

Comment:

By Don McCanne, M.D.

We took their lands and then…

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