Summary: President Biden yesterday gave a critically important speech on the need to fight MAGA Republican efforts to destroy US democracy. Our health care system is similarly in need of improved alignment with democratic principles, achievable by adopting single payer.

Video of President Biden’s Speech on Preserving Democracy

Full Transcript of President Biden’s Speech in Philadelphia

“Donald Trump and the MAGA Republicans represent an extremism that threatens the very foundations of our republic.”

“The Republican Party today is dominated, driven, and intimidated by Donald Trump and the MAGA Republicans, and that is a threat to this country.”

“The soul of America is defined by the sacred proposition that all are created equal in the image of God. That all are entitled to be treated with decency, dignity, and respect. That all deserve justice and a shot at lives of prosperity and consequence. And that democracy…must be defended, for democracy makes all these things possible. Folks, it’s up to us.”

Comment:

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

Last night, President Biden delivered a powerful and much-needed speech about preserving US democracy. Standing in front of Philadelphia’s Independence Hall, arguably the birthplace of modern democracy, he forcefully called out MAGA Republicans for their attempts to replace loyalty to our republic and its rules of fair play with lies, manipulations, and violence in pursuit of absolute power, outside of the historic to-and-fro of our political parties. He publicly emphasized, for the first time, that his hopes of bipartisan cooperation have been dashed by the new Republican party’s “semi-fascism” (a term he used recently, not in the speech). We should be deeply grateful for his (finally) saying in this high-profile way what many historians and observers have long noted: Trump and his followers threaten to destroy our democracy. A functioning democracy is essential as we strive in the US for greater humanity and equity.

However, as I listened, I did wonder how the same words would apply to achieving an admirable, highly democracy-compatible US health care system. Here’s my adaptation:

“Our reliance on private insurers and price-gauging drug companies represents an extremism that threatens the very foundations of our health system.”

“The health sector today is dominated, driven, and intimidated by profiteers, and that is a threat to our medical care and our well-being.”

“The soul of America’s health care is defined by the sacred proposition that all deserve quality health care without financial burden. That all patients are entitled to be treated promptly, respectfully, and with clinical focus, undistracted by burdensome insurance rules or lack of insurance. That all deserve a shot at lives of excellent health and long duration. And that universal health system … must be defended, for covering everyone and removing excess profits make all these things possible. Folks, it’s up to us.”

Universal single payer health insurance, favoring people over profits, is well-aligned with the laudable democracy-preserving exhortations of President Biden. Let’s adopt it to enhance our personal and democratic well-being!

http://healthjusticemonitor.org…

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Summary: In a sad echo of 2020, US longevity again fell in 2021 – from 77 to 76 years. Two proximate causes – COVID and chronic disease – have everything to do with insurance gaps. And rising fatal accidents and overdoses reflect a sense of desperation driven substantially by medical care inaccessibility and debt. Single payer would make a huge difference.

U.S. Life Expectancy Falls Again in ‘Historic’ Setback, New York Times, August 31, 2022, by Roni Caryn Rabin

While the pandemic has driven most of the decline in life expectancy, a rise in accidental deaths and drug overdoses also contributed, as did deaths from heart disease, chronic liver disease and cirrhosis, the new report found.

Comment:

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

Once again, life expectancy In the US fell, by a year in a year. Stunning, unprecedented. This horrendous backsliding continues an on-and-off declining trend since 2014, and follows a sharp dip in 2020. The huge two-year drop has never been seen before.

See below a graphic representation. Longevity is now far below where it was in 1999, indeed takes us back to 1995. No other nation has experienced this drastic decline. The fall is greatest among Native Americans, and longevity for Black Americans remains the lowest of any group.

What’s the role of health insurance? The NYT doesn’t say. But insurance is a prime culprit. As HJM discussed recently, at least 1/4 of COVID deaths are attributable to uninsurance. Many chronic disease deaths are due to un- and under-insurance. Our lax gun laws and opioid regulation contribute to the accidental deaths and drug overdoses, but also reflect a sense of desperation in part driven by impaired access to health care, along with rising medical bills and medical bankruptcies.

Our insurance system is failing us. Single payer would break this fall.

Figure by Charlie Swanson, except 2021 blue arrow by Jim Kahn (real health spending may have dropped due to lower elective care, hence the backward lean).

http://healthjusticemonitor.org…

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Summary: Private equity sees large financial returns in the nursing home business, and is willing to maximize that profit by cutting services at the expense of resident well-being. The result is a leaner and riskier existence, with higher death rates. Private equity is degrading care for our aged and infirm.

When Private Equity Takes Over a Nursing Home, The Daily Newsletter of The New Yorker, August 25, 2022, by Jessie Li

After an investment firm bought St. Joseph’s Home for the Aged, in Richmond, Virginia, the company reduced staff, removed amenities, and set the stage for a deadly outbreak of COVID-19.

St. Joseph’s Home for the Aged was once a beloved nursing home with a family-oriented ambiance, where nuns lived with residents and the waiting list for a room was three years long. There were manicured gardens, a lively aviary and an aquarium, and warm common areas with “a china cabinet here, an upright piano there,” as Yasmin Rafiei writes. Then, in June last year, the home was sold to a private-equity firm called the Portopiccolo Group. The situation is not uncommon: since the turn of the millennium, there’s been a trend toward private-equity investment in nursing homes. Researchers at the University of Pennsylvania found that, “when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent,” as Rafiei writes. At St. Joseph’s, which was renamed Karolwood Gardens, residents began eating meals alone in their rooms, nursing staff plummeted, and the home experienced a string of COVID-19 infections and deaths. Rafiei delves into the question of why deaths skyrocket in private-equity-owned homes, and tells a deeply reported story of St. Joseph’s devastating transformation.

Financial and Quality Metrics of A Large, Publicly Traded U.S. Nursing Home Chain in the Age of Covid-19, International Journal of Health Services, February 4, 2022, by David E. Kingsley and Charlene Harrington

This descriptive case study examined the structure, operations, strategies, care outcomes, and owners of the Ensign Group Inc. the second largest U.S. for-profit chain, between 2007 and 2021. Ensign, as a holding company, has a complex organizational structure that uses more than 430 corporate entities to manage its 228 nursing homes and senior living facilities. Ensign’s small board, executives, and institutional investors protected and enhanced shareholders interests rather than ensuring that its nursing homes met professional standards and regulatory requirements.

The financial power that institutional investors bring to corporate governance reinforces the agency theory of management and a philosophy that shareholder interests are the sole mission of corporations, while their nursing homes provide mediocre care at best and deadly care at worst. By protecting and enhancing shareholder interests as the summum bonum of management, excess capital is accumulating and driving governance to benefit investors rather than ensuring that NHs meet professional standards and regulatory requirements.

Comment:

By Don McCanne, M.D.

What are the two words that communicate this despicable transformation that is taking place throughout our health care system? Private equity!

What could exemplify this more than a beloved nursing home where patients are cared for as if they are family members being taken over by an entity that changes its mission to enhancing its profits by reducing as much as possible the services rendered to its patients, regardless of the deterioration in the quality of care that the patients receive? The full New Yorker article by Yasmin Rafiei provides detail on Portopiccolo Group’s takeover of St. Joseph’s Home for the Aged and related research.

The Kingsley and Harrington study provides an academic description of corporate strategies in the nursing home industry, strategies that clearly favor investors over patients.

Private equity. Whatever happened to patient service? Everywhere you turn now, it’s private equity. And it’s not as if it’s filling some unmet need. Much of our health care dollars are now being directed to shareholders, including millionaires and billionaires, when tens of millions of people remain without adequate care because of being uninsured or underinsured.

We really need to dump private equity in health care and replace those two words with the two words that we know will work for all of us: Single payer!

http://healthjusticemonitor.org…

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Summary: A new study finds that privately-insured individuals with chronic illness are far more likely to have medical debt that is delinquent or in collections, and credit problems. And the debt is larger. Our insurance system is punishing people for being ill.

Association of Chronic Disease with Patient Financial Outcomes Among Commercially Insured Adults, JAMA Internal Medicine, August 22, 2022, by Nora V. Becker et al.

From Abstract: Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

From Discussion: Further research in this area is needed to determine the relative importance of these pathways, as the policy implications of each are different. If poor financial well-being leads to additional chronic disease, policy makers should consider new social safety-net policies to reduce poverty rates and should explicitly incorporate improvements in physical health—and correspondingly reduced health care spending—as a benefit of antipoverty programs. If, in contrast, chronic disease diagnoses are directly leading to adverse financial outcomes, then improving commercial insurance benefit design [JGK – For a different solution, see below.] would be warranted to provide additional protection from out-of-pocket medical expenses, particularly for conditions identified as being costly for patients. In addition, policy makers should consider expanding access to disability benefits and implementing other social safety net policies to help patients recoup income loss after illness.

Comment:

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

These findings come as no surprise – in our health insurance system with very high patient cost-sharing (deductibles, copays, and uncovered services), individuals with greater ongoing medical needs inevitably have more medical expenses, more debt, more low credit scores, and more bankruptcies.

The cost-sharing doesn’t control healthcare costs. So why do we design a health insurance system this way, to financially punish the ill?

You know the answer: it’s profitable for insurers. Costs shift from shareholders to patients. It’s also profitable for drug makers and providers who charge high prices and garner out-sized profits.

When will we adopt an insurance system that is humane – that serves and protects the ill? And that is, in the process, efficient, saving money for the healthcare system.

It sounds magical. It is. It’s called single payer.

(We also need far better income protection for individuals who are disabled by chronic illness.)

http://healthjusticemonitor.org…

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Summary: Recently House of Representatives Speaker Nancy Pelosi led a delegation to Taiwan, affirming US support for the country’s continued independence as China stridently pursues reunification. She praised Taiwan’s economic vitality, but forgot to highlight the country’s fine approach to health insurance: single payer.

Letters from an American, August 20, 2022, by Heather Cox Richardson

Pelosi … championed Taiwan as a leading democracy, “a leader in peace, security and economic dynamism: with an entrepreneurial spirit, culture of innovation and technological prowess that are envies of the world.” She explicitly said her visit was intended to reaffirm “our shared interests [in]…advancing a free and open Indo-Pacific region.” “By traveling to Taiwan, we honor our commitment to democracy: reaffirming that the freedoms of Taiwan—and all democracies—must be respected.”

Comment:

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

So, what kind of health insurance does Taiwan have?

Oh, yeah, single payer, since 1995.

Seems like having universal health insurance paid by the government doesn’t cripple the economy. Vibrant capitalism, supported by a generous and efficient social welfare foundation.

Who knew? (Lots of us, of course.)

Health care costs low, equity and longevity high. Part of the formula for economic robustness.

I wish Ms. Pelosi had made this point.

http://healthjusticemonitor.org…

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Summary: Amazon just entered the medical provider business, buying a large medical firm. Their goal: to make money by finding insured, well-off, and inexpensive patients. It’s a business model, to maximize profits. What we need is a health improvement model, to … maximize health!

Amazon’s acquisition of a medical firm may not disrupt healthcare, but could disrupt your life, Los Angeles Times, August 18, 2022, by Michael Hiltzik

Amazon plainly believes that there is profit to be made from the business model of One Medical.

One Medical aims its services, which amount to providing faster appointments, “wellness” services and “routine and preventive care,” at a relatively affluent market segment. It does so partially by charging an annual fee of $199.

Then there’s the firm’s practice of geographical segregation. One Medical says it places its offices in “locations convenient to where consumers work, shop and live.” This works to One Medical’s advantage by “limiting its exposure to uninsured, poor, and costly patients.”

“Amazon may be able to make this a viable business venture that returns a significant profit to their investors,” David Blumenthal, a primary care physician who is the Commonwealth Fund’s president, told me. But “unless they substantially change the model this will just be another selective deal serving a part of the population that is already favored by the current healthcare system.”

“Most of health care spending is on sick patients and can’t be easily reduced,” Amitabh Chandra, a healthcare expert at Harvard Business School, said in an interview on the school’s website after the Amazon announcement.

Amazon’s high-profile misstep was Haven, a joint venture with Jamie Dimon’s JPMorgan Chase & Co. and Warren Buffett’s Berkshire Hathaway, launched in a blare of publicity in 2018 and humiliatingly shut down in 2021.

Haven aimed to reduce American healthcare costs by focusing on “technology solutions,” but the Bezos/Dimon/Buffett triumvirate didn’t understand what healthcare economist Uwe Reinhardt and colleagues identified in 2003 as the main reason for high healthcare costs in America, with an article titled “It’s the Prices, Stupid.”

The key flaw in the American healthcare system is the encroachment of business principles into what used to be regarded as a public service, back when Blue Cross and Blue Shield were nonprofit insurers and most hospitals were nonprofit providers.

The structure that would be most likely to bring universal healthcare to Americans at an affordable price would be a single-payer system with the government as the payer. But even Medicare, which was once the quintessential single-payer program, has been moving away from that principle, thanks to the spread of private Medicare Advantage plans.

Comment:

By Don McCanne, M.D.

Whereas quite a few individuals are being served fairly well by our current health care system, far too many are not because of deficiencies and voids, especially in the way we pay for health care. Even though we spend more than other nations, we fall below many other wealthy nations in our health care outcomes, largely because of these deficiencies.

Part of the problem is demonstrated by the proposed Amazon acquisition of One Medical. It is structured as a business deal to make a profit for private investors (concierge fees, marketing to the healthy and wealthy, avoiding care for the sick and poor) while avoiding the public service concept of health care for all.

Now even our traditional public insurance programs are also being converted to cater to private investor interests as exemplified by private Medicare Advantage and ACO REACH models. We’re clearly headed in the wrong direction.

As Michael Hiltzik states, “The structure that would be most likely to bring universal healthcare to Americans at an affordable price would be a single-payer system with the government as the payer.”

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.