PNHP

Financialization – Structural Harm to US Health Care

Financialization – Structural Harm to US Health Care

An excellent commentary in NEJM defines and describes the role of financial actors and actions in US health care. Increasingly, insurers and providers are purchased by financial organizations or adopt financial strategies. The focus on health care is disrupted.

The Financialization of Health in the United States, NEJM, January 11, 2024, by JD Bruch, V Roy, CM Grogan

We believe that health policy discussions concerning quality, equity, and cost must grapple with the emerging influence of the financial sector within the U.S. health care system. …

“Financialization” builds on, but also departs from [corporatization and privatization]. It involves the transformation of public, private, and corporate health care entities into salable and tradable assets from which the financial sector may accumulate capital. Financialization captures … demands of financial markets for short-term profit growth and the distribution of this growth to financial actors that are external to health care entities and U.S. households.

The rise of financialization in the health sector can be traced to economy-wide shifts that occurred in the 1970s and 1980s. … regulatory and policy changes empowered financial actors to make the U.S. health care system a core part of their growth strategies. At the same time, health care entities increasingly began to operate under “shareholder primacy,” a corporate governance strategy that prioritizes the interest of shareholders over other potential stakeholders …

Shifting Patterns of Ownership and Accumulation

One of the most prominent features of financialization in health care is the growing number of health care entities acquired directly by financial actors. For example, in the past decade, PE firms completed more than 8000 transactions involving health care entities, with an estimated combined value of nearly $1 trillion. Leveraging capital from institutional investors (e.g., state pension plans), PE firms fully acquire hospitals, nursing homes, physician practices, dialysis clinics, hospice operators, and a range of other health care operators at a rapid speed. Strapping these acquired health care companies with large amounts of debt, PE firms then engage in quick buy-and-sell turnarounds to make a profit for their partners. Real estate investment trusts (REITs) … acquire health care properties and lease the real estate back to health care facilities (i.e., sale-leasebacks).

… financialization can [also] take the form of indirect control by financial actors that obtain shares in a health care entity, often by means of early-stage investments or through the stock market. For example, venture capitalists fund health care start-ups in exchange for early equity. … Other financial actors — such as pension funds, mutual funds, and hedge funds — have also become heavily intertwined with the health care system. …

From Hospitals to Medical Credit Cards

[H]ospitals, insurance companies, and pharmaceutical firms are increasingly behaving more like financial firms. … In response to uncertainty in reimbursement and enabled by government antitrust deregulation in the 1980s, hospitals began to pursue mergers and acquisitions to increase market power while also pursuing nonoperating income by launching investment arms … can expose hospitals to fluctuations in financial markets. … [N]onprofit hospitals focus on building financial reserves with their investment arms and patient revenue streams because they are preoccupied with maintaining strong credit ratings, which increase their access to the municipal bond market. … finance and business are now the most common professional backgrounds for boardroom members at top-ranked U.S. hospitals.

Publicly traded health care entities such as health insurers and pharmaceutical companies have also become increasingly financialized, pursuing growth through price increases and mergers and acquisitions while distributing accumulated capital to financial market actors — all to maximize shareholder value. …

As health care entities race to generate growth for financial actors and shareholders, patients are facing higher costs in the form of out-of-pocket expenses and rising premiums. [P]hysician practices and hospitals are increasingly partnering with financial institutions to market medical credit cards and installment loans with steep deferred interest rates. …

The Role of the State

… [T]he substantial public financing of the U.S. health care system — which accounts for 60% of national health care expenditures — provides a steady, reliable, and attractive flow of revenue for private companies and the financial actors that invest in them. … capital is flowing to financial actors, including in Medicare Advantage organizations, nursing homes, hospice operators, and other entities …

Third, by means of myriad public policy decisions over a long period, the United States has created an extremely expensive, fragmented, and unequal health care system … contributed to a surge in medical debt and a dependence on medical credit cards.

Confronting Financialization and Its Implications

… Uwe Reinhardt described “value shifting” in health care — a phenomenon in which value is “taken away from some members of society and channeled to the owners of capital.” … Ultimately, the financial sector’s increasing grip on the health care system invites a pressing question: Is the country getting a good deal? …

inequities endemic to and produced by the financial sector — such as unequal access to financial services — may engender health inequities.

… the financial sector … has become a structural determinant of health.

Comment:

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

This NEJM commentary provides a thoughtful tour of the increasingly pervasive role of financial institutions, practices, and norms in US health care. Distinct from, but mutually reinforcing with, privatization and corporatization. The authors correctly conclude that financialization constitutes a structural determinant of health, fostering health inequities. Their solution, however, falls short – more evidence needed.

No, we don’t need more data. We know what we need to know: (a) There is no credible evidence that financialization (or corporatization) fosters health. (b) A profit focus leads to extracting resources from health care, shifting dollars to shareholders. (c) A profit focus also diminishes attention to patient needs, and thus creates a moral hazard for health care providers. (d) We have evidence from dozens of other wealthy countries that universal coverage with standard comprehensive health insurance prevents health care inequities. Let’s not spend another 5-10 years studying financialization and other structural impediments to health care.

Lest we forget – the primary mission of our health system is … to provide quality health care.

Please, no more nibbling at the edges. Let’s sink our teeth into real health care reform. Single payer will empower patients and providers, and disempower the financial mindset in health.

https://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.

Majority of debtors to US hospitals now people with health insurance

Analysts say a ‘sea change’ occurred in the American healthcare system from when only a tenth of debt came from the insured

By Jessica Glenza
The Guardian, January 11, 2024

People with health insurance may now represent the majority of debtors American hospitals struggle to collect from, according to medical billing analysts.

This marks a sea change from just a few years ago, when people with health insurance represented only about one in 10 bills hospitals considered “bad debt”, analysts said.

“We always used to consider bad debt, especially bad debt write-offs from a hospital perspective, those [patients] that have the ability to pay but don’t,” said Colleen Hall, senior vice-president for Kodiak Solutions, a billing, accounting and consulting firm that works closely with hospitals and performed the analysis.

“Now, it’s not as if these patients across the board are even able to pay, because [out-of-pocket costs are] such an astronomical amount related to what their general income might be.”

Although “bad debt” can be a controversial metric in its own right, those who work in the hospital billing industry say it shows how complex health insurance products with large out-of-pocket costs have proliferated.

“What we noticed was a breaking point right around the 2018-2019 timeframe,” said Matt Szaflarski, director of revenue cycle intelligence at Kodiak Solutions. The trend has since stabilized, but remains at more than half of all “bad debt”.

In 2018, just 11.1% of hospitals’ bad debt came from insured “self-pay” accounts, or from patients whose insurance required out-of-pocket payments, according to Kodiak. By 2022, the proportion who did (or could) not pay their bills soared to 57.6% of all hospitals’ bad debt.

Kodiak receives every billing transaction for more than 1,800 hospitals across the US, a little less than one-third of all hospitals in the country. It was able to perform the analysis by looking at this in-house database.

The cost of healthcare in the US is a perennial political concern – it eats up more than 18% of gross domestic product, far more, and often for worse health outcomes, than in other peer democracies. As much as 31% of the cost of US healthcare is probably driven by the administration of complex bills that now beset the public.

Now, medical debt and its impact on Americans’ lives is an issue of increasing political perseveration. A recent investigation by KFF Health News and NPR found more than 100 million Americans have medical debt of some kind, debt which often forces families to make heart-wrenching sacrifices.

In part, those sacrifices are driven by hospitals’ extraordinary collection practices. Hospitals refer patients to aggressive debt collectors, use state courts to garnish wages, place liens on people’s homes and report debt to credit agencies, which can drastically worsen future job and housing prospects. Although there are some attempts to rein in these practices, billing analysts like Szaflarski say they do not address the core issue – health plans designed by insurers which force hospitals to become debt collectors.

“These stories really grind my gears,” said Szaflarski. “The idea of patient responsibility” – those deductibles and coinsurance requirements – “was not an idea created by healthcare providers. They were vehicles created by payers,” referring to insurers.

Ariel Levin, the director of coverage policy for the American Hospital Association, says the organization is discussing multiple solutions – such as removing hospitals from the billing equation entirely – to challenges they say are created by insurer decisions.

“Something else we’re exploring recently is how to remove providers from the cost-sharing altogether and require health insurers to collect it,” Levin said.

Even seasoned professionals such as Levin have found it hard to decipher hospital bills, such as when her baby needed surgery.

“It was really hard to look at my plan, even though I should be able to read the fine print and understand,” Levin said.

Deductibles have come under particular scrutiny as the share of workers subject to high deductibles has risen in the last decade. There is not a single definition for a high-deductible health plan, but typically such plans require a payment of $1,000 or more before insurance kicks in for a single person – though costs can soar far above that. Because deductibles reset every year, they can be especially punishing for chronically ill patients – and they can be far more expensive than $1,000 a year.

“Obamacare” plans – that is insurance plans people buy as individuals on state exchanges – are notorious for such high deductibles. Federal regulations allow insurers on state exchanges to charge an individual as much as $9,450 out of pocket in 2024 – not including monthly payments called premiums. That limit is predicted to grow to $14,100 by 2030. And because healthcare costs are rising faster than wages, those expenses are predicted to eat up an ever-larger share of Americans’ paychecks.

Notably, it is unclear whether rising costs for patients alone explain the breaking point the Kodiak analysis saw in 2018. George W Bush signed an act in 2003 allowing insurers to sell such plans, and they quickly grew to represent about 30% of the private employer insurance market by 2012. That proportion remains about the same today, and “cost-sharing” has continued to increase across all kinds of health plans.

“We have seen now that a lot of the debt we purchase and get rid of is also for insured patients,” said Ruth Landé, vice-president of hospital relations at RIP Medical Debt, and the former leader of a hospital billing team. RIP Medical Debt purchases hospitals’ debt portfolios and forgives the debt – part of an effort to relieve Americans of a burden many see as tacitly unfair.

Further, patient advocates criticize bad debt as a metric in its own right. Hospitals view bad debt as bills patients could pay but choose not to. But hospitals rarely screen patients for their ability to pay, and a raft of evidence shows patients who experience medical debt are often low-income and would probably qualify for discounted or free care if they went through hospitals’ lengthy application process.

Landé said when RIP acquires debt portfolios and matches accounts with third-party income data, it often shows the vast majority of patients with past-due debt would probably be eligible for free or discounted care if their finances were assessed. RIP provides debt relief to people with income that is four times the federal poverty level or less.

“It’s obvious to [hospitals] that if someone comes to them and is uninsured there’s a need there,” said Landé. “But if they’re insured,” and can’t afford their insurance, “their processes and systems are not designed to detect that need.”

This article was amended on January 11, 2024 because the American Hospital Association’s Ariel Levin did not say all hospitals would prefer to remove themselves from the billing equation; rather, Levin discussed that as a possible solution to some of the challenges created by insurer decisions.

https://www.theguardian.com…

UK Doctor Strike Reveals Need to Resist Conservative Politics & Corporate Predation

A physician strike in the UK National Health Service reflects how British politicians have betrayed the NHS through austerity funding and support for corporate grabs in health care. In the US we face similar barriers. We must preserve democracy at the ballot box, and build community control.

Yet Another Blow for the National Health Service in England: A Doctors’ Strike, The New York Times, Jan. 3, 2024, by Mark Landler

Thousands of young doctors walked off the job in England, dealing another blow to the country’s already-reeling National Health Service and raising concerns about a cascade of cancelled medical appointments and surgeries.

The junior doctors have been seeking a 35 percent wage increase, which they say is needed to counteract a more than 25 percent cut in real wages since 2008.

The waiting list for procedures at N.H.S. hospitals has reached 7.7 million people, up from 4.6 million people before the coronavirus pandemic. Prime Minister Rishi Sunak pledged last year to cut waiting times, making it one of five bedrock goals of his conservative government. Instead, the list has lengthened by 300,000 people.

The doctors complain about long hours, relentless pressure and pay that has failed to keep pace with double-digit inflation, though that has eased recently – issues that have afflicted other health systems, including those in the United States.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

For the past few decades, we have recognized that the health system in the United States is the most expensive of all nations, while falling far short on measures of quality, comprehensiveness, equity, and universality. Many studies show that we could greatly improve coverage and access while saving money by enacting single payer financing. Health care would be affordable and available to everyone. Single payer models include Canada’s public insurance approach with mostly private providers, and Britain’s National Health Service, built largely on government ownership of care delivery.

However, the news of the UK doctor strikes reminds us that there is a major roadblock to adopting and effectively implementing single payer: the nexus of conservative politics and corporatization of medical services. Two nasty, interacting c’s.

We’ve reported on how conservative, corporate-influenced policies in the UK precipitated the current crisis. Note, this is conservative with a small c, both Tories (the worst offenders) and Labor (seriously complicit). Neo-liberalism undermines the public orientation of the NHS.

In the US, while we may dissect why we have not enacted single payer, it is largely due to conservative political opposition and to both conservative and moderate political support of market over government approaches to health insurance and care provision. Tragically, this preference for the market created the severe deterioration in health care services that we see today.

Those paying attention are painfully aware of the harm done by using health care dollars for the primary mission of personal wealth enhancement rather than improving the health of our population. This is exemplified by private equity’s leveraged purchase of delivery system sectors (e.g., physician groups) to capture wealth for the investors – patients and providers be damned.

Unfortunately, widespread corporate for-profit ownership of health care delivery will likely undermine single payer functioning. Thus, single payer alone would be inadequate. Far too large of a percentage of our health care delivery system is now owned by those motivated primarily by profits rather than by patient care.

So, instead of private, for-profit control of the delivery system, what about non-profit community ownership? Community hospitals and primary and multi-specialty clinics, dialysis clinics, and long term care. Couldn’t we do this on a community basis yet have it funded equitably via national single payer? Functioning like a national health service but with more local control.

What lesson does the current British NHS boondoggle provide for us in today’s fraught political environment? The UK experience demonstrates that public insurance and public ownership together are inadequate, if politicians don’t sustain it. Also in the US, even with a Democratic President, the private actors have too much sway. Biden, who called Obamacare a BFD, strongly supported private health plans in the exchange and in Medicare. Although there are recent baby steps to regulate Medicare drug prices, Medicare Advantage is running amok.

That’s bad enough. But imagine a government health system under the control of Trump appointees. No more constraints on exploitive corporate behaviors. No more attention to real health insurance needs. A deadly free-for-all. Oh, and also – no more democratic governance norms.

Whoa! The first task before us is to elect a government that cares about us – all of us. This may seem like a formidable task before us, but we have to do it! See 13 New Year’s resolutions in pursuit of this essential goal. From there, we must galvanize communities to fight for greater control of health services.

https://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.

Dr. Sidney Wolfe’s Towering Life of Public Service

For Sid, outrage was a moral imperative; the only humane response to inhumane policies and practices.

By Robert Weissman
Common Dreams, January 2, 2024

America has lost a towering public health leader and an unparalleled consumer champion, Public Citizen has lost one of our founders and I and many others have lost a great friend. My dear friend Sid Wolfe passed away early Monday. He was 86 years old.

Dr. Sidney Wolfe founded the Health Research Group in 1971 with Ralph Nader, part of the enterprise that launched as Public Citizen that same year. Sid invented a new approach of “research-based advocacy” to get dangerous drugs and devices off the market, win new protections for worker health and safety, address doctor misconduct, challenge the Food and Drug Administration (FDA) to do its job, and hold pharmaceutical companies accountable.

Sid was brilliant (he won a MacArthur “genius” grant) and fearless in his advocacy. But what was most singular about him professionally was his passion for advancing health justice. There was a distinctive fierceness and fury to his work. Everyone who knew or even encountered Sid—allies and adversaries alike—experienced his intensity.

Here’s why he brought that to his work for more than 50 years: Ralph Nader once coined the term “pitiless abstraction” to describe the mental gymnastics of corporate executives and lawyers who know that their decisions – for example, to allow dangerous cars on the market – would cost the lives of substantial numbers of people but who took refuge in the fact that they had no idea who those people were. They were just abstractions.

By contrast, for Sid, the victims of drug company or other corporate wrongdoing or FDA failures weren’t abstractions. Like those executives, he didn’t know the victims’ names. But he did know they were real, breathing human beings, as deserving of care and protection as our family members and those close to us.

So, when the FDA compromised its mission and permitted a dangerous drug on the market, or when a drug company concealed risks, or employers exposed workers to toxics, or when the private health insurance system deprived people of access to care, Sid was outraged. The anonymous people injured or killed by those actions or inactions were just as precious as anyone he knew.

Sid’s sense of injustice about drugs, devices, and a health system that imposed avoidable and needless suffering reflected the underlying science. Sid carried out cutting-edge research of the highest caliber. Under his leadership and the standards he established, the positions Health Research Group stakes out and advocates are rooted in science and evidence. When we recommend against approval of a drug, for example, it’s because the available data shows that its risks are too great. Sure, sometimes there are judgment calls. But Sid saw that in the overwhelming number of cases when the FDA sided with a drug company against our recommendation, it was ignoring the best science, responding instead to improper influence and refusing to uphold its core public health and consumer protection mission. With lives and people’s well-being at stake, outrage was exactly the right response.

“Outrage,” in fact, was Sid’s catchphrase, his cri de coeur. Every issue of Health Research Group’s Health Letter contains an “Outrage of the Month,” penned by Sid until he handed over leadership of the group about a decade ago. For Sid, outrage was a moral imperative; the only humane response to inhumane policies and practices.

If you look back over Sid’s TV appearances or review his writings, as I have been doing over the last many weeks, you see every time the intensity of his belief and commitment to advancing health.

Sid first partnered with Ralph Nader to call attention to a deadly problem with intravenous fluids. In early 1971, a doctor phoned Sid to complain about the government’s failure to ban contaminated intravenous fluids. Hundreds of patients who had received fluids from Abbott Laboratories had developed severe bacterial infections, and dozens had died.

Instead of ordering a product recall, the government merely warned doctors to watch for infections and stop using the fluids if they spotted any. Sid called his then-acquaintance Ralph, who suggested they write to the U.S. Food and Drug Administration (FDA) demanding a ban and release the letter to the press.

Within a few days of the letter hitting the news, Abbott recalled the contaminated fluids. “I was very surprised that we’d won,” Sid said. “It was very satisfying to see that if you did your homework and had the facts on your side, you could succeed.”

As the New York Times later reported: “Dr. Wolfe started getting calls on other issues. He was hooked. He proposed that he and Mr. Nader begin a health research group, the first specialty group within Public Citizen.”

During those early days at Public Citizen, Sid told Ralph that the Health Research Group job would be the last one he ever had. He was true to his word.

Sid said that he learned from that initial experience with Abbott fluids that 1) government agencies are often in possession of clear, unequivocal evidence and not using their powers to get documented serious hazards off the market; 2) “government agencies must have outside pressure to use their authority to save lives and injuries.” Generating that outside pressure became his mission.

Sid headed the Health Research Group from 1971 until 2013, when at the age of 76 he handed the reins over to Dr. Michael Carome. Sid didn’t retire. Instead, he remained at Public Citizen and continued his work, although, as he proudly said, he downgraded his hours to 45 or so a week. Mike Carome was an extraordinary director of Health Research Group until retiring earlier this year. Sid kept working. In July, Dr. Robert Steinbrook became the third director of the Health Research Group. Full of vigor until diagnosed with a brain tumor, Sid had planned on working for many years more with Robert and the team at Health Research Group.

Sid innovated a whole new way to advocate for drug and medical device safety and public health through his approach of research-based advocacy. This involved doing academic-level, independent, rigorous analysis of safety and efficacy information. But the goal wasn’t to publish in academic journals (although Sid often did); it was to deploy that analysis for advocacy campaigns to get dangerous products off the market or advance health and safety policies. That meant bringing the evidence to policy makers and pressuring them to respond to the evidence and public health, rather than corporate entreaties. It meant translating the information to easy-to-understand language for the public, so they could demand appropriate change.

And it meant sticking with issues as long as it took. In some cases, the FDA acted on safety recommendations Public Citizen made decades earlier. Sid regarded those FDA actions less as victories or as “I told you so moments,” than as failures. The agency should have acted decades earlier and many people were needlessly hurt in the interim.

Here’s what I mean: The FDA banned surgical powdered latex gloves – which pose serious risks both to patients and health workers — in 2016. We had first petitioned the agency for this action in 1998. “The fact that it took the FDA 18 years to propose banning powdered surgical gloves from the market highlights how recklessly negligent the agency is,” Sid said. “There is absolutely no new scientific information today that we didn’t have in 1998 about the dangers posed by cornstarch powder and by latex when used in surgical and patient examination gloves.”

Research-based advocacy also meant finding new ways to gather data, such as anonymously surveying FDA drug reviewers about degrading standards at their agency, or surveying county jail staff about inmates with serious mental illness, or collecting and publishing information on every doctor in the United States who had been disciplined at a time when that information was not otherwise available.

Research-based advocacy meant getting information to consumers, and in this, too, Sid was endlessly creative. With his colleagues at Health Research Group, he published multiple editions of Worst Pills, Best Pills, a monumental book that provided people with information about the side effects of medications and warned of drug interactions. With the first edition in 1988, the book sold 2.5 million copies – the proceeds from those sales helped pay for Public Citizen’s headquarters building. Worst Pills, Best Pills has been supplemented by a website, WorstPills.org, which is updated regularly, and Worst Pills, Best Pills News, a monthly newsletter with a peak circulation of more than 150,000. Sid appeared regularly on the Donahue Show – Phil Donahue became a close friend of Sid’s and of Public Citizen – explaining in authoritative and easy-to-understand terms the risks of various medicines and the best available alternatives.

Research-based advocacy also meant using litigation, based on scientific evidence, to force recalcitrant agencies to act. The superb lawyers at our Litigation Group worked with Sid on countless legal actions to force government agencies to respond to our petitions and to disclose vital health information.

Sid’s body of work and his achievements – accomplished in partnership with amazing colleagues in Health Research Group, other Public Citizen staff and allies outside the organization – are jaw-dropping. Under Sid’s guidance, Public Citizen:

  • Helped to force 28 dangerous medications off the market, limiting the use of 10 more and adding strong warnings to dozens of others.
  • Pushed the Occupational Safety and Health Administration to set more than a dozen worker-protective health standards.
  • Testified before hundreds of FDA advisory committees urging against approval of dangerous drugs and devices, and for limited use or strong warning labels of others, with substantial influence over countless decisions and helping prevent many dangerous products from ever making it to market.
  • Won a ban of Red Dye No. 2, obtained warning labels about Reye’s syndrome on the side of aspirin bottle, and helped impose restrictions on silicone breast implants.
  • Sold 2.5 million copies of Worst Pills, Best Pills.
  • Documented weakening standards at the FDA following passage of the first Prescription Drug User Fee Act, which made drug companies a major revenue source for FDA.
  • Won earlier public access to safety and efficacy information for products being considered for approval by the FDA, enabling more effective advocacy by consumer advocates.
  • Advocated for decades against drug company marketing of dangerous opioids and demanded accountability for the drug companies and the corporate CEOs who fueled the deadly opioid addiction epidemic.

That mind-blowing list is very abbreviated. Sid and colleagues also did vital and path-breaking research and advocacy on doctor discipline, mental health, tobacco, pharmaceutical marketing, drug company payments to doctors, medical devices, health insurance and the imperative of Medicare for All, unnecessary Cesarean sections, unregulated supplements, medical resident work hours, and more.

Sid helped build Public Citizen into the vital and durable institution it is today. He made a name for the organization by making a difference. He inspired legions of medical students and made Public Citizen a name admired in the public health community – and feared by Big Pharma. He reached millions of consumers with his health information and literally helped enable us to buy the building where I sit writing this remembrance.

For half a century, Sid taught so much to all of us at Public Citizen, myself very much included: How to be strategically creative and innovative. How to translate expertise into policy talk and, even more importantly, public messaging. How to use the media to disseminate information and demand change. How to do research and maintain standards of excellence. The need to insist on accountability. How to operate with integrity and fearlessness. The power of persistence and never giving up. How to stay motivated for the long haul. Why passion makes a difference. Never to accept injustice. How to make a difference.

Sid and I grew very close in our more than a decade working together, rooted in our collaborations and also our bond as native Clevelanders. When I came to Public Citizen, Sid helped me immensely, in ways large and small, get settled in. Over the years, I came to admire him and his work all the more, to enjoy his sly and sometimes silly sense of humor, and appreciate his humanity, decency and friendship.

Public Citizen will miss the one-of-a-kind Dr. Sidney Wolfe and I will miss him terribly as my friend.

As we remember him, we know this: Sid saved the lives of tens and tens of thousands of people, almost none of whom will know the debt they owe to Sid. There’s just no way to know about the drug that might have killed you but didn’t because it was pulled from the market or never approved – due to Sid’s work. Very few of the millions of people who benefited from safety warnings that Sid and his colleagues forced onto drugs will know why they were able to avoid serious health problems. The millions and millions of workers who avoided exposure to workplace toxins and hazards because of rules that Sid and colleagues forced into place will never know how Sid protected them from dangers and disease.

None of that was of any concern to Sid. He knew that Health Research Group’s work had made (and continues to make) a difference, he knew the impact on real people, and he was proud of the work.

At age 86, he had intended to continue that work. We will honor the awesome achievements of the great Dr. Sidney Wolfe by doing exactly that.

By continuing to campaign against unsafe drugs and devices, to hold the FDA and Big Pharma accountable, to fight for Medicare for All, and more. By refusing to fall prey to the logic of “pitiless abstractions” and remembering always that the policies about which we advocate make a profound difference – often, a life-and-death difference – to real human beings. And by trying to bring to our work, in everything we do, Sid’s fire and passion, brilliance and integrity, and determination and love.

Robert Weissman is the president of Public Citizen.

https://www.commondreams.org…

Prescription for Healthcare—moral injury and burnout

Interview with Drs. Carol Paris and Diljeet Singh

By Rob Stone, M.D. and Karen Green Stone
WFHB Community Radio (Bloomington, Ind.)

Interview with Dr. Paris (December 9, 2023)

Interview with Dr. Singh (January 1, 2024)

PNHP past president Dr. Carol Paris and PNHP vice president Dr. Diljeet Singh discuss the issue of moral injury among physicians—and how it differs from the more commonly used term, “burnout”—on back-to-back episodes of the Prescription for Healthcare podcast.

Both physicians lament the fact that doctors are often not able to prescribe an ideal course of treatment because a for-profit insurance company denies it.

“The reality is that there are all these other entities hiding in the exam room,” says Dr. Paris. “The insurance company, the pharmaceutical company, the hospital, or the owner of the venture-capital owned practice that the physician is practicing in.”

Dr. Singh adds, “As long as there’s a third person in this system who’s just trying to make money, that’s going to disrupt the sense of trust and openness” that should exist between patients and their physicians.

full Dr. Paris interview:
https://wfhb.org…

full Dr. Singh interview:
https://wfhb.org…

HJM AI-Assisted 2023 Review

2023 was another year of deteriorating US health insurance performance, especially as post-COVID protections lapsed, and continued modest gains toward single payer. For the annual summary, we set up a ChatGPT-based artificial intelligence bot on the HJM website to allow natural language interaction with HJM content – called HJM Ai-Chat. Below are sample queries and responses.

Q: How did the US health care system perform in 2023?

In 2023, the US healthcare system faced significant challenges and shortcomings, as highlighted by the provided information. Here’s a summary of its performance in 2023:

  • Financial Barriers to Care: A survey by the Commonwealth Fund revealed that US health insurance, across all types, posed widespread financial barriers to care, leaving a large percentage of insured working-age adults struggling to afford healthcare. This underscores the financial burdens and difficulties faced by individuals and families in accessing essential medical services, indicating a systemic issue within the healthcare system.
  • Privatization Challenges: The founders of Physicians for a National Health Program emphasized the growing hold of giant for-profit corporations on the healthcare system, including banks and for-profit ownership of health providers. This increasing involvement of for-profit entities has made it harder to address the systemic dysfunctions and challenges within the healthcare system, contributing to growing dissatisfaction among doctors and the public.
  • Dysfunctional System: The healthcare system continued to face significant dysfunctions, leading to massive medical bills, unaffordable lifesaving treatments, and growing dissatisfaction among healthcare professionals. This dysfunction has created a strong interest and constituency for fundamental health reform, reflecting the urgent need for comprehensive healthcare financing reform to address the systemic issues and dysfunctions within the US healthcare system.

These insights collectively indicate that the US healthcare system faced significant challenges and dysfunctions in 2023, highlighting the pressing need for comprehensive and equitable healthcare financing reform.

Sources:

Q: What were the problems with job-based insurance in 2023?

In 2023, job-based insurance faced several significant problems, as highlighted by the provided information. Here’s a summary of the key issues with job-based insurance in 2023:

  • Biased Reporting: The Chamber of Commerce’s online poll claimed overwhelming worker support for job-based health benefits. However, the methods and reporting were biased, leading to a skewed representation of worker sentiments. This biased reporting obscured the true challenges and concerns faced by workers regarding job-based insurance.
  • Erosion of Benefits: The traditional appeal of employer-sponsored plans has diminished due to skyrocketing deductibles, which have obscured the lower wage effect. This erosion of benefits has undermined the attractiveness of job-based insurance as a reliable and comprehensive healthcare option for workers and their families.
  • Lack of Solidarity: Relying on decent job-based insurance has undermined the principle of solidarity, which is a fundamental value in ensuring healthcare for everyone. The Affordable Care Act (ACA) aimed to enhance solidarity while preserving employer-sponsored plans, but the rapid growth of high deductible plans and the failure to provide decent coverage for everyone have led to an erosion of solidarity in healthcare coverage.

These problems with job-based insurance in 2023 underscore the need for comprehensive healthcare financing reform to address the evolving challenges and ensure equitable access to high-quality healthcare for all individuals and families.

Sources:

Q: What happened with Medicaid post-COVID disenrollment in 2023?

In 2023, the post-COVID disenrollment from Medicaid led to significant challenges and disruptions in healthcare coverage for many individuals. Here’s a summary of the key developments related to Medicaid disenrollment post-COVID in 2023:

  • Disenrollment Estimates: In 20 reporting states, it was estimated that approximately 13% of Medicaid enrollees would be disenrolled when the continuous enrollment requirement ended. However, the estimates varied widely across states, ranging from about 8% to over 30% of total enrollees. The primary reasons for disenrollment included an increase in income and incomplete renewals or missing documentation.
  • Impact on Coverage: The potential disenrollment of millions of people from Medicaid coverage following the end of the public health emergency (PHE) posed a significant risk of leaving many individuals uninsured. However, it was noted that many children would likely be eligible for CHIP, and adults would likely be eligible for Marketplace or other coverage. Successfully transitioning these individuals into alternative coverage options could help reduce the number of individuals who lose coverage altogether.

These developments underscore the complexities and potential consequences of the post-COVID disenrollment from Medicaid, emphasizing the need for ongoing efforts to ensure access to comprehensive and equitable healthcare coverage for all individuals.

Sources:

Q: What did new evidence from 2023 reveal about the prevalence and severity of medical debt in the US?

New evidence from 2023 revealed alarming insights into the prevalence and severity of medical debt in the US, shedding light on the significant financial burdens faced by individuals and families. Here’s a summary of the key findings:

  • The prevalence of medical debt: A multi-year survey of US adults found that medical debt affected 18% of households, indicating a substantial portion of the population grappling with healthcare-related financial challenges.
  • Risk factors for medical debt: The survey highlighted that individuals with no insurance, high deductible private insurance, or Medicare Advantage faced a higher risk of accumulating medical debt. This underscores the vulnerability of certain segments of the population to healthcare-related financial burdens.
  • Impact on social determinants of health: Medical debt was found to exacerbate social determinants of health, leading to increased food insecurity, the inability to pay for housing and utilities, and heightened risk of eviction or foreclosure. These consequences underscore the far-reaching impact of medical debt on overall well-being and stability.

The new evidence from 2023 underscores the urgent need for comprehensive healthcare financing reform to address the pervasive and detrimental effects of medical debt on individuals and families across the US.

Sources:

Q: In 2023, what percentage of US families skipped or delayed medical care for financial reasons?

  • In 2023, the percentage of US families who skipped or delayed medical care due to financial reasons was alarmingly high. According to the provided information, the data from Gallup in January 2023 revealed that 38% of Americans reported postponing medical treatment in 2022 due to cost, marking a significant 12-point increase from the previous year. This trend indicates a growing financial barrier to accessing necessary healthcare services.
  • Furthermore, the data highlighted that insured adults also faced challenges, with 29-42% of them or their family members delaying or skipping needed healthcare or prescription drugs due to unaffordability over the past 12 months. This percentage varied across different types of insurance coverage, with the highest rates observed among those enrolled in Medicaid (39%) and individuals with Medicare (42%).
  • These findings underscore the widespread impact of financial barriers on healthcare access, affecting a significant portion of US families across different insurance categories. The high percentage of families experiencing cost-driven delays in obtaining care or missing care, coupled with the prevalence of medical debt, paints a concerning picture of the challenges individuals and families face in accessing essential medical services.

The data from 2023 emphasizes the urgent need for comprehensive healthcare financing reform to address the pervasive financial barriers that hinder access to healthcare for a substantial portion of the US population.

Sources:

Q: How are other wealthy countries doing with health insurance in 2023?

In 2023, other wealthy countries have continued to demonstrate more efficient and equitable approaches to health insurance compared to the United States. Here’s a summary of the key insights from the provided information:

  • Automatic Enrollment and Comprehensive Coverage: Dr. Danielle Ofri’s experience highlighted the inefficiencies of the US health insurance system, where an email glitch led to her automatic enrollment in a basic plan, excluding her family. This contrasts with the streamlined and comprehensive coverage provided in other wealthy nations, where individuals and families are not subjected to the bureaucratic hurdles and uncertainties associated with annual re-enrollment.
  • Lessons from Other Countries: An op-ed in the New York Times emphasized the importance of learning from other wealthy nations, underscoring that single payer is the only plausible path to achieving efficient and equitable healthcare financing in the US. This suggests that other countries have established successful models that prioritize accessibility and fairness in healthcare coverage.
  • Comparative Health Outcomes and Expenditure: The data from John Abramson’s publication highlighted the stark disparities in health outcomes and healthcare expenditure between the US and other comparable countries. Despite the US spending significantly more on healthcare per person, the health outcomes remain inferior, indicating the need for a reevaluation of the US healthcare system in comparison to those of other wealthy nations.

These insights collectively indicate that other wealthy countries have continued to prioritize efficient, comprehensive, and equitable health insurance systems, providing valuable lessons for addressing the shortcomings of the US healthcare system.

Sources:

Q: What were the major developments with single payer reform in 2023?

In 2023, there were significant developments and discussions surrounding single payer reform, reflecting the ongoing push for comprehensive healthcare financing reform. Here’s a summary of the major developments:

  • The issue of corporate takeover of primary care emerged as a significant challenge for single payer reform. The large-scale corporate appropriation of primary care was highlighted as enabling profiteering that dominates the US healthcare system, potentially jeopardizing the doctor-patient relationship and the viability of single payer financing. This underscores the need to address corporate dominance in healthcare to ensure the success of single payer reform.
  • Discussions emphasized the typical features of single payer systems, highlighting key elements necessary to achieve universal, equitable, efficient, and affordable access to care. These features include universal coverage, identical comprehensive benefits for everyone, standardized payment rates, minimal cost-sharing, centralized capital spending decisions, negotiated drug and medical equipment prices, and inclusion of long-term care as an essential need. These features underscore the fundamental principles and goals of single payer reform.
  • Legislative efforts led by Bernie Sanders in the Senate and Pramila Jayapal in the House were highlighted as providing the basis for comprehensive single payer reform. The focus was on the need for a system that brings health care justice to all individuals, emphasizing the importance of understanding the principles that underpin an ethically superior healthcare system and selecting politicians with the moral fortitude to enact such a system.

These developments in 2023 underscore the ongoing efforts to address the challenges and principles of single payer reform, reflecting the continued push for a more just and equitable healthcare system.

Sources:

Q: What were key health reform developments in California in 2023?

In 2023, California saw several key health reform developments, reflecting the ongoing efforts to address healthcare access, equity, and financing. Here’s a summary of the significant developments:

  • The 2023 CHCF California Health Policy Survey revealed concerning findings related to healthcare costs and medical debt. Half of Californians reported skipping or delaying healthcare due to cost, with half of them experiencing worsened conditions as a result. Additionally, more than one-third of respondents reported having medical debt, with disparities in debt rates among different income and racial groups. These findings underscore the urgent need for comprehensive healthcare reform to address access limitations and financial burdens.
  • A proposed law in the California Senate aimed to advance the state’s single payer process by instructing state officials to engage with the federal government on approvals and coordination for a state single payer bill. This legislative effort highlighted the ongoing push for a government-run health system in California, reflecting the state’s commitment to exploring avenues for comprehensive healthcare financing reform.
  • California enacted SB 770, establishing a formal process to explore federal waivers necessary for state-level “unified financing,” such as a single-payer health care system, building on the findings of the Healthy California for All Commission. This legislation marked a potent mechanism to advance single payer, emphasizing the state’s commitment to pursuing unified financing and high-quality healthcare for all Californians.

These developments in 2023 underscore the ongoing efforts to address healthcare access, equity, and financing in California, reflecting the state’s commitment to comprehensive healthcare reform.

Sources:

Q: Will single payer save money for families?

Yes, single payer healthcare has the potential to save money for families, as evidenced by comprehensive research and analysis. Here’s a summary of the key findings:

  • Research conducted by academic teams at Yale University and the University of California, San Francisco (UCSF) concluded that single payer healthcare, such as Medicare for All, will save money overall. These findings are based on rigorous, peer-reviewed scientific papers, which have undergone close examination by experts in the field for validity and reliability.
  • The evidence indicates that single payer healthcare will generate substantial savings by eliminating unnecessary paperwork and insurance company profits, reducing drug costs, and other cost-saving factors. These savings are projected to more than offset the cost of improving coverage and expanding it to everyone.
  • A specific example from California’s context revealed that nearly 9 out of 10 individuals who used a cost calculator for single payer found that they would save money. The average savings were reported to be more than $5000 per year, demonstrating the potential financial benefits for households.

These findings provide strong support for the assertion that single payer healthcare has the capacity to save money for families, offering a more cost-effective and equitable approach to healthcare financing.

Sources:

Q: What are some amusing & informative videos about health care from 2023

In 2023, there were several amusing and informative videos about healthcare that effectively conveyed the complexities of the US healthcare system and the need for reform. Here are some noteworthy videos from 2023:

  • Dr. Glaucomflecken’s 30 Days of US Healthcare Series: This series of 2-minute videos covered a wide range of crucial topics, including job benefits, deductibles, co-insurance, surprise billing, pharmacy benefit managers, insurance kickbacks, hospital price transparency, and more. Dr. Glaucomflecken’s amusing skits, in which he plays all roles, provided a master class on concisely conveying the issues with US health insurance in a biting and entertaining manner.
  • John Stewart’s Insightful Video: John Stewart’s video effectively highlighted how the government-funded healthcare system benefits private for-profit corporations, particularly insurers, at the expense of the public. This video provided valuable insights into the dynamics of the US healthcare system and its impact on individuals and private corporations.

These videos offered engaging and informative content, distilling complex healthcare policy discussions into entertaining and insightful snippets. They effectively conveyed the fundamental issues plaguing the US health insurance system in an accessible and engaging manner.

Sources:

Q: Are there arguments for single payer that might resonate with my politically conservative uncle?

It’s great to see the engagement and discussions around healthcare reform and the potential for single payer. Here are some compelling arguments for single payer that might resonate with politically conservative individuals, such as your uncle:

  • Efficiency and Cost Savings: Single payer healthcare systems have been shown to be more efficient in terms of administrative costs. For example, a study by the Political Economy Research Institute at the University of Massachusetts Amherst found that a single payer system could result in approximately $600 billion in annual savings on administrative costs. This aligns with conservative principles of fiscal responsibility and reducing government waste.
  • Market Competition and Freedom of Choice: Contrary to common misconceptions, a single payer system can actually enhance market competition by leveling the playing field for healthcare providers. It allows individuals the freedom to choose their healthcare providers without being restricted by narrow networks or in-network requirements, fostering a more competitive and consumer-driven healthcare market.
  • Simplicity and Streamlined Access: A single payer system simplifies the complex web of insurance plans and billing processes, providing streamlined access to healthcare services. This aligns with conservative values of reducing bureaucracy and promoting individual autonomy.
  • Protection from Financial Burdens: Single payer systems provide comprehensive coverage and protection from financial burdens, ensuring that individuals and families are not overwhelmed by medical expenses. This resonates with the conservative principle of personal responsibility and financial stability.

These arguments emphasize the potential benefits of single payer healthcare in terms of efficiency, market competition, simplicity, and financial protection, aligning with principles that may resonate with politically conservative individuals.

Sources:

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Private Equity Hospital Purchase Raises Risks for Patients

A new study in JAMA of 5 million hospitalizations over 10 years at 300 US hospitals found that private equity acquisition was associated with a 25% rise in serious adverse clinical events, likely due to fewer employees. Private equity strategies in health put patients at risk.

Serious Medical Errors Rose After Private Equity Firms Bought Hospitals, The New York Times, December 26, 2023, by Reed Abelson and Margot Sanger-Katz

The rate of serious medical complications increased in hospitals after they were purchased by private equity investment firms.

The study, published in JAMA, found that, in the three years after a private equity firm bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.

“This is a big deal because it’s the first piece of data that I think pretty strongly suggests that there is a quality problem when private equity takes over,” said Dr. Ashish Jha, the dean of Brown University School of Public Health, who has studied hospital safety extensively.

Over the last two decades, private equity firms have become major players in health care, purchasing not just hospitals but also a growing number of nursing homes, physician practices and home health care companies. The firms pool money from institutional investors and individuals to form investment funds, often buying hospitals and other entities through high levels of debt, with an eye to reselling them in a few years.

Several media reports have shown that some of the acquired hospitals have been forced to close because of financial distress, and some have come under regulatory scrutiny for quality problems.

The researchers examined a range of errors that Medicare tracks. All of the eight individual measures studied in the paper worsened in the hospitals purchased by private equity funds.

“They are preventable adverse events that everyone thinks shouldn’t happen in hospitals,” said Dr. David Blumenthal, the former president of the Commonwealth Fund.

The researchers said the most likely explanation for the increased errors was fewer hospital employees.

Changes in Hospital Adverse Events and Patient Outcomes Associated with Private Equity Acquisition, December 26, 2023, JAMA, by Sneha Kannan, Joseph Dov Bruch and Zirui Song

Key Points:

Question: How do quality of care and patient outcomes change after private equity acquisition of hospitals?

Findings: In a difference-in-differences examination of 662 095 hospitalizations at 51 private equity–acquired hospitals and 4 160 720 hospitalizations at 259 matched control hospitals [from 2009-2019] using 100% Medicare Part A claims data, private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections.

Meaning: Private equity acquisition of hospitals, on average, was associated with increased hospital-acquired adverse events despite a likely lower-risk pool of admitted Medicare beneficiaries, suggesting poorer quality of inpatient care.

Comment:

By Don McCanne, M.D.

Haven’t we heard enough? Study after study has shown that when private equity, with its primary mission of creating wealth for its investors, takes control of sectors of health care, our costs of health care increase and our access and quality of health care outcomes deteriorate. Meanwhile, other studies demonstrate that a well-designed single payer system would not only control costs and improve outcomes, but would make health care equitably accessible for everyone.

Why do we give our health care dollars to billionaires for their own personal enrichment while we tolerate mediocrity and worse in our health care system – when we could take those same health care dollars and spend them much more efficiently in creating a health care nirvana for all of us? It is true that it will require a legislative solution, but the legislators must understand that that is the demand of their constituents. Isn’t it?

Editor: Happy New Year. Next post will be the 2023 summary.

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Thoughts & Prayers Do Not Protect Our Children

Unintentional firearm deaths require action. This is an especially appropriate reminder during the holiday season, with its focus on family.

Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0-17 Years – National Violent Death Reporting System, United States, 2003-2021, CDC, December 15, 2023

Summary:

What is already known about this topic?

Unintentional injury is a leading cause of death among U.S. children and adolescents aged 0-17 years, and firearms are a leading injury method.

What is added by this report?

Approximately one half of unintentional firearm injury deaths among children and adolescents occurred at their home; playing with or showing the firearm to another person was the most common precipitation. Overall, firearms used in unintentional injury deaths were often stored both loaded and unlocked and were commonly accessed from nightstands and other sleeping areas.

What are the implications for public health practice?

Unintentional firearm injury deaths are preventable. (Bold by HJM) Securing firearms (e.g., locked, unloaded, and separate from ammunition) is protective against unintentional firearm injury deaths among children and adolescents, underscoring the importance of promoting secure firearm storage.

MOTHERS FOR DEMOCRACY, Thoughts & Prayers are NOT Enough, A one-minute video, December 14, 2023

Also viewable on the Mothers for Democracy website (may need to scroll down)

Comment:

By Don McCanne, M.D.

This video has gone viral, and it is easy to understand why: thoughts and prayers are meaningless when we can do something about the number one killer of children in the United States!

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Largest ACO Program Saves Piddling Amounts for Medicare

A new analysis finds that that MSSP, the oldest and largest Medicare accountable care organization (ACO) program, has lost money for individuals it covers and overall for Medicare saves just 75¢ per $1000.

Estimated Savings From the Medicare Shared Savings Program, JAMA Health Forum, Dec. 15, 2023, by Andrew M. Ryan & Adam A. Markovitz

The Medicare Shared Savings Program (MSSP) was launched in 2012 to improve efficiency and generate financial savings for the Centers for Medicare & Medicaid Services (CMS). Under the program, voluntarily constituted accountable care organizations (ACOs)—groups of clinicians, hospitals, and other institutional participants—face accountability for the total costs of care received by traditional Medicare beneficiaries. If medical spending is below a specific target (benchmark), ACOs are eligible for financial bonuses. For CMS to break even or achieve net savings for traditional Medicare beneficiaries in the MSSP, gross reductions in medical spending must equal or exceed the sum of bonus payments paid to ACOs.

Results: The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to Medicare Advantage benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of … 0.075% of combined spending.

Comment:

By Kip Sullivan, J.D. and Jim Kahn, M.D., M.P.H.

The Physician Group Practice Demonstration, which was conducted by the Centers for Medicare and Medicaid Services (CMS) between 2005 and 2010, was the first test of the “accountable care organization” (ACO) concept. It failed: The ACOs cut traditional Medicare spending by a mere 3 tenths of a percent, and those teensy savings would have been losses if the evaluation had taken diagnostic upcoding and participation bias into account.

Despite the failure of this first ACO experiment, Congress inserted into the Affordable Care Act (ACA) provisions authorizing CMS to establish more ACO demonstrations within the traditional Medicare program, as well as a permanent ACO program known as the Medicare Shared Savings Program (MSSP). We reported in 2022 that the CMS ACO programs, including MSSP, were not working: they had saved or lost just a few tenths of a percent between 2012 and 2018.

This new analysis confirms the earlier studies we reviewed. The authors reported that bonuses CMS paid to the ACOs exceeded the gross savings some of them achieved, for a net loss of between $584 million and $1.4 billion over the 2013-2021 period. These are large sums of money, but represent only a few tenths of a percent of total spending for those ACO enrollees. Due to patient, physician, and organization participation bias, the actual net loss may be greater.

The analysis also examined the effect of the MSSP’s financial performance on Medicare Advantage (MA) costs. MA monthly capitation (premium) rates are calculated in part based on traditional Medicare costs. Thus, gross MSSP savings reduce MA capitation levels. (The provider bonuses which create MSSP net losses affect geographic adjustments but not overall MA capitation, per CMS rules.) The authors’ estimated savings to MA are larger than the MSSP’s loss to traditional Medicare, resulting in net savings for the entire Medicare program of $4-5 billion over 9 years, or $500 million per year. Again, sounds like a huge amount of money. But it represents less than 1/1000th of Medicare spending for the relevant time period; just 75 pennies per $1000 in program cost.

So, will MSSP (and ACOs generally) be a significant way to control Medicare costs? No, evidently not. And, as we’ve reported previously, the Medicare Advantage program is overcharging CMS by at least $100 billion per year – that’s about 200 times higher than MSSP savings. ACO REACH is even worse, inserting contractors between CMS and medical providers, creating more incentives to deny care.

Fiddling with payment incentive programs is not a real solution for our extravagantly expensive medical costs. Single payer is the real solution, combining efficiency with universal access.

Kip Sullivan is a member of the Health Care for All Minnesota policy committee.

Jim Kahn is an emeritus professor at UCSF and editor of HJM.

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Medicare Advantage Under-Performance

A commentary on Medicare Advantage in a high-profile medical journal delicately discusses issues with MA performance. We believe the evidence warrants a much more critical stance. We need not accept the inevitability of Medicare capture by under-performing private insurance.

The Predominance of Medicare Advantage, New England Journal of Medicine, December 14, 2023, by Gretchen Jacobson and David Blumenthal

If current trends persist, more than half the 66 million beneficiaries of Medicare will be enrolled in Medicare Advantage plans in 2023. This constitutes a historic milestone in the evolution of a unique federal program that has profoundly benefited older and disabled Americans and deeply influenced the evolution of our health care system. When President Lyndon Johnson and his congressional allies secured the enactment of Medicare in 1965, it is safe to say they never imagined that most eligible Americans would be enrolled in the types of payment and service arrangements that Medicare Advantage offers, rather than the traditional fee-for-service system. The anticipated predominance of Medicare Advantage raises obvious questions about why it has developed, what it means for the quality and cost of care available to Medicare beneficiaries, and what it means for our health care system as a whole.

Comment:

By Ana Malinow, M.D. and David Leibowitz, M.D.

This article on Medicare Advantage (MA) will be read by thousands of physicians, many of whom have not yet grasped how MA exerts a major influence over the practice of medicine and patient care. For this reason, a health policy report published in the NEJM is important. Sadly, the Journal has opted to platform an article that glosses over the profound problems with the entire concept of MA. We list a few here.

Unlike MA, traditional Medicare does not employ prior authorization except under very limited circumstances. The article mentions that “most [MA plans] require beneficiaries to receive a referral or other authorization as a condition for covering the costs of specialized or complex care.” It would be more accurate to state that “nearly all” MA plans require beneficiaries to receive prior authorization, given that 99% of beneficiaries in MA are in plans that require prior authorization for some services. Prior authorization determines access to care, which the article declares “seems to be similar in MA and traditional Medicare… Patient and physician complaints about denials of care as a result of the prior-authorization requirements of MA plans seem to have increased in recent years, but there are only limited data on rates of denials.”

Data on denials and access to care are not limited. A 2022 study from the Office of Inspector General shows 13% of denied prior authorization claims are inappropriately denied by MA plans, services that would have been covered had the beneficiary been on traditional Medicare. Further, 18% of denied payment requests were inappropriately denied by MA plans. Three large MA companies are being sued for inappropriately using AI to systematically deny care. Hospitals across the country are dropping MA, because, as one hospital executive confirmed, these plans “pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

How MA is paid is important, and the article discussed this at length. In addition to benchmarks and bids, the authors write “Payments to plans are further adjusted for two factors: quality of care and the health status (risk) of enrollees… Plans with higher star ratings are provided higher benchmarks against which to bid and receive a larger share of the difference between their bid and benchmark, which results in larger rebates. In 2023, 51% of plans were rated 4 stars or better.”

What the article does not discuss is how meaningless star quality ratings are. When over half of the plans score 4 stars of more, you wonder about the Lake Wobegon effect, where “all the women are strong, all the men are good-looking, and all the children are above average.” The Medicare Payment Advisory Commission (MedPAC), the federal agency that advises Congress on Medicare, is clear in its condemnation of the stars. In its 2023 Status Report to Congress, MedPAC stated that “quality in Medicare Advantage cannot be meaningfully evaluated” using the current star program. Despite its limitations, the quality bonus program accounts for more than $15 billion in annual payments to MA plans. In 2022, the NEJM published a series of articles by Lisa Rosenbaum explaining why the concept of quality measurement is questionable at best, if not totally useless.

Because star quality ratings fail to measure quality of care, especially for beneficiaries with serious and complex illness, the statement “[t]he quality of care in Medicare Advantage as compared with traditional Medicare seems to be equivalent or better, on the whole, and some evidence shows that Medicare Advantage has reduced disparities in quality in some parts of the country” does not withstand scrutiny. MA plans cover fewer cancer centers of excellence, MA beneficiaries are preferentially admitted to lower quality skilled nursing facilities, and MA beneficiaries in the last year of life, in poorer health or who belong to a racial or ethnic minorities are substantially more likely to disenroll and join traditional Medicare. Finally, when properly adjusted for risk selection and upcoding, MA is equivalent or worse than traditional Medicare on key quality metrics.

The third and major factor to plan payment is risk adjustment, which the authors dismiss by stating, “In fact, controversy rages over whether plans engage systematically in “upcoding” — the recording of diagnoses that are not expected to require treatment or that may be exaggerated or even fabricated.”

There is no controversy about whether plans engage in upcoding. Multiple publications, from the New York Times, in a highly critical expose of the MA industry, which they dubbed the “insatiable cash monster,” to Physicians for National Health Program, to MedPAC, have reported on the prevalence of upcoding and associated costs. In the 2023 status report, MedPAC reported that in two years, 2022 and 2023, MA “coding intensity” generated $44 billion of tax-payer dollars for the plans.

The authors supply the reader with assumptions of “may” and “seems” that would not otherwise be tolerated by NEJM. For example, that “Innovative care-delivery systems, care coordination, and comfort with managed care may also be driving some MA enrollment” or that “These systems may also enable plans to coordinate care.” There is no evidence for these statements, so why include them?  “Current beneficiaries are also more familiar with managed care and may be more comfortable with such arrangements than previous generations.” Why conflate familiarity with desire?

Further assumptions are found in the statement that “Another factor in the growth of MA may be obstacles to disenrollment. Beneficiaries who switch from Medicare Advantage to traditional Medicare may find that insurers that offer Medigap plans charge higher premiums for preexisting conditions or refuse to cover them at all.”

The facts are clear. Under federal law, newly Medicare-eligible enrollees have a 6-month “Medigap Open Enrollment” period, when they can purchase any Medigap policy without medical underwriting, meaning the enrollee cannot be denied coverage due to a pre-existing condition. Unless the enrollee lives in Maine, Connecticut, New York, or Massachusetts, purchasing a Medigap plan outside the 6-month window will either be impossible or exorbitantly expensive. The inability to purchase a Medigap policy poses a huge obstacle to any Medicare beneficiary on MA for longer than 6 months thinking about switching to traditional Medicare. This is especially fraught given the 40% of sick enrollees with financial barriers to care.

Instead of declaring profits are excessive, they ponder, “Another question concerns whether the profits earned by MA plans have become excessive. These profits seem at least in part the result of federal policy decisions and may not in all cases represent true efficiencies or higher value.” There is no question profits have become excessive, and profits are in greater part the result of compromised federal policy decisions, and not true efficiencies. According to a report by Wendell Potter, not only are government programs (Medicare and Medicaid in particular) the source of 90% of new health plan revenues of major insurance companies, but profits from all sources by the top seven US health insurance companies have climbed by almost 300% in the past 10 years to $70 billion in 2022. Why seed doubt?

It is true that “the fundamental features that make MA attractive to beneficiaries and investors remain in place,” despite feeble attempts by the federal government to rein in some of the worst abuses by MA companies. However, we are skeptical that tweaking around the MA edges, suggested by the authors, will result in both programs having a “level playing field” to test the role of competitive markets in health care. Do we need to keep retesting this hypothesis when we know “competitive markets” in health care do not reduce costs or improve outcomes? The neoliberal concept popular since Reagan/Thatcher has been to imagine that a freely competitive market is self-regulating. The nature of health care is such that it cannot function as a free competitive market, as first demonstrated by Kenneth Arrow.

The authors conclude that “the power of the Medicare Advantage industry and the huge numbers of older voters enrolled in Medicare Advantage plans also make it politically difficult to dramatically alter the course of the program.” This encourages readers to accept the status quo, that the for-profit companies raiding our public coffers are here to stay, and the best we can hope for is more of the same.

Readers of the NEJM should know that we must heighten our demands. Just because an expensive, opaque, self-serving, cruel system is “popular” among the industry and among seniors who have no other choice, does not make the system inevitable. There are two bills, one in the Senate and a better one in the House, that call for comprehensive, equitable, affordable, accessible, universal and improved Medicare for All. This is where we should be focusing our attention, not on a system that just because it is predominant, must be endured.

Dr. Ana Malinow is past president of Physicians for a National Health Program, a long-time single payer activist and writer, and recently retired as Professor of Pediatrics from UCSF.

Dr. David Leibowitz spent the first half of his career heading a research lab, at Columbia and Indiana Universities, and the second half in the community practice of Heme/Onc in the SF Bay Area.

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Building the Democratic Party By Helping the Middle Class

George Packer reviews recent books which propose that for the Democrats to achieve stable power, they must provide economic assistance to the struggling middle class, not fight cultural battles. Single payer’s economic stability can foster progressive cultural norms.

What Does the Working Class Really Want?, The Atlantic, Dec. 11, 2023, by George Packer

From the late 1970s until very recently, the brains and dollars behind both parties supported versions of neoliberal economics: one hard-edged and friendly to old-line corporate interests such as the oil industry, the other gentler and oriented toward the financial and technology sectors. This consensus left the battleground open to cultural warfare. The educated professionals who dominate the country’s progressive party have long cared less about unions, wages, and monopoly power than about race, gender, and the environment. …

[There is an] outpouring of new books that pay political attention to those overlooked Americans of all races who lack a college degree, many employed in jobs that pay by the hour—factory workers, home health aides, delivery drivers, preschool teachers, hairdressers, restaurant servers, farm laborers, cashiers. During the pandemic, they were called “essential workers.” Now they’ve been discovered to hold the key to power, giving rise to yet another round of partisan dreaming of realignment, this time hinging on the working class. But these Americans won’t benefit from their new status as essential voters until the parties spend less effort coming up with what they think the working class wants to hear, and more effort actually delivering what it wants and needs. …

Joshua Green’s fast-paced, sober, yet hopeful The Rebels: Elizabeth Warren, Bernie Sanders, Alexandria Ocasio-Cortez, and the Struggle for a New American Politics argues that a Democratic renewal is already under way. … Green traces the Democrats’ estrangement from working Americans back to the ’70s; he begins his story with a moment in 1978, when Jimmy Carter abandoned unions for Wall Street. The narrative reaches a climax in 2008, when the financial crisis destroyed home values and retirement savings while taxpayer dollars rescued the banks that had triggered it, convincing large numbers of Americans that the system was rigged by financiers and politicians. Because of policy choices by the Obama administration—Democrats’ last spasm of neoliberalism—much of the blame fell on the former party of the common people. Yet out of the wreckage rose a new group of Democratic stars who sounded like their New Deal predecessors, many of whom were every bit as radical. Taking aim at corporate elites, Green’s protagonists want to increase economic equality through worker power and state intervention. Though Sanders and Warren failed as presidential candidates, Green argues that their populism transformed the party, including the formerly moderate Joe Biden, who has pushed a remarkably ambitious legislative agenda with working-class interests at its center. …

One party supports unions, the child tax credit, and some form of universal health care, while the other party does everything in its power to defeat them. One president passed major legislation to renew manufacturing and rebuild infrastructure, while his predecessor cut taxes on the rich and corporations. Yet polls since 2016 have shown Republicans closing the gap with Democrats on which party is perceived to care more about poor Americans, middle-class Americans, and “people like me.” …

Now, encouraged perhaps by the excesses and failures of a professional-class social justice movement, and by the relative success of Biden’s pro-worker agenda, they seem to be finding their voice. [P]olling data from Wisconsin and Massachusetts provide evidence that Americans are less divided on cultural issues than activists on both sides, who benefit by stoking division, would like: “If you look at the country’s voters, and put aside the culture wars, what you find are genuine differences between the parties’ voters over economic issues.” The real disagreements have to do with taxation, regulation, health care, and the larger problem of inequality. Democrats’ way forward seems obvious: emphasize differences on economics by turning left; mute differences on culture by tacking to the middle. If the party can free itself from the moneyed interests of Wall Street and Silicon Valley, and the cultural radicalism of campus and social media, it might start to win in red states.

Comment:

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

George Packer is a wonderful writer on politics: progressive, incisive, clear. In this piece, he argues that for the Democrats to achieve a solid and enduring electoral majority, they must first and foremost address the economic needs of the working class. The political and moral need to bolster the working class (and poor!) is unassailable. However, the moderation of cultural stances that he proposes will generate controversy on the left.

Where does single payer come in? The article says, “some form of universal health care”. That’s not enough, because anything short of comprehensive, financially unimpaired coverage will fall short. We in the single payer movement clearly still have education and organizing to do even with savvy progressive thinkers.

Does single payer – a profound economic hand up – also foster progressive cultural norms? I propose that it does: when vulnerable middle-class families have the reassurance of stable and affordable health care, they won’t blame others for depriving them of this critical need. Through sharing in a common social good, the “other” of different social groups is more likely to become “one of us”. That doesn’t get us to the full array of progressive cultural values, but it sure helps.

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