PNHP

Diagnosing and treating systemic racism

Diagnosing and treating systemic racism

By Michele K. Evans, M.D., Lisa Rosenbaum, M.D., Debra Malina, Ph.D., Stephen Morrissey, Ph.D., and Eric J. Rubin, M.D., Ph.D.
The New England Journal of Medicine, June 10, 2020

The role of the physician in times of social injustice and societal distress is difficult to navigate. Since the importation of enslaved Africans as chattel to provide the labor that built this country began, Americans have functioned within the intricate injustices that are the vestiges of that institution. Slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to the present, and that legacy infects medicine as it does all social institutions.

In an effort to engender trust in what they would like to see as a “postracial” society, some U.S. clinicians proclaim that they ”don’t see color.” But color must be seen. By looking through a racially impervious lens, clinicians neglect the life experiences and historical inequities that shape patients and disease processes. They may inadvertently feed the robust structural racism that influences access to care, quality of care, and resultant health disparities.

In the review of systems, we query patients about exposure to toxicants, but we never ask about one of the most dangerous toxicants: racism. The work of David Williams details the morbidity and risk of death related to perceived discrimination. Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations.

Even as the social contract between the government and the American people has frayed in the complex struggle over the pandemic, racial injustice, and police brutality, physicians must reflect on the condition of medicine’s own contract with society. Our society expects physicians to live up to standards of professionalism, deliver state-of-the-art, timely care with competence and integrity, and promote the public good. To carry out these duties, physician-citizens must recognize the harm inflicted by discrimination and racism and consider this environmental agent of disease as a vital sign — alongside blood pressure, pulse, weight, and temperature — that provides important information about a patient’s condition. Medical skill has allowed us to respond rapidly to a novel virus to save lives; we must also use our expertise to address racism and injustice and to protect vulnerable people from harm.

Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well. It is time to reimagine the medical interaction and the doctor–patient relationship, recommitting ourselves to the quiet work of doctoring and building trust with individual patients. We can become more conscious of our biases when we care for minority patients and push ourselves to go the extra mile.

As the vulnerability and inadequacy of our health care system are once again exposed, it is also time to reconceive that system, including the development of its workforce.

Direct action to eliminate persistent health disparities obliges us to redouble our demands for a system that recognizes health care as a human right, providing an avenue to health equity for all.

Although effecting such fundamental transformation may feel impossible, the energy, idealism, and visions of young people have long fueled movements for change. Martin Luther King, Jr., was 26 when he led the Montgomery bus boycott and 34 when he delivered his powerful “I have a dream” oration. If we blend our voices with those of the newest members of our profession to advocate for the most vulnerable and to reinvigorate every aspect of their care, perhaps we can use our current public health crisis as a catalyst to, as Reverend Al Sharpton put it, “turn this moment into a movement.”

The full article can be accessed for free at this link:
https://www.nejm.org…

Comment:

By Don McCanne, M.D.

We’ve heard these phrases before:

  • “society expects physicians to promote the public good”
  • “As the vulnerability and inadequacy of our health care system are once again exposed, it is time to reconceive that system”
  • “a system that recognizes health care as a human right”
  • “health equity for all”
  • “turn this moment into a movement”

Nowhere in this article did the authors mention a universal, accessible, equitable, and efficiently-administered national health program – a single payer model of an improved Medicare for All – but that would provide a tremendous start and major contribution to a strong foundation for treating systemic racism. It’s doable and affordable.

Let’s turn this moment into a movement.

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

COVID-19 and Health Financing: Perils and Possibilities

By Adam Gaffney, David U. Himmelstein, Steffie Woolhandler
International Journal of Health Services, June 9, 2020

Abstract

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the United States could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly those from disadvantaged groups. While the United States has a relatively generous supply of Intensive Care Unit beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive health care reform – for example, via national health insurance – is needed to provide full protection to American families during the COVID-19 outbreak and in its aftermath.

From “Potential Policy Solutions”

(At the link below, there is a convenient table that can be converted into a high-resolution PDF that lists various legislative proposals, their policy mechanisms, current status, and potential advantages and disadvantages.)

While many of these proposals, especially the emergency Medicare expansions, could provide some aid to those affected by COVID-19, full protection, in the long-term, would require systemic reform. Addressing financing dysfunctions on a disease-by-disease basis, after all, is neither efficient nor fair. The COVID-19 outbreak hence serves as a reminder of the benefits of a unified, national health program. A Medicare for All reform, much discussed in Democratic presidential primary debates, would achieve universal coverage and address the problem of underinsurance. Such a reform might have additional advantages specific to an outbreak of an infectious disease. For instance, it could provide public health authorities with novel tools to combat epidemics, such as Taiwan’s use of its national health insurance database for case finding early in the epidemic. A well-structured national health insurance reform would also facilitate moving to a more rational and equitable allocation of ICUs and other healthcare resources through health planning and the public-financing of hospital capital expansion. This could help ensure an adequate supply and distribution of resources in the face of future epidemics. At the same time, the nation needs to dramatically increase funding of its public health agencies. A doubling of funding — from around 2.5% of national health expenditures to 5.0% — will not end the current epidemic, but it could help ensure readiness for the next one.

The outbreak has already exposed the multifold inadequacies of the US’ uniquely unequal, privatized and fragmented health financing system. It also illuminates other inequities — including exclusionary policies that deter immigrants from using social assistance programs, lack of universal paid sick leave, and inadequate protections for workers — that weaken our social fabric and endanger the public’s health. As of this writing, it is unclear how severe the COVID-19 outbreak will ultimately prove to be in the US, although the rapidly climbing death toll is already a tragedy. Whatever the future holds, however, the transformation of the nation’s healthcare system and social safety-net is urgently needed.

https://pnhp.org…

Comment:

By Don McCanne, M.D.

Although we have the most expensive health care system in the world, the COVID-19 pandemic provides stark evidence that our health care financing system is highly dysfunctional, wasting tremendous resources while impairing health care access for far too many individuals and families and failing to prevent the financial hardship that should never occur with a high performance system.

Temporary patches have been proposed, but comprehensive reform is absolutely essential. We would be much better off starting with that right now.

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

Millions at high risk of severe COVID-19 outcomes lack coverage to cover costs

By Steven Ross Johnson
Modern Healthcare, June 10, 2020

More than 18 million people who were most at risk of experiencing severe outcomes from COVID-19 at the start of the outbreak had the least access to healthcare because they were either uninsured or underinsured, according to a new study.

Researchers found some of the most vulnerable populations—including African Americans, Native Americans, lower-income individuals, those residing in rural areas and in states that have not expanded Medicaid—were both more likely to be at high risk of severe COVID-19 illness and lack adequate healthcare coverage to get care if they did get sick, according the study, published Wednesday in the Journal of General Internal Medicine.

African Americans were 42% and Native Americans 90% more likely to be at risk for severe COVID-19 compared to whites. High-risk persons from those racial groups were 51% and 53% more likely to have inadequate healthcare coverage compared to whites at high risk. Hispanics at high medical risk were more than twice as likely as whites to have inadequate coverage.

Researchers say the findings point to a critical need for policymakers to provide more robust support for testing and treating COVID-19 as rising unemployment causes more people to lose their insurance and states seek to re-open businesses, increasing the risk for more cases.

“In a way lower-income people and racial minorities are in double jeopardy because of the way our healthcare system is financed,” said lead study author Dr. Adam Gaffney, a pulmonary specialist at the Cambridge Health Alliance in Boston. “

Gaffney said being uninsured or underinsured meant it was more likely those who got sick would delay seeking treatment because of cost concerns. Results of a Gallup survey released last December found a quarter of those polled reported they or a family member had postponed treatment for a serious medical condition over the past year because of the cost. That percentage increased from 19% in 2018.

Since the start of the outbreak lawmakers have taken a number of actions to provide funding to help cover the costs related to getting tested and treated for COVID-19. Such measures have provided hospitals with nearly $300 billion in relief aid to reimburse providers for expenses and lost revenues incurred during the pandemic.

Passage of the Families First Coronavirus Response Act in March mandated that insurers cover costs related to COVID-19 testing with no out-of-pockets expenses to consumers. The cost of treatment for COVID-19 has no such cost-sharing protections.

Most healthcare insurers have offered to waive copays and deductibles for the treatment of COVID-19. But a report released last month by the patient advocacy organization Public Citizen found at least 15 of the 23 fee waivers being offered are set to expire by July 1.

That report found only two of the 25 largest insurers offering fee waivers offer to cover costs for both in-network and out-of-network care. Up to 60% of people in private insurance plans may not be eligible for fee waivers at all since they exclude those in self-insured plans unless an employer underwrites for those plans to opt-in for that coverage.

Gaffney said more support was needed to address the rising level of need. An estimated 36 million people have lost their jobs since the beginning of the outbreak with as many as 25 million expected to lose their employer-based health insurance as a result.

“The protection is inadequate,” Gaffney said. “I think we need to take further steps as this epidemic continues to ensure full coverage not just for COVID testing but for COVID treatment as well.”

https://www.modernhealthcare.com…

18 Million Americans Lack Adequate Health Insurance While Facing Greater Risk of Severe Coronavirus, Study Finds

By Jason Lemon
Newsweek, June

More than 18 million Americans, most of whom are minorities and low-income individuals, are uninsured or underinsured while also being at increased risk of developing severe cases of COVID-19, a new study by researchers at Harvard Medical School and CUNY’s Hunter College has shown.

“Our study shows that minority communities face double jeopardy from COVID: on the one hand, they are at higher risk of severe complications from coronavirus, and on the other hand, they are more likely to be uninsured and underinsured, and hence to avoid care or to face potentially ruinous medical bills,” Dr. Adam Gaffney, the study’s lead author who is a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School, told Newsweek.

“Our dysfunctional health care financing is one important contributing factor behind pernicious racial health inequities in American society,” Gaffney said.

The study, which was published Wednesday in the Journal of General Internal Medicine, used data compiled by the Centers for Disease Control and Prevention regarding age, race and health risks. It looked specifically at health issues—such as asthma, diabetes, kidney disease, heart disease and severe obesity—that increase the risk of an individual developing a severe case of COVID-19. The researchers then analyzed this data in connection to whether the individuals had adequate insurance.

When the data was reviewed, the results showed that minorities, with the exception of Asians, and low income individuals were more likely to have underlying health issues that can increase the severity of a new coronavirus infection. Additionally, this higher-risk group, which is estimated to be about 18.2 million people, was more likely to be uninsured or underinsured.

These issues were compounded further in states that have not permitted Medicaid expansion under the Affordable Care Act, which would allow more people to access government-run health insurance. The research showed that black Americans were 42 percent more likely to be at risk for severe COVID-19 while they were also 51 percent more likely to have inadequate health care coverage than high-risk non-Hispanic whites. With Native Americans, the disparity was even greater, as they were 90 percent more likely to be at high risk for severe COVID-19, and 53 percent more likely to have inadequate health care coverage.

Gaffney acknowledged that steps have been taken by the government and insurance companies to address some of the problems with inadequate insurance coverage amid the coronavirus pandemic. However, he said this was not enough, while pointing out that the large uninsured and underinsured population creates an additional public health risk.

“To control this pandemic on an ongoing basis, people have to be unafraid to obtain care when they need it, whether for testing or treatment. But a Gallup poll in May found that 14 percent of Americans would avoid health care because of costs even if they had symptoms consistent with COVID. If people stay home with symptoms because they’re afraid of a giant bill, they put their own health at risk,” the doctor said.

“This also could impede efforts to reduce viral spread. This pandemic is laying bare the weaknesses, the gaps, and the inequities of the U.S. health care system,” he said.

The study used data that was compiled prior to millions of Americans losing their jobs due to the economic fallout caused by the pandemic. Gaffney noted that many more people have now lost their employer-sponsored health insurance as millions have filed for unemployment.

“These trends will only exacerbate the inequities we identified in our study,” he said.

Dr. Steffie Woolhandler, a co-author of the study who is a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School, said that the issue with health care coverage goes beyond the coronavirus pandemic.

“It’s not just COVID care that’s unaffordable,” Woolhandler said in a statement emailed to Newsweek. “Patients with heart disease, asthma and diabetes need protection too. Medicare for All is the long-term answer,” she said.

Although data has not been fully collected and compiled, numerous reports across the country have revealed that minority and low-income communities have been disproportionately affected by the pandemic. Experts have pointed to economic inequalities as well as a higher prevalence of some pre-existing health conditions, which aligns with new Harvard/CUNY study.

Minorities are also disproportionately represented in many professions deemed essential as stay-at-home orders were implemented across the country. This means they were more likely to continue going to work and interact with a wider range of individuals during lockdowns, potentially exposing them to a greater risk of contracting the virus.

https://www.newsweek.com…

18.2 million at increased risk of severe COVID-19 are uninsured or underinsured: Harvard study 

Racial minorities who are most likely to be inadequately insured against the costs of illness among those at increased risk of severe complications from coronavirus

FOR IMMEDIATE RELEASE, June 10, 2020

Contact: Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org, 312-782-6006
Dr. Adam Gaffney, Physicians for a National Health Program, agaffney@cha.harvard.edu

Even before soaring unemployment caused millions of Americans to lose their health insurance, 18.2 million individuals at increased risk of severe COVID-19 were either uninsured or underinsured, according to a new study published today in the Journal of General Internal Medicine by researchers at Harvard Medical School and CUNY’s Hunter College. Although most of those at high medical and financial risk were white, racial minorities were overrepresented.

Researchers determined who was at risk of severe COVID-19 based on age and medical risk factors such as diabetes. They found that Blacks, Native Americans, lower-income individuals of all races/ethnicities, and those residing in rural areas or in states that had not expanded Medicaid were doubly disadvantaged: they were both more likely to be at high risk of severe COVID-19 and to lack adequate coverage. For instance, compared to non-Hispanic whites, Blacks were 42% and Native Americans 90% more likely to be at risk for severe COVID-19, and high-risk persons from those racial groups were 51% and 53% more likely to have inadequate coverage compared to high-risk whites. Persons in states that failed to expand Medicaid were 6% more likely to be high risk, and 52% more likely to have inadequate coverage compared to those in states that accepted the ACA’s Medicaid expansion. Hispanics at high medical risk were more than twice as likely as non-Hispanic whites to have inadequate coverage.

“The pandemic is laying bare the lethal inequality of American society and American health care,” said lead author Dr. Adam Gaffney, a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School. “Our ICU has been flooded with poor and minority patients; having COVID-19 is scary enough without worrying that you’ll be bankrupted by medical bills,” he added.

Despite recent federal actions to help fund COVID-19 care, and some insurers’ promises to upgrade coverage for the disease, many American still lack protection from COVID-19’s costs.  The Families First Coronavirus Response Act mandated full coverage for COVID-19 testing, but not for treatment, and the CARES Act provided some funding for hospitals treating uninsured patients, but the protection is far from adequate. While some private insurers have promised to waive copays and deductibles for treatment as well as testing, this promise doesn’t apply to out-of-network care, or to the majority of privately-insured workers whose employers are self-insured. Moreover, most of these waivers will expire by July 1. A Gallup poll found that many remain fearful of treatment costs, with 14% of Americans saying they would avoid care because of costs even if they develop symptoms of COVID-19.   

“These promises of new protections for patients with COVID-19 are full of holes,” noted senior author Dr. Danny McCormick, a primary care physician and associate professor at Harvard Medical School. “COVID-19 threatens the health of people everywhere, but only in the U.S. will it also ruin patients financially. When people avoid testing and care because they fear the costs, it fuels the epidemic’s spread,” he added. 

The investigators also noted that the new federal legislation and insurers’ promises won’t help patients with COVID-19-like symptoms who are found to have a different diagnosis. “It’s not just COVID care that’s unaffordable,” said co-author Dr. Steffie Woolhandler, Distinguished Professor of Public Health at CUNY’s Hunter College and a Lecturer in Medicine at Harvard Medical School. “Patients with heart disease, asthma, and diabetes need protection too. Medicare for All is the long-term answer. But in the meantime, passage of the stopgap Medicare expansion bills introduced by Sen. Bernie Sanders and Rep. Pramila Jayapal would ensure that patients can get the care they need during the crisis, regardless of their diagnosis.”

“18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured,” Adam W. Gaffney, M.D., M.P.H., Laura Hawks, M.D., David H. Bor, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D., Danny McCormick, M.D., Journal of General Internal Medicine, published online ahead of print June 10, 2020. DOI: 10.1007/s11606-020-05899-8

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

COVID-19 and Health Financing: Perils and Possibilities

This study, authored by PNHP president Adam Gaffney, M.D., M.P.H. and PNHP co-founders Steffie Woolhandler, M.D., M.P.H. and David Himmelstein, M.D. was published online in the International Journal of Health Services on June 9, 2020. Click HERE to read the study on the SAGE Journals website.

Abstract

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the US could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly for those from disadvantaged groups. While the US has a relatively generous supply of ICU beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive healthcare reform, e.g. via national health insurance, is needed to provide full protection to American families during the COVID-19 outbreak, and in its aftermath.

As of this writing, the United States is experiencing the world’s largest COVID-19 outbreak.1 Deaths are continuing to rise, and the hospital infrastructure of some cities has been severely strained. While every country faces unique challenges responding to this serious public health threat,2,3 the US’ underfunded public health infrastructure, fragmented medical care system, and paltry social protections have imposed particular impediments to control and mitigation of the epidemic.

As US policymakers contend with the widespread dissemination of COVID-19, addressing the structural weaknesses of the US public health and healthcare financing system — particularly for disadvantaged groups — must be a priority, both for this epidemic and the next. In this article, we explore how underfunding of the nation’s public health agencies impaired the early response to the epidemic; how financial barriers that obstruct care for many in the US healthcare system could hamper efforts to contain it moving forward; the adverse financial ramifications for patients from the outbreak; and potential policies to ameliorate health financing deficiencies in the months and years ahead.

1. Underfunded Public Health

Federal, state and local public health agencies are the frontline defense against novel epidemics. Years of inadequate funding of these agencies, however, has hampered the nation’s response to the outbreak.

Despite nominal increases in public health spending over the past decade, there has been a progressive decline in such funding as a proportion of total health spending4 (Figure 1).5 Certain agencies and spending areas have seen particularly notable cuts. The budget of the Centers for Disease Control and Prevention (CDC), for instance, fell by about 10% (accounting for inflation) between 2010 and 2019, while CDC spending on state/local emergency preparedness fell by about a third from 2003 to 2019.6 The Prevention and Public Health Fund, a pool of public health funds established by the Affordable Care Act to help support state and local public health agencies, has seen multiple cuts since its creation.6 As budgets’ have grown tighter, state and local public health agencies have experienced a major decline in staffing, shedding some 50,000 personnel since 2008.7

Steps taken by the Trump administration further undercut the nation’s infectious disease readiness, including leaving some 700 staff position at the CDC unfulfilled during the 2017 hiring freeze8 and disbanding the office focused on federal pandemic preparedness.9 While the full story of the disastrous rollout of diagnostic testing has not yet been fully told, chronic underfunding of public health agencies appears to have left the nation ill-prepared for the arrival of the epidemic. For instance, case and contact tracing — measures that have been successfully deployed in nations such as Taiwan, South Korea, and Singapore,2,10 and that controlled the 2002-03 SARDS outbreak11-13 — were quickly abandoned in the US, as local health agencies became overwhelmed.14 Efforts to renew such efforts are currently underway in certain states, notably Massachusetts, but these are exceptions to the rule.

2. COVID-19 and Healthcare Affordability: Implications for Disease Control, Health, and Family Finances

In March 2020, as widespread dissemination of the novel coronavirus became obvious, case identification and contact tracing rapidly gave way to broad social distancing measures, including stay-at-home orders and closures of non-essential businesses, aimed at “flattening the epidemic curve.”3,15 Even if ultimately effective, epidemiologists predict that the outbreak will recrudesce once social distancing measures are eased, an eventuality that might be ameliorated or prevented through ramped up testing, case finding, and contact tracing. Such an intervention, however, requires a high-performing, and readily accessible, health system.2

Yet 30 million Americans, 9% of the population, had no health coverage before the epidemic,16 while 44 million more were underinsured — i.e. had coverage that required high copays, deductibles, or other out-of-pocket expenses.17 Overall, about a quarter of non-elderly adults were either uninsured, or avoided seeing a doctor in a given year because of costs, with (as shown in Figure 2) especially high rates in some states, such as Texas and Florida. As the economy spirals and millions of individuals are thrown out of work, the number of Americans uninsured or otherwise unable to afford care for COVID-19 will soar. News outlets carried stories early in the outbreak about patients with suspected coronavirus infections hit by “surprise” bills from hospitals, adding up to thousands of dollars.18-21 Although the widespread inaccessibility of coronavirus testing has thus far been the major bottleneck in the US, fear of costs could keep many infected patients from care in the future, hampering the case identification efforts needed to contain an outbreak. To address this likelihood, Congress passed the Families First Coronavirus Response Act, signed into law by President Trump on March 18. The law expands coverage of testing (and associated visits) both for the uninsured and those with copays and deductibles, which could alleviate such fears for some.

This measure, however, only covers the cost of testing — not treatment. As described in greater depth below, the Trump administration has also promised to use bailout funds to compensate hospitals for the costs of treated uninsured individuals with COVID-19. Such protection, however, is likely to be inadequate, and some individuals will no doubt still be deterred from obtaining medical care. Indeed, a poll conducted in early April found that 14% of Americans said they would avoid medical care due to cost if they developed symptoms consistent with COVID-19; the proportion was even higher among ethnic minorities and those with low incomes.22 Those who remain undiagnosed because they fear the financial consequences of a trip to the hospital may continue to go to work, attend school, or use public transportation, furthering spread. Lack of federally-mandated paid sick-leave is also likely to impede disease mitigations efforts. In 2019, about a quarter of civilian workers lacked paid sick leave, and the rate is substantially higher among those in service occupations.23 Staying home may not be financially tenable for some such individuals. As will be discussed later, new legislation expanded sick pay benefits for some American workers — but left millions out.

High healthcare costs could also threaten the health of patients infected with COVID-19. Fear of incurring out-of-pocket costs frequently deters patients from seeking urgently needed healthcare, even for “high-severity” conditions like acute asthma24 and myocardial infarction.25 Uninsured patients presenting to US emergency rooms with pneumonia or exacerbations of obstructive lung disease (potential COVID-19 symptoms) are more likely than those with insurance to be discharged home instead of admitted to hospital, likely reflecting patients’ desire to avoid ruinous bills and hospitals’ reticence to bear the costs of care.26 It is plausible that individuals with severe COVID-19 who nevertheless avoid medical care could suffer cardiopulmonary arrest in their homes. A surge in the number of patients found dead in their homes by paramedics in New York City during the outbreak suggests that many individuals with COVID-19 are dying before arriving to the hospital.27 However, it is unknown whether lack of healthcare access could have been a contributing factor in some or any of these deaths.

Yet even if inadequate coverage causes no physical harm, however, it can still inflict “financial toxicity.”28 For those with employer-sponsored insurance, the average cost of a hospitalization for pneumonia for patients with complications and co-morbidities was $20,292 in 2018, some of which may have to be paid out-of-pocket in the form of a deductible.29 Elderly patients with Medicare coverage, many on low fixed incomes, also face deductibles exceeding a $1,000 for a pneumonia hospitalization.30 Those facing severe protracted critical illness, however, may face even higher costs. A recent study found that out-of-pocket costs in the last year of life for the uninsured requiring ICU care averaged more than $26,000.31 Even for the insured these costs are often substantial, averaging $10,022 for those with private coverage.31 Such sums could be ruinous to the 4 in 10 US adults who are unable to cover even a $400 expense in the event of an emergency.32 Those unable to pay can face lawsuits, home foreclosure, and bankruptcy proceedings when hospitals seek to recover unpaid medical debts.33,34 And many individuals exposed to financial pressures from COVID-19-related medical costs may be forced to skimp on other important household expenses, such as rent or food, risking downstream deleterious health effects. For many, the financial harms of medical bills will be compounded by lost wages due to job loss, illness, or self-quarantine.

Epidemics tend also to have a disproportionate impact on oppressed populations.35 The H1N1 epidemic, for instance, led to higher hospitalization rates among racial/ethnic minorities relative to white populations,36,37 and a disproportionately high death rate among Hispanic children.37 Clear evidence is already mounting that Black and Hispanic are bearing the heaviest burden of severe COVID-19 disease and death as well.38,39 Yet Black and Hispanic Americans — and those with low-incomes more generally — are less likely to be insured,16 and have fewer household resources on average to cover the cost of copays and deductibles. At the same time, the Trump administration’s harsh anti-immigrant policies — including a recent rule change that deems immigrants to be “public charges” if they use public health programs, and hence potentially ineligible for upgrades in their immigration status — have sown fear in immigrant communities. These policies deter enrollment in health programs and could dissuade millions of immigrants from seeking care, including for COVID-19,40 despite the existence of an exemption for the care and treatment of communicable diseases.41 A 2018 survey, for instance, found that 13.7% of adults in immigrant families are avoiding participation in government benefit programs because they fear the consequences for their immigration status.42

Overall, the confluence of xenophobic policies, rising uninsurance, mass unemployment, and a major epidemic seems destined to exacerbate existing deep inequalities in health and healthcare.

3. COVID-19 and the Seriously Ill: Hospital Infrastructure and Affordability

The fragmented and privatized US healthcare financing system also has distinct implications for those who develop severe illness from COVID-19. While the US is unique among high-income nations in its lack of universal coverage, it is less of an outlier with respect to its healthcare infrastructure. Figure 3 displays hospital and ICU bed supply in 8 nations in North America and Europe. On the one hand, the US is towards the lower end of peer nations with respect to bed supply. It has similar beds per capita as four of the nations in this sample (the United Kingdom, Canada, the Netherlands, and Spain), but substantially less than three (France, Belgium, and Germany). On the other hand, the US has a relatively generous supply of ICUs, with more ICU beds per capita than every nation in the sample except Germany. US ICU density — about 25 beds per 100,000 population depending on how it is counted — is more than twice that of France and Canada, and many-fold higher than the United Kingdom’s.43-47 Patients in US ICUs have, historically, been on average less severely ill than those in other nations as a consequence of this more generous supply,44,45 suggesting more surge capacity.48

Such aggregate statistics, however, obscure three potential problems. First, a large epidemic (with a rapid peak) could overwhelm (or severely strain) the hospital and ICU infrastructure of any nation49 — as in Italy50, New York, and potentially other US cities in coming weeks. Second, while the US’ laissez-faire approach to financing healthcare infrastructure has led to marked growth in ICU infrastructure51.52, it has also led to arbitrary regional imbalances in supply. There is a six-fold difference in ICU beds per capita between the hospital referral region with the highest and the lowest bed density in the US.43 As Carr, Addyson, and Kahn note, geographic variation in ICU density in the US means that a pandemic “could quickly exceed critical care capacity in some areas while leaving resources idle in others,” a reality that “reflects the limitations of a private health system in which planning occurs primarily from the hospital perspective.”43 This distributive problem reflects larger imbalances in the availability of healthcare infrastructure that stem from a profit-driven financing system, exemplified by ongoing hospital expansion in healthcare-dense areas, and the simultaneous closure of hospitals in rural and poorer areas. Consequently, while supply may be ample in some areas, it is inadequate in others in the face of an epidemic. Moreover, there are no mechanisms to redeploy resources to where they are needed, or to shift patients to less-stressed areas.

A lack of health planning, in other words, has left the nation’s healthcare system ill-prepared for an emergency, whether with respect to the distribution of infrastructure, or the stockpiling of ventilators or personal protective equipment for healthcare workers. And with no unified governance, federal, state, and local governments continue to compete with hospitals for supplies.

4. Potential policy solutions

The challenge posed by COVID-19 in the context of these deficiencies in healthcare financing has prompted a range of reform proposals. The Table summarizes achieved and proposed reforms, as well as their benefits and limitations.

The Families First Coronavirus Response Act, signed into law by President Trump in March, provides coverage for the costs of diagnostic testing and related healthcare visits for the uninsured, as earlier noted.53 While this may encourage testing for such individuals, the law didn’t address the problem of high treatment costs (for instance, for those admitted to the hospital for COVID-19 pneumonia). The Act also required that all public and private insurers cover testing and related visits without cost-sharing,53 but, like the coverage of testing for the uninsured, does nothing to lower the far-higher out-of-pocket costs for treatment of COVID-19. Moreover, it’s unlikely to allay immigrants’ fears about enrolling in public health programs or seeking care.

Another initiative to cover the uninsured would allow uninsured individuals to purchase private plans outside of the typical “open enrollment” period, a step taken thus far by several states,54 although not yet by the federal government. Such a move might modestly increase insurance uptake, although coverage would remain unaffordable for many, including the millions of Americans rapidly joining the ranks of the uninsured.

A plan announced April 3 by the Trump administration would allocate a portion of the $100 billion in hospital relief provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in late March, to cover costs of COVID-19 treatment for the uninsured.55 However, this program offers incomplete protection to patients: coverage is contingent both on the availability of funds and the participation of providers.56

Other provisions have been aimed at reducing medical costs for those with insurance. An announcement from the Internal Revenue Service that some plans with high-deductibles will be permitted (but not required) to exempt COVID-19-related care from the plan deductible57 might reduce out-of-pocket costs for some, but will likely have a limited effect. Additionally, some, but not all insurers, have announced plans to eliminate cost-sharing for COVID-19 related treatment, but many individuals will remain exposed to such costs absent federal action. Moreover, neither of these reforms does anything to address the problem of medical costs for other conditions, which will be increasingly unaffordable as workers lose jobs, income, and insurance benefits as recession deepens.

Addressing the lack of paid sick leave is also a policy priority. The Families First Coronavirus Response Act requires employers to provide workers with about 10 days of emergency sick leave, but it exempts the largest employers from the requirement, allows small employers to apply for exemptions, applies only to COVID-19 affected individuals, and expires at the end of 2020.58,59 Due to the exemptions, it might cover as few as 20% of American workers.58,59

A variety of other health financing reforms have been achieved or proposed to deal with the COVID-19 crisis. In early March, for instance, President Trump signed into law an $8.3 billion bill that increases funding for state and local health departments, vaccine and treatment development, medical supply purchases, and community health centers (CHC), clinics that provide care for substantial numbers of uninsured individuals.60 While the additional research and development funds will be useful — and might speed the development of useful therapeutics — the law did little to guarantee the affordability of treatments that emerge from the publicly-funded research.60 The new law also allows Medicare to pay providers for “telehealth” services, enabling remote electronic health visits from doctors that might unburden emergency rooms and reduce the risk of nosocomial coronavirus transmission. (Private insurers are also expanding coverage for telehealth services).61 But the effects of this provision are likely to be modest, particularly for poor patients, many of whom lack adequate internet access.62 Moreover, telehealth does little to allay patients’ cost concerns. Indeed, as phone conversation with physicians are increasingly re-classified as telehealth visits, some patients are finding that they face copays or deductibles for what may have been a previously free telephone call.63

Meanwhile, mounting job losses instigated by the epidemic and the ongoing public health measures taken to control it look likely to lead to enormous losses in health coverage: an estimated 7.3 million workers could become uninsured by June 1 if predicted unemployment increases come to fruition.64 In response, lawmakers have proposed additional reforms to expand coverage to this population. A bill introduced by House Democrats in April 2020, for instance, would provide full subsidization of COBRA plans, which would allow many individuals to maintain their employer-sponsored health benefits after job loss. Such a reform, however, would exclude many of the uninsured, while doing nothing to protect out-of-work individuals form the high copays and deductibles imposed by many employer-sponsored private plans.

Others have proposed using the Medicare program to expand coverage during the crisis. In April, Representative Pramila Jayapal and Senator Bernie Sanders introduced the Health Care Emergency Guarantee Act, which would expand Medicare coverage to all the uninsured, and simultaneously provide wrap-around coverage of copays and deductibles for the insured. Later that month, Jayapal joined Massachusetts Representative Joseph Kennedy in introducing the Medicare Crisis program, a more limited bill that would provide Medicare coverage to the unemployed, bolster state Medicaid programs, and cover all COVID-19 related care costs. Both proposals, particularly the more comprehensive Health Care Emergency Guarantee Act, would realize major expansions of coverage, protecting millions of Americans from burdensome healthcare costs for the duration of the crisis.

While many of these proposals, especially the emergency Medicare expansions, could provide some aid to those affected by COVID-19, full protection, in the long-term, would require would systemic reform. Addressing financing dysfunctions on a disease-by-disease basis, after all, is neither efficient nor fair. The COVID-19 outbreak hence serves as a reminder of the benefits of a unified, national health program. A Medicare for All reform, much discussed in Democratic presidential primary debates, would achieve universal coverage and address the problem of underinsurance. Such a reform might have additional advantages specific to an outbreak of an infectious disease. For instance, it could provide public health authorities with novel tools to combat epidemics, such as Taiwan’s use of its national health insurance database for case finding early in the epidemic.10 A well-structured national health insurance reform would also facilitate moving to a more rational and equitable allocation of ICUs and other healthcare resources65 through health planning and the public-financing of hospital capital expansion. This could help ensure an adequate supply and distribution of resources in the face of future epidemics. At the same time, the nation needs to dramatically increase funding of its public health agencies. A doubling of funding — from around 2.5% of national health expenditures to 5.0% — will not end the current epidemic, but it could help ensure readiness for the next one.66

“Epidemics,” wrote the German pathologist Rudolf Virchow, “are like large sign-posts from which statesman of stature can read that a disturbance has occurred in the development of his [sic] nation.”67 (pp. 22) COVID-19 is such a sign-post. The outbreak has already exposed the multifold inadequacies of the US’ uniquely unequal, privatized and fragmented health financing system. It also illuminates other inequities — including exclusionary policies that deter immigrants from using social assistance programs, lack of universal paid sick leave, and inadequate protections for workers — that weaken our social fabric and endanger the public’s health. As of this writing, it is unclear how severe the COVID-19 outbreak will ultimately prove to be in the US, although the rapidly climbing death toll is already a tragedy. Whatever the future holds, however, the transformation of the nation’s healthcare system and social safety-net is urgently needed.

Table: Legislation, policies, and proposals to address health financing challenges related to COVID-19

Click HERE to view a high-res PDF of this table.

Figure 1: Public Health Spending as a Percent of National Health Expenditures: 2009 – 2018

Source of data: National Health Expenditures Accounts, 2009-2018.5

Figure 2: Inadequately insured non-elderly adults by state (%)

Source: Author’s analysis of the 2018 Behavioral Risk Factor Surveillance System. Inadequately insured include those who are uninsured, or those who are insured but failed to see a doctor when needed due to cost. Includes adults 18 – 64 years in age. Map created with Microsoft Excel. Inadequate insurance rate for states not shown: Hawaii – 14%; New Hampshire – 18%; Massachusetts — 16%; Connecticut – 17%; Rhode Island – 19%; New Jersey – 22%; Delaware – 22%; Maryland – 19%; District of Columbia – 13%.

Figure 3: Hospital and ICU Bed Supply in 8 Nations

Notes: Hospital beds / 10,000 population are from OECD74 (2016 for the US and 2017 for other nations). ICU beds for the United States is drawn from Wallace et al.47, who reported 77,809 beds in 2009; total population denominator for that year (306,771,529) is drawn from the US Census. ICU beds for Canada is for 2009-10 and is drawn from Fowler et al.; these beds only include those with capacity for mechanical ventilation.46 ICU beds for European nations are drawn from Rhodes et al., and reflect years 2010-11; they include “intermediate care beds” and hence may overstate capacity relative to the US and Canada.75 Of note, the ICU bed supply in these 8 nations were also studied by Wunsch et al., who found roughly similar figures for most nations in 2005 (albeit with a substantial increase over time in the UK);44 we selected these same nations for presentation here for consistency.

References

  1. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/map.html. Accessed April 5, 2020.
  2. Legido-Quigley H, Asgari N, Teo YY, et al. Are high-performing health systems resilient against the COVID-19 epidemic? The Lancet. March 2020. https://www.thelancet.com… Accessed March 7, 2020.
  3. Anderson R, Heestereek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020.
  4. Himmelstein DU, Woolhandler S. Public Health’s Falling Share of US Health Spending. Am J Public Health. 2016;106(1):56-57. doi:10.2105/AJPH.2015.302908
  5. Centers for Medicare & Medicaid Services. National Health Expenditures by type of service and source of funds, CY 1960-2018. https://www.cms.gov… Accessed April 2, 2020.
  6. The Impact of Chronic Underfunding of America’s Public Health System: Trends, Risks, and Recommendations, 2019. tfah. https://www.tfah.org… Accessed April 2, 2020.
  7. Leider JP, Coronado F, Beck AJ, Harper E. Reconciling Supply and Demand for State and Local Public Health Staff in an Era of Retiring Baby Boomers. Am J Prev Med. 2018;54(3):334-340. doi:10.1016/j.amepre.2017.10.026
  8. Sun L. Nearly 700 vacancies at CDC because of Trump administration’s hiring freeze. Washington Post. https://www.washingtonpost.com… Accessed April 2, 2020.
  9. Cameron B. President Trump closed the White House pandemic office. I ran it. The Washington Post. https://www.washingtonpost.com… Published March 13, 2020. Accessed April 2, 2020.
  10. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. March 2020. doi:10.1001/jama.2020.3151
  11. Fraser C, Riley S, Anderson RM, Ferguson NM. Factors that make an infectious disease outbreak controllable. PNAS. 2004;101(16):6146-6151. doi:10.1073/pnas.0307506101
  12. Hellewell J, Abbott S, Gimma A, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. The Lancet Global Health. 2020;0(0). doi:10.1016/S2214-109X(20)30074-7
  13. Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? The Lancet Infectious Diseases. 2020;0(0). doi:10.1016/S1473-3099(20)30129-8
  14. Dolan J, Mejia B. L.A. County gives up on containing coronavirus, tells doctors to skip testing of some patients. Los Angeles Times. https://www.latimes.com… Published 2020. Accessed March 22, 2020.
  15. Parodi SM, Liu VX. From Containment to Mitigation of COVID-19 in the US. JAMA. March 2020. doi:10.1001/jama.2020.3882
  16. Cohen RA, Terlizzi EP, Martinez ME. Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2018. National center for health statistics; 2019. https://www.cdc.gov… Accessed August 20, 2019.
  17. Collins SR, Bhupal HK, Doty MM. Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured. Commonwealth Fund; 2019. https://www.commonwealthfund.org… Accessed November 25, 2019.
  18. Kliff S. Kept at the Hospital on Coronavirus Fears, Now Facing Large Medical Bills. The New York Times. https://www.nytimes.com… Published March 2, 2020. Accessed March 5, 2020.
  19. Conarck B. A Miami man who flew to China worried he might have coronavirus. He may owe thousands. Miami Herald. https://www.miamiherald.com… Published February 24, 2020. Accessed March 5, 2020.
  20. Abrams A. Total Cost of Her COVID-19 Treatment: $34,927.43. Time. https://time.com… Accessed March 22, 2020.
  21. Rosenthal E, Huetteman E. He Got Tested for Coronavirus. Then Came the Flood of Medical Bills. The New York Times. https://www.nytimes.com… Published March 30, 2020. Accessed March 31, 2020.
  22. Inc G. In U.S., 14% With Likely COVID-19 to Avoid Care Due to Cost. Gallup.com. https://news.gallup.com… Published April 28, 2020. Accessed April 28, 2020.
  23. Employee Benefits in the United States – March 2019. Bureau of Labor Statistics https://www.bls.gov… Accessed March 9, 2020.
  24. Wharam JF, Zhang F, Landon BE, Soumerai SB, Ross-Degnan D. Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Affairs. 2013;32(8):1398-1406. doi:10.1377/hlthaff.2012.1426
  25. Smolderen KG, Spertus JA, Nallamothu BK, et al. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA : the journal of the American Medical Association. 2010;303(14):1392-1400. doi:10.1001/jama.2010.409
  26. Venkatesh AK, Chou S-C, Li S-X, et al. Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition. JAMA Intern Med. April 2019. doi:10.1001/jamainternmed.2019.0037
  27. Winter T. “Cardiac calls” to 911 in New York City surge, and they may really be more COVID cases. NBC News. https://www.nbcnews.com… Accessed April 29, 2020.
  28. Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. The oncologist. 2013;18(4):381-390. doi:10.1634/theoncologist.2012-0279
  29. Potential costs of coronavirus treatment for people with employer coverage. Peterson-Kaiser Health System Tracker. https://www.healthsystemtracker.org… Accessed March 22, 2020.
  30. Damico A, 2020. How Much Could Medicare Beneficiaries Pay For a Hospital Stay Related to COVID-19? The Henry J Kaiser Family Foundation. March 2020. https://www.kff.org… Accessed April 2, 2020.
  31. Khandelwal N, White L, Curtis JR, Coe NB. Health Insurance and Out-of-Pocket Costs in the Last Year of Life Among Decedents Utilizing the ICU. Critical Care Medicine. 2019;47(6):749. doi:10.1097/CCM.0000000000003723
  32. Board of Governors of the Federal Reserve System. Report on the Economic Well-Being of U.S. Households in 2018.; 2019:64. https://www.federalreserve.gov… Accessed March 4, 2020.
  33. Lucas JH Elizabeth. ‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes. Kaiser Health News. September 2019. https://khn.org… Accessed November 22, 2019.
  34. Himmelstein DU, Lawless RM, Thorne D, Foohey P, Woolhandler S. Medical Bankruptcy: Still Common Despite the Affordable Care Act. Am J Public Health. 2019;109(3):431-433. doi:10.2105/AJPH.2018.304901
  35. DeBruin D, Liaschenko J, Marshall MF. Social justice in pandemic preparedness. Am J Public Health. 2012;102(4):586-591. doi:10.2105/AJPH.2011.300483
  36. Information on 2009 H1N1 Impact by Race and Ethnicity. Centers for Disease Control and Prevention; 2010. https://www.cdc.gov… Accessed March 3, 2020.
  37. Dee DL, Bensyl DM, Gindler J, et al. Racial and ethnic disparities in hospitalizations and deaths associated with 2009 pandemic Influenza A (H1N1) virus infections in the United States. Ann Epidemiol. 2011;21(8):623-630. doi:10.1016/j.annepidem.2011.03.002
  38. Radio BF Nashville Public. Long-Standing Racial And Income Disparities Seen Creeping Into COVID-19 Care. Kaiser Health News. April 2020. https://khn.org… Accessed April 6, 2020.
  39. Garg S. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6915e3
  40. Zallman L, Finnegan KE, Himmelstein DU, Touw S, Woolhandler S. Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care. JAMA Pediatr. July 2019:e191744-e191744. doi:10.1001/jamapediatrics.2019.1744
  41. U.S. Citizenship and Immigration Services. Public Charge. USCIS. https://www.uscis.gov… Published March 13, 2020. Accessed March 15, 2020.
  42. Bernstein H, Gonzalez D, Karpman M, Zuckerman S. One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018. Urban Institute. https://www.urban.org… Published May 20, 2019. Accessed August 13, 2019.
  43. Variation in Critical Care Beds Per Capita in the United States: Implications for Pandemic and Disaster Planning. JAMA. 2010;303(14):1371-1372. doi:10.1001/jama.2010.394
  44. Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36(10):2787-2793, e1-9. doi:10.1097/CCM.0b013e318186aec8
  45. Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of Medical Admissions to Intensive Care Units in the United States and United Kingdom. American Journal of Respiratory and Critical Care Medicine. 2011;183(12):1666-1673. doi:10.1164/rccm.201012-1961OC
  46. Fowler RA, Abdelmalik P, Wood G, et al. Critical care capacity in Canada: results of a national cross-sectional study. Crit Care. 2015;19:133. doi:10.1186/s13054-015-0852-6
  47. Wallace DJ, Angus DC, Seymour CW, Barnato AE, Kahn JM. Critical Care Bed Growth in the United States. A Comparison of Regional and National Trends. Am J Respir Crit Care Med. 2014;191(4):410-416. doi:10.1164/rccm.201409-1746OC
  48. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712-2719. doi:10.1097/CCM.0b013e318298a139
  49. Toner E, Waldhorn R. What Hospitals Should Do to Prepare for an Influenza Pandemic. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 2006;4(4):397-402. doi:10.1089/bsp.2006.4.397
  50. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? The Lancet. doi:10.1016/S0140-6736(20)30627-9
  51. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Critical care medicine. 2010;38(1):65-71. doi:10.1097/CCM.0b013e3181b090d0
  52. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Critical care medicine. 2004;32(6):1254-1259.
  53. Adler MF Christen Linke Young, and Loren. What are the health coverage provisions in the House coronavirus bill? Brookings. March 2020. https://www.brookings.edu… Accessed March 15, 2020.
  54. McIntire ME, Clason L. States reopen insurance enrollment as coronavirus spreads. Roll Call. https://www.rollcall.com… Accessed March 15, 2020.
  55. Stephanie A. Trump Administration to Pay Hospitals to Treat Uninsured Coronavirus Patients; Hospitals would have to agree not to bill patients or issue unexpected charges – ProQuest. Wall Street Journal. https://search-proquest-com… Published April 3, 2010. Accessed April 5, 2020.
  56. Update on COVID-19 Funding for Hospitals and Other Providers. The Henry J Kaiser Family Foundation. April 2020. https://www.kff.org… Accessed April 28, 2020.
  57. IRS: High-deductible health plans can cover Coronavirus costs. Internal Revenue Service. https://www.irs.gov… Accessed March 11, 2020.
  58. Board TE. Opinion. There’s a Giant Hole in Pelosi’s Coronavirus Bill. The New York Times. https://www.nytimes.com… Published March 14, 2020. Accessed March 15, 2020.
  59. Lowey NM. Text – H.R.6201 – 116th Congress (2019-2020): Families First Coronavirus Response Act. https://www.congress.gov… Published March 14, 2020. Accessed March 15, 2020.
  60. 6 things to know about the coronavirus funding package. POLITICO. https://www.politico.com… Accessed March 9, 2020.
  61. Cohen JK. New telemedicine strategies help hospitals address COVID-19. Modern Healthcare. https://www.modernhealthcare.com… Published March 6, 2020. Accessed March 10, 2020.
  62. Drake C, Zhang Y, Chaiyachati KH, Polsky D. The Limitations of Poor Broadband Internet Access for Telemedicine Use in Rural America: An Observational Study. Ann Intern Med. 2019;171(5):382. doi:10.7326/M19-0283
  63. Hancock J. Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are Getting Billed. Kaiser Health News. April 2020. https://khn.org… Accessed April 28, 2020.
  64. Woolhandler S, Himmelstein DU. Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance. Ann Intern Med. April 2020. doi:10.7326/M20-1491
  65. Gaffney A, Waitzkin H. Policy, Politics, and the Intensive Care Unit. In: Civetta, Taylor & Kirby’s Critical Care. Fifth.; :11.
  66. Gaffney A, Physicians for a National Health Program. Eight Needed Steps in the Fight Against COVID-19. Boston Review. http://bostonreview.net… Published April 2, 2020. Accessed April 6, 2020.
  67. Virchow R. Collected Essays on Public Health and Epidemiology. Vol 1. (Rather LJ, ed.). Canton, MA: Science History Publications, U.S.A.; 1985.
  68. Dawson L, Long M, Mar 23 KPP, 2020. The Families First Coronavirus Response Act: Summary of Key Provisions. The Henry J Kaiser Family Foundation. March 2020. https://www.kff.org… Accessed April 2, 2020.
  69. H.R. 6201, Families First Coronavirus Response Act: Title-By-Title Summary. https://appropriations.house.gov…
  70. Simmons-Duffin S. Some Insurers Waive Patients’ Share Of Costs For COVID-19 Treatment. NPR.org. https://www.npr.org… Accessed April 28, 2020.
  71. The Worker Health Coverage Protection Act. Committee on Education & Labor Summary. https://edlabor.house.gov… Accessed April 28, 2020.
  72. Himmelstein DU, Campbell T, Woolhandler S. Health Care Administrative Costs in the United States and Canada, 2017. Ann Intern Med. January 2020. doi:10.7326/M19-2818
  73. Crowley R, Daniel H, Cooney TG, Engel LS, for the Health and Public Policy Committee of the American College of Physicians. Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care. Ann Intern Med. 2020;172(2_Supplement):S7. doi:10.7326/M19-2415
  74. OECD Statistics: Health Care Resources. https://stats.oecd.org… Accessed March 7, 2020.
  75. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP. The variability of critical care bed numbers in Europe. Intensive Care Med. 2012;38(10):1647-1653. doi:10.1007/s00134-012-2627-8

Health policy trade-offs: keep good, dump bad

Cutting through the Jargon: Health Care Reform Design Issues and Trade-Offs Facing Us Today

By Linda J. Blumberg
Urban Institute, June 2020

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

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

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

Answers to These Five Central Questions Frame Policy Proposals

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

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

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

From the Conclusion

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

https://www.urban.org…

Comment:

By Don McCanne, M.D.

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

Full Repeal of the ACA

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

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

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

Replace the Current System with an Enhanced Single-Payer Program

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

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

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

Hospital CEOs paid millions while many workers furloughed

Hospitals Got Bailouts and Furloughed Thousands While Paying C.E.O.s Millions

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

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

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

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

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

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

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

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

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

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

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

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

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

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

Oliver Wyman’s four economic scenarios for health care in 2030

Healthcare 2030: Four Economic Scenarios

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

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

Below, we examine the range of possible scenarios.

Scenario 1: Status Quo Continues

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

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

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

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

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

Scenario 2: Healthcare As A No Profit Zone

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

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

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

Scenario 3: Triumph of Value – Incumbent-Led

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

(For details, use link below.)

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

Scenario 4: Triumph of Value – Innovator-Led

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

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

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

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

https://www.mmc.com…

Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

Challenging inequality through the ‘civil rights of health’

Flattening the Curve and Closing the Gap: The Civil Rights of Health During a Global Pandemic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://lpeblog.org…

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

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

Abstract

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

Conclusion

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

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

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

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

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

https://papers.ssrn.com…

Comment:

By Don McCanne, M.D.

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

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

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

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

ACOs are shifting the workforce to non-physician practitioners

Accountable Care Organizations’ Increase In Nonphysician Practitioners May Signal Shift For Health Care Workforce

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

Abstract

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

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

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

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

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

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

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

COVID-19 demonstrates need for universal health care

By Johnathon Ross, M.D., M.P.H.
The Columbus (Ohio) Dispatch, Letters, June 3, 2020

The social distancing needed to fight the COVID-19 outbreak shut down the economy. Most of the country has avoided overwhelming our dangerously unprepared, fragmented and profit-seeking health system. We now face a looming severe recession.

Over 30 million have lost their jobs and many will lose their employer-based health insurance. Even before the pandemic, 30 million were uninsured and 44 million more underinsured. One in three Americans already go without needed medical care because of costs. Medical bankruptcies are commonplace.

As the economy spirals downward, unaffordable health care bills will compound the suffering already caused by this pandemic.

Recent legislation eliminated cost-sharing for COVID-19-related diagnostic testing. However, it didn’t cover treatment for COVID-19 or any other illnesses. Nearly a third of Americans now face a potential health care financial disaster.

This COVID-19 crisis proves we need health care as a human right, not an employment benefit. An improved and expanded Medicare for All would guarantee affordable seamless lifelong coverage for everyone in the United States, eliminate cost barriers for needed care, whether for COVID-19 or other conditions, and ensure that precious health care dollars are spent on care — not wasteful bureaucracy and corporate profits.

We must demand fundamental reform now.

Johnathon Ross, M.D., secretary, Single Payer Action Network of Ohio, Toledo

https://www.dispatch.com…