PNHP

The Association of Childbirth with Medical Debt in the USA, 2019–2020

The Association of Childbirth with Medical Debt in the USA, 2019–2020

By Jordan Cahn, M.D., M.Sc.; Ayesha Sundaram, M.D.; Roopa Balachandar, M.D.; Alexandra Berg, M.D.; Aaron Birnbaum, M.D.; Stephanie Hastings, D.O.; Matthew Makansi, M.D.; Emily Romano, M.D.; Ariel Majidi, M.D.; Danny McCormick, M.D., M.P.H., and Adam Gafney, M.D., M.P.H.
Journal of General Internal Medicine, May 18, 2023

Abstract

Background: Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs.

Objective: To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA.

Design: Cross-sectional.

Participants: We analyzed female “sample adults” 18–49 years old in the 2019–2020 National Health Interview Survey, a nationally representative household survey.

Main Measures: Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors.

Key Results: Our sample included n = 12,163 women, n=645 with a live birth in the past year. Postpartum women were younger, more likely to have Medicaid, and lived in larger families than those not postpartum. 19.8% of postpartum women faced difficulty with medical bills versus 15.1% who were not; in multi-variable regression, postpartum women had 48% higher adjusted odds of medical debt problems (95% CI 1.13, 1.92). Results were similar when examining inability to pay medical bills, and similar differences were seen for privately insured women. Among postpartum women, those with lower incomes and with asthma or gestational diabetes, but not hypertension, had significantly higher adjusted odds of medical debt problems.

Conclusions: Postpartum women experience higher levels of medical debt than other women; poorer women and those with common chronic diseases may have an even higher burden. Policies to expand and improve health coverage for this population are needed to improve maternal health and the welfare of young families.

full study:
https://link.springer.com…

Doctors support the Medicare for All Act of 2023

PNHP urges Congress to pass bill that would guarantee free and comprehensive health care for everyone living in the United States

FOR IMMEDIATE RELEASE: May 17, 2023

Media Contact: Gaurav Kalwani, PNHP communications specialist, gaurav@pnhp.org

Physicians for a National Health Program (PNHP), an organization of over 25,000 physicians who support publicly financed Medicare for All, supports the Medicare for All Act of 2023, introduced in the House by Representatives Pramila Jayapal and Debbie Dingell, and in the Senate by Senator Bernie Sanders. The bill has 112 original cosponsors in the House, and 14 original cosponsors in the Senate.

“As we lurch from crisis to crisis in our health care system, insurance companies and private investors continue to rake in billions while Americans suffer and physicians are prevented from carrying out their sacred duty,” said PNHP president and adult and pediatric intensivist Dr. Philip Verhoef. “We need to eliminate this greed and guarantee health care for each and every person in this country. We need Medicare For All today, and this bill gets it done.” 

At a town hall hosted by Senator Sanders on Tuesday, May 16, former PNHP president Dr. Adam Gaffney and PNHP board member Dr. Sanjeev Sriram spoke about the injustices of the current system. “As a critical care physician, I have seen patients with life-threatening illnesses from chronic conditions that were not treated because they could not afford the care,” said Dr. Gaffney. “Medicare for All will solve that.” 

Dr. Sriram remarked on the current crisis in Medicaid following the end of the COVID-19 public health emergency. “If you don’t pick up the phone at the right time, or if you don’t fill out a form correctly,” he said, “your family and your kids could lose your Medicaid.” As many as 17 million people may lose coverage as states unwind the continuous enrollment requirement.

The Medicare for All Act of 2023 would provide comprehensive coverage to all persons living in the United States, with no copays, deductibles, or restrictive networks. It would save the United States hundreds of billions in administrative costs and waste, while also saving thousands of lives every year. Under this bill, reproductive health care and gender affirming care are fully covered and freely provided, as is dental, vision, and long-term care.

“We only have two options – allow people to continue to suffer and die, or pass Medicare for All,” said Dr. Verhoef. “For PNHP and millions of others across the country, the choice is simple.”

Read more information about the bills and what you can do HERE.

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.

The toxic brew of sexism and racism in American medicine

By Brenda Gazzar
Code Wack Podcast, May 15, 2023

Why is it that infant mortality rates in America differ by race? Why are some American babies more likely to be born premature or underweight? And how could single-payer health care help?

To find out, we spoke with Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for Medicare for All. This is the first of a two-part series with Dr. Singh.

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! Why is it that the richest Black women have about the same infant mortality rates as the poorest White women? Why do Black babies tend to have more risk factors like being born premature or underweight? And how could single payer help? To find out, we spoke to Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for single-payer Medicare for All.

Welcome to Code WACK, Dr. Singh. We’re so glad you could join us today.

Singh: So happy to be here with you.

Q: So tell us a little bit about yourself. Where do you live and what do you do?

Singh: I am a gynecologic oncologist. I live and work in the Norfolk, Virginia Beach area of Virginia. Although I’m new to here. I’ve lived in Chicago and Washington DC for long periods of time, both of them. And I also work as, I don’t know if it’s work, it might be, I also “fun” as, as the vice president for Physicians for a National Health Plan and I’ve been involved in that organization for a long time.

Q: Did you have a specific experience that led you to support single-payer health care?

Singh: It’s hard to say that because I’ve been involved now for over 20 years. I think. Being involved with Physicians for a National Health Plan (PNHP) allows me to tolerate all of the bad things about our current profit driven system that make it hard for people to get care that make it unfair, that impact negatively their outcomes that limit the amount of time I get to have with them that limit the time and we spend with patients versus writing papers, filling out forms, doing things for insurance companies. So I’ll say like, there wasn’t a specific experience that made me do join, but every time I have a really bad experience with a healthcare insurance provider, I think to myself, okay, I’m doing that work for Physicians for a National Health Plan, trying to get everybody health care, trying to fix our system. But I mean, I think I have a bad experience with our healthcare system every day – like so many of my patients and the women I take care of, unfortunately.

Q: Wow. Thank you for sharing that. We’d like to talk about the recent study by the National Bureau of Economic Research, which showed the richest Black mothers and their babies are twice as likely to die as the richest White mothers and their babies. It was in the New York Times, I’m sure you caught it. The study examined women in California specifically and found that the richest Black women have infant mortality rates at about the same level as the poorest White women. Black babies tended to have more risk factors like being born premature or underweight. What are your thoughts about these inequities?

Singh: So I thought it was a really interesting study in a lot of ways, but I do want to point out the number one piece was it they were comparing to women in Sweden and everybody in America, all the kids, all the people having kids do worse in America no matter what their income, no matter what their race, which is kind of shocking considering we spend twice as much on every single person in America as they do in most of the rest of the world, for us to have such worse outcomes. The issue about why Black women are having these increasing maternal mortality, Black babies are having these increasing infant mortality. I mean, the other thing that’s interesting in that study was White women actually had higher rates of low birth weight and prematurity. And that’s thought to be related to White women at the highest income level being more likely to have twins and have gotten pregnant through infertility [treatments].

You know? And so it was kind of interesting that although they had higher rates of low birth weight and prematurity, they still had the best outcomes. Right? So we know it’s actually not that thing. You mentioned that those babies have bad outcomes because they have high risk factors. There’s something else in the system, and we know it’s everything in our system, right? It’s the access to healthcare, and we are along a person’s life, a person who decides to be a mother, do they get the opportunity to engage with health care? How much preventive work do they do before they get pregnant? During their pregnancy? What kind of care do they get? And then immediately postpartum, right? I mean, the maternal mortality rates, the all cause mortality rates that just came out. And that was in JAMA said, all-cause mortality, not just pregnancy, but homicide, drug-related death for women is up in America 2018 even compared to 2020 and all dramatically higher than the rest of the world.

Wow.

Singh: So how do we connect race to bad health outcomes? I think the majority of the data is saying to us, it’s about racism and how that manifests is really complicated, right? So there’s the chronic stressors for people who experience racism. There’s the unconscious bias of healthcare providers and how they take care of people of different races and gender. And then there’s the way we listen to and talk to women in general, and then how it impacts pregnant women as in, you know, we know if a woman shows up pregnant or not pregnant in an emergency room and she’s in pain, she’s going to wait longer than a man would wait. She’s less likely to get pain medicine. She’s less likely to get any kind of test to evaluate the pain, and she’s more likely to be given an antidepressant, right, which that’s all kind of crazy making if you think about it.

That is crazy.

And I think the tragic piece of this is, is that Black women are kind of literally at the intersection of that, right? They’re getting all the negative impact of being a woman, of being female, and then they’re getting all the negative impact of race and racism and, you know, yeah, we could talk for a while like all the things that have poor impact. But I think that sort of summarizes it. And I think we have to be really, really clear that there is a lot of sexism and misogyny and racism that’s built into American medicine. And one of the reasons we don’t have universal healthcare is because back in the 1940s when Truman was trying to introduce universal health care, the American Medical Association did not want to cover Black people, period. They wanted them to be cared for separately. So, you know, and that’s the beginning, right? Like that’s early in the history of modern medicine as it exists now in America.

Q: Right, and this happened less than a century ago, as you said in the 1940s?

Singh: Yeah, in the 1940s. Actually, if people in the audience are interested, the 1619 podcast episode four speaks of it so 
 it’s a really nice short way to get a good history of racism in America and how kind of worked into it. There’s also a really wonderful journalist and writer Linda Villarosa, who has a book called Under the Skin, yeah. She talks about the traditional ways of thinking. I mean, you know, now we look at these things that we think it’s stupid, right? Like, ‘oh, well Black women have worse outcomes because they’re genetically inferior or different.’ And now we look at it and we’re like, ‘wow, that would be like saying, wow, everybody who has blue eyes must be weaker than everybody who has brown eyes.’

Like, you know, even scientifically it didn’t make sense connecting skin color to other characteristics. And the funniest, or the most complicated thing about that for me is like, but now we know there is a way that race, you know, impacts genes. It’s the trauma of racism that causes those epigenetic changes that we almost think, you know, the trauma of generations before us might impact the younger generations. And that’s where even like the thing you mentioned about, you know, the highest income Black women, right? We know then race must be a part of it if it’s not about socioeconomic status. But then if we think of the generational trauma even of her parents and her ancestry and how that impacts how genes function, not what genes we have, but how well our genes work, you know, and that’s what we call epigenetics and how those things impact health outcomes and we know they do. Yeah. It’s hard to imagine that nobody could see that before and that they chose to blame it on other factors. And it’s not that low socioeconomic status and lack of insurance and poverty doesn’t play a role in health. Absolutely it does, but it’s not the only factor.

Q: Mm-Hmm. Got it. Thank you. Right. So I know that you’re not an OBGYN, but do you happen to have any stories you can share related to the study’s findings about black women and their babies?

Singh: So I am an OB-GYN. I just don’t practice obstetrics so to be a gynecologic oncologist, first you become an OB-GYN, then you do a cancer fellowship. But I don’t take care of pregnant women except for when some context related to me comes up. But, you know, I mean, I hate to be like a media hound and you know, like talk about Serena Williams, but to me, like she’s the most telling, right, because she is the greatest athlete of all time, right? . So she knew her body. She had a history of a blood clot. She was pregnant. She had an emergency C-section. She was having symptoms of a possible new blood clot and she could not get people to listen to her about shortness of breath and that she might have a blood clot.

And she had to push so hard and advocate so hard to get the CAT scan that diagnosed her, you know, pulmonary embolism that is life-threatening and to imagine, right, somebody not as empowered as she is and talk about somebody who’s in good health, right? And she had this pregnancy related complication but didn’t get listened to 
 because she has everything, right? She had money, she had fame, she had a platform, she had credibility when it came to health and that her, you know, exchange with the healthcare system was so challenge and then imagining women who don’t have that piece of, you know, she’s extremely articulate. She’s been on the world stage since she was like a preteen and, you know, understands how to voice her feelings. That to me is the story that tells us the role that both race and gender play in how women interact with health care and how that has the potential to lead to bad outcomes.

Cuz if it hadn’t been her, if it had been somebody who just said, you know, oh, you must be right, I’m just in pain cause I had a c-section, the likelihood she would’ve fallen into that statistic of a maternal mortality is high and we never would’ve heard that story. And you know, we can take every one of those 26 deaths per a hundred thousand lives births. And there’s a story like that there, you know, are some of those deaths not preventable, you know, not preventable. Possibly the literature tells us, you know, in countries like New Zealand where they have five, you know, maternal deaths for a hundred thousand births, and here in America we’re in this range of 26 to 50 something for Black women and you know that there’s a story in at least, you know, 50 of those women of something preventable because somehow in the rest of the world, we are successfully preventing those deaths.

Q: Mm-Hmm. Right. Good point. Let’s talk about some of the reasons this is happening. You mentioned racism and Tiffany Green, an economist who focuses on public health and obstetrics at the University of WisconsinMadison told the New York Times that it’s not race, it’s racism. And this is about the environments where we live, where we work, where we play, where we sleep. What do you think she meant by that?

Singh: There’s two pieces to it. There’s the racism that means that in a predominantly Black neighborhood, you’re more likely to live near a landfill, right? And the pollution that comes from that and the environmental impact of that. You’re potentially more likely to not have access to fresh fruits and vegetables. You’re potentially less likely to have access to non-dairy milk alternatives. Right? There’s all these things I’m going to keep in there the complexity of socioeconomic status. That if you take the highest income Black women and they’re still having these bad outcomes, that there is something beyond the environmental interplay when it comes to those kinds of things and then we’re talking about an environment where they are subjected to some element of daily ongoing chronic stress. Their symptoms are not listened to or ignored based on the color of their skin alone.

I won’t say every Black woman of high socioeconomic status didn’t come from low
. Right. They might, she might have, people might have a history of coming from, so it’s, you know, higher, but that epigenetics or, you know, other generational trauma and how that impacts, I think it all plays in. And I think when I talk about racism in like, what does it mean, you know, it means like how do people talk to you when you come to the hospital? It means how do people listen to you? It means what do they think when they’re going to take care of it? You, and, and I do find it challenging when I talk to physicians, groups and medical students about this because I think the unconscious bias part of things is really challenging. Right. You know, the fact that the father of modern gynecology, right, Marian Sims experimented and practiced surgery on Black women slaves with no anesthesia.

And the fact that he could say like, well they don’t feel pain the same way, which was this tenant of slavery of how they could get away with treating people so poorly. But it’s hard to imagine those women didn’t cry. It’s hard to imagine those women didn’t react to being cut open.

Oh my gosh, that’s horrible.

Right? And so the, the kind of recently in 2015, there was an editorial in a major OBGYN journal written by somebody justifying his behavior, saying, well, he was just a creature of his time. He was a physician taking care of somebody. And it’s just hard for me to imagine they didn’t express pain. But meanwhile, you come now and there’s studies from 2015, 2016, and I think it came from in Virginia, somebody interviewed and did studies on University of Virginia, I believe medical students and asked them about pain tolerance. And there were medical students in our day and age who thought Black people have higher pain tolerance based on skin color again, right.

That’s this weird genetic thing of like, really pain tolerance is like built into a gene that’s connected to the melanin in your skin? Like it makes no scientific sense, but it has been a part of “science” in quotes – eugenics – not real science, but it was put forward. And I think we have to remember right, medicine is science, but medicine is culture. And so the misogynist and racist culture that our medicine grew up in, fixing misogyny and racism in medicine in many ways is not hard. In many ways it’s really difficult cause it’s so deeply ingrained.

Q: I see. So could single payer, Medicare for All affect these high rates of infant and maternal mortality among Black women in America and if so how?

Singh: So I think everybody having access to the same basic level of health care, not having to prove that you are pregnant. And so you can get Medicaid if you didn’t have insurance. Not having to make choices about what work you do in order to have insurance absolutely could make dramatic changes. And there’s a lot of well-spoken, well thought of policy advocates who say, you know, universal health care could be the most pro-women anti-racist policy we could move forward and I 1000% agree that if you automatically had access to care and the care was the same for everybody, right? It’s not like, ‘oh, you have Medicaid, it doesn’t reimburse as well so not every doctor in this hospital takes your insurance, so we’re going to put you in a slightly different category.’ Or, ‘oh, you’re from the free clinic. Hmm. That must mean you are addicted to drugs’ or you know, like all the biases and stuff.

If it were all the same, that would change. And as we think about like, how do New Zealand and Sweden and Canada and Denmark and the UK and Germany have maternal mortality rates that are, you know, five versus 50 for Black women. Right? How do they do that? Well, everybody gets health care and most people get care within the same system and they get access to everything long before they became pregnant and cared for long after. So I think by kind of raising the bar on health care, on prevention, absolutely will make a difference. Is it the only thing we need to fix? Nah, we got other things that we would need to fix as well.

Thank you Dr. Singh of PNHP. Stay tuned next time when we talk to Dr. Singh about why Black women face a greater risk of gynecologic cancers.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org


Insane Drug Prices & Gaming = Huge Profits for Pharma & PBMs

Summary: Two news items this week lay bare US drug cost problems. The underlying cause is prices several-fold higher than elsewhere. Exacerbating that is convoluted gaming – moving money around to boost and retain profits. Who wins? Pharma and Pharmacy Benefit Managers (partnered with insurers). And loses? The rest of us.

Senators Call Out PBMs, Drugmakers for High Prescription Drug Costs, MedPage Today, May 11, 2023, by Shannon Firth

Drugmakers and pharmacy benefit managers (PBMs) traded the blame over high drug prices during a hearing of the Senate Health, Education, Labor and Pensions Committee on Wednesday.

Each side argued the other was trying to fleece patients and the government, but Sen. Bernie Sanders (I-Vt.), chairman of the committee, argued there was plenty of blame to go around.

“Let’s be clear, while Americans pay outrageously high prices for prescription drugs, the pharmaceutical companies and the PBMs make enormous profits every year,” he said.

In 2021, the 10 major drug companies made $100 billion in profits, and in 2022, the three largest PBMs made over $27 billion, Sanders noted. Moreover, the three pharmaceutical companies that produce insulin — Eli Lilly, Novo Nordisk, and Sanofi — have hiked the price of the drug dozens of times over the last two decades for “the same exact product,” he added.

Meanwhile, 1.3 million Americans have been forced to ration their insulin because of its high cost, and some, including 23-year-old Alec Raeshawn Smith, have died. 


Several lawmakers argued that PBMs benefit from higher list prices because higher prices mean higher rebates, and PBMs keep a portion of rebates. 


In their testimony, the PBM witnesses all stated that they pass about 98% of their rebate onto their customers, which include employers, health plans, and unions. 


Notably, however, because of vertical integration, the three largest PBMs, CVS Health, Express Scripts, and OptumRx 
 are all owned by or partnered with health plans. UnitedHealth Group owns OptumRx, Cigna owns Express Scripts, and CVS Health and Aetna merged in 2018.

Sen. Markwayne Mullin (R-Okla.) likened this setup to “the fox guarding the henhouse.” He pointed out that when PBMs say 98% of rebates go to customers, health plans are included among their customers.

“So you’re rebating yourselves. That is just — wow — [a] great business model,” he said.

Wonking Out: Attack of the Pharma Phantoms, New York Times, May 12, 2023, by Paul Krugman

The U.S. health care system, unlike health systems in other countries, isn’t set up to bargain with drug companies for lower prices. In fact, until the Biden administration passed the Inflation Reduction Act, even Medicare was specifically prohibited from negotiating over drug prices. As a result, the U.S. market has long been pharma’s cash cow: On average, prescription drugs cost 2.56 times — 2.56 times — as much here as they do in other countries.

Strange to say, however, pharmaceutical companies report earning hardly any profits on their U.S. sales. 
 a striking chart comparing 2022 revenue and profit for six major pharma companies:


 2022 was an exceptionally profitable year for these companies, but the pattern — large revenue in the U.S. market, with very low reported profits — has been consistent over time.

How do the pharma giants do that? Mainly by assigning patents and other forms of intellectual property to overseas subsidiaries located in low-tax jurisdictions. Their U.S. operations then pay large fees to these overseas subsidiaries for the use of this intellectual property, magically causing profits to disappear here and reappear someplace else, where they go largely untaxed.

Comment:

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

These two pieces, a news report on a Senate hearing and an op-ed by a prominent economist, succinctly characterize the massive cost problems we face with prescription drugs.

First, prices are more than 2.5 times as high in the US as in comparison wealthy countries.

Second, drug companies avoid paying US taxes on those profits by setting up intellectual property havens in other countries with low tax rates. They pay themselves (their foreign entities) inflated amounts for patent use, thereby shifting profits to where they can keep them.

Third, PBMs – an invented intermediary structure — manipulate prices and rebate schemes to grab another huge slice of income and profits. The “rebates” are largely to the insurance companies with which they share corporate structure.

Single payer would replace this convoluted profit-maximizing drug marketing maze with a straightforward, proven and transparent system of drug price negotiation and payment. This shift would save enough money, along with administrative simplification, to make single payer the economic unicorn: a “free lunch” — a cost–saving expansion to universal high-quality insurance.

http://healthjusticemonitor.org…

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

Primary Care Corporate Takeover a Challenge for Single Payer

Summary: The large-scale corporate appropriation of primary care reflects and enables the profiteering that now dominates US health care. The doctor-patient relationship suffers. Single payer financing may falter if corporations own the vast majority of providers. What are our reform options?

Corporate Giants Buy Up Primary Care Practices at Rapid Pace, The New York Times, May 8, 2023, by Reed Abelson

Why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices?

The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.

And there’s an added lure: The growing privatization of Medicare means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.

The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Nearly seven of 10 of all doctors are either employed by a hospital or a corporation. Experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. [The article provides examples of how corporate control of primary care leads to abusive practices to increase revenue.]

“We’re dealing with incredible levels of burnout within the profession,” said Dr. Max Cohen, who practices near Portland, Ore.

Comment:

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

There is not much new here in this report of the corporate takeover of our health care system except maybe for the rapidity and boundlessness with which it is taking place.

Recently single payer financing gained in popularity as people recognized how it could transform our defective insurance system to bring truly affordable, accessible, equitable care with free choices for all. But with corporations now controlling medical delivery including linchpin primary care providers, care has become less affordable and thus less accessible for many, certainly less equitable, and our choices are limited to the dictates of the corporate entity.

The complexity that this has produced was explained by Steffie Woolhandler and David Himmelstein, the founders of Physicians for a National Health Program, in a recent Jacobin interview and HJM post. Just a few years back, all we needed was a public financing program that displaced private ownership of health insurers (single payer).

But now with Wall Street’s takeover of the health care delivery system, reform of ownership of provider resources is needed. Community rather than corporate control of care seems to be what we need, but imagine the hurdle in transferring ownership of our entire health care system from the titans of Wall Street to the inhabitants of Main Street. Difficult times lie ahead, but what can we do? One thing for sure, we cannot leave control of our health care in the hands of the billionaires.

Are there any ideas out there that would actually work, short of socialized medicine (which, of course, would)? We’re contemplating this, and welcome ideas healthjusticemonitor@gmail.com.

http://healthjusticemonitor.org…

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

Single Payer Would Radically Transform Health Policy Research

Summary: The May 2023 issue of Health Affairs, the leading health policy journal, has 20 articles. In our assessment, 9 of them would be unnecessary and another 7 simplified if the US had truly universal and standard health insurance. These health policy resources could be redirected to critical non-insurance issues in access, equity and disparities, and outcomes.

Health Affairs Table of Contents May 2023

(Parenthetical assessments by HJM)

Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts (Largely a coverage issue; simplified.)

The Role of Financial Incentives in Biosimilar Uptake in Medicare: Evidence from the 340B Program (Drug pricing issue; simplified.)

Benchmarking Changes and Selective Participation in The Medicare Shared Savings Program (ACO issue; likely moot.)

Trend Toward Older Maternal Age Contributed to Growing Racial Inequity in Very-Low-Birthweight Infants in the US (Partially an insurance issue; simplified)

Federal Funding for Discovery and Development of Costly HIV Drugs Was Far More Than Previously Estimated (Informs drug pricing; still needed.)

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use (Coverage issue; moot.)

Insurer Market Power and Hospital Prices in the US (Insurer patterns; moot.)

Hospital-Physician Integration Is Associated with Greater Use of Cardiac Catheterization and Angioplasty (Provider ownership & practice issues; likely still relevant.)

The Costs of Disparities in Preventable Heart Failure Hospitalizations in The US South, 2015–17 (Partially insurance issue; simplified.)

Enrollment and Characteristics of Dual-Eligible Medicare and Medicaid Beneficiaries in Integrated Care Programs (Insurance issue; moot.)

The Neighborhood Atlas Area Deprivation Index for Measuring Socioeconomic Status: An Overemphasis on Home Value (Equity; still relevant)

Changes In Health Coverage During The COVID-19 Pandemic (Insurance issue; moot.)

Buprenorphine Treatment for Opioid Use Disorder: Comparison of Insurance Restrictions, 2017–21 (Insurance issue; moot.)

‘We’ll Decide for You’: A Patient Is Rushed at Hospital Discharge (Partially insurance issue; simplified.)

Inequities In the Use of High-Quality Home Health (Largely insurance issue; simplified.)

Risk Adjustment and Health Equity (Insurance issue; probably moot.)

The Neighborhood Atlas Area Deprivation Index and Recommendations for Area-Based Deprivation Measures (Equity issue; still relevant.)

The Health Plan Price Transparency Data Files Are a Mess- States Can Help Make Them Better (Insurance complexity issue; moot.)

Identifying Scalable Strategies to Maintain Coverage as Medicaid Continuous Enrollment Ends (Insurance issue; moot.)

Why International Recruitment Won’t Solve the US Nursing Staffing Crisis (Largely financial issue; simplified.)

Comment:

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

Much health policy research examines the harms of and potential fixes for un- and underinsurance – problems created by our chaotically fragmented health insurance.

Our review of the table of contents of the premier US health policy journal suggests that the government and academic health policy community focuses on issues that would disappear with universal high quality health insurance, including drug price regulation – under single payer.

The considerable collective skills of health policy researchers should, could, and would be re-directed to the issues that are not fully resolved with single payer, such as disparities in access, care, and outcomes related to economic status and race.

Health policy researchers would also be called upon to study and refine the performance of single payer. For example, how should drug prices be set? How do provider reimbursement levels affect care patterns and outcomes? What is the impact of covering long-term care? How do clinical outcomes in the real world vary by choice of medical strategies? In another post, I’ll more fully describe a single payer health policy research agenda.

The contributions of health policy research must be unleashed by removing from the research portfolio the highly frustrating and largely futile research focused on trying to fix our irremediably broken insurance system. Policy band-aids, no matter how cleverly designed, won’t fix major pathology.

Liberate and empower health policy research!

http://healthjusticemonitor.org…

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Call for a National Health System

Summary: PNHP founders Woolhandler and Himmelstein propose that progressive health reform needs updating to respond to the widespread takeover of providers by for-profit corporations. The original vision of insurance reform should be expanded to include ownership of provider organizations.

We Don’t Just Need Medicare for All — We Need a National Health System, An Interview with Steffie Woolhandler and David U. Himmelstein, Jacobin, May 2, 2023

The founders of Physicians for a National Health Program put single-payer health care on the map. Now, discussing the next phase of the movement, they say even single-payer won’t be enough to fix the problems caused by continued privatization. 


Steffie Woolhandler

There’s two countervailing things going on. One is that giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP. So when we started, we were mostly up against the insurance industry and pharmaceutical industry. But now there’s all sorts of involvement by banks and for-profit ownership of health providers, so that makes things harder.

The other thing is that the health care system continues to be so dysfunctional. People with or without insurance face massive medical bills, the complete inability to afford lifesaving treatments like insulin and sometimes cancer treatments. The growing dissatisfaction among doctors is now often called burnout or sometimes moral injury. Whatever you call it, physicians recognize that the system’s not functioning very well. So the system’s own problems and dysfunctions continually create an interest in and constituency for fundamental health reform.

Giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP.

David U. Himmelstein

We need to have a deep understanding of what the problems in the current system are, and the shifts in the organization of the current system need to guide both our program and our political work. So I think we need to update what the vision of single-payer health care is from when we first conceived of it.

We thought we could control the health care system by replacing insurance companies with a single public financing system. And I think that was true as long as health care was essentially carried out by small-scale practices, mostly individual hospitals, that were not parts of large chains, not controlled by giant corporations. But at this point, we have the vertical and horizontal integration of ownership of the health care system. So for instance UnitedHealthcare employs seventy thousand doctors. Just taking away the insurance business isn’t going to be an adequate reform of the health care system.

We need to reconsider our reforms to think about how we seize ownership of health care assets from the corporations that have come to dominate them, and how patients and people doing health care work can really take ownership of this system. I don’t think it’s possible any more by just taking control of insurance. I don’t see a lot of advocacy for radical reform of the health care system, and that I think is the next phase that either PNHP or some new form will need to take up.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

Looking forward rather than backward, progressives need to update the vision of health reform that we and others articulated in the 1980s. Back then, a public financing program that displaced private ownership of health insurers would have had the leverage needed to broadly transform health care. But Wall Street’s subsequent takeover of health care delivery – hospitals and nursing homes, doctors’ practices, and even hospices – necessitates reform of who owns provider resources. Communities, not corporations should control care.

We hope that by speaking out on this issue, we can encourage the health reform movement to take on the critical ownership issues.

A few comments on the mostly accurate PNHP history presented in the article. It was founded 37, not 35 years ago. We note that Ron Sable, and subsequently Quentin Young, and then Claudia Fegan took over day-to-day oversight when PNHP moved from Cambridge to Chicago. Former Executive Directors Ida Hellander and Matt Petty made important contributions to PNHP. We are currently members, but not leaders, of the organization.

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 97

Some Changes Needed in Our Current Healthcare System

May 1, 2023

Podcast host Joe Sparks suggests ways to hold commercial health insurance companies accountable for their widespread denial of care, and to stem some of the most egregious profiteering that takes place in U.S. health care.

Even with these policy changes, he adds, “If we want to truly fix our health care system, we must implement Medicare for All.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Suing for Inflated Bariatric Surgery Fees

Summary: Aggressive collection tactics by a large bariatric surgery practice exemplify widespread problems with our health insurance: complex payment arrangements, confusing and misleading financial contracts, widely variable prices, medical debt, expensive litigation, and rising private equity.

Lose Weight, Gain Huge Debt: NY Provider Has Sued More Than 300 Patients Who Had Bariatric Surgery, KFF Health News, April 20, 2023, by Fred Schulte

Seven months after Lahavah Wallace’s weight loss operation, a New York bariatric surgery practice sued her, accusing her of “intentionally” failing to pay nearly $18,000 of her bill. 


Wallace denies the allegations, which the bariatric practice has leveled against patients in hundreds of debt-collection lawsuits filed over the past four years, court records in New York state show.

In about 60 cases, the lawsuits demanded $100,000 or more from patients. Some patients were found liable for tens of thousands of dollars in interest charges or wound up shackled with debt that could take a decade or more to shake. Others are facing the likely prospect of six-figure financial penalties, court records show. 


[Wallace] said she turned over checks from her insurer to the bariatric group and was stunned when the medical practice hauled her into court citing an “out-of-network payment agreement” she had signed before her surgery.

“I really didn’t know what I was signing,” Wallace told KFF Health News. “I didn’t pay enough attention.” 


The bariatric group has cited these out-of-network payment agreements in at least 300 lawsuits filed against patients from January 2019 through 2022 demanding nearly $19 million to cover medical bills, interest charges, and attorney’s fees, a KFF Health News review of New York state court records found. 


In most cases, the medical practice had agreed to accept an insurance company’s out-of-network rate as full payment for its services — with caveats, according to court filings.

In the agreements they signed, patients promised to pay any coinsurance, meeting any deductible, and pass on to the medical practice any reimbursement checks they received from their health plans within seven days.

Patients who fail to do so “will be held responsible for the full amount charged for your surgery, plus the cost of legal fees,” the agreement states.

That “full amount” can be thousands of dollars higher than what insurers would likely pay, KFF Health News found — while legal fees and other costs can layer on thousands more. 


Wallace, the Brooklyn legal assistant, was billed $60,500 for her lap sleeve gastrectomy, though how much her insurance actually paid remains to be hashed out in court.

Michael Arrigo, a California medical billing expert at No World Borders, called the prices “outrageous” and “unreasonable and, in fact, likely unconscionable.” 


Private Equity Arrives


 In August 2019, the private equity firm Sentinel Capital Partners bought 65% of the MSO for $156.5 million, according to Garber’s affidavit. The management company is now known as New You Bariatric Group. The private equity firm did not respond to requests for comment.

Comment:

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

This exposĂ© of one firm exposes problems that plague all of health care. The aggressive legal tactics employed by this surgery practice drew press attention because they’re so egregious and extensive. But the fundamental issues permeate our insurance system.

1) Complex payment arrangements: Scores of public insurance programs (Traditional Medicare with and without direct contracting, Medi-gap policies, Medicare Advantage and Medicaid plans in profusion) and thousands of private insurance plans from work and ACA exchanges. Out-of-network payments regulated by ambiguous laws. All of this contributes hugely to more than $600 billion per year in excess administrative costs.

2) Confusing and misleading financial contracts with patients: The patients of this bariatric surgery practice were told that it would accept out-of-network payments offered by insurers 
 except if 
 here’s the fine print 
 they failed to take care of all tasks within 7 days, in which case their obligation would shift to “the full amount charged for your surgery, plus the cost of legal fees”. And, it seems, the practice charged very high prices.

3) Widely variable prices: Which brings us to prices. It turns out that prices listed by different practices for these standard surgeries vary widely in nearby areas. This is generally true of medical prices: the amount “charged” (aka “billed”, aka “chargemaster”) is entirely discretionary, and varies hugely across providers. Insurers typically negotiate much lower “allowed” charges. Discerning a truly fair local price is impossible. This surgical practice aims high, which means the sued patients are on the hook for amounts far in excess of actual costs.

4) Medical debt: Which leads to medical debt. As detailed in the article, this is the result for many sued patients. And, as covered in HJM, estimates of the current prevalence of medical debt are in the range of 40-50%, with a median debt of $2,500 or more.

5) Expensive litigation: Collections lawyers are happy to line up when liabilities of tens of thousands of dollars are in the offing from poorly-represented patients who didn’t read the fine print in their contracts, and the lawyers will keep 1/3 of the yield. That adds to administrative costs. And the litigation clogs the courts and traumatizes patients.

6) Rising private equity: As the last excerpted paragraph notes, the surgery practice payment lawsuits accelerated once private equity entered the scene. Private equity is rapidly expanding its role in provider ownership, as reported in HJM. Pursuit of income and profit as their guiding light.

Single payer would solve problems 1, 2, 3, 4, and 5. And greatly mitigate 6.

http://healthjusticemonitor.org…

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Oracle Health Data Profit Fantasies

Summary: Oracle Health, acquired by Cerner, is pursuing a global cloud-based health records repository. Except that they can’t even succeed in five Veteran’s Administration hospitals. And their grand vision fails to address core healthcare financing challenges. When will we turn our attention from profit-seeking business models to health coverage basics?

Oracle’s plan to build national health records database ‘going great,’ Feinberg says, Healthcare Dive, April 21, 2023, by Rebecca Pifer

(David Feinberg was CEO of Cerner and then became chairman of Oracle Health when it acquired Cerner.)

Healthcare Dive: When the deal closed, Oracle said it planned to focus the unit on medical software usability and voice-enabled user interfaces, and would expand Cerner’s business to more countries. Can you give me an update on these priorities?

Feinberg: I remember those three things being listed. It’s more now. Our vision is to create a cloud-enabled health platform that brings all kinds of information together to make individuals and communities healthier around the world. That includes the electronic health record, and Oracle’s human capital management, enterprise resource planning, supply chain management, claims processing, clinical trials – so we have a platform that normalizes data and then tees it up for whoever needs it, a mom taking care of kids at home, or a government looking at public health issues.

Healthcare Dive: Larry Ellison announced Oracle has plans to build a health records database to link the thousands of separate hospital databases. How is this going?

Feinberg: It’s going great. We have a new product we just launched called Seamless Exchange. A clinician gets a new patient, and this patient has records from multiple places. With one click, we take all of that information and we make a longitudinal story of that patient.

Healthcare Dive: What are the next steps?

Feinberg: I want all information that’s applicable to my health. That includes social determinants, that includes claims processing, so many other pieces of information.

Healthcare Dive: How will Oracle pull that additional data?

Feinberg: Oracle Financial Services processes 80% or 90% of the world’s credit card transactions
 So we have the clinical data. Oracle Financial Services also does claims data. We think we can be the trusted intermediary between clinical care and the payment of clinical care that dramatically decreases the cost.

VA Halts Future Launches of its Oracle Cerner Health Record System, Military.com, April 21, 2023, by Patricia Kime

The Department of Veterans Affairs has abandoned plans to introduce its new electronic health records system at more facilities, announcing Friday that it has halted all future deployments as if moves to fix the system at the five places where it is currently used.

Comment:

By Don McCanne, M.D.

So it looks like Oracle wants to take over the entire health care information technology system. In whose interest is this?

In these days when the medical-industrial complex dominates, it seems that Oracle’s designs are on enhancing shareholder value, probably not just for individual shareholders and for the corporate executives, but especially for the dominant shareholders representing the shift of wealth from the masses to the billionaire element in our society.

Is this in the interest of the health care professionals and the health care industry at large? It does provide a framework for an overlay of their health information technology, but for the purpose of enhancing income produced by the IT system. Any income for the actual health care delivery system would be to keep them satisfied so they would continue to use Oracle products.

But shouldn’t the health care delivery system be designed to, above all, meet the needs of patients? What does this IT system do for those individuals who could qualify for Medicaid but are left out because of political decisions in their states? What about for those who are left un- or under-insured because of employer-labor disputes? What about those who are medically underserved due to well-documented problems such as racial inequities? Why would we ignore all our health policy lessons about how to provide optimal care for everyone?

Creating more wealth-generators in health care without fixing the profound deficiencies in our health care system is obviously continuing down the wrong path, blatantly disregarding real needs. At least they understand this at the VA. They’ve halted the launch of the Oracle Cerner Health Record System because it is not working for the patients, and the patients are what health care is all about. Oracle can’t manage data for five health facilities, but they’re eager to take on health data around the world.

Shouldn’t we get serious about health system improvement? Clear goals on how to optimize access to care for everyone (not maximize profits), using proven methods (not shoddy IT).

http://healthjusticemonitor.org…

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Rescuing Primary Care, Part 2

Summary: In Part 1, we discussed how primary care is being acquired and distorted by huge corporations pursuing massive profits. Today, we present a competing vision: a broad social movement to reclaim primary care as a “common good” focused on public benefit.

Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good, Annals Of Family Medicine, March/April 2023, by Kevin Grumbach

Abstract

The state of family medicine and primary care in the United States is precarious, afflicted by chronic underinvestment. Family physicians and their allies should not expect different policy outcomes without adopting a different theory of change and tactical approach to reform. I argue: (1) high-quality primary care is a common good, as asserted by the National Academies of Sciences, Engineering, and Medicine; (2) a market-based health system captured by extractive capitalism is inimical to primary care as a common good; (3) professionalism has both aided and constrained family physicians as agents of change for primary care as a common good; and, (4) to actualize primary care as a common good, family physicians must embrace “counterculture professionalism” to join with patients, primary care workers, and other allies in a social movement demanding fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. This restructuring should take the form of a publicly financed system of universal coverage for direct primary care, with a minimum of 10% of total US health spending allocated to Primary Care for All.

Over past decades, several waves of health reform and advocacy efforts offered hope of revitalizing the specialty of family medicine and the primary care sector: the rise of managed care in the 1990s; the Joint Principles of the Patient- Centered Medical Home in 2007; enactment of the Patient Protection and Affordable Care Act in 2010; the launching of Family Medicine for America’s Health in 2013. Yet the reality on the ground has not fundamentally improved for family physicians and others working in primary care, or for patients struggling to obtain high-quality primary care. Between 2005-2015, the number of primary care physicians per capita in the United States declined, primary care visits per capita decreased, and waiting times for new primary care appointments lengthened. The earnings gap between primary care physicians and physicians in other specialties widened and burnout remains high. Most tellingly, only about 5% of national health expenditures in the United States are spent on primary care—one-half or less than the proportion spent in Canada and Europe. 


A Social Movement for Primary Care as a Common Good

To actualize primary care as a common good, family physicians must embrace what I call “counterculture professionalism” to join with patients, community members, primary care workers, and other allies to build a broad-based social movement demanding a fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. A social movement must have clarity about what it wants to achieve, and how to achieve it. 


By social movement, I mean a coming together of people and organizations united by a sense of common purpose counter to the dominant power. The consequential issues of our times—climate change, systemic racism, inequality of wealth, gun violence, reproductive rights, among others—are all contests for the common good. Progress requires an activated citizenry working in solidarity to challenge profits, power, and privilege that harm collective well-being. High quality primary care for all is not simply a parochial interest for family medicine. In the US context, it is a radical proposition that calls for family physicians to find common cause with others who share this goal.

Comment:

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

Kevin Grumbach (a colleague at UCSF) is a long-time leader in the single payer movement and in family medicine. He is thoroughly frustrated by the failure of typical policy tools – laws and high-profile reports – to mitigate the declining role of primary care in US health care. Our population suffers as a result.

Addressing family medicine doctors, Kevin proposes a broad-based social movement to reclaim primary care. His call to action is stirring. Kevin is realistic about the challenges facing social change, given powerful entrenched opponents. Yet he sees a movement as the only chance to revive primary care, given the futility of traditional policy levers.

Should the single payer movement endorse “primary care for all”, leaving specialist and hospital care for the time being in the hands of existing insurers and providers? Kevin proposes that a “successful PC4All program might prompt the nation to consider not only primary care, but all health care, to be a common good, and to join other countries with advanced capitalist economies in implementing a comprehensive, tax-financed universal health care program.”

Is “primary care for all” a stepping-stone for “health care for all”?

Maybe the more circumscribed revolution has a greater chance of success, demonstrating the value of a public approach to health care financing, and building the large and strong coalition needed for comprehensive health system transformation.

Lots to contemplate here.

http://healthjusticemonitor.org…

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