PNHP

U.S. Health Care — Down the Rabbit Hole

U.S. Health Care — Down the Rabbit Hole

By Michael Flynn, M.D.
Louisville Medicine, Vol. 69, No. 6, pg. 35-36, November 2021

All of the other first world/industrial countries have health care systems whose function is to provide health care to all the citizens of each country. The purpose is simple in that the goal is to provide universal health care managed by the government. The method varies from government provided health insurance to a totally government-run health care system as in the United Kingdom. Funding also varies involving an assortment of taxation methods ranging from general taxation to multiple source funding, such as combinations of taxation (central and local), employer, employee and out-of-pocket sources. Some countries allow private health insurance, regulate fees, supervise and regulate drug costs. Health insurance is mandatory/compulsory in most and some countries do not allow for-profit health insurance.

The Scandinavian countries, the European Union, the United Kingdom, Canada, Australia, New Zealand, Japan, South Korea, Taiwan and some South American countries all have different forms of universal health care, functioning market economies and have not been bankrupted by providing this benefit to their citizens.

In the US, we have a health care industry, which functions in a magical arena, the competitive medical market place. While all those other first world countries consider health care an essential public service, in the US health care is a commodity to be exploited by an assortment of profit-seeking entities.

Most other first world countries have health care systems managed by the central government. In the US, we have a patchwork or more correctly a crazy quilt of different entities, some focused on providing health care and others focused on extracting profit from the health care industry. Medicare is government health insurance for older citizens and some with disabilities. Medicaid provides government health insurance as a federal/state collaboration for the poor and individuals with certain disabilities. Medicaid covers different things in different states. The US Public Health Service is trained to respond to national health crises and emergencies. The Army, Navy and Air Force all have health care systems within the Department of Defense providing health care to active-duty military and their families, retired military and dependents and politicians. Senators McCain and McConnell and Presidents Reagan and Trump were all treated at military facilities without cost. The VA health system, while not without challenges, generally does a good job caring for veterans.

And then we have the uniquely American approach to health care, over 1,000 for-profit health insurance companies whose primary goal is profit, not providing health care. Actually using the revenue from premiums charged to customers anticipating health insurance is considered a “Medical Loss Ratio”.1 The Medicare administrative costs are in the 2-3% range, for-profit health insurance companies are allowed to keep 20% as administrative cost as per the ACA and often find ways to keep higher amounts in certain plans.2 Each health insurance company may have 10-30 different plans with a range of premiums and coverage. The end result is an insanely complex and confusing health care environment inflicted on the American public.

How did we get into this mess? From the mid-1970s to the mid-2010s, the number of administrators/managers has increased by an astonishing amount: over 3,000%. There are now 10 managers/administrators for each physician.3 These people do not work in ICUs or ERs, they do not do COVID-19 tests or vaccinate. They may help, but they also interfere and are paid salaries that are often multiple times higher than the nurses, respiratory therapists and physicians who provide medical care.

The pharmaceutical industry functions without restraint, a very different situation compared to most other first world countries. Medicare is prevented by law from negotiating with the pharmaceutical companies, an astonishingly stupid economic policy.4 The for-profit health insurance companies extract hundreds of billions of dollars annually out of our health care as profit, outrageous administrative costs, advertising, political contributions and investor dividends.5 Over 60% of bankruptcies filed in the US are the result of citizens unable to pay medical bills, a situation that simply does not exist in most other first world countries.6

As disturbing as the current situation is, it is already getting worse. Private equity firms are purchasing nursing homes, hospitals, health systems, physician practices, outpatient surgery centers, laboratories, imaging facilities and whatever else they can get their hands on.7

The Wolves of Wall Street are about to devour US health care. The process involves buying the non-professional component of a practice, “improving efficiency” with the expectation of a return on investment of 15-30% annually and selling for a profit in three to five years.8 This is not meant to be a long, happy marriage. The investor invasion into health care creates the fundamental conflict of interest. “You can’t serve two masters. You can’t serve patients and investors.”7 About 70% of US nursing homes are investor owned.9 The resulting “improved efficiency” involves reduced staffing, increased use of medications and decreased quality of care.

The horror stories of patients left on toilets for hours, or lying in bed with unchanged loaded diapers abound. In one nursing home in Florida, a patient died from a feces-contaminated decubitus ulcer.10 When the family was understandably unhappy and hired a lawyer to determine accountability, they encountered a nightmare corporate structure. One company owned the building, another company obtained the license to run a nursing home, another company provided professional staff and another the custodial staff. The owners and managers had spread control among 15 companies and five layers of firms.

A large dermatology practice in California purchased by a private equity company produced a disturbing lesson in corporate governance.7 The practice’s “nonclinical” assets were bought by the private equity company, leaving the physicians in control of all medical decisions after agreeing to pay a management fee to handle administrative tasks such as billing and marketing. The new management team established daily and monthly financial goals, rewarding the offices meeting the goals with cash rewards. The performance of revenue enhancing procedures, Botox, laser treatments and Mohs surgery, for instance, was encouraged. Private equity groups buy existing labs and hire pathologists. The doctors are encouraged to send biopsy specimens to company owned labs and pathologists. Corporate approval was necessary to get office supplies, even toilet paper. Without consulting the medical staff, a manager changed to a cheaper brand of sutures and needles. The quality was so poor that needles would break off during injection and physicians had to dig them out of the skin and repeat the injection.

These are just a few examples of the litany of conflicts of interest between the goal of providing good patient care and the goal of feeding the investors’ profit demands. Sadly, we are left with the unanswered fundamental question of whether health care in the US is a commodity, to be exploited by for-profit companies and private equity investors, or is it an essential public service and a government responsibility. The rest of the first world knows the right answer.

Dr. Michael B. Flynn is a retired surgical oncologist.

https://viewer.joomag.com…

References

  1. https://www.healthinsurance.org…
  2. https://healthcare.gov…
  3. New York Times, Business Section, June 9, 2019
  4. https://cnn.com…
  5. New York Times, Sunday Review, November 17, 2019
  6. Am J Med, 2009, 122:741-6
  7. https://www.bloomberg.com…
  8. https://pe-insights.com…
  9. New York Times, September 6, 2020
  10. https://www.nytimes.com…

Physician Burnout: Fix the Doctor or Fix the System?

By Nancy C. Greep, M.D.; Steffie Woolhandler, M.D., M.P.H.; and David Himmelstein, M.D.
The American Journal of Medicine, Commentary, November 1, 2021

Burnout—emotional exhaustion and depersonalization (ie, treating patients like objects)—affects almost half of American physicians, even before the coronavirus disease 2019 (COVID-19) pandemic.1 Burnout diminishes the quality of physician’s lives2 and undermines patient care by leading to more medical errors and physicians leaving practice.3

Physicians report that administrative burdens (eg, filling out forms, dealing with multiple formularies, prior authorization and network restrictions, and documenting quality metrics) are important contributors to burnout. Other factors include cumbersome electronic health records (EHRs), productivity pressures, long work hours, poor work-life balance, and loss of autonomy.4

Two types of remedies for burnout have been suggested: personal interventions to decrease stress and improving the work environment. The former category includes everything from resilience training, mindfulness, yoga, battle buddies and psychotherapy to doctors’ dining rooms. However, these approaches, many of which put the onus of fixing burnout on already overburdened and time-pressured physicians, have mostly had little or no enduring effect.4

Suggestions for improving the work environment have included improving patient flow, using scribes, enlarging workspaces, having a social worker readily available, flexible scheduling, more vacations, and an executive wellness officer.5 Although many such changes have merit, they generally require protected time for the physician, additional personnel or space, and expense. Moreover, they would not address the underlying cause of burnout.

As with most maladies, finding a cure requires understanding the cause. In the case of burnout, the main cause is not nonresilient physicians or suboptimal work environments. Rather it is our failed health care system, a system characterized by impaired access to care, high and uncontrolled costs, and suboptimal quality care for many. These shortcomings stem from a dysfunctional insurance system and the invasion of the profit motive into what should be a public service.

The insurance system’s dysfunction is attributable to the multiplicity of health insurers, their pursuit of profit, and the tethering of private insurance to employment. A multipayer system leads to billing nightmares. The profit motive means insurers seek to decrease costs by restricting care through prior authorizations and narrow networks. Because private insurance is tied to employment, patients lose their coverage, and often their doctors, when they lose their jobs, or their employer switches insurers. As a result, physicians are deprived of the gratification derived from long-term relationships with their patients.

For-profit enterprises have procured many hospitals, physician practices, dialysis units, nursing homes, home health agencies, and other health care entities.6 They prioritize their bottom line, a priority that often conflicts with physicians’ obligation to prioritize optimal care.7 The drive for profit, which has infected even many nonprofit health care organizations, has reduced physicians’ clinical autonomy and changed their role from leaders to expendable, albeit it, highly paid workers.8

To address burnout, we advocate moving to a single-payer, nonprofit insurance system, eliminating patients’ out-of-pocket costs, and removing the profit motive from patient care. We are not alone: A single-payer system has been endorsed by the American College of Physicians and the Society of General Internal Medicine. How might such reform mitigate physician burnout?

Access: Because everyone would be equally and well insured, there would be no need to check whether a patient had insurance, a drug was on their insurer’s formulary, or a specialist to whom one wants to refer a patient was in the patient’s network. No time would be wasted searching for charity care or workarounds for uninsured or underinsured patients. Prior authorization requirements would be largely eliminated, as they have in many nations. Billing would be streamlined, and billing personnel redeployed to facilitate better care. Coding would be simplified and documentation for quality metrics decreased. EHRs could be redesigned for patient care rather than billing, and current commercially driven impediments to interoperability reduced. With administrative tasks decreased, and EHRs made more user friendly, physicians could spend more time facing patients and less time interacting with a computer—both during and after visits.

Cost: Physicians’ offices would not have to collect copays or determine if a patient had met their annual deductible. Physicians could prescribe medications, imaging studies, and ancillary tests without worrying whether a patient could afford them.

Quality: Freeing clinicians from administrative and EHR burdens would allow them to devote more time to their patients and to thinking and learning. Eliminating insurance-mandated changes in providers would facilitate long-term doctor-patient relationships, a better understanding of patients’ priorities and concerns, and the avoidance of redundant workups that often result from breaks in continuity. Patients would no longer have to skip medications because of cost. The pressure to meet productivity targets would be reduced, decreasing one source of errors. Care would be directed by clinicians and not by bureaucrats and businessmen.

Converting to a nonprofit single-payer system will not be easy. For-profit medical enterprises will need to convert to nonprofit status and our multipayer system of insurance replaced by a single insurer, the federal government. Although a majority of the public and of physicians already support such reform,9 congresspeople, many of whom receive large donations from the corporate medical industrial complex, will need to vote for it.

It is unrealistic to expect that burnout would completely disappear with single payer reform. Care of sick patients will remain emotionally and physically taxing in any health care system. Stress from maintenance of certification would continue. Although a single-payer system would help alleviate health disparities, caring for disadvantaged patients who face challenges the physician cannot fix, like homelessness, would continue to cause provider distress.

We recognize that our view is somewhat speculative as little hard data is available on the effects of single payer on burnout. However, a recent Canadian Medical Association survey offers optimism. More than 80% of Canadian physicians said that their emotional and psychologic well-being was high, and only 30% met criteria for burnout.10 To verify whether the level of burnout is lower in a nonprofit single-payer system such as Canada, a study using the same questionnaire in both countries at the same time would be informative.

https://www.amjmed.com…

References

  1. Shanafelt T, Hasan O, Dyrbye L. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
    Mayo Clin Proc. 2015; 90: 1600-1613. https://doi.org/10.1016/j.mayocp.2015.08.023
  2. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013; 88: 1358-1367. https://doi.org/10.1016/j.mayocp.2013.07.016
  3. Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018; 93: 1571-1580. https://doi.org/10.1016/j.mayocp.2018.05.014
  4. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018; 283: 516-529. https://doi.org/10.1111/joim.12752
  5. Gergen Barnett KA. In Pursuit of the Fourth Aim in Health Care. Med Clin North Am. 2017; 101: 1031-1040. https://doi.org/10.1016/j.mcna.2017.04.014
  6. Physicians for a National Health Program. The case against privatization. Available at: https://pnhp.org/2018/12/03/the-case-against-privatization-of-u-s-health-care/. Accessed September 13, 2021.
  7. Relman AS. The problem of commercialism in medicine. Camb Q Healthc Ethics. 2007; 16: 375. https://doi.org/10.1017/S0963180107070466
  8. Relman AS. The new medical-industrial complex. N Engl J Med. 1980; 303: 963-970. https://doi.org/10.1056/nejm198010233031703
  9. Pew Research Center. More Americans now favor single payer health coverage than in 2019. Available at: https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/. Accessed September 20, 2021.
  10. Canadian Medical Association. National Physician Health Survey 2018. Available at: https://www.cma.ca/physician-wellness-hub/resources/measurements-outcomes/2018-national-physician-health-survey/. Accessed June 17, 2021.

A successful Medicare should never be privatized

By Elizabeth R. Rosenthal, M.D.
The Riverdale Press, Bronx, N.Y., October 31, 2021

As a physician for 54 years, my career is just about the same age as Medicare.

When I was in practice, I appreciated that it always paid me promptly, in contrast to corporate insurance companies, which tried very hard not to pay me what was promised. Now retired, I worry about the ongoing attempts to further privatize this popular and effective public program.

We all know privatizing Social Security would harm us. Privatizing Medicare is worse — and insidious. As a volunteer Medicare advisor, I’ve seen patients lured into Medicare Advantage plans and then feel betrayed when illness strikes: What they need isn’t covered.

Original public Medicare treats health care as a social need, not as a profit-making commodity. We trust Medicare because it provides affordable, comprehensive health care equitably. Decades of research shows that Medicare improves the health of senior citizens. Medicare actually increases our life expectancy — dramatically. Hence its popularity.

But now accelerated privatization threatens Medicare. We must urgently oppose this. Privatizing began in 1997 and has been called Medicare Advantage since 2003, interposing profit-seeking middlemen — corporate health insurance companies — between physician and patient. It harms our health care and increases its costs — paid by taxpayers.

Medicare Advantage plans shift incentives away from the delivery of health care to profit-taking. For a health insurance company, the more health care it delivers, the smaller its profit. This perverse incentive leads to denials and delays of care — the reasons for prior authorizations. Never mind that in more than 75 percent of appeals against denials, patients win: Most patients are too sick and stressed to appeal, letting insurers win.

Presently, 40 percent of Medicare recipients are in Medicare Advantage plans, the most profitable of all for-profit plans. For-profit insurers want even more of this golden goose.

The corporate middlemen — the insurer — pockets 15 to 20 cents of every dollar paid by the government for Medicare Advantage recipients, contrasted to original Medicare’s 3 cents per dollar. Paying for bloated administrative costs — the wages of those who deny care — tens of millions annually for each chief executive, hundreds of millions in advertising, and out-sized profits for shareholders, all means less money for patient care — 80 to 85 cents, not Medicare’s 97 cents.

Unfortunately, because Medicare was designed with coverage gaps to protect corporate insurance, it can be expensive for seniors. It requires a monthly premium, out-of-pocket costs, and 20 percent of the doctor bill as well as deductibles for hospital stays. To be fully covered, seniors must purchase costly — too often, unaffordable — private insurance: a supplemental, or “Medigap,” plan, and a private plan for prescription drugs.

These gaps allow Medicare Advantage to lure patients with added benefits such as gym memberships and limited coverage for eye care, dental, hearing and prescription drugs. They require the same monthly Part B premium as original Medicare, but tout having no other upfront costs.

The fine print is hidden: Small physician networks, particularly specialists — many do not take these plans as they pay less and require more trouble to actually receive payment. If one becomes seriously ill, out-of-network specialists and hospitalization can make Medicare Advantage plans ruinous.

I like to call them “Medicare Disadvantage.”

Even worse is a new privatizing gimmick called “direct contracting entities,” or DCEs. Patients who chose original Medicare can be assigned to a Medicare Advantage plan without recourse. Some of these entities are Wall Street firms, entirely focused on profits. Green-lighting today’s pilot program will put all Medicare recipients at risk.

There is a better path forward. An expanded and improved Medicare for All would fix these problems. A federal bill, H.R. 1976, would bring everyone affordable, comprehensive medical care without the corrupting effects of profit-making entities. It would save patients, taxpayers and our government hundreds of billions per year. During the coronavirus pandemic, the vaccine rollout — an example of federal health care — was popular.

We New Yorkers don’t have to wait for Congress to enact a federal bill. We have a state bill: the New York Health Act. It would bring affordable, comprehensive health care for all residents of New York with progressive taxation replacing premiums and out-of-pocket costs. Only the wealthiest would spend more on health care than they do now.

It has a majority of co-sponsors in each chamber in Albany.

Let us all make sure our elected representatives know we oppose privatizing Medicare, and that we want Medicare for All. Call your state and federal representatives.

It’s only health justice if we protect everyone.

https://riverdalepress.com…

Let the Games End!

Summary: Two unrelated news stories highlight ways that powerful actors in our healthcare system manipulate complex reimbursement rules and procedures, approaching and crossing legal boundaries. Detecting and stopping abuse in our complex profit-focused system is impossible. We need to end this gaming, with a simple fair payment system.

5 things about DOJ’s upcoding allegations against Kaiser, Modern Healthcare, October 26, 2021, by Alex Kacik

Kaiser Permanente allegedly coerced employees to upcode claims for Medicare Advantage beneficiaries, resulting in an estimated 75% error rate, according to a new complaint from the U.S. Justice Department.

The federal government intervened in six related lawsuits in July and filed a complaint Monday, outlining how Kaiser physicians allegedly changed medical records often months after care was provided to boost the Oakland, California-based integrated health system’s Medicare Advantage reimbursement. More than half of Kaiser physicians said they were forced to add diagnoses they did not consider, evaluate or treat, according to one of the whistleblowers and former Kaiser medical coder, Randi Osinek. 


5. Some of the diagnoses that Kaiser allegedly added via the chart reviews did not even exist; many allegedly did not require or affect patient care or treatment. These chart reviews were often added months or even a year or more after the visit so that Kaiser could get risk adjusted payments for the newly added diagnoses, according to the complaint.

Wall Street Is Pressing ER Docs To Fleece Patients, Daily Poster, October 27, 2021, by Maureen Tkacik

Robert McNamara, a Temple University medical school professor who has been working for decades to galvanize ER doctors in opposition to the “corporate practice of medicine,” had proposed a resolution that would essentially force all ER staffing companies seeking to do business with ACEP [American College of Emergency Physicians] to periodically furnish their physicians with data on the services and procedures the company had billed for under their license numbers.


 Unsurprisingly, the ACEP Board expressed extreme reluctance to adopting the proposal, noting that four separate attorneys it had consulted believed there was “substantial risk” 


“ACEP engaged outside counsel to advise on whether securing regular reporting of billing in a physician’s name could inadvertently subject that physician to potential liability under the False Claims Act [emphasis added], since provision of this information could now leave them considered to be ‘knowing,’” they wrote.

In other words: emergency room doctors are better off not knowing what their private equity overlords are billing under their license numbers, because they are less likely to go to jail for Medicare fraud if they didn’t actually know they were committing it.

Comment:

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

Our health system’s arcane payment rules + big-profit corporate mentality = the perfect medium for intensive gaming, both legal and illegal. These two stories illustrate different manifestations of the problem — albeit just the tip of the iceberg quantitatively, a faint hint of the true scale of abuse.

Kaiser Permanente is considered by many an admirable actor in the HMO world, with a history of innovative care models. Yet, in this article in Modern Healthcare, we learn that the US Department of Justice is taking KP to court for orchestrated efforts to increase physician disease severity coding – even to add false diagnoses – to bump Medicare Advantage revenues by tens of millions of dollars. HJM has covered “risk adjustment” exploitation before. The money at stake with exaggerated coding is astronomical, eliciting the worst behaviors among corporate actors in health.

Organizations like ACEP were founded to represent the interests of doctors, which should include fair and transparent billing. But the Daily Poster describes that ACEP has increasingly focused on preserving ER profit, including for private equity investments. It abets a corporate model that hides potentially fraudulent billing. HJM recently addressed the hazards of private equity. The new article describes deep ties that two former heads of ACEP have to PE. One even dismissed the problem of surprise billing – rampant in ERs staffed by private equity-funded companies which seek to profit from out-of-network charges. The doctors are coerced into being complicit, with plausible deniability.

How can we end this gaming, abuse, and extraction of resources from the health system? Single payer would use simple, fair rules. For example: annual global budgets for hospitals and their ERs. Ambulatory care doctors would typically be paid fee-for-service, with no need for exploitable risk adjustment data. If capitation is permitted (a discussion), it would rely on a standard clinically-focused electronic health record containing legitimate, consistent diagnostic information.

Let the billing games end!

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.

Medicaid Coverage Reduces Pre-Pregnancy Depression

Summary: This study compared perinatal mental health outcomes for low-income women in states that expanded Medicaid with states that did not. They found a substantial drop in pre-pregnancy depression, which they attribute to better diagnosis and treatment and/or reduced financial worry. Health coverage reduces morbidity.

Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health, Health Affairs, October 2021, by CE Margerison et al.

Abstract: Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their family. A possibly contributing factor to poor perinatal mental health is discontinuity in health insurance coverage, which is particularly important among low-income people. We examined impacts of Medicaid expansion on prepregnancy depression screening and self-reported depression and postpartum depressive symptoms and well-being among low-income people giving birth. Medicaid expansion was associated with a 16 percent decline in self-reported prepregnancy depression but was not associated with postpartum depressive symptoms or well-being. Associations between Medicaid expansion and prepregnancy mental health measures increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.

From Methods: We used a difference-in-differences study design, which estimates the change in outcomes post–Medicaid expansion compared with preexpansion among pregnant people in expansion states compared with those in nonexpansion states. 
 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) phases 7 (2012–15) and 8 (2016–18).

From Discussion: Potential mechanisms by which health insurance may improve mental health include increased diagnosis and treatment (whether pharmaceutical or behavioral) or reduced financial distress.

Comment:

By Isabel Ostrer, M.D.

Poor perinatal mental health affects between 13 and 25 percent of people who have recently given birth. The number is even high among those with lower incomes. Unfortunately, it is precisely this group that is at greatest risk of lacking health insurance coverage because of our convoluted, multi-payer health care system.

Although all low-income (defined as those earning < 133% of the federal poverty line) pregnant Americans are required to have access to health insurance, this same benefit doesn’t apply pre-conception in states that did not expand Medicaid. In fact, in the remaining 12 Medicaid non-expansion states, nonnpregnant, nondisabled adults without dependents must earn exactly $0 to qualify for Medicaid coverage. In many cases, the insurance that applies during pregnancy expires 60 days postpartum.

This study found, unsurprisingly, that Medicaid expansion was associated with a 22% increase in prepregnancy Medicaid insurance. But moreover, it found a significant decrease – 16% – in self-reported prepregnancy depression.

Health insurance coverage leads to improved mental health. This is particularly important for new parents. But all Americans deserve health insurance and the positive physical and mental health benefits that come with it. Single payer is the most straightforward way to achieve universal coverage.

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.

VA Privatization Worsens Care

Summary: A new study finds that knee replacement done at Veterans Affairs hospitals has better clinical outcomes than surgery farmed out by the VA to private providers in the community. The VA – socialized medicine – works well.

Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA, Health Affairs, Aug. 1, 2021, by AH Harris et al.

From the abstract: The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community…We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased.

From the article: Since the passage of the Choice Act [in 2014] the VA has evolved from a health care delivery system – with 90% of its budget allocated to providing care – into a deliverer and purchaser of care in the community…the VA has devoted 22% of its fiscal year 2021 health care funds to purchasing community care. This percentage may increase even further with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (also known as the MISSION Act).

Comment and graph:

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

Private hospitals and medical groups itching to get their hands on VA funds have used complaints about VA wait times to push Congress to ship VA dollars to private sector care, despite the fact that wait times are generally shorter at the VA’s own facilities.

Previous studies have found that VA care is generally better than care in the civilian sector. (see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215146/, https://www.hsrd.research.va.gov/publications/esp/quality.pdf, and https://www.rand.org/pubs/external_publications/EP67588.html). As shown in the chart below, this new study indicates that the outsourcing of knee replacement substantially increases patients’ complications.

The right way to address VA waits is to assure adequate funding, not to divert funds from superior VA facilities to inferior nearby community hospitals.

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.

How Private Equity Harms Health Care, Especially in Physician Practices

Summary: A far-reaching new review of private equity investment in physician practices makes clear that PE tactics – aggressive and sometimes illegal – extract money from the health care system, often without delivering quality in return. Concerns exist regardless of payment model.

Private Equity Investment As A Divining Rod For Market Failure: Policy Responses To Harmful Physician Practice Acquisitions, USC-Brookings Schaffer Initiative for Health Policy Report, October 2021, by Erin Fuse Brown et al

Private Equity and Health Care Delivery: Value-Based Payment as a Guardrail?, JAMA, August 11, 2021, by Brian W. Powers et al

How Private Equity is Ruining American Health Care, Bloomberg, May 20, 2020, by Heather Perlberg

Comment:

By Allison K. Hoffman, J.D. and Hannah Leibson

For the past few years, private equity investment in health care has been surging. To put numbers on this explosive growth, from 2000 to 2018, the valuation of private equity deals in the health care sector rose from $5 billion to over $100 billion.

This sharp rise has raised alarm bells among health policy researchers and policy makers concerned about the negative impact this investment may have on health care spending (especially for public programs like Medicare), quality outcomes, and patient care.

A recent JAMA article by Powers and co-authors seeks to quell blanket concerns with private equity investment, arguing that “context matters” and suggesting that value-based payment models might counterbalance the profit-seeking nature of outside investors. This piece draws attention to two health care delivery organizations, CareMore Health and Oak Street Health, operating under value-based payment systems. Both systems saw positive patient outcomes after private equity investments were secured.

The authors contrast these examples to fee-for-service payment systems, where they argue the impact of private equity investments is “likely to be unfavorable” because this investment only “amplifies” the negative incentives created when financial performance is not tied to quality of care.

Drawing from these two case studies and based, they say, on the lack of evidence otherwise, the authors argue that “private equity could have an important role in acceleration of value-based transformation in the health care system, as well as access to new models of care delivery.” The article’s optimism, based on these two case studies, is borne of simplistic thinking of what payment systems can actually produce—or, in this case, resist.

A thorough report on private equity and health care delivery issued this month by Erin Fuse Brown and others through the USC-Brookings Schaffer Initiative for Health Policy makes abundantly clear why. The report is cautious in its tone yet chronicles the many ways in which private equity investment produces or capitalizes on unattractive aspects of the payment and delivery systems, from surprise billing, to upcoding in the Medicare Advantage program, to outright fraud. The report describes that value-based models, in particular, can create incentives “to stint on care.”

Likewise, a Bloomberg article by Heather Perlberg notes that to get the quick results private equity investment demands cost-cutting becomes a major focus, telling stories of physicians struggling to obtain the bare minimum materials necessary to safely carry out their practice. In the worst case scenarios, private equity investors unsophisticated in the nuances of the businesses they enter can sink the very ships they try to buoy.

Unless outcome parameters in value-based models are precise and comprehensive—and maybe even then—sophisticated private equity players will find sweet spots where they can cut corners, while still checking all the value-based boxes. Years of evidence from these models that purport to drive value, from Medicare Advantage to ACOs to direct contracting, have largely not saved money or improved care as promised. But they have made it abundantly clear that developing good quality metrics is hard, and metrics can be gamed.

The USC-Brookings report recounts a historical example that provides just the kind of evidence from private equity investing that the JAMA article suggests does not exist. They recount the physician practice management companies, where investors, including private equity, bought up physician practices in the 1990s to take advantage of the rise of managed care. Attempting to generate economies of scale through rapid growth, they proved to be little more than a shell game of short-term revenue growth to increase the value of equity shares—value that deflated as quickly as it grew.

Even if there were zero empirical evidence, there is a fundamental structural problem with outside profit seeking investors in healthcare that should produce skepticism. The authors of the JAMA article note this problem in their intro and then too quickly set it aside. Private equity’s whole game is invest, profit, exit—typically in less than five years. And the profit potential must be quite rich to entice them to invest in the first place. Unless private equity radically transforms the quality of care, which seems unlikely, these companies become just another party looking to extract money from the health care system, including from public programs like Medicare, driving up costs without producing concomitant value.

The rising influence of private equity investments, especially in primary care, leave the American health care system increasingly beholden to parties who are ultimately not concerned with boosting patient care. One must have great, unwarranted, and blind faith in incentives to think that they can sufficiently counterbalance the motive to extract all possible profit before jumping ship.

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.

Heart Attack Care Better in Canada than the US

Summary: This study compared quality of care (eg, best clinical practices like prescribing the right medicines) for young adults (≀55) with an acute myocardial infarction. A low quality of care score was nearly 3 times more likely in the US than in Canada. So Canada, with inexpensive single payer, provides better care.

Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada, JAMA Netw Open, October 20, 2021, by V. Raparelli et al.

From Abstract:

Design, Setting, and Participants: This retrospective cohort analysis used data from 4048 young adults (aged ≀55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Analyses were adjusted for biological sex and social determinants of health.

Results: 
 [B]eing treated in the US was associated with a low Quality of Care Score both in-hospital (OR = 2.93) and post-AMI (OR = 2.67).

Comment:

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

Today’s reflection is concise: Canada’s single payer system delivers higher quality of care, while saving money, compared with the U.S. Better care processes help explain this astounding graph from OECD countries, which shows the US diverging on costs and longevity from other wealthy countries.

Costs less, works better. “Dominant”, in cost-effectiveness jargon. “Tastes great, less filling”, to quote the famous 1973 beer commercial. How many ways do we need to say it and show it?

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.

Free Medications Increase Use and Lower Healthcare Costs

Summary: This important Canadian study found that making essential medicines free – removing financial barriers – raises adherence, lowers medical costs, and generally raises patient perceptions of well-being, including overall health.

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial, PLOS Medicine, May 21, 2021, by N Persaud et al

From author summary:

What did the researchers do and find?

  • We conducted a randomized controlled trial of free essential medicines distribution in 786 people who reported trouble affording medicines in a setting where healthcare services are publicly funded.
  • Free medicine distribution improved adherence to medicines appropriately prescribed after 2 years (absolute risk difference, 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004).
  • Free distribution had inconsistent effects on surrogate health outcomes over 2 years and lowered total healthcare costs by a median of CAN$1,117 (95% CI CAN$445 to CAN$1,778, p = 0.006).

What do these findings mean?

  • Distributing a comprehensive set of essential medicines at no charge to primary care patients improved medicine adherence and reduced healthcare costs.

Comment:

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

Medicines work only if you take them.  As every doctor knows, many patients don’t take what we prescribe.  High costs are only one reason – a lesson sadly reinforced by experience with COVID-19 vaccinations – but they’re a big one.

Canada’s single payer health insurance system pays all doctor and hospital costs, but many Canadians lack coverage for prescription medications – a shortcoming that progressive activists and politicians have been pushing to fix.

This trial carried out in Ontario shows that full coverage for prescription medications would substantially increase the proportion of patients who take what we prescribe – increase “adherence” in doctor-speak.  Surprisingly, total health care costs were lower among patients in the free medication group – by 38%. As the authors note: “Healthcare spending in all categories except home care costs were lower in the free distribution group, and hospitalizations accounted for the largest share of spending.”

Moreover, for 10 of the 14 survey-based measures of patient-oriented outcomes the free med group did better, with 2 showing a non-significant trend to improvement with free meds and 2 showing no trend. “The 3 largest effects . . . were in the ability to ‘make ends meet’ or afford basic necessities (57.8% absolute increase; 95% CI 50.5% to 65.1%), care quality (31.5% absolute increase; 95% CI 23.7% to 39.2%), and overall health (30.9% absolute increase; 95% CI 22.8% to 39.0%).”

Canada needs to move ahead with universal drug coverage, which is known as Pharmacare in that nation.  In the U.S. we need Pharmacare, and the rest of the coverage that Canadians already enjoy.

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.

Public Health Capacity Needs a Major Boost

Summary: To achieve a healthy nation, we need not only single payer healthcare, but also robust public health practice. During COVID, an already underfunded and understaffed public health system suffered a buffeting while – and because – it was trying to do its job of mitigating the pandemic. It’s time to rebuild public health capacity.

Threats, Resignations and 100 New Laws: Why Public Health Is in Crisis, The New York Times, October 18, 2021, by Mike Baker and Danielle Ivory

State and local public health departments across the country have endured not only the public’s fury, but widespread staff defections, burnout, firings, unpredictable funding and a significant erosion in their authority to impose the health orders that were critical to America’s early response to the pandemic.

While the coronavirus has killed more than 700,000 in the United States in nearly two years, a more invisible casualty has been the nation’s public health system. Already underfunded and neglected even before the pandemic, public health has been further undermined in ways that could resound for decades to come. A New York Times review of hundreds of health departments in all 50 states indicates that local public health across the country is less equipped to confront a pandemic now than it was at the beginning of 2020.

“We have learned all the wrong lessons from the pandemic,” said Adriane Casalotti, chief of public and government affairs for the National Association of County and City Health Officials, an organization representing the nearly 3,000 local health departments across the nation. “We are attacking and removing authority from the people who are trying to protect us.”

Comment:

By Don McCanne, M.D.

A side bar indicated that Colin Powell died of Covid-19, in spite of having been vaccinated. Did those whose actions are promoting the dissemination of the Covid virus really want this to happen?

I am literally shedding tears for our nation.

We just want excellent health care and public health practice for everyone. Is that really too much to ask?

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.

Wall Street’s Latest Attack on Traditional Medicare

By Brenda Gazzar
Code Wack Podcast, October 18, 2021

Part 2 of a two-part podcast featuring Dr. Ed Weisbart, national board member and Missouri chapter chair of Physicians for a National Health Program, discussing the latest threat to traditional Medicare called “Direct Contracting Entities.” What are they? How do they make money? Why is this a problem? And what can we do about it?

Transcript

Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host Brenda Gazzar.

So what in the world are direct contracting entities and how might they affect the health care of American seniors? Will this pilot program ultimately help or hinder quality care? Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program, weighs in on this troubling development.

Welcome to Code WACK!, Dr. Weisbart.

Q: There’s a so-called innovation to traditional Medicare being introduced, a pilot program called direct contracting entities or DCEs. That sure doesn’t sound anything like health care. Can you tell us what a direct contracting entity is and why we should care about this?

Weisbart: As a recent article in Health Affairs blog said, this is Orwellian in the way it’s titled, so if you find that this new phrase ‘direct contracting entity’ is confusing to you, it’s the craziest way to call it, cause if you remember from the previous episode, traditional Medicare is very direct, right? Medicare has a direct relationship with doctors so that sounds like a direct contracting entity but that’s not at all what this means. This new name direct contracting entities is a program that was begun under the Trump administration overtly to introduce the private industry – venture capital and private equity and for profit insurance – to introduce them into the 60% of Medicare that they don’t have access to today.

So, most Medicare members have said, I don’t want the commercial industry. I don’t want a for-profit middle person intermediary. I just want Medicare. Most — 60% have said that. And so, the industry has said “well, you know, we want some of that game. We want a part of that pie” and so they persuaded the Centers for Medicare and Medicaid Innovation to start what’s still a pilot program, where much as in Medicare Advantage, or as in accountable care organizations or in a few other programs,  Medicare would no longer pay doctors and hospitals. If you are in a direct contracting entity, Medicare would no longer pay your doctor and hospital for the most part. Instead, they would pay these new for-profit, venture capital private equity or insurance company or publicly traded companies. All of your money for health care would go there, and then they would be in charge of doling out the payments to doctors and hospitals and such.

It’s a little bit more nuanced than that. There are some variations to this but, in general, direct contracting entities, in direct opposition to the way the name sounds, creates a new level of fiscal intermediaries, a new at-risk group, whose interest is in you not getting care, not in you getting care. It’s a dreadful concept, it’s a dreadful concept. It’s something that it’s still in the pilot phases right now so we can stop it before it gets crazy out of control and we need to stop this new initiative, direct contracting entities.

Q: I see. So what does it mean for someone who’s in a DCE?

Weisbart: If you’re in one, you still retain all of your traditional Medicare benefits. Direct contracting entities can’t tell you “no, you can’t go to the doctor or no, you can’t go to the hospital,” at least on paper, but we know that their game will be to nudge you, to guide you. Nobody is really responsible for making sure that you know you have all those choices. You might get a letter once telling you you have that but the direct contracting entity is not going to want to emphasize that so they’re going to be guiding you to fewer choices, fewer hospitals and getting in the way of health care.

Q: Hmmm. So it’s basically creating a middleman


Weisbart: That’s exactly right.

Q: 
that takes a cut of the money that should be going directly to the providers?

Weisbart: And venture capital, Wall Street, private equity, they know this. They’ve looked at this model and some folks call it the Medicare Gold Rush now you know having this incredible rush of money coming into new startup industries and ventures to take advantage of this new entity called direct contracting entities.

Wall Street wouldn’t be investing so incredibly heavily, so incredibly quickly as they are right now if there weren’t a way for them to make a ton of money off of this, and where does that money come from? They’re investing in it because they know that there’s still money left in the Medicare Trust Fund that they can drain. They think that they can get the premiums to go higher for Part B. I don’t know what they’re really thinking but they’re not investing this money because they’re out to improve public health so we’re all going to pay for this. We have to stop it before it’s gotten out of control.

Q: Hmmm. So Dr. Weisbart, to clarify, the DCEs then do operate with a capitation system?

Weisbart: Yes, direct contracting entities themselves are capitated for your care by the federal government. That’s the concept. The direct contracting entities receive varying degrees and varying scopes of capitation for your health care, a monthly fee or an annual fee to cover some or all of your healthcare expenses so it’s exactly what you said. The direct contracting entity gets the money in, and then every dollar that they have to pay out on health care, frankly, is a dollar away from their bottom line, from their profits, from their return on invested capital to Wall Street. Every dollar that they pay, that they have to pay out comes out of their capitation so they have a compelling business interest to maximize those capitations by gaming the system, and to minimize how much they pay out by either directly or indirectly interfering with your care. They can’t completely say “no you can’t go for that care”, they can’t do that, but they can really kind of make it seem like they can.

Q: Um, so when doctors get a set amount per patient, healthier patients cost them less to treat than unhealthy patients. Doesn’t this incentivize doctors to avoid taking on sick patients?

Weisbart: Yeah. The other side of that equation is one of the key reasons I went to medical school. I thought the idea that if you “capitate” physicians — if you pay doctors a certain amount per month to take care of people in general — that would mean that it’s to my advantage to keep you healthy. If I can keep you healthy, well then you’re going to cost less and I’ll be able to make more money. If I did something stupid to you that was you know expensive or harmful, you would then become more expensive to take care of, and I would be partially paying for that. So I thought capitation was a brilliant idea.

What I didn’t know, and what I know now, is that the way to make money under capitation is not by making people healthier. Healthcare prevention takes a decade to pay off. Really good preventive medicine takes a decade to pay off and then it’s not a business case for prevention. We should do it, but it’s not a big money maker. The way to make money under capitation is to not have sick people in your practice. That’s the way to make money so I think you’re right. Capitation rewards you for not having sick people.

And there’s ways to modify and adjust it, but it’s a game of Whack a Mole. You’re always staying a step ahead of that so there is no good way to pay doctors and so because no matter what you do, you’re going to have some kind of an issue, but the most important thing to do I think is to remove the perverse incentives. Stop having it so that we doctors can make more money by shunning the sick. You don’t want to put us in that situation and stop putting it so that we doctors can make more money by doing unnecessary expensive things. You want to get rid of those kind of perverse incentives.

Q: How then do you think that’s affecting patients?

Weisbart: Like I said I went to medical school because I believed in this model of capitation in one form or another so I used to live and practice within the largely capitated system, and I was in charge of I think there were about 10 medical offices scattered around Chicago and we had one in particular that like all the others was largely capitated and it was a terrific place. They did great care. They were top of the charts on patient satisfaction, and on mammograms and all that stuff and they were profitable. Hooray. It proves the case. Then they got one patient in with a very expensive form of hemophilia and it was going to cost a million dollars a year. Actually it did cost  a million dollars a year to treat this one person.

And so, of course, you pay that, you know, we had to figure out ways to come up with the money for it because it’s a lot of money but we did, but I was in charge of the group, right. So there was a business imperative on me to make him not like us. We didn’t do any of these things but I was thinking about you know let’s not answer the phone if we know it’s him. Let’s put him on hold.  You know if he comes in for his visit, let’s make him wait an hour or two. We didn’t ever do that but let’s lose his chart a little bit. Let’s not call him with those test results. Playing that through the intent would be that after six months or so he would say you know that used to be a great office you know, but I don’t know what’s happened to them but it’s gone downhill and I’m going to find me a new doctor.

And maybe he would call and threaten us and tell us, you know, how terrible things were and that he was going to get a new doctor and I’d say, “oh, I’m so sorry.” We didn’t do any of those things but I’m still atoning for the fact that I thought all that through because that was the business pressure, was to make a sick person not want to go to our doctors.

Q: Right and what do you think is at stake then for patients?

Weisbart: For patients, as Dixon from PNHP recently said, nobody – literally nobody – is asking for the system to get more complicated. Nobody is saying, you know, if we’re just a little bit more complicated, that would fix things. Nobody is saying that but that’s what this will do, so you won’t be able to follow the money, right. Who is it going to? You won’t be able to track where your money’s going. You’re gonna have somebody in the middle of your care with direct contracting entities, who will say they’re your advocate and ally trying to help you through the system, but in reality, the business pressure on them, their motivation is not quite the same as what your physician in the exam room usually is.

So from a patient point of view, I think it’s a whole new exposure to a whole new level of complexity that’s going to drive up the cost of your care with no reason to think it’s going to improve quality. There are all sorts of analyses that say there’s no reason to think that. It’s not going to make health care better. It’s going to make it more expensive and more profitable for the foxes that are raiding the chicken coop.

Q: And how do you think the DCEs and the pilot program, if it moves forward, would affect the Medicare for All movement?

Weisbart: It really complicates it. When the movement was really first kind of growing with that name, there was a movement to not call it Medicare for All, but to call it single payer, because structurally that’s what it is — it is one payer, you know, let’s just have one payer. Get rid of all of these insurance companies and just have one payer, and let it be Medicare, have one payer — single payer. It really simplifies things.

There was a movement to have it just be called the single-payer movement and that group lost out to the group that said no nobody knows what a payer is, nobody knows what single payer is. Everybody knows and loves Medicare. Medicare is pretty simple. Let’s kind of go straight with that. So let’s make it Medicare for All. It fits on the bumper sticker better. It’s nice. Well, the world has changed a lot, and the Medicare program is under such direct attack (with) Medicare Advantage now, with all these denials and referrals and prior authorizations and networks. Most people don’t really understand when they have Medicare Advantage that they really don’t even have Medicare, so the more we let traditional Medicare get corroded by things like Medicare Advantage or direct contracting entities, the more we corrode Medicare itself, the harder it is to say, you know, let’s get Medicare for All. We’ve always said improved Medicare right it’s always been improved Medicare. I myself have often run into people who say, why would I want Medicare for all you know the problems I’ve had? And they are almost always problems with Medicare Advantage, and so we’ve had to have the discussion of that’s not Medicare, and once they understand that then they’re much more happy with “oh, yeah, let’s get rid of all of that stuff.”

So, confound that by having a third stream in here, having people with Medicare Advantage, having people in direct contracting entities, and then an even smaller group that’s holding on to that precious for dear life traditional Medicare, it makes our message so much more complicated. Now there’s two things to say “no, that’s not what we mean” about. Yeah, we can go back to the language of single payer. We can emphasize the improved Medicare for All, but it makes our job more complicated and it puts us on the defense, right,  because now we’re talking about how do we protect Medicare, but I would say that every problem is potentially an opportunity.

It’s giving us a chance to get people to really try to understand what Medicare Advantage is and isn’t. We should stop “advantaging” Advantage. We should not let DCEs enter this new space so it’s giving us an opportunity to reinform and educate people and point out the absurd complexity, and point out the Gold Rush coming in to take our money away. I think there’s a whole new suite of organizing tools that we can develop because of these outrageous new attacks so I think it’s potentially galvanizing us.

Q: Thank you, Dr. Weisbart. Was there anything we didn’t touch on or anything else you wanted to mention?

Weisbart: If somebody’s really wonky and wants to read more, there’s two great new pieces in the Oct. 1 week of the Health Affairs blog on this. I think if you just go to the Health Affairs blog and look up direct contracting entities, you’ll find two really terrific pieces from Rick Gilfillan and Don Berwick. So read those. They are dense but are really important. So join us. Go to PNHP.org, even if you are not a doctor.

Thank you Dr. Ed Weisbart.

Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

Activists Should Continue to Fight for National Single Payer Rather Than Taking Cues From the Democratic Party

We need to put our efforts together and force reluctant Democrats in Congress to pass what 80% of Democratic voters, and 60% of the entire electorate, already support: expansion of national, single payer, improved Medicare for all, not just for some.

By Claire M. Cohen, M.D.
Common Dreams, October 18, 2021

It is a mistake for activists to once again allow Democratic politicians corrupted by big money to determine the nature of the struggle for single-payer Healthcare. We must have a strong fight on the national level in order to win this. Otherwise, we are abandoning a struggle that has strong public support and giving Congress a free pass to do nothing.

The United States is not Canada. Due, in large part, to the racist culture of the United States, successful struggles for progressive policies on state levels do not automatically translate into national victories. In his article in Jacobin, Gerald Friedman’s main example, Medicaid, proves the point. The Medicaid Program, unlike Medicare, was set up so that states have great discretion and authority on how to implement their own programs. More “progressive” states in the Northeast and on the West Coast have had more coverage, fewer restrictions, and less means testing in their Medicaid programs for decades. States with more reactionary and racist governments, especially in the South, have had more means-testing and restrictions leading to less coverage. The better health outcomes of the more progressive states have not led the more reactionary states to see the error of their ways. If anything, these reactionary states have dug in their heals. In fact, as of this year, there are 12 states that are still refusing to expand Medicaid despite being offered large “carrots” by the Biden Administration. Also, my state Pennsylvania, which currently has a reactionary legislative majority, is taking its lead from those reactionary states, and going in a more regressive direction! Given the racial demographics of the states, it could well be that having some states successfully obtain single-payer would mean an increase in racial disparities nationwide.

The Southern states did not get rid of slavery or segregation because of the example of the Northern states. History shows that, if anything, they retrenched and fought steadfastly for their “peculiar” institutions. It was only when these struggles became national fights (the Civil War, the Civil Rights, and the Black Liberation struggle) that they were successful.

Furthermore, it was Medicare’s implementation as a national program that enabled it to have a powerful effect in ending segregation in medicine throughout the country. Yes, there were local struggles, but they were expected to meet the national mandates. It is a mistake to conflate local struggles for national goals with local struggles limited to local or state attainments.

Advocates for de-emphasizing the national struggle for single-payer (or even laying it down) in order to put the emphasis on achieving state single-payer programs seem to think that working for state single-payer programs will be a much easier battle. But peculiarities about the American governance system and HHS policy, in particular, are likely to make things more complicated and difficult. Secretary of Health and Human Services Becerra, with his reversals in order to be in line with Biden Administration health policy, has already shown that he can not be counted on to give favorable interpretations of section 1332 of the ACA, making it easier for states to implement their own single-payer programs. And even if Secretary Becerra decides to allow flexible interpretation of 1332, what is to stop states from being regressive (like Pennsylvania) instead of progressive?

Finally, there are two suggestions in the Friedman paper that appear confusing. In their paper, Friedman et al discuss states using Medicare Part C to establish a state single-payer system. But isn’t that in essence establishing a state Medicare Advantage? Is this what we want: the privatization of single-payer right off the gate? Also, they talk about not prohibiting employers from offering separate health insurance. Unless I’m missing something, I can see a multi-state company offering its employees United Healthcare, or CVS offering its employers Aetna, or even better yet, Walgreen offering its employees a DCE. My experience working as an employee in a big hospital chain is that it would not hurt them one bit to do this. So would that state really have a single-payer system?

The Democratic Party has been famous for watering down and derailing progressive struggles for at least fifty years. And activists have too often been complicit in their own failure by ceding to Democrats. Just because Biden lays down Medicare For All does not mean we have to or should. We need to do just like the Freedom Riders did during the Civil Rights movement, they forced the hands of the reluctant Kennedy brothers. We need to put our efforts together and force reluctant Democrats in Congress to pass what 80% of Democratic voters, and 60% of the entire electorate already support: expansion of national, single-payer, improved Medicare for all, not just for some. As Frederick Douglas said,” If there is no struggle, there is no progress. Power concedes nothing without a demand.” Let us not be so ready to concede in the face of President Biden’s obstinateness. Keep the struggle for national single-payer going until we win.

Dr. Claire M. Cohen is a black child psychiatrist in Pittsburgh who is a member of National Single Payer, PNHP and the Western PA Coalition for Single Payer Healthcare. You can contact her at cmcmd80@gmail.com.

https://www.commondreams.org…