By Brenda Gazzar
Code Wack Podcast, October 11, 2021

Part one 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 differences between traditional Medicare and Medicare Advantage plans. Plus, why should we be concerned about the impact of Medicare Advantage plans on the Medicare Trust Fund?

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Transcript

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

It seems like Medicare has been popping up in the news lately, in good ways and bad! But what’s always true is that our country struggles between treating health care as a public good and treating it as a profit-making venture. This conflict of visions is very apparent when comparing traditional Medicare to Medicare Advantage plans. 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, is joining us today to talk about the latest attack on Medicare — and what we can do about it.

Q: Welcome to Code WACK!, Dr. Weisbart. So let’s talk about traditional Medicare versus Medicare Advantage. What are the main differences between these that consumers should know about?

Weisbart: So they’re really two entirely different programs. Traditional Medicare is a public program paid for straight through our tax dollars to the Medicare program and then Medicare, traditional Medicare, has relationships with doctors and hospitals and everything so it’s just nice and is clean. Medicare pays the doctors and hospitals.

Medicare Advantage is completely different. The people who have chosen to go into Medicare Advantage,  Medicare no longer pays doctors on your behalf. Medicare no longer pays the hospitals on your behalf. Instead, Medicare pays an insurance company, a Medicare Advantage insurance company, Humana,  Blue Cross. There’s many of them but they pay the insurance company and then you have what’s very similar to employer-style insurance, and that means that they can tell you which doctors you can and can’t go to. Traditional Medicare doesn’t do that. Medicare Advantage can tell you which hospitals you can and can’t go to. Traditional Medicare doesn’t do that, only Medicare Advantage does that. So, Medicare Advantage, you have a group in between you and Medicare, whose mission is a business mission trying to find a way to make a profit off of you being sick and such. That doesn’t belong in health care.

Q: So it sounds like (it’s) very similar to having private insurance.

Weisbart: It is — except that’s nowhere near as good as traditional Medicare. So really from a consumer’s point of view there’s probably three important things to consider … between traditional Medicare and Medicare Advantage. The first is a difference in coverage, the second is a difference in access, the third would be a difference in cost as a consumer, so the coverage in theory is the same, right? Traditional Medicare and Medicare Advantage plans both cover the same benefit package of what’s medically necessary, although in traditional Medicare you have a lot more doctors and hospitals to pick from. Medicare Advantage plans do cover the same range of benefits, but they get to decide what’s medically necessary and they may make different decisions. They have a business interest in making different decisions so they could take a narrower view of what is actually necessary than traditional Medicare does. The coverage is technically the same, but in real life the coverage for Medicare Advantage is not the same as in traditional Medicare.

The second difference is access, as I was alluding to with traditional Medicare you can go to any doctor or hospital that takes it which is like 93% of adult medicine doctors and you don’t need a referral. You don’t need to ask for permission. You don’t need to get prior authorization. If you want to go to a doctor that’s in Medicare’s network, you can go to that doctor , that’s almost any doctor and hospital, whereas Medicare Advantage, you typically have to get a referral typically from your primary care physician or from the Medicare Advantage plan, or it’s, if you’ve given up your traditional Medicare, and you’ve gone into Medicare Advantage, you want something that’s probably expensive because you’re that sick, you suddenly have to start getting permission and approval. That’s not treating you like an adult. That’s taking away your choice.

But the third difference is the cost difference as a consumer. With traditional Medicare there are copays and deductibles and so people who can afford to do it typically will buy a Medigap policy to take care of the copays and deductibles and if you do that, and you’ve got pretty darn good health insurance with traditional Medicare.

With Medicare Advantage, it’s different. You can’t buy a supplemental policy to go on top of Medicare Advantage. So when Medicare Advantage Plans charge you copays and deductibles, you can’t buy Medigap to cover that. If the Medicare Advantage plan says you’re going to have to pay all the costs for your out of network care, you want to go to the doctors across town instead of this side of town. You’re on vacation in Florida or wherever, and you want to go to the doctor there, and the Medicare Advantage plan says that’s out of network and is not covered, or they’re only going to pay half or what have you, you cannot buy insurance to supplement Medicare Advantage. So, in Medicare Advantage there’s actually a limit to how much it can go. You can’t have more than $7,550 in out of pocket expenses.

That’s a lot of money. There is no limit like it in traditional Medicare because if you buy a supplement, you’ve got almost no out of pocket costs, no matter what’s going on. So the reason people often pick Medicare Advantage if they do is because the premiums are lower than a Medigap supplement, so you can look at a Medicare Advantage plan, look at the low premiums and think ‘I’m indestructible, I’m not going to get sick. I don’t have to worry about if I get sick.’ ‘Well, why are you buying insurance in the first place,’ but they think that. They see the lower premium but they don’t realize that that comes with an exposure to now nearly $8,000 in out of pocket expenses, an exposure that doesn’t exist in traditional Medicare if you buy a supplemental policy, usually a couple couple hundred bucks for the supplemental policy which is not cheap but if you buy that, then you don’t have exposure at all.

The trade off is do I pay the premium for a supplemental policy of maybe a couple 100 bucks a month or do I avoid that but risk if I get sick having thousands and thousands of dollars out of pocket? So Medicare Advantage is a way worse deal.

Q: Wow right. That’s very interesting and we are talking about, you know, the sickest population, the over 65 is among the sickest in the country. Okay, how do the programs differ from a doctor’s perspective?

Weisbart: The differences from a doctor’s perspective are pretty similar to the differences from a patient’s perspective, in the sense that traditional Medicare is really easy to deal with, right, it’s really easy to deal with. If a patient comes in to see you and they have traditional Medicare at the end of the visit, we submit our bill to Medicare, and before too long Medicare pays the bill and there’s very little second guessing. There’s very little denials, very little of any of that stuff. So traditional Medicare from a doctors point of view is great. I can do the work that I need to do.  I don’t have to worry about where to send my patient. If I have a patient that needs radiology and Xray needs surgical centers or something done, pretty much all of those places take traditional Medicare and take the supplement so I can send my patients to the place that I think is the best for them.

Medicare Advantage is a whole different thing. (With) Medicare Advantage, you know, they have a game of delaying when they pay you, arguing down how much they’ll pay, saying ‘no, that’s not medically necessary, we’re not going to pay for it. Oh, you sent your patient to that radiologist — not so fast doctor we like this radiologist,’ and you know it’s a nightmare and the doctor may not know which one it is,  so the patient goes there and then comes back and has to tell us ‘gosh, doc you sent me to the wrong place,’ well how am I supposed to know? It’s a nightmare.  With Medicare Advantage, it’s frankly a nightmare for me and traditional Medicare from a doctor’s perspective is a breeze.

Q: Wow, thank you. In terms of health policy, what are the implications of having two competing programs when it comes to healthcare equity?

Weisbart: So, whenever you set up two different systems that compete against each other and they’re not really comparable, you have a disaster on your hands. So from a health policy perspective what we’ve done is we’ve created one option that’s designed to make profit for private commercial industry, and another enterprise that’s designed to improve the health of people, and as a result the for-profit one, well they want, the Medicare Advantage plans, well they want to find the healthiest people they can. If you’re actually genuinely sick, they don’t want you. It’s called cherry picking. They’re trying to find the healthiest people. If you are actually sick they don’t want you there, that’s called lemon dropping, and then once they’ve got the healthiest group of people, they want to make that group of people look sick. They want to find the more diagnoses, the more crazy things that they can find so that they can charge the government more. They can charge Medicare more, so from a health policy perspective, what we have is the Medicare Advantage plans are literally draining the Medicare Trust Fund.

When you hear the Medicare Trust Fund is in trouble, that’s not because of Medicare, that’s because of Medicare Advantage, so they’re draining the Medicare Trust Fund and when you do that, then of course that means that the premiums that seniors have to pay or Medicare people have to pay for part B, go up. So if somebody’s trying to find more profit in the system, they either have to block your health care which is of course what Medicare Advantage plans are designed to do, or they have to drain more money out of the system by draining the Medicare Trust Fund and resulting in higher premiums. So it’s a terrible idea. It’s a terrible idea.

And we talked about health equity and one of the areas of health equity that’s not fully recognized, I don’t think, is the problem with rural communities. We know that people who are sick are more likely to want to get out of Medicare Advantage once they’ve gotten sick. People in rural communities are twice as likely as people in nonrural communities to want to get out of Medicare Advantage. You go in because like I said the premiums are lower because we’ve so overpaid in Medicare Advantage, that they can afford to throw a few pennies at us for the premiums so the premiums are lower, so you go into it when you’re sick and especially, especially if you’re in an underserved kind of community, a rural community or any other underserved community. That’s not where the Medicare Advantage plans have their networks, because they put their networks in the most profitable areas not the sickest areas.

So, from a policy perspective, it does not accomplish our goals. Traditional Medicare, good-old fashioned Medicare that we’ve had since 1965, that’s done a phenomenal job at controlling the cost of health care, at rescuing seniors from bankruptcy and from poverty, at giving seniors wide choice over their own health care, and at actually making seniors healthier, and frankly, very little of that is true for Medicare Advantage.

Thank you Dr. Ed. Weisbart. Join us next time when we talk about the latest sneak attack on traditional Medicare.

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…

By Samuel Dickman, M.D.
The Guardian, October 6, 2021

I’m a Texas abortion provider. Since the state’s new anti-abortion law – known as Senate Bill 8 – went into effect three weeks ago, my job transformed from physician to dystopian travel agent for a journey that, for most of my patients, will probably never happen.

SB8 is not just a set of roadblocks but rather a near-total ban on abortion. Politicians have rendered abortion care impossible to access for people who can’t afford to travel hundreds of miles out of state. Many of those who can’t get an abortion will be pushed deeper into poverty as a result.

I’ve written previously about the ways that the US, and Texas especially, segregates care by class and race. This abortion ban is no exception: wealthy Texans will find the means to obtain safe abortion care, as they always have. But patients I care for, who are mostly low-income and people of color, can’t afford enormous travel expenses to get medical care. They can’t afford to take multiple days off work, usually without pay. They can’t afford the additional childcare or elder care. They can’t afford the gas money, or the bus fare. They can’t afford a safe place to sleep overnight. These costs are on top of the actual fee for the procedure, often $500 or more out of pocket, a sum that for many patients takes weeks or months to save. Most of my patients now can’t afford to get an abortion – but they also can’t afford not to.

Last week, I had to tell a young woman already seven weeks pregnant that her only option for an abortion was an eight-hour drive to New Mexico. (I’ve changed patient details to protect confidentiality.) She has no car and no access to a checking account. She sobbed as she explained that her father, whom she lives with, would probably become violent if he found out she got an abortion. Less than a month ago, I could have provided a medical intervention that protected her autonomy and privacy, in a way that kept her safe from an abusive father. Imagine me now: bearing witness to her plight, powerless to help – not for lack of tools but because of legal obstruction – and having to tell her about her limited options. Now imagine being her and having to hear them.

In the last days before SB8 went into effect, I provided an abortion for a patient whose pregnancy was the result of being raped. I was able to help her end her pregnancy safely, and privately. If a patient like her came to see me today, there would be no legal option to get an abortion in Texas. And because of the enormous cost of getting care outside of Texas, they would very likely end up having to carry that pregnancy to term.

This fight is not just about Texas. As other states pass copycat laws, the US will quickly become a patchwork of abortion deserts, further isolating low-income patients like mine. Research shows that people denied an abortion are far more likely to experience serious adverse financial events like evictions and bankruptcies.

Enough. We must guarantee access to abortion care at the national level by passing the Women’s Health Protection Act, which would prohibit state-level bans and unnecessary restrictions on providers. We must also eliminate the Hyde amendment, which senselessly prohibits all federal programs like Medicaid from covering abortion care, once again targeting those with the lowest incomes. And in the long term we must work to provide coverage of all reproductive health services, including contraception and abortion, through a universal health program.

Healthcare shouldn’t be a luxury available only to the rich – and that includes abortion.

Dr. Samuel Dickman, an internist, is an abortion provider and health policy researcher in Texas.

https://www.theguardian.com…

PNHP president Dr. Susan Rogers presented to the League Of Women Voters Davis Area MAS/MAL Unit on October 6, 2021. For more information, including presentation slides and a link to LWV’s position on health care, visit https://lwvc.wordpress.com.

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Video Recording

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Transcript

Dr. Michelle Famula: Good evening.  Thank you for joining us this evening.  Welcome to the League of Women Voters Davis Area October Health Care Forum: Health Reform and Social Justice: Opportunities for Reducing Inequity and Addressing Health Disparities: An Evening with Dr. Susan Rogers, President of Physicians for a National Health Program.

My name is Michelle Famula and I chair the Davis League of Women Voters Health Care Committee.  I am here co-hosting tonight with my colleague, Komal Hak, the chair of our Social Justice Committee.

This evening’s forum is being collaboratively sponsored by the League of Women Voters Davis Area and forty-four League chapters across California and across the country.  From New York, Pennsylvania, Connecticut, Massachusetts, to Kansas, Missouri, Alabama, Georgia, Florida, Louisiana, Texas, Arizona and Washington state.

Clearly, health care reform and health care inequity is an issue of importance to voters across the nation, and we are fortunate to be able to discuss that this evening.

Tonight’s program has three main goals:

• first, to stimulate a better understanding of health reform for the general voting public;
• second, to raise awareness of the League’s non-partisan approach to legislative issues; and,
• finally, to help create a better understanding of our health care system for voters, what is and what isn’t working, and how it could be better.

Tonight’s forum will run for two hours.  It begins with a presentation from Dr. Rogers, whose focus on reform will help to further define and explain the impacts of a Single Payer approach to reform, an approach our Governor in California’s Healthy California for All Commission is currently exploring as a unified financing model.

We will follow Dr. Rogers presentation with a discussion session with Dr. Rogers, Komal and I, to further explore some of the areas of health disparity and care inequity.  Some of the areas Dr. Rogers defines in her presentation that are present in the U.S. today, and how national health reform legislation might help address their root causes.

We will conclude tonight’s forum with your audience questions for Dr. Rogers.  If you have not already submitted your questions on line, please feel free to enter them in the chat throughout this program, and we will try to get to as many questions as possible this evening.

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Komal Hak: Good evening everyone.  My name is Komal Hak.  I am currently leading the Social Justice Committee for the Davis League.

It is my great pleasure to introduce this evening’s featured speaker, Dr. Susan Rogers, President of Physicians for a National Health Plan (PNHP).

Dr. Rogers received her medical degree from the University of Illinois College of Medicine in Chicago, and completed her residency in Internal Medicine at Cook County Hospital.  She spent most of her career at Cook County Hospital, now renamed Stroger Hospital of Cook County, where she was a primary care physician in one of the neighborhood clinics before becoming a hospitalist and director of medical student programs for the department of medicine.  She has received numerous teaching awards from students and residents.  She retired in 2014, but remains a voluntary Attending Physician there.

Dr. Rogers was also previously the Medical Director of Near North Health Service Corp, a Federally Qualified Health Center in Chicago and remained on their board for many years after she left her directorship there.  She continues as an active faculty as an Assistant Professor of Medicine at Rush University.

Dr. Rogers is the past co-president of Health Care for All – Illinois, and is currently President of Physicians for a National Health Program, a national organization of over 23,000 physicians and allied health professionals, whose mission is to advocate for Single Payer Medicare for All.

Dr. Rogers is a Fellow of the American College of Physicians and a member of the National Medical Association and the American Public Health Association.

Welcome, Dr. Rogers.

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Dr. Susan Rogers: Thank you so much for that introduction.

Slide 1: Why We Need Single Payer/Medicare for All; Susan Rogers, MD, FACP, October 6, 2021

What I want to talk about is Single Payer.  That is what I advocate for and that is the reform that I think this country needs so that everyone can get access to care and be taken care of medically.  Because right now, that isn’t happening, I think as we are all aware.

Slide 2: Purpose of Health Insurance

• Protect financial assets in the face of illness
• Improve access to care
• Protect health

When we think about health care, the way we access health care is through insurance.  Why do we need insurance?  We need it because it protects our assets in case we get sick; it improves our access to care because we cannot get care if we cannot show that we can pay, and it is also to protect our health.   But unfortunately, the health care system that we have now with the insurance, the landscape, the fragmentation, and the for-profit way it functions, it does not do these things.  So it really does not protect us the way that we think insurance should.

So let’s look at what are we spending now?  We talk a lot about how much health care costs.

Slide 3: US Public Spending per Capita for Health Exceeds TOTAL Spending of Other Nations:

• UK: $4,650
• Japan: $4,820
• France: $5,380
• Canada: $5,420
• Holland: $5,770
• Sweden: $5,780
• Germany: $6,650
• Switzerland: $7,730

US: Public: 7,619; Private: 3,981; Total: $11,600

We spend a phenomenal amount of money on health care in this country.  This just compares us to other industrialized nations in the world.  Here we are at the bottom.  The Blue Line is what we spend already in public dollars, that is government funds.  That provides care dollars that pays for the premiums of all government employees, police men, Congress, all government employees.  It paid the premium for me, before I retired, since I was a county employee.  All of our teachers, so when you think about it, this is a lot of people.   We are already spending, through government dollars, more than every other country but Switzerland.

We spend all that money and yet, we have phenomenal out of pocket expenses.  So that we can get the care that we need in our current system.

Now we are spending over twice as much as many countries do, three times as much as some.  What do we get for all this?

Slide 4: Life Expectancy

• US: 78.6 years
• Germany: 81.1 years
• UK: 81.3 years
• Canada: 82.0 years
• Sweden: 82.5 years
• France: 82.6 years
• Italy: 83.0 years

We don’t get to live as long.  That is one of the parameters that we look at to see how well countries are doing.  We don’t live as long.  We have never had a life expectancy over 80.  Even before Covid, we’ve never had a life expectancy that large.

I don’t know how we can say that we are the best system in the world with numbers like this.

Slide 5: Life expectancy versus health expenditure per capita

[European countries climbed in life expectancy post World War II, with little increase in expenditure, where the US expenses go up without any improvement in life expectancy]

I like this slide because it really puts in perspective how far off the US is.  All of the gray lines on the left hand side of the graph are countries that essentially have some sort of system where almost everybody is covered in those countries, most of those countries do have universal health care coverage so that everybody has access to health care.  Not only does everybody have access to health care, they are not spending anywhere near as much as we are now.

Yet here we are way out on the right, spending more money and getting worse results.

If you were doing something, if you were trying to learn a skill or you were trying to make something better, and you knew that you were way out on the far right of this graph where the United States is, you would say “I need to change what I am doing, I need to do something different; there is no way that what I am doing here is working.”  And yet we still insist that we have the best health care system in the world.  That we do everything better here, when obviously we are not better.

Slide 6: Redlining

Chicago Red Line Railroad Service

Average Life Expectancy at birth, 2010-15 by Census Tract: Englewood to Streeterville: 90, 85, 80, 75, 70, 65, 60, No Data;

Talk about Life Expectancy.  I put this slide in here because when we look at life expectancy, it is not the same for everyone.  We all know that we all don’t live as long; my mother-in-law is 92, so there people who live way beyond the normal life expectancy.  But even within cities, within small areas: this is a graph of the Red Line, the train taht public transportation in Chicago.

If you start down here in Englewood, which is a poor, concentrated poverty neighborhood, mostly Black, on the South side of Chicago.  If you get on the train, and you get off at a stop called Streeterville, which is a wealthy neighborhood that is almost all White, on the Lake, your life expectancy drops by 30 years.  So here we have neighborhoods in Chicago with a life expectancy of over 90 and other areas that start at 60.

Here, even within the same city, we have stark inequities.  We have to say “What are we doing wrong?”  It is not just adults that are dying; our infants are dying.

Slide 7: Infant Mortality: Deaths in the first year of life per 1,000 live births

• US: 5.9
• Canada: 4.5
• France: 3.6
• Germany: 3.3
• Australia: 3.3
• Italy: 2.7
• Sweden: 2.4

We have the worst infant mortality of any industrialized nation.  Two and three times as much as some of them.

When we define “infant mortality,” that is an infant who dies within a year of being born.  Within that number we have to look at the inequities that are there.

Slide 8: Infant mortality per 1,000 live births, by maternal race/ethnicity, 2017

• Black, non-Hispanic: 11
• American Indian or Alaskan Native, non-Hispanic: 9
• Native Hawaiian or Other Pacific Islander, non-Hispanic: 7
• ALL races and ethnicities: 5
• Hispanic: 4
• White, non-Hispanic: 4
• Asian, non-Hispanic: 3

That is all of us in the middle.  On the far left, Blacks have the absolute worst infant mortality of all groups, and here are Whites over on the right.  There is a large inequity here in infant mortality.

Slide 9: Maternal Mortality Ratios in Selected Communities, 2018 or Latest Year

• New Zealand: 1.7
• Norway: 1.8
• Netherlands: 3.0
• Germany: 3.2
• Switzerland: 4.3
• Sweden: 4.6
• UK: 6.5
• Canada: 8.6
• France: 8.7
• US: 17.4

Even if we look at Maternal Mortality.  Look at the US compared to other countries.  Our maternal mortality is twice large, three times as some.  And then there are others that have a minimal mortality.   Maternal mortality deaths are not a lot, I think 700 or 800 total during the year, but the point is we are so far above and beyond what other countries do, and yet we still say “We have the best in the world.”  This is the barometer that the World Health Organization and other countries use to reflect on how healthy a country is.

Slide 10: Pregnancy-related Deaths per 100,000 live births

• White Women: 13
• American Indian/Alaska Native Women: 30
• Black Women: 41

Even if we look at White women, they have a higher maternal mortality than other industrialized countries.  The inequity is there in all the racial groups.  All of them; Black women, American Indians, White women.

A lot of these parameters that we look at affect White people in this country too.  Even if you look at the wealthiest socio-economic group, White people in this country still die sooner than the wealthiest groups in other industrialized nations in Europe.  If you look at the poorest groups in this country, the poorest groups here die sooner, and have worst outcomes than the poorest groups in other countries.  So even if we don’t look at us all combined, if we compare similar groups in other countries, we are still faring much worse.

Slide 10: Covid-19 Hospitalization and Death Rates among Active Epic Patients by Race/Ethnicity, as of July 2020

Hospital Rate/Death Rate (Total Active Patients)

• Total: 12.9/3.3 (49.4 million)
• White: 7.4/2.3 (34.1 million)
• Black: 24.6/5.6 (7.9 million)
• Hispanic: 30.4/5.6 (5.1 million)
• Asian: 15.9/4.3 (1.4 million)

And then we look at what Covid did.  Covid really visualized and made obvious what some of the inequities are.   What has happened in this country is a lot of these inequities people aren’t even aware that they exist.   They may have heard about them, but they are not on their radar screen.  When all of these inequities came up, the President of the American Medical Association, which used to represent most doctors in this country – they don’t any more – even she said “We need to do more studies.”   The studies have shown why, and I will get into that in a little bit, why these inequities are here.

It has nothing to do with genetics.  There are reasons why, and it has to do with the way our society functions.

Slide 11: A factory building

This is just a picture of an area in Chicago where there is an iron works plant.  This is a Black neighborhood.  This is where a lot of neighborhoods are, in the middle of environmental pollution.  Whether it is in the air, in the water, whether it is in the soil, and yet we tolerate this.  Flint Michigan still does not have clean water.  It has been over 5-6 years.  A White neighborhood in the Chicago area would never tolerate that, but why is that acceptable to the government in the city in minority neighborhoods?  What we have to remember too, is that when redlining and segregation, and Black neighborhoods evolved and grew in urban areas, this is where these plants were placed.  This is where these factories were built.  They were built around minority neighborhoods.  So this wasn’t just an occurrence – this was planned to be like this.

Slide 12: Social Determinants of Health

• Economic Stability: Employment, Income, Expenses, Debt, Medical Bills, Support
• Neighborhood and Physical Environment: Housing, Transportation, Safety, Parks, Playgrounds, Walkability, Zip Code/Geography
• Education: Literacy, Language, Early childhood education, Vocational training, Higher education
• Food: Hunger, Access to healthy options
• Community and Social Context: Social integration, Support systems, Community engagement, Discrimination, Stress
• Health Care System: Health coverage, Provider availability, Provider linguistic and cultural competence, Quality of care
• Health Outcomes: Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations

We talk about the “Social Determinants of Health” because this is important in how healthy we are.  It is not just related to how we have access to health care or whether or not we have health insurance.

We look at our economic stability, where we live, our education, our access to food, what the community is, and the health care system in that.   One of the things that these social determinants of health negatively impact more on Black and Brown and immigrant communities than they do on White communities.

This is clearly a reflection of segregation that was actually going on in this country since the 1900s, but it became legal with the New Deal – they wouldn’t give mortgages to anyone Black trying to buy a home.  So they put limitations on where they were able to live.  The reason why these social determinants impact minorities and people of color is because of the neighborhoods that they have only been allowed to live in.  Those neighborhoods were never supported the way other neighborhoods are.

Slide 13: Racial disparities in concentrated poverty

Percentage of poor Whites and Blacks living in concentrated poverty by metropolitan area (it is more apparent as a graph than as statistics)

• New York: 18/26
• Los Angeles: 5/18
• Chicago: 4/35
• Houston: 4/18
• Atlanta: 3/17
• Washington DC: 3/16
• Dallas: 7/21
• Riverside CA: 6/14
• Phoenix: 9/28
• Philadelphia: 11/34
• Minneapolis/St Paul: 13/23
• San Diego: 4/14
• St Louis: 2/29
• Tampa: 3/24
• Baltimore: 2/16
• Seattle: 3/4
• Denver: 2/9
• Oakland: 4/6

What we have now is areas of concentrated poverty.  I like this slide because it shows a couple things.  One, concentrated poverty is where at least 30% of the people who live in that community are below the federal poverty line.  Remember, the federal poverty line is just a number that determines whether you can get a certain benefit or not.  It has nothing to do with whether you are poor or not.  Even if you live 200, 300, 400 times the federal poverty line, you are still often poor.  It doesn’t determine who is poor or not, it just determines what benefits you can get.

If you live in a community of concentrated poverty, where 30% of the people in that community are below the federal poverty line, you are living in an area that does not have the social supports that you would need to be able to flourish: it doesn’t have good schools, it is not safe, there is violence, it does not have grocery stores, it has what we call “fast food swamps” because there is often four to five times as many fast food restaurants as there are in other neighborhoods.

What this shows, if you look at Chicago, 35% of the people of the people living in an area of concentrated poverty are Black, whereas less than 5% are White.  That is because Whites, no matter how poor they are, can still live where people are better off, where the economics are better.  White poverty is not the same as Black poverty.  What Black people suffer, and immigrants, and other people of color suffer by living in areas of concentrated poverty is different from White people living in this country who might still be at the same level of poverty, because they live in an environment that can still be supportive to encourage them to flourish, where we don’t have that in this country.

One in four Blacks in this country live in areas of concentrated poverty.

One in six Hispanics.

Yet, just one in thirteen White Americans live in areas of concentrated poverty.

Slide 14: Access

Slide 15: Congressional Budget Office Projections: Millions without Insurance; 2019 – 2029: 30, 32, 33, 34, 34, 34, 34, 35, 35, 35

Let’s talk a little bit about Access.  The Congressional Budget Office projects that by 2029 there will be 30 million people who do not have insurance.  That is, they will not have any access to care.  Even when the Affordable Care Act was created, it was never planned to cover everyone.  It was never planned to provide insurance to everyone.  They even projected that even if the insurance mandate was left in tact, there still would be 30 million people who do not have insurance.  Even in the best of times, there will still be many people who will not have insurance.

Slide 16: Uninsured by Race/Ethnicity, 2018

• White, non-Hispanic: 5.4%
• Black: 9.7%
• Hispanic: 17.9%
• Native American: 20.2%
• Asian: 6.8%

If we look at who is insured by race, well this is no surprise.  The group that is most insured are White people in this country.  The groups that are most likely to be uninsured are Blacks, Hispanic and Native American.

Slide 17: Reasons for Being Uninsured among Uninsured Nonelderly Adults, 2019

• Coverage not affordable: 73.7%
• Not Eligible for Coverage: 25.3%
• Do not need or want: 21.3%
• Signing up was too difficult or confusing: 18.4%
• Cannot find a plan that meets needs: 18.0%
• Lost job: 2.8%

The reasons people are uninsured, the vast majority, is because they cannot afford it.  They often have jobs that do not provide it.  Low wage jobs do not give people theaccess or the means to buy their own insurance, even on the Exchange.  They make too much to get subsidized through the ACA, so coverage is not affordable.  There are a variety of other reasons but that is the majority reason why people do not have insurance.

Slide 18: Medicaid Enrollment, 1987-2019

• 1987: 20 million
• 1994 – 2008: 40 million
• 2014: 50 million
• 2015: 70 million

Let’s look a little bit at MediCaid.  One of the things that the Affordable Care Act did was it did expand MediCaid so this was a way that people could access insurance.  MediCaid actually provides medical insurance coverage to more people than any other single program.  If you look at private health insurance that may provide more but there are so many different private programs that it can’t be looked at as one type of insurance.  But MediCaid covers low income children, adults, seniors, those with disabilities.  It covers one in five people in this country.  20% of people get their care through MediCaid.

MediCaid is federally-funded but state delivered.  One of the things about MediCaid is that people who have disabilities, especially adults who have significant medical issues, need health care but because of their disabilities but still may be able to work.  However, because they have to meet the minimum requirements to receive MediCaid, they are doomed to a life of poverty so that they can maintain their access to the health care that they need.

Here we are: dooming adults who could be functional and productive in this country.  We are dooming them to poverty so that they can access health care.

MediCaid also covers almost half of the births in this country.

MediCaid is a big issue here.  It is a big way that a lot of people in this country receive their care.  However, it is underfunded and it does not even cover the costs of taking care of the people it does.  We are the only industrialized country that has split system for poor people.  We are the only ones.  There are poor people in all of these other industrialized countries that have better metrics than we do, but they have access to the same health care that everyone else does.  Here, in the US, we make a distinction.  We have a separate system that is underfunded, separate and un-equal system; they don’t even pretend to be separate and equal.  It is a separate but unequal system.

Slide 18: Status of State MediCaid Expansion Decisions

Rejected MediCaid Expansion: Wisconsin, Wyoming, Kansas, Texas, Mississippi, Alabama, Florida, Georgia, North Carolina, Tennessee (Oklahoma, Missouri)

Here is what happens with MediCaid expansion.  Most of the states that did not adopt the expansion were in the South, where actually most of the working age Black men live.  So here they are and they are excluded from having access to MediCaid.  Keep in mind that in 1965 with the Civil Rights Act and the Voting Rights Act, when MediCaid became an entity.  It was proposed by President Johnson, along with MediCare.  But the Southern States would not allow benefits in their states unless they had control of them.  This is why MediCaid is federally-funded but state controlled.  This was because these Southern States did not want to provide access to the Blacks who lived in their areas in their states.

This was on purpose.  This is what happened with MediCaid, so it was never created so that all people could have access because states are allowed to make their own decisions about what they will cover.  There are certain things that MediCaid has to cover, but there is still a lot of flexibility with what the states were allowed to do.  This was never meant to solve the inequities that poor people had in access to care.

Slide 19: Indian Health Service: Grossly Underfunded

Medical spending 207 per user:

• Indian Health Service: $3,332
• MediCaid: $7,789
• Veterans’ Administration: $8,759
• National Average: $9,207

Indian Health Service.  I hate that it is still called the Indian Health Service.  Look at their funding.  It is abysmal.  Many of the tribal areas do not have fresh water.  It is abysmal the conditions that we allow them to live in and that we support, and don’t address.

Slide 20: Single Payer MediCare for All

• Automatic enrollment
• Federal guarantee
• Covers all medically necessary services
• All residents of the United States

“Everybody in, nobody out”

Single Payer for All – everyone would be enrolled, automatically.  You are enrolled as soon as you are born, you are dis-enrolled when you die.  It is federally guaranteed.  It covers all medically necessary services.  And, everybody in the country is included and covered.

Slide 21: Choice

Slide 22: There is Restricted Choice with Private Health Insurance

• Privatized health insurance limits choice to the networks of doctors and hospitals with whom they have negotiated contracts and drug benefits are tiered
• Costs more to go out of network which can create a surprise bill
• Difficult, if not impossible, to determine what your plan offers or what services are covered
• Less than half of those employed have choice of insurance plans
• Regardless of what you and your provider decided, the insurance company makes the final decision of what you can get done and what your treatment plan will include.

Let’s talk about choice.  Everybody talks about “You need to have a choice.” They offer all these plans.  It is not the choice of a plan that you want.  In fact, it isn’t even that you have a choice of a plan because your employer often offers only one plan.  Maybe one is private insurance and the other is a Health Maintenance Organization (HMO).  It is not like you have a lot of choices even through your employer.

What it does is it limits your choice.  What private insurance does is it limits your choice of doctors and hospitals – that is the choice that you really want.  You want to go to the doctor that you want to see.  You want to go to the hospital that you want to go to.  You don’t want the choice of insurance plan.  You want the choice of doctor and hospital.   If you end up going out of network, which may happen, and you don’t even know that you are out of network, you end up with bills.  It is difficult, if not impossible, to figure out what your plan really has.

So even though you and your provider may decide on what you want or what you need, it is still up to the insurance company to approve that.

You don’t have choice about any-thing.  Your doctor doesn’t even have a choice.  It is almost as if the insurance company is practicing medicine without a license, because they are making the decisions about whether you need something, or whether you can have access to it.

Slide 23: Benefits

Slide 24: Health Insurance Reform (ACA)

• 10 essential benefits, but no national standard benefit package
• Coverage of preexisting conditions
• Stipulation that health insurers have medical loss ratios (MLR) of 80%-85%

Let’s talk about benefits.  When the ACA came out, it did reform insurance, and it did mandate that they have essential benefits, which was new.  The biggest of which was the coverage of preexisting conditions.  But it did say in these essential benefits that in ten areas there had to be benefits in all those areas, such as physical therapy, pediatrics, obstetrics, long term care.  But it didn’t set a national standard, so each plan can offer different things.

You have no way of knowing. The plan may say “Yes, we cover your diabetes.”  But it may mean you only get two strips to measure your sugar two days out of the month.  The rest you would have to pay.  And there is no way that you would ever know that, until you tried to get it, and you got refused.

It does cover preexisting conditions, which is a big benefit.

And one of the things that it did say was that they have what they call a medical loss ratio which is that 80 cents of every dollar of your premium has to go to provide health care.  But they play around with that, and what they decide health care really is.  All they will do then is as costs go up, they increase your premium so that they can maintain that 20% profit so that their salary is paid, and they never really going to lose any money.

Slide 25: Single Payer MediCare for All

• Comprehensive Coverage
  • Preventive services
  • Hospital care
  • Physician services
  • Dental, Eye services
  • Mental health services
  • Medication expenses
  • Reproductive health services
  • Physical/Occupational Therapy
  • Home Care/Nursing home care/Long term care
• “All medically necessary services”
• No co-pays or deductibles

Single Payer would cover all the things you need.  By making the coverage for everybody, when you have coverage that is acceptable to wealthier people, then it will be OK.  You know you are getting covered for everything medically necessary.  One of the things that is not currently covered is nursing home care.  Through MediCare, we don’t cover dental, we don’t cover eye, we don’t cover hearing; mental health services are often very abysmal.

This would expand coverage for everyone.

Slide 26: Quality

Slide 27: Improved Quality with Single Payer

• Single tiered system would foster quality by making it acceptable to everyone
• Help reduce racial health inequities with increased access
• System would provide continuity of care
• Preventive care would be a priority
• It could make possible the creation of a unified, useful and confidential Electronic Health Record (HER) like the Veteran’s Administration has
• Facilitates real health planning by putting resources where they are needed rather than where they make money.

Let’s talk about quality.

With Single Payer, we would have better quality because it would foster quality by making coverage acceptable to everyone.  It could reduce the inequities that we see because it would improve access.

I mentioned the social determinants of health, so I am not naïve in thinking that once we increase access, things will be fine.  It won’t be.  But that is a necessary step for you to be healthy, is to have access to health care, along with the other social determinants of health.

The system would provide continuity of care.  Right now, the only place where you can go if you don’t have insurance, is an emergency room.  They HAVE to see you.   However, you may be diagnosed with something that may not be an emergency, and require hospital admission then, but may require further care later, but you won’t have access to that further care.  That is the problem with what we have now: once you have been discharged from the ER, you really have no way to access follow up on whatever it is that you went to the emergency room for.

Single Payer would provide continuity of care.

You would be able to get preventive care.  Right now, we don’t do much, and we don’t do good preventive care at all.  Insurance companies don’t want to pay it: if you do a screening exam for cancer, and they find a cancer, then they have to pay for that; so they don’t want to screen and find anything.  You often have to go through hoops, just to get a colonoscopy or a mammogram.

It would help to make an Electronic Medical Record that talks to everybody, so that if you see a doctor in New York and then get a follow up with a doctor in California, both of those doctors can see your medical record.  That is the way the Veterans Administration functions.  I worked with at VA for a couple of years.  It made it so much easier because I knew what all had happened with that particular veteran in terms of their health care.

You could provide real health planning by putting resources where they are needed, rather than where they make money.  Right now, we have areas that are medical deserts, hospitals have closed.  We have counties in rural areas that do not have a hospital.  So there are a lot of medical deserts that are there because of the funding payer mix they are not able to survive.

What Single Payer will do with global budgeting, and I will get into that in a minute, it would build resources and you would have hospitals and clinics where they are needed versus where they can make money.  Where I am in Chicago, with Stroger Cook County Hospital.  Within this mile radius there is Rush University Hospital, there’s University of Illinois Hospital, there’s a large VA hospital.  Why do we need all of those clumped together?  Why shouldn’t they spread out? We should look at it the same as we do a fire department.  You would never stop at a stop light and see a fire station on each corner.

That makes no sense: you want the fire stations to be close to where they can put out fires.  Which means that they have to be spread out in a manner where everybody has ample equitable availability to the fire department to put out a fire.  Just like it is important that if the house next door to you catches on fire, you want it to be put out.  Just like the person standing next to you in line is ill, you want them to be healthy, so that you don’t get sick, especially with Covid, when we have communicable diseases.

So let’s talk about costs, because that is the biggest thing that everyone talks about: are health care costs too much?

Slide 28: Costs

Slide 29: Average Annual Worker and Employee Contributions to Premiums and Total Premiums for Family Coverage, 1999-2019

Employer Contribution/Worker Contribution//Total:

• 1999: $4,247/$1,543//$5,791
• 2010: $9,773/$3,997//$13,770
• 2019: $14,561/$6,015//$20,576

This is what we are paying now through employer-based health insurance.  This bottom line is what the average family premium was for an employer was $20,000.  Often, your employer pays 2/3rds of that, which leaves you.  You never see this money because it never gets into your check.  It is deducted from your salary.  You are paying a third of that, which could have gone into your salary if we had a Single Payer program.

This is what is kept by the employer to help pay that entire premium.

Slide 30: Four in Ten Adults with Employer-Sponsored Insurance Report Having High Deductible Plans

Among Adults with Employer Sponsored Health Insurance:

Percent who say their annual deductible is:

• No Deductible: 15%
• Lower Deductible (<$1,500 individual, <$3,000 family): 44%:
• Higher Deductible ($1,500-$2,999 individual, $3,000-$4,999 family): 20%
• Highest Deductible ($3,000+ individual, $5,000+ family): 21%

What has happened?  Along with your paying that, you also have a high deductible.  One of the things that happened when the Affordable Care Act was established was they focused on the costs of premiums – but they really didn’t pay attention to deductibles.

This is why deductibles have sky-rocketed so much.  This is how insurance companies make even more money, is that this is an out-of-pocket expense that you have to pay before your insurance company pays a dime for your care.  And keep in mind that this deductible is only paid down when you pay for a benefit that is covered.   If you buy a pair of eyeglasses and that is not covered by your insurance, that doesn’t bring down your deductible.  That is further money that you have to pay out of pocket.  Most insurance companies now have high deductible plans.

What this does is it makes it so that people can not access their insurance because people cannot pay down their plan.  If you look at the Bronze Plan on the Exchange, which is the cheapest premium there is, that plan also has the highest deductible.  Some of those Bronze deductibles are over $12,000 a year.  Tell how somebody who needs help paying their premium is able to pay $12,000 a year so that they can access their insurance?  This is how they have played with the system so that they never have to pay for your care, until you pay down your deductible.

It is not fair, but it is legal.  This is how they have played the game.  What this has done is it has created a system we call Under-Insurance.

Slide 31: Under-Insurance Growing

Percent of Adults 19-64 under-insured (insured all year, out-of-pocket expenses >10% of income, or >5% if low income, or Deductible was >5% of income)

• 2003: 9%
• 2005: 9%
• 2010: 16%
• 2012: 16%
• 2014: 17%
• 2016: 22%
• 2018: 23%

Under-insurance is where you have to pay, depending upon your income, you pay either 5% or 10% of your income for health care.  That makes you un-insured, if you are paying that much money just to keep your insurance going.  You are not insured.  This is why people go broke.  This is why people make Go Fund Me posts on Facebook because they cannot afford their care.  What you have in your wallet isn’t an insurance card; you have an insured DONOR card, because you are paying every month to this insurance company for something you are never going to benefit from.  It is just like if I gave you the car of your dreams but didn’t give you the keys.  The car is only good for you to post pictures in Facebook of you sitting in it; it is yours but you can’t use it, because you don’t have the keys.

Slide 32: Medical Debt Leaves People with Lingering Financial Problems

Percentage of adults aged 19-64 who had the following financial problems in the past two years because of medical bill problems/debt:

• 37%: used all of savings
• 40%: received a lower credit rating
• 31%: took on credit card debt
• 26%: unable to pay basic necessities (food, rent, heat)
• 20%: delayed education or career goals
• 11%: took out mortgage against your home or took out a loan
• 3%: had to declare bankruptcy

If we look at who has financial problems because of medical bills, a lot of people have used all of their savings, they declare bankruptcy.  It is not sustainable.  The prices continue to go up.  More and more people are going to have financial problems because of this.

Where is all of our money going that we are spending?  We are spending these phenomenal amounts of money but we often cannot get the care we need.  We spend a phenomenal amount on billing.  The way that we can get a hospital and a doctor get paid is through administrative costs through billing.  It is a coding process, it is complicated, it requires a lot of expertise, a lot of time.  A lot of physicians end up spending 25% of their income just on these administrative costs.  Hospitals spend 25% of their income on administration.

Slide 33: Unnecessary Administrative Costs

Duke University Hospital System (3 hospitals)

• Hospital Bed: 957
• Billing Clerks: 1,600

This is just a typical large institution.  Duke University has more billing clerks than they have than they have hospital beds.   I don’t know if you have ever been in a hospital, or you went to visit someone, or you work in a hospital, you know some times it is difficult to find a nurse, but you can clearly find a billing clerk when you need one.

This is what has happened.  Administrative costs are taking all this money out of health care, without using our health care dollars for something that does not provide health.

Slide 34: Cost of a heart bypass in selected countries as of 2019 in US dollars

• US: $123,000
• Israel: $28,000
• Costa Rica: $27,000
• Mexico: $27,000
• South Korea: $26,000
• Singapore: $17,000
• Columbia: $15,000
• Poland: $14,000
• Turkey: $14,000

Also, if we look at what things cost in this country: you can google any procedure, anything, and you will see comparisons of what we pay compared to other countries.   This is what we spend.  We spend 5, 10 times, one hundred times as much as other countries for procedures.  This is for cardiac bypass.  You can see that we are such an outlier here.

And then what we spend on drugs.   We spend phenomenal amounts on drugs, and pharmaceutical companies always say, “We need all this money because we have to do all of this research.” But we have paid for that research through our taxes, because the National Institutes of Health (NIH) has done all that research.

The NIH did a lot of the research on the vaccine that we have for covid.  But there was a provision called the Bayh-Dole Provision that allows private firms to monetize publicly funded research.  This is how these pharmaceutical companies latch on to these drugs.  When they do their clinical trials, which is actually the cheapest part of research, and then they make all of this money and then they put it in patents.  Which means that nobody else can make that drug and patents last for 20 years.  And then they may do a little adjustment, so they add more time to the patent.  It is a game.

Slide 35: Profits Dwarf Cancer Drug R&D Costs

Analysis of all drugs approved 2006-2015, from firms with only one approved drug

• Research & Development Costs: $720
• Research & Development + 7% for Risk: $906
• Revenue from Drug: $6,699

But they are not spending all of this money on research, which is what they want you to believe.

Slide 36: Goldman Sachs asks in biotech research report: ‘Is curing patients a sustainable business model?’  The success of the drug has gradually exhausted the available pool of treatable patients.

There was a drug that came out to treat Hepatitis C: people don’t have symptoms, it can cause cirrhosis and eventually death.  It can increase your risk of liver cancer.  The company who made it, Gilead, actually made a comment about “is curing patients a sustainable business model?”

For these pharmaceutical companies, their goal and mission is to make money.   It is not to provide low cost, curable drugs to the people who live here.  It is not in their mission.

If we had negotiated prices, we would have saved $71 billion over the past six years, if we had paid the prices the VA negotiated.

Slide 37: Medicare would have saved $71 billion over 6 years if it paid the VA prices.

Spending for top 50 drugs (billions of $s)

Year/Medicare Spending/Cost at VA Prices

• 2011: $26.3/$13.4
• 2012: $24.7/$12.4
• 2013: $22.3/$12.4
• 2014: $25.4/$15.8
• 2015: $30.0/$17.9
• 2016: $32.5/$18.0

The VA has a system.  They have one network for all of their VAs across the country.  They buy their drugs from the dispenser, they don’t go through the pharmacies.  They found a way to do it cheaper.

And now, even though we have this data, the government, the Congress is still talking about whether we should allow MediCare to negotiate drug prices.

Slide 38: What have market forces done for health care in the last 20 years?

• Increase in the number of un/under-insured
• Decrease in choice of provider b/c networks
• Diversion of health care resources to areas of profit rather than need
• Underfunding of less profitable endeavors
• Unaffordable prescription drugs, increased costs of technology
• Dissatisfied patients and frustrated physicians

AND HIGHER COSTS!!!!!

The market has done nothing.  OK, let the market figure this out?  It won’t.

All that the market has done is create a worsening of the problems that we have now.  Everybody is unhappy.  Physicians are frustrated.

I think that we should really be concerned because there is more and more physicians who are leaving health care.

Because the situation is not sustainable for them.  The physicians are frustrated.  They cannot do what they spent all of these years learning how to do, which is take care of patients, because the decisions aren’t there any more.  The patients are frustrated because they cannot get the care they need.  Physicians are frustrated because they cannot provide the care that they want to.  They spend more time with administrative costs doing administrative work.

The market has done nothing to control costs.  The government has to control costs.  It is not doing that.

Slide 39: Single Payer offers Real Tools to Contain Costs

• Global budgeting of hospitals, similar to budgeting for police, fire departments
• Capital investment planning separate from operating costs
• Emphasis on primary care, coordination of care
• Bulk purchasing of pharmaceuticals
• Decrease in malpractice costs

Single Payer offers real tools to contain costs.  One is global budgeting, where a hospital would have a budget.  When the pandemic occurs and they spend more money, then they would get more money from the government to provide that care.  If they spend less, that money goes into the next year’s budget; it is not profit.  They can’t decide to build something or provide a service that makes more money.

Capital investment would be separate.  So they can’t just decide they want to build something with that extra money.  It has to be approved.

This is tricky, because we still have to have a lot of oversight.  We have to make sure that minority neighborhoods and other poor neighborhoods are still treated equitably, because we have to make sure that this does not go the way public education has gone.  Public education is governmnt funded but clearly it is not equal.   There are schools in poor neighborhoods that are not funded because it is built on property taxes which itself is inequitable.

We have to have a system that provides equitable services.  That will require oversight.

Slide 40: Single Payer MediCare for All makes Economic Sense

29 studies: The savings would fund full coverage.

247 economists: “The time is now for MediCare for All”

“Health care is not a service that follows standard market rules.  It should therefore be provided as a public good.”

This makes economic sense.  There have been economic studies to show this.   Even the Koch Brothers did a study that showed that we would save money.  We have to treat health care as a public good because it doesn’t follow standard market rules.

Slide 41: Most Doctors now favor Single Payer

Support has sharply increased

• 2008: Oppose: 58%; Support: 42%
• 2017: Support: 56%; Oppose: 41%; No Opinion: 3%

Doctors now support Single Payer.  More and more doctors, mostly Democrat doctors, still, more and more physicians support Single Payer.  Even some sub-specialists.  Now some of the high paid specialists are supporting more Single Payer.

Slide 42: Lower Health Costs with National Health Program

Health Costs as Percent of GDP: Canada vs US

• 1960-1974: Canada and US same slope of spending increase levels
• 1964: Canada’s National Health Program started
• 1973: Canada’s NHP fully implemented
• 1974 on: US costs continue same slope, Canada spending slope flattens

I want to show this because there is a way to do this right.

If we followed what Canada did back in the 1970s, we wouldn’t be on the trajectory that we are now, with our private health insurance plan.  If we had followed Canada with a Single Payer plan that is government funded and everybody had the same benefit, we would not be anywhere near where we are.

Slide 5/43: Life expectancy versus health expenditure per capita

[European countries climbed in life expectancy post World War II, with little increase in expenditure, where the US expenses go up without any improvement in life expectancy]

I show this slide again because here we are, this far thing on the right, and we refuse to look at the right way to do this.  Just like, if you refuse to change the way you are doing something, rather than looking at the way it is being done right.  We refuse to do that.

Slide 44: Insurance, Drug and Health Lobbyists:

Congress: “I’m just not seeing any good solutions”

(burying Single Payer with campaign contributions from insurance, drug, medical and hospital lobbyists)

This is why we cannot get this fixed.  You know, as time has gone on, especially after Citizens United, I don’t see much difference any more between the Congress and private corporations.  Private corporations have bought Congress with all of their lobbying.  This is why the government is not making any solutions or doing anything to change what we have now.

Slide 45: For more information…Health Policy Websites

• The Commonwealth Fund: www.commonwealthfund.org
• Kaiser Family Foundation: www.kff.org
• Health Affairs Blog: http://healthaffairs.org/blog
• Physicians for a National Health Program: www.PNHP.org
• Lown Institute: www.lowninstitute.org

This is a list of web sites that are phenomenal in terms of the information that you can get from here for statistics, discussions.  These are all useful in terms of helping you figure out what is wrong and how we can get it better.

With further privatization of public health insurance in terms of MediCaid and MediCare, once this becomes totally privatized, that is frightening.  It is happening now.  MediCare Advantage is really worse than traditional MediCare – it may be a little cheaper in the beginning, but in the end it is not going to be cheaper for those who choose it.  And it is almost impossible for you to get a supplemental plan if you go back to traditional MediCare because you won’t be able to see the provider of your choice because of the narrow networks of MediCare Advantage.

Take a look at these web sites.  You may get some answers.  And, these web sites are good to follow.  PNHP – Physicians for a National Health Program has a lot of good information, a lot of videos that you will find useful.

I hope I have convinced everyone here that Single Payer is the way that we can fix this because the problems are rooted in our private health insurance.

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Komal Hak: Thank you, Dr. Rogers.  That was a comprehensive presentation.  It addressed a lot of implications of disparities.

I want to start out our discussion with a reflection on your thoughts regarding our current health care system, but also how we have come to accept these inequities in our delivery system?  When did we become not necessarily complacent, but almost complicit in this?  In the 1970s, it seemed from your charts that there was an almost divergence.  How did we allow this to really happen?  What do you think were the underlying factors?

Dr. Rogers: If you look at the culture of this country, the sense of a “public good” has never been embraced by the whole country.  We have a sense that you have to earn things, you have to earn access to health care.  By earning, I mean that you have to pay for it.  If you can’t pay for it, don’t expect it to be as good as what other people who pay for it get.  That’s what has happened, and it is not just with health care.  It is not just with health care; I mentioned education before, and unfortunately this country does not have the sense that everyone should be entitled to some things.

I think it is rooted in how this country was built.  This country was never built to be equitable.  Ever.  And if you look at the past 150 years since the end of the Civil War, it has maintained all of these structures to continue these inequities.  And because this country is so segregated purposely, people can live so they can avoid things they don’t want to see.

I remember a person I worked with was complaining about the ride to her house from the airport: she had to see neighborhoods she didn’t want to see.  It is easier to pretend that they don’t exist, or if they do exist, it is their fault, you know.

Komal Hak: That is why it is so important for public education.  A lot of people don’t even realize they are playing a part in systemic racism.  In the last year, a lot more people have been, well, the people who want to, educate themselves – have been educating themselves.  I think that kind of public education is really important, and that isn’t just for health care.  Like you said even like our school system.

How do we now help enact this change?  Yes, it has to come from a social background to actually act upon it.  How can we make the public trust our health care system, and these policies to work towards building a better future, and a more equitable future.

Dr. Famula: I think that there has been quite an issue around trust in our health care establishment.  I think that what you find now, and some of it has to do with how we are financing health systems, and how we have removed agency from both patients and providers.

What we have found and what we are continuing to find in Covid is tremendous dis-trust of what were considered to be the hallmark agencies.  You mentioned the National Institutes of Health (NIH), and the Centers for Communicable Diseases (CDC) and the Food and Drug Administration (FDA).  I have really been concerned about this erosion of trust really in all of our government institutions.

You know that in health care, we say people should “trust their own doctor” if you want to encourage people to get the vaccine, put it through their own doctor, and not through clinics.  And yet, so many cannot name “their own doctor,” or the doctor they had three years ago isn’t their own doctor any more because their employer changed insurance coverage.

I see this as a big part of trust.  I am curious, Dr. Rogers, how you see the system, and how it plays into how people are, or are not, trusting the health care system now.

Dr. Rogers: The trust part has been decimated.   Even when we say “ask your doctor,” the health inequities in this country – a large percentage doesn’t have a doctor.  Has never had a doctor.  They may just go to the emergency room, or they end up going to the hospital because things got so out of hand.  So there isn’t access to even have that relationship.

It is hard to describe what has happened in this country, as to why the FDA isn’t trusted.  Why health care isn’t trusted.  I saw a tweet a physician wrote, “the patient complained when I asked her about getting the vaccine, she didn’t know what was in it.  The doctor responded, you didn’t ask me what was in the 4 medicines I just wrote you the prescription for.”   People are choosing what they want to believe.  I don’t think it has anything to do with trust.   You just choose not to believe what that group says – because I think in general patients that have relationships with their doctors believe their doctors, or they would have changed doctors if they could.  But that relationship has been eroded by the insurance companies because you can’t always follow your own doctor.

When my daughter was pregnant with her first child, had to switch OBs because the insurance changed.  She didn’t want to do that.  And then the hospital where the other OB was 40 minutes from her house.  This whole system is not made to work on trust, it is made to make money.  It’s “I don’t care if you go to the doctor you like, you are going to the doctor B who is just as good as doctor A,” as though that will work.

Physicians are looked at as employees now, treated as employees.  I know that I was in primary care 14 years before I was a specialist, and I worked in a county neighborhood clinic.  I saw those patients over and over and over again, and that is why I love primary care.

I am sad that so many medical students who are looking forward to that kind of experience won’t be able to see that.  They could if we got Single Payer system.

The system, the economic system, the economics of health care have made it difficult to build those relationships.  Trust comes from relationships.  If the health system actively destroys those relationships, because it is not in their economic interests, it is creating the problem.

It is part of the whole disruption of what was there, what used to be normal.  Not just in health care, everything has been disrupted here.

Dr. Famula: It has changed the architecture of the entire system.

Dr. Rogers: I am not sure how we can build it back.  We look at hospitals: hospital A is a great hospital, they care about you and all, and yet during the pandemic they made billions of dollars, while people went without care.

Komal Hak: I want to share a story.  One of my friends, I think it was two weeks before she was due, her hospital dropped her as a patient.  She had had this continuity of care with her OB and the whole team, up to a week before she was due, she was sobbing, she was sobbing on the phone to her insurance company.  That caused her a lot of trauma, trauma to the point where giving birth again and going through that process now is a triggering affect.

This is just one example.  I know plenty of people who are living as two income households.  The fact that she couldn’t stay with her provider, and then had to go through this kind of trauma right before, will decrease her likelihood of getting pregnant again.

There is lots of talk about how birth rates are going down for my generation and younger generations.  We have to realize the cause and effect: the health care delivery system and private insurance companies are having on these quote unquote Millennials are just being selfish.  These terms that come up, like “African Americans are just lazy.”   No, there is a historical context that have led up to this point where their circumstantial needs that are not being met.

Some good things are coming out.  Someone commented in our chat was Henrietta Lacks’ cells.  The family is now filing a lawsuit on.  We didn’t even know that information, that these things were happening.  In the past, all of the medical experimentation that was going on without consent.  Even currently, in the ICE shelters, I think it was last year that sterilization was happening without consent.

The more knowledge of this that is being presented to the public – I think bringing that awareness will help.  And understanding that awareness will help providers and community partners deliver that care.  Maybe we do make things a little smaller.  We address these problems of mistrust by having community providers who speak the language, who understand culturally competent care, people who are representing the population they serve.  Having mobile units go out.

It will take a lot more workforce and a lot more effort and funding.  It will maybe this is the kind of policy markup the public and the voters can get behind, but we also need champions of change to put forward these policies.

What are your thoughts on this kind of work?   Do you think it is possible to have health care policies with this kind of radical change happening in the next couple of years?

Dr. Rogers: As long as we have a profit driven health care system, the relationships will always be transactional.  They are not going to be personal.  I don’t really care how nice the cashier is at the grocery store, just don’t break the eggs – it’s impersonal.  But with health care, it has to be personal.  You are often talking about things that are very personal, that may have significant impacts.  But even from the source, if you look at how insurance companies try to downplay that – they talk about the choices you want with a health plan, not the doctor but the PLAN.  They think that the plan is what is important.  Forget the person who is treating you.

The obvious defect in this loss and disruption are so obvious with health care because it is something that we all get impacted by.  Even if it is not personal, it is by somebody that we know, in our family, who we work with, but we all see it, even if we don’t personally live it.

It comes from the top.  There is a man, Wendell Potter, you may have heard about him.  He is very active with PNHP, and he also has a blog.  Wendell was a big Vice President with Cigna Health Insurance.

There came a case, and this was on the news, about a young woman who was in her early 20s; I don’t know what her medical issue was, but she needed a liver transplant, and Cigna said “No, it is not necessary.”  Or, it’s not time, she’s not ready, we need to wait.  There was a big uproar and all that.  People protested.  The whole thing.  Finally, there was such a media thing that Cigna backtracked, and they said OK.  But then the next day, or two days later, she died.

Their decision was made too late.  That is what caused Wendell Potter to leave Cigna.  He kind of knew this stuff was going on, but this was his tipping point.  Now he is a fervent Single Payer supporter, anti-health insurance.  Because he looks back and he is embarrassed by some of the things he did.  Because he was very good at writing up and delivering the lies that insurance companies had created.

The insurance companies are so far away from the problems.  If we look at how this is impacted.  Look at the Cleveland Clinic.  A massive institution.  It is almost like a city in itself in Cleveland, Ohio.  People come from around the world with cash in their pockets to pay for their health care for whatever they need.  Yet, the community across the street has the worst health outcomes of the entire state of Ohio.  Because they are not welcome in the Cleveland Clinic.

Komal Hak: Aren’t there drivers of funding?  I don’t know too much.  You would think if your community is healthy, you would get some funding or some grants, to keep some kind of accountability.

Dr. Rogers: You shouldn’t need grants.  If you have Medicaid you should have enough.  But the CEO there said they would prioritize patients for care, and MediCaid would go to the bottom because their reimbursement is the least.  It shouldn’t be that if I take your gall bladder out, or I treat your hypertension, that I should get more for each service depending on what you can pay me.  It should cost the same.

It is that culture that sends the message that it is OK to be like that.  The fact that we tolerate it.  I know you know friends, and we make jokes, I don’t know what’s wrong with me.  Well, you should go to Mayo Clinic.

Komal Hak: Web MD.  Web MD has become many people’s diagnosis, physician.  It’s hard.  You don’t want to pay for the cost.  Even with decent insurance, that $20 co-pay over time becomes too much of a financial burden.

Dr. Rogers: We talk a lot about what is affordable health care.  That is such a relative term.  What is affordable to me may not be affordable to you, and it certainly is not affordable to somebody who is homeless.  What is affordable health care?  It should be free at the point of care.  Then it is affordable to everyone, and there is no way around that.  There is absolutely no way around that.  Working at Cook County Hospital, I have seen so many homeless patients.  It is a difficult decision to discharge them from the hospital, knowing they are homeless in the middle of winter.

Dr. Famula: I would like to take us back to one of the things that you have alluded to and we have talked about, and several people have brought it up in the chat as well, is the idea of having access to primary care providers.  And more broadly, having access to the right workforce.  We know that there are shortages in nursing.  We know that there are shortages in primary care providers.  I am curious what you think has led to this imbalance in the system in the match with workforce with what the country really needs, and how health reform might be able to address that in an effective way.

Dr. Rogers: What has happened is that sub-specialists make so much money.   What is driving a lot of people to go into that are medical school loans and student loans.  After college and medical school, you may owe several hundreds of thousands of dollars in debt.  Let me tell you, what I got paid, as a Primary Care Provider (PCP), I’d still be paying off that loan.  And I still wouldn’t have been able to buy a house, and I still wouldn’t have a nice car.

That is what feeds into hospitals.  The whole system revolves around making money.  Those doctors that make the most money are the ones that are the most supported by the hospital.   Insurance companies don’t pay PCPs, they don’t pay primary care doctors, pediatricians, they don’t pay family practitioners.

We are just thinking, we aren’t performing procedures.  We don’t generate any money for the hospital.  I see a patient, sometimes they have to be admitted.   But most of my patients go home when they leave me.

However, the specialists, and the surgeons, they are doing procedures and they are generating money.  So they are not going to complain about their salaries.  That is part of the medical-industrial complex.

Dr. Famula: I am wondering in reform.  How does that fit into reform from your vision of it?  If we are looking at any type of Single Payer or, I want to say government funded but it is not really government funded, we are paying into all of this right now.  And yet we have a system like this, despite all of the number of people that come through MediCare or MediCaid or even the VA system, how does that change, from your perspective, in a Single Payer, or any kind of health reform, Public Option, anything?

How would that be able to be change, do you think?

Dr. Rogers: If we got rid of the for-profit system, there would not be this medical-industrial complex.  Because it wouldn’t be driven by money.  It would be driven by taking care of people.  And doing what we are supposed to do, because this is what we want to do.  There is nothing wrong with doing procedures and doing surgeries.  Those things are needed.  But you shouldn’t take out an extra gall bladder that doesn’t need to come out just because you want the money.

A Single Payer system would help because there is more need out there, and the people who are getting un-needed care will get less of that, and people who need care will get more of that.

One of the things that PNHP supports is paying Primary Care Physicians more, paying Pediatricians more, paying Family Practice doctors more.  One of the things, too, physicians who take care of MediCaid patients don’t get reimbursed to cover their costs.

Hospitals don’t get reimbursed to cover their costs.  Those are the hospitals that are closing.  Our hospitals whose payer mix is MediCaid and MediCare are in trouble because they do not reimburse enough.

I know the Congress has to know this, but because of the lobbying money, because when they decided to give money back to hospitals who were losing money through Covid, how they decided to pay them was based on how much money they earned the year before.  Of course, a hospital that had MediCare and MediCaid patients brought in less income.  Because their payer mix did not pay as much.  So who got the most money?  The hospitals with the most private insured patients, who were sitting on billions of dollars in endowment who were not in any financial distress.

Whereas the other hospitals got less money.

This is a policy that continues this structure.  I don’t know if they thought about it or they just go on with the money.  I get money from Pharma so I have to vote this way.  It is part of the structure.  The structural racism that prevented money from going to poor hospitals and poor communities.

These policies get made without looking at the whole picture.  Even with algorithms.  There has been a lot of talk in medical care about using algorithms to decide what you should do and what you shouldn’t do.  One of these algorithms, they looked at patients who spent the most money on health care.  They used that as a surrogate, meaning they were sicker.  But what it didn’t think about was that “I’m too poor to spend much money on my health care but I am actually sicker.”  So that algorithm disenfranchises poor sick patients.

We have a structure that doesn’t see the whole picture – in every aspect, because it chooses not to.  Those are active choices by policymakers.

Dr. Famula: When we have patients that are identified by the payer that they come in with to the health care system, we know we are going to get differential reimbursements.  I am presuming that if we all have the same payer, then it really doesn’t matter where the patient took the bus from to come to our clinic, we are going to get reimbursed, based on the care that we provide.  Not based on whether or not this governor in this state has decided to reimburse at this rate for this impoverished population, versus what the insurance has to negotiate in order to be able to get contracts with the hospital.

Dr. Rogers: Exactly.  This hospital doesn’t have to make more money to build a new cancer treatment center so that it can make even more money.  That motive will be gone because they can’t build that cancer center.  They have to get approved for that.  The hospital doesn’t need the money that it used to have.  It doesn’t need that office full of billers.  A whole other wing full of billers because they won’t need that anymore.

It would make a much more efficient system, and everybody would get the same care.  We would have to stay on top of it because we all know that there are ways to work around things that should be disbursed and distributed equally, but they are not.  We talk about the algorithms – even with getting mortgage loans, they are approved and you can’t be denied because you want to buy in a Black neighborhood.  There are still ways to deny people.

There has to be oversight and some acknowledgement that this is the right thing to do.

It is like, with Teen-Agers saying “I only doing it because you said I had to.”  Even though you know it is the right thing for them to do.  Eventually they will learn.  But it has to be part of the culture that that is the right thing to do.  I worry that we are very far from that, but we have to start.

Komal Hak: If primary care providers, and clinics and hospitals could get paid in this way, there would be a lot better, holistic integrated care.  I didn’t know until maybe a few months ago that a lot of Federally Qualified Health Centers don’t get paid for mental health visits if it is on the same day.  I think that is ridiculous, such a loss for the general public, for the community health aspect of it.  It would be great if a patient comes in, they have already taken care of child care.  There are so many different factors.  Transportation, say they made it to the clinic.  Of course you want to serve the whole patient.  But because of funding needs and financial restrictions, you are unable to.  They would have to come in on a separate day – more child care, more time out of your day, call off work.  There are so many factors that would make them more at a financial loss, increasing the disparity gap.  I could not believe what I learned.  Removing that factor would make society better, holistically, and we could maybe focus more on preventative health and treatinng the patient as a whole.

It is kind of bewildering how these systems have even come to be.

Dr. Rogers: They are made because there is a sense that people will just try to get more, and that they don’t deserve it.  It is free, so they want it.  It is that part of the culture too, especially against poor people.  Whatever I can get today, I want it all.  It is out of ignorance that these policies are made because they don’t choose to learn about the community that they are delivering care to.

Even when I went to Cook County as an Intern, I was 24 years old, I had spent a lot of time in school.  I had to learn some things, and acknowledge that everybody didn’t grow up the way that I did.  Not that I was wealthy or whatever, but there has to be some acknowledgement of a world different from the sphere that you live in.  Clearly, these inequities show that this country is not homogenous.

One of the things that is going to happen, because prices are going up so much, and more and more people who cannot afford health care that the system is going to collapse.  It is not sustainable.

An example that I remember from medical school in parasitology, is that a good parasite never kills its host.  These insurance companies are parasites.  They are killing us.  They are going to kill more and more – it is not sustainable.

Komal Hak: We need to be the antibiotic.

Dr. Rogers: That’s a good one.

Dr. Famula: I want to talk about care quality, because I think when we talk about how health care is financed or it is delivered, a lot of people are concerned that “I won’t be able to get as high quality care as I can get right now.”  Other people who have recently experienced the health care system.  You talked about delays of authorizations, which I think is a very common thing that people experience, anywhere from getting an MRI of their knee to being approved for hospitalization.

I am curious if you could comment about quality of care and how you would see reform impacting the quality of care.  You talked about life expectancy, and we are no shining star there.  Clearly, infant mortality is a disgrace for this nation, as apparently is how we treat pregnancy when 50% of that is on government assistance because we don’t have the kind of available health care for women that they really need to have healthy pregnancies.

Recently, in your own state of Illinois, they got permission US Health and Human Services Secretary Xavier Beccera to go ahead and continue MediCaid coverage as a pilot to go through the first year after delivery and not just the first sixty days.  As anyone who has ever been pregnant knows, if you are going to have a health care problem, if it doesn’t occur in the first sixty days, that doesn’t mean that you are going to have a healthy infant for that whole year – while you try to figure out how to take care of the mother.

Quality is a real issue.  I am interested in how you think health reform can address that.

Dr. Rogers: Health reform can address quality in several ways.  For one, it would allow for continuity of care.  People don’t get half treated for something because you can follow up, and you can get what is needed, and you can get all of the care that you need.

Making the care equitable and not have hospitals prioritize which patients they want to take care of.  That is what is done in this country.  People criticize Canada and say that people have to wait for so long for care, and that is why their system is better.  What people don’t realize is that people in the U.S. are waiting forever sometimes.  I would rather wait three months rather than forever for something that I needed.

Depending upon your frame of reference, what is quality will differ.  That is why we have medical guidelines: this is how you treat certain things, you need this antibiotic, you are doing the thing, and as a non-health care worker, you don’t understand that aspect of the quality because you don’t know how to treat things, and that is why you come, but I think quality will improve by making it equitable.  In that everybody gets the same.  Then you know you are following a standard of care.

There may be people that think that I am getting better care at this hospital because I have a view, and, emotionally, you will probably feel better with that view, but it is not much.  So there are things that people expect, like a nice car.  It varies.  If you have only driven a real high end car all the time, the bottom line of a Ford may not be acceptable to you.  But, we have to make sure services in all areas are equitable.  So that if you have hospitals that are bare bones and uncomfortable, people won’t go there, especially if they have a choice of going anywhere.

Quality is a hard one to figure.  One of the things is with a Single Payer system, especially with public hospitals that are affiliated with medical schools and academic centers that will grow and flourish.

Now we have hospitals, I look at Cook County, it is struggling even now.  Cook County is affiliated with medical schools.  It is an academic center – there is research going on there.  When you are affiliated with a medical school, you have to have a certain level of what you are providing.  I had to do certain things in order to get on the faculty of Rush University.

If hospitals are affiliated with medical schools, and they can be, the quality would be more equitable.  Everything is never going to be exactly the same. But if we have a Single Payer system, it shouldn’t be that in a poorer community, your hospital is so substandard.

Right now, there are some hospitals that get radiology equipment that is phenomenally expensive as hand-me-downs from other larger hospitals that are upgrading theirs.  It doesn’t mean that that machine won’t work, but you are creating two tiers here.  That is what we are doing now: we are creating different tiers of care, depending upon how it gets paid.  If we eliminated that, it would be much easier to create one tier.

But the culture of this country, the racism in this country, the anti-immigrant culture in this country, all of that is going to make it difficult.  There is nothing magic about having Single Payer.  It is not going to make all patients want to go to all hospitals.  It just won’t, because of the way this country is, but it will help.  At least the first thing is to acknowledge that the inequity is there, and then do what you can to level the playing field by making patients all equal in terms of payer mix.  That is a start.  Nobody is worth more than anybody else.

Komal Hak: I think it also would affect the workforce.  We see a lot of workforce leaving underfunded clinics and health centers.  They also need to be paid for their quality of life and cost of living.  That would equalize the workforce as well.  Then struggling clinics wouldn’t be losing their workforce, and thus able to address their patient population.

Also, with the wait time, with the quality of care.  We wouldn’t be seeing as many acute instances.  I think it would lead to more preventative care.  Just naturally, equalizing that playing field, where people aren’t necessarily going to the hospital now – oh, my gosh, I need to go or I might die, or this pain is so bad I cannot handle, my tooth pain is now a root canal – I would just go, a simple procedure, less expensive procedure, which would reduce costs overall.

Dr. Rogers: I have seen some horrendous things that patients tolerated for weeks to months, that possibly could have been curable.  By the time they come in, it is more expensive to treat them. But people don’t know where they can go.  And even if they go to a hospital if they are uninsured.  I cannot tell you how many patients were admitted to my service that came with a map printed off Mapquest of how to get to Cook County Hospital because “they will take care of you there.”  Because they were some place else that wouldn’t take care of them.  Here they are, they are sent to a hospital that is far away from where they live, which means they won’t have follow up, and their family won’t visit.  The consequences of things like that people don’t even think about.

Komal Hak: I wanted to go to one last question before we go to the audience question and answer: how can reform address the social determinants of health?  Lack of housing, food insecurity, safety, and financial security that are usually seen as outside the health system.  How do you see reform would address that, for individuals and for communities as a whole?

Dr. Rogers: There are a couple of ways.  If the community became healthier because they had access to care, people could possibly become more productive.  The other thing is that when you have a hospital in your neighborhood, that hospital creates jobs.  There are people in that neighborhood who could work at that hospital.  Also, people that work at that hospital, they may need a grocery store to stop at close to work before they go home.  There is going to be restaurants.  There are going to be other stores.  There is going to increase business.

A hospital in a community is a positive for that community.  It helps address some of that.  And then it becomes an area that not necessarily that you want to avoid, because there are some positive things that make neighborhoods attractive, that make them inclusive, make people want to go in that neighborhood.  Whenever you have an area that provides jobs, it is a domino effect on the rest of the community.  It will help.

The other thing, too, is there are a lot of communities that have a lot of mental health issues, a lot of homeless issues.  Those could help be addressed and dealt with.

These are things that take time.  Aspirin for a headache?  It is not going to be that easy.  I don’t even know if anybody takes aspirin for a headache anymore.  It is not a quick fix.  It is something that will take time.  To build new facilities takes time.

It is not an overnight change, but we have to at least start and we have to acknowledge what the problem is.  This country does not acknowledge the problem.  They just keep talking about “we have to make care affordable.”  And again I ask, affordable for who?

Dr. Famula: The sooner we have something as basic as health care delivered in an equitable way, I think as a society it compels us to see how everything about life needs to be delivered in a more equitable way.  It can have a domino effect, I believe.

I want to get to some of the viewer questions.  I will start with one that has come up repeatedly in the chat because I think that it is something that everybody – you are talking to a group of people who are actively engaged, who like to inspire voters and community participation, and the recurring question is: while we are waiting for the government to completely address this, what can we do as individuals and what can we inspire other voters and engaged individuals to start doing now to try to address some of these inequities within our health system.

Dr. Rogers: That is getting into the role of activism, and that involves a lot of things: calling your Congress person, making visits to the Congress person.  You don’t need to do this by yourself.  Two or three people together can go talk to them.  And they are receptive, but you have to be vigilant and keep going.

Become involved in social activism in organizations.   I know that Physicians for a National Health Program (PNHP) has chapters throughout the country in different states.  You don’t have to be a physician to be a member.  There are a lot of “MediCare for All” groups.  “Health Care NOW.”  There are other social activist groups, Public Citizen.  There are a lot of groups out there that do this work, this activism work, to address these inequities.

One of the things, too, is to start seeing first hand: what goes on: volunteer at a hospital.  I don’t know if you can now, because of Covid.  There are a lot of restrictions on what you can volunteer to do because of Covid.  But to see what is happening.  Volunteer at a school and see.  A lot of schools need help, especially with the younger grades.

Develop that sense of social activism.  That is the grassroots where all of this comes from.  I do my talks to you.  Then there are other people who do other things.  So we all have our roles that we like.  I say find something you like doing because then you will keep doing it.  If you don’t like talking on the phone, then calling Congress people maybe isn’t what you should say you will do.  Find something that you like doing, and grow with that.  I think that will open other doors.  It is really this grassroots, social activism that has to spread to every day people, not just politicians but to every day people as to why this would work.  Organize a talk in your community, in your church or school.  Do something on Single Payer.

Get involved and energize yourself so that you can keep motivated.  It really is the grassroots.  When there are rallies, go to them.

Komal Hak: I think it is also important to note that we don’t always have to call our Congress members and our Legislators.  Also write to them.  They are saying that social media is a huge driver for legislators.  They pay attention to that.  There is also a “quick actions” that is already automated on line and you can just click it.  You can use google or search engines to search for the policies on health care that are present in your state.

There are also web sites that will do kind of like a layperson’s understanding of that bill.  That way you can see if you want to support or not and get a better understanding.  I found out about bills that way.  I found out that about the telehealth bill that just was passed in California.  Right now there is a drug pricing bill that people are pushing for.

I didn’t realize how many nuances there are in the infrastructure bill.  We want to vocalize that we want money, funding for let’s say community health centers, or road infrastructure.  Depending on what you want to advocate for, there are avenues.  We need to learn to be specific.  Not just “oh, we need an infrastructure bill.”  We need to learn the nuances of what is being put in the bill itself.

All of this can be done by searching on line, and finding avenues.  By searching on line at reputable web sites, making sure they are informative, non-partisan so that you can become informed in you decision making.

Dr. Rogers: Like you said, learn as much about the topic as you can because that is the way you will be able to convince other people.  Start with family or good friends, that if you say something wrong, they will forgive you.  That is a good way to start.

The web sites that I listed at the end of my talk are very useful to go to for information.

Komal Hak: A chat question: how do we build trust in African American community?  How is that possible?  What steps could be taken?

Dr. Rogers: When you say trust, trust around what?

Komal Hak: Health care.  Getting people’s trust to go, to seek health care when they need it.

Dr. Rogers: That is a difficult issue because of the history of how Blacks have been treated, and how Blacks continue to be treated.  There is still so much bias within the health care community.  The problem with bias and structured racism is that it keeps going on and people aren’t even aware of it.  It is just sort of considered the norm.

That is a hard one.  And a lot of people don’t trust physicians not just because of the racial thing or the racial history, but they have had bad experiences.  It is hard.  You have to be able to show them that you are different if you are a health care provider.  That is difficult now days because you may never see them again.  I know that as a hospitalist I found that, and I found it kind of frustrating – that’s why I liked being a primary care doctor.  You get to see the same patients over and over and over, and you are do develop a relationship.

Even in the hospital, as a hospitalist, you develop a relationship.

If you are talking about building trust, it is a time dependent process.  It is not quick.  It is just like if you are dating someone.  You don’t trust them after two dates.  It takes time to get to know them.  For people to understand that you are on their side.  Especially with health care, you want them to take this medicine, or you want them to have this test or whatever.  It takes time for people to trust you.  So be patient with it.

If you can get one person, it can spread to their family.  Oh yeah, go to Doctor A because they are good.  Acknowledge that it takes time, and don’t get frustrated.  Because it does take time.  It can be done.

Dr. Famula: One other thing I would like to add to that it is really important for patients to recognize how valuable continuity of care is really in having a successful outcome working with a clinician.  As a former clinician in primary care, I thought that continuity of care was just critical.  So often, just to be able to see what did and didn’t happen, to appreciate a particular patient, and now maybe some new condition is happening, or know what their prior conditions were, it really colors how you go through that diagnostic evaluation of what is going on here or what is in their best interest.

When you have that continuity, it is trusting on both sides.  It let’s you move through the process much more effectively.  To me, that is one of the biggest problems in our current system of your insurer deciding who your doctors are, as opposed to you picking a doctor, and then saying, oh and by the way, this is my insurance.

That is the way it used to be back in the 1970s.  Your doctor would say who is your insurance?  OK, we will send them the forms to them, as opposed to now your saying well insurance company, who can I go see?

Dr. Rogers: It is interesting because now when you talk about being able to see the same provider when you want, I look at “concierge medicine.”  This whole structure that when you have the money, you can get the structure to work for you.  That’s who can do that.  Again, we have to change that system, that you can’t just get that when you have money.  It has to be for everybody.

Komal Hak: There is a question about explaining the hospital-medical-industrial complex.

Dr. Rogers: They feed on each other.  They are both for-profit driven industries.  If we look at insurance, hospitals and even pharma, they need each other to function.

One of the things that insurance companies are doing is they are taking over areas so that they become a monopoly.  When you look at large hospitals, people want to go to a hospital that is close to where they live.  So they have these networks where most of the doctors in that hospital will be on the insurance plans that people in that neighborhood would join because that is the hospital that they would want to go to.

They feed off each other, but they are both driven by wanting to get money.  The insurance company wants your premium dollars; the hospital wants the insurance company to pay their bills.  The insurance company doesn’t really care what the hospital charges.  Because it doesn’t matter if they spend $100 on ten things, or $1,000 on one thing.  They just look at the amount of money that they are going to spend because they have to make sure that that 20% is left for their profit.  It is all together.  They are motivated by the money.  They are going to make sure that they are going to deny care. Hospitals don’t always like that because then they have to go after you for the bill and you don’t have the money.  That is how they work together.

This sickness is driven by profit.

Komal Hak: Do you think subsidizing medical schools would drive more physicians towards staying in primary care field?

Dr. Rogers: Subsidizing tuition will do several things.  One, it will increase the number of people who otherwise would not go to medical school go to medical school.  Medical school students are becoming wealthier and wealthier.  They come from wealth and that wealth can pay their tuition.  They don’t have to take loans.  They still choose to go to a high-priced specialty, so that they can stay wealthy because that is how they grew up.

One of the problems is that it is making medical students less diverse because of that tuition.

I think for sure many students are going into specialties because of their loans and choosing specialties that will pay well enough so that they can do that.  One of the things I try to tell students, is that you still have to choose something that you like, that will make you happy.  You will never make enough money to make you happy.  You will just be an unhappy rich person.  You won’t be broke being an Internist, I‘m not broke.  But I don’t have a boat.  There is still a way to have a productive, functional life as a primary care physician.

It is awful.  It is not just medical school.  It starts at undergrad.  You can’t go to medical school until you do your undergrad first, so now you have eight years of tuition.   I know when I went to medical school, it cost me more to live – my rent, my food, my transportation costs more than my tuition.

Komal Hak: NYU has offered free tuition.  But the cost of living I think is $30,000 a year without tuition, that is still unlivable for people who aren’t working full time, and you can’t go to medical school and work, even part time.  It is an impossible feat.  Being cognizant of that, a year of medical school would be $80,000 a year; medical school is a half million dollars worth of debt, with interest being accrued.  As a Resident, you make almost next to nothing, depending on how long your residency is.

Dr. Rogers: It is a big commitment and it impacts your family.  It is a difficult journey, even without the finance issue.  There has to be a way, because you want to attract people who are going into it for the right reasons.  You want people who have empathy, who want to do it because they care about people.

One of the things that I am really concerned about is the way the health system is going with the electronic medical records and doctors are looked at as employees, you have 15 minutes to see this patient.  “I am sorry your husband died but I just can’t talk to you about it.” That is not the way it should be.

Komal Hak: Health reform would definitely address this.

Dr. Rogers: It would make it so that yes, you may still be an employee of a group, but that group is not there to make money, to make such a large profit, the way it is now.  You are there to provide care.  You are there to treat your patient.  So you have a little bit more flexibility.

Komal Hak: Michelle, did you see the same thing when you saw students at the student health center?

Dr. Famula: In terms of what people’s costs for education were, and choices that they made afterward?

Komal Hak: The reform would alleviate the need to churn people out.

Dr. Famula: It is complicated.  We have the system we have now and people don’t yet see what it could be.  That could still be a driver.  But, absolutely, in the end, when you have what appears to be insurmountable debt, it makes decisions about what kind of career choices you make when you can clearly see the differences in annual incomes.

I wanted to try to capture one other thing that came up on the chat that I wanted to ask Dr. Rogers.  If your organization or you personally have seen effective ways of dealing with “employer costs.”  There are two different ways of looking at this: first, government is an employer.  It is siphoning so much of our tax dollars to put it into private health insurance, at the municipality level, at the school level, really all different agencies within the governments that we pay for.  We are paying for their health insurance.  Someone mentioned Congress, if they have the health insurance that we have.

Our tax dollars are paying a lot of insurance companies to provide “care” at tremendous costs that takes those dollars away from the programs we aare trying to see thrive.

And at the same time, we have a similar thing in the private sector where employers are not able to pay people in salary what they have to pay in benefits.  We don’t hear very much from employers about the high cost of health care enough to mobilize them to take some kind of action on trying to change our health care financing system.

Has PNHP worked with this?  Are there organizations that are looking at trying to stimulate either government or other private sector employers to get more involved in this issue of health financing reform?

Dr. Rogers: We don’t have a specific aspect of PNHP that addresses that by itself, but we are in coalitions with labor.  Labor works however more with the employees versus employers.

One of the things that employers get is a tax advantage they get for paying for a health insurance premium.  This started back in the 1940s with World War II.  Because wages were frozen, they offered health insurance to employees.  That was in lieu of paying them more money, they paid for their health insurance.  The government responded by saying, OK it’s a win-win: you don’t have to pay a tax on that money that goes to the insurance company rather than to the salary of that employee.

Salaries are much greater now than they were in the 1940s.  That is a phenomenal amount of tax benefit that large corporations get, that they will lose if we have a Single Payer system.  What it would be is employees would then pay what we call a progressive tax.

Rather than not getting that salary, they would pay a certain percentage of what is their salary, which is actually more fair: what is happening now is that health insurance policy costs $20,000 for your family whether you make $30,000 a year or $300,000 a year.  You are paying the same for that insurance.  Your tax would be based on your salary, so your tax would be much less than the person making $300,000 a year.  So it would be more appropriate.

But the employer would lose that tax benefit.  They will fight that.  They will find a way to avoid it.  But they still will not be having to pay that insurance premium, so it won’t be a tax on that.  It could be a win-win.  I am not sure how company taxes function, how they do this.  You would think that employers would want that.  Then they would have a healthier workforce.  People wouldn’t come to work sick.  And that people could continue to do their job.  Because they feel well.  Somebody stay home two days with a cold versus get everybody in the office sick, and then everybody has to take five days off.  It is to everybody’s benefit if the whole workforce is covered and they have access.

It is the same thing, we should have maternity leave.  We are the only industrialized country that does not mandate maternity leave.

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Dr. Famula: Komal, I am going to turn it over to you to do our closing.

Komal Hak: It was a great topic to be ending.  I really want to thank you both, Dr. Rogers and Michelle for tonight’s presentation.  And to our audience.  Thank you for taking the time out tonight to inform our audience and myself, and everyone else who will see this recording later.

We hope that tonight’s program has helped increase understanding of our U.S. health care system and has prompted further consideration of opportunities for reform.  We hope our League forum can raise non-partisan awareness of legislative health care issues, and we really want to create a better understanding of our current health care system, and to see what is and what isn’t working in all of our communities, and how it can be improved and made equitable so that it is a level playing field for everyone.

The recording of this program is available at our Davis Area LWVC web site,  https://lwvdavisarea.org.

I want to thank everyone for joining us this evening.  All of our League forums are free for the community and others.

I would love to thank the League co-sponsors and our featured speaker, Dr. Rogers.  Thanks to everyone so much, have a great night.

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Transcription: Jon Li, Institute for Public Science & Art