PNHP

Medical Journals are Allergic to Data on Racism

Medical Journals are Allergic to Data on Racism

Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health, Health Affairs Blog, April 20,2021, by Nancy Krieger, et al.

We conducted a literature search for … papers including the word “racism” that were published between January 1, 1990 and December 31, 2020 by four leading medical journals (all with impact factors for 2019 exceeding 30). These journals were: the New England Journal of Medicine (NEJM), The Lancet, JAMA, and the British Medical Journal (BMJ). We focused deliberately on the term “racism” because naming racism is a critical step in addressing its impacts. And given evidence of some journals censoring its use, this focus allowed us to assess the extent to which use of this term has been permitted.

For comparative purposes, we also searched publications in one of the longstanding and leading global public health journals, the American Journal of Public Health (AJPH), and we additionally examined the Annual Review series for four disciplines (medicine, public health, sociology, and psychology) as a gauge of the extant evidence base. …

The four medical journals published markedly lower numbers of papers including the word “racism” compared to AJPH, despite their publishing many more papers between 1990-2020 (14,192 for AJPH, vs. 40,411 for JAMA, 43,378 for NEJM, 63,971 for The Lancet, and 78,545 for BMJ). Although we did not include Health Affairs in this analysis, Rhea Boyd (one of the authors of this post) and colleagues noted in an earlier Health Affairs Blog post, “A quick search of the Health Affairs website reveals only 114 pieces include the word racism in the 39-year history of the journal.” …

Exhibit 2: Analysis of article type for journal articles that included the word ‘racism.’

For the four leading medical journals, upwards of 90 percent of publications including the word “racism”… were commentaries, viewpoints, or letters. The percentage that were either original empirical investigations or review articles with a significant data component ranged from 4 percent (BMJ and NEJM) to at most 10 percent (The Lancet) (exhibit 2). By contrast, for AJPH, 60 percent of identified articles were empirical studies or review articles with significant data, and only 40 percent were commentaries, viewpoints, or letters. …

Non-publication of this research conveys the message that racism and its impact on people’s health are not important and not topics that warrant scientific study or publication, thereby minimizing concerns about these harms among scientists, funding agencies, and the broader public.

Second, non-publication of scientific research on racism and health by leading journals, especially in this era of evidence-based clinical medicine, fosters ignorance about these issues among health professionals, who as trusted sources of information then transmit this ignorance to their patients, clients, and the broader public.

Third, this non-publication of evidence undercuts and limits the important kinds of evidence needed by policy makers, health agencies, funders, lawyers, and advocates for their complementary work to prevent racism and rectify how it harms health.

Fourth, non-publication of this work effectively excludes scholars who study racism and health from high-impact journals, harming not only knowledge dissemination but also potentially the career pathways of these scholars.

Comment:

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

In recent months younger colleagues and others we know have had several studies documenting stark racial inequities in health care rejected by major journals based on: (1) minor quibbles about methods that have not been raised about closely similar analyses of age-, insurance or income-based disparities; or (2) claims that race-based disparities may simply reflect overuse of care by White people, and hence are not indicative of racism.

Our experience is apparently not unique.  This meticulous survey documents major medical journals’ refusal to publish data on racism.  While the journals have accepted commentaries and letters on racism, they continue to boycott studies documenting the patterns of care and outcomes indicative of structural racism.  So while we’re now allowed to say that racism in the health care system exists, we’re not allowed to provide the data that’s key to addressing it.

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Physicians’ group launches new campaign to move the medical profession to Medicare for All

The 24,000-member Physicians for a National Health Program to target local, state, and specialty medical societies with Medical Resolutions Campaign

FOR RELEASE ON JULY 12, 2021

Contact: Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org
Dr. Susan Rogers, Physicians for a National Health Program President, s.rogers@pnhp.org

Physicians for a National Health Program, a nonprofit advocacy organization with more than 24,000 members, today launched its national Medical Society Resolutions (MSR) campaign. The goal of the MSR campaign is to organize the medical profession to support single-payer Medicare for All by passing pro-single-payer resolutions in local, state, and specialty medical societies throughout the U.S.

Surveys show that a majority of American doctors now support improved Medicare for All, but most physicians’ professional organizations do not reflect the changing views of their members.

“Covid-19 has made the need for Medicare for All even more urgent,” said Dr. Susan Rogers, a Chicago-based internal medicine physician and president of PNHP, “but we can’t win single-payer reform without the full support of the medical profession.” Dr. Rogers added, “Even though a large and growing number of physicians favor Medicare for All, the organizations that claim to represent us don’t yet endorse the policies we need to provide universal, equitable, and comprehensive coverage to everybody in the U.S. Our local, state, and specialty medical societies have the power to influence the national debate on health care, and we need them to use that power to win Medicare for All.”

The Medical Society Resolutions campaign follows two years of unprecedented movement towards Medicare for All within organized medicine:

PNHP members are also active in a sister campaign led by Public Citizen to pass single-payer resolutions in city and county councils. To date, the campaign has passed 65 local resolutions in favor of Medicare for All, including major cities such as Philadelphia, Oakland, Detroit, Minneapolis, Seattle, San Francisco, Cook County (Chicago), Los Angeles, Knoxville, and Milwaukee.

For more information on the PNHP Medical Resolutions Campaign, visit medicalsocietyresolutions.org.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 24,000 members support single-payer national health insurance.

CMS Direct Contracting Scheme Will Privatize Medicare

Comment:

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

Medicare offers enrollees a choice of “traditional” Medicare (government-administered coverage for virtually all physicians and hospitals in the US) or Medicare Advantage (private insurance plans with restricted provider panels). Nearly 60% of enrollees select traditional Medicare, and financial analyses by CMS, MedPAC, and others consistently show that traditional Medicare is less costly than Medicare Advantage.

However, in 2020, the Trump Administration launched a new CMS experiment, the Global Professional Direct Contracting (GPDC) model, that is designed to privatize traditional Medicare. That’s right, end the public part of Medicare as we know it.

GPDC transfers cost and care management to private for-profit insurer and investor contracting entities. Under this model, CMS could auto-assign more than 30 million beneficiaries who have chosen traditional Medicareinto entities managed by private for-profit companies, without their understanding or consent. These entities are similar to Medicare Advantage plans even though the enrollees explicitly rejected this type of coverage. Although not technically permissible, contracting entities could shift enrollees to Medicare Advantage.

The direct contracting experiment, as designed, has four profound flaws:

  • Violates the spirit and public insurance essence of traditional Medicare.
  • Undoes the fundamental choice made by Medicare enrollees.
  • Will increase costs.
  • Likely will not improve quality or allow for objective quality assessment, based on the Medicare Advantage experience.

You’ll notice that this post includes no document link at the top. That’s because this program is happening behind closed doors, on the sly. No public discussion of a massive transformation of traditional Medicare. I know about it because of the excellent sleuthing of colleagues, who have assembled a compelling analysis and report. This will be public soon, but we agreed that there is great urgency to let people know about this threat, so they can speak against it.

Here’s the solution:

  1. Immediately suspend GPDC, pending full review and revision, including participation by relevant stakeholders and external experts.
  2. Restrict direct contracting to entities that are >75% owned by providers, not investors or insurers.
  3. Limit GPDC to < 500,000 participants.
  4. Traditional Medicare enrollees must be:
    • assured full understanding of the program;
    • enrolled only if they actively “opt in;” and,
    • properly informed of their ongoing right to see out-of-network providers and to opt out of GPDC.
  5. Participating providers must submit all medical claims to CMS to permit effective evaluation of cost (to CMS and enrollees), access to care, and health outcomes.
  6. CMS must end GPDC if, overall, it fails to lower costs and improve the care experience within three years.

The integrity of Medicare is at stake.

http://healthjusticemonitor.org…

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Even U.S. privileged have worse health outcomes than average for other wealthy nations

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries, JAMA Internal Medicine, March, 2021;181:339-44, by Ezekiel J. Emanuel et al.

From the Abstract:

Objective: To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries…

Conclusions and Relevance: This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.

Comment:

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

US society and medical care are bad for almost everyone’s health. While Black and Native Americans, and the poor, suffer the most, even white residents of the wealthiest 1% of counties have worse health outcomes on many measures than the average of other wealthy nations.

This terrible indictment of our society indicates the need for fundamental changes in medical care and beyond. A society that values corporations’ drive for profit above all else is bad for everyone’s health.

http://healthjusticemonitor.org…

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How Would Medicare for All Affect Physician Revenue?

By Christopher Cai, M.D.
Journal of General Internal Medicine, Viewpoint, July 8, 2021

Organized medicine in the USA is shifting its position toward single-payer reform, one version of which, “Medicare for All,” has gained substantial support in Congress. The American Medical Association recently left the Partnership for America’s Healthcare Future, a lobbying group that spent more than one hundred million dollars annually opposing both a public option and Medicare for All in federal election campaigns. In 2020, the American College of Physicians and the Society of General Internal Medicine went a step further, endorsing both public option and single-payer reforms.

Yet, physician opinion on Medicare for All remains split, with most doctors concerned that such reform might decrease their income. While physicians are highly paid, these concerns are understandable given the burden of student debt, the length of medical training, and Medicare’s lower fees relative to private insurers’.

Are such concerns supported by evidence? The nonpartisan Congressional Budget Office (CBO) recently estimated payments to physicians in 2030 under current policies and five options for Medicare for All. It projects that without reform the weighted average of public and private payments to physicians will increase to 116% of the 2019 weighted average, versus between 108% and 117% under the various Medicare for All options analyzed.1 But because the CBO expects Medicare for All to increase society-wide utilization of care, it also predicts that providers’ total revenues would increase, even if fee levels were to decline.

More specifically, the CBO projects that in 2030 providers’ total outpatient revenues would be between 5 and 9% higher under Medicare for All than without reform; physician services currently account for 78% of such revenue.1,2 These estimates assume that Medicare for All would not significantly alter the supply of physicians, which is currently limited by the supply of residency and medical school spots.1

Some scholars project even larger boosts to physicians’ take-home pay because the CBO estimates may understate practices’ savings from streamlined billing. If, as studies suggest, Medicare for All would free up roughly 5% of doctors’ work hours currently spent on billing, allowing them to increase patient care, per-physician revenue could rise by between $39,816 and $157,412 annually.2 While those figures may be an overestimate, since some providers might choose to spend the freed-up time on leisure activities rather than increased patient care, they may underestimate revenue changes, as fee-for-service providers have, in the past, responded to decreased Medicare reimbursement rates by increasing volume of services.1 The latter won’t apply to salaried providers, such as those working in capitated healthcare systems, but these providers are still likely to feel the benefits of administrative streamlining.

Other prominent economic analyses of Medicare for All have also projected net increases in physicians’ revenue, even if current Medicare payment rates do not increase.3 Yet despite projecting increases in physicians’ revenues, almost all estimates of the overall costs of single-payer reform project savings, due to savings from administrative simplification.3 Hence, it appears possible to design a single-payer reform that would offer universal coverage without cost sharing, while increasing net revenue to providers and decreasing national health expenditures.3

History offers hopeful messages about the likely effect of single-payer reform on doctors’ incomes. When Canada transitioned to single-payer in the mid-20th century, physician income increased, and physicians remained the highest paid professionals in the nation.4 Since then, physician income in Canada has grown faster than the incomes of other workers. Yet, caution is warranted in interpreting these trends, which may not be duplicated in a reform initiated five decades or more after Canada’s system was fully implemented in 1971. Medicare’s history offers mixed lessons. Limitation on increases in Medicare’s payments to physicians (known as the sustainable growth rate or SGR) included in the 1997 Balanced Budget Act threatened sharp cuts in Medicare’s fee schedule. Yet Congress annually overrode the threatened cuts, and eventually repealed the SGR formula.

How would increases in revenue projected by the CBO be distributed among various physician specialties? Since both Congressional Medicare for All bills provide comprehensive benefits with little or no cost sharing (copayments or deductibles), individuals who currently cannot get medical care because of cost would increase their utilization of care. As a result, doctors who serve patients who are undertreated at present may experience the greatest increases in demand for their services, and in their revenues. Primary care providers are likely to fall into this category, given the degree to which hypertension, diabetes, hyperlipidemia, and other chronic conditions are currently undertreated. Anticipating this, the Congressional legislation would set aside funding to establish an Office of Primary Care, charged with developing policies to increase the number of primary care practitioners.

Although primary care doctors might get the biggest income boosts under single payer, specialists would continue to be high earners. The 1966 implementation of Medicaid/Medicare resulted in an increase in per-capita surgical procedures among the elderly.5 In Canada, the specialist:primary care income ratio has remained quite high; in 2019, gross clinical payments to thoracic surgeons averaged $588,000 (Canadian dollars) compared to $280,000 for family medicine physicians. Malpractice insurance costs, currently the highest for proceduralists, would likely fall as they did in Canada, since patients would no longer have to sue to cover future medical costs. And in many doctors’ practices, the case mix is likely to change for the better. As patients with unmet medical needs increase their utilization, the limited supply of hospital beds and physicians would likely cause a modest decrease in the delivery of low-value services.5 In essence, doctors could shift their efforts to address the greatest needs, without fear of losing income. To prevent waitlists, an increase in residency training programs may be necessary.

Medicare for All may also decrease inequities in physician pay. Increased demand and federal funding for primary care may modestly mitigate the racial and gender pay gaps in medicine, as nonwhite and non-male physicians are more likely to specialize in primary care fields.6 In addition, using a funding scheme called “global budgeting,” Medicare for All would likely increase revenue for underfunded safety net hospitals and clinics, which disproportionately employ physicians of color.7 However, the root causes of such pay disparities are racism and sexism, and thus, even with Medicare for All, additional anti-racist and anti-sexist reforms will be needed in the workplace.

Proposals for a Medicare “public option” or “Medicare Advantage for All” would sacrifice most of the administrative savings that Medicare for All could garner, making universal first dollar coverage unaffordable, minimizing increases in the utilization of care, and hence physicians’ practice revenues. Additionally, current fee schedules would likely persist under a public option reform, preserving the status quo that offers outsized rewards for performing procedures and caring for privately insured patients.

In sum, the available evidence—including the CBO’s authoritative estimate—suggests that physicians would prosper under single-payer reform. By supporting Medicare for All, physicians—and organized medicine—can get a twofer: acting in physicians’ self-interest while advancing legislation that would be enormously beneficial to patients.

Contributors: I am grateful for the feedback of Dr. Steffie Woolhandler, Dr. David Himmelstein, Dr. Samuel Dickman, Dr. Iris Borowsky, and Dr. Steve Borowsky on previous versions of this manuscript.

Author Affiliations: Department of Medicine, Internal Medicine Residency Program at Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Disclosures: Dr. Cai has previously worked as a paid summer health policy fellow for US Representative Pramila Jayapal, the lead cosponsor of the Medicare for All Act of 2021, as a paid summer researcher for Physicians for a National Health Program (PNHP), a nonprofit which favors single-payer health reform, and as an unpaid board member of Students for a National Health Program (SNaHP) and PNHP.

https://link.springer.com…

References

  1. How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems That Are Based on Medicare’s Fee-for-Service Program: Working Paper 2020-08 [Internet]. Congressional Budget Office; [cited 2021 Jan 30]. Available from: https://www.cbo.gov…
  2. Gaffney A, Woolhandler S, Himmelstein D. Congressional Budget Office Scores Medicare-for-All: Universal Coverage for Less Spending [Internet]. Health Affairs Blog. February 16 2021. Available from: https://www.healthaffairs.org…
  3. Cai C, Runte J, Ostrer I, Berry K, Ponce N, Rodriguez M, et al. Projected costs of single-payer healthcare financing in the United States: a systematic review of economic analyses. PLoS Med 2020;17(1):e1003013. Article  Google Scholar
  4. Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health 2011;101(7):1198–208. Article  Google Scholar
  5. Gaffney A, McCormick D, Bor D, Woolhandler S, Himmelstein D. Coverage Expansions and utilization of physician care: evidence from the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions. Am J Public Health 2019;109(12):1694–701. Article  Google Scholar
  6. Medscape 2020 Physicians’ Compensation Report [Internet]. [cited 2021 Feb 5]. Available from: https://www.medscape.com…
  7. Cai C, Kahn J. Medicare for All Would Improve Hospital Financing [Internet]. Health Affairs Blog 2019. Available from: https://www.healthaffairs.org…

New rules are nice, but a new program would be better

By Ken Lefkowitz
The Washington Post, Letters, July 8, 2021

Regarding the July 2 Politics & the Nation article “New rules are issued to protect patients from surprise medical billing”:

The new Biden administration rules to protect patients against “surprise billing” for out-of-network services is commendable, but their impact on medical costs will most certainly be diluted. Health insurers’ networks are negotiated so the insurer can save costs in our free-market, for-profit health-care system. We can expect that to counter the savings lost by insurers under the new rules, health-care providers will turn to another avenue to make up for the reduced profits, such as increasing premiums for coverage.

It is time to stop tweaking our for-profit system and implement Medicare-for-all, a cost-effective single-payer approach. It will cover all residents with no networks, premiums, deductibles or co-pays. It has proved to be less costly in other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide negotiating leverage to stabilize doctors, hospitals and pharmacy costs. Three major studies — one by the University of Massachusetts, one published in the Lancet and another appearing in the Annals of Medicine — have estimated annual savings on health-care spending between $500 billion and $600 billion per year if Medicare-for-all were adopted.

The writer is a member of the New Jersey Universal Healthcare Coalition and Physicians for a National Health Program.

https://www.washingtonpost.com…

Insurers issue defective & deceptive provider directories

San Diego sues Molina, HealthNet, Kaiser, Modern Healthcare, June 25, 2021, by Nona Tepper

The city of San Diego sued three health insurers on Friday, alleging Kaiser Permanente, HealthNet and Molina Healthcare all advertised false networks of providers in an attempt to get consumers to sign up for their plans.

“Consumers should be able to trust their health insurers when seeking medical attention,” San Diego City Attorney Mara Elliot said in a statement. “Error-filled directories create dangerous barriers to healthcare services, with patients struggling to find a directory-listed doctor who will accept their insurance.” California law requires health insurers to update their printed provider directories quarterly and online listings weekly, the complaint said. These payers knew they were advertising false networks.

The complaints allege that up to 35% of the providers in Kaiser Permanente and HealthNet’s directories were listed inaccurately, and 80% of clinicians in Molina Healthcare’s directory were falsely listed as in-network.

Insurers’ error-riddled provider directories allowed them to attract more prospective enrollees and command higher prices, according to the suit. Falsely inflating their network size also made it harder for competitors to compete in the marketplace, the complaint said.

Each complaint said that insurers’ inaccurate listings disproportionately impacted low-income enrollees — who were more likely to be Black or Hispanic, according to the lawsuit — individuals with disabilities, people seeking mental healthcare, seniors lacking digital literacy, and women.

Each complaint noted that this was not the first warning insurers received.

Comment:

By Don McCanne, M.D.

The dishonesty of these insurers in maintaining deceptive provider directories not only represents an unfair business practice, but it is also a violation of law that results in financial harm to patients, the very population that they should be serving.

If we had a single payer Medicare for All program, there would be no need for provider lists because all legal health care professionals and institutions would be automatically covered under one system. Further, we would not need to pay hundreds of billions of dollars to these superfluous intermediaries. (But think of a future for integrated systems such as Kaiser Permanente strictly as health care delivery systems and not as risk-bearing insurers.)

For those who say that we have a moral obligation to support the insurers, think again. Our moral obligation is to the patients, and we need to terminate the burden that the insurers are placing on them, and, incidentally, the burden that they are placing on the health care delivery system itself.

http://healthjusticemonitor.org…

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Yet Another Medicare Advantage Cheating Scheme

Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans, Medical Care, February, 2021, by David J. Meyers and Amal Trivedi

From the Abstract:

Background: In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees’ number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments.. . .

Results: Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans.

Comment:

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

It’s long been known that Medicare Advantage (MA) plans selectively recruit low-cost Medicare enrollees and evict the expensively-ill, such as those who require nursing home care. As a result, Medicare pays MA plans 4% more than it would cost to care for their patients in the traditional Medicare program.

In response, CMS has tried to risk adjust MA plan premiums based on patients’ diagnoses. MA plans have counter-attacked by pressing clinicians to more assiduously code every diagnosis that might raise the risk score. That’s entirely legal. But this study shows that they’ve  gone even further than that, combing through patients’ medical records for possible indicators of diagnoses that physicians never entered as actual diagnoses. So if, for instance, a doctor never mentioned renal failure, but noted a slightly high creatinine level on one blood test (which might have come down on a subsequent test), that might trigger an MA plan to claim the extra payment for renal failure.

After 40 years of unsuccessful attempts to rein-in MA plans’ profit-driven efforts to cheat the taxpayers, it’s time to end the MA program and return to fully public Medicare.

http://healthjusticemonitor.org…

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Voting Rights Are Health Care Rights

When politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.

By Susan Rogers, M.D.
Common Dreams, July 6, 2021

Republican lawmakers in 43 states have introduced proposals that will severely limit Americans’ ability to vote, both in person and by mail. And last week’s Supreme Court ruling on Arizona’s voting rules opened the door for states to impose even more restrictions on voting. As a result, our most vulnerable neighbors—primarily low-income and people of color—will not be able to freely and fully exercise their constitutional right to vote.

As a physician who spent my career treating underserved communities, I know that when my patients lose their right to vote, they lose their right to the health care they need and deserve.

What do voting rights have to do with health care? In a free and functioning democracy, elected officials would implement health policies that are both popular and proven to best serve the needs of their constituents. But when politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.

When it comes to health care, the stakes couldn’t be higher. The U.S. spends $4 trillion per year on health care, almost twice as much as any other industrialized country, but we suffer from the worst performance on nearly every measurable health outcome, from life expectancy to maternal mortality. Thirty million Americans are uninsured, and an additional 40 million are underinsured. Nearly every family has a health care horror story: surprise bills, insurance company denials, medical bankruptcy, and—as I have seen much too frequently in my own practice—patients who delay treatment until it is too late.

Meanwhile, the industries that profit from our fractured health system are thriving: UnitedHealth Group, the nation’s largest insurer, reported 2020 profits of $15.4 billion; Cigna’s 2020 profits of $8.5 billion marked a staggering 66% increase over 2019.

Not surprisingly, Americans are outraged, and a majority of voters now support Medicare for All, which would improve Medicare’s benefits to also include necessary health services such as dental, vision, mental health, and reproductive care, and then expand coverage to everyone in the nation. Many studies, including a recent report from the Congressional Budget Office, show that Medicare for All could vastly improve our nation’s health outcomes while also decreasing overall health care costs.

If most voters want Medicare for All reform, why are we still trapped on the sinking ship of our fractured health system? Members of Congress (like all elected officials) respond to power, and political power comes in two forms: money and votes.

When it comes to money, the hospital, pharma, and insurance industries will always have ordinary people beat.

How can the average American compete, since these same industries have caused so much financial harm? Almost half of U.S. adults have skipped paying for essential items and bills so they could afford their medications, and nearly one in five skipped treatment for a health problem in the last year because of cost. The pandemic has pushed millions more Americans—particularly people of color—into poverty.

But, the one thing that every American should have, regardless of our income, zip code, or the color of our skin, is our vote. In an era of unprecedented corporate influence (the lobbying group America’s Health Insurance Plans spent nearly $4 million on lobbying so far this year), our vote is increasingly our only voice in the health care debate; our vote is the firewall that keeps health care from being entirely shaped by those that seek to profit from it.

Any attempt to restrict Americans’ ability to vote, particularly in communities of color, will result in worse health care and worse health outcomes for the most vulnerable.

My patients are desperate for equitable and universal coverage that can only be achieved with Medicare for All. But we won’t get real health care reform until we elect representatives that actually represent us. Health care will never be a right unless voting is a right—for all.

Dr. Susan Rogers is recently retired from Stroger Hospital of Cook County in Chicago, but continues as a volunteer attending hospitalist and internist there. While at Stroger Hospital, she was co-director of medical student programs for the Department of Medicine and received numerous teaching awards from medical students and residents. She is an Assistant Professor of Medicine at Rush University, where she continues to be an active member of the Committee of Admissions. Dr. Rogers currently serves as president of Physicians for a National Health Program, a nonprofit research and education organization whose more than 23,000 members support single-payer Medicare for All reform.

https://www.commondreams.org…

Democracy and Single Payer

Comment:

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

On the 4th of July, my thoughts turn to our system of governance, as it relates to health reform.

Our democracy is under siege. First, the President who lost his re-election bid tried to retain power by claiming he won and fomenting a coup. Crisis averted, barely. The vast majority of GOP officials still support this “big lie” about the election. Then, in June, a Democratic Senator – Joe Manchin of W. Virginia – published an op-ed declaring his fealty to the filibuster (anti-majority) and bipartisanship (a myth) over voting rights. This would allow GOP-controlled swing states to selectively disenfranchise Democrats, especially poor people of color living in big cities. Subsequently, Manchin expressed support for a scaled-back but still strong voting rights bill. Encouraging. Last week, the U.S. Supreme Court upheld state laws that manipulate voting rules in ways that will likely selectively disenfranchise blacks, relying on a 6-3 conservative majority enabled by Mitch McConnell’s abandonment of long-standing norms regarding Supreme Court appointments. Worrisome. The future of voting bills and rights – with implications for 2022 Congressional midterms and Biden’s ability to govern – will play out later this month. These events are thoroughly and thoughtfully chronicled by Heather Cox Richardson in Letters from an American. I also recommend Paul Krugman’s forceful take-down of the GOP’s thorough abandonment of reality in favor of ideology and self-interest. Dire challenges loom for democracy.

So what does this have to do with single payer financing of health care?

A lot, actually. The parallels are numerous. For today’s blog, I offer a list. If you care to suggest others, please reply to the email or add comments on the website. In future posts, I’ll delve into specific issues.

Democracy and single payer …

  • Both honor human rights, highlighting human dignity – the ability to participate in collective decisions, and the right to healthcare and health.
  • Both foster equality – everyone is treated the same. No preferential voice, no preferential care. Nobody excluded.
  • Both reflect and strengthen community values – society working collectively to address important decisions and solutions.
  • Both honor majority rule – fair voting to maximize the right and ability to cast ballots, and adoption of a health care financing approach favored by most Americans.
  • Both use simplicity to achieve performance & efficiency – one straightforward, unconvoluted set of rules for everyone, simplifying and maximizing access.
  • Both reduce manipulation of the system for gain by those in control – by requiring neutral voting rules and eliminating exorbitant profits from the provision of health.
  • Both recognize that some societal functions are most efficiently and effectively accomplished by government agencies –e.g., fairly designed and enforced voting, and financing for essential services like health care.

I think I always knew intuitively that single payer is profoundly democratic. Now I’m beginning to understand the details.

Finally, the day-to-day struggles for both causes are linked:

Empowering the maximum number of people with the vote will bolster the prospects for single payer. Because voters – especially those the GOP is trying to exclude – support single payer. And achieving single payer will build commitment to progressive, democratic values, and showcase the advantages of a benevolent government. Linking the battles may prove synergistically enabling, helping achieve both worthy causes.

Enjoy the holiday weekend, and next week let’s all dig in again to fight for justice in democracy and health care.

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High deductibles can kill patients, especially if they’re poor

Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care, Circulation, June 2021, by Shih-Chuan Chou et al.

Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low- deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. Members from higher-poverty neighborhoods were a subgroup of interest.

From Discussion: The contrasting findings between members from neighborhoods of different poverty levels merit particular attention. After HDHP switches, members from lower-poverty neighborhoods reduced invasive procedures after nonspecific chest pain ED visits without changes in ED visits for nonspecific chest pain, hospitalizations, non-invasive testing, or AMI admissions. However, members living in higher-poverty neighborhoods reduced non-specific chest pain ED visits, disproportionately reduced hospitalizations from index ED visits, and significantly increased AMI hospitalization in 30 days after index ED visits. Our findings support that, although HDHPs can reduce potentially low-value acute care among those with higher socioeconomic status, the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.

There is growing evidence that exposing low socioeconomic status populations to high cost-sharing leads to the deferral of appropriate care.

What Is New? High deductible health plan enrollment was associated with increased 30-day acute myocardial infarction rate after emergency department visits for nonspecific chest pain among patients living in neighborhoods with higher poverty rates.

Comment:

By Don McCanne, M.D.

Keep in mind that high deductibles are a tool used by private insurers to discourage patients from obtaining health care that the insurer might have to pay for. It is a profit-motivated business tool and not a tool to provide assistance to a patient in obtaining beneficial health care. It especially negatively impacts those with greater financial needs. Of note, this study evaluated private commercial and Medicare Advantage plans and not patients in the public Medicare program which avoids high deductibles (though even modest deductibles may be a hardship for those of limited financial means).

In this study of emergency department patients presenting with chest pain, it was found that those with low socioeconomic status who had high deductibles “reduced non-specific chest pain ED visits” and “significantly increased acute myocardial infarction hospitalization in 30 days after index ED visits.” They conclude, “the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.”

We can conclude that “potentially negative health implications” from deferred diagnosis of acute myocardial infarctions includes the potential for death. Since the delays were due to high deductibles, we can further conclude that high deductibles used by private health plans kill people.

We don’t need high deductibles, and we certainly don’t need expensive private insurers who use them to create more wealth for themselves at a cost of providing optimal patient service. After many decades, their profit-maximizing behavior only grows worse. Time to replace them with a single payer improved Medicare for All – no profits, just patient service.

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Medicare for All Explained Podcast: Episode 59

Interview with Traci Gleason

July 1, 2021

Missouri Budget Project vice president Traci Gleason urges the state legislature to respect the will of voters and expand Medicaid. She says fears that the program would be too costly are overblown since “no state that has expanded Medicaid has had to come back and raise taxes in order to pay for it.”

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

https://medicareforallexplained.podbean.com