PNHP

Californians Crave Single Payer!

Californians Crave Single Payer!

Summary: Three diverse California groups – doctors in training, low income populations, and leaders of community-based organizations — recently showed high support for single payer. Very encouraging trend, invigorating! Let’s harness that energy.

Health reform debate, USC Keck School of Medicine, September 21, 2021, single-payer presenter Paul Song, M.D.

See Dr. Song’s PowerPoint deck HERE.

Community Voices Priorities and Preferences of Californians with Low Incomes for Health Care Reform, September 2021, by The Healthy California for All Commission

From the Executive Summary:

Both the public opinion poll and the CBO leader interviews and surveys conducted show strong support for a single, statewide, government-run health care program that covers all people who live in California. The poll suggests that 65% of Californians with low incomes support the concept, with people of color showing greater support: 76% of African Americans, 71% of Latinos, 73% of Asian/Pacific Islanders, 65% of Native Americans and 54% of whites. Similarly, a majority of CBO leaders indicated support for the concept of a single statewide government-run health care program.

Comment:

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

Look what’s happening in California: So much support for single payer, from different corners … two diverse examples arrived in the last couple of days.

All of us who educate and advocate for single payer have been in debates, arguing the merits of single payer versus strategies that are pure market (“skin in the game”) and blended (like the ACA). Usually we’re quite pleased to swing opinion 10-20%. Look what happened when Paul Song spoke at USC Keck School of Medicine – a 41-point swing! To 89% support! Paul is a brilliant presenter. But, also, the times are changing … more and more people in health care and out recognize the gaping flaws in the current health care non-system, and the excellent performance of single payer.

Who recognizes it especially well? The population that is most vulnerable and in need. In statewide polling of low income populations and of community-based organization leaders, the Health California for All Commission found a clear consensus: “strong support for a single, statewide, government-run health care program that covers all people who live in California”. That sounds like … single payer.

There’s lots of work left to do. Lots more people to convince, including importantly our legislators. Bills to write, battles to wage. But I think we’ve turned a corner … to widespread recognition of what is known so well outside our country’s borders: single payer is a stunningly efficient and effective solution.

http://healthjusticemonitor.org…

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

Texas’ Abortion Law Could Worsen the State’s Maternal Mortality Rate

By Abigail Abrams
TIME, September 22, 2021

Texas’ controversial six-week abortion ban has been in effect just 21 days, and physicians and researchers are already warning that the impact could be dire: if the law remains in effect, Texas could see a significant increase in maternal mortality.

A new analysis from Dr. David Eisenberg, a board certified obstetrician-gynecologist who provides abortions in Missouri and Illinois, estimates that with the new law in effect, the state could see increases in maternal mortality of up to 15% overall, and up to 33% for Black women next year. The estimate is based on previous research that has established a clear link between abortion restrictions and maternal mortality. Black patients are often disproportionately impacted by abortion restrictions, and they are far more likely to die in to pregnancy-related deaths than white or Hispanic women.

“When you eliminate the ability for people who become pregnant to decide what’s best for them and their health and their family, it has a negative impact on the health of themselves, as well as their families and the communities they come from,” says Eisenberg, the former medical director of Planned Parenthood of the St. Louis Region and Southwest Missouri.

The Texas law, known as Senate Bill 8, prohibits abortion once an ultrasound detects cardiac activity. In practice, that means that no one in the state can provide an abortion after roughly six weeks into a pregnancy, which is before many people discover they are pregnant. In addition to the law’s impact on patients, its extreme limit could also cause many abortion clinics to close their doors, which would further reduce access to care for state residents.

While the Texas law is unprecedented in its private enforcement mechanism, many other states have passed limits on abortion in recent years, and researchers have shown that these are associated with negative health outcomes. In a study published in March in the journal Contraception, Eisenberg and his co-authors found that from 1995 to 2017, the maternal mortality rate increased most significantly in states that enacted the most restrictive abortion laws. In 2017, states that restricted abortion had a maternal death rate (28.5 maternal deaths per 100,000 live births) that was nearly double (15.7 maternal deaths per 100,000 live births) those that had passed laws protecting access to abortion.

In another study, published in the American Journal of Preventive Medicine in 2019, researchers looked at maternal mortality data from 38 states and Washington, D.C. and found that gestational limits on abortion and Planned Parenthood clinic closures each significantly increased maternal mortality. They found that laws restricting abortion based on gestational age ​​increased maternal mortality by 38% and that a 20% reduction in Planned Parenthood clinics increased a state’s maternal mortality rate by 8%.

Since the study was based on statistical analyses of state-level data, researchers could not look at complicating factors for each individual patient. But Summer Sherburne Hawkins, the study’s lead author and an associate professor at Boston College’s School of Social Work, says the analysis shows the direct impact of abortion restrictions like the one in Texas.

“Based on our research, restricting abortion based on gestational age, as has been done in Texas, will likely have detrimental effects on women’s health,” she says. “It could have increases in maternal mortality.”

Eisenberg’s new analysis builds on this idea and pulls from his previous research published in Contraception. He found the Global Health Data Exchange showed a 6% increase in maternal mortality in states that restricted abortion access relative to neutral states. The CDC WONDER database showed a 24% increase in states that restricted abortion access relative to neutral states. The median increase, 15%, is what he predicts could take place in Texas if its current abortion law remains in place.

Abortion providers in the state are already seeing patients who they fear could end up in dangerous circumstances. Dr. Bhavik Kumar, a staff physician at Planned Parenthood Center for Choice in Houston, says the law has forced him to turn away patients who will likely not be in a place to have a healthy pregnancy. Planned Parenthood has become a “traffic control” center with care coordinators helping people find resources to travel out of state for care or explore other options, he says. But not all patients can travel long distances to receive care.

Kumar says he saw a patient last week who is navigating a meth addiction and is homeless, who he doubts will be able to travel out of state to get an abortion. Another of his patients already has seven children, one of whom is in the hospital with a terminal illness. She likely will not be able to leave the state—and her children—to get an abortion either, but she also knows she will struggle to take care of another child, Kumar says.

The Texas law means these patients must make incredibly difficult choices as they seek care. If they cannot obtain abortions, they may be forced to deal with the mental and physical stress of carrying unwanted pregnancies to term.

“There’s also consequences with morbidity, meaning people having more complicated pregnancies that take a toll on their health, having more complications, and having a lower quality of life,” Kumar says. “And that’s not just for them. It’s also for their families and the children that they are forced to have.”

The U.S. faces a crisis of maternal mortality

The new Texas law is the latest in a wave of restrictions on abortion nationwide. For more than a decade, largely conservative states like Texas that have steadily implemented a series of laws and regulations making it more logistically and financially difficult for women to access all kinds of reproductive health care. Even amid this trend, Texas stands out as one of the most challenging places to obtain an abortion and to give birth to a child.

The U.S. has faced a crisis of maternal mortality for years. It has the highest rate of maternal mortality in the developed world, and the country’s numbers have worsened significantly over the last 30 years, according to a new report the U.S. Commission on Civil Rights released Sept. 15. This is in large part due to growing disparities in access to quality care for women of color. “As an individual, as a Texan, I’m appalled that, at a time where we need stronger hospitals and a higher quality of hospital care for Texans, we’re going in the wrong direction,” Norma Cantú, chair of the Commission on Civil Rights, said in response to a question from TIME last week.

The maternal mortality rate in Texas is already higher than the U.S. average, and Black women bear the brunt of this tragedy: they account for just 11% of live births, but make up 31% of maternal deaths in the state. In 2013, Texas created an expert committee to examine this issue. It found that many of the maternal deaths in Texas are preventable and recommended that the state extend health insurance coverage for poor mothers to one year after they have a baby. But lawmakers have not done that. Instead, in May the state passed a law extending Medicaid coverage for six months after childbirth.

Texas has the highest rate of uninsured residents in the country, the highest rate of uninsured women of childbearing age, and its leaders have refused to expand Medicaid under the Affordable Care Act, which would have allowed more low-income Texans to access the public health insurance program. Texas also has the strictest income limit for Medicaid eligibility in the country: a single Texan parent with three children must earn $277 or less a month to be eligible. During pregnancy, that cap increases to $4,373.

The new Texas abortion law is being challenged in court. The Department of Justice has asked a federal judge in the Western District of Texas to block the law while it sues Texas, and the next hearing is set for Oct. 1. But even if the law is temporarily blocked, it is written in a way that could make it difficult for abortion providers to resume their regular work until they have a final verdict.

The effects of even a temporary ban are likely to reverberate. When Texas enacted a law in 2013 that required abortion clinics to obtain admitting privileges at local hospitals and imposed other restrictions, half the clinics in the state closed. Even after the Supreme Court ruled that law unconstitutional in 2016, few clinics returned. As a result, huge swaths of the state became abortion deserts. Under the new law, the average Texan must drive 14 times farther than they had to previously to access an abortion.

In recent weeks, lawmakers from other conservative states have said they see Texas as a model and hope to pass similar legislation, and in December, the conservative Supreme Court is scheduled to hear a case about an abortion restriction in Mississippi. While those who oppose abortion are celebrating what they see as a win for their movement, physicians and researchers like Eisenberg—as well as residents in conservative states—say they are bracing for a coming wave of maternal deaths.

https://time.com…

If USC is ready for single payer, it’s time!

Summary: The University of Southern California medical school is often regarded as high class. But at least two of its current top leaders share health justice goals, and endorse single payer. The tide of support is turning!

Steve Shapiro brings a big-picture approach to medicine at USC, USC News, September 14, 2021, by Leigh Hopper

Steve Shapiro takes the macro view of medicine. This spring, he became the first senior vice president for health affairs at USC, where he will oversee — and build bridges between — clinical operations at Keck Medicine of USC and research and medical training at the Keck School of Medicine of USC.

Question: You’ve said that L.A. traffic will give you more time for audiobooks. Any recommendations, audio or otherwise?

S. Shapiro: I’ve just finished a couple of books. One was called Broken, Bankrupt and Dying by our chief medical officer at LAC+USC, Brad Spellberg. It’s the best argument I’ve heard for a single-payer system, as well as explaining the nuances of what single-payer means. It’s really impressive.

Broken, Bankrupt, and Dying, by Brad Spellberg (chief medical officer at LAC+USC)

I believe we should move forward with a universal, single-payer, national insurance plan, with no deductible or coinsurance, but with copays for speciality care and prescription drugs, funded by central collected taxes that everyone pays, but while still giving the individual a choice about whether they want to use the public insurance or buy their own private insurance. The resolution to the seeming paradox between a single-payer plan and offering choices is to give government-sponsored insurance to all residents, but also allow and encourage a thriving private insurance market that people can choose to purchase into if they would like. Let the public plan and private markets compete. Give people options.

I think this collective ideal makes the most sense. I think it will offer the best coverage at the best price, and will help reform healthcare delivery to eliminate waste and improve outcomes. I also think it is the most politically palatable, minimizing triggering opposition by including aspects that should appeal to people on both sides of the aisle.

But you know what? At this point, I’ll accept almost any universal system that can muster the political and social support behind it to get it done. I have no use for a philosophically optimal system that can never be implemented. I want something that can get done. So I’m keeping an open mind while advocating for what I think is best, and I’d encourage you to do that too.

Comment:

By Don McCanne, M.D.

For those of us on the West Coast, USC School of Medicine has the reputation, perhaps unfairly, of being the medical school with Rolls Royces in the doctors’ parking lot. For those who might doubt the social mission of USC medical school, these leaders at USC have provided very reassuring comments that show that they share health justice goals with the rest of us.

This book by Brad Spellberg describes many of the intolerable deficiencies and injustices of the current US healthcare system while proposing many corrections that must take place. Though there will be some debate over the specifics, the general approach of establishing a national health insurance program seems to have reached the point where there should be broad public acceptance. At least we now have reassurance that the institutions of the health professions are moving into alignment on the issues. Let’s all move in together and get it done.

http://healthjusticemonitor.org…

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

Dr. Ana Malinow on “Thom Hartmann Program”

PNHP past president Dr. Ana Malinow appeared on the “Thom Hartmann Program” on September 20, 2021. Dr. Malinow sounded the alarm about Direct Contracting Entities (DCEs), which grew out of a Trump Administration pilot program and which pose a grave threat to the Traditional Medicare program.

She encouraged viewers to register for a September 23 webinar to learn more about this latest Medicare privatization threat…and what can be done to stop it.

Allowing For-Profit Hospice: The Worst Health Policy Idea Ever?

Summary: For-profit ownership has reached two-thirds of hospice agencies. Yet for-profit status is associated with fewer services, less clinically skilled staff, more formal complaints, more discharges of sicker patients, and more hospital and emergency department use. Removing for-profit ownership is part of health reform.

Hospice Tax Status and Ownership Matters for Patients and Families (behind a paywall), JAMA Internal Medicine, August 1, 2021, by Melissa D. Aldridge

From the article:

The increase in ownership of hospices by private equity (PE) firms and publicly traded companies…follows almost 2 decades of steady growth of for-profit ownership of hospice agencies, from one-third of hospices in 2000 to almost two-thirds by 2017. Why is this noteworthy? It is difficult to identify a health care sector more detrimentally affected by the mismatch between profit maximization incentives and quality of care than hospice. Whereas some have argued that tax status (ie, whether a hospice is for profit or nonprofit) is unrelated to hospice quality, an increasing body of evidence suggests otherwise. The requirement for for-profit organizations to distribute net income to shareholders provides strong incentives to generate consistent profits over short time periods. …

For-profit compared with nonprofit hospices provide narrower ranges of services to patients, use less skilled clinical staff, care for patients with lower-skilled needs over longer enrollment periods, have higher rates of complaint allegations and deficiencies, and provide fewer community benefits, including training, research, and charity care. For-profit hospices are more likely than nonprofit hospices to discharge patients prior to death, to discharge patients with dementia, and to have higher rates of hospital and emergency department use. In one analysis of 355 hospices, 90% of those with the lowest spending on direct patient care (eg, patient home visits) and the highest rates of hospital use were for-profit hospices.

Comment:

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

Allowing for-profit hospices is crazy. The deranged care documented in the commentary above (each statement is referenced in the original article) is the predictable result of reimagining dying patients as prudent shoppers in a commercial transaction. Medicare pays for the overwhelming majority of hospice care and could proscribe the participation of for-profits – it excluded for-profit home care agencies until 1980.

With more and more health care providers being snapped up by for-profit firms, and evidence of their misbehaviors mounting, proscribing for-profit ownership has become an essential element of health care reform.

http://healthjusticemonitor.org…

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

Crowdsource ideas on government role in single payer

Summary: Today is an experiment: crowdsource day at Health Justice Monitor! We know that HJM readers think about healthcare reform and discuss it with family and friends, and we’d like to learn from that – garner the most persuasive arguments. Please share your ideas. If this works well, we’ll incorporate it regularly.

Comment:

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

What do you find to be the most persuasive arguments to counter the concern, “Our government can be counted on to get it wrong! Inefficient and ineffective! Look at the post office, the public schools, and Medicaid.”

My usual response is, “Our government gets it right when people in all social strata need the service (e.g., the fire department and Medicare among the elderly) and is especially good at disbursing funds (e.g., social security). Where government services fall short is when the beneficiaries are those without political power, e.g., Medicaid for the poor.”

A possible rejoinder is, “Yeah, but what if enough rich people buy out of the single payer system to support a parallel private healthcare system. They pay their taxes and also for their own upscale medical care. Like they do for private schools.”

To that I say, the “There aren’t enough people able and willing to pay twice for health care. Sure, a few super rich will buy out, but the vast majority – including large segments of society with powerful political voice – will stay in, as will almost all doctors. Just like Medicare today.”

What would you say in this discussion? What has actually worked well in conversations with skeptics?

Send your thoughts to healthjusticemonitor@gmail.com, subject line including “Crowdsource ideas on government role in single payer.” Brief please – 25-50 words. And, let us know if / how you want to be identified.

We’ll curate (edit, trim, organize) and compile in a Google document which we’ll share. (To assure a focus on content and civility, we’re not currently planning to make this site interactive.)

Many thanks. Looking forward to your ideas.

http://healthjusticemonitor.org…

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

Am I a Single Payer Zealot?

Summary: Yes, I am.

Health Care Unions Defending Newsom From Recall Will Want Single-Payer Payback, KHN (Kaiser Health News), September 13, 2021, by Angela Hart

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom’s single-payer commission. He said it will work through “tension” in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism,” Ross said. “I’m not ruling out any bold stroke on single-payer; I would just want to know how we get it done.”

Comment:

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

If believing that we should jettison $800 billion in administrative bloat and transfer the savings to health care makes me a zealot, I accept the label.

If favoring full health care equity is zealotry, I’m on board.

If removing financial barriers to care and thereby avoiding 80,000 deaths per year is zealous, that’s me.

If patient choice of doctor is a zealot’s errand, where do I sign up?

If reducing physicians’ billing burden so they can focus on clinical care is zealotry untrammeled, count me in.

If rejecting “incremental approaches” that end with tens of millions uninsured or underinsured, and trillions of healthcare dollars diverted to profits for shareholders brand me a zealot, I’ll wear that insignia with pride.

If saying, “enough already, it’s time for the US to join the global consensus on health care as a human right” leads to whispers of out-of-control zeal, I’ll shout it from the mountain tops.

Am I a single payer zealot? Guilty as charged.

(p.s., the KHN article mistakenly asserts that creating single payer in California will cost $400 billion / year. Instead, it will *reduce* spending from the current level of about $400 billion …)

http://healthjusticemonitor.org…

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