Columbia University, Irving Medical Center, January 12, 2021

The COVID-19 pandemic has exacerbated the deep fissures in our nation’s health care system, accentuating tragic disparities largely along racial and ethnic lines and highlighting the need for an immediate exploration of the underlying structural racism so that health care can become more inclusive and equitable, according to Maya Sabatello, LLB, PhD, associate professor of medical sciences in the Division of Ethics in the Department of Medical Humanities and Ethics and in the Department of Medicine at Columbia University Vagelos College of Physicians and Surgeons.

Sabatello, an expert on human rights and the ethical, legal, and social implications of genetics, proposes a COVID-19 Truth and Reconciliation Commission. “These commissions began as a way to help authoritarian governments recover from their abusive pasts and transition toward democracy without being punitive,” Sabatello says. “The United States may not be a fragile democracy, but our health care system—who controls it, who benefits from it—resembles an autocratic regime.”

In a paper published in the American Journal of Bioethics, Sabatello and colleagues outline a forward-looking path to break the cycle of disparity and create a nationally equitable health care system.

Why do you think a Truth and Reconciliation Commission could help address the inequities exposed by the pandemic?

Truth and Reconciliation Commissions are an attempt to establish and publicly record the experiences and scale of the physical and emotional harm caused by past injustices. They help us think about the experiences of victims and perpetrators so we can develop ways to address and overcome systemic issues. A Truth and Reconciliation Commission is aimed at acknowledging wrongdoing and learning from injustices in order to move forward.

A Truth and Reconciliation Commission would allow racial and ethnic communities that have been targets of structural racism and have been disproportionately impacted by the COVID-19 pandemic to speak up and share their experiences in a forum that aims to lead to real change. This would include Black/African American, Latinx, and Indigenous communities but should also be inclusive of other groups experiencing structural discrimination. It would also give clinicians a forum to have conversations around the systemic issues they face in providing equal care so that they can help reconstruct the system. Additionally, it’s a constructive way for administrators of health care systems and politicians to hear the perspectives and the pain that’s caused by their decisions in order to promote systemic and structural changes.

https://www.cuimc.columbia.edu…

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Structural Racism in the COVID-19 Pandemic: Moving Forward

By Maya Sabatello, Mary Jackson Scroggins, Greta Goto, Alicia Santiago, Alma McCormick, Kimberly Jacoby Morris, Christina R. Daulton, Carla L. Easter & Gwen Darien
The American Journal of Bioethics, Published online: December 19, 2020

Abstract

The COVID-19 pandemic has taken a substantial human, social and economic toll globally, but its impact on Black/African Americans, Latinx, and American Indian/Alaska Native communities in the U.S. is unconscionable. As the U.S. continues to combat the current COVID-19 cycle and prepares for future pandemics, it will be critical to learn from and rectify past and contemporary wrongs. Drawing on experiences in genomic research and intersecting areas in medical ethics, health disparities, and human rights, this article considers three key COVID-19-related issues: research to identify remedies; testing, contact tracing and surveillance; and lingering health needs and disability. It provides a pathway for the future: community engagement to develop culturally-sensitive responses to the myriad genomic/bioethical dilemmas that arise, and the establishment of a Truth and Reconciliation Commission to transition the country from its contemporary state of segregation in healthcare and health outcomes into an equitable and prosperous society for all.

Conclusions

The COVID-19 pandemic gives a face to decades of segregation, racism and structural discrimination. It forces us to look to the generations of especially Blacks/AAs, Latinxs and AI/ANs that have often endured mistreatment in all aspects of life—from limited educational and employment opportunities to high levels of poverty and environmental neglect, insufficient, often absent, access to basic healthcare services, police brutality, and overrepresentation in the criminal justice system.

The opportunities for moving forward are plenty. Although the COVID-19 pandemic raises numerous questions, it intersects with other areas in which there is an abundance of knowledge that can inform the discussion. In this article, we drew on scholarship in genomics to highlight challenges that are likely to arise. These include collection, use and storage of data for research, fair and equitable access to the benefits of research, testing and surveillance concerns, and lingering healthcare needs and long-term disability among individuals, families, and communities at large. Community engagement and multi-leveled commitment will be vital for ensuring tailored and culturally sensitive approaches to assure that historical wrongs are addressed and remedied. The COVID-19 pandemic calls for self-reflection, broad public engagement and cultural humility to transform our troubled health, socioeconomic and political infrastructures into a sustainable, equitable and prosperous society for all.

Free access to the full article:
https://www.tandfonline.com…

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Comment:

By Don McCanne, M.D.

This is yet another article that shows how the COVID-19 pandemic has given a face to decades of segregation, racism and structural discrimination. This one is somewhat unique in that it recommends a Truth and Reconciliation Commission. This, of course, would not obviate the need to enact and implement a single payer, improved Medicare for All, but it would be a great step forward.

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By Nishant Uppal, Parsa Erfani, and Raquel Sofia Sandoval
STAT, January 12, 2021

Targeted vaccination efforts are essential in prisons and jails, where 90 of the 100 largest Covid-19 cluster outbreaks in the United States have occurred.

The spread of Covid-19 in ICE detention centers has also been rampant. On average, the monthly rate of cases in detention was 13.4 times higher than in the general population during the first five months of the pandemic. Yet ICE has been lax in implementing Covid-19 public health measures to protect detainees.

In collaboration with Physicians for Human Rights, we recently interviewed 50 formerly detained individuals. In this evaluation, published Jan. 12, those interviewed explained how ICE failed to comply with its own Covid-19 pandemic response requirements in at least 22 of its facilities — often denying detainees consistent access to soap, masks, and proper symptom-based testing and isolation.

We believe that, first and foremost, ICE should not be detaining individuals and that individuals who are currently detained should be released. But until that happens, the vaccine rollout is an opportunity for ICE to recognize that it is accountable for the health of detainees, who are at a similar risk level for Covid-19 as incarcerated individuals. They live in crowded, congregate facilities with limited social distancing, often sleeping only 3 feet from one another, as our interviews showed. Like incarcerated individuals, ICE detainees must be prioritized for Covid-19 vaccination.

The federal government must abide by its responsibility to detained migrants and spearhead a vaccine-distribution plan for all ICE detention facilities. Only by vaccinating the people most vulnerable to Covid-19 can we move closer towards an equitable post-pandemic future.

Nishant Uppal, Parsa Erfani, and Raquel Sofia Sandoval are students at Harvard Medical School, medical evaluators at the Harvard Student Human Rights Collaborative Asylum Clinic, and research associates at the Peeler Immigration Lab at Harvard Medical School.

https://www.statnews.com…

Physicians for Human Rights: “Praying for Hand Soap and Masks”
https://phr.org…

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Comment:

By Don McCanne, M.D.

The rate of active cases of COVID-19 is 13.4 times higher for these detainees than it is for the general population. These are human beings. Of course we have to make available for them COVID-19 vaccine.

It is disappointing to see that most of the comments to the STAT article were dismissive, concentrating primarily on their immigrant status. But didn’t this land belong to the Native Americans, only to be cheated out of much of it by our ancestors? Admittedly, that is a different issue from being vaccinated during a pandemic, but isn’t their immigration status primarily a matter of timing?

Fortunately these Harvard medical students understand the differences and recognize that all of us should have our medical needs met.

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George Yancy interviews Eric Foner, history professor at Columbia
Truthout, January 12, 2021

What will history make of the horror and disbelief experienced by the world on January 6, when the United States Capitol was violently broken into and vandalized by Trump supporters who attempted to stop the counting of the Electoral College votes legitimately won by President-elect Joe Biden?

The painful and unforgettable events that transpired that day, leaving five people dead, not only speak to the fragility of American democracy but also reveal deeply embedded realities about white supremacy and its current and historical efforts to undermine democratic institutions and ideals.

Eric Foner: As an historian, I was particularly shocked by seeing the Confederate flag displayed in the Capitol. I can’t think of another time in history where the Confederate flag was prominently on display. Maybe there was such a moment. I don’t know. But again, that’s Trump. He has, among many other things, closely identified himself with the Confederacy, with the Confederate flag, Confederate monuments, and all that. It is pretty clear what people who carry the Confederate flag around think it says. This is not just heritage, so to speak. It’s not just respect of history. This is a symbol of white supremacy. Everybody knows that.

George Yancy: But, you know, there is a sense in which America is seen by many Americans as buttressed by a kind of theological destiny, where American “exceptionalism” speaks to a kind of unique mission and superiority that the U.S. has been bestowed. How do you think about the concept of “American exceptionalism” in relationship to the events on January 6?

Eric Foner: You know, to my mind, as a historian, American exceptionalism is the great obstacle to understanding America. It’s built into our culture. It’s very hard for us, even for those who realize how ridiculous it is, to get away from it. But it is ingrained in our culture. And it has all sorts of deleterious effects. You can start at a very simple level and say, well, “American exceptionalism” means that American history is different from other histories of other countries. Well, but that’s obvious. Chinese history is not the same as French history which is not the same as Brazilian history. So to say that different countries have different histories isn’t saying very much. But, of course, if we move up the ladder a little, American exceptionalism says more than that. It says that we have nothing to learn from the rest of the world. There’s no point in knowing about the rest of the world because we are so exceptional that what applies to them doesn’t apply to us.

This struck me years ago when Obamacare was being debated in the Congress. We’re aware that every other country has some kind of health care system, but nobody said why don’t we see what these other countries are doing. What’s going on in Germany or France or England or in Canada? They’re not all the same. They all have distinctive systems, but maybe we can learn something from their experiences. Nobody thinks we can learn anything from other people. And that’s very different from the Progressive Era a century or so ago. Americans really wanted to learn from other places about the processes of urbanization, industrialization, class conflict, which were happening all throughout the industrialized world. And American reformers and social scientists went over to Europe to see what policies were being adopted there.

A very good historian, Daniel T. Rodgers, wrote a book entitled Atlantic Crossings, which has to do with the idea of going back and forth. Now they don’t go back and forth. America tells other people what to do. Sometimes we tell them verbally. Sometimes we tell them by force of arms. Think of Iraq, for example. If you don’t want to be like us, then we’re going to force you to be, whether you want it or not.

https://truthout.org…

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Comment:

By Don McCanne, M.D.

American exceptionalism. We can’t learn from other nations. We tell them what to do. We do not provide health care to everyone, yet we also do not listen to other nations that have done that. It is not that we do not have clear minds in people who know how to do it. A single payer improved Medicare for All would work just fine. It’s rather that we are exceptional. And what do we get for that exceptionalism?

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By Michelle M. Doty, Roosa S. Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams
Health Affairs, December 9, 2020

Abstract

A high-performing health care system strives to achieve universal access, affordability, high-quality care, and equity, aiming to reduce inequality in outcomes and access. Using data from the 2020 Commonwealth Fund International Health Policy Survey, we report on health status, socioeconomic risk factors, affordability, and access to primary care among US adults compared with ten other high-income countries. We highlight health experiences among lower-income adults and compare income-related disparities between lower- and higher-income adults across countries. Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout. The presence of these disparities should strengthen the resolve to find solutions to eliminate income-related inequality in affordability and primary care access.

From the Introduction

Despite decades of wide-ranging policies in the US and other countries to eliminate health inequality, income-related disparities in health outcomes and access have persisted, and in the case of the US, they have widened over time. Although the health disadvantage in the US predates the coronavirus disease 2019 (COVID-19) pandemic, the US health care system is under renewed scrutiny because the pandemic has exposed stark disparities in economic outcomes and mortality from the virus for socioeconomically disadvantaged people, as well as Black and Latino people, in the US. In other countries, the crisis triggered by the COVID-19 pandemic has aggravated existing challenges to access and prompted calls to strengthen the resiliency of national health systems.

For more than two decades the Commonwealth Fund International Health Policy surveys have been used to benchmark US health system performance with that of other high-income countries. These studies have documented that compared with other high-income countries, the US ranks last or near last on health outcomes, access, affordability, and equity. Numerous studies have found that income-related inequality in morbidity, life expectancy, and accessibility is greater in the US than in other advanced economies. Although the US health disadvantage is well known, timely cross-national comparisons of health care experiences by income can help policy makers assess relative health system performance and guide policies that have the potential to eliminate income-related health disparities and improve health outcomes for all.

From the Discussion

Our study confirms findings from previous research that adults with lower incomes in the US were far more likely than those in the other high-income nations studied here to go without needed health care because of costs, to face medical bill burdens, and to struggle to afford basic necessities such as housing and healthy food.

Furthermore, findings indicate that income-related disparities in health status, affordability, and primary care access were most pronounced in the US, supporting other evidence that the US health disadvantage is considerable. Notably, income-related disparities in affordability and access were smallest in Germany, and only in the US were there consistently wide income disparities on all measures related to accessible primary care.

Yet these problems are not confined to the economically disadvantaged. Several studies have found that US adults with higher incomes or socioeconomic status may experience poorer health than their counterparts in peer countries. We found that higher-income adults in the US were more likely than their peers in most countries studied to forgo needed health care because of the cost. The relatively high prices Americans pay for health care, as well as the growing problem of underinsurance, fail to protect insured adults in the US from high out-of-pocket spending, leading to problems with affordability and access to care even among those with higher incomes.

Several characteristics differentiate the US health system from those in other high-income countries in this study, which may contribute to the larger income-related inequalities observed in the US.

First, the US lacks universal health coverage, which matters for population health outcomes.

Second, despite decades of research demonstrating that countries with robust primary care have greater equity, better quality, and lower per capita costs, the US underinvests in primary care.

Third, relative to most of the high-income countries in this study, the US underinvests in the upstream social determinants of health and social services that would support healthy living conditions, livelihoods, and better health for the population.

Conclusion

The US has the opportunity to commit to policy and practice changes that will make progress toward eliminating income-related health inequality, ultimately improving both outcomes and equity on a national scale. Decisive action is needed to advance policies that will improve insurance coverage, increase affordability, strengthen primary care, and increase investments that address the social determinants of health.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

In an ongoing series of international health policy surveys of eleven wealthy nations, the Commonwealth Fund shows, once again, that the United States ranks last or near the last on health outcomes, access, affordability, and equity, even though our health care spending is the highest per capita of all these nations.

Three factors are particularly important: 1) the U.S. lacks universal health coverage, 2) we underinvest in primary care, and 3) we underinvest in upstream social determinants of health and social services. Income inequality is a major contributor.

We can do this. We have the funds. We merely need to enact and implement a well designed, single payer, improved Medicare for all that includes attention to the social determinants of health. Why do we insist on staying with a system that costs more and yet keeps us near the bottom in performance? Our incoming president wants us at or near the top, and yet he has rejected the model that will get us there. Will there be anyone there who can teach him?

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By Christina Amutah, B.A., Kaliya Greenidge, Adjoa Mante, A.B., Michelle Munyikwa, Ph.D., Sanjna L. Surya, B.A., Eve Higginbotham, M.D., David S. Jones, M.D., Ph.D., Risa Lavizzo-Mourey, M.D., M.B.A., Dorothy Roberts, J.D., Jennifer Tsai, M.D., M.Ed., and Jaya Aysola, M.D., D.T.M.H., M.P.H.
The New England Journal of Medicine, January 6, 2021

Conceptions of race have evolved and become more nuanced over time. Most scholars in the biologic and social sciences converge on the view that racism shapes social experiences and has biologic consequences and that race is not a meaningful scientific construct in the absence of context. Race is not a biologic category based on innate differences that produce unequal health outcomes. Rather, it is a social category that reflects the impact of unequal social experiences on health. Yet medical education and practice have not evolved to reflect these advances in understanding of the relationships among race, racism, and health. More than a decade after the Institute of Medicine (IOM, now the National Academy of Medicine, or NAM) issued its report Unequal Treatment, racial/ethnic disparities in the quality of care persist, and in some cases have worsened. Such inequalities stem from structural racism, macrolevel bias intrinsic in the design and operations of health care institutions, and implicit bias among physicians. The majority of U.S. physicians have an implicit bias favoring White Americans over Black Americans, and a substantial number of medical students and trainees hold false beliefs about racial differences.

These widespread problems are reflected in the fact that race is one of the most entrenched and polarizing topics in U.S. medical education. Efforts to advance health equity in medical education have ranged from implicit-bias training to supplementary curricula in structural competency, cultural humility, and antiracism. Researchers have highlighted the domains of misuse of race in medical school curricula and their potential role in propagating physician bias. In examining more than 880 lectures from 21 courses in one institution’s 18-month preclinical medical curriculum, we found five key domains in which educators misrepresent race in their discussions, interpretations of race-based data, and assessments of students’ mastery of race-based science.

Indeed, in all the authors’ home institutions we found similar misrepresentations of race.15 Social medicine or equivalent courses discuss race in a nuanced manner, but misrepresentations arise in all other courses, including organ-system blocks and basic science classes. Consideration of these five domains in the preclinical curricula (Table 1) inform our recommendations for correcting content that may reinforce or instill race-based biases (Table 2). (Use the link below to access the full article and the Tables.)

From the Recommendations

Medical education and research are intertwined and jointly responsible for perpetuating misunderstandings of race. Students carry such misinformation with them into the clinic, where their implicit biases and misconceptions perpetuate disparities in health care. We are not arguing that race is irrelevant, and our framework is not meant to trigger discussion of the advantages and disadvantages of using race in medicine; rather, we wish to provide evidence-based guidelines for defining and using race in generating and imparting medical knowledge. Race, though not a biologic concept, can be a starting point from which to generate hypotheses about environmental exposures and social processes that produce disparities in health outcomes. It is also vital to use race/ethnicity to measure and mitigate unequal treatment attributable to structural and individual implicit biases. Discussing race and naming racism are essential to promoting an antiracist culture. Rather than abandoning the use of race in medicine, we believe we should transform the way it is used, embracing a more rigorous, multidisciplinary, and evidence-based understanding of how race, racism, and race-based science contribute to inequities in health and health care.

https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

We all have our concepts of race and the consequences of racism, and in medicine it is particularly important to get it right, but we haven’t. The concepts presented in this article are relatively complex and cannot be communicated in brief excerpts. Thus the full article should be read and studied. Some may think that this article covers nuances of the topic, but it should be read as if these concepts represent the fundamentals.

Although this article indicates the need to introduce these concepts into the medical school curriculum, it should be obvious that those of us out in the field missed this in our training and thus would benefit, at a minimum, by the simple task of reading the full article.

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Senate control opens up new possibilities, but the party will still need to contend with arcane rules and the challenges of a narrow majority.

By Sarah Kliff and Margot Sanger-Katz
The New York Times, January 7, 2021

The Democrats’ new congressional majority puts a variety of health policy ideas suddenly into reach, even if big structural changes remain unlikely.

A series of tweaks bolstering the Affordable Care Act stands the best chance of passage. Legislators could make insurance subsidies more generous, get coverage to low-income Americans in states that haven’t expanded Medicaid, and render moot a pending Supreme Court lawsuit that aims to overturn the entire law.

But structural overhauls like “Medicare for all,” which would move all Americans to a government-run health plan, face a much tougher road. So would elements of Joe Biden’s health agenda, such as a public option, which would give Americans a choice between a new public plan and private insurance.

There are six areas of health policy where congressional aides and health policy experts could see Democrats focusing their efforts this year. Smaller policy reforms are expected to be easier, both legally and politically, while more ambitious policies may not easily slot into reconciliation’s strict rules — or the political preferences of enough Democratic lawmakers.

Affordable Care Act expansions

One priority is raising the income ceiling for those who receive subsidies, expanding the number of people who qualify for help. Another is rewriting formulas to peg the size of the subsidy to a more generous health insurance plan, a way to increase the amount of assistance.

Texas v. California came about because of legislation that a Republican-controlled Congress passed in 2017, lowering the penalty for not carrying health insurance to zero dollars. Democrats could use reconciliation to reverse those changes.

Closing the Medicaid gap

In his campaign plan, President-elect Biden proposed fixing this problem by allowing these patients to enroll in a new public health plan. That type of policy may be too complex to move through reconciliation, but simpler policy options could also do the trick.

Reducing drug prices

Experts thought that certain drug pricing controls might be possible with reconciliation, since they have clear budgetary effects. But the politics of passage could be difficult with narrow majorities in both the House and Senate and such strong opposition from the drug industry.

A public option

President-elect Biden included a public health insurance option, available to all Americans, in his 2020 campaign platform. The slim majority in the Senate, however, may make it hard to move this type of plan forward.

Medicare for all

The larger obstacle to such a plan is more likely political than procedural. Currently, a majority of House Democrats back Medicare for all, but that would not be nearly enough votes to pass such a bill. An even smaller share of senators back the plan.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Sarah Kliff and Margot Sanger-Katz are very astute observers of the national health policy and politics agenda. You can rely on their reporting to provide an accurate prediction of the policy agenda under the Biden administration.

It is most likely that health reform activities will be limited to making adjustments to the Affordable Care Act which will allow more individuals to participate and will provide limited additional financial relief for those already in the program, but, basically, there will be little fundamental change to our expensive, administratively wasteful, and inadequate health care financing infrastructure. Particularly disconcerting is that the private insurance sector will have an even greater role in health care financing through an expansion of the ACA exchanges, and an expansion of the Medicaid managed care programs. When the private insurers are a major source of our health care financing dysfunctions, it seems disingenuous to expand their role.

President-elect Biden has stated that he will not approve a single payer Medicare for All program. That does not mean that we should walk away and wait another four years. It does mean that the political threshold has not been met to expect enactment in the near future, and that means that our task is to expand our efforts to educate the public as to the features of the single payer model that make it a moral imperative. So, instead of having less to do because of Biden’s rejection of the model, it means that we need to greatly intensify our advocacy efforts, and that means we have a lot of work to do. It is an imperative that a national, single payer, improved Medicare for All remain the ultimate, compelling goal.

A word needs to be said about the public option. Right now there is fairly intense political activity to try to convince Biden and Congress to enact a Medicare-like public option as an incremental step towards the eventuality of single payer Medicare for All. It is proposed that the public option could be created and then later expanded into a universal Medicare for All.

First of all, a model that would be suitable for a single payer system cannot be created as a stand-alone option in our fragmented system of health care financing. Single payer needs to be financed with progressive taxes, but you cannot expect individuals to pay for their own private plans, whether or not employer-sponsored, and also pay progressive taxes to buy coverage for others who choose the public option. Also, much of the financial feasibility of the single payer system derives from eliminating hundreds of billions of dollars in administrative excesses, but with a public option in a market of private plans, most of the administrative waste would be perpetuated, Also, the administrative savings of our traditional Medicare program would not be duplicated in a public option that must be designed much like our current private plans to be able to compete in the marketplace – a dysfunctional model that we are trying to eliminate. The lack of administrative efficiency in both the structure of the public option and in the administrative complexity that it places on the health care delivery system would allow opponents of single payer to say that the public option proves that single payer cannot save money.

If such a public option were designed as a transitional program to be replaced by single payer in about four years – an approach supported by many of the public option advocates – the definitive single payer model must be mandated in the initial legislation or else it would be abandoned when it became obvious that it didn’t work, as indicated above. It cannot work because it is not a single payer system and forgoes almost all of the single payer efficiencies.

Some say we should have a four year transitional public option anyway. Why? Avoid disruption? Disrupting one-fourth of the system each year would be more complex and more expensive than disrupting the entire system in a single step. Disrupting health care coverage for people over 65 by placing them on Medicare was done as a single step on July 1, 1966. It was a beneficial disruption, and it worked just fine.

Beneficial disruption is sort of like John Lewis’ good trouble. After yesterday’s disaster we sure could use a large dose of good trouble right now.

Peace.

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By Brian M. Rosenthal
The New York Times, January 5, 2021

When the coronavirus began spreading through New York, Gov. Andrew M. Cuomo ordered state-run hospitals to stop suing patients over unpaid medical bills, and almost all of the major private hospitals in the state voluntarily followed suit by suspending their claims.

But one chain of hospitals plowed ahead with thousands of lawsuits: Northwell Health, which is the state’s largest health system and is run by one of Mr. Cuomo’s closest allies.

The nonprofit Northwell sued more than 2,500 patients last year, records show, a flood of litigation even as the pandemic has led to widespread job losses and economic uncertainty.

They hit teachers, construction workers, grocery store employees and others, including some who had lost work in the pandemic or gotten sick themselves.

After this article was published Tuesday morning, Northwell abruptly announced it would stop suing patients during the pandemic and would rescind all legal claims it filed in 2020.

Across the country, medical debt lawsuits have grown increasingly common in recent years, as health care costs have risen and insurance companies have shifted more of the burden onto patients through larger deductibles and co-payments. The cases are rarely contested in court and usually lead to default judgments, allowing hospitals to garnish wages and freeze accounts to extract money, sometimes without the patient’s knowledge.

Northwell had not been alone in pursuing debt through the courts during the pandemic. About 50 hospitals in New York have sued a total of 5,000 patients since March, according to a search of filings in courts around the state.

In an interview last month, Richard Miller, the system’s chief business strategy officer, defended the cases, saying Northwell had the right to collect what it was owed.

“We have no interest in pursuing these cases legally. It’s not what we want to do,” Mr. Miller said, before the hospital changed course on Tuesday. “Unfortunately, in some cases, they’re not leaving us much of an option.”

St. Peter’s Health Partners, which runs a chain of hospitals in the Albany area and filed about 1,000 lawsuits last year, and Oneida Health, a health care system near Syracuse that filed about 500 lawsuits, both said in statements that they temporarily stopped suing in the spring but resumed over the summer.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Is this any way to finance our health care system? Sue people who cannot afford to pay their medical bills? We have discussed this many times before, and we have discussed a better financing system that would prevent medical debt, besides guaranteeing health care for everyone – single payer improved Medicare for All.

Why is this still an issue?

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By Adam Gaffney, David U. Himmelstein, Steffie Woolhandler, and James G. Kahn
Health Affairs, January 2021

Abstract

The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic–induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints—for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7–10 percent and hospital use by 0–3 percent. Modest administrative savings could offset the costs of such increases.

Conclusion

The supply-focused framework advanced in this article challenges the long-dominant paradigm among US health economists that health care demand (and costs) must be curbed by forcing patients to have “skin in the game.” Many health care systems have constrained utilization and cost growth without resorting to cost barriers while achieving universal coverage and a more equitable distribution of care. The US can do the same.

https://www.healthaffairs.org…

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Universal Healthcare Less Costly Than Previously Projected: Harvard / UCSF Study

Physicians for a National Health Program, January 5, 2021

Previous projections of the costs of universal coverage, much cited by its opponents, have concluded that expanded coverage would lead to surging healthcare use and costs. But a new study by researchers from Harvard Medical School, the University of California San Francisco and the City University of New York at Hunter College published January 5 in Health Affairs concludes that predictions of large cost increases are likely wrong. The researchers, citing real-world experience with society-wide coverage expansions in the US and ten other wealthy nations, conclude that universal coverage increases the overall use of care only modestly, or, in some cases, not at all.

The researchers find that a factor rarely considered in the previous analyses – the finite supply of doctors’ and nurses’ hours and hospitals beds – has constrained cost and utilization increases in essentially all past coverage expansions, and would similarly prevent a surge in use under Medicare for All or other universal coverage reforms. The study finds strong evidence that new services provided to the people who gain coverage would likely be offset by reductions in useless or low-value care currently over-provided to the well-off.

Overall, the study estimates that a Medicare for All reform offering first-dollar universal coverage would lead to a 7-10% increase in outpatient visits, and a 0-3% increase in hospital use, figures far lower than most previous analyses, which could be readily offset by administrative cost savings.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

This report refutes the claim that the surge in health care utilization under a single payer Medicare for All program would not be affordable for the nation. Under modest supply-side constraints, health care would be prioritized according to need, causing the health care professionals to reduce unnecessary care for patients with minimal needs thereby making way for patients with greater needs. That trade-off produces the benefit of improved efficiency.

Another important conclusion is that it is unnecessary to erect financial barriers to care such as deductibles and other cost sharing which otherwise might cause patients to forgo essential health care services.

Also the reduction in administrative costs by switching to a more efficient single payer Medicare for All can produce enough savings to pay for most or all of the costs of increasing the patient population while decreasing out-of-pocket cost sharing.

It is not that we can’t afford Medicare for All, rather it is that we cannot afford not to do it.

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