By Brenda Gazzar
Code Wack Podcast, August 23, 2021

Join Linda Rae Murray, MD, MPH, & Brenda Gazzar as they take a deep dive on the structural reasons for America’s fragmented healthcare system and what we can do to fix it.

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Transcript

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

How has the public sector in America been under attack? How can we better protect Black and other Americans who are disproportionately affected by COVID and chronic conditions? To find out, we spoke to Dr. Linda Rae Murray, a physician who spent 40 years in clinical practice helping the medically underserved. She retired in 2014 from her post as the chief medical officer for the Cook County Department of Public Health of the Cook County Health and Hospital System in Illinois. 

Welcome to Code WACK!, Dr. Murray.

Murray: My pleasure.

Q: Looking at the pandemic specifically, how did social, structural, and personal racial inequities combine to affect Black Americans?

Murray: So let’s back up a little bit. Pandemics also are an interaction between the environment and human beings and so we have had pandemics, certainly a number of them through my career as a physician, HIV probably being the most impactful. It is a pandemic whether people think of it like that or not and it’s not a surprise that we have the kind of pandemic we have now with the respirable, transmittable organism. We have known that this was going to happen. That is also related frankly to climate change and our interaction with other species on the planet. So let me just say that in the beginning.

And whenever you have a challenge like this, and you have inequities, then the people who do not have the same level of resources are more vulnerable. That’s exactly what that means. So if I own three or four homes, and I leave New York City and go to the Hamptons or some other place where you know the population isn’t as dense and I can order in my food. Obviously you have less contact, you have less problems and my income is not impacted. But if I’m an ordinary American white or black working, say, for a public transportation system or in a factory, then I don’t have those options. If I don’t go to work, then I don’t get paid, I can’t pay my bills, etc. So certainly for Native Americans, African Americans, Latinx people in this country, those realities of our daily lives explain the huge differences that we’ve seen in mortality for COVID, but we should be clear that as a rich country we’ve done very badly in this global pandemic, and our lack of a public health infrastructure, the fact that we’ve historically underfunded public health, and don’t understand the role of public health has meant that many Americans of all races have died unnecessarily from preventable deaths that wouldn’t have occurred if we had a functional public health system and a functional health system in the United States.

Q: Hmmm. Yeah. Why do you think there’s been such an attack on public health over the years?

Murray: This is an attack on American people. It’s an attack on “the public sector.” If you think back to your sort of ninth-grade Civics course, government is what we do collectively. You can have good government and bad government but whatever you have, it’s what we collectively as a society use to structure what’s going on and so, this constant attack on government as though that were the problem or the public sector creates a problem… Look during the last election where people, Republicans were chanting they wanted to keep (the) government out of their Medicare. So there’s a real cognitive dissonance there.

Medicare is in fact the best medical system we have running in the country. It is a governmental system and it does provide sort of a single-payer-like system to help take care of people. Most Americans that are involved with Medicare think it’s great so when it’s framed as though it’s not government, that’s a problem. Most Europeans think rich people are rich because they got lucky. Most Americans think rich people are rich because they worked hard. Now most rich people, especially of our age now, are rich because their parents were rich. They didn’t do nothing.

So I think that it means we have to really as Americans be better educated. We have to have some sense of history and understand how the country works. We can have disagreements on what you should do about it but you cannot continue, for example, to allow people to make unlimited profit and expect not to have fires year around in Europe and the United States and Canada, not to have these floods. This is a direct result of us running amok and thinking that we can continually without any change, maximize profit and still in the world, starvation and malnutrition are still the leading causes of death in the world.

Q: Wow. Can you talk about some of these other things that you alluded to, like housing, exposure to environmental hazards, living next to freeways, how those during the pandemic affected African Americans?

Murray: You can almost pick anything. I think the biggest single issue if I had to pick one that affects Blacks during the pandemic is the necessity of trying to go to work. And then if you’re unable to work, either because your plant got closed down, or because you’re sick or whatever,  the loss of any support. We did a little bit, which we think is amazing. We had some unemployment etc. but in other parts of the world, people were getting 80% or 90% of their regular income from the very beginning and in structures that already provide universal health care, etc.

So we’re a country that we don’t provide most of those social supports, and what we do provide is state by state. People forget we’re not approaching this pandemic as a nation. Let’s pretend for a minute that we were being invaded by another country. Okay? We would not allow every governor to decide how to fight that invasion. It’s another structural problem that goes to voting and everything else. The way our Constitution is set up, we have 50-plus public health departments in this country. Health care is a state power. It’s devolved to the states. They have the real legal authority to decide who can be a doctor, who can be a nurse, and what the response of governmental public health is.

So we’ve had 50 different responses, plus our territories, to this pandemic. We have not been able to have a coordinated response. Even though I personally, for example, thought that (Donald) Trump’s contribution to this pandemic was horrific, I don’t want to in any way excuse him, but even he had not been the president, our response would not have been adequate, because we have not invested in the public health infrastructure, we don’t have a coordinated approach, and we don’t think about these things in a rational way so at every point in our society, I don’t care whether it’s school systems, transportation, internet. You know there are major places in the country where people don’t have internet access, not just the rural areas.  I live in the southside of Chicago and our internet service over here on the southside is notoriously bad and slow compared to whiter areas of the city. So when you create centuries of inequities on all levels, then when you have a crisis, those inequities just get more exposed and often widened.

Q: Yeah, right, thank you. What about the role of the health insurance system in healthcare inequities?

Murray: If I had my way, we’d get rid of health insurance. Think about what that means. I think little kids understand this, but what does health insurance mean? Does it mean we’re making a bet that we won’t get sick? I mean, all of us are going to die. All of us, and most of us will not die before having some other malfunctions that cause us pain or discomfort, etc. So, we should just prepare to take care of people and do it in the best way possible. So I don’t know what health insurance…you mean as a funding mechanism, so then we should ask ourselves, is this a basic human right or not? I think health is a basic human right, and so the cost of doing that should be shared. In this country we spend more on medical care than anywhere else in the world several times over. We have more than enough money to take care of every man, woman, child, every dog and cat in the United States, and provide the highest quality medical care, but we have to have a system.

We have to build a system that is designed to do that, not to make profits. We have to build a workforce that looks like the population. There are fewer black men entering medical school today than when I graduated medical school, fewer in number. So that means we have to not allow that to happen.

Q: Um-hmmm. Why else do you support Medicare for All?

Murray: Well, why not? Mostly it’s because I believe that health care, medical care especially but health care, which is broader than medical care, is a basic human right and I’ve seen around the world other countries that have this principle — that it’s a basic human right — and try to structure services to address that do much better, have much better outcomes. So the United States, we may have the most expensive medical care system in the world but we have the worst health of any rich country in the world. I mean that’s the reality. Our system is a failure. You can see it whether you look at life expectancy,  maternal mortality, stroke. You can look at a whole range of things in comparison to other rich countries, other rich capitalist countries in the world and this has been true for a while — since the 50s —  and it continues to be true, and the gaps continue to widen.

Thank you, Dr. Linda Rae Murray.

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

https://heal-ca.org…

By Kip Sullivan and James G. Kahn, M.D., M.P.H.
STAT, August 23, 2021

For the last half-century, Congress has endorsed essentially the same approach to cutting health care costs, an approach that came to be called “managed care” by the mid-1980s. Based on the assumption that U.S. health care costs are double those of other wealthy nations because doctors order services patients don’t need, the solution is to “manage” doctors and provide financial incentives that nudge them to cut services.

The managed care approach has not only failed to cut costs, it has contributed to health care inflation by encouraging mergers and driving up administrative costs. The failure of the accountable care organization (ACO), a prominent iteration of managed care, illustrates the problem.

The ACO label was invented at a 2006 meeting of the Medicare Payment Advisory Commission (MedPAC). The concept was tested between 2005 and 2010 in the Physician Group Practice (PGP) Demonstration. In 2009, even as early results of the PGP project were showing that the accountable care concept wouldn’t work, Congress added provisions to the Affordable Care Act requiring the Centers for Medicare and Medicaid Services (CMS) to insert accountable care organizations into the traditional Medicare program.

ACOs are hospital-clinic chains that sign contracts with insurers (in Medicare’s case, with CMS) to share financial risk. That means an accountable care organization splits profits with CMS if profits are made and shares losses if losses occur. They work like this: CMS sets expenditure targets for accountable care organizations at the beginning of each year. At the end of the year, CMS sends ACOs that have spent less than their target a “shared savings payment.” In some programs, ACOs that exceed their target pay CMS a penalty.

In an article published online this month in the Journal of General Internal Medicine, we reviewed evaluations of all four of Medicare’s accountable care experiments that CMS has conducted since 2005. All four failed to affect Medicare spending; their impacts ranged from tiny savings of a few tenths of a percent to equally tiny losses. If we include in our calculations the costs that accountable care organizations incur in their futile efforts to reduce Medicare spending, such as contracting with insurance companies to manage risk and hiring more nurses, these organizations actually raise health care costs.

ACOs are supposed to work best for a population living with many chronic illnesses, such as Medicare enrollees. If these programs can’t cut Medicare costs, they clearly can’t cut costs for the whole country.

Why did accountable care organizations fail?

We see two main reasons for the failure of accountable care organizations: The diagnosis was wrong and the prescription was wrong.

The key assumption underlying the nation’s managed care experiment is that U.S. health care costs are high because Americans get too many medical services, and this overuse is caused by the fee-for-service method of paying doctors. Fee for service creates a financial incentive for doctors to order more tests and do more procedures, something doctors allegedly cave in to. That, anyway, was the diagnosis promoted in the early 1970s by proponents of health maintenance organizations, an early form of managed care, and it is the diagnosis offered today by ACO proponents.

In its June 2009 “Report to Congress,” for example, the Medicare Payment Advisory Commission claimed that the “ACO’s role is to create a set of incentives strong enough to overcome the incentives in the [fee-for-service] system to drive up volume….”

But the assumption that overuse is widespread, and that all overuse is caused by doctors caving in to fee-for-service incentives, is wrong. Over the last two decades, research has clearly demonstrated that overuse of medical care isn’t why health care costs are rising. Per capita health care costs in the U.S. are high compared with other nations because the prices at which medical services and drugs are sold is excessive.

In any sector of the economy, total spending is a function of price and quantity (or volume). Price times quantity yields total spending. American policymakers have focused on the quantity factor when they should have focused on the price factor. In a Health Affairs article aptly titled, “It’s The Prices, Stupid,” health policy expert Gerard F. Anderson and colleagues concluded that (the italics are ours) “the difference in spending [between the US and other countries] is caused mostly by higher prices for health care goods and services in the United States.”

Why are U.S. prices so high? Because incessant consolidation of its health care system gives those who sell medical services and drugs the power to raise prices. And the huge cost of administering the country’s stunningly complex health care system motivates sellers to raise prices: Excessive administrative costs account for 15% of the $4 trillion the U.S. spends annually on health care, or more than $2,000 per person.

The accountable care organization solution has failed not just because it addressed the wrong problem (overuse rather than excessive prices and inefficiency) but also because these organizations were never clearly defined. From the moment the ACO label was concocted by the Medicare Payment Advisory Commission at its November 9, 2006, meeting, accountable care organizations have always been “defined” in terms of the aspirations of its proponents.

The following “definition” by accountable care organization proponents Mark McClellan, a former CMS administrator and a former FDA commissioner, and colleagues is typical: “ACOs consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth …. while caring for a defined population of patients.” Is it possible to be more vague than that? “Providers” are “held accountable” (by unidentified parties using unidentified means) for “measured improvements” (measured at an unknown cost to providers and the measurer) in the “cost and quality” of health care delivered to a (poorly) “defined population.”

In addition to being vague, the ACO proposition has failed because it rested on a false premise: doctors work primarily for money and can be induced to stop ordering unnecessary services if they could make money by doing so. But most physicians don’t work primarily for money. They are motivated to provide high-quality care, solve complex challenges, and see their patients prosper. Behavioral economists call these intrinsic motivations — and they are undermined by the monetary penalties and rewards deployed by accountable care organizations.

These twin defects in the ACO proposal — a wrong diagnosis along with a poorly defined and evidence-free prescription — have plagued the managed care experiment since health maintenance organizations were formalized in the 1970s. The widespread adoption of the cost-containment tactics pioneered by those organizations was the primary cause of an explosive growth in administrative costs and mergers, both of which drove up prices, that began in the late 1980s.

Health maintenance organizations, accountable care organizations, and other managed care “reforms” have not just failed — they have backfired, aggravating the problem they were supposed to solve.

It is long past time to abandon managed care. We should rely instead on lessons learned from other countries that have adopted single-payer systems, price controls, and universal coverage with uniform benefits. The results in cost control and longevity are impressive.

Kip Sullivan is a member of the advisory board of Health Care for All Minnesota. Dr. James G. Kahn is emeritus professor of health policy at the University of California San Francisco.

https://www.statnews.com…

By Brenda Gazzar
Code Wack Podcast, August 16, 2021

Featuring Dr. Linda Rae Murray, MD, MPH, former Chief Medical Officer – Primary Care for the Cook County Bureau of Health Services & “full-time troublemaker,” discussing the artificial separation between social, structural, and personal racism.

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Transcript

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

How has American medicine played a role in propagating racism? How does racism put Black people and Native Americans at a higher risk for illness and death? To find out, we spoke to Dr. Linda Rae Murray, a physician who spent 40 years in clinical practice helping the medically underserved. She retired in 2014 from her post as the chief medical officer for the Cook County Department of Public Health of the Cook County Health & Hospital System in Illinois. She’s been a voice for social justice and health as a basic human right for more than fifty years. 

Welcome to Code WACK!, Dr. Murray.

Murray: My pleasure.

Q: So I’d love to hear a little bit about you. When you graduated from medical school in 1977, what was the landscape like for female African American physicians?

Murray: Well, I don’t think there’s anything unusual about that time period. In 1977, we were entering a period of retrenchment in the United States. Conservatism and Reaganism was coming to the fore but the situation for Black physicians of all genders has never been good, so it wasn’t good then. This is a period as I started my residency training where the public sector was under attack. Public hospitals were being defunded. We lost a number of hospitals around the country and we lost a number of public hospitals in St. Louis, Philadelphia and other places.

Q: One of the biggest problems in American healthcare has been racism. It’s well documented, but still many Americans don’t acknowledge it. Can you give us some examples of social and structural racism in health care?

Murray: Well, the medical care system, and health care in general is a part of our culture and society and so structural racism is the underpinning of what goes on in America and so I am always concerned about how that racism seeps into the structure of a country. So I don’t care what you start with, you can start with where services are available. When I was a resident, only the United States and South Africa were the only ones that didn’t try to provide universal coverage for its population. Today it’s only us in terms of rich countries.

And so when you talk about structural racism in medicine, American medicine plays a special role in propagating through up until really the 1950s the notion that (Black people) were biologically inferior — that was a major strong strain of American medicine, and how the structure is set up with everything we do, what kind of jobs you have or don’t have, what kind of exposures you have, an inability to access diagnostic services and curative services. These are all things that are obvious in medical care settings, but the real harm that structural racism does goes far beyond the medical setting, far beyond the hospital or the exam room. It goes into all aspects of American life.

Q: Hmmm. Thank you. This idea that people of color are biologically inferior, how does and how did that manifest itself?

Murray: So I want to be careful here about our language again. Western racism in the modern era, in the past couple of 100 years, is based on a hierarchy and so all of those hierarchies put Africans at the bottom of racial hierarchy so when we say people of color, that’s an important political concept but in terms of racial hierarchy, Africans are at the bottom — and so I don’t care whether you’re talking about the Bell Curve, which argues that that’s why Blacks have poor education outcomes, or whether you’re talking about old-fashioned “eugenics movement,” this is a notion that has run through our history so from a medical point of view in terms of American medicine, this notion that these negative traits and positive traits, they are inherited and that far outweighs whatever else happens to people.

So that concept we still have today whether you’re talking about outcomes at the Olympics or sportscasters that argue that, you know, Blacks are somehow differently made as beings. And, you know, so a Black basketball player will be skilled, a white basketball player would be smart. You see these kinds of differences that exist all along. I am concerned as we look at modern genetics. We’ve done some studies as recently as 2016 that showed an extraordinarily surprising number of medical students and residents believe certain myths about African Americans, about Blacks. For example, the notion that our skin is thicker. Nowhere in medical schools is that taught but that notion was there among, like I said, a surprising number of physicians and medical students. That’s also the nature of structural problems. They are baked into the society, and most people are unaware that they’re even there. They just are considered part of the normal universe and so those things are still with us and they’re still a major concern.

Q: Right. And so how are these myths most detrimental to Black patients?

Murray: Well, they’re most detrimental for Black people because we die younger and from diseases that can be prevented, I mean that’s the very nature, that’s the very definition of health inequity, and here I want to bring back other people who are not white, in terms of that hierarchy. So, for example, Native Americans, our Indigenous groups in North America, have mortality rates and often health outcomes that are equal to or worse than Blacks depending on which disease entity you look at so there’s no question that racism kills people, to put it bluntly.

It doesn’t just mean it kills people when police shoot you. It kills people with everyday things, whether you don’t get your blood pressure treated, whether you don’t have access to cancer screening, whether you’re just stressed out by the fact that you’re unemployed, and you don’t have good nutrition and all of these activities of life, all of these things in our society imprint themselves on our bodies, and when you have societies that are unequal, where oppression is going on, where people are under stress, then those show up. So it’s not an accident for example with COVID, people who had to go to work, who did not have the privilege of working remotely, are the people who got COVID more frequently, and if you didn’t have spacious living quarters with nutrition, good transportation, all of the things that we know put you at higher risk, then you got COVID and you’re more likely to get sick from it and be hospitalized and die.

Q: Okay, thank you so much. Social and structural racism in health care obviously differ from personal racism. How do you think the three work together to negatively impact Black Americans’ experience with health care?

Murray: I think we try to make too much of an artificial separation between these things and let me just say that, personally mediated racism at the personal level changes. So, you know, 100 years ago, the use of the N word might be considered normal and not even in certain parts of the country, just a normal descriptor. Today, what the young people call microaggressions, which I think is a euphemism, it’s still racism, the level of which these things are expressed in polite society changes. So again, things that might be said about women when I was a young woman would not be acceptable to say today in a public setting, that doesn’t mean they’re still not said. It doesn’t mean those ideas still aren’t there. We as individuals live in a societal setting. And so, all of those levels of which racism operates reinforce each other, they’re not separate, and so it doesn’t do any good to have people be polite, if in fact you are not allowing Black people to vote. It doesn’t matter if you’re polite, if educational opportunities are different, or where you can live are different. So those structural conditions haven’t changed, I think, in any measurable way so we still are being impacted.

It’s almost like climate change, you know, you might have people talking more intelligently about climate change today but as we’ve just seen from our recent report, the climate is still getting warmer and we’re still changing at a more and more rapid rate so we have to address not only structural racism, we also have to address class biases, and gender biases in our society and unless we do them all together and really, really reject the basis on which our country operates, which is an individualistic profit-driven perspective, then we’re going to be killing lots of people. These things also kill lots of white Americans. They are just unaware of it or choose to ignore it. It’s not an accident that the life expectancy for example for white Americans has been dropping, and it’s part of those same structural problems that are going on.

Thank you Dr Linda Rae Murray. 

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

https://heal-ca.org…

August 14, 2021

Bronx-based OB/GYN resident Dr. Ashley Duhon shares the Sister Song definition of reproductive justice as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”

She adds that “we are failing our patients in every aspect of [reproductive justice], and a lot of that has to do with access to health care.”

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

https://medicareforallexplained.podbean.com