PNHP national board member and PNHP-California president Dr. Paul Song presented a Tuesday Talk to Doctors in Politics on January 12, 2021. He spoke about how the COVID-19 pandemic has unmasked the flaws in U.S. health care, including the glaring ineffectiveness of employer-sponsored coverage, and how the industry was spending millions to push back against the obvious solution: single-payer Medicare for All.
Eric Foner on American exceptionalism
Capitol Mob Reveals Ongoing Refusal to Accept Black Votes as Legitimate
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.
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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U.S. ranks near last in equity, affordability and access to primary care
Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries
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…
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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Misrepresenting race in medical schools
Misrepresenting Race — The Role of Medical Schools in Propagating Physician Bias
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.
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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So, where does health care reform fit in all of this?
With New Majority, Here’s What Democrats Can (and Can’t) Do on Health Care
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.
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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The pandemic did not stop some hospitals from suing patients for unpaid bills
One Hospital System Sued 2,500 Patients After Pandemic Hit
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.
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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COVID-19 thrives in our profit-first health care system
By Sydney Dawes
The Athens (Ohio) News, January 6, 2021
In our country, hospital are closings, health care workers are being laid off and substandard working conditions for nurses exist. In addition, we have seen a lack of protective equipment, insurance companies’ massive profits without paying for hospital costs and millions of people uninsured and unwilling to have COVID tests because of the cost.
All these conditions are a result of hospital and staffing decisions being made on a financial basis. Since elective surgeries were canceled or postponed, hospitals have lost a primary funding source.
Here are the numbers and facts according to Physicians for a National Health Program (PNHP):
- 80 hospitals in the U.S. closed last year.
- 80,000 nurses and health care workers were laid off or furloughed.
- 58,025 of the 138,707 private practice doctor’s offices closed from March to June of 2020. That is a reduction of almost 42 percent.
Furthermore, staffing schedules, personal protection equipment and unsafe working conditions prevail in the country. Failures to track COVID-19 data has led to more than 1,700 health care worker deaths, which jeopardizes public health further. With fewer hospitals and doctors available, less staff, and protection equipment available, we are essentially enabling COVID-19 to spread.
In our privately managed health care system, priority is placed on financial need more than patient need. National Nurses United declare that “employers have taken advantage of every opportunity presented during the pandemic to maximize profits,” as stated in their white paper “Deadly Shame.”
In addition, insurance companies report excessive profits from covid while paying for less service. The New York Times states: “Some of the largest companies, including Anthem, Humana and UnitedHealth Group, are reporting second-quarter earnings that are double what they were a year ago. Although many hospitals have been overwhelmed by the coronavirus outbreaks raging from state to state, insurers have shelled out billions of dollars less in medical claims in the last three months. The companies’ staggering pandemic profits stand in stark contrast to the scores of small medical practices and rural hospitals that are struggling to stay open…”
An enormous amount of money stays with the wealthy and is not getting to the sick. COVID tests often are costly and is not readily available, especially for 30 million people who remain uninsured. There are 70 million others who have such high deductibles that they avoid going to the doctor to get tested or treated for COVID when sick.
COVID-19 grows and thrives with these financial barriers to COVID testing and treatment, and uninsured populations. Are there really financial barriers in the USA compared to other countries?
According to the Commonwealth Fund Data, in eight categories of skipping medical help because of costs, people in the USA as more than twice as likely to skip tests/treatments/ and seeing a doctor when sick compared with even the highest rates of other countries.
The solution is to immediately implement the following items as an emergency measure:
Free testing and treatment: All testing, treatment and follow-up services must be made easily available to everyone at no cost.
Budget all expenditures based on serving medical needs, not serving insurance or administrative profits. All hospitals, clinics, doctors paid on need assessment and COVID treatment, not on profitability. Fund this from insurance company windfall profits and expanded Medicare.
Assure worker protections now. Supply PPE for all staff and nurses; implement safe scheduling of hours and working conditions; boost hiring; provide sick leave for workers, and family leave.
Follow the 8 steps of COVID-19 Response as recommended by the Physicians for Health Plan.
Pass into law the Expanded and Improved Medicare for All so we can manage COVID and prevent future flat-footed responses to pandemics.
Editor’s note: Arlene Sheak enjoyed living and working in Athens County 45 years.She has been an activist with the Single Payer Action Network (SPAN) of Ohio for 18 years.
We can easily afford to include everyone in Medicare for All
Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?
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…
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.
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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Universal Healthcare Less Costly Than Previously Projected: Harvard/UCSF Study
Health Affairs study finds that previous projections of costs under single-payer Medicare for All ignore evidence that the finite supply of beds, nurses, and physicians will prevent a surge in health care use and costs.
For Immediate Release: January 5, 2021
CONTACT:
Adam Gaffney, M.D., M.P.H., Harvard Medical School and Cambridge Health Alliance, agaffney@cha.harvard.edu
Steffie Woolhandler, M.D., M.P.H., City University of New York Hunter College and Harvard Medical School, swoolhan@hunter.cuny.edu
James G. Kahn, M.D., M.P.H., University of California San Francisco School of Medicine, JGKahn@ucsf.edu
With the COVID-19 pandemic accelerating, job and health insurance losses accumulating, and a Democratic administration soon to be in charge in Washington, debate over health care reform looks set to return to the national stage. Previous projections of the costs of universal coverage, much cited by single-payer 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, the City University of New York at Hunter College, and the Public Citizen Health Research Group 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 U.S. and 10 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.
Health economists have traditionally assumed that because society-wide coverage expansion would reduce cost barriers, patients’ use of health care—and consequently costs—would soar. They cite decades of careful research showing that individuals with better insurance coverage use more health care. However, the authors of the Health Affairs study note that after society-wide reforms, all care must still be provided using the same supply of doctors, nurses, and hospital beds, a supply that is mostly fixed, at least in the short run. The authors note that most projections of the costs of universal coverage have ignored the fact that the supply of health care is constrained, and have failed to account for countervailing changes in the use of care by individuals whose coverage did not change. They present evidence that after society-wide coverage expansions, the newly insured do (as economists predict) increase their use of care, but this is offset by small, nearly imperceptible reductions in care to persons who were already well-insured.
The researchers based their conclusion on analyses of coverage expansions in 11 nations. In those cases, the median increase in the number of hospitalizations society-wide was only 2.4%, while doctor visits increased by only 4.6%. Moreover, because hospitalizations and visits were already on the rise before most of these coverage expansions, the increases were even smaller when accounting for those pre-existing trends.
Overall, the study estimates that a Medicare-for-All program 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, and which could be readily offset by administrative cost savings.
“The experience of previous coverage expansions seems paradoxical: while insurance coverage soars, overall health care use rises only modestly,” noted lead author Dr. Adam Gaffney, a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance. “Our findings clash with the traditional economic teaching: that giving people free access to care would cause demand and utilization to soar. That traditional thinking ignores the ‘supply’ side of the health care equation: doctors’ and nurses’ time and hospital beds are limited, and mostly already fully occupied. When doctors get busier, they prioritize care according to need, and provide less unnecessary care to those with minimal needs to make way for patients with real needs.”
“Past society-wide coverage expansions haven’t caused surges in health care use,” noted study co-author Dr. Steffie Woolhandler, Distinguished Professor at the City University of New York at Hunter College, Lecturer at Harvard Medical School, and Research Associate at Public Citizen, “so analysts who’ve confidently projected a tsunami of health care use and costs after Medicare for All are ignoring history.”
“The supply-focused framework we advance in our study,” commented senior author Dr. James G. Kahn, Emeritus Professor at the University of California San Francisco School of Medicine, “challenges the idea that ‘skin in the game’ is needed to control health care costs. Many other nations have achieved universal coverage at affordable cost, without imposing big copayments or deductibles. We can too.”
“Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?” by Adam Gaffney, M.D., M.P.H., David U. Himmelstein, M.D., Steffie Woolhandler, M.D., M.P.H., and James G. Kahn, M.D., M.P.H. Health Affairs, January 5, 2021. doi: 10.1377/hlthaff.2020.01715
Health insurance brokers manipulate commissions and bonuses
Op-Ed: Beware of Health Insurance Brokers — Commissions are often linked to premiums
By Katy Talento, Sc.M., and Ge Bai, Ph.D.
MedPage Today, January 2, 2021
Health insurance brokers market themselves to employers as a buyer’s agent, promising to use their expertise to find employers the best deal. A new study, however, reported a positive association between health insurance broker commissions and premiums paid by employers offering fully insured group health plans to their workers.
What’s more, brokers are also paid various types of bonuses by insurance carriers, based on the amount of total business the broker has placed with the carrier, the amount of new business delivered to the carriers, or other types of metrics based on profit delivered to the carriers.
If you’re an employer looking for fully insured health insurance plans, your broker has every incentive to sell you a higher-priced plan compared to a lower-priced plan, a plan structured to produce more profit for the carrier rather than savings to you, a plan sold by the carrier that has a better bonus structure compared to a better plan for you offered by another carrier.
Larger employers often hire one of a handful of major insurance carriers to administer a self-funded plan, in which the employer pays all of the medical claims incurred by its workers. The carrier is merely a claims processor, writing checks to hospitals and doctors out of the employer’s own bank account. What incentive does that carrier have to make sure the employer isn’t being overcharged, billed erroneously, fraudulently, or billed for inappropriate and unnecessary care at more expensive sites of care? None. They just mail the check. It’s not their money on the line.
So fully insured employers buy plans sold by agents who have no incentive to keep costs down or recommend the most suitable plan; self-funded employers have carriers that have no incentive to keep costs down or quality high. That economic jujitsu is stealing prosperity and growth from American businesses, and stealing the American dream from the working class.
Ge Bai, Angela Park, et al, Medical Care Research and Review: The Commissions Paid to Brokers for Fully Insured Health Insurance Plans, December 16, 2020:
https://journals.sagepub.com…
Comment:
By Don McCanne, M.D.
When the Affordable Care Act was drafted, one of the goals was to protect and perpetuate employer-sponsored health plans, the part of the health insurance market that was said to be functioning well. No doubt the health insurance brokers that sell these plans were in agreement with this assessment.
The insurance brokers are strictly administrative intermediaries who provide no health care services whatsoever, but they add significantly to the costs of health plans offered by employers though broker commissions and bonuses. The brokers can increase these payments from the insurers by manipulating the insurance products sold to the employers, often increasing the brokers’ own profits without providing any added value to the employer or the insured employees. These brokers are yet one more reason why health care costs are so high in the United States in a system rife with mediocrity and wasteful administrative excesses.
The brokers no doubt contend that they are providing a valuable service to the employers by not leaving them stuck with a one-size-fits-all plan but instead customizing the plan to fit the wishes of the employer. But what customization is offered? Higher deductibles and other cost sharing that erect financial barriers to health care? Narrow provider networks that may exclude professionals and hospitals that the employees may prefer or even need? Limiting services covered by the plan? Using tiering or stepped therapy that create more barriers to care? Regardless, they will certainly select plans that will provide higher commissions and bonuses without bothering to explain those features to the employers buying the plans.
So then the employer has a choice of private plans, fulfilling President-elect Biden’s assurances that private health plans will always be available.
Wait. Shouldn’t these plans be compared to the dreaded one-size-fits-all plan? What would a single payer improved Medicare for All plan offer? All essential services would be covered, throughout life. Hundreds of billions of dollars in administrative waste would be eliminated (including the fees of superfluous brokers). The financial barriers of cost sharing would be essentially eliminated. Individuals would have the freedom to choose their own health care professionals and institutions. Equitable, progressive tax policies would be used to fund the system, making care affordable for each of us.
Market advocates claim that choices in insurance plans reduce costs while improving quality, yet the opposite is true since markets do not work in health care, except at the extreme margin. What we really want is the comprehensive, effective, equitable, affordable one-size-fits-all plan that really does take care of all of us without threatening our financial security. We certainly don’t need to pay the brokers to advise us that we should go ahead and accept improved Medicare for All. By now, we can figure that out on our own.
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How safe is the coronavirus vaccine? Dr. Rob Davidson weighs in.
By Brenda Gazzar
Code Wack Podcast, January 4, 2021
Featuring Dr. Rob Davidson, practicing emergency room doctor and head of Committee to Protect Medicare. How can we overcome vaccine hesitancy among Americans? Why do some communities have serious concerns around seeking medical care? Host Brenda Gazzar and Dr. Rob Davidson, discuss the Committee to Protect Medicare’s vaccine campaign, the latest mRNA vaccine technology and why he trusts the new COVID-19 vaccines.
Transcript
(10-second music)
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.
After nearly a year of living in the coronavirus pandemic, the COVID vaccines are finally here. What do we know about them and their safety?
I spoke with Dr. Rob Davidson, an ER physician and head of the Committee to Protect Medicare, on why he’s taking the vaccine and urging others to do so as well.
(5-second stinger music)
Thanks for joining us, Dr. Rob!
Q: Tell me about the Committee to Protect Medicare’s vaccine campaign. Who is the campaign targeting and what issues will you focus on?
Dr. Rob: Essentially, it’s going to be a campaign, primarily having doctors in communities where they work, communities where they can basically talk directly to the patients that they serve, trying to convince people in certain demographics that the vaccine is safe, that it is important — important for their own community, for their own families, primarily looking at African American communities. Right now in the state of Michigan, probably in the state of Florida as well, and certainly looking at members of our organization in different states, trying to kind of mimic this. And we did during the (presidential) campaign, a little more political work, more targeting of message to particular groups of voters. We feel like some of those techniques of messaging, to individuals through social media, through text campaigns, emails are other ways that we can hopefully communicate with individuals within certain communities as a way to work in parallel with state governments, with local governments, with the federal government on their mass messaging campaigns, what they’re doing on TV or through digital ads, we can be doing that at more granular level in very specific communities.
Q: Got it. So you’re looking at recruiting doctors of color to help convince their communities that the vaccine is safe and would be a good thing to do in light of this crisis?
Dr. Rob: Yeah, that’s certainly part of it. I mean a number of members of our organization are physicians and also who are people of color, who are very clear that — and we understand that, I understand, I’m sure you understand and a lot of people listening understand — many communities of color are very suspicious of the big industrial medical complex for various reasons, including the Tuskegee syphilis experiments, including Henrietta Lacks and just many other issues that people have endured from the sort of medical industrial complex and the government health complex and these suspicions are real. They’re valid and we don’t want to discount those suspicions or those concerns so it isn’t so much having people talk at people. It’s more having people engage with folks in their community, to try to understand what the concerns are and try to alleviate those concerns as much as possible.
Q: Right, and people of color are much more likely to contract and die from COVID.
Dr. Rob: That’s the kicker here. They’ve been so disproportionately impacted, you know, for various reasons, be it a lack of health care, be it the fact that a lot of jobs in those communities are front-facing jobs in the public that can’t be done from home via Zoom, or via any other means. So they just have been more at risk — these essential workers that are a part of the next wave of people getting the vaccine. I’m extremely hopeful that we can get a number of those folks, significant numbers, to decrease the impact on those communities.
Q: There are many objections to getting vaccines, in general, and to getting the COVID vaccine specifically. As a physician, what concerns about vaccines do you have — and with the COVID vaccine, do you have any concerns about them?
Dr. Rob: The way I look at vaccines is this. Are there some side effects? Absolutely. Are there potential risks? For sure, with any vaccine. But do the benefits of that vaccine in an individual, and also in a population, outweigh the risks of the vaccine? I think for this, for the coronavirus, for COVID-19, that is absolutely true by everything we had talked about previously; the massive numbers of cases, over 300,000 people dead — probably going to be half a million dead or so by the time we get most of our population vaccinated — the disproportionate impact on communities of color, what it has done to our economy because of the measures that need to be taken to try to mitigate the spread of the virus. I think all of that together is such a massive risk to populations and to communities and to individuals that the vaccine, with the current safety profile that we know of, to me is a no brainer for me. And I will advocate for it for my patients and again, across our vaccine campaign.
You know the current risks, to me the only issue is, did this come to market faster than any other vaccine ever? Yes, that is absolutely true. It’s also the only vaccine developed in the midst of a pandemic that has been killing this unprecedented number of people, and killed our economy, and is sickening so many people. So the need was there for this rapid development.
The technology has been there since 2011 where they’ve been working on antibodies against certain types of cancer. So, so that technology has been there. I trust the technology. I appreciate the mRNA technology if people don’t know how it all works.
They take a bit of genetic code from the virus called RNA and they put it in a little carrier, they inject it, it gets into your muscle cells, and then that RNA, that bit of genetic code is taken up by your own body’s system and your body makes this protein that looks like viral protein. …There’s no actual part of the virus (in the vaccine). This has all been manufactured in the lab, this genetic code, and then as soon as the protein is made, the RNA goes away. It’s dissolved. And the only thing left is your own body’s protein that looks like a virus. So your body says, this doesn’t look like self and makes antibodies and that’s how you develop an immune response.
Relative to any other vaccine technology out there, the live attenuated or where they take pieces of the virus, pieces of the bacterium, to me, this appears to be the most straightforward, safest way one could get vaccinated. Probably it will be a technology they use for other vaccines in the future. So I trust it. I trust it.
Thank you, Dr. Rob.
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As it was, and how it needs to be
Putting Health First: Two South County doctor brothers who serve mostly Latinos aren’t concerned about clients’ papers or pocketbooks.
By Yvette Cabrera
Los Angeles Times, February 13, 1995
SAN JUAN CAPISTRANO — Back in the 1960s, after Mexican farm workers left the fields at each sunset, Dr. Monte McCanne’s office in this tiny agricultural town would begin to fill with laborers and their children. The doctor was always in, sometimes as late as 10 p.m., and he never rejected a patient who couldn’t pay.
Now in his 34th year of practice, McCanne, a primary-care physician who also provides obstetric services, says patients continue to come to him for medical care because he still welcomes all, even those uninsured, undocumented or unable to pay.
“I’ve always thought that…all I had to do was walk out the door and down the street and I’d find people in desperate need,” said McCanne, 60.
Former city planner Raymundo Becerra said: “I see Monte as a key player in the community who very humbly and quietly does his work. He is an old-town family doctor who has the love and respect of the Latinos here.”
About 75% of McCanne’s patients are Latino.
Even when Becerra arrived in San Juan Capistrano in 1973, he was surprised to meet so many people who were patients of Monte McCanne.
And now it seems like everyone has been delivered by Monte, “sometimes even three generations,” said Becerra.
Monte McCanne is not alone. His brother, Don McCanne, 57, is a San Clemente physician who also provides care regardless of his patients’ ability to pay.
“When other doctors wouldn’t take (obstetrics) patients without insurance, the McCannes would always accept them,” said Thomas E. Shaver, a surgeon at Mission Hospital Regional Medical Center in Mission Viejo.
“Despite financial hardships that go along with taking care of people without insurance . . . the (McCannes) have really committed their entire professional lives to caring for the Hispanic community in that area,” Shaver said.
At work, instead of typical medical garb, Monte McCanne wears one of the many guayaberas he has received. These lightweight cotton shirts are popular in Mexico’s coastal states of Veracruz and Guerrero.
“Between the two of us we’ve probably done (dubious number edited out – DM) worth of free work…But once you’ve eaten, how much money do you really need?” said Monte McCanne, who, like his brother, is married and maintains a modest lifestyle.
The McCannes are links in a family legacy that has provided for the less fortunate. Their grandfather, a real estate agent who owned orange groves in Pomona, delivered fruit to the mainly Latino residents of low-income neighborhoods in the south side of that city.
Their father, a former architect and schoolteacher who completed medical school while his children were growing up, opened two medical practices in Pomona in the 1950s to provide desperately needed health care. When he opened weekend clinics in San Juan Capistrano and San Clemente in the 1960s, his two sons–doctors themselves–took charge. (Don McCanne’s twin brother also followed in their father’s footsteps: He is an obstetrician for Kaiser Permanente in Fontana).
“We certainly filled a need. When we came here, nobody wanted to serve the indigent,” said Don McCanne, who arrived in San Clemente in 1966, five years after his brother settled in San Juan Capistrano. “But there are always going to be people who have difficulty in obtaining medical care.”
Slowly, word spread through the barrios about the brothers who never asked if their patients were documented residents.
Marcela Conde’s three daughters are the fourth generation of her family whom the McCannes have treated.
“The McCannes have great personalities. When I talk to them they don’t give me the run-around,” said Conde, 23, who was delivered by Monte McCanne and who had two of her daughters delivered by Don McCanne. “My whole family goes to them, from my grandmother and mother to my aunts and sister.”
Having a sibling who’s a doctor nearby has been a blessing for the brothers. They have rotated on-call duties since 1966 and have left town together only once, when their father died 20 years ago.
Though the brothers have the same desire to help the indigent, in many ways they are different. Don McCanne speaks limited Spanish while Monte is bilingual.
Don McCanne is active in his community, serving as chairman of the Mariners Bank in San Juan Capistrano and as a board member at Samaritan Medical Center in San Clemente, while Monte prefers to keep a lower profile.
Don McCanne said he is obsessive when it comes to following rules, while his brother is more casual and “warmer.”
Yet, when it comes to dosages of dedication, the siblings are like twins. Both work late into the evening and on weekends.
Some people object to the McCannes providing health care to illegal residents.
“Orange County is bankrupt. We simply do not have the resources to take care of the world,” said Nancy Thomson, coordinator of Citizens for Responsible Immigration, based in Orange. “These doctors do not have the right to give their services to people who” are here illegally.
Don McCanne responded by saying, “I’m a physician. I take care of people. And I know that offends some people, but every single person deserves adequate health care.”
He added that “the private patients pay the bills and keep us financially viable.”
Long hours, a progression of patients, low Medi-Cal reimbursement rates. Why do the McCannes continue this course?
“There’s a lot of gratification. It’s just the overall feeling of doing something good,” said Don McCanne.
Doctors Have Right to Serve Anyone
Los Angeles Times, Letters to the Editor, February 19, 1995
It was heartwarming to read in “Putting Health First,” (Feb. 13) about the two doctors, (Monte and Don) McCanne, who have committed their lives to serving the Hispanic community of south Orange County without regard to ability to pay or proof of citizenship.
When doctors are too often perceived as primarily concerned with their own bottom lines, it’s reassuring to know that these men give so freely of their talents.
In contrast, I was sickened by the outright meanness expressed by Nancy Thomson, coordinator of Citizens for Responsible Immigration, in her objection to the McCannes providing medical health care to illegal residents. Her position that Orange County’s bankruptcy somehow means that “these doctors do not have the right to give their services to people who” are here illegally is incredible. Is she so lacking in care for her fellow man that she would deny the doctors’ right to deliver their own services to whomever they please?
And what about Newt Gingrich’s position that private charity should replace government in caring for the needy? These doctors are reducing the county’s cost of caring for the indigent in emergency rooms. Their basic humanity stands in sharp contrast to the barely concealed bigotry of the anti-immigration groups.
A. McINTYRE
San Clemente
Congratulations to the McCanne brothers. Their work and altruism is a true reflection of the Libertarian views. They are helping others without a law requiring them to do so and without any laws telling them they cannot.
ANNA M. APOIAN
Corona
I am a middle-class, third-generation American. Thirty years ago, my daughter, Lisa, was very ill and none of the fancy doctors in South County knew what was wrong. Dr. Monte McCanne diagnosed leukemia and sent us to Children’s Hospital of Orange County for affordable care, as we had no insurance at the time. Dr. Monte remained our family physician for many years.
Nancy Thomson of Citizens for Responsible Immigration says: “These doctors do not have the right to give their services to people who” are here illegally. These doctors have the right to give whatever they like to whomever they like. Thomson is a disgrace to humanity.
JOAN DANIELS
Laguna Niguel
Boos to Nancy Thomson for her position that “these doctors do not have the right to give their services to people who” are here illegally. Come on.
But kudos to Drs. Don and Monte McCanne for their medical services to the poor and indigent for long years, regardless of the ability to pay. These men have to be among the brightest luminaries in our community.
FATHER RICHARD WOZNIAK
Associate Pastor
La Purisima Catholic Church
Orange
Comment:
By Don McCanne, M.D.
Okay, this looks like kind of a weird Quote of the Day, but it seems to be appropriate for the very last day of a very difficult year. I had long ago forgotten about this article published a quarter of a century ago, but one of our sons stumbled on it yesterday through Google, and he sent it to us.
So what is the story behind this story? Simply, we believed that everyone should have health care and linking that care to the ability to pay frequently was just not right. I joined the practice in July, 1966, the month when Medicare and Medicaid were implemented. Medicare was great. It paid fair rates and opened up referral channels to specialized care. Medicaid helped to reduce our losses on care for the indigent, although we had to rely on other sources for our own (modest) net incomes. Even the uninsured were not there for charity. They paid their fees when they could, though it didn’t seem fair after seeing them labor in the agricultural fields. Private insurance worked well in the earlier years of our practice, but the managed care revolution erected significant barriers to care in the form of limited provider networks, higher deductibles and other cost sharing, and burdensome administrative excesses such as prior authorization requirements.
We became convinced more than ever that we needed a national health insurance program that covered everyone. What a pleasure that would have been to be able to just take care of the patients and ignore the payment issues. In fact, I began speaking and writing on a program that I called “UNIVERSAL MEDICARE – Health Care for Everyone.” I had red, white, and blue bumper stickers made up with this slogan. I read about Physicians for a National Health Program and immediately joined them, though California lagged the East Coast and Chicago in activating the organization.
Unfortunately, Monte developed a disabling neurological problem and had to retire. By this time a community health center was established in San Juan Capistrano, so we were able to close the practice knowing that our patients could still receive care. Our more affluent patients had no problem finding other physicians who were enthusiastic about practicing in an Orange County coastal community. Although we certainly missed our patients, we didn’t feel like we abandoned them.
It was at that point, over two decades ago, that I decided to devote my remaining productive years to advocate for health care reform, primarily as a volunteer for Physicians for a National Health Program (all of us at PNHP are volunteers, except for the small, highly dedicated staff).
So what is the point of today’s message? I look at Quentin, Jack, Bud, Bob and some of the other icons of the health care reform movement who have left us, and I realize that there is so much more work left to do, and it’s going to have to be done by you. I just hope that some of us can provide a modicum of inspiration to help move the process forward. We are so close. We have the policy worked out, but we still have to align the politics. 2021 is ripe for lighting that fuse. Liftoff time!
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