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Pope Francis: A better kind of politics

Pope Francis: A better kind of politics

Fratelli Tutti; On the Fraternity and Social Friendship

Encyclical Letter of the Holy Father, Francis

Chapter Five: A Better Kind of Politics

168. The marketplace, by itself, cannot resolve every problem, however much we are asked to believe this dogma of neoliberal faith. Whatever the challenge, this impoverished and repetitive school of thought always offers the same recipes. Neoliberalism simply reproduces itself by resorting to the magic theories of “spillover” or “trickle” – without using the name – as the only solution to societal problems. There is little appreciation of the fact that the alleged “spillover” does not resolve the inequality that gives rise to new forms of violence threatening the fabric of society. It is imperative to have a proactive economic policy directed at “promoting an economy that favours productive diversity and business creativity” and makes it possible for jobs to be created and not cut. Financial speculation fundamentally aimed at quick profit continues to wreak havoc. Indeed, “without internal forms of solidarity and mutual trust, the market cannot completely fulfil its proper economic function. And today this trust has ceased to exist”. The story did not end the way it was meant to, and the dogmatic formulae of prevailing economic theory proved not to be infallible. The fragility of world systems in the face of the pandemic has demonstrated that not everything can be resolved by market freedom. It has also shown that, in addition to recovering a sound political life that is not subject to the dictates of finance, “we must put human dignity back at the centre and on that pillar build the alternative social structures we need”.

169. In some closed and monochrome economic approaches, for example, there seems to be no place for popular movements that unite the unemployed, temporary and informal workers and many others who do not easily find a place in existing structures. Yet those movements manage various forms of popular economy and of community production. What is needed is a model of social, political and economic participation “that can include popular movements and invigorate local, national and international governing structures with that torrent of moral energy that springs from including the excluded in the building of a common destiny”, while also ensuring that “these experiences of solidarity which grow up from below, from the subsoil of the planet – can come together, be more coordinated, keep on meeting one another”. This, however, must happen in a way that will not betray their distinctive way of acting as “sowers of change, promoters of a process involving millions of actions, great and small, creatively intertwined like words in a poem”. In that sense, such movements are “social poets” that, in their own way, work, propose, promote and liberate. They help make possible an integral human development that goes beyond “the idea of social policies being a policy for the poor, but never with the poor and never of the poor, much less part of a project that reunites peoples”. They may be troublesome, and certain “theorists” may find it hard to classify them, yet we must find the courage to acknowledge that, without them, “democracy atrophies, turns into a mere word, a formality; it loses its representative character and becomes disembodied, since it leaves out the people in their daily struggle for dignity, in the building of their future”.

Pope Francis’s Social Encyclical:
http://w2.vatican.va…

Short summary of Pope Francis’s Social Encyclical:
https://www.vaticannews.va…

Long summary of Pope Francis’s Social Encyclical:
https://www.vaticannews.va…

Comment:

By Don McCanne, M.D.

Once we have “a better kind of politics,” we should be able to have health care for all. Let’s work on that.

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Hawaii Was Creating A Plan For Universal Health Care. It’s Time To Return To It.

Even before the pandemic arrived on our shores, our health care system was in crisis.

By Stephen B. Kemble, M.D.
Honolulu Civil Beat, IDEAS, October 4, 2020

In 2009 Hawaii passed a law to create the Hawaii Health Authority, or HHA, and charged the group with designing a universal health care system that would cover all residents of the islands.

The HHA evoked the fundamental questions at the core of health care in the United States today. Should health care be a commodity, sold by corporations to those with the ability to pay? Or should it be a public good that is assured for all, similar to roads, schools, national parks and national security?

I was an original member of the HHA, appointed by Gov. Neil Abercrombie. The HHA met regularly from 2011 until April 2013 but at that point the Abercrombie administration pivoted away from the HHA and toward the federal government’s Affordable Care Act. The ACA was largely written by the insurance industry in order to cement the industry’s central role in health care. At the heart of the ACA was a move to expand coverage by getting greater numbers of people on competing private healthcare plans.

So, what has happened to health care in Hawaii under the ACA?

In the past decade Hawaii’s per capita health care costs have doubled, and they continue to rise at a rate of about 7% per year with no end in sight. Our physician workforce has declined precipitously, decimated by reforms promoted by the Affordable Care Act.

Even before the pandemic arrived on our shores this year, our health care system was in crisis.

To begin to understand why that’s happened, let’s go back to what existed before the Affordable Care Act went into effect. At that point, a patient’s experience of seeing a doctor in Hawaii generally followed expectations. The doctor would talk to you and examine you, make at least a provisional diagnosis and explain it to you, and formulate a plan for further diagnostic tests and/or treatment of the diagnosed conditions.

Even if — unlike in every other economically advanced nation in the world — our health care was being financed largely through corporations, the system in Hawaii was relatively stable. Needed care was generally accessible, and monthly health insurance premiums in Hawaii were among the least expensive in the country.

At that time doctors were paid with fee-for-service: They provided a service and they got paid for it. In 1974 Hawaii set itself apart from the rest of the United States by passing the Prepaid Health Care Act, mandating that employers must provide health insurance to anyone working 20 hours a week or more. Both the Prepaid Act and federal Medicaid rules assured comprehensive benefits.

The Prepaid Act also required that all employer-based insurance must be equivalent to the benefits of the state’s largest health care plan (which was then as now HMSA), a requirement that has effectively banned deductibles and limited co-pays to 10% or 20% of fees. Doctors’ fees were largely standardized due to HMSA’s dominance; other smaller plans used physician networks and fees similar to HMSA. Kaiser had its own prepaid system.

Doctors practiced in small independent practices, and all of them accepted HMSA, other employer-based plans and Medicare. Most also accepted Medicaid. Our per capita Medicare spending was the lowest in the country in 2008.

In essence, things worked. Patients got care in the expected way, and doctors knew how and how much they would be paid. The only problem was that throughout the United States, health care costs were rising faster than the cost of living, and generally faster on the continent than in Hawaii.

The ACA In Practice

The ACA introduced payment reforms called “value-based payment,” founded on the idea that health care costs in the United States were the highest in the world because doctors, paid with fee-for-service, were providing unnecessary services to their patients to make as much money as possible.

This unfounded idea ignored the fact that in the United States the per capita rates of physician visits and hospital days are relatively low compared to other developed countries — in countries in which everyone has health care, fee-for-service payments are often used and the cost of health care per capita is around half of what the United States spends.

Despite claims to the contrary, patients in the United States see doctors less frequently than patients in many other countries.

Despite the lack of any evidence of over-utilization of primary care services, value-based reform efforts have focused mainly on primary care. The “solution” to the non-existent problem of over-utilization has been to pay doctors and hospitals an up-front per patient fee, a system known as “capitation.” Since 2017 HMSA has paid primary care doctors a flat monthly fee for each patient attributed to the doctor’s practice.

Capitation introduces perverse incentives into the doctor-patient relationship. For example, a flat fee rewards doctors who skimp on care and it encourages the avoidance of sicker and more complex patients who may need more care.

There are efforts to counter these perverse incentives but they have devolved into a byzantine bureaucratic nightmare.

Under the system as it exists now, in order to receive adjusted payments, doctors are required to report detailed data on their patients so that insurers can measure the doctor’s quality of care and the patient’s severity of illness and likely cost of treatment. Doctors must now provide metrics, which necessitates their investing in extra staffing and computer systems.

Doctors who fail to provide these metrics face penalties — in the case of Medicare, a reduction in payment of 2% each year, which has caused the majority of independent Hawaii doctors to refuse new Medicare patients. In July 2019, Wallet Hub rated Hawaii 51st — worst in the nation — for finding doctors who would accept new patients with Medicare.

The ever increasing bureaucracy in the U.S. health care system is forcing doctors to spend more time with paperwork and less with patients.

In addition to being hugely cumbersome, these metrics fail to capture the true picture. Severity of illness depends on a lot more than diagnosis codes, and accurately predicting all of the factors that contribute to the cost of treatment turns out to be impossibly complex and expensive.

Doctors, hospitals and health plans can also game the system by including as many diagnoses as possible and choosing the most severe diagnosis codes — for example, classifying a patient’s illness as pneumonia with sepsis as opposed to simply pneumonia. In America today there is an entire industry of coding consultants to drive up revenues.

Here in Hawaii HMSA intended to base each doctor’s capitation rate on the doctor’s prior fee-for-service revenues but HMSA failed to account for the increased overhead necessitated by capitation. Three recent surveys found most Hawaii primary care doctors have seen their personal income decrease under capitation, many to the point that they can no longer continue an independent practice.

Coding determines how much money insurance companies will pay out. The system is ripe for fraud: Here, for example, the same patient is assigned different, more dire codes to create a much larger bill.

The only way that physicians can now maintain their incomes is to increase their number of patients, which means spending less time with each patient, which further amplifies the incentive to avoid sicker and more complex patients. A survey by Aimed Alliance just prior to the COVID-19 pandemic found 80% of Hawaii doctors blame HMSA’s capitation as a significant cause of our physician shortage. Prior to the pandemic, we were 25% short of needed doctors and losing 3% to 4% of our doctors per year. Now the losses are accelerating.

Meanwhile, with Medicaid: Our state government used to administer our Medicaid program, but by 2009 the state had turned the administration of Medicaid entirely over to insurance corporations. The corporations created numerous rules that blocked care and forced doctors to jump through all kinds of new hoops.

As a result, we have seen heightened inflation in Hawaii’s Medicaid costs, with rates rising at a rate 3% faster than the national average, and most independent Hawaii primary care doctors no longer accept Medicaid. On the neighbor islands, where many patients are on Medicaid, large number of doctors have stopped practicing altogether and departed.

Here Connecticut’s story suggests a solution. In 2000 Connecticut also contracted its Medicaid program out to competing private insurance companies. But in 2012 the state took Medicaid back. It used the resulting administrative savings to enhance fee-for-service payments to primary care doctors and to fund community-based programs for complex high-risk patients. Four years later, physician participation had improved substantially, per capita ER costs were down 25%, hospital costs were down 6% and overall per capita Medicaid costs had dropped 14%.

Where We Are

These days if a patient in Hawaii can still find a primary care doctor to see them, a typical visit starts with questionnaires about the reason for the visit, a medical history and questions required to satisfy metrics, all administered by the receptionist or medical assistant. The patient is prompted to get preventive health tests, such as colonoscopies and mammograms. They may see a physician assistant or nurse instead of the doctor.

In the last half century, health care across the United States has been smothered by bureaucracy — the number of health care administrators has soared while the number of physicians has risen very slowly. Hawaii is no exception to this trend.

If they do see the doctor, it is often briefly with little time to ask questions and minimal or no physical exam. Since the doctor is pressed for time, patients may be discouraged from coming to the office and treated over the phone, and they are more likely to be referred to urgent care or the ER, or for diagnostic imaging or to a specialist, instead of the doctor obtaining a thorough history and doing a physical exam.

Multiple studies show that the true reasons U.S. health care costs are so high are the excessive administrative demands of our current system, coupled with the fact that for-profit health care is riddled with parasites. In 2018 the CEOs of the three largest health insurance corporations each took in over $20 million in annual compensation. Some pharmaceutical company CEOs had even higher annual compensation that year, anywhere from $28.5 million to over $100 million each. The CEO of Regeneron, the company that two days ago supplied President Trump with experimental COVID-19 antibody treatment, was the highest paid CEO in the health care field that year: He took in $117.8 million.

In Hawaii, our system is actually less mercenary than in many other states. All of our hospitals are run as not-for-profit entities. All of our employer-based health care programs, while run by corporations, are not-for-profit. And three of the five corporations administering Medicaid for us are not-for-profit.

But our system is rife with huge amounts of administrative waste.

In Canada, administrative costs in the health care system are only a quarter of what they are in the United States.
The overall amount spent on health care in Canada is much lower than it is in the United States — and health outcomes in Canada are now superior to health outcomes in the United States.

The Way Forward

It is time to take another look at the recommendations of the Hawaii Health Authority.

Instead of starting with the system we have and asking, “How can we make it a little better while trying to keep all current stakeholders happy?” the HHA started by defining what a truly cost-effective system would look like and asked, “How can we get there from here?”

We recommended creating a comprehensive “all payer” system akin to what exists in several European countries, which would greatly simplify, unify and streamline health care in Hawaii.

Under this system, which would adhere to the state’s 1974 Prepaid Health Care Act, government regulation would ensure that every health plan in the state would offer the same benefits with no deductibles and minimal co-pays. Anyone who wasn’t covered by their employer or Medicare would be covered by Medicaid. Money would be saved by reducing administrative burdens and costs.

Using fee-for-service, all physicians would be paid the same fees in the same way by all payers, including Medicaid. Billing and payment would be kept as straightforward as possible. Management of care would be left to doctors and their patients. Collective negotiation between organized physicians and the state would keep physician fees reasonable for doctors, health plans and taxpayers.

The reforms recommended by the HHA would reduce overall health care costs, restore professional autonomy to physicians, assure reasonable fees and again make Hawaii an attractive place to practice medicine, including on the neighbor islands.

The HHA is already in Hawaii law as HRS 322H. All that is required now is the backing of Gov. David Ige to appoint new members who are committed to cost-effective universal health care and not the special interests of the health insurance companies.

If the governor empowers the HHA to fulfill its statutory mission, Hawaii could again have the most cost-effective health care system in the country and regain its reputation as a leader in health care.

Dr. Stephen Kemble practices psychiatry at Queen Emma Clinic and teaches it at the John A. Burns School of Medicine.

https://www.civilbeat.org…

Draining the Pool: Our Collective Responsibility to End Racism in Medicine

By Vanessa E. Van Doren, M.D.; Tracey L. Henry, M.D., M.P.H., M.S.
Society of General Internal Medicine, SGIM Forum, October 2020

I grew up in a die-hard liberal part of the country. As I have learned the myriad ways in which racism rears its head, I have discovered that my northeast “culture” perpetuates its own forms of racism and classism. This manifests as a dearth of Black people in leadership positions, huge racial disparities in income and life expectancy, subtle messaging about who is welcome, and condescension about “the South” and “flyover states,” often aimed at places with large Black populations. I love Boston—it is my home. I am proud of our high standard of education, social services, and low rates of uninsurance. But loving something doesn’t mean there is no room to improve.

I want to examine our collective discomfort with criticizing what we consider important parts of our identity, and few professions are more entwined with identity and ideas of self-worth than that of the physician. The long, expensive training, and the way our hours in the hospital pull time away from relationships and outside interests, make many of us feel like we are doctors before anything else. Challenging the traditions upon which our profession is built may mean challenging the framework for our whole personhood. It can call into question the value of the sacrifice we made to pursue this calling. Unsurprisingly, this often results in outrage and defensiveness. At the same time, to justify that sacrifice, it is immensely important that we do the uncomfortable work of evaluating whether our institutions are living up to their moral promise. If we can establish a culture where this introspection both is normalized and necessitates collective action, I believe that we can build that equitable system together.

Physician as Hero

Emory was my last interview because I canceled all subsequent ones after coming here. I knew this is where I wanted to be. Two things stood out to me that day. First, while every program had something to say about “diversity and inclusion,” Emory’s diverse program leadership exemplified this ideal. Second, the intense pride in resident and faculty voices when they talked about advocating for their patients at Grady—one of the country’s largest public hospitals—contrasted with awkward silences at many other programs when I inquired about care for uninsured patients.

I am now in my third year at Emory. I consistently am struck by the lengths to which my colleagues will go to care for their individual patients, but unfortunately, even our best is not enough. Inequality routinely plays out in horrific ways here: hospitalizations, evictions, deaths. The majority of patients I have watched die due to COVID-19 were Black and Brown. Even when I help someone get better in the hospital, I often discharge them back to the street or to unsafe housing or without needed supplies.

I am equally struck by how powerless we as healthcare workers feel in addressing, or even learning about, upstream causes of this inequality. In a state rife with voter suppression, where Medicaid is virtually impossible to access, and where long-standing racist policing leads to immeasurable harm, the challenges often feel insurmountable. Despite the expertise we develop through our work with marginalized patients, health policy and political advocacy make us nervous.

Much like our criminal justice system, the entire institution of medicine is steeped in the tradition of racism.1 Experimentation, without analgesia or consent, on Black bodies laid the groundwork for many modern surgeries and medications. For hundreds of years, Black people were excluded from care or only seen in poorer-quality segregated hospitals, and to a great extent de-facto segregated medical care continues today. Black patients are less likely to receive adequate pain control2 compared to white patients with the same injury. Even after controlling for income, Black patients receive consistently worse care and suffer worse outcomes.3 Somehow, these facts still are not routinely taught in medical schools.

Physician as Human

After the murders of Ahmaud Arbery and Rayshard Brooks in Georgia, Emory’s Internal Medicine leadership immediately condemned racist police violence, and many joined local demonstrations. They held a conference for the internal medicine faculty and residents to discuss both the impact of racism on our community and the importance of examining our own practices. One of our program directors talked about the day her eight-year-old son was seen as a threat because of the color of his skin. Another faculty member openly introspected about his own lack of barriers as a straight, wealthy, cis-gendered, able-bodied white man. Residents talked about microaggressions: both as victim and perpetrator.

By holding this conference, our leadership set an important standard—that we all internalize racism, and that the only way to reduce how much we perpetuate it is to unflinchingly examine and own up to our own biases. This is the first step in the continuous work of being anti-racist. Within a week, the program rolled out a Racism and Social Justice lecture series, highlighting racism and bias in medicine, the impact of microaggressions, and ways to advocate for structural change. With full program support, Emory residents have begun educating ourselves, lobbying our representatives about police reform and hate crimes legislation, promoting voter registration, joining street medic trainings, and soliciting donations to local grassroots organizations.

We are now considering long-term residency program reforms to address key questions: How can we increase diverse recruitment? What changes must we make to our core curriculum? How can we ensure that we apply the same standard of care to all our patients regardless of race or whether we see them at our private or public hospitals?

Draining the Pool Together

Our patients are neck-deep in water, and rather than burning ourselves out as we individually prop each person’s mouth above drowning-level, we need to work together to drain the pool.

Education about our country and profession’s history of racism must become a required competency interwoven throughout the medical curriculum. Only then can we begin to understand, respect, and bridge our Black patients’ distrust of the medical system as part of a comprehensive effort to provide equitable care. We must also examine how our own institutional policies and practices contribute to structural racism. If and when we identify such policies, we must change them. There can be no excuses.

Education about our complex healthcare system also must become a required competency if we are to be informed policy advocates. We need to retire the “physician as hero” narrative that lets us substitute feel-good stories about helping one patient for long-term advocacy and systemic change.

We must recruit a physician workforce that reflects our patient population, both for equitable patient care and to equalize access to positions of power. On a national level, the physician workforce remains overwhelmingly white and wealthy. While programs that implement diverse leadership and recruitment are mounting, we still have a long way to go.

We need to think about the connections between the educational debt, inhumane hours, and extreme hierarchies that define medical training and how this shapes physicians’ willingness to push for change. We all know that pushing leadership to make change could put a promotion or recommendation in jeopardy; this is a big reason that more physicians (particularly those still in training) do not speak up. Physician culture teaches us that the wisest course of action is to keep your head down, get through, and get yours. It is no surprise that as a group we are politically apathetic and unimaginative about envisioning better institutions. We must examine how often the phrase “this is the best we can do” shields those in power from discomfort or loss of their own privilege. And if our own concern for career advancement leads us to stop pushing when we feel similarly threatened, we must acknowledge that we may be doing the same thing.

Finally, allies must also start shouldering their share of the work and risk inherent in advocating for better systems. If we do not share this burden, it will continue to predominantly rest on women of color,4 adding to the barriers they already face in this field and disproportionately taking time away from career development and self-care. This is a very concrete way that allies can “give back some of their privilege.”

If we can move beyond our lone hero complexes to join together, and if we can be imaginative and brave enough to envision and advocate for something better, I believe we can build the system we all hoped to work within when we decided to become doctors.

Dr. Van Doren (Twitter: @vvd186) is a PGY-3 in the Emory University School of Medicine’s J. Willis Hurst Internal Medicine Residency program and a current participant in the Health, Equity, Advocacy, and Policy Track. Dr. Henry (Twitter: @docwithapurpose) is a general internist in the Division of General Medicine and Geriatrics at Emory University, an attending physician for the inpatient teaching services at Grady Memorial Hospital, and assistant health director and supervising attending in the Primary Care Center.

https://connect.sgim.org…

References

  1. Washington, HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York, N.Y.: First Anchor Books; 2006.
  2. Meghani SH, Byun E, Gallagher RM. Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174.
  3. Bridges, KM. Critical Race Theory: A Primer. St Paul, M.N.: Foundation Press; 2019.
  4. Grubbs, V. Diversity, equity, and inclusion that matter. NEJM. https://www.nejm.org/doi/full/10.1056/NEJMpv2022639. July 10, 2020. DOI: 10.1056/NEJMpv2022639.

President Trump could still come to the rescue

Trump’s Positive Coronavirus Test Upends Campaign in Final Stretch

By Jonathan Martin, Maggie Haberman and Matt Stevens
The New York Times, October 2, 2020

President Trump’s announcement early Friday that he had contracted the coronavirus upended the presidential race in an instant, inviting significant questions about his cavalier attitude toward the pandemic and the future of his campaign just 32 days before the election.

Mr. Trump had already been trailing in the polls to Joseph R. Biden Jr., in part because of his mishandling of a virus that has unsettled the day-to-day lives of voters for over six months. He compounded his difficulties by disregarding and at times belittling the basic precautions, such as wearing a mask, that his health advisers were urging Americans to take to protect themselves.

Now, though, his personal indifference toward the virus could threaten his own health, the stability of the country and his already dimming hopes for re-election.

After the coronavirus shut down the country in March, though, Mr. Trump finally ran headlong into a foe that could not be attacked, ignored or fully overwhelmed with his usual tactics.

Yet that did not stop him from trying to effectively will it away. Not only did he repeatedly predict that the virus would fade on its own, he has also consistently minimized the threat, prodding states, schools, businesses and even athletic teams to return to normal.

Not only has he defied the advice of his health advisers on masks, he has also repeatedly mocked the practice, putting him out of step with the majority of the country and even some in his party.

https://www.nytimes.com…

NYT Reader Comment:

By Don McCanne, M.D.

Although President Trump has always been reluctant to admit an error in judgment, he has the opportunity to save perhaps hundreds of thousands of lives by doing so now. He should be frank with his ardent supporters as he explains to them why they and the rest of us must follow the science in extinguishing this scourge. Making a dent in the economy is a small price to pay for preserving human life on a wholesale basis.

https://www.nytimes.com…

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Medicare for All Explained Podcast: Episode 43

Interview with Prof. Karl Kim

October 1, 2020

University of Hawaii professor and director of the National Disaster Preparedness Training Center Karl Kim points to substantial planning and response failures that have made COVID-19 so deadly in the United States. He also points to our lack of a national health system or any sort of robust public health apparatus, saying, “There’s been a systematic disinvestment in health care, and we are paying the price.”

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

https://medicareforallexplained.podbean.com

Investors extracting assets from hospitals

Investors Extracted $400 Million From a Hospital Chain That Sometimes Couldn’t Pay for Medical Supplies or Gas for Ambulances

Prospect Medical, which mostly serves low-income patients, has suffered a litany of problems: broken elevators, dirty surgical gear, bedbugs and more. Its owners, including Leonard Green & Partners and Prospect’s CEO, have cashed in.

By Peter Elkind with Doris Burke
ProPublica, September 30, 2020

In the decade since Leonard Green & Partners, a private equity firm based in Los Angeles, bought control of a hospital company named Prospect Medical Holdings for $205 million, the owners have done handsomely.

Leonard Green extracted $400 million in dividends and fees for itself and investors in its fund — not from profits, but by loading up the company with debt. Prospect CEO Sam Lee, who owns about 20% of the chain, made $128 million while expanding the company from five hospitals in California to 17 across the country. A second executive with an ownership stake took home $94 million.

The deal hasn’t worked out quite as well for Prospect’s patients, many of whom have low incomes. (The company says it receives 80% of its revenues from Medicare and Medicaid reimbursements.) At the company’s flagship Los Angeles hospital, persistent elevator breakdowns sometimes require emergency room nurses to wheel patients on gurneys across a public street as a security guard attempts to halt traffic. Paramedics for Prospect’s hospital near Philadelphia told ProPublica that they’ve repeatedly gone to fuel up their ambulances only to come away empty at the pump: Their hospital-supplied gas cards were rejected because Prospect hadn’t paid its bill. A similar penury afflicts medical supplies. “Say we need 4×4 sponges, dressing for a patient, IV fluids,” said Leslie Heygood, a veteran registered nurse at one of Prospect’s Pennsylvania hospitals, “we might not have it on the shelf because it’s on ‘credit hold’ because they haven’t paid their creditors.”

In March, Prospect’s New Jersey hospital made national headlines as the chief workplace of the first U.S. emergency room doctor to die of COVID-19. Before his death, the physician told a friend he’d become sick after being forced to reuse a single mask for four days. At a Prospect hospital in Rhode Island, a locked ward for elderly psychiatric patients had to be evacuated and sanitized after poor infection control spread COVID-19 to 19 of its 21 residents; six of them died. The virus sickened a half-dozen members of the hospital’s housekeeping staff, which had been given limited personal protective equipment. The head of the department died.

The litany goes on.

https://www.propublica.org…

Comment:

By Don McCanne, M.D. 

Above is the opening of a long investigative report by ProPublica. If it were fiction, it might be an interesting read, but for those of us concerned about the abuses of the medical-industrial complex, it is a very painful read indeed.

Most operating revenues here come from public funds – Medicare and Medicaid – while debt is used to build cash reserves. Massive dividends are going to private equity investors while patients are being shortchanged on their care.

Should we continue to grant the private sector enormous control over our health care dollars, or is it time to insist on public administration of our funds – 60 percent of which we already pay through the tax system and most of the rest through channels such as private insurance, forgone wage increases and out-of-pocket expenses?

We need single payer, improved Medicare for All, but that would be only the beginning. Today’s report cries out for a massive increase in regulatory oversight. It’s time to exercise people power.

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Reasons for being uninsured

Reasons for Being Uninsured Among Adults Aged 18–64 in the United States, 2019; NCHS Data Brief No. 382

By Amy E. Cha, Ph.D., M.P.H., and Robin A. Cohen, Ph.D.
CDC, National Center for Health Statistics, September 2020

Data from the National Health Interview Survey

Key findings

  • In 2019, 14.5% of adults aged 18–64 were uninsured in the United States.
  • Among uninsured adults aged 18–64, the most common reason for being currently uninsured was that coverage was not affordable.
  • The percentage of uninsured adults who were uninsured because coverage was not affordable increased with age, from 66.8% among those aged 18–29 to 80.9% among those aged 50–64.
  • Hispanic adults (30.4%) were more likely than non-Hispanic white adults (22.3%) to indicate that they were uninsured due to ineligibility.
  • Men (26.8%) were more likely than women (14.6%) to indicate that they were uninsured because coverage was not needed or wanted.

Summary

In 2019, 14.5% of adults aged 18–64 were uninsured at the time of interview. Among uninsured adults aged 18–64, the most common reason for being currently uninsured was because they perceived that they could not afford the cost of coverage, followed by not being eligible, not wanting coverage, the process of signing up was too difficult or confusing, could not find a plan that meets their needs, and they signed up for coverage, but the plan has not started yet. In 2019, the percentage of adults who were uninsured due to cost was higher among women, adults aged 50–64, and adults in fair or poor health. The percentage of adults who were uninsured due to ineligibility did not vary by age but was higher among women and adults in fair or poor health. In contrast, the percentage of adults who were uninsured because coverage was not needed or wanted was higher among men, adults aged 18–29, and adults with excellent, very good, or good health. Individuals without health insurance experience barriers to health care such as not having a usual source of care and postponing or forgoing care due to cost, which may lead to negative health outcomes.

https://www.cdc.gov…

Comment:

By Don McCanne, M.D.

This report is important because it shows how well (or not) our health care financing system was working under full implementation of the Affordable Care Act but before the onset of the COVID-19 pandemic. It demonstrates that 14.5% of adults under age 65 were uninsured, and the primary reason was the fact that health insurance coverage was not affordable.

This confirms that the current health care financing system is not functioning satisfactorily, so intervention is an imperative.

What choices do we have?

  • Maintain the status quo. No politician supports this, and they shouldn’t because it would perpetuate personal financial hardship, physical suffering and premature death.
  • Continue to implement President Trump’s largely random policies designed to reduce government spending and regulation. The numbers of uninsured will continue to increase and actual health care will continue to be less and less affordable. Financial hardship, suffering and death would increase. Not acceptable.
  • Enact and implement Joe Biden’s proposals for reform that would tweak the current system, leaving in place the Affordable Care Act and possibly adding a public option. Health care spending would increase, the burden of our profound administrative waste would increase, and many would still be left without adequate coverage. It would fail to achieve the goals of universality, affordability and administrative efficiency. We can do better, much better.
  • Enact and implement a well designed, single payer, improved Medicare for All. Coverage for all essential health care services would include absolutely everyone. Since it is funded through equitable progressive taxes, it would be affordable for each of us. The current administrative waste would be largely recovered, returning to society enough funds to pay, through equitable taxes, for the additional care required by those currently uninsured or underinsured. Universal, affordable, equitable, efficient – meeting all of our goals in a system we can afford.

We do need gifted leadership to move forward. Unfortunately that leadership was difficult to identify in last night’s presidential debate. It’s clear the current team has failed us. So do we take our chances on a new team that has already rejected the single payer Medicare for All model? Or might their political position be malleable?

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Competing visions for the future of health policy

By Matthew Fiedler, Ph.D.
The New England Journal of Medicine, September 24, 2020

There is broad agreement that policy changes could improve the U.S. health care system. But that is often where agreement ends, and different policymakers have starkly different visions for how policy should change. While Covid-19 is dominating policy discussions for now, two other health care policy issues are still poised to feature prominently in the 2020 U.S. elections: what role government should play in ensuring broad health insurance coverage and how to cope with the lack of competition in many health care provider markets.

To understand current U.S. debates over health insurance, the first step is to recognize that there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values. At the risk of oversimplifying, there are two broad camps. The first holds that federal policy should aim for universal coverage and deeply subsidize coverage for low- and moderate-income people, a position that reflects judgments that health insurance substantially improves health and financial security, that improving the financial well-being of lower-income people is particularly important, and that governments should have broad latitude to intervene in the health care system to improve their citizens’ well-being. Policymakers in the second camp generally disagree with each of these judgments, at least to some degree, and believe that even existing federal coverage programs, particularly those serving lower-income people, are too expansive.

Policymakers in the first camp have generally supported one of two broad policy approaches. The first seeks to fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure, effectively continuing the approach taken under the Affordable Care Act (ACA), which drove a large decline in the uninsured rate over the past decade. These approaches would make coverage more affordable for people who currently lack it, including by encouraging all states to expand their Medicaid programs under the ACA to cover all low-income adults (or creating alternative mechanisms to cover this group) and by expanding the ACA’s subsidies for people who purchase coverage on the individual market. They would also seek to ensure that people actually enroll in coverage for which they are eligible, through streamlined enrollment procedures and, in some cases, automatic enrollment. Democratic presidential nominee Joe Biden has adopted this basic approach to expanding coverage, although the form of autoenrollment in his plan would fall short of achieving universal coverage.

Others in the first camp have supported instead replacing the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars. Many proposals in this vein, including the one from Senator Bernie Sanders (I-VT), would enroll everyone in a government-run plan with minimal cost sharing, but such a program could in principle include cost sharing or allow a choice of private plans. Relative to approaches to expanding coverage that maintain the current U.S. patchwork of coverage types, this type of system would most likely be simpler and thus impose smaller administrative and hassle costs on patients and health care providers, but it would require the federal government to collect much more revenue and would involve much greater disruption to existing coverage arrangements. Proposals eliminating a role for private insurers would be particularly simple but would forfeit any benefits that may flow from innovation by private insurers in areas such as benefit design or utilization management.

By contrast, the Trump administration’s policy agenda places it squarely in the second camp. As the president entered office, his administration supported legislation that would repeal or sharply curtail many of the ACA’s coverage provisions, including its Medicaid expansion, subsidies for obtaining coverage on the individual market, and the mandate that all individuals obtain insurance, while also reducing eligibility and funding for the pre-ACA Medicaid program. The Congressional Budget Office concluded that several proposals the administration supported would have increased the number of uninsured by more than 20 million, thereby returning the uninsured rate to roughly its pre-ACA level, and would have substantially reduced federal spending. Although only the individual mandate was ultimately repealed, the Trump administration has included similar proposals in its annual budgets and is asking the U.S. Supreme Court to strike down the entire ACA in a case being heard this fall.

(The article also discusses market concentration, competition, impact of COVID-19, and other policies such as capping prices or introducing a public option.)

Regardless, in light of the deep differences among 2020 candidates, voters’ choices this fall — whether driven by health care or other issues — will shape the health care system for years to come.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

Matthew Fiedler has provided us with an extremely brief but fairly concise description of the major alternatives in health care reform: one camp holds that federal policy should aim for universal coverage with government subsidization to make health care affordable; the other camp believes that even current, inadequate federal coverage programs are too expensive and should be curtailed.

The first camp is divided between those who would replace the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars (single payer Medicare for All), and those who would fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure (expand the Affordable Care Act).

The second camp is exemplified by the Trump administration’s efforts to reduce or eliminate existing government health programs even though that would greatly increase the number of uninsured while substantially reducing government spending on health care.

Fiedler states, “there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values,” but that the forthcoming election “will shape the health care system for years to come.”

This choice matters. Will we have essential health care for everyone that is affordable for each of us, or will we perpetuate financial hardship, personal suffering and even premature death by minimizing a government role in health care?

Will those who support financial hardship, suffering and death please stand up so we know who you are. I don’t see anyone standing. So let’s get with it in ending this scourge on America.

Vote. And then follow up with the demand to our elected public stewards that they do the right thing.

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Fair drug prices through an international price index

Average International Market Pricing For US Pharmaceuticals—Lessons From Europe

By Marc A. Rodwin
Health Affairs Blog, September 24, 2020

The Trump administration and House Democrats share one idea regarding pharmaceutical price controls: They agree that the US should use an international price index that averages prices paid by other countries (mostly European) to cap the US prices. PhRMA has long opposed such policies, recently renewing its opposition. Unacknowledged and perhaps unknown to those proposing this reform is that at least 25 EU nations employ a pharmaceutical price index to cap their own drug prices. European nations use their price index somewhat differently than in US proposals. This blog post draws lessons from index price caps that are used in France, Germany, and other European nations. It concludes that, to be most effective, US pharma index price cap proposals should be modified to reflect real purchase prices and be employed as part of a broader cost-control strategy.

In July 2020, President Donald Trump signed an executive order indicating he would soon implement an earlier international price index (IPI) proposal that would cap drug prices in Medicare Part B (for drugs used in hospitals). The earlier proposal, included in a 2018 notice of proposed rulemaking would, as part of a broader reform of Part B payment, create an IPI based on the prices of sixteen nations (Austria, Belgium, Canada, Czech Republic, Finland, France, Germany, Greece, Ireland, Italy, Japan, Portugal, Slovakia, Spain, Sweden, and United Kingdom). The proposal aimed to phase down prices toward the IPI for selected single source drugs. The Centers for Medicare and Medicaid Services estimated it would reduce spending by 30 percent for selected drugs. However, as initially proposed, the policy would be difficult to implement because it lacks an enforcement mechanism.

In contrast, the House Democrats bill would cap drug prices for all of Medicare and private insurers based on an Average International Market (AIM) Index, which is the volume-weighted average of each drug price in Australia, Canada, France, Germany, Japan, and the United Kingdom. The legislation would establish Medicare drug prices by negotiation between the Department of Health and Human Services (HHS) and each pharmaceutical manufacturer, with prices capped at 120 percent of the AIM Index. The HHS would negotiate prices for at least 25 new branded drugs a year that lacked competition; it could negotiate up to 250 drugs prices each year. Medicare Part D health plans that cover drugs purchased outside of hospitals would retain the option to employ other measures to negotiate lower prices. In selecting which drug prices to negotiate, HHS would prioritize drugs for which the greatest savings could be achieved. Manufacturers would have to offer the price as set by Medicare to insurers covering drugs outside of Medicare, as well—but private insurers could negotiate their own prices. Subsequently, price increases would only be allowed to control for inflation. Manufacturers that did not conclude a price negotiation or comply with the price agreement would be assessed an excise tax, set initially at 65 percent of their annual gross sales and increasing 10 percent each quarter up to a maximum of 95 percent. Firms that charged Medicare or private insurers more than the price cap could be subject to a monetary penalty 10 times the difference between the negotiated price and the price charged.

The good news is that these approaches are not purely theoretical; we have the experiences of European nations to learn from. When considering these proposals, policy makers should consider the following key lessons:

  1. The IPI should be based on maximum reimbursement after discounts or on net prices—not on official prices.
  2. Employ health technology assessment (HTA) to determine the therapeutic value of new drugs to cap reimbursement, in addition to employing a cap based on an IPI.
  3. Employ index prices to cap prices for drugs that are superior to existing products, but cap prices of other drugs based on the price of comparable products.
  4. Use competitive bidding to obtain drugs at lower prices than maximum reimbursement allowed.

Conclusion

If the US employs an IPI, it should calculate the index price using real maximum reimbursement in other nations rather than official prices as is done in the congressional and Trump administration IPI proposals. Even more important, an IPI is insufficient to effectively control pharmaceutical prices and spending. It is one tool that should be employed as part of a broader pharmaceutical price and cost-control strategy. That strategy can include: capping prices based on a drug’s cost-effectiveness or added therapeutic value, reimbursing new drugs no more than standard therapies unless independent HTA confirms that the new drug is superior, setting global drug spending budgets, and employing markets to obtain purchase prices below price caps.

Marc A. Rodwin, professor of law at Suffolk University Law School, teaches and conducts research on pharmaceutical and health policy, and biomedical ethics. He is currently evaluating health technology assessment and pricing policies in Europe and the US. He is the author of Conflicts of Interest and the Future of Medicine: The United States, France, and Japan (Oxford, 2011); and Medicine, Money, & Morals: Physicians’ Conflicts of Interest (Oxford, 1993).

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Drug prices in the United States range from $4 for some generics offered through membership programs to $2,125,000 for Zolgensma – a treatment for spinal muscular dystrophy. The average drug spending is about $1,200 per person per year – $346 billion in 2019 – per capita spending that is twice the average of other high-income nations.

Why? Prices are too high. Why? Essentially, we have refused to demand that the government regulate drug prices. We won’t even demand that the government negotiate better drug prices for the Medicare program.

We are back to proposals to allow drug purchases through Canada to take advantage of their lower prices. But there are tremendous logistical problems with that, not to mention that Canada, with one-tenth of the population of the United States, can hardly be expected to meet our needs without threatening the drug supply for their own citizens. Besides, it is somewhat silly for U.S. firms to ship to Canada drugs at a lower price and then send them back here with various private and government administrative costs added on to the prices. I have long said that we don’t need to import drugs from Canada; we need to import Canadian drug prices instead.

The anti-regulatory posturing on drug pricing may be coming to an end. As Marc Rodwin states, “The Trump administration and House Democrats agree that the US should use an international price index that averages prices paid by other countries (mostly European) to cap the US prices,” though the Democrats’ proposal is far more comprehensive. More importantly, Rodwin provides us with key lessons derived from the experiences of European nations.

We may struggle with trying to reprice a two million dollar drug, but we cannot allow that to set a new standard in price gouging by the pharmaceutical industry.

We really do need single payer, improved Medicare for All that includes comprehensive prescription coverage, but we need to be sure that our tax system is paying fair prices for our drugs. I just paid a $567 copay for a drug covered under Medicare Part D. Though I can afford that, too many can’t. We need a health care financing system that makes health care affordable for everyone. Instead of paying prices that too many cannot afford, we can make funding through progressive taxes the great equalizer. Everyone can afford that, even President Trump (his taxes for a year not being much more than my copay for one drug?)

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Trump’s America First Healthcare Plan

Executive Order on An America-First Healthcare Plan

The White House, September 24, 2020

Section 1. Purpose. Since January 20, 2017, my Administration has been committed to the goal of bringing great healthcare to the American people and putting patients first.

On December 22, 2017, I signed into law the repeal of the burdensome individual-mandate penalty…

Executive Order 13813 of October 12, 2017… My Administration increased the availability of renewable short-term, limited-duration healthcare plans… My Administration expanded health reimbursement arrangements… My Administration also issued a rule to increase the availability of association health plans…

Economic Report of the President (February 2020), my Administration’s expansion of health savings accounts…

my Administration acted to dramatically increase the accessibility and availability of telehealth services for Medicare beneficiaries…

waivers allow States to move away from the ACA’s rigid structure …

my Administration has paved the way for a new wave of innovation to allow patients to safely send their own medical records to care providers of their choosing…

CMS has acted to offer Medicare beneficiaries prescription drug plans with the option of insulin capped at $35 in out-of-pocket expenses…

Executive Order 13937 of July 24, 2020 low-income Americans who receive care from a federally qualified health center will have access to insulin and injectable epinephrine at prices lower than ever before…

Executive Order 13938 of July 24, 2020 my Administration will be the first to complete a rulemaking to authorize the safe importation of certain lower-cost prescription drugs from Canada…

Executive Order 13939 taking action to eliminate wasteful payments to middlemen by passing drug discounts through to patients…

Executive Order 13948 of September 13, 2020 ensure that Medicare patients receive the lowest price that drug companies offer comparable foreign nations…

Further Consolidated Appropriations Act, 2020, I also signed into law the repeal of the medical device tax, the annual fee on health-insurance providers, and the “Cadillac” tax on certain employer-sponsored health insurance…

Executive Order 13877 make sure patients have access to meaningful price and quality information prior to the delivery of care…

My Administration implemented a “site neutral” payment system between hospital outpatient departments and physicians’ offices…

The ACA is neither the best nor the only way to ensure that Americans who suffer from pre-existing conditions have access to health-insurance coverage. I have agreed with the States challenging the ACA, who have won in the Federal district court and court of appeals, that the ACA, as amended, exceeds the power of the Congress. The ACA was flawed from its inception and should be struck down. However, access to health insurance despite underlying health conditions should be maintained, even if the Supreme Court invalidates the unconstitutional, and largely harmful, ACA.

My Administration has always been committed to ensuring that patients with pre-existing conditions can obtain affordable healthcare, to lowering healthcare costs, to improving quality of care, and to enabling individuals to choose the healthcare that meets their needs.

My Administration has taken unprecedented action to improve the quality of and access to care for individuals with HIV, as part of our goal of ending the epidemic of HIV in the United States by 2030.

February 9, 2018, I signed into law the repeal of the Independent Payment Advisory Board…

October 24, 2018… billions of dollars of funding for important programs to support prevention and recovery…

June 6, 2018… improve options for veterans to receive care outside of Department of Veterans Affairs (VA) healthcare providers…

Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017… more power to discipline employees…

December 18, 2018… support for research into sickle cell disease…

In response to the COVID-19 pandemic, my Administration launched Operation Warp Speed…

Sec. 2. Policy. It has been and will continue to be the policy of the United States to give Americans seeking healthcare more choice, lower costs, and better care and to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.

Sec. 3. Giving Americans More Choice in Healthcare. The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall maintain and build upon existing actions to expand access to and options for affordable healthcare.

Sec. 4. Lowering Healthcare Costs for Americans. (a) The Secretary of Health and Human Services, in coordination with the Commissioner of Food and Drugs, shall maintain and build upon existing actions to expand access to affordable medicines, including accelerating the approvals of new generic and biosimilar drugs and facilitating the safe importation of affordable prescription drugs from abroad.

Sec. 5. Providing Better Care to Americans. (a) The Secretary of Health and Human Services and the Secretary of Veterans Affairs shall maintain and build upon existing actions to improve quality in the delivery of care for veterans.

Executive Order:
https://www.whitehouse.gov…

Fact Sheet:
https://www.whitehouse.gov…

President Trump Delivers Remarks on the America First Healthcare Plan (video begins at 54 minutes):
https://www.youtube.com…

Transcript of speech:
https://www.whitehouse.gov…

Comment:

By Don McCanne, M.D.

Although introduced with only limited fanfare, apparently the America First Healthcare Plan is the great health care plan that President Trump has been promising us. If you skim through the excerpts above, you’ll see that it is not much of a plan. The most significant change is to support the legal action to strike down the Affordable Care Act. The most highly emphasized positive measure is to establish as official U.S. policy “that Americans with pre-existing conditions can obtain the insurance of their choice,” though no mechanism is established to implement that policy once the Affordable Care Act is struck down. The majority of the measures are actually detrimental. His trademark dishonesty permeates his speech (even throwing in a gratuitous use of the term “communists”).

President Trump has not offered a credible “Replace” plan once the Affordable Care Act is eliminated. But Joe Biden’s proposal to merely tweak the current system is unsatisfactory as well, though not to as great of a degree. (And there are other issues that make this election important.)

We desperately need single payer, improved Medicare for All. Does anyone see a clear path forward from here?

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J. Gruber: No market-based solutions to cost control

Q&A: ACA Architect Predicts The Future Of Healthcare

Interview of Jonathan Gruber by Caroline Miller
American Healthcare Journal, September 9, 2020

Caroline Miller: Ten years on, how would you grade the Affordable Care Act?

Jonathan Gruber: Before the ACA was in place, people could say, “Well, we’ve got these market-based solutions, and they work,” but they never would. The ACA moved the bar in terms of saying, “Well, here’s a real market-based solution to healthcare.” If you’ve got something better, let’s see how it does.

I think having the law in place and covering those people sort of put the lie to the whole idea of “replace,” or that there’s some ambiguous market-based solution out there that’ll work.

CM: I know you helped design the single-payer system in Vermont. What are the lessons learned from that experiment, and should Green Mountain Care be a cautionary tale moving forward for Democrats on the federal level now that it’s become a priority for progressives?

JG: I think the bottom line is it shows that it’s just too expensive. Not in the sense that it’s too expensive for society. I said that single payer would probably lower social healthcare costs. It’s too expensive in the sense that single payer is a transfer of the burden on the private sector, to the burden of putting it explicitly on taxation, and people don’t like that transfer.

In Vermont, I found that if they did single payer, total healthcare costs would fall by at least 10 percent. That was a conservative estimate. But since they were moving away from employer insurance to government insurance, to pay for it, they would have had to more than double the entire tax bill of the state of Vermont, and that just killed it.

You could say that shouldn’t have killed it, because overall we should care about society’s total healthcare costs and who cares who bears them, but in fact people do care who bears them.

Right now, America has a system financed by a hidden tax: When our employers give us health insurance, they just pay us lower wages. Single payer would replace that with an explicit tax, which is literally raising people’s taxes, and as Vermont shows, that’s a politically difficult transition.

CM: What do you think the U.S healthcare system will look like in 2030?

JG: The bigger question is, will we take serious steps to control costs? Things like regulating prices, or forcing people into more rigorous value-based care? And that, I simply do not know.

If I had to guess, I’d say healthcare in 2030 will look a lot like healthcare in 2019, plus some “digital health stuff.”

CM: What would you say it should look like?

JG: After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices. I do not see a purely competitive market-based solution to the excessive prices we charge in healthcare. Healthcare costs are a pricing problem. Our prices for things like specialist services, medical equipment and drugs are too high. I think we have to put in a smart regulatory regime where we start to bring those under control.

https://americanhealthcarejournal.com…

Comment:

By Don McCanne, M.D.

Jonathan Gruber says, “After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices.”

And what better way than enacting and implementing a well designed, single-payer, improved Medicare for All? But the people have to demand it.

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“Building the movement for health care justice” town hall

PNHP president-elect Dr. Susan Rogers and Dr. Abdul El-Sayed (who gave the keynote address at PNHP’s 2019 Annual Meeting) participated in a national Medicare-for-All town hall on September 23, 2020. This blockbuster virtual event was organized by Public Citizen and the Medicare for All Resolutions campaign, and featured three panel discussions led by Sen. Bernie Sanders, Rep. Pramila Jayapal, and Rep. Ayanna Pressley.

For more information on how to get involved with Public Citizen’s Medicare-forAll efforts, visit HealthJusticeTownHall.org.