Families USA, July 2020

Results in Brief

• Because of job losses between February and May of this year, 5.4 million laid-off workers became uninsured.
• These recent increases in the number of uninsured adults are 39% higher than any annual increase ever recorded. The highest previous increase took place over the one-year period from 2008 to 2009, when 3.9 million nonelderly adults became uninsured.
• Nearly half (46%) of the increases in the uninsured resulting from the COVID-19 pandemic and economic crash have occurred in five states: California, Texas, Florida, New York, and North Carolina.
• In eight states 20% or more of adults are now uninsured: Texas, where nearly three in ten adults under age 65 are uninsured (29%); Florida (25%); Oklahoma (24%); Georgia (23%); Mississippi (22%); Nevada (21%); North Carolina (20%); and South Carolina (20%). All but Oklahoma are also among the 15 states with the country’s highest spike in new COVID-19 cases during the week ending on July 12.
• Five states have experienced increases in the number of uninsured adults that exceed 40%: Massachusetts, where the number nearly doubled, rising by 93%; Hawaii (72%); Rhode Island (55%); Michigan (46%); and New Hampshire (43%).
• No federal COVID-19 legislation signed into law has attempted to restore or preserve comprehensive health insurance, which improves health outcomes, limits financial insecurity, and promotes economic recovery. Federal lawmakers can fill that gap in the next COVID-19 bill.

https://www.familiesusa.org…

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Health Care Administrative Costs in the United States and Canada, 2017

By David U. Himmelstein, M.D., Terry Campbell, M.H.A., Steffie Woolhandler, M.D., M.P.H.
Annals of Internal Medicine, January 21, 2020

Total Costs of Health Care Administration: Health care administrative costs in the United States in 2017 totaled $812.0 billion, $2497 per capita ($2696 per insured person), or 34.2% of total spending in the categories for which data are available. The comparable estimates for Canada are $551 per capita ($593, assuming U.S. wage rates in doctors’ offices), or 17.0% of expenditures. The difference amounts to over $1900 per capita (or over $2100 per insured person), equivalent to more than $600 billion in excess administrative spending in the United States.

https://www.acpjournals.org…

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Comment:

By Don McCanne, M.D.

The COVID-19 pandemic and its economic consequences have caused the greatest losses in health insurance enrollment in U.S. history: 5.4 million laid-off workers have become uninsured. However, it is important to understand that all was not well before the pandemic. Nearly 28 million people were already uninsured and tens of millions more were underinsured – unable to afford the out-of-pocket costs that were not covered by insurance.

Of major significance, these are nonelderly adults. Medicare – for those over 65 – continued to provide stable coverage after the onset of the pandemic. There would be no uninsured now had we had in place a single payer Medicare for All program.

The experience in California also provides us with some important lessons. As one of the most progressive states, California went out of its way to maximize the benefits of the Affordable Care Act and other public programs. Thus we can get a perspective of how well the financing system works when stressed. The number of workers in California who became uninsured due to job loss between February and May 2020 was 689,000. In total, 3,227,000 adults are uninsured in California. There are now about 27% more uninsured adults in California than there were in 2018.

Regardless of all of the praise ACA receives, the program clearly is not working as it should. There are proposals to temporarily fill in some of the gaps, but these proposals fall far short of the comprehensive reform that we need, and most of them would be only temporary, at the end of the pandemic defaulting to our current unsatisfactory financing system.

The primary reason given for not enacting single payer Medicare for All is that it costs too much. Yet comparing our highly inefficient health care financing system with Canada’s single payer system indicates that more than $600 billion in annual administrative waste is recoverable – more than enough to expand the provision of comprehensive health care services to absolutely everyone, permanently, without spending more in inflation adjusted dollars than we already do.

One major candidate for president would forgo this in order to perpetuate, with tweaks, our clearly inadequate health care financing system with its profoundly inefficient and costly administrative excesses. The other major candidate is supporting a repeal of ACA without offering any effective substitute, leaving us worse off than we already are.

I mean, when California has one of the very best programs and it alone has over 3,000,000 adults who are uninsured? That’s unacceptable. It’s criminal! We need to change the system: single payer improved Medicare for All. Now!

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Maggie Mills
Common Dreams, July 11, 2020

A recent study by Yale epidemiologists found that Medicare-for-All would prevent 68,000 deaths a year. These 68,000 deaths are not quiet, peaceful deaths. They are gasping-for-air, writhing-in-pain, bleeding out, wasting, violent, gruesome deaths. These deaths often follow extended periods of physical pain, emotional distress, and financial ruin.

The same study found that Medicare-for-All would save the United States 45 billion dollars annually. In the midst of a pandemic-motivated corporate bailout estimated at between $6 and $10 trillion so far, the ‘’but how will we pay for it” argument has largely been abandoned. And yet, the nominee for the Democratic Party has unequivocally stated that he will veto Medicare-for-All, the Democrats in Congress have proposed a bill to bail out insurance companies that subsidizes COBRA payments rather than provides healthcare for their constituents, and 27 million Americans and counting have lost their employer-based coverage as unemployment soars. Three of the four members of Congress with the highest campaign contributions from the pharmaceutical industry are Democrats, and the healthcare lobby accounts for a third of the contributions to the DCCC in the 2019-2020 election cycle. As usual, the Republicans brazenly broadcast their disdain for the poor, sick, and disabled. Put simply, both Democrats and Republicans receive many millions of dollars from the healthcare lobby to ensure that the industry profits at the expense of human life. There is no relief in sight from either establishment party, not even in the shadow of economic collapse.

I write this not to rage against the bipartisan, healthcare and pharma lobby funded machine. Although, the American public should at minimum educate themselves as to why every developed nation on earth has managed to provide healthcare to its citizens as a right, except for the US.

I write this to appeal, hell, plead, with my fellow Americans to pay attention to the suffering that exists all around us- to recognize our well, able-bodied privilege, and to come together to tear this cruel system down.

I have MS. I have a growing Rolodex of injuries, illnesses, and disabilities. I am exhausted. My prospects are limited. I am a victim of the unwinnable battle with our healthcare system. I work full time to keep my increasingly unaffordable health insurance. Ironically, I will lose this insurance when my full time job makes me too sick to continue working full time. I cannot vote for a candidate that doesn’t support Medicare-for-All.

I have been told that I am part of the Democratic Party’s disunity problem for my decision. I have been told that I am part of the problem as if prioritizing my own ability to remain in the world is petty or immature. I have been told this by people who think millions of lives are expendable in the name of political party loyalty and who refuse to acknowledge that we cannot patiently wait for incremental change when our lives are at stake. I have only been told this by people who are well, able-bodied, or who have excellent health insurance. I am angry and indignant because people who casually vote to sacrifice the most vulnerable of their fellow citizens are the problem, and not the other way around.

Class does not prevent illness and disability, though their onset tends to push the afflicted into poverty. People with disabilities make up 12% of the US population, yet account for more than half of the population living in long-term poverty. Medical bills are responsible for an astounding 66.5% of bankruptcies. As of January, it was estimated that as many as 25% of Americans delayed getting healthcare because of cost, resulting in great physical pain, mental anguish, and death. These numbers have surely grown exponentially during the pandemic.

We should be outraged at the injustices that our fellow citizens suffer at the hands of this predatory healthcare system. We should be outraged at the violence that it inflicts on its innocent victims. We should be outraged that this violence has been normalized as if there is nothing to be done to stop it. We should not accept it, nor should we be quiet about it. We should educate our neighbors, withhold our votes, and shout that we will do so from the streets. Tens of millions uninsured, underinsured, bankrupt, suffering, and dead constitutes an unforgivable injustice. Please allies, I beg of you, demand justice.

And please, allies; recognize that by settling for anything less than universal healthcare and by voting for someone who does not support Medicare-for-All, we are committing a deliberate and willing act of violence against the poor, sick, and disabled among us.

Maggie Mills is an artist and assistant professor of art at Cedar Crest College.

https://www.commondreams.org…

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Comment:

By Don McCanne, M.D.

The important message from this article is that many Democrats who emphatically support single payer Medicare for All are so disappointed in the fact that the presumed Democratic Party candidate for president is outspoken in his opposition to Medicare for All that some are considering not supporting him in the general election – the Democratic Party’s disunity problem.

What other options are there? Not showing up to vote? There are many other important issues that are certainly worthy of a vote. Defecting to the Green Party? We still have a predominantly two party system so casting a vote for a third party candidate will have a similar net impact as not voting at all, except for the personal satisfaction of having cast a protest vote. Vote for President Trump? With our highly polarized politics, without overlap in the middle, abruptly flipping on all policies would defy reason.

Many people have cautioned that if the Democrats endorse Medicare for All, President Trump may be reelected by those opposing Medicare for All, and getting him out of office is their highest priority. That is ridiculous. Even Democrats who want to keep their current health plans are not going to vote for Trump just to prevent enactment of Medicare for All. In fact, many Republicans, though not a majority, also support Medicare for All.

The disunity is not in opposed views on Medicare for All, and it is not even in opposition to the reelection of Donald Trump. Rather than disunity, the problem is disappointment in the fact that Joe Biden continues to reject Medicare for All.

The current health care situation is horrendous for many of those with significant health care needs, and that can be any of us at any given time. So what can we do? Simply, don’t let up. Continue with advocacy through education, coalitions, and grassroots efforts. Some say that is not enough, so go ahead and expand your efforts. Any and all activities that will take us beyond the threshold for action are certainly welcome. Just don’t fall into the trap of walking away because of the perception of a disunity problem.

Though PNHP does support single payer Medicare for All, PNHP does not endorse any political candidates nor political parties. Political views expressed here are those of the author and not of PNHP.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Melissa Repko
CNBC, July 8, 2020

Walgreens Boots Alliance will soon have doctor offices inside of hundreds of its U.S. drugstores.

The pharmacy chain said Wednesday it has struck a deal with VillageMD, which will staff and run the primary-care clinics. The companies said they will open the clinics in 500 to 700 stores in more than 30 U.S. markets over the next five years.

Walgreens will invest $1 billion in equity and convertible debt in VillageMD over the next three years as part of the deal, including a $250 million equity investment completed Wednesday. Most of the money will be used by VillageMD to open the clinics and integrate its technology with Walgreens.

VillageMD will recruit and pay employees’ salaries, cover other operating expenses and pay Walgreens to use the space. Walgreens said it will own about 30% of the primary-care company after the multiyear investment.

The company wants to turn its drugstores into health and wellness destinations where people spend more time and money.

Through the new partnership, patients will be able to visit the Village Medical at Walgreens clinics for a wide range of medical services from annual checkups to walk-in appointments if they feel sick. Each clinic will have nine exam rooms, a waiting area and a four-person physician-led staff that coordinates with store pharmacists. They can also request a home visit or get care around the clock through telemedicine.

Walgreens and VillageMD will face stiff competition. Walmart has opened four primary-care clinics, with plans for more. The big-box giant’s clinics, called Walmart Health, emphasize its signature low costs and upfront pricing. Amazon’s acquisition of online pharmacy PillPack underscores its broader health-care ambitions. And CVS Health, which acquired health insurer Aetna, plans to open 1,500 HealthHUB stores by the end of 2021. The redesigned stores have a variety of health-related features such as expanded clinics, wellness rooms for yoga and more medical-related products.

“We want to be everywhere in America where people need health care,” (Walgreens co-Chief Operating Officer Alex Gourlay said). “That’s always been our position and always will be.”

https://www.cnbc.com…

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Walmart quietly registers insurance business in its latest move into health care

By Melissa Repko
CNBC, July 8, 2020

Walmart is making yet another move in the health-care world: It’s getting into the insurance business.

The Bentonville, Arkansas-based retailer confirmed to CNBC on Wednesday that it will start selling health insurance plans. It has job openings listed on its careers website for “Walmart Insurance Services LLC.” In the job posts, it says it’s looking to hire insurance agents in the Dallas area to sell supplemental Medicare insurance.

Walmart currently provides insurance information at Walmart Health, its primary clinic locations, and has an education program called Healthcare Begins Here that helps people find an insurance policy.

The big-box retailer has opened primary-care clinics, made health-care acquisitions and spoken about its broader ambitions. It previously teamed up with insurer Humana to offer a Walmart-branded Medicare prescription drug plan, but this marks the first time the retailer is setting up as an insurance broker.

The retailer has opened four Walmart Health clinics in the U.S., with plans for more. The clinics offer a wide range of low-cost services, such as an annual checkup for $30 or a strep test for $20.

https://www.cnbc.com…

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Comment:

By Don McCanne, M.D.

Our health care financing system is highly inequitable. In spite of being the most expensive health care system, we fall behind most other wealthy nations in leaving too many individuals uninsured or underinsured, with impaired access to care. We’ve been trying to fix that by advocating for single payer Medicare for All. But, as we have been directing our attention to health care financing, what has been happening with the health care delivery system?

Well, horizontal and vertical consolidation has changed the market dynamics in health care. The private insurance companies and the benefit managers have been moving in and becoming an integral part of the health care delivery system. The expansion of control by the medical-industrial complex has changed the nature of traditional relationships between patients and their health care professionals. Today’s articles on Walgreens and Walmart provide examples of how control of health care is shifting away from the health care professionals and institutions and more towards the investment community.

This is serious. How is a single payer Medicare for All program going to be able to manage making appropriate payments to the health care delivery system when it has become part of an amalgamation with other business interests, many of which we have been trying to remove from health care financing if for no other reason than their profound administrative waste?

Earlier this week we discussed the importance of planning in health care. Adam Gaffney stated, “We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities.”

In the future, when you are taken by ambulance to a hospital emergency department, after they ask you for your insurance card, instead of asking who your physician is, will they be asking, “Are your medical records at Walgreens or Walmart?” That might please the advocates of market competition, but it shouldn’t be about markets. It should be about patient service.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Achieving Universal, Affordable, Quality Health Care (Pages 28-37)

(Excerpts)

We are going to at last build the health care system the American people have always deserved: One that finally provides universal health care coverage; reduces prescription drug prices, premiums, and out-of-pocket costs; reins in overall health care expenses; and tackles the deep-seated inequities in our health care system. We will build a health care system that is driven by the needs of patients and the people who care for them, instead of the profit motives of big corporations.

Democrats will always fight to save Americans’ lives by making it easier and more affordable to go to the doctor, get prescription medicines, and access preventive testing and treatments. Our policy agenda is designed to produce real results for the American people—not hollow platitudes. As Democrats, we fundamentally believe health care is a right for all, not a privilege for the few.

Responding to the Coronavirus Pandemic

We must start by making COVID-19 testing widely available, convenient, and free to everyone. That includes expanding programs to proactively extend testing services to populations we know are especially vulnerable, including the homeless and those living in nursing homes and long-term care facilities. We must also expand funding so state and local public health departments can hire sufficient staff to adequately conduct contact tracing for everyone who tests positive for the novel coronavirus. Only through testing, tracing, and targeted quarantining can we hope to fully understand the scope of the pandemic, contain it, and stop it.

In a public health crisis, we all have to rely on each other. That’s why Democrats support making COVID-19 testing, treatment, and any eventual vaccines free to everyone, regardless of their wealth or their immigration status.

In the midst of this pandemic, we will provide direct, increased support to states to enroll eligible adults in Medicaid, have the federal government cover a higher percentage of the bill, and add incentives for states which have not yet expanded Medicaid to do so.

For people who risk losing their insurance coverage if they lose their jobs in this pandemic, Democrats believe the federal government should pick up 100 percent of the tab for COBRA insurance, which keeps people on their employer-sponsored plans. For those who are still unemployed or do not have access to employer-sponsored health care when their COBRA eligibility period expires and are eligible for premium-free coverage, we will take action to automatically roll them over to other coverage options, so they do not experience any gap in health care. We will also re-open the Affordable Care Act marketplaces, even outside of the normal open enrollment season, and expand subsidies to make it easier for people to buy coverage.

Democrats will also make available on the marketplace a platinum-level, federally administered health insurance option with low fees and no deductibles, so that everyone will have access to this high-quality, low-cost plan. Low-income Americans will be automatically enrolled in this federally-administered option at zero cost to them.

We will keep these emergency measures in place until the pandemic ends and unemployment falls significantly.

Democrats will direct the federal government to work with private-sector manufacturers to dramatically scale up the United States’ domestic manufacturing capacity for both personal protective equipment and essential medicines.

Reinvesting in Public Health

Democrats will act swiftly to stand up a comprehensive, national public health surveillance program for COVID-19 and future infectious diseases, including recruiting 100,000 contact tracers to help state and local health departments identify people at risk of contracting or spreading the coronavirus.

We will substantially increase funding for the Centers for Disease Control and Prevention and for state and local public health departments, many of which suffered deep budget cuts during the Great Recession. And we will restore American leadership on global public health by working with our allies and partners around the world, including through the World Health Organization.

Securing Universal Health Care Through a Public Option

We will give all Americans the choice to select a high-quality, affordable public option through the Affordable Care Act marketplace. The public option will provide at least one plan choice without deductibles, will be administered by the traditional Medicare program, not private companies, and will cover all primary care without any co- payments and control costs for other treatments by negotiating prices with doctors and hospitals, just like Medicare does on behalf of older people. The lowest-income Americans not eligible for Medicaid will be automatically enrolled in the public option at no cost to them, although they may choose to opt out at any time. Everyone will be eligible to choose the public option or another Affordable Care Act marketplace plan, even those who currently get insurance through their employers, because Democrats believe working people shouldn’t be locked in to expensive or insufficient health care plans when better options are available.

For the 4.8 million adults who should be eligible for Medicaid, but who live in states where Republican governors have refused to expand the program, Democrats will make the public option available without premiums. And we will enable millions of older workers to choose between their employer-provided plans, the public option, or enrolling in Medicare when they turn 60, instead of having to wait until they are 65.

Democrats will also empower the states, as laboratories of democracy, to use Affordable Care Act innovation waivers to develop locally tailored approaches to health coverage, including by removing barriers to states that seek to experiment with statewide universal health care approaches.

We also know that finally covering every American through the public and private insurance system alone is not enough to guarantee universal access. That is why Democrats support doubling investments in community health centers and rural health clinics, including increased support for dental care, mental health care, and substance use services like medication-assisted treatment. We will expand the National Health Service Corps to address critical shortages of health care providers in rural areas, including primary care nurses, dental professionals, and mental health and substance use counselors.

Bringing Down Drug Prices and Taking on the Pharmaceutical Industry

Democrats will take aggressive action to ensure that Americans do not pay more for prescription drugs than people in other advanced economies. We will empower Medicare to at last be able to negotiate prescription drug prices for all public and private purchasers—for families and businesses, as well as older Americans—no matter where they get their coverage. We will also ensure and enforce that the price of brand-name and outlier generic drugs cannot rise faster than the inflation rate. We will cap out-of-pocket drug costs for seniors, and ensure that effective treatments for chronic health conditions are available at little or no cost.

Reducing Health Care Costs and Improving Health Care Quality

We will make it easier for working families to afford high-quality insurance in the Affordable Care Act marketplaces by ensuring that no one pays more than 8.5 percent of their income in premiums and eliminating the cap on subsidies.

We will work to increase price transparency in the health care system across all payers, and reduce paperwork through uniform medical billing.

Democrats will support policies that increase the number of primary care practitioners, registered nurses, dentists, and dental therapists, especially in rural and low-income metropolitan areas, so it’s easier for every American to access preventive and primary health care.

Expanding Access to Mental Health and Substance Use Treatment

Democrats will aggressively enforce the federal mental health parity law and ensure that health insurers adequately cover mental health and substance use treatment.

Expanding Long-Term Care Services and Supports

Democrats support measures to eliminate state waiting lists for home and community based care, including through a significant expansion of the home care workforce, and will work to develop a broader approach to eliminate the institutional bias within Medicaid.

Eliminate Racial, Gender, and Geographic Health Inequities

Democrats are committed to eliminating health disparities by race, ethnicity, gender, and geography. We recognize it is not enough to have a commitment: We must have a plan. That is why Democrats will launch a sustained, government-wide effort, with leadership at the highest levels, to eliminate racial, ethnic, gender, and geographic gaps in insurance rates, access to quality care, and health outcomes. That includes tackling the social, economic, and environmental inequities—the social determinants of health like poor housing, hunger, inadequate transportation, mass incarceration, air and water pollution, and gun violence—that contribute to worse health outcomes for low-income Americans and communities of color.

(More on Black people and Latinos, pollution, maternal mortality, data collection to understand disparities, Indian Health Service, reproductive health care services, sexual assault and domestic abuse, LGBTQ+ discrimination, and HIV/AIDS treatment and prevention.)

We will expand access to health care for people living and working across the United States by extending Affordable Care Act coverage to Dreamers, and working with Congress to lift the five-year waiting period for Medicaid and Children’s Health Insurance Program eligibility for low-income, lawfully present immigrants.

Democrats believe that gun violence is a public health crisis. We believe that expanding access to mental health care is key to confronting the epidemic of suicides-by-firearm, including among veterans. Democrats will ensure the Centers for Disease Control and Prevention have sufficient resources to study gun violence as a public health issue and support evidence-based programs for preventing gun violence.

Strengthening and Supporting the Health Care Workforce

We will invest in community health worker care-forces around the nation proven to prevent, manage and better treat chronic illness now burdening tens of millions of Americans, and empower first-time mothers with nurse home visiting. We will close provider gaps and increase diversity in the health care profession by creating a robust pipeline of talent with career ladders for work advancement. And we will also increase opportunities for community health workers to come from the communities they serve.

Investing in Health Science and Research

We will support increased and sustainable funding for federal health and medical research across agencies, including at the National Cancer Institute and other components of the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Research and Quality. We will increase the federal investment in research and development for new medications through the National Institutes of Health, and make sure that there is a return on that investment for taxpayers.

Democrats also support increasing funding for research into health disparities by race, gender, age, geographic area, and socioeconomic status, with a particular focus on how the social determinants of health contribute to differences in health outcomes.

Rep. Pramila Jayapal, Co-chair
Vivek Murthy, Co-chair
Donald Berwick
Abdul El-Sayed
Sherry Glied
Mary Kay Henry
Chris Jennings
Rep. Robin Kelly

https://joebiden.com…

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Comment:

By Don McCanne, M.D.

When the neoliberals commandeered the Democratic primary process and bumped Bernie Sanders out of the running, it was recognized that Joe Biden would have to do something to reunite the Democrats since the flame of the popular progressive revolution had been extinguished, and the Democrats were left with a candidate basically representing the status quo. Perhaps the greatest disappointment was that single payer Medicare for All had been removed from the agenda.

The report of the recommendations of the Biden-Sanders Unity Task Force(s) is 110 pages long and covers many areas of policy. The ten page section on health care basically perpetuates the current health policies, led by the Affordable Care Act, while adding a public option and reducing Medicare eligibility age to 60. The most glaring feature is invisible – the total lack of any mention of single payer Medicare for All.

Single payer Medicare for All is not simply an expansion of Medicare to cover everyone. It is a comprehensive revision of the financing of health care making it universal, comprehensive, efficient, effective, equitable, accessible, and affordable for everyone, for life. The Biden-Sanders Unity Task Force proposal meets none of those criteria.

Biden has said that we cannot afford single payer Medicare for All, yet his model perpetuates much of the excessive spending in health care, failing to recover hundreds of billions of dollars in administrative waste. For administrative efficiency he suggests reducing paperwork through uniform medical billing, but we already have that in Form 1500. He also suggests price transparency as if Nobel laureate Kenneth Arrow never explained why health care markets don’t work. Biden’s proposals would significantly add to our health care spending, and thus would be much more expensive than an efficient single payer Medicare for All.

The goal of the Unity Task Force is to bring disappointed progressives back into the fold. It is likely that President Trump is going to orchestrate his own defeat, and Joe Biden will be elected by default. Regardless, it is important that progressives not give up on single payer. Assuming Biden is elected, it is imperative that we continue to educate everyone on the virtues of the single payer model. If President Biden truly understood the single payer model (and he doesn’t), he would certainly sign legislation enacting it.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

By Adam Gaffney, M.D., M.P.H.
Dissent, Summer 2020

When the COVID-19 pandemic hit, my life as a critical care physician in a Boston-area hospital changed quickly. Massachusetts weathered the third biggest outbreak, in total cases, in the nation. Patients who had contracted the novel coronavirus filled our intensive care units. Their lungs failed; our days started early and ran late. To expand capacity, we acquired more ventilators and brought in new staff. Our surgical recovery room was converted into an open-ward ICU exclusively for critically ill COVID-19 patients.

Another change: we began to cooperate with other hospitals in a novel way.

The ICU capacity at our region’s mid-sized hospitals could evaporate overnight with a surge of admissions of patients in respiratory failure. Much larger institutions nearby had more space and some specialized technologies, like extracorporeal membrane oxygenation (ECMO)—a sort of external artificial lung that pushes oxygen into the bloodstream and sucks out the carbon dioxide, which can help some of those with refractory lung failure. When I wasn’t treating patients, I joined daily phone meetings with physicians working throughout the greater Boston area. We shared data and learned where we could send critically ill patients when we ran out of beds. Something similar played out in New York, where the crisis, by necessity, spurred unprecedented cooperation among the state’s hospitals.

Pandemics lay bare the need for cooperation in health services. But cooperation, and planning, will be equally important after the pandemic is over, and must go well beyond meetings. We need to envision a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

Planning has been a dirty word in healthcare for decades. Competition is today’s idol. But it was not always so: in the postwar era, though the United States failed to achieve European-style reform, a “health planning” movement emerged. The Hill−Burton Act of 1946 provided billions of federal dollars to expand existing hospitals and build new ones, particularly in underserved regions. In the 1960s and 1970s, state and later federal legislation—culminating in the 1974 National Health Planning and Resources Development Act—created planning bodies tasked with assessing local community health needs, approving new capital projects, and ensuring an adequate distribution of health infrastructure. But in the absence of universal healthcare financing for patients, à la Medicare for All, the movement was only marginally effective—and the rise of a new capitalist healthcare paradigm in the Reagan era easily brushed it aside.

The consequence has been simultaneous excess and deficit in health infrastructure. Today, market forces dictate the life and death of American hospitals. The epidemic of rural hospital closures, for instance, is not the consequence of a lack of rural health needs, but of the cold reality that serving those needs is unprofitable. A large academic hospital closed in Philadelphia last year not because its disproportionately low-income and minority patients no longer needed its services, but because those patients did not generate sufficient revenue. One Journal of the American Medical Association study found that, per capita, Manhattan has the most hospital beds among the five boroughs but had the fewest COVID-19 hospitalizations. Little wonder, then, that the virus battered outer boroughs’ hospitals with such ferocity.

The lack of planning is evident not only in the mismatch of hospitals and patients but in the distribution of basic supplies. “California’s Coronavirus Testing Still A Frustrating Patchwork Of Haves And Have-Nots” ran the headline of an NPR story that described glaring geographic disparities in access to testing months into the pandemic. The logic of competition that informs our national approach to healthcare has also meant chaotic and wasteful bidding wars for testing supplies and personal protective equipment (PPE) among hospitals and state and local governments.

The Medicare for All bills in Congress, if enacted, would do much to advance planning: they mandate dedicated funding streams for healthcare capital expenditures. Adequate investment in stockpiles of PPE and other equipment—and the capacity to rapidly distribute it—could also be undertaken by such a system. But we need to think of other ways that planning could prepare us for the pandemics of the future.

Maintaining a large, unused, yet readily deployable ICU “surge capacity,” for instance, is illogical in market terms: it costs money but delivers no revenue outside of plague years. But that unused reserve capacity benefits society. We need to rethink hospital design, with areas that can be used in times of emergencies but otherwise be idled. Israel’s Ramban Health Care Campus—which has a large underground parking garage that can be converted into a 2,000-bed hospital within hours—offers one example. Similar innovations could be envisioned for the inevitable calamities of our future—and be made available to everyone on a truly equal basis.

That necessitates, of course, abandoning the market ethos that currently drives the expansion and contraction of healthcare infrastructure. It requires discarding the false promise of anarchical medical competition as the salve of our healthcare cost crisis. It does not mean returning to the last era of health planning, but instead reinventing planning for the post-COVID age.

Adam Gaffney is a pulmonary and critical care physician, a public health researcher, and an Instructor in Medicine at Harvard Medical School. He serves as president of Physicians for a National Health Program and is the author of To Heal Humankind: The Right to Health in History.

https://www.dissentmagazine.org…

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Comment:

By Don McCanne, M.D.

In a 2011 Quote of the Day, I wrote, “One fundamental concept that has appeared repeatedly on the pages of Physicians for a National Health Program (PNHP) is that excellence is a product of cooperation, not competition. It is not choice between private for-profit and public systems, but rather it is equity within public systems that facilitates excellence.”

Imagine all participants in the health care system working together to improve the efficiency and effectiveness of health care delivery. Obviously health planning is fundamental to this concept,

Instead, in the United States, we rely on markets and competition which shred coordinated planning and cooperation. That is not only very expensive, it creates many of the inefficiencies, deficiencies, and dysfunctions in health care delivery.

The current pandemic has been very instructive in this regard. Instead of providing leadership in a cooperative effort, the federal government has passed much of the responsibility to the states that have had to rely on competitive bidding in the markets for limited supplies, which has driven prices up, not down. When the research community needs to cooperate in developing drugs and vaccines, the United States has gone so far as to withdraw from the World Health Organization – the entity in which nations cooperate in such goals that would improve health throughout the world. The Trump administration has even promoted agreements in which they hope American firms will gain control of the world markets for these new drugs and vaccines, wherein business success trumps public health, at a cost to those on the losing end (competition creates winners and losers, whereas, with cooperation, everyone wins). They also intend to punish our colleges and universities that follow certain recommended public health standards aimed at reducing transmission of the coronavirus, by revoking the visas of international students, an important source of revenue for these institutions. Not only is this not cooperation, it is not even competition. It is simply madness.

Imagine. Working together. For the benefit of patients. Instead of competition and markets, we need cooperation and public service – features characteristic of the single payer model of Medicare for All. Planning together. We have the money. We simply need an infusion of social solidarity.

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By Sharon Begley
STAT, July 7, 2020

You won’t find the usual suspects like Massachusetts General Hospital or the Mayo Clinic at the top of a new ranking of U.S. hospitals. That’s because the rating system relies not just on traditional quality measures, but also on a hospital’s community-minded policies and avoidance of unnecessary care.

The rankings show that those hospitals with good clinical outcomes tend to score poorly in addressing inequities that affect the health of their communities. And even when hospitals perform many low-value procedures — those that research has shown to be of limited or no benefit — their patients generally have a low risk of dying both in the hospital and after being discharged, as well as a low risk of having to be readmitted.

No previous hospital rankings use “civic leadership,” which includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. The Lown Institute, a nonprofit think tank in Brookline, Mass., incorporated both measures into its rankings of 3,282 hospitals because “it is time for hospitals to rethink what it means to be great,” said Lown’s president, physician Vikas Saini.

Civic leadership matters because the health of the people in a hospital’s community “reflect things outside the four walls of a hospital,” he said. “If one patient is going back to a community without a lot of resources, where health equity is low, and another is going back to a wealthier community, their [long-term] health will be very different even if the quality of care in the hospital was identical. Hospitals have an obligation to improve the health of the outside community.”

A number of hospitals renowned for their quality of care got A+ or A for patient outcomes but a D for civic leadership, including Massachusetts General Hospital, the Cleveland Clinic, the Mayo Clinic, and the University of Washington in Seattle. Teaching hospitals such as these do pretty well on supporting their communities, but pay equity — multimillion-dollar salaries for top executives — sinks them in Lown’s calculation of civic leadership. Not a single hospital in the top 100 for patient outcomes was in the top 100 for civic leadership, and vice versa.

Many hospitals perform high numbers of low-quality procedures, which tend to be lucrative (and waste an estimated $100 billion per year in health care spending). “The right thing to do financially isn’t necessarily the right thing to do for patients,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit backed by large employers that aims to identify and promote high-quality, high-value health care and whose hospital ratings emphasize patient safety.

She called Lown’s decision to downgrade a hospital for performing many low-quality procedures “a breakthrough” in hospital ratings. “We know inappropriate care is an extremely significant problem for the health care system,” Binder said. “It’s also a terrible tragedy for individual patients to go through an unnecessary procedure.”

Few patients are likely to reject a hospital based on how much it pays its CEO relative to its custodians. But Binder called civic leadership an important metric. “If there is anything you want out of a hospital, it’s ethics,” she said. Charity care, community support, and pay equity “are informative about a hospital’s culture.”

The American Hospital Association, however, said in a statement that the report offers consumers no “accurate and useful information,” instead offering “a hodgepodge of composite score, ranking, star ratings, and letter grades that will, at best, confuse consumers and likely mislead them.”

https://www.statnews.com…

Lown Institute – Hospitals Index:
https://lownhospitalsindex.org

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Comment:

By Don McCanne, M.D.

Some hospitals are great at pleasing the principal players in the medical-industrial complex. To no surprise, many of these hospitals score high on current arbitrary measures of hospital performance, not to mention that they also have impressive financial statements. But Vikas Saini and his colleagues at the Lown Institute have studied extensively problems with the health care delivery system, and they identify another crucial factor that contributes to high performance of hospitals, and that is “civic leadership.”

Civic leadership includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. As Leah Binder of the Leapfrog Group stated, “If there is anything you want out of a hospital, it’s ethics.”

When you look at the features of single payer Medicare for All, you see that its infrastructure represents the epitome of ethics or civic leadership that stands in contrast to the mere business foundation of the medical-industrial complex. Single payer is universal, equitable, affordable for everyone, allocated efficiently, and always there when needed – ethical features that are simply not innate in a system controlled exclusively by the medical-industrial complex.

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The United States is the only developed nation unable to balance cost, efficacy and social good in setting prices.

By Elisabeth Rosenthal
The New York Times, July 6, 2020

The last vaccine to quell a global viral scourge was the polio inoculation, which ended outbreaks that killed thousands and paralyzed tens of thousands each year in the United States. The March of Dimes Foundation covered the nominal drug cost for a free national vaccination program, estimated at $50,000.

It came in the mid-1950s, before health insurance for outpatient care was common, before new drugs were protected by multiple patents, before medical research was regarded as a way to become rich. It was not patented because it was not considered patentable under the standards at the time.

Now we are looking for viral deliverance when drug development is one of the world’s most lucrative businesses, ownership of drug patents is disputed in endless court battles, and monopoly power often lets manufacturers set any price, no matter how extraordinary. A new cancer treatment can cost a half-million dollars and old staples like insulin have risen manifold in price to thousands of dollars annually.

And the American government has no effective way to fight back.

If a Covid-19 vaccine yields a price of, say, $500 a course, vaccinating the entire population would bring a company over $150 billion, almost all of it profit.

Kevin Schulman, a physician-economist at Stanford Business School, called that amount “staggering.” But Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said that from society’s perspective “$150 billion might not be an unreasonable sum” to pay to tame an epidemic that has left millions unemployed and cost the economy trillions.

Every other developed country has evolved schemes to set or negotiate prices, while balancing cost, efficacy and social good. The United States instead has let business calculations drive drug price tags, forcing us to accept and absorb ever higher costs. That feels particularly galling for treatments and vaccines against Covid-19, whose development and production is being subsidized and incentivized with billions in federal investment.

Manufacturers have traditionally claimed that only the lure of windfall profits would encourage them to take the necessary risks, since drug development is expensive and there’s no way of knowing whether they’re putting their money on a horse that will finish first, or scratch.

More recently they have justified high prices by comparing them to the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals.

Such logic would be disastrous if it were applied to a successful Covid vaccine. Covid-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe Covid-19 mean weeks of highly expensive intensive care.

There is no simple, direct mechanism for regulators or legislators to control pricing. Our laws, in fact, favor business: Medicare is not allowed to engage in price negotiations for medicines covered by its part D drug plan. The Food and Drug Administration, which will have to approve the manufacturer’s vaccine for use as ‘safe and effective,’ is not allowed to consider proposed cost.

Other countries, such as Britain, take a more head on approach: a national body does a cost-benefit analysis regarding the price at which a new drug is worth being made available to its citizens. Health authorities then use that information to negotiate with a drug maker on price and to develop a national reimbursement scheme.

The federal government could, for example, invoke a never-before-used power called “march-in rights,” through which it can override a patent holder’s rights if it doesn’t make its medicines “available to the public on reasonable terms.”

We could, alternatively, allow Medicare to negotiate drug prices — a proposal that has been raised by politicians and beaten back by industry again and again.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Perhaps the most appalling measure of the gall of the private pharmaceutical industry is that they believe that they should be able to claim ownership of the financial value of beneficial results from their drug products.

If a drug that is given to 10,000 patients can prevent 100 people from having a $200,000 hospitalization, then, by this reasoning, that $20,000,000 savings belongs to the drug company. It would be collected in the form of a $2,000 marginal price increase from each of the 10,000 patients who receive the drug. This is not theoretical since such reasoning has already been implemented in driving up drug prices, at least indirectly, and has even been under consideration in international trade agreements under pricing of drugs based on “value.”

And the policy community? Katherine Baicker, dean of the University of Chicago Harris School of Public Policy seems to think that “$150 billion might not be an unreasonable sum” to pay for Covid-19 vaccine based on value (though consider that the national polio vaccine program cost $50,000, and, no, inflation does not explain most of the difference). Baicker, as a director of Eli Lilly, is also not likely bothered by the outrageous increases in insulin prices.

Considering the rigid resistance of the industry to establishing fair drug prices, we really should consider beginning the process of nationalizing the pharmaceutical industry. Perhaps then industry leaders would consider changing their tune, but I doubt it. They are truly driven by greed, as this “value pricing” scheme indicates.

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