From Laggard To Leader: Why Health Care In The United States Is Failing, And How To Fix It, Health Affairs, Jan. 22, 2025, by Donald M. Berwick, et al.

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Health care in the United States is among the most technologically advanced in the world, but it is largely failing to meet the needs of the nation. The US can claim international excellence in important areas of care, such as cancer treatment, and it leads the world in biomedical innovation and building a well-prepared and dedicated clinical workforce. However, Americans are faced with staggering health costs, inadequate access to care, pervasive health inequities, and lagging life expectancy compared with other developed nations. In this article, we propose bold national goals: affordable and equitable care for all, an additional decade of health after retirement, elimination of racial and ethnic disparities in health, substantial reduction in health care expenditures, and, most important, improved health outcomes. To achieve these goals, we recommend changes to ensure coverage for all, invest in primary care and social determinants of health, create financing to incentivize population health, and improve transparency and accountability. Major systemic transformation of the US health care system is not just required; it is a moral and economic imperative.

Yielding to pragmatism, we have based the following principles and action agenda on several key assumptions: First, we assume that the private market for health insurance will continue to exist, with many competing private health plans, and second, we assume that employer-sponsored health insurance will continue to be the largest source of coverage in the private sector. We also assume sufficient political will to enable a substantial increase in regulation of the health care market, as well as much stronger governmental leadership in the health care sector than exists today. Given the urgency of the need for change, we dare to hope for bipartisanship.

Principle 1

Our first principle is that all Americans should have access to affordable, comprehensive health coverage and care. We propose eliminating all medical debt.

Congress should create a Medicare-Plus public option available to all Americans, including those with employer-sponsored coverage. Premiums, deductibles, and copays would be set on the basis of income, no family paying more than 5 percent of income on health care.

Principle 2

Our second principle is that integrated primary care should provide an anchor for the health and well-being of all Americans. This requires a massive restructuring.

Principle 3

Our third principle is that improvements in health outcomes should be incentivized through population-based payment. Payers should minimize fee-for-service payment and substitute payment for care of populations. To reduce overuse and underuse of services, physicians should be, as much as possible, salaried.  Congress should empower CMS to lead an all-payer effort to rebalance payment levels for primary and specialty care.

Principle 4

Our fourth principle is that social determinants of health and health equity should be prioritized.

Principle 5

Our fifth principle is that financing should be simplified to minimize administrative complexity and enhance efficiency. Market-based pricing has failed in the commercial market, and payment complexity continues to exploit patients and breed waste. Financing and administrative operations should prioritize simplicity and uniformity. Americans should not be guessing how much they may be charged based on where they seek care. Hospital pricing should be standardized, transparent, and, within reason, uniform. … CMS should also create a mandatory Medicare Advantage administrative contractor to provide, on a uniform basis, all preauthorization, claims adjudication, and claims review activities.

Principle 6

Our sixth principle is that transparency and organizational professionalism should serve as foundations for accountability. Leaders of medical organizations, such as hospitals, health systems, and group practices, including executives and governing boards, should affirm and adhere to the ethical mandate of putting patients’ needs first.

Principle 7

Our seventh principle is that health systems should embrace data-driven decision making and a culture of continuous learning.

Principle 8

Our eighth principle is that robust governance and accountability measures are necessary to protect the health and needs of communities. Without much stronger accountability to patients and the workforce, fragmented, siloed systems, with varying costs, levels of access, and quality will continue to plague Americans seeking care.

From the Conclusion

Our proposed path forward is impossible unless Americans take equally seriously the need to stamp out price gouging and waste. Administrative pricing will need to be more actively used, high prices for specialty services will need to be reconsidered, health plan games such as upcoding in Medicare Advantage will need to be ended, predictable global payments will need to replace much of fee-for-service payment, useless administrative complexity will need to yield to simplification, and much more thorough price transparency will be required so that authentic competition can emerge. Profiteering in its many forms must be made unacceptable and, indeed, illegal.

Americans spend by far the most in the world but do not have the best care as a result – not even close. Incremental reform has failed in the past and will not work in the future. Only a systemic transformation can achieve the goals of equitable, accessible, affordable, and high-quality health care for all Americans. Why should Americans not, as a nation, have health and health care that stand as a model of excellence for the world?

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Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

Donald Berwick – a hero of ours for his decades of focus on patient well-being – and his colleagues shine much-needed light on the problems with our health care system and propose various measures to improve it. Their recommendations align reasonably with the policies which we single payer supporters have pursued for so long. We agree with administrative simplification, expanding primary care, limiting health care costs for financially struggling families, and shifting the system focus from profits to patients.

It is long past time that the nation listens to and adopts these ideas so that we can all have superior, comprehensive health care at a price that each of us can afford.

However, we are skeptical that the proposed changes can succeed in their goals within the current fragmented system. For example, a public option is notoriously vulnerable to attracting sicker and more expensive patients, which increases prices, which leads to insolvency. Many will remain uninsured. Efforts to standardize hospital prices sacrifice the administrative efficiency gains of hospital global budgets, and don’t address pricing outside hospitals. Effective control of gaming (e.g., diagnostic upcoding and risk selection) within capitated systems like Medicare Advantage have dismally failed, because the extremely competent profit-seeking financial intermediaries defeat regulatory efforts.

Thus, unfortunately, the proposals would leave in place the fragmented approach that underlies the problems that we have. We can’t solve these problems without fundamental simplification of our stunningly complex structure and processes, combined with a (not-for-profit!) government payer – as we would have in a well-designed single payer system.

Still, most of the article’s proposals constitute meaningful steps toward the high-performance health care system that we need. Perhaps we can arrive at specific policies and wrangle the politics that will be required to implement them as intended. Indeed, this may foster enactment and implementation of our ideal system: meaningful defragmentation and radical simplification may open an easier pathway to the less expensive and higher-performing single payer system. Let’s take their suggestions seriously, with the ultimate goal always in mind.

https://healthjusticemonitor.org…

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Changes in Patient Care Experience After Private Equity Acquisition of US Hospitals, JAMA, Jan. 9, 2025, by Anjali Bhatia, et al.

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Conclusions and Relevance: Patient care experience worsened after private equity acquisition of hospitals. These findings raise concern about the implications of private equity acquisitions on patient care experience at US hospitals.

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A Private Equity Hospital Gets a True-Crime Twist, The American Prospect, Jan. 14, 2025, by Maureen Tkacik

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Another looted carcass of a for-profit hospital chain filed for Chapter 11 bankruptcy protection over the weekend, just days after it was the subject of an infuriating Senate Budget Committee report. Perhaps more pertinently, the filing comes ten weeks after the Pennsylvania attorney general sued its two founders and the private equity firm Leonard Green & Partners to claw back around $650 million in dividends they extracted from the company while clinicians were laid off en masse, ambulance drivers were forced to pay for their own gas, and rates of bedsores, sepsis, and other hospital-acquired conditions soared to some of the worst in the country.

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Private Equity in Health Care Shown To Harm Patients, Degrade Care And Drive Hospital Closures, Sen. Chuck Grassley, Jan. 7, 2025

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Today, Sens. Chuck Grassley (R-Iowa) and Sheldon Whitehouse (D-R.I.), in their respective categories as Ranking Member and Chairman of the Senate Budget Committee during the 118th Congress, released a bipartisan staff report on the findings of their investigation into ways in which private equity investment in health care has negative consequences for patients and providers.

Grassley said, “A dependable health care system is essential to the vitality of a community. As always, sunshine is the beast disinfectant. This report is a step toward ensuring accountability, so that hospitals’ financial structures can best serve patients’ medical needs.”

Whitehouse said, “As our investigation revealed, these financial entities are putting their own profits over patients, leading to health and safety violations, chronic understaffing, and hospital closures.” “Private equity investors have pocketed millions while driving hospitals into the ground and then selling them off, leaving towns and communities to pick up the pieces.”

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Comment:

By Don McCanne, M.D.

For a great many years now, we’ve thought that we could simply improve Medicare by expanding its benefits, eliminate the waste of the private insurance industry, and include everyone so that we would end up with a truly altruistic health care system capable of controlling costs by eliminating wasteful spending and improving performance. We would then have a health care system that would be the envy of all other nations.

While we have been busy trying to convince voters and legislators that this would be the route to take, private interests have been increasingly directing the mission of our health care system from providing the best care for patients to creating greater wealth for administrators and investors. Perhaps the most obvious is shifting the goals of private insurance from paying for optimal health care services for patients to insurance products designed specifically to divert health care dollars to profits, resulting in higher costs and poorer performance.

Another example of how our health care dollars are diverted to corporate interests is the growth of private equity investment in providers. Investor organizations purchase components of our health care delivery system, drain them of assets, and then place them into bankruptcy or simply shut them down when they are no longer capable of providing care because of financial insolvency.

Sadly, our task is no longer simply to improve and expand Medicare, but also to seek greater regulation and even ownership of providers. Many believe that this would be best accomplished by increasing community control and ownership.

This also means that political control must be in the hands of individuals who insist that patients should come before profits. These views have been strongly held by progressives who have been sidelined by neoliberals and conservatives. When conservatives gained control in Canada and in England, the services of their respective single payer and national health service systems deteriorated, primarily due to longer wait times due to inadequate public funding. Wouldn’t it be nice if set aside political divisions and agreed that this should be about policies that work for everyone?

So now we not only have the task of installing a financing system that would enable everyone to have access to comprehensive health care through single payer (improved Medicare for All), but now we also must gain control of private funding of the health care delivery system. Since we have a new government that wants to further reduce taxes for the very wealthy and pay for that by reducing beneficial government services for the rest of us, you can see that a very difficult task awaits us.

We can do it with a three-step process. The first is labor intensive: we must educate the public of the great benefits that will ensue by making these changes. To do this, we must simplify the communication of the concepts so that everyone will understand clearly why we have to do this. Second, we must join together, as individuals and organizations, in a political process that will convince legislators that this is the solution that we have all been waiting for. With overwhelming public demand, they will have to lead us to the third phase – enacting and implementing our vision for universal, patient-oriented financing and care.

We do have an inkling of good news. We now have politicians from both major parties, Sen. Grassley and Sen. Whitehouse, who have brought before Congress, through the Senate Budget Committee, the fact that problems in our health financing system are serious enough that it requires the attention and action of Congress.

So now all we have to do is flesh out the three-step action plan. Let’s get to work!

(Later this week: Review of the policy landscape.)

https://healthjusticemonitor.org…

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Americans Are Angry About Their Health Insurance – With Good Reason, Common Dreams, Jan. 1, 2025, by Claudia Fegan, MD (National Coordinator, PNHP)

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As a physician, I have seen patients suffer and die in order to pad the bottom lines of corporate health insurers – and in recent years I have seen this problem getting much worse.

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How should we react when a man is shot to death on the street on his way to work? Our humanity tells us that we should be shocked and horrified.

So why did hundreds of thousands of people have the exact opposite reaction when UnitedHealthcare’s CEO was executed in New York City? Because Americans are furious with health insurance corporations – and they have every right to be.

In the immediate aftermath of the shooting, many Americans took to social media to celebrate. Sympathetic statements were met with rancor – and in the case of UnitedHealth Group’s own statement, over 70,000 “laugh reactions” before the company made that tally private.

As a physician who’s treated countless victims of gun violence, and whose life’s work is to care for all of my patients, I found this response to be deeply unnerving.

For decades, health insurance corporations like United have been taking in as much money as possible in premiums and paying out as little as possible in medical claims. They have tried everything from requiring “prior authorization” of care, to excluding high-quality providers from their networks, to imposing a Byzantine series of charges including ever-growing copays, coinsurance and deductibles. When all else fails, many insurers simply deny claims.

Behind each of these practices are millions of Americans who are made to suffer. I hear these stories routinely in my practice, and they never become easier to stomach. I have seen patients with aggressive cancer who avoided seeing a doctor for months because they feared bankruptcy; patients with chronic conditions like diabetes who are denied treatments that would improve their quality of life; and gunshot victims whose fight to recover and gain a semblance of normalcy is complicated by their health plans saying no, no, and no again.

I have seen patients suffer and die in order to pad the bottom lines of corporate health insurers – and in recent years I have seen this problem getting much worse.

Are we listening? And what are we going to do about it? Both the Affordable Care Act and the Medicare Advantage program have only succeeded in ballooning the profits of firms like United – without improving Americans’ health or sparing their wallets.

What would help is a proven reform proposal that is long overdue: a single-payer national health program. Such a system would provide universal coverage and comprehensive benefits – with zero out-of-pocket costs.

Americans are crying out in pain. We should listen to those cries and we should finally, after decades of delay, do something about it.

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Comment:

By Don McCanne, M.D.

I started in practice before Medicare and Medicaid were implemented. What a relief it was to see seniors finally able to receive care without facing significant financial barriers to that care. And others living in poverty were also able to receive care since their financial barriers were removed, and Medicaid did cover overhead, allowing dedicated physicians to practice without worrying about negative cash flows.

But there were still too many patients who remained uninsured or whose employer-sponsored plans were shifting more expenses to the patient through higher premiums and cost sharing, while limiting patient choices through managed care manipulations.

With my growing dissatisfaction with our health care system, it was in 1989 that I read an article in JAMA, written by Steffie Woolhandler and David Himmelstein, co-founders of Physicians for a National Health Program, that described a single, tax-funded national health program that they supported. That was it! Precisely what we needed! I immediately became affiliated with their organization. Claudia Fegan became one of my mentors, leading me through the early stages of my involvement. She has been an inspiration to me ever since.

Her article explaining how the defects in our health care financing system only continue to grow certainly resonates with me. We now have the most expensive health care system which performs worse than all other modern nations. We recently estimated in HJM as many as 200,000 deaths each year due to insurance problems like those described by Dr. Fegan. You can see why I am absolutely elated to see her article as she continues to fight for the cause of health care justice for all.

The tragedy of the assassination pains us all, but the enormity of the public reaction to the injustice that the private insurers inflict upon the American people suggests that there is hope that we will finally fix the system. If our legislators and administration do not respond to the current protests, it means that we need to raise our voices even louder (while refraining from assassinations and Jan. 6-type events, since, in our mission, we revere life).

https://healthjusticemonitor.org…

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Health Insurers Gave $120 Billion To Shareholders While Denying Your Claim, The Lever, Dec. 11, 2024, by Veronica Riccobene

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As rising health care costs and inadequate insurance coverage have one in three Americans saddled with medical debt, the nation’s top health insurers have dumped billions into enriching their executives and top shareholders through lucrative stock buybacks.

All in all, the country’s largest health insurers have invested over $120 billion into repurchasing their own shares since the passage of the Affordable Care Act in 2010. These include UnitedHealth Group; Cigna; Elevance Health, the parent company of Anthem Blue Cross Blue Shield; and CVS Health, which acquired Aetna in 2018.

These companies, along with Kaiser Permanente, a nonprofit health care organization, control over half of the commercial market share of the U. S. Health insurance industry. Since 2010, they’ve raked in a combined $9 trillion in revenue, netting more than $371 billion in profits.

Meanwhile, one in four Americans say they’ve avoided seeking health care in the past year because of the cost. Half of all U.S. adults say they’d be unable to afford an unexpected $500 medical expense, and medical bills account for 40 percent of U.S. bankruptcies.

Major insurers have abandoned patients for shareholder enrichment, according to former health insurance executive Wendell Potter. “Health insurers corrupted the concept of managed care and turned it into something that has really been more of managing cost, but also depriving people of the care that they need,” said Potter. “There’s no other country in the world that has a system like this that enables middlemen to siphon off so much money from middle-class and working-class folks that need health care,“ he added.

Nearly two in three Americans now say they believe health care should be the government’s responsibility, according to polling organization Gallup.

Data shows buybacks soared after Congressional Republicans and the Trump administration slashed corporations’ tax burden through the Tax Cuts and Jobs Act of 2017. Proponents of the Trump tax cuts argued that corporations would reinvest their savings into research and workers – but instead, buybacks exploded. Corporate buybacks are on track to surpass $1 trillion annually by 2025.

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Comment:

By Don McCanne, M.D.

Remember, this is only one game that corporations play to move our health care dollars to their own profit line. Their combined maneuvers to reduce health spending on us as they boost their own profits is what has made the health care system in the United States the most expensive and poorest-performing system of wealthy nations.

This is certainly not news to those of us who have now worked decades to try to bring us the model of health care reform that would enable everyone to have access to comprehensive health care without increasing the total health care spending in the U.S., and that model is a single payer system that would be similar to an improved version of Medicare that covered everyone. Many studies have now shown us that this is precisely the reform that we need to provide health care for everyone without creating any personal financial hardship.

The problem is that we still have too many politicians and members of the media that respond in a rote manner with phrases such as, “We can’t afford that” (we can), or “The people don’t want the government involved” (countered by numerous surveys), or “But that’s socialized medicine” (not a bad concept when it is applied to our traditional Medicare as well), or etc., etc.

The solution is that we can no longer accept any of these phrases that tend to reject the concept when we know that single payer is exactly what we need. Now, in such instances, we need to be emphatically but politely curt as we immediately reject the negative comment whenever it is brought up and replace it with politely stern corrections, with special attention to the true facts (“politely stern”: are we creating a new, more appropriate communication standard?).

Anyway, no more passive dismissals. We need to enact and implement a system that works well for all of us, and we need to do it now. We must bring an end to the decades of delay: Health Care Justice for All – NOW and FOREVER!

PEACE AND CHARITY BE WITH US.

https://healthjusticemonitor.org…

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This week, a careful reader asked me to justify this estimate from November 2021: “The US excess mortality age 20-64 is about 1.4 per 1000 per year. Some of that is due to non-insurance factors. If 1.0 per 1000 is attributable to insurance, applied to the 190 million in this age range, that’s 190,000 extra deaths per year.”

In 2021, I was making a rough estimate by assigning most of the inter-country difference among adults 20-64 to health insurance. Perhaps I didn’t sufficiently emphasize the uncertainty of that estimate. Today, to “triangulate,” I took a different approach. I looked up death rates for major risk factors and diagnoses more common in the US than in other wealthy nations. This is not yet sufficiently refined for academic publication, but it’s a solid first cut, so I’m sharing it with HJM readers.

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This finding of 195,032 annual deaths not explained by risk factors and diseases more common in the US is close to my prior estimate of 190,000. As noted, several of the totals may actually have medical insurance as a contributing cause – e.g., medical debt forcing people into poverty, or suicides associated with insurance worries or lack of access to mental health care. Thus, the 195,032 is likely a low estimate of insurance-related deaths.

To me, this high mortality burden is consistent with our fragmented and flawed insurance system, with half of adults experiencing financial barriers to care in any given year, often with reported health consequences. Growing rates of care denials are likely increasing the human toll, based on both reports of personal experiences and national surveys of physicians.

These kinds of estimates are imprecise, and indeed the uncertainty bounds are hard to specify. However, they are meaningful despite uncertainty. Whether the excess deaths due to insurance gaps total 195,000 per year, or 220,000, or 170,000, that’s hundreds of thousands too many deaths. The 45,000 estimated in 2009 for those lacking insurance altogether (ignoring under-insurance) is also too much, inexcusable.

We need universal public insurance providing broad benefits to everyone, to save lives and money.

https://healthjusticemonitor.org…

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Sources:

• Bor J, et al. PNAS Nexus, 2023, “Missing Americans: Early death in the United States 1933–2021”
• Dehry SE, et al. Population Research and Policy Review, 2023, “Excess Deaths in the United States Compared to 18 Other High‑Income Countries”
• Ward ZJ, et al. EClinicalMedicine, 2022, “Excess mortality associated with elevated body weight in the USA by state and demographic subgroup”
• Peterson-KFF Health System Tracker, 2021, “Country Comparison: Prevalence of obesity”
• Commonwealth Fund, 2024, “Comparing Deaths from Gun Violence in the U.S. to Other Countries”
• Morbidity and Mortality Weekly Report, 2022, “Motor Vehicle Crash Deaths — United States and 28 Other High-Income Countries, 2015 and 2019”
• Roser M. Our World in Data, 2020, “Why is life expectancy in the US lower than in other rich countries?”

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Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.