PNHP

The Tragicomedy of Medicaid

The Tragicomedy of Medicaid

Millions have been disenrolled from Medicaid, nominally due to the “unwinding” of COVID eligibility rules … but also due to administrative glitches. Lots of other problems with Medicaid. It’s a crisis, worthy of the deep scrutiny and biting wit of John Oliver.

Medicaid: Last Week Tonight with John Oliver (HBO), (28 minute video), April 18, 2024

John Oliver discusses why millions of people have been kicked off of Medicaid, why Medicaid access was difficult even before the current “unwinding”, and what would happen if fruits and vegetables could talk.

[Alert: Oliver uses profanity for emphasis]

Comment:

By Jim Kahn, M.D., M.P.H.

It’s so tragic it’s comic. Medicaid – health insurance for 90 million US poor – is a vivid example of the chaos and inefficiency that result when a program is designated and designed for individuals who lack political power and social standing. The beneficiaries are disrespected and poorly served. As HJM discussed, in most states private “managed care” insurers exploit the massive Medicaid cash cow to extract profits via restricted services and higher government spending. This essential health insurance lifeline is frayed.

What we need is a public insurance system that serves everyone, and thus is subject to natural quality control. Everybody needs it, so it works. Think social security, fire departments, and highways. They function well, fulfilling important societal functions.

In the health insurance arena, that’s single payer / Medicare for All. Successfully implemented around the world. Generous, equitable, and efficient. Advocated by John Oliver.

Oliver’s plea in this video for better management of Medicaid unwinding is appropriate, but IMO doomed to succumb to the dysfunctional dynamics of the Medicaid system. Hence my – and Oliver’s – plea for real system reform.

Universal public insurance is a heavy political lift, due to all the private entities – most of all insurers – who will lose tens of billions in profits. So we need to keep up the fight. John Oliver is our best cheerleader.

https://healthjusticemonitor.org…

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.

Political Party Split vs. Concurrence on Government Guarantee of Health Care

The Dem and GOP party split is nearly equal. Yet, we largely concur on worries about health care availability and affordability, and on a government role to assure we all have health care. Medicare for All / single payer is the path.

Changing Partisan Coalitions in a Politically Divided Nation, Pew Research Center, April 9, 2024

The combined effects of change and continuity have left the country’s two major parties at virtual parity: About half of registered voters (49%) identify as Democrats or lean toward the Democratic Party, while 48% identify as Republicans or lean Republican.

The continuing close division in partisan identification among voters is consistent with the relatively narrow margins in the popular votes in most national elections over the past three decades.

American Anxieties, GALLUP, April 9, 2024

Tell me if you personally worry about this problem a great deal, a fair amount, only a little or not at all.

The availability and affordability of healthcare [fifth item on the list]

  • 51% – A great deal
  • 27% – A fair amount
  • 21% – Only a little/Not at all

Comment:

By Don McCanne, M.D.

Over three-fourths of our nation (78%) is concerned about the lack of availability and affordability of health care. And yet the political activity we see is some nominal support of private insurance patches on the part of Democrats, when private insurance is proving often to be a detrimental method of funding health care, and Republican proposals to pass more of the costs on to patients through high deductibles and schemes such as health savings accounts. These political “solutions” actually result in the perpetuation of problems with both the availability and affordability of health care.

With three-fourths of the nation quite concerned, that certainly includes both Republicans and Democrats. Surely most of them do not believe that health care reform calls for a mandate of a private sector solution because that is what is available to everyone right now through the private insurance market. Without insurance, most cannot afford to pay for a major medical event or at least do not want it to displace other expenditures such as a down payment on the home they wanted to buy, the kids’ college education expenses, or funding of their retirement programs. But today, the private insurance industry and other intermediaries have become additional major sources of increased expenses and barriers to health care since those entities are on a mission to prioritize increasing investor wealth over patient health.

The majority of Americans want the federal government to guarantee health care and don’t trust insurers. Almost everyone approves of the government making health care available and affordable for people over 65, in the form of Medicare. In recent years, efforts have been made to privatize Medicare and that needs to be reversed by eliminating private insurers in order to return to patient care as guiding priority. Also, the benefits need to be expanded (vision, hearing, long term care, etc.) and deductibles and copayments should be eliminated so that Medigap insurance would no longer be necessary. Then, with other improvements, this version of Medicare should be expanded to include absolutely everyone, and it would be made equitable by funding it with progressive taxes, recovering some of the excessive revenues that have been moving into the coffers of the billionaires and the mega trillion dollar corporations.

Surely the large majority of us who are concerned about the availability and affordability of care can see the fairness in the rewards of our productivity that have been siphoned off by the super-rich being returned to us in funding for health care for all. No more silly knee jerk reactions against the labels “single payer” or “Medicare for All.” They will be labels that we can all be proud of because we earned them.

https://healthjusticemonitor.org…

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.

Medicare for All Explained Podcast: Episode 110

We don’t Need Health Insurance Companies

April 15, 2024

Podcast host Joe Sparks relates a recent experience filling a prescription at Costco to remind us that corporate health insurers add nothing of value to U.S. health care.

When he asked his pharmacist how much his prescription would cost if he paid out of pocket, he was surprised to learn that, “I paid four times less when I did not use my insurance.”

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

https://medicareforallexplained.podbean.com

Big corporations are quietly taking over your medical practice. Some doctors and experts say it’s ruining healthcare.

By Shelby Livingston
Business Insider, April 11, 2024

  • Big businesses such as hospital systems, insurers, and PE firms are gobbling up medical clinics.
  • Some doctors and industry experts fear corporate owners could prioritize profits ahead of patients.
  • The federal government is dialing up scrutiny of PE firms and other corporate owners in healthcare.

Independent doctors are almost a thing of the past.

UnitedHealth Group struck a deal in March to buy the nine-state doctor group of the struggling hospital system Steward Health Care. The same month, the powerful healthcare conglomerate, which owns the nation’s largest health insurer, got the green light to take over a decades-old independent Oregon medical practice, adding another 100 healthcare providers to its roster. It picked up a 400-doctor group in New York about a year before.

These are just the purchases we know about; there could be many more. Physician practice deals often go unannounced and get little attention from regulators, but they add up. Near the end of 2023, UnitedHealth’s Optum, the business unit housing its clinics and surgery centers, said it employed or was affiliated with 90,000 doctors. That’s a whopping 10% of all doctors in the US.

Though it’s the hungriest, UnitedHealth is just one buyer in the market for physicians. Little by little, big businesses have taken over healthcare in the US.

Hospitals have been scooping up medical practices for decades to create giant health systems. Insurance companies fought back with their own clinic purchases. Private equity firms increasingly staked claims to nursing homes and groups of specialists such as emergency physicians and dermatologists.

And in the last few years, tech companies and retailers like Amazon, CVS Health, and Walgreens added thousands of doctors to their payrolls when they bought primary-care chains.

Nearly 78% of US doctors are employed by hospitals or other corporate entities, such as insurers and PE firms, according to research from consultancy Avalere and the Physicians Advocacy Institute. For the first time, more medical practices were owned by corporate entities (30%) than hospitals (28%) as of January 2024, the research found.

There’s mounting evidence that this trend toward corporatization could harm patients. Research has found that prices go up when hospitals and private-equity firms buy medical groups. Sometimes, care gets worse, but there’s still much unknown about how corporate ownership affects medical care, especially when it’s a giant like UnitedHealth or CVS doing the buying.

Some doctors and experts in the industry fear corporate owners could prioritize their investors and profits ahead of patients, and doctors could lose the ability to make their own decisions about what’s best for a patient.

“The big guys aren’t cheaper. They don’t deliver better customer service, they aren’t more timely, none of that. They’re just able to negotiate higher prices,” said Farzad Mostashari, the CEO of Aledade, a company that aims to help primary care practices stay independent.

The federal government is starting to pay attention. In March, it launched an inquiry into PE firms and other corporate owners’ “increasing control over healthcare” and how this might threaten patients’ access to affordable and quality care.

The feds also zeroed in on UnitedHealth, reportedly facing an antitrust investigation by the US Justice Department into how its medical group acquisitions affect consumers and competitors. News of the probe surfaced before a cyberattack on UnitedHealth’s technology business, Change Healthcare, caused hospitals and clinics nationwide to forgo billions in payments — raising more questions about UnitedHealth’s chokehold on the healthcare industry.

Doctors are hot commodities

It’s tough to lump the many buyers of medical practices together, as they’re pursuing different strategies. But, in essence, they’re all hiring doctors for their relationships with patients, who bring opportunities for more profits. US healthcare spending reached $4.5 trillion in 2022, representing almost a fifth of the national GDP.

Hospitals rely on doctors — especially those who provide primary care — to refer patients for lucrative procedures or surgeries. Insurers like UnitedHealthcare and CVS’ Aetna are required by federal law to spend most of the money they collect in premiums on medical care. Still, they can pocket more of those premiums by sending patients to clinics they own.

Pharmacies hope that buying medical practices will give more prescriptions to fill and get more customers to buy over-the-counter products at the front of the store.

“They all realize that patients will follow what their doctors tell them to do or where their doctors tell them to go,” said Chas Roades, a longtime healthcare consultant. “So it allows them to both drive traffic to a downstream profit model that they’re interested in growing, and I think it also is a way to get consumers to trust them.”

Meanwhile, independent doctors have a tough time going it alone. Reimbursement is shrinking, and small practices don’t have the ability to negotiate higher rates as big hospital systems do. Plus, running a modern medical practice is expensive, requiring investments in staffing, technology, and electronic health records. The pandemic made things even more challenging, spurring many doctors to sell their private practices.

The quiet takeover of physician practices

Much of the takeover of physician practices has slid under the radar. That’s because acquisitions valued below $119.5 million don’t have to be reported to federal regulators, and many practice purchases don’t meet that threshold. Publicly traded UnitedHealth, for instance, rarely announces its purchases of medical groups and surgery centers.

“We’re really flying blind here with respect to understanding how many acquisitions by which entities and what geographies and what specialties,” said Yashaswini Singh, an assistant professor at Brown University who studies healthcare consolidation.

This lack of disclosure has made consolidating doctor practices difficult to study. Research into private equity’s effects on healthcare is just emerging, and there’s little to no academic, peer-reviewed research on how other corporate owners’ acquisitions affect healthcare prices and quality, Singh said.

Studies, including Singh’s research, have shown, however, that PE ownership leads to steeper prices and more utilization, meaning patients may have more frequent doctor’s appointments. Together, that drives healthcare costs higher. Research also suggests that PE ownership of nursing homes and hospitals worsens the quality of care. One paper found that patients who went to nursing homes owned by private equity firms had a 10% greater chance of dying.

And yet, private equity companies are rapidly expanding their presence in healthcare. A 2023 study found that one private equity firm owned 30% of the market share for physician practices in over a quarter of metropolitan areas across the US. A single PE firm owned over half the market share in some areas.

‘An unsatisfying way of practicing medicine’

Acquisitions by other corporate giants might not produce the same outcomes as PE firms, said Zirui Song, an associate professor of healthcare policy and medicine at Harvard Medical School who studies private equity in healthcare. PE firms are unique in holding on to their acquisitions for only a few years and saddling their acquired companies with debt and fees. Owners who hang on to their medical groups might be more motivated to improve services, he said.

Anecdotally, though, many doctors don’t like working for corporate overlords, Roades said. Older physicians who own equity in their medical practice get a nice payday when they sell, but the younger ones left behind are closely managed and measured in terms of cost and productivity, he added.

It’s “an unsatisfying way of practicing medicine. We’re seeing a growing number of disgruntled early and mid-career physicians in these groups who find themselves suddenly working for large corporations, and this is not what they wanted to do with their lives,” he said.

After a few years working at Optum-owned Oregon Medical Group, Dr. Nick Jones opened a direct primary care practice, a type of clinic that charges a monthly fee instead of billing insurance. He said there’s a sense of powerlessness for primary-care doctors in the traditional healthcare system — whether they’re employed by Optum, a large hospital system, a private-equity firm, or a nonprofit clinic.

With thousands of patients to treat, they face a mountain of administrative paperwork and have no control over their schedules. These problems stem from the fact that primary-care doctors are underpaid in the traditional “fee-for-service” healthcare system, in which doctors are paid for every visit, he said.

While he felt supported at his previous Optum-owned clinic because of his office manager, “the financial underpinnings and the economics of medicine” made it unsustainable and stressful, Jones said. “There was a three or four month wait for patients to see me. There was still too much on our plate to do, and [during the pandemic] there weren’t enough medical assistants or case managers or nutritionists or other support to make 20 patients a day feel like the right thing to do.”

Doctors worry corporate giants put profits over patients

The insurers and retailers say care is better and cheaper when integrated under one roof, connected to the health plan, pharmacy, or other provider organizations.

For its part, Optum says it wants to improve the health and well-being of people and lower the cost of care with integrated care teams and better technology. It says it’s helping clinics transition to providing “value-based” or “accountable” care, which means that its doctors get paid fixed fees upfront that, in theory, encourages them to keep patients healthy and order fewer unnecessary tests.

Optum said in a statement it continues “to focus on supporting physicians, advance practice clinicians, and nurses in closing gaps in care and helping the health system perform better for everyone.”

A spokesperson pointed to a study by Optum published in JAMA Network Open in December 2022 that found seniors in value-based care arrangements were less likely than seniors in traditional payment models to visit the emergency room, or be admitted at the hospital for COPD, asthma, stroke, or heart attack.

But there are potential dangers. Patients may end up with fewer choices as bigger companies edge out competitors.

California health system Emanate Health sued Optum in 2023 for anticompetitive behavior. It alleged that Optum canceled its contracts with Emanate hospitals and steered patients away after Emanate refused to agree to certain terms. Among the terms: Emanate primary-care doctors would serve only Optum patients, and Optum would get first dibs if Emanate decided to sell its primary-care practices.

Care might also feel less personal. Some One Medical patients complained that since the chain folded into Amazon, their appointments were shortened, and certain features for seniors, like having health coaches available during patient visits, went away, according to a report from The Washington Post.

Patients could end up spending less time with doctors and face higher costs

Dr. Mitch Li, an emergency physician who started Take Medicine Back, a group that opposes corporate owners pushing into healthcare, said patients will spend less time with their doctors and potentially face higher costs from predatory billing practices.

“The corporate practice of medicine is the reason why healthcare costs are out of control,” Li said.

Above all, some doctors fear having to make decisions that benefit the owner’s bottom line, even though they may not be the best option for a patient.

Dr. Michelle Cooke, a primary-care physician, previously practiced at an Atlanta clinic owned by a hospital system. Though the system was not-for-profit, it didn’t operate like that, and over time, the job became unbearable, she said.

She had more than 3,000 patients assigned to her care — far more than typical — and appointments were too short, especially for the chronically ill, she said. The hospital system would prioritize lucrative physicals for Medicare patients rather than seeing patients with an urgent need.

“It really got to the point where I feel like I was working to feed the corporation,” Cooke said. “It really wasn’t incentivizing what the patients needed.”

Cooke has since opened a direct primary care practice, where she sees just a few hundred patients and can spend more time with them. She said she’s found that she prescribes less medication now because she has time to educate patients on lifestyle habits and nutrition.

The federal government and states are dialing up the scrutiny

The Federal Trade Commission, the US Department of Justice, and the Department of Health and Human Services are stepping up scrutiny of healthcare deals, particularly those backed by private-equity firms. The agencies also signaled that they want to look at smaller deals that typically wouldn’t trigger an antitrust review.

Several states have also increased their oversight of local healthcare consolidation. Some state lawmakers are also trying to strengthen laws prohibiting corporations from practicing medicine. Most states have these bans on the books, but companies have found various ways around them.

It’s unclear if any of these efforts will meaningfully slow the corporatization of healthcare. And, to be sure, some physician practices may not have survived without an infusion of capital from a corporate buyer.

A bill introduced by Oregon State Rep. Ben Bowman would have closed certain loopholes and put more distance between corporate entities and their medical practices. Bowman told Business Insider he wanted to prevent big businesses from eroding doctors’ autonomy.

“A physician who went to medical school who took an oath — their highest ethical duty is to care for their patients. Whether it’s a private equity firm or a large corporation, their highest ethical duty is to generate a return on investment for their shareholders. Those two incentives are fundamentally at odds,” Bowman said.

The bill, opposed by Amazon and CVS, died in March, but Bowman said he plans to reintroduce it in 2025.

Around the same time the bill died, UnitedHealth’s Optum and The Corvallis Clinic — the small Oregon medical practice that Optum struck a deal to buy — requested that their tie-up receive an emergency exemption from state review because of the Oregon clinic’s deteriorating finances.

The proposed acquisition, first announced in December, had received plenty of pushback from state residents. The request also came as hospitals and clinics nationwide faced cash shortfalls because of the cyberattack on UnitedHealth’s Change Healthcare.

A week later, Oregon’s health authority approved the request.

https://www.businessinsider.com…

Cross-National Insurance Contrasts in Amusing 1-minute Videos

Two entertaining YouTube shorts highlight how the US lags on health insurance. Unaffordable premiums if you lose your job, and outrageous cost-sharing to give birth.

POV Losing Your Job in the US vs France, YouTube Short, Roya @royaventurera, March 29, 2024

[American accent] “Does this mean I lose my health care too? … You’re lucky you’re insured, you can actually continue your coverage through a program called Cobra, on average it’s about $700 every month … That’s almost my entire unemployment benefit! …

[French accent] what happens to my health care? Don’t worry your health care is not tied to employment in France …

Cost of Giving Birth Around the World vs US, YouTube Short, Roya @royaventurera, March 30, 2024

France? gratuit [free], Spain … Mexico … Brazil … all free

US? about 2-3 thousand dollars … if you do have insurance, otherwise could be 10-30-100 thousand … highest maternal mortality of any developed nation …

Comment:

By Jim Kahn, M.D., M.P.H.

These little dialogues bring a smile to my face (if not raucous laughter). I appreciate that, despite our dire insurance situation and my determination to reform the system.

The videos also remind us that all we need to do is adopt proven approaches to health insurance from other low (and middle!) income countries.

  1. Look around, outside our borders.
  2. Imitate.

Such an easy recipe.

https://healthjusticemonitor.org…

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.

Protecting public health care from private investors

Private equity ownership of the places where we seek care risks undermining cost, quality, access, efficiency, and equity.

By Danyaal Raza, M.D., M.P.H. and Karen S. Palmer
Toronto Star, April 9, 2024

Private equity investment firms exist to make money for their investors. It’s their job. Over the past decade, private equity firms around the world have increasingly invested in the health care industry, including Canada’s long-term care sector and a growing number of private for-profit surgical centres.

Private equity firms are investment management companies. They buy other private companies with the intent to improve their performance, often selling them again a few years later at considerable profit to their shareholders.

In Canada, a single private equity firm already owns the largest national network of independent surgical centres — 53 operating rooms spread across 14 centres — in Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and B.C.

Surgeries performed in these surgical centres are funded through a mix of public and private payments. Approximately 90 per cent are publicly funded through partnerships with provincial health systems. The remaining 10 per cent are private pay, including through private insurance or out-of-pocket for those who can afford it.

Some of that money is used to pay for patient care, but some — our public dollars — is extracted to enrich shareholders who expect a return on their investment.

Should profit-driven investors own health care facilities? Does it even matter, so long as patients get care?

Yes, it does.

Studies show that private equity ownership is associated with worse quality of care — such as a substantial increase in infections, falls, and other adverse events — and higher costs of health services around the world, including in the U.S., U.K., Sweden, Netherlands, and Germany.

Private equity ownership turns health care from a social good into a financial asset, extracting wealth for investors. There is no evidence that private equity ownership leads to systematic improvements in care. The primary focus is on financial gain for shareholders.

It’s not just surgical centres that are owned by these firms. Private equity has also scooped up nursing homes in Ontario, raising alarms about cost and quality of care. Tragically, these care homes had the highest mortality rates during the emergency phase of the COVID-19 pandemic and those with the highest profit margins suffered the lowest quality of care.

Although private equity ownership of Canada’s health care system is relatively new, it has become a mainstream and troubling phenomenon in the U.S. So much so that 25 per cent of U.S. hospital emergency departments are now staffed by private equity-owned staffing firms. Many worry that the growing financialization of health care inserts corporate values into treatment, raising concerns about the corporate practice of medicine.

Even the U.S. Federal Trade Commission has taken notice. For the first time ever, it is suing both a medical group and its private equity backers, alleging anti-competitive practices that drive up the cost of health care. Their concern is that this can exert pressure on health care professionals to “subordinate their own medical judgment to corporate decision-makers’ profit motives at the expense of patient health.”

Private equity firms are opaque and secretive. They don’t have to publicly disclose information about their finances, operations, business risks, or legal liabilities. Canadians are asking: What mechanisms are in place—like anti-trust and anti-competition legislation, regulation, and enforcement mechanisms — to guard against consolidation and the harms from monopoly corporate ownership and control of our health care delivery system?

Private equity ownership of the places where we seek care risks undermining cost, quality, access, efficiency, and equity. If we aspire to building a health care system that meets the demands of 21st century medicine, we must put in safeguards to ensure that corporate ownership, including by private equity firms, does not undermine all that we value in our health care system.

Dr. Danyaal Raza is a family physician at St. Michael’s Hospital, Unity Health Toronto and past chair of Canadian Doctors for Medicare. Karen S. Palmer is an adjunct professor at Simon Fraser University and University of Toronto and policy advisor to Canadian Doctors for Medicare.

https://www.thestar.com…

Latest Corporate Intermediary Scam, For Out-of-Network Charges

Here’s the latest corporate innovation to extract resources from health care, by creating yet another inefficient but highly profitable intermediary. This time it’s for out-of-network charges. Who pays more? Patients.

Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill, The New York Times, April 7, 2024, by Chris Hammy

MultiPlan is a little-known data analytics firm that works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.

Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.

But when when employees see a provider outside the network, many insurance companies consult with MultiPlan, which typically recommends that the employers pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a saving for the employer. But, the Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, according to testimony by two of its executives. Last year alone, MultiPlan told investors it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

The little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay. In addition, providers have seen their pay slashed, and employers have been hit with high fees. In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient.

After MultiPlan’s founder sold it to private equity investors in 2006, the company pursued a more aggressive approach. It embraced pricing tools that used algorithms to recommend lower payments, and no longer protected patients from having to pay the difference.

Once insurers were no longer obligated to use the nonprofit database, FAIR Health, they began looking for ways to combat billing and other charges they considered egregious. Insurers contended that overbilling would skew payments too high. Cigna: “We need someone external to Cigna to develop acceptable rates.” UnitedHealthcare emphasized companies still using FAIR Health, “understand they don’t want to be on that program anymore.”

UnitedHealthcare had a big incentive to encourage this change. When it processed claims from employer plans using FAIR Health, the insurer collected no additional fee. But when it used MultiPlan, it typically charged employers 30 to 35 percent of the difference between the billed amount and the portion paid.

MultiPlan, too, charged a percentage of the savings, meaning it could make more by recommending lower payments. (FAIR Health charged a flat fee.)

While UnitedHealthcare was MultiPlan’s largest customer, Cigna and Aetna also embraced its tools and fee model. Other insurers that work with MultiPlan include Kaiser Permanente, Humana and some Blue Cross Blue Shield plans. Employers with self-funded plans administered by insurers include large companies like Coca-Cola and AstraZeneca and smaller organizations like school districts and union locals.

Comment:

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

Theoretically, health insurance should allow us to equitably pool our funds in order to make health care both accessible and affordable for everyone participating. We have had a goal to expand that to include everyone. However, we have relied heavily on the private insurance industry which has engaged in business activities designed to increase profits for its shareholders and compensation for its executives. These activities have impaired access and resulted in an increase in medical debt for those for whom the system should be designed: the patients.

Not only are the insurers placing financial pressures on the physicians, hospitals, nursing homes and the many other providers of health care services, but they have also been attempting to further increase their incomes through increases in insurance premiums, deductibles, copayments, excessive prior authorization requirements, narrow provider networks, and limitations in coverage. Frequently these are applied in a manner that denies patients needed care, care that they can usually obtain if they are enrolled in a government program such as Medicare, Medicaid, VA Health if their particular program has not been overly privatized.

So what is the insurance industry offering us now? An example in the article: The physician provides medical services and bills $1000 for them. The self-insured employer pays the fee determined by MultiPlan which is only $200 of the $1000. The amount “saved” for the employer is $800 of which MultiPlan receives 7% or $56 and the insurer receives 35% or $280. A $800 balance remains which “the patient is potentially on the hook for.” Whether the patient or the physician is out the remaining $800 of the medical bill, clearly the insurers are no longer fulfilling what we consider the traditional function of insurers, yet they are leaching much of our health care dollars for worthless functions.

This is yet another intermediary strategy to extract profits. This time it focuses on out-of-network charges (those unregulated by the “No Surprises” Act). The “business model” is to add complexity via inserting extra corporate actors in a previously simpler arrangement. Just like Pharmacy Benefit Managers insert themselves between drug companies and pharmacies. They promise savings, but actually increase costs. This removes resources that should be spent on health care, and redirects them to shareholders of for-profit entities. Patients pick up the slack.

We’ve long said that it is time to get rid of the private insurers and their add-on leaches, and this development seems to make it even more of an imperative. It is high time to improve Medicare and to expand it to cover everyone as a single payer system that is equitably funded through progressive taxes.

Of the multitude of New York Times reader comments for this article the most popular was by a Canadian physician commenting on their single payer system who wrote,” The US needs to get their act together.

https://healthjusticemonitor.org…

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.

Do No Harm

Exploring Chicago’s rich history of physician activism

By Judith Weinstein
Chicago Health, April 8, 2024

The day that physician residents and fellows at Northwestern Medicine voted 794 to 148 to unionize, some shared their joy on social media.

“So proud of the community of residents and fellows who made this happen. Unions increase workers’ democratic voice; raise wages and build wealth; and improve conditions for all workers. WE DID IT,” wrote third-year resident Hebron Kelecha, MD, on X (formerly Twitter).

Northwestern Medicine’s physicians-in-training aren’t Illinois’ first group to unionize (800 residents at University of Illinois Chicago unionized in 2011), but Northwestern’s group is the largest in the Midwest, with almost 1,300 doctors.

While the idea of physicians unionizing is relatively new, activism among physicians isn’t. Physicians regularly advocate for their patients. Many operate under the Hippocratic concept of, “First, do no harm.” 

But what if the harm is coming from beyond anything the physician and patient can control, such as from the environment, structural racism, insurance companies’ denial of care, or lack of access to healthy food?

The antibiotic prescribed for a single mother’s urinary tract infection, for example, may be less important to her than finding a job that pays a living wage, securing childcare for her two children, and moving to a safer neighborhood. The hernia repair operation that a laid-off factory worker needs may be less important to him than his lack of health insurance, his need to acquire skills in order to find a new job, and his concern about making rent payments while unemployed.

That’s when a physician might switch from advocacy — working on behalf of an individual patient — to activism, which involves pushing for social and political changes that impact entire communities. Still, if physicians take an oath to do no harm, is fighting the systems that harm their patients considered activism? Or are they simply doing their job?

Twenty years ago, an issue of the American Medical Association’s Journal of Ethics focused on physician activism. In his opening letter, Editor Jeffrey Kullgren wrote, “If we are truly dedicated to improving the lives and well-being of our patients, and if we honestly care enough about the vulnerable persons that have trusted us to care for them, we have an obligation not only to provide health care of the highest quality, but also in some way, shape, or form to be active in public policy changes needed to better their lives.”

Former U.S. Surgeon General Antonia C. Novello, MD, DrPH, embodies that concept. “I loved the practice of medicine, where the focus is on individual patients, but early in my career I realized that my strongest interest is in improving the health of large population groups,” Novello said in an interview in the same Journal of Ethics issue. “I wanted to be able to do something about the major health issues facing people in this country, such as the need to increase access to healthcare for the uninsured, the need to ensure that the healthcare in this country is high-quality care, and the need to improve the health status of Americans through greater emphasis on prevention and healthy lifestyles.”

To address the issues, Novello went from the medical clinic to the political arena. Yet, for many physicians, activism — especially in the wake of Covid-19 — increasingly happens in the clinic and on the streets.

The legacy of Quentin D. Young, MD

Chicago is an epicenter of corporate and political power. It’s a city of health insurance and pharmaceutical companies, and the headquarters for many medical associations, including the American Medical Association. One of the country’s largest safety-net hospitals also calls Chicago home. John H. Stroger, Jr. Hospital (formerly known as Cook County Hospital or more commonly “County”) has attracted and shaped many physician activists, including the legendary Quentin D. Young, MD.

Young was born in 1923 on Chicago’s South Side, the son of immigrants from Eastern Europe. He attributed his activism to an early awakening to injustices far and near, including the impacts of segregation on Black people’s health. In 1981, he co-founded the Health and Medicine Policy Research Group (HMPRG) — an organization that would “uncover and challenge health inequities in Illinois.” The choice to list health before medicine in the name was deliberate.

Young believed fervently in healthcare for all — “Everyone in, nobody out!” was his mantra — achievable only through a universal-financing mechanism. Countries typically achieve universal health coverage through single-payer financing. Medicare, for example, is a form of single-payer healthcare; however, it’s not universal health coverage because not all U.S. citizens qualify for Medicare — only those age 65 and over.

The United States is the only high-income country in the world without universal health coverage. While most Americans agree that healthcare is a basic human right, how to finance such care, especially via the government, is as divisive a topic as abortion or politics. 

“For Quentin, it was a moral argument,” says Margie Schaps, HMPRG’s executive director since 1993. “He wasn’t a believer in incrementalism. If you want transformative change, small steps will not get you there. And Quentin wanted transformative change.”

The revolution did not happen in Young’s lifetime, but other generations of physicians influenced by his moral argument picked up the mantle. 

A direct descendant in the physician activist family is David Ansell, MD.  

Today’s physician activist leadership

To talk with Ansell is to receive a crash course in the social determinants of health and the industrial healthcare complex. He’s currently senior vice president for Community Health Equity at Rush University Medical Center and associate provost for Community Affairs.

Ansell went to medical school in upstate New York to “do good for people.” But when handed a stethoscope branded by Eli Lilly, he thought about leaving for forestry school. 

Unfortunately for the trees, Ansell stayed the course and upon graduation headed to Chicago with one intention: to train under Young, then-chair of medicine at Cook County Hospital.

“I came to Chicago because I was an activist, and I learned how better to be an activist,” Ansell says. 

Ansell’s 2011 book, County: Life, Death and Politics at Chicago’s Public Hospital, includes an introduction from Young and chronicles the history of Cook County and his years there.

Activism is part of the social medicine skills that Ansell and co-author Kristen Pallok, MD, describe as key in the 2022 AMA Journal of Ethics article “Should Clinicians Be Activists?” The article also explores reasons physicians may shy away from activism.

Some physicians may consider themselves apolitical, or they view any treatment as better than no treatment. Others might disagree that healthcare is a human right, or fear for their employment. And some physicians don’t think they have the time or expertise for health activism.

Ansell has never been one of those physicians. Rush University leadership tapped him after he’d spent 30 years working at Chicago’s safety net hospitals (more than half at County, the rest at Mount Sinai Hospital) to serve as its inaugural chief medical officer.

I thought, what the heck? It’s across the street,” Ansell recalls. 

The view from Rush changed his perspective entirely. 

“I understood for the first time how structural racism in health inequities were built into one street,” Ansell says. “There were two worlds, all tied to a capitalist system where White people have better insurance, and Black and Brown people are at the bottom.” 

He saw the contrast between those worlds most starkly in organ transplant patients. “In my 30 years at [Cook] County and Sinai, none of my patients ever got a life-saving organ transplant. But the organs transplanted into White patients all came from Black and Brown bodies.” 

Achieving equity

While demonstrating via sit-ins and marches can be an effective form of activism, using research to take on a system and force it to change is especially powerful. Under Ansell’s direction, Rush became one of the first hospitals in the country to establish health equity as a system strategy and measurable organizational priority.

Ansell believes that an increasing number of medical students come to Rush because of this strategy. The health equity and social justice leadership course is often oversubscribed, but medical students train across all curricula in anti-racism and health equity. 

And for Ansell, universal healthcare offers a direct path to more equitable healthcare. 

“The nature of our health system perpetuates this inequity that puts Black and Brown people at the bottom of the pile; it’s a caste system. Single-payer, or something like it, where everyone gets the same card at birth, will improve outcomes for the population,” he says, adding, “But that’s not enough.”

Physicians for a National Health Program (PNHP) advocates for universal, comprehensive single-payer national health insurance, joining with other organizations to fight racism and advance social justice. Founded in 1987 in Cambridge, Massachusetts, by Steffie Woolhandler, MD, and David Himmelstein, MD, the program moved its headquarters to Chicago in 1991. The city’s strong activist cohort that included physicians Young, Gordy Schiff, MD, and Claudia Fegan, MD, made the new home appealing.

Susan Rogers, MD, the immediate-past-president of PNHP, spent most of her clinical career as an internist at Stroger Hospital. She currently serves on the faculty of Rush University and its medical school admissions committee.

Rogers grew up in Hyde Park “which was so totally integrated, I never knew there were all-White or all-Black neighborhoods,” she says. 

In 7th grade, her mother took her and her two siblings to march with Martin Luther King, Jr., to protest school segregation. “It was then I realized how awful things were. My mother was pushing this, so I thought, this must be important.” At the brand-new Kenwood High School, as the Vietnam War was escalating, “that’s when I had a sense of using my voice to protest for change.”

As a Black student at the small western college that Rogers first attended, she “wasn’t exactly welcomed,” so she returned to Chicago to study biology at Roosevelt University. Unsure of whether she wanted to be a teacher, nurse, or doctor, she went on to graduate from medical school at the University of Illinois. 

Rogers loved being an attending at Stroger Hospital. “I went to County to take care of Black people. That is part of my activism.”

Educating doctors in activism

Now, Rogers and the Rush admissions committee look for a wide array of applicants. Some of them have volunteered locally or globally, and many are attracted to Rush because of its affiliation with Stroger Hospital. 

That said, Rogers notes the lack of Black physicians in the U.S., which correlates with the demographics of medical school applicants. Per Rogers, most applicants come from families with incomes in the top 20%, and many are children of physicians. 

Rogers attributes much of the inequality in health outcomes to income inequality and to institutionalized racism. 

“Because this country is so segregated, people don’t grow up really knowing people who did not grow up like them,” she says.

Philip Verhoef, MD, PhD, succeeded Rogers as PNHP’s president. His activism began during his training as a pediatrics resident at the University of California-Los Angeles, where he became involved with Doctors for America, a nonprofit dedicated to improving healthcare access.

Verhoef moved to Chicago to get additional training in critical care at the University of Chicago Medicine. “That is really when I became activated in the single-payer movement. PNHP was based in Chicago, and there were a lot of activists,” he says.

Now, though, Verhoef says he understands why younger physicians might avoid activism. Sometimes saddled with hundreds of thousands of dollars of debt, just starting their practices or families, they have neither time nor energy for activism. That lack of resources also applies to physicians on the front lines of inequity in emergency rooms, trauma centers, and safety-net hospitals.

While an event sparks some physicians into activism — such as the Flint, Michigan water crisis, exposed by a pediatrician — Verhoef sees himself as an educator for activists, through his role with PNHP. “Students don’t know the system they’re getting into.”

Like Ansell, Verhoef says that activism requires a certain skill set. “Let’s teach [doctors] how to be an activist, not just an advocate, because it’s part of your professional identity. 

We are at the top of the food chain, and people listen to us.” 

The medical residents and fellows at Northwestern University’s Feinberg School of Medicine experienced just how powerful their voices can be when they secured unionization. 

Verhoef says he sees clear benefits in their action. “We built many of our hospitals to function on the backs of resident labor, ripe for exploitation. Why do we work as much as we do and have no say in this process?”

Yet, he says, there’s more work ahead. “We need to start using our voices to get the healthcare we want and deserve in this country. That is our moral obligation as healthcare professionals.”

More physicians than ever, it seems, are doing exactly that.

https://chicagohealthonline.com…

May Day 2028 National Strike: Focus on Medicare for All

Prominent labor leader Shawn Fain has proposed a national strike of unionized workers four years from now, to highlight and advance the needs of workers and their families. This riveting vision will be super-charged with a focus on unified public funding of health care.

The UAW’S 2028 National Strike Should Center Medicare for All, JACOBIN, March 31, 2024, by Jonathan Michels & Will Cox

United Auto Workers president Shawn Fain has called on unions to come together for a national strike on International Workers Day, May 1, 2028. This is a radical idea – and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

Shawn Fain’s call to utilize labor power – four hundred thousand working members and six hundred thousand retirees make up the UAW alone – for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers – union and nonunion alike – willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028.

Fain frames workers as warriors locked in a struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

Of all the social reforms before the American public today, single payer is not only the most popular – a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care – it also has the potential to be the most transformative.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. It is the process of organizing and building solidarity that is much more important than the turn out for a single event, march, or rally.

In order to win public goods, the union movement will have to become a mass movement.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests – and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector – from the factory worker to the academic, from physicians to food service workers.

You need a broad social coalition and labor needs to be out front.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Comment:

By Don McCanne, M.D.

How long have we been doing this? (a long time)

How close are we to our goal? (not very close at all)

Do we anticipate a legislative solution? (not soon, but we should forge ahead anyway)

Do people want something done with our health care system?

There does seem to be wide agreement that our system is not working as it should be. Medical debt is a major problem faced not only by the uninsured but also by the insured who have difficulty paying premiums, deductibles, copayments, and disallowed charges. People frequently find that they cannot afford the care or medications they need.

People do not oppose government participation in health care since many enroll in Medicare, Medicaid, VA health, and other government programs as appropriate. Polls indicate support for publicly funded programs. Politicians promote government programs. Biden is supporting the ACA plans, and Trump is supporting government plans “better than Obamacare” though he hasn’t stated what that would be.

The point is that when the public realizes that we can have a plan that will ensure access to health care for everyone while keeping it affordable for everyone, eradicating the problem of medical debt, maybe it is time for mass public action. The JACOBIN article suggests a date of May 1, 2028 (and it is well worth reading the fairly long article in its entirety), but actually the organizing can begin right now.

Yes, there is a political divide in our nation. But the divide here is not so much left and right as it is all of us workers on all levels and the billionaires. We want health care for all the people, and, yes, we’ll include the billionaires.

https://healthjusticemonitor.org…

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.

MAGA Mike Johnson Explores Medicare for All

GOP Representative Mike Johnson, aiming to gain Dem support for his threatened position as Speaker, told a reporter he is willing to consider Medicare for All. He said that universal public insurance works well in countries with robust market economies and even conservative governments.

Embattled House Speaker Reaches Across Aisle to Dems on Health Reform, USA Wire Service, April 1, 2024, by Bir Nisan

Mike Johnson (R, LA), Speaker of the US House of Representatives, is struggling with a razor thin GOP majority and a looming vote on his leadership position due to a petition from Marjorie Tayler Greene (R, CO). He is contemplating desperate measures to garner support.

In an interview, Mr. Johnson offered a surprising reply to the question, “Are you seeking Democratic votes for your Speaker position?”

“Public perceptions of my absolute partisanship are mistaken. Of course, I vigorously advance Republican values and policies. However, when opportunities arise, I’m open to building alliances across the aisle.

“Here’s one example. My staff recently reviewed international experience with health insurance. They found that having public agencies pay for all medical care works very well in numerous nations. It saves money and is popular. All of these countries have thriving free market economic systems, and many have conservative governments.”

Rep. Pramila Jayapal (D, WA), lead sponsor for H.R. 3421, the Medicare for All Act (113 co-sponsors), expressed enthusiasm for the Speaker’s sentiment. “I’m surprised, given his past positions on health reform, not to mention on many other priority progressive issues. But if the Speaker has seen the light on this issue, we’re more than willing to work together.”

Other GOP lawmakers declined comment.

Johnson added, “As a very religious person, I believe health care is a moral imperative. They say only Nixon could undertake rapprochement with China. Well, maybe only Mike Johnson can join a cross-party coalition for Medicare for All in the US.”

Comment:

By Jim Kahn, M.D., M.P.H.

Amidst the most severe and vitriolic political divisions in memory, and a historically intense presidential election campaign, this report is eye-catching, even shocking.

Could it be that the Speaker, to this point a stalwart opponent of Democratic (let alone progressive) legislation, is offering an olive branch on comprehensive insurance reform? Has his staff done their homework and convinced him of what we in the single payer movement have been saying for years? That is, that single payer allows us to achieve the moral goal of universal access to health insurance, within the context of (and strengthening) a robust market economy?

It feels like a dream.

Well, yes, it is a dream. An April Fool’s fantasy.

Sorry my friends. Maybe someday this story, or one like it, will come true.

Meantime, let’s focus on strengthening the role of Democrats, and progressives in particular, in Washington DC and across the nation. And continue our quest for generous, efficient, people-oriented health insurance – single payer.

https://healthjusticemonitor.org…

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.

The UAW’s 2028 National Strike Should Center Medicare for All

United Auto Workers president Shawn Fain has called on unions to come together for a national strike in 2028. This is a radical idea — and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

By Jonathan Michels and Will Cox
Jacobin, March 31, 2024

Fresh off their historic labor victory against the country’s Big Three automakers, the United Auto Workers (UAW) are laying the groundwork for workers across multiple sectors to join them in a general strike on International Workers Day, May 1, 2028.

UAW president Shawn Fain’s call to utilize labor power — four hundred thousand working members and six hundred thousand retirees make up the UAW alone — for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers — union and nonunion alike — willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A New Opening for Militancy

Roderick Jaynes hurriedly inspects his welding work as another massive slab of steel shuttles toward him on the production line. Jaynes grips the welding gun to secure pieces of galvanized metal underneath the slab.

A shower of welding sparks lights up around the autoworker, only to dissipate against his heavy leather jacket. Jaynes sucks in a mouthful of purified air circulating inside his helmet, which prevents him from breathing in toxic weld smoke.

The voltage on the welding guns is turned up high so that they burn hot and fast, allowing him to keep pace with the quick tempo of the production line. The goal is to do the job right but also quickly, so you don’t cause the rest of your team to fall behind.

The kind of solidarity displayed on the assembly line must be replicated at the bargaining table as UAW workers at Daimler Truck North America (DTNA) gear up for a contract battle, which includes the possibility of a strike. With a looming contract expiration on April 26, contentious negotiations are already underway, pitting Daimler Truck against seven thousand plant workers throughout Georgia, North Carolina, and Tennessee. On March 8, 96 percent of UAW workers across DTNA voted to give their leadership the ability to call a strike when the contract expires, if necessary.

Daimler Truck posted record-high revenues of $60.3 billion in 2023, an increase of 10 percent compared to the previous year. UAW members who work at DTNA, meanwhile, say they are beaten down by stagnant wages, increased cost-of-living expenses, and a demoralizing work environment.

The focus of the UAW leadership on eliminating tiered contracts, organizing nonunion auto plants, and inciting workers to understand that the union’s struggle is part of a larger class struggle would have been unthinkable several years ago, when the union was mired by corruption at the highest levels. Fain’s class-war rhetoric evokes the radical strains of the UAW that animated the labor upsurge of the 1930s and 1940s. Even if this revived militancy is not uniform across all of the union’s locals, the sharp turn has ignited energy among many rank-and-file members like Jaynes, a UAW member and production worker at a DTNA plant in North Carolina.

Jaynes hopes union negotiators will align their contract to enable them to participate in the unified May Day contract expiration in 2028 outlined by Fain. Calling for a strike is not to be taken lightly. Strikes are won when they have overwhelming support from the workers who have the most at stake. The ability to move hugely profitable products — in this case, cars, trucks, and buses — along with the power to stop production and shut down assembly and parts plants, into which corporations like Daimler Truck invest massive amounts of money, puts autoworkers in a unique position to make demands from capital.

“Workers in heavy industry have tremendous power to twist capitalists’ arms,” Jaynes told Jacobin.

“Auto, steel, rubber, aerospace, military defense production, oil have always played a really key role in the labor movement, and that remains true today, despite changes in the global economy,” he said. “I think that that was really hammered home for a lot of people after the [2023] UAW strike, when people said, ‘Holy shit, autoworkers really have power!’”

From Rights on Paper to Rights in Action

Most of the credit for turning the union around has been heaped upon Fain, but his ascent to the UAW presidency represented a decisive victory for rank-and-file members who have been fighting for years for a more democratic, more militant approach within the union. In the wake of a protracted federal corruption probe that sent two UAW presidents to jail, UAW members voted in 2021 by an overwhelming margin to adopt a “one member, one vote” method for selecting their leadership — a development that paved the way for the election of a new reform leadership, headed by Fain, in late 2022 and early 2023.

These victories were made possible, in part, by the efforts of a newly formed reform caucus within the union, Unite All Workers for Democracy (UAWD). One problematic aspect of this process, it’s worth adding, is that it involved the direct involvement of the state into the affairs of the UAW; it was a federal consent decree stemming from the government’s probe into corruption within the union that led to the referendum vote for “one member, one vote.”

The shakeup in the UAW set the stage for the UAW’s militant “stand-up” strike in 2023 against the Big Three (Ford, General Motors, and Stellantis) and fueled the union’s subsequent campaign to organize autoworkers at nonunion workplaces. That effort is already paying off. The UAW recently announced that ten thousand autoworkers signed union cards at thirteen worksites, including a majority of workers at two plants in the heart of the anti-union South.

The stand-up strike showed that labor still has the power to force concessions from management. More importantly, the labor campaign provided an example of a rank-and-file movement that can link its struggle to the larger political economy.

“This new union leadership has created a new opening to building a labor movement that is more militant but also, taking that a step further, that can bring up political demands,” Jaynes said. “The significance of Fain’s call to align contracts is that they are thinking along these lines.”

There is a lot at stake for workers on the line in an actual strike. Strike threats that arise from within the labor movement are often made to achieve strategic goals. For example, Sara Nelson, international president of the Association of Flight Attendants–CWA, called for workers to discuss the possibility of a general strike to end the government shutdown in 2019.

Outside the labor movement, there are periodically well-meaning calls for a general strike. However, as Joe Burns points out, the recent “dizzying number” of calls for a general strike mostly emanate from social media and are primarily issued by activists disconnected from unions and workers.

But Fain and the UAW, riding a wave of goodwill from the 2023 strike, appear poised to revive a fighting spirit among workers not seen since its early days as a militant union. Just a little over a year after the UAW’s founding, autoworkers in Flint, Michigan, staged a sit-down strike in late 1936 and early 1937. Known as the “strike heard ‘round the world,” the action grew the UAW membership rolls from 88,000 members to 400,000 within a year and helped transform labor in America into a fighting force capable of bringing capital to its knees.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028. Although this type of solidarity among unions is a tall order, “there is an actual game plan laid out that could lead to a general strike on May 1, 2028,” said Barry Eidlin, an associate professor of sociology at McGill University in Montreal.

“That is far different from the usual just sort of posting up on some telephone poles and . . . issuing some call on Twitter for a general strike and expecting people to do that,” Eidlin said.

In numerous speeches, Fain frames workers as warriors locked in struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

“We have the right to strike,” Fain told UAW delegates in 2023. “We have the right to arbitration, to collective bargaining. But we have not yet won the rights that will fundamentally change this union and change this country.”

“We’ve not yet won racial and economic justice in the workplace for all of our members,” he said. “We’ve not yet won retirement security and health care and pensions for all.”

Labor movements coalesce around common interests. Likewise, public goods like Medicare for All are capable of uniting the public across the political spectrum. Of all the social reforms before the American public today, single payer is not only the most popular — a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care — it also has the potential to be the most transformative.

Authors Beatrice Adler-Bolton and Artie Vierkant point out that health is one of the pillars underlying the entire structure of our political economy, and yet there is a contradictory relationship between health and labor under capitalism. “Capitalism has defined ‘health’ itself as a capacity to submit oneself to labor,” note Adler-Bolton and Vierkant in their book Health Communism.

To directly confront the health economy is to take on capitalism itself. On the one hand, a national health program is merely a needed social reform that is commonplace in other wealthy countries. On the other hand, conservative forces in the United States correctly understand single payer’s revolutionary potential, as evidenced by their decades-long opposition against its passage.

Fain is already connecting autoworkers to the larger class struggle, because he understands the accumulation of wealth in our economy rests on the shoulders of American labor.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

The UAW’s clarion call for class struggle should resonate with single-payer supporters, who face tremendous opposition from entrenched, well-financed private interests that stand in the way of transformational change. Instead of the Big Three automakers, the single-payer movement must slay the hydra of American capital, including private health insurers, Big Pharma, hospitals, private equity firms, and interest groups such as the American Medical Association.

Even if a general strike fails to materialize in 2028, connecting the autoworkers’ struggle to broader social movements is a roadmap for the single-payer movement if it wants to build the kind of power that can help it win. All of the traditional avenues — relying on electoral politics, reasoning with the boss, lobbying legislators — have proven to be dead ends because they fail to confront the imbalance of power head on.

Medicare for All Is Freedom

Backaches. Knee pain. Burnt flesh from hot metal slag. UAW workers know all too well that assembly work is dangerous and wreaks havoc on the body.

“It’s part of the nature of the work of being an industrial worker,” Jaynes offered. “If you’re not looking out for yourself, if you’re not wearing the proper PPE [personal protective equipment], knee pads, you’re gonna fuck up your body.”

Jaynes regularly engages in physical conditioning at home to avoid greater injury on the job. Nevertheless, he shrugged off the idea that risk to life and limb was out of the ordinary.

“There’s an understanding that we deserve to be fairly compensated for that work and for the hazards to our health,” he said, “and conditions need to be improved where they can be improved, and yeah, we need good health care.”

Few issues have as much potential as health care to unite the American working class in a common struggle. The reason public goods appeal to working people is that they are based around meeting human needs and not profits. Medicare for All, for instance, would guarantee workers health care no matter what happens to their jobs.

Health care costs are a drain on workers’ take-home pay, even for those fortunate enough to have employer-provided insurance. In 2023, workers paid an average premium of $8,435 for individual coverage through their employer and a whopping $23,968 just to cover their family, according to a survey conducted by the Kaiser Family Foundation. While workers’ wages fail to keep up with inflation, health care corporations continue to rake in billions.

Nonunionized workers are particularly vulnerable to layoffs and poor working conditions, but health care is precarious even among organized workers. When your health care depends on your job, your employer literally has the coercive power of life and death. Apart from a paycheck, the tie that binds most workers to their jobs today is their health benefits.

Medicare for All would cut the cord.

Under a single-payer system, health care would be free at the point of service. Premiums, deductibles, and copayments would be eliminated. Everyone would have the same health coverage, including the foreman, the CEO, the person working next to them on the assembly line, and even their recently retired coworker.

With health care no longer tied to employment, workers would be emboldened to leave their jobs or stay and agitate for a union. Self-employed workers such as writers and artists could focus on their craft and less on scraping together part-time gigs to pay for their medical bills.

In Canada and other Western countries with universal health programs, the public is at least protected from the threat of losing their medical benefits. For Canadian workers, single payer is like the ultimate strike fund.

“The basics are all covered in terms of hospital care, physician care, specialty care, all that stuff is covered,” said Eidlin, who is based in Canada. “So for [Canadian] unions, that stuff is not stuff that they have to bargain about at the negotiating table. They can bargain for other things.”

With health care off the table under a single-payer system, unions are free to devote more energy to bargaining for things like increased staffing, worker safety, and better wages.

Not so in the United States, where our dysfunctional, multitiered health system requires unions to commit resources toward maintaining hard-won private welfare states through the provision of basic health benefits for their members.

Consequently, health and safety have been catalysts for the overwhelming majority of American labor struggles. Among the many issues that touched off the Flint sit-down strike of 1936–37 was the horrific wave of autoworker deaths from heat exposure just months earlier. This concern for health and safety was reiterated following the strike at the first national convention of the Congress of Industrial Organizations (CIO) in 1938, when UAW president Walter Reuther, along with other leaders in the CIO, called for a national health insurance program.

We can look to the West Virginia teachers’ strike over health insurance or the widespread labor uprisings fueled by the COVID-19 pandemic as recent examples. Even large unions like the UAW, Teamsters, and the United Mine Workers of America have historically been forced to include private health plans as just another bargaining chip in lieu of competing demands, including national health insurance.

When employees depend on the employer to absorb the cost of medical care, they are playing a rigged game.

History shows that transformative social change will not be won without significant upheaval in workplaces, said Ed Bruno, former director of the United Electrical Radio and Machine Workers of America, and past Southern director for National Nurses United.

“Just think back again about the civil rights movement or the rise of industrial unions or the rise of public sector unions in the states that have collective bargaining,” Bruno said in 2019 amid the Southern Workers Assembly’s campaign to use Medicare for All as a vehicle to organize workers at nonunionized workplaces.

“You’re talking about strikes, sit-downs, sit-down strikes, mass picketing — all of which were illegal. When we think about winning Medicare for All, to think about that divorced from a significant level of action in the workplaces and in communities . . . it’s crazy.”

Labor Is the Missing Piece

Despite national health insurance enjoying broad popular support for almost a century in the United States, a mass movement of millions willing to join together in struggle has so far failed to materialize. Though the connections between labor and national health insurance are plentiful, the single-payer movement is rife with missed opportunities stemming, in part, from an insufficient level of coordination among advocates and workers strong enough to beat back the private forces bent on destroying the so-called lost reform.

The current strategy is primarily focused on legislative efforts, which the history of the single-payer movement shows are unable to match the ability of a powerful grassroots rank-and-file movement to not only mediate conditions on the shop floor but also transform social relations outside the workplace. Parts of a winning coalition operate today, but the critical missing piece to win social reforms is collective power with rank-and-file leadership.

Class struggle is broader than the workplace. It was workers’ “self-emancipation” that won child labor laws, the eight-hour workday, unemployment compensation, Medicare/Medicaid, and workplace health and safety standards. Unlike the majority of wealthy countries, the United States doesn’t have a national health program — a deadly exceptionalism that correlates to American unions’ failure to mobilize workers.

Fain’s call for a militant, national strike in 2028 that connects the UAW’s demands to a broader class perspective represents a clear opportunity to reorient the single-payer movement.

Workplace injuries and deaths in the early twentieth century were endemic and often catalysts for labor uprisings. Protections against worker illness and financial ruin and, later, compulsory health insurance netted support from a cross section of the public, including women suffragists and socialists, along with academics advocating for social welfare reforms.

The movement for national health insurance really picked up steam after World War II, as the UAW and other unions carried forward a sense of renewed concern about social welfare that grew out of the Great Depression. Following labor’s lead and two-thirds of the public, President Harry Truman felt compelled to make “health security for all” a top priority.

Legislation to secure universal health care ultimately stalled in Congress, succumbing to a neoliberal onslaught led by the American Medical Association (AMA). The AMA weaponized respectability by enlisting physicians in a multimillion-dollar smear campaign.

Simultaneously, the conservative bureaucratization of the nation’s large unions severed them from the type of rank-and-file struggles that secured broad social programs prior to the late 1940s. As a result, the weakening of the Left’s ability to mobilize grassroots support for national health insurance quickened the demise of Truman’s proposed legislation by 1950.

“Labor leaders and policy intellectuals believed they could make change from within the system and so did not need the organized activity of union members to back up their efforts,” wrote Beatrix Hoffman, a professor of history at Northern Illinois University. “The lack of rank-and-file participation greatly weakened the cause of union-led health reform as it became associated with ‘labor bosses’ rather than ordinary workers.”

Around the time that Ohio senator Robert A. Taft proclaimed Truman’s health proposal “the most socialistic measure that this Congress has ever had before it,” the lawmaker was putting the finishing touches on a bill that would become the Taft-Hartley Act. The legislation used anti-communist hysteria and witch hunts to gut the unions of many of their progressive rank-and-file leaders, stem the labor tide, and empower private industry to claw back some of the social and economic gains that workers fought for and won during the 1930s and 1940s.

Due to myriad factors, including red-baiting and anti-union legislation that purged the most radical elements of the labor movement, unions shifted their focus away from winning universal social goods. Labor’s pivot toward creating private welfare states for a shrinking portion of the working class hobbled the fight for a national health program in the decades to come.

As labor historian Alan Derickson has noted, “Health security for some thus precluded the possibility of health security for all.”

The fight to secure medical coverage for the elderly during the 1960s presented opportunities for unions to focus renewed attention on social concerns. Under pressure to contain the ballooning costs of retiree health benefits, workers under the UAW and other unions linked arms with civil rights and anti-poverty activists and seniors to secure the passage of Medicare and Medicaid in 1965 over the virulent opposition of the AMA and hospitals.

For most of the last fifty years, the weakness of US labor could be characterized as a narrowing of vision at best and, at worst, collaborationism. By the 1980s, the UAW conceded previous contract wins and settled for labor gains limited to its members rather than connecting their struggle to the broader concerns of the working class.

The inspiring yet short-lived Labor Party of the 1990s challenged the calcified labor movement to leverage its power in the class struggle. The Labor Party platform explicitly called for a national health program and expanded workplace rights. Visionary cofounder Tony Mazzocchi, referring to the universality of single payer, is sometimes credited within the single-payer movement for coining the oft-repeated slogan “everybody in, nobody out.”

Unfortunately, the US struggle for transformative social programs has been marked by means-tested poverty programs that contribute to the abandonment of public goods such as a national health program. Big business, desperate to avoid the overwhelmingly popular Medicare for All, colluded with corporate foot soldiers within the Democratic Party in 2010 to ram through the Affordable Care Act (ACA), a divisive, multitiered poverty program, and portray it as a victory for workers.

Any health care is better than none, but the ACA is analogous to a labor concession contract written by the boss. The limited poverty program further entrenches private insurance, and by linking Medicaid eligibility to state-administered means testing, the ACA deepens class divisions among the public — all while extracting profits from taxpayers.

Barring a few notable exceptions like National Nurses United and the United Electrical, Radio, and Machine Workers of America (UE), support for Medicare for All among the leadership of the country’s largest unions today is mostly relegated to endorsements instead of organizing a supermajority of members to join the cause.

“[Single payer] hasn’t been on the table in fifteen years now,” cautioned Eidlin. “You’re not going to get any kind of groundswell of support for Medicare for All or any other broader social vision unless and until you start putting it back on the table as an item for political debate.”

“Stand Up” for Single Payer

Despite Fain’s class-war rhetoric clearly invigorating both unionized and nonunionized workers, no other unions to date have publicly answered the call to join the UAW on the picket line on May Day, 2028. External threats against organized labor loom over the next four years, from the possibility of a second Donald Trump administration to legal attempts by corporate America to gut the National Labor Relations Act (NLRA).

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. One-off events often fail to build collective power. Rather, it is the process of organizing and building solidarity that is much more important than the turnout for a single event, march, or rally.

The questions at hand are: Will UAW workers see their struggle as part of a wider working-class conflict and reconnect with movements for broad social programs like Medicare for All? And will single-payer supporters link their struggle to them?

Organized labor is the strongest engine of a movement, but there are also inherent contradictions among union leadership who, against workers’ interests, pay fealty to the political oligarchy.

President Joe Biden ran in 2020 on an anti-single-payer platform. He even pledged to veto any Medicare for All legislation that crossed his desk. The UAW’s recent endorsement of Biden makes it clear there is a need for continued class struggle inside and outside the union.

The outcome of the union contract battle at DTNA in North Carolina could be a bellwether for how widespread the call for militant class struggle extends among rank-and-file UAW workers. This, in turn, might help determine whether the auto union is willing to step to the front of social movements, be it on the shop floor or in the community.

It will take more than inspiring rhetoric from labor officials to convince the public that the UAW and other unions are serious about linking their struggles to broader social concerns, and to motivate people to join workers in the fight.

“It is not enough [for the UAW to] sign their names to support Medicare for All,” Jaynes said. “There’s a tendency a lot of times in unions for the leadership to, you know, have lofty political ideas and . . . they’ll pass some resolutions at conventions, but there’s in many cases not enough efforts to mobilize the rank and file, organize the rank and file, and provide political education for people.”

“In order to win public goods, the union movement will have to become a mass movement,” he said.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests — and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector — from the factory worker to the academic, from physicians to food service workers.

Health policy alone does not hold the answer for how to win transformative social change. It is only an indicator of what a movement is able to leverage to win these programs.

“It’s not like we don’t know how to do these policies,” said Eidlin. “It’s really a matter of generating the political force necessary to get these policies in action. You need a broad social coalition and labor needs to be out front.”

Single-payer supporters should link up with rank-and-file campaigns even when they are not specifically focused around Medicare for All. This is not a call for single-payer supporters to show up uninvited, but instead to look to rank-and-file leadership and to actively join their campaigns.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Jonathan Michels is an independent journalist and heath care worker based in Atlanta, Georgia, and a national board member of Physicians for a National Health Program.

Will Cox is a current member of the Southern Workers Assembly and former staff organizer with the National Nurses Organizing Committee.

https://jacobin.com…

In Health Care, Fake Good News Beats Disaster

The Affordable Care Act is far from perfect, we hear again. That’s true. But health insurance with the GOP in power would be far worse, and would cut off the potential for truly effective comprehensive health care financing reform.

A Tsunami of Fake Good News, Healing and Stealing, March 23, 2024, by John Canham-Clyne

Really, the ACA is getting us there! Just give us 500 years!

Since the ACA passed in 2010, the percentage of American adults who have health insurance that actually protects them from financial ruin has barely changed. According to biennial Commonwealth Fund surveys, the percentage of U.S. adults who are insured all year but who aren’t underinsured only grew from 56% to 57% between 2010 and 2022. That pace leads to everyone in the U.S. being fully insured in around 500 years.

The number of people who have been kicked off Medicaid over the past year far outstrips the year-to-year increase of roughly 5 million people enrolled in private Obamacare exchange plans.

It’s also true that several million fewer people were uninsured in 2023 than 2014, so we can expect to hear phrases like “the national uninsured rate reached an all-time low” nearly as often as “record ACA enrollment” for the rest of the year. At the same time, the ACA’s failure to control costs has driven deductibles, copays and coinsurance to record heights in employer-sponsored health insurance, Medicare and many of the ACA exchange plans. This dramatic increase in the number of people who are underinsured largely cancels the gains from the reduction in the uninsured rate.

In the end, what matters about health insurance is whether or not it allows people to get the health care they need. The number of adults ages 19-64 who report skipping at least one of four different types of health care due to cost in the past year is higher now than it was when Obama signed the ACA in 2010. (The four types skipped: 1) Didn’t see Doc for problem, 2) Didn’t fill Rx, 3) Skipped test/treatment/FU, 4) Didn’t get specialist care.)

The weakness of Biden’s opponent can’t turn the ACA into a credibly successful law. Fourteen years after passage, more adults than ever before are skipping treatment or prescriptions because of cost, even though we still spend twice as much as other wealthy nations on “healthcare.” That won’t stop the tsunami of fake good news from washing over us for the next 8 months.

Comment:

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

Maybe the timing doesn’t seem right to talk about the lack of success of the Affordable Care Act just before the presidential elections, but actually the timing probably couldn’t be better.

First of all, ACA has been effective in maintaining a modest level of health care coverage, even if overpriced and inadequate. Biden’s opponent has offered an alternative that is far worse: no standards for fair or good insurance, and likely for most Americans a Hobbesian choice: catastrophic insurance that fails to fund ongoing needs, or a largely self-funded health savings account that would run out when medical catastrophe hits. Voters must realize that we need to elect a Democratic President and a Congress composed of Representatives and Senators with progressive views if we expect to replace our current dysfunctional financing system with one that will work for all of us: a single payer, improved Medicare for All program.

Sure, we don’t want to be taken in by a good guy with fake good news. But it would be far worse to yield to the phony guy with the hidden horrendous news. It is crucial that we, the public, understand what is going on, and (at the risk of repeating ourselves) elect leaders accordingly. A system that will provide all of us access to comprehensive, high quality health care, that each of us can afford through progressive public financing, is exactly what we should be aiming for, and election time is when we have the greatest control over that. Let’s not settle for mediocrity for the next 500 years. Let’s go for the real thing now!

https://healthjusticemonitor.org…

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.