PNHP

Private Equity Hospital Purchase Raises Risks for Patients

Private Equity Hospital Purchase Raises Risks for Patients

A new study in JAMA of 5 million hospitalizations over 10 years at 300 US hospitals found that private equity acquisition was associated with a 25% rise in serious adverse clinical events, likely due to fewer employees. Private equity strategies in health put patients at risk.

Serious Medical Errors Rose After Private Equity Firms Bought Hospitals, The New York Times, December 26, 2023, by Reed Abelson and Margot Sanger-Katz

The rate of serious medical complications increased in hospitals after they were purchased by private equity investment firms.

The study, published in JAMA, found that, in the three years after a private equity firm bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.

“This is a big deal because it’s the first piece of data that I think pretty strongly suggests that there is a quality problem when private equity takes over,” said Dr. Ashish Jha, the dean of Brown University School of Public Health, who has studied hospital safety extensively.

Over the last two decades, private equity firms have become major players in health care, purchasing not just hospitals but also a growing number of nursing homes, physician practices and home health care companies. The firms pool money from institutional investors and individuals to form investment funds, often buying hospitals and other entities through high levels of debt, with an eye to reselling them in a few years.

Several media reports have shown that some of the acquired hospitals have been forced to close because of financial distress, and some have come under regulatory scrutiny for quality problems.

The researchers examined a range of errors that Medicare tracks. All of the eight individual measures studied in the paper worsened in the hospitals purchased by private equity funds.

“They are preventable adverse events that everyone thinks shouldn’t happen in hospitals,” said Dr. David Blumenthal, the former president of the Commonwealth Fund.

The researchers said the most likely explanation for the increased errors was fewer hospital employees.

Changes in Hospital Adverse Events and Patient Outcomes Associated with Private Equity Acquisition, December 26, 2023, JAMA, by Sneha Kannan, Joseph Dov Bruch and Zirui Song

Key Points:

Question: How do quality of care and patient outcomes change after private equity acquisition of hospitals?

Findings: In a difference-in-differences examination of 662 095 hospitalizations at 51 private equity–acquired hospitals and 4 160 720 hospitalizations at 259 matched control hospitals [from 2009-2019] using 100% Medicare Part A claims data, private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections.

Meaning: Private equity acquisition of hospitals, on average, was associated with increased hospital-acquired adverse events despite a likely lower-risk pool of admitted Medicare beneficiaries, suggesting poorer quality of inpatient care.

Comment:

By Don McCanne, M.D.

Haven’t we heard enough? Study after study has shown that when private equity, with its primary mission of creating wealth for its investors, takes control of sectors of health care, our costs of health care increase and our access and quality of health care outcomes deteriorate. Meanwhile, other studies demonstrate that a well-designed single payer system would not only control costs and improve outcomes, but would make health care equitably accessible for everyone.

Why do we give our health care dollars to billionaires for their own personal enrichment while we tolerate mediocrity and worse in our health care system – when we could take those same health care dollars and spend them much more efficiently in creating a health care nirvana for all of us? It is true that it will require a legislative solution, but the legislators must understand that that is the demand of their constituents. Isn’t it?

Editor: Happy New Year. Next post will be the 2023 summary.

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Thoughts & Prayers Do Not Protect Our Children

Unintentional firearm deaths require action. This is an especially appropriate reminder during the holiday season, with its focus on family.

Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0-17 Years – National Violent Death Reporting System, United States, 2003-2021, CDC, December 15, 2023

Summary:

What is already known about this topic?

Unintentional injury is a leading cause of death among U.S. children and adolescents aged 0-17 years, and firearms are a leading injury method.

What is added by this report?

Approximately one half of unintentional firearm injury deaths among children and adolescents occurred at their home; playing with or showing the firearm to another person was the most common precipitation. Overall, firearms used in unintentional injury deaths were often stored both loaded and unlocked and were commonly accessed from nightstands and other sleeping areas.

What are the implications for public health practice?

Unintentional firearm injury deaths are preventable. (Bold by HJM) Securing firearms (e.g., locked, unloaded, and separate from ammunition) is protective against unintentional firearm injury deaths among children and adolescents, underscoring the importance of promoting secure firearm storage.

MOTHERS FOR DEMOCRACY, Thoughts & Prayers are NOT Enough, A one-minute video, December 14, 2023

Also viewable on the Mothers for Democracy website (may need to scroll down)

Comment:

By Don McCanne, M.D.

This video has gone viral, and it is easy to understand why: thoughts and prayers are meaningless when we can do something about the number one killer of children in the United States!

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Largest ACO Program Saves Piddling Amounts for Medicare

A new analysis finds that that MSSP, the oldest and largest Medicare accountable care organization (ACO) program, has lost money for individuals it covers and overall for Medicare saves just 75¢ per $1000.

Estimated Savings From the Medicare Shared Savings Program, JAMA Health Forum, Dec. 15, 2023, by Andrew M. Ryan & Adam A. Markovitz

The Medicare Shared Savings Program (MSSP) was launched in 2012 to improve efficiency and generate financial savings for the Centers for Medicare & Medicaid Services (CMS). Under the program, voluntarily constituted accountable care organizations (ACOs)—groups of clinicians, hospitals, and other institutional participants—face accountability for the total costs of care received by traditional Medicare beneficiaries. If medical spending is below a specific target (benchmark), ACOs are eligible for financial bonuses. For CMS to break even or achieve net savings for traditional Medicare beneficiaries in the MSSP, gross reductions in medical spending must equal or exceed the sum of bonus payments paid to ACOs.

Results: The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to Medicare Advantage benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of … 0.075% of combined spending.

Comment:

By Kip Sullivan, J.D. and Jim Kahn, M.D., M.P.H.

The Physician Group Practice Demonstration, which was conducted by the Centers for Medicare and Medicaid Services (CMS) between 2005 and 2010, was the first test of the “accountable care organization” (ACO) concept. It failed: The ACOs cut traditional Medicare spending by a mere 3 tenths of a percent, and those teensy savings would have been losses if the evaluation had taken diagnostic upcoding and participation bias into account.

Despite the failure of this first ACO experiment, Congress inserted into the Affordable Care Act (ACA) provisions authorizing CMS to establish more ACO demonstrations within the traditional Medicare program, as well as a permanent ACO program known as the Medicare Shared Savings Program (MSSP). We reported in 2022 that the CMS ACO programs, including MSSP, were not working: they had saved or lost just a few tenths of a percent between 2012 and 2018.

This new analysis confirms the earlier studies we reviewed. The authors reported that bonuses CMS paid to the ACOs exceeded the gross savings some of them achieved, for a net loss of between $584 million and $1.4 billion over the 2013-2021 period. These are large sums of money, but represent only a few tenths of a percent of total spending for those ACO enrollees. Due to patient, physician, and organization participation bias, the actual net loss may be greater.

The analysis also examined the effect of the MSSP’s financial performance on Medicare Advantage (MA) costs. MA monthly capitation (premium) rates are calculated in part based on traditional Medicare costs. Thus, gross MSSP savings reduce MA capitation levels. (The provider bonuses which create MSSP net losses affect geographic adjustments but not overall MA capitation, per CMS rules.) The authors’ estimated savings to MA are larger than the MSSP’s loss to traditional Medicare, resulting in net savings for the entire Medicare program of $4-5 billion over 9 years, or $500 million per year. Again, sounds like a huge amount of money. But it represents less than 1/1000th of Medicare spending for the relevant time period; just 75 pennies per $1000 in program cost.

So, will MSSP (and ACOs generally) be a significant way to control Medicare costs? No, evidently not. And, as we’ve reported previously, the Medicare Advantage program is overcharging CMS by at least $100 billion per year – that’s about 200 times higher than MSSP savings. ACO REACH is even worse, inserting contractors between CMS and medical providers, creating more incentives to deny care.

Fiddling with payment incentive programs is not a real solution for our extravagantly expensive medical costs. Single payer is the real solution, combining efficiency with universal access.

Kip Sullivan is a member of the Health Care for All Minnesota policy committee.

Jim Kahn is an emeritus professor at UCSF and editor of HJM.

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Medicare Advantage Under-Performance

A commentary on Medicare Advantage in a high-profile medical journal delicately discusses issues with MA performance. We believe the evidence warrants a much more critical stance. We need not accept the inevitability of Medicare capture by under-performing private insurance.

The Predominance of Medicare Advantage, New England Journal of Medicine, December 14, 2023, by Gretchen Jacobson and David Blumenthal

If current trends persist, more than half the 66 million beneficiaries of Medicare will be enrolled in Medicare Advantage plans in 2023. This constitutes a historic milestone in the evolution of a unique federal program that has profoundly benefited older and disabled Americans and deeply influenced the evolution of our health care system. When President Lyndon Johnson and his congressional allies secured the enactment of Medicare in 1965, it is safe to say they never imagined that most eligible Americans would be enrolled in the types of payment and service arrangements that Medicare Advantage offers, rather than the traditional fee-for-service system. The anticipated predominance of Medicare Advantage raises obvious questions about why it has developed, what it means for the quality and cost of care available to Medicare beneficiaries, and what it means for our health care system as a whole.

Comment:

By Ana Malinow, M.D. and David Leibowitz, M.D.

This article on Medicare Advantage (MA) will be read by thousands of physicians, many of whom have not yet grasped how MA exerts a major influence over the practice of medicine and patient care. For this reason, a health policy report published in the NEJM is important. Sadly, the Journal has opted to platform an article that glosses over the profound problems with the entire concept of MA. We list a few here.

Unlike MA, traditional Medicare does not employ prior authorization except under very limited circumstances. The article mentions that “most [MA plans] require beneficiaries to receive a referral or other authorization as a condition for covering the costs of specialized or complex care.” It would be more accurate to state that “nearly all” MA plans require beneficiaries to receive prior authorization, given that 99% of beneficiaries in MA are in plans that require prior authorization for some services. Prior authorization determines access to care, which the article declares “seems to be similar in MA and traditional Medicare… Patient and physician complaints about denials of care as a result of the prior-authorization requirements of MA plans seem to have increased in recent years, but there are only limited data on rates of denials.”

Data on denials and access to care are not limited. A 2022 study from the Office of Inspector General shows 13% of denied prior authorization claims are inappropriately denied by MA plans, services that would have been covered had the beneficiary been on traditional Medicare. Further, 18% of denied payment requests were inappropriately denied by MA plans. Three large MA companies are being sued for inappropriately using AI to systematically deny care. Hospitals across the country are dropping MA, because, as one hospital executive confirmed, these plans “pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

How MA is paid is important, and the article discussed this at length. In addition to benchmarks and bids, the authors write “Payments to plans are further adjusted for two factors: quality of care and the health status (risk) of enrollees… Plans with higher star ratings are provided higher benchmarks against which to bid and receive a larger share of the difference between their bid and benchmark, which results in larger rebates. In 2023, 51% of plans were rated 4 stars or better.”

What the article does not discuss is how meaningless star quality ratings are. When over half of the plans score 4 stars of more, you wonder about the Lake Wobegon effect, where “all the women are strong, all the men are good-looking, and all the children are above average.” The Medicare Payment Advisory Commission (MedPAC), the federal agency that advises Congress on Medicare, is clear in its condemnation of the stars. In its 2023 Status Report to Congress, MedPAC stated that “quality in Medicare Advantage cannot be meaningfully evaluated” using the current star program. Despite its limitations, the quality bonus program accounts for more than $15 billion in annual payments to MA plans. In 2022, the NEJM published a series of articles by Lisa Rosenbaum explaining why the concept of quality measurement is questionable at best, if not totally useless.

Because star quality ratings fail to measure quality of care, especially for beneficiaries with serious and complex illness, the statement “[t]he quality of care in Medicare Advantage as compared with traditional Medicare seems to be equivalent or better, on the whole, and some evidence shows that Medicare Advantage has reduced disparities in quality in some parts of the country” does not withstand scrutiny. MA plans cover fewer cancer centers of excellence, MA beneficiaries are preferentially admitted to lower quality skilled nursing facilities, and MA beneficiaries in the last year of life, in poorer health or who belong to a racial or ethnic minorities are substantially more likely to disenroll and join traditional Medicare. Finally, when properly adjusted for risk selection and upcoding, MA is equivalent or worse than traditional Medicare on key quality metrics.

The third and major factor to plan payment is risk adjustment, which the authors dismiss by stating, “In fact, controversy rages over whether plans engage systematically in “upcoding” — the recording of diagnoses that are not expected to require treatment or that may be exaggerated or even fabricated.”

There is no controversy about whether plans engage in upcoding. Multiple publications, from the New York Times, in a highly critical expose of the MA industry, which they dubbed the “insatiable cash monster,” to Physicians for National Health Program, to MedPAC, have reported on the prevalence of upcoding and associated costs. In the 2023 status report, MedPAC reported that in two years, 2022 and 2023, MA “coding intensity” generated $44 billion of tax-payer dollars for the plans.

The authors supply the reader with assumptions of “may” and “seems” that would not otherwise be tolerated by NEJM. For example, that “Innovative care-delivery systems, care coordination, and comfort with managed care may also be driving some MA enrollment” or that “These systems may also enable plans to coordinate care.” There is no evidence for these statements, so why include them?  “Current beneficiaries are also more familiar with managed care and may be more comfortable with such arrangements than previous generations.” Why conflate familiarity with desire?

Further assumptions are found in the statement that “Another factor in the growth of MA may be obstacles to disenrollment. Beneficiaries who switch from Medicare Advantage to traditional Medicare may find that insurers that offer Medigap plans charge higher premiums for preexisting conditions or refuse to cover them at all.”

The facts are clear. Under federal law, newly Medicare-eligible enrollees have a 6-month “Medigap Open Enrollment” period, when they can purchase any Medigap policy without medical underwriting, meaning the enrollee cannot be denied coverage due to a pre-existing condition. Unless the enrollee lives in Maine, Connecticut, New York, or Massachusetts, purchasing a Medigap plan outside the 6-month window will either be impossible or exorbitantly expensive. The inability to purchase a Medigap policy poses a huge obstacle to any Medicare beneficiary on MA for longer than 6 months thinking about switching to traditional Medicare. This is especially fraught given the 40% of sick enrollees with financial barriers to care.

Instead of declaring profits are excessive, they ponder, “Another question concerns whether the profits earned by MA plans have become excessive. These profits seem at least in part the result of federal policy decisions and may not in all cases represent true efficiencies or higher value.” There is no question profits have become excessive, and profits are in greater part the result of compromised federal policy decisions, and not true efficiencies. According to a report by Wendell Potter, not only are government programs (Medicare and Medicaid in particular) the source of 90% of new health plan revenues of major insurance companies, but profits from all sources by the top seven US health insurance companies have climbed by almost 300% in the past 10 years to $70 billion in 2022. Why seed doubt?

It is true that “the fundamental features that make MA attractive to beneficiaries and investors remain in place,” despite feeble attempts by the federal government to rein in some of the worst abuses by MA companies. However, we are skeptical that tweaking around the MA edges, suggested by the authors, will result in both programs having a “level playing field” to test the role of competitive markets in health care. Do we need to keep retesting this hypothesis when we know “competitive markets” in health care do not reduce costs or improve outcomes? The neoliberal concept popular since Reagan/Thatcher has been to imagine that a freely competitive market is self-regulating. The nature of health care is such that it cannot function as a free competitive market, as first demonstrated by Kenneth Arrow.

The authors conclude that “the power of the Medicare Advantage industry and the huge numbers of older voters enrolled in Medicare Advantage plans also make it politically difficult to dramatically alter the course of the program.” This encourages readers to accept the status quo, that the for-profit companies raiding our public coffers are here to stay, and the best we can hope for is more of the same.

Readers of the NEJM should know that we must heighten our demands. Just because an expensive, opaque, self-serving, cruel system is “popular” among the industry and among seniors who have no other choice, does not make the system inevitable. There are two bills, one in the Senate and a better one in the House, that call for comprehensive, equitable, affordable, accessible, universal and improved Medicare for All. This is where we should be focusing our attention, not on a system that just because it is predominant, must be endured.

Dr. Ana Malinow is past president of Physicians for a National Health Program, a long-time single payer activist and writer, and recently retired as Professor of Pediatrics from UCSF.

Dr. David Leibowitz spent the first half of his career heading a research lab, at Columbia and Indiana Universities, and the second half in the community practice of Heme/Onc in the SF Bay Area.

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Building the Democratic Party By Helping the Middle Class

George Packer reviews recent books which propose that for the Democrats to achieve stable power, they must provide economic assistance to the struggling middle class, not fight cultural battles. Single payer’s economic stability can foster progressive cultural norms.

What Does the Working Class Really Want?, The Atlantic, Dec. 11, 2023, by George Packer

From the late 1970s until very recently, the brains and dollars behind both parties supported versions of neoliberal economics: one hard-edged and friendly to old-line corporate interests such as the oil industry, the other gentler and oriented toward the financial and technology sectors. This consensus left the battleground open to cultural warfare. The educated professionals who dominate the country’s progressive party have long cared less about unions, wages, and monopoly power than about race, gender, and the environment. …

[There is an] outpouring of new books that pay political attention to those overlooked Americans of all races who lack a college degree, many employed in jobs that pay by the hour—factory workers, home health aides, delivery drivers, preschool teachers, hairdressers, restaurant servers, farm laborers, cashiers. During the pandemic, they were called “essential workers.” Now they’ve been discovered to hold the key to power, giving rise to yet another round of partisan dreaming of realignment, this time hinging on the working class. But these Americans won’t benefit from their new status as essential voters until the parties spend less effort coming up with what they think the working class wants to hear, and more effort actually delivering what it wants and needs. …

Joshua Green’s fast-paced, sober, yet hopeful The Rebels: Elizabeth Warren, Bernie Sanders, Alexandria Ocasio-Cortez, and the Struggle for a New American Politics argues that a Democratic renewal is already under way. … Green traces the Democrats’ estrangement from working Americans back to the ’70s; he begins his story with a moment in 1978, when Jimmy Carter abandoned unions for Wall Street. The narrative reaches a climax in 2008, when the financial crisis destroyed home values and retirement savings while taxpayer dollars rescued the banks that had triggered it, convincing large numbers of Americans that the system was rigged by financiers and politicians. Because of policy choices by the Obama administration—Democrats’ last spasm of neoliberalism—much of the blame fell on the former party of the common people. Yet out of the wreckage rose a new group of Democratic stars who sounded like their New Deal predecessors, many of whom were every bit as radical. Taking aim at corporate elites, Green’s protagonists want to increase economic equality through worker power and state intervention. Though Sanders and Warren failed as presidential candidates, Green argues that their populism transformed the party, including the formerly moderate Joe Biden, who has pushed a remarkably ambitious legislative agenda with working-class interests at its center. …

One party supports unions, the child tax credit, and some form of universal health care, while the other party does everything in its power to defeat them. One president passed major legislation to renew manufacturing and rebuild infrastructure, while his predecessor cut taxes on the rich and corporations. Yet polls since 2016 have shown Republicans closing the gap with Democrats on which party is perceived to care more about poor Americans, middle-class Americans, and “people like me.” …

Now, encouraged perhaps by the excesses and failures of a professional-class social justice movement, and by the relative success of Biden’s pro-worker agenda, they seem to be finding their voice. [P]olling data from Wisconsin and Massachusetts provide evidence that Americans are less divided on cultural issues than activists on both sides, who benefit by stoking division, would like: “If you look at the country’s voters, and put aside the culture wars, what you find are genuine differences between the parties’ voters over economic issues.” The real disagreements have to do with taxation, regulation, health care, and the larger problem of inequality. Democrats’ way forward seems obvious: emphasize differences on economics by turning left; mute differences on culture by tacking to the middle. If the party can free itself from the moneyed interests of Wall Street and Silicon Valley, and the cultural radicalism of campus and social media, it might start to win in red states.

Comment:

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

George Packer is a wonderful writer on politics: progressive, incisive, clear. In this piece, he argues that for the Democrats to achieve a solid and enduring electoral majority, they must first and foremost address the economic needs of the working class. The political and moral need to bolster the working class (and poor!) is unassailable. However, the moderation of cultural stances that he proposes will generate controversy on the left.

Where does single payer come in? The article says, “some form of universal health care”. That’s not enough, because anything short of comprehensive, financially unimpaired coverage will fall short. We in the single payer movement clearly still have education and organizing to do even with savvy progressive thinkers.

Does single payer – a profound economic hand up – also foster progressive cultural norms? I propose that it does: when vulnerable middle-class families have the reassurance of stable and affordable health care, they won’t blame others for depriving them of this critical need. Through sharing in a common social good, the “other” of different social groups is more likely to become “one of us”. That doesn’t get us to the full array of progressive cultural values, but it sure helps.

https://healthjusticemonitor.org…

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British National Health Service Crippled by Privatization & Austerity Funding

A NY Times opinion video lays it out vividly: The British NHS is an adored public institution, now 75 years old. In recent years it has stumbled … sabotaged by UK leaders who starve budgets and foster ill-advised private initiatives.

How Britain Put One of the World’s Best Health Care Systems on Life Support, Video Op-Ed (7 minutes), New York Times, Dec. 7, 2023, by Adam Westbrook

[HJM spoiler: privatization and under-funding!]

Comment:

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

This excellent opinion video uses seven minutes to concisely, vividly, and powerfully capture the causes of NHS collapse: privatization and under-funding. Both Labor and especially Tory leaders starve the beloved NHS in favor of ill-conceived expensive privatization schemes often involving US corporations. A national treasure has been pushed into crisis by politicians beholden to for-profit interests. Brexit amplified the problems by lowering access to health professionals.

Although I commend the NY Times for offering this impressive opinion video, I must take it to task for obscuring the video’s main point in the written introduction. The video clearly highlights that NHS problems derive from privatization and under-funding. Yet, the introduction does not highlight, or even mention, those issues. Indeed it implies that privatization could be part of the solution. “[A] s the Opinion video above argues, [the] NHS is in jeopardy owing to mismanagement by British politicians. The system was founded in 1948 to provide free health care to all residents and has proudly stood as a much-loved symbol of British identity and the welfare state. The [recent operating] crisis has led to calls for Britain to scrap universal health care and return to a private or hybrid health system, like in the United States and other European countries. But as the Opinion video argues, the NHS woes are not a function of how it’s funded but the result of something else entirely.” Umm, why so obscure?

Why not state outright that privatization and intentional austerity budgets are the core problems, as convincingly portrayed by the video? The US is certainly not worth emulating, and successful health insurance in other wealthy countries reflects the public commitment to universal standard insurance. A normal op-ed introduction echoes the op-ed’s key points, so why coy here?

Happily, the video speaks for itself, eloquently. Share it widely!

Comment:

By Don McCanne, M.D.

The lesson is extremely important for single payer proponents. Conservatives profess that competition in private markets is the key to success in health care and that governments, as in single payer or a national health service, would destroy the functioning of the health care system. This video shows that one of the finest health care systems in the world, the government-run British NHS, has been crippled by converting it to a private, market-driven system, the exact opposite of what the conservatives are preaching.

Thus when the conservatives say that we can’t have single payer because we have to keep the government out, we can use the video to answer that we must have the government in control, and the conservatives have to keep their private market from controlling our health care.

We should distribute the link to this video widely so that people can understand that in the real world, the private market is destructive to health care and that we need a well designed, government-funded, government-administered single payer system.

Remember, it was John McCain, a Republican, who gave a thumbs down to prevent repeal of a government health care program: Obamacare. We can all join together to get universal health care done with a system proven to be effective: single payer.

https://healthjusticemonitor.org…

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Implosion of Commercial Health Insurance

Commercial health insurance, on a decades-long decline in affordability, dipped to a new low. Family insurance is unaffordable at small firms, children with commercial insurance are inadequately covered, and three-quarters of consumers can’t promptly pay medical bills.

Family health Insurance Is No Longer Affordable Through Small Employers, KFF, Nov. 28, 2023, by Drew Altman

One thing that really jumped out from our 25th annual KFF employer health benefit survey: Small employers no longer have affordable coverage for workers with families.

Workers employed by small firms – those with fewer than two hundred employees – would need to pay $8,334 on average towards the premiums each year for family coverage. But enrolling a family at these firms can often be much more – a quarter of covered workers at small firms must pay $12,000 annually or more to enroll in family coverage.

But that doesn’t include what workers pay for deductibles or other out-of-pocket costs which are also typically higher at small firms. 57% have to pay $3000 or more before at least one member of the family meets the deductible and the plan starts covering most services. For 35% of covered workers at small firms, the deductible is at least $5000.

The bottom line: For many of the almost 50 million people working for the 3.2 million smaller companies in America, family coverage is no longer affordable. It is likely to be prohibitive for the really small companies, the pizza shop, the dry cleaners, or the bakery. Salaries at firms of less than 200 employees are $44,600 on average compared to $63,200 for workers at larger firms.

Between two-in-ten and three-in-ten lower income workers with employer coverage reported problems paying their medical bills, or that they could not pay them at all, in the last year. It’s logical that affordability challenges are always much worse for people who are chronically ill or who have major illnesses and need more care, but that’s also the opposite of how a health system should work.

Study finds high rates of inadequate health insurance coverage for commercially insured children, Academic article: Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021, Columbia University Mailman School of Public Health, Nov. 28, 2023, by Jamie R. Daw, et al.

1 in 5 children in the U.S. have inadequate health insurance, i.e. insurance that either has unreasonable out-of-pocket costs or doesn’t have benefits that meets the child’s medical needs.

Inadequate insurance is particularly high among kids with commercial insurance (approximately 1 in 3 commercially insured vs. 1 in 10 publicly insured kids).

Survey reveals 72% of consumers unable to pay health care bills immediately, Medical Economics, Nov. 29, 2023, by Todd Shryock

A survey commissioned by AccessOne found that 72% of consumers find themselves unable or unwilling to pay their health care bills immediately.

Nearly half of those surveyed (48%) have taken drastic measures to curb expenses, including postponing essential care and forgoing prescription medications.

The survey also found that almost a third of respondents expressed no confidence whatsoever in their ability to settle a medical bill exceeding $500. 32% turn to personal credit cards, exacerbating their financial burden.

Comment:

By Don McCanne, M.D.

Those who believe that the Affordable Care Act should work well for all of us, if only we take advantage of what it has to offer, should be paying more attention to what is going on.

These three new sources show us that employer-sponsored plans are still leaving health care unaffordable for employees of small businesses, but that is now extending into larger businesses as well.

Commercial health insurance is leaving far too many children inadequately covered, which certainly exposes the falsehood that our private plans are working well for those who can afford them.

In spite of our various insurance programs, supposedly made universal by Obamacare, health care consumers are facing ever greater health care debt that they are no longer able to manage and causes them to forgo further essential care.

Note that these reports deal with only the most fundamental function of health insurance: paying medical bills. We are now also being inundated with manipulations that are designed to move our health care dollars away from patient care and to wealth creation for the billionaire investors that are taking away our choices in health care.

Enough!

Time for an equitable, publicly funded and publicly administered health care system that will provide each of us with affordable care, care that we need, when we need it:  Single Payer!

https://healthjusticemonitor.org…

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Why Doctors and Pharmacists Are in Revolt

Once accustomed to a status outside the usual management-labor hierarchy, many health professionals now feel as put upon as any clock-punching worker.

By Noam Scheiber
The New York Times, December 3, 2023

Dr. John Wust does not come off as a labor agitator. A longtime obstetrician-gynecologist from Louisiana with a penchant for bow ties, Dr. Wust spent the first 15 years of his career as a partner in a small business — that is, running his own practice with colleagues.

Long after he took a position at Allina Health, a large nonprofit health care system based in Minnesota, in 2009, he did not see himself as the kind of employee who might benefit from collective bargaining.

But that changed in the months leading up to March, when his group of more than 100 doctors at an Allina hospital near Minneapolis voted to unionize. Dr. Wust, who has spoken with colleagues about the potential benefits of a union, said doctors were at a loss on how to ease their unsustainable workload because they had less input at the hospital than ever before.

“The way the system is going, I didn’t see any other solution legally available to us,” Dr. Wust said.

At the time he and his colleagues voted to unionize, they were one of the largest groups of private-sector doctors ever to do so. But by October, that distinction went to a group that included about 400 primary-care physicians employed in clinics that are also owned by Allina. The union that represents them, the Doctors Council of the Service Employees International Union, says doctors from dozens of facilities around the country have inquired about organizing over the past few years.

And doctors are not the only health professionals who are unionizing or protesting in greater numbers. Health care workers, many of them nurses, held eight major work stoppages last year — the most in a decade — and are on pace to match or exceed that number this year. This fall, dozens of nonunion pharmacists at CVS and Walgreens stores called in sick or walked off the job to protest understaffing, many for a full day or more.

The reasons for the recent labor actions appear straightforward. Doctors, nurses and pharmacists said they were being asked to do more as staffing dwindles, leading to exhaustion and anxiety about putting patients at risk. Many said that they were stretched to the limit after the pandemic began, and that their work demands never fully subsided.

But in each case, the explanation runs deeper: A longer-term consolidation of health care companies has left workers feeling powerless in big bureaucracies. They say the trend has left them with little room to exercise their professional judgment.

“People do feel put upon — that’s real,” said John August, an expert on health care labor relations at the Scheinman Institute at Cornell University. “The corporate structures in health care are not evil, but they have not evolved to the point of understanding how to engage” with health workers.

Allina said that it had made progress on reducing doctors’ workloads and that it was partnering with health care workers to address outstanding issues. CVS said it was making “targeted investments” in pharmacies to improve staffing in response to employees’ feedback, while Walgreens said it was committed to ensuring that workers had the support they needed. Walgreens added that it had invested more than $400 million over two years to recruit and retain staff members.

Professionals in a variety of fields have protested similar developments in recent years. Schoolteachers, college instructors and journalists have gone on strike or unionized amid declining budgets and the rise of performance metrics that they feel are more suited to sales representatives than to guardians of certain norms and best practices.

But the trend is particularly pronounced in health care, whose practitioners once enjoyed platinum-level social status at high school reunions and Thanksgiving dinners.

For years, many doctors and pharmacists believed they stood largely outside the traditional management-labor hierarchy. Now, they feel smothered by it. The result is a growing worker consciousness among people who haven’t always exhibited one — a sense that they are subordinates constantly at odds with their overseers.

“I realized at end of the day that all of us are workers, no matter how elite we’re perceived to be,” said Dr. Alia Sharif, a colleague of Dr. Wust’s at Allina who was heavily involved in the union campaign. “We’re seen as cogs in the wheel. You can be a physician or a factory worker, and you’re treated exactly the same way by these large corporations.”

The details vary across health care fields, but the trend lines are similar: A before-times in which health care professionals say they had the leeway and resources to do their jobs properly, followed by what they see as a descent into the ranks of the micromanaged.

As a pharmacy intern and pharmacist at CVS in Massachusetts beginning in the late 1990s, Dr. Ed Smith found the stores consistently well staffed. He said pharmacists had time to develop relationships with patients.

Around 2004, he became a district manager in the Boston area, overseeing roughly 20 locations for the company. Dr. Smith said CVS executives were attentive to input from pharmacists — raising pay for technicians if there was a shortage, or upgrading clunky software. “Every decision was based on something that we said we needed,” he recalled.

Dr. Wust looked back on his days in an independent practice of about 25 doctors with a similar wistfulness. “We were all partners,” he said. “It was relative workplace democracy. Everybody got a vote. Everybody’s concerns were heard.”

Over time, however, consolidation and the rise of ever-larger health care corporations left workers with less influence.

As so-called pharmacy benefit managers, which negotiate discounts with pharmacies on behalf of insurers and employers, bought up rivals, retail giants like Walgreens and CVS made acquisitions as well, to avoid losing market power.

The chains closed many of their newly owned locations, driving more customers to existing stores. They sought to cut costs, especially labor costs, as the benefit managers reined in drug prices.

Around 2015, Dr. Smith stepped down from his role as a district manager and became a frontline pharmacist again, reluctant to supervise co-workers under conditions he considered subpar. “I couldn’t ask my pharmacists to do what I couldn’t accomplish,” he said.

Among his frustrations, he said, was the need to strictly limit the number of workers each pharmacy could schedule. “Every week that you’re over your labor budget, you get a call, regardless of prescription volume, from your district manager,” Dr. Smith said. “If your budget for tech hours is 100 and you used 110, you get a phone call. It’s not much money — maybe $180 — but you’re getting a call.”

Asked how labor budgets were applied, CVS said managers were “provided guidance” based on expected volume and other factors, with adjustments made to ensure adequate staffing.

Dr. Smith and other current and former CVS and Walgreens pharmacists said their stores’ allotment of hours for pharmacists and pharmacy technicians had dropped most years in the decade before the pandemic.

The pharmacists also described being held to increasingly strict performance metrics, such as how quickly they answered the phone, the portion of prescriptions that are filled for 90 days rather than 30 or 60 days (longer prescriptions mean more money up front) and calls made urging people to fill or pick up prescriptions.

For years, Walgreens and CVS pharmacists could largely ignore these narrower metrics so long as overall profits and customer satisfaction stayed high. But in the early to mid-2010s, both companies elevated the importance of these indicators, several pharmacists said.

At Walgreens, many pharmacy managers began reporting to a districtwide retail supervisor rather than a supervisor trained as a pharmacist. “It coincided with more pushing of the metrics,” said Dr. Sarah Knolhoff, a Walgreens pharmacist from 2009 to 2022.

“Never having been a pharmacist, they would push the pharmacy the same way they would push the front end,” Dr. Knolhoff added, alluding to the rest of the store.

CVS said that performance metrics were needed to ensure safety and efficiency for patients but that in recent years it had reduced the number of metrics it tracked. Walgreens announced last year that it would no longer rely on “task-based metrics” in performance reviews for pharmacy staff members, though it still used them to track store-level performance.

The transition for doctors and nurses came around the same time. As independent medical practices found they had lost leverage in negotiating reimbursement rates with insurers, many doctors went in house at larger health systems, which could use their size to secure better deals.

The passing of the Affordable Care Act in 2010, along with federal rule-making efforts, rewarded bigness by tying reimbursement to certain health outcomes, like the portion of patients who must be readmitted. Getting bigger helped a hospital system diversify its patient population, the way an insurer does, so that certain groups of high-risk patients weren’t financially ruinous.

Administrators increasingly evaluated their medical staff according to similar metrics tied to patients’ health and put a variety of incentives and mandates in place.

Doctors and nurses chafed at the changes. “Corporate tells you how to manage your patient,” said Dr. Frances Quee, president of the Doctors Council, which represents about 3,000 doctors, most of them at public hospitals. “You know that’s not how you’re supposed to manage your patient, but you can’t say anything because you’re scared you’re going to be fired.”

At Allina, primary care doctors are given incentives to talk to patients about their high-risk or chronic medical conditions, even if those conditions are well managed and aren’t relevant to a visit.

“Is that a valuable use of our 25 minutes together?” said Dr. Matt Hoffman, a primary care doctor at an Allina clinic that unionized in October. “No, but it means Allina gets more money from Medicare.”

Dr. Wust said hospital administrators increasingly relied on management theories borrowed from other industries, like manufacturing, that sought to minimize excess capacity.

For example, he said, obstetricians at Allina had one or two hold spots a day of 15 minutes each, in case of a patient emergency, when he began working at the system. Several years ago, Allina took away these buffers, instructing obstetricians to double book instead.

Asked about the hold spots, Allina said, “We’re always looking at how we’re using our resources to deliver high-quality care.” It said the incentives tied to high-risk conditions could still be achieved if a doctor stated that the problem was no longer relevant. Dr. Josh Scheck, another Allina primary care doctor, said he found the nudge helpful and not very time consuming to address. He said the health system had allowed his clinic to experiment with ways to make its work flow more efficient.

Other health workers complained that some of the metrics they’re evaluated on, like patient satisfaction, made them feel like retail clerks or dining employees rather than medical professionals.

Adam Higman, an expert on hospital operations at the consulting firm Press Ganey, said consolidation and the increased use of metrics had arisen in response to a need to lower U.S. health care costs, long the world’s highest per capita, and ensure that the spending actually benefits patients.

He pointed to data showing that more empathetic and communicative doctors and nurses — factors that affect patients’ experience — lead to healthier patients.

But Mr. Higman acknowledged that many health systems had increased tensions with doctors and nurses by failing to involve them more in developing and putting in place the system of metrics on which they are judged. “The progressive, smart health systems and medical groups are listening to physicians, looking at their experience and turnover and creating venues to have discussions,” he said. “If not, that’s one of the contributing factors to organizing.”

The pandemic magnified these strains.

As retail chains rolled out Covid-19 vaccines, pharmacists complained of being overworked to the point of skipping bathroom breaks and said they worried constantly about making mistakes that could harm patients. (CVS said it began closing most pharmacies for 30 minutes each afternoon last year to give pharmacists a consistent break. Walgreens said “dedicated pharmacist meal breaks” began in all stores in 2020.)

Doctors and nurses found that their already backed-up inboxes were suddenly bursting, as frightened patients clamored for medical advice. Administrators sought to squeeze more patients into overloaded hospitals and clinics.

The breaking point came when the height of the pandemic passed, but conditions barely improved, according to many workers. Although health systems had promised to add staffing, many found themselves running deficits amid inflation and a shortage of doctors and nurses.

Professionals who had never considered themselves candidates for union membership began to organize. When she started at Allina in 2009, Dr. Sharif said, “I would not have put unions and physicians in the same mind — it would have been a totally alien concept.” She reached out to the Doctors Council last year for help unionizing her colleagues.

Dr. Quee, the union president, said that inquiries from doctors were up more than threefold since the second group of Allina doctors unionized last month — and that as a result, the Doctors Council was hiring more organizers. (Allina is appealing the outcome of the union vote at the hospital but not at its clinics.) Even pharmacists are reaching out. “Two days ago, pharmacists called me from Florida,” she said. “We’ve never done pharmacists before.”

In September, Dr. Smith, who long ago shifted from CVS district manager to frontline pharmacist, took on an additional role: labor organizer. After CVS fired a district manager who had refused to close some stores on weekends to address understaffing, Dr. Smith helped organize a series of coordinated sick days and walkouts in the Kansas City, Mo., area, where he has worked for the company in recent years.

The walkouts affected roughly 20 locations and drew the company’s chief pharmacy officer and a top human resources official to town for a meeting with the renegades. A few weeks later, CVS said it would rein in vaccination appointments and add work hours for pharmacy technicians, though it had not increased their pay.

CVS said several Kansas City-area pharmacists had called in sick on certain days in September, “resulting in about 10 unexpected pharmacy closures” on one day and part of another. In response, it said, executives met with pharmacists to listen to and address their concerns.

During an interview in October, while Dr. Smith and his colleagues were still awaiting the company’s response, he made clear that his patience had run out. “I’ve been asking and asking and asking for improvements for years,” he said. “Now we’re not asking any more — we’re demanding it.”

https://nytimes.com…

PPO becomes PP-No: Providers Refuse Medicare Advantage

Hospitals and provider systems are increasingly opting out of Medicare Advantage (MA) networks, frustrated by low payment rates and rising payment denials. Even “preferred provider” MA plans, which should cover any Medicare provider, are being declined by prestigious health systems.

Hospital Vitals: Financial and Operational Trends: U.S. hospitals face diminished reserves, mounting reimbursement challenges, Syntellis and American Hospital Association, November 2023

 Seniors Scramble as Scripps, Other Health Systems Terminate Medicare Advantage Plans, Times of San Diego, November 2, 2023, by Mark Miller, Reuters

Scripps Health, a major Southern California healthcare provider, announced in September that beginning next year, its popular clinic and coastal medical groups will no longer accept patients enrolled in Medicare Advantage, the managed-care alternative to traditional Medicare offered by commercial insurance companies. That has left 32,000 San Diego seniors rushing to find either new healthcare options or new insurance for 2024.

Disabled people who qualify for Medicare before they turn 65 also are affected. And Scripps is not alone — at least a half-dozen other health systems around the U.S. are terminating Advantage contracts.

… [T]he Scripps Health decision underscores an important downside to Medicare Advantage plans: there is no guarantee that you will be able to stick with your preferred doctors and hospitals. Medicare Advantage plans can drop healthcare providers from their networks — and that happens when providers and insurers cannot agree on contract terms.

Last week Scripps Health CEO and President Chris Van Gorder told Reuters that his institution is on track to lose $75 million or more on care it provides to Medicare Advantage patients this year. The two key issues that led to the decision to stop working with advantage plans, he said, were the rates insurance companies were willing to pay, and the tendency of sicker patients to seek treatment at top-notch medical centers such as those run by Scripps.

He said that Scripps also has struggled with the administrative burden of dealing with Medicare Advantage “prior authorization” procedures — essentially, a process where an insurance company determines if it will cover a prescribed procedure, service or drug.

Comment:

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

The Medicare Advantage vs. provider battle is ratcheting up. For decades, providers and managed care insurers maneuvered for market position and vigorously negotiated reimbursement rates for “in network” care. Providers with loyal patients obtained higher payments, and those needing patients settled for less; similarly, insurers with large market share could drive tougher bargains. Mergers in both realms shifted power and payment levels over time.

Now, Medicare Advantage plans, ever on the prowl for new ways to raise income and profits, are clamping down on payment, with big jumps in denials and delays. As a result, prestigious providers like Scripps are declining Medicare Advantage; quite a few examples listed here.

I have personal experience with how this phenomenon affects coverage even beyond limited provider networks. I’m insured by Medicare Advantage, despite my many misgivings about MA, because the University of California retirement system offers no way for me to be on traditional Medicare while still insuring the rest of my family (a topic for another day). My MA plan is a “preferred provider organization” (PPO). This means I can see any provider who participates in Medicare and agrees to accept my MA-PPO. For years this worked terrifically well, providing me untrammeled access to top notch Bay Area providers. But recently, a highly regarded academic medical center announced a failure to reach contractual agreement with my MA company. I investigated; reading between the lines, it’s all about money: rates are too low and payment hassles and denials are too high. PPO became PP-No.

Thus, Medicare Advantage increasingly butts heads with the best providers. I’m not taking sides … both insurers and health systems suffer from “profit obsession syndrome” (POS, my own clever name). Yet I do know that this dynamic bodes poorly for access to optimal care, meaning compromised clinical outcomes.

Whereas if we had single payer, hospitals would be paid with reliable global budgets, and reimbursement levels would be standard and fair. Every ideal patient-provider match would be possible. Health would be maximized. Isn’t that what it’s about?

https://healthjusticemonitor.org…

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Sick of Outrageously Excessive CEO Compensation?

If you care about health, you certainly should be.

By Sam Pizzigati
Inequality.org, November 30, 2023

This past summer the Wall Street Journal took a crack at listing the world’s ten highest-paid corporate CEOs. Nine of the ten, the Journal found, last year pulled down over $100 million. The tenth on the list had to make do with a mere $99 million. And all of these chiefs turned out to share a common home base: the United States.

That U.S. connection should come as no surprise. CEOs in the United States have been pocketing far lusher paychecks than their counterparts elsewhere in the world for quite some time now, giving shills for that excess plenty of practice honing their rationales for it.

At their most basic, those rationales all boil to one word: incentives. Hefty rewards for executives, the argument goes, incentivize top-tier performance. Execs who stand to take home mega millions will move heaven and earth to deliver quality products and services that gain their corporations beaucoup customers and higher share prices.

Where ought the debunking of that notion begin? How about focusing on CEO pay in an American industry that can actually make the difference between life and death for average Americans, an industry where the pay top execs pocket far, far outpaces the compensation of their global counterparts?

Let’s, in other words, talk health care.

America’s top health care execs would rather we not. They’re doing quite nicely these days flying under the radar, their paychecks getting nowhere near the scrutiny that Wall Street’s finest and high tech’s most ebullient superstars have been enduring.

Just how lavishly well are America’s health care CEOs doing these days? In 2022, a down year for the stock market, the CEOs of over 300 publicly traded U.S. health care companies combined to make some $4 billion, analysts at STAT reported this past August. The ten highest-paid of these execs just by themselves pocketed $1.4 billion.

“No matter how you slice it,” notes John McDonough, a veteran Harvard health policy prof, “the people at the top — the CEOs of these companies — are making enormous gains every year compared to ordinary Americans.”

Health insurance company CEOs have annually rated as among the health care industry’s most royally rewarded. In 2022, America’s five top-paid health insurer chiefs all pulled down over $20 million, Insurance Business magazine reported earlier this month.

The lowest-paid of these top five, UnitedHealth Group’s Andrew Witty, had to make do with a mere $20.9 million, a reward 331 times greater than the pay that went to UnitedHealth’s most typical employees.

Top execs in the “insurtech” side of the health care industry — firms that claim to be using high tech to make health insurance more efficient — seem to have an even greater compensation upside. Alignment Healthcare’s John Kao took home $34.1 million in 2022 after a $46-million payday in 2021. Bright Health’s George Mikan two years ago took in $180 million.

The chief execs of U.S.-based health care companies clearly have all the incentive they could possibly need to deliver outstanding performances. The quality of health care in the United States — by the reasoning of the defense team for sky-high U.S. CEO pay — should be unparalleled worldwide.

Especially compared to Canada.

Our neighbor to the north has not a single mega-million health care exec. The reason? Right after World War II, in the province of Saskatchewan, Canadians started setting up a tax-funded nonprofit health care system that guarantees free universal health services. By the early 1960s, all Canada’s provinces and territories had joined in on the effort.

The top executives in Canada’s health care system today make a fraction of the compensation that goes to health care execs in the United States. In 2021, the CEO of Ontario Health “raked in” just $826,000. The top health exec in the province of Alberta that same year collected a mere $583,443.

Canadians, according to the rationale of apologists for U.S. CEO pay, ought to be paying dearly for the low pay that goes to the execs who run Canada’s health care system. People in the United States, by the apologist logic, ought to be enjoying far better health care and health than people in Canada. In fact, the reverse has become the case, as analysts have been documenting for years.

By 2010, as a Population Health Metrics research journal analysis detailed just over a dozen years ago, a healthy 19-year-old Canadian could “expect to have 52 more years of perfect health versus 49.3 more years for Americans.”

Compared to Canadians, a PBS report would observe in 2020, “Americans have for years paid far more for health care while staying sicker and dying sooner.”

Other still more recent research has placed Canadian and U.S. health outcomes in a more global context. In 2021, the Commonwealth Fund in New York compared the performance of health care systems in 11 high-income countries around the world: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK, and the United States.

“The United States ranks last overall,” the Commonwealth Fund data analysts point out, “despite spending far more of its gross domestic product on health care.”

U.S. performance on metrics that measure everything from access to health care to health outcomes, declare the Commonwealth Fund researchers , “falls well below the average of the other countries and far below the two countries ranked directly above it.”

The United States, the Commonwealth Fund added this past January, also “has the lowest life expectancy at birth” and “the highest death rates for avoidable or treatable conditions.”

Two leading research centers, The Peterson Center on Healthcare and KFF, piled on with still more unnerving health care data this past October.

Back in 1980, the Peterson-KFF Health System Tracker illustrates, life expectancy at birth showed no major differences between the United States and comparable advanced industrialized nations. But the global life-expectancy gap “has grown substantially in the following decades,” with Americans in 2021 averaging just 76.4 years in life expectancy and its peer countries averaging 82.3.

What’s going on here? How can the United States be spending so much on health care and seeing so little in return? Where does America’s health care CEO pay fit in to all this?

We’ve had no shortage of culprits when it comes to explaining how unhealthy the United States has become. Many observers point to poor diets, for instance, or the lack of adequate exercise.

But analysts like Stephen Bezruchka, a population health professor emeritus at the University of Washington, are urging us to look deeper into how our American society has evolved since the middle of the 20th century. We have over those years, they note, become a much less equal nation. Our richest are making much more — as the CEO pay data confirm — and paying a much smaller share of their hefty incomes in taxes.

“Healthier societies have a smaller gap between the rich and the poor than we do,” notes Dr. Bezruchka. “That gap causes an enormous amount of stress in our society — road rage, air rage, stress at work, child abuse.”

Dr. Bezruchka has come to call stress “the 21st century tobacco.”

“We have learned,” he warns, “that inequality kills.”

CEO compensation in the United States has contributed mightily to that inequality. Top execs don’t just collect big paychecks. To make sure they can end up collecting those paychecks, American CEOs regularly make corporate decisions that boost corporate profits at the expense of their employees and the public at large. Their fortunes also bankroll the politicos who oppose high taxes on high incomes — and the programs to help modest-income families those high taxes could be underwriting.

Curbing excessive CEO pay clearly won’t solve all the problems that face us. But curbing that excess would certainly make for a wonderfully substantive start.

https://inequality.org…