Summary: A US Senate committee issued a report documenting and condemning “widespread” abusive marketing practices for the private health plans known as Medicare Advantage. This follows NYT reporting on the Medicare Advantage “cash monster.” It’s time to recognize the failure of privatizing Medicare … and instead embrace single payer.

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Deceptive Marketing Practices Flourish in Medicare Advantage, November 3, 2022, by the Majority Staff of the U.S. Senate Committee on Finance

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Part I: Executive Summary

The Centers for Medicare and Medicaid Services (CMS) revealed earlier this year that the number of Medicare beneficiary complaints about private sector marketing for Medicare Advantage (MA) plans more than doubled from 2020 to 2021. The Senate Finance Committee … launched an inquiry in August 2022, collected information on marketing complaints from 14 states and found evidence that beneficiaries are being inundated with aggressive marketing tactics as well as false and misleading information, such as:

Seniors shopping at their local grocery store are approached by insurance agents and asked to switch their Medicare coverage or MA plan.

Insurance agents selling new MA plans tell seniors that their doctors are covered by the new plans. Seniors who switch plans find out months later that their doctor is actually out-of-network, and they have to pay out-of-pocket to visit their doctor.

Seniors receive mailers that look like official business from a Federal agency, yet the mailer is a marketing prompt from an MA plan or its agent or broker.

An insurance agent calls seniors 20 times a day, attempting to convince them to switch their Medicare coverage.

Widespread television advertisements with celebrities claim that seniors are missing out on benefits, including higher Social Security payments, in order to prompt seniors to call MA plan agent or broker hotlines.

Each one of these vignettes represents documented instances of aggressive or deceptive MA and Part D marketing practices that this investigation found to be widespread, not isolated events. Other examples submitted by the states are documented in this report.

The Committee received evidence of fraudulent and misleading marketing practices from states and other stakeholders – painting a consistent national picture. These issues were reported more frequently with respect to MA plans compared to stand-alone Part D plans. In addition, nine of the ten states reporting quantitative complaint information found an increase in complaints from 2020 to 2021 that mirrored the trend found by CMS.

Information submitted by states demonstrates that beneficiaries are inundated with fraudulent and misleading communications across all modes of communication (in-person, television, telemarketer, and robo-calls). An egregious example submitted by the states includes marketing materials designed to look like official communications from Federal agencies. A number of states also raised concerns with the use of “Medicare” in the naming and branding of marketing companies to suggest that a marketing company is representing the Medicare program. These practices are intentionally deceptive as they blur the lines between official government communication and private health plan marketing.

The investigation also uncovered a range of predatory actions. Agents were found to sign up beneficiaries for plans under false pretenses, such as telling a beneficiary that coverage networks include preferred providers even when they do not. Of particular concern to the Committee were reports across states of agents changing vulnerable seniors’ and people with disabilities’ health plans without their consent.

The burden of deceptive and predatory marketing practices falls unequally across the already vulnerable Medicare population. The Committee heard that unscrupulous actors are targeting individuals dually eligible for Medicare and Medicaid (so-called “dual eligibles” who are allowed to switch MA plans once every quarter) as well as individuals with cognitive impairments. False and misleading marketing advertisements and fraudulent sales practices undermine access to care and the trust beneficiaries have in the Medicare program.

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Comment:

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

As I approached my 65th birthday in May, the calls began. “This is the Medicare Medical Care Help Center” was the frequent opener. Guess what? They were not from Medicare, instead were telemarketers peddling Medicare Advantage plans. I also received – and continue to receive – numerous mailings. Lucky for me, I’m not cognitively impaired, and my University of California retirement supports a generous health plan that works for me and my family. I recognized this marketing blitz as high pressure sales, and ignored it. Reading the impressive Senate report, it turns out that CMS prohibits many of these marketing practices (such as private brokers using the “Medicare” name). Countless seniors have been fooled and harmed.

So, can we fix these problems? That’s what the Senate report recommends – better oversight. I excluded that portion of the Executive Summary, because I believe the problems with Medicare Advantage are far too pervasive and structurally embedded to be remedied with fine-tuning.

Medicare Advantage (MA) is a fundamentally flawed idea. As reported in the NY Times, MA plans overbill the federal government by tens of billions of dollars per year. Financial barriers to care for sick individuals are greater in MA than in traditional Medicare. Mortality for MA beneficiaries is highly variable, hurt by lower spending, and unrelated to quality measures. Recent letters to CMS list the problems (here & here).

Traditional Medicare is also under privatization assault. ACO REACH, despite its clever “equity” marketing, echoes the flawed MA model: it uses corporate “direct contracting entities” that will reap billions in profits as fiscal agents for capitated coverage. See here, here, and other HJM posts.

We’ve seen abundant evidence that privatization of Medicare is a disaster masquerading as a solution, to address a problem that never existed. Traditional (non-privatized) Medicare was and remains better – it is cheaper and has greater access to care.

Single payer – improved Medicare for All – is the right solution.

http://healthjusticemonitor.org…

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Summary: Evidence from around the world and in the US confirms the value of primary care for health care access, quality, and outcomes. Yet through inadequate financing we cause its shrinkage and stresses over time. Single payer would remedy this critical imbalance.

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Is Primary Care in Critical Condition?, Medical Economics, October 28, 2022, by Timothy Kelley

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In 2006 the American College of Physicians (ACP) declared that primary care, “the backbone of the nation’s healthcare system, is at grave risk of collapse.” That year, in a landmark New England Journal of Medicine article, Thomas Bodenheimer, M.D., M.P.H., a professor at the University of California, San Francisco (UCSF) and founding director of its Center for Excellence in Primary Care, identified “a confluence of factors that could spell disaster.” Patients are increasingly dissatisfied with their care, he wrote, and primary care physicians are unhappy with their jobs. “The quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field,” says the Bodenheimer jeremiad.

Other countries seem to get it even if the U.S. doesn’t. Study after study has shown that other wealthy countries outperform the U.S. on almost any healthcare metric you might imagine while devoting a far smaller share of their gross domestic product to healthcare. One explanation: They put more emphasis on primary care.

With an extra medical assistant on the core team working as a scribe, says Bodenheimer, physicians can see more patients because they’re relieved of many of the documentation tasks that overwhelm their days and that they often take home to work on after a long workday is over. The nonphysician members of interprofessional teams, he says, can save physicians even more time by seeing some patients themselves “if you let them do what they’re capable of doing,” he says. Some studies have shown that pharmacists can do a better job of taking care of people with diabetes than physicians and that physical therapists can do the same for people with musculoskeletal problems, says Bodenheimer.

However, recent innovations such as the accountable care organization (ACOs) and the patient-centered medical home (PCMH) have failed to transform primary care as many had envisioned …. PCMHs, in particular, get low marks from Bodenheimer: “They’ve been pretty much a flop.”

Bodenheimer notes that annual U.S. healthcare expenditures totaled more than $4 trillion in 2020, with just 5% of that spending going to primary care compared with 12% in European countries. “Primary care really should get 10% of the healthcare dollar rather than 5%,” he says. “If we do that, we’ll have enough money to hire the people — the nurses and pharmacists and physical therapists, for example — to be on teams that can help the physicians take care of their overly large panels and make life a lot better for the physician. And that would attract more medical students to go into primary care and could reverse the whole downward trend.”

So there it is. Just move $200 billion around, and you’ll get many more physicians eager to embrace what is arguably U.S. healthcare’s most crucial, most problematic — and potentially most rewarding — challenge.

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Comment:

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

There is a consensus that we should be doing better with primary care if we want to achieve our goal of higher quality care for everyone and better outcomes. International evidence supports this. And within the US more primary care translates to lower mortality.

However, our health care infrastructure is set up with models catering more to the business of medicine rather than to the medical care of the patients.

Tom Bodenheimer suggests that the answer is in spending health care dollars more appropriately on the primary care team designed to provide optimal care rather than on service models more appropriate for building income and wealth.

He has been distributing his message for some time now. Isn’t it time that all of us become more aggressive in applying it?

Single payer would permit us to support and grow primary care through appropriate financial support and reward for this fundamental pillar of health care.

http://healthjusticemonitor.org…

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The Marx-Kahn family Halloween display.

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Summary: This week three city councils in the Midwest, West, and Southeast passed resolutions backing nationwide single payer. This brings local endorsements to over 100. Combined with growing popular and physician support, are we approaching an irresistible force?

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Three Cities Pass Medicare for All Resolutions in Past Week, October 26, 2022, Public Citizen

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In a show of growing momentum behind passing Medicare for All legislation, Denver, Colorado, Gainesville, Florida, and Kent, Ohio all passed city council resolutions in recent days backing a nationwide universal healthcare program, sending a strong signal to Congress that their constituents care about ending for-profit healthcare.

The three cities join more than 100 localities that have endorsed Medicare for All.

During the pandemic, more than one million Coloradans – including 34% of those in Denver – saw their incomes reduced; many lost their job-based insurance, and people of color were hit hardest, according to the Colorado Health Institute’s 2021 Health Access Survey. In Denver County, the U.S. Census Bureau estimates that 12% of residents under 65 are uninsured.

In Ohio’s 13th district, where Kent is located, more than 43,000 people are uninsured, and over 117,000 people live below the poverty threshold. Kent Councilwoman Heidi Schaffer-Bish works with Coleman Health Services and encounters many people struggling to make ends meet when it comes to healthcare. “We’ve seen that government-based healthcare works, and private insurance through your employer does not,” said Shaffer-Bish.

In Alachua County, where Gainesville is located, the U.S. Census Bureau notes that 11.5% of people under the age of 65 are uninsured.

Brittany Shannahan, a Medicare For All organizer at Public Citizen, stated: “These resolutions, city-by-city, are helping to pressure our representatives to act to make guaranteed healthcare for all a reality. The chorus of voices is growing.”

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Comment:

By Lily Meyersohn

Shannahan is correct in announcing that the “chorus of voices is growing” on a nationwide single payer healthcare program. This is not just three cities; this is a national movement. In recent years, support for the program has risen in the general public and among key stakeholder groups like physicians.

In Medicare for All: A Citizen’s Guide (2021), physicians and progressive activists Abdul-El Sayed and Micah Johnson write that “there is one stakeholder in American healthcare that matters most: the American public.” And “public support for M4A is high. A nationally representative Pew Research study [from 2019] found that most Americans agree “it is the responsibility of the federal government to make sure all Americans have health care coverage. And a majority of Americans support M4A as a way to achieve this goal.”

This is a sea change from prior decades: “From 1998 to 2008, the Kaiser Family Foundation conducted ten polls asking Americans whether they supported a single-payer national health insurance program. None found majority support. Between 2017 and May 2020, the same organization conducted fifteen similar polls. Every poll found majority support for M4A.”

Physicians, too, are shifting toward single payer. Sayed and Johnson note that the American Medical Association “played a central role in fighting previous attempts at national health insurance.” But now the organization’s membership is in steep decline. “Both physician preferences and power may be changing fast. Most individual physicians today support M4A.”

Recently we’ve experienced COVID fatigue: people fed up and tired of the pandemic. If the 100+ localities that have endorsed M4A – including the three cities that signed on this past week – can teach us anything, it is that people across the country are fed up and tired of our abominable health care system. Maybe we should call that “Mixed Insurance Plan Fatigue.” From fatigue comes a determination for change!

http://healthjusticemonitor.org…

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Lily Meyersohn is a researcher at the Institute for Public Accuracy, where she covers pandemic policy and American health care issues. She can be reached at lilymeyersohn@gmail.com.

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Summary: Massive private equity investment has substantially transformed US health care. A highly respected health news service, KHN, highlights the trend and its downsides. The Private Equity Stakeholder Project documents these investments and resulting patient care problems. Single payer would correct the skewed health system dynamics that favor private equity.

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Patients For Profit: How Private Equity Hijacked Health Care, How Private Equity Is Investing in Health Care: A Video Primer, KHN (Kaiser Health News), October 26, 2022, by Hannah Norman

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See video (3 minutes)

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“A common move is to ‘roll up’ a string of businesses under one more established ‘platform’ and find new ways to make money. But as a result, patient care can suffer.” (2:25)

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Private Equity Stakeholder Project: Healthcare

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Private equity increasingly makes up a substantial portion of investment in U.S. healthcare companies, touching virtually every sector of the industry, and is expected to continue to grow. Asset managers have record levels of available capital earmarked for healthcare investment; as of 2019, private equity firms had $29.2 billion in capital waiting to be invested in healthcare.

This is despite the fact that private equity investment in healthcare companies carries substantial risk to patients, workers, and investors. The typical private equity investment playbook—pursuing outsized returns over short time horizons while using high levels of debt—may lead to behavior that jeopardizes patient care.

For example, private equity-owned healthcare companies have seen the following issues:

• Reduced staffing, or filling beds without adequate staffing ratios
• Over-reliance on unlicensed staff to reduce labor costs
• Failure to provide adequate training
• Pressure on providers to provide unnecessary and potentially costly services
• Violation of regulations required for participants in Medicare and Medicaid such as anti-kickback provisions, creating litigation risk

PESP has studied the impacts of private equity investment in key healthcare sectors, including safety net hospitals, behavioral health, nursing homes, prisons and detention centers and dental care. We have also written about the practice of taking debt-funded dividends from healthcare companies; private equity’s role in medical debt collection; and the relationship of private equity ownership and Medicare fraud. PESP also tracks private equity healthcare acquisitions on a monthly basis, highlighting notable transactions in a variety of sectors.

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Comment:

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

Private equity (PE) is a menace to US health care, extracting profits and leaving care underfunded and patients at risk. HJM has written frequently about specific PE issues among providers (eg, here), capitated “direct contracting” (including ACO REACH) by PE and other corporations in Medicare (eg, here), and the dangerous growing corporate ownership of providers. The broad PE critique offered by today’s sources is important.

The rising prices that plague US healthcare reflect growing provider power through corporate acquisitions and mergers – often driven by PE. Massive private health insurers are only too happy to pass along the high costs and associated high profits to payers (CMS and private employers, mainly) and patients (in the form of punishing cost-sharing and financial barriers to care). Private equity is turbo-charged exploitation enabled by our complex, fragmented, and chaotic insurance landscape.

How will single payer help? It will correct the distorted power imbalance, with a global payer that can effectively negotiate prices with large provider groups, reducing costs. It will simultaneously empower small providers (remember solo practice?) by treating them the same as the largest providers. It will simplify billing administration for physicians, removing the incentive to sell to corporations to shed the annoyingly complex paperwork. Many providers and patients prefer a non-corporate setting with greater autonomy and personalization, and will have that choice.

In short, single payer will unravel and replace the play space for aggressive corporate profit-taking. In so doing, it will support smaller providers and, of course, patients. Investor gains will yield to equitable, accessible, and affordable health care.

P.S. See the first comment — additional resources from NY PNHP

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Summary: Many voters are willing to cast their ballot for the candidate who supports reform to reduce health care costs. Yet the GOP seems to hate health insurance. Can’t we agree on reliable insurance for all, and a simple uniform way to pay for it?

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West Health – Gallup 2022 Healthcare in America Report, October 20, 2022

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In the next election, how likely are you to vote for a candidate from a political party you don’t typically support if reducing healthcare costs was their top priority?

Very or somewhat likely:

• Democrats – 40%
• Republicans – 22%

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Republicans look to Obamacare’s ‘family glitch’ for post-midterm fight, POLITCOPRO, October 20, 2022, by Daniel Payne

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House Republicans on Thursday asked the Treasury Department to preserve documents related to the administration’s fix of Obamacare’s “family glitch,” preparing for an investigation of what they claim was an “illegal expansion” of health coverage should the GOP regain control of the chamber in the midterms.

In a letter to Treasury Secretary Janet Yellen obtained by POLITICO, Republicans on the Ways and Means Committee told the administration to save and share with the committee information related to the new rule, which extended health insurance subsidies to 1 million Americans.

The letter signals a larger investigation Republicans are planning if they win the House in November, according to a congressional staffer familiar with the matter.

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Comment:

By Don McCanne, M.D.

No surprises here. Many Democrats would be willing to break party ranks to support efforts to reduce health care costs. But how likely is that – a Democratic opponent more reform-minded than the Dem? Far fewer Republican voters prioritize reform, but 20% isn’t nothing – and that situation arises all the time. Yet GOP leaders are so opposed to health insurance that they will fight to reduce it if they regain control. These are the strange political positions staked out around a broken health care system desperately in need of reform.

Suppose we all agreed that we need to provide comprehensive high-quality care to absolutely everyone. I bet even Republicans would endorse that. The only political decision is whether to pay for it through a progressive tax system that is affordable for everyone – a sharp contrast to today’s haphazard financial burdens, barriers to care, and medical debt. Isn’t that a political decision we could all live with? Why not?

http://healthjusticemonitor.org…

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Summary: Two news stories highlight visionary women pursuing community benefit. One, a lawyer and new MacArthur fellow, seeks drug patent law changes that favor access for patients over benefit to Big Pharma stockholders. Another, an heiress, advocates for high taxation of inherited wealth. Both missions align well with single payer.

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Priti Krishtel, Health Justice Lawyer, MacArthur Fellows Program, Class of 2022

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Priti Krishtel is a health justice lawyer exposing the inequities in the patent system to increase access to affordable, life-saving medications on a global scale. By distilling the technical aspects of the patent system to show its sometimes devastating impact on people’s lives, Krishtel is galvanizing a movement to center people instead of only commercial interests in our medicines patent policy.

… In 2006, Krishtel co-founded the Initiative for Medicines, Access, and Knowledge (I-MAK) to ensure the public had a voice in the pharmaceutical patent system. Krishtel and the organization are drawing attention to weaknesses within the patent system while identifying needed reforms to make it more responsive to the public good. Patents are intended to incentivize innovation by ensuring that only the patent holder can sell and profit from the product for a fixed time. However, many pharmaceutical companies seek to extend their monopolies by filing multiple patents on small changes (such as changes in dosage) to existing drugs over several years. This stifles competition, delays generic production, and keeps medicines out of the hands of people who need them the most. I-MAK has successfully contested patents worldwide, saving governments billions of dollars in public health spending and giving millions of people access to life-saving treatments. … I-MAK brings together a range of stakeholders—including patient groups, policymakers, and patent lawyers and judges—to deepen collective understanding of the impact of the patent system across different communities. … Their proposed reforms include ensuring only meaningful inventions are rewarded with a patent, increasing oversight from other government branches, and increasing public participation in the patent process.

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She’s Inheriting Millions. She Wants Her Wealth Taxed Away, New York Times, October 21, 2022, by Emma Bubola

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Marlene Engelhorn, 30, heir to a fortune, isn’t interested in philanthropy, believing it only perpetuates existing power dynamics. She’s calling for structural change to how the ultrarich are taxed.

By the time her extraordinarily wealthy grandmother died last month, Marlene Engelhorn already knew who she wanted to be the ultimate beneficiary of the enormous inheritance coming her way: the tax man.

“The dream scenario is I get taxed,” said Ms. Engelhorn, the co-founder of a group called Tax Me Now.

Ms. Engelhorn, a 30-year-old who grew up in Vienna, is part of a growing movement of young, leftist millionaires who say they want governments to take a much larger share of their inherited wealth, arguing that these unearned fortunes should be democratically allocated by the state.

For more than a year, Ms. Engelhorn has been campaigning for tax policies that would redistribute her eight-figure windfall — and anyone else’s.

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Comment:

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

We all need inspiration in the pursuit of community values. That’s especially true in today’s world where the profit-takers have such firm control of the rules of the game – influencing laws and regulations that favor them and exploiting those to the max.

Ms. Krishtel and Ms. Engelhorn exhibit admirable community values, talent, and determination. Ms. Krishtel works on pivotal details of patent law, and Ms. Engelhorn targets inheritance taxes for the wealthy. I was exhilarated reading about them.

Single payer, of course, also embodies community health and prosperity over private gain. The profiteers are wealthy health system stakeholders — insurers, pharma, provider conglomerates, and the private equity firms that participate in all those roles. Community includes all the patients and providers who deserve a better system.

There are so many of us engaged in social justice crusades. Let’s draw renewed energy and vision from these amazing women.

http://healthjusticemonitor.org…

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Summary: Anne Case & Angus Deaton are leaders in defining the links between rising hopelessness, declining health, and political division. A linchpin is the growing economic penalty from lacking a college degree; another is increasingly unaffordable healthcare. Single payer is harder to achieve in this polarized context, but more needed to overcome our political disarray.

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There Are Two Americas Now: One With a B.A. and One Without, NY Times, October 5, 2022, by Thomas Edsall

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The Republican Party has become crucially dependent on a segment of white voters suffering what analysts call a “mortality penalty.”

This penalty encompasses not only disproportionately high levels of so-called deaths of despair — suicide, drug overdoses and alcohol abuse — but also across-the-board increases in several categories of disease, injury and emotional disorder.

“Red states are now less healthy than blue states, a reversal of what was once the case,” Anne Case and Angus Deaton, economists at Princeton, argue in a paper they published in April, “The Great Divide: Education, Despair, and Death.”

… the correlation between Republican voting and life expectancy “goes from plus 0.42 when Gerald Ford was the Republican candidate — healthier states voted for Ford and against Carter — to minus 0.69 in 2016 and minus 0.64 in 2020. States classified as the least healthy voted for Trump and against Biden.”

… the ballots cast for Donald Trump by members of the white working class “are surely not for a president who will dismantle safety nets but against a Democratic Party that represents an alliance between minorities — whom working-class whites see as displacing them and challenging their once solid if unperceived privilege — and an educated elite that has benefited from globalization and from a soaring stock market, which was fueled by the rising profitability of those same firms that were increasingly denying jobs to the working class.”

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The Great Divide: Education, Despair, and Death, Annual Review of Economics, April 2022, by Anne Case and Angus Deaton

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Abstract

Deaths of despair, morbidity, and emotional distress continue to rise in the United States, largely borne by those without a college degree—the majority of American adults—for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the United States is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a bachelor’s degree. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the politics of despair, or how less-educated people have abandoned and been abandoned by the Democratic Party. Whereas healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID-19, finding that mortality in 2020 maintained or exacerbated existing relative mortality differences between those with and without college degrees.

Excerpts

[T]he economy has increasingly come to serve some, but not all, Americans, and where a central division is between those who do and those who do not have a 4-year college degree. While the college wage premium has soared to unprecedented levels, the inequality between these two groups involves much more than money. The college degree has now become “a condition of dignified work and of social esteem” as well as a matter of life and death, with adult life expectancy rising for the college educated and falling for the rest.

In our book [2020], we developed an account of the rising tide of despair, focusing on declining employment opportunities for those without a BA, especially the fall in good jobs, those that offer a sense of belonging, meaning, and purpose and prospects for advancement. This was aggravated by an ever more expensive health care system—more than twice as expensive as in other rich countries—a fifth of which is financed by an approximately flat tax on workers in amounts that often make low-skilled workers unemployable. An employer-sponsored individual (family) health plan cost $7,470 ($21,342) in 2020, $3.73 ($10.67) per hour for a 2,000-hour year, money that comes out of wages and take-home pay (KFF 2020). We also noted the lack of a comprehensive safety net in the United States for those who are neither elderly nor children … Both the safety net and the financing of health care are radically different in other rich countries where—with a few exceptions—there are few deaths of despair. …[W]e emphasized the corrosive effects of American meritocracy on the unsuccessful, on Young’s “populists” who have to live with the meritocratic hubris of the well-credentialed … and who, as they strive not to blame themselves, believe—with much justification— that society is rigged against them. …

Deaths of despair among Blacks and among Hispanics began to rise after 2010; like those for Whites, the increases are largely confined to those without a 4-year college degree. About three-quarters of the increase for Blacks and Hispanics without a BA is accounted for by drug overdoses.

A Politics of Despair

If the majority of Americans are failing to thrive while a minority prospers, why does the democratic process not work to improve their material and health outcomes? … [L]iving in a functioning democracy is good in and of itself, and the lack of effective political voice is one reason to despair. Woolhandler et al. (2021) in a Lancet Commission report on public policy and health in the Trump era … describe a negative feedback loop in which “the neoliberal policies that inflicted economic hardship and worsened health” did not, as might have been expected in a well-functioning democratic state, generate a political demand for better safety nets and health provision, because less-educated whites see such policies as favoring minorities at their expense. … Blacks and more educated whites react in the opposite direction, widening political polarization, which on net favors the right and provides an opening for populist politicians such as Donald Trump. …

[A]fter the US presidential election of 2016, several studies noted correlations between deaths of despair, changes in life expectancy, and the Republican share of the vote (Monnat 2016, Bor 2017). Bor (2017) finds a correlation of −0.67 across counties between changes in life expectancy from 1980 and 2014 and the share of each county’s vote going to Trump. There is a similar cross-county correlation of Trump’s vote share with the fraction of each county’s White population without a college degree …

The economy began to turn against the white working class around 1970. Real wages began to decline for workers without a BA, and there was a long, slow decline—interrupted but never fully restored during economic booms—in job opportunities for less-educated men, much of which was driven by the decline in employment in American manufacturing. Globalization was important, though less important than automation, as was the relentless increase in the cost of health care, much of which is paid for through what is essentially a head tax on wages. …

Since the 1970s, there has been a slow-rolling and still ongoing divorce between Democrats and the white working class, a divorce that is central to the politics of despair. Especially after the catastrophic 1968 Democratic National Convention, the party slowly oriented itself away from its traditional working-class and union base toward what it is today, a coalition of minorities and educated professionals. …

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Comment:

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

The political realignment that has taken place has racial minorities joining the better educated professionals, improving their own educational levels and their own health status, whereas less educated largely white populations have aligned with the Republicans as their despair and sense of being abandoned has risen. Hence worse health and rising drugs, depression, and suicide in GOP-dominated states. With the conservatives more volubly exploiting these issues, our hopes for reaching social solidarity on a universal health care system diminish.

Is there pride in being uneducated? In being at high risk of those factors that lead to deaths of despair? Of having a shorter life expectancy? Of being used by the conservative political forces to impede social progress in our nation? If these concepts were better understood, we could raise social solidarity and accomplish goals such as health care justice for all.

Providing universal, stable, affordable, high-quality care would sharply decrease political alienation and hopelessness, and tangibly convey the virtues of a community orientation over private profit. No wonder single payer is so frightening to the conservative purveyors of political schism. Halloween is coming, time to embrace our worse fears!

http://healthjusticemonitor.org…

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