Summary: Eric Reinhart brilliantly issues a call for physicians – long a conservative force in health care – to expand their political horizon from their own recent labor awakening to join the progressive movement to transform our desperately ailing health system.

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The Political Education of US Physicians, JAMA Network Open, June 27, 2023, by Eric Reinhart

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Since the beginning of Ronald Reagan’s presidency, the proportion of workers in the United States who belong to a union has declined by approximately 50%, while income inequality has increased by approximately 20%. Today, just 10% of all US workers are employed in unionized positions. But following the recession that started in 2007 and 2008 and then the temporary resurgence of a social democracy during a pandemic that exposed neoliberal policy as a public health disaster, labor organizing against exploitation and public abandonment has been increasing. Amid growing concern about workforce attrition associated with the demoralization of nurses and physicians in a flailing medical industry shaped by profit rather than ethics, health care workers have become increasingly involved in this revival of labor politics.

A wave of nurses’ strikes and house staff unionization has put this ideological shift front and center in contemporary health care politics. There are now approximately 70 000 physician union members in the US, representing 7% of physicians—a nearly 30% increase relative to a decade ago. …

It is into this context that the analysis of housing affordability and housing-related benefits for house staff by Brewster et al interjects. Using data from the 2022 to 2023 academic year, Brewster et al found that compensation levels at 60% of 855 institutions administering residency programs imposed rent-burdened status on their resident physicians (ie, they required residents to devote >30% of monthly income to rent). Brewster et al also found that while inflation-adjusted rental prices increased by 18% between 2000 and 2022, inflation-adjusted first-year resident salaries decreased by 0.2% during that same period. Concluding with a call for more equitable compensation, Brewster et al note that resident labor unions have been associated with improved access to housing stipends.

This adds to what should be already clear rationale for physicians, nurses, and other health care workers to unionize to protect their own interests and to protect patient safety by improving working conditions. But there is another intertwined and more fundamental issue at stake: the political education of the most influential workers in what may be the most powerful industry in the US.

Worst-among-peer-nations life expectancy, alongside globally unparalleled health care spending and rapidly declining trust in medicine, public health, and government, make undeniable that the US is in need of a basic reorganization of its health systems. After allowing health care over the last half century to be dominated by private entities motivated by profit and enabled by depoliticized concepts of charity as substitutes for rights guaranteed by public systems, to achieve meaningful change will require a repoliticization of care. This must be linked with mass movements to demand public investment in universal health care and, even more importantly for public health, infrastructures for everyday nonmedical care that are essential for preventing disease and shrinking the currently elephantine footprint of reactive US medicine.

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Comment:

By Ana Malinow, M.D.

In a fiery “Invited Commentary.” Eric Reinhart responded to a concurrent article on lopsided housing affordability and resident salaries in JAMA Network Open. Reinhart blasts medical training exploitation for its “high medical-education costs, undercompensation, excessive work hours, and an infantilizing hierarchical culture characterized by intensive personality policing under the veneer of racist, misogynistic, and classist professionalism norms and their self-defensive moralisms.”

Wow.

The effort Reinhart believes would best achieve the “political education of US physicians” is the unionization movement currently taking hold in many institutions training residents today. He rightly maintains that by unionizing, residents have a chance to better their own working conditions, with spillover effects into better patient care.

But the goal of unionizing residents goes further to open the eyes of future doctors, who for too long have been blind to the paradox that is their training and the health care system in which they work.

For the last 100 years, Reinhart rightly asserts, the medical education of doctors has been political, but not in the way that raises awareness, but one that is “overwhelmingly conservative, profoundly uncritical, and reflexively protective of an ethically bankrupt field that has spent a century building up a capitalist health care industry.” It has been an anti-solidarity education that lulls doctors with the expectation of lucrative salaries and social position into complicity, working silently and thus propping up a health care system that immorally puts profits over patients. US physicians “have been professionalized into a convenient political nihilism” instead of questioning the paradox under which they labor. They accept, buttress, and uplift the for-profit, market-driven, repulsive health capitalism we call the U.S. health care system.

“Medical trainees deserve an explicitly political education,” Reinhart concludes, that “must be linked with mass movements.” This call must be heeded now more than ever, as for-profit insurance companies, private equity, venture capitalists, and corporations such as Amazon and Best Buy devour what is left of our public programs (Medicare and Medicaid especially), hospice, emergency departments, independent physician practices, and community and rural hospitals. An Obama-era scheme called “value-based payment” (VBP) is spreading across our health care system like wildfire, buttressing the profit-takers and, like wildfires, leaving widespread destruction behind. With the collusion of the Centers for Medicare and Medicaid Services, VBP and its corporations will soon take over the last bastions of non-corporate care provision and truly public financing, traditional Medicare and the Veterans Health Administration.

Through unionization, physicians begin to understand that extending care beyond the clinic into the community “hinges on power and policy” and beyond that, leads to “political organizing and struggle.” As physicians, we must join and amplify grassroots organizations that are fighting to end privatization of our public programs through local organizing, mobilization, and direct action. This grows the mass movement we need to achieve national single payer and end the paradox we serve. It would be a profoundly valuable use of physicians’ high incomes and social standing.

Reinhart’s is an incisive, impressive, and important essay, which I implore every physician to read. It’s a critical piece of our medical education.

http://healthjusticemonitor.org…

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Summary: Surprise, surprise – our fragmented, profit-driven, gap-permeated health insurance “system” leads to terrible consumer experiences accessing health care. It’s time, finally, to adopt a simple, efficient and generous solution – single payer.

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Survey of Consumer Experiences with Health Insurance, KFF, June 15, 2023, by Karen Pollitz, et al.

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Key Findings:

• Most insured adults give their health insurance positive ratings, though people in poorer health tend to give lower ratings. … 84% of people who describe their physical health status as at least “good” rate insurance positively, compared to 68% of people in “fair” or “poor” health.
• Despite rating their insurance positively, most insured adults report experiencing problems using their health coverage; people in poorer health are more likely to report problems. A majority of insured adults (58%) say they have experienced a problem using their health insurance in the past 12 months – such as denied claims, provider network problems, and pre-authorization problems.
• Nearly half of insured adults who had insurance problems were unable to satisfactorily resolve them, with some reporting serious consequences.
• Among those with the greatest mental health needs, many adults across insurance types find their coverage lacking and report forgoing needed care. Among insured adults who report being in “fair” or “poor” mental health, four in ten (43%) say there was a time in the past year when they did not get mental health services or medication they thought they needed …
• Affordability of premiums and out-of-pocket costs are a concern, particularly for those with private health coverage, and for some, contributed to not getting care.
• Insured adults overwhelmingly support public policies to make insurance simpler to understand and to help them avoid or resolve insurance problems.

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Adults with Medicare are the most positive in their overall ratings with nine in ten (91%) rating their coverage positively, including half who say it is “excellent.”

Marketplace enrollees, regardless of health status, are the most likely to rate their insurance negatively.

Over the years, Congress has enacted a number of measures to make health insurance more understandable and easier to navigate, and to hold health insurers and public programs accountable for the coverage they promise. Alone, these measures are unlikely to eliminate all the problems people encounter with health insurance, especially those related to affordability, but they may help to reduce somewhat the dizzying complexity of health insurance in the U.S. And they may inform oversight so that regulators can better monitor how well insurance works when people need to use it. At the same time, stronger oversight and accountability could entail more administrative costs – a trade-off we did not probe in this survey.

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Comment:

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

This comprehensive survey should be read in its entirety to understand the startling inadequacy of US health insurance under our complex combination of public and private plans and no insurance at all. Despite its failings, it is the most expensive health system of all nations.

One of the major deficiencies in our system is the very high administrative costs which waste funds that could be filling the voids in care, so it is ironic that Congress responds to the recognized problems with even more administrative burdens. Which “may help to reduce somewhat the dizzying complexity of health insurance in the US” … wow, how low can we set expectations?

Viewing the report, much of the problem lies with the tools used by the private insurance industry, but when you think about that, it is not too difficult to understand why. Private insurance is designed primarily to make generous profit for the owners – the billionaire shareholders whose goal is further wealth accumulation. On the other hand, truly public insurance is owned by the people of the nation and is designed specifically to deliver health care to those who need it.

When you read the findings, it’s obvious that all we would have to do to correct the deficiencies is to make the entire insurance program public. The simplest, most efficient, most effective, and most equitable way would be to enact and implement a single payer (an improved Medicare for All) that includes everyone, a single payer that we, the people, own. The problems listed in the Key Findings above would melt away.

But this does mean that elected leaders would have to put in place policies that serve the people rather than the private insurers and their investors. This last point we must tackle seriously now. Really! Access to health care is at stake, as the report vividly describes.

http://healthjusticemonitor.org…

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Summary: The corporate takeover of medicine has forced doctors to deviate from their healing mission to attend to financial optimization for their employers. This is indeed a moral crisis. Harkening back to the huge benefit that Medicare offered seniors 57 years ago reminds us of the universal medical access and health focus we would achieve with Medicare for All.

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A Moral Crisis of America’s Doctors, The New York Times, June 15, 2023, by Eyal Press

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The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.

In July, 2018, psychiatrist Wendy Dean published an article with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Doctors on the front line of America’s profit-driven health care system were susceptible to such wounds as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults. It can be seen in emergency rooms that were understaffed because of budgetary constraints. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. The staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms.

As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.

Young doctors are noticing how the emphasis on the bottom line routinely puts them in moral binds, and they in particular are contemplating how to resist. “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. “Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are a part of the betrayal. They’re the instruments of betrayal.”

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Comment:

By Don McCanne, M.D.

Well, this is depressing. Read the full article if you’re in the mood to be in a funk. But does it really have to be this way? Do we have to put up with a health care financing system that is causing moral injury? I think that the clear answer is “no,” and I have proof.

My twin and I joined our father and brother in practice in 1966, a few months before Medicare was initiated. Just imagine what took place for our patients over 65. Suddenly essentially all financial barriers to care were removed for that patient population. We could get them all of the care that they needed. It didn’t take me long to figure out that we should expand Medicare to cover everyone, and I’ve been advocating for it ever since.

In the meantime, corporatization, such as with the Medicare Advantage plans and ACO REACH, has played havoc with the program, and CMS is continuing in that vein such as with the forthcoming 10 year “Making Primary Care” experimental program. But that does not mean that we cannot reverse these nefarious aberrations and reestablish Medicare as a traditional health care financing program like it was before, even better than other private and public insurance plans were before greed became the primary driving force.

Obviously we need reform. Absent politics, the easiest step to correct almost all of our deficiencies would be the enactment and implementation of a single payer financing system. It will be difficult to design the system to reduce the impact of corporatization so that the funds go to patient care rather than private investors. But it sure would be nice to have a health care financing system like it was for our senior patients in 1967. No longer would our young physicians feel like they are instruments of betrayal.

http://healthjusticemonitor.org…

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Summary: An excellent op-ed in the New York Times properly highlights lessons from other wealthy nations. Diving deeper into those examples reveals that single payer is the only plausible path to achieving efficient and equitable health care financing in the US.

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I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours, New York Times, June 14, 2023, by Aaron E. Carroll

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[H]ealth care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings. …

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore. …

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do. …

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services. …

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system. …

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. …

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

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Comment:

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

Dr. Carroll offers many cogent observations: the failure of our health system, the paramount importance of universal coverage, the valuable role of public providers, and the wisdom of investing in non-medical social welfare programs. He appropriately highlights admirable examples of universal coverage in other wealthy countries. I even accept his observation that the Canadian single payer system isn’t the most popular among single payer approaches.

What he fails to do is note the critical features of successful national insurance systems. Here they are:

1) Universal coverage with an identical broad benefit package. That is, everyone has the same excellent coverage, and the same payment rates. This is a far cry from universal coverage as defined in the US. It is essential for both equity and efficiency.

2) This universal coverage is provided by the government or not-for-profit insurers. Even in Switzerland and the Netherlands, cited as examples for feasibility of a private insurance model, these insurers provide standard comprehensive benefits without taking profit. He alludes to the not-for-profit highly regulated use of insurers. But he fails to point out that this model has nothing to do with how US private insurers operate.

3) Additional private insurance, such as for access to more providers or to cover cost-sharing, is a very small portion of total health spending, typically just a few percent. It’s the exception, not the system; the frill, not the core.

4) Cost-sharing is low, maximum hundreds of dollars instead of thousands or tens of thousands in the US. That’s critical for access to care, with nearly half of adults delaying or skipping care for financial reasons.

5) Providers deal with only one payer, instead of dozens here. This allows them to focus on clinical care instead of payment activities, which currently consume about 15% of US health care costs.

6) Drug prices and provider payment rates are regulated and negotiated centrally. This assures reasonable prices, not the outlandish levels so often seen in the US.

So … if the US is to learn from foreign experience, as it should, it’s not just about universal coverage. It’s about excellent identical insurance, with no profit motive, no or little cost-sharing for patients, simplicity for providers, and negotiated uniform prices. Our private insurers don’t and can’t align with these essential conditions. Ergo, single payer.

http://healthjusticemonitor.org…

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Summary: CMS is proposing a 10-year comparison of primary care payment models (fee-for-service and capitation, with support for care delivery systems). At first glance, why not? On closer scrutiny, this is another delay for an experiment in our current flawed system that will yield limited and equivocal results. Let’s focus on real reform.

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Making Care Primary (MCP) Model, Centers for Medicare & Medicaid Services, June 8, 2023

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On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. Launching July 1, 2024, the 10.5-year model will improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months.

To support team-based care, MCP will include prospective payments for primary care that will reduce organizations’ reliance on fee-for-service payments. Risk-adjusted enhanced services payments, which will also be paid prospectively and represent an additional investment in primary care, will allow participants to expand care management, screen for health-related social needs, and integrate with specialty care.

Track 1 – Building Infrastructure. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants can begin earning financial rewards for improving patient health outcomes in this track.

Track 2 – Implementing Advanced Primary Care. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities. Participants will be able to earn increased financial rewards for improving patient health outcomes.

Track 3 – Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2, to sustain care delivery activities while participants have the opportunity to earn greater financial rewards for improving patient health outcomes.

To be eligible to participate in MCP, an organization must be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.

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Comment:

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

At first glance, this may seem like a decent idea: explore different payment models for primary care within Medicaid and, if they agree, private insurers. Compare results over an extended period of time, between supplemented FFS, FFS-capitation, and fully capitated approaches.

But, then, it hits us: Here we go again! Ten more years of fiddling with a broken system, while avoiding real financing reform.

Of course, we need to ask, based on recent trends in Medicare and more broadly … who is going to own these “legal entities”? Private equity? The billionaires?

The hazards of capitation are clear: Increase the monthly payment level for providers who have better health outcomes, that is, healthy patients who may not need much care. And link these payments to diagnostic (up)coding via risk adjustment. The truly sickest and costliest patients can go elsewhere, to providers paid fee-for-service. Avoiding the chronically ill might not be the goal of the traditional health care providers with their Hippocratic traditions, but, under this CMS model, certainly it would be a primary goal of their entrepreneurial employers and their billionaire investors. That’s what we’ve seen in Medicare Advantage and in CMS ACOs.

If past experience informs, the benefits of new strategies will be modest and mixed, hard to interpret but with each slight drop in cost or isolated gain in outcomes lauded by CMS as major successes. Corporations will manipulate the evaluation findings to serve business purposes.

The unclear role of private payers is telling. What we need is primary care for all, not clunky semi-coordination of different payers in a hard-to-interpret demonstration project.

Real reform can’t be off the agenda for the next decade, while we wait for this and other tweaks to our broken system. This CMS proposal requires a response from us. We already have a great start: Medicare for All legislation in both the Senate and the House (Thank you Sanders, Jayapal, Dingell, and the many others). We need to go to the streets, not with guns, but with our placards and loud, passionate voices! And this time, let’s not just go home when the shouting is done. Let’s complete the job!

http://healthjusticemonitor.org…

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Summary: Our medical system defines efficiency as maximizing revenue-generating care. This compromises clinical interactions and indeed access to care, as highlighted in today’s excerpts. Single payer defines efficiency as eliminating wasteful non-clinical tasks and paying fair prices … to achieve universal access to high quality care.

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Twitter post (video 2 min), Dr. Mark Lewis (@marklewismd), May 28, 2023

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This son of a preacher man worries that he’s losing both the spirit of medicine and the identity of the patient when we reduce clinical encounters to measurable (and, not coincidentally, billable) “value units.”

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This Nonprofit Health System Cuts Off Patients with Medical Debt, New York Times, June 1, 2023, by Sarah Kliff and Jessica Silver-Greenberg

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Doctors at the Allina Health System, a wealthy nonprofit in the Midwest, aren’t allowed to see poor patients or children with too many unpaid medical bills.

Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.

But a wealthy nonprofit health system in the Midwest is among those taking things a step further: withholding care from patients who have unpaid medical bills.

Allina Health System, which runs more than 100 hospitals and clinics in Minnesota and Wisconsin and brings in $4 billion a year in revenue, sometimes rejects patients who are deep in debt, according to internal documents and interviews with doctors, nurses and patients.

Although Allina’s hospitals will treat anyone in emergency rooms, other services can be cut off for indebted patients, including children and those with chronic illnesses like diabetes and depression. Patients aren’t allowed back until they pay off their debt entirely. …

About 20 percent of hospitals nationwide have debt-collection policies that allow them to cancel care, according to an investigation last year by KFF Health News. Many of those are nonprofits. The government does not track how often hospitals withhold care.

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Comment:

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

Efficiency is good. That view is integral to my identity as a health economist. By efficiency, I mean the ability to achieved agreed-upon goals with the fewest possible resources, via minimized waste. Put differently: to maximize reaching our goals with the resources we have. In health care, to raise access to care and reduce disease.

Yet in today’s health care system efficiency is used in the service of revenue and profit. Provider organizations are adept at using “relative value units” (the payment unit for outpatient care) and aggressive billing practices to maximize revenue. Even not-for-profits adopt these industry norms and practices. The result is reduced time with patients and, as we see with Allina, denial of care access. This harm affects physicians too: burnout from intense work conditions and the moral hazard of providing suboptimal care.

My colleague, retired gastroenterologist and long-time single payer advocate John Roark, puts it very well: “Business profits have commandeered something that’s laudable. Corporations, rhetoric aside, aren’t really interested in other things. It’s much more likely that with single payer the health care system would make a more honest attempt to treat human beings as human beings.”

Right on, John. Treat human beings as human beings, not revenue centers to be pursued and cost centers to be shunned.

http://healthjusticemonitor.org…

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Summary: The author of Sickening: How Big Pharma Broke American Health Care and How We Can Repair It trenchantly describes the fiscal and health damage done to the US from the medical-industrial complex. He calls for transcending ideologies and parties to fix the problems. We say, yes, let’s join in a middle way to provide all with health care and fund it collectively.

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America’s Broken Health Care: Diagnosis and Prescription, Imprimis, A Publication of Hillsdale College, February 2023, by John Abramson

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By 2019, prior to COVID, life expectancy in the U.S. had fallen relative to that in the other countries so much that 500,000 Americans were dying each year in excess of the death rates of the citizens of those other countries. To exclude poverty as a factor in these numbers, a study looked at the health of privileged Americans—specifically, white citizens living in counties that are in the top one percent and the top five percent in terms of income. This high-income population had better health outcomes than other U.S. citizens, but it still had worse outcomes than average citizens of the other developed countries ….

Now combine this with the fact that we in the U.S. are paying an enormous excess over those other countries on health care. In the U.S., we spend on average $12,914 per person per year on health care, whereas that figure in the other comparable countries is $6,125. …

Which means that our health care system is broken and needs fixing.

Prior to leaving office in 1961, President Eisenhower famously warned the nation about what he called the “military-industrial complex.” I suggest that we now have a medical-industrial complex that is sucking America’s wealth away from the other things that will make us healthier and create better lives for the American people. …

Big Pharma is comprised of for-profit companies. The job of for-profit companies is to maximize returns to their investors. Accusing drug companies of being greedy is like accusing zebras of having stripes. They are doing their job, and we’re not going to change them. So it is our job – not only doctors, but the American people as a whole – to insist on guardrails to ensure that the pharmaceutical industry serves, rather than harms, public health.

What is needed is very clear. First, we need to ensure that the evidence base of medicine is accurate and complete, which requires independent, transparent peer review. Second, we need to implement health technology assessment, so that we and our doctors know which drugs and devices are the most effective. Third, we need to control the price of brand name drugs.

This is not rocket science – so why doesn’t it happen? Largely because the greatest bipartisan agreement among our political leaders is that it is fine for them to accept large contributions from drug companies. Huge amounts of money flow about equally to Democrats and Republicans. This is why meaningful reform will require the formation of a coalition of Americans to demand action. And a plea I would make is that people on the conservative side who have an aversion to government and people on the progressive side who have an aversion to free markets come together with open minds to find a middle way to solve the problem of declining health and spiraling costs.

We need to transcend our ideologies – to think of the good for our country and its people on this issue. Neither the people who tend to the Republican side alone nor the people who tend to the Democratic side alone will be able to break up the medical-industrial complex that has a stranglehold on American health care. Instead of focusing on our disagreements, we need to focus on what we agree about – namely, that it would be better if Americans were healthier and didn’t spend over twice as much money (much of it to little or no benefit) on health care as citizens of other wealthy nations.

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Comment:

By Don McCanne, M.D.

The United States has the most expensive health care system with the poorest outcomes of all wealthy nations, and it seems to be due to ideological divisions in our preferences for conservative concepts of free markets in health care versus progressive concepts of government control of those markets.

Dr. Abramson suggests that “people on the conservative side who have an aversion to government and that people on the progressive side who have an aversion to free markets come together with open minds to find a middle way to solve the problem of declining health and spiraling costs.”

What if we sat aside concepts about government versus markets and agreed simply upon making health care available to everyone and agreeing to join together to fund that care? That seems to be an entry to a middle way as long as we don’t get hung up on labels of markets versus government. We’re all still the same people interacting together.

If we still feel a need to get into useless disputes, we can argue over horses, zebras and stripes.

http://healthjusticemonitor.org…

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Summary: With the acquisition of One Medical, Amazon becomes a primary care middleman. It wants to access your medical records and sell the data, sacrificing your privacy.

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To become an Amazon Clinic patient, first you sign away some privacy, Washington Post, May 1, 2023, by Geoffrey A. Fowler

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This Amazon form is asking for something more extraordinary: “use and disclosure of protected health information.” It authorizes Amazon to have your “complete patient file” and notes that the information “may be re-disclosed,” after which it “will no longer be protected by HIPAA.”

Wait, you agreed to what? Amazon is essentially pushing people to waive some of their federal privacy protections, say the lawyers at the Electronic Privacy Information Center whom I asked to inspect the jargon. Amazon is required by law to say doing so is voluntary — but in practice you must agree to become a patient at its Clinic. There’s only one button to click: “Continue.”

What could go wrong? There are lots of icky ways Amazon could use your health information: to upsell you on other services, to target marketing for its giant advertising business, or to build out artificial intelligence or patient-risk models.

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What you really give away when you sign up for Amazon Clinic, Komando.com, May 2, 2023, by Albert Khoury

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Though Amazon declares it’s “compliant with HIPAA and all other applicable laws and regulations,” there’s more to the fine print.

When you sign up for treatment through Amazon Clinic, you “authorize” all entities involved. This includes doctors, pharmacies and labs to share your Protected Health Information (PHI) with Amazon.

Here’s what constitutes PHI:

• Contact Information (for example, email address).
• Demographic Information (for example, date of birth).
• Account and Payment Information (for example, insurance information).
• Your complete patient file, including medical and billing records related to the services that any HCP supplies to you through Amazon Clinic.

Amazon has the right to “retain, use and disclose this information” for two purposes: If an HCP you used through Amazon Clinic no longer provides service there, Amazon will “coordinate healthcare services” on your behalf. How nice of them.

Here’s the kicker: Amazon can use your PHI “in relation to any Amazon services” to “facilitate services from other providers.” Who exactly are these providers? Doctors? Other businesses?

Amazon Clinic is not actually a clinic. It’s a service that connects you with third parties such as HealthTap, HelloAlpha and SteadyMD, delivering telehealth services with clinicians.

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Amazon Clinic Chief Sees Intersection of Retail and Healthcare, PYMTS, April 6, 2023

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The future of healthcare will look a lot more like retail with customer experience coming first and artificial intelligence (AI) playing a larger role in that transformation.

These were among the takeaways from a series of discussions during the CNBC Healthy Returns 2023 Summit last week, as leaders from healthcare, Big Tech and the investment world discussed how the consumerization of healthcare and applications of AI will transform healthcare as we know it, in some cases on a time horizon of as little as three years.

Amazon Clinic Chief Medical Officer and General Manager Dr. Nworah Ayogu said during his segment that one reason many people are not receiving needed care is access, which Amazon is addressing with acquisitions like One Medical and its expanding network of retail clinics.

“I would think of Amazon Clinic as a marketplace, similar to what Amazon does well on its retail site, connecting buyers and sellers to the products they need,” Ayogu said. “I think we’re doing the same thing with Amazon Clinic. I would think of it more as a marketplace where you can find providers and provider groups for your issue.”

… As for broader implications for Big Tech bringing AI into the healthcare space, (Breyer Capital CEO, Jim) Breyer said, “My personal view over the last 12 months is that our mega-cap companies … are not just doubling or tripling down on healthcare and medicine. It’s 10x 50x over the next couple of years.”

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Comment:

By Steve Auerbach, M.D.

Those of us who read JAMA or NEJM, or even Health Affairs, are clearly reading the wrong journals to keep up with healthcare practice in the United States. Unfortunately to find out who and what is controlling healthcare one needs to read business and finance articles like the above. You will learn that Amazon, the online retail conglomerate and data-mining company, which has been expanding into healthcare for years, has been marketing their so-called Amazon “Clinic” in anticipation of their purchase of OneMedical. I received an unsolicited email to sign up.

Amazon Clinic is both more and less than meets the eye. It is less because it is not a clinic, but just a virtual message-based service that connects consumers with third-party telehealth providers. It is more because, in return for connecting you to third party partner telehealth companies (such as HealthTap, Hello Alpha, and SteadyMD … which you could sign up for directly), Amazon requires you to you to “authorize” data sharing. That is, all entities involved can share all your protected health information (contact info, demographics, financial and medical records) with any service they connect you with and  “retain, use and disclose this information to ‘coordinate healthcare services’ on your behalf and to ‘facilitate services from other providers.’” This applies for Amazon itself and any other company with which they do business.

And this being Amazon, they can then link your healthcare data with all of your other Amazon purchase, search, and financial and credit data. Amazon’s power comes from their combination of self-interest and self-dealing: The same company sells drugs, medical supplies, medical equipment, and data. So no doubt your medical and other personal data will be linked back to all the other data they and their business partners have collected on you.

What could possibly go wrong? And since the Supreme Court’s decision in the Sorrell v IMS Health and similar decisions, “corporate free speech” overrides privacy and protection concerns.

We need, and could have, guaranteed access to universal healthcare, paid for through progressive taxation affordable for all and without point of service financial or administrative barriers. The overall system would be publicly accountable while leaving the doctor-patient relationship between just the doctor and patient.  We don’t want to turn our entire lives over to corporate overlords. We need to support national M4A and local single payer movements, while also working with anti-privatization and anti-monopoly allies to fight the hyper-financialization of our health care and lives.

http://healthjusticemonitor.org…

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