Summary: Since 2017, for the first time, US child and young adult deaths from firearms exceeded those from motor vehicles. Why? Because we’ve improved car safety, and failed abysmally to improve gun safety. Why? Because gun organizations have opposed research and regulation. This must change.

Crossing Lines — A Change in the Leading Cause of Death among U.S. Children, New England Journal of Medicine, April 16, 2022, by Lois K. Lee et al.

Injuries are the most common cause of death among children, adolescents, and young adults between 1 and 24 years of age in the United States; indeed, injuries are responsible for more deaths among children and adolescents than all other causes combined. For more than 60 years, motor vehicle crashes were the leading cause of injury-related death among young people. Beginning in 2017, however, firearm-related injuries took their place to become the most common cause of death from injury. This change occurred because of both the rising number of firearm-related deaths in this age group and the nearly continuous reduction in deaths from motor vehicle crashes. The crossing of these trend lines demonstrates how a concerted approach to injury prevention can reduce injuries and deaths — and, conversely, how a public health problem can be exacerbated in the absence of such attention. Between 2000 and 2020, the number of firearm-related deaths among children, adolescents, and young adults increased from 6998 to 10,186, according to the Centers for Disease Control and Prevention (CDC).

In 2000, motor vehicle-related injuries resulted in 13,049 deaths among young people. Twenty years later, there has been a nearly 40% decrease, with 8234 motor vehicle traffic deaths recorded in 2020.

Although substantial federal funding has been devoted to research on motor vehicle crashes, the firearm industry and gun-rights organizations, led by the National Rifle Association (NRA), have been effective at keeping federal dollars from financing firearm-related research. Between 1996 and 2019, little federal research funding was appropriated for firearm-injury prevention.

Comment:

By Don McCanne, M.D.

We do have some good news. Our industry designed to provide the beneficial essential task of transporting human beings has been effective in reducing injuries and deaths through better design of vehicles and improvement of public safety standards. The industry and our public stewards are to be commended.

On the other hand, we have an industry designed to produce detrimental lethal projectiles, and what do we do? We protect and embellish that industry to the degree that it has moved into first place as the most common cause of death among children and young adults.

Think about that. We sacrifice our children to an industry that many believe does not provide substantial benefit to society. We defer to gun-rights organizations despite broad public support for gun regulation.

Look at the tremendous gains we made with traffic safety – for an enormous industry that is essential to our commerce. The gun industry? Some of us wish it would disappear, but since its preservation seems assured, let’s focus on harm mitigation. The horrendous record on injury and death tells us we’re long past due for accelerated research and regulation to improve safety. Our children deserve no less, especially after seeing the tragic consequences of our decades of delay.

http://healthjusticemonitor.org…

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Summary: The Healthy California for All Commission issued a final report laying out the huge benefits to be derived from “unified financing” – one payment mechanism for all health care. Costs down, health care up. The impressive affirmation of fundamental principles plus technical findings bolster efforts for single payer.

Key Design Considerations for a Unified Health Care Financing System in California, Report to the Healthy California for All Commission, April 2022

[T]he concept of unified financing [UF] describes a statewide system to arrange, pay for, and assure health care in which:

• All Californians will be entitled to receive a standard package of health care services;
• Entitlement will not vary by age, employment status, disability status, income, immigration status, or other characteristics; and
• Distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage will be eliminated within the system of unified financing.

The analysis done in connection with the Commission’s work found that:

• Under almost all scenarios analyzed, in the first year of implementation unified financing is expected to result in lower total health care expenditures than under the status quo;
• If, as expected, UF reduces the rate of growth of health spending, savings over time would be achieved under all scenarios examined, even when long-term care services and supports (LTSS) are included as covered services;
• Assuming that the federal and state governments support UF at the level they would have supported under status quo fragmented financing, the savings from UF will accrue to California employers and households, who will on average pay less to support UF than they pay in the status quo;
• Financing can be stable over time, but will depend on controlling cost growth and securing agreements with the federal government about the rate of growth in federal payments.

Next Steps …

4. Role of Health Plans: Evaluate whether health plans under the status quo add value by furthering access, affordability, quality and equity while accounting for excessive administrative costs and profits and burden on providers. If health plans are retained and reimagined under UF, what functions would they perform?

5. Uniform Clinical Data Record: [E]xplore the potential benefits …

Comment:

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

Don’t let the precise technical prose fool you – this is a full-throated endorsement of the critical core of single payer: unified financing for universal coverage. That is, replacing our cacophony of insurance products and uninsurance with 100% coverage with standard comprehensive benefits saves money while protecting family health and finances.

The Healthy California for All Commission is an outgrowth of AB 1400, and has been working hard since January 2020, guided by the State of California and supported by University of California experts. The single payer voice within the Commission was strong, and came through in this report’s principles and findings.

Importantly, the report (Fig. 1) confirms that savings from simpler administration and lower drug prices (15.4%) exceed increases in utilization (11%, or 7% if income-related copays). This is the pivotal dynamic and irresistible appeal of unified financing: streamlining permits more health care, with net savings. It is the “free lunch” so rare in economics.

Thus, we move a little closer to single payer. The report lays out important next steps, both technical (e.g., better data on health spending) and bureaucratic / political (e.g., seeking federal waivers and cooperation).

Two tasks from the report excerpt above warrant emphasis:

Role of Health Plans: “excessive administrative costs and profits and burden on providers … if retained and reimagined, what functions?” Exactly. Health plans are an expensive & inexcusable drain on our current system. There is no evidence of net benefit. They should be eliminated entirely (in deference to direct fee-for-service), or radically restructured into claims processors.

Uniform Clinical Data Record: Ooh, I get to talk geeky. Currently we struggle with incompatible electronic health records and claims files. Assembling this information into one integrated data system would enhance patient care, research on treatment effectiveness, and detection of fraud and waste. Gotta love top notch data!

There remain many challenges ahead. But today I feel really good about the great State of California so clearly and unequivocally confirming the principles we’ve been fighting for.

http://healthjusticemonitor.org…

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Summary: An excellent commentary describes how two decades of paying to improve quality metrics has failed. Quality hasn’t improved, and we’ve spent billions of dollars and hours on quality indicators of dubious validity. We’ve compromised the practice of medicine, and increased disparities. Universal insurance is the foundation for improving quality.

Reassessing Quality Assessment – The Flawed System for Fixing a Flawed System, New England Journal of Medicine, April 13, 2022, by Lisa Rosenbaum, M.D.

[R]ecently, there has been growing recognition of the QI movement’s shortcomings. One study, for instance, showed that only 37% of MIPS measures for ambulatory internal medicine were valid, and even CMS and the Government Accountability Office have acknowledged the need to improve the quality of measuring quality. …

[O]nce a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure. Consultants get hired. Electronic health records (EHRs) are changed. And the measures become a source of intense organizational focus. Not only does it become difficult to modify measures that aren’t clearly working, but a tremendous amount of resources are directed toward the appearance of quality rather than its substance. …

[V]alue-based payment initiatives can also worsen inequities, even though addressing them ought to be at the forefront of our QI efforts. Indeed, after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties. In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. And hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.

Punishing the hospitals and patients most in need of support makes “zero sense,” says Wadhera. He notes the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices. And though such consequences create hard-to-quantify indirect costs, truly unquantifiable is the loss to society as consummate community physicians become a dying breed. “Community doctors want to practice medicine,” said Wadhera. “They don’t want to practice quality measurement.”

Some early QI leaders recognized the risk of demoralizing the workforce.

Comment:

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

This thoughtful perspective highlights critical points about our efforts to improve quality with financial incentives, often under the rubric of “value-based care”.

First, financial incentives largely failed to improve quality. There have been a few focal benefits, but rare.

Second, they harm the practice of medicine, by distracting physicians from a focus on clinical care to documentation of quality metrics.

Third, and related, the imperative to increase revenue with quality scores makes coding even more onerous. Unwelcome added time in the EHR is the result.

Fourth, medicine “plays to the code” – any modest gains in measured tasks result in less attention to important quality activities that aren’t in the metric set.

Fifth, the onerous requirements for all this coding, too much for small physician offices, instigated a shift to corporate ownership of providers. That increases costs. (And makes medicine more corporate, which many of us dislike.)

Finally, disparities – inferior resources for the poor and sick – are exacerbated. Exactly the opposite of what we want.

The poor theoretical basis of financial incentives in medicine was pointed out long ago, by among others two HJM bloggers and a behavioral economist. Financial incentives diminish the intrinsic motivation that is so widespread and valuable in medicine.

Recently, several leaders in quality improvement described well the failings of numerical quality scores and proposed a new “criterion” approach. The details need working out, but the move away from competitive scoring linked to reimbursement is very welcome indeed.

The other critical element of improving quality is to remove the distraction of missing, inadequate, and inconsistent insurance. Just cover everybody, with exactly the same benefits and same payments. (Single payer!) Let physicians focus on their clinical mission, provide resources to help them keep improving, and measure success with non-punitive outcome tracking and by talking with patients.

http://healthjusticemonitor.org…

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Summary: More fetuses and babies are dying from syphilis, a completely preventable outcome with adequate access to quality prenatal care. This is a another marker of failure of our systems for health care financing and public health.

Babies Die as Congenital Syphilis Continues a Decade-Long Surge Across the US, California Healthline, April 12, 2022, by Anna Maria Barry-Jester

For a decade, the number of babies born with syphilis in the U.S. has surged, undeterred. Data released Tuesday by the Centers for Disease Control and Prevention shows just how dire the outbreak has become.

In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.

About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness, and organ damage.

“The really depressing thing about it is we had this thing virtually eradicated back in the year 2000,” said William Andrews, a public information officer for Oklahoma’s sexual health and harm reduction service.

From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.

Comment:

By Don McCanne, M.D.

Though we spend far more per capita on health care than any other nation, we have a flawed health care financing system that leaves millions who are insured in financial hardship and millions more with no insurance coverage at all. We finance our health care delivery system in a manner designed to create personal wealth for a few while failing to ensure health care access for all.

At least in the past we could be proud of some of the basics of our health care system such as the provision of prenatal and other public health services that reduced afflictions such as congenital syphilis. But public health capacity has decreased, and recent statistics demonstrate that we are moving backwards even in basic disease control that we previously took for granted. Shockingly, maternal mortality is also rising.

So where are we? Our partly public health care financing system is becoming more privatized, and our health care delivery system is experiencing increasing dominance by private equity firms and other corporate middlemen. And now our public health delivery is becoming more reliant on the private sector. On all three levels – our system of financing health care, ownership of health care delivery, and our support of our public health services – we are failing. We spend enough money (the public’s money either directly or indirectly) but fall short on much-needed public oversight.

One little niche in which we are beginning to fulfill the American entrepreneurial dream – the manufacture and marketing of infant caskets. (Excuse me while I attempt to wipe the tears from my eyes.)

http://healthjusticemonitor.org…

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Summary: Investigative reporting by Bloomberg highlights the work of whistleblowers and the federal government to combat fraudulent upcoding by Medicare Advantage plans. But Medicare itself greatly worsens the problem, by failing to properly regulate aggressive (largely legal) upcoding.

Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say, Bloomberg, April 12, 2022, by John Tozzi

Each year, [Medicare Advantage] plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC. …

The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” …

Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them. They mine data from patient charts, send staff to do health-risk assessments in patients’ homes and prod doctors to review potentially missed diagnoses. …

By 2011, Group Health’s finances deteriorated, and it was facing downgrades from credit raters. That fall, Group Health’s chief executive officer met a counterpart from a Buffalo plan called Independent Health, which had just formed a new subsidiary focused on risk adjustment called DxID. …

[Whistleblower] Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

The plan got paid for one patient’s depression diagnosis even though a physician said it had resolved and the patient now had “an amazingly sunny disposition,” according to Ross’s complaint. It claimed another patient had kidney complications from diabetes even after a doctor had explicitly ruled that diagnosis out.

Comment:

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

This article highlights how even the most respected HMOs, like Group Health and Kaiser, fall prey to the temptations of increased revenue from highly suspect diagnostic upcoding practices. It’s terrific that whistleblowers and the federal government team up to catch and punish offenders, and perhaps discourage others.

However, the real money isn’t in the fraud, it’s in the legal upcoding that Medicare Advantage plans do and Medicare (CMS) fails to properly regulate. It’s well understood that MA plans have a much greater incentive than traditional Medicare to find and document diagnoses, because these added codes raise the capitation payments to MA whereas they don’t affect traditional Medicare reimbursements. CMS knows about this bias, and is permitted to adjust the payment levels to counteract it. But they put a cap on the size of the adjustment, even as upcoding grows rapidly in magnitude. The difference between upcoding and the allowable adjustment represents pure profit for MA plans.

The amounts at risk are staggering. CMS estimates $100 billion so far. Rick Kronick, a prominent health policy researcher, looks at trends and estimates a far greater toll in years to come. In a Nov 2021 article on the impact of sharply rising Medicare Advantage coding intensity he estimated that “total Medicare payments to MA will be $600 billion higher over the 2023-2031 period than … if the coding intensity adjustment were set [accurately] … $85 billion will be paid by beneficiaries in higher Part B premiums, and $515 billion in higher net Medicare spending.”

That’s highway robbery (by the MA plans) and dereliction of duty (by CMS).

Risk adjustment is being massively gamed by private insurers. Time to change the game, to single payer.

http://healthjusticemonitor.org…

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Summary: The electronic health record is now ubiquitous. Doctors complain about its time demands and its emphasis on billing. This review quantifies that burden – more than 4 hours per day, far higher than in countries with simpler insurance.

How much time do physicians spend in the EHR?, KevinMD, April 10, 2022, by Thrisha Gogineni, James G. Kahn, Sigal Maya

Doctors often find the Electronic Health Record (EHR) time-consuming and annoying. … We assembled evidence on hours dedicated to the EHR each day by physicians. The result is impressive – 4.5 hours.

Ninety percent of office-based physicians in the US use an EHR system. However, many report negative experiences. Two recent studies found that physician EHR effort lowers clinical focus and contributes to burnout. EHRs are often described as having poor usability and being unintuitive and inefficient, detracting from clinical focus and sometimes even leading to patient harm.  These systems also decrease collaboration and communication between doctors and nurses.

… To estimate the magnitude of EHR burden in the U.S. and potential savings with streamlined EHR function, we collated existing published evidence. …

The figure summarizes what we found. Median daily physician EHR time ranged from 3.5 to six hours with the observation, log file, and web tracking methods. … The time burden of the EHR in US was significantly higher than in other countries where reported daily EHR time was one hour.

This is a striking amount of time.

Greater demands in the U.S. for billing and regulation related documentation contribute to the excess time burden of EHR systems compared with other countries. …

Only half of a doctor’s day remains for direct clinical interactions with patients.

The essential lesson from this EHR evidence is that the time burden it imposes on physicians is substantial in the US, occupying hours that could otherwise be spent building truly meaningful relationships with patients (not “meaningful use” metrics!) and providing quality care.

Comment:

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

Doctors are forced to use the electronic health record, including entry of large amounts of clinically-irrelevant data, especially billing-related details about procedures and overly precise diagnostic codes. This degrades the clinical experience for doctor and patient alike.

This study (full disclosure: I’m an author) assembles evidence on the time burden. It is indeed large.

Although the EHR can improve access to medical information, it is a data-hungry beast that exacts a huge toll as measured in hours, clinical focus, communication quality, and quite likely clinical outcomes.

Single payer would permit us to streamline the EHR to focus on clinically relevant information, as in other wealthy countries.

(P.S. a podcast on this is coming, I’ll let you know)

http://healthjusticemonitor.org…

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Summary: “Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States. U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.” This says it all.

Health and Health Care for Women of Reproductive Age, The Commonwealth Fund, April 6, 2022, by Munira Z. Gunja et al

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States.

U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

U.S. women of reproductive age have among the highest rates of multiple chronic conditions and the highest rate of mental health needs.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands.

Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons. America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.

Comment:

By Don McCanne, M.D.

How is the United States doing in providing adequate health care for its residents? Let’s just look at women of reproductive age – a group that plays such an important role in family and community life and should not be afflicted by medical risks more characteristic of older age.

Compared to other wealthy nations that spend less on health care than us, our record is miserable. Not only do our insurance programs leave many unacceptable gaps in coverage, we leave ten million women with no insurance coverage at all, thus potentially unnecessarily exposed to physical and financial suffering and even death. We are already spending the funds that could prevent this, but we are spending them on the wrong health care financing system – a highly dysfunctional, fragmented system designed to benefit venture capitalists and private equity investors, with insurance and much patient care being primarily a tool to enable wealth accumulation.

We are spending enough money to do it right, but it appears that our health care infrastructure is now so distorted by capital interests that even single payer Medicare for All may not be enough to ensure adequate health care for all. Maybe all of us, as communities, need to play a greater role. For those who missed it, several HJM contributors last week published an article in The Nation how communities, not corporations, should own our most vital health care assets.

With public financing and community control, women of reproductive age would no longer have to worry about their own health care access and affordability, and also would no longer have to worry about health care for their loved ones, or for everyone else.

Maybe women are best positioned to lead the march toward health care justice for all.

http://healthjusticemonitor.org…

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Summary: An excellent review of 12-year financial trends for the largest six insurers reveals: a) skyrocketing revenue and profits, b) based mainly on growth in the public insurance sector, and c) acquisition of pharmacy benefit plans. Half of Americans are in their plans.

A decade-long look at how Big Insurance profiteers American taxpayers and the sick, Wendell Potter NOW, April 4, 2022

Those six companies–Anthem, Centene, Cigna, CVS/Aetna, Humana, and UnitedHealth–are massively bigger today than they were 12 years ago [when the ACA was passed] as a result of numerous mergers and acquisitions and a new love interest: the government. In 2010, the companies took in a combined total of $245.2 billion dollars in revenue. Last year, that number had more than quadrupled to $1.1 trillion. …

Two of those companies–United and CVS/Aetna–have grown so fast they have leapfrogged into the top five of the Fortune 500 of America’s biggest companies. Only Walmart, Amazon and Apple took in more money last year than those two companies. (Cigna, the third largest in terms of revenue and my former employer, is now the 13th largest on the Fortune list.)

The big six insurers’ profits have soared along with their revenues. Last year they made $60.7 billion in profits collectively, compared to $16.9 billion in 2010. …

Relatively little of the six companies’ growth in health plan revenues and profits has come from private paying customers. By far most of the money they now collect to administer health plans comes from us as taxpayers. That’s because all of the companies have shifted their focus away from the private sector and toward various government-funded programs: Medicare, Medicaid, federal employees and the military. …

In 2010, 16.9 million Americans were enrolled in the Medicare Advantage, Medicare supplement and Medicaid plans operated by the big six. In 2021, that number had increased by 46 million–373%–to 63 million. …

Thanks to the many mergers and acquisitions since then, one of every two of us are now enrolled in one of their health plans. (And 31.1 million of us remain uninsured.) …

AND THEN THERE IS …

The Big Three of the Big Six make more money “managing” Americans’ prescription medications than by administering our health insurance plans. Aetna supersized itself when it merged with CVS, which operates the country’s largest pharmacy benefit management [PBM] company, Caremark, in 2017. Cigna bulked up the next year when it merged with Express Scripts, the second largest PBM. And United’s fastest growing and most profitable division is Optum, which encompasses the country’s third largest PBM. Together, CVS, Cigna, and United control nearly 80% of the national PBM market. At all three companies, the PBMs now generate more profits than their health plan businesses.

Those three companies are also far bigger than the biggest company that actually makes prescription medications. Johnson & Johnson, the biggest U.S. drug company, ranks a distant 36 on the Fortune 500. To put that in perspective, J&J was #33 on the Fortune list in 2010. Cigna, which is now #13 was #129 in 2010.

Comment:

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

The Affordable Care Act will strengthen the hand of private insurers, single payer advocates said in 2010. Oh how I wish we’d been wrong.

Wendell Potter’s review highlights just how right we were. Half of us are enrolled in plans (both private and public) run by the top six insurers, with $1.1 trillion in annual revenues and $61 billion in profits. (Lest you think, oh, that’s not such a big profit margin, consider that the rate of return on real investment is 6 to 9 times higher.)

Most of the gains are for publicly funded programs, primarily Medicare Advantage and Medicaid Managed Care.

They’ve even taken over pharmacy benefit management companies (PBMs), which specialize in extracting more profits from health care.

All in all, a dismal state of affairs. Profits grow exponentially, while access to care and health outcomes plummet. Shareholders gain and beneficiaries lose.

Time for disintermediation. Seriously.

http://healthjusticemonitor.org…

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