By Brenda Gazzar
Code Wack Podcast, April 4, 2022

Why should people who have great health insurance care about people who don’t? Listen as guest Dr. Paul Y. Song, radiation oncologist and president of Physicians for a National Health Program – California, and host Brenda Gazzar, discuss the roots of America’s unequal healthcare system. Why did the Lyndon B. Johnson Administration develop two different public insurance programs – Medicare for retirees – and Medicaid for low-income people? How is that decision still impacting American communities over 50 years later?  What can we do now that would help?

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Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on our callous healthcare system, how it hurts us and what we can do about it. I’m your host Brenda Gazzar. This time on Code WACK! What are inequities in American health care and why should everyone – even those with great health insurance – be concerned about them? The truth is they can have far-reaching consequences for us all — impacting public health, creating conditions for the spread of disease and even hindering economic productivity. We recently spoke to Dr. Paul Song, president of Physicians for a National Health Program-California, about how the COVID pandemic highlighted these longstanding  inequalities and what the Biden administration can do about them.

Welcome back to Code WACK!, Dr. Song!

Q: We’ve talked a lot about inequities in health care. How do these inequities affect people of color specifically?

Song: Unfortunately, with regard to our healthcare system, the majority of disadvantaged communities of color are in the Medi-Cal system – very few work in jobs that provide real healthcare benefits. If you look at people who work at Walmart or some of those other stores, they don’t really get health insurance. So they’re asked to then get their health care through the government, which is through Medi-Cal, or many times through a subsidy, through the exchange, for which many of them can’t afford. And you know unfortunately we saw it again exposed during COVID is that when you saw the disproportionate amount of deaths among communities of color compared to white communities or more affluent communities, it really was a reflection of the long lack of health care that these people have had, meaning many of them had uncontrolled diabetes or high blood pressure that was uncontrolled. So when they got COVID, they were more likely to succumb to its effects.

At the same time, some of them, particularly frontline workers who were cleaning hotels or working grocery stores or in the food service industry or construction, many of them didn’t have health care and yet when they got sick, they couldn’t afford to go get tested. They couldn’t afford to go to the emergency room. They subsequently lived in multi-generational homes. They passed this on to all of the relatives in their houses and, you know, unfortunately it was very detrimental to communities of color disproportionately compared to everyone else.

Q: Right. And this is something that we’ve seen even before COVID, correct? COVID just kind of brought it to light even more.

Song: Correct and COVID just really did expose so much that’s broken and then you actually had hospitals in poorer communities that actually had to ration care because one, when you have a hospital like Martin Luther King Hospital, 75% of their revenue comes from Medi-Cal or uninsured compared to a hospital like Cedars (Sinai) or UCLA (Medical Center), where it’s such a small fraction. When you are getting reimbursed so little, you don’t have the luxury to go invest in additional ICU beds or ventilators or respiratory therapists. You’re basically scraping by just to serve your community. So when you get overwhelmed with people that are sick and you don’t have enough of those things that are required to really adequately address the problem, you’re going to have more death and, and that’s what we saw as well.

Q: Right. Great. Thank you. The last time we talked about the three major sources of health insurance and the obvious and not so obvious inequities inherent to each. Let’s talk about solutions. Instead of addressing inequities with more market reforms, what do you think is the first step the Biden administration should take toward promoting health equity in our country?

Song: Wow, it’s a complicated question, but for me, I think the answer’s quite simple. One is I think, due to the political climate, I don’t think we’re anywhere close to getting a federal Medicare for All, but I would like to see the Biden administration immediately sign a waiver allowing states to innovate and develop their own in-state single payer solutions. Next one I would do is instead of keeping Medi-Cal as is, I would immediately put all those enrollees on Medi-Cal into our Medicare system and just further make Medicare the de facto fallback insurance for everyone who needs it, whether it be seniors or the really poor. And so if you had between the seniors and then number of people on Medi-Cal, if you’ve just rolled that into one and gave everyone the same benefits as the Medicare beneficiaries, rather than Medicaid, I would feel like that would be significant, a significant starter until we got to a full federal single-payer Medicare for All system.

Q: Great, and that would allow them to be seen by doctors more quickly. So like you said, they wouldn’t have to wait a year before they got treated for cancer?

Song: I think it would do a lot. It would help lower income communities and their hospitals get much better reimbursement because now you’d be reimbursing at Medicare rates versus Medi-Cal or Medicaid rates and then as a result, these hospitals could invest more in equipment, in building out ICUs, bringing in more staff. It would also incentivize more doctors in these communities to take care of patients and as a result, I think it would increase access to care versus the system we have right now.

Q: Is this an idea that was ever considered seriously by any administration?

Song: No. Again, I think if you go back to Medicaid, it was always meant to be a second class in some respects, subtle wink and a nod apartheid system, right, who are mostly the poor that would qualify for this. It was predominantly people of color back in the 60s when Lyndon Johnson, you know, proposed this instead of trying to make Medicare and Medicaid, all one, they had to have this separate system. I think that if you were able to roll all that into one, it would have a significant impact on lower income communities and it would greatly reduce the disparity in health care that exists right now and until we got to a full Medicare for All, then you could have those people who got coverage through their employer continue to do so. It wouldn’t take away the complexities of our healthcare system, which is part of the administrative waste and all of the shenanigans that go on. But at least it would elevate the healthcare level for those that are the most disadvantaged and particularly in communities of color to those of what our seniors would be getting.

(5-second stinger)

Thank you, Dr. Paul Song.

Do you have a personal story you’d like to share about our ‘wack’ healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

April 2, 2022

Podcast host Joe Sparks highlights testimony from a recent U.S. House Committee on Oversight and Reform hearing on “Examining Pathways to Universal Health Coverage,” including remarks from Rep. Cori Bush on the urgent need for single payer, and powerful personal stories from patients and activists who have struggled to navigate our fragmented, expensive, and unjust health care system.

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

https://medicareforallexplained.podbean.com

By David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; Adam Gaffney, M.D., M.P.H.; Don McCanne, M.D.; and John Geyman, M.D.
The Nation, March 31, 2022

We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.

However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.

But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.

These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.

The rise of corporate ownership of American health care has been stunning. For-profits now own the vast majority of hospices, nursing homes, urgent care and dialysis clinics, imaging facilities, ambulance companies, and home care agencies. They garner nearly one-third of the total revenue of psychiatric and substance-use treatment hospitals, and control a growing share of general hospitals. Meanwhile, insurers are buying up clinics and doctors, eliminating any semblance of clinical independence. Optum—a subsidiary of UnitedHealth, the nation’s largest insurer—controls more than 1,500 clinics with 60,000 doctors, and CVS/Aetna already runs 1,200 Minute Clinics, with plans to expand its offerings in primary and behavioral care. Increasingly, Americans’ insurer is also their doctor.

Even more malevolent actors have now entered the fray. Private equity firms’ health care acquisitions totaled about $750 billion over the last decade, more than $119 billion in 2019 alone. KKR and Blackstone now employ or control more than 40,000 doctors, physician assistants, and nurse practitioners, and provide staffing for about one-third of US emergency rooms. Those companies were largely responsible for the epidemic of surprise bills. And private equity has been gobbling up primary care practices and mental health, orthopedics, and vision care providers; they already employ nearly 10 percent of dermatologists.

At least UnitedHealth and CVS plan to stay in business for the foreseeable future, and may be constrained by the worry that substandard care will damage their reputation. Private equity companies face no such constraints. They promise investors quick profits, and often sell off the businesses they’ve bought within five years, often after stripping their assets and loading them with debts that hobble future operations. Philadelphia’s Hahnemann Hospital epitomized the danger of private equity takeovers. Its billionaire owner shuttered the vital safety net hospital, whose downtown real estate was worth more for condos than for caregiving. Moreover, private equity owners are exempt from SEC (and most other) reporting requirements, allowing them to hide their actions (and the identity of the investors). patients and staff don’t have the right to know whom to blame for misbehavior.

A raft of evidence warns that for-profit ownership undermines quality. Two giant for-profit chains (one based in Germany) have gained dominance in dialysis, even as research has documented for-profit dialysis centers’ high death rates—driven in part by their over-prescribing of sometimes dangerous medications that boost dialysis firms’ profits. For-profit hospices shun (even insured) patients whose extensive care needs make them unprofitable, provide a narrower range of services, use less-skilled clinical staff, and have high rates of substantiated complaints of substandard care. And the for-profits that have long dominated the nursing home industry skimp on nursing care are more often cited for quality deficiencies, and have a higher death rate.

Even against the background of for-profit abuses, a transition to private equity ownership signals further deterioration of care. In the wake of PE nursing home takeovers, nurse staffing has declined and fatality rates have risen, resulting in 20,150 excess deaths. Meanwhile, the owners shield their assets from lawsuits by injured patients (or their survivors) by transferring ownership of the nursing home’s real estate to a separate subsidiary. Private equity firms that buy up dermatology practices intensify a focus on selling cosmeceuticals and elective procedures, and some gin up profits by performing unneeded surgeries on frail nursing home residents with Alzheimer’s disease. Their tendency to overdiagnose melanoma appears partly responsible for a growing epidemic of unnecessary, but lucrative, skin cancer operations.

While the conflict between financial ambition and clinical mission is most acute in for-profit organizations, even in esteemed nonprofits finances now often drive priorities.

Johns Hopkins Hospital sued thousands of its patients for medical debt, including many who worked for it, often garnishing their wages. The University of Virginia health care system filed more than 36,000 lawsuits against patients for unpaid medical bills over a six-year period, emptying their bank accounts, putting liens on their homes, and sending some spiraling into bankruptcy, as a Kaiser Health News investigation found. Meanwhile, the nonprofit (Catholic) Ascension health system, which owns 140 hospitals, partnered in a billion-dollar private equity fund, whose first investment was in a debt collection business accused of illegally demanding money from patients, even while they were still in the emergency room.

Yet bad behavior goes beyond debt collection. A memo from nonprofit Mayo Clinic’s CEO, who also oversees the clinic’s network of hospitals outside Minnesota (sited in locales chosen for their business opportunities rather than clinical needs), prodded the staff to prioritize care for patients with the best-paying insurance—a rare explicit statement of a ubiquitous management strategy that’s usually left unsaid.

The parent corporation of Boston’s Massachusetts General and Brigham and Women’s hospitals, which reaped a profit (technically, a surplus) of $3.2 billion last year and is now headquartered in the Prudential Tower, devoted $100 million to “rebranding” when the firm changed its name, and touted its new chief marketing officer for his expertise at selling Oreos and Ritz Crackers during his stint at Nabisco.

In both the for-profit and nonprofit sectors, in other words, the corporate takeover of care has been driven by market rules and incentives rigged to favor the biggest—and most avaricious—fish. Corporate control has driven up costs and bureaucracy, and failed to deliver the improved clinical coordination, efficiency, or quality promised by advocates of market-based health policies.

In the context of this galloping corporate takeover of health care delivery, replacing current insurers with a single NHI plan is necessary but not sufficient; it would funnel payments to corporate owners rather than to the people and facilities who care for patients. That would continue to delegate control of care to profit-seeking middlemen with little involvement in providing care. In the past, such corporate providers have proven impervious to regulators’ efforts to restrain profit-driven abuses, including the efforts of public payers who already provide the lion’s share of health providers’ revenues (e.g., almost all payment for dialysis and hospice care). Health firms’ growing financial power and the entry of behemoths like Amazon amplify the ability of corporations to evade regulation.

Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?

In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.

Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.

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Dr. David U. Himmelstein is a Distinguished Professor of Public Health at the City University of New York at Hunter College.

Dr. Steffie Woolhandler is a Distinguished Professor of Public Health at the City University of New York at Hunter College.

Dr. Adam Gaffney is a critical care physician and an assistant professor at Harvard Medical School.

Dr. Don McCanne, a retired family physician in San Juan Capistrano, Calif., serves as senior health policy fellow for Physicians for a National Health Program, and founded the popular health policy blog McCanne Health Justice Monitor.

Dr. John Geyman is a professor emeritus of family medicine at the University of Washington School of Medicine in Seattle, where he previously chaired the Department of Family Medicine.

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https://www.thenation.com…

By Adam Gaffney, M.D., M.P.H.
The Nation, March 29, 2022

At the stroke of midnight last Tuesday, the US government stopped covering the cost of Covid-19 testing and treatment for the uninsured. Funding for the Covid-19 Uninsured Program, established at the outset of the pandemic, had run dry, and Congress had failed to replenish it. The uninsured can now be subject to ruinous medical bills after a Covid-19 hospitalization, a threat that will surely drive some to avoid seeking care; notably, one testing company has said it plans to charge uninsured patients $125 per Covid-19 test, a fine that will deter testing and hence disease control efforts. In two weeks, Covid-19 vaccine administration for the uninsured will also no longer be reimbursable, likely reducing timely access to vaccination. With yet another pandemic wave looming on the horizon, the evaporation of support for a disadvantaged population at elevated risk of Covid-19 could worsen the spread and impact of this virus.

Two years ago, as Covid-19 first swept my state, my primary focus as a critical care physician was clinical work. I was seeing waves of patients with severe Covid-19 pneumonia fill the ICU of the safety net Boston-area hospital where I still work today. But being a health care researcher as well, I worried about how our nation’s fragmented, inequitable health care system would cope with the pandemic. With some 30 million Americans uninsured, and even more underinsured, I feared that high deductibles and copays would deter patients with respiratory symptoms from SARS-CoV-2 testing and delay their care—inadvertently contributing to viral spread and severe outcomes from this new disease. Though that outcome was attenuated by unprecedented measures taken by governments and insurers, we’re now inching toward a worst-case scenario. While it’s true that it has always been arbitrary to institute universal health care for one illness, we ought to be pushing toward greater universality instead of retreating from it; American health care should become more like Covid-19 care rather than the reverse. Indeed, without change, the latter will be rationed by ability to pay at a moment when treatment breakthroughs have made the need for speedy access to medical care more urgent than ever.

In the spring of 2020, it seemed unlikely that the government would put into place so many provisions to finance pandemic care. An April poll found that about 1 in 10 Americans would avoid care because of costs even if they believed they had Covid. My earliest Covid-19-focused research study estimated that nationwide some 18 million Americans at increased risk of severe Covid-19 due to advanced age or medical conditions were uninsured or underinsured. Nonetheless, the federal government outperformed my cynical expectations and took important if inadequate actions to provide semi-universal coverage for this specific illness. The Families First Coronavirus Response Act, expanded by the CARES Act, required full coverage of Covid-19 testing by insurers, and provided funds (now depleted) for testing and treatment of uninsured Covid-19 patients. Thus far, some $18 billion has been paid out for Covid-related care for the uninsured, including an average of $360 per uninsured person for Covid-19 testing. The federal government would later also directly purchase—and freely distribute—Covid-19 vaccines, and it took a similar approach with monoclonal antibodies and the new oral antiviral pills.

Such measures have played an important role in making the Covid-19 medical response—particularly the vaccine rollout—more equitable than much else in American health care. To be sure, inequality remained: In another investigation, for example, colleagues and I demonstrated that in 2020 the uninsured were less likely to have a Covid-19 test than those with health coverage, yet faced a greater burden of infection. In a third study, we found that even accounting for differences in age, the uninsured were vaccinated more slowly than those with health insurance, although vaccines were free—perhaps because they lacked an established relationship with a health care provider who might help address their concerns, or feared costs given past experiences. Work by others produced further evidence that America’s inequitable health care system hampered our Covid-19 response: County-level primary care physician density is tied to vaccine rates, even with control for various factors such as political orientation. Still, there is little doubt that absent expanded government coverage and support for Covid-19 care, things would have been infinitely worse.

But today, the stakes of this issue are higher than ever. At the start of the pandemic, outpatient treatment options for Covid-19 were so limited that most of it was really just triage: determining, for instance, who could stay home, and who should be evaluated in an emergency room or hospitalized. And for those of us caring for Covid-19 patients in hospital wards or ICUs, treating Covid-19 initially meant the (complex) provision of respiratory support and management of complications as they arose: There were no specific Covid-19 drugs. But things have changed: We soon learned that the use of the steroid dexamethasone prevented deaths among those needing oxygen for Covid-19 pneumonia; it is plausible that delayed initiation of such an agent could worsen outcomes for some who stay home despite low oxygen levels. Other drugs that tamp down the immune system in severe Covid-19 have also been found to save lives. Other work found mixed evidence of benefit for the intravenous antiviral drug remdesivir, perhaps because the benefits only emerge when given early. But with out-of-pocket costs for Covid-19 hospitalizations averaging $4,000 for the privately insured, and with the uninsured losing all coverage for hospitalization, the sorts of financially driven delays in care we observe across the health care system (including in emergencies) could also keep patients from benefiting from prompt intervention for Covid-19.

Yet the issue is far more crucial when it comes to new antiviral therapeutics for Covid-19, which must be taken early when it is still a cold and not yet pneumonia resulting in hospitalization. Remdesivir, paxlovid, and monoclonal antibodies each, if given early enough, vastly reduce the risk of hospitalization for high-risk Covid-19 patients. And the benefits of booster vaccines in restoring waning protection for high-risk individuals are now beyond doubt. In other words, we have the technological means for an effective medical response to this virus. Yet, even as this knowledge has accumulated, efforts to build a robust infrastructure to deliver it are faltering. In addition to pulling out the rug from under the uninsured, deficient funding will undercut the broader medical response to Covid-19: The Biden administration has said funding inadequacies will limit further purchases of these antiviral agents and fourth doses of vaccines, for instance.

It is perhaps naive to think that a single disease would forever remain carved out of the profit-oriented logic of American health care, although these recent changes are even more abrupt than I would have predicted. Even if a compromise is reached and funding replenished in coming days, it will only be a (much needed) Band-Aid—a temporary and inadequate fix for a virus that is not going away, to a health care system whose deficiencies will continue to undercut our pandemic response without deeper reform. Make no mistake: Congress must take action to restore coverage for Covid-19 care for the uninsured, and to fund the broader pandemic medical response, today. But a universal medical response, achievable through realization of a comprehensive national health program, will be needed to combat Covid-19 for many years to come.

Dr. Adam Gaffney is a critical care physician, an assistant professor at Harvard Medical School, and immediate past president of Physicians for a National Health Program.

https://www.thenation.com…