PNHP

Primary Care, Which Saves Lives, is Struggling to Survive

Primary Care, Which Saves Lives, is Struggling to Survive

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

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

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

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

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

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

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

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

Comment:

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

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

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

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

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

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

http://healthjusticemonitor.org…

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.

Medicare for All Explained Podcast: Episode 88

November 1, 2022

Podcast host Joe Sparks describes some of the most pressing and entrenched problems in U.S. health care … and how single payer would address those problems.

“People can’t afford health care,” he says. Medicare for All “would allow people to get the care they need, when they need it, without having to worry about cost.”

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

https://medicareforallexplained.podbean.com

I’m A Doctor. Here’s Why We Need Universal Healthcare

From each vantage point—as a patient, a provider, and a small business owner—I see everyday how for-profit corporations fail to provide adequate access and coverage for vital health care services.

By Belinda McIntosh, M.D.
Common Dreams, November 1, 2022

On September 19th, Atlanta became one of the latest municipalities to pass a resolution endorsing national universal health coverage. This important local action is aspirational in its urging of the United States Congress to pass the Medicare for All Act of 2021 – 2022 (H.R. 1976). However, the need for the affordable insurance this legislation would provide for every American is huge and pressing.

Luckily, the momentum behind Medicare for All is growing as Americans increasingly see that access to adequate, affordable, and equitable healthcare is an urgent need. The passage of this resolution comes just weeks after the Georgia State Democratic Convention adopted a similar resolution in support of an improved Medicare for All national health insurance program. Since 2018, over 100 cities and counties across the country have passed resolutions in support of Medicare for All. Last October, the American Public Health Association issued a policy statement declaring that healthcare is a human right and calling for the adoption of a single-payer health system to provide universal coverage in the best, most efficient, and equitable way.

Here is why national universal health coverage is so important to me. I am a private practice physician, a mother, and a cancer survivor. As a physician, I spend countless hours fighting with insurance companies to help my patients get the care they need. I watch them struggle to pay their medical bills. And I see the negative outcomes when they decline recommended treatments because they simply cannot afford to pay. As a physician who trained and worked in private and public healthcare systems for twenty years, I regularly see the encroachment of health management corporations into medical decision-making. As a private practice physician and a small business owner with a pre-existing health condition, I struggle to find appropriate health coverage for myself and my family.

From each vantage point—as a patient, a provider, and a small business owner—I see everyday how for-profit corporations fail to provide adequate access and coverage for vital health care services. I had to do something different. So I joined Physicians for a National Health Program and began advocating for change.

On September 27th, the same day that I addressed the Atlanta City Council’s Community Development/Human Services Committee and thanked them for passing the resolution in support of Medicare for All, I attended a rally on the steps of Grady Hospital, Atlanta’s largest public hospital. Doctors were gathered there to protest Governor Brian Kemp’s disastrous and stubborn refusal to expand Medicaid in Georgia, a policy that prevents access to care, results in negative health outcomes, and exacerbates a concerning trend of rural hospital closures. Georgia is one of only twelve states that has not expanded Medicaid, a provision in the Affordable Care Act that extends Medicaid coverage to almost all adults earning up to 138% of the federal poverty level. Georgia also ranks 41st in healthcare access and 43rd in healthcare outcomes.

The action taken by Atlanta City Council in passing a resolution endorsing Medicare for All comes at a critical time when Atlanta is experiencing a monumental casualty due to the failed policy of the Georgia’s Governor and its state legislature—the closure of a large city hospital.

In early September, Wellstar Health Systems, which owns and operates the Atlanta Medical Center (AMC), announced that the hospital will be closing its doors on November 1. AMC is one of two hospitals that the city of Atlanta relies on to care for the uninsured and most economically disadvantaged residents of Fulton and Dekalb Counties. Besides Grady, AMC is also the only other Level 1 trauma center in the city, providing treatment for the most severely injured. In the shadow of the impending crisis of AMC’s closure, doctors from Grady addressed the public about the importance of expanding Medicaid in Georgia, a move that would insure hundreds of thousands of Georgians who live in poverty, bring revenue to the hospitals who serve them, and potentially avert more disastrous hospital closures. In the past ten years, eight rural hospitals in Georgia have closed, with deadly consequences. Now similar impacts will be felt on a large city scale within a ten-minute walk of City Hall and a short drive from the state Capitol.

Expanding Medicaid in Georgia is one part of the solution to our healthcare dilemma. But it is not enough. We must guarantee adequate and equitable health coverage for all Americans regardless of their socioeconomic status, their zip code, or whether or not they are employed.

The Atlanta City Council, in passing a resolution in support of Medicare for All, inspires those in other cities and counties to take similar stands for affordable healthcare. Such actions amplify the voices of Americans who lack health insurance or are dissatisfied with their health care coverage. A recent AP-NORC pollshowed that 56% of Americans are dissatisfied with America’s healthcare system and only 10% of respondents said that our health care is handled well or very well.

Perhaps the radical idea was thinking that corporations could be relied upon to provide reasonable coverage at a reasonable cost for the majority of Americans. As it turns out, that is simply not what corporations are about. Corporations are about profits. We need a national single payer health insurance program. It is time to join the growing wave of support for passage of the Medicare for All Act of 2021.

Dr. Belinda McIntosh is a psychiatrist residing in Atlanta.

https://www.commondreams.org…

Gaining Momentum in the National Single Payer Movement

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

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

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

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

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

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

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

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

Comment:

By Lily Meyersohn

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

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

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

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

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

http://healthjusticemonitor.org…

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

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.

Exposing the Private Equity Threat

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

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

See video (3 minutes)

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

Private Equity Stakeholder Project: Healthcare

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

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

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

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

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

Comment:

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

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

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

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

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

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

http://healthjusticemonitor.org…

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Medicare Advantage? Medicare Disadvantage would be a better name.

By Jessica Schorr Saxe, M.D.
The Charlotte Observer, October 25, 2022

Along with leaves changing color and the omnipresence of pumpkin spice comes the avalanche of ads, commercials and telephone calls, entreating us to believe that Medicare Advantage is the best thing since the invention of the Internet. With open enrollment season upon us, it’s critical to examine that claim.

In traditional Medicare, the government pays doctors and hospitals directly. Recipients usually pay premiums and must meet deductibles, and many choose a supplemental “Medigap” plan to help with out-of-pocket costs.

Medicare Advantage was designed about 20 years ago as an alternative to traditional Medicare, meant to provide innovative ways of delivering care at lower cost. It pays insurers — middlemen — a monthly fee per patient to manage their care. Premiums are often lower than traditional Medicare, and can offer perks such as gym memberships or limited dental or vision care.

However, while traditional Medicare gives access to any participating provider, Medicare Advantage plans limit care to doctors and hospitals in their networks. They are also more likely to deny needed care by requiring prior authorizations for tests or procedures.

Earlier this year, the federal government reported that 13% of denials in Medicare Advantage would not have been refused under traditional Medicare. Medicare Advantage plans are also increasingly ending nursing home and rehabilitation care before providers consider patients ready to go home. While medical professionals make those decisions under traditional Medicare, in Medicare Advantage the insurer decides.

So instead of innovating care, Medicare Advantage seems to mainly withhold it. It has also proven to be costly. Because such plans get higher government payouts for sicker patients, insurers have an incentive to exaggerate the sickness of enrollees.

According to federal audits, 8 of 10 of the largest companies have submitted inflated bills, and 4 of 5 of the very largest have faced federal lawsuits accusing them of fraud. In 2020 alone, these exaggerated risk scores generated $12 billion in excess payments. Because of this and other factors, the government actually spends 4% more for Medicare Advantage enrollees than those in traditional Medicare.

Despite all this, the low premiums and perks may still be attractive to seniors who are not (yet) sick. The situation often changes when they develop an illness. They may find that a specialist or hospital they wish to see is out of network. They may experience delays or denials of care due to administrative barriers. Their out-of-pocket costs will often be higher.

A little known fact about Medicare is that when patients are enrolled in Medicare Advantage for over 12 months but want to change to traditional Medicare, Medigap plans are no longer obligated to take them without underwriting, which involves passing a health screen. In other words, if you get cancer and want to go to a cancer center not covered by your Medicare Advantage plan, you may be stuck.

Surely this program should be called Medicare Disadvantage. When a middleman makes profits from “managing” your healthcare, they inevitably do so by limiting the care you get. Medicare recipients, beware! And as citizens and taxpayers, we should all demand that Congress take Medicare out of the hands of corporations, freeing billions of dollars in savings to deliver actual health care.

Dr. Jessica Schorr Saxe is a retired family physician in Charlotte and chairwoman of Health Care Justice – NC.

https://www.charlotteobserver.com…

Why Are Political Barriers to Health Reform So Great?

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

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

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

Very or somewhat likely:

  • Democrats – 40%
  • Republicans – 22%

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

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

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

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

Comment:

By Don McCanne, M.D.

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

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

http://healthjusticemonitor.org…

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Two Women Prioritize Helping the Public over Protecting the Rich

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

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

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

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

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

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

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

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

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

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

Comment:

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

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

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

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

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

http://healthjusticemonitor.org…

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.

The Rise of Despair and Conservative Politics

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

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

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

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

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

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

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

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

Abstract

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

Excerpts

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

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

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

A Politics of Despair

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

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

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

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

Comment:

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

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

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

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

http://healthjusticemonitor.org…

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Prevalence and Correlates of Patient Rationing of Insulin in the United States: A National Survey

By Adam Gaffney, M.D., M.P.H.; David U. Himmelstein, M.D.; and Steffie Woolhandler, M.D., M.P.H.
Annals of Internal Medicine, October 18, 2022

Background: Insulin is life saving for many patients with diabetes, but high prices and inadequate insurance coverage may impede access to it. A single-center study (1) and web-based surveys (2) suggest that cost-related insulin nonadherence may be common, although reliable national data are lacking.

Objective: To determine the prevalence and correlates of insulin rationing.

Methods: We analyzed the 2021 National Health Interview Survey (NHIS) done by the Centers for Disease Control and Prevention, which collected data for 1 randomly selected adult in a nationally representative sample of U.S. households (response rate = 52.8%). …

full study:
https://www.acpjournals.org…

Adults Give US Healthcare Cs and Ds

Summary: A national poll of US adults yields terrible scores for our healthcare system: more “poor” and “fail” marks than “excellent” and “good”. The Gallup organization calls these Cs and Ds, but that’s a generous interpretation – we’re failing. We need a total do-over, adopting methods proven in other wealthy nations.

Majorities Rate Cost, Equity of U.S. Healthcare Negatively, Gallup News – Politics, October 6, 2022, by Nicole Willcoxon

Comment:

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

Yowzah. That’s massive under-performance. Only 21% of US adults think our healthcare system grade is good or excellent. Only 7% for costs, 22% for equity, and 31% for access. Quality of care scores highest – 47% say it’s good or excellent. But what is quality without access?

Sad, but not surprising. Indeed, we’ve performed at the bottom of wealthy countries for a long time. See HJM on the latest Commonwealth comparison here, and cross-national satisfaction surveys here and here.

If only we had better examples of how to pay for healthcare. If we could find, somewhere in the world, places that spend less while faring much better on access and outcomes. Oh, wait, all those countries that do better, they also cost a lot less.

Sorry I’m dripping with sarcasm today. It’s SO frustrating that we don’t learn our lesson. To paraphrase Winston Churchill, “Americans always do the right thing, after first trying everything else.” Well, we’ve tried everything else. Time to do the right thing – single payer!

http://healthjusticemonitor.org…

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.