By Kip Sillivan
Health Affairs, Comment, January 24, 2022

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Response to “The Case For ACOs: Why Payment Reform Remains Necessary,”by Michael E. Chernew and J. Michael McWilliams

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This defense of CMS’s never-ending ACO experiment is unconvincing. The authors ignore evidence that is inconsistent with their assertions, and the evidence they do cite does not support their claims.

The authors would have us accept these assertions:

(1) There is “a lot” of overuse of medical services within the traditional Medicare program, and the cause of this overuse is the fee-for-service (FFS) method of payment;

(2) ACOs and direct contracting entities (DCEs) are the solution to the alleged rampant overuse;

(3) ACOs/DCEs can improve equity, the FFS Medicare program cannot;

(4) The toxic consequences of ACOs/DCEs (consolidation, upcoding, denial of services, wasting tax dollars on profit for shareholders) either do not exist or can be “mitigated.”

These assertions are wrong or at best inaccurate.

Assertion 1. The authors avoid stating that research supports their claim about “a lot” of overuse. Instead, they assert that the claim “is widely acknowledged” and go on to cite the Choosing Wisely campaign and two studies that contradict their claim.

The Choosing Wisely campaign is a useful educational project, but its website makes it clear that its list of “low value” services should not be construed to be a measure of overuse. The website states: “Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.” Moreover, the website sheds no light on what role, if any, FFS plays in causing over- or underuse of these services.

The two studies the authors cite are one they co-authored (Schwartz et al.) and a “preliminary” report by the Institute of Medicine (IOM). The study by Schwartz et al. examined the frequency with which “low value” services (including some listed by Choosing Wisely) are used within traditional Medicare. For example, Schwartz et al. inquired how often bone mineral density tests are repeated at intervals of less than two years. They concluded that “low-value” services could account for somewhere between 0.6 and 2.7 percent of total spending, and the larger number probably included appropriately used services. The authors made no attempt to compare these small percentages with the cost of rooting out all inappropriate use of bone mineral density testing etc. Nor did they attempt to demonstrate that FFS is the cause of inappropriate use of “low value” services.

The second study cited – the final report by the IOM on the brouhaha about regional variation in spending — did not demonstrate that variation is caused by either overuse or underuse, nor did it determine causes of over- and underuse. As Kaiser Health News noted, the IOM’s “researchers did not provide any definitive answers to the overarching questions about regional variation.” The literature on regional variation in spending should be viewed as a possible source of hypotheses worth further research, not as the basis for any conclusions on the extent and causes of inappropriate use.

Despite a half century of claims that Medicare beneficiaries get too much medical care, and that HMOs, PPOs, ACOs, and now DCEs must be inserted into Medicare to combat overuse, no study has demonstrated widespread overuse within Medicare, and none has demonstrated that what overuse exists is caused by FFS payment.

Assertion 2. The authors’ assertion that ACOs are the solution to the alleged overuse in traditional Medicare ignores evidence that CMS’s ACO programs have all failed to reduce Medicare spending and may increase systemwide spending when ACO overhead costs are taken into account. This failure is due in part to the absence of “a lot” of overuse; the difficulty of distinguishing appropriate from inappropriate use; the poor definition of ACOs; and disinterest in ACO boosterism among physicians and patients.

ACOs have had small and mixed effects on the few (crudely adjusted) quality measures used.

Assertion 3. The authors opine that “the ACO framework can greatly facilitate equity-oriented initiatives by directing more resources for populations with unmet needs” while FFS Medicare cannot. This claim defies common sense and, not surprisingly, is unsupported by evidence. The reverse is true. The method by which ACOs are paid – on a per enrollee/assignee basis – guarantees worsening of disparities because it shifts resources from ACOs and providers that treat sicker patients to those that treat healthier patients. This happens because the per-enrollee/assignee payments require “risk adjustment” to ensure the per-head payment is lower for the healthy and higher for the sick. But risk adjustment is extremely crude (the risk adjuster CMS uses for ACOs and DCEs explains just 12 percent of the variation in spending), and one consequence of crude risk adjustment is overpayment for healthy beneficiaries and underpayment for the sick (see page 30 of MedPAC’s June 2014 report).

Some evidence indicates ACOs respond to the grossly inaccurate risk adjustment of per-head payments by cherry-picking and lemon-dropping doctors and patients.

The authors concede that “[r]isk adjustment is a central component of population-based payment models,” then go on to ignore completely the disparity-worsening impact of crude risk adjustment of per-head payments.

Assertion 4. The authors are merciless in their criticism of FFS, but they can’t find any problem caused by ACOs (consolidation, upcoding, etc.) that can’t be fixed or at least ameliorated. Again, we are expected to accept their evidence-free opinion on these important issues. Their last refuge: They ask us to believe that the toxic consequences of ACOs/DCEs are trivial compared with the alleged epidemic of overuse in traditional Medicare. Reasonable people might be willing to put up with toxic side effects of ACOs/DCEs (consolidation, upcoding, cherry-picking, lemon-dropping, denial of necessary services, higher administrative costs, and diversion of scarce resources to venture capitalists) if we had any evidence that ACOs and DCEs work as advertised. However, the evidence indicates ACOs have failed, and DCEs, which are slightly tweaked ACOs, will fail as well.

In conclusion: If we count CMS’s first ACO experiment (the Physician Group Practice Demonstration which began in 2005), the ACO experiment is now 17 years old. All four of CMS’s ACO programs – the PGP demo, the Pioneer ACO program, the Medicare Shared Savings Program, and the Next Generation program – have failed to cut costs, and have had trivial and mixed effects on the tiny handful of quality measures. It is time to terminate the ACO experiment. The Biden administration should immediately terminate the DCE demonstration, and Congress should repeal the sections of the Affordable Care Act that authorized experimentation with ACOs and DCEs.

Original article:
https://www.healthaffairs.org…

By Barbara Caress
The American Prospect, January 24, 2022

Rep. Pramila Jayapal has called it the “biggest threat to Medicare you’ve never even heard of.” It’s known as Direct Contracting (DC), a program concocted by the Trump administration and not yet ended by the Biden administration to fully privatize Medicare.

DC is patterned after Medicare Advantage, the publicly financed, privately owned, hugely profitable version of Medicare now enrolling 26 million people at an annual cost of $343 billion. Simply put, DC is Medicare Advantage (MA) on steroids.

The growth of Medicare Advantage is a 35-year-long saga of a program conceived as a cheaper, better Medicare transformed into a behemoth that has not saved one cent nor produced better outcomes. Yet MA has beaten back every attempt to make it accountable for its cost and care. Like the Hydra, each victory adds more heft.

The politics of MA are complicated, not merely because, like the oil and gas industry, it generates enough money for large insurance companies to convert $150 million of profits into campaign contributions. By design, Medicare Advantage covers the costs of health care that are not covered at all or only partially paid by Medicare. Its 26 million enrollees are a silent majority, potentially available to threaten any elected official brave enough to challenge the program. But that leaves the public with worse health coverage and a model of privatization that could prove disastrous.

Why Medicare Advantage Was Invented

Medicare’s sole purpose in 1965 was to extend health coverage to the elderly by paying their doctor and hospital bills. In a Faustian bargain, Congress sacrificed Medicare’s regulatory role in return for the support of the hospital-operated Blue Cross Association and physician-owned Blue Shield plans, which set payment policies. The only constraint, medical necessity, was defined as any treatment ordered by a licensed doctor.

The actuary to the House Ways and Means Committee had confidently predicted an initial $2.2 billion price tag, increasing over 25 years to $12.4 billion in 1990. Instead, the initial price doubled by 1969 and reached $12.4 billion in 1973, just four years later.

In 1970, pediatrician Paul Ellwood, the apostle of managed care, presented a solution to reduce health care spending that he dubbed a “health maintenance organization” (HMO). Elwood was no fan of Medicare, famously calling it “a crappy insurance policy.” He believed private, prepaid, integrated physician practices could be incentivized to provide better care at less cost. At the time, nonprofit HMOs like Kaiser and Group Health had an admirable record of lower cost and better outcomes than traditional fee-for-service health care.

Then-President Nixon shared Ellwood’s enthusiasm, but with a different agenda. Here’s a transcript of a taped conversation between Nixon and John Ehrlichman, his chief domestic-policy adviser.

Ehrlichman: “Edgar Kaiser is running his Permanente deal for profit … the reason he can do it … I had Edgar Kaiser come in … talk to me about this and I went into it in some depth. All the incentives are toward less medical care, because …”

President Nixon: [Unclear.]

Ehrlichman: “… the less care they give them, the more money they make.”

President Nixon: “Fine.”

Nixon was later presented with a plan, which became the HMO Act of 1973, to reduce federal spending in a manner that promised to be undetectable to participants. The alternatives to HMOs as a cost-containment strategy were politically unpalatable—either reducing benefits or reimposing price controls. The HMO program promised no blowback from beneficiaries or providers, at a time when the administration was struggling to gain leverage over inflation. HMOs fell out of favor due to narrow provider networks and instances of denied care. But it led to a subtler alternative: Medicare Advantage.

How the MA Money Machine Churns

Unlike the Defense Department’s TRICARE and the Veterans Health Administration, Medicare is not a public health care system. It is public financing that relies on a joint public-private insurance arrangement. The rules are set by the Centers for Medicare & Medicaid Services (CMS) and Congress, and the claims processed by insurance companies under contract to the federal government. Money from the Medicare Trust Fund, taxes, and beneficiary premiums secure services from the private U.S. health care system.

Medicare Advantage changes one critical element: the intermediary between the money and the services. Medicare still pays, but with MA it turns over all parts of the insurance function, including enforcing the rules for medical necessity and deciding how much to pay providers, to private companies. Retirees can choose from 3,834 plans offered by nine different companies in 2022. Four in ten Medicare beneficiaries have joined. Humana and UnitedHealthcare own half the MA plans.

Traditional Medicare leaves lots of holes that retirees must otherwise fill out of their own pockets. It does not cover vision, hearing, dental, or long-term care. Beneficiaries are responsible for monthly premiums, deductibles, and coinsurance (known as “cost-sharing”). And unlike commercial insurance, it has no cap on out-of-pocket spending. The extra cost added up to $6,509 per person in 2018, according to an AARP-commissioned study.

Twenty-six million people find MA a deal they cannot refuse. They gave up their hard-earned red, white, and blue Medicare card for one supplied by Humana, UnitedHealth, Anthem, Aetna, Kaiser, or another company. Like HMOs, the plans offer less freedom of choice, with limited provider networks and prior-approval requirements in exchange for sharply reduced and capped out-of-pocket expenses, and additional benefits like gym memberships.

Most recent retirees do not find the restrictions new or particularly burdensome. Anyone previously insured through an employer health plan dealt with very similar constraints.

The MA profit-making formula is simple: get a large sum of money from the Feds, spend less than traditional Medicare, give some of the excess to beneficiaries, and pocket the difference. Over the last 12 years (2009–2021), Medicare paid the MA plans $140 billion more than would have been spent if the same people stayed in Medicare. Put another way, Medicare during these years would have saved enough to pay for the enhanced Child Tax Credit in 2022, and then some.

MA plans follow the design of commercial insurance, with the beneficiary choosing between either an HMO, with a closed provider panel, or a PPO, which rewards participants who stay in its provider network. Either way, the insurance company constructs reimbursements and utilization checks to spend less than traditional Medicare.

MA companies have perfected the art of denying claims by requiring preauthorization of many services, especially expensive ones. For example, doctors treating UAW retirees for orthopedic injuries, a frequent legacy of assembly line work, must get MA prior approval for 246 specific procedures, or else the plan does not guarantee payment. MA plans deny 4 percent of claims for prior authorization and 8 percent for post-service payment requests. Very few people appeal. When they do, the HHS Office of Inspector General found that denials were reversed more than three-quarters of the time.

Just to see how it would fall out, Aaron Schwartz and colleagues at the University of Pennsylvania reprocessed 6.5 million traditional Medicare Part B claims as if they were subject to MA prior authorization. Approximately one million might have been denied, accounting for 25 percent of Part B spending.

“Our study found that health care spending for enrollees in Medicare Advantage plans is 10 to 25 percent lower than for comparable enrollees in traditional Medicare,” said Amy Finkelstein, an MIT economist and one of the authors of an influential 2017 paper. Insurance companies earned gross margins of $2,256 per enrollee in 2020, more than double what they made in the group market.

Spending less would make perfect sense if MA enrollees were healthier. They are not. “Medicare Advantage enrollees do not differ significantly from beneficiaries in traditional Medicare,” the Commonwealth Fund reported in October, “in terms of their age, race, income, chronic conditions, satisfaction with care, or access to care.” Health outcomes are similarly no better or worse.

Federal Regulators Lose the War

Over the past 30 years, laws were passed and regulations issued to contain costs and protect MA beneficiary access to care. Managed-care sponsors found ways around the rules.

Assuming HMOs to be more efficient, in 1985 the government set the payment rate at 95 percent of what would otherwise have been spent in Medicare. The plans needed to match traditional Medicare benefits but could make their own arrangements with hospitals, doctors, and labs, and keep the difference.

With the freedom to choose how much they paid out and where and whom they enrolled, the companies scammed the program by finding healthier retirees living in counties where rates were high. No plan operating in any U.S. county enrolled a sicker-than-average group of elderly people, according to a comprehensive Mathematica study commissioned by the Reagan administration. Despite this, expenditures for MA were approximately 5.7 percent higher than they would have been for traditional Medicare, despite getting 5 percent less from the feds.

The Clinton administration tried again to save money with HMOs. “We think that payment rates that are 90 percent, rather than the current 95 percent, of community fee-for-service rates are appropriate,” said Bruce Vladeck, Clinton’s head of the Health Care Financing Administration (HCFA). He wasn’t able to go that far, but significant cutbacks were made in 1997’s Balanced Budget Act (BBA).

The BBA established a national growth cap and, under threat of penalty, forced the HMOs to stop cherry-picking. Since health care costs were increasing faster than the cap, and the plans had less ability to exploit healthier enrollees, the BBA effectively cut HMO margins. But the howl from the private plans was so loud that Congress subsequently loosened the buckle in 1999 and 2000. Even with the changes, BBA managed care did not save Medicare money. Plans were still outpacing traditional Medicare costs by 2 percent.

George W. Bush’s Medicare Modernization Act (MMA) removed the BBA caps and increased funding, adding millions to MA payments. The price tag for excess spending during the first decade of the 21st century was $150 billion.

“We, right now, give $15 billion every year as subsidies to private insurers under the Medicare system. Doesn’t work any better through the private insurers,” Sen. Barack Obama said in 2008, during the first presidential debate with Sen. John McCain. “They just skim off $15 billion. That was a giveaway and part of the reason is because lobbyists are able to shape how Medicare works.” Candidate Obama pledged to make MA no more costly than traditional Medicare.

By tweaking some elements, the Affordable Care Act (ACA), according to the Congressional Budget Office, would reset MA spending to no more than 101 percent of traditional Medicare. The result was to be an estimated $136 billion saved over ten years.

Just two years later, the plans got it all back. “The insurance industry chalked up one of its greatest political victories in recent memory on Monday,” Politico reported on April 3, 2013, “as the Obama administration reversed course on a proposal to cut Medicare Advantage rates.” With a sleight of hand so obvious that CMS’s actuary publicly repudiated the move (“conflicts with the Office’s professional judgment”), CMS increased MA rates by 3.3 percent, rather than cutting them by 2.3 percent.

In March 2021, MedPAC, an independent Medicare monitor that reports to Congress, reviewed the impact of the ACA. It found that “aggregate plan payments under the ACA were similar to [traditional Medicare] levels for only one year before rising above.”

No one even mentions MA as a cost-containment strategy anymore. The larger and richer the plans have become, the less leverage the feds have to regulate the industry. While the funding still comes from the U.S. Treasury, dispersed under the aegis of Congress, most of the power has passed to the companies.

Risk Adjustment and Star Bonuses

Insurance companies have consistently found innovative ways to protect their bottom lines. A major one involves claiming MA enrollees are sick, even if they aren’t.

Doctors and hospitals in MA networks are frequently offered extra payments simply to record every ailment, whether treating it or not (a practice known as “risk coding”). In an 8,000-word article in respected health policy journal Health Affairs, Drs. Don Berwick and Richard Gilfillan detail how upcoding affords almost unlimited opportunities to manipulate the system to make money. They present the hypothetical case of Ms. Jones, a 72-year-old MA enrollee being treated for type 2 diabetes and congestive heart failure. With a risk adjustment score of 1.029, the annual payment for her is $9,000. Her physicians are paid extra to code all her ailments. Now her scorecard adds morbid obesity, major depression, COPD, and a pressure ulcer on her right heel. With no additional medical care or cost, the MA company is now paid $32,000, because Ms. Jones’s risk score totals 3.633.

As a result of this upcoding, Medicare gave MA plans $9 billion more in 2019 than it would have if the same beneficiaries had enrolled in traditional Medicare.

Another way MA reaps more funds is through star bonus payments. CMS began publishing evaluations of MA plans in 2009 to assist beneficiaries in plan selection. Numerical values were assigned to variables measuring care processes, outcome, patient experience, and access. The numbers are summarized on a scale of five stars.

In the original star publication, 1 in 7 plans scored four or 4.5 stars, and none were awarded five. For the 2022 plan year, 7 out of 10 received four-plus stars and 16 percent of plans were given fives. Is there improved quality, or teaching to the test?

MA companies began paying more attention to the star variables after the ACA anointed the system as a quality control mechanism and authorized bonuses based on stars. Critically, bonus payments are not budget-neutral. The more plans that qualify, the more the feds spend. MedPAC estimates that bonus payouts added about $6 billion to the 2019 MA bill.

Do bonus payments result in better care? The answer is no. Under the headline “The Medicare Advantage Quality Bonus Program Has Not Improved Plan Quality,” University of Michigan researchers compared four million MA claims to the same number of commercial insurance claims. “[T]hese results suggest that the quality bonus program did not produce the intended improvement in overall quality performance of MA plans.”

The New Profit-Taking

“A lot of the new capital is moving into setting up new Medicare Advantage plans because they’re growing rapidly, and the future is bright,” Peter Orszag, CEO of Financial Advisory at investment firm Lazard and former Obama OMB administrator, told Business Insider. The possibility for payouts like the one for Ms. Jones has lured hedge funds and venture capitalists to invest in data mining companies and care aggregators, which are developing new ways to maximize MA’s profitable deals. Berwick and Gilfillan found investors spent $50 billion to buy into MA-focused firms in a recent 18 months.

Direct contracting would privatize the remainder of traditional Medicare. Drawing on the MA experience, Direct Contracting Entities (DCEs) would serve as intermediaries between traditional Medicare beneficiaries and their medical-care providers. The DCE would receive an MA-like monthly payment for a specific population. It would make deals with networks of providers, “manage” beneficiary care and costs, and pay the bills, while keeping the difference. Medicare’s only role would be as banker.

In December 2021, CMS reiterated its invitation to “organizations that currently operate in Medicare Advantage” to become DCEs, targeting the very MA insurers and investor-controlled provider firms that are driving MA overpayments. One such firm, Oak Street, a for-profit organizer of MA providers, labeled MA as its “core market” and direct contracting as its “opportunity” in a November 2021 corporate presentation.

While the Biden administration put a halt to the most extreme form of direct contracting, it has moved ahead with two others. Fifty-three bidders have been designated in the first class of DCEs. They include 28 investor-controlled plans including Oak Street, six insurers, and 19 health care provider–owned companies. The investor and insurer DCEs will be operating in 38 states and have access to 84 percent of all beneficiaries.

Many on Wall Street are licking their chops. Clover, a 50,000-member, San Francisco–based MA plan, expects to harvest a direct-contracting bonanza large enough to justify its $1.2 billion IPO. HHS senior official Liz Fowler (an architect of the Affordable Care Act) projects the transition of all traditional Medicare to DC to be complete by 2030.

According to the Biden administration, Direct Contracting will facilitate “the next evolution of risk-sharing arrangements to produce value and high-quality health care.” Berwick and Gilfillan believe that “the Direct Contracting model seems to have ignored the lessons learned from the experience of MA.”

One of the principal lessons learned by private MA is how managing care is so easily morphed into managing costs, and how much excess revenue that produces. The private Medicare companies have succeeded in getting the feds to turn over more and more to them while obliterating the notion that HMOs would save money or improve care. Their power to extend their reach to all $880 billion in Medicare spending is embedded in the program itself. The more money and beneficiaries they control, the more juice they have to control more.

Taking Medicare Public, Again

Last fall, 13 U.S. senators (eight Democrats and five Republicans) sent a letter promising to “stand ready to protect MA from payments cuts.” The letter was part of a long stream of such letters ritualistically issued by lawmakers at the urging of the industry, every time anyone announces consideration of MA cost control. This latest version of the pledge was precipitated by a draft of the Build Back Better Act that would include hearing, vision, and dental benefits in the regular Medicare menu for the first time, threatening one of the main selling points of MA.

The campaign against the new benefits was intense and a little weird. AHIP, the insurance industry lobbying group, stated that adding these services could negatively affect the benefits available to MA recipients, because it might lead to a cut in the payments made to MA plans. AHIP’s press release stated it would be bad for all seniors, even though all seniors are not in MA plans. Politico quoted an industry insider describing a recent $2.6 million ad campaign against the new Medicare benefits. “We know members are already telling leadership: ‘We can’t take attack ads saying we’re cutting Medicare.’ They know the public isn’t going to distinguish between the private and public pieces of it.”

What the senators and lobbyists understand is that MA depends on the threat of an uprising of unhappy seniors. It’s a potent terror. Some electeds are swayed by campaign contributions. But these would matter very little without the potential mobilization of 64 million beneficiaries, their concerned children, and grandchildren.

The experts have proposed sophisticated technical fixes to remedy MA’s overpayments. It might work, as the Balanced Budget Act and the ACA did, for a while. The Department of Justice has filed cases against such large MA providers as Kaiser, United, and Anthem for submitting false risk adjustment claims. The Justice Department has even opened an inquiry into Oak Street’s practices.

But neither more regulation nor billion-dollar fines will suffice. The history of the MA dance shows that by the time the music ends, the private partner has swept the public one off her feet. He’s taken control over every step.

To put a stop to MA’s distortions and its systematic theft would require a campaign to make Medicare a more public health insurer. From the start, it ceded significant financial authority to private hospitals, doctors, pharmaceutical, and insurance companies. The more beneficiaries and money handed over to MA, the greater its power to resist. The ascendency of DC is the latest and most serious warning sign that the private profit-maximizers are close to victory. Nothing short of full public control can keep that from happening.

Protection of public Medicare requires that its beneficiaries be offered a better way to get affordable health care. I feel guilty that my enrollment in a UnitedHealthcare MA plan contributes to that company’s money and power. Yet I am on MA because without it, Medicare is a very risky proposition. I could be impoverished trying to pay for my health care. MA is the only plan I can afford.

History shows that the federal government’s attempt to harness the perceived benefits of managed care to Medicare by attempting to separate for-profit entities from profit-maximizing behavior has failed. Instead of throwing more money at MA to reform it, trying to cut MA payments, or regulating, perhaps the solution is starving the beast. With reduced cost-sharing and service expansion, people would have less incentive to enroll in MA. The fewer beneficiaries, the less money paid out, the less power.

A campaign to improve Medicare might be the only political avenue open to those who want to save it.

https://prospect.org…

By Walker Bragman
Jacobin, January 21, 2022

Last Thursday, the Supreme Court blocked President Joe Biden’s vaccine-or-test mandate for businesses with more than a hundred employees. The ruling was a blow for the Biden administration — particularly to its efforts to get Americans vaccinated, which have been sluggish in recent months amid widespread hesitancy and skepticism of the jabs.

Despite the fact that the vaccines are highly effective at preventing severe infections, hospitalizations, and death from COVID-19, just 36 percent of Americans today are fully vaccinated with a booster and about a quarter have not even gotten a single dose. A poll from September found that more than 80 percent of the unvaccinated did not plan on getting the shots.

The court’s ruling comes at a particularly bad time for the White House. The Omicron variant is surging across the country, bringing with it record-high COVID hospitalizations and case numbers, and new lows for the president’s approval numbers.

Biden has blamed vaccine hesitancy on “dangerous misinformation on cable TV and social media.” But a good deal of the blame lies with his own administration and its failure to do everything in its power to combat that misinformation and make it as easy as possible for people to get vaccinated — such as by trying to establish a national health insurance program like Medicare for All or a public option. Experts say such an effort could have been the best way to turn the tables on the country’s ongoing battle with COVID.

Surveys of the unvaccinated have found that they are more likely to be uninsured and have lower incomes. One study from the Kaiser Family Foundation in June found that uninsured Americans were twice as likely to be unvaccinated.

A national health insurance program would help stem the spread of disinformation that is discouraging some people from getting vaccinated.

“The evidence is clear: When Americans have access to primary care without financial barriers, they are more likely to trust their health providers’ advice and get vaccinated against COVID-19,” said Dr Susan Rogers, an internal medicine physician in Chicago and president of the pro-single-payer group Physicians for a National Health Program. “However, our fragmented health system prevents most Americans from building a trusting relationship with a provider.”

The Role of Primary Care Providers

From a public health perspective, national health insurance makes sense — especially during a pandemic.

A March 2021 report by the progressive group Public Citizen found that hundreds of thousands of US COVID deaths could have been avoided under a single-payer system, noting that under such a system, hospitals would be better funded and providers better able to coordinate care for patients. Americans would stop skipping doctor visits due to cost or lack of insurance. People of color, in particular, the report notes, “would no longer face disproportionately high rates of uninsurance, reducing an important contributor to racial disparities in access to health care.”

There is another benefit to having national health insurance that could directly impact vaccine rollout: It would increase access to primary care physicians, who have proven to be a vital point of contact in efforts to vaccinate the country.

The role primary care physicians play in vaccinations is well established. A survey from early last year of five thousand patients from CVS found that primary care physicians were the most important experts people consider in the decision of whether or not to get vaccinated against COVID.

That’s likely in part because primary care doctors have long been closely associated with vaccinations. A survey published in July in the Annals of Family Medicine found that in 2017, primary care physicians delivered more than half of vaccinations in Medicare Part B Fee-For-Service, including between 25 and 50 percent of vaccinations in the majority of counties.

Biden has indicated he is aware of the role this critical group plays in convincing people to get vaccinated. In September, he called on doctors to reach out to their unvaccinated patients to talk to them about the vaccines.

“Tonight I’m asking each of you to reach out to your unvaccinated patients over the next two weeks and make a personal appeal to them to get the shot,” the president said.

Many Americans, however, do not have a personal doctor to talk to them about such matters. A study published in December 2019 in the Journal of the American Medical Association (JAMA) Internal Medicine revealed that a quarter of all Americans don’t have a primary care provider — and that number was rising.

According to the study, one of the main reasons that fewer and fewer people have a primary care physician is because of health insurance requirements.

“Financial barriers, especially among uninsured Americans, may prevent some people from accessing primary care,” noted the report.

According to Rogers, “Uninsured Americans may go years without seeing a primary care provider due to cost,” while “those with commercial insurance plans face not only high copays and deductibles that discourage regular care, but also constantly changing provider networks that make it nearly impossible to stay with the same primary care physician long term.”

The solution, she says, is a nationalized health insurance option. “A Medicare for All system would guarantee that everybody in the U.S. had access to regular primary care, with full choice of provider and no cost barriers to stand in the way,” she said.

Having access to a trusted medical professional would also go a long way to combatting medical misinformation about COVID vaccines. A November survey from the Kaiser Family Foundation found that 78 percent of American adults — almost eight in ten — either believed or were uncertain about false statements related to the pandemic or the vaccines. The unvaccinated, along with Republicans, were more likely to hold such misconceptions.

Such misinformation is killing people. An NPR survey from December found that counties that voted for Trump in 2020 had lower vaccination rates and higher death rates than those that voted for Biden.

Weekly tracking by Morning Consult reveals that countries with free and/or universal health care have far lower rates of vaccine hesitancy than the United States. Of the countries surveyed, only Russia fared worse.

Biden Abandons Reform

While Biden promised to establish a public insurance option during the 2020 presidential campaign, since he took office, major health care reform has vanished from the national discussion.

Back in April, when the White House released the fact sheet for its $1.8 trillion American Families Plan — the follow-up to the American Rescue Plan Biden signed in March, which the Build Back Better Act was based on — there was a line committing to the goal of establishing a public option. But the policy itself was not included in the bill.

Alex Lawson, the executive director of the progressive group Social Security Works, tells Jacobin that health care reform, outside of expanding the Affordable Care Act and subsidizing more private health insurance plans offered on the ACA marketplace, was never a priority for Biden’s administration — even though it could have made vaccine rollout easier.

“Biden could have anointed somebody in the Senate to carry [the public option] for the White House. It could have been a White House priority for sure,” he said. “But lacking a White House priority, which was sort of obvious to me, at least, the only thing that could have made it happen otherwise is a Senate champion.”

When the White House released its proposed budget in May, it included more private insurance subsidies pushed by industry lobbyists, but funds for a public option were conspicuously absent. Senator Patty Murray (D-WA) and Representative Frank Pallone (D-NJ) pledged to continue fighting for such a bill, but as of earlier this month, the work was still supposedly underway.

At the time Biden released his budget, Lawson told NBC that he thought that a public option was, for the time being, dead. “I don’t think there’s a dynamic where we see it at the center of a political fight again,” he said.

But experts say pushing for these health care reforms could encourage greater vaccine adoption rates — and potentially resuscitate Biden’s dismal poll numbers.

Polling consistently shows high levels of support for a nationalized health insurance program. A Morning Consult survey from last March found that 55 percent of voters supported Medicare for All, with just 32 percent opposed, and 68 percent favored the idea of a public option.

At this point, moving forward on a public option would likely prove all but impossible for a president who has been unable to deliver on his major agenda items. Such a push would put Biden not just on a collision course not only with conservative Senators Joe Manchin (D-WV) and Kyrsten Sinema (D-AZ), but also highly profitable corporate health care interests with limitless cash.

Shortly after Biden took office, the health care industry set to work to prevent any major reform to the current system. One group that was particularly aggressive was Partnership for America’s Health Care Future (PAHCF), a front group for health insurers, pharmaceutical companies, and hospital chains.

PAHCF ran ads claiming that a public option would mean “higher costs, and fewer options for Americans,” while deceptively arguing that any changes to the US health care system would harm communities of color — even though they disproportionately experience barriers to care and worse health outcomes under the current private health insurance-based system.

Public option proposals at the state level, meanwhile, have also come up against stiff opposition. When Washington state passed its public option plan in 2019, hospitals lobbied for and secured a loophole allowing them to not accept the insurance. PAHCF has a state-focused affiliate that has fought state public option proposals in Colorado, Nevada, and Connecticut.

“The majority of Americans — and their physicians — support an equitable and publicly financed national health system called Medicare for All,” Rogers says. “Unfortunately, those who profit most from our broken system, namely commercial insurance and pharmaceutical companies, have billions to spend on lobbying, political donations and fear-mongering ad campaigns. Medicare for All advocates must organize in every community so that our voices and our votes are more powerful than the lobbying might of health care profiteers.”

https://www.jacobinmag.com…

By Jonathan Michels
Jacobin, January 19, 2022

A recent exposé in the Los Angeles Times brings to light the horrific increase in amputations in majority-black, working-class South Los Angeles. After decades without access to health-promoting infrastructure like supermarkets, parks, and doctors, diabetic residents are losing their toes, feet, and legs.

Nightmare scenarios like these owe in part to the nation’s shortage of primary care physicians, which has made it nearly impossible for people to obtain preventive services or to secure an appointment with their provider quickly enough to receive the specialty care that might have enabled them to keep their limbs.

Thankfully, we’re beginning to see more investment in addressing the nation’s primary care shortage. In March of 2021, when he signed the American Rescue Plan, President Biden directed $1 billion to a program called the National Health Service Corps (NHSC). Not many people know about the NHSC, even though it’s been around since 1972. The NHSC commissions medical, nursing, dental, nurse practitioner, and physician assistant students to practice primary care in designated underserved areas, both rural and urban. In return, NHSC recipients receive student loan reimbursement or financial assistance to pay for college.

Before enrolling in a physician assistant graduate program, I worked for fourteen years as a health care worker at two of the largest medical centers in North Carolina. I know firsthand how a lack of primary care services leads to patients suffering from bankruptcy, chronic disease, avoidable surgery, and even death.

I applied for an NHSC scholarship because I saw the program as a way to deliver quality care to underserved patients, and a once-in-a-lifetime opportunity to serve in an organization whose mission actually aligned with my own values and beliefs: principally, that health care should be a public good. When I graduate in 2023, I will practice medicine among the largest cohort in the National Health Service Corps’ nearly fifty-year history.

Although it’s admittedly much too small to remedy America’s dysfunctional health care system, socialists should look to the NHSC as a model for universal programs like tuition-free college and as a way to focus our health care system around meeting human needs rather than the whims of the free market. Additionally, members of the NHSC are primed to take a leading role in the Medicare for All movement.

An Oasis of Humanity

In 1972, the NHSC commissioned its first twenty “officers,” most of them doctors, to treat patients in communities suffering from physician shortages. The ultimate aim of the program, however, “was to ‘sensitize‘ NHSC doctors to the health needs of the poor and increase the chances that these doctors, after their tours, would choose the psychic satisfaction of treating the needy over the financial rewards of practicing in more affluent communities.”

Although the demographics of the NHSC program grew to include an increasing proportion of mid-level practitioners, social workers, and mental and behavioral health professionals, the program’s commitment to meeting basic human needs is unchanged. Today, the NHSC remains a little-known oasis of humanity within the United States’ tapped-out, profit-driven health care system.

More than half of all NHSC providers serve in a federally qualified health center “where patients are seen regardless of their ability to pay.”

One study by the Kaiser Family Foundation found that federally funded community health centers serve nearly 26 million children and adults — roughly one in twelve Americans — in more than 10,400 urban and rural locations. Nearly half of all patients receive Medicaid. In some areas, these health centers are the only places one can go to receive primary care services like vaccinations and basic health screenings that have shown to improve health outcomes and lower the risk of disease.

Service corps members work to improve the health of thousands of Americans each day, but in 2000, researchers estimated that the program still met “only 12 percent of the need for primary health providers in underserved areas.” The increased capacity of the program afforded by the American Rescue Plan will likely improve that figure, but it won’t be enough to remedy the overwhelming deficiency in primary care providers, which is only expected to worsen in the next decade due to a combination of retiring physicians and a growing elderly population. The United States may be short as many as 55,200 primary care physicians by 2033, according to a report conducted by the Association of American Medical Colleges.

One of the main reasons American medical students forego careers in primary care is the exorbitant cost of medical school tuition. The median debt level of medical students is $200,000, possibly more at a private institution. The prospect of crushing debt prompts students to specialize in higher-paying fields like radiology and orthopedic surgery.

New York University Medical School eliminated tuition in 2018 in the hope that more students, relieved of their heavy debt burden, would opt to work in less lucrative areas of medicine like primary care. The NHSC goes a step further by directly placing providers in the communities where they are needed the most. And it doesn’t rely on the charity of rich donors. It’s funded by the public and for the public, just like the larger programs that will be necessary to remedy the larger problems at play, namely Medicare for All and tuition-free college.

The creation and expansion of the NHSC are genuine achievements, but other countries are able to accomplish even more with even fewer financial resources at their disposal. Even in the face of a devastating economic blockade, Cuba shows the extraordinary heights a society can reach when it prioritizes public health.

Cuba’s Latin American School of Medicine (ELAM) offers free education to students from all over the world, including the United States. “While graduates from US medical schools leave saddled with six-figure debts,” wrote Medea Benjamin in Jacobin, “the only debt ELAM students have is a commitment to practice medicine in low-income and medically underserved communities.”

Sounds a lot like the NHSC — except Cuba’s commitment to public health extends far beyond primary care. The result is that Cuba produces more doctors per capita than any other nation in the world, with health outcomes that rival those in far wealthier countries. In addition, the country’s “army of white coats” routinely deploys into underserved areas even outside of its own borders, risking their lives for strangers in order to stave off grave health crises ranging from Ebola to COVID-19.

The NHSC is operating at nowhere near this scale, but it gives us a glimpse in an American context of what’s possible — and ironically, despite the United States’ unceasing attacks on Cuba for over half a century, could inspire us to strive for more.

Our Own Army of White Coats

In the short term, there are several things that can be done to blunt the United States’ shortage of primary care providers. One solution is to find creative ways to retain NHSC providers who are already practicing primary care beyond their defined service obligation. Another option is to increase funding for the NHSC in an effort to enlarge its field strength.

These measures could not only address the primary care shortage, but might also strengthen the movement for Medicare for All. The recent expansion of the NHSC workforce may not be the sweeping social change that many of us hoped might emerge from the carnage of the pandemic, but it could represent one of the best opportunities we have in marshaling medical workers in support of a universal, single-payer program.

Transformative health reform like Medicare for All is unlikely to pass in the United States without the support of health care workers who understand that our greatest health victories have been won through building public infrastructures to protect and sustain our health. What if NHSC providers’ commitment to service could be used to motivate them to move beyond the arm’s length distance that clinicians are encouraged to keep from their patients, and instead join them and their coworkers in advocating for Medicare for All?

This hands-on approach toward raising consciousness has radicalized many health workers and clinicians in the past, and is still the answer today. Conservative physicians with the British Medical Association stymied efforts to nationalize health care in the UK throughout the 1940s. But several decades of practicing within the National Health Service inculcated doctors and residents to the point where they are now willing to take collective action to defend it against further attacks.

Our own history can also be instructive. Six years before the creation of the NHSC, a cadre of American doctors, nurses, and social workers with the Medical Committee for Human Rights (MCHR) volunteered to treat underserved communities in the Jim Crow South. In an effort to provide a long-term solution for the lack of primary care services endemic to the South’s medical apartheid system, local health care workers and community advocates working alongside MCHR members formed the country’s first federally funded health center in 1965. Thousands of other community health centers followed, many of them the same clinics where NHSC recipients currently provide primary care.

The MCHR eventually developed into a national network of health workers focused on securing a universal, national health program. Doctors like Quentin Young used their credibility as caregivers to mobilize their colleagues and the public in opposition against pernicious organizations like the American Medical Association and inspired generations of other health workers to do the same.

NHSC recipients took their first step toward acknowledging the need for a system that treats health care as a human right rather than a commodity when they signed up to practice primary care in underserved communities. The human solidarity that the NHSC elicits is an outlier at the moment, but it could provide an example of how we can transform a system intent on extracting cold currency from caregiving into one of service and sacrifice for the public good.

https://www.jacobinmag.com…

By Anabel Munoz
ABC 7 Los Angeles (KABC), January 18, 2022

The reverend Martin Luther King Jr. challenged injustices across all levels of American society, including health care. On Monday, two physicians reflected on Dr. King’s work and a shared mission for the future to combat health care inequities.

Dr. Susan Rogers, president of Physicians for a National Health Program, remembers when Dr. Martin Luther King Jr. visited her hometown.

“When I was in seventh grade, Dr. King came to Chicago to march against the segregated neighborhoods that he found were just as bad in the northern cities like Chicago as they were in the deep South,” said Rogers.

It was also in Chicago that Dr. King said: “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death,” according to the Associated Press. It was at a news conference in connection with the Medical Committee for Human Rights.

“The situation of health care in this country was abysmal for minorities. The segregation of hospitals,” said Rogers.

Dr. Rogers is now president of Physicians for a National Health Program (PNHP.) Alongside colleagues like Dr. Paul Song, who leads the California chapter, the group advocates for a more just system through Medicare for All.

“Physicians for National Health Program was actually founded by a doctor by the name of Quentin Young, who was actually, ironically, Martin Luther King’s physician,” said Dr. Song. “Dr. Young during the riots, and also during the protests, organized a group of doctors to basically go down to all the freedom marches, to really help if anyone was injured during those marches to provide medical assistance.”

Dr. Song stressed that while a lot of disadvantaged communities may have achieved equalities in one way or another, gross divides in health care remain. Many of those inequities have been exacerbated here in Southern California during the pandemic.

“I think right now in California, we face a very pivotal moment,” added Song. “We still have roughly three million people that are uninsured. We have millions of people that are underinsured, meaning, even though they have a piece of paper that says they have insurance, that their co-pays and deductibles make it so expensive that they can’t seek the care.”

“One of the things that COVID did highlight was how your life expectancy is more determined by your zip code than your genetic code,” said Dr. Rogers.

Those hardest hit are often frontline workers and people in low-income and communities of color.

“Dr. King’s words have always resonated with me. And I think he really goes back to the book of Matthew about caring for the least among us,” said Song. “That we’re not defined by how many billionaires we create in society, but really about how we care for the most marginalized, our poor brothers and sisters. Really, those that don’t have a voice in our society.”

https://abc7.com…