Health Care Reform Articles - June11, 2019

The Business of Health Care Depends on Exploiting Doctors and Nurses

by Danielle Ofri - NYT - June 9, 2019

You are at your daughter’s recital and you get a call that your elderly patient’s son needs to talk to you urgently. A colleague has a family emergency and the hospital needs you to work a double shift. Your patient’s M.R.I. isn’t covered and the only option is for you to call the insurance company and argue it out. You’re only allotted 15 minutes for a visit, but your patient’s medical needs require 45.
These quandaries are standard issue for doctors and nurses. Luckily, the response is usually standard issue as well: An overwhelming majority do the right thing for their patients, even at a high personal cost.
It is true that health care has become corporatized to an almost unrecognizable degree. But it is also true that most clinicians remain committed to the ethics that brought them into the field in the first place. This makes the hospital an inspiring place to work.
Increasingly, though, I’ve come to the uncomfortable realization that this ethic that I hold so dear is being cynically manipulated. By now, corporate medicine has milked just about all the “efficiency” it can out of the system. With mergers and streamlining, it has pushed the productivity numbers about as far as they can go. But one resource that seems endless — and free — is the professional ethic of medical staff members.

This ethic holds the entire enterprise together. If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.
The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.
By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.
There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.
In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt. Imagine a plumber or a lawyer doing 30 percent more work without billing for it. But in health care there is a wondrous elasticity — you can keep adding work and magically it all somehow gets done. The nurse won’t take a lunch break if the ward is short of staff members. The doctor will “squeeze in” the extra patients.

The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”
For most doctors and nurses, it is unthinkable to walk away without completing your work because dropping the ball could endanger your patients. I stop short of accusing the system of drawing up a premeditated business plan to manipulate medical professionalism into free labor. Rather, I see it as a result of administrative creep. One additional task after another is piled onto the clinical staff members, who can’t — and won’t — say no. Patients keep getting their medications and their surgeries and their office visits. From an administrative perspective, all seems to be purring along just fine.
But it’s not fine. This month the World Health Organization recognized the serious effects of burnout from chronic workplace stress. Burnout levels among doctors are at new highs, far worse than among the general population, and increasing relentlessly. Burnout among nurses is similarly rising and is highest among those on the front line of patient care. Doctors and nurses commit suicide at higher rates than in almost any other profession. Higher levels of burnout are also associated with more medical errors and compromised patient safety.
This status quo is not sustainable — not for medical professionals and not for our patients.
Mission statements for health care systems and hospitals are replete with terms like “excellence,” “high-quality” and “commitment.” While these may sound like Madison Avenue buzzwords on a slick brochure, they represent the core values of the people who labor in these institutions. Health care is by no means perfect, but what good exists is because of individuals who strive to do the right thing.
It is this very ethic that is being exploited every day to keep the enterprise afloat.
The health care system needs to be restructured to reflect the realities of patient care. From 1975 to 2010, the number of health care administrators increased 3,200 percent. There are now roughly 10 administrators for every doctor. If we converted even half of those salary lines to additional nurses and doctors, we might have enough clinical staff members to handle the work. Health care is about taking care of patients, not paperwork.
Those at the top need to think about the ramifications of their decisions. Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine.
https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html?

Mar-a-Lago Comes for British Health

Of privatization, cronyism and trade deals.

by Paul Krugman - NYT - June 6, 2019

Probably everyone who followed Donald Trump’s visit to Britain has a favorite scene of diplomatic debacle. But the moment that probably did the most to poison relations with our oldest ally — and undermine whatever chance there was for the “phenomenal” trade deal Trump claimed to be offering — was Trump’s apparent suggestion that such a deal would involve opening up Britain’s National Health Service to U.S. private companies.
It says something about the qualities of our current president that the best argument anyone has made in his defense is that he didn’t know what he was talking about. He does, however, know what the N.H.S. is — he just doesn’t understand its role in British life.
After all, last year he tweeted that Britons were marching in the streets to protest a health system that was “going broke and not working.” Actually, the demonstrations were in favor of the N.H.S., calling for more government funding.
But never mind what was going on in Trump’s mind. Let’s focus instead on the fact that no American politician, Trump least of all, has any business giving other countries advice on health care. For we have the worst-performing health care system in the advanced world — and Trump is doing all he can to degrade it further.

As it happens, the British and American health systems lie at opposite ends of a spectrum defined by the relative roles of the private and public sectors.
Although the Affordable Care Act expanded health coverage and increased the role of Medicaid, most Americans still get their insurance (if they get it at all) from private companies and get treated at for-profit hospitals and clinics. In other countries, like Canada, the government pays the bills, but health providers are private. Britain, however, has true socialized medicine: The government owns the hospitals and pays the doctors.
So how does that system work? Far better than is dreamed of in conservative philosophy.
First of all, medical bills simply aren’t an issue for British families. They don’t have to worry about being bankrupted by the cost of treatment, or having to forgo essential care because they can’t afford the deductibles.
You might think that providing this kind of universal coverage is prohibitively expensive. In reality, however, Britain spends less than half as much per person on health care as we do.

Is the health care any good? Judging from the results, yes. Britons have higher life expectancy than we do, much lower infant mortality, and much lower “mortality amenable to health care.”
Does this mean that America should adopt a British-type system? Not necessarily.
There are, it turns out, multiple ways to provide universal health care: Canadian-style single-payer also works, as do systems of competing private providers, as in Switzerland, as long as the government does a good job of regulation and provides adequate subsidies for lower-income families.
But the N.H.S. works. It has its problems — what system doesn’t? — but there’s a reason the British love it.
Now, my experience in dealing with U.S. conservatives on health care issues is that they simply refuse to believe that other countries’ systems work better than our own. Their ideology says that the private sector is always better than government, and this trumps any and all evidence.
Indeed, it leads them to reject the government-run pieces of our own system that work fairly well. Which brings me to the reason Donald Trump is the last person who should be criticizing the N.H.S.
You see, America does have its own miniature version of the N.H.S.: the Department of Veterans Affairs’ Veterans Health Administration, which runs a network of hospitals and clinics. And like the N.H.S., the V.H.A. works pretty well.
Some of you are probably shaking your heads, because you’ve heard terrible things about the V.H.A. — tales of vast inefficiency and long waits for treatment. But there’s a reason you’ve heard these tales: They’ve been systematically spread by politicians and right-wing organizations that seize on problem cases as part of a drive to dismantle and privatize the system.

The reality, according to independent studies, is that on average, V.H.A. wait times are if anything shorter than those in the private sector, and V.H.A. hospitals provide better care.
But this good record may soon change. Historically policy at the V.H.A., like policy at the N.H.S., has been set largely by medical professionals. But last year reporting by ProPublica revealed that much of Veterans Affairs’ policy is now being set, not by duly appointed officials, but by a trio of Trump cronies whom insiders call the “Mar-a-Lago crowd.”
Leading the troika, by the way, is Ike Perlmutter, the chairman of Marvel Entertainment. And if you believe that Perlmutter’s influence will lead to lower costs and better care for our nation’s veterans, you probably also believe that Captain America is real.
Which brings us back to those N.H.S. remarks. Whatever the president thought he was saying, his host country had every reason to hear them as a hint that a trade deal would bring Trump-style privatization and cronyism to British health care. And that would indeed be “phenomenal.”
https://www.nytimes.com/2019/06/06/opinion/health-care-nhs-trump.html?action=click&module=Opinion&pgtype=Homepage

Why we're fighting the American Medical Association

The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All

by Jonathan Michels, Will Cox, Alankrita Siddula and Rex Tai - The Guardian - June 6, 2019

This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.
The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.
The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.
By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.
The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine”. In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism”.
The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.
Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.
Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.
In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.
Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.
The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.
Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.
The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.

• Jonathan Michels is a premedical student at the University of North Carolina at Greensboro and a student board member of Physicians for a National Health Program (PNHP), an organization that advocates for an improved and expanded Medicare for All health system

• Will Cox is a longtime healthcare worker and social justice organizer and serves on the board of the North Carolina chapter of PNHP

• Alankrita Siddula is a medical student at Rush University in Chicago and a member of Students for a National Health Program (SNaHP)

• Rex Tai is a medical student at the University of Illinois at Chicago. He is a midwest regional delegate for SNaHP and has a background organizing for criminal justice reform and harm reduction in opioid treatment

 https://www.theguardian.com/commentisfree/2019/jun/06/why-were-fighting-the-american-medical-association 

Nurses Know the Human Costs of Care. That’s Why Many Want ‘Medicare for All.’

by Jeneen Interlandi - NYT - May 27, 2019

The experiences that have turned the members of National Nurses United, the nation’s largest union for nurses, into vocal advocates for a universal, government-run health care system are numerous and horrific.
Renelsa Caudill, a Washington, D.C.-area cardiac nurse, remembers being forced to pull a cardiac patient out of the CT scanner before the procedure was complete. The woman had suffered a heart attack earlier that year and was having chest pains. The doctor wanted the scan to help him decide if she needed a potentially risky catheterization, but the woman’s insurance, inexplicably, had refused to cover the test.
Melissa Johnson-Camacho, an oncology nurse in Northern California, remembers a mother who had to ration the special bags that were helping to keep her daughter’s lungs clear. The bags were supposed to be changed every day, so that the daughter did not drown in her own fluids, but they cost $550 each.
And Karla Diederich, also from California, remembers saying a final goodbye to her friend and fellow intensive care nurse Nelly Yap in their hospital’s parking lot. Ms. Yap was dying of metastatic cancer. She was scheduled for another round of chemotherapy, but the hospital had changed owners while she was on sick leave and she’d lost her job — and insurance — as a result. “Nelly spent most of her life taking care of other people,” Ms. Diederich says. “And when she needed that care herself, it was not there.”

The women say that their professional experiences have led them to an inescapable conclusion: The motives of gargantuan for-profit health care industries — hospitals, pharmaceuticals, insurance — are incompatible with those of health care itself. They argue that a single-payer system, run by the federal government and available to all United States residents regardless of income or employment status, is the only way to fully eliminate the obstacles that routinely prevent doctors and nurses from doing their jobs.
Several proposals now working their way through Congress would aim to create just such a system. The nurses’ support for such proposals — the union has endorsed a bill put forth by Representative Pramila Jayapal of Washington — is somewhat surprising, because the zero-sum nature of American health policy tends to place them on the losing end of any major system overhaul. The money it will take to provide many more services to many more patients will have to come from somewhere, the thinking goes. And the paychecks of doctors and nurses are a likely source.
That calculus has not deterred the nurses.
Perhaps that’s because they see so much time and money wasted by the bureaucracy of the current system. By most estimates, the administrative costs of American health care surpass those of any other developed nation. Or maybe it’s because of the innumerable avoidable medical crises they constantly find themselves confronting. Patients go into heart failure because they can’t afford blood pressure medication, or gamble with their diabetes for want of insulin, then turn up in the hospital needing care that’s far more expensive than any preventive measure would have been.
Or maybe they just know that a steady job with decent health benefits does not exempt anyone from the arbitrary agonies of our current system. Ms. Johnson-Camacho recalls having to discharge a patient without essential chemotherapy — not because the patient was uninsured but because his insurer refused to cover the drug that had been prescribed. “I had just finished explaining to him how important it was to take this medication faithfully,” she says. “I told him, ‘Every day you skip it is a day that the cancer has to potentially spread.’ And then we had to send him home without it.”
Ms. Johnson-Camacho says another patient — a young man with a treatable form of cancer — was so overwhelmed by the cost of his care, and so terrified of burdening his family with that cost, that he told her he was planning to kill himself.

Anyone who has been to a hospital or seen a family member grapple with illness has at least one story like this. Nurses, who encounter the system daily for years or decades, have hundreds, and they know better than most how brutally such stories can end. “It’s barbaric,” Ms. Diederich says. “Crucial medical decisions are being made by businessmen whose primary goal is to make a profit. Not by medical professionals who are trying to treat their patients.”
The next remaking of American health care is still a long way off. Recent congressional hearings and a report from the Congressional Budget Office have helped to clarify the long roster of questions that lawmakers will have to address if they are serious about any of the many bills now circulating. But concrete answers to those questions have yet to materialize, and in the meantime, American patients are ambivalent. Polling suggests that a majority now support the idea of universal health care, but many are still wary of the trade-offs such an overhaul would require.
Proponents who want to persuade those skeptics would do well to have nurses make the case. “People say they are scared to have the government take control of their health care,” Ms. Diederich says. “But they should be scared of the people who are in control now.”

https://www.nytimes.com/2019/05/27/opinion/nurses-medicare-for-all-health-insurance.html?

 

The Case for Medicare for All
by James G. Kahn - New Labor Forum - 2019, Vol. 28(2) 52–56 - 2019

Should we support Medicare buy-ins? Only your health economist knows for sure!
Interest in “Medicare for All” health reform is accelerating in Congress. Many of the November 2018 “blue wave” winners advocated vocally for single-payer health insurance. In the House of Representatives, now controlled by Democrats, the bill H.R. 1384 (Rep. Pramila Jayapal [D-WA], replacing H.R. 676) is the mainstay, and committee hearings have been announced, while in the Senate, Bernie Sanders (D-VT) has introduced his version, S. 1804.
Public support for single-payer insurance is astoundingly high, with 68 percent in a recent poll placing high importance on achieving it. The most vociferous supporters are progres- sives and minorities, but single payer garners support from across the political spectrum. Perhaps it’s unsurprising that so many people are pulling for a reform that is both efficient and generous—how often do those go together? Single payer insurance is not just a policy tweak, nor another layer of complexity on our health-care non-system. It’s revolutionary and transformative and has the potential to both benefit from and build powerful coalitions.
The same cannot be said for all approaches offered by Democrats. They have also proposed several bills for Medicare expansions—mecha- nisms for individuals to “buy in” to Medicare coverage. At first, they sound attractive, an incremental insurance expansion in the direc- tion of Medicare for All. But close consideration reveals fundamental flaws. There is a long list of reasons that all of us—and especially the labor movement—should oppose these Medicare-for- All impostors in favor of the real deal.

Let’sstartbyclarifyingkeyterms.“Medicare for All” and “single payer” refer to plans that scrap existing health insurers (private, Medicaid, safety net programs, etc.) in favor of a single universal public insurance program, an “improved Medicare for All.” Everyone is cov- ered, cradle to grave, with an identical compre- hensive benefits package. Health-care providers use a single billing schedule and mechanism. All current public funding (65 percent of health spending) shifts to the new program; private insurance premiums and out-of-pocket spend- ing end; and progressive additional taxes pick up the slack. Single payer raises costs by increasing access to care, but saves even more money through administrative efficiency, lower drug costs, and other approaches, such as restricting the use of ineffective procedures. Over time, comprehensive budgets for the entire system—called “global budgets”—slow the growth of health spending. Thus, everyone is covered while costs are brought under control.
Medicare buy-in is fundamentally different than Medicare for All—a slight tweak (indeed an added complexity) to our already Rube Goldberg health system, instead of the needed wholesale revamping.
“Medicare buy-in” or “public option” plans are an entirely different entity. These set up mechanisms (e.g., in the state health exchanges) for populations less than 65 years old (the eligi- bility age for Medicare) to join Medicare or a similar public program by paying a premium. Initially, it sounds like a gentler alternative— easing passage in Congress, increasing “choice” of health insurance, and slowly building our premier public health insurance plan. However, looks are deceiving. Medicare buy-in is funda- mentally different than Medicare for All—a slight tweak (indeed an added complexity) to our already Rube Goldberg health system, instead of the needed wholesale revamping. And certainly not a meaningful step toward Medicare for All.

There are crossover versions as well. One plan outlines a many-decades-long process of building to a predominantly public insurance system. Even within some single-payer bills, some more problematic features of the current financing system are continued, such as subsi- dies for for-profit providers. (See Max Fraser’s “Organized Money” column in this issue, which details the maneuvers of the health-care indus- try to prevent meaningful Medicare for All.)
For those interested in details of all of these plans, Vox recently published a thorough, clear, and nuanced review of Democratic “Medicare” reform plans. This review adopted a neutral stance: all the plans would increase coverage. The authors remained agnostic on the relative merits of Medicare for All and Medicare buy-in expansions—an “It’s all good” perspective.
[S]ingle payer is the only solution consistent with universal, affordable health care and with the solidarity values long supported by the labor movement.
But is it? Where should labor position itself? Supportive of any “Medicare” expansion? Or resolutely committed to Medicare for all? After 25 years researching, writing, educating, and advocating in this arena, I propose that single payer is the only solution consistent with univer- sal, affordable health care and with the solidarity values long supported by the labor movement.
Why? There are 13 reasons that Medicare for All is superior to Medicare buy-ins:

1. Medicare for All insures everyone. Only with single payer do we reach 100 percent coverage. Medicare buy-ins will leave 5 percent or more of the pop- ulation uninsured (15 million people), and even more underinsured, with inad- equate plans. This matters—having reli- able insurance enhances happiness and health. There’s no reason we shouldn’t seek full coverage, if it’s affordable . . . which it is (see point 7).
2. Medicare for All insures everyone well. Underinsurance—substantial deductibles, financial caps, and uncov- ered providers and services—leads to foregone and delayed medical care. In the current system (preserved under Medicare buy-ins) under-coverage is rife, as a cost-control mechanism for employers and insurers. With single payer, coverage is first-to-last dollar, for all medically appropriate care, and with no provider restrictions. This assures optimal access to care.
3. Medicare for All keeps everyone in the same game. If everyone is covered by the same insurance, everyone will share a commitment to that insurance. Think how well public fire departments and utilities, such as garbage collection, work. This shared experience has both practical and solidarity benefits. On the applied side, it assures that implementa- tion challenges are resolved in a suit- able fashion, with excellent performance standards preserved. In the current piecemeal financing system, insurance for the poor (like Medicaid) and for the middle class (private plans), lacking powerful political support, suffer under- funding and onerous rules. Shared par- ticipation also fosters social cohesion. This benefit should not to be under-val- ued. Single payer would represent a major statement for solidarity and thus provide a foundation for a society that values and pursues social justice.
4. Medicare for All removes health care as a bargaining burden. In contract negotiations, the time-consuming effort
to achieve and protect health care would be off the table if the country adopts Medicare for All. The bargaining focus would return to wages, non-medical benefits, work conditions, and other central labor concerns.

In contract negotiations, the time-consuming effort to achieve and protect health care would be off the table if the country adopts Medicare for All.

5. Medicare for All delinks health care and employment. Assuring health insur- ance regardless of work setting, indeed regardless of work status, allows work- ers to make job and training choices based on personal and professional pref- erences. No more suffering a dead-end job for the insurance. This would empower individuals to change jobs or take on new business ventures as desired. With the option to exit, workers would have increased leverage to improve sub- optimal work situations.
   
6. Medicare for All enhances adminis- trative efficiency. Our health-care sys- tem wastes $400 billion per year in unnecessary complexity of billing and payment. That’s about $1400 per person per year in excess paperwork. Single payer would thus result in a one-time 10 to12 percent savings in health spending, about evenly split between the insur- ance and provider sides. These funds would shift to clinical care.
   
7. Medicare for All controls health-care costs in other ways. Aside from adminis- trative streamlining, single payer saves money in other ways. The two most important: 1) Drug costs drop by about 30 percent, through the use of a single- drug formulary and tough price negotia- tions with pharmaceutical companies. The U.S. Veterans Administration already has these savings, as do other wealthy nations. 2) Growth in spending is
   

controlled over time, through the use of the above-mentioned global budgets. Only an integrated system with central fiscal authority can accomplish this. Instead of impossibly complex oversight of specific clinical decisions (“utilization review”) or “accountable care” strategies that have proven ineffective, single payer would impose financial limits and pro- viders would figure out how to work within them. The resolution of program performance and costs would be accept- able, because everyone would need them to be (see point 3).
8. Medicare for All enhances quality. Single payer sets the stage for improved quality. With a single billing system, there would be comprehensive uniform clinical data, which would facilitate technically sound monitoring of care choices and clinical outcomes, includ- ing evaluation of care innovations.
With a single billing system, there would be comprehensive uniform clinical data, which would facilitate technically sound monitoring of care choices and clinical outcomes...
9. Medicare for All reduces clinical waste and fraud. According to the U.S. Institute of Medicine, about 20 percent of care is unnecessary, not indicated, or just plain fraudulent. The same comprehensive clin- ical data systems that enhance quality may also save substantial money by detecting and reducing waste and fraud.
10. Medicare for All empowers patients. Under a single-payer health plan, indi- viduals can choose the doctors they like. There are no restricted provider net- works, so people will choose based on quality, reputation, and personal prefer- ence rather than insurer approval.
11. Medicare for All empowers doctors (and other providers). Health-care

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providers, relieved of administrative hassles, can focus fully on clinical issues. The electronic health record, which has become an onerous intrusion on provider time and patient communi- cation, can with simple insurance once again serve its proper role of clinical documentation. Doctors can return to full-time—doctoring!
12. Medicare for All fosters a comfort- able and lasting patient-doctor rela- tionship. With patients empowered to choose preferred doctors, and doctors empowered to concentrate on clinical care, the patient-doctor relationship will experience a renaissance. Medicine will be more humane and effective.
13. Medicare for All ends battles to pro- tect myriad pieces of the current health system. Achieving single payer requires a massive political struggle, to be sure. However, with an unsympa- thetic administration in Washington D.C. and in some states, there are end- less ongoing battles, to preserve fund- ing and functionality for Medicaid, to regulate private insurers, to protect tra- ditional Medicare. Under single payer, these battles would cease.
Ultimately, Medicare for All Supports Core Labor Values
For complicated reasons, largely centered on employer-based health-care plans, some unions have opposed single payer. This misses larger considerations: single payer is about supporting working people (and the unemployed, and the rich) with the resources needed for a comfort- able, secure life. The labor movement did as much as any great social reform to foster health and security. Single payer is the next great step in this tradition.
Determined opponents of single payer will strive to undercut these critical strengths, even within the context of Medicare-for-All bills. For example, the current version of Senator Sanders’ bill, S. 1804, allows for use of “Accountable Care Organizations” (ACOs)— structures that try to financially incentivize

medical groups to lower costs, developed under Obamacare. There are two big problems with this approach. First, there’s no evidence that ACOs (also known as “risk sharing”) meaning- fully reduce costs or increase quality. It was a reasonable idea, but large tests demonstrated that it doesn’t work, except in the most tentative and miniscule ways. Second, using ACOs requires organizing providers into large groups, which insurers will attempt to exploit as a back- door to retaining a (profitable) role in health- care financing. Thus, we must work with the champions of Medicare for All in Congress to retain the core elements of true reform and resist counterproductive add-ons.
Beyond this it is important to end the confu- sion among plans—to clarify the differences between the impostors and the real thing. Let coworkers know what the real Medicare for All is: Everyone is covered, with the same compre- hensive benefits package, from cradle to grave. This is critical to reduce the opposition of some unions, which represent a large portion of workers with employer-provided health care, but a small portion of working people overall. Everyone needs to understand that true Medicare for All is the only way to assure excellent access to health care, regardless of income and employment, and to empower pro- viders and patients to focus on quality care and on each other, not on insurance glitches and administrative paperwork. We all need to reach out to elected representatives.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or pub- lication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Author Biography
James G. Kahn, MD, MPH, has been a professor of health economics at the University of California San Francisco for 30 years and has been active in Physicians for a National Health Program, including president of the California chapter, since 1994.

Medicare-for-all is political suicide for Democrats

by John Delaney - Washington Post - June 7, 2019

John Delaney, a Democrat, represented Maryland’s 6th Congressional District from 2013 to 2019 and is a candidate for president.

Medicare-for-all is bad policy for the country and bad politics for the Democratic Party. The Democratic nomination for president shouldn’t go to anyone who supports it, and Medicare-for-all shouldn’t be in the party’s 2020 platform. If we Democrats become the party of Medicare-for-all, advocating that every U.S. citizen is forced into a government-run health-insurance program, President Trump will be reelected and Republicans will control both houses of Congress — ensuring that today’s health-care system will be endangered by renewed GOP attacks.

I was alarmed last weekend at the California Democratic Party Convention to see some of my fellow candidates for the nomination and many convention attendees embracing Medicare-for-all.

The current health-care system needs improving, not dismantling — by Republicans or by Democrats. That’s why I have proposed a mixed-model universal plan that would guarantee health-care coverage through a government plan but would leave Medicare alone and leave private insurance available for those who wish to buy it, with limited tax credits if they opt out of the new plan entirely. The plan would also close the loophole that prevents the government from negotiating drug prices, an essential step for lowering costs.

Crucially, my plan would be fully paid for by steps such as ending the corporate tax deduction for employer-sponsored insurance, allowing the government to negotiate on prescription drug prices and instituting a cost-sharing requirement for higher-income individuals.

Medicare-for-all legislation proposed by Sen. Bernie Sanders (I-Vt.), one of my opponents for the Democratic nomination for president, would basically make private insurance illegal; the federal government would pay all health-insurance costs. That sounds good — if you really, really like the government — but there is one fundamental flaw: Overwhelming evidence shows that, under Medicare, the government doesn’t pay the true costs of health care. According to data from the Urban Institute, Medicare pays providers 89 percent of costs, with higher reimbursements from private insurance companies making up the difference.

Over time, the government’s not paying the cost of health care would become a significant problem. In a free-market system — which would still exist even under Medicare-for-all — health-care providers are not going to pursue or maintain a business model that loses money. This year, the New York Times reported that Medicare-for-all would mean “some hospitals, especially struggling rural centers, would close virtually overnight, according to policy experts. Others, they say, would try to offset the steep cuts by laying off hundreds of thousands of workers and abandoning lower-paying services like mental health.”

Moreover, lower reimbursement rates and a lack of competition (remember, there is only one payer: the federal government) would mean there is no market incentive to innovate, develop new treatments or expedite care. Over time, that would be bad for patients and for medical innovation. Medicare-for-all would clearly lead to a decrease in both health-care access and quality.

But the impact would go beyond hospitals. It’s remarkable that this never seems to get talked about during these debates, but under Medicare-for-all, 150 million Americans would lose their current health insurance and be forced to switch to something new. These are people who have employer-based coverage, union coverage or private plans they pay for fully.  Gallup polling data indicates that about 70 percent of those with private insurance are happy with their coverage. The coverage works for tens of millions of Americans, and it is one of the most valued things in their lives; Medicare-for-all would take it away.

Medicare-for-all might be popular as a slogan or as a tagline. But it is political suicide. If the Democratic Party emerges as the party that closed hospitals and made millions of people shift out of a health-care plan they like, the electoral cost will be severe. People on both sides of the debate recognize that Medicare-for-all is a significantly more disruptive policy change than the Affordable Care Act. But when the ACA, which was a good law and smart policy, affected people’s existing coverage options and led to higher prices for some, Democrats paid a significant political price. Medicare-for-all would guarantee that this disruption affects 150 million Americans. 

It has been baffling over the past few years to watch so many Democrats rush to embrace Medicare-for-all, and it has been disappointing and sad to see many of them now try to equivocate on their position. The Sanders bill is crystal clear in what it would do, and Sanders, to his credit, is upfront about what he believes. But a lot of other candidates are trying to play it both ways with complicated and strange answers. We need to just drop this thing. 

 

https://www.washingtonpost.com/opinions/medicare-for-all-is-political-suicide-for-democrats/2019/06/06/8c41f14c-87d1-11e9-a491-25df61c78dc4_story.html?utm_term=.612a0c33bc9d 

Warning of ‘Pig Zero’: One Drugmaker’s Push to Sell More Antibiotics

by Danny Hakim and Matt Richtell - NYT - June 7, 2019

 

Facing a surge in drug-resistant infections, the World Health Organization issued a plea to farmers two years ago: “Stop using antibiotics in healthy animals.”
But at last year’s big swine industry trade show, the World Pork Expo in Des Moines, one of the largest manufacturers of drugs for livestock was pushing the opposite message.
“Don’t wait for Pig Zero,” warned a poster featuring a giant picture of a pig peeking through an enormous blue zero, at a booth run by the drugmaker Elanco.
The company’s Pig Zero brochures encouraged farmers to give antibiotics to every pig in their herds rather than waiting to treat a disease outbreak caused by an unknown Patient Zero. It was an appealing pitch for industrial farms, where crowded, germ-prone conditions have led to increasing reliance on drug interventions. The pamphlets also detailed how feeding pigs a daily regimen of two antibiotics would make them fatter and, as any farmer understands, a heavier pig is a more profitable pig.

The rise of drug-resistant germs, caused by overuse of antibiotics, is one of the world’s most nettlesome health predicaments. Excessive use of the medicines has allowed germs to develop defenses against them, rendering a growing number of drugs ineffective for people and animals. The practices of livestock farmers, who for decades have used huge quantities of the drugs deemed important to humans, have long been viewed as one of the roots of the problem, but the role of the companies that make the drugs has received less scrutiny.
Antibiotics continue to be an important part of the business of companies like Elanco, which spun off from Eli Lilly in September, its share price soaring to $33 from $24. While Elanco is developing antibiotic alternatives for animals, like vaccines and enzymes, the antibiotics promoted by the Pig Zero campaign are exactly the kinds that global public health officials are trying to curb. And Elanco is no outlier — its rivals are also urging aggressive use of their own antibiotic cocktails.
“The reality is that antibiotics and large-scale industrial farming really grew up together,” said Dr. Gail Hansen, a former state epidemiologist and state public health veterinarian in Kansas, who sits on advisory boards addressing antibiotic resistance. She equated the problem with climate change. “By the time people understand and believe it,” Dr. Hansen said, “it may be too late.”
Elanco had already been put on notice about the drugs used in its Pig Zero push. In 2015, the Food and Drug Administration warned Novartis Animal Health, which had been acquired by Elanco, that the same antibiotic cocktail was “unsafe” and “misbranded,” because it was being illegally marketed to fatten pigs, rather than to simply treat disease. One of the drugs, tiamulin, has been a top seller for Elanco; the W.H.O. views it as medically important to humans, but American regulators do not. Pig Zero trumpets the benefits of coupling tiamulin with chlortetracycline, a drug made by Elanco’s competitors that both American and international regulators consider medically important to humans.
In an interview at Elanco’s headquarters outside Indianapolis, Jeffrey Simmons, the chief executive, said the company had decided to change the program’s marketing and to stop distributing the Pig Zero brochure after The New York Times began asking questions about it.

“We’re trying to be stewards and leaders at the same time,” said Mr. Simmons, adding that the brochure “wasn’t misrepresentation, necessarily, relative to the label or the science, or how a farmer would look at it.”
Dr. Shabbir Simjee, Elanco’s chief medical officer, said drugs like those in the campaign “would never be administered” in a herd “without some animals being physically sick,” adding that “there would need to be some animals showing clinical signs.”
He likened treating a herd to caring for children in a nursery: “If one child gets sniffles, you usually find that the whole class ends up with a cold, and this is exactly the same principle.”
But children almost certainly would not all be treated with preventive antibiotics in such a situation, and many scientists believe animals often should not be treated that way, either.
The connection of overuse of antibiotics in livestock to human health takes two paths: As bacteria develop defenses against drugs widely used in animals, those defense mechanisms can spread to other bacteria that infect humans; and, resistant germs are transmitted from livestock to humans — through undercooked meat, farm-animal feces seeping into waterways, waste lagoons that overflow after natural disasters like Hurricane Florence, or when farm workers and others come into contact with animals.

New F.D.A. regulations put in effect in the waning days of the Obama administration prohibited farms from fattening livestock by lacing their feed with medically important antibiotics. The new rules, along with rising consumer demand for antibiotic-free meat, cut antibiotic use significantly in 2017. But such drugs are still routinely given to pigs and cattle, accounting for almost 80 percent of medically important livestock antibiotics in the United States and nearly 5,000 tons of active ingredient. Worldwide use is projected to keep rising sharply as growing middle classes in places like China and Brazil demand more meat.

Ellen Silbergeld, a professor at Johns Hopkins University, who has worked with the W.H.O. on drug resistance, called the continuing promotion of the drugs by pharmaceutical companies “very dangerous.”
“The reason they’re doing it, though, is money, honey,” she added. “That’s what it’s all about. That’s what it’s always been about.”
Now, the industry has an important ally in Washington: President Trump, who appointed one of Elanco’s former executives, Ted McKinney, as under secretary of agriculture for trade and foreign agricultural affairs. Mr. McKinney told international food safety regulators at a meeting last summer in Rome that they were too singularly focused on consumers, at the expense of pharmaceutical companies and research scientists working to meet growing global demand for food. “We have got to rededicate a focus on them as our customers,” he said.

In 2015, Mr. Simmons, Elanco’s chief executive, joined a White House summit meeting to pledge the company’s commitment to curbing antibiotic use.
Sylvia M. Burwell, then the health and human services secretary, hailed the gathering as a “hopefully historic step to protect the health of our nation.” Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention at the time, warned that antibiotic resistance “could result in the medicine chest being empty when we need it most.”
Mr. Simmons outlined Elanco’s lofty aims. “We’re going to create antibiotic alternatives,” he said, adding, “We believe strongly that there are solutions, there are pipelines, there are options.”

A farm boy from upstate New York, he was a nearly 30-year veteran of Eli Lilly when Elanco spun off last year with its 5,800 employees. His wife helps run a church food bank. Mr. Simmons sits in an unassuming cubicle on Elanco’s campus.
He refers to himself as a “purpose-driven leader” on a mission to fight hunger — echoing the megachurch founder Rick Warren’s best-selling book “The Purpose-Driven Life,” which Mr. Simmons has read and taken to heart. He uses social media to spread a sort of protein-affordability gospel: “#Protein is a nutritious part of a balanced diet, but many don’t have access to it,” he once wrote on Twitter. “We can/must change this!”
While microbiologists emphasize the urgency of fighting antibiotic resistance, agrochemical industry veterans like Mr. Simmons say it must be balanced against hunger and the world’s growing demand for food. He often recounts his time as an executive in Brazil, when an anguished guard in his gated community sought help feeding his two children.
“I’m not doing it for a paycheck or profits,” Mr. Simmons said in an interview. “Purpose has to override that.”
(He does get a paycheck, though. His total compensation was $5.4 million last year.)

Financial disclosures for Elanco and its rival Zoetis, which spun off from Pfizer in 2013, show the two companies sell roughly $2 billion annually in livestock antibiotics. In Elanco’s case, antibiotic sales represent more than one-third of its overall business. Some antibiotics, like monensin, a top seller for Elanco, belong to a class not used in people, and thus are not considered a resistance threat. But so-called shared-class antibiotics, like chlortetracycline, are used in humans and animals, creating risk for resistant infections.
Mr. Simmons said that while Elanco “started as an antibiotic company,” antibiotics that are medically important for people and used in livestock feed now make up only 5 percent of its sales. “We’re not building our company on that 5 percent,” he said. But the company has also said that 12 percent of Elanco’s sales overall, including antibiotics used in feed and administered in other ways, come from medically important antibiotics.

While consumer demand has made developing alternatives an industry imperative, few companies are eager to cede ground on existing business.
Del Holzer, who was the director of meat and poultry for Elanco’s global industry food team from 2012 to 2017, said the company and its competitors want to take positive steps and look good, to a point.
“They want to do the right thing,” said Mr. Holzer, who now works for a division of the agriculture giant Cargill, an Elanco competitor that develops antibiotic alternatives. “But they say, ‘My bottom line is my shareholders will be really pissed at me.’”

An antibiotic boom

When antibiotics were first discovered more than a century ago, no one intended them for animals. But then an American company, Lederle Laboratories, announced in 1950 that chickens grew faster when they were fed chlortetracycline, one of the drugs included in the Pig Zero campaign.
By the early 1960s, almost half of livestock antibiotics were aimed at making animals fatter. Drugs were marketed by the barrel; a 50-pound chlortetracycline bag advertised in 1972 in The Herald, in Jasper, Ind., cost $9.25.
A Purina Pig Chow ad that appeared in an Iowa newspaper in the early 1960s promised that it was “power packed with the potent vitamins, minerals and anti-biotics pigs need for fast growth and good health.” Another ad, in a Missouri paper, promoted “full-o-pep Pig Grower,” a feed laced with antibiotics.

Yet scientists already had misgivings. In 1969, the Swann Committee report, commissioned by the British Parliament, concluded the problem of antibiotic resistance was significant. In 1976, a landmark study published in Nature found that resistant E. coli strains could be passed from chickens fed with antibiotics to other chickens, and then to farm workers.
“It was pretty obvious to me that the prudent thing to do would be to take low levels of antibiotics out of animal feed,” said Dr. Hansen, the former state epidemiologist in Kansas. As an F.D.A. employee in 1978, she gathered evidence for Congress linking antibiotic use in livestock to resistant infections in humans, but no action was taken.
“The science was there, the evidence was pretty easy,” she said. “It was a slam dunk.”
The pharmaceutical industry has pushed back. In 1997, researchers from Elanco were among those who authored a lengthy review in the Journal of Applied Microbiology dismissing concerns about antibiotic use in animals, writing, “We are confronted by a lack of information, a wall of ignorance.”
Pharma companies kept a stranglehold on basic information. Various estimates by academics and public policy groups claim as much as 80 percent of American antibiotic sales go to livestock. But the industry has assailed such projections, calling some “agenda-driven junk science,” while simultaneously lobbying to block legislation requiring more disclosure of antibiotic use.
Mr. Simmons of Elanco has long played down livestock’s role in spreading resistant microbes to humans.
“The most serious pathogens are not related to antibiotics used in food animals,” he said. “Of the 18 major antibiotic-resistant threats that the C.D.C. tracks, only two, campylobacter and nontyphoidal salmonella, are associated with animals.”
But such oft-repeated statements, made even in Elanco’s securities filings, refer only to food-borne strains like antibiotic-resistant salmonella that can be found in raw chicken, for example, while ignoring the myriad ways pathogens can be transferred.

There is a growing body of research establishing links between Clostridium difficile, or C. diff, in livestock and humans, viewed by the C.D.C. as an urgent threat. Broad-spectrum antibiotics in livestock provide “a survival advantage to antibiotic-resistant C. difficile strains,” according to a 2018 study by Australian researchers. Similar studies exist for E. coli and methicillin-resistant Staphylococcus aureus, known as MRSA — the C.D.C. even lists different animals like cows, goats, sheep and deer that can pass E. coli to humans.
“We’ve seen antibiotic-resistant bacteria that can leak into the environment through water and dust, jump to the skin of farmers and swap genes with other bacteria,” said Sarah Sorscher, deputy director of Regulatory Affairs at the Center for Science in the Public Interest, an advocacy group. “And that’s still just scratching the surface on the science. By the time we understand the full magnitude of this threat, it may be too late.”
There has been progress. In 2017, when the F.D.A. effectively banned the use of medically important antibiotics to fatten livestock, their consumption fell by a third that year.
But health experts say the regulations did not go far enough and see a sleight of hand at work, with industry marketing now presenting routine antibiotic use as a “proactive” necessity and weight gain an ancillary benefit, as Elanco did in the Pig Zero marketing campaign.
Before her death last year, Representative Louise M. Slaughter, a New York Democrat who was the only microbiologist serving in Congress, lamented the F.D.A.’s new rules as being riddled with loopholes.
“It’s useless,” she said of the regulations. “That’s why the industry’s supporting it.”

A recent tour of Elanco’s labs at its Indiana headquarters swept past a virology lab and a large machine analyzing the DNA of thousands of hamster cells. Amid beakers and hardware, scientists in coats and protective glasses discussed their efforts to find alternatives to antibiotics.

Aaron Schacht, Elanco’s head of research and development, said those alternatives could include enhancing the animals’ own immune function, immunizing them against particular pathogens or reshaping their gut bacteria to favor the good ones.
“Could we eliminate the need for broad-spectrum antibiotics? I think it’s possible,” he said. “Now let’s let the science play out.”
But change comes in fits and starts. Mr. Holzer, the former Elanco official, said the drugmaker had created “country-specific websites” where “there were certain things you couldn’t talk about in the U.S., but then talk about in Poland.”
“It’s a bit of a hypocritical thing,” he added. “Elanco wants to lead the charge on antibiotic use but then sells into these countries that could become the biggest part of the problem. The idea is that as long as we don’t lose antibiotics in country XYZ, we can take our hit in the U.S., and get the P.R. for it.”
Elanco called Mr. Holzer’s comments “completely inaccurate.” Colleen Dekker, a spokeswoman, said the company no longer included “growth promotion” — fattening up animals — as an approved use for medically important antibiotics worldwide, “regardless of what local regulations allow.” The company was also intentionally decreasing its sales of such drugs, she said, showing that “this is far more than a ‘P.R. effort.’”
But for Pig Zero, the company sees a problem only in the marketing. Going forward, Ms. Dekker said, such drugs would be sold “more from a health perspective” than from “a weight-gain perspective.” Mr. Simmons said of The Times’s inquiries, “We had a lot of dialogue about Pig Zero that probably we wouldn’t have had,” adding, “That’s good.”
https://www.nytimes.com/2019/06/07/health/drug-companies-antibiotics-resistance.html?smid=nytcore-ios-share
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research-article2019 NLFXXX10.1177/1095796019837941New Labor ForumKahn